document.write('');
document.write('  <table cellspacing="3" cellpadding="3" style="border: 1px solid Black">');
document.write('<form method="post" action="http://8234.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td bgcolor="Black" colspan="2"><font color="White" face="Arial" size="3"><b>Bestellformular für Edelstahl-Badheizkörper</b></font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td colspan="2"><font face="Arial" size="2">Bitte füllen Sie das Formular sorgfältig und vollständig aus, mit * gekennzeichnete Felder sind Pflichtfelder! Beachten Sie auch unsere AGB und die Hinweise zum Datenschutz! </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2"><b>Anrede *</b></font></td>');
document.write('      <td><font face="Arial" size="2">');
document.write('        <select style=" font-family: Arial;" name="user_input[id5]">');
document.write('          <option value="0">Firma');
document.write('</option>');
document.write('          <option value="1">Frau');
document.write('</option>');
document.write('          <option value="2">Herr</option>');
document.write('        </select>');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2"><b>Name, Vorname *</b></font></td>');
document.write('      <td><font face="Arial" size="2">');
document.write('        <input style=" font-family: Arial;" type="text" name="user_input[id1]" value="" size="35">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2"><b>Strasse, Hausnummer *</b></font></td>');
document.write('      <td><font face="Arial" size="2">');
document.write('        <input style=" font-family: Arial;" type="text" name="user_input[id7]" value="" size="35">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2"><b>PLZ, Wohnort *</b></font></td>');
document.write('      <td><font face="Arial" size="2">');
document.write('        <input style=" font-family: Arial;" type="text" name="user_input[id6]" value="" size="35">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2"><b>Telefon *</b></font></td>');
document.write('      <td><font face="Arial" size="2">');
document.write('        <input style=" font-family: Arial;" type="text" name="user_input[id8]" value="" size="35">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2"><b>E-Mail *<br></b></font><font face="Arial" size="2">');
document.write('<BR>');
document.write('</font></td>');
document.write('      <td><font face="Arial" size="2">');
document.write('        <input style=" font-family: Arial;" type="text" name="user_input[id2]" value="@" size="35">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2"><b>gewünschte Versandart *<br></b></font><font face="Arial" size="2">Lieferung zzgl 39,- Euro Versandkosten pro HK</font></td>');
document.write('      <td><font face="Arial" size="2">');
document.write('        <select style=" font-family: Arial;" name="user_input[id10]">');
document.write('          <option value="0">Abholung');
document.write('</option>');
document.write('          <option value="1">Lieferung</option>');
document.write('        </select>');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2"><b>gewünschtes Modell *<br></b></font><font face="Arial" size="2">Alle Preise incl. gesetzlicher Mwst.</font></td>');
document.write('      <td><font face="Arial" size="2">');
document.write('        <select style=" font-family: Arial;" name="user_input[id12]">');
document.write('          <option value="0">Bitte Modell auswählen!');
document.write('</option>');
document.write('          <option value="1">GL  1 - Tornillo /  617 W /  492,80 €');
document.write('</option>');
document.write('          <option value="2">GL  1 - Tornillo /  755 W /  596,76 € ');
document.write('</option>');
document.write('          <option value="3">GL  1 - Tornillo / 1165 W / 830,00 €');
document.write('</option>');
document.write('          <option value="4">GL  2 - Acajou   /  407 W /  417,67 €');
document.write('</option>');
document.write('          <option value="5">GL  2 - Acajou   /  616 W /  502,97 €');
document.write('</option>');
document.write('          <option value="6">GL  2 - Acajou   /  881 W /  748,87 €');
document.write('</option>');
document.write('          <option value="7">GL  3 - Badi    /  861 W /  681,06 €');
document.write('</option>');
document.write('          <option value="8">GL  3 - Badi    /  1035 W /  786,52 €');
document.write('</option>');
document.write('          <option value="9">GL  3 - Badi    /  1379 W /  997,43 €');
document.write('</option>');
document.write('          <option value="10">GL  3 - Badi    /  1552 W /  1098,39 €');
document.write('</option>');
document.write('          <option value="11">GL  4 - Ipele  /  1067 W /  809,01 €');
document.write('</option>');
document.write('          <option value="12">GL  5 - Kotibe /  502 W /  461,32 €');
document.write('</option>');
document.write('          <option value="13">GL  5 - Kotibe /  806 W /  637,08 €');
document.write('</option>');
document.write('          <option value="14">GL  6 - Framire /  514 W /  541,12 €');
document.write('</option>');
document.write('          <option value="15">GL  7 - Kempas /  427 W /  495,30 €');
document.write('</option>');
document.write('          <option value="16">GL  8 - Merbau /  624 W /  667,73 €');
document.write('</option>');
document.write('          <option value="17">GL  9 - Samba /  1390 W /  1085,07 €');
document.write('</option>');
document.write('          <option value="18">GL 10 -  Sapelli /  956 W /  659,07 €');
document.write('</option>');
document.write('          <option value="19">GL 11 -  Frake /  308 W / 222,74 €');
document.write('</option>');
document.write('          <option value="20">GL 12 -Amazaque /  415 W /  344,53 €');
document.write('</option>');
document.write('          <option value="21">GL 14 - Jatoba / 1367 W /  926,46 €');
document.write('</option>');
document.write('          <option value="22">GL 15 - Bambu / 830 W /  659,07 €</option>');
document.write('        </select>');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2"><b>benötigte Stückzahl *</b></font></td>');
document.write('      <td><font face="Arial" size="2">');
document.write('        <select style=" font-family: Arial;" name="user_input[id13]">');
document.write('          <option value="0">1');
document.write('</option>');
document.write('          <option value="1">2');
document.write('</option>');
document.write('          <option value="2">3');
document.write('</option>');
document.write('          <option value="3">4');
document.write('</option>');
document.write('          <option value="4">5');
document.write('</option>');
document.write('          <option value="5">6');
document.write('</option>');
document.write('          <option value="6">7');
document.write('</option>');
document.write('          <option value="7">8');
document.write('</option>');
document.write('          <option value="8">9</option>');
document.write('        </select>');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2"><b>weiteres Modell<br></b></font><font face="Arial" size="2">hier können Sie ein 2. Modell bestellen!</font></td>');
document.write('      <td><font face="Arial" size="2">');
document.write('        <select style=" font-family: Arial;" name="user_input[id14]">');
document.write('          <option value="0">Bitte Modell auswählen!');
document.write('</option>');
document.write('          <option value="1">GL  1 - Tornillo /  617 W /  492,80 €');
document.write('</option>');
document.write('          <option value="2">GL  1 - Tornillo /  755 W /  596,76 € ');
document.write('</option>');
document.write('          <option value="3">GL  1 - Tornillo / 1165 W / 830,00 €');
document.write('</option>');
document.write('          <option value="4">GL  2 - Acajou   /  407 W /  417,67 €');
document.write('</option>');
document.write('          <option value="5">GL  2 - Acajou   /  616 W /  502,97 €');
document.write('</option>');
document.write('          <option value="6">GL  2 - Acajou   /  881 W /  748,87 €');
document.write('</option>');
document.write('          <option value="7">GL  3 - Badi    /  861 W /  681,06 €');
document.write('</option>');
document.write('          <option value="8">GL  3 - Badi    /  1035 W /  786,52 €');
document.write('</option>');
document.write('          <option value="9">GL  3 - Badi    /  1379 W /  997,43 €');
document.write('</option>');
document.write('          <option value="10">GL  3 - Badi    /  1552 W /  1098,39 €');
document.write('</option>');
document.write('          <option value="11">GL  4 - Ipele  /  1067 W /  809,01 €');
document.write('</option>');
document.write('          <option value="12">GL  5 - Kotibe /  502 W /  461,32 €');
document.write('</option>');
document.write('          <option value="13">GL  5 - Kotibe /  806 W /  637,08 €');
document.write('</option>');
document.write('          <option value="14">GL  6 - Framire /  514 W /  541,12 €');
document.write('</option>');
document.write('          <option value="15">GL  7 - Kempas /  427 W /  495,30 €');
document.write('</option>');
document.write('          <option value="16">GL  8 - Merbau /  624 W /  667,73 €');
document.write('</option>');
document.write('          <option value="17">GL  9 - Samba /  1390 W /  1085,07 €');
document.write('</option>');
document.write('          <option value="18">GL 10 -  Sapelli /  956 W /  659,07 €');
document.write('</option>');
document.write('          <option value="19">GL 11 -  Frake /  308 W / 222,74 €');
document.write('</option>');
document.write('          <option value="20">GL 12 -Amazaque /  415 W /  344,53 €');
document.write('</option>');
document.write('          <option value="21">GL 14 - Jatoba / 1367 W /  926,46 €');
document.write('</option>');
document.write('          <option value="22">GL 15 - Bambu / 830 W /  659,07 €</option>');
document.write('        </select>');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2"><b>benötigte Stückzahl</b></font></td>');
document.write('      <td><font face="Arial" size="2">');
document.write('        <select style=" font-family: Arial;" name="user_input[id16]">');
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');
document.write('</option>');
document.write('          <option value="5">5');
document.write('</option>');
document.write('          <option value="6">6');
document.write('</option>');
document.write('          <option value="7">7');
document.write('</option>');
document.write('          <option value="8">8');
document.write('</option>');
document.write('          <option value="9">9</option>');
document.write('        </select>');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2"><b>weiteres Modell<br></b></font><font face="Arial" size="2">hier können Sie ein 3. Modell bestellen!</font></td>');
document.write('      <td><font face="Arial" size="2">');
document.write('        <select style=" font-family: Arial;" name="user_input[id15]">');
document.write('          <option value="0">Bitte Modell auswählen!');
document.write('</option>');
document.write('          <option value="1">GL  1 - Tornillo /  617 W /  492,80 €');
document.write('</option>');
document.write('          <option value="2">GL  1 - Tornillo /  755 W /  596,76 € ');
document.write('</option>');
document.write('          <option value="3">GL  1 - Tornillo / 1165 W / 830,00 €');
document.write('</option>');
document.write('          <option value="4">GL  2 - Acajou   /  407 W /  417,67 €');
document.write('</option>');
document.write('          <option value="5">GL  2 - Acajou   /  616 W /  502,97 €');
document.write('</option>');
document.write('          <option value="6">GL  2 - Acajou   /  881 W /  748,87 €');
document.write('</option>');
document.write('          <option value="7">GL  3 - Badi    /  861 W /  681,06 €');
document.write('</option>');
document.write('          <option value="8">GL  3 - Badi    /  1035 W /  786,52 €');
document.write('</option>');
document.write('          <option value="9">GL  3 - Badi    /  1379 W /  997,43 €');
document.write('</option>');
document.write('          <option value="10">GL  3 - Badi    /  1552 W /  1098,39 €');
document.write('</option>');
document.write('          <option value="11">GL  4 - Ipele  /  1067 W /  809,01 €');
document.write('</option>');
document.write('          <option value="12">GL  5 - Kotibe /  502 W /  461,32 €');
document.write('</option>');
document.write('          <option value="13">GL  5 - Kotibe /  806 W /  637,08 €');
document.write('</option>');
document.write('          <option value="14">GL  6 - Framire /  514 W /  541,12 €');
document.write('</option>');
document.write('          <option value="15">GL  7 - Kempas /  427 W /  495,30 €');
document.write('</option>');
document.write('          <option value="16">GL  8 - Merbau /  624 W /  667,73 €');
document.write('</option>');
document.write('          <option value="17">GL  9 - Samba /  1390 W /  1085,07 €');
document.write('</option>');
document.write('          <option value="18">GL 10 -  Sapelli /  956 W /  659,07 €');
document.write('</option>');
document.write('          <option value="19">GL 11 -  Frake /  308 W / 222,74 €');
document.write('</option>');
document.write('          <option value="20">GL 12 -Amazaque /  415 W /  344,53 €');
document.write('</option>');
document.write('          <option value="21">GL 14 - Jatoba / 1367 W /  926,46 €');
document.write('</option>');
document.write('          <option value="22">GL 15 - Bambu / 830 W /  659,07 €</option>');
document.write('        </select>');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2"><b>benötigte Stückzahl</b></font></td>');
document.write('      <td><font face="Arial" size="2">');
document.write('        <select style=" font-family: Arial;" name="user_input[id17]">');
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');
document.write('</option>');
document.write('          <option value="5">5');
document.write('</option>');
document.write('          <option value="6">6');
document.write('</option>');
document.write('          <option value="7">7');
document.write('</option>');
document.write('          <option value="8">8');
document.write('</option>');
document.write('          <option value="9">9</option>');
document.write('        </select>');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2"><b>Bemerkung<br></b></font><font face="Arial" size="2">Hier z.B. eventuell abweichende Lieferanschrift');
document.write('<BR>');
document.write('oder bei gewünschten Abweichungen bzw. Sonderanfertigungen die genaue Beschreibung und Maße eingeben (Bitte Möglichkeiten vorher per Telefon bzw. email klären).');
document.write('<BR>');
document.write('<BR>');
document.write('</font></td>');
document.write('      <td><font face="Arial" size="2">');
document.write('        <textarea style=" font-family: Arial;" name="user_input[id4]" style="width:100%" rows="5"></textarea>');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Verdana" size="1">Ich bestätige, daß ich die AGB und den Hinweis zum Datenschutz zur Kenntnis genommen habe:</font></td>');
document.write('      <td><font face="Verdana" size="2">');
document.write('        <input style=" font-family: Verdana;" type="checkbox" name="user_input[id202]" value="1" >');
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="8234">');
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('');