document.write('<meta http-equiv="Content-Type" content="text/html; charset=us-ascii">' + 
'' + 
'<form name="maternitycardform" action="http://ahco.ardentra.com/import/importRedirect.asp" method="POST" id="maternityform">' + 
'<table cellpadding="4" cellspacing="0" class="style4">' + 
'	<tr>' + 
'		<td align="right">&nbsp;<a href="https://www.maternityadvantage.com/checkout/login.asp"><img src="http://maternityadvantage.com/img/cart.jpg" width="15" height="15" border="0" /></a> ' + 
'		|' + 
'		<a href="https://www.ahco.biz/members/index.cfm?id=11714" target="_blank">' + 
'		member login </a></td>' + 
'	</tr>' + 
'	<tr>' + 
'		<td><a href="http://www.maternityadvantage.com">' + 
'		<img src="http://maternityadvantage.com/img/maternitylogo2.jpg" alt="Maternity Advantage Logo" width="252" height="49" border="0" title="Maternity Advantage Logo" /></a></td>' + 
'	</tr>' + 
'	<tr>' + 
'		<td>' + 
'		<img src="http://maternityadvantage.com/img/graphicbordertext1.jpg" alt="Maternity Advantage" width="700" height="100" border="0" /></td>' + 
'	</tr>' + 
'	<tr>' + 
'		<td>' + 
'		<table cellpadding="4" cellspacing="0" class="style1">' + 
'			<tr>' + 
'				<td style="width: 213px">&nbsp;</td>' + 
'				<td><span class="maintext14"><strong>Pregnant? No Insurance?' + 
'				</strong></span></td>' + 
'			</tr>' + 
'			<tr>' + 
'				<td style="width: 213px">' + 
'				<ul>' + 
'					<li><span class="bullet">We can work with the doctor of your choice<br>' + 
'					&nbsp;</span></li>' + 
'					<li><span class="bullet">Hospital<br>' + 
'					&nbsp;</span></li>' + 
'					<li><span class="bullet">Extremely Affordable Lab Referrals<br>' + 
'					&nbsp;</span></li>' + 
'					<li><span class="bullet">Sonograms ' + 
'					<br>' + 
'					&nbsp;</span></li>' + 
'					<li><span class="bullet">Prescription Assistance</span> <br>' + 
'					&nbsp;<br />' + 
'					</li>' + 
'					<li><span class="bullet">Advocacy<br>' + 
'					&nbsp;</span></li>' + 
'					<li><span class="bullet">Financial Solutions <br>' + 
'					&nbsp;</span></li>' + 
'				</ul>' + 
'				</td>' + 
'				<td><span class="maintext14">' + 
'				<table width="400" height="100%" border="0" align="left" cellpadding="0" cellspacing="0" class="maintext">' + 
'					<tr>' + 
'						<td>' + 
'						<p class="maintext12">' + 
'						<span class="maintext12" class="maintext14">Maternity ' + 
'						Advantage can help make your pregnancy affordable.</span></p>' + 
'						<span class="maintext14"></span>' + 
'						<p class="maintext12">' + 
'						<span class="maintext12" class="maintext14">For an ' + 
'						overview and immediate information: </span></p>' + 
'						<span class="maintext14">' + 
'						<p class="maintext12">' + 
'						<span class="maintext12" class="maintext14">Name:<span class="required">' + 
'						</span>' + 
'						<input type="text" name="firstName" size="10" value="First Name" style="background: #FFFF99; color: #000000" />' + 
'						<input type="text" name="lastName" size="10" value="Last Name" style="background: #FFFF99; color: #000000" />' + 
'						</span><span class="maintext14">' + 
'						<span class="maintext12" class="maintext14">(required)</span></span></p>' + 
'						<p class="maintext12">' + 
'						<span class="maintext12" class="maintext14">Phone: (<input name="homeArea" type="text" size="3" maxlength="3" style="background: #FFFF99; color: #000000; width: 3em;" />)' + 
'						<input name="homePre" type="text" size="3" maxlength="3" style="background: #FFFF99; color: #000000; width: 3em;" /> ' + 
'						-' + 
'						<input name="homeEnd" type="text" size="4" maxlength="4" style="background: #FFFF99; color: #000000; width: 4em;" /> ' + 
'						(required)</span></p>' + 
'						<p><span class="maintext14"><span class="maintext12">' + 
'						E-mail:' + 
'						<input type="text" name="email" size="20" style="background: #FFFF99; color: #000000" />' + 
'						</span>' + 
'						<span class="maintext12" class="maintext14">(required)</span><span class="maintext12"><br />' + 
'						</span></span></p>' + 
'						<div align="left">' + 
'							<table width="100%" border="0" align="center" cellpadding="0" cellspacing="0">' + 
'								<tr align="left" valign="top">' + 
'									<td width="24%">' + 
'									<input name="formname" type="hidden" id="formname" value="enrollb" />' + 
'									</td>' + 
'									<td width="43%">' + 
'									<div align="center">' + 
'										<span class="maintext12">' + 
'										<span class="bottomnav">' + 
'										<a href="http://maternityadvantage.com/reuse/privacypolicy.asp">' + 
'										We respect your privacy</a></span>' + 
'										</span><br />' + 
'										<input type="image" src="http://maternityadvantage.com/img/submitpink.jpg" align="top" width="75" height="40" />' + 
'									</div>' + 
'									</td>' + 
'									<td width="33%">&nbsp;</td>' + 
'								</tr>' + 
'							</table>' + 
'						</div>' + 
'						<input type="hidden" name="customerID" value="1" />' + 
'						<input type="hidden" name="sourceID" value="466" />' + 
'						<input type="hidden" name="typeID" value="1" />' + 
'						<input type="hidden" name="referral" value="11714" />' + 
'						<input type="hidden" name="redirect" value="ahcodirect.com/11714/" />' + 
'						</span></td>' + 
'					</tr>' + 
'				</table>' + 
'				</span></td>' + 
'			</tr>' + 
'		</table>' + 
'		</td>' + 
'	</tr>' + 
'	<tr>' + 
'		<td align="center">' + 
'		<img src="http://maternityadvantage.com/img/form2_logos.jpg" width="504" height="55" /></td>' + 
'	</tr>' + 
'	<tr>' + 
'		<td align="center">&copy; 2007 Maternity Advantage. All rights reserved |' + 
'		<a href="http://maternityadvantage.com/privacypolicy.asp">Privacy Policy</a></td>' + 
'	</tr>' + 
'</table>' + 
'</form>' + 
'' + 
'' + 
'')