document.write ("<table width='694' border='0' align='center' cellpadding='10' cellspacing='0' bgcolor='#FFFFFF'>");
document.write ("  <tr>");
document.write ("    <td style='border:solid 1 black'><table width='100%' border='0' cellpadding='5' cellspacing='0' bordercolor='#000000' bgcolor='#FFFFFF' id='Text'>");
document.write ("        <form  method='post' name='magazine' onSubmit='return cek3()'>");
document.write ("	<span class='Title' style='padding-left:5px'>Magazine Request Form</span><br>");
document.write ("          <input type='hidden' name='magreq' value='ok'>");
document.write ("          <tr>");
document.write ("            <td colspan='3'>Please fill in your details below to proceed to our ");
document.write ("              Affiliate Page, you shall shortly be contacted via email informing ");
document.write ("              you of your Affilliate Login Passcode!</td>");
document.write ("          </tr>");
document.write ("          <tr>");
document.write ("            <td width='47%'>Name *</td>");
document.write ("            <td width='1%'>&nbsp;</td>");
document.write ("            <td width='52%'>Location *</td>");
document.write ("          </tr>");
document.write ("          <tr>");
document.write ("            <td><input name='nama' type='text' id='nama' size='30' /></td>");
document.write ("            <td>&nbsp;</td>");
document.write ("            <td width='52%'><input name='lokasi' type='text' id='lokasi' size='30' /></td>");
document.write ("          </tr>");
document.write ("          <tr>");
document.write ("            <td>Email *</td>");
document.write ("            <td>&nbsp;</td>");
document.write ("            <td>Home number including code *</td>");
document.write ("          </tr>");
document.write ("          <tr>");
document.write ("            <td><input name='email' type='text' id='email' size='30' /></td>");
document.write ("            <td>&nbsp;</td>");
document.write ("            <td><input name='telepon1' type='text' id='telepon1' size='30' /></td>");
document.write ("          </tr>");
document.write ("          <tr>");
document.write ("            <td>Address *</td>");
document.write ("            <td>&nbsp;</td>");
document.write ("            <td>Work number including code *</td>");
document.write ("          </tr>");
document.write ("          <tr>");
document.write ("            <td><input name='alamat' type='text' id='alamat' size='30' /></td>");
document.write ("            <td>&nbsp;</td>");
document.write ("            <td><input name='telepon2' type='text' id='telepon2' size='30' /></td>");
document.write ("          </tr>");
document.write ("          <tr>");
document.write ("            <td>Nationality</td>");
document.write ("            <td>&nbsp;</td>");
document.write ("            <td>Mobile number including code *</td>");
document.write ("          </tr>");
document.write ("          <tr>");
document.write ("            <td><input name='nasional' type='text' id='nasional' size='30' /></td>");
document.write ("            <td>&nbsp;</td>");
document.write ("            <td><input name='telepon3' type='text' id='telepon3' size='30' /></td>");
document.write ("          </tr>");
document.write ("          <tr>");
document.write ("            <td colspan='3'><p><strong>Tick the various products/services you/your ");
document.write ("                clients would like to receive more information on :</strong><br />");
document.write ("              </p></td>");
document.write ("          </tr>");
document.write ("          <tr valign='top'>");
document.write ("            <td>Investment Funds :<br /> <input type='radio' name='q1' value='Yes' />");
document.write ("              Yes &nbsp; <input type='radio' name='q1' value='No' />");
document.write ("              No </td>");
document.write ("            <td>&nbsp;</td>");
document.write ("            <td>Sports Spread Betting :<br /> <input type='radio' name='q7' value='Yes' />");
document.write ("              Yes &nbsp; <input type='radio' name='q7' value='No' />");
document.write ("              No </td>");
document.write ("          </tr>");
document.write ("          <tr valign='top'>");
document.write ("            <td>A professional 2nd opinion or Independent Assessment of Existing ");
document.write ("              Portfolio :<br /> <input type='radio' name='q2' value='Yes' />");
document.write ("              Yes &nbsp; <input type='radio' name='q2' value='No' />");
document.write ("              No </td>");
document.write ("            <td>&nbsp;</td>");
document.write ("            <td>Medical Insurance :<br /> <input type='radio' name='q8' value='Yes' />");
document.write ("              Yes &nbsp; <input type='radio' name='q8' value='No' />");
document.write ("              No</td>");
document.write ("          </tr>");
document.write ("          <tr valign='top'>");
document.write ("            <td>Online Fund Trading Platform :<br /> <input type='radio' name='q3' value='Yes' />");
document.write ("              Yes &nbsp; <input type='radio' name='q3' value='No' />");
document.write ("              No</td>");
document.write ("            <td>&nbsp;</td>");
document.write ("            <td>Trip/Travel Insurance :<br /> <input type='radio' name='q9' value='Yes' />");
document.write ("              Yes &nbsp; <input type='radio' name='q9' value='No' />");
document.write ("              No </td>");
document.write ("          </tr>");
document.write ("          <tr valign='top'>");
document.write ("            <td>Private Placement or Venture Capital Opportunities : <br /> <input type='radio' name='q4' value='Yes' />");
document.write ("              Yes &nbsp; <input type='radio' name='q4' value='No' />");
document.write ("              No </td>");
document.write ("            <td>&nbsp;</td>");
document.write ("            <td>Life Insurance :<br /> <input type='radio' name='q10' value='Yes' />");
document.write ("              Yes &nbsp; <input type='radio' name='q10' value='No' />");
document.write ("              No </td>");
document.write ("          </tr>");
document.write ("          <tr valign='top'>");
document.write ("            <td>SMS/Text Alerts to your mobile phone for portfolio prices, index ");
document.write ("              movements, currency rates, etc :<br /> <input type='radio' name='q5' value='Yes' />");
document.write ("              Yes &nbsp; <input type='radio' name='q5' value='No' />");
document.write ("              No </td>");
document.write ("            <td>&nbsp;</td>");
document.write ("            <td>Financial and Lifestyle publishing and Magazines :<br /> <input type='radio' name='q11' value='Yes' />");
document.write ("              Yes &nbsp; <input type='radio' name='q11' value='No' />");
document.write ("              No </td>");
document.write ("          </tr>");
document.write ("          <tr valign='top'>");
document.write ("            <td>CFD Online Trading Platforms :<br /> <input type='radio' name='q6' value='Yes' />");
document.write ("              Yes &nbsp; <input type='radio' name='q6' value='No' />");
document.write ("              No </td>");
document.write ("            <td>&nbsp;</td>");
document.write ("            <td>Property news and investment oppurtunities :<br /> <input type='radio' name='q12' value='Yes' />");
document.write ("              Yes &nbsp; <input type='radio' name='q12' value='No' />");
document.write ("              No </td>");
document.write ("          </tr>");
document.write ("          <tr>");
document.write ("            <td><input type='submit' name='Submit32' value='Submit' /></td>");
document.write ("            <td>&nbsp;</td>");
document.write ("            <td>&nbsp;</td>");
document.write ("          </tr>");
document.write ("        </form>");
document.write ("      </table></td>");
document.write ("  </tr>");
document.write ("</table>");