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<html>
<body>
<form>
<table>
<tr>
<td>Your Name</td>
<td><input type='text' name='name'></td>
</tr>
<tr>
<td>Computer Name</td>
<td><input type='text' name='computer'></td>
</tr>
<tr>
<td>Product</td>
<td><input type='text' name='product'></td>
</tr>
<tr>
<td>License Key</td>
<td><input type='text' name='license'></td>
</tr>
<tr>
<td colspan='2' align='center'>
<input type="submit" value="Submit">
</td>
</tr>
</table>
</form>
<p>To get installed information, you can go to <a href='http://www.belarc.com/en/products_belarc_advisor' target='belarc'>Belarc Advisor</a> for a free download (for personal use).</p>
</body>
</html>