document.write("<TABLE border=0><tr><td>")

document.write("<form method='GET' action='http://www.netdoc.com/index.php'>")
document.write("<input type='hidden' name='option' value='com_gmaps' />")
document.write("<input type='hidden' name='task' value='viewmap' />")
document.write("<input type='hidden' name='mapId' value='20081' />")
document.write("<input type='hidden' name='Itemid' value='141' />")
document.write("Zip Code: <input type='text' name='zip' value=''/>")
document.write(" Within: <select name='distance'>")
document.write("			<option value='5' >5 miles</option>")
document.write("			<option value='10' >10 miles</option>")
document.write("			<option value='25' selected='selected'>25 miles</option>")
document.write("			<option value='50' >50 miles</option>")
document.write("			<option value='75' >75 miles</option>")
document.write("			<option value='100' >100 miles</option>")
document.write("			</select>")
document.write(" <input type='submit' name='submit' value='submit' />")
document.write("</form>")

document.write("</td></tr></table>")