document.write('<form action="http://www.hickoryriver.com/cybermail/fb.php" method="post">');
document.write('<input type="hidden" name="id" value="9" />');
document.write('<input type="hidden" name="action" value="fb" />');
document.write('<input type="hidden" name="submit" value="true" />');

document.write('<h2>Tipp City, OH Restaurant</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="30" maxlength="80" value="" />');
document.write('</div>');

document.write('<div class="fb_label">');
document.write('1 First Name*:');
document.write('</div>');
document.write('<div class="fb_field">');
document.write('<input type="text" name="customFieldData[27]" size="25" maxlength="25" value="" />');
document.write('</div>');
document.write('<div class="fb_label">');
document.write('2 Last Name*:');
document.write('</div>');
document.write('<div class="fb_field">');
document.write('<input type="text" name="customFieldData[37]" size="25" maxlength="25" value="" />');
document.write('</div>');
document.write('<div class="fb_label">');
document.write('3 Address:');
document.write('</div>');
document.write('<div class="fb_field">');
document.write('<input type="text" name="customFieldData[38]" size="25" maxlength="25" value="" />');
document.write('</div>');
document.write('<div class="fb_label">');
document.write('4 City:');
document.write('</div>');
document.write('<div class="fb_field">');
document.write('<input type="text" name="customFieldData[39]" size="25" maxlength="25" value="" />');
document.write('</div>');
document.write('<div class="fb_label">');
document.write('5 State:');
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document.write('<div class="fb_field">');
document.write('<input type="text" name="customFieldData[40]" size="25" maxlength="25" value="" />');
document.write('</div>');
document.write('<div class="fb_label">');
document.write('6 Zip Code*:');
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document.write('<div class="fb_field">');
document.write('<input type="text" name="customFieldData[41]" size="5" maxlength="5" value="" />');
document.write('</div>');
document.write('<div class="fb_label">');
document.write('How did you hear about us?:');
document.write('</div>');
document.write('<div class="fb_field">');
document.write('<input type="text" name="customFieldData[43]" size="25" maxlength="25" value="" />');
document.write('</div>');

document.write('<div class="fb_field" style="line-height:28px;">');
document.write('<label><input type="checkbox" name="mailingListId[6]" value="6" />Tipp City, OH Restaurant</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" />');
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