<form action="" method="post">
				<p>Title: <select name="title" id="title"><option value="0" selected="SELECTED">---</option><option value="Mr.">Mr.</option><option value="Ms.">Ms.</option><option value="Mrs.">Mrs.</option><option value="Miss.">Miss.</option></select></p>
				<div style="float: left; margin-right: 25px">
					<p>First Name:</p>
					<p><input type="text" name="fname" id="fname" /></p>
					<p>Address 1:</p>
					<p><input type="text" name="addr1" id="addr1" /></p>
					<p>City:</p>
					<p><input type="text" name="city" id="city" /></p>
					<p>Zip/Postal Code:</p>
					<p><input type="text" name="zip" id="zip" /></p>
					<p>Phone #:</p>
					<p><input type="text" name="phone" id="phone" /></p>
				</div>
				<div style="float: left">
					<p>Last Name:</p>
					<p><input type="text" name="lname" id="lname" /></p>
					<p>Address 2:</p>
					<p><input type="text" name="addr2" id="addr2" /></p>
					<p>State/Province: </p>
					<p><input type="text" name="state" id="state" /></p>
					<p>Country:</p>
					<p><input type="text" name="country" id="country" /></p>
					<p>Email:</p>
					<p><input type="text" name="email" id="email" /></p>
				</div>
				<div style="clear: both"></div>
				<p><input type="checkbox" /> <strong>I declare that I am atleast 18 years of age, or older.</strong></p>
				<p><input type="checkbox" /> <strong>I have read and accept the <a href="tos.php" class="tos">terms and conditions</a> and the data protection policy.</strong></p>
				<p style="text-align: justify; font: 10px Verdana; color: #BBBBBB;">This present sweepstake/competition is carried out with the objective to incorporate your personal information in the marketing database, property of mysite. Should you not wish that your personal information forms part of this mentioned database, we kindly ask you not to participate in this competition/sweepstake. Furthermore, if you do not inform us otherwise, your participation in this sweepstake is automatically treated as your permission to include your personal information in our sponsors´ database. Should you oppose to your personal information forms part of these databases mentioned above, please click here.</p>
				<p><input style="margin-top: 10px; width: 132px; height: 30px" type="image" src="img/confirm.png" /></p>
				</form>