/* Callback Request Form */
document.write('<div class="callbackbox"><div class="innerbox"><h4>Request a Call Back</h4>');
document.write('Fill out the form below and we will give you a call back at the time you indicate is most convenient.');
document.write('<form name="CallBack" method="get" action="http://www.insolvencynetwork.co.uk/cgi-bin/GetMail.pl">');
document.write('<table width="500px" border="0px" cellspacing="0px" cellpadding="0px"><tr>');
document.write('<td class="formcolumn"><span class="formlabel">Name</span><br /><input name="Name" type="text" size="30"></td>');
document.write('<td class="formcolumn"><span class="formlabel">Contact Number</span><br /><input name="Number" type="text" size="30"></td>');
document.write('</tr><tr><td class="formcolumn"><span class="formlabel">Time to Call</span><br /><select name="TimeToCall">');
document.write('<option value="none" selected="selected">Please select...</option>');
document.write('<option value="Weekday Morning">Weekday Morning</option>');
document.write('<option value="Weekday Afternoon">Weekday Afternoon</option>');
document.write('<option value="Weekday Evening">Weekday Evening</option>');
document.write('<option value="Weekend Morning">Weekend Morning</option>');
document.write('<option value="Weekend Afternoon">Weekend Afternoon</option>');
document.write('</select></td><td class="formcolumn"><span class="formlabel">Total Debt</span><br /><select name="TotalDebt">');
document.write('<option value="none" selected="selected">Please select...</option>');
document.write('<option value="Under 5k">Under &pound;5,000</option>');
document.write('<option value="5k-10k">&pound;5,000 - &pound;10,000</option>');
document.write('<option value="10k-20k">&pound;10,000 - &pound;20,000</option>');
document.write('<option value="Over 20k">Over &pound;20,000</option>');
document.write('</select></td></tr><tr><td colspan="2" class="formcolumn">');
document.write('<input type="submit" class="submitbutton" value="Send Request"></td>');
document.write('</tr></table></form></div></div>');