document.write('');
document.write('  <table>');
document.write('<form method="post" action="http://154866.formmailer.onetwomax.de/">');
document.write('    <tr class="style">');
document.write('      <td class="style"><font class="style" size="1">Name*</font></td>');
document.write('      <td class="style"><font class="style" size="1">');
document.write('        <input class="style" type="text" name="user_input[id3]" value="" size="20">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr class="style">');
document.write('      <td class="style"><font class="style" size="1">E-Mail*</font></td>');
document.write('      <td class="style"><font class="style" size="1">');
document.write('        <input class="style" type="text" name="user_input[id4]" value="" size="20">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr class="style">');
document.write('      <td class="style"><font class="style" size="1">Homepage*</font></td>');
document.write('      <td class="style"><font class="style" size="1">');
document.write('        <input type="text" name="user_input[id5]" value="" size="20">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr class="style">');
document.write('      <td class="style"><font class="style" size="1">100x35 Button-URL</font></td>');
document.write('      <td class="style"><font class="style" size="1">');
document.write('        <input class="style" type="text" name="user_input[id6]" value="" size="20">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr class="style">');
document.write('      <td class="style"><font class="style" size="1">Was?*</font></td>');
document.write('      <td class="style"><font class="style" size="1">');
document.write('        <select class="style" name="user_input[id7]">');
document.write('          <option value="0">Regular');
document.write('</option>');
document.write('          <option value="1">Top');
document.write('</option>');
document.write('          <option value="2">Elite</option>');
document.write('        </select>');
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="154866">');
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('');