function sendForm(form) {
	if (form.policy.checked == false) {
		alert('Please indicate that you have read the policy by checking the box.');
		return false;
	} else {
		return confirm('Is all information correct?\n\nHit OK to submit or CANCEL to make changes.');
	}
}

document.writeln('');
document.writeln('<form method="POST" action="/cgi-bin/moneymn/FormB/swiss_annuity.cgi" onsubmit="return sendForm(this)">');
document.writeln('<INPUT TYPE="HIDDEN" NAME="subject" 	VALUE="Request for Swiss Annuity Booklet">');
document.writeln('<INPUT TYPE="HIDDEN" NAME="ok_url" 	VALUE="http://moneymanagementradio.com/swiss_annuity_thanks">');
document.writeln('<INPUT TYPE="HIDDEN" NAME="required" 	VALUE="name,submit_by,address1,city,state,zip">');
document.writeln('<INPUT TYPE="HIDDEN" NAME="data_order" 	VALUE="name,submit_by,address1,address2,city,state,zip,Origin">');
document.writeln('<INPUT TYPE="HIDDEN" NAME="submit_to" 	VALUE="info">');
document.writeln('<input type="hidden" name="Origin" value="This is a Money Matters, Marc Cuniberti inquiry - please note as such. Please mail a Swiss Annuity Booklet to this person.">');
document.writeln('');
document.writeln('');
document.writeln('<table border="0" cellpadding="3" cellspacing="0" style="border-collapse: collapse" bordercolor="#111111" id="AutoNumber1">');
document.writeln('  <tr>');
document.writeln('    <td align="right">Name:</td>');
document.writeln('    <td><input type="text" name="name" size="20"></td>');
document.writeln('  </tr>');
document.writeln('  <tr>');
document.writeln('    <td align="right">Email:</td>');
document.writeln('    <td><input type="text" name="submit_by" size="20"></td>');
document.writeln('  </tr>');
document.writeln('  <tr>');
document.writeln('    <td align="right">Address1:</td>');
document.writeln('    <td><input type="text" name="address1" size="20"></td>');
document.writeln('  </tr>');
document.writeln('  <tr>');
document.writeln('    <td align="right">Address2:</td>');
document.writeln('    <td><input type="text" name="address2" size="20"></td>');
document.writeln('  </tr>');
document.writeln('  <tr>');
document.writeln('    <td align="right">City:</td>');
document.writeln('    <td><input type="text" name="city" size="20"></td>');
document.writeln('  </tr>');
document.writeln('  <tr>');
document.writeln('    <td align="right">State:</td>');
document.writeln('    <td><input type="text" name="state" size="20"></td>');
document.writeln('  </tr>');
document.writeln('  <tr>');
document.writeln('    <td align="right">Zip:</td>');
document.writeln('    <td><input type="text" name="zip" size="20"></td>');
document.writeln('  </tr>');
document.writeln('  <tr>');
document.writeln('    <td align="right" colspan="2">');
document.writeln('<input type="checkbox" value="ON" name="policy"> ');
document.writeln('I have read the <a href="/policy">Privacy Policy</a>');
document.writeln('</td>');
document.writeln('  </tr>');
document.writeln('  <tr>');
document.writeln('    <td align="right" colspan="2">');
document.writeln('    <p align="center"><input type="submit" value="Submit"></td>');
document.writeln('  </tr>');
document.writeln('</table>');
document.writeln('</form>  ');
document.writeln('  ');