document.write("<title>Internet Dentist Marketing</title>\n");
document.write("Fill out the following information and click 'Submit'.<br>\n");
document.write("<scr"+"ipt language=javascr"+"ipt>\n");
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document.write("</scr"+"ipt>\n");
document.write("<form  method=POST action=\"http://www.internet--dentist.com/cgi-bin/csFormbuilder/csFormbuilder.cgi\" name=\"form_17\"  >\n");
document.write("<input type=hidden name=form-id value=\"17\">\n");
document.write("<input type=hidden name=command value=\"mailform\">\n");
document.write("<link rel=\"stylesheet\" type=\"text/css\" href=\"http://www.internet--dentist.com/cgi-scr"+"ipt/csFormbuilder/forms/internetdentist.css\">\n");
document.write("<table border=\"0\" cellspacing=\"0\" cellpadding=\"3\">\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" >Name:</td><td align=left valign=top nowrap class=\"textLabel\"><input  onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Name\"  size=\"35\"   maxlength=\"35\" > <!-- tr ph 0--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" >*City:</td><td align=left valign=top nowrap class=\"textLabel\"><input  onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"City\"  size=\"35\"   maxlength=\"35\" > <!-- tr ph 1--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" >*State:</td><td align=left valign=top nowrap class=\"textLabel\"><input  onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"State\"  size=\"3\"   maxlength=\"3\" > <!-- tr ph 2--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" >*Email:</td><td align=left valign=top nowrap class=\"textLabel\"><input  onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Email\"  size=\"35\"   maxlength=\"35\" > <!-- tr ph 3--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" >Website URL:</td><td align=left valign=top nowrap class=\"textLabel\"><input  onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"URL\"  size=\"35\"   maxlength=\"35\" > <!-- tr ph 4--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\"  valign=\"top\" >Service: </td><td align=left valign=top nowrap class=\"textLabel\"><table border=0 cellspacing=2 cellpadding=0><tr><td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=checkbox name=\"Service\" value=\"Hosting\"></td><td class=\"textLabel\">Hosting</td></tr>\n");
document.write("<tr><td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=checkbox name=\"Service\" value=\"Website (re)Development\"></td><td class=\"textLabel\">Website (re)Development</td></tr>\n");
document.write("<tr><td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=checkbox name=\"Service\" value=\"Domination in local market\"></td><td class=\"textLabel\">Domination in local market</td></tr>\n");
document.write("<tr><td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=checkbox name=\"Service\" value=\"Redefining practice direction\"></td><td class=\"textLabel\">Redefining practice direction</td></tr>\n");
document.write("<tr><td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=checkbox name=\"Service\" value=\"Accelerating practice growth\"></td><td class=\"textLabel\">Accelerating practice growth</td></tr>\n");
document.write("<tr><td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=checkbox name=\"Service\" value=\"Domination in regional, state or national market\"></td><td class=\"textLabel\">Domination in regional, state or national market</td></tr>\n");
document.write("<tr><td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=checkbox name=\"Service\" value=\"Copy writing (creating pages that sell)\"></td><td class=\"textLabel\">Copy writing (creating pages that sell)</td></tr>\n");
document.write("</table>\n");
document.write(" <!-- tr ph 5--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" >Comments</td><td align=left valign=top nowrap class=\"textLabel\"><textarea  onfocus=\"className='textFieldFocus'\" name=\"Comments\"  rows=\"5\" cols=\"30\"   maxlength=\"300\"  ONCHANGE=\"TAMax(this,document.getElementById('Comments_D'),300);\" ONBLUR=\"TAMax(this,document.getElementById('Comments_D'),300);className='textField';\" ONKEYUP=\"TAMax(this,document.getElementById('Comments_D'),300);\"></textarea><br><span id=\"Comments_D\">300</span>&nbsp;characters remaining.   <!-- tr ph 6--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" >Verify Code:</td><td align=left valign=top nowrap class=\"textLabel\"><img id=\"Verification_img\" align=absmiddle border=0 width=59 height=15 src=\"\"><input type=hidden id=\"Verification_sid\" name=\"Verification_sid\" value=\"\"> <scr"+"ipt language=javascr"+"ipt src=\"http://www.internet--dentist.com/cgi-bin/csFormbuilder/vimage.cgi?command=g&f=Verification\"></scr"+"ipt>&nbsp;<input  onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Verification\"  size=\"6\"   maxlength=\"6\" > <!-- tr ph 7--></td></tr>\n");
document.write("<tr><td colspan=2 align=\"left\"><input onmouseover=\"className='buttonfieldFocus'\" onmouseout=\"className='buttonfield'\" class=\"buttonfield\" type=submit value=\"Submit\"></td></tr>\n");
document.write("</table>\n");
document.write("</form>\n");