document.write('<form name="tfwdgt" action="http://app1.talkfusion.com/fusion2/widget_thankyou.asp" method="post" target="_blank">');
document.write('<input type="hidden" name="id" value="16102_813">');
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document.write('<div style="background:url(http://app1.talkfusion.com/fusion2/img/webform_title.png) repeat-x bottom #1079BB; padding:15px 10px; color: #ffffff; font:bold 16px Arial, Helvetica, sans-serif; text-align:center">');
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document.write('<div style="font:normal 12px arial, helvetica, sans serif; background-color: #FFFFFF; padding:10px 15px; color: #0A3855">');
document.write('Your Name:<br /><input type="text" name="gstname" style="margin:4px 0px; width:98%"><br>');
document.write('Your Email:<br /> <input type="text" name="gstemail" style="margin:4px 0px; width:98%"><br>');
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document.write('</div></div></form>');