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document.write('<input type="hidden" name="id" value="2" />');
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document.write('<h2>Sign-up for our e-mail newsletter today!</h2>');

document.write('<div class="fb_label">');
document.write('Email:');
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document.write('<div class="fb_field">');
document.write('<input type="text" name="email" size="30" maxlength="80" value="" /><br /><br />');
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document.write('Check the lists you would like to be added to.  You can choose one or the other or both:<br/>Mailing List <input type="checkbox" name="mail_list" value="Mailing_List"> Email List <input type="checkbox" name="email_list" value="E-Mail_List"><br /><br /></div>');

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document.write('First Name*:');
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document.write('Last Name*:');
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document.write('Mailing Address:');
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document.write('Mailing City:');
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document.write('<input type="text" name="customFieldData[4]" size="50" maxlength="50" value="" /><br /><br />');
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document.write('State:');
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document.write('Zip:');
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document.write('Phone:');
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document.write('<input type="text" name="customFieldData[7]" size="15" maxlength="15" value="" /><br /><br />');
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document.write('Organization/Church:');
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document.write('<div class="fb_field" style="line-height:28px;">');
document.write('<label><input type="checkbox" name="mailingListId[1]" value="1" checked="checked" />Hopeline Mailing List</label>');
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