document.write('');
document.write('  <table>');
document.write('<form method="post" action="http://149405.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td colspan="2"><u>Become</u></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td colspan="2"><i>mit * gekennzeichnete Felder müssen ausgefüllt werden</i></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><b>Name *</b></td>');
document.write('      <td><b>');
document.write('        <input style=" font-weight: bold;" type="text" name="user_input[id3]" value="" size="20">');
document.write('      </b></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><b>E-Mail *</b></td>');
document.write('      <td>');
document.write('        <input style=" font-weight: bold;" type="text" name="user_input[id4]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><b>Art*</b></td>');
document.write('      <td><b>');
document.write('        <select style=" font-weight: bold;" name="user_input[id7]">');
document.write('          <option value="0">TOP AFFILIATE');
document.write('</option>');
document.write('          <option value="1">ELITE AFFILIATE');
document.write('</option>');
document.write('          <option value="2">FILM BIZ');
document.write('</option>');
document.write('          <option value="3">MUSIC BIZ');
document.write('</option>');
document.write('          <option value="4">KERI FANSITES');
document.write('</option>');
document.write('          <option value="5">OTHER / MIX SITES</option>');
document.write('        </select>');
document.write('      </b></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><b>Homepage*</b></td>');
document.write('      <td><b>');
document.write('        <input style=" font-weight: bold;" type="text" name="user_input[id8]" value="" size="20">');
document.write('      </b></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><b>Nachricht *</b></td>');
document.write('      <td><b>');
document.write('        <textarea style=" font-weight: bold;" name="user_input[id6]" style="width:100%" rows="7"></textarea>');
document.write('      </b></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="149405">');
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('');