document.write ('<table cellpadding="0" cellspacing="0" border="0">');
document.write ('<tr>');
document.write ('<td align="center" valign="middle">');
document.write ('<form action="https://www.agayn.com/boutique/newsletter.php" method="get" target="_blank">');
document.write ('<input type="hidden" name="aff" value="vidgfrance">');
document.write ('<input type="hidden" name="discl" value="0">');
document.write ('<input type="hidden" name="op" value="1">');
document.write ('Entrez votre email et recevez <B>10 euros</B> de Bons Cadeaux:');
document.write ('<br>');
document.write ('<input size="<? print ((0!=$fldsize)?$fldsize:"40") ?>" type="text" name="email">');
document.write ('<br>');
document.write ('<center><input type="submit" value="Valider"></center>');
document.write ('</form>');
document.write ('</td>');
document.write ('</tr>');
document.write ('</table>');