Помогите

Собственно,нужно заполнить такую форму(боюсь ошибиться,ибо сумма немалая)

First Name ____
Last Name ____
Password ____
Re-enter Password ____
Email ___
We use your email address to notify you when your order ships, or for any problems with your order.
Please make note of your name and password for future orders.
Bill To: (must match credit card)
Address 1 ______
Address 2 ______
(Apt, Suite, Floor # if applicable)
City ______
State/Province _______ Click here for State Abbreviations(сайт америкосовский)
Zip/Postal Code _______
Phone XXX-XXX-XXXX
Country _______
Ship To: (only if different than billing, else leave blank)
Full Name _______
Address 1 _______
Address 2 _______
(Apt, Suite, Floor #)
City ______
State/Province ______ Click here for State Abbreviations
Zip/Postal Code ______
Country _____