document.write(unescape("%3Cscript src='include/bme_jscript.js' type='text/javascript'%3E%3C/script%3E"));
document.write("<div align='center'>");
document.write("<form style='display:inline;' action='http://lb.benchmarkemail.com//code/lbform' method=post name='frmLB' accept-charset='UTF-8' onSubmit='return _checkSubmit();' >");
document.write("<input type=hidden name=successurl value='http://lb.benchmarkemail.com//Code/ThankYou' />");
document.write("<input type=hidden name=errorurl value='http://lb.benchmarkemail.com//Code/Error' />");
document.write("<input type=hidden name=token value='mFcQnoBFKMRpngCHhQkjxsnww8QViHurNuVh6XmA2xI%3D' />");
document.write("<input type=hidden name=doubleoptin value='0' />");
document.write("<table id=tblFormData width='100%' border='0' cellspacing='0' cellpadding='0'  style='border: 1px solid ;color: #ffffff; font-family:Arial; font-size:12px'>");
document.write("  <tr><td width='100%' valign=top id=tblForm ><div style='padding:5px;'>");
document.write("  <table id=tblFieldData border=0 cellpadding=0 cellspacing=0 style='color: #ffffff font-family:Arial; font-size:12px'><tr><td valign=top align=left><div style='width:120px;float:left;padding-top:5px; color: #ffffff;'><b>Email <span style='color:#ffffff;font-size:125%;'> *</span> </b></div><div style='float:left;padding-top:3px;'><input type=text style='width:120px' name=fldEmail maxlength=100 /></div></td></tr><tr><td valign=top align=left><div style='width:120px;float:left;padding-top:5px; color: #ffffff;'><b>First Name</b></div>");
document.write("        <div style='float:left;padding-top:3px;'><input type=text style='width:120px' name=fldfirstname maxlength=100 /></div></td></tr><tr><td valign=top align=left><div style='width:120px;float:left;padding-top:5px; color: #ffffff;'><b>Last Name</b></div>");
document.write("    <div style='float:left;padding-top:3px;'><input type=text style='width:120px' name=fldlastname maxlength=100 /></div></td></tr></table></div></td></tr><tr><td valign=top id='tdSep' style='background-color:;' ><img src='http://www.benchmarkemail.com/images/blank.gif' height=1 width=1 /></td></tr><tr><td valign=top style='padding-top:10px;padding-bottom:10px;' align=center><input type='submit' id='btnSubmit' value='Submit' style='font-size:12px;font-family:Arial;padding-left:10px;padding-right:10px;color:#000000;' /></td></tr></table>");
document.write("</form>");
document.write("<a href='http://www.benchmarkemail.com/' target=_new style='text-decoration:none;font-family:Arial,Helvetica,sans-serif;font-size:10px;color:#999999;'>Bulk Email</a><span style='text-decoration:none;font-family:Arial,Helvetica,sans-serif;font-size:10px;color:#999999;'> by Benchmark Email</span></div>");