document.write("<!-- Web Form Generator 2.0 --><center><form method=\"post\" action=\"http://clients.profollow.com/scripts/addlead.pl\"><input type=\"hidden\" name=\"meta_web_form_id\" value=\"68257957\"><input type=\"hidden\" name=\"meta_split_id\" value=\"\"><input type=\"hidden\" name=\"unit\" value=\"smkgevaluation\"><input type=\"hidden\" name=\"redirect\" value=\"http://clients.profollow.com/thankyou-coi.htm?m=audio\" id=\"redirect_02cd2c6747a40190b2daa807b30e49a3\"><input type=\"hidden\" name=\"meta_redirect_onlist\" value=\"\"><input type=\"hidden\" name=\"meta_adtracking\" value=\"\"><input type=\"hidden\" name=\"meta_message\" value=\"1\"><input type=\"hidden\" name=\"meta_required\" value=\"from\"><input type=\"hidden\" name=\"meta_forward_vars\" value=\"0\"><table><tr><td colspan=2><center><div align=\"center\"><strong>Fill In Your Stop Smoking Evaluation Form.  All answers are important for an accurate evaluation.</strong></div><div align=\"center\"><strong>&nbsp;</strong></div><div align=\"center\"><em><strong>(Even though the boxes look small, you should have as much space as you need in the boxes)&nbsp;</strong></em></div><div align=\"center\"><em><strong>&nbsp;</strong></em></div><div align=\"center\"><em><strong>&nbsp;</strong></em></div></center></td></tr><tr><td>How long have you been smoking:</td><td><input type=\"text\" name=\"custom How long have you been smoking\" value=\"\" size=\"20\"></td></tr><tr><td>How many cigarettes do you smoke a day:</td><td><input type=\"text\" name=\"custom How many cigarettes do you smoke a day\" value=\"\" size=\"20\"></td></tr><tr><td>Have you ever quit before:</td><td><input type=\"text\" name=\"custom Have you ever quit before\" value=\"\" size=\"20\"></td></tr><tr><td>What was your longest quit time:</td><td><input type=\"text\" name=\"custom What was your longest quit time\" value=\"\" size=\"20\"></td></tr><tr><td>Are you looking to quit for yourself or is someone pressuring you to quit:</td><td><input type=\"text\" name=\"custom Are you looking to quit for yourself or is someone pressuring you to quit\" value=\"\" size=\"20\"></td></tr><tr><td>Why do you want to quit:</td><td><input type=\"text\" name=\"custom Why do you want to quit\" value=\"\" size=\"20\"></td></tr><tr><td>Have you ever been hypnotized before:</td><td><input type=\"text\" name=\"custom Have you ever been hypnotized before\" value=\"\" size=\"20\"></td></tr><tr><td>Name:</td><td><input type=\"text\" name=\"name\" value=\"\" size=\"20\"></td></tr><tr><td>Phone:</td><td><input type=\"text\" name=\"custom Phone\" value=\"\" size=\"20\"></td></tr><tr><td>Email:</td><td><input type=\"text\" name=\"from\" value=\"\" size=\"20\"></td></tr>    <tr><td colspan=2><center><div align=\"center\"><strong>These evaluations, normally $97,</strong></div><div align=\"center\"></div><div align=\"center\"><strong>are free for a limited time only.</strong></div><div><strong> </strong></div></center></td></tr><tr><td align=\"center\" colspan=\"2\"><input type=\"submit\" name=\"submit\" value=\"Get Your Free $97 Evaluation\"></td></tr></table></form></center>");

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