document.write('');
document.write('  <table>');
document.write('<form method="post" action="http://40714.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td colspan="2"><font face="Verdana" size="3"><b>Betreuungsanfrage</b></font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td colspan="2"><font face="Verdana" size="2"><b><i>mit * gekennzeichnete Felder müssen ausgefüllt werden</i></b></font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Verdana" size="2"><b>* Name:</b></font></td>');
document.write('      <td><font color="#000000" face="Arial" size="2">');
document.write('        <input type="text" name="user_input[id7]" value="" size="40">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Verdana" size="2"><b>* Adresse:</b></font></td>');
document.write('      <td><font color="#000000" face="Arial" size="2">');
document.write('        <textarea name="user_input[id8]" style="width:100%" rows="5"></textarea>');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Verdana" size="2"><b>* E-Mail:</b></font></td>');
document.write('      <td><font color="#000000" face="Arial" size="2">');
document.write('        <input type="text" name="user_input[id4]" value="" size="20">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Verdana" size="2"><b>* Telefon:</b></font></td>');
document.write('      <td><font color="#000000" face="Arial" size="2">');
document.write('        <input type="text" name="user_input[id9]" value="" size="20">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Verdana" size="2"><b>* Anzahl Katzen:</b></font></td>');
document.write('      <td><font color="#000000" face="Arial" size="2">');
document.write('        <input type="text" name="user_input[id10]" value="" size="40">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Verdana" size="2"><b>* Betreuung VON  BIS:</b></font></td>');
document.write('      <td><font color="#000000" face="Arial" size="2">');
document.write('        <input type="text" name="user_input[id11]" value="" size="40">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Verdana" size="2"><b>Freigänger</b></font></td>');
document.write('      <td><font color="#000000" face="Arial" size="2">');
document.write('        <select name="user_input[id18]">');
document.write('          <option value="0">Nein');
document.write('</option>');
document.write('          <option value="1">Ja</option>');
document.write('        </select>');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Verdana" size="2"><b>Wohnungskatze/n</b></font></td>');
document.write('      <td><font color="#000000" face="Arial" size="2">');
document.write('        <select name="user_input[id20]">');
document.write('          <option value="0">Ja');
document.write('</option>');
document.write('          <option value="1">Nein</option>');
document.write('        </select>');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font face="Verdana" size="2"><b><i>Weitere Informationen:</i></b></font></td>');
document.write('      <td><font color="#000000" face="Arial" size="2">');
document.write('        <textarea name="user_input[id6]" style="width:100%" rows="7"></textarea>');
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="40714">');
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('');