document.write('<form action="/app/newsletter/subscribe/confirm/default" method="post" id="subscribe">Your Name: <input type="text" name="first_name" value="" class="txt" onfocus="this.value=\'\'" />&nbsp;&nbsp;&nbsp;Your Email: <input type="text" name="subscriber_email" value="" class="txt" onfocus="this.value=\'\'" />&nbsp;&nbsp;&nbsp;<input type="submit" value="Subscribe" id="validateSelects" /></form>');