#!/usr/local/bin/perl -w

use strict;
use CGI;
my $q = CGI::new();

my $name = $q->param('Name')    || '';
my $addy = $q->param('Address') || '';

print $q->header;
print <<HTML;
  <form>
  Name: <input type="text" name="Name" value="$name">
  Address: <input type="text" name="Address" value="$addy">
  <input type="submit" value="Refresh">
  </form>
HTML