document.write('<form method="post" enctype="multipart/form-data" action="http://pub38.bravenet.com/emailfwd/senddata.php" accept-charset="utf-8">')
document.write('<input type="hidden" name="usernum" value="3193535440">')
document.write('<input type="hidden" name="cpv" value="2">')
document.write('<table border="0" cellpadding="0" cellspacing="0" align="center">')
document.write('<tr>')
document.write('<td><h2 style="border-bottom:1px solid black;">Member News Form</h2><br /><br /></td></tr><tr><td>')
document.write('<label for="NameFirstLast" style="float:left;width:140px;font-weight:normal;">Name (First and Last):</label><input type="text" name="NameFirstLast" id="NameFirstLast" value="" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div>')
document.write('<label for="Email" style="float:left;width:140px;font-weight:normal;">E-Mail Address:</label><input type="text" name="Email" id="Email" value="" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div>')
document.write('<label for="YourAge" style="float:left;width:140px;font-weight:normal;">Your Age:</label><input type="text" name="YourAge" id="YourAge" value="" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div>')
document.write('<label for="WhatDidYouDo" style="display:block;margin-bottom:5px;font-weight:normal;">What Did You Do?</label><textarea name="WhatDidYouDo" id="WhatDidYouDo" style="width:400px;height:200px;"></textarea><div style="clear:left;height:20px;"> </div>')
document.write('<label for="OtherComments" style="display:block;margin-bottom:5px;font-weight:normal;">Other Comments</label><textarea name="OtherComments" id="OtherComments" style="width:400px;height:100px;"></textarea><div style="clear:left;height:20px;"> </div>')
document.write('<label style="float:left;width:140px;font-weight:normal;" for="YourRating">Your Rating of this Activity or Book, etc.:</label><select name="YourRating" id="YourRating"><option value="1">1 - Worst</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10 - Best</option></select><div style="clear:left;height:20px;"> </div>')
document.write('<label for="ReviewSignature" style="float:left;width:140px;font-weight:normal;">Name or Handle to Use for Credit Line:</label><input type="text" name="ReviewSignature" id="ReviewSignature" value="" maxlength="" style="width:200px;"><div style="clear:left;height:20px;"> </div>')
document.write('</td><tr><td align="right">')
document.write('<input type="submit" value=" Submit "> <input type="reset" value=" Reset ">')
document.write('</td></tr></table></form> ')