LJ 48:

<HTML>
<Head>
<Title>Enter your birthday</Title>
</Head>
<Body>
<H1>Enter our birthday database!</H1>
<Form method="POST"
action="/cgi-bin/enter-birthday-info.pl">

<P>First name: <input type="text" size="15"
maxsize="15" name="firstname"></P>
<P>Last name: <input type="text" size="15"
maxsize="15" name="lastname"></P>
<P>E-mail address: <input type="text"
size="50" maxsize="50"
name="email"></P>

<P>Your birthday:
<select name="month">
<option value="1">January
<option value="2">February
<option value="3">March
<option value="4">April
<option value="5">May
<option value="6">June
<option value="7">July
<option value="8">August
<option value="9">September
<option value="10">October
<option value="11">November
<option value="12">December
</select>
<select name="day">
<option value="1">1
<option value="2">2
<option value="3">3
<option value="4">4
<option value="5">5
<option value="6">6
<option value="7">7
<option value="8">8
<option value="9">9
<option value="10">10
<option value="11">11
<option value="12">12
<option value="13">13
<option value="14">14
<option value="15">15
<option value="16">16
<option value="17">17
<option value="18">18
<option value="19">19
<option value="20">20
<option value="21">21
<option value="22">22
<option value="23">23
<option value="24">24
<option value="25">25
<option value="26">26
<option value="27">27
<option value="28">28
<option value="29">29
<option value="30">30
<option value="31">31
</select>,
19 <!-- Assume the 20th century  -->
<select name="yeartens">
<option value="0">0
<option value="1">1
<option value="2">2
<option value="3">3
<option value="4">4
<option value="5">5
<option value="6">6
<option value="7">7
<option value="8">8
<option selected value="9">9
</select>
<select name="yearones">
<option value="0">0
<option value="2">2
<option value="3">3
<option value="4">4
<option value="5">5
<option value="6">6
<option value="7">7
<option selected value="8">8
<option value="9">9
</select>
</P>
<input type="submit">
</Form>
</Body>
</HTML>