document.write('');
document.write('  <table bgcolor="#FFFCCC">');
document.write('<form method="post" action="http://71247.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td colspan="2"><font color="#CC0000" face="verdana" size="3">gut informiert - Newsletter von communicanis</font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="verdana" size="2">Name + Vorname</font></td>');
document.write('      <td><font face="verdana" size="2">');
document.write('        <input style=" font-family: verdana;" type="text" name="user_input[id3]" value="" size="40" maxlength="25">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="verdana" size="2">E-Mail</font></td>');
document.write('      <td><font face="verdana" size="2">');
document.write('        <input style=" font-family: verdana;" type="text" name="user_input[id4]" value="" size="40" maxlength="25">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Verdana" size="2">Postleitzahl, Ort</font></td>');
document.write('      <td><font face="Verdana" size="2">');
document.write('        <input style=" font-family: verdana;" type="text" name="user_input[id6]" value="" size="40">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="verdana" size="2">Newsletter</font></td>');
document.write('      <td><font face="verdana" size="2">');
document.write('        <select style=" font-family: verdana;" name="user_input[id5]">');
document.write('          <option value="0">Ich bitte um Informationen von communicanis.');
document.write('</option>');
document.write('          <option value="1">Ich melde mich vom Newsletter ab.</option>');
document.write('        </select>');
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="71247">');
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('');