\n");
document.write(" | First Name: | \n");
document.write(" | \n");
document.write("
\n");
document.write(" | Last Name: | \n");
document.write(" | \n");
document.write("
\n");
document.write(" | Address 1: | \n");
document.write(" | \n");
document.write("
\n");
document.write(" | City: | \n");
document.write(" | \n");
document.write("
\n");
document.write(" | State/Province: | \n");
document.write(" | \n");
document.write("
\n");
document.write(" | Zip Code: | \n");
document.write(" | \n");
document.write("
\n");
document.write(" | Country: | \n");
document.write(" | \n");
document.write("
\n");
document.write(" | Email Address: | \n");
document.write(" | \n");
document.write("
\n");
document.write(" | Home Phone: | \n");
document.write(" | \n");
document.write("
\n");
document.write(" | Date of Birth: | \n");
document.write(" | \n");
document.write("
\n");
document.write("\n");
document.write(" \n");
document.write(" You \n");
document.write(" are required to provide two forms of identification.
\n");
document.write(" This information will “never” be released to anyone.
\n");
document.write(" It is for the sole purpose of confirming your legal age.
\n");
document.write(" Please choose two of the following four ID options. | \n");
document.write(" \n");
document.write(" \n");
document.write(" \n");
document.write(" |
\n");
document.write("\n");
document.write(" | Social Security Number (USA): | \n");
document.write(" | \n");
document.write("
\n");
document.write(" | Social Insurance Number (Canada): | \n");
document.write(" | \n");
document.write("
\n");
document.write(" | Passport Number: | \n");
document.write(" | \n");
document.write("
\n");
document.write(" | Drivers License (State & Number): | \n");
document.write(" | \n");
document.write("
\n");
document.write("\n");
document.write(" \n");
document.write(" | | \n");
document.write(" \n");
document.write(" \n");
document.write(" \n");
document.write(" |
\n");
document.write("\n");
document.write(" | Additional Comments: | \n");
document.write(" | \n");
document.write("
\n");
document.write("