document.write("<form enctype=\"multipart/form-data\" method=\"post\" action=\"http://www.freedback.com/mail.php\" accept-charset=\"utf-8\">");
document.write("	<div>");
document.write("		<input type=\"hidden\" name=\"acctid\" id=\"acctid\" value=\"cc3mn6c5znjl8q68\" />");
document.write("		<input type=\"hidden\" name=\"formid\" id=\"formid\" value=\"293964\" />");
document.write("");
document.write("		<input type=\"hidden\" name=\"required_vars\" id=\"required_vars\" value=\"name,email\" />");
document.write("	Just complete this form. Click on Submit when ready to send.</div>");
document.write("	<table cellspacing=\"5\" cellpadding=\"5\" border=\"0\">");
document.write("		<tr>");
document.write("			<td valign=\"top\">");
document.write("				<strong>Name:</strong>			</td>");
document.write("			<td valign=\"top\">");
document.write("");
document.write("				<input type=\"text\" name=\"name\" id=\"name\" size=\"40\" value=\"\" />			</td>");
document.write("		</tr>");
document.write("		<tr>");
document.write("			<td valign=\"top\">");
document.write("				<strong>Maiden name</strong>			</td>");
document.write("			<td valign=\"top\">");
document.write("				<input type=\"text\" name=\"field-10637fdfcf395a0\" id=\"field-10637fdfcf395a0\" size=\"40\" value=\"\" />			</td>");
document.write("");
document.write("		</tr>");
document.write("		<tr>");
document.write("			<td valign=\"top\">");
document.write("				<strong>Email address:</strong>			</td>");
document.write("			<td valign=\"top\">");
document.write("				<input type=\"text\" name=\"email\" id=\"email\" size=\"40\" value=\"\" />			</td>");
document.write("		</tr>");
document.write("");
document.write("		<tr>");
document.write("			<td valign=\"top\">");
document.write("				<strong>Graduation Year?</strong>			</td>");
document.write("			<td valign=\"top\">");
document.write("				<input type=\"text\" name=\"field-1db7a385a7719ff\" id=\"field-1db7a385a7719ff\" size=\"40\" value=\"\" />			</td>");
document.write("		</tr>");
document.write("		<tr>");
document.write("");
document.write("			<td valign=\"top\">");
document.write("				<strong>Any comments or other information?</strong>			</td>");
document.write("			<td valign=\"top\">");
document.write("				<textarea name=\"field-4c1b720bfe14db0\" id=\"field-4c1b720bfe14db0\" rows=\"6\" cols=\"40\"></textarea>			</td>");
document.write("		</tr>");
document.write("		<tr>");
document.write("			<td colspan=\"2\" align=\"center\">");
document.write("");
document.write("				<input type=\"submit\" value=\" Submit Form \" />			</td>");
document.write("		</tr>");
document.write("	</table>");
document.write("    <span class=\"style7\"><br>");
document.write("    </span>");
document.write("</form>");