document.write("\n

\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n

First Name:	Last Name:
E-mail address:	Phone:
Age:	Location:
\n I hereby give my consent to receiving personalised messaging and online advertising by email or any other equivalent medium \n \n I hereby agree with the Privacy Policy \n

\n

");