document.writeln("<form action=\"http://www.azmortgagecompany.com/scripts/contact.php\" method=\"post\" id=\"form1\">");
document.writeln("<table border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"center\" class=\"table-box2\" style=\"margin-top:10px; margin-left:auto; margin-right:auto; padding:3px;\">");
document.writeln("<tr><td bgcolor=\"#BB8267\" align=\"center\" style=\"font-size:14px; color:#FFFFFF\"><strong>Quick Application</strong></td></tr>");
document.writeln("<tr><td align=\"center\"><div class=\"errors\"></div></td></tr>");
document.writeln("<tr>");
document.writeln("	<td>Name (First/Last):</td>");
document.writeln("</tr>");
document.writeln("<tr>");
document.writeln("	<td><input type=\"text\" id=\"firstname_from\" name=\"firstname_from\" class=\"required\" style=\"width:71px; font-size:10px;\" /> <input type=\"text\" id=\"lastname_from\" name=\"lastname_from\" class=\"required\" style=\"width:71px; font-size:10px;\" /></td>");
document.writeln("</tr>");
document.writeln("");
document.writeln("<tr>");
document.writeln("	<td>Email:</td>");
document.writeln("</tr>");
document.writeln("<tr>");
document.writeln("	<td><input name=\"email_from\" type=\"text\" id=\"email_from\" class=\"required\" style=\"width:150px; font-size:10px;\" /></td>");
document.writeln("</tr>");
document.writeln("<tr>");
document.writeln("	<td>Phone:</td>");
document.writeln("</tr>");
document.writeln("<tr>");
document.writeln("	<td><input name=\"home_phone\" type=\"text\" class=\"required\" id=\"home_phone\" maxlength=\"17\" style=\"width:150px; font-size:10px;\" /></td>");
document.writeln("</tr>");
document.writeln("<tr>");
document.writeln("	<td>Reason For Loan:</td>");
document.writeln("</tr>");
document.writeln("<tr>");
document.writeln("	<td><select name=\"loanReason\" class=\"required\" id=\"loanReason\" style=\"width: 150px; font-size:10px;\">");
document.writeln("                <option value=\"\">-- Select One --</option>");
document.writeln("                <option value=\"Purchase\">Purchase</option>");
document.writeln("                <option value=\"Refinance\">Refinance</option>");
document.writeln("              </select></td>");
document.writeln("</tr>");
document.writeln("<tr>");
document.writeln("	<td>Loan Amount:</td>");
document.writeln("</tr>");
document.writeln("<tr>");
document.writeln("	<td><input name=\"loanAmount\" type=\"text\" class=\"required\" id=\"loanAmount\" style=\"width:150px; font-size:10px;\" /></td>");
document.writeln("</tr>");
document.writeln("<tr>");
document.writeln("	<td>Comments:</td>");
document.writeln("</tr>");
document.writeln("<tr>");
document.writeln("	<td><textarea name=\"comments\" rows=\"3\" id=\"comments\" style=\"width:150px; font-size:10px;\"></textarea></td>");
document.writeln("</tr>");
document.writeln("<tr>");
document.writeln("<td align=\"center\">Security Code:</td>");
document.writeln("</tr>");
document.writeln("<tr>");
document.writeln("<td align=\"center\">");
document.writeln("  <input type=\"text\" name=\"security_code\" maxlength=\"6\" id=\"security_code\" class=\"required\" style=\"width:100px; font-size:10px;\" />");
document.writeln("  <br />");
document.writeln("  <img src=\"http://www.azmortgagecompany.com/scripts/captcha-image.php\" alt=\"Security Image\" name=\"captcha\" width=\"100\" height=\"20\" border=\"1\" id=\"captcha\" /><br />");
document.writeln("  [ <a href=\"#\" onClick=\"document.getElementById(\'captcha\').src = document.getElementById(\'captcha\').src + \'?\' + (new Date()).getMilliseconds()\">Refresh Image</a> ]</td>");
document.writeln("</tr>");
document.writeln("<tr><td height=\"20\" align=\"center\"><input type=\"submit\" value=\"Submit\" /></td></tr>");
document.writeln("</table>       ");
document.writeln("</form>");