document.write('');
document.write('  <table>');
document.write('<form method="post" action="http://125096.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td colspan="2">TREFFER abonieren (auch für Nichtmitglieder)</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>Vorname*</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id5]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Name *</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id3]" value="" size="20">');
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="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Mitglied *</td>');
document.write('      <td>');
document.write('        <select name="user_input[id7]">');
document.write('          <option value="0">nein');
document.write('</option>');
document.write('          <option value="1">ja</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Format *<br>(Geben Sie an ob Heft-');
document.write('<BR>');
document.write('oder Bildschirmformat) </td>');
document.write('      <td>');
document.write('        <select name="user_input[id8]">');
document.write('          <option value="0">Bildschirm');
document.write('</option>');
document.write('          <option value="1">Heft');
document.write('</option>');
document.write('          <option value="2"></option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Kommentar</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>Stornieren<br>(Hier können Sie Ihr');
document.write('<BR>');
document.write('Abo storniern.)</td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id9]" value="1" >');
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="125096">');
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('');