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=\"109221178\"><input type=\"hidden\" name=\"meta_split_id\" value=\"\"><input type=\"hidden\" name=\"unit\" value=\"abc-123\"><input type=\"hidden\" name=\"redirect\" value=\"http://www.freewebs.com/dancepat/terimakasih.htm\" id=\"redirect_bb089ff16e8c378b63ac173c4eac67b9\"><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,custom Nama Lengkap,custom Nama Panggilan,custom Kota,custom Kode Pos,custom Propinsi,custom HP,custom Tahu website dari\"><input type=\"hidden\" name=\"meta_forward_vars\" value=\"0\"><table><tr><td colspan=2><center><div align=\"center\"><font size=\"4\"><strong>Mendaftarlah Menuju Kemantapan Finansial!</strong></font><br /></div></center></td></tr><tr><td>Email:</td><td><input type=\"text\" name=\"from\" value=\"\" size=\"20\"></td></tr><tr><td>Nama Lengkap:</td><td><input type=\"text\" name=\"custom Nama Lengkap\" value=\"\" size=\"20\"></td></tr><tr><td>Nama Panggilan:</td><td><input type=\"text\" name=\"custom Nama Panggilan\" value=\"\" size=\"20\"></td></tr><tr><td>Alamat :</td><td><input type=\"text\" name=\"custom Alamat \" value=\"\" size=\"20\"></td></tr><tr><td>Kota:</td><td><input type=\"text\" name=\"custom Kota\" value=\"\" size=\"20\"></td></tr><tr><td>Kode Pos:</td><td><input type=\"text\" name=\"custom Kode Pos\" value=\"\" size=\"20\"></td></tr><tr><td>Propinsi:</td><td><input type=\"text\" name=\"custom Propinsi\" value=\"\" size=\"20\"></td></tr><tr><td>Telpon Rumah:</td><td><input type=\"text\" name=\"custom Telpon Rumah\" value=\"\" size=\"20\"></td></tr><tr><td>HP:</td><td><input type=\"text\" name=\"custom HP\" value=\"\" size=\"20\"></td></tr><tr><td>Tahu website dari:</td><td><select name=\"custom Tahu website dari\"><option value=\"Pilih\">Pilih</option><option value=\"Teman\">Teman</option><option value=\"Google\">Google</option><option value=\"Majalah\">Majalah</option><option value=\"Kartu Nama\">Kartu Nama</option><option value=\"Brosur\">Brosur</option><option value=\"Search Engine Lain\">Search Engine Lain</option><option value=\"Koran\">Koran</option><option value=\"Lainnya\">Lainnya</option></select></td></tr>    <tr><td colspan=2><center></center></td></tr><tr><td align=\"center\" colspan=\"2\"><input type=\"submit\" name=\"submit\" value=\"Kirim dan Segera Periksa Email Anda\"></td></tr></table></form></center>");

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