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<html>
<head>
<style type="text/css">
div.label {
float: left;
width: 300px;
}
input,p span {
display: inline-block;
margin-left: 50x;
}
</style>
</head>
<body>
<form>
<h1>Money Transfer</h1>
<fieldset>
<legend>Recipient</legend>
<p>
<div class="label">Name or company*:</div>
<input
type="text"
name="recipientName" />
</p>
<p>
<div class="label">Account number*:</div>
<input
type="text"
name="recipientAccount" />
</p>
<p>
<div class="label">Bank code*:</div>
<input
type="text"
name="recipientBankCode" />
</p>
<p>
<div class="label">Bank name:</div>
<span>will be inserted automatically.</span>
</p>
</fieldset>
<fieldset>
<legend>Transfer Details</legend>
<p>
<div class="label">Amount*:</div>
<input
type="text"
name="amount" />
</p>
<p>
<div class="label">Reason:</div>
<input
type="text"
name="reasonLine1" />
</p>
<p>
<div class="label">&nbsp;</div>
<input
type="text"
name="reasonLine2" />
</p>
<p>
<div class="label">&nbsp;</div>
<input
type="text"
name="reasonLine3" />
</p>
<p>
<div class="label">&nbsp;</div>
<input
type="text"
name="reasonLine4" />
</p>
</fieldset>
<p>
<div class="label">Fulfillment:</div>
<input
type="text"
name="fulfillmentDate" />
(YYYY.MM.DD) Leave empty if you wish immediate fulfillment
</p>
<p>
<div class="label">Transferor Account*:</div>
<select name="transferorAccount">
<option>Account 4711</option>
<option>Account 08/15</option>
</select>
</p>
<input
type="submit"
value="Submit" />
</form>
</body>
</html>