document.writeln("<form action=\"https://www.whitefence.com/WebObjects/WhiteFence.woa/wa/selfRegister\" method=\"POST\" name=\"selfReg\" class=\"widget\">");
document.writeln("<input name=\"scKey\" type=\"radio\" value=\"bundleMyServices\" checked=\"checked\"/> Bundles");
document.writeln("<input name=\"scKey\" type=\"radio\" value=\"highSpeedInternetAccess\"/> Internet");
document.writeln("<input name=\"scKey\" type=\"radio\" value=\"cableSatellite\"/> Television");
document.writeln("<input name=\"scKey\" type=\"radio\" value=\"localPhone\"/> Phone");
document.writeln("<input name=\"scKey\" type=\"radio\" value=\"electricity\"/> Electricity");
document.writeln("<script language=\"JavaScript\" type=\"text/javascript\" src=\"http://www.whitefence.com/addy/scripts/addyajax.js\"></script>");
document.writeln("<div class=\"widget-street\">Street Address:<br><input id=\"streetAddress\" name=\"streetAddress\" class=\"widget-streetaddress\" tabindex=\"1\"></div>");
document.writeln("<div class=\"widget-apt\">Apt/Suite:<br><input id=\"apartmentNumber\" name=\"apartmentNumber\" class=\"widget-apt\" tabindex=\"2\"></div>");
document.writeln("<div class=\"widget-zip\">Zip Code:<br><input id=\"zipcode\" name=\"zipcode\" class=\"widget-zip\" tabindex=\"3\" onkeyup=\"javascript:ZipCheck();\"></div>");
document.writeln("<input id=\"Submit\" type=\"image\" src=\"http://www.whitefence.com/qsrimages/ucb/button.gif\" tabindex=\"6\" value=\"Submit\" name=\"Submit\" class=\"widget-go\">");
document.writeln("<input type=\"hidden\" name=\"city\">");
document.writeln("<input type=\"hidden\" name=\"state\">");
document.writeln("<input type=\"hidden\" name=\"bpID\" value=\"1076497\">");
document.writeln("<input type=\"hidden\" name=\"eID\" value=\"1076998\">");
document.writeln("</form>");