Literal question
<svar a="all" v="PR70A418"><span class="em">4. Month and year of birth and age last birthday</span><br /><div class="i1">Print</div><br /><div class="i2">Month</div><br /><div class="i3">_____</div><br /><div class="i2">Year</div><br /><div class="i3">_____</div><br /><div class="i2">Age</div><br /><div class="i3">_____</div><br /></svar></p>
<p><svar a="PR70A461" v="PR70A418 PR70A461"><span class="em">5. Month of birth<br /></span><div class="i1">Fill one circle</div><br /><div class="i2">[] January - March<br />[] April - June<br />[] July - September<br />[] October - December</div><br /></svar></p>
<p><svar v="PR70A418"><span class="em">6. Year of birth</span><br /><div class="i1">Fill one circle for first three numbers</div><br /><div class="i2">[] 186_<br />[] 187_<br />[] 188_<br />[] 189_<br />[] 190_<br />[] 191_<br />[] 192_<br />[] 193_<br />[] 194_<br />[] 195_<br />[] 196_<br />[] 197_</div><br /><div class="i1">Fill one circle for last number</div><br /><div class="i2">[] 0<br />[] 1<br />[] 2<br />[] 3<br />[] 4<br />[] 5<br />[] 6<br />[] 7<br />[] 8<br />[] 9</div><br /></svar>