<form action="<?php echo $_SERVER[PHP_SELF]; ?>" method=post>
Full Name: <input type=text name=fullname placeholder="John Smith" required /><br>
Email: <input type=email placeholder="jsmith@example.com" required /><br>
Date of Birth: <select name=month>
<br>
Location: <input type=text name=loc placeholder="Chicago, IL U.S.A." required /><br><br>
Username: <input type=text name=username placeholder="jsmithrocks234" required /><br>
Password: <input type=password name=pass1 required /><br>
Confirm Password: <input type=password name=pass2 required /><br><br>
<input type=submit name=submit value=" Join " />