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document.write('      <td colspan="2">Bestellung</td>');
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document.write('    <tr>');
document.write('      <td colspan="2"><font color="white">mit * gekennzeichnete Felder müssen ausgefüllt werden</font></td>');
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document.write('      <td><font color="white"><b>Name *</b></font></td>');
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document.write('      <td><font color="white"><b>Vorname*</b></font></td>');
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document.write('      <td><font color="white"><b>Adresse*</b></font></td>');
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document.write('    <tr>');
document.write('      <td><font color="white"><b>PLZ*</b></font></td>');
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document.write('        <input type="text" name="user_input[id8]" value="" size="5">');
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document.write('    <tr>');
document.write('      <td><font color="White"><b>Ort*</b></font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id9]" value="" size="40">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="White"><b>Telefon*</b></font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id13]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="white"><b>Geburtsdatum*</b></font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id14]" value="" size="20">');
document.write('      </td>');
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document.write('    <tr>');
document.write('      <td><font color="white"><b>Bitte wählen Sie *</b></font></td>');
document.write('      <td>');
document.write('        <select style=" font-weight: bold;" name="user_input[id11]">');
document.write('          <option value="0">Cinchkabel 75cm White Bird CU 250 €');
document.write('</option>');
document.write('          <option value="1" selected>Cinchkabel 75cm White Bird SI 300 €');
document.write('</option>');
document.write('          <option value="2">Cinchkabel 75cm White Bird mit Sonderstecker Metall 250€');
document.write('</option>');
document.write('          <option value="3">');
document.write('</option>');
document.write('          <option value="4">LS Kabel 2 x 3M White Bird mit Bananenstecker in');
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document.write('          <option value="5">Single Wiring 480€');
document.write('</option>');
document.write('          <option value="6">Bi Wiring 490€');
document.write('</option>');
document.write('          <option value="7">LS Kabel mit Kabelschuhen auf Anfrage möglich');
document.write('</option>');
document.write('          <option value="8">');
document.write('</option>');
document.write('          <option value="9">Digital NF Kabel 75cm White Bird  150€');
document.write('</option>');
document.write('          <option value="10">');
document.write('</option>');
document.write('          <option value="11">oder wie unten im Nachrichtentext beschrieben</option>');
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document.write('    <tr>');
document.write('      <td><font color="White"><b>E-Mail *</b></font></td>');
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document.write('        <input type="text" name="user_input[id4]" value="" size="40">');
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document.write('    <tr>');
document.write('      <td><font color="white"><b>Nachricht</b></font></td>');
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document.write('        <textarea name="user_input[id5]" style="width:100%" rows="10"></textarea>');
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document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="white"><b>Einverständiniserklärung<br></b></font>Widerufsbelehrung');
document.write('<BR>');
document.write('Datenschutz und');
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document.write('akzeptiert</td>');
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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="137782">');
document.write('        <input type="submit" name="submit" value="Abschicken">');
document.write('        <input type="reset" name="reset" value="Zur&uuml;cksetzen">');
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document.write('    </tr>');
document.write('    <tr>');
document.write('      <td colspan="2" align="center"><font size="-2">Powered by <a href="http://www.onetwomax.de" target="_blank">OneTwoMax</a> Formmailer Script</font></td>');
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document.write('</form>');
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