document.write('<form name="form1" onsubmit="validate();" method="post" action="/results/trip/">');
document.write("<table width='100%' border='0' align='center' cellPadding='0' cellSpacing='0' class='quote'>");
document.write("<tbody>");
document.write("    <tr valign='top'> ");
document.write("          <td width='3%' class='formbg'>&nbsp;1.</td>");
document.write("          <td width='40%' class='formbg'>");
document.write("			Select the traveler&#39;s place of residence</span></td>");
document.write("          <td colspan='5' align='left' class='formbg'>");
document.write(" 			<select name='CountryOfResidence' size='1' id='CountryOfResidence'>");
document.write("					<option value=''>Select place of residence</option>");
document.write(" 				<option value='2'>Non-USA </option>");
document.write( getUSStatesForCombo());
document.write("				</select>");
document.write("	<input name='affiliate' type='hidden' value='ztravel'></td>");
document.write("    </tr>");
document.write("    <tr valign='top'> ");
document.write("          <td class='formblackbold'>&nbsp;2.</td>");
document.write("          <td class='formblackbold'>Enter the traveler&#39;s age(s)</td>");
document.write("          <td>&nbsp;<input onkeypress='return numbersonly(event);' maxLength='2' size='2' id='Age1' name='Age1' onChange='this.value=extractNumeric(this.value)'></td>");
document.write("          <td>&nbsp;<input onkeypress='return numbersonly(event);' maxLength='2' size='2' id='Age2' name='Age2' onChange='this.value=extractNumeric(this.value)'></td>");
document.write("          <td>&nbsp;<input onkeypress='return numbersonly(event);' maxLength='2' size='2' id='Age3' name='Age3' onChange='this.value=extractNumeric(this.value)'></td>");
document.write("          <td>&nbsp;<input onkeypress='return numbersonly(event);' maxLength='2' size='2' id='Age4' name='Age4' onChange='this.value=extractNumeric(this.value)'></td>");
document.write("          <td>&nbsp;<input onkeypress='return numbersonly(event);' maxLength='2' size='2' id='Age5' name='Age5' onChange='this.value=extractNumeric(this.value)'></td>");
document.write("    </tr>");
document.write("    <tr valign='top' > ");
document.write("           <td height='28' class='formbg'>&nbsp;3.</td>");
document.write("           <td class='formbg'>");
document.write("               Enter the trip cost per person</td>");
document.write("          <td class='formbg'>&nbsp;$");
document.write("				<input size='5' name='TripCost1' maxlength='5' type='text' id='TripCost1' onKeyPress='return isNumericKey(event)' onChange='this.value=extractNumeric(this.value)'>");
document.write("		 </td>");
document.write("          <td class='formbg'>&nbsp;$");
document.write("				<input size='5' name='TripCost2' maxlength='5' type='text' id='TripCost2' onKeyPress='return isNumericKey(event)' onChange='this.value=extractNumeric(this.value)'>");
document.write("		 </td>");
document.write("          <td class='formbg'>&nbsp;$");
document.write("			<input size='5' name='TripCost3' maxlength='5' type='text' id='TripCost3' onKeyPress='return isNumericKey(event)' onChange='this.value=extractNumeric(this.value)'>");
document.write("		 </td>");
document.write("          <td class='formbg'>&nbsp;$");
document.write("				<input size='5' name='TripCost4' maxlength='5' type='text' id='TripCost4' onKeyPress='return isNumericKey(event)' onChange='this.value=extractNumeric(this.value)'>");
document.write("	 </td>");
document.write("          <td class='formbg'>&nbsp;$");
document.write("			<input size='5' name='TripCost5' maxlength='5' type='text' id='TripCost5' onKeyPress='return isNumericKey(event)' onChange='this.value=extractNumeric(this.value)'>");
document.write("		 </td>");
document.write("	</tr>");
document.write("   <tr valign='top'> ");
document.write("            <td class='formblackbold'>&nbsp;4.</td>");
document.write("            <td class='formblackbold'>Select the trip start date </td>");
document.write("            <td colspan='5'> ");
document.write("                 <select size='1' id='DepartureMonth' name='DepartureMonth' onChange='setperiods();'>");
document.write(getMonthHTML());
document.write("                 </select>&nbsp;");
document.write("                 <select size='1' id='DepartureDay' name='DepartureDay' onChange='setperiods();'>");
document.write(getDayHTML());
document.write("				 </select>&nbsp;");
document.write("                 <select size='1' id='DepartureYear' name='DepartureYear' onChange='setperiods();'>");
document.write(getYearHTML());
document.write("                 </select>");
document.write("			</td>");
document.write("</tr>");
document.write("   <tr valign='top'> ");
document.write("            <td class='formbg'>&nbsp;5.</span></td>");
document.write("            <td class='formbg'>Select the trip end date </td>");
document.write("            <td colspan='5' class='formbg'> ");
document.write("                  <select size='1' id='ReturnMonth' name='ReturnMonth' onChange='setperiods();'>");
document.write(getMonthHTML());
document.write("			  </select>&nbsp;");
document.write("                  <select size='1' id='ReturnDay' name='ReturnDay' onChange='setperiods();'>");
document.write(getDayHTML());
document.write("				</select>&nbsp;");
document.write("                 <select size='1' id='ReturnYear' name='ReturnYear' onChange='setperiods();'>");
document.write(getYearHTML());
document.write("                 </select>");
document.write("           </td>");
document.write("    </tr>");
document.write("   <tr><td height='1'>");
document.write('				<input type="hidden" id="DD" name="DD" value="">');
document.write('                <input type="hidden" id="MM" name="DM" value="">');
document.write('                <input type="hidden" id="DY" name="DY" value="">');
document.write('                <input type="hidden" id="RD" name="RD" value="">');
document.write('                <input type="hidden" id="RM" name="RM" value="">');
document.write('                <input type="hidden" id="RY" name="RY" value="">');
document.write('                <input type="hidden" id="ra" name="ra" value="">');			
document.write('			<input type="hidden" id="ta1" name="ta1" value="">');
document.write('                <input type="hidden" id="ta2" name="ta2" value="">');
document.write('                <input type="hidden" id="ta3" name="ta3" value="">');
document.write('                <input type="hidden" id="ta4" name="ta4" value="">');
document.write('                <input type="hidden" id="ta5" name="ta5" value="">');
document.write('                <input type="hidden" id="tc1" name="tc1" value="">');
document.write('                <input type="hidden" id="tc2" name="tc2" value="">');
document.write('                <input type="hidden" id="tc3" name="tc3" value="">');
document.write('                <input type="hidden" id="tc4" name="tc4" value="">');
document.write('                <input type="hidden" id="tc5" name="tc5" value="">');
document.write('                <input type="hidden" id="tl" name="tl" value="">');
document.write(' </td></tr>');
document.write("</tbody>");
document.write(" </table>");
document.write("<br />");
document.write(getCompareButtonRow());
document.write("</form>");