document.write('');
document.write('  <table>');
document.write('<form method="post" action="http://95578.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td align="center" colspan="2"><font color="#012B65" face="Arial" size="3"><b></b></font></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><font color="#012B65" face="Arial" size="2"><b>Name *</b></font></td>');
document.write('      <td><font face="Arial" size="2">');
document.write('        <input style=" border: 1px solid #012B65; background-color: #EBEBEB; 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 color="#012B65" face="Arial" size="2"><b>E-Mail *</b></font></td>');
document.write('      <td><font face="Arial" size="2">');
document.write('        <input style=" border: 1px solid #012B65; background-color: #EBEBEB; 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 color="#012B65" face="Arial" size="2"><b>Betreff *</b></font></td>');
document.write('      <td><font face="Arial" size="2">');
document.write('        <input style=" border: 1px solid #012B65; background-color: #EBEBEB; 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 color="#012B65" face="Arial" size="2"><b>Nachricht *</b></font></td>');
document.write('      <td><font face="Arial" size="2">');
document.write('        <textarea style=" border: 1px solid #012B65; background-color: #EBEBEB; font-family: Arial;" 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="95578">');
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('');