document.write('<form name="form" method="post" action="https://websalesjissen.jp/pay/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;">郵便番号<font color="red">※</font></td>');
document.write('<td width="350" align="left" style="background-color:;"><input type="text" name="_zip" size="25" 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><br> </td>');
document.write('</tr>');
document.write('</table>');
document.write('<table width="500" cellspacing="0" cellpadding="10" border="0" bordercolor="" style="border-collapse: collapse; font-size:13px;">');
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="1520824544">');
document.write('<input type="hidden" name="conf_file" value="form_conf.html">');
document.write('<input type="hidden" name="char_code" value="1">');
document.write('<input type="hidden" name="char_code2" value="0">');
document.write('<input type="hidden" name="ppitem_id" value="23">');
document.write('</form>');