document.write('');
document.write('  <table align="center" cellspacing="5" cellpadding="5">');
document.write('<form method="post" action="http://51657.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td colspan="2"><font color="#000000" face="Arial" size="4">Bestellen Sie jetzt:</font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td colspan="2">die mit * gekennzeichnete Felder müssen ausgefüllt werden</td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="right"><font face="Arial" size="3"><b>Vorname und Nachname *</b></font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id3]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="right"><font face="Arial" size="3"><b>Straße und Hausnummer</b></font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id7]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="right"><font face="Arial" size="3"><b>PLZ und Ort</b></font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id8]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="right"><font face="Arial" size="3"><b>Land</b></font></td>');
document.write('      <td>');
document.write('        <select name="user_input[id9]">');
document.write('          <option value="0">Deutschland');
document.write('</option>');
document.write('          <option value="1">Österreich');
document.write('</option>');
document.write('          <option value="2">Schweiz');
document.write('</option>');
document.write('          <option value="3">Italien</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="right"><font face="Arial" size="3"><b>Telefon</b></font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id10]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="right"><font face="Arial" size="3"><b>E-Mail *</b></font></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 align="right"><font face="Arial" size="3"><b>Zahlungsweise</b></font></td>');
document.write('      <td>');
document.write('        <select name="user_input[id11]">');
document.write('          <option value="0">per Überweisung');
document.write('</option>');
document.write('          <option value="1">per Vorkasse</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="4"><b><i>Artikelauswahl</i></b></font></td>');
document.write('      <td></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="right"><font face="Arial" size="3"><b><i>Blasmusikklänge unter der Alpspitze CD</i></b></font></td>');
document.write('      <td>');
document.write('        <select 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');
document.write('</option>');
document.write('          <option value="10">10</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="right"><font face="Arial" size="3"><b><i>Blasmusikklänge unter der Alpspitze MC</i></b></font></td>');
document.write('      <td>');
document.write('        <select name="user_input[id6]">');
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');
document.write('</option>');
document.write('          <option value="10">10</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="right"><font face="Arial" size="3"><b><i>Blasmusik zwischen Alpspitze und Zugspitze MC</i></b></font></td>');
document.write('      <td>');
document.write('        <select name="user_input[id13]">');
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');
document.write('</option>');
document.write('          <option value="10">10</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="right"><font face="Arial" size="3"><b><i>Chronik über 200 Jahre</i></b></font></td>');
document.write('      <td>');
document.write('        <select name="user_input[id14]">');
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');
document.write('</option>');
document.write('          <option value="10">10</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="right"><font face="Arial" size="3"><b><i>Cap der Musikkapelle</i></b></font></td>');
document.write('      <td>');
document.write('        <select name="user_input[id15]">');
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');
document.write('</option>');
document.write('          <option value="10">10</option>');
document.write('        </select>');
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="51657">');
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('');