<form action="http://alldemos.kmitascripts.com/kmitam/submit.php" method="post" > <div align="justify"><span class="text">Kmita Mail can be easily used for collecting information for registration for some event or registration of Internet Username and Password. The data submitted in the form can be stored in an MySQL database (PHP only) which can be integrated with various other application like Member login . </span><br /> <br /> </div> <table width="95%" height="255" border="0" align="center" cellpadding="1" cellspacing="3"> <tr> <td height="25" class="text_justify_no_side_border"><div align="right"> <input type="hidden" name="formname" value="callback" /> First Name</div></td> <td width="12" height="25" class="text_justify_no_side_border">&nbsp;</td> <td width="400" height="25" class="text_justify_no_side_border"><input name="Name" type="text" id="Name" /></td> </tr> <tr> <td height="25" class="text_justify_no_side_border"><div align="right"> Last Name</div></td> <td height="25" class="text_justify_no_side_border">&nbsp;</td> <td height="25" class="text_justify_no_side_border"><input name="Last_Name" type="text" id="Last_Name" /></td> </tr> <tr> <td height="25" class="text_justify_no_side_border"><div align="right">Email Address </div></td> <td height="25" class="text_justify_no_side_border">&nbsp;</td> <td height="25" class="text_justify_no_side_border"><input name="re_Email" type="text" id="re_Email" /></td> </tr> <tr> <td height="25" class="text_justify_no_side_border"><div align="right">Country</div></td> <td height="25" class="text_justify_no_side_border">&nbsp;</td> <td height="25" class="text_justify_no_side_border"><font size="2"> <select name="Country" class="normalform" id="Country"> <option value="India">India</option> <option value="USA" selected="selected">USA</option> <option value="Canada">Canada</option> <option value="France">France</option> <option value="UK">UK</option> <option value="Germany">Germany</option> <option value="Mexico">Mexico</option> <option value="Belgium">Belgium</option> <option value="Other">Other</option> </select> </font></td> </tr> <tr> <td height="25" class="text_justify_no_side_border"><div align="right">Day Phone Number</div></td> <td height="25" class="text_justify_no_side_border">&nbsp;</td> <td height="25" class="text_justify_no_side_border"><input name="Day_Telephone" type="text" id="Day_Telephone" /> 0000 0000-0000000</td> </tr> <tr> <td height="25" class="text_justify_no_side_border"><div align="right">Night Phone Number</div></td> <td height="25" class="text_justify_no_side_border">&nbsp;</td> <td height="25" class="text_justify_no_side_border"><input name="Night_Telephone" type="text" id="Night_Telephone" /> 0000 0000-0000000</td> </tr> <tr> <td height="25" class="text_justify_no_side_border"><div align="right">Prefferred time of calling</div></td> <td height="25" class="text_justify_no_side_border">&nbsp;</td> <td height="25" class="text_justify_no_side_border"><input name="Preferred_time_from" type="text" id="Preferred_time_from" size="10" maxlength="15" /> to <input name="Preferred_time_to" type="text" id="Preferred_time_to" size="10" maxlength="15" /> in hrs 00:00</td> </tr> <tr> <td height="25" class="text_justify_no_side_border"><img src="http://alldemos.kmitascripts.com/kmitaadmin/kmitam/image.php" width="150" height="80" />&nbsp;</td> <td height="25" class="text_justify_no_side_border">&nbsp;</td> <td height="25" valign="top" class="text_justify_no_side_border"><p>Enter the characters shown in the above image [0-9, A-F]:<br /> <br /> <input name="secnum" type="text" id="secnum" /> </p>  </td> </tr> <tr> <td height="25" class="text_justify_no_side_border">&nbsp;</td> <td height="25" class="text_justify_no_side_border">&nbsp;</td> <td height="25" class="text_justify_no_side_border"><input name="submit" type="submit" /></td> </tr> </table> <p>&nbsp;</p> </form>