username password
password1.1 password1.2
C1 C1 C1
C2[] C2[] C2[3] C2[] C2.sub1
C3.s1 C3.s2 C3.s2 C3[]
R1 R1 R1 R1
R2.s1 R2.s1 R2.s2 R2.s2
Select 1 Select 2 Select 3
Submit Form Reset Form
Result: