document.write('');
document.write('  <table align="center" bgcolor="#336667">');
document.write('<form method="post" action="http://47992.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td bgcolor="#336667"><font color="#FFFFFF">Vorname</font></td>');
document.write('      <td><font color="#FFFFFF">');
document.write('        <input type="text" name="user_input[id7]" value="" size="45">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr class="Vorname" bgcolor="#336667">');
document.write('      <td class="Vorname"><font color="#FFFFFF">Name</font></td>');
document.write('      <td><font color="#000000">');
document.write('        <input type="text" name="user_input[id3]" value="" size="45">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#FFFFFF">E-Mail</font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id4]" value="" size="45">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#FFFFFF">E-Mail2</font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id15]" value="" size="45">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#FFFFFF">Webadresse</font></td>');
document.write('      <td><font color="#FFFFFF">');
document.write('        <input type="text" name="user_input[id17]" value="" size="45">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#FFFFFF">Hausnummer/Adresse</font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id14]" value="" size="45">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#FFFFFF">Ort</font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id12]" value="" size="45">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr class="Personendaten" bgcolor="#336667">');
document.write('      <td><font color="#FFFFFF">Geburtstag</font></td>');
document.write('      <td><font color="#FFFFFF">');
document.write('        <input style=" color: #000000;" type="text" name="user_input[id8]" value="" size="45">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#FFFFFF">Festnetznummer</font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id10]" value="" size="45">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#FFFFFF">Handynummer</font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id11]" value="" size="45">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#FFFFFF">Faxnummer</font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id16]" value="" size="45">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#FFFFFF">Nachricht</font></td>');
document.write('      <td>');
document.write('        <textarea name="user_input[id6]" style="width:100%" rows="4"></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="47992">');
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('</form>');
document.write('  </table>');
document.write('');