\n");
document.write(" | First Name: | \n");
document.write(" | \n");
document.write("
\n");
document.write(" | Last Name: | \n");
document.write(" | \n");
document.write("
\n");
document.write(" | Address 1: | \n");
document.write(" | \n");
document.write("
\n");
document.write(" | Address 2: | \n");
document.write(" | \n");
document.write("
\n");
document.write(" | City: | \n");
document.write(" | \n");
document.write("
\n");
document.write(" | State/Province: | \n");
document.write(" | \n");
document.write("
\n");
document.write(" | Zip Code: | \n");
document.write(" | \n");
document.write("
\n");
document.write(" | Email Address: | \n");
document.write(" | \n");
document.write("
\n");
document.write(" | Home Phone: | \n");
document.write(" | \n");
document.write("
\n");
document.write(" | Business Phone: | \n");
document.write(" | \n");
document.write("
\n");
document.write("| \n");
document.write("I'd like to find a CIA: | \n");
document.write("\n");
document.write("Yes
\n");
document.write(" |
\n");
document.write(" | My Area Code: | \n");
document.write(" | \n");
document.write("
\n");
document.write(" | Other nearby area codes: | \n");
document.write(" | \n");
document.write("
\n");
document.write(" | How did you find this Web site?: | \n");
document.write(" | \n");
document.write("
\n");
document.write(" | Other nearby Area Codes (work, etc.): | \n");
document.write(" | \n");
document.write("
\n");
document.write(" | Other nearby zip codes (work, etc.): | \n");
document.write(" | \n");
document.write("
\n");
document.write(" | Comments: | \n");
document.write(" | \n");
document.write("
\n");
document.write("| \n");
document.write("I'd like to receive your newsletter: | \n");
document.write("\n");
document.write("Yes
No
\n");
document.write(" |
\n");
document.write("