document.writeln('            <img src="http:\/\/www.123dieet.nl\/images\/box-123dieet.gif" width="350" height="160">\r\n\r\n            <form method="post" target="_blank" name="dieet" action="http:\/\/www.123dieet.nl\/123dieet.php">\r\n<table><tr><td valign="middle">\r\n\r\n  <table border="0" align="center" cellspacing="0" cellpadding="5">\r\n\r\n<input type="hidden" name="referrer" value=""> \r\n\r\n<SCRIPT LANGUAGE="JavaScript"><!--\r\ndocument.dieet.referrer.value = document.referrer;\r\n\/\/--><\/SCRIPT>\r\n\r\n    <tr> \r\n      <td valign="top">Naam: <\/td>\r\n      <td valign="top"><input name="naam" size="30" type="text"><\/td>\r\n    <\/tr>\r\n    <tr> \r\n      <td valign="top">E-mailadres: <\/td>\r\n      <td valign="top"><input name="email" size="30" type="text"><\/td>\r\n    <\/tr>\r\n    <tr> \r\n      <td valign="top"> <\/td>\r\n      <td valign="top"><input type="submit" name="Submit" value="Ik wil ook afvallen >>" \/><\/td>\r\n    <\/tr>\r\n  <\/table>\r\n\r\n<\/td><\/tr><\/table>\r\n<\/form>\r\n');