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document.write('<form method="post" action="http://110205.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td colspan="2">ACHTUNG BAUARBEITEN BITTE PER E-MAIL ANFRAGEN');
document.write('<BR>');
document.write('<BR>');
document.write('mit * gekennzeichnete Felder müssen ausgefüllt werden</td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Erste Kategorie auswählen:*</td>');
document.write('      <td>');
document.write('        <select name="user_input[id7]">');
document.write('          <option value="0">Kanuverleih');
document.write('</option>');
document.write('          <option value="1">Kanuschule');
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document.write('          <option value="2">Kanureisen');
document.write('</option>');
document.write('          <option value="3">Kanuurlaub');
document.write('</option>');
document.write('          <option value="4">Kanuschule');
document.write('</option>');
document.write('          <option value="5">Kanucamp');
document.write('</option>');
document.write('          <option value="6">Kanuhändler');
document.write('</option>');
document.write('          <option value="7">Kanurastplätze');
document.write('</option>');
document.write('          <option value="8">Kanu-Vereine');
document.write('</option>');
document.write('          <option value="9">Kanu-Literatur');
document.write('</option>');
document.write('          <option value="10">Kanuhersteller');
document.write('</option>');
document.write('          <option value="11">Kanu-Zubehör');
document.write('</option>');
document.write('          <option value="12">Kanutouren</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Zweite Kategorie auswählen:*</td>');
document.write('      <td>');
document.write('        <select name="user_input[id8]">');
document.write('          <option value="0">Kanuschule');
document.write('</option>');
document.write('          <option value="1">Kanuverleih');
document.write('</option>');
document.write('          <option value="2">Kanureisen');
document.write('</option>');
document.write('          <option value="3">Kanuurlaub');
document.write('</option>');
document.write('          <option value="4">Kanuschule');
document.write('</option>');
document.write('          <option value="5">Kanucamp');
document.write('</option>');
document.write('          <option value="6">Kanuhändler');
document.write('</option>');
document.write('          <option value="7">Kanurastplätze');
document.write('</option>');
document.write('          <option value="8">Kanu-Vereine');
document.write('</option>');
document.write('          <option value="9">Kanu-Literatur');
document.write('</option>');
document.write('          <option value="10">Kanuhersteller');
document.write('</option>');
document.write('          <option value="11">Kanu-Zubehör');
document.write('</option>');
document.write('          <option value="12">Kanutouren</option>');
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document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Land auswählen:*</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">Polen');
document.write('</option>');
document.write('          <option value="3">Schweiz');
document.write('</option>');
document.write('          <option value="4">Schweden');
document.write('</option>');
document.write('          <option value="5">Frankreich');
document.write('</option>');
document.write('          <option value="6">Finnland');
document.write('</option>');
document.write('          <option value="7">Dänemark');
document.write('</option>');
document.write('          <option value="8">Norwegen');
document.write('</option>');
document.write('          <option value="9">Niederlande');
document.write('</option>');
document.write('          <option value="10">Tschechien');
document.write('</option>');
document.write('          <option value="11">Slowakai');
document.write('</option>');
document.write('          <option value="12">Irland');
document.write('</option>');
document.write('          <option value="13">Großbritanien');
document.write('</option>');
document.write('          <option value="14">Italien');
document.write('</option>');
document.write('          <option value="15">Spanien');
document.write('</option>');
document.write('          <option value="16">Italien');
document.write('</option>');
document.write('          <option value="17">Griechenland');
document.write('</option>');
document.write('          <option value="18">Portugal');
document.write('</option>');
document.write('          <option value="19">Türkei');
document.write('</option>');
document.write('          <option value="20">Russland');
document.write('</option>');
document.write('          <option value="21">Alaska');
document.write('</option>');
document.write('          <option value="22">Kanada');
document.write('</option>');
document.write('          <option value="23">USA');
document.write('</option>');
document.write('          <option value="24">Mittelamerika');
document.write('</option>');
document.write('          <option value="25">Brasilien');
document.write('</option>');
document.write('          <option value="26">Argentinien</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Bundesland auswählen (nur BRD):*</td>');
document.write('      <td>');
document.write('        <select name="user_input[id10]">');
document.write('          <option value="0">kein Bundesland gewählt');
document.write('</option>');
document.write('          <option value="1">Mecklenburg-Vorpommern');
document.write('</option>');
document.write('          <option value="2">Schleswig-Holstein');
document.write('</option>');
document.write('          <option value="3">Brandenburg');
document.write('</option>');
document.write('          <option value="4">Niedersachsen');
document.write('</option>');
document.write('          <option value="5">Hamburg');
document.write('</option>');
document.write('          <option value="6">Bremen');
document.write('</option>');
document.write('          <option value="7">Berlin');
document.write('</option>');
document.write('          <option value="8">Nordrhein-Westfalen');
document.write('</option>');
document.write('          <option value="9">Sachsen-Anhalt');
document.write('</option>');
document.write('          <option value="10">Sachsen');
document.write('</option>');
document.write('          <option value="11">Hessen');
document.write('</option>');
document.write('          <option value="12">Rheinland-Pfalz');
document.write('</option>');
document.write('          <option value="13">Thüringen');
document.write('</option>');
document.write('          <option value="14">Saarland');
document.write('</option>');
document.write('          <option value="15">Baden-Württemberg');
document.write('</option>');
document.write('          <option value="16">Bayern</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Firma oder Einrichtung*</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>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>Vorname*</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id11]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Ort*</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id12]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Strasze*</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id14]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>PLZ*</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id15]" value="" size="5">');
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>Webadresse*</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id16]" 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[id22]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Lagebeschreibung*</td>');
document.write('      <td>');
document.write('        <textarea name="user_input[id18]" style="width:100%" rows="5"></textarea>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Leistungen und Service*</td>');
document.write('      <td>');
document.write('        <textarea name="user_input[id19]" style="width:100%" rows="5"></textarea>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Preise*:</td>');
document.write('      <td>');
document.write('        <textarea name="user_input[id20]" style="width:100%" rows="5"></textarea>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Premiumeintrag für 89 €/Jahr</td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id23]" value="1" >');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Ust. ID. Nr . für Ausland</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id24]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>AGB akzeptiert*</td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id21]" value="1" >');
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="110205">');
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('    <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>');
document.write('    </tr>');
document.write('</form>');
document.write('  </table>');
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