document.writeln("<p><b>Envie-nos suas inquérito diretamente através do formulário (todos os campos são obrigatórios)<\/b><\/p>");
document.writeln("<TABLE style=\"width:100%; text-align:left\" class=\"feedback\">");
document.writeln("<FORM id=\"orderform\" name=\"orderform\" action=\"http:\/\/www.lmlq.com\/ver2.0\/eng\/breakday\/deal.asp\" method=\"post\">");
document.writeln("<TR> ");
document.writeln("<TD>Seu Nome:<\/TD> ");
document.writeln("<TD><INPUT maxLength=250 size=40 name=gname> ");
document.writeln("<FONT color=#ff0000>*<\/FONT><\/TD>");
document.writeln("<\/TR> ");
document.writeln("<TR> ");
document.writeln("<TD>Companhia:<\/TD> ");
document.writeln("<TD><INPUT maxLength=250 size=40 name=gtitle> ");
document.writeln("<FONT color=#ff0000>*<\/FONT><\/TD><\/TR> ");
document.writeln("<TR> ");
document.writeln("<TD>país<\/TD> ");
document.writeln("<TD>");
document.writeln("<SELECT onChange=\"return countryChange()\" name=country>");
document.writeln("<OPTION selected>--- All Countries &amp; Territories (A to Z) ---<\/OPTION>");
document.writeln("<OPTION value=AF>Afghanistan<\/OPTION>");
document.writeln("<OPTION value=AL>Albania<\/OPTION>");
document.writeln("<OPTION value=DZ>Algeria<\/OPTION>");
document.writeln("<OPTION value=AS>American Samoa<\/OPTION>");
document.writeln("<OPTION value=AD>Andorra<\/OPTION>");
document.writeln("<OPTION value=AO>Angola<\/OPTION>");
document.writeln("<OPTION value=AI>Anguilla<\/OPTION>");
document.writeln("<OPTION value=AQ>Antarctica<\/OPTION>");
document.writeln("<OPTION value=AG>Antigua and Barbuda<\/OPTION>");
document.writeln("<OPTION value=AR>Argentina<\/OPTION>");
document.writeln("<OPTION value=AM>Armenia<\/OPTION>");
document.writeln("<OPTION value=AW>Aruba<\/OPTION>");
document.writeln("<OPTION value=AU>Australia<\/OPTION>");
document.writeln("<OPTION value=AT>Austria<\/OPTION>");
document.writeln("<OPTION value=AZ>Azerbaijan<\/OPTION>");
document.writeln("<OPTION value=BS>Bahamas<\/OPTION>");
document.writeln("<OPTION value=BH>Bahrain<\/OPTION>");
document.writeln("<OPTION value=BD>Bangladesh<\/OPTION>");
document.writeln("<OPTION value=BB>Barbados<\/OPTION>");
document.writeln("<OPTION value=BY>Belarus<\/OPTION>");
document.writeln("<OPTION value=BE>Belgium<\/OPTION>");
document.writeln("<OPTION value=BZ>Belize<\/OPTION>");
document.writeln("<OPTION value=BJ>Benin<\/OPTION>");
document.writeln("<OPTION value=BM>Bermuda<\/OPTION>");
document.writeln("<OPTION value=BT>Bhutan<\/OPTION>");
document.writeln("<OPTION value=BO>Bolivia<\/OPTION>");
document.writeln("<OPTION value=BA>Bosnia and Herzegovina<\/OPTION>");
document.writeln("<OPTION value=BW>Botswana<\/OPTION>");
document.writeln("<OPTION value=BV>Bouvet Island<\/OPTION>");
document.writeln("<OPTION value=BR>Brazil<\/OPTION>");
document.writeln("<OPTION value=IO>British Indian Ocean Territory<\/OPTION>");
document.writeln("<OPTION value=BN>Brunei Darussalam<\/OPTION>");
document.writeln("<OPTION value=BG>Bulgaria<\/OPTION>");
document.writeln("<OPTION value=BF>Burkina Faso<\/OPTION>");
document.writeln("<OPTION value=BI>Burundi<\/OPTION>");
document.writeln("<OPTION value=KH>Cambodia<\/OPTION>");
document.writeln("<OPTION value=CM>Cameroon<\/OPTION>");
document.writeln("<OPTION value=CA>Canada<\/OPTION>");
document.writeln("<OPTION value=CV>Cape Verde<\/OPTION>");
document.writeln("<OPTION value=KY>Cayman Islands<\/OPTION>");
document.writeln("<OPTION value=CF>Central African Republic<\/OPTION>");
document.writeln("<OPTION value=TD>Chad<\/OPTION>");
document.writeln("<OPTION value=CD>Channel Island<\/OPTION>");
document.writeln("<OPTION value=CL>Chile<\/OPTION>");
document.writeln("<OPTION value=CN>China (Mainland)<\/OPTION>");
document.writeln("<OPTION value=CX>Christmas Island<\/OPTION>");
document.writeln("<OPTION value=CC>Cocos (Keeling) Islands<\/OPTION>");
document.writeln("<OPTION value=CO>Colombia<\/OPTION>");
document.writeln("<OPTION value=KM>Comoros<\/OPTION>");
document.writeln("<OPTION value=CG>Congo<\/OPTION>");
document.writeln("<OPTION value=ZR>Congo, The Democratic Republic Of The<\/OPTION>");
document.writeln("<OPTION value=CK>Cook Islands<\/OPTION>");
document.writeln("<OPTION value=CR>Costa Rica<\/OPTION>");
document.writeln("<OPTION value=CI>Cote D\"Ivoire<\/OPTION>");
document.writeln("<OPTION value=HR>Croatia (local name: Hrvatska)<\/OPTION>");
document.writeln("<OPTION value=CU>Cuba<\/OPTION>");
document.writeln("<OPTION value=CY>Cyprus<\/OPTION>");
document.writeln("<OPTION value=CZ>Czech Republic<\/OPTION>");
document.writeln("<OPTION value=DK>Denmark<\/OPTION>");
document.writeln("<OPTION value=DJ>Djibouti<\/OPTION>");
document.writeln("<OPTION value=DM>Dominica<\/OPTION>");
document.writeln("<OPTION value=DO>Dominican Republic<\/OPTION>");
document.writeln("<OPTION value=TP>East Timor<\/OPTION>");
document.writeln("<OPTION value=EC>Ecuador<\/OPTION>");
document.writeln("<OPTION value=EG>Egypt<\/OPTION>");
document.writeln("<OPTION value=SV>El Salvador<\/OPTION>");
document.writeln("<OPTION value=GQ>Equatorial Guinea<\/OPTION>");
document.writeln("<OPTION value=ER>Eritrea<\/OPTION>");
document.writeln("<OPTION value=EE>Estonia<\/OPTION>");
document.writeln("<OPTION value=ET>Ethiopia<\/OPTION>");
document.writeln("<OPTION value=FK>Falkland Islands (Malvinas)<\/OPTION>");
document.writeln("<OPTION value=FO>Faroe Islands<\/OPTION>");
document.writeln("<OPTION value=FJ>Fiji<\/OPTION>");
document.writeln("<OPTION value=FI>Finland<\/OPTION>");
document.writeln("<OPTION value=FR>France<\/OPTION>");
document.writeln("<OPTION value=FX>France Metropolitan<\/OPTION>");
document.writeln("<OPTION value=GF>French Guiana<\/OPTION>");
document.writeln("<OPTION value=PF>French Polynesia<\/OPTION>");
document.writeln("<OPTION value=TF>French Southern Territories<\/OPTION>");
document.writeln("<OPTION value=GA>Gabon<\/OPTION>");
document.writeln("<OPTION value=GM>Gambia<\/OPTION>");
document.writeln("<OPTION value=GE>Georgia<\/OPTION>");
document.writeln("<OPTION value=DE>Germany<\/OPTION>");
document.writeln("<OPTION value=GH>Ghana<\/OPTION>");
document.writeln("<OPTION value=GI>Gibraltar<\/OPTION>");
document.writeln("<OPTION value=GR>Greece<\/OPTION>");
document.writeln("<OPTION value=GL>Greenland<\/OPTION>");
document.writeln("<OPTION value=GD>Grenada<\/OPTION>");
document.writeln("<OPTION value=GP>Guadeloupe<\/OPTION>");
document.writeln("<OPTION value=GU>Guam<\/OPTION>");
document.writeln("<OPTION value=GT>Guatemala<\/OPTION>");
document.writeln("<OPTION value=GN>Guinea<\/OPTION>");
document.writeln("<OPTION value=GW>Guinea-Bissau<\/OPTION>");
document.writeln("<OPTION value=GY>Guyana<\/OPTION>");
document.writeln("<OPTION value=HT>Haiti<\/OPTION>");
document.writeln("<OPTION value=HM>Heard and Mc Donald Islands<\/OPTION>");
document.writeln("<OPTION value=HN>Honduras<\/OPTION>");
document.writeln("<OPTION value=HK>Hong Kong<\/OPTION>");
document.writeln("<OPTION value=HU>Hungary<\/OPTION>");
document.writeln("<OPTION value=IS>Iceland<\/OPTION>");
document.writeln("<OPTION value=IN>India<\/OPTION>");
document.writeln("<OPTION value=ID>Indonesia<\/OPTION>");
document.writeln("<OPTION value=IR>Iran (Islamic Republic of)<\/OPTION>");
document.writeln("<OPTION value=IQ>Iraq<\/OPTION>");
document.writeln("<OPTION value=IE>Ireland<\/OPTION>");
document.writeln("<OPTION value=IL>Israel<\/OPTION>");
document.writeln("<OPTION value=IT>Italy<\/OPTION>");
document.writeln("<OPTION value=JM>Jamaica<\/OPTION>");
document.writeln("<OPTION value=JP>Japan<\/OPTION>");
document.writeln("<OPTION value=JO>Jordan<\/OPTION>");
document.writeln("<OPTION value=KZ>Kazakhstan<\/OPTION>");
document.writeln("<OPTION value=KE>Kenya<\/OPTION>");
document.writeln("<OPTION value=KI>Kiribati<\/OPTION>");
document.writeln("<OPTION value=KW>Kuwait<\/OPTION>");
document.writeln("<OPTION value=KG>Kyrgyzstan<\/OPTION>");
document.writeln("<OPTION value=LA>Lao People\"s Democratic Republic<\/OPTION>");
document.writeln("<OPTION value=LV>Latvia<\/OPTION>");
document.writeln("<OPTION value=LB>Lebanon<\/OPTION>");
document.writeln("<OPTION value=LS>Lesotho<\/OPTION>");
document.writeln("<OPTION value=LR>Liberia<\/OPTION>");
document.writeln("<OPTION value=LY>Libyan Arab Jamahiriya<\/OPTION>");
document.writeln("<OPTION value=LI>Liechtenstein<\/OPTION>");
document.writeln("<OPTION value=LT>Lithuania<\/OPTION>");
document.writeln("<OPTION value=LU>Luxembourg<\/OPTION>");
document.writeln("<OPTION value=MO>Macau<\/OPTION>");
document.writeln("<OPTION value=MK>Macedonia<\/OPTION>");
document.writeln("<OPTION value=MG>Madagascar<\/OPTION>");
document.writeln("<OPTION value=MW>Malawi<\/OPTION>");
document.writeln("<OPTION value=MY>Malaysia<\/OPTION>");
document.writeln("<OPTION value=MV>Maldives<\/OPTION>");
document.writeln("<OPTION value=ML>Mali<\/OPTION>");
document.writeln("<OPTION value=MT>Malta<\/OPTION>");
document.writeln("<OPTION value=MH>Marshall Islands<\/OPTION>");
document.writeln("<OPTION value=MQ>Martinique<\/OPTION>");
document.writeln("<OPTION value=MR>Mauritania<\/OPTION>");
document.writeln("<OPTION value=MU>Mauritius<\/OPTION>");
document.writeln("<OPTION value=YT>Mayotte<\/OPTION>");
document.writeln("<OPTION value=MX>Mexico<\/OPTION>");
document.writeln("<OPTION value=FM>Micronesia<\/OPTION>");
document.writeln("<OPTION value=MD>Moldova<\/OPTION>");
document.writeln("<OPTION value=MC>Monaco<\/OPTION>");
document.writeln("<OPTION value=MN>Mongolia<\/OPTION>");
document.writeln("<OPTION value=MS>Montserrat<\/OPTION>");
document.writeln("<OPTION value=MA>Morocco<\/OPTION>");
document.writeln("<OPTION value=MZ>Mozambique<\/OPTION>");
document.writeln("<OPTION value=MM>Myanmar<\/OPTION>");
document.writeln("<OPTION value=NA>Namibia<\/OPTION>");
document.writeln("<OPTION value=NR>Nauru<\/OPTION>");
document.writeln("<OPTION value=NP>Nepal<\/OPTION>");
document.writeln("<OPTION value=NL>Netherlands<\/OPTION>");
document.writeln("<OPTION value=AN>Netherlands Antilles<\/OPTION>");
document.writeln("<OPTION value=NC>New Caledonia<\/OPTION>");
document.writeln("<OPTION value=NZ>New Zealand<\/OPTION>");
document.writeln("<OPTION value=NI>Nicaragua<\/OPTION>");
document.writeln("<OPTION value=NE>Niger<\/OPTION>");
document.writeln("<OPTION value=NG>Nigeria<\/OPTION>");
document.writeln("<OPTION value=NU>Niue<\/OPTION>");
document.writeln("<OPTION value=NF>Norfolk Island<\/OPTION>");
document.writeln("<OPTION value=KP>North Korea<\/OPTION>");
document.writeln("<OPTION value=MP>Northern Mariana Islands<\/OPTION>");
document.writeln("<OPTION value=NO>Norway<\/OPTION>");
document.writeln("<OPTION value=OM>Oman<\/OPTION>");
document.writeln("<OPTION value=Other>Other Country<\/OPTION>");
document.writeln("<OPTION value=PK>Pakistan<\/OPTION>");
document.writeln("<OPTION value=PW>Palau<\/OPTION>");
document.writeln("<OPTION value=PS>Palestine<\/OPTION>");
document.writeln("<OPTION value=PA>Panama<\/OPTION>");
document.writeln("<OPTION value=PG>Papua New Guinea<\/OPTION>");
document.writeln("<OPTION value=PY>Paraguay<\/OPTION>");
document.writeln("<OPTION value=PE>Peru<\/OPTION>");
document.writeln("<OPTION value=PH>Philippines<\/OPTION>");
document.writeln("<OPTION value=PN>Pitcairn<\/OPTION>");
document.writeln("<OPTION value=PL>Poland<\/OPTION>");
document.writeln("<OPTION value=PT>Portugal<\/OPTION>");
document.writeln("<OPTION value=PR>Puerto Rico<\/OPTION>");
document.writeln("<OPTION value=QA>Qatar<\/OPTION>");
document.writeln("<OPTION value=RE>Reunion<\/OPTION>");
document.writeln("<OPTION value=RO>Romania<\/OPTION>");
document.writeln("<OPTION value=RU>Russian Federation<\/OPTION>");
document.writeln("<OPTION value=RW>Rwanda<\/OPTION>");
document.writeln("<OPTION value=KN>Saint Kitts and Nevis<\/OPTION>");
document.writeln("<OPTION value=LC>Saint Lucia<\/OPTION>");
document.writeln("<OPTION value=VC>Saint Vincent and the Grenadines<\/OPTION>");
document.writeln("<OPTION value=WS>Samoa<\/OPTION>");
document.writeln("<OPTION value=SM>San Marino<\/OPTION>");
document.writeln("<OPTION value=ST>Sao Tome and Principe<\/OPTION>");
document.writeln("<OPTION value=SA>Saudi Arabia<\/OPTION>");
document.writeln("<OPTION value=SN>Senegal<\/OPTION>");
document.writeln("<OPTION value=SC>Seychelles<\/OPTION>");
document.writeln("<OPTION value=SL>Sierra Leone<\/OPTION>");
document.writeln("<OPTION value=SG>Singapore<\/OPTION>");
document.writeln("<OPTION value=SK>Slovakia (Slovak Republic)<\/OPTION>");
document.writeln("<OPTION value=SI>Slovenia<\/OPTION>");
document.writeln("<OPTION value=SB>Solomon Islands<\/OPTION>");
document.writeln("<OPTION value=SO>Somalia<\/OPTION>");
document.writeln("<OPTION value=ZA>South Africa<\/OPTION>");
document.writeln("<OPTION value=KR>South Korea<\/OPTION>");
document.writeln("<OPTION value=ES>Spain<\/OPTION>");
document.writeln("<OPTION value=LK>Sri Lanka<\/OPTION>");
document.writeln("<OPTION value=SH>St. Helena<\/OPTION>");
document.writeln("<OPTION value=PM>St. Pierre and Miquelon<\/OPTION>");
document.writeln("<OPTION value=SD>Sudan<\/OPTION>");
document.writeln("<OPTION value=SR>Suriname<\/OPTION>");
document.writeln("<OPTION value=SJ>Svalbard and Jan Mayen Islands<\/OPTION>");
document.writeln("<OPTION value=SZ>Swaziland<\/OPTION>");
document.writeln("<OPTION value=SE>Sweden<\/OPTION>");
document.writeln("<OPTION value=CH>Switzerland<\/OPTION>");
document.writeln("<OPTION value=SY>Syrian Arab Republic<\/OPTION>");
document.writeln("<OPTION value=TW>Taiwan<\/OPTION>");
document.writeln("<OPTION value=TJ>Tajikistan<\/OPTION>");
document.writeln("<OPTION value=TZ>Tanzania<\/OPTION>");
document.writeln("<OPTION value=TH>Thailand<\/OPTION>");
document.writeln("<OPTION value=TG>Togo<\/OPTION>");
document.writeln("<OPTION value=TK>Tokelau<\/OPTION>");
document.writeln("<OPTION value=TO>Tonga<\/OPTION>");
document.writeln("<OPTION value=TT>Trinidad and Tobago<\/OPTION>");
document.writeln("<OPTION value=TN>Tunisia<\/OPTION>");
document.writeln("<OPTION value=TR>Turkey<\/OPTION>");
document.writeln("<OPTION value=TM>Turkmenistan<\/OPTION>");
document.writeln("<OPTION value=TC>Turks and Caicos Islands<\/OPTION>");
document.writeln("<OPTION value=TV>Tuvalu<\/OPTION>");
document.writeln("<OPTION value=UG>Uganda<\/OPTION>");
document.writeln("<OPTION value=UA>Ukraine<\/OPTION>");
document.writeln("<OPTION value=AE>United Arab Emirates<\/OPTION>");
document.writeln("<OPTION value=UK>United Kingdom<\/OPTION>");
document.writeln("<OPTION value=US>United States<\/OPTION>");
document.writeln("<OPTION value=UM>United States Minor Outlying Islands<\/OPTION>");
document.writeln("<OPTION value=UY>Uruguay<\/OPTION>");
document.writeln("<OPTION value=UZ>Uzbekistan<\/OPTION>");
document.writeln("<OPTION value=VU>Vanuatu<\/OPTION>");
document.writeln("<OPTION value=VA>Vatican City State (Holy See)<\/OPTION>");
document.writeln("<OPTION value=VE>Venezuela<\/OPTION>");
document.writeln("<OPTION value=VN>Vietnam<\/OPTION>");
document.writeln("<OPTION value=VG>Virgin Islands (British)<\/OPTION>");
document.writeln("<OPTION value=VI>Virgin Islands (U.S.)<\/OPTION>");
document.writeln("<OPTION value=WF>Wallis And Futuna Islands<\/OPTION>");
document.writeln("<OPTION value=EH>Western Sahara<\/OPTION>");
document.writeln("<OPTION value=YE>Yemen<\/OPTION>");
document.writeln("<OPTION value=YU>Yugoslavia<\/OPTION>");
document.writeln("<OPTION value=ZM>Zambia<\/OPTION>");
document.writeln("<OPTION value=ZW>Zimbabwe<\/OPTION><\/SELECT><\/TD><\/TR> ");
document.writeln("<TR> ");
document.writeln("<TD>&nbsp;<\/TD> ");
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document.writeln("<TR> ");
document.writeln("<TD>Tel:<\/TD> ");
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document.writeln("<FONT color=#ff0000>*<\/FONT><\/TD>");
document.writeln("<\/TR> ");
document.writeln("<TR> ");
document.writeln("<TD>E-mail:<\/TD> ");
document.writeln("<TD><INPUT maxLength=250 size=40 name=gemail> ");
document.writeln("<FONT color=#ff0000>*<\/FONT><\/TD><\/TR> ");
document.writeln("<TR> ");
document.writeln("<TD>Endereço:<\/TD> ");
document.writeln("<TD><INPUT maxLength=250 size=40 name=address> ");
document.writeln("<FONT color=#ff0000>*<\/FONT> <\/TD><\/TR> ");
document.writeln("<TR> ");
document.writeln("<TD vAlign=top><p align=\"left\">Mensagem:* <\/p><\/TD> ");
document.writeln("<TD><textarea name=\"gcontent\" rows=\"8\" style=\"width:98%\"><\/textarea><\/TD>");
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