document.write('<form action="Feedbackmail.php" method="post" name="frm_feedback" id="frm_feedback"  >');
document.write('<table width="100%" border="0" align="center" cellpadding="3" cellspacing="1" class="text1" id="Table2">');
document.write('<center>');
document.write('<colgroup>');
document.write('<col width="145" />');
document.write('<col width="286" />');
document.write('</colgroup>');
document.write('</center>');
document.write('<tbody>');
document.write('<tr>');
document.write('<td height="15" colspan="2" align="center" bgcolor="#CE221E" class="ais_A2" nowrap><span class="style3">For more information, please fill out the following</span></td>');
document.write('</tr>');
document.write('<tr>');
document.write('<td width="73" height="25" align="center" bgcolor="#FFFFFF"><p align="left"><b>Name</b></p></td>');
document.write('<center>');
document.write('<td width="362" height="25" align="left" bgcolor="#FFFFFF"><p>');
document.write('  <input name="realname" class="TextFieldEffect1"   size="40" maxlength="30" />');
document.write('</p></td>');
document.write('</center>');
document.write('</tr>');
document.write('<tr>');
document.write('<td width="73" height="25" align="center" bgcolor="#FFFFFF"><p align="left"><b>Phone</b></p></td>');
document.write('<td width="362" height="25" align="left" bgcolor="#FFFFFF"><p>');
document.write('<input name="phone" class="TextFieldEffect1"    size="40" maxlength="250" />');
document.write('</p></td>');
document.write('</tr>');
document.write('<tr>');
document.write('<td width="73" height="25" align="center" bgcolor="#FFFFFF"><p align="left"><b>E-mail</b></p></td>');
document.write('<td width="362" height="25" align="left" bgcolor="#FFFFFF"><p>');
document.write('<input name="email" class="TextFieldEffect1"   size="40" maxlength="250" />');
document.write('</p></td>');
document.write('</tr>');
document.write('<tr>');
document.write('<td colspan="2" align="left" valign="top" bgcolor="#FFFFFF"><strong>What   would you like to protect?</strong></td>');
document.write('</tr>');
document.write('<tr>');
document.write('<td width="73" align="left" valign="top" bgcolor="#FFFFFF"><p align="right">&nbsp;</p></td>');
document.write('<td width="362" align="left" valign="top" bgcolor="#FFFFFF"><input name="protect" class="TextFieldEffect1"   size="40" maxlength="250" /></td>');
document.write('</tr>');
document.write('<tr>');
document.write('<td colspan="2" bgcolor="#FFFFFF"><p align="center">');
document.write('<input name="Submit" type="submit" class="TextFieldEffect1" value="Submit" />');
document.write('&nbsp;');
document.write('<input name="reset" type="reset" class="TextFieldEffect1" id="FormsButton62" value="Clear" />');
document.write('</p></td>');
document.write('</tr>');
document.write('</tbody>');
document.write('</table>');
document.write('</form>');