   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=\"392858231\"><input type=\"hidden\" name=\"meta_split_id\" value=\"\"><input type=\"hidden\" name=\"unit\" value=\"basich2\"><input type=\"hidden\" name=\"redirect\" value=\"http://www.healthylife-healthyplanet.com/Thank-you.html\" id=\"redirect_6c16f70c69078859addb0a1534a89e49\"><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 Address,custom City,custom State,custom Zip,custom I found HealthyLife-HealthyPlanet through,custom My level of interest in Green Cleaners is,custom I agree to pay 2 dollars for shipping and handling\"><input type=\"hidden\" name=\"meta_forward_vars\" value=\"0\"><table><tr><td colspan=2><center><div align=\"center\">Please fill out the following form to get periodic information on achieving a Healthy Life and Healthy Planet delivered to your inbox.&nbsp; You can also recieve&nbsp;a sample of Biodegradable Cleaner. <em><font size=\"2\">(Allow 4-6 weeks for delivery of the sample)</font></em><br /><br /><font size=\"2\">*Due to large number of requests and increased cost of shipping, a $2.00 shipping and handling fee is required to receive the sample.&nbsp; A credit card or paypal account is required for payment.</font></div></center></td></tr><tr><td>Email:</td><td><input type=\"text\" name=\"from\" value=\"\" size=\"20\"></td></tr><tr><td>Name:</td><td><input type=\"text\" name=\"name\" value=\"\" size=\"20\"></td></tr><tr><td>Address:</td><td><input type=\"text\" name=\"custom Address\" 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><select name=\"custom State\"><option value=\" \"> </option><option value=\"AK\">AK</option><option value=\"AL\">AL</option><option value=\"AR\">AR</option><option value=\"AZ\">AZ</option><option value=\"CA\">CA</option><option value=\"CO\">CO</option><option value=\"CT\">CT</option><option value=\"DC\">DC</option><option value=\"DE\">DE</option><option value=\"FL\">FL</option><option value=\"GA\">GA</option><option value=\"HI\">HI</option><option value=\"ID\">ID</option><option value=\"IL\">IL</option><option value=\"IN\">IN</option><option value=\"IA\">IA</option><option value=\"KS\">KS</option><option value=\"KY\">KY</option><option value=\"LA\">LA</option><option value=\"ME\">ME</option><option value=\"MD\">MD</option><option value=\"MA\">MA</option><option value=\"MI\">MI</option><option value=\"MN\">MN</option><option value=\"MS\">MS</option><option value=\"MO\">MO</option><option value=\"MT\">MT</option><option value=\"NE\">NE</option><option value=\"NV\">NV</option><option value=\"NH\">NH</option><option value=\"NJ\">NJ</option><option value=\"NM\">NM</option><option value=\"NY\">NY</option><option value=\"NC\">NC</option><option value=\"ND\">ND</option><option value=\"OH\">OH</option><option value=\"OK\">OK</option><option value=\"OR\">OR</option><option value=\"PA\">PA</option><option value=\"PR\">PR</option><option value=\"RI\">RI</option><option value=\"SC\">SC</option><option value=\"SD\">SD</option><option value=\"TN\">TN</option><option value=\"TX\">TX</option><option value=\"UT\">UT</option><option value=\"VT\">VT</option><option value=\"VA\">VA</option><option value=\"WA\">WA</option><option value=\"WV\">WV</option><option value=\"WI\">WI</option><option value=\"WY\">WY</option></select></td></tr><tr><td>Zip:</td><td><input type=\"text\" name=\"custom Zip\" value=\"\" size=\"20\"></td></tr><tr><td>Phone:</td><td><input type=\"text\" name=\"custom Phone\" value=\"\" size=\"20\"></td></tr><tr><td>I found HealthyLife-HealthyPlanet through:</td><td><select name=\"custom I found HealthyLife-HealthyPlanet through\"><option value=\"Pick one\">Pick one</option><option value=\"Google (or other search engine)\">Google (or other search engine)</option><option value=\"Friends Recommendation\">Friends Recommendation</option><option value=\"Link from Freebie Site\">Link from Freebie Site</option><option value=\"Link from other Webpage\">Link from other Webpage</option><option value=\"Other\">Other</option></select></td></tr><tr><td>My level of interest in Green Cleaners is:</td><td><select name=\"custom My level of interest in Green Cleaners is\"><option value=\"Pick one\">Pick one</option><option value=\"Very interested - I am into the environment\">Very interested - I am into the environment</option><option value=\"Very Interested - I want to keep my family safe\">Very Interested - I want to keep my family safe</option><option value=\"Interested - I like to do my part if I can\">Interested - I like to do my part if I can</option><option value=\"Interested - If I can help the planet but it doesn't cost me more I'll do it\">Interested - If I can help the planet but it doesn't cost me more I'll do it</option><option value=\"Neutral - sounds good but even better if its free\">Neutral - sounds good but even better if its free</option><option value=\"Not interested - I just like getting stuff in the mail\">Not interested - I just like getting stuff in the mail</option></select></td></tr><tr><td colspan=\"2\"><input type=\"checkbox\" name=\"custom Yes I would like information sent to me about a Home Business Opportunity\"> Yes I would like information sent to me about a Home Business Opportunity</td></tr><tr><td colspan=\"2\"><input type=\"checkbox\" name=\"custom I want to Supercharge my Vitality\"> I want to Supercharge my Vitality</td></tr><tr><td colspan=\"2\" align=\"left\">I agree to pay 2 dollars for shipping and handling:</td></tr><tr><td colspan=\"2\"><input type=\"radio\" name=\"custom I agree to pay 2 dollars for shipping and handling\" value=\"Yes\"> Yes</td></tr><tr><td colspan=\"2\"><input type=\"radio\" name=\"custom I agree to pay 2 dollars for shipping and handling\" value=\"No (I only want information)\"> No (I only want information)</td></tr>    <tr><td colspan=2><center></center></td></tr><tr><td align=\"center\" colspan=\"2\"><input type=\"submit\" name=\"submit\" value=\"Send me Information!\"></td></tr></table></form></center>");

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