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<h1>Dummy Customer Entry Form</h1>
<table>
    <tr>
        <td>
        Title:
            <p>
                <select id="ctitle">
                </select>
            </p>
        </td>
        <td>
            Last Name:
            <p><input type="text" id="clname"/></p>
        </td>
        <td>
            First Name:
            <p><input type="text" id="cfname"/></p>
        </td>
    </tr>
    <tr>
        <td>
            Street 1:
            <p><input type="text" id="castr1"/></p>
        </td>

        <td>
            Street 2:
            <p><input type="text" id="castr2"/></p>
        </td>        

        <td>
            City:
            <p><input type="text" id="ccity"/></p>
        </td>        
    </tr>
    <tr>
        <td>
            State:
            <p><input type="text" id="cstate"/></p>
        </td>

        <td>
            Country:
            <p>
                <select id="ccntry">
                </select>
            </p>
        </td>
    </tr>        
<tr>
        <td>
            Card Type:
            <p><select id="cctype"></select></p>
        </td>

        <td>
            Card No:
            <p><input type="text" id="ccardno"/></p>
        </td>        

        <td>
            Expiry (MM/yyyy):
            <p><input type="text" id="ccexpiry"/></p>
        </td>       
    </tr>                
</table>
                <input type="button" value="submit"/>

body{
    font-size:10pt;
    background-color:#FFCCFF;
    font-family:Arial;
}
h1{
    font-size:16pt;
    font-weight:bold;
}