document.write('<form action="http://www.instructor.com.au/emails/fb.php" method="post">');
document.write('<input type="hidden" name="id" value="4" />');
document.write('<input type="hidden" name="action" value="fb" />');
document.write('<input type="hidden" name="submit" value="true" />');

document.write('<h2>Subscribe</h2>');

document.write('<div class="fb_label">');
document.write('Email:');
document.write('</div>');
document.write('<div class="fb_field">');
document.write('<input type="text" name="email" size="30" maxlength="80" value="" />');
document.write('</div>');

document.write('<div class="fb_label">');
document.write('First Name*:');
document.write('</div>');
document.write('<div class="fb_field">');
document.write('<input type="text" name="customFieldData[1]" size="20" maxlength="20" value="" />');
document.write('</div>');
document.write('<div class="fb_label">');
document.write('Surname*:');
document.write('</div>');
document.write('<div class="fb_field">');
document.write('<input type="text" name="customFieldData[2]" size="20" maxlength="20" value="" />');
document.write('</div>');
document.write('<div class="fb_label">');
document.write('Mobile phone:');
document.write('</div>');
document.write('<div class="fb_field">');
document.write('<input type="text" name="customFieldData[4]" size="10" maxlength="10" value="" />');
document.write('</div>');



document.write('<div class="fb_label">');
document.write('&nbsp;</div>');
document.write('<div class="fb_field">');
document.write('<input type="submit" value="Submit" />');
document.write('</div>');
document.write('</form>');