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<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Strict//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-strict.dtd">
<html xmlns="http://www.w3.org/1999/xhtml" xml:lang="en" lang="en">
<head>
<meta http-equiv="Content-Type" content="text/html; charset=utf-8"/>
<title>Example form</title>
<style rel="stylesheet" type="text/css" media="screen">
fieldset {
background-color: #dfdfdf;
border: 1px solid #ccc;
margin: 2em 0;
padding: 1em;
}
</style>
</head>
<body>
<form id="" action="" method="post">
<fieldset id="name">
<legend>Name</legend>
<label>Title
<select id="title1" name="title1">
<option selected="selected">Mr.</option>
<option>Mrs.</option>
<option>Ms.</option>
</select>
</label>
<label>First name
<input id="first-name" name="first-name" type="text" />
</label>
<label>Last name
<input id="las-name" name="last-name" type="text" />
</label>
<br />
</fieldset>
<fieldset id="address">
<legend>Address</legend>
<label>Street
<input id="street" name="street" type="text" />
</label>
<br />
<label>City
<input id="city" name="city" type="text" />
</label>
<label>State
<input id="state" name="state" type="text" />
</label>
<label>Zip code
<input id="zip" name="zip" type="text" />
</label>
<br />
<label>Country
<input id="country" name="country" type="text" />
</label>
<br />
</fieldset>
<fieldset id="payment">
<legend>Payment option</legend>
<fieldset id="credit_card">
<legend>Credit card</legend>
<label><input id="visa" name="visa" type="radio" /> Visa</label>
<label><input id="mastercard" name="mastercard" type="radio" /> Mastercard</label>
<label><input id="discover" name="discover" type="radio" /> Discover</label>
<br />
</fieldset>
<label>Card number
<input id="card_number" name="card_number" type="text" />
</label>
<label>Expiration date
<input id="expiration" name="expiration" type="text" />
</label>
<br />
<input class="submit" type="submit" value="Submit" />
<br />
</fieldset>
</form>
</body>
</html>
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