document.write("<!-- Web Form Generator 2.0 --><center><form method=\"post\" action=\"http://www.aweber.com/scripts/addlead.pl\"><input type=\"hidden\" name=\"meta_web_form_id\" value=\"1478364558\"><input type=\"hidden\" name=\"meta_split_id\" value=\"\"><input type=\"hidden\" name=\"unit\" value=\"rpamembers\"><input type=\"hidden\" name=\"redirect\" value=\"http://www.rpamembers.org/Membership/EmailList/BasicEmail2.htm\" id=\"redirect_de05d869da46a6ceec0c8c956ed60920\"><input type=\"hidden\" name=\"meta_redirect_onlist\" value=\"\"><input type=\"hidden\" name=\"meta_adtracking\" value=\"Membership List\"><input type=\"hidden\" name=\"meta_message\" value=\"1\"><input type=\"hidden\" name=\"meta_required\" value=\"name,custom Last,from\"><input type=\"hidden\" name=\"meta_forward_vars\" value=\"0\"><table><tr><td colspan=2><center><DIV align=left><FONT color=#333333><FONT face=Arial><STRONG>Please check the boxes below for emails sent to specific membership levels only.</STRONG></FONT><FONT face=Arial><STRONG> </STRONG>(You may check as many as you wish!) </FONT></FONT></DIV></center></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\" value=\"\" size=\"20\"></td></tr><tr><td>Email:</td><td><input type=\"text\" name=\"from\" value=\"\" size=\"20\"></td></tr><tr><td>Renewal Month for MY  Membership:</td><td><select name=\"custom Renewal Month for MY  Membership\"><option value=\"January\">January</option><option value=\"February\">February</option><option value=\"March\">March</option><option value=\"April\">April</option><option value=\"May\">May</option><option value=\"June\">June</option><option value=\"July\">July</option><option value=\"August\">August</option><option value=\"September\">September</option><option value=\"October\">October</option><option value=\"November\">November</option><option value=\"December\">December</option><option value=\"Not Sure\">Not Sure</option></select></td></tr><tr><td colspan=\"2\"><input type=\"checkbox\" name=\"custom Certified Membership Interests\"> Certified Membership Interests</td></tr><tr><td colspan=\"2\"><input type=\"checkbox\" name=\"custom Student Practitioner Interests\"> Student Practitioner Interests</td></tr><tr><td colspan=\"2\"><input type=\"checkbox\" name=\"custom Student Or Associate Member Interests\"> Student Or Associate Member Interests</td></tr><tr><td colspan=\"2\"><input type=\"checkbox\" name=\"custom Teacher Interests\"> Teacher Interests</td></tr>    <tr><td colspan=2><center></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=333399&d=HBxMzBwMPoLqpkamTj6crIwc\" style=\"margin-top: 8px;\"></center>");

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      ((domain) ? "; domain=" + domain : "") +
      ((secure) ? "; secure" : "");
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      unique_track = new Image();
      unique_track.src = "http://forms.aweber.com/form/displays.htm?id=jCzsHMxsLKysHA==";