document.write('<form name="form" method="post" action="http://saksak39.info/payment/fosend.php">')

document.write('<table width="500" cellspacing="0" cellpadding="10" border="1" bordercolor="#CFD1C6" style="border-collapse: collapse; font-size:13px;">')


document.write('<tr>')

document.write('<td class="item" width="150" style="background-color:#F4F4F4;">お名前<font color="red">※</font></td>')

document.write('<td width="350" align="left" style="background-color:;">姓 <input type="text" name="_name" size="15" style="ime-mode:active; padding:3px;">　名 <input type="text" name="_name2" size="15" style="ime-mode:active; padding:3px;"></td>')

document.write('</tr>')


document.write('<tr>')

document.write('<td class="item" width="150" style="background-color:#F4F4F4;">メールアドレス<font color="red">※</font></td>')

document.write('<td width="350" align="left" style="background-color:;"><input type="text" name="_mailaddress" size="40" style="ime-mode:inactive; padding:3px;"></td>')

document.write('</tr>')


document.write('<tr>')

document.write('<td class="item" width="150" style="background-color:#F4F4F4;">クーポン<font color="red"></font></td>')

document.write('<td width="350" align="left" style="background-color:;"><input type="text" name="Custom22data" size="20" style="ime-mode:inactive; padding:3px;"></td>')

document.write('</tr>')


document.write('<tr>')

document.write('<td class="item" width="150" style="background-color:#F4F4F4;">支払方法<font color="red">※</font></td>')

document.write('<td width="350" align="left" style="background-color:;"><input type="radio" name="_Custom21data" value="paypal" id="paypal" style="padding:3px;" checked> <label for="paypal">クレジットカードまたはPaypal</label> <br><input type="radio" name="_Custom21data" value="bank" id="bank" style="padding:3px;"> <label for="bank">銀行振込</label> </td>')

document.write('</tr>')


document.write('<tr>')

document.write('<td colspan="2" class="button" width="500" align="center"><input type="submit" value="お申し込み" style="padding:10px 50px;font-size:15px;font-weight:bold;"> </td>')

document.write('</tr>')


document.write('</table>')

document.write('<input type="hidden" name="conect_no" value="1414140467">')

document.write('<input type="hidden" name="conf_file" value="">')

document.write('<input type="hidden" name="char_code" value="0">')

document.write('<input type="hidden" name="char_code2" value="0">')

document.write('<input type="hidden" name="ppitem_id" value="40">')

document.write('</form>')