document.write('');
document.write('  <table>');
document.write('<form method="post" action="http://132159.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td>Firma</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id12]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Name_Vorname</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id13]" value="" size="20">');
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[id14]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>PLZ</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id5]" value="" size="5">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Ort</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id15]" value="" size="20">');
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[id16]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Telefax</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id8]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Mail</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id17]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Webseite</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id9]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Rubrik</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id18]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Beschreibung</td>');
document.write('      <td>');
document.write('        <textarea name="user_input[id10]" 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="132159">');
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('');