document.write('<form action="https://www.fundingway.com/ace/app_zip2.php" method="post" name="zipselect">');
document.write('<table style="background-color: transparent;" width="95%" border="0" cellspacing="0" cellpadding="2">');
document.write('<tr>');
document.write('<td width="43%" align="right">Name :&nbsp; </td>');
document.write('<td width="57%"><input name="firstname" type="text" id="firstname" size="20" style="width:100px;"></td></tr>');
document.write('<tr><td width="43%" align="right">Middle :&nbsp; </td>');
document.write('<td align="left"><input name="mi" type="text" id="mi" size="1" maxlength="1"></td>');
document.write('</tr>');
document.write('<tr><td align="right">Last :&nbsp;</td>');
document.write('<td><input name="lastname" type="text" id="lastname" size="25" style="width:100px;"></td>');
document.write('</tr>');
document.write('<tr><td align="right">Email :&nbsp;</td><td><input name="email" type="text" id="email" size="25" style="width:100px;"></td>');
document.write('</tr>');
document.write('<tr><td align="right">ZipCode:</td><td align="left"><input name="app_refererurl" type="hidden" id="app_refererurl" value="">');
document.write('<input type="hidden" name="app_aff_id" value="ap00316"/>');
document.write('<input type="hidden" name="aff_sub_id" value="home"/>');
document.write('<input name="zip_zipcode" type="text" id="zip_zipcode" size="6" maxlength="5"></td>');
document.write('</tr>');
document.write('<tr>');
document.write('<td colspan="2" align="center"><input type="image" src="images/apply.gif" name="Submit" value="Submit"></td>');
document.write('</tr></table></form>');