poa-dapps-voting/newBallot.html

<form action="">
  <div class="new-ballot-inputs">
    <div class="left">
      <label for="key">Mining key</label>
      <input type="text" id="mining-key">
      <label for="affected-key-type">Affected key type</label>
      <select type="text" id="affected-key-type" class="key-select">
        <option name="affected-key-type-select" value="0">mining key</option>
        <option name="affected-key-type-select" value="1">voting key</option>
        <option name="affected-key-type-select" value="2" selected>payout key</option>
      </select>
      <label for="affected-key">Affected key</label>
      <input type="text" id="affected-key">
    </div>
    <div class="right">
      <label for="memo">Memo</label>
      <textarea id="memo"></textarea>
      <div class="new-ballot-description">
        Please type your memo, for example, add or remove mining key, full name,
        and a reason.
      </div>
      <input type="radio" name="type" id="type_add" value=1 checked>
      <label class="radio" for="type_add">Add</label>
      <input type="radio" name="type" id="type_remove" value=0>
      <label class="radio" for="type_remove">Remove</label>
    </div>
  </div>
  <div class="personal-data-inputs hidden">
    <div class="left">
      <label for="full-name">Full name</label>
      <input type="text" id="full-name">
      <label for="address">Address</label>
      <input type="text" id="address">
      <label for="state">State</label>
      <input type="text" id="state">
    </div>
    <div class="right">
      <label for="zip">Zip code</label>
      <input type="number" id="zip">
      <label for="license-id">License id</label>
      <input type="number" id="license-id">
      <label for="license-expiration">License expiration</label>
      <input type="date" id="license-expiration">
    </div>
  </div>
  <button type="button" class="new-ballot-add" step=1>Continue</button>
</form>