document.write('');
document.write('  <table align="center" bgcolor="#FFDF00">');
document.write('<form method="post" action="http://93271.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td>Datum *</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id16]" value="TT.MM.JJJJ" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Titel / Veranstaltung *</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id5]" value="" size="20" maxlength="150">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Beginn *</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id17]" value="00:00 Uhr" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Nachricht *</td>');
document.write('      <td>');
document.write('        <textarea name="user_input[id6]" style="width:100%" rows="7"></textarea>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Anschrift d. Veranstaltung*</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[id8]" value="00000" size="20" maxlength="5">');
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[id10]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Ihr Name / Ansprechpartner*</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>Telefonnummer *</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id15]" value="" size="20" maxlength="30">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Ihre Homepage URL</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id13]" value="www.mustermannistdolle.de" 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>Landkreis</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>Bundesland</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 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="93271">');
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('');