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document.write('<form method="post" action="http://161114.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td colspan="2">Gutschein(e) hier anfordern</td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td colspan="2">mit * gekennzeichnete Felder müssen ausgefüllt werden</td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Anrede</td>');
document.write('      <td>');
document.write('        <select name="user_input[id10]">');
document.write('          <option value="0">Frau');
document.write('</option>');
document.write('          <option value="1">Herr ');
document.write('</option>');
document.write('          <option value="2">Firma</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Vorname/Nachname/Titel *</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id3]" value="" size="40">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Strasse*</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id9]" value="" size="40">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Land/PLZ/Wohnort*</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id11]" value="" size="40">');
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="40">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Telefon</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id12]" value="" size="40">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Betreff</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id5]" value="" size="40">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Welchen  Betrag*</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>Versand*<br>Art der Zusendung</td>');
document.write('      <td>');
document.write('        <select name="user_input[id13]">');
document.write('          <option value="0">Mit der Post ');
document.write('</option>');
document.write('          <option value="1">Per E-mail</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr bgcolor="#cc99cc">');
document.write('      <td>Andere Lieferadresse<br>Bitte hier ');
document.write('<BR>');
document.write('eintragen wenn ');
document.write('<BR>');
document.write('Sie den Gutschein ');
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document.write('an eine andere ');
document.write('<BR>');
document.write('Adresse zugesandt ');
document.write('<BR>');
document.write('haben wollen.');
document.write('<BR>');
document.write('Die Rechnung geht ');
document.write('<BR>');
document.write('an Ihre Adresse </td>');
document.write('      <td>');
document.write('        <textarea name="user_input[id14]" style="width:100%" rows="5"></textarea>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr bgcolor="#ffcccc">');
document.write('      <td>Nachricht<br>Haben Sie noch ');
document.write('<BR>');
document.write('Fragen - dann ');
document.write('<BR>');
document.write('teilen Sie es ');
document.write('<BR>');
document.write('uns bitte hier in ');
document.write('<BR>');
document.write('diesem Feld mit</td>');
document.write('      <td>');
document.write('        <textarea name="user_input[id6]" style="width:100%" rows="5"></textarea>');
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="161114">');
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>');
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