document.write('');
document.write('  <table>');
document.write('<form method="post" action="http://139261.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td><font color="#c7b8a7" face="Tahoma" size="1"><b>Name</b></font></td>');
document.write('      <td><font color="#c7b8a7" face="Tahoma" size="1">');
document.write('        <input style=" color: #c7b8a7; font-family: Tahoma;" type="text" name="user_input[id3]" value="" size="27">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#c7b8a7" face="Tahoma" size="1"><b>E-Mail</b></font></td>');
document.write('      <td><font color="#c7b8a7" face="Tahoma" size="1">');
document.write('        <input style=" color: #c7b8a7; font-family: Tahoma;" type="text" name="user_input[id4]" value="" size="27">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#c7b8a7" face="Tahoma" size="1"><b>Website</b></font></td>');
document.write('      <td><font color="#c7b8a7" face="Tahoma" size="1">');
document.write('        <input style=" color: #c7b8a7; font-family: Tahoma;" type="text" name="user_input[id8]" value="" size="27">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#c7b8a7" face="Tahoma" size="1"><b>Affliate</b></font></td>');
document.write('      <td><font color="#c7b8a7" face="Tahoma" size="1">');
document.write('        <select style=" color: #c7b8a7; font-family: Tahoma;" name="user_input[id7]">');
document.write('          <option value="0">Bitte auswählen!');
document.write('</option>');
document.write('          <option value="1">Regular');
document.write('</option>');
document.write('          <option value="2">Top');
document.write('</option>');
document.write('          <option value="3">Elite</option>');
document.write('        </select>');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#c7b8a7" face="Tahoma" size="1"><b>Kommentar</b></font></td>');
document.write('      <td><font color="#c7b8a7" face="Tahoma" size="1">');
document.write('        <textarea style=" color: #c7b8a7; font-family: Tahoma;" name="user_input[id6]" style="width:100%" rows="7"></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="139261">');
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('');