<tr>
		<td>Roll no.:</td>
		<td><input type="text" maxlength="15"></td>
	</tr>
	
	<tr>
		<td>IEN no.:</td>
		<td><input type="text" maxlength="30"></td>
	</tr>
	
	<tr>
		<td>Official college email-id:</td>
		<td><input type="text" maxlength="30"></td>
	</tr>
	
	<tr>
		<td>Contact no.:</td>
		<td><input type="text" maxlength="30"></td>
	</tr>
	
	<tr>
		<td>Year & Department:</td>
		<td>
			<input class="btn type="radio" name="year">First year
			<input class="btn type="radio" name="year">Second year
			<input class="btn type="radio" name="year">Third year<br>
			
			<input type="radio" name="dep">Computer
			<input type="radio" name="dep">Mechanical
			<input type="radio" name="dep">Civil
			<input type="radio" name="dep">Electrical
			<input type="radio" name="dep">Chemical
		</td>
	</tr>
	
	<tr>
		<td>Comment / Complaint box:</td>
		<td>
			<textarea name="comm" cols="50" rows="10">
			</textarea>
		</td>
	</tr>
	
	<tr>
		<td></td>
		<td>
			<input type="Submit" name="Submit" value="Submit">
			<input type="Reset" name="Reset" value="Reset">
		</td>
	</tr>
</table>
</form>
</td>
</tr>
</table>