document.write('<form action="http://www.soulchoice.org/Cybermail/fb.php" method="post">');
document.write('<input type="hidden" name="id" value="2" />');
document.write('<input type="hidden" name="action" value="fb" />');
document.write('<input type="hidden" name="submit" value="true" />');

document.write('<h2>Receive the Full Story</h2>');

document.write('<div class="fb_label">');
document.write('Email:');
document.write('</div>');
document.write('<div class="fb_field">');
document.write('<input type="text" name="email" size="30" maxlength="80" value="" />');
document.write('</div>');

document.write('<div class="fb_label">');
document.write('1 First Name:');
document.write('</div>');
document.write('<div class="fb_field">');
document.write('<input type="text" name="customFieldData[1]" size="25" maxlength="25" value="" />');
document.write('</div>');
document.write('<div class="fb_label">');
document.write('2 Last Name:');
document.write('</div>');
document.write('<div class="fb_field">');
document.write('<input type="text" name="customFieldData[2]" size="25" maxlength="25" value="" />');
document.write('</div>');
document.write('<div class="fb_label">');
document.write('3 Age:');
document.write('</div>');
document.write('<div class="fb_field">');
document.write('<input type="text" name="customFieldData[3]" size="3" maxlength="3" value="" />');
document.write('</div>');
document.write('<div class="fb_label">');
document.write('4 Specific Interest in:');
document.write('</div>');
document.write('<div class="fb_field">');
document.write('<input type="text" name="customFieldData[4]" size="25" maxlength="25" value="" />');
document.write('</div>');

document.write('<div class="fb_field" style="line-height:28px;">');
document.write('<label><input type="checkbox" name="mailingListId[2]" value="2" checked="checked" />Recieve Further Information</label>');
document.write('</div>');
document.write('<div class="fb_field" style="line-height:28px;">');
document.write('<label><input type="checkbox" name="mailingListId[3]" value="3" checked="checked" />Receive the Full Story</label>');
document.write('</div>');


document.write('<div class="fb_label">');
document.write('&nbsp;</div>');
document.write('<div class="fb_field">');
document.write('<input type="submit" value="Submit" />');
document.write('</div>');
document.write('</form>');