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<html>
<head>
<title>table</title>
</head> <body>
<h2 align="center" bgcolor="Red"><u><font face="arial" color="#073B6C">Application Form </font></u></h2> <form> <table border="0" cellpadding = "5" cellspacing = "4" width = "300" height = "400" align = "center" bgcolor = "#FFFFFF" style="border:1px solid #C8C6C6;">
<tr>
<td colspan = "4" ><font face="arial" color="#ea2f41">Personal details</td>
</tr> <tr> <td>First Name</td> <td> <input type = "text" name = "First name"></td>
<td>Marital Status</td> <td> <select> <option>Unmarried </option> <option>Married </option> </select> </td> </tr>
<tr>
<td>Middle Name</td> <td> <input type = "text" name = "Middle name"></td>
<td>Date of Birth</td> <td> <select> <option>Date </option> <option>1 </option> <option>2 </option> <option>3 </option> <option>4 </option> </select> <select> <option>Month </option> <option>Jan </option> <option>Feb </option> <option>Mar </option> </select> <select> <option>Year </option> <option>1997 </option> <option>1998 </option> <option>1999 </option> </select> </td>
</tr> <tr>
<td>Surname</td> <td> <input type = "text" ></td>
<td>Email</td> <td> <input type = "text" ></td>
</tr> <tr>
<td>Gender</td> <td> <select> <option>select </option> <option>Male </option> <option>Female </option> </select> </td> <td>Mobile No.</td> <td> <input type = "text" name = "Middle name"></td>
</tr> <tr>
<td>Community</td> <td> <select> <option>select </option> <option>BC-d </option> <option>OC </option> </select> </td> <td>Alternate Mobile</td> <td> <input type = "text" name = "Middle name"></td>
</tr> <tr>
<td colspan = "4" ><font face="arial" color="#ea2f41">Residental Address</td>
</tr> <tr>
<td>House Number</td> <td> <input type = "text" name = "Middle name"></td>
<td>Mandal</td> <td> <select> <option>select </option> <option>Amalapuram </option> <option>Mummidivaram </option> </select> </td> </tr>
<tr>
<td>Street Name</td> <td> <input type = "text" name = "Middle name"></td>
<td>Muncipality</td> <td> <select> <option>select </option> <option>Guntur </option> <option>Vijayawada </option> </select> </td> </tr>
<tr>
<td>District</td> <td> <select> <option>East Godavari </option> <option>West Godavari </option> <option>Krishna </option> </select> </td> <td>Village/Town/City</td> <td> <select> <option>select </option> <option>kakinada </option> <option>Kurnool </option> </select> </td> </tr> <tr>
<td colspan = "4" ><font face="arial" color="#ea2f41">Identification Marks</td>
</tr> <tr>
<td>Identification Marks1</td> <td> <input type = "text" ></td> </tr>
<tr>
<td>Identification Marks2</td> <td> <input type = "text" ></td> </tr> <tr>
<td>Thumb Impression</td> <td> <input type = "text" ></td> </tr> <tr>
<td>Name of Health Facility</td> <td> <input type = "Checkbox" >PHC
<input type = "Checkbox" >CHC <input type = "Checkbox" >AH
<input type = "Checkbox" >DH
</tr>
<tr>
<td colspan = "4" ><font face="arial" color="#ea2f41"> Enrollment Under Disability Conditions</td> </tr> <tr>
<td> 1. Thalasemia Major</td> <td> <input type = "text" ></td> </tr> <tr>
<td> 2. Sickel cell Disease</td> <td> <input type = "text" ></td> </tr> <tr>
<td> 3. Severe Hemophilia</td> <td> <input type = "text" ></td>
</tr> <tr>
<td colspan = "4" </td>
<table border="0" cellpadding = "2" cellspacing = "2" width = "100%" align = "center" bgcolor = "#EFEEEE" style="border:1px solid #C8C6C6;">
<tr>
<td>Name</td> <td> <input type = "text" ></td> <td>Contact Number</td> <td> <input type = "text" ></td> </tr> <tr>
<td>Address</td> <td> <input type = "text" ></td> <td>Email-ID</td> <td> <input type = "text" ></td> </tr>
<tr>
<td> </td> <td> </td> <td> </td> <td> <textarea cols="22" rows="4"> </textarea ></td> </tr> </td> </table> </tr>
</table> </form>
</body> </html>
<head>
<title>table</title>
</head> <body>
<h2 align="center" bgcolor="Red"><u><font face="arial" color="#073B6C">Application Form </font></u></h2> <form> <table border="0" cellpadding = "5" cellspacing = "4" width = "300" height = "400" align = "center" bgcolor = "#FFFFFF" style="border:1px solid #C8C6C6;">
<tr>
<td colspan = "4" ><font face="arial" color="#ea2f41">Personal details</td>
</tr> <tr> <td>First Name</td> <td> <input type = "text" name = "First name"></td>
<td>Marital Status</td> <td> <select> <option>Unmarried </option> <option>Married </option> </select> </td> </tr>
<tr>
<td>Middle Name</td> <td> <input type = "text" name = "Middle name"></td>
<td>Date of Birth</td> <td> <select> <option>Date </option> <option>1 </option> <option>2 </option> <option>3 </option> <option>4 </option> </select> <select> <option>Month </option> <option>Jan </option> <option>Feb </option> <option>Mar </option> </select> <select> <option>Year </option> <option>1997 </option> <option>1998 </option> <option>1999 </option> </select> </td>
</tr> <tr>
<td>Surname</td> <td> <input type = "text" ></td>
<td>Email</td> <td> <input type = "text" ></td>
</tr> <tr>
<td>Gender</td> <td> <select> <option>select </option> <option>Male </option> <option>Female </option> </select> </td> <td>Mobile No.</td> <td> <input type = "text" name = "Middle name"></td>
</tr> <tr>
<td>Community</td> <td> <select> <option>select </option> <option>BC-d </option> <option>OC </option> </select> </td> <td>Alternate Mobile</td> <td> <input type = "text" name = "Middle name"></td>
</tr> <tr>
<td colspan = "4" ><font face="arial" color="#ea2f41">Residental Address</td>
</tr> <tr>
<td>House Number</td> <td> <input type = "text" name = "Middle name"></td>
<td>Mandal</td> <td> <select> <option>select </option> <option>Amalapuram </option> <option>Mummidivaram </option> </select> </td> </tr>
<tr>
<td>Street Name</td> <td> <input type = "text" name = "Middle name"></td>
<td>Muncipality</td> <td> <select> <option>select </option> <option>Guntur </option> <option>Vijayawada </option> </select> </td> </tr>
<tr>
<td>District</td> <td> <select> <option>East Godavari </option> <option>West Godavari </option> <option>Krishna </option> </select> </td> <td>Village/Town/City</td> <td> <select> <option>select </option> <option>kakinada </option> <option>Kurnool </option> </select> </td> </tr> <tr>
<td colspan = "4" ><font face="arial" color="#ea2f41">Identification Marks</td>
</tr> <tr>
<td>Identification Marks1</td> <td> <input type = "text" ></td> </tr>
<tr>
<td>Identification Marks2</td> <td> <input type = "text" ></td> </tr> <tr>
<td>Thumb Impression</td> <td> <input type = "text" ></td> </tr> <tr>
<td>Name of Health Facility</td> <td> <input type = "Checkbox" >PHC
<input type = "Checkbox" >CHC <input type = "Checkbox" >AH
<input type = "Checkbox" >DH
</tr>
<tr>
<td colspan = "4" ><font face="arial" color="#ea2f41"> Enrollment Under Disability Conditions</td> </tr> <tr>
<td> 1. Thalasemia Major</td> <td> <input type = "text" ></td> </tr> <tr>
<td> 2. Sickel cell Disease</td> <td> <input type = "text" ></td> </tr> <tr>
<td> 3. Severe Hemophilia</td> <td> <input type = "text" ></td>
</tr> <tr>
<td colspan = "4" </td>
<table border="0" cellpadding = "2" cellspacing = "2" width = "100%" align = "center" bgcolor = "#EFEEEE" style="border:1px solid #C8C6C6;">
<tr>
<td>Name</td> <td> <input type = "text" ></td> <td>Contact Number</td> <td> <input type = "text" ></td> </tr> <tr>
<td>Address</td> <td> <input type = "text" ></td> <td>Email-ID</td> <td> <input type = "text" ></td> </tr>
<tr>
<td> </td> <td> </td> <td> </td> <td> <textarea cols="22" rows="4"> </textarea ></td> </tr> </td> </table> </tr>
</table> </form>
</body> </html>
