document.write('');
document.write('  <table align="center">');
document.write('<form method="post" action="http://81930.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td colspan="2"></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td colspan="2"><font face="verdana" size="1">mit * gekennzeichnete Felder müssen ausgefüllt werden</font></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="15">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>E-Mail oder Handy*</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 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="81930">');
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('');