document.write('');
document.write('  <table>');
document.write('<form method="post" action="http://169169.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td colspan="2">mit * gekennzeichnete Felder müssen ausgefüllt werden</td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Name *</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>Vorname *</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id11]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Straße und Hausnummer*</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id12]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>E-Mail *</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>Wohnort *</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id13]" value="Groß-Zimmern" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>&nbsp;</td>');
document.write('      <td></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Welchen Artikel möchten Sie? *</td>');
document.write('      <td>');
document.write('        <select name="user_input[id5]">');
document.write('          <option value="0">Kuscheldecke</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Artikelanzahl *</td>');
document.write('      <td>');
document.write('        <select name="user_input[id10]">');
document.write('          <option value="0">1');
document.write('</option>');
document.write('          <option value="1">2');
document.write('</option>');
document.write('          <option value="2">3');
document.write('</option>');
document.write('          <option value="3">4');
document.write('</option>');
document.write('          <option value="4">5');
document.write('</option>');
document.write('          <option value="5">6');
document.write('</option>');
document.write('          <option value="6">7');
document.write('</option>');
document.write('          <option value="7">8');
document.write('</option>');
document.write('          <option value="8">9');
document.write('</option>');
document.write('          <option value="9">10');
document.write('</option>');
document.write('          <option value="10">11');
document.write('</option>');
document.write('          <option value="11">12');
document.write('</option>');
document.write('          <option value="12">13');
document.write('</option>');
document.write('          <option value="13">14');
document.write('</option>');
document.write('          <option value="14">15');
document.write('</option>');
document.write('          <option value="15">16');
document.write('</option>');
document.write('          <option value="16">17');
document.write('</option>');
document.write('          <option value="17">18');
document.write('</option>');
document.write('          <option value="18">19');
document.write('</option>');
document.write('          <option value="19">20</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>(Der Preis je Decke beträgt 6 € inkl. MwSt. )</td>');
document.write('      <td></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>&nbsp;</td>');
document.write('      <td></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Artikel gegen Mehr-Gebühr zuschicken<br>(Die Mehr-Gebühr liegt an der Anzal der Artikel, die Sie bestellen möchten, ab.</td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id7]" value="1" >');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>&nbsp;</td>');
document.write('      <td></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Wir holen den/die Artikel ab.</td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id9]" value="1" >');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>&nbsp;</td>');
document.write('      <td></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>&nbsp;</td>');
document.write('      <td></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Bitte bestätigen Sie ihre Artikelbestellung *</td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id8]" value="1" >');
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="169169">');
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('    <tr>');
document.write('      <td colspan="2" align="center"><font size="-2">Powered by <a href="http://www.onetwomax.de" target="_blank">OneTwoMax</a> Formmailer Script</font></td>');
document.write('    </tr>');
document.write('</form>');
document.write('  </table>');
document.write('');