<form method="post" onsubmit="return validateDomain(this.domain)">
www.<input type="text" name="domain" value="<? print $_POST['domain']; ?>"> <input type="submit" value="Submit" /><br />
<input type="radio" name="tld" value="com" selected="selected" />.com <input type="radio" name="tld" value="net" />.net <input type="radio" name="tld" value="co.uk" />.co.uk 
</form>