I wish I could say which one I need. I am still new to php and have not ventured down all the avenues just yet.
Here is my code for my hosting page. This has all the fields, if you need my processorder.php file, let me know.
Here's the page www.enfinityhost.com/hosting.php
<html>
<head>
<title>Order Hosting - EnfinityHost.com</title>
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1">
<link rel="stylesheet" href="../default.css" type="text/css">
</head>
<body>
<form action="orderprocess.php" method="post">
<table width="631" bgcolor="#FFFFFF">
<tr><td width="623" align="right">Please fill out this simple form carefully. We will need these details to set up your account. </td></tr>
<tr>
<td height="542" align="right">
<table width="520" bordercolor="#FFFFFF" border="0" cellpadding="1" cellspacing="1" id="contact">
<tr bgcolor="#3366CC">
<td colspan="3">
<div align="center"> <strong><font color="#FFFFFF" face="Arial, Helvetica, sans-serif">Hosting
Order Form</font></strong> </div></td>
</tr>
<tr>
<td width="130" bgcolor="#CCCCCC"><div align="right"><strong>First Name:</strong></div></td>
<td width="390" bgcolor="#CCCCCC" colspan="2"><input type="text" name="first" size="45" maxlength="45"></td>
</tr>
<tr>
<td bgcolor="#CCCCCC"><div align="right"><strong>Last Name:</strong></div></td>
<td bgcolor="#CCCCCC" colspan="2"><input type="text" name="last" size="45" maxlength="45"></td>
</tr>
<tr>
<td bgcolor="#CCCCCC"><div align="right"><strong>Email:</strong></div></td>
<td bgcolor="#CCCCCC" colspan="2"><input type="text" name="email" size="45" maxlength="45"></td>
</tr>
<tr>
<td bgcolor="#CCCCCC"><div align="right"><strong>Address:</strong></div></td>
<td bgcolor="#CCCCCC" colspan="2"> <div align="justify">
<input type="text" name="address" size="45" maxlength="45">
</div></td>
</tr>
<tr>
<td bgcolor="#CCCCCC"><div align="right"><strong>City:</strong></div></td>
<td bgcolor="#CCCCCC" colspan="2"><input type="text" name="city" size="45" maxlength="45"></td>
</tr>
<tr>
<td bgcolor="#CCCCCC"><div align="right"><strong>State/Province:</strong></div></td>
<td bgcolor="#CCCCCC" colspan="2"><input type="text" name="state" size="45" maxlength="45"></td>
</tr>
<tr>
<td bgcolor="#CCCCCC"><div align="right"><strong>Country:</strong></div></td>
<td bgcolor="#CCCCCC" colspan="2"><select name="country">
<option value=>Select</option>
<option value="USA"> United States of America</opion>
<option value="Canada">Canada</option>
</select></td>
</tr>
<tr>
<td bgcolor="#CCCCCC"><div align="right"><strong>Zip / Postal Code:</strong></div></td>
<td bgcolor="#CCCCCC" colspan="2"><input type="text" name="zip" size="45" maxlength="45"></td>
</tr>
<tr>
<td bgcolor="#CCCCCC"><div align="right"><strong>Phone Number:</strong></div></td>
<td bgcolor="#CCCCCC" colspan="2"><input type="text" name="phone" size="45" maxlength="15"></td>
</tr>
</table>
<table width="520" bordercolor="#FFFFFF" border="0" cellpadding="1" cellspacing="1" id="account">
<tr><td bgcolor="#FFFFFF" colspan="3"><p> </p></tr>
<tr bgcolor="#3366CC">
<td height="23" colspan="3">
<div align="center"> <strong><font color="#FFFFFF" face="Arial, Helvetica, sans-serif">Account Information</font></strong> </div></td>
</tr>
<tr>
<td width="130" bgcolor="#CCCCCC"><div align="right"><strong>Domain Name:</strong></div></td>
<td width="390" bgcolor="#CCCCCC" colspan="2"><input type="text" name="domain" size="45" maxlength="45" value="http://www."><a href="https://www.registryrocket.com/default.asp?ec=ADD7CF9E-249C-42F3-9256-0" onclick="window.open('https://www.registryrocket.com/default.asp?ec=ADD7CF9E-249C-42F3-9256-0'); return false"><font size="-2"> Not registered?</a></td>
</tr>
<tr>
<td bgcolor="#CCCCCC"><div align="right"><strong>Username:</strong></div></td>
<td bgcolor="#CCCCCC" colspan="2"><input type="text" name="username" size="45" maxlength="45"></td>
</tr>
<tr>
<td bgcolor="#CCCCCC"><div align="right"><strong>Password:</strong></div></td>
<td bgcolor="#CCCCCC" colspan="2"><input type="password" name="password" size="45" maxlength="45">
(6 - 12 char)</td>
</tr>
<tr>
<td bgcolor="#CCCCCC"><div align="right"><strong>Confirm password:</strong></div></td>
<td bgcolor="#CCCCCC" colspan="2"><input type="password" name="password2" size="45" maxlength="45"></td>
</tr><tr>
<td bgcolor="#CCCCCC"><div align="right"><strong>Front Page Ext?</strong></div></td>
<td bgcolor="#CCCCCC" colspan="2"><input type="checkbox" name="frontpage" value="yes"></td>
</tr>
</table>
<table width="520" bordercolor="#FFFFFF" border="0" cellpadding="1" cellspacing="1" id="package">
<tr><td bgcolor="#FFFFFF" colspan="3"><p> </p></tr>
<tr bgcolor="#3366CC">
<td colspan="3">
<div align="center"> <strong><font color="#FFFFFF" face="Arial, Helvetica, sans-serif">Hosting
Packages </font></strong> </div></td>
</tr>
<tr>
<td cosplan="3" bgcolor="#CCCCCC"><center>
<select name="package" style="width:470px">
<option value=>Select Package & Terms</option>
<option value="eh_100m">eh_100 - 100 MB Disk Space, 1.0 GB Transfer, 2 MySQL - $5.00 USD/Month</option>
<option value="eh_100y">eh_100 - 100 MB Disk Space, 1.0 GB Transfer, 2 MySQL - $50.00 USD/Year</option>
<option value="eh_250m">eh_250 - 250 MB Disk Space, 2.5 GB Transfer, 5 MySQL - $10.00 USD/Month</option>
<option value="eh_250y">eh_250 - 250 MB Disk Space, 2.5 GB Transfer, 5 MySQL - $100.00 USD/Year</option>
<option value="eh_500m">eh_500 - 500 MB Disk Space, 5.0 GB Transfer, 10 MySQL - $15.00 USD/Month</option>
<option value="eh_500y">eh_500 - 500 MB Disk Space, 5.0 GB Transfer, 10 MySQL - $150.00 USD/Year</option>
</select></center>
</td>
</tr>
<tr><td bgcolor="#FFFFFF" colspan="3"><p> </p></tr>
<tr bgcolor="#3366CC">
<td colspan="3">
<div align="center"> <strong><font color="#FFFFFF" face="Arial, Helvetica, sans-serif">Additional Features</font></strong> </div></td>
</tr>
<tr><td bgcolor="#FFFFFF" colspan="3"><p> </p></td></tr>
<tr>
<td colspan="3" align="right"><table width="510">
<tr>
<td align="right" width="130"><font size="-2">Comment's or Requests:</font></td>
<td align="right" width="330"><textarea name="comments" rows="3" cols="40">
</textarea></td></tr></table></td></tr>
<tr><td bgcolor="#FFFFFF" colspan="3"><p> </p></tr>
<tr>
<td bgcolor="#FFFFFF" colspan="3"><table width="515">
<tr><td width="249"><p>
<input type="checkbox" name="agreement" value="accepted">
I accept the EnfinityHost.com<br>
<a href="tos.php" onclick="window.open('tos.php','popup','width=539,height=500,scrollbars=yes,resizable=no,toolbar=no,directories=no,location=no,menubar=no,status=no,left=0,top=0'); return false">TOS/Acceptable Use Policy</a>
</p></td><td align="right" width="254"><input type="submit" value="Continue"></td></tr></table></td></tr>
<tr>
<td bgcolor="#FFFFFF" colspan="3"></td>
</tr>
</table>
</td>
</tr>
</table>
</form>
</body>
</html>