document.write("<form method=\"post\" action=\"https://ymlp.com/subscribe.php?id=gmqjhsjgmguu\">\n<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\">E-mail address:</font></td><td valign=\"top\"><input type=\"text\" name=\"YMP0\" size=\"20\" /></td></tr>\n<tr><td colspan=\"2\"><font size=\"2\" face=\"verdana,geneva\">Sélectionnez votre centre d\'intérêt:</font></td></tr>\n<tr><td colspan=\"2\"><select name=\"intrests\"><option value=\"CAT74\">Jeunes MLT</option><option value=\"CAT83\">Entreprises MLT</option></select></td></tr>\n<td colspan=\"2\"><input type=\"radio\" name=\"action\" value=\"subscribe\" checked /> <font size=\"2\" face=\"verdana,geneva\">S\'abonner</font><input type=\"radio\" name=\"action\" value=\"unsubscribe\" /> <font size=\"2\" face=\"verdana,geneva\">Se désabonner</font></td><tr><td colspan=\"2\"><input type=\"submit\" value=\"Envoyer\"  />&nbsp;</td></tr>\n</table>\n</form>\n");