HTML: Form Fields

gistfile1

<div id="form">
			<div id="stylized" class="myform">
              <form id="create_account" name="create_account" method="post">
                  <label>First Name:<span class="small">Add Your First Name</span></label>
                  <input type="text" name="fname" id="fname" value="<?= $_POST['fname']?>" />
                  <br />
                  <label>Last Name:<span class="small">Add Your Last Name</span></label>
                  <input type="text" name="lname" id="lname" value="<?= $_POST['lname']?>" />
                  <br />
                  <label> Address:<span class="small">Your Address</span></label>
                  <input type="text" name="domain" id="domain" value="<?= $_POST['address']?>" />
                  <br />
                  <label> City:<span class="small">Your City</span></label>
                  <input type="text" name="domain" id="domain" value="<?= $_POST['city']?>" />
                  <br />
                  <label> State:<span class="small">Your State</span></label>
                  <!--<input name="state" type="text" class="required inputTxtbox">-->
                  <select name="state_id" class="required">
											<option value="6">Alabama</option>
											<option value="7">Alaska</option>
											<option value="8">Arizona</option>
											<option value="9">Arkansas</option>
											<option value="10">California</option>
											<option value="11">Colorado</option>
											<option value="12">Connecticut</option>
											<option value="13">Delaware</option>
											<option value="14">District of Columbia</option>
											<option value="15">Florida</option>
											<option value="16">Georgia</option>
											<option value="17">Hawaii</option>
											<option value="18">Idaho</option>
											<option value="19">Illinois</option>
											<option value="20">Indiana</option>
											<option value="21">Iowa</option>
											<option value="22">Kansas</option>
											<option value="23">Kentucky</option>
											<option value="24">Louisiana</option>
											<option value="25">Maine</option>
											<option value="27">Maryland</option>
											<option value="28">Massachusetts</option>
											<option value="29">Michigan</option>
											<option value="30">Minnesota</option>
											<option value="31">Mississippi</option>
											<option value="32">Missouri</option>
											<option value="33">Montana</option>
											<option value="34">Nebraska</option>
											<option value="35">Nevada</option>
											<option value="36">New Hampshire</option>
											<option value="37">New Jersey</option>
											<option value="38">New Mexico</option>
											<option value="39">New York</option>
											<option value="40">North Carolina</option>
											<option value="41">North Dakota</option>
											<option value="43">Ohio</option>
											<option value="44">Oklahoma</option>
											<option value="45">Oregon</option>
											<option value="46">Pennsylvania</option>
											<option value="48">Puerto Rico</option>
											<option value="49">Rhode Island</option>
											<option value="50">South Carolina</option>
											<option value="51">South Dakota</option>
											<option value="52">Tennessee</option>
											<option value="53">Texas</option>
											<option value="54">Utah</option>
											<option value="55">Vermont</option>
											<option value="56">Virginia</option>
											<option value="57">Washington</option>
											<option value="58">West Virginia</option>
											<option value="60">Wisconsin</option>
											<option value="61">Wyoming</option>
										</select>
                  <br />
                  <label> Country:<span class="small">Your Country</span></label>
                  <!--<input name="country" type="text" class="required inputTxtbox">-->
                  <select name="country_id" class="required">
											<option value="6">United States</option>
											<option value="7">Canada</option>
				   </select>
                  <label> Zip:<span class="small">Your Zip Code</span></label>
                  <input type="text" name="domain" id="domain" value="<?= $_POST['zip']?>" />
                  <br />
                  <label>Email:<span class="small">Add a Valid Address</span></label>
                  <input type="text" name="email" id="email" value="<?= $_POST['email']?>" />
                  <br />
                  <label>Phone:<span class="small">Add Your Phone #</span></label>
                  <input type="text" name="phone" id="phone" value="<?= $_POST['phone']?>" />
                  <br />
                  <!-- <div id="termsCond">
                      <a href="/terms" target="_blank">You agree to the Following Terms</a>
                      <br /><br />
                  </div> -->
                  <br />
                  <button type="submit" class="hand"></button>
                  <div class="spacer"></div>
                  <br>
              </form>