document.write('<div class="body_right">'
				+ '<div class="form_cntr">'
					+ '<div class="form_hdr">START HERE and Receive Your FREE Consultation</div>'
					+ '<div class="form_body">'
						+ '<div class="form_field_cntr">'
				+ '<div class="form_field_span">'	
					+ 'First Name:<br />'
					+ '<input type="text" class="textInput" name="firstname" size="20">'
				+ '</div>'
				+ '<div class="form_field_span2">'
					+ 'Last Name:<br />'
					+ '<input type="text" class="textInput" name="lastname" size="20">'
				+ '</div>'
			+ '</div>'
						+ '<div class="form_field_cntr">'	
				+ '<div class="form_field_span">'
					+ 'Home Phone:<br />'
					+ '<input type="text" class="textInput" name="hacode" size="2" maxlength="3"> - <input type="text" class="textInput" name="hphone1" size="2" maxlength="3"> - <input type="text" class="textInput" name="hphone2" size="3" maxlength="4">'
				+ '</div>'
				+ '<div class="form_field_span2">'
					+ 'Work Phone:<br>'
					+ '<input type="text" class="textInput" name="wacode" size="2" maxlength="3"> - <input type="text" class="textInput" name="wphone1" size="2" maxlength="3"> - <input type="text" class="textInput" name="wphone2" size="3" maxlength="4"> ext. <input type="text" class="textInput" name="ext" size="3" maxlength="5">'
				+ '</div>'
			+ '</div>'
						+ '<div class="form_field_cntr">'	
				+ '<div class="form_field_span">'
					+ 'Email:<br>'
					+ '<input type="text" class="textInput" name="email" size="20">'
				+ '</div>'
				+ '<div class="form_field_span2">'
					+ 'Tax Debt ($):<br>'
					+ '<input type="text" class="textInput" name="taxdebt" size="20">'
				+ '</div>'
			+ '</div>'
						+ '<div class="form_field_cntr">'
				+ '<div class="form_field_span">'
					+ 'How Did You Find Us?:<br>'
					+ '<select name="source" class="textInput_pull">'
					+ '<option value="Yahoo">Yahoo</option>'
					+ '<option value="Google">Google</option>'
					+ '<option value="MSN">MSN</option>'
					+ '<option value="BBB">BBB</option>'
					+ '<option value="Other">Other</option>'
					+ '</select>'
				+ '</div>'
			+ '</div>'
						+ '<div class="form_field_cntr">'	
				+ '<div class="form_field_comment">'
					+ 'Comments:<br>'
					+ '<textarea name="comments" class="textInput" rows="3" cols="40"></textarea></div>'
				+ '</div>'
				+ '<div class="form_field_submit">'
					+ '<input type="submit" value="Submit">'
				+ '</div>'
			+ '</div>'
					+ '<div class="form_footer"></div>'
				+ '</div>'
			+ '</div>');