document.write('');
document.write('  <table>');
document.write('<form method="post" action="http://152085.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td><font color="#660033" face="Comic Sans MS" size="-1">Name *</font></td>');
document.write('      <td><font color="#660033" face="Comic Sans MS">');
document.write('        <input type="text" name="user_input[id3]" value="" size="50">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#660033" face="Comic Sans MS" size="-1">Vorname*</font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id9]" value="" size="50">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#660033" face="Comic Sans MS" size="-1">Strasse und Hausnummer*</font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id10]" value="" size="50">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#660033" face="Comic Sans MS" size="-1">PLZ*</font></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><font color="#660033" face="Comic Sans MS" size="-1">Wohnort*</font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id12]" value="" size="50">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#660033" face="Comic Sans MS" size="-1">Land *</font></td>');
document.write('      <td>');
document.write('        <select name="user_input[id17]">');
document.write('          <option value="0">Deutschland');
document.write('</option>');
document.write('          <option value="1">Österreich');
document.write('</option>');
document.write('          <option value="2">Schweiz');
document.write('</option>');
document.write('          <option value="3">anderes Land/other country</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#660033" face="Comic Sans MS" size="-1">E-Mail *</font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id4]" value="" size="50">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#660033" face="Comic Sans MS" size="-1">Telefonnummer (Festnetz)*</font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id13]" value="" size="50">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#660033" face="Comic Sans MS" size="-1">Handynummer*</font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id15]" value="" size="50">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#660033" face="Comic Sans MS" size="-1">Betreff *</font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id5]" value="" size="50">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#660033" face="Comic Sans MS" size="-1">Anfrage, Terminwünsche, Bestellungen*</font></td>');
document.write('      <td>');
document.write('        <textarea name="user_input[id6]" style="width:100%" rows="20"></textarea>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#660033" face="Comic sans MS" size="-1">Versand (Päckchen, Paket, Maxibrief) oder Laden</font></td>');
document.write('      <td>');
document.write('        <select name="user_input[id27]">');
document.write('          <option value="0">versicherter Versand (Regelfall)');
document.write('</option>');
document.write('          <option value="1">Maxibrief o h n e Einschreiben');
document.write('</option>');
document.write('          <option value="2">wird im Laden abgeholt</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#660033" face="Comic sans MS" size="-1">Backformen: Leihen , Kaufen, sonstiges ? *</font></td>');
document.write('      <td><font face="Comic Sans MS" size="-1">');
document.write('        <select name="user_input[id26]">');
document.write('          <option value="0">Bitte entscheiden !');
document.write('</option>');
document.write('          <option value="1">Backformen nur leihen');
document.write('</option>');
document.write('          <option value="2">Backformen nur kaufen');
document.write('</option>');
document.write('          <option value="3">leihen oder eventuell kaufen');
document.write('</option>');
document.write('          <option value="4">Sonstiges, Fragen , Zubehör usw.</option>');
document.write('        </select>');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#660033" face="Comic Sans MS" size="-1">Bäckerstärke mitbestellen? *</font></td>');
document.write('      <td>');
document.write('        <select name="user_input[id19]">');
document.write('          <option value="0">Bitte entscheiden !');
document.write('</option>');
document.write('          <option value="1">Ja (1 Dose mit 200 g) 1,90 €');
document.write('</option>');
document.write('          <option value="2">Ja (2 Dosen) 3,70 €');
document.write('</option>');
document.write('          <option value="3">Ja (3 Dosen) 5,50 €');
document.write('</option>');
document.write('          <option value="4">Nein</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#660033" face="Comic Sans MS" size="-1">Soll ein Rücksendeaufkleber mitgeschickt werden? *</font></td>');
document.write('      <td>');
document.write('        <select name="user_input[id20]">');
document.write('          <option value="0">Bitte entscheiden !');
document.write('</option>');
document.write('          <option value="1">Ja, bitte einen Rücksendeaufkleber mitschicken.');
document.write('</option>');
document.write('          <option value="2">Nein</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#660033" face="Comic Sans MS" size="-1">Kontaktaufnahme (bei  Rückfragen)*</font></td>');
document.write('      <td>');
document.write('        <select name="user_input[id24]">');
document.write('          <option value="0">bitte entscheiden');
document.write('</option>');
document.write('          <option value="1">egal, Sie können mich überall erreichen');
document.write('</option>');
document.write('          <option value="2">bitte nur e-mail Kontakt');
document.write('</option>');
document.write('          <option value="3">bitte nur Handykontakt');
document.write('</option>');
document.write('          <option value="4">bitte nur e-mail oder Handykontakt</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#660033" face="Comic Sans MS" size="-1">AGB gelesen und anerkannt*</font></td>');
document.write('      <td>');
document.write('        <select name="user_input[id7]">');
document.write('          <option value="0">bitte auswählen');
document.write('</option>');
document.write('          <option value="1">ja');
document.write('</option>');
document.write('          <option value="2">nein, dann bitte abbrechen</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#660033" face="Comic Sans MS" size="-1">Widerrufsbelehrung zur Kenntnis genommen*</font></td>');
document.write('      <td>');
document.write('        <select name="user_input[id8]">');
document.write('          <option value="0">bitte auswählen');
document.write('</option>');
document.write('          <option value="1">ja');
document.write('</option>');
document.write('          <option value="2">nein, dann bitte abbrechen</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#660033" face="Comic Sans MS" size="-1">Mindestalter 18 Jahre *</font></td>');
document.write('      <td>');
document.write('        <select name="user_input[id16]">');
document.write('          <option value="0">bitte auswählen');
document.write('</option>');
document.write('          <option value="1">ja');
document.write('</option>');
document.write('          <option value="2">nein, dann bitte abbrechen</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#660033" face="Comic sans MS" size="-1">Datenschutz zur Kenntnis genommen*</font></td>');
document.write('      <td>');
document.write('        <select name="user_input[id23]">');
document.write('          <option value="0">bitte auswählen');
document.write('</option>');
document.write('          <option value="1">ja');
document.write('</option>');
document.write('          <option value="2">nein, dann bitte abbrechen </option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#660033" face="Comic sans MS" size="-1">Wir kamen Sie auf uns</font></td>');
document.write('      <td>');
document.write('        <select name="user_input[id28]">');
document.write('          <option value="0">Bitte auswählen:');
document.write('</option>');
document.write('          <option value="1">durch Surfen im Internet');
document.write('</option>');
document.write('          <option value="2">durch Berichte in Zeitungen');
document.write('</option>');
document.write('          <option value="3">durch Berichte im Fernsehen');
document.write('</option>');
document.write('          <option value="4">durch Bekannte/Mundpropaganda');
document.write('</option>');
document.write('          <option value="5">durch Messen, Veranstaltungen');
document.write('</option>');
document.write('          <option value="6">durch andere Werbung (Flyer usw.)');
document.write('</option>');
document.write('          <option value="7">schon einmal bestellt');
document.write('</option>');
document.write('          <option value="8">Sonstiges (bitte im &quot;betreff&quot; schreiben)</option>');
document.write('        </select>');
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="152085">');
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('');