document.write('<form method="get" name="camerarepairform" onsubmit="d(\'submit_btn\').style.display=\'none\'; loadimage(\'_\' + \'form_forward.asp?contact_name=\' + d(\'contact_name\').value + \'&amp;email=\' + d(\'email_address\').value + \'&amp;telephone=\' + d(\'telephone_number\').value + \'&amp;camera_make=\' + d(\'camera_make\').value + \'&amp;camera_model=\' + d(\'camera_model\').value + \'&amp;serial_no=\' + d(\'serial_no\').value + \'&amp;fault=\' + d(\'fault_details\').value + \'&amp;dest=\' + d(\'dest\').value + \'&amp;domain=\' + d(\'domain\').value,\'repair\'); return false;"><div style="float: left; margin-right: 12px"><p><label for="contact_name">Contact name:</label><br /><input id="contact_name" name="contact_name" type="text" /></p><p><label for="email_address">Email address:</label><br /><input id="email_address" name="email_address" type="text" /></p><p><label for="telephone_number">Telephone number:</label><br /><input id="telephone_number" name="telephone_number" type="text" /></p> <p><label for="camera_make">Make of camera:</label><br /><input id="camera_make" name="camera_make" type="text" /></p><p><label for="camera_model">Model no.:</label><br /><input id="camera_model" name="camera_model" type="text" /></p><p><label for="serial_no">Camera serial no.:</label><br /><input id="serial_no" name="serial_no" type="text" /></p></div><div><p><label for="fault_details">Fault details:</label><br /><textarea id="fault_details" rows="16" cols="30" name="fault_details"></textarea></p></div><div style="clear: both;"><input id="submit_btn" type="submit" value="request repair quote" /><input type="hidden" name="domain" id="domain" value="digitalcamerarepair.com.au"><input type="hidden" id="dest" name="dest" value="enquiries@phototech.com.au"></div></form>');