document.write("<link href=\"http://altprofits.com/ml/screen.css\" rel=\"stylesheet\" type=\"text\/css\" \/>");
document.write("<form id=\"myform\" method=\"post\" action=\"http://altprofits.com/mlist/user/process.php\">");
document.write("<fieldset>");
document.write("<legend>Free Newsletter in Your Email<\/legend>");
document.write("<b>Email</b><input type=\"text\" id=\"email\" name=\"Email\" \/> ");
document.write("<b>Name</b><input type=\"text\" value=\"\" id=\"field1\" name=\"d[1]\" \/>");
document.write("<b>Profile</b><input type=\"text\" id=\"field3\" name=\"d[3]\" \/>");
document.write("<input name=\"pommo_signup\" value=\"true\" type=\"hidden\" \/>");
document.write("<div><input type=\"submit\" name=\"pommo_signup\" id=\"submit\" value=\"Subscribe\" class=\"submit\" \/><\/div>");
document.write("<\/fieldset>");
document.write("<\/form>");