<form action=<? echo $_SERVER['PHP_SELF']; ?> method=post onSubmit="MM_validateForm('vorname','','R','vorname','','R','name','','R','strassenr','','R','plz','','RisNum','ort','','R','tel','','NisNum','email','','NisEmail');return document.MM_returnValue">
<div align="left"><font color="#FFFFFF" size="2" face="Verdana, Arial, Helvetica, sans-serif"><strong>
</strong></font>
<table width="99%" border="0" cellspacing="0" cellpadding="2">
<tr>
<td height="71" colspan="2" valign="top" class="normtext"><table width="332" border="1" cellpadding="0" cellspacing="0" bordercolor="#FFFFFF" bgcolor="#F7F7F7">
<tr>
<td width="20" align="center" valign="top" bgcolor="#CCCCCC" class="normtext"><div align="center"><font color="#FFFFFF" size="2" face="Verdana, Arial, Helvetica, sans-serif"><strong>
<input name="preisliste" type="checkbox" id="preisliste" value="anfordern">
</strong></font></div></td>
<td width="306" valign="middle" class="normtext"><strong>Preisliste
anfordern<br>
</strong></td>
</tr>
<tr>
<td height="21" align="center" valign="top" bgcolor="#CCCCCC" class="normtext"><font color="#FFFFFF" size="2" face="Verdana, Arial, Helvetica, sans-serif"><strong>
<input name="geschenkgutschein" type="checkbox" id="geschenkgutschein" value="bestellen">
</strong></font></td>
<td class="normtext"><strong>Geschenkgutschein
bestellen</strong> <br>
im Wert von <font color="#FFFFFF" size="2" face="Verdana, Arial, Helvetica, sans-serif"><strong>
<input name="geschenkgutscheinwert" type=text class="normtext" id="geschenkgutscheinwert" style="font-size:9pt" size="5">
</strong></font>€<br>
</td>
</tr>
<tr>
<td align="center" valign="top" bgcolor="#CCCCCC"><font color="#FFFFFF" size="2" face="Verdana, Arial, Helvetica, sans-serif"><strong>
<input name="probierpaketp6" type="checkbox" id="probierpaketp6" value="bestellen">
</strong></font></td>
<td class="normtext"><strong>Probierpaket P6 </strong>(Beschreibung siehe oben)<strong><br>
</strong></td>
</tr>
<tr>
<td align="center" valign="top" bgcolor="#CCCCCC"><font color="#FFFFFF" size="2" face="Verdana, Arial, Helvetica, sans-serif"><strong>
<input name="probierpaketp12" type="checkbox" id="probierpaketp12" value="bestellen">
</strong></font></td>
<td class="normtext"><strong>Probierpaket P12 </strong>(Beschreibung siehe oben) <strong><br>
</strong></td>
</tr>
<tr>
<td align="center" valign="top" bgcolor="#CCCCCC"><font color="#FFFFFF" size="2" face="Verdana, Arial, Helvetica, sans-serif"><strong>
<input name="privat" type="checkbox" id="privat" value="bestellen">
</strong></font></td>
<td class="normtext"><strong>Probierpaket Privat</strong> (Beschreibung siehe oben)<br></td>
</tr>
</table>
<br>
<table width="332" border="1" cellpadding="0" cellspacing="0" bordercolor="#FFFFFF" bgcolor="#F7F7F7">
</table></td>
</tr>
<tr>
<td height="11" valign="top" class="normtext"><strong>Anrede:</strong></td>
<td width="69%" class="normtext"><font color="#FFFFFF" size="2" face="Verdana, Arial, Helvetica, sans-serif"><strong>
<input name="herr" type="checkbox" id="herr" value="Herr">
</strong></font>Herr<font size="2" face="Verdana, Arial, Helvetica, sans-serif">
<input name="frau" type="checkbox" id="frau" value="Frau">
</font>Frau </td>
</tr>
<tr>
<td class="normtext"><strong>Vorname:</strong></td>
<td width="69%"><font color="#FFFFFF" size="2" face="Verdana, Arial, Helvetica, sans-serif"><strong>
<input name="vorname" type=text id="vorname" style="font-size:9pt" size="25">
</strong></font></td>
</tr>
<tr>
<td class="normtext"><strong>Name:</strong></td>
<td><font color="#FFFFFF" size="2" face="Verdana, Arial, Helvetica, sans-serif"><strong>
<input name="name" type=text id="name" style="font-size:9pt" size="25">
</strong></font></td>
</tr>
<tr>
<td class="normtext"><strong>Firma:</strong></td>
<td><font color="#FFFFFF" size="2" face="Verdana, Arial, Helvetica, sans-serif"><strong>
<input name="firma" type=text id="firma" style="font-size:9pt" size="25">
</strong></font></td>
</tr>
<tr>
<td class="normtext"><strong>Str. / Nr.:</strong></td>
<td><font color="#FFFFFF" size="2" face="Verdana, Arial, Helvetica, sans-serif"><strong>
<input name="strassenr" type=text id="strassenr" style="font-size:9pt" size="25">
</strong></font></td>
</tr>
<tr>
<td class="normtext"><strong>PLZ:</strong></td>
<td><font color="#FFFFFF" size="2" face="Verdana, Arial, Helvetica, sans-serif"><strong>
<input name="plz" type=text id="plz" style="font-size:9pt" size="25">
</strong></font></td>
</tr>
<tr>
<td class="normtext"><strong>Ort:</strong></td>
<td><font color="#FFFFFF" size="2" face="Verdana, Arial, Helvetica, sans-serif"><strong>
<input name="ort" type=text id="ort" style="font-size:9pt" size="25">
</strong></font></td>
</tr>
<tr>
<td class="normtext"><strong>Tel.:</strong></td>
<td><font color="#FFFFFF" size="2" face="Verdana, Arial, Helvetica, sans-serif"><strong>
<input name="tel" type=text id="tel" style="font-size:9pt" size="25">
</strong></font></td>
</tr>
<tr>
<td class="normtext"><strong>E-Mail:</strong></td>
<td><font color="#FFFFFF" size="2" face="Verdana, Arial, Helvetica, sans-serif"><strong>
<input name="email" type=text id="email" style="font-size:9pt" size="25">
</strong></font></td>
</tr>
<tr>
<td valign="top" class="normtext"><strong>Anmerkung:</strong></td>
<td><textarea name="anmerkung" cols="25" rows="4" id="anmerkung"></textarea></td>
</tr>
<tr>
<td valign="top" class="normtext"><strong>AGB:</strong></td>
<td valign="top" class="normtext"><font color="#FFFFFF" size="2" face="Verdana, Arial, Helvetica, sans-serif"><strong>
<input name="AGB" type="checkbox" class="normtext" id="AGB" value="AGB">
</strong></font> Ich bestätige, dass ich die AGB gelesen habe. <a href="../download/AGB.pdf" target="_blank" class="link">AGB Downloaden (PDF)</a></td>
</tr>
<tr>
<td colspan="2"> <br> <input name="absenden" type="submit" class="normtext" id="absenden" value="Senden">
<input name="reset" type="reset" class="normtext" value="Zurücksetzen">
</td>
</tr>
</table>
</div>
</form>