<html>
<head>
<title></title>
<style type="text/css">
.style1
{
width: 195px;
}
</style>
</head>
<body>
<fieldset>
<legend>
<h3>
Personal Information</h3>
</legend>
<table style="width: 442px">
<tr>
<td class="style1">
Name:
</td>
<td>
<input type="text" style="height: 21px; width: 197px" /><br />
</td>
</tr>
<tr>
<td class="style1">
Email:
</td>
<td>
<input type="text" style="height: 22px; width: 197px" /><br />
</td>
</tr>
<tr>
<td class="style1">
Date of birth:
</td>
<td>
<input type="text" style="height: 25px; width: 194px" /><br />
</td>
</tr>
</table>
</fieldset>
<br /><br />
<fieldset>
<legend>
<h3>
Contact Information</h3>
</legend>
<table style="width: 442px">
<tr>
<td class="style1">
Contact_Number:
</td>
<td>
<input type="text" style="height: 21px; width: 197px" /><br />
</td>
</tr>
<tr>
<td class="style1">
Fax_Number:
</td>
<td>
<input type="text" style="height: 22px; width: 197px" /><br />
</td>
</tr>
<tr>
<td class="style1">
Mobile_Number:
</td>
<td>
<input type="text" style="height: 25px; width: 194px" /><br />
</td>
</tr>
</table>
</fieldset>
</body>
</html>