document.write('<form action="http://www.daytonasystemsinc.com/mysplashcarwash/fireblast/fb.php" method="post">');
document.write('<input type="hidden" name="id" value="2" />');
document.write('<input type="hidden" name="action" value="fb" />');
document.write('<input type="hidden" name="submit" value="true" />');

document.write('<h2>Subscribe</h2>');

document.write('<div class="fb_label">');
document.write('Email:');
document.write('</div>');
document.write('<div class="fb_field">');
document.write('<input type="text" name="email" size="20" maxlength="80" value="" />');
document.write('</div>');

document.write('<div class="fb_label">');
document.write('First Name*:');
document.write('</div>');
document.write('<div class="fb_field">');
document.write('<input type="text" name="customFieldData[12]" size="40" maxlength="40" value="" />');
document.write('</div>');
document.write('<div class="fb_label">');
document.write('Last Name*:');
document.write('</div>');
document.write('<div class="fb_field">');
document.write('<input type="text" name="customFieldData[13]" size="40" maxlength="40" value="" />');
document.write('</div>');
document.write('<div class="fb_label">');
document.write('Address:');
document.write('</div>');
document.write('<div class="fb_field">');
document.write('<input type="text" name="customFieldData[14]" size="40" maxlength="40" value="" />');
document.write('</div>');
document.write('<div class="fb_label">');
document.write('City:');
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document.write('<div class="fb_field">');
document.write('<input type="text" name="customFieldData[15]" size="40" maxlength="40" value="" />');
document.write('</div>');
document.write('<div class="fb_label">');
document.write('State:');
document.write('</div>');
document.write('<div class="fb_field">');
document.write('<input type="text" name="customFieldData[20]" size="3" maxlength="3" value="" />');
document.write('</div>');
document.write('<div class="fb_label">');
document.write('Zip:');
document.write('</div>');
document.write('<div class="fb_field">');
document.write('<input type="text" name="customFieldData[21]" size="10" maxlength="10" value="" />');
document.write('</div>');
document.write('<div class="fb_label">');
document.write('Birthday:');
document.write('</div>');
document.write('<div class="fb_field">');
document.write('<input type="text" name="customFieldData[22]" size="10" maxlength="10" value="" />');
document.write('</div>');
document.write('<div class="fb_label">');
document.write('Phone1:');
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document.write('<div class="fb_field">');
document.write('<input type="text" name="customFieldData[23]" size="15" maxlength="15" value="" />');
document.write('</div>');
document.write('<div class="fb_label">');
document.write('Phone2:');
document.write('</div>');
document.write('<div class="fb_field">');
document.write('<input type="text" name="customFieldData[24]" size="15" maxlength="15" value="" />');
document.write('</div>');

document.write('<div class="fb_field" style="line-height:28px;">');
document.write('<label><input type="checkbox" name="mailingListId[1]" value="1" checked="checked" />Splash Mailing List</label>');
document.write('</div>');
document.write('<div class="fb_field" style="line-height:28px;">');
document.write('<label><input type="checkbox" name="mailingListId[2]" value="2" checked="checked" />Daytona Systems</label>');
document.write('</div>');


document.write('<div class="fb_label">');
document.write('&nbsp;</div>');
document.write('<div class="fb_field">');
document.write('<input type="submit" value="Submit" />');
document.write('</div>');
document.write('</form>');