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<hidden
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></hidden>

<image
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></image>

<checkbox
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<checkbox
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<checkbox
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<checkbox
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<checkbox
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>
</textinput>

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>
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<textinput
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>
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>
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>
</textinput>

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>
</textinput>

<textinput
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>
</textinput>

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>
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<label
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></label>

<label
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<label
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<label
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></label>

<label
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<label
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></label>

<label
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></label>

<label
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<label
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></label>

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></label>

<label
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></label>

<label
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<label
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<label
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<label
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<label
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></label>

</form>