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document.write('<h1>WHERE DO YOU WANT TO BE?</h1>');
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document.write('<h2>If you carry on as you are now, how likely are you to achieve each of the above? Rate each of your answers above on a scale from 1 (&lsquo;definitely not&rsquo;) up to 10 (&lsquo;without a doubt&rsquo;).</h2>');
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document.write('<h2>What are the three biggest shifts or improvements you would like to make in your life and/or career in the next three YEARS?</h2>');
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document.write('<h2>If you carry on as you are now, how likely are you to achieve each of the above? Rate each of the above on a scale from 1 (&lsquo;definitely not&rsquo;) up to 10 (&lsquo;without a doubt&rsquo;).</h2>');
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document.write('<h2>If you carry on as you are now, how likely are you to achieve each of the above? Rate each of the above on a scale from 1 (&lsquo;definitely not&rsquo;) up to 10 (&lsquo;without a doubt&rsquo;).</h2>');
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document.write('<h2>If you carry on as you are now, how likely are you to achieve each of the above? Rate each of the above on a scale from 1 (&lsquo;definitely not&rsquo;) up to 10 (&lsquo;without a doubt&rsquo;).</h2>');
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document.write('<label for="field_159">1</label>');
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document.write('<label for="field_165">1</label>');
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document.write('<label for="field_171">1</label>');
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document.write('<label for="field_177">1</label>');
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document.write('<label for="field_184">If you stay on your current path, what regrets do you think you will have?</label>');
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document.write('<h2>What improvements would you like to make in the following areas of your life?</h2>');
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document.write('<label for="field_186">Financial situation</label>');
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document.write('<label for="field_188">Family/home/life partner</label>');
document.write('<input type="text" class="text" id="field_188" name="field_188" value="" />');
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document.write('<label for="field_189">Social relationships</label>');
document.write('<input type="text" class="text" id="field_189" name="field_189" value="" />');
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document.write('<label for="field_190">Leisure time</label>');
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document.write('<label for="field_191">Health/Self-care</label>');
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document.write('<label for="field_192">Personal character</label>');
document.write('<input type="text" class="text" id="field_192" name="field_192" value="" />');
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document.write('</li>');
document.write('<li>');
document.write('<label for="field_193">Learning</label>');
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document.write('<h2>Personal Details</h2>');
document.write('<div class="textile"></div>');
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document.write('<label for="field_195">NAME:</label>');
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document.write('<li>');
document.write('<label for="field_196">DATE OF BIRTH:</label>');
document.write('<input type="text" class="text" id="field_196" name="field_196" value="" />');
document.write('');
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document.write('<li>');
document.write('<label for="field_197">WORK PHYSICAL ADDRESS:</label>');
document.write('<textarea class="text text_medium" id="field_197" name="field_197"></textarea>');
document.write('</li>');
document.write('<li>');
document.write('<label for="field_198">TEL:</label>');
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document.write('<li>');
document.write('<label for="field_199">CELL:</label>');
document.write('<input type="text" class="text" id="field_199" name="field_199" value="" />');
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document.write('<li>');
document.write('<label for="field_200">FAX:</label>');
document.write('<input type="text" class="text" id="field_200" name="field_200" value="" />');
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document.write('<li>');
document.write('<label for="field_118">E-mail address</label>');
document.write('<input type="text" class="text" id="field_118" name="field_118" value="" />');
document.write('<span class="required">*</span>');
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document.write('<li>');
document.write('<label for="field_201">How much do you currently earn per year before tax or deductions?</label>');
document.write('<ul>');
document.write('<li>');
document.write('<label for="field_202">');
document.write('<input type="checkbox" id="field_202" name="field_202" value="1" />');
document.write('Less than R100 000');
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document.write('</li>');
document.write('<li>');
document.write('<label for="field_203">');
document.write('<input type="checkbox" id="field_203" name="field_203" value="1" />');
document.write('R100 000 &ndash; R200 000');
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document.write('</li>');
document.write('<li>');
document.write('<label for="field_204">');
document.write('<input type="checkbox" id="field_204" name="field_204" value="1" />');
document.write('R200 000 &ndash; R300 000');
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document.write('</li>');
document.write('<li>');
document.write('<label for="field_205">');
document.write('<input type="checkbox" id="field_205" name="field_205" value="1" />');
document.write('R300 000 &ndash; R500 000');
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document.write('</li>');
document.write('<li>');
document.write('<label for="field_206">');
document.write('<input type="checkbox" id="field_206" name="field_206" value="1" />');
document.write('R500 000 &ndash; R750 000');
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document.write('</li>');
document.write('<li>');
document.write('<label for="field_207">');
document.write('<input type="checkbox" id="field_207" name="field_207" value="1" />');
document.write('R750 000 &ndash; R1 000 000');
document.write('</label>');
document.write('</li>');
document.write('<li>');
document.write('<label for="field_208">');
document.write('<input type="checkbox" id="field_208" name="field_208" value="1" />');
document.write('R1 000 000 &ndash; R1 500 000');
document.write('</label>');
document.write('</li>');
document.write('<li>');
document.write('<label for="field_209">');
document.write('<input type="checkbox" id="field_209" name="field_209" value="1" />');
document.write('R1 500 000 &ndash; R2 000 000');
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document.write('</li>');
document.write('<li>');
document.write('<label for="field_210">');
document.write('<input type="checkbox" id="field_210" name="field_210" value="1" />');
document.write('R2 000 000 &ndash; R 4 000 000');
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document.write('</li>');
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document.write('<label for="field_211">');
document.write('<input type="checkbox" id="field_211" name="field_211" value="1" />');
document.write('More than R4 000 000');
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document.write('</li>');
document.write('</ul>');
document.write('</li>');
document.write('<li>');
document.write('<label for="field_212">How much would you like to be earning per year, in three years&rsquo; time?</label>');
document.write('<span style="float: left;">R&nbsp;</span><input type="text" class="text text_currency" id="field_212" name="field_212" value="" />');
document.write('');
document.write('</li>');
document.write('<li>');
document.write('<label for="field_213">If you carry on as you are now, how likely are you to achieve each of the above? Rate yourself on a scale from 1 (&lsquo;definitely not&rsquo;) up to 10 (&lsquo;without a doubt&rsquo;).</label>');
document.write('<select id="field_213" name="field_213">');
document.write('<option selected="selected">1</option>');
document.write('<option>2</option>');
document.write('<option>3</option>');
document.write('<option>4</option>');
document.write('<option>5</option>');
document.write('<option>6</option>');
document.write('<option>7</option>');
document.write('<option>8</option>');
document.write('<option>9</option>');
document.write('<option>10</option>');
document.write('</select>');
document.write('</li>');
document.write('</ul>');
document.write('');
document.write('<input type="submit" value="Submit" />');
document.write('</form>');
document.write('</div>');
document.write('<scr' + 'ipt type="text/javascript">');
document.write('var validator = new Validator(\'ml_form_form\', \'\', \'below\', \'message\');');
document.write('validator.AddValidation(\'field_198\', \'numeric\', \'\', \'Please enter a number\');');
document.write('validator.AddValidation(\'field_199\', \'numeric\', \'\', \'Please enter a number\');');
document.write('validator.AddValidation(\'field_200\', \'numeric\', \'\', \'Please enter a number\');');
document.write('validator.AddValidation(\'field_118\', \'required\', \'\', \'Please enter a value\');');
document.write('validator.AddValidation(\'field_118\', \'email\', \'\', \'Please enter an e-mail address\');');
document.write('validator.AddValidation(\'field_212\', \'float\', \'\', \'Please enter a number\');');
document.write('</scr' + 'ipt>');
document.write('');