<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Strict//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-strict.dtd">
<html xmlns="http://www.w3.org/1999/xhtml" xml:lang="ru" lang="ru" dir="ltr">
<style type="text/css">
.form
{
background: #F1FDF2;
font-family: Arial;
margin:0px auto;
border:1px solid #ccc;
height:460px;
width:430px;
padding:0;
}
table
{
margin:10px auto;
padding:0;
height:440px;
width:400px;
}
tr
{
height:10px;
}
td img
{
vertical-align:bottom;
height:60px;
}
.text_cell
{
font-family: Arial;
text-align: justify;
font-weight:bolder;
font-size:12px;
}
</style>
<div class="form">
<form method="post" action="#">
<table border="1" cellspacing="0" cellpadding="0">
<tbody>
<col width=100>
<col width=100>
<col width=100>
<col width=100>
<tr>
<td colspan="3" style="border-bottom:2px solid #27A417;">Cover Details</td>
<td rowspan="2" align="center"> </td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td> </td>
<td> </td>
<td colspan="2"> </td>
</tr>
<tr>
<td> </td>
<td colspan="2"> </td>
<td> </td>
</tr>
<tr>
<td colspan="4"> </td>
</tr>
<tr>
<td> </td>
<td colspan="3"> </td>
</tr>
<tr>
<td> </td>
<td> </td>
<td colspan="2">
<select>
<option selected="selected">Day</option>
<option value="">01</option>
<option value="">02</option>
<option value="">...</option>
<option value="">...</option>
</select>
<select style="display:inline;">
<option selected="selected">Math</option>
<option value="">Jan</option>
<option value="">Dec</option>
<option value="">...</option>
<option value="">...</option>
</select>
</td>
</tr>
<tr>
<td> </td>
<td> </td>
<td colspan="2"> </td>
</tr>
<tr>
<td> </td>
<td> </td>
<td colspan="2"> </td>
</tr>
<tr>
<td class="text_cell">Your<br/>occupation:</td>
<td><input type="text" name="occupation" value="" size="12"/></td>
<td colspan="2"> </td>
</tr>
</tbody>
</table>
</form>
</div>
</body>
</html>