var style = "" + 
'<style type="text/css">' +
'.selectStyle {' +
'	border: solid 1px #4c4c4c;' +
'	background-color:#f9f9f9;' +
'	color:#333333;		' +
'}' +
'</style>';
document.write(style);

var form = "" + 

'<center>' + 

'	<form name="preQualify" id="preQualify" method="GET" onSubmit="showFeed(\'preQualify\', document.preQualify.elements[\'submit\']); return false;">' + 		
'	<div class="filter_div" style="text-align:left; width:250px;background-color:#e6e6e6;color:#333333;border:solid brown 2px;-moz-border-radius:8px;-webkit-border-radius:8px; padding:5px; font-size:12px;">' + 

'	<input type="hidden" name="type" value="6014">' + 
	
'		 Select your residence state: <br>' + 
'		<select name="state_selection" id="state_selection" class="selectStyle"><option value="">Select One...</option><option value="al">Alabama</option><option value="ak">Alaska</option><option value="az">Arizona</option><option value="ar">Arkansas</option><option value="ca">California</option><option value="co">Colorado</option><option value="ct">Connecticut</option><option value="de">Delaware</option><option value="dc">District of Columbia</option><option value="fl">Florida</option><option value="ga">Georgia</option><option value="hi">Hawaii</option><option value="id">Idaho</option><option value="il">Illinois</option><option value="in">Indiana</option><option value="ia">Iowa</option><option value="ks">Kansas</option><option value="ky">Kentucky</option><option value="la">Louisiana</option><option value="me">Maine</option><option value="md">Maryland</option><option value="ma">Massachusetts</option><option value="mi">Michigan</option><option value="mn">Minnesota</option><option value="ms">Mississippi</option><option value="mo">Missouri</option><option value="mt">Montana</option><option value="ne">Nebraska</option><option value="nv">Nevada</option><option value="nh">New Hampshire</option><option value="nj">New Jersey</option><option value="nm">New Mexico</option><option value="ny">New York</option><option value="nc">North Carolina</option><option value="nd">North Dakota</option><option value="oh">Ohio</option><option value="ok">Oklahoma</option><option value="or">Oregon</option><option value="pa">Pennsylvania</option><option value="ri">Rhode Island</option><option value="sc">South Carolina</option><option value="sd">South Dakota</option><option value="tn">Tennessee</option><option value="tx">Texas</option><option value="ut">Utah</option><option value="vt">Vermont</option><option value="va">Virginia</option><option value="wa">Washington</option><option value="wv">West Virginia</option><option value="wi">Wisconsin</option><option value="wy">Wyoming</option><option value="ab">Alberta</option><option value="bc">British Columbia</option><option value="mb">Manitoba</option><option value="nb">New Brunswick</option><option value="nl">Newfoundland</option><option value="nt">Northwest Territories</option><option value="ns">Nova Scotia</option><option value="nu">Nunavut</option><option value="on">Ontario</option><option value="pe">Prince Edward Island</option><option value="qc">Quebec</option><option value="sk">Saskatchewan</option><option value="yt">Yukon Territory</option></select>' + 
		
'		<br>' + 
'		 <br> Approximate your total unsecured debt (credit card or medical bills debt, unsecured loans, etc.)<br><select name="unsecured_debt" id="unsecured_debt" class="selectStyle"><option value="20000">Over $20,000</option><option value="15000">$15,000 - $20,000</option><option value="10000">$10,000 - $15,000</option><option value="5000">$5,000 - $10,000</option><option value="1000">$1,000 - $5,000</option><option value="1000">Up to $1,000</option></select>' +
'	<br><center><br>' + 
'	<input type="submit" name="submit" value=":: Find Debt Relief ::" class="button" style="margin-right:15px;margin-top:5px;cursor:pointer;">' + 
'	</center>' + 
'	</div>	' + 
'	</form>' + 
'	</center>';

document.write(form);