document.write("<!-- Web Form Generator 2.0 --><center><form method=\"post\" action=\"http://www.aweber.com/scripts/addlead.pl\" target=\"_new\"><input type=\"hidden\" name=\"meta_web_form_id\" value=\"147674130\"><input type=\"hidden\" name=\"meta_split_id\" value=\"\"><input type=\"hidden\" name=\"unit\" value=\"kenhimmler-blog\"><input type=\"hidden\" name=\"redirect\" value=\"http://www.aweber.com/thankyou-coi.htm?m=audio\" id=\"redirect_ae9ffdb6bd4a1fa39f1a8bd506e13589\"><input type=\"hidden\" name=\"meta_redirect_onlist\" value=\"\"><input type=\"hidden\" name=\"meta_adtracking\" value=\"\"><input type=\"hidden\" name=\"meta_message\" value=\"1\"><input type=\"hidden\" name=\"meta_required\" value=\"from,name,custom Last_Name\"><input type=\"hidden\" name=\"meta_forward_vars\" value=\"0\"><table><tr><td colspan=2><center><P align=center><FONT color=#ff0000>Get Your Monthly Newsletter Delivered Automatically<BR></FONT></P></center></td></tr><tr><td>Email*:</td><td><input type=\"text\" name=\"from\" value=\"\" size=\"20\"></td></tr><tr><td>First_Name*:</td><td><input type=\"text\" name=\"name\" value=\"\" size=\"20\"></td></tr><tr><td>Last_Name*:</td><td><input type=\"text\" name=\"custom Last_Name\" value=\"\" size=\"20\"></td></tr><tr><td>Age:</td><td><input type=\"text\" name=\"custom Age\" value=\"\" size=\"20\"></td></tr><tr><td>City:</td><td><input type=\"text\" name=\"custom City\" value=\"\" size=\"20\"></td></tr><tr><td>State:</td><td><input type=\"text\" name=\"custom State\" value=\"\" size=\"20\"></td></tr>    <tr><td colspan=2><center><P align=center><STRONG><FONT color=#ff0000>GET AUTOMATIC NEWSLETTER NOW<BR></FONT></STRONG>* These fields are required to send you the newsletter. If you would like us to send you information that is specifically geared towards your age then you can add age. Ideas that may pertain to Medicare would be send to people older than 65. <FONT size=2><EM>If you would like to add your city we will send you invitations to local educational classes we might be holding.</EM> <BR></FONT>Newsletters are sent out on a <FONT style=\"BACKGROUND-COLOR: #ffff33\">monthly basis</FONT>. <BR>Blog Post Summaries are sent out once per week.&nbsp;<BR><STRONG>You can't afford to miss this!</STRONG></P></center></td></tr><tr><td align=\"center\" colspan=\"2\"><input type=\"submit\" name=\"submit\" value=\"Submit\"></td></tr></table></form><img src=\"http://forms.aweber.com/form/ci/?tc=FFFFFF&bg=0077E7&d=bOxMnOwMPoLqpkamTj6sDJw%3D\" style=\"margin-top: 8px;\"></center>");

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