document.write('<form action="http://www.leapfrogstore.co.uk/mail/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('<ul><li><ul><li>Enter your email address to receive special discounts and offers from LeapFrog via email.</li></ul></li></ul>');

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="19" maxlength="50" value="" />');
document.write('</div>');

document.write('<div class="fb_label">');
document.write('First Name*:');
document.write('</div>');
document.write('<div class="fb_field">');
document.write('<input type="text" name="customFieldData[1]" size="19" maxlength="50" value="" />');
document.write('</div>');
document.write('<div class="fb_label">');
document.write('Surname (Family Name)*:');
document.write('</div>');
document.write('<div class="fb_field">');
document.write('<input type="text" name="customFieldData[2]" size="19" maxlength="50" 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" />LeapFrog Deals</label>');
document.write('</div>');


document.write('<div class="fb_label">');
document.write('&nbsp;</div>');
document.write('<div class="fb_field">');
document.write('<input name="image" type=image src=http://leapfrogstore.co.uk/images/button/button_submit.gif width=54 height=22 border=0>');
document.write('</div>');
document.write('</form>');