document.write('');
document.write('  <table>');
document.write('<form method="post" action="http://61848.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td><font color="red" face="Arial" size="4"><b>Ich möchte weitere Informationen zur</b></font></td>');
document.write('      <td></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2"><b>Industriekultur e.V.</b></font></td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id8]" value="1" >');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2"><b>Industriekultur allgemein</b></font></td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id9]" value="1" >');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2"><b>Technikgeschichte allgemein</b></font></td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id10]" value="1" >');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2"><b>Ich interessiere mich für:</b></font></td>');
document.write('      <td>');
document.write('        <select name="user_input[id12]">');
document.write('          <option value="0">Industriekultur allgemein');
document.write('</option>');
document.write('          <option value="1">Technikgeschichte allgemein');
document.write('</option>');
document.write('          <option value="2">Bergbau, Montanwesen');
document.write('</option>');
document.write('          <option value="3">Eisen-, Straßenbahnen');
document.write('</option>');
document.write('          <option value="4">Hüttenwesen, Metallindustrie');
document.write('</option>');
document.write('          <option value="5">Landwirtschaftstechnik');
document.write('</option>');
document.write('          <option value="6">Mühlen');
document.write('</option>');
document.write('          <option value="7">Textil');
document.write('</option>');
document.write('          <option value="8">Glas');
document.write('</option>');
document.write('          <option value="9">Schifffahrt, Wasserbau');
document.write('</option>');
document.write('          <option value="10">Verkehr, Transport');
document.write('</option>');
document.write('          <option value="11">Wohnen, Siedlungen');
document.write('</option>');
document.write('          <option value="12">Sonstiges, und zwar:</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2"><b>außerdem</b></font></td>');
document.write('      <td>');
document.write('        <select name="user_input[id22]">');
document.write('          <option value="0">Industriekultur allgemein');
document.write('</option>');
document.write('          <option value="1">Technikgeschichte allgemein');
document.write('</option>');
document.write('          <option value="2">Bergbau, Montanwesen');
document.write('</option>');
document.write('          <option value="3">Eisen-, Straßenbahnen');
document.write('</option>');
document.write('          <option value="4">Hüttenwesen, Metallindustrie');
document.write('</option>');
document.write('          <option value="5">Landwirtschaftstechnik');
document.write('</option>');
document.write('          <option value="6">Mühlen');
document.write('</option>');
document.write('          <option value="7">Textil');
document.write('</option>');
document.write('          <option value="8">Glas');
document.write('</option>');
document.write('          <option value="9">Schifffahrt, Wasserbau');
document.write('</option>');
document.write('          <option value="10">Verkehr, Transport');
document.write('</option>');
document.write('          <option value="11">Wohnen, Siedlungen</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2"><b>und</b></font></td>');
document.write('      <td>');
document.write('        <select name="user_input[id23]">');
document.write('          <option value="0">Industriekultur allgemein');
document.write('</option>');
document.write('          <option value="1">Technikgeschichte allgemein');
document.write('</option>');
document.write('          <option value="2">Bergbau, Montanwesen');
document.write('</option>');
document.write('          <option value="3">Eisen-, Straßenbahnen');
document.write('</option>');
document.write('          <option value="4">Hüttenwesen, Metallindustrie');
document.write('</option>');
document.write('          <option value="5">Landwirtschaftstechnik');
document.write('</option>');
document.write('          <option value="6">Mühlen');
document.write('</option>');
document.write('          <option value="7">Textil');
document.write('</option>');
document.write('          <option value="8">Glas');
document.write('</option>');
document.write('          <option value="9">Schifffahrt, Wasserbau');
document.write('</option>');
document.write('          <option value="10">Verkehr, Transport');
document.write('</option>');
document.write('          <option value="11">Wohnen, Siedlungen</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Arial" size="2"><b>Sonstiges, und zwar</b></font></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><font color="red" face="Arial" size="4"><b>Angaben zur Person</b></font></td>');
document.write('      <td></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="red" face="Arial" size="2"><b>Name *</b></font></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><font color="red" face="Arial" size="2"><b>E-Mail *</b></font></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><font color="red" face="Arial" size="2"><b>Straße</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="red" face="Arial" size="2"><b>PLZ</b></font></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><font color="red" face="Arial" size="2"><b>Wohnort</b></font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id15]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="red" face="Arial" size="2"><b>Land</b></font></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><font color="red" face="Arial" size="2"><b>Bundesland</b></font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id17]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="red" face="Arial" size="2"><b>Fon</b></font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id18]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="red" face="Arial" size="2"><b>oder</b></font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id19]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="red" face="Arial" size="2"><b>Fax</b></font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id21]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td colspan="2">mit * gekennzeichnete Felder müssen ausgefüllt werden</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="61848">');
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('');