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document.writeln('					<tr>');
document.writeln('  <td>');
document.writeln('    <h1 class="sitemason_title"><font size="2" face="Verdana, Arial, Helvetica, sans-serif"><strong>New York Social Diary User Poll</strong></font></h1>');
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document.writeln('</tr>			<tr>');
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document.writeln('		');
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document.writeln('    <div style="text-align:left; width:150px; float:left;">');
document.writeln('      <label class="label" for="Sex">Sex:</label>');
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document.writeln('        <option value="Male">Male</option>');
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document.writeln('    <div style="text-align:left; width:150px; float:left;">');
document.writeln('      <label class="label" for="Age">Age:</label>');
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document.writeln('      <select name="Age">');
document.writeln('        <option value="18-25">18-25</option>');
document.writeln('        <option value="26-35">26-35</option>');
document.writeln('        <option value="36-45">36-45</option>');
document.writeln('        <option value="46-65">46-65</option>');
document.writeln('        <option value="66 &amp; over">66 & over</option>');
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document.writeln('    <div style="text-align:left; width:150px; float:left;">');
document.writeln('      <label class="label" for="Education">Education:</label>');
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document.writeln('      <select name="Education">');
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document.writeln('        <option value="College">College</option>');
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document.writeln('				&nbsp;<br>');
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document.writeln('    <div style="text-align:left; width:150px; float:left;">');
document.writeln('      <label class="label" for="status">Status:</label>');
document.writeln('    </div>');
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document.writeln('      <select name="status">');
document.writeln('        <option value="Single">Single</option>');
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document.writeln('        <option value="Domestic Partner">Domestic Partner</option>');
document.writeln('        <option value="Divorced">Divorced</option>');
document.writeln('        <option value="Widowed">Widowed</option>');
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document.writeln('      <label class="label" for="Children">Children</label>');
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document.writeln('      <select name="Children">');
document.writeln('        <option value="None">None</option>');
document.writeln('        <option value="1-2">1-2</option>');
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document.writeln('    <div style="text-align:left; width:150px; float:left;">');
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document.writeln('        <option value="0 - $30,000">0 - $30,000</option>');
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document.writeln('        <option value="$50,000 - $100,000">$50,000 - $100,000</option>');
document.writeln('        <option value="$100,000 - $250,000">$100,000 - $250,000</option>');
document.writeln('        <option value="$250,000 - $500,000">$250,000 - $500,000</option>');
document.writeln('        <option value="$500,000 - $999,000">$500,000 - $999,000</option>');
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document.writeln('  </div>');
document.writeln('  <br clear="all">');
document.writeln('  <div align="center" style="clear: both;" class="sitemason_body">');
document.writeln('				&nbsp;<br>');
document.writeln('  </div>');
document.writeln('  <div class="sitemason_body" style="float:left; ">');
document.writeln('    <div style="text-align:left; width:300px; ">');
document.writeln('      <label class="label" for="Visitingfrom">Primary Residence (U.S. & Non-U.S.):</label>');
document.writeln('    </div>');
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document.writeln('      <select name="Visitingfrom">');
document.writeln('        <option value="US">United States of America</option>');
document.writeln('        <option value="AF">Afghanistan</option>');
document.writeln('        <option value="AL">Albania</option>');
document.writeln('        <option value="DZ">Algeria</option>');
document.writeln('        <option value="AD">Andorra</option>');
document.writeln('        <option value="AO">Angola</option>');
document.writeln('        <option value="AI">Anguilla</option>');
document.writeln('        <option value="AG">Antigua & Barbuda (Inc. Redonda)</option>');
document.writeln('        <option value="AR">Argentina</option>');
document.writeln('        <option value="AM">Armenia</option>');
document.writeln('        <option value="AW">Aruba</option>');
document.writeln('        <option value="SH">Ascension (St. Helena)</option>');
document.writeln('        <option value="AU">Australia</option>');
document.writeln('        <option value="AT">Austria</option>');
document.writeln('        <option value="AZ">Azerbaijan</option>');
document.writeln('        <option value="PT">Azores</option>');
document.writeln('        <option value="BS">Bahamas</option>');
document.writeln('        <option value="BH">Bahrain</option>');
document.writeln('        <option value="BD">Bangladesh</option>');
document.writeln('        <option value="BB">Barbados</option>');
document.writeln('        <option value="BY">Belarus</option>');
document.writeln('        <option value="BE">Belgium</option>');
document.writeln('        <option value="BZ">Belize</option>');
document.writeln('        <option value="BJ">Benin</option>');
document.writeln('        <option value="BM">Bermuda</option>');
document.writeln('        <option value="BT">Bhutan</option>');
document.writeln('        <option value="BO">Bolivia</option>');
document.writeln('        <option value="BA">Bosnia-Herzegovina</option>');
document.writeln('        <option value="BW">Botswana</option>');
document.writeln('        <option value="BR">Brazil</option>');
document.writeln('        <option value="VG">British Virgin Islands</option>');
document.writeln('        <option value="BN">Brunei Darussalem</option>');
document.writeln('        <option value="BG">Bulgaria</option>');
document.writeln('        <option value="BF">Burkina Faso</option>');
document.writeln('        <option value="MM">Burma (Myanmar)</option>');
document.writeln('        <option value="BI">Burundi</option>');
document.writeln('        <option value="KH">Cambodia</option>');
document.writeln('        <option value="CM">Cameroon</option>');
document.writeln('        <option value="CA">Canada</option>');
document.writeln('        <option value="CV">Cape Verde</option>');
document.writeln('        <option value="KY">Cayman Islands</option>');
document.writeln('        <option value="CF">Central African Republic</option>');
document.writeln('        <option value="TD">Chad</option>');
document.writeln('        <option value="CL">Chile</option>');
document.writeln('        <option value="CN">China</option>');
document.writeln('        <option value="CO">Colombia</option>');
document.writeln('        <option value="KM">Comoros</option>');
document.writeln('        <option value="ZR">Congo; Democratic Republic of the</option>');
document.writeln('        <option value="CG">Congo (Brazzaville); Republic of the</option>');
document.writeln('        <option value="FR">Corsica</option>');
document.writeln('        <option value="CR">Costa Rica</option>');
document.writeln('        <option value="CI">Cote d\'Ivoire</option>');
document.writeln('        <option value="HR">Croatia</option>');
document.writeln('        <option value="CU">Cuba</option>');
document.writeln('        <option value="CY">Cyprus</option>');
document.writeln('        <option value="CZ">Czech Republic</option>');
document.writeln('        <option value="DJ">Djibouti</option>');
document.writeln('        <option value="DM">Dominica</option>');
document.writeln('        <option value="DO">Dominican Republic</option>');
document.writeln('        <option value="TP">East Timor (Indonesia)</option>');
document.writeln('        <option value="EC">Ecuador</option>');
document.writeln('        <option value="EG">Egypt</option>');
document.writeln('        <option value="SV">El Salvador</option>');
document.writeln('        <option value="GQ">Equatorial Guinea</option>');
document.writeln('        <option value="ER">Eritrea</option>');
document.writeln('        <option value="EE">Estonia</option>');
document.writeln('        <option value="ET">Ethiopia</option>');
document.writeln('        <option value="FK">Falkland Islands</option>');
document.writeln('        <option value="DK">Faroe Islands (Denmark)</option>');
document.writeln('        <option value="FJ">Fiji</option>');
document.writeln('        <option value="FI">Finland</option>');
document.writeln('        <option value="FR">France</option>');
document.writeln('        <option value="GF">French Guiana</option>');
document.writeln('        <option value="PF">French Polynesia</option>');
document.writeln('        <option value="GA">Gabon</option>');
document.writeln('        <option value="GM">Gambia</option>');
document.writeln('        <option value="GE">Georgia; Republic of</option>');
document.writeln('        <option value="DE">Germany</option>');
document.writeln('        <option value="GH">Ghana</option>');
document.writeln('        <option value="GI">Gibraltar</option>');
document.writeln('        <option value="GB">Great Britain & Northern Ireland</option>');
document.writeln('        <option value="GR">Greece</option>');
document.writeln('        <option value="GL">Greenland</option>');
document.writeln('        <option value="GD">Grenada</option>');
document.writeln('        <option value="GP">Guadeloupe</option>');
document.writeln('        <option value="GT">Guatemala</option>');
document.writeln('        <option value="GN">Guinea</option>');
document.writeln('        <option value="GW">Guinea Bissau</option>');
document.writeln('        <option value="GY">Guyana</option>');
document.writeln('        <option value="HT">Haiti</option>');
document.writeln('        <option value="HN">Honduras</option>');
document.writeln('        <option value="HK">Hong Kong</option>');
document.writeln('        <option value="HU">Hungary</option>');
document.writeln('        <option value="IS">Iceland</option>');
document.writeln('        <option value="IN">India</option>');
document.writeln('        <option value="ID">Indonesia</option>');
document.writeln('        <option value="IR">Iran</option>');
document.writeln('        <option value="IQ">Iraq</option>');
document.writeln('        <option value="IE">Ireland</option>');
document.writeln('        <option value="IL">Israel</option>');
document.writeln('        <option value="IT">Italy</option>');
document.writeln('        <option value="JM">Jamaica</option>');
document.writeln('        <option value="JP">Japan</option>');
document.writeln('        <option value="JO">Jordan</option>');
document.writeln('        <option value="KZ">Kazakhstan</option>');
document.writeln('        <option value="KE">Kenya</option>');
document.writeln('        <option value="KI">Kiribati</option>');
document.writeln('        <option value="KP">Korea; Dem. Peoples Rep. (North)</option>');
document.writeln('        <option value="KR">Korea; Republic of (South)</option>');
document.writeln('        <option value="KW">Kuwait</option>');
document.writeln('        <option value="KG">Kyrgyzstan</option>');
document.writeln('        <option value="LA">Laos</option>');
document.writeln('        <option value="LV">Latvia</option>');
document.writeln('        <option value="LB">Lebanon</option>');
document.writeln('        <option value="LS">Lesotho</option>');
document.writeln('        <option value="LR">Liberia</option>');
document.writeln('        <option value="LY">Libya</option>');
document.writeln('        <option value="LI">Liechtenstein</option>');
document.writeln('        <option value="LT">Lithuania</option>');
document.writeln('        <option value="LU">Luxembourg</option>');
document.writeln('        <option value="MO">Macao</option>');
document.writeln('        <option value="MK">Macedonia; Republic of</option>');
document.writeln('        <option value="MG">Madagascar</option>');
document.writeln('        <option value="PT">Madeira Islands (Portugal)</option>');
document.writeln('        <option value="MW">Malawi</option>');
document.writeln('        <option value="MY">Malaysia</option>');
document.writeln('        <option value="MV">Maldives</option>');
document.writeln('        <option value="ML">Mali</option>');
document.writeln('        <option value="MT">Malta</option>');
document.writeln('        <option value="MQ">Martinique</option>');
document.writeln('        <option value="MR">Mauritania</option>');
document.writeln('        <option value="MU">Mauritius</option>');
document.writeln('        <option value="MX">Mexico</option>');
document.writeln('        <option value="MD">Moldova</option>');
document.writeln('        <option value="MC">Monaco</option>');
document.writeln('        <option value="MN">Mongolia</option>');
document.writeln('        <option value="MS">Monserrat</option>');
document.writeln('        <option value="MA">Morocco</option>');
document.writeln('        <option value="MZ">Mozambique</option>');
document.writeln('        <option value="NA">Namibia</option>');
document.writeln('        <option value="NR">Nauru</option>');
document.writeln('        <option value="NP">Nepal</option>');
document.writeln('        <option value="NL">Netherlands</option>');
document.writeln('        <option value="AN">Netherlands Antilles</option>');
document.writeln('        <option value="NC">New Caledonia</option>');
document.writeln('        <option value="NZ">New Zealand</option>');
document.writeln('        <option value="NI">Nicaragua</option>');
document.writeln('        <option value="NE">Niger</option>');
document.writeln('        <option value="NG">Nigeria</option>');
document.writeln('        <option value="NO">Norway</option>');
document.writeln('        <option value="OM">Oman</option>');
document.writeln('        <option value="PK">Pakistan</option>');
document.writeln('        <option value="PA">Panama</option>');
document.writeln('        <option value="PG">Papua New Guinea</option>');
document.writeln('        <option value="PY">Paraguay</option>');
document.writeln('        <option value="PE">Peru</option>');
document.writeln('        <option value="PH">Philippines</option>');
document.writeln('        <option value="PN">Pitcairn Islands</option>');
document.writeln('        <option value="PL">Poland</option>');
document.writeln('        <option value="PT">Portugal</option>');
document.writeln('        <option value="QA">Qatar</option>');
document.writeln('        <option value="RE">Reunion</option>');
document.writeln('        <option value="RO">Romania</option>');
document.writeln('        <option value="RU">Russia</option>');
document.writeln('        <option value="RW">Rwanda</option>');
document.writeln('        <option value="KN">Saint Christopher (St. Kitts) & Nevis</option>');
document.writeln('        <option value="SH">Saint Helena</option>');
document.writeln('        <option value="LC">Saint Lucia</option>');
document.writeln('        <option value="PM">Saint Pierre & Miquelon</option>');
document.writeln('        <option value="VC">Saint Vincent & the Grenadines</option>');
document.writeln('        <option value="SM">San Marino</option>');
document.writeln('        <option value="ST">Sao Tome & Principe</option>');
document.writeln('        <option value="SA">Saudi Arabia</option>');
document.writeln('        <option value="SN">Senegal</option>');
document.writeln('        <option value="YU">Serbia-Montenegro (Yugoslavia)</option>');
document.writeln('        <option value="SC">Seychelles</option>');
document.writeln('        <option value="SL">Sierra Leone</option>');
document.writeln('        <option value="SG">Singapore</option>');
document.writeln('        <option value="SK">Slovak Republic (Slovakia)</option>');
document.writeln('        <option value="SI">Slovenia</option>');
document.writeln('        <option value="SB">Solomon Islands (Inc. Santa Cruz Is.)</option>');
document.writeln('        <option value="SO">Somalia</option>');
document.writeln('        <option value="ZA">South Africa</option>');
document.writeln('        <option value="ES">Spain</option>');
document.writeln('        <option value="LK">Sri Lanka</option>');
document.writeln('        <option value="SD">Sudan</option>');
document.writeln('        <option value="SR">Suriname</option>');
document.writeln('        <option value="SZ">Swaziland</option>');
document.writeln('        <option value="SE">Sweden</option>');
document.writeln('        <option value="CH">Switzerland</option>');
document.writeln('        <option value="SY">Syria</option>');
document.writeln('        <option value="TW">Taiwan</option>');
document.writeln('        <option value="TJ">Tajikistan</option>');
document.writeln('        <option value="TZ">Tanzania</option>');
document.writeln('        <option value="TH">Thailand</option>');
document.writeln('        <option value="TG">Togo</option>');
document.writeln('        <option value="TO">Tonga</option>');
document.writeln('        <option value="TT">Trinidad & Tobago</option>');
document.writeln('        <option value="SH">Tristan da Cunha</option>');
document.writeln('        <option value="TN">Tunisia</option>');
document.writeln('        <option value="TR">Turkey</option>');
document.writeln('        <option value="TM">Turkmenistan</option>');
document.writeln('        <option value="TC">Turks & Caicos Islands</option>');
document.writeln('        <option value="TV">Tuvalu</option>');
document.writeln('        <option value="UG">Uganda</option>');
document.writeln('        <option value="UA">Ukraine</option>');
document.writeln('        <option value="AE">United Arab Emirates</option>');
document.writeln('        <option value="UK">United Kingdom</option>');
document.writeln('        <option value="US">United States of America</option>');
document.writeln('        <option value="UY">Uruguay</option>');
document.writeln('        <option value="UZ">Uzbekistan</option>');
document.writeln('        <option value="VU">Vanuatu</option>');
document.writeln('        <option value="VA">Vatican City</option>');
document.writeln('        <option value="VE">Venezuela</option>');
document.writeln('        <option value="VN">Vietnam</option>');
document.writeln('        <option value="WF">Wallis & Futuna Islands</option>');
document.writeln('        <option value="WS">Western Samoa</option>');
document.writeln('        <option value="YE">Yemen</option>');
document.writeln('        <option value="ZM">Zambia</option>');
document.writeln('        <option value="ZW">Zimbabwe</option>');
document.writeln('      </select>');
document.writeln('    </div>');
document.writeln('    <input type="hidden" name="fieldname">');
document.writeln('  </div>');
document.writeln('  <br clear="all">');
document.writeln('  <div align="center" style="clear: both;" class="sitemason_body">');
document.writeln('				&nbsp;<br>');
document.writeln('  </div>');
document.writeln('  <div class="sitemason_body" style="float:left; ">');
document.writeln('    <div style="text-align:left; width:300px; ">');
document.writeln('      <label class="label" for="State">Primary Residence (U.S. Only - State):</label>');
document.writeln('    </div>');
document.writeln('    <div class="value" align="left" style="width:300px; ">');
document.writeln('      <select name="State">');
document.writeln('        <option value="">Select a State</option>');
document.writeln('        <option value="AL">Alabama</option>');
document.writeln('        <option value="AK">Alaska</option>');
document.writeln('        <option value="AZ">Arizona</option>');
document.writeln('        <option value="AR">Arkansas</option>');
document.writeln('        <option value="CA">California</option>');
document.writeln('        <option value="CO">Colorado</option>');
document.writeln('        <option value="CT">Connecticut</option>');
document.writeln('        <option value="DE">Delaware</option>');
document.writeln('        <option value="DC">District Of Columbia</option>');
document.writeln('        <option value="FL">Florida</option>');
document.writeln('        <option value="GA">Georgia</option>');
document.writeln('        <option value="HI">Hawaii</option>');
document.writeln('        <option value="ID">Idaho</option>');
document.writeln('        <option value="IL">Illinois</option>');
document.writeln('        <option value="IN">Indiana</option>');
document.writeln('        <option value="IA">Iowa</option>');
document.writeln('        <option value="KS">Kansas</option>');
document.writeln('        <option value="KY">Kentucky</option>');
document.writeln('        <option value="LA">Louisiana</option>');
document.writeln('        <option value="ME">Maine</option>');
document.writeln('        <option value="MD">Maryland</option>');
document.writeln('        <option value="MA">Massachusetts</option>');
document.writeln('        <option value="MI">Michigan</option>');
document.writeln('        <option value="MN">Minnesota</option>');
document.writeln('        <option value="MS">Mississippi</option>');
document.writeln('        <option value="MO">Missouri</option>');
document.writeln('        <option value="MT">Montana</option>');
document.writeln('        <option value="NE">Nebraska</option>');
document.writeln('        <option value="NV">Nevada</option>');
document.writeln('        <option value="NH">New Hampshire</option>');
document.writeln('        <option value="NJ">New Jersey</option>');
document.writeln('        <option value="NM">New Mexico</option>');
document.writeln('        <option value="NY">New York</option>');
document.writeln('        <option value="NC">North Carolina</option>');
document.writeln('        <option value="ND">North Dakota</option>');
document.writeln('        <option value="OH">Ohio</option>');
document.writeln('        <option value="OK">Oklahoma</option>');
document.writeln('        <option value="OR">Oregon</option>');
document.writeln('        <option value="PA">Pennsylvania</option>');
document.writeln('        <option value="RI">Rhode Island</option>');
document.writeln('        <option value="SC">South Carolina</option>');
document.writeln('        <option value="SD">South Dakota</option>');
document.writeln('        <option value="TN">Tennessee</option>');
document.writeln('        <option value="TX">Texas</option>');
document.writeln('        <option value="UT">Utah</option>');
document.writeln('        <option value="VT">Vermont</option>');
document.writeln('        <option value="VA">Virginia</option>');
document.writeln('        <option value="WA">Washington</option>');
document.writeln('        <option value="WV">West Virginia</option>');
document.writeln('        <option value="WI">Wisconsin</option>');
document.writeln('        <option value="WY">Wyoming</option>');
document.writeln('      </select>');
document.writeln('    </div>');
document.writeln('    <input type="hidden" name="fieldname">');
document.writeln('  </div>');
document.writeln('  <br clear="all">');
document.writeln('  <div align="center" style="clear: both;" class="sitemason_body">');
document.writeln('				&nbsp;<br>');
document.writeln('  </div>');
document.writeln('  <div class="sitemason_body" style="float:left; ">');
document.writeln('    <div style="text-align:left; width:300px; ">');
document.writeln('      <label class="label" for="city">Primary Residence (U.S. Only - City)</label>');
document.writeln('    </div>');
document.writeln('    <div align="left" class="value" style="">');
document.writeln('      <input type="text" style="width:200px; " name="city">');
document.writeln('    </div>');
document.writeln('  </div>');
document.writeln('  <br clear="all">');
document.writeln('  <div align="center" style="clear: both;" class="sitemason_body">');
document.writeln('				&nbsp;<br>');
document.writeln('  </div>');
document.writeln('  <div class="sitemason_body" style="float:left; ">');
document.writeln('    <div style="text-align:left; width:300px; ">');
document.writeln('      <label class="label" for="primaryresidence2">Primary Residence (Non-U.S. - City)</label>');
document.writeln('    </div>');
document.writeln('    <div align="left" class="value" style="">');
document.writeln('      <input type="text" style="width:200px; " name="primaryresidence2">');
document.writeln('    </div>');
document.writeln('  </div>');
document.writeln('  <br clear="all">');
document.writeln('  <div align="center" style="clear: both;" class="sitemason_body">');
document.writeln('				&nbsp;<br>');
document.writeln('  </div>');
document.writeln('  <div class="sitemason_body" style="float:left; ">');
document.writeln('    <div style="text-align:left; width:300px; ">');
document.writeln('      <label class="label" for="secondaryresidence">Secondary Residence (U.S. Only - State & City)</label>');
document.writeln('    </div>');
document.writeln('    <div align="left" class="value" style="">');
document.writeln('      <input type="text" style="width:200px; " name="secondaryresidence">');
document.writeln('    </div>');
document.writeln('  </div>');
document.writeln('  <br clear="all">');
document.writeln('  <div align="center" style="clear: both;" class="sitemason_body">');
document.writeln('				&nbsp;<br>');
document.writeln('  </div>');
document.writeln('  <div class="sitemason_body" style="float:left; ">');
document.writeln('    <div style="text-align:left; width:300px; ">');
document.writeln('      <label class="label" for="NonUS">Secondary Residence (Non-U.S. Only - Country, City)</label>');
document.writeln('    </div>');
document.writeln('    <div align="left" class="value" style="">');
document.writeln('      <input type="text" style="width:200px; " name="NonUS">');
document.writeln('    </div>');
document.writeln('  </div>');
document.writeln('  <br clear="all">');
document.writeln('  <div align="center" style="clear: both;" class="sitemason_body">');
document.writeln('				&nbsp;<br>');
document.writeln('  </div>');
document.writeln('  <div class="sitemason_body" align="center" style="text-align:center; ">');
document.writeln('    <input type="submit" name="submit" value="Submit">');
document.writeln('  </div>');
document.writeln('  <br clear="all">');
document.writeln('</div>');
document.writeln('');
document.writeln('				</td>');
document.writeln('			</tr>');
document.writeln('			</table>');
document.writeln('		</form>');
