<form action="success.php" method=post name="order_form" style="margin-top: 50px;"><table class="ea_table_form" border="0">



<tr><td class="ea_td_right"><span class="ea_name_field">ФИО</span><span class="ea_required_text">*</span></td><td><input type="text" name="name" class="ea_name ea_input" value=""/><br/><em><span id="comment_name" class="comment_field">Иванов Иван Сергеевич</span></em></td></tr><tr><td colspan="2" height="10"></td></tr>

<tr><td class="ea_td_right" valign="top"><span class="ea_name_field">Телефон</span><span class="ea_required_text">*</span></td><td nowrap="nowrap"><input type="text" name="phone" class="ea_phone ea_input"  value="" /></td></tr><tr><td colspan="2" height="10"></td></tr>


<tr><td class="ea_td_right"><span class="ea_name_field">Полный адрес</span><span class="ea_required_text">*</span></td><td align="left"><input type="text" name"address" class="ea_adress ea_input" ><br>
<em>
<span id="comment_name" class="comment_field">Индекс город улица квартира</span>
</em></tr>

<tr><td class="ea_td_center" colspan="2"><br><input type="submit" class="ea_submit" name="submit" value="Отправить" /></td></tr>

<tr><td colspan="2" height="10"></td></tr></table>
<input type="hidden" name="s1" class="price_field_s1" value="1190" />
<input type="hidden" name="s2" class="price_field_s2" value="300" />
<input type="hidden" name="s3" class="price_field_s3" value="3890" />
</form>