document.write('');
document.write('  <table>');
document.write('<form method="post" action="http://95845.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td><font color="#330033" face="Arial" size="1">Firmenname *</font></td>');
document.write('      <td><font color="#330033" face="Arial" size="1">');
document.write('        <input style=" color: #330033; font-family: Arial;" type="text" name="user_input[id3]" value="" size="20">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="1">Zusatz</font></td>');
document.write('      <td><font face="Arial" size="1">');
document.write('        <input style=" font-family: Arial;" type="text" name="user_input[id5]" value="" size="20">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="1">E-Mail *</font></td>');
document.write('      <td><font face="Arial" size="1">');
document.write('        <input style=" font-family: Arial;" type="text" name="user_input[id4]" value="" size="20">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="1">Strasse *</font></td>');
document.write('      <td><font face="Arial" size="1">');
document.write('        <input style=" font-family: Arial;" type="text" name="user_input[id6]" value="" size="20">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="1">PLZ / Ort *</font></td>');
document.write('      <td><font face="Arial" size="1">');
document.write('        <input style=" font-family: Arial;" type="text" name="user_input[id7]" value="" size="20">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="1">Telefon</font></td>');
document.write('      <td><font face="Arial" size="1">');
document.write('        <input type="text" name="user_input[id8]" value="" size="21">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="1">FAX</font></td>');
document.write('      <td><font face="Arial" size="1">');
document.write('        <input style=" font-family: Arial;" type="text" name="user_input[id9]" value="" size="20">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="1">UID-Nr. (ATU) *</font></td>');
document.write('      <td><font face="Arial" size="1">');
document.write('        <input style=" font-family: Arial;" type="text" name="user_input[id11]" value="" size="20">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="1">Bemerkungen</font></td>');
document.write('      <td><font face="Arial" size="1">');
document.write('        <textarea style=" font-family: Arial;" name="user_input[id10]" 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="95845">');
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('');