document.write("<form method=\"post\" action=\"https://ymlp.com/subscribe.php?id=gwsssjhgmgj\">\n<table border=\"0\" align=\"center\" cellspacing=\"0\" cellpadding=\"5\">\n<tr><td colspan=\"2\"><font size=\"2\" face=\"verdana,geneva\">Fill out your e-mail address<br />to receive our 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 valign=\"top\"><font size=\"2\" face=\"verdana,geneva\">Skin Type:</font></td><td valign=\"top\"><input type=\"checkbox\" name=\"YMP2[0]\" value=\"Normal\" />Normal<br /><input type=\"checkbox\" name=\"YMP2[1]\" value=\"Dry\" />Dry<br /><input type=\"checkbox\" name=\"YMP2[2]\" value=\"Sensitive\" />Sensitive<br /><input type=\"checkbox\" name=\"YMP2[3]\" value=\"Aging\" />Aging<br /><input type=\"checkbox\" name=\"YMP2[4]\" value=\"Oily\" />Oily<br /><input type=\"checkbox\" name=\"YMP2[5]\" value=\"Combination\" />Combination<br /><input type=\"checkbox\" name=\"YMP2[6]\" value=\"Pigmentation\" />Pigmentation<br /></td></tr>\n<tr><td colspan=\"2\"><font size=\"2\" face=\"verdana,geneva\">Select your interest:</font></td></tr>\n<tr><td colspan=\"2\"><select name=\"intrests\"><option value=\"CAT1\">All Age</option><option value=\"CAT3\">20s</option><option value=\"CAT5\">30s</option><option value=\"CAT7\">40s</option><option value=\"CAT8\">50s</option><option value=\"CAT9\">60s+</option></select></td></tr>\n<tr><td colspan=\"2\"><input type=\"submit\" value=\"Submit\"  />&nbsp;</td></tr>\n<tr><td colspan=\"2\"><img src=\"http://chiclet.ymlp.com/chiclet_gwsssjhgmgjobg.png?id=2015102920092824\"></td></tr>\n</table>\n</form>\n");