document.write('<script language="javascript">function clear_form() { document.execute.reset(); }</script>');
document.write('<form action="http://www.yourwebreviewed.com/saveTest.php" method="post" name="execute" target="_blank" OnSubmit="setTimeout(\'clear_form()\', 200); return true">');
document.write('  <table width="53%" border="0" align="center" cellpadding="4" cellspacing="0">');
document.write('    <tr align="center">');
document.write('      <td colspan="2"><h5>Add your testimonial to our website</h5></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td width="31%" align="right" valign="top">Your Comment:</td>');
document.write('      <td width="69%"><textarea name="comment" cols="40" rows="6" id="comment"></textarea></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="right" valign="top">Your Name:</td>');
document.write('      <td valign="top"><input name="name" type="text" id="name" size="45"></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="right" valign="top">Where are you from?:</td>');
document.write('      <td valign="top"><input name="from" type="text" id="from" size="45"></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="right" valign="top">Confirmation:</td>');
document.write('      <td valign="top"><font size="1">By submitting this form you give full authorization to use any of the information entered into the "Your Comment" area above on our website or within promotional print items.  We may however, wish to contact you for further confirmation.  Please supply either a phone number or e-mail address below for contact reasons only.  The contact information will not be used or displayed on our website.</font><br><input name="contact" type="text" id="contact" size="45"></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="right" valign="top">&nbsp;</td>');
document.write('      <td valign="top">');
document.write('	  <input type="hidden" name="owner" value="15" />');
document.write('	  <input type="hidden" name="url" value="www.pro-heating.com" />');
document.write('	  <input type="submit" name="Submit" value="Save Testimonial"></td>');
document.write('    </tr>');
document.write('  </table>');
document.write('</form>');