document.write('');
document.write('  <table align="center" style="border: 1px solid #000000">');
document.write('<form method="post" action="http://138703.formmailer.onetwomax.de/">');
document.write('    <tr bgcolor="#000000">');
document.write('      <td align="right"><font color="#E5FFFF" face="Arial" size="3"><b>Banner URL:</b></font></td>');
document.write('      <td align="right"><font color="#E5FFFF" face="Arial" size="3"><b>');
document.write('        <input style=" color: #000000; font-family: Arial;" type="text" name="user_input[id5]" value="" size="30" maxlength="200">');
document.write('      </b></font></td>');
document.write('    </tr>');
document.write('    <tr bgcolor="#000000">');
document.write('      <td align="right"><font color="#E5FFFF" face="Arial" size="3"><b>Seiten URL:</b></font></td>');
document.write('      <td align="right"><font color="#E5FFFF" face="Arial" size="3"><b>');
document.write('        <input style=" color: #000000; font-family: Arial; font-weight: bold;" type="text" name="user_input[id3]" value="" size="30" maxlength="200">');
document.write('      </b></font></td>');
document.write('    </tr>');
document.write('    <tr bgcolor="#000000">');
document.write('      <td align="right"><font color="#E5FFFF" face="Arial" size="3"><b>E-Mail:</b></font></td>');
document.write('      <td align="right"><font color="#E5FFFF" face="Aril" size="3"><b>');
document.write('        <input style=" color: #000000; font-family: Arial; font-weight: bold;" type="text" name="user_input[id4]" value="" size="30" maxlength="50">');
document.write('      </b></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="138703">');
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>');
document.write('');