document.write('
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  1. [response]
  2.  
  3. <p>Name:<br />
  4. [text srf_name /50 id:srf_name tabindex:2]</p>
  5.  
  6. <p>Company:<br />
  7. [text srf_company /50 id:srf_company tabindex:3]</p>
  8.  
  9. <p style="margin-bottom: 0">Phone:</p>
  10. <table class="table" id="sr_form_phone" >
  11.     <tr class="rowa">
  12.         <td class="col1 cell">&#40;[text srf_area_code 2/3 id:srf_area_code tabindex:4]&#41;</td>
  13.         <td class="col2 cell"></td>
  14.         <td class="col3 cell">[text srf_phone_prefix 2/3 id:srf_phone_prefix tabindex:5]</td>
  15.                 <td class="col4 cell">-</td>
  16.                 <td class="col5 cell">[text srf_phone 4/4 id:srf_phone tabindex:6]</td>
  17.     </tr>
  18.     <tr class="rowb">
  19.         <td class="col1 cell">area code</td>
  20.         <td class="col2 cell"></td>
  21.         <td class="col3 cell">phone</td>
  22.                 <td class="col4 cell"></td>
  23.                 <td class="col5 cell"></td>
  24.     </tr>
  25.  </table>
  26.  
  27. <div class="clear"></div>
  28.  
  29. <p style="margin: 10px 0 -22px 0">Type of Service Needed:</p>
  30. [select srf_type_of_service tabindex:7 id:srf_type_of_service "Service1" "Service2" "Service3" "Other"]
  31.  
  32. <p style="margin: 10px 0 -22px 0">Contact Me:</p>
  33. [select srf_time_frame tabindex:8 id:srf_time_frame "1 Day" "1 Week" "1 Month"]
  34.  
  35. <p>[submit id:srf_submit "Submit Request"]</p>
');