
<form method="post" action="confirm.php">
<dl class="info">
<dt>Contact Information</dt>
<dd>
<table>
<tr><td width="250">Title</td>
<td><input name="title" type="text" size="30"></td></tr>
<tr><td>First name *</td>
<td><input name="firstName" type="text" size="30"></td></tr>
<tr><td>Last name *</td>
<td><input name="lastName" type="text" size="30"></td></tr>
<tr><td>Email address *</td>
<td><input name="email" type="text" size="30"></td></tr>
<tr><td>Phone number *</td>
<td><input name="phone" type="text" size="30"></td></tr>
<tr><td>Fax number *</td>
<td><input name="fax" type="text" size="30"></td></tr>
</table>
</dd>
<dt>Billing Address</dt>
<dd> <table>
<tr><td width="250">Organisation *</td>
<td><input name="organisation" type="text" size="30"></td></tr>
<tr><td>Street / P.O. Box</td>
<td><input name="street" type="text" size="30"></td></tr>
<tr><td>City *</td>
<td><input name="city" type="text" size="30"></td></tr>
<tr><td>Postal/ZIP code *</td>
<td><input name="postcode" type="text" size="30"></td></tr>
<tr><td>Country *</td>
<td><input name="country" type="text" size="30"></td></tr>
</table>
</dd>
<dt>Registration Information</dt>
<dd>
<table> <tr><td width="250">Registration Type</td>
<td><select name="regType" size="1">
<option value="conf">Conference (Regular)</option>
<option value="confws">Conference + Workshop (Regular)</option>
<option value="confstud">Conference (Student)</option>
<option value="confwsstud">Conference + Workshop (Student)</option>
<option value="ws">Workshop only</option>
</select></td></tr>
<tr><td width="250">Poster/Paper</td>
<td><select name="posterpaper" size="1">
<option value="poster">Poster</option>
<option value="paper">Paper</option>
<option value="NONE">NONE</option>
</select></td></tr>
<tr><td width="250">Special dietary requirements:<br><em>(e.g. vegetarian)</em></td>
<td><input name="dietaryRequirements" type="text" size="30"></td></tr>
<tr><td>Special needs:<br><em>(e.g. wheelchair access)</em></td>
<td><input name="specialNeeds" type="text" size="30"></td></tr>
<tr><td>Name to appear on Badge: *<br></td>
<td><input name="badgeName" type="text" size="30"></td></tr>

</table>
</dd>
<dt>Submit Information</dt>
<dd>
<table>
<tr><td width="250">&nbsp;</em></td>
<td><input type="submit" value="Submit"></td></tr>
<tr><td>* Required fields.</td></tr>
</table>
</dd>
</dl>
</form>
