document.writeln("<form action=\"scripts/contact.php\" method=\"post\" id=\"form1\">");
document.writeln("<table border=\"0\" cellspacing=\"0\" cellpadding=\"0\" height=\"275\" class=\"formtext\">");
document.writeln("<tr>");
document.writeln("	<td>Name:<br /><input name=\"name_from\" type=\"text\" id=\"name_from\" /></td>");
document.writeln("</tr>");
document.writeln("<tr>");
document.writeln("	<td>Phone Number:<br /><input name=\"phone\" type=\"text\" id=\"phone\" maxlength=\"17\" /></td>");
document.writeln("</tr>");
document.writeln("<tr>");
document.writeln("	<td>Best Time to Call:<br /><input name=\"time\" type=\"text\" id=\"time\" /></td>");
document.writeln("</tr>");
document.writeln("<tr>");
document.writeln("	<td>Email:<br /><input name=\"email_from\" type=\"text\" id=\"email_from\" /></td>");
document.writeln("</tr>");
document.writeln("<tr>");
document.writeln("	<td>Case Details:<br /><textarea name=\"details\" cols=\"15\" rows=\"2\" id=\"details\"></textarea></td>");
document.writeln("</tr>");
document.writeln("<tr>");
document.writeln("<td align=\"center\">Security Code:<br /><input name=\"security_code\" type=\"text\" class=\"required\" id=\"security_code\" size=\"10\" />");
document.writeln("  <br />");
document.writeln("  <img src=\"scripts/captcha-image.php\" alt=\"Security Image\" name=\"captcha\" width=\"120\" height=\"40\" border=\"1\" id=\"captcha\" /></td>");
document.writeln("</tr>");
document.writeln("<tr><td align=\"center\"><input type=\"submit\" value=\"Submit\" class=\"submit\" /></td></tr>");
document.writeln("</table>       ");
document.writeln("</form>");
document.writeln("<p>&nbsp;</p><br />");
document.writeln("<a href=\"http://maps.google.com/maps?f=q&hl=en&geocode=&q=4835+East+Cactus+Road,+Suite+310&sll=33.59707,-111.97624&sspn=0.012475,0.028667&ie=UTF8&ll=33.59707,-111.97624&spn=0.012475,0.028667&z=16&iwloc=addr\"><img src=\"images/map.jpg\" alt=\"\" /></a>");