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

First Name *

Last Name *

Date Of Birth *

Email *

Url(Optional)

Telephone *

Shoesize(Optional)

Flying Skill Level (1 Low - 100 High)(Optional)

Addressoz Title

Addressoz *

Addressoz Footer

Post Code *

Country *

Card Type *

VISAMastercardAMEX

Name *

Card Number *

Security Code *

Expiry Date(Optional)

 YearJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberMonth