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=\"512221394\">    <input type=\"hidden\" name=\"meta_split_id\" value=\"\">    <input type=\"hidden\" name=\"unit\" value=\"herb-shop\">    <input type=\"hidden\" name=\"redirect\" value=\"http://www.drchristophersherbshop.com/verify1.html\" id=\"redirect_9b23361d49d0e479af9f831599f76414\">    <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=\"name,from\">    <input type=\"hidden\" name=\"meta_forward_vars\" value=\"0\">    <table>    <tr><td colspan=2><center></center></td></tr><tr><td>First Name:</td><td><input type=\"text\" name=\"name\" value=\"\" size=\"20\"></td></tr><tr><td>Email:</td><td><input type=\"text\" name=\"from\" value=\"\" size=\"20\"></td></tr><tr><td>Birthday Month:</td><td><select name=\"custom Birthday Month\"><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></select></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>        </center>");

        function setCookie(name, value, expires, path, domain, secure) {
        var curCookie = name + "=" + escape(value) +
        ((expires) ? "; expires=" + expires.toGMTString() : "") +
        ((path) ? "; path=" + path : "") +
        ((domain) ? "; domain=" + domain : "") +
        ((secure) ? "; secure" : "");
        document.cookie = curCookie;
    }

    function getCookie(name) {
        var dc = document.cookie;
        var prefix = name + "=";
        var begin = dc.indexOf("; " + prefix);
        if (begin == -1) {
        begin = dc.indexOf(prefix);
        if (begin != 0) return null;
        } else
        begin += 2;
        var end = document.cookie.indexOf(";", begin);
    if (end == -1)
        end = dc.length;
        return unescape(dc.substring(begin + prefix.length, end));
    }


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