document.writeln('<form method="post" action="http://www.claibornehughes.com/new_feedback_form_3/confirmation" target="_self">');
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document.writeln('    <tr>');
document.writeln('      <td bgcolor="#000000">');
document.writeln('        <table width="100%" border="0" cellspacing="1" cellpadding="3">');
document.writeln('          <tr>');
document.writeln('            <td bgcolor="#6D7BA6" align="center">');
document.writeln('              <font face="" size="4" color="#FFFFFF">');
document.writeln('                <b>Send Feedback</b>');
document.writeln('              </font>');
document.writeln('            </td>');
document.writeln('          </tr>');
document.writeln('          <tr>');
document.writeln('            <td align="center" bgcolor="#FFFFE0">');
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document.writeln('                <tr>');
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document.writeln('                    <font face="" size="4" color="#000000">Your Name:</font>');
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document.writeln('                  <td align="left">');
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document.writeln('                  </td>');
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document.writeln('                <tr>');
document.writeln('                  <td align="right">');
document.writeln('                    <font face="" size="4" color="#000000">Your Email:</font>');
document.writeln('                  </td>');
document.writeln('                  <td align="left">');
document.writeln('                    <input name="from_address" type="text" maxlength="45" size="28" value="">');
document.writeln('                  </td>');
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document.writeln('                  <td align="center" colspan="2">');
document.writeln('                    <table>');
document.writeln('                      <tr>');
document.writeln('                        <td align="left">');
document.writeln('                          <font face="" size="4" color="#000000">Comments:</font>');
document.writeln('                          <br>');
document.writeln('                          <textarea name="content" rows="5" cols="40"></textarea>');
document.writeln('                          <br>');
document.writeln('                          <input type="hidden" name="referer" value="http://www.claibornehughes.com/new_page_builder_18">');
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document.writeln('                </tr>');
document.writeln('                <tr>');
document.writeln('                  <td colspan="2" align="center">');
document.writeln('                    <input type="submit" name="send" value="Send Feedback">');
document.writeln('                  </td>');
document.writeln('                </tr>');
document.writeln('                <tr>');
document.writeln('                  <td colspan="2" align="center">');
document.writeln('                    <a href="http://www.sitemason.com/" target="Sitemason"><img src="http://www.sitemason.com/images/brand.gif" width="77" height="28" hspace="0" vspace="0" border="0"></a>');
document.writeln('                  </td>');
document.writeln('                </tr>');
document.writeln('              </table>');
document.writeln('            </td>');
document.writeln('          </tr>');
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document.writeln('      </td>');
document.writeln('    </tr>');
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