document.write('');
document.write('  <table align="center" style="border: 1px solid #800000">');
document.write('<form method="post" action="http://140575.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td align="left"><font color="#800000" face="Arial" size="4">CD *Schatz, Ich Bin Ein Kapitaen!*</font></td>');
document.write('      <td align="left">');
document.write('        <select name="user_input[id8]">');
document.write('          <option value="0">Keine');
document.write('</option>');
document.write('          <option value="1">1 Stk');
document.write('</option>');
document.write('          <option value="2">2 Stk');
document.write('</option>');
document.write('          <option value="3">3 Stk');
document.write('</option>');
document.write('          <option value="4">4 Stk');
document.write('</option>');
document.write('          <option value="5">5 Stk');
document.write('</option>');
document.write('          <option value="6">6 Stk');
document.write('</option>');
document.write('          <option value="7">7 Stk');
document.write('</option>');
document.write('          <option value="8">8 Stk');
document.write('</option>');
document.write('          <option value="9">9 Stk');
document.write('</option>');
document.write('          <option value="10">10 Stk');
document.write('</option>');
document.write('          <option value="11">11 Stk');
document.write('</option>');
document.write('          <option value="12">12 Stk');
document.write('</option>');
document.write('          <option value="13">13 Stk');
document.write('</option>');
document.write('          <option value="14">14 Stk');
document.write('</option>');
document.write('          <option value="15">15 Stk</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#800000" face="Arial" size="4">CD *Schanzoesische Francons*</font></td>');
document.write('      <td align="left">');
document.write('        <select name="user_input[id15]">');
document.write('          <option value="0">Keine');
document.write('</option>');
document.write('          <option value="1">1 Stk');
document.write('</option>');
document.write('          <option value="2">2 Stk');
document.write('</option>');
document.write('          <option value="3">3 Stk');
document.write('</option>');
document.write('          <option value="4">4 Stk');
document.write('</option>');
document.write('          <option value="5">5 Stk');
document.write('</option>');
document.write('          <option value="6">6 Stk');
document.write('</option>');
document.write('          <option value="7">7 Stk');
document.write('</option>');
document.write('          <option value="8">8 Stk');
document.write('</option>');
document.write('          <option value="9">9 Stk');
document.write('</option>');
document.write('          <option value="10">10 Stk</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#800000" face="Arial" size="4">Schnittchen-Shirt</font></td>');
document.write('      <td align="left">');
document.write('        <select name="user_input[id16]">');
document.write('          <option value="0">Keins');
document.write('</option>');
document.write('          <option value="1">Damen S');
document.write('</option>');
document.write('          <option value="2">Damen M');
document.write('</option>');
document.write('          <option value="3">Damen L');
document.write('</option>');
document.write('          <option value="4">Herren M');
document.write('</option>');
document.write('          <option value="5">Herren L');
document.write('</option>');
document.write('          <option value="6">Herren XL</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#800000" face="Arial" size="4">Button</font></td>');
document.write('      <td align="left">');
document.write('        <select name="user_input[id17]">');
document.write('          <option value="0">Keinen');
document.write('</option>');
document.write('          <option value="1">1 Stk');
document.write('</option>');
document.write('          <option value="2">2 Stk');
document.write('</option>');
document.write('          <option value="3">3 Stk');
document.write('</option>');
document.write('          <option value="4">4 Stk');
document.write('</option>');
document.write('          <option value="5">5 Stk');
document.write('</option>');
document.write('          <option value="6">6 Stk');
document.write('</option>');
document.write('          <option value="7">7 Stk');
document.write('</option>');
document.write('          <option value="8">8 Stk');
document.write('</option>');
document.write('          <option value="9">9 Stk');
document.write('</option>');
document.write('          <option value="10">10 Stk</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="right">        ');
document.write('<BR>');
document.write('       </td>');
document.write('      <td align="left"><font color="#800000" face="Arial" size="4"><b>   ');
document.write('<BR>');
document.write('   </b></font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#800000" face="Arial" size="4">Name und Vorname</font></td>');
document.write('      <td align="left">');
document.write('        <input type="text" name="user_input[id6]" value="" size="40">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#800000" face="Arial" size="4">Strasse, Nr.</font></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><font color="#800000" face="Arial" size="4">Postleitzahl</font></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><font color="#800000" face="Arial" size="4">Ort</font></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><font color="#800000" face="Arial" size="4">Land</font></td>');
document.write('      <td>');
document.write('        <select name="user_input[id12]">');
document.write('          <option value="0">Schweiz');
document.write('</option>');
document.write('          <option value="1">Deutschland');
document.write('</option>');
document.write('          <option value="2">Frankreich');
document.write('</option>');
document.write('          <option value="3">Oesterreich');
document.write('</option>');
document.write('          <option value="4"></option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#800000" face="Arial" size="4">Telefonnummer</font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id14]" value="" size="40">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#800000" face="Arial" size="4">E-Mail-Adresse</font></td>');
document.write('      <td>');
document.write('        <input style=" font-family: Arial;" type="text" name="user_input[id4]" value="" size="40">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td valign="top"><font color="#800000" face="Arial" size="4">Mitteilungen</font></td>');
document.write('      <td>');
document.write('        <textarea name="user_input[id5]" style="width:100%" rows="7"></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="140575">');
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('');