document.write('<!--LP_FORM_START-->');
document.write('		  <section class="area-form" id="form">');
document.write('			  <h2>お問合せ・お見積もり依頼</h2>');
document.write('			  <div class="wrap inner">');
document.write('				');
document.write('					  <div class="flow-list-2">');
document.write('						  <p>');
document.write('							  <b>簡単</b>');
document.write('							  <span>3</span>');
document.write('							  <b>ステップ</b>');
document.write('						  </p>');
document.write('						  <ol>');
document.write('							  <li class="active">入力</li>');
document.write('							  <li>確認</li>');
document.write('							  <li>完了</li>');
document.write('						  </ol>');
document.write('					  </div>');
document.write('			  ');
document.write('					  <form method="post" name="sfm-form" id="sfm-form" action="//99-denki.com/washer/area/confirm.html">');
document.write('						  <table class="form-table">');
document.write('							  <tr class="required-input">');
document.write('								  <th>郵便番号 <span class="required">必須</span></th>');
document.write('								  <td>');
document.write('									  <input type="text" id="postcode1" name="postcode1_s" size="10" maxlength="7" inputmode="numeric" placeholder="例）1234567" value="">');
document.write('									  <div class="ERR" ></div>');
document.write('								  </td>');
document.write('							  </tr>');
document.write('							  <tr class="required-input">');
document.write('								  <th>お名前 <span class="required">必須</span></th>');
document.write('								  <td>');
document.write('									  <input class="text" type="text" name="name_s" id="name" size="30" placeholder="例）東京太郎" value=""/>');
document.write('									  <div class="ERR" ></div>');
document.write('								  </td>');
document.write('							  </tr>');
document.write('			  ');
document.write('							  <tr class="required-input">');
document.write('								  <th>携帯電話番号 <span class="required">必須</span></th>');
document.write('								  <td>');
document.write('									  <input type="tel" name="tel_s" id="tel" placeholder="例）09012345678" value=""/>');
document.write('									  <div class="ERR" ></div>');
document.write('								  </td>');
document.write('							  </tr>');
document.write('							  <tr>');
document.write('								  <th>メールアドレス <span class="form_any">任意</span></th>');
document.write('								  <td>');
document.write('									  <input type="email" name="mail" id="email" class="half-width" placeholder="例）example@flets-hikari.com" value="">');
document.write('								  </td>');
document.write('							  </tr>');
document.write('						  </table>');
document.write('			  ');
document.write('						  <!-- PC / スマホアクセスを判別（メール件名振り分け） -->');
document.write('						  <input type="hidden" name="subject" value="【99電気_日中_PC】提供エリア確認メール" />');
document.write('						  <!-- 注文番号 -->');
document.write('						  <input type="hidden" name="orderid" id="orderid" value="20240707194725" />');
document.write('			  ');
document.write('						  <div align="center">');
document.write('							  <input type="hidden" name="action" value="conf" />');
document.write('							  <input class="button alert click" id="btn_area" type="submit" name="submit" value="提供エリアを確認" />');
document.write('							  <!--<input type="reset" name="reset" value="リセット" />-->');
document.write('						  </div>');
document.write('					  </form>');
document.write('					  <div id="cookie-data"></div>');
document.write('				  </div>');
document.write('		  </section>');
document.write('		  ');
document.write('<script>');
document.write('var lpQuery = location.search;');
document.write('var element = document.forms[0]; ');
document.write('element.action = element.getAttribute(\'action\')+lpQuery;');
document.write('</script>');