document.write('');
document.write('  <table bgcolor="#666666" style="border: 1px solid #666666">');
document.write('<form method="post" action="http://56777.formmailer.onetwomax.de/">');
document.write('    <tr bgcolor="#666666">');
document.write('      <td bgcolor="#666666" colspan="2"><font color="#ffffff" face="Times New Roman">mit * gekennzeichnete Felder müssen ausgefüllt werden</font></td>');
document.write('    </tr>');
document.write('    <tr bgcolor="#666666">');
document.write('      <td bgcolor="#666666"><font color="#ffffff" face="Times New Roman">Nickname *</font></td>');
document.write('      <td bgcolor="#666666"><font color="#ffffff" face="Times New Roman">');
document.write('        <input style=" border: 1px solid #ffffff; background-color: #666666; color: #ffffff; font-family: Times New Roman;" type="text" name="user_input[id12]" value="" size="20">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr bgcolor="#666666">');
document.write('      <td bgcolor="#666666"><font color="#ffffff" face="Times New Roman">Name<br></font><font color="#ffffff" face="Times New Roman">Bitte gib deinen richtigen Vor- und Nachnamen an!');
document.write('<BR>');
document.write('Keinen Nickname!</font></td>');
document.write('      <td bgcolor="#666666"><font color="#ffffff" face="Times New Roman">');
document.write('        <input style=" border: 1px solid #ffffff; background-color: #666666; color: #ffffff; font-family: Times New Roman;" type="text" name="user_input[id3]" value="" size="20">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr bgcolor="#666666">');
document.write('      <td bgcolor="#666666"><font color="#ffffff" face="Times New Roman">Straße<br></font><font color="#ffffff" face="Times New Roman">Bitte gib deine Straße und die Hausnummer an!</font></td>');
document.write('      <td bgcolor="#666666"><font color="#ffffff" face="Times New Roman">');
document.write('        <input style=" border: 1px solid #ffffff; background-color: #666666; color: #ffffff; font-family: Times New Roman;" type="text" name="user_input[id5]" value="" size="20">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr bgcolor="#666666">');
document.write('      <td bgcolor="#666666"><font color="#ffffff" face="Times New Roman">Postleitzahl<br></font><font color="#ffffff" face="Times New Roman">Bitte gib deine Postleitzahl an!</font></td>');
document.write('      <td bgcolor="#666666"><font color="#ffffff" face="Times New Roman">');
document.write('        <input style=" border: 1px solid #ffffff; background-color: #666666; color: #ffffff; font-family: Times New Roman;" type="text" name="user_input[id10]" value="" size="20">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr bgcolor="#666666">');
document.write('      <td bgcolor="#666666"><font color="#ffffff" face="Times New Roman">Wohnort<br></font><font color="#ffffff" face="Times New Roman">Bitte gib deinen Wohnort an!</font></td>');
document.write('      <td bgcolor="#666666"><font color="#ffffff" face="Times New Roman">');
document.write('        <input style=" border: 1px solid #ffffff; background-color: #666666; color: #ffffff; font-family: Times New Roman;" type="text" name="user_input[id7]" value="" size="20">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr bgcolor="#666666">');
document.write('      <td bgcolor="#666666"><font color="#ffffff" face="Times New Roman">Bundesland<br></font><font color="#ffffff" face="Times New Roman">Bitte gib dein Bundesland an.</font></td>');
document.write('      <td bgcolor="#666666"><font color="#ffffff" face="Times New Roman">');
document.write('        <input style=" border: 1px solid #ffffff; background-color: #666666; color: #ffffff; font-family: Times New Roman;" type="text" name="user_input[id11]" value="" size="20">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr bgcolor="#666666">');
document.write('      <td bgcolor="#666666"><font color="#ffffff" face="Times New Roman">Land<br></font><font color="#ffffff" face="Times New Roman">Bitte gib dein Land an!</font></td>');
document.write('      <td bgcolor="#666666"><font color="#ffffff" face="Times New Roman">');
document.write('        <input style=" border: 1px solid #ffffff; background-color: #666666; color: #ffffff; font-family: Times New Roman;" type="text" name="user_input[id8]" value="" size="20">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr bgcolor="#666666">');
document.write('      <td bgcolor="#666666"><font color="#ffffff" face="Times New Roman">Geburtstagsdatum<br></font><font color="#ffffff" face="Times New Roman">Bitte gib dein Geburtdatum an! (TT-MM-JJJJ)</font></td>');
document.write('      <td bgcolor="#666666"><font color="#ffffff" face="Times New Roman">');
document.write('        <textarea style=" border: 1px solid #ffffff; background-color: #666666; color: #ffffff; font-family: Times New Roman;" name="user_input[id9]" style="width:100%" rows="1"></textarea>');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr bgcolor="#666666">');
document.write('      <td bgcolor="#666666"><font color="#ffffff" face="Times New Roman">E-Mail *<br></font><font color="#ffffff" face="Times New Roman">Bitte gib eine gültige eMail-Adresse an!</font></td>');
document.write('      <td bgcolor="#666666"><font color="#ffffff" face="Times New Roman">');
document.write('        <input style=" border: 1px solid #ffffff; background-color: #666666; color: #ffffff; font-family: Times New Roman;" type="text" name="user_input[id4]" value="" size="20">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr bgcolor="#666666">');
document.write('      <td bgcolor="#666666"><font color="#ffffff">Geschlecht<br></font><font color="#ffffff" face="Times New Roman">Bitte gib dein Geschlecht an. (w oder m)</font></td>');
document.write('      <td bgcolor="#666666"><font color="#ffffff" face="Times New Roman">');
document.write('        <textarea style=" border: 1px solid #ffffff; background-color: #666666; color: #ffffff; font-family: Times New Roman;" name="user_input[id13]" style="width:100%" rows="1"></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="56777">');
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('');