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document.write('<form method="post" action="http://170143.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td align="center" colspan="2">Fotokissenformular</td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="center" colspan="2">mit * gekennzeichnete Felder müssen ausgefüllt werden</td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Nachname *</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[id10]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Anschrift*</td>');
document.write('      <td>');
document.write('        <textarea name="user_input[id7]" style="width:100%" rows="5"></textarea>');
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>Bildunterschrift<br><font size="1">Nur Ausfüllen, wenn Text unter dem Bild gewünscht');
document.write('<BR>');
document.write('(max. 18 Zeichen möglich)</font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id5]" value="" size="20" maxlength="18">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Stofffarbe* für Kissenrückseite</td>');
document.write('      <td>');
document.write('        <select name="user_input[id9]">');
document.write('          <option value="0">Stofffarben:');
document.write('</option>');
document.write('          <option value="1">Bw, Standard');
document.write('</option>');
document.write('          <option value="2">Bw, Einsatz');
document.write('</option>');
document.write('          <option value="3">Khaki');
document.write('</option>');
document.write('          <option value="4">Marineblau');
document.write('</option>');
document.write('          <option value="5">Sonstige, nach Absprache</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Sprachrekorder<br><font size="1">Möchten Sie einen Sprachrekorder zu Ihrem Kissen bestellen?</font></td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id11]" value="1" >');
document.write('        Ja, ich möchte einen Sprachrekorder bestellen');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Nachricht<br><font size="1">Weitere Wünsche und Ideen bitte hier eintragen</font></td>');
document.write('      <td>');
document.write('        <textarea name="user_input[id6]" style="width:100%" rows="7"></textarea>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>AGB*<br><font size="1">AGB\'s gelesen und akzeptiert</font></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="170143">');
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('');