Código PHP:
<form name="form1" method="post" action="">
<p>
<label>
<input type="radio" name="RadioGroup1" value="radio" id="RadioGroup1_0">
New</label>
<br>
<label>
<input type="radio" name="RadioGroup1" value="radio" id="RadioGroup1_1">
Renew</label>
<br>
<label>
<input type="radio" name="RadioGroup1" value="radio" id="RadioGroup1_2">
Permanent</label>
</p>
<p>Address Change Membership #:
<input name="text1" type="text" id="text1" size="5" maxlength="5">
<input name="text2" type="text" id="text2" size="5" maxlength="5">
<input name="text3" type="text" id="text3" size="5" maxlength="5">
<input name="text4" type="text" id="text4" size="5" maxlength="5">
<input name="text5" type="text" id="text5" size="5" maxlength="5">
</p>
<p>
<label>Name
<input name="name" type="text" id="name" size="30" maxlength="40">
</label>
<label>Title
<input name="title" type="text" id="title" size="5" maxlength="5">
</label>
</p>
<p>
<label>Mailing Address
<input name="mailing_address" type="text" id="Mailing Address" size="25" maxlength="40">
</label>
<br>
</p>
<label>City
<input name="city" type="text" id="city" size="30" maxlength="40">
</label>
<label>State
<select name="state" id="state">
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
</select>
</label>
<p>
<label>Postal Code
<input name="postal_code" type="text" id="postal_code" size="7" maxlength="10">
</label>
<label>Country
<select name="country" id="country">
<option value="" >Please select...</option>
<option value="1" >Afghanistan</option>
<option value="2" >Albania</option>
<option value="3" >Algeria</option>
</select>
</select>
</label>
</p>
<p>
<label>E-Mail
<input name="email" type="text" id="email" size="25" maxlength="35">
</label>
<label>Office Phone
<input name="office_phone" type="text" id="office_phone" size="15" maxlength="20">
</label>
</p>
<p>
<label>Home Phone
<input name="home_phone" type="text" id="home_phone" size="15" maxlength="20">
</label>
<label>Fax
<input name="fax" type="text" id="fax" size="15" maxlength="20">
</label>
</p>
<p>Method of payment</p>
<p>
<label>Check or Money Order
<input type="checkbox" name="check" id="check">
</label>
<label>Visa
<input type="checkbox" name="visa" id="visa">
</label>
</p>
<p>
<label>Credit Card Number #
<input name="creditcard#" type="text" id="creditcard#" size="20" maxlength="25">
</label>
</p>
<p>Choose the level of membership desired below.<br>
</p>
</form>