document.writeln('<form name="frmInput" method="post" action="/contact.php">');

document.writeln('<input type="hidden" name="action" value="SEND" />');

document.writeln('<table border="0" cellspacing="2" cellpadding="0" align="center">');

document.writeln('<tr>');
document.writeln('<td align="right" width="60"><span class="required">*</span>&nbsp;&nbsp;<span class="label">Name:</span></td>');
document.writeln('<td><input type="text" name="" size="30" maxlength="50" /></td>');
document.writeln('</tr>');

document.writeln('<tr>');
document.writeln('<td align="right" width="60"><span class="required">*</span>&nbsp;&nbsp;<span class="label">Email Address:</span></td>');
document.writeln('<td><input type="text" name="" size="20" maxlength="100" /></td>');
document.writeln('</tr>');

document.writeln('<tr>');
document.writeln('<td align="right" width="60"><span class="label">Website:</span></td>');
document.writeln('<td><input type="text" name="" size="20" maxlength="100" /></td>');
document.writeln('</tr>');

document.writeln('<tr>');
document.writeln('<td align="right" width="60"><span class="required">*</span>&nbsp;&nbsp;<span class="label">Direct To:</span></td>');
document.writeln('<td><select name="">');
document.writeln('<option value="Comments/Feedback">Comments/Feedback</option>');
document.writeln('<option value="Rule Submissions">Rule Submissions</option>');
document.writeln('<option value="Glossary Submissions">Glossary Submissions</option>');
document.writeln('<option value="Typos/Corrections">Typos/Corrections</option>');
document.writeln('<option value="Link Exchange">Link Exchange</option>');
document.writeln('<option value="Hate Mail">Hate Mail</option>');
document.writeln('</select></td>');
document.writeln('</tr>');

document.writeln('<tr><td colspan="2">');
document.writeln('<span class="label">Message:</span><br /><textarea name="" cols="40" rows="5"></textarea><br />');
document.writeln('<table border="0"><tr><td valign="top"><input type="checkbox" name="" value="1" /></td>');
document.writeln('<td valign="top">Check this box if you would like to receive the Beirut-Guide.com newsletter.</td>');
document.writeln('</tr></table>');
document.writeln('</td></tr>');

document.writeln('<tr><td colspan="2" align="center"><input type="submit" value="Submit" /></td></tr>');

document.writeln('</table>');

document.writeln('</form>');