code:

<form action="modqueue.php" method="post">
<input type="hidden" name="userid" value="40558">
<input type="hidden" name="postid" value="504938037">
<input type="hidden" name="act" value="2">
<input type="hidden" name="action" value="submitrequest">
<div class="standard">
<h2>ModQueue Probation Request</h2>
<div class="inner">
Request an admin to put a user on probation using the form below. Probation is a warning period during which the user is not allowed to post. All fields, including reason, are required. Requests by moderators will go into a queue awaiting administrator approval. Administrators requests will be processed immediately.<br>
<br>
<hr size=1>
<table>
<tr>
<td align="right" valign="top" nowrap><b>User:</b></td>
<td>Pocket_Pool</td>
<td rowspan=3><img src="//fi.somethingawful.com/images/probation.jpg" border=0 width=100 height=100></td>
</tr>
<tr>
<td align="right" valign="top" nowrap><b>History:</b></td>
<td>None</td>
</tr>
<tr>
<td colspan=2>
<b>Block posting for:</b>
<select name="data">
<option value=1>6 hours
<option value=2>12 hours
<option value=8>18 hours
<option value=3>1 day
<option value=4>3 days
<option value=5>1 week
<option value=9>2 weeks
<option value=6>1 month
<option value=7>100,000 hours
</select>
</td>
</tr>
</table>
<hr size=1>
<b>Reason for probation:</b> (visible to <b>ALL</b> forum members!)<br>Will be used as the warning reason in Leper's Colony. <span style="color:red;font-size:11px;font-weight: bold;"><blink>PLEASE capitalize the first letter of sentences and end them with a period or something!</blink></style><br>
<textarea name="reason" rows=6 cols=50></textarea><br>
<br>
<b>Moderator Notes:</b> (optional, visible only to mods and admins!)<br>Use this to leave private notes for other mods/admins about your request.<br>
<textarea name="notes" rows=6 cols=50></textarea><br>
<br>
<hr size=1>
<input type="submit" class="bginput" name="submit" value="Submit" accesskey="s">
</div>
</div>
</form>