document.write("<form method=\"post\" action=\"https://ymlp.com/subscribe.php?id=gmjeejwgmgq\"><table border=\"0\" align=\"center\" cellspacing=\"0\" cellpadding=\"5\">\n<tr><td colspan=\"2\"><font size=\"2\" face=\"verdana,geneva\">Veuillez saisir votre adresse e-mail<br />pour recevoir notre newsletter!</font></td></tr>\n<tr><td valign=\"top\"><font size=\"2\" face=\"verdana,geneva\">Adresse e-mail:</font></td><td valign=\"top\"><input type=\"text\" name=\"YMP0\" size=\"20\" /></td></tr>\n<tr><td valign=\"top\"><font size=\"2\" face=\"verdana,geneva\">nom:</font></td><td valign=\"top\"><input type=\"text\" name=\"YMP1\" size=\"20\" /></td></tr>\n<tr><td valign=\"top\"><font size=\"2\" face=\"verdana,geneva\">prénom:</font></td><td valign=\"top\"><input type=\"text\" name=\"YMP2\" size=\"20\" /></td></tr>\n<tr><td colspan=\"2\"><input type=\"submit\" value=\"Envoyer\"  />&nbsp;</td></tr>\n<tr><td colspan=\"2\"><img src=\"http://chiclet.ymlp.com/chiclet_gmjeejwgmgqzjc.png?id=201109081434234\"></td></tr>\n</table>\n</form>\n");