Código:
<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<title>Document</title>
</head>
<body>
<h2>Formulario para compañia de claro</h2>
<img src="logoClaro.png ">
<form action="">
<table>
<tr>
<td><label for="">Primer nombre:</label></td>
<td><input type="text"></td>
</tr>
<tr><td><label for="">Segundo nombre:</label></td>
<td><input type="text"></td>
</tr>
<tr>
<td><label for="">Primer apellido:</label></td>
<td><input type="text"></td>
</tr>
<tr>
<td>Segundo apellido:</td>
<td><input type="text"></td>
</tr>
<tr>
<td><label for="">Sexo</label></td>
<td><input type="radio" name="sexo" id=""
value="Masculino">Masculino</td>
<td><input type="radio" name="sexo" id=""
value="Femenino">Femenino</td>
</tr>
<tr>
<td><label for="">Fecha de nacimiento:</label></td>
<td><input type="date" name="" id=""></td>
</tr>
<tr>
<td><label for="">ciudad de nacimiento:</label></td>
<td><input type="text" name="" id=""></td>
</tr>
<tr>
<td><label for="">Provincia:</label></td>
<td><select name="" id="">
<option value="">Azua</option>
<option value="">Bahoruco</option>
<option value="">Barahona</option>
<option value="">Dajabon</option>
<option value="">Distrito Nacional</option>
<option value="">Duarte</option>
<option value="">Elias piña</option>
<option value="">El Seibo</option>
<option value="">Espaillat</option>
<option value="">Hato Mayor </option>
<option value="">Hermanas mirabal</option>
<option value="">Independencia</option>
<option value="">La Altagracia</option>
<option value="">La Romana</option>
<option value="">La Vega</option>
<option value="">Maria Trinidad Sanchez</option>
<option value="">Monseñor Nouel</option>
<option value="">Monte Cristi</option>
<option value="">Monte Plata</option>
<option value="">Pedernales</option>
<option value="">Peravia</option>
<option value="">Puerto plata</option>
<option value="">Samana</option>
<option value="">San Cristobal</option>
<option value="">San Jose de Ocoa</option>
<option value="">San Juan</option>
<option value="">San Pedro de Macoris</option>
<option value="">Sanchez Ramirez</option>
<option value="">Santiago</option>
<option value="">Santiago Rodriguez</option>
<option value="">Santo Domingo</option>
<option value="">Valverde</option>
</select></td>
</tr>
<tr>
<td><label for="">Pais de origen:</label></td>
<td><select name="" id="">
<option value="">Argentina</option>
<option value="">Bolivia</option>
<option value="">Brasil</option>
<option value="">Chile</option>
<option value="">Haiti</option>
<option value="">Colombia</option>
<option value="">Costa Rica</option>
<option value="">Cuba</option>
<option value="">Ecuador</option>
<option value="">El salvador</option>
<option value="">Guatemala</option>
<option value="">Honduras</option>
<option value="">Mexico</option>
<option value="">Nicaragua</option>
<option value="">Panama</option>
<option value="">Paraguay</option>
<option value="">Puerto Rico</option>
<option value="">Peru</option>
<option value="">Republica Dominicana</option>
<option value="">Uruguay</option>
<option value="">Venezuela</option>
</select></td>
</tr>
<tr>
<td><label for="">Estado civil:</label></td>
<td><input type="radio" name="Estado civil" id=""
value="Soltero">Soltero</td>
<td><input type="radio" name="Estado civil" id=""
value="Casado">Casado</td>
<td><input type="radio" name="Estado civil" id="" value="Union
Libre">Union Libre</td>
</tr>
<tr>
<td><label for="">Numero de Cedula</label></td>
<td><input type="text" name="" id=""></td>
</tr>
<tr>
<td><label for="">Numero de celular:</label></td>
<td><input type="text"></td>
</tr>
<tr>
<td><label for="">Telefono del Trabajo:</label></td>
<td><input type="text"></td>
</tr>
<tr>
<td><label for="">correo electronico:</label></td>
<td><input type="email" name="" id=""></td>
</tr>
<tr>
<td><label for="">Servicio a Solicitar:</label></td>
<td><input type="radio" name="Servicio a Solicitar" id="">Internet
Movil</td>
<td><input type="radio" name="Servicio a Solicitar" id="">Internet
Fijo</td>
<td><input type="radio" name="Servicio a Solicitar" id="">Fibra
Optica</td>
</tr>
<tr>
<td><label for="">Entrada para subir una imagen:</label></td>
<td><input type="file" name="" id=""></td>
</tr>
<tr>
<td><label for="">Caja de comentarios:</label></td>
<td><textarea cols="21" rows="7"></textarea></td>
</tr>
<tr>
<td><button type="submit">Enviar</button></td>
<td><button type="submit">Limpiar</button></td>
</tr>
</table>
</form>
</body>
</html>
