document.write('<style>\n#flexiform dt { margin: 0px; padding: 0px; float: none; width: auto; text-align: left; font-weight: bold; }\n#flexiform dd { margin: 0px 0px 0px 0px; padding: 0px; float: none; width: auto; }\n\n\n\n\n\n</style>\n<div id=\"flexiform\">\n\n  <p></p>\n\n  <form method=\"post\" action=\"http://forms.flexikit.net/public/javascript_collect/8887790\">\n\n    <dl>\n    \n      \n      <dt>\n        Title\n        <div style=\"color: #777; font-weight: normal; font-size: 98%;\"></div>\n      </dt>\n      <dd>\n        \n        \n        \n          <input type=\"text\" name=\"results[40]\" size=\"20\" value=\"\" class=\"flexiform-text\" />\n          \n        \n        \n      </dd>\n    \n      \n      <dt>\n        First Name\n        <div style=\"color: #777; font-weight: normal; font-size: 98%;\"></div>\n      </dt>\n      <dd>\n        \n        \n        \n          <input type=\"text\" name=\"results[41]\" size=\"60\" value=\"\" class=\"flexiform-text\" />\n          \n        \n        \n      </dd>\n    \n      \n      <dt>\n        Surname\n        <div style=\"color: #777; font-weight: normal; font-size: 98%;\"></div>\n      </dt>\n      <dd>\n        \n        \n        \n          <input type=\"text\" name=\"results[42]\" size=\"60\" value=\"\" class=\"flexiform-text\" />\n          \n        \n        \n      </dd>\n    \n      \n      <dt>\n        Address\n        <div style=\"color: #777; font-weight: normal; font-size: 98%;\"></div>\n      </dt>\n      <dd>\n        \n        \n        \n          <textarea name=\"results[43]\" rows=\"5\" cols=\"30\" /></textarea>\n        \n        \n        \n      </dd>\n    \n      \n      <dt>\n        Town/City\n        <div style=\"color: #777; font-weight: normal; font-size: 98%;\"></div>\n      </dt>\n      <dd>\n        \n        \n        \n          <input type=\"text\" name=\"results[44]\" size=\"60\" value=\"\" class=\"flexiform-text\" />\n          \n        \n        \n      </dd>\n    \n      \n      <dt>\n        Telephone Number\n        <div style=\"color: #777; font-weight: normal; font-size: 98%;\"></div>\n      </dt>\n      <dd>\n        \n        \n        \n          <input type=\"text\" name=\"results[45]\" size=\"60\" value=\"\" class=\"flexiform-text\" />\n          \n        \n        \n      </dd>\n    \n      \n      <dt>\n        Email Address\n        <div style=\"color: #777; font-weight: normal; font-size: 98%;\"></div>\n      </dt>\n      <dd>\n        \n        \n        \n          <input type=\"text\" name=\"results[46]\" size=\"60\" value=\"\" class=\"flexiform-text\" />\n          \n        \n        \n      </dd>\n    \n      \n      <dt>\n        I am seeking advice on (please tick)\n        <div style=\"color: #777; font-weight: normal; font-size: 98%;\"></div>\n      </dt>\n      <dd>\n        \n           \n          \n          \n          <input name=\"results[47][]\" type=\"checkbox\" value=\"Mortgages\" class=\"flexiform-check\" /> Mortgages<br />\n          \n          <input name=\"results[47][]\" type=\"checkbox\" value=\"Loans 	\" class=\"flexiform-check\" /> Loans 	<br />\n          \n          <input name=\"results[47][]\" type=\"checkbox\" value=\"Life Assurance 	\" class=\"flexiform-check\" /> Life Assurance 	<br />\n          \n          <input name=\"results[47][]\" type=\"checkbox\" value=\"Mortgage Payment Protection 	\" class=\"flexiform-check\" /> Mortgage Payment Protection 	<br />\n          \n          <input name=\"results[47][]\" type=\"checkbox\" value=\"House & Contents Insurance\" class=\"flexiform-check\" /> House & Contents Insurance<br />\n          \n          \n          \n        \n      </dd>\n    \n    </dl>\n\n    <p><input type=\"submit\" value=\"Submit Form\" id=\"flexiform-submit\" /></p>\n  </form>\n\n  <p></p>\n\n</div>');