From http://html5doctor.com/demos/forms/forms-example.html

Printer: print.up

First Name *
Last Name *
Date Of Birth *
Email *
Telephone *
Shoesize
9
Flying Skill Level (1 Low - 100 High)
0
Addressoz Title
Addressoz *
Addressoz Footer
Post Code *
Country *
Card Type *
Name *
Card Number *
Security Code *