document.write('<form action="http://ecarnaples.com/fireblast/fb.php" method="post">');
document.write('<input type="hidden" name="id" value="1" />');
document.write('<input type="hidden" name="action" value="fb" />');
document.write('<input type="hidden" name="submit" value="true" />');

document.write('<h2>Ambassador main mailing list</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_field" style="line-height:28px;">');
document.write('<label><input type="checkbox" name="mailingListId[2]" value="2" checked="checked" />Naples local mailing list</label>');
document.write('</div>');
document.write('<div class="fb_field" style="line-height:28px;">');
document.write('<label><input type="checkbox" name="mailingListId[3]" value="3" checked="checked" />Ambassador main mailing list</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>');