document.write('');
document.write('  <table>');
document.write('<form method="post" action="http://25395.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td colspan="2">Bitte fülle alle Felder des Fomulars aus.</td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Name *</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>Telefon</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id9]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>E-Mail *</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>Wo soll die Aktion durchgeführt werden?</td>');
document.write('      <td>');
document.write('        <select name="user_input[id5]">');
document.write('          <option value="0">in ganz Deutschland');
document.write('</option>');
document.write('          <option value="1">in einer bestimmten Stadt');
document.write('</option>');
document.write('          <option value="2">egal, dass könnt Ihr entscheiden</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Wer soll  die Aktion durchführen?</td>');
document.write('      <td>');
document.write('        <select name="user_input[id6]">');
document.write('          <option value="0">ich möchte die Aktion selber durchführen');
document.write('</option>');
document.write('          <option value="1">Fans for Kids soll die Aktion durchführen');
document.write('</option>');
document.write('          <option value="2">ich möchte die Aktion gemeinsam mit Fans for Kids durchführen');
document.write('</option>');
document.write('          <option value="3">Das weiss ich noch nicht</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Wie dürfen wir mit Dir Kontakt aufnehmen?</td>');
document.write('      <td>');
document.write('        <select name="user_input[id8]">');
document.write('          <option value="0">per Mail');
document.write('</option>');
document.write('          <option value="1">telefonisch');
document.write('</option>');
document.write('          <option value="2">ist mir egal</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Erkläre uns Deine Idee</td>');
document.write('      <td>');
document.write('        <textarea name="user_input[id10]" style="width:100%" rows="5"></textarea>');
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="25395">');
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('');