Posted By

jona777than on 09/23/10

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Last Edited at 09/23/10 07:16am

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<form method="post" action="" id="pp_order_form" name="pp_order_form">
<div class="form_wrapper">
	<p><label for="first_name">First Name:</label><br>
	<input type="text" name="first_name" id="first_name" value="" style="width: 100px;"/></p>
	
	<p><label for="last_name">Last Name:</label><br>
	<input type="text" name="last_name" id="last_name" value="" style="width: 100px;"/></p>
	
	<p><label for="address">Address:</label><br>
	<input type="text" name="address" id="address" value="" style="width: 125px;"/></p>
	
	<p><label for="city">City:</label><br>
	<input type="text" name="city" id="city" value="" style="width: 100px;"/></p>
	
	<p><label for="state">State:</label><br>
	<input type="text" name="state" id="state" value="" style="width: 25px;" maxlength="2" /></p>
	
	<p><label for="zip">Zip:</label><br>
	<input type="text" name="zip" id="zip" value="" style="width: 55px;"/></p>
	
	<p><label for="email">Email Address:</label><br>
	<input type="text" name="email" id="email" value="" style="width: 125px;" /></p>
	
	<p align="center"><input type="submit" name="submit_order" id="submit_order" value="Submit Order" /></p>
</div>
</form>

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