#3 Basic Information

[Misdafatma Alza Astrafiyah]

<form id="user-content-feedbackform">
<fieldset class="">
<legend>Basic Information</legend>
Name:
<input id="user-content-username" size="35" type="text">

Age:
<input id="user-content-age" size="6" type="text">

Sex: <input name="sex" type="radio" value="male"> Male <input name="sex" type="radio" value="female"> Female </fieldset>
<fieldset class="">
<legend>Shipping Address</legend>
Country:
<input id="user-content-country" size="35" type="text">

State/Province:
<input id="user-content-state" size="35" type="text">

Address #1:
<input id="user-content-addr1" size="35" type="text">

Address #2:
<input id="user-content-addr2" size="35" type="text">

</fieldset>
<fieldset class="">
<legend>Comments</legend>
Any additional instructions:
<textarea id="user-content-feedback" style="height: 150px; width: 350px;"></textarea>

<input type="submit"></fieldset>
</form>