document.write('<script type=\"text/javascript\" src=\"https://assets.bravenet.com/bn/js/emailfwd/bn_email_forms.min.js\"></script><link rel=\"stylesheet\" href=\"https://pub33.bravenet.com/emailfwd/v2/bnet-form.css.php?usernum=2798844518&formid=4060&formpadding=0\"><form method=\"post\" class=\"bnet-form\" enctype=\"multipart/form-data\" action=\"#bn-ajax-post:2798844518:33:4060\"><div class=\"bn-form-header\"><div class=\"bn-form-legend\"><div>The \'X\' Zone \'X\' Mas Mall Storefront Data Information:</div></div> <div class=\"bn-form-desc\"><p>Please fill out the fields below. Please send your graphics to admin@rel-mar.com</p></div></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">Name. <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-1\" placeholder=\"your first and last name\" validator=\"\" value=\"\" required=\"required\"></span></label></div><div class=\"fields-wrapper\"><label class=\"bn-row\"><span class=\"bn-label\">Your Email Address. <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-2\" placeholder=\"you must enter a valid email address\" validator=\"email\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper\"><label class=\"bn-row\"><span class=\"bn-label\">What is the name of your website? </span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-169797087053539\" placeholder=\"\" validator=\"\" value=\"\"></span></label></div><div class=\"fields-wrapper\"><label class=\"bn-row\"><span class=\"bn-label\">What is your website address? </span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-169797091658671\" placeholder=\"\" validator=\"\" value=\"\"></span></label></div><div class=\"fields-wrapper\"><div class=\"bn-row rowcb\"><span class=\"bn-label\">Can visitors contact you through your email address for more information on the product for sale in your store? </span> <span class=\"bn-input\"><span class=\"bn-optionwrapper\"><label class=\"bn-radio\"><input type=\"radio\" name=\"Field-169797047877953\" value=\"Yes\" checked=\"checked\"> <span class=\"bn-inner-label\">Yes</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-radio\"><input type=\"radio\" name=\"Field-169797047877953\" value=\"No\"> <span class=\"bn-inner-label\">No</span></label></span></span></div></div><div class=\"fields-wrapper\"><label class=\"bn-row\"><span class=\"bn-label\">In what City, Province/State where you live? </span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-169797034662661\" placeholder=\"\" validator=\"\" value=\"\"></span></label></div><div class=\"fields-wrapper\"><label class=\"bn-row\"><span class=\"bn-label\">What Country do you live in? </span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-169797038895547\" placeholder=\"\" validator=\"\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">What would you like for the name of your store? <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><textarea name=\"Field-3\" placeholder=\"enter your comments here\" validator=\"\" required=\"required\"></textarea></span></label></div><div class=\"fields-wrapper\"><label class=\"bn-row\"><span class=\"bn-label\">Please give a description of the product and/or merchandise that you will be selling in your store. </span> <span class=\"bn-input\"><textarea name=\"Field-169797012593682\" placeholder=\"\" validator=\"\"></textarea></span></label></div><div class=\"fields-wrapper\"><label class=\"bn-row\"><span class=\"bn-label\">Tell visitors to your store about yourself and why they should buy your product. </span> <span class=\"bn-input\"><textarea name=\"Field-169797023950082\" placeholder=\"\" validator=\"\"></textarea></span></label></div><div class=\"fields-wrapper\"><label class=\"bn-row\"><span class=\"bn-label\">Provide a link where your customers to purchase your product, service or merchandise. </span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-169797030345721\" placeholder=\"\" validator=\"\" value=\"\"></span></label></div><div class=\"fields-wrapper\"><label class=\"bn-row\"><span class=\"bn-label\">What is your refund policy? </span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-169797096479045\" placeholder=\"\" validator=\"\" value=\"\"></span></label></div><div class=\"fields-wrapper\"><label class=\"bn-row\"><span class=\"bn-label\">Are there any comments that you would like to share with your customers and/or prospective purchasers? </span> <span class=\"bn-input\"><textarea name=\"Field-1697971109603102\" placeholder=\"\" validator=\"\"></textarea></span></label></div>  <input type=\"hidden\" name=\"carboncopy\" value=\"\"> <input type=\"hidden\" name=\"thankyou\" value=\"\"> <input type=\"hidden\" name=\"thankyoutext\" value=\"Thank you for your form submission\"> <input type=\"hidden\" name=\"subject\" value=\"\"><div class=\"bn-form-submit\"><button type=\"submit\" class=\"formbtn\">Click Here To Submit Your Form</button></div> <style type=\"text/css\">.bnet-form ::-webkit-input-placeholder {');
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