document.write("<title>Contact Us</title>\n");
document.write("Fill out the following information and click 'Submit'. All fields are required.<br />\n");
document.write("<scr"+"ipt language=javascr"+"ipt>\n");
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document.write("<form  method=POST action=\"http://www.unemploymentor.com/forms/csFormbuilder.cgi\" name=\"form_1\"  >\n");
document.write("<input type=hidden name=form-id value=\"1\">\n");
document.write("<input type=hidden name=command value=\"mailform\">\n");
document.write("<link rel=\"stylesheet\" type=\"text/css\" href=\"http://www.unemploymentor.com/forms/forms/Contact.css\">\n");
document.write("<table border=\"0\" cellspacing=\"0\" cellpadding=\"3\">\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"right\" >*Your name:</td><td align=left valign=top nowrap class=\"textLabel\"><input  onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"name\"  > <!-- tr ph 0--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"right\" >*Email:</td><td align=left valign=top nowrap class=\"textLabel\"><input  onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Email\"  > <!-- tr ph 1--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"right\" >*Subject:</td><td align=left valign=top nowrap class=\"textLabel\"><textarea  onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" name=\"subject\"  rows=\"5\" cols=\"50\"  ></textarea>   <!-- tr ph 2--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"right\" >Verify Authentication Code:</td><td align=left valign=top nowrap class=\"textLabel\"><img id=\"Verification_img\" align=absmiddle border=0 width=59 height=15 src=\"\"><input type=hidden id=\"Verification_sid\" name=\"Verification_sid\" value=\"\"> <scr"+"ipt language=javascr"+"ipt src=\"http://www.unemploymentor.com/forms/vimage.cgi?command=g&f=Verification\"></scr"+"ipt>&nbsp;<input  onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Verification\"  > <!-- tr ph 3--></td></tr>\n");
document.write("<tr><td colspan=2 align=\"left\"><input onmouseover=\"className='buttonfieldFocus'\" onmouseout=\"className='buttonfield'\" class=\"buttonfield\" type=button value=\"Back\" onClick=\"history.back();\"><input onmouseover=\"className='buttonfieldFocus'\" onmouseout=\"className='buttonfield'\" class=\"buttonfield\" type=submit value=\"Submit\"></td></tr>\n");
document.write("</table>\n");
document.write("</form>\n");