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<div style="text-align:center">
<form action="" enctype="multipart/form-data" method="post">
<input type='hidden' name='MAX_FILE_SIZE' value='100000'>
<table cellspacing="1" cellpadding="5" style="border:1px solid #B7CBCF" width="400">
<tr><td colspan="2">Personal information</td></tr>
<tr><td align="right" bgcolor="#B7CBCF">Surname</td><td bgcolor="#E6E6E6"><input type="text" name="name" class="text" value=""/></td></tr>
<tr><td align="right" bgcolor="#B7CBCF">FirstName</td><td bgcolor="#E6E6E6"><input type="text" name="fname" class="text" value=""/></td></tr>
<tr><td colspan="2">Login information</td></tr>
<tr><td align="right" bgcolor="#B7CBCF">Username</td><td bgcolor="#E6E6E6"><input type="text" name="username" class="text" value="" /></td></tr>
<tr><td align="right" bgcolor="#B7CBCF">MDCN Full Reg</td><td bgcolor="#E6E6E6"><input type="password" name="mdcn_reg" class="text" value="" /></td></tr>
<tr><td align="right" bgcolor="#B7CBCF">Re-MDCN Full Reg</td><td bgcolor="#E6E6E6"><input type="password" name="mdcn_reg2" class="text" value="" /></td></tr>
<tr><td align="right" bgcolor="#B7CBCF">&nbsp;</td><td bgcolor="#E6E6E6"><input type="submit" class="button" value="Register" /></td></tr>
</table>
</form>
</div>
</div>