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document.writeln('		<form method="post" name="form1" enctype="multipart/form-data" action="http://www.onepuntacaracol.com/request_form">');
document.writeln('<input type="hidden" name="referer" value="http://www.onepuntacaracol.com/request_info" />');
document.writeln('<input type="hidden" name="form__current_page" value="1" />		<table id="sitemason_hAPa9y" class="sitemason_form" border="0" cellspacing="0" cellpadding="0">			<tr>');
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document.writeln('		');
document.writeln('		<div>');
document.writeln('  <div class="sitemason_body" style="float:left; ">');
document.writeln('    <div style="text-align:left; width:150px; float:left;">');
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document.writeln('      <select name="state">');
document.writeln('        <option value="">Select a State</option>');
document.writeln('        <option value="AL">Alabama</option>');
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document.writeln('        <option value="CA">California</option>');
document.writeln('        <option value="CO">Colorado</option>');
document.writeln('        <option value="CT">Connecticut</option>');
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document.writeln('        <option value="GA">Georgia</option>');
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document.writeln('        <option value="IA">Iowa</option>');
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document.writeln('        <option value="MN">Minnesota</option>');
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document.writeln('        <option value="NM">New Mexico</option>');
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document.writeln('        <option value="NC">North Carolina</option>');
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document.writeln('        <option value="TX">Texas</option>');
document.writeln('        <option value="UT">Utah</option>');
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document.writeln('        <option value="WI">Wisconsin</option>');
document.writeln('        <option value="WY">Wyoming</option>');
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document.writeln('        <option value="FM">Federated States Of Micronesia</option>');
document.writeln('        <option value="GU">Guam</option>');
document.writeln('        <option value="MH">Marshall Islands</option>');
document.writeln('        <option value="MP">Northern Mariana Islands</option>');
document.writeln('        <option value="PW">Palau</option>');
document.writeln('        <option value="PR">Puerto Rico</option>');
document.writeln('        <option value="VI">Virgin Islands</option>');
document.writeln('        <option value="AE">Armed Forces Africa</option>');
document.writeln('        <option value="AA">Armed Forces Americas</option>');
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document.writeln('  <br clear="all" />');
document.writeln('  <div class="sitemason_body" style="float:left; ">');
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document.writeln('        <option value="5">5</option>');
document.writeln('        <option value="6">6</option>');
document.writeln('        <option value="7">7</option>');
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document.writeln('        <option value="9">9</option>');
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document.writeln('      <label class="label" for="1st_date">Date of Stay (1st choice)</label>');
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document.writeln('      <input type="text" style="width:200px; " name="1st_date" />');
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document.writeln('      <label class="label" for="2nd_date">Date of Stay (2nd choice)</label>');
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document.writeln('  <br clear="all" />');
document.writeln('  <div class="sitemason_body" style="float:left; ">');
document.writeln('    <div style="text-align:left; width:150px; float:left;">');
document.writeln('      <label class="label" for="comments">Questions/Comments:</label>');
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document.writeln('      <textarea rows="6" style="width:200px; " name="comments"></textarea>');
document.writeln('    </div>');
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document.writeln('  <br clear="all" />');
document.writeln('  <div class="sitemason_body" align="center" style="text-align:center; ">');
document.writeln('    <input type="submit" name="submit" value="Submit" />');
document.writeln('  </div>');
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document.writeln('</div>');
document.writeln('');
document.writeln('				</td>');
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