document.write('');
document.write('  <table>');
document.write('<form method="post" action="http://133232.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td colspan="2"><font size="4"><b>BESTELLUNG STAMMBAUM DER BIBEL</b></font></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[id24]">');
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>Name/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[id7]" value="" size="40">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Länderkennung/PLZ*</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id8]" value="" size="10">');
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[id9]" 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[id10]" value="" size="40">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Mobil</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>*****************************</td>');
document.write('      <td></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="right">Stückzahl*</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id13]" value="" size="5">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="right">Stammbaum der Bibel als Poster<br>Lieferung erfolgt gerollt</td>');
document.write('      <td>');
document.write('        <select name="user_input[id12]">');
document.write('          <option value="0">Bitte wählen Sie aus');
document.write('</option>');
document.write('          <option value="1">');
document.write('</option>');
document.write('          <option value="2">Poster 35 x 50cm á € 22,00</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>*****************************</td>');
document.write('      <td></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="right">Stückzahl*</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id14]" value="" size="5">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="right">Stammbaum der Bibel als Druck<br>Aufgezogen und versiegelt</td>');
document.write('      <td>');
document.write('        <select name="user_input[id15]">');
document.write('          <option value="0">Bitte wählen Sie aus');
document.write('</option>');
document.write('          <option value="1">Druck 40 x 57 cm  á € 106,-');
document.write('</option>');
document.write('          <option value="2">Druck 56 x 80 cm  á € 220,-');
document.write('</option>');
document.write('          <option value="3">Druck 84 x 120 cm  á €7 607,-');
document.write('</option>');
document.write('          <option value="4">Druck 120 x 160cm  á € 1.633,-');
document.write('</option>');
document.write('          <option value="5">Druck 140 x 200cm  á € 3.275,- </option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="right">*****************************</td>');
document.write('      <td></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="right">Stückzahl*</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id19]" value="" size="5" maxlength="2">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="right">Gemälde in Handarbeit</td>');
document.write('      <td>');
document.write('        <select name="user_input[id18]">');
document.write('          <option value="0">Bitte wählen Sie aus');
document.write('</option>');
document.write('          <option value="1">Gemälde 140 x 90 cm á € 4.825.-</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Anmerkungen<br>Haben Sie Fragen zu den Produkten?');
document.write('<BR>');
document.write('Bitte tragen Sie sie hier ein!</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>Wir danken für Ihre Bestellung!</td>');
document.write('      <td></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Ein Hinweis:<br>Ihre Adressangaben werden von uns selbstverständlich vertraulich behandelt und nicht an Dritte weitergegeben!</td>');
document.write('      <td></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="133232">');
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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