document.write("<form method=\"post\" action=\"https://ymlp.com/subscribe.php?id=gusuuhbgmgs\">\n<table align=\"center\" border=\"0\" cellpadding=\"5\" cellspacing=\"0\">\n<tbody>\n<tr>\n<td><span style=\"font-family: verdana, geneva; font-size: 10pt;\">Vul uw gegevens in om onze nieuwsbrief te ontvangen:</span></td>\n</tr>\n<tr>\n<td valign=\"top\"><input size=\"20\" placeholder=\"E-mailadres\" name=\"YMP0\" type=\"text\" /></td>\n</tr>\n<tr>\n<td valign=\"top\"><input size=\"20\" placeholder=\"Naam\" name=\"YMP1\" type=\"text\" /></td>\n</tr>\n<tr>\n<td valign=\"top\"><input size=\"20\" placeholder=\"Voornaam\" name=\"YMP2\" type=\"text\" /></td>\n</tr>\n<tr>\n<td><input value=\"Verzenden\" type=\"submit\" />&nbsp;</td>\n</tr>\n</tbody>\n</table>\n</form>");