//<script LANGUAGE="JAVASCRIPT">
			
				function submitMyForm(){
					
					if(document.customForm54100.onsubmit())
						{
							ValidateCustomForm(document.customForm54100,0);
							document.customForm54100.submit();
						}
				}
				
				document.writeln('<div>');
				document.writeln('	<h5 class="paddingbottom">Win a laptop with learndirect</h5>');
				
				document.writeln('</div>');
				document.writeln('<div style="float:right;clear:both;line-height:20px;font-size:1.0em;"><p>* Required fields</p>');
				document.writeln('</div>');	
				document.writeln('<div class="leftContainer">');
				document.writeln('	<div id="genericCRMForm">');

				document.writeln('<scr' + 'ipt language="javascript" src="/jsfiles/incCustomFormValidate.js"></sc' + 'ript>');
				document.writeln('<scr' + 'ipt language="javascript" src="/jsfiles/incWsPafLookup.js"></sc' + 'ript>');
				document.writeln('		<scr'+'ipt language="Javascript">');
				document.writeln('	  		//Status for PAF Function');
				document.writeln('			function funPAFLookupStatus(sStatus){');
				document.writeln('				if (sStatus == "BEGIN") {');
				document.writeln('					document.getElementById("spanPAFStatus").innerText = "Please wait..";');
				document.writeln('				}');
				document.writeln('				else if (sStatus == "ERROR") {');
				document.writeln('					document.getElementById("spanPAFStatus").innerText = " Error.";');
				document.writeln('				}');
				document.writeln('				else {');
				document.writeln('					document.getElementById("spanPAFStatus").innerText = "Lookup Complete";');
				document.writeln('				}');
				document.writeln('			}');
				document.writeln('			</scr'+'ipt>');				
				document.writeln('<form name="customForm54100" action="/CustomFormProcess.asp" method="post" onsubmit="return ValidateCustomForm(this,0)">');
				document.writeln('<input type="hidden" name="Title" value="Win a laptop with learndirect">');
				document.writeln('<input type="hidden" name="ID" value="54100">');
				document.writeln('<input type="hidden" name="nConfirmationNum" value="450">');
			 	document.writeln('<input type="hidden" name="NumQuestions" value="-1">');
			 	document.writeln('<input type="hidden" name="NumFields" value="-1">');
				//Set the Template and Custom ID
				if (gnTemplateID != null) {
					document.writeln('<input type="hidden" name="TemplateID" value="' + gnTemplateID + '" />');
				}
				if (gnCustomID != null) {
					document.writeln('<input type="hidden" name="CustomID" value="' + gnCustomID + '" />');
				}
				var sColorSchemeID // USE FOR SUBMIT AND CHECK ADDRESS IMAGES URL
				if (gnColorSchemeID != null) {
					if (gnColorSchemeID == '1988') {
						sColorSchemeID = "home"
					}
					else if (gnColorSchemeID == '1989') {
						sColorSchemeID = "listen"
					}
					else if (gnColorSchemeID == '1990') {
						sColorSchemeID = "music"
					}
					else if (gnColorSchemeID == '1991') {
						sColorSchemeID = "talk"
					}
					else if (gnColorSchemeID == '1992') {
						sColorSchemeID = "club"
					}
					else if (gnColorSchemeID == '1993') {
						sColorSchemeID = "shop"
					}
					else if (gnColorSchemeID == '1994') {
						sColorSchemeID = "competition"
					}
					else if (gnColorSchemeID == '1996') {
						sColorSchemeID = "presenters"
					}
					else if (gnColorSchemeID == '1995') {
						sColorSchemeID = "gigs"
					}
					else {
						sColorSchemeID = "home"
					}
					document.writeln('<input type="hidden" name="ColorSchemeID" value="' + gnColorSchemeID + '" />');
				}
				
			//</script>	 	
      
			
document.writeln('<div class="formwrap generic">');
	
		document.writeln('	<label class="generic">*<input type="hidden" name="FirstNameRequired" value>');
	
	document.writeln('first name:</label>');
document.writeln('	<div class="elementwrap" style="line-height:20px;">');

  
			document.writeln('       <input type="text" id="txtFirstName" name="txtFirstName" value=""  class="genericTxt" size="20" maxLength="80">');
		
document.writeln('    <input type="hidden" name="FirstNameLabel" value="First Name">');
document.writeln('	</div>	');	
document.writeln('</div>	');	


document.writeln('<div class="formwrap generic">');
	
		document.writeln('	<label class="generic">*<input type="hidden" name="LastNameRequired" value>');
	
	document.writeln('surname:</label>');
document.writeln('	<div class="elementwrap" style="line-height:20px;">');

  
			document.writeln('       <input type="text" id="txtLastName" name="txtLastName" value=""  class="genericTxt" size="20" maxLength="80">');
		
document.writeln('    <input type="hidden" name="LastNameLabel" value="Surname">');
document.writeln('	</div>	');	
document.writeln('</div>	');	


document.writeln('<div class="formwrap generic">');
	
		document.writeln('	<label class="generic">*<input type="hidden" name="GenderRequired" value>');
	
	document.writeln('gender:</label>');
document.writeln('	<div class="elementwrap" style="line-height:20px;">');

  
	document.writeln('  	<label class="genericRadio">male</label><input class="genericRadio" type="radio" name="txtGender" value="Male" id="txtGender">');
	document.writeln('  	<label class="genericRadio">female</label><input class="genericRadio" type="radio" name="txtGender" value="Female" id="txtGender">');
				
  
document.writeln('    <input type="hidden" name="GenderLabel" value="Gender">');
document.writeln('	</div>	');	
document.writeln('</div>	');	


document.writeln('<div class="formwrap generic">');
	
		document.writeln('	<label class="generic">*<input type="hidden" name="BirthdateRequired" value>');
	
	document.writeln('date of birth:</label>');
document.writeln('	<div class="elementwrap" style="line-height:20px;">');

  
  
document.writeln('  	<select name="BirthDay" class="genericDay"><option value>DD<option value="1">1<option value="2">2<option value="3">3<option value="4">4<option value="5">5<option value="6">6<option value="7">7<option value="8">8<option value="9">9<option value="10">10<option value="11">11<option value="12">12<option value="13">13<option value="14">14<option value="15">15<option value="16">16<option value="17">17<option value="18">18<option value="19">19<option value="20">20<option value="21">21<option value="22">22<option value="23">23<option value="24">24<option value="25">25<option value="26">26<option value="27">27<option value="28">28<option value="29">29<option value="30">30<option value="31">31</select>');
document.writeln('  	<select name="BirthMonth" class="genericMonth"><option value>MM<option value="1">January<option value="2">February<option value="3">March<option value="4">April<option value="5">May<option value="6">June<option value="7">July<option value="8">August<option value="9">September<option value="10">October<option value="11">November<option value="12">December</select>');
document.writeln('      <select class="genericYear" name="BirthYear" size="1">');
document.writeln('       <option value>YYYY</option>');
  		
document.writeln('	      <option value="2010">2010</option>');
  		
document.writeln('	      <option value="2009">2009</option>');
  		
document.writeln('	      <option value="2008">2008</option>');
  		
document.writeln('	      <option value="2007">2007</option>');
  		
document.writeln('	      <option value="2006">2006</option>');
  		
document.writeln('	      <option value="2005">2005</option>');
  		
document.writeln('	      <option value="2004">2004</option>');
  		
document.writeln('	      <option value="2003">2003</option>');
  		
document.writeln('	      <option value="2002">2002</option>');
  		
document.writeln('	      <option value="2001">2001</option>');
  		
document.writeln('	      <option value="2000">2000</option>');
  		
document.writeln('	      <option value="1999">1999</option>');
  		
document.writeln('	      <option value="1998">1998</option>');
  		
document.writeln('	      <option value="1997">1997</option>');
  		
document.writeln('	      <option value="1996">1996</option>');
  		
document.writeln('	      <option value="1995">1995</option>');
  		
document.writeln('	      <option value="1994">1994</option>');
  		
document.writeln('	      <option value="1993">1993</option>');
  		
document.writeln('	      <option value="1992">1992</option>');
  		
document.writeln('	      <option value="1991">1991</option>');
  		
document.writeln('	      <option value="1990">1990</option>');
  		
document.writeln('	      <option value="1989">1989</option>');
  		
document.writeln('	      <option value="1988">1988</option>');
  		
document.writeln('	      <option value="1987">1987</option>');
  		
document.writeln('	      <option value="1986">1986</option>');
  		
document.writeln('	      <option value="1985">1985</option>');
  		
document.writeln('	      <option value="1984">1984</option>');
  		
document.writeln('	      <option value="1983">1983</option>');
  		
document.writeln('	      <option value="1982">1982</option>');
  		
document.writeln('	      <option value="1981">1981</option>');
  		
document.writeln('	      <option value="1980">1980</option>');
  		
document.writeln('	      <option value="1979">1979</option>');
  		
document.writeln('	      <option value="1978">1978</option>');
  		
document.writeln('	      <option value="1977">1977</option>');
  		
document.writeln('	      <option value="1976">1976</option>');
  		
document.writeln('	      <option value="1975">1975</option>');
  		
document.writeln('	      <option value="1974">1974</option>');
  		
document.writeln('	      <option value="1973">1973</option>');
  		
document.writeln('	      <option value="1972">1972</option>');
  		
document.writeln('	      <option value="1971">1971</option>');
  		
document.writeln('	      <option value="1970">1970</option>');
  		
document.writeln('	      <option value="1969">1969</option>');
  		
document.writeln('	      <option value="1968">1968</option>');
  		
document.writeln('	      <option value="1967">1967</option>');
  		
document.writeln('	      <option value="1966">1966</option>');
  		
document.writeln('	      <option value="1965">1965</option>');
  		
document.writeln('	      <option value="1964">1964</option>');
  		
document.writeln('	      <option value="1963">1963</option>');
  		
document.writeln('	      <option value="1962">1962</option>');
  		
document.writeln('	      <option value="1961">1961</option>');
  		
document.writeln('	      <option value="1960">1960</option>');
  		
document.writeln('	      <option value="1959">1959</option>');
  		
document.writeln('	      <option value="1958">1958</option>');
  		
document.writeln('	      <option value="1957">1957</option>');
  		
document.writeln('	      <option value="1956">1956</option>');
  		
document.writeln('	      <option value="1955">1955</option>');
  		
document.writeln('	      <option value="1954">1954</option>');
  		
document.writeln('	      <option value="1953">1953</option>');
  		
document.writeln('	      <option value="1952">1952</option>');
  		
document.writeln('	      <option value="1951">1951</option>');
  		
document.writeln('	      <option value="1950">1950</option>');
  		
document.writeln('	      <option value="1949">1949</option>');
  		
document.writeln('	      <option value="1948">1948</option>');
  		
document.writeln('	      <option value="1947">1947</option>');
  		
document.writeln('	      <option value="1946">1946</option>');
  		
document.writeln('	      <option value="1945">1945</option>');
  		
document.writeln('	      <option value="1944">1944</option>');
  		
document.writeln('	      <option value="1943">1943</option>');
  		
document.writeln('	      <option value="1942">1942</option>');
  		
document.writeln('	      <option value="1941">1941</option>');
  		
document.writeln('	      <option value="1940">1940</option>');
  		
document.writeln('	      <option value="1939">1939</option>');
  		
document.writeln('	      <option value="1938">1938</option>');
  		
document.writeln('	      <option value="1937">1937</option>');
  		
document.writeln('	      <option value="1936">1936</option>');
  		
document.writeln('	      <option value="1935">1935</option>');
  		
document.writeln('	      <option value="1934">1934</option>');
  		
document.writeln('	      <option value="1933">1933</option>');
  		
document.writeln('	      <option value="1932">1932</option>');
  		
document.writeln('	      <option value="1931">1931</option>');
  		
document.writeln('	      <option value="1930">1930</option>');
  		
document.writeln('	      <option value="1929">1929</option>');
  		
document.writeln('	      <option value="1928">1928</option>');
  		
document.writeln('	      <option value="1927">1927</option>');
  		
document.writeln('	      <option value="1926">1926</option>');
  		
document.writeln('	      <option value="1925">1925</option>');
  		
document.writeln('	      <option value="1924">1924</option>');
  		
document.writeln('	      <option value="1923">1923</option>');
  		
document.writeln('	      <option value="1922">1922</option>');
  		
document.writeln('	      <option value="1921">1921</option>');
  		
document.writeln('	      <option value="1920">1920</option>');
  		
document.writeln('	      <option value="1919">1919</option>');
  		
document.writeln('	      <option value="1918">1918</option>');
  		
document.writeln('	      <option value="1917">1917</option>');
  		
document.writeln('	      <option value="1916">1916</option>');
  		
document.writeln('	      <option value="1915">1915</option>');
  		
document.writeln('	      <option value="1914">1914</option>');
  		
document.writeln('	      <option value="1913">1913</option>');
  		
document.writeln('	      <option value="1912">1912</option>');
  		
document.writeln('	      <option value="1911">1911</option>');
  		
document.writeln('	      <option value="1910">1910</option>');
  		
document.writeln('      </select> ');
  
document.writeln('    <input type="hidden" name="BirthdateLabel" value="Date of Birth">');
document.writeln('	</div>	');	
document.writeln('</div>	');	


document.writeln('<div class="formwrap generic">');
	
		document.writeln('	<label class="generic">*<input type="hidden" name="EmailRequired" value>');
	
	document.writeln('email address:</label>');
document.writeln('	<div class="elementwrap" style="line-height:20px;">');

  
			document.writeln('       <input type="text" id="txtEmail" name="txtEmail" class="genericTxt" size="20" maxLength="80">');
		
document.writeln('    <input type="hidden" name="EmailLabel" value="Email address">');
document.writeln('	</div>	');	
document.writeln('</div>	');	


document.writeln('<div class="formwrap generic">');
	
		document.writeln('	<label class="generic">*<input type="hidden" name="DayPhoneRequired" value>');
	
	document.writeln('daytime phone:</label>');
document.writeln('	<div class="elementwrap" style="line-height:20px;">');

  
			document.writeln('       <input type="text" id="txtDayPhone" name="txtDayPhone" class="genericTxt" size="20" maxLength="15">');
		
document.writeln('    <input type="hidden" name="DayPhoneLabel" value="Daytime Phone">');
document.writeln('	</div>	');	
document.writeln('</div>	');	


document.writeln('<div class="formwrap generic">');
	
		document.writeln('	<label class="generic">*<input type="hidden" name="AddressRequired" value>');
	
	document.writeln('address:</label>');
document.writeln('	<div class="elementwrap" style="line-height:20px;">');

  
			

			document.writeln('       <input type="text" id="txtAddress" name="txtAddress" class="genericTxt" size="20" maxLength="100">');
		
		
document.writeln('    <input type="hidden" name="AddressLabel" value="Address">');
document.writeln('	</div>	');	
document.writeln('</div>	');	


document.writeln('<div class="formwrap generic">');
	
		document.writeln('	<label class="generic">*<input type="hidden" name="Address2Required" value>');
	
	document.writeln('address 2:</label>');
document.writeln('	<div class="elementwrap" style="line-height:20px;">');

  
			document.writeln('       <input type="text" id="txtAddress2" name="txtAddress2" class="genericTxt" size="20" maxLength="30">');
		
document.writeln('    <input type="hidden" name="Address2Label" value="Address 2">');
document.writeln('	</div>	');	
document.writeln('</div>	');	


document.writeln('<div class="formwrap generic">');
	
		document.writeln('	<label class="generic">*<input type="hidden" name="PostcodeRequired" value>');
	
	document.writeln('postcode:</label>');
document.writeln('	<div class="elementwrap" style="line-height:20px;">');

  
			//<script LANGUAGE="JAVASCRIPT">
			document.writeln('		<img src="/images/bg/'+sColorSchemeID+'/postcode_btn.gif" value="check address" class="Imgsubmit" id="btnPostCodeLookup" onclick="funPAFPostalLookup(document.getElementById(\'txtPostcode\').value);funShowHomeCountry();" />');
			//</script>
			
			document.writeln('      <input class="pcode"  type="text" id="txtPostcode" name="txtPostcode" maxLength="30" />');
		
		
document.writeln('    <input type="hidden" name="PostcodeLabel" value="Postcode">');
document.writeln('	</div>	');	
document.writeln('</div>	');	


			document.writeln('		<div class="formwrap generic"><label class="generic notReq" id="spanPAFStatus"></label>');
			document.writeln('		<div class="elementwrap"><div id="selectAddress" style="display:none"><select class="generic" id="selPostCode" name="selPostCode" onclick="funPopulateAddress();"></select></div></div></div>');


					document.writeln('	  <div class="formSpacer"></div>');
					
				//<script LANGUAGE="JAVASCRIPT">
				document.writeln('	  <div class="formwrap generic">');
				document.writeln('		<p class="question"><a href="/CustomFormRules.asp?id=54100"><u>Rules</u></a></p>');
				document.writeln('	  </div>');
				//</script>
				
				//<script LANGUAGE="JAVASCRIPT">
				document.writeln('	 <div class="formwrap generic">');
				document.writeln('		<input type="checkbox" class="genericRadio" name="ExtraOptIn" value="1" id="ExtraOptIn"><label class="genericRadio" for="ExtraOptIn">Please tick here if you would like to receive more offers or information from learndirect. </label> ');
				document.writeln('		<input type="hidden" name="ExtraOptInText" value="Please tick here if you would like to receive more offers or information from learndirect. ">');
				document.writeln('	</div>');
				//</script>	
		
				//<script LANGUAGE="JAVASCRIPT">
				document.writeln('	  <div class="formwrap generic">');
				document.writeln('		<input type="checkbox" class="genericRadio" name="AgreeCheckBox" value="1" id="AgreeCheckBox"><label class="genericRadio" for="AgreeCheckBox">*I have read and agreed to the <a href="/article.asp?id=487570" target="_blank">terms and conditions</a> and Gold\'s <a href="/article.asp?id=487576" target="_blank">privacy policy</a></label> ');
				document.writeln('		<input type="hidden" name="AgreeRequired" value="">');
				document.writeln('		<input type="hidden" name="AgreeLabel" value="Please tick the box agreeing to the station\'s privacy policy">');
				document.writeln('	  </div>');
				//</script>
				
				//<script LANGUAGE="JAVASCRIPT">
				document.writeln('	  <div class="formSpacer"></div>');
				document.writeln('		<div class="formwrap generic">');
				document.writeln('		<input type="image" src="/images/bg/' + sColorSchemeID + '/register_btn.gif" title="send" class="genericReg" /><label class="genericReg"><a href="javascript:submitMyForm();"><strong>Submit</strong></a></label>');
				document.writeln('		</div>');
				document.writeln('		</form>');
				document.writeln('	  </div>');
				document.writeln('</div>');
			//</script>