document.write('');
document.write('  <table>');
document.write('<form method="post" action="http://156833.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2"><b>Kontaktinformationen</b></font></td>');
document.write('      <td><font face="Arial" size="2"><b></b></font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2">Anrede</font></td>');
document.write('      <td><font face="Arial" size="2">');
document.write('        <select name="user_input[id14]">');
document.write('          <option value="0">Herr');
document.write('</option>');
document.write('          <option value="1">Frau</option>');
document.write('        </select>');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2">Name</font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id3]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2">Vorname</font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id4]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2">Adresse</font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id5]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2">PLZ</font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id6]" value="" size="5">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Ort</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id7]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td colspan="2"><font face="Arial" size="2"><b>Bestellung</b></font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2">Produkt</font></td>');
document.write('      <td><font face="Arial" size="2">');
document.write('        <select name="user_input[id15]">');
document.write('          <option value="0">Kundenmagazin Herbst 2009');
document.write('</option>');
document.write('          <option value="1">Geschaeftsbericht 2008');
document.write('</option>');
document.write('          <option value="2">Geschaeftsbericht 2007');
document.write('</option>');
document.write('          <option value="3">Geschaeftsbericht 2006');
document.write('</option>');
document.write('          <option value="4">Vademekum 2009');
document.write('</option>');
document.write('          <option value="5">Vademekum 2008</option>');
document.write('        </select>');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2">Anzahl</font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id16]" value="" size="5">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td colspan="2" align="center" valign="middle">');
document.write('        <input type="hidden" name="mq" value="\'">');
document.write('        <input type="hidden" name="action" value="send_mail">');
document.write('        <input type="hidden" name="entry" value="156833">');
document.write('        <input type="submit" name="submit" value="Abschicken">');
document.write('        <input type="reset" name="reset" value="Zur&uuml;cksetzen">');
document.write('      </td>');
document.write('    </tr>');
document.write('</form>');
document.write('  </table>');
document.write('');