Mine

<?php
$name = $_POST['first'];
$last = $_POST['last'];
$address = $_POST['street'];
$city = $_POST['city'];
$region = $_POST['region'];
$postcode = $_POST['postcode'];
$phone = $_POST['phone'];
$email = $_POST['email'];
$website = $_POST['website'];
$username = $_POST['username'];
$package = $_POST['package'];
$other = $_POST['other'];

// check for valid input
if ($name != "" AND $last != "" AND $address != "" AND $city != "" AND $postcode != "" AND $phone != "" AND $email != "" AND $website != "" AND $username != "" AND $package != "") {

  $sendto = "support@zeebie.co.uk"; //change to your email address obviously
  $subject = "Signup From Zeebie.co.uk";
  $message = "Hosting Signup:
From: $name $last
Address: $address , $city , $region , $postcode
Phone: $phone
Email: $email
Website: $website
Username: $username
Package: $package
Message: $other";
  // send
  mail("$sendto", "$subject", "$message");
  echo "Your application was sent.";
}
?>
	
<form id="form1" class="wufoo" method="post" action="<?=$_SERVER['PHP_SELF'] ?>" enctype="multipart/form-data">


<h2>Signup</h2>

<ul id="formFields">

<li>
<label class="desc" for="field1">Name</label>
<span>
<input id="field1" name= "first"
class="field text" size="8" value=""/>
<label class="tam">First</label></span>
<span>
<input id="field2" name= "last"
class="field text" size="14" value=""/>
<label class="tam">Last</label></span>
<p class="tam"></p>
</li>

<li>
<label class="desc" for="strret">Address</label>
<div class="full">
<input id="street" name="street" class="field text medium" type="text" value="" />
<label class="">Street Address</label>
</div>
<div class="full">
<input class="field text large" type="text" value="" />
<label class="">Address Line 2</label>
</div>
<div class="left">
<input id="city" name="city" class="field text medium" type="text" value="" />
<label class="">City</label>
</div>
<div class="right">
<input id="region" name="region" class="field text medium" type="text" value="" />
<label class="">State / Province / Region</label>
</div>
<div class="left">
<input id="postcode" name="postcode" class="field text medium" type="text"  maxlength="15"value="" />
<label class="">Postal / Zip Code</label>
</div>
<div class="right">
<select class="field select medium" id="country" name="country"> 
<option value=""  selected="selected"></option>
<option value="Afghanistan">Afghanistan</option>
<option value="Albania">Albania</option>
<option value="Algeria">Algeria</option>
<option value="Andorra">Andorra</option>
<option value="Antigua and Barbuda">Antigua and Barbuda</option>
<option value="Argentina">Argentina</option>
<option value="Armenia">Armenia</option>
<option value="Australia">Australia</option>
<option value="Austria">Austria</option>
<option value="Azerbaijan">Azerbaijan</option>
<option value="Bahamas">Bahamas</option>
<option value="Bahrain">Bahrain</option>
<option value="Bangladesh">Bangladesh</option>
<option value="Barbados">Barbados</option>
<option value="Belarus">Belarus</option>
<option value="Belgium">Belgium</option>
<option value="Belize">Belize</option>
<option value="Benin">Benin</option>
<option value="Bhutan">Bhutan</option>
<option value="Bolivia">Bolivia</option>
<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
<option value="Botswana">Botswana</option>
<option value="Brazil">Brazil</option>
<option value="Brunei">Brunei</option>
<option value="Bulgaria">Bulgaria</option>
<option value="Burkina Faso">Burkina Faso</option>
<option value="Burundi">Burundi</option>
<option value="Cambodia">Cambodia</option>
<option value="Cameroon">Cameroon</option>
<option value="Canada">Canada</option>
<option value="Cape Verde">Cape Verde</option>
<option value="Central African Republic">Central African Republic</option>
<option value="Chad">Chad</option>
<option value="Chile">Chile</option>
<option value="China">China</option>
<option value="Colombia">Colombia</option>
<option value="Comoros">Comoros</option>
<option value="Congo">Congo</option>
<option value="Costa Rica">Costa Rica</option>
<option value="C&ocirc;te d'Ivoire">C&ocirc;te d'Ivoire</option>
<option value="Croatia">Croatia</option>
<option value="Cuba">Cuba</option>
<option value="Cyprus">Cyprus</option>
<option value="Czech Republic">Czech Republic</option>
<option value="Denmark">Denmark</option>
<option value="Djibouti">Djibouti</option>
<option value="Dominica">Dominica</option>
<option value="Dominican Republic">Dominican Republic</option>
<option value="East Timor">East Timor</option>
<option value="Ecuador">Ecuador</option>
<option value="Egypt">Egypt</option>
<option value="El Salvador">El Salvador</option>
<option value="Equatorial Guinea">Equatorial Guinea</option>
<option value="Eritrea">Eritrea</option>
<option value="Estonia">Estonia</option>
<option value="Ethiopia">Ethiopia</option>
<option value="Fiji">Fiji</option>
<option value="Finland">Finland</option>
<option value="France">France</option>
<option value="Gabon">Gabon</option>
<option value="Gambia">Gambia</option>
<option value="Georgia">Georgia</option>
<option value="Germany">Germany</option>
<option value="Ghana">Ghana</option>
<option value="Greece">Greece</option>
<option value="Grenada">Grenada</option>
<option value="Guatemala">Guatemala</option>
<option value="Guinea">Guinea</option>
<option value="Guinea-Bissau">Guinea-Bissau</option>
<option value="Guyana">Guyana</option>
<option value="Haiti">Haiti</option>
<option value="Honduras">Honduras</option>
<option value="Hong Kong">Hong Kong</option>
<option value="Hungary">Hungary</option>
<option value="Iceland">Iceland</option>
<option value="India">India</option>
<option value="Indonesia">Indonesia</option>
<option value="Iran">Iran</option>
<option value="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Israel">Israel</option>
<option value="Italy">Italy</option>
<option value="Jamaica">Jamaica</option>
<option value="Japan">Japan</option>
<option value="Jordan">Jordan</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kiribati">Kiribati</option>
<option value="North Korea">North Korea</option>
<option value="South Korea">South Korea</option>
<option value="Kuwait">Kuwait</option>
<option value="Kyrgyzstan">Kyrgyzstan</option>
<option value="Laos">Laos</option>
<option value="Latvia">Latvia</option>
<option value="Lebanon">Lebanon</option>
<option value="Lesotho">Lesotho</option>
<option value="Liberia">Liberia</option>
<option value="Libya">Libya</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lithuania">Lithuania</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macedonia">Macedonia</option>
<option value="Madagascar">Madagascar</option>
<option value="Malawi">Malawi</option>
<option value="Malaysia">Malaysia</option>
<option value="Maldives">Maldives</option>
<option value="Mali">Mali</option>
<option value="Malta">Malta</option>
<option value="Marshall Islands">Marshall Islands</option>
<option value="Mauritania">Mauritania</option>
<option value="Mauritius">Mauritius</option>
<option value="Mexico">Mexico</option>
<option value="Micronesia">Micronesia</option>
<option value="Moldova">Moldova</option>
<option value="Monaco">Monaco</option>
<option value="Mongolia">Mongolia</option>
<option value="Morocco">Morocco</option>
<option value="Mozambique">Mozambique</option>
<option value="Myanmar">Myanmar</option>
<option value="Namibia">Namibia</option>
<option value="Nauru">Nauru</option>
<option value="Nepal">Nepal</option>
<option value="Netherlands">Netherlands</option>
<option value="New Zealand">New Zealand</option>
<option value="Nicaragua">Nicaragua</option>
<option value="Niger">Niger</option>
<option value="Nigeria">Nigeria</option>
<option value="Norway">Norway</option>
<option value="Oman">Oman</option>
<option value="Pakistan">Pakistan</option>
<option value="Palau">Palau</option>
<option value="Panama">Panama</option>
<option value="Papua New Guinea">Papua New Guinea</option>
<option value="Paraguay">Paraguay</option>
<option value="Peru">Peru</option>
<option value="Philippines">Philippines</option>
<option value="Poland">Poland</option>
<option value="Portugal">Portugal</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Qatar">Qatar</option>
<option value="Romania">Romania</option>
<option value="Russia">Russia</option>
<option value="Rwanda">Rwanda</option>
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
<option value="Saint Lucia">Saint Lucia</option>
<option value="Saint Vincent">Saint Vincent</option>
<option value="Samoa">Samoa</option>
<option value="San Marino">San Marino</option>
<option value="Sao Tome and Principe">Sao Tome and Principe</option>
<option value="Saudi Arabia">Saudi Arabia</option>
<option value="Senegal">Senegal</option>
<option value="Serbia and Montenegro">Serbia and Montenegro</option>
<option value="Seychelles">Seychelles</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapore">Singapore</option>
<option value="Slovakia">Slovakia</option>
<option value="Slovenia">Slovenia</option>
<option value="Solomon Islands">Solomon Islands</option>
<option value="Somalia">Somalia</option>
<option value="South Africa">South Africa</option>
<option value="Spain">Spain</option>
<option value="Sri Lanka">Sri Lanka</option>
<option value="Sudan">Sudan</option>
<option value="Suriname">Suriname</option>
<option value="Swaziland">Swaziland</option>
<option value="Sweden">Sweden</option>
<option value="Switzerland">Switzerland</option>
<option value="Syria">Syria</option>
<option value="Taiwan">Taiwan</option>
<option value="Tajikistan">Tajikistan</option>
<option value="Tanzania">Tanzania</option>
<option value="Thailand">Thailand</option>
<option value="Togo">Togo</option>
<option value="Tonga">Tonga</option>
<option value="Trinidad and Tobago">Trinidad and Tobago</option>
<option value="Tunisia">Tunisia</option>
<option value="Turkey">Turkey</option>
<option value="Turkmenistan">Turkmenistan</option>
<option value="Tuvalu">Tuvalu</option>
<option value="Uganda">Uganda</option>
<option value="Ukraine">Ukraine</option>
<option value="United Arab Emirates">United Arab Emirates</option>
<option value="United Kingdom" selected="selected">United Kingdom</option>
<option value="United States">United States</option>
<option value="Uruguay">Uruguay</option>
<option value="Uzbekistan" >Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Vatican City">Vatican City</option>
<option value="Venezuela">Venezuela</option>
<option value="Vietnam">Vietnam</option>
<option value="Yemen">Yemen</option>
<option value="Zambia">Zambia</option>
<option value="Zimbabwe">Zimbabwe</option>
</select>
<label class="field">Country</label>
</div>
<p></p></li>

<li>
<label class="desc" for="phone">Phone Number</label>
<div>
<input id="phone" name="phone" class="field text medium" type="text" value="44"/> 
</div>
</li>

<li>
<label class="desc" for="email">Email</label>
<div>
<input id="email" name="email" class="field text medium" type="text" maxlength="255"value=""/> 
</div>
</li>

<li>
<p class="instruct">If you are using your own domain, Please set your nameservers to :<br />
ns1.#<br />
ns2.#</p>
<label class="desc" for="website">Website Address</label>
<div>
<input name="website" type="text" id="website" value="yourname.zeebie.co.uk" size="50" maxlength="255"/> 
</div>
</li>

<li>
<p class="instruct">This will be the used to login to cPanel.</p>
<label class="desc" for="username">Username</label>
<div>
<input id="username" name="username" class="field text medium" type="text" maxlength="255" value=""/> 
</div>
</li>

<li>
<p class="instruct">You can later upgrade from free to paid if you wish.</p>
<label class="desc" for="package">Package</label>
<div>
<select class="field select medium "id="package" name="package"> 
<option value="Free Package">Free Package</option>
<option value="Paid Package">Paid Package</option>
</select>
</div>
</li>

<li>
<p class="instruct">Any other information you wish to give us.</p>
<label class="desc" for="other">Other</label>
<div>
<textarea id="other" name="other" rows="10" cols="50" class="field textarea medium"></textarea>
</div>
</li>

</ul>

<div class="buttons">
<input id="submit" name="submit" class="button" type="submit" value="Submit" />
<input id="reset" name="reset" class="button" type="reset" value="Reset" />
</div>

</form>