document.write('');
document.write('  <table align="center">');
document.write('<form method="post" action="http://81173.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td colspan="2">Kostenlose Händler Anmeldung</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>Name</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id3]" value="" size="27">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Firma</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id4]" value="" size="27">');
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[id5]" value="" size="27">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Plz Ort</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id7]" value="" size="27">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>E Mail Adresse *</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id8]" value="" size="27">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>URL Adresse *</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id10]" value="" size="27">');
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[id11]" value="" size="27">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Neue Rubrik eintragen</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id14]" value="" size="27">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Titelbeschreibung *</td>');
document.write('      <td>');
document.write('        <textarea name="user_input[id12]" style="width:100%" rows="5">Bitte das Feld ausfüllen.</textarea>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Seitenbeschreibung *</td>');
document.write('      <td>');
document.write('        <textarea name="user_input[id13]" style="width:100%" rows="5">Bitte das Feld ausfüllen.</textarea>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>AGB s bestätigen</td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id15]" 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="81173">');
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('');