function sendJSRequest(callback,data,url){
	
	var select1_0value = "";
if(document.form406775.select1_0.checked){
	select1_0value = encodeURIComponent(document.form406775.select1_0.value);
}
data = '&select1_0=+'+select1_0value+'+' + data;
var select1_1value = "";
if(document.form406775.select1_1.checked){
	select1_1value = encodeURIComponent(document.form406775.select1_1.value);
}
data = '&select1_1=+'+select1_1value+'+' + data;
var select1_2value = "";
if(document.form406775.select1_2.checked){
	select1_2value = encodeURIComponent(document.form406775.select1_2.value);
}
data = '&select1_2=+'+select1_2value+'+' + data;
var select1_3value = "";
if(document.form406775.select1_3.checked){
	select1_3value = encodeURIComponent(document.form406775.select1_3.value);
}
data = '&select1_3=+'+select1_3value+'+' + data;
var select1_4value = "";
if(document.form406775.select1_4.checked){
	select1_4value = encodeURIComponent(document.form406775.select1_4.value);
}
data = '&select1_4=+'+select1_4value+'+' + data;
var select1_5value = "";
if(document.form406775.select1_5.checked){
	select1_5value = encodeURIComponent(document.form406775.select1_5.value);
}
data = '&select1_5=+'+select1_5value+'+' + data;
var select2_0value = "";
for(i=0; i<document.form406775.select2_0.length; i++){
	if(document.form406775.select2_0[i].checked){
		select2_0value = encodeURIComponent(document.form406775.select2_0[i].value);
	}
}
data = '&select2_0=+'+select2_0value+'+' + data;


	//ローディング表示
	document.getElementById("LoadingBox406775").style.visibility = "visible";	
	 
	 //
	var s = document.createElement("script");
    s.charset = "utf-8";
    s.src = url + "?_callback=" + callback + "&" + data;
    document.body.appendChild(s);
	
  }

  //コールバック関数 ( 受信時に実行 )
  function on_loaded1(res)
  {
	
	//レスポンスされた文字列を表示
    document.getElementById("output406775").innerHTML=res
	
  }

  document.write('<div id="output406775">')
document.write(decodeURIComponent('%3Cdiv%20id%3D%22fc2form%22%3E'))
document.write(decodeURIComponent('%3Cdiv%20class%3D%22toparea%22%3E%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3Cdiv%20class%3D%22message%22%3E%E4%B8%8B%E8%A8%98%E3%83%95%E3%82%A9%E3%83%BC%E3%83%A0%E3%81%B8%E5%85%A5%E5%8A%9B%E3%81%97%20%5B%20%E7%A2%BA%20%E8%AA%8D%20%5D%20%E3%83%9C%E3%82%BF%E3%83%B3%E3%82%92%E6%8A%BC%E3%81%97%E3%81%A6%E3%81%8F%E3%81%A0%E3%81%95%E3%81%84%E3%80%82%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3Cform%20name%3D%22form406775%22%3E'))
document.write(decodeURIComponent('%3Cdiv%20class%3D%22title%22%3E%3Cli%3E%E3%81%94%E5%B8%8C%E6%9C%9B%E3%81%AE%E6%9C%AC'))
document.write(decodeURIComponent('%3C%2Fli%3E%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3Cdiv%20class%3D%22comment%22%3E'))
document.write(decodeURIComponent('%3Cdiv%3E%3Cinput%20type%3D%22checkbox%22%20name%3D%22select1_0%22%20value%3D%22%E9%A2%A8%E3%81%A8%E6%9C%A8%E3%81%AE%E8%A9%A9%E3%81%B2%E3%81%A8%E3%82%8A%E3%82%A2%E3%83%B3%E3%82%BD%E3%83%AD%E3%82%B8%E3%83%BCje%20t%27aime...%E3%81%B2%E3%81%A8%E3%82%8A%EF%BC%88%E9%A2%A8%E3%81%A8%E6%9C%A8%E3%81%AE%E8%A9%A9%EF%BC%89%22%20%3E%20%E9%A2%A8%E3%81%A8%E6%9C%A8%E3%81%AE%E8%A9%A9%E3%81%B2%E3%81%A8%E3%82%8A%E3%82%A2%E3%83%B3%E3%82%BD%E3%83%AD%E3%82%B8%E3%83%BCje%20t%27aime...%E3%81%B2%E3%81%A8%E3%82%8A%EF%BC%88%E9%A2%A8%E3%81%A8%E6%9C%A8%E3%81%AE%E8%A9%A9%EF%BC%89%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3Cdiv%3E%3Cinput%20type%3D%22checkbox%22%20name%3D%22select1_1%22%20value%3D%22%E3%83%84%E3%83%B3%E3%83%87%E3%83%AC%E3%83%BC%E3%82%B7%E3%83%A7%E3%83%B3%E5%90%9B%E3%81%8C%E3%82%B9%E3%82%AD%EF%BC%88%E5%9C%B0%E7%90%83%E3%81%B8%E2%80%A6%EF%BC%89%22%20%3E%20%E3%83%84%E3%83%B3%E3%83%87%E3%83%AC%E3%83%BC%E3%82%B7%E3%83%A7%E3%83%B3%E5%90%9B%E3%81%8C%E3%82%B9%E3%82%AD%EF%BC%88%E5%9C%B0%E7%90%83%E3%81%B8%E2%80%A6%EF%BC%89%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3Cdiv%3E%3Cinput%20type%3D%22checkbox%22%20name%3D%22select1_2%22%20value%3D%22%E3%83%9E%E3%82%A4%E3%82%BB%E5%85%84%E5%BC%9F%EF%BC%88%E9%A2%A8%E3%81%A8%E6%9C%A8%E3%81%AE%E8%A9%A9%EF%BC%89%22%20%3E%20%E3%83%9E%E3%82%A4%E3%82%BB%E5%85%84%E5%BC%9F%EF%BC%88%E9%A2%A8%E3%81%A8%E6%9C%A8%E3%81%AE%E8%A9%A9%EF%BC%89%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3Cdiv%3E%3Cinput%20type%3D%22checkbox%22%20name%3D%22select1_3%22%20value%3D%22Depression%20de%20karl%20Maisse%E3%82%AB%E3%83%BC%E3%83%AB%E3%83%BB%E3%83%9E%E3%82%A4%E3%82%BB%E3%81%AE%E6%86%82%E9%AC%B1%EF%BC%88%E9%A2%A8%E3%81%A8%E6%9C%A8%E3%81%AE%E8%A9%A9%EF%BC%89%22%20%3E%20Depression%20de%20karl%20Maisse%E3%82%AB%E3%83%BC%E3%83%AB%E3%83%BB%E3%83%9E%E3%82%A4%E3%82%BB%E3%81%AE%E6%86%82%E9%AC%B1%EF%BC%88%E9%A2%A8%E3%81%A8%E6%9C%A8%E3%81%AE%E8%A9%A9%EF%BC%89%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3Cdiv%3E%3Cinput%20type%3D%22checkbox%22%20name%3D%22select1_4%22%20value%3D%22%E7%9B%AE%E8%A6%9A%E3%82%81%E3%81%AE%E6%97%A5%EF%BC%88%E5%9C%B0%E7%90%83%E3%81%B8%E2%80%A6%EF%BC%89%22%20%3E%20%E7%9B%AE%E8%A6%9A%E3%82%81%E3%81%AE%E6%97%A5%EF%BC%88%E5%9C%B0%E7%90%83%E3%81%B8%E2%80%A6%EF%BC%89%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3Cdiv%3E%3Cinput%20type%3D%22checkbox%22%20name%3D%22select1_5%22%20value%3D%22%E8%A7%A6%E3%81%A3%E3%81%A6%E3%80%81%E3%82%AD%E3%82%B9%E3%81%97%E3%81%A6%EF%BC%88%E3%82%AE%E3%82%A2%E3%82%B9%EF%BC%89%E2%80%BB%E7%84%A1%E6%96%99%22%20%3E%20%E8%A7%A6%E3%81%A3%E3%81%A6%E3%80%81%E3%82%AD%E3%82%B9%E3%81%97%E3%81%A6%EF%BC%88%E3%82%AE%E3%82%A2%E3%82%B9%EF%BC%89%E2%80%BB%E7%84%A1%E6%96%99%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3Cdiv%20class%3D%22title%22%3E%3Cli%3E%E5%88%A9%E7%94%A8%E6%A9%9F%E9%96%A2'))
document.write(decodeURIComponent('%3Cb%20id%3D%22coution2%22%3E%20%E2%80%BB%20%3C%2Fb%3E'))
document.write(decodeURIComponent('%3C%2Fli%3E%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3Cdiv%20class%3D%22comment%22%3E'))
document.write(decodeURIComponent('%3Cdiv%3E%3Cinput%20type%3D%22radio%22%20name%3D%22select2_0%22%20value%3D%22%E9%83%B5%E4%BE%BF%E6%8C%AF%E6%9B%BF%22%20%3E%20%E9%83%B5%E4%BE%BF%E6%8C%AF%E6%9B%BF%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3Cdiv%3E%3Cinput%20type%3D%22radio%22%20name%3D%22select2_0%22%20value%3D%22%E7%82%BA%E6%9B%BF%22%20%3E%20%E7%82%BA%E6%9B%BF%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3Cdiv%20class%3D%22title%22%3E%3Cli%3E%E5%90%8D%E3%80%80%E5%89%8D'))
document.write(decodeURIComponent('%3C%2Fli%3E%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3Cdiv%20class%3D%22comment%22%3E%3Cinput%20name%3D%22name%22%20type%3D%22text%22%20maxlength%3D%2250%22%20value%3D%22%22%3E'))
document.write(decodeURIComponent('%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3Cdiv%20class%3D%22title%22%3E%3Cli%3EHN%EF%BC%88%E4%BB%BB%E6%84%8F%E3%81%A7%E3%81%99%EF%BC%89'))
document.write(decodeURIComponent('%3C%2Fli%3E%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3Cdiv%20class%3D%22comment%22%3E%3Cinput%20name%3D%22text2%22%20type%3D%22text%22%20class%3D%22form-textline%22%20size%3D%2225%22%20maxlength%3D%22500%22%20value%3D%22%22%3E%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3Cdiv%20class%3D%22title%22%3E%3Cli%3E%E3%83%A1%E3%83%BC%E3%83%AB%E3%82%A2%E3%83%89%E3%83%AC%E3%82%B9'))
document.write(decodeURIComponent('%3C%2Fli%3E%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3Cdiv%20class%3D%22comment%22%3E%3Cinput%20name%3D%22mail%22%20type%3D%22text%22%20maxlength%3D%22100%22%20value%3D%22%22%20style%3D%22ime-mode%3Adisabled%3B%22%3E'))
document.write(decodeURIComponent('%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3Cdiv%20class%3D%22title%22%3E%3Cli%3E%E4%BD%8F%E3%80%80%E6%89%80'))
document.write(decodeURIComponent('%3C%2Fli%3E%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3Cdiv%20class%3D%22comment%22%3E%3Cinput%20name%3D%22address%22%20type%3D%22text%22%20maxlength%3D%221000%22%20value%3D%22%22%3E'))
document.write(decodeURIComponent('%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3Cdiv%20class%3D%22title%22%3E%3Cli%3E%E4%BD%95%E3%81%8B%E3%81%82%E3%82%8C%E3%81%B0%E3%81%A9%E3%81%86%E3%81%9E'))
document.write(decodeURIComponent('%3C%2Fli%3E%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3Cdiv%20class%3D%22comment%22%3E%3Ctextarea%20name%3D%22text1%22%20cols%3D%2230%22%20rows%3D%223%22%20class%3D%22form-textbox%22%3E%3C%2Ftextarea%3E%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3Cdiv%20class%3D%22submit%22%3E%3Cdiv%20id%3D%22LoadingBox406775%22%20style%3D%22clear%3Aleft%3Bpadding%3A3px%3Bvisibility%3Ahidden%3Bposition%3Arelative%3Btop%3A23%3Bbackground-color%3A%20%23FFFFFF%3Bborder%3A%201px%20solid%20%23999999%3Btext-align%3A%20center%3B%22%3E%3Cimg%20src%3D%22http%3A%2F%2Fform1.fc2.com%2Fparts%2Floading1.gif%22%3E%3Cimg%20src%3D%22http%3A%2F%2Fform1.fc2.com%2Fparts%2Floading2.gif%22%3E%3C%2Fdiv%3E%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3Cdiv%20class%3D%22submit%22%3E%3Cinput%20type%3D%22button%22value%3D%22%E7%A2%BA%E8%AA%8D%22onclick%3DsendJSRequest%28%22on_loaded1%22%2C%22%26name%3D%22%2BencodeURIComponent%28this.form.name.value%29%2B%22%26text2%3D%22%2BencodeURIComponent%28this.form.text2.value%29%2B%22%26mail%3D%22%2BencodeURIComponent%28this.form.mail.value%29%2B%22%26address%3D%22%2BencodeURIComponent%28this.form.address.value%29%2B%22%26text1%3D%22%2BencodeURIComponent%28this.form.text1.value%29%2B%22%26Submit1%3D%22%2B1%2B%22%26id%3D%22%2B406775%2C%22http%3A%2F%2Fform1.fc2.com%2Fparts%2F%22%29%20class%3D%22button%22%3E%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3C%2Fform%3E'))
document.write(decodeURIComponent('%3Cdiv%20class%3D%22bottomarea%22%3E%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3Cdiv%20style%3D%22font-size%3A12px%3Bmargin-top%3A3px%3B%22%3E%3Ca%20href%3D%22http%3A%2F%2Fform.fc2.com%2F%22%20target%3D%22_blank%22%3E%5B%20FC2%E3%83%A1%E3%83%BC%E3%83%AB%E3%83%95%E3%82%A9%E3%83%BC%E3%83%A0%20%5D%3C%2Fa%3E%3C%2Fdiv%3E'))
document.write(decodeURIComponent('%3Cstyle%20type%3D%22text%2Fcss%22%3E'))
document.write(decodeURIComponent('%3C%21--'))
document.write(decodeURIComponent('%23fc2form%20%7B%0A%09border%3A%201px%20solid%20%23666666%3B%0A%09padding%3A%2010px%3B%0A%09width%3A%20370px%3B%0A%09font-size%3A%2012px%3B%0A%7D%0A%23fc2form%20.toparea%7B%0A%0A%7D%0A%23fc2form%20.message%7B%0A%09clear%3A%20left%3B%0A%7D%0A%23fc2form%20%23coution1%7B%0A%09font-weight%3A%20bold%3B%0A%09color%3A%20%23FF0000%3B%0A%7D%0A%23fc2form%20%23coution2%7B%0A%09font-size%3A%208px%3B%0A%09font-weight%3A%20bold%3B%0A%09color%3A%20%23FF0000%3B%0A%7D%0A%23fc2form%20.title%7B%0A%09clear%3A%20left%3B%0A%09float%3A%20left%3B%0A%09width%3A%20150px%3B%0A%7D%0A%23fc2form%20.comment%7B%0A%09float%3A%20left%3B%0A%09width%3A%20200px%3B%0A%7D%0A%23fc2form%20.submit%7B%0A%09text-align%3A%20center%3B%0A%09clear%3A%20left%3B%0A%7D%0A%23fc2form%20.button%7B%0A%09%0A%7D%0A%23fc2form%20.bottomarea%7B%0A%0A%7D%0A%2F%2A----------------------------------------%2A%2F%0A%23fc2form%20%23order%20hr%7B%0A%09clear%3A%20left%3B%0A%7D%0A%23fc2form%20%23order%20.title%7B%0A%09%0A%7D%0A%23fc2form%20%23order%20.comment%7B%0A%09%0A%7D%0A%23fc2form%20%23order-sub%20.title%7B%0A%09width%3A%20130px%3B%0A%09margin-left%3A%2010px%3B%0A%7D%0A%23fc2form%20%23order-sub%20.comment%7B%0A%09%0A%7D%0A%23fc2form%20%23order-total%20.title%7B%0A%09%0A%7D%0A%23fc2form%20%23order-total%20.comment%7B%0A%09%0A%7D%0A%23fc2form%20%23order-select%20.title%7B%0A%09%0A%7D%0A%23fc2form%20%23order-select%20.comment%7B%0A%09%0A%7D'))
document.write(decodeURIComponent('--%3E'))
document.write(decodeURIComponent('%3C%2Fstyle%3E'))
document.write('</div>')