document.write('<div id="contact">');
document.write('<div id="message"></div>');
document.write('<form method="post" action="form/contact2.php" name="contactform2" id="contactform2">');
            
document.write('<fieldset>');
document.write('<label for=name accesskey=U><span class="required">*</span> Name</label>');
document.write('<input name="name" type="text" id="name" size="30" value="" />');
									
document.write('<label for=email accesskey=E><span class="required">*</span> Email</label>');
document.write('<input name="email" type="text" id="email" size="30" value="" />');
          							
document.write('<input name="choose" type="checkbox" value="promotions" id="choose" class="box1" /><span class="txt"> Promotions &nbsp; &nbsp; </span>');
document.write('<input name="choose" type="checkbox" value="news" id="choose" class="box2" /><span class="txt"> News </span>');
           						 	
document.write('<label for=verify accesskey=V><span class="required">*</span> 7+1 =</label>');
document.write('<input name="verify" type="text" id="verify" size="4" value="" style="width: 30px;" /> &nbsp;');
document.write('<span class="note">Just for verification.</span>');

document.write('<p>Rest Easy... Your information will not be shared with ANY partners or affillates!</p>');
document.write('<input type="submit" class="submit" id="submit" value=" Sign Up!" />');
document.write('</fieldset>');
document.write('</form>');
document.write('</div>');