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=\"1262208097\"><input type=\"hidden\" name=\"meta_split_id\" value=\"\"><input type=\"hidden\" name=\"unit\" value=\"richwrengeneral\"><input type=\"hidden\" name=\"redirect\" value=\"http://www.aweber.com/thankyou-coi.htm?m=audio\" id=\"redirect_3cfe855b19d2363466cc365c057fc08f\"><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><font color=\"red\" size=\"5\"><br /> <br /> Please use the form below to reach us</font></center></td></tr><tr><td>Name:</td><td><input type=\"text\" name=\"name\" value=\"First\" size=\"20\"></td></tr><tr><td>Surname:</td><td><input type=\"text\" name=\"custom Surname\" value=\"Last\" size=\"20\"></td></tr><tr><td>Email:</td><td><input type=\"text\" name=\"from\" value=\"your contact email\" size=\"20\"></td></tr><tr><td>Contact Number(s):</td><td><input type=\"text\" name=\"custom Contact Number(s)\" value=\"\" size=\"20\"></td></tr><tr><td>Sales Agent:</td><td><select name=\"custom You Referred to us By\"><option value=\"Kevin Kemp - Director Licensee\">Kevin Kemp - Director Licensee</option><option value=\"Paul Murcoch - Director\">Paul Murcoch - Director</option><option value=\"Office Manager\">Office Manager</option><option value=\"Other Sales Staff\">Other Sales Staff</option></select></td></tr><tr><td>I was referred to you by:</td><td><select name=\"custom I was referred to you by\"><option value=\"Your Internet Site\" selected>Your Internet Site</option><option value=\"Your Newsletter\">Your Newsletter</option><option value=\"Past Satisfied Client\">Past Satisfied Client</option><option value=\"Friend\">Friend</option><option value=\"Radio\">Radio</option><option value=\"T. V\">T. V</option><option value=\"Newspaper\">Newspaper</option><option value=\"Other - Tell us more\">Other - Tell us more</option></select></td></tr><tr><td valign=\"top\">Your Message Here:</td><td><textarea name=\"custom your Message Here\" rows=\"10\" cols=\"20\"></textarea></td></tr>    <tr><td colspan=2><center></center></td></tr><tr><td align=\"center\" colspan=\"2\"><input type=\"submit\" name=\"submit\" value=\"Richardson & Wrench  Help me\"></td></tr></table></form></center>");

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