document.write('<div class="subform" style="text-align:center; width: 170px; border:1px solid; background: #EBEAE9; margin: auto;">')
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	  document.write('<input name="cm-name" id="name" type="text" size="20" maxlength="50"" />')
	document.write('</div>')
	document.write('<div>')
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	  document.write('<input type="text" name="cm-zukuk-zukuk" id="zukuk-zukuk" size="20" maxlength="50"" />')
	document.write('</div>')
	document.write('<div>')
	  document.write('<label for="zipcode" class="sublabel" style="width:60px;">ZipCode:</label><br />')
	  document.write('<input type="text" name="cm-f-khhdd" id="zipcode"size="10" />')
	document.write('</div>')
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	document.write('<input type="hidden" name="cm-f-khhdl" id="gp_id" value="1051"/>')
	document.write('<input type="hidden" name="cm-f-khhdr" id="gp_company" value="Island Fitness"/>')
	document.write('<input type="hidden" name="cm-f-khhdy" id="gp_address" value="5800 Padre Blvd Suite 201" />')
	document.write('<input type="hidden" name="cm-f-khhdj" id="gp_csz" value="South Padre Island, TX 78597" />')
	document.write('<input type="hidden" name="cm-f-khhdt" id="gp_phone" value="956-761-4220" />')
	document.write('<input type="hidden" name="cm-f-guhw" id="gp_logo" value="1051if_logo.jpg" />')
	document.write('<input type="hidden" name="cm-f-wjkz" id="gp_cbsa" value="15180" />')
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