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=\"199448277\"><input type=\"hidden\" name=\"meta_split_id\" value=\"\"><input type=\"hidden\" name=\"unit\" value=\"wlevaluation\"><input type=\"hidden\" name=\"redirect\" value=\"http://clients.profollow.com/thankyou-coi.htm?m=audio\" id=\"redirect_22449a23f2a36f581068d7963d1b93b8\"><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>&nbsp;Fill In Your Stop Smoking Evaluation Form. All answers are important for an accurate evaluation.<br>&nbsp;<br><em>(Even though the boxes look small, you should have as much space as you need in the boxes) </em></strong></div><div align=\"center\"><strong><em>&nbsp;</em></strong></div><div align=\"center\"><strong><em>&nbsp;</em></strong><br></div></center></td></tr><tr><td>1-How much weight do you want to lose:</td><td><input type=\"text\" name=\"custom How much weight do you want to lose\" value=\"\" size=\"20\"></td></tr><tr><td>2-how long have you been carrying around this extra weight:</td><td><input type=\"text\" name=\"custom 2-how long have you been carrying around this extra weight\" value=\"\" size=\"20\"></td></tr><tr><td>3-How many times have you tried losing weight:</td><td><input type=\"text\" name=\"custom 3-How many times have you tried losing weight\" value=\"\" size=\"20\"></td></tr><tr><td>4-Are you tired of fighting a losing battle:</td><td><input type=\"text\" name=\"custom 4-Are you tired of fighting a losing battle\" value=\"\" size=\"20\"></td></tr><tr><td>5-Are you ready to feel the freedom from the seduction of food and food marketing:</td><td><input type=\"text\" name=\"custom 5-Are you ready to feel the freedom from the seduction of food and food marketing\" value=\"\" size=\"20\"></td></tr><tr><td>6-What are you willing to do to make this happen:</td><td><input type=\"text\" name=\"custom 6-What are you willing to do to make this happen\" value=\"\" size=\"20\"></td></tr><tr><td>Name:</td><td><input type=\"text\" name=\"name\" 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><div align=\"center\"><strong>&nbsp;</strong></div><div align=\"center\"><strong>&nbsp;These evaluations, normally $97,</strong><br><strong>are free for a limited time only.</strong><br></div><br></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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