document.write('');
document.write('  <table style="border: 1px solid Black">');
document.write('<form method="post" action="http://18403.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td colspan="2"><font face="Verdana" size="2"><b>Windhundhalsband exklusiv</b></font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Verdana" size="2"><b>Name, Vorname</b></font></td>');
document.write('      <td><font face="Verdana" size="2">');
document.write('        <input style=" font-family: Verdana;" type="text" name="user_input[id1]" value="" size="30">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Verdana" size="2"><b>E-Mail</b></font></td>');
document.write('      <td><font face="Verdana" size="2">');
document.write('        <input style=" font-family: Verdana;" type="text" name="user_input[id2]" value="" size="30">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Verdana" size="2"><b>Strasse, Hausnummer</b></font></td>');
document.write('      <td><font face="Verdana" size="2">');
document.write('        <input style=" font-family: Verdana;" type="text" name="user_input[id11]" value="" size="30">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Verdana" size="2"><b>Wohnort mit Postleitzahl</b></font></td>');
document.write('      <td><font face="Verdana" size="2">');
document.write('        <input style=" font-family: Verdana;" type="text" name="user_input[id10]" value="" size="30">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Verdana" size="2"><b>Ich bestelle ein Halsband für meinen.....</b></font></td>');
document.write('      <td><font face="Verdana" size="2">');
document.write('        <select style=" font-family: Verdana;" name="user_input[id13]">');
document.write('          <option value="0">Podenco / Podencomix');
document.write('</option>');
document.write('          <option value="1">Galgo / Galgomix');
document.write('</option>');
document.write('          <option value="2">Grey / Greymix');
document.write('</option>');
document.write('          <option value="3">sonstiger Windhund');
document.write('</option>');
document.write('          <option value="4">anderer Mischling');
document.write('</option>');
document.write('          <option value="5">andere Rasse</option>');
document.write('        </select>');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Verdana" size="2"><b>Farbe Ihres Hundes</b></font></td>');
document.write('      <td><font face="Verdana" size="2">');
document.write('        <input style=" font-family: Verdana;" type="text" name="user_input[id7]" value="" size="30">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Verdana" size="2"><b>Halsumfang</b></font></td>');
document.write('      <td><font face="Verdana" size="2">');
document.write('        <input style=" font-family: Verdana;" type="text" name="user_input[id9]" value="cm" size="30">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Verdana" size="2"><b>Modell<br></b></font><font face="Verdana" size="1">bitte angeben: Nummer des gewünschten Modells oder Lederhalsband</font></td>');
document.write('      <td><font face="Verdana" size="2">');
document.write('        <textarea style=" font-family: Verdana;" name="user_input[id202]" style="width:100%" rows="5"></textarea>');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Verdana" size="2"><b>Nachricht</b></font></td>');
document.write('      <td><font face="Verdana" size="2">');
document.write('        <textarea style=" font-family: Verdana;" name="user_input[id4]" style="width:100%" rows="7"></textarea>');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Verdana" size="2"><b>Sonderwunsch<br></b></font><font face="Verdana" size="2">geben Sie hier einen Farbwunsch oder Halsbandlänge etc. ein</font></td>');
document.write('      <td><font face="Verdana" size="2">');
document.write('        <textarea style=" font-family: Verdana;" name="user_input[id203]" style="width:100%" rows="5"></textarea>');
document.write('      </font></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="18403">');
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('');