<FORM>
生日：
19<INPUT TYPE="INT" NAME="birth" SIZE=2 MAXLENGTH=2>年
  <INPUT TYPE="INT" NAME="month" SIZE=2 MAXLENGTH=2>月
  <INPUT TYPE="INT" NAME="date" SIZE=2 MAXLENGTH=2>日<BR>
電話：<INPUT TYPE="INT" NAME="area" SIZE=2 MAXLENGTH=2>-
      <INPUT TYPE="INT" NAME="num" SIZE=8 MAXLENGTH=8>
</FORM>