document.write('<form action="http://juc.mailbroadcasting.com/fb.php" method="post">');
document.write('<input type="hidden" name="id" value="1" />');
document.write('<input type="hidden" name="action" value="fb" />');
document.write('<input type="hidden" name="submit" value="true" />');

document.write('<h2>CCMT Maillists Subscription Form</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_field" style="line-height:28px;">');
document.write('<label><input type="checkbox" name="mailingListId[1]" value="1" checked="checked" />Jami\'yyatul Ulama Canada (CCMT) Mail-List</label>');
document.write('</div>');
document.write('<div class="fb_field" style="line-height:28px;">');
document.write('<label><input type="checkbox" name="mailingListId[5]" value="5" checked="checked" />Halal Monitoring Authority (HMA) Mail-List</label>');
document.write('</div>');
document.write('<div class="fb_field" style="line-height:28px;">');
document.write('<label><input type="checkbox" name="mailingListId[6]" value="6" checked="checked" />Darul Iftaa of CCMT Mail-List</label>');
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>');