Data Entered:

" + "

Normally, the data would be mailed or submitted to a server, but since this is just a demo, we replace the usual Submit button with a mockup that just calls some code to display what was typed in.

" + "" + "" + "" + "" + "" + "" + "" + "" + "" + "" + "" + "" + "" + "" + "

" + sUSLastName + "	" + form.elements["LastName"].value + "
" + sUSFirstName + "	" + form.elements["FirstName"].value + "
" + sUSAddress + "	" + form.elements["StreetAddress"].value + "
" + sCity + "	" + form.elements["City"].value + "
" + sStateCode + "	" + form.elements["State"].value + "
" + sZIPCode + "	" + form.elements["ZIP"].value + "
" + sPhone + "	" + form.elements["Phone"].value + "
" + sFax + "	" + form.elements["Fax"].value + "
" + sEmail + "	" + form.elements["Email"].value + "
" + sSSN + "	" + form.elements["SSN"].value + "
" + sDateOfBirth + "	" + form.elements["BirthYear"].value + "/" + form.elements["BirthMonth"].value + "/" + form.elements["BirthDay"].value + "
" + sCreditCardNumber + "	" + form.elements["CreditCardNumber"].value + "
" + sExpirationDate + "	" + form.elements["ExpirationYear"].value + "/" + form.elements["ExpirationMonth"].value + "/" + form.elements["ExpirationDay"].value + "
" + sOtherInfo + "	" + form.elements["OtherInfo"].value + "

" document.writeln(outputTable) document.close() return true }

Please Fill this Form

Fields marked with an asterisk (*) must be entered.

* Last Name:
* First Name:
Title:
Company Name:
* Street Address:
* City:
* State:
* ZIP Code:
* Phone:
Fax:
Email:
Social Security Number:
* Date of Birth:	* YYYY: * MM: * DD:
* Credit Card Type: Visa MasterCard American Express Diner's Club Carte Blanche Discover en Route JCB	* Credit Card Number: (view sample valid numbers) * Expiration Date: * YYYY: * MM: DD:
* Sex:	Male Female
Other information:
Press to submit