And if you have trouble getting the code here is the page source.
<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<title></title>
<meta http-equiv="content-type" content="text/html; charset=utf-8" />
<!-- Notice this is all in the HEAD of the document before the BODY starts -->
<?php $Name = $_POST['Name'];
$Birthday = $_POST['Birthdate'];
$WelpingDate = $_POST['WelpingDate'];
$Registration = $_POST['Registration'];
$Owner = $_POST['Owner'];
$Address = $_POST['Address1'];
$Phone = $_POST['Phone'];
$EMail = $_POST['EMail'];
if $_POST['CB1'] == true{
$I1 = $_POST['I1']};
else{ $I1 == ''};
if $_POST['CB2'] == true{
$I2 = $_POST['I2']};
else{ $I1 == '' };
if $_POST['CB3'] == true{
$I3 = $_POST['I3']};
else{ $I1 == '' };
if $_POST['CB4'] == true{
$I4 = $_POST['I4']};
else{ $I1 == '' };
if $_POST['CB5'] == true{
$I5 = $_POST['I5']};
else{ $I1 == '' };
if $_POST['CB6'] == true{
$I6 = $_POST['I6']};
else{ $I1 == '' };
if $_POST['CB7'] == true{
$I7 = $_POST['I7']};
else{ $I1 == '' };
if $_POST['CB8'] == true{
$I8 = $_POST['I8']};
else{ $I1 == '' };
if $_POST['CB9'] == true{
$I9 = $_POST['I9']};
else{ $I1 == '' };
if $_POST['CB10'] == true{
$I10 = $_POST['I10']};
else{ $I1 == '' };
$Upload = $_POST['Uploaded_File']; ?>
<style type="text/css">
#CustomForm{
position: absolute;
top: 0px;
left: 50px;
height: 733px;
width: 908px;
background-image:url('ShotRecordBackground.png');
z-index: 1;
}
#MyHeaderTitle{
color: black;
font-family:'ArgentumShine';
position: absolute;
top: 9px;
left: 340px;
height: auto;
width: auto;
z-index: 2;
}
#MySubHeaderTitle{
color: black;
font-family: arial;
font-weight: bold;
font-size: 10pt;
position: absolute;
top: 30px;
left: 425px;
height: auto;
width: auto;
z-index: 2;
}
#CustomName{
color: black;
font-family: arial;
font-weight: bold;
font-size: 8pt;
position: absolute;
top: 31px;
left: 135px;
height: auto;
width: auto;
z-index: 2;
}
#CustomBirthdate{
color: black;
font-family: arial;
font-weight: bold;
font-size: 8pt;
position: absolute;
top: 47px;
left: 135px;
height: auto;
width: auto;
z-index: 2;
}
#CustomWelpingdate{
color: black;
font-family: arial;
font-weight: bold;
font-size: 8pt;
position: absolute;
top: 62px;
left: 135px;
height: auto;
width: auto;
z-index: 2;
}
#CustomRegid{
color: black;
font-family: arial;
font-weight: bold;
font-size: 8pt;
position: absolute;
top: 77px;
left: 135px;
height: auto;
width: auto;
z-index: 2;
}
#CustomOwnerName{
color: black;
font-family: arial;
font-weight: bold;
font-size: 8pt;
position: absolute;
top: 31px;
left: 800px;
height: auto;
width: auto;
z-index: 2;
}
#CustomAddress{
color: black;
font-family: arial;
font-weight: bold;
font-size: 8pt;
position: absolute;
top: 47px;
left: 800px;
height: auto;
width: auto;
z-index: 2;
}
#CustomPhone{
color: black;
font-family: arial;
font-weight: bold;
font-size: 8pt;
position: absolute;
top: 62px;
left: 800px;
height: auto;
width: auto;
z-index: 2;
}
#CustomEmail{
color: black;
font-family: arial;
font-weight: bold;
font-size: 8pt;
position: absolute;
top: 77px;
left: 800px;
height: auto;
width: auto;
z-index: 2;
}
#Photobox{
position: absolute;
top: 121px;
left: 575px;
height: 215px;
width: 380px;
background-image:inherit; <!-- Upload img -->
z-index: 1;
}
#CustomDate1{
color: black;
font-family: arial;
font-weight: bold;
font-size: 7pt;
position: absolute;
top: 155px;
left: 65px;
height: auto;
width: auto;
z-index: 2;
}
#Custom6WDHPPVCV{
color: black;
font-family: arial;
font-weight: bold;
font-size: 7pt;
position: absolute;
top: 155px;
left: 135px;
height: auto;
width: auto;
z-index: 2;
}
#CustomDate2{
color: black;
font-family: arial;
font-weight: bold;
font-size: 7pt;
position: absolute;
top: 170px;
left: 65px;
height: auto;
width: auto;
z-index: 2;
}
#Custom6WHWFLEATICK{
color: black;
font-family: arial;
font-weight: bold;
font-size: 7pt;
position: absolute;
top: 170px;
left: 135px;
height: auto;
width: auto;
z-index: 2;
}
#CustomDate3{
color: black;
font-family: arial;
font-weight: bold;
font-size: 7pt;
position: absolute;
top: 186px;
left: 65px;
height: auto;
width: auto;
z-index: 2;
}
#Custom9WDHPPVCV{
color: black;
font-family: arial;
font-weight: bold;
font-size: 7pt;
position: absolute;
top: 186px;
left: 135px;
height: auto;
width: auto;
z-index: 2;
}
#CustomDate4{
color: black;
font-family: arial;
font-weight: bold;
font-size: 7pt;
position: absolute;
top: 201px;
left: 65px;
height: auto;
width: auto;
z-index: 2;
}
#Custom9WHWFLEATICK{
color: black;
font-family: arial;
font-weight: bold;
font-size: 7pt;
position: absolute;
top: 201px;
left: 135px;
height: auto;
width: auto;
z-index: 2;
}
#CustomDate5{
color: black;
font-family: arial;
font-weight: bold;
font-size: 7pt;
position: absolute;
top: 217px;
left: 65px;
height: auto;
width: auto;
z-index: 2;
}
#Custom12WDHPPVCV{
color: black;
font-family: arial;
font-weight: bold;
font-size: 7pt;
position: absolute;
top: 217px;
left: 135px;
height: auto;
width: auto;
z-index: 2;
}
#CustomDate6{
color: black;
font-family: arial;
font-weight: bold;
font-size: 7pt;
position: absolute;
top: 232px;
left: 65px;
height: auto;
width: auto;
z-index: 2;
}
#Custom12WBordetella{
color: black;
font-family: arial;
font-weight: bold;
font-size: 7pt;
position: absolute;
top: 232px;
left: 135px;
height: auto;
width: auto;
z-index: 2;
}
#CustomDate7{
color: black;
font-family: arial;
font-weight: bold;
font-size: 7pt;
position: absolute;
top: 247px;
left: 65px;
height: auto;
width: auto;
z-index: 2;
}
#Custom12WHWFLEATICK{
color: black;
font-family: arial;
font-weight: bold;
font-size: 7pt;
position: absolute;
top: 247px;
left: 135px;
height: auto;
width: auto;
z-index: 2;
}
#CustomDate8{
color: black;
font-family: arial;
font-weight: bold;
font-size: 7pt;
position: absolute;
top: 263px;
left: 65px;
height: auto;
width: auto;
z-index: 2;
}
#Custom15WParvo{
color: black;
font-family: arial;
font-weight: bold;
font-size: 7pt;
position: absolute;
top: 263px;
left: 135px;
height: auto;
width: auto;
z-index: 2;
}
#CustomDate9{
color: black;
font-family: arial;
font-weight: bold;
font-size: 7pt;
position: absolute;
top: 278px;
left: 65px;
height: auto;
width: auto;
z-index: 2;
}
#Custom15WRabies{
color: black;
font-family: arial;
font-weight: bold;
font-size: 7pt;
position: absolute;
top: 278px;
left: 135px;
height: auto;
width: auto;
z-index: 2;
}
#CustomDate10{
color: black;
font-family: arial;
font-weight: bold;
font-size: 7pt;
position: absolute;
top: 293px;
left: 65px;
height: auto;
width: auto;
z-index: 2;
}
#Custom15WHWFLEATICK{
color: black;
font-family: arial;
font-weight: bold;
font-size: 7pt;
position: absolute;
top: 293px;
left: 135px;
height: auto;
width: auto;
z-index: 2;
}
#textbox{
position: absolute;
top: 360px;
left: 105px;
height: auto;
width: auto;
border-style: solid;
border-style: ridge;
z-index: 2;
}
p {
color: red;
font-family: arial, ArgentumShine;
font-weight: normal;
font-size: 12pt;
margin: 2px;
text-align: center;
}
</style>
</head>
<body>
<!-- Create Custom Form and Header -->
<div id="CustomForm"></div>
<div id="MyHeaderTitle">HOGAN'S BASSETS.COM</div>
<div id="MySubHeaderTitle"><i>Custom Shot Record</i></div>
<!-- Dog ID's -->
<div id="CustomName"><?php echo $Name; ?></div>
<div id="CustomBirthdate"><?php echo $Birthdate; ?></div>
<div id="CustomWelpingdate"><?php echo $WelpingDate; ?></div>
<div id="CustomRegid"><?php echo $Registration; ?></div>
<!-- Owner ID's -->
<div id="CustomOwnerName"><?php echo $Owner; ?></div>
<div id="CustomAddress"><?php echo $Address; ?></div>
<div id="CustomPhone"><?php echo $Phone; ?></div>
<div id="CustomEmail"><?php echo $EMail; ?></div>
<!-- Photo Posted -->
<div id="Photobox"><?php echo $Upload; ?></div>
<!-- Post Vacinations -->
<div id="CustomDate1"><?php echo $I1; ?></div>
<div id="Custom6WDHPPVCV">6 Week-DHP-PV-CV</div>
<div id="CustomDate2"><?php echo $I2; ?></div>
<div id="Custom6WHWFLEATICK">Heartworm/Flea/Tick</div>
<div id="CustomDate3"><?php echo $I3; ?></div>
<div id="Custom9WDHPPVCV">9 Week-DHP-PV-CV</div>
<div id="CustomDate4"><?php echo $I4; ?></div>
<div id="Custom9WHWFLEATICK">Heartworm/Flea/Tick</div>
<div id="CustomDate5"><?php echo $I5; ?></div>
<div id="Custom12WDHPPVCV">12 Week-DHP-PV-CV</div>
<div id="CustomDate6"><?php echo $I6; ?></div>
<div id="Custom12WBordetella">12 Week-Bordetella</div>
<div id="CustomDate7"><?php echo $I7; ?></div>
<div id="Custom12WHWFLEATICK">Heartworm/Flea/Tick</div>
<div id="CustomDate8"><?php echo $I8; ?></div>
<div id="Custom15WParvo">15 Week-Parvo</div>
<div id="CustomDate9"><?php echo $I9; ?></div>
<div id="Custom15WRabies">15 Week-Rabies</div>
<div id="CustomDate10"><?php echo $I10; ?></div>
<div id="Custom15WHWFLEATICK">Heartworm/Flea/Tick</div>
<!-- <div id="textbox"><p>This is text in a sizeable box</p></div> -->
</body>
</html>
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