<form name="myform" method="get" action="process.php">
  <p><label>Name: <input type="text" name="myname" maxlength="15"></label></p>
  <p><label><input type="checkbox" name="age15" value="15" checked> 15 Years</label></p>
  <p><label><input type="checkbox" name="age30" value="30" checked> 30 Years</label></p>
  <p><label><input type="checkbox" name="age45" value="45"> 45 Years</label></p>
  <p><label><input type="checkbox" name="age60" value="60"> 60 Years</label></p>
  <p><input type="submit" value="Send"></p>
</form>