document.write("<label>Pais<br />");
document.write("    <select style=\'background-color:#FBFBFB;border:1px solid #DDDDDD;color:#555555;font-family:'Lucida Grande',Verdana,Arial,'Bitstream Vera Sans',sans-serif;font-size:12px;margin-bottom:12px;max-width:270px;padding-left:2px;\' name='pais' class='input'>");
document.write("      <option value='' >Selecione</option>");
document.write("      <option value='' >------------------</option>");
document.write("      <option value='BRA' selected >Brasil</option>");
document.write("      <option value='' >------------------</option>");
document.write("      <option value='POR' >Portugal</option>");
document.write("      <option value='ESP' >Espanha</option>");
document.write("      <option value='MEX' >Mexico</option>");
document.write("      <option value='ARG' >Argentina</option>");
document.write("      <option value='CHL' >Chile</option>");
document.write("      <option value='PER' >Peru</option>");
document.write("      <option value='COL' >Col?mbia</option>");
document.write("      <option value='VEN' >Venezuela</option>");
document.write("      <option value='' >------------------</option>");
document.write("      <option value='BOL' >Bolivia</option>");
document.write("      <option value='BRA' >Brasil</option>");
document.write("      <option value='CAB' >C.Verde</option>");
document.write("      <option value='CRI' >Costa Rica</option>");
document.write("      <option value='CUB' >Cuba</option>");
document.write("      <option value='ECU' >Ecuador</option>");
document.write("      <option value='ESA' >Salvador</option>");
document.write("      <option value='FIL' >Filipinas</option>");
document.write("      <option value='GUA' >Guatemala</option>");
document.write("      <option value='HON' >Honduras</option>");
document.write("      <option value='NIC' >Nicaragua</option>");
document.write("      <option value='PAN' >Panama</option>");
document.write("      <option value='PAR' >Paraguai</option>");
document.write("      <option value='AND' >Andorra</option>");
document.write("      <option value='PUE' >Porto Rico</option>");
document.write("      <option value='DOM' >Rep.Dom</option>");
document.write("      <option value='USA' >USA</option>");
document.write("      <option value='URU' >Uruguai</option>");
document.write("      <option value='' >------------------</option>");
document.write("      <option value='ZZZ' >Outros</option>");
document.write("    </select>");
document.write("  </label>");
document.write("</p>");
document.write("<p>");
document.write("  <label>CEP<br />");
document.write("    <input type='text' name='cp' size='25' maxlength='60'  />");
document.write("  </label>");
document.write("</p>");
document.write("<p>");
document.write("  <label>Idade<br />");
document.write("    <select style=\'background-color:#FBFBFB;border:1px solid #DDDDDD;color:#555555;font-family:'Lucida Grande',Verdana,Arial,'Bitstream Vera Sans',sans-serif;font-size:12px;margin-bottom:12px;max-width:270px;padding-left:2px;\' name='fec_ncto' class='input'>");
document.write("      <option value=''>Selecione</option>");
document.write("      <option value='01-01-1995'>Posterior a 1995</option>");
document.write("      <option value='01-01-1994'>1994</option>");
document.write("      <option value='01-01-1993'>1993</option>");
document.write("      <option value='01-01-1992'>1992</option>");
document.write("      <option value='01-01-1991'>1991</option>");
document.write("      <option value='01-01-1990'>1990</option>");
document.write("      <option value='01-01-1989'>1989</option>");
document.write("      <option value='01-01-1988'>1988</option>");
document.write("      <option value='01-01-1987'>1987</option>");
document.write("      <option value='01-01-1986'>1986</option>");
document.write("      <option value='01-01-1985'>1985</option>");
document.write("      <option value='01-01-1984'>1984</option>");
document.write("      <option value='01-01-1983'>1983</option>");
document.write("      <option value='01-01-1982'>1982</option>");
document.write("      <option value='01-01-1981'>1981</option>");
document.write("      <option value='01-01-1980'>1980</option>");
document.write("      <option value='01-01-1979'>1979</option>");
document.write("      <option value='01-01-1978'>1978</option>");
document.write("      <option value='01-01-1977'>1977</option>");
document.write("      <option value='01-01-1976'>1976</option>");
document.write("      <option value='01-01-1975'>1975</option>");
document.write("      <option value='01-01-1974'>1974</option>");
document.write("      <option value='01-01-1973'>1973</option>");
document.write("      <option value='01-01-1972'>1972</option>");
document.write("      <option value='01-01-1971'>1971</option>");
document.write("      <option value='01-01-1970'>1970</option>");
document.write("      <option value='01-01-1969'>1969</option>");
document.write("      <option value='01-01-1968'>1968</option>");
document.write("      <option value='01-01-1967'>1967</option>");
document.write("      <option value='01-01-1966'>1966</option>");
document.write("      <option value='01-01-1965'>1965</option>");
document.write("      <option value='01-01-1964'>1964</option>");
document.write("      <option value='01-01-1963'>1963</option>");
document.write("      <option value='01-01-1962'>1962</option>");
document.write("      <option value='01-01-1961'>1961</option>");
document.write("      <option value='01-01-1960'>1960</option>");
document.write("      <option value='01-01-1959'>1959</option>");
document.write("      <option value='01-01-1958'>1958</option>");
document.write("      <option value='01-01-1957'>1957</option>");
document.write("      <option value='01-01-1956'>1956</option>");
document.write("      <option value='01-01-1955'>1955</option>");
document.write("      <option value='01-01-1954'>1954</option>");
document.write("      <option value='01-01-1953'>1953</option>");
document.write("      <option value='01-01-1952'>1952</option>");
document.write("      <option value='01-01-1951'>1951</option>");
document.write("      <option value='01-01-1950'>1950</option>");
document.write("      <option value='01-01-1949'>1949</option>");
document.write("      <option value='01-01-1948'>Antes de 1949 </option>");
document.write("    </select>");
document.write("  </label>");
document.write("</p>");
document.write("<p>");
document.write("  <label>Sexo<br />");
document.write("    <select style=\'background-color:#FBFBFB;border:1px solid #DDDDDD;color:#555555;font-family:'Lucida Grande',Verdana,Arial,'Bitstream Vera Sans',sans-serif;font-size:12px;margin-bottom:12px;max-width:270px;padding-left:2px;\' name='sexo' class='input'>");
document.write("      <option value='' >Selecione</option>");
document.write("      <option value='H' >Masculino</option>");
document.write("      <option value='M' >Feminino </option>");
document.write("    </select>");
document.write("  </label>");
document.write("</p>");
document.write("<p>");
document.write("  <label>Ocupa&ccedil;&atilde;o<br />");
document.write("    <select style=\'background-color:#FBFBFB;border:1px solid #DDDDDD;color:#555555;font-family:'Lucida Grande',Verdana,Arial,'Bitstream Vera Sans',sans-serif;font-size:12px;margin-bottom:12px;max-width:270px;padding-left:2px;\' name='ocupacion' class='input'>");
document.write("   		<option value='' selected>Selecione</option>");
document.write("		<option value='5'>Do Lar</option>");
document.write("        	<option value='6'>Estudante / Universit&aacute;rio</option>");
document.write("        	<option value='1'>Executivo / Empres&aacute;rio</option>");
document.write("        	<option value='3'>Estagi&aacute;rio</option>");
document.write("        	<option value='12'>Profissional liberal/Aut&oacute;nomo</option>");
document.write("		<option value='9'>Funcion&aacute;rio Registrado</option>");
document.write("    </select>");
document.write("  </label>");
document.write("</p>");
document.write("<p>");
document.write("  <label>&Aacute;rea de Atua&ccedil;&atilde;o<br />");
document.write("    <select style=\'background-color:#FBFBFB;border:1px solid #DDDDDD;color:#555555;font-family:'Lucida Grande',Verdana,Arial,'Bitstream Vera Sans',sans-serif;font-size:12px;margin-bottom:12px;max-width:240px;padding-left:2px;\' name='sector' class='input'>");
document.write("      <option value=''>Selecione</option>");
document.write("      <option value='15' >Publicidade / Comunicaçao</option>");
document.write("      <option value='2' >Informatica(Is, Mis, Dp)</option>");
document.write("      <option value='3' >Inform&aacute;tica(Internet)</option>");
document.write("      <option value='4' >Inform&aacute;tica(Desenv. de Software)</option>");
document.write("      <option value='5' >Consultor&iacute;a</option>");
document.write("      <option value='6' >Educaçao</option>");
document.write("      <option value='7' >Arquitetura / Engenharia / Construçao</option>");
document.write("      <option value='8' >Governo / Exercito</option>");
document.write("      <option value='9' >Servicios juridicos</option>");
document.write("      <option value='10' >Fabricaçao / Produçao / Operaçoes</option>");
document.write("      <option value='11' >Medicina</option>");
document.write("      <option value='12' >Pesquisa e Desenvolvimento</option>");
document.write("      <option value='13' >Vendas / Comercializaçao</option>");
document.write("      <option value='14' >Outros</option>");
document.write("      <option value='1' >Contabilidade / Finanças</option>");
document.write("    </select>");
document.write("  </label>");
document.write("</p>");
document.write("<label>&Aacute;reas de Interesses:</label>");
document.write("<br />");
document.write("<table width='300px' border='0' cellspacing='0' cellpadding='0' align='center'>");
document.write("  <tr>");
document.write("    <td><input type='checkbox' name='listas' value='17' >");
document.write("      <a name='1'><b><font size='1' face='Arial, Helvetica, sans-serif' color='#21759B'>Alimentos e Bebidas</font></b></a></td>");
document.write("    <td><input type='checkbox' name='listas' value='41' >");
document.write("      <a name='8'><b><font size='1' face='Arial, Helvetica, sans-serif' color='#21759B'>Automotivo</font></b></a></td>");
document.write("  </tr>");
document.write("  <tr>");
document.write("    <td><input type='checkbox' name='listas' value='25' >");
document.write("      <a name='30'><b><font size='1' face='Arial, Helvetica, sans-serif' color='#21759B'>Conte&uacute;do Feminino</font></b></a></td>");
document.write("    <td><input type='checkbox' name='listas' value='690' >");
document.write("      <a name='90'><b><font size='1' face='Arial, Helvetica, sans-serif' color='#21759B'>Conte&uacute;do Masculino</font></b></a></td>");
document.write("  </tr>");
document.write("  <tr>");
document.write("    <td><input type='checkbox' name='listas' value='9' >");
document.write("      <a name='41'><b><font size='1' face='Arial, Helvetica, sans-serif' color='#21759B'>Esportes e Lazer</font></b></a></td>");
document.write("    <td><input type='checkbox' name='listas' value='30' >");
document.write("      <a name='7'><b><font size='1' face='Arial, Helvetica, sans-serif' color='#21759B'>Neg&oacute;cios e Finan&ccedil;as</font></b></a></td>");
document.write("  </tr>");
document.write("  <tr>");
document.write("    <td><input type='checkbox' name='listas' value='5' >");
document.write("      <a name='2418'><b><font size='1' face='Arial, Helvetica, sans-serif' color='#21759B'>Sa&uacute;de/Beleza/Bem Estar</font></b></a></td>");
document.write("    <td><input type='checkbox' name='listas' value='1133' >");
document.write("      <a name='9'><b><font size='1' face='Arial, Helvetica, sans-serif' color='#21759B'>Tecnologia e Inform&aacute;tica</font></b></a></td>");
document.write("  </tr>");
document.write("  <tr>");
document.write("    <td><input type='checkbox' name='listas' value='691' >");
document.write("      <a name='13'><b><font size='1' face='Arial, Helvetica, sans-serif' color='#21759B'>Bebe & Cia</font></b></a></td>");
document.write("    <td><input type='checkbox' name='listas' value='1164' >");
document.write("      <a name='690'><b><font size='1' face='Arial, Helvetica, sans-serif' color='#21759B'>Casa e Jardim</font></b></a></td>");
document.write("  </tr>");
document.write("  <tr>");
document.write("    <td><input type='checkbox' name='listas' value='13' >");
document.write("      <a name='11'><b><font size='1' face='Arial, Helvetica, sans-serif' color='#21759B'>Emprego e Forma&ccedil;&atilde;o</font></b></a></td>");
document.write("    <td><input type='checkbox' name='listas' value='8' >");
document.write("      <a name='1133'><b><font size='1' face='Arial, Helvetica, sans-serif' color='#21759B'>Entretenimento</font></b></a></td>");
document.write("  </tr>");
document.write("  <tr>");
document.write("    <td><input type='checkbox' name='listas' value='2420' >");
document.write("      <a name='691'><b><font size='1' face='Arial, Helvetica, sans-serif' color='#21759B'>Not&iacute;cias</font></b></a></td>");
document.write("    <td><input type='checkbox' name='listas' value='1165' >");
document.write("      <a name='5'><b><font size='1' face='Arial, Helvetica, sans-serif' color='#21759B'>Ofertas e Promo&ccedil;&otilde;es</font></b></a></td>");
document.write("  </tr>");
document.write("  <tr>");
document.write("    <td><input type='checkbox' name='listas' value='1150' >");
document.write("      <a name='692'><b><font size='1' face='Arial, Helvetica, sans-serif' color='#21759B'>Telefonia & Celular</font></b></a></td>");
document.write("    <td><input type='checkbox' name='listas' value='11' >");
document.write("      <a name='2420'><b><font size='1' face='Arial, Helvetica, sans-serif' color='#21759B'>Viagem e Turismo</font></b></a></td>");
document.write("  </tr>");
document.write("</table>");

