document.write('<div align="center">');
document.write('<div style="width: 500px; align: center; background-color: #f5f5f5; border: 1px dotted #ccc; padding: 5px; margin: 0px auto;" >');
document.write('<form method="POST" action="suggestSite.php" name="suggest">');
document.write('<div class="pInTable">');
document.write('<h2>SUGGEST A SITE FOR THIS PAGE:</h2>');
document.write('</div>');
document.write('<table summary="Submit Physical Therapy / Physiotherapy Site" width="400" border="0">');
document.write('<tr>');
document.write('<td><p>URL of Site:<br><input type="text" size="25" name="URL" value="http://"></></td>');
document.write('<td><p>Site Title:<br><input type="text" size="25" name="Title" value=""></p>');
document.write('</td>');
document.write('</tr>');
document.write('<tr>');
document.write('<td colspan="2"><p>Your Email:<br><input type="text" size="25" name="email" value=""></p>');
document.write('<input type="hidden" name="page" value="' + unescape(location.href) + '">&nbsp;&nbsp;<input type="submit" value="Submit" name="B2"></td>');
document.write('</tr>');
document.write('</table>');
document.write('</form>')		;		
document.write('</div><!-- local style -->');
document.write('</div><!-- center -->');