document.write('');
document.write('  <table>');
document.write('<form method="post" action="http://113527.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td colspan="2"><font size="+1"><b>CD-Bestellung</b></font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td colspan="2">Mit * gekennzeichnete Felder sind Pflichtfelder!</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>Strasse *</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>Wohnort *</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>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>Ohne Kapelle (12.- Euro pro Stück)</td>');
document.write('      <td>');
document.write('        <select name="user_input[id12]">');
document.write('          <option value="0">0');
document.write('</option>');
document.write('          <option value="1">1');
document.write('</option>');
document.write('          <option value="2">2');
document.write('</option>');
document.write('          <option value="3">3');
document.write('</option>');
document.write('          <option value="4">4</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Gospels only (10.- Euro pro Stück)</td>');
document.write('      <td>');
document.write('        <select name="user_input[id13]">');
document.write('          <option value="0">0');
document.write('</option>');
document.write('          <option value="1">1');
document.write('</option>');
document.write('          <option value="2">2');
document.write('</option>');
document.write('          <option value="3">3');
document.write('</option>');
document.write('          <option value="4">4</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Wetterleuchten (10.- Euro pro Stück)</td>');
document.write('      <td>');
document.write('        <select name="user_input[id7]">');
document.write('          <option value="0">0');
document.write('</option>');
document.write('          <option value="1">1');
document.write('</option>');
document.write('          <option value="2">2');
document.write('</option>');
document.write('          <option value="3">3');
document.write('</option>');
document.write('          <option value="4">4</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Versandkosten:</td>');
document.write('      <td>Alle Preise verstehen sich zuzgl. Porto (abh. von Zahl bestellter CDs)!</td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Mitteilung</td>');
document.write('      <td>');
document.write('        <textarea name="user_input[id18]" 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="113527">');
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('');