document.write('<span style="font-family:Arial; font-size:10pt;">');
document.write('<table align=center border="0" cellspacing="0" cellpadding="0"><tr><td align="right">');
document.write('Name &nbsp;</td><td><input type="text" name="first_name" value="First" size="30" ');
document.write('onfocus="if (this.value==\'First\'){this.value=\'\';};return false;" onblur="{if (this.value==\'\'){this.value=\'First\';return false;}; initialCap(this);}">');    
document.write('<input type="text" name="last_name" value="Last    (Enter names as if using a credit card.)" size="48" ');
document.write('onfocus="if (this.value==\'Last    (Enter names as if using a credit card.)\'){this.value=\'\';};return false;" ');
document.write('onblur="{if (this.value==\'\'){this.value=\'Last    (Enter names as if using a credit card.)\';return false;}; initialCap(this);}">');
document.write('</td></tr><tr><td align="right">Address &nbsp;</td><td><input type="text" name="address1" size="82">');
document.write('</td></tr><tr><td align="right">City &nbsp; </td><td><input type="text" name="city" onSelect="clrzip(this.form)"; ');
document.write('onKeyUp="Complete(this, event)"  onblur="{this.value = this.value.substr(0, 1).toUpperCase() + this.value.substr(1); fillzip(this.form)}">');
document.write(' &#160; &#160;State <select name="state" onClick="setCountry(this.form)"><option value="AL">Alabama<option value="AK">Alaska<option value="AZ">Arizona');
document.write('<option value="AR">Arkansas<option value="CA">California<option value="CO">Colorado<option value="CT">Connecticut');
document.write('<option value="DE">Delaware<option value="FL">Florida<option value="GA">Georgia<option value="HI">Hawaii<option value="ID">Idaho');
document.write('<option value="IL">Illinois<option value="IN">Indiana<option value="IA">Iowa<option value="KS">Kansas<option value="KY">Kentucky');
document.write('<option value="LA">Louisiana<option value="ME">Maine<option value="MD">Maryland<option value="MA">Massachusetts');
document.write('<option value="MI">Michigan<option value="MN">Minnesota<option value="MS">Mississippi<option value="MO">Missouri');
document.write('<option value="MT">Montana<option value="NE">Nebraska<option value="NV">Nevada<option value="NH">New Hampshire');
document.write('<option id="NJ" selected value="NJ">New Jersey<option value="NM">New Mexico<option value="NY">New York<option value="NC">North Carolina');
document.write('<option value="ND">North Dakota<option value="OH">Ohio<option value="OK">Oklahoma<option value="OR">Oregon<option value="PA">Pennsylvania');
document.write('<option value="RI">Rhode Island<option value="SC">South Carolina<option value="SD">South Dakota<option value="TN">Tennessee');
document.write('<option value="TX">Texas<option value="UT">Utah<option value="VT">Vermont<option value="VA">Virginia<option value="WA">Washington');
document.write('<option value="WV">West Virginia<option value="WI">Wisconsin<option value="WY">Wyoming<option value=" ">');
document.write('<option value="AB">Alberta<option value="BC">British Columbia<option value="NF">Labrador<option value="MB">Manitoba');
document.write('<option value="NB">New Brunswick<option value="NF">Newfoundland<option value="NS">Nova Scotia<option value="NT">NWT/Nunavut');
document.write('<option value="ON">Ontario<option value="PE">Prince Edward Is.<option value="QC">Quebec<option value="SK">Saskatchewan');
document.write('<option value="YT">Yukon</select> &#160;Zip ');
document.write('<input name="zip" type="text" onBlur="checkZip(this.value)" size="7" maxlength="10"> &#160;Ctry <input type=text name="country" value=" " size=2>');
document.write('</td></tr><tr><td align="right">Phone &#160;</td><td><input type=text name="night_phone_a" size="3" ');
document.write('onKeyUp="{intOnly(this); return autoTab(this, 3, event);}" maxlength="3">-');
document.write('<input type="text" id="phone" name="night_phone_b" size="3" onKeyUp="{intOnly(this); return autoTab(this, 3, event);}" maxlength="3">');
document.write('-<input type="text" name="night_phone_c" size="4" onKeyUp="{intOnly(this); return autoTab(this, 4, event);}" maxlength="4">');
document.write(' &#160; Email <input type="text" Name="email" size="48" onblur="checkEmail(this)"></td></tr></table></span>');