+<form method="POST">\r
+<table class="wrapper" width="300">\r
+ <tr>\r
+ <td colspan="2" class="title"><?=_Assure Someone?></td>\r
+ </tr>\r
+ <tr>\r
+ <td class="DataTD" width="125"><?=_Email?>: </td>\r
+ <td class="DataTD" width="125"><input type="text" name="email"></td>\r
+ </tr>\r
+ <tr>\r
+ <td class="DataTD" width="125"><?=_Date of Birth?><br>\r
+ (<?=_dd/mm/yyyy?>)</td>\r
+ <td class="DataTD" width="125"><?=$DoB?></td>\r
+ </tr>\r
+ <tr>\r
+ <td class="DataTD" colspan="2"><input type="submit" name="process" value="<?=_Next?>"></td>\r
+ </tr>\r
+</table>\r
+</form>\r