document.write('<BR><div align=center style="font-size:13px; font-family:Arial; padding:20px;"><div style="width:70%; background:#ffff99; padding:15px; text-align:center; font-size:16px;" align=center><form action="http://response.alphaconfidence.com/submit2/form-step1a.php" method="POST" style="padding:0px; margin:0px;">');
document.write('<input type="hidden" name="listname" value="carlosxumahold" />');
document.write('<input type="hidden" name="meta_web_form_id" value="660334126" />');
document.write('<input type="hidden" name="meta_adtracking" value="JSport" />');
document.write('<input type="hidden" name="meta_message" value="1" />');
document.write('<input type="hidden" name="aid" value="12" />');
document.write('<input type="hidden" name="infusion_xid" value="8b0cf81d67c4566fce55b4dfe2e45d5d" />');
document.write('<input type="hidden" name="infusionsoft_version" value="1.24.6.55" />');
document.write('E-mail:&nbsp; <input size="20" name="Contact0Email" type="text" value="Enter Your E-mail" onfocus="this.value=\'\'">');
document.write(' <input type="submit" name="submit" style="font-size:16px; margin:0px; background:maroon; color:yellow; font-weight:bold; padding-right:6px; padding-left:6px;"></form></div></div>');