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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:#fffdda;">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>')

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document.write('<tr>')

document.write('<td class="item" width="150" style="background-color:#fffdda;">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>')

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document.write('<tr>')

document.write('<td class="item" width="150" style="background-color:#fffdda;">郵便番号<font color="red">※</font></td>')

document.write('<td width="350" align="left" style="background-color:;"><input type="text" name="_zip01" size="" style="ime-mode:inactive; padding:3px;"> - <input type="text" name="_zip02" size="" style="ime-mode:inactive; padding:3px;"></td>')

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document.write('<tr>')

document.write('<td class="item" width="150" style="background-color:#fffdda;">都道府県<font color="red">※</font></td>')

document.write('<td width="350" align="left" style="background-color:;">')

document.write('<select name="_pref">')
document.write('<option value="">選択してください</option>')
document.write('<option value="北海道">北海道</option>')
document.write('<option value="青森県">青森県</option>')
document.write('<option value="秋田県">秋田県</option>')
document.write('<option value="岩手県">岩手県</option>')
document.write('<option value="宮城県">宮城県</option>')
document.write('<option value="山形県">山形県</option>')
document.write('<option value="福島県">福島県</option>')
document.write('<option value="茨城県">茨城県</option>')
document.write('<option value="栃木県">栃木県</option>')
document.write('<option value="群馬県">群馬県</option>')
document.write('<option value="埼玉県">埼玉県</option>')
document.write('<option value="千葉県">千葉県</option>')
document.write('<option value="東京都">東京都</option>')
document.write('<option value="神奈川県">神奈川県</option>')
document.write('<option value="山梨県">山梨県</option>')
document.write('<option value="長野県">長野県</option>')
document.write('<option value="新潟県">新潟県</option>')
document.write('<option value="富山県">富山県</option>')
document.write('<option value="石川県">石川県</option>')
document.write('<option value="福井県">福井県</option>')
document.write('<option value="岐阜県">岐阜県</option>')
document.write('<option value="静岡県">静岡県</option>')
document.write('<option value="愛知県">愛知県</option>')
document.write('<option value="三重県">三重県</option>')
document.write('<option value="滋賀県">滋賀県</option>')
document.write('<option value="京都府">京都府</option>')
document.write('<option value="奈良県">奈良県</option>')
document.write('<option value="和歌山県">和歌山県</option>')
document.write('<option value="大阪府">大阪府</option>')
document.write('<option value="兵庫県">兵庫県</option>')
document.write('<option value="鳥取県">鳥取県</option>')
document.write('<option value="島根県">島根県</option>')
document.write('<option value="岡山県">岡山県</option>')
document.write('<option value="広島県">広島県</option>')
document.write('<option value="山口県">山口県</option>')
document.write('<option value="徳島県">徳島県</option>')
document.write('<option value="香川県">香川県</option>')
document.write('<option value="愛媛県">愛媛県</option>')
document.write('<option value="高知県">高知県</option>')
document.write('<option value="福岡県">福岡県</option>')
document.write('<option value="佐賀県">佐賀県</option>')
document.write('<option value="長崎県">長崎県</option>')
document.write('<option value="熊本県">熊本県</option>')
document.write('<option value="大分県">大分県</option>')
document.write('<option value="宮崎県">宮崎県</option>')
document.write('<option value="鹿児島県">鹿児島県</option>')
document.write('<option value="沖縄県">沖縄県</option>')
document.write('</select>')

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document.write('<tr>')

document.write('<td class="item" width="150" style="background-color:#fffdda;">市区町村<font color="red">※</font></td>')

document.write('<td width="350" align="left" style="background-color:;"><input type="text" name="_addr" size="35" style="ime-mode:active; padding:3px;"></td>')

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document.write('<tr>')

document.write('<td class="item" width="150" style="background-color:#fffdda;">それ以降の住所<font color="red">※</font></td>')

document.write('<td width="350" align="left" style="background-color:;"><input type="text" name="_addr2" size="35" style="ime-mode:active; padding:3px;"></td>')

document.write('</tr>')


document.write('<tr>')

document.write('<td class="item" width="150" style="background-color:#fffdda;">電話番号<font color="red">※</font></td>')

document.write('<td width="350" align="left" style="background-color:;"><input type="text" name="_telephone" size="35" style="ime-mode:inactive; padding:3px;"></td>')

document.write('</tr>')


document.write('<tr>')

document.write('<td class="item" width="150" style="background-color:#fffdda;">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="bank" id="bank" style="padding:3px;"> <label for="bank">銀行振込</label><br> </td>')

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document.write('<tr>')

document.write('<td colspan="2" class="button" width="500" align="center"><input type="image" src="http://hyper-omori.com/payment_p/img/1387180003.png" style="padding:3px;"> </td>')

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document.write('<input type="hidden" name="enc_val" value="文字">')

document.write('<input type="hidden" name="view_mode" value="">')

document.write('<input type="hidden" name="conect_no" value="1480422400">')

document.write('<input type="hidden" name="conf_file" value="">')

document.write('<input type="hidden" name="char_code" value="2">')

document.write('<input type="hidden" name="char_code2" value="2">')

document.write('<input type="hidden" name="ppitem_id" value="441">')

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