document.write('<script type=\"text/javascript\" src=\"https://assets.bravenet.com/bn/js/emailfwd/bn_email_forms.min.js\"></script><link rel=\"stylesheet\" href=\"https://pub13.bravenet.com/emailfwd/v2/bnet-form.css.php?usernum=1041286426&formid=4060&formpadding=0\"><form method=\"post\" class=\"bnet-form\" enctype=\"multipart/form-data\" action=\"#bn-ajax-post:1041286426:13:4060\"><div class=\"bn-form-header\"><div class=\"bn-form-legend\"><div>ドクターアグオンラインサロン　退会申し込み</div></div> <div class=\"bn-form-desc\"><p>ドクターアグオンラインサロンをご利用ありがとうございました。退会に当たって以下にお名前等をご記入ください。');
document.write('</p></div></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">お名前 <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-1\" placeholder=\"お名前\" validator=\"\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">お名前（ローマ字） <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-168018380719869\" placeholder=\"Name\" validator=\"\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">Email Address <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-2\" placeholder=\"you must enter a valid email address\" validator=\"email\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><div class=\"bn-row rowcb\"><span class=\"bn-label\">退会の理由をお知らせいただけますか（複数回答可） </span> <span class=\"bn-input\"><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-168018427271277[]\" value=\"入会の目的を果たした\"> <span class=\"bn-inner-label\">入会の目的を果たした</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-168018427271277[]\" value=\"金銭的な理由で退会する\"> <span class=\"bn-inner-label\">金銭的な理由で退会する</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-168018427271277[]\" value=\"ドクターアグの発信頻度が少なかった\"> <span class=\"bn-inner-label\">ドクターアグの発信頻度が少なかった</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-168018427271277[]\" value=\"自分にこのサロンはあわなかった\"> <span class=\"bn-inner-label\">自分にこのサロンはあわなかった</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-168018427271277[]\" value=\"他\"> <span class=\"bn-inner-label\">他</span></label></span></span></div></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">コメントありますか？ </span> <span class=\"bn-input\"><textarea name=\"Field-3\" placeholder=\"enter your comments here\" validator=\"\"></textarea></span></label></div>  <input type=\"hidden\" name=\"carboncopy\" value=\"yuji7508@icloud.com\"> <input type=\"hidden\" name=\"thankyou\" value=\"\"> <input type=\"hidden\" name=\"thankyoutext\" value=\"ドクターアグオンラインサロンの退会が完了しました。');
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document.write('今までご利用ありがとうございました。　');
document.write('');
document.write('またどこかでお会いしましょう！');
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