<html>
<head>
<meta name="generator" content="HTML Tidy, see www.w3.org">
<title>Mail-Formular</title>
<!--....-->
<script type="text/javascript">
<!--
function auswahl(objSelect)
{
arrLayers = ['Bankeinzug', 'Kreditkarte'];
for(j = 0; j<arrLayers.length;++j)
{
document.getElementById(arrLayers[j]).style.display=
(objSelect.options[objSelect.selectedIndex].text==arrLayers[j])
?'block'
:'none';
}
}
//-->
</script>
<!--....-->
<style type="text/css">
<!--
#Bankeinzug,#Kreditkarte{
display:none;
}
-->
</style>
</head>
<body bgcolor="#000000" text="#EBEBEB">
<br>
<br>
<form name="Formular" action="http://w...m.cgi" method="post">
<input name="recipient" type="hidden" value="katalog....de">
<center>
<h1>Katalogbestellung</h1>
<font size="2">Hier können Sie sich den Katalog
reservieren.<br>
Der Katalog wird Ihnen gegen eine Schutzgebühr <strong>(<font
color="red">5 Euro</font>)</strong> nach Erscheinen (etwa Oktober
2004) zugestellt.<br>
Sie erhalten auf dieses Formular eine Mail mit den erforderlichen
Angaben!</font><br>
<br>
</center>
<table cellspacing="0" border="0" cellpadding="0" width="681"
align="center">
<tr>
<td colspan="4">
<hr size="7" width="80%">
</td>
</tr>
<tr>
<td align="left" width="118">
<div align="right">Anrede :</div>
</td>
<td width="1"> </td>
<td colspan="2" width="562">
<p align="left"><input type="radio" name="Anrede" checked value=
"Herr"> Herr <input type="radio" name="Anrede" value="Frau">
Frau</p>
</td>
</tr>
<tr>
<td colspan="4"> </td>
</tr>
<tr>
<td align="left" width="118">
<div align="right">Nachname :</div>
</td>
<td width="1"> </td>
<td colspan="2" width="562">
<div align="left"><input type="text" size="40" name=
"Nachname"></div>
</td>
</tr>
<tr>
<td colspan="4"> </td>
</tr>
<tr>
<td align="left">
<div align="right">Vorname :</div>
</td>
<td> </td>
<td colspan="2">
<div align="left"><input type="text" size="40" name=
"Vorname"></div>
</td>
</tr>
<tr>
<td colspan="4"> </td>
</tr>
<tr>
<td align="left">
<div align="right">Straße / Nr.:</div>
</td>
<td> </td>
<td colspan="2">
<div align="left"><input type="text" size="40" name=
"Strasse/Nr"></div>
</td>
</tr>
<tr>
<td colspan="4"> </td>
</tr>
<tr>
<td align="left">
<div align="right">PLZ :</div>
</td>
<td> </td>
<td colspan="2">
<div align="left"><input type="text" size="40" name="PLZ"></div>
</td>
</tr>
<tr>
<td colspan="4"> </td>
</tr>
<tr>
<td align="left">
<div align="right">Ort :</div>
</td>
<td> </td>
<td colspan="2">
<div align="left"><input type="text" size="40" name="Ort"></div>
</td>
</tr>
<tr>
<td colspan="4"> </td>
</tr>
<tr>
<td align="left">
<div align="right">Land :</div>
</td>
<td> </td>
<td colspan="2">
<div align="left"><input type="text" size="40" name="Land" value=
"Deutschland"></div>
</td>
</tr>
<tr>
<td colspan="4"> </td>
</tr>
<tr>
<td align="left">
<div align="right">Telefon :</div>
</td>
<td> </td>
<td colspan="2">
<div align="left"><input type="text" size="40" name=
"Telefon"></div>
</td>
</tr>
<tr>
<td colspan="4"> </td>
</tr>
<tr>
<td align="left" width="118">
<div align="right">EMail :</div>
</td>
<td width="1"> </td>
<td colspan="2" width="562">
<div align="left"><input type="text" size="40" name="Email"></div>
</td>
</tr>
<tr>
<td colspan="4" align="left"> </td>
</tr>
<tr>
<td align="left">
<div align="right">Firma / Dienststelle:</div>
</td>
<td> </td>
<td colspan="2">
<div align="left"><input type="text" size="40" name=
"Firma/Dienststelle"></div>
</td>
</tr>
<tr>
<td colspan="4"> </td>
</tr>
<tr>
<td align="left">
<div align="right">Zahlungsweise :</div>
</td>
<td> </td>
<td colspan="2">
<div align="left"><!--....-->
<select name="zahlungsweise" onchange="auswahl(this)">
<option>Vorkasse</option>
<option>Bankeinzug</option>
<option>Rechnung</option>
<option>Kreditkarte</option>
</select>
<div id="Bankeinzug">
<table>
<tr>
<td align="left">
<div align="right">Name und Sitz der Bank</div>
</td>
<td> </td>
<td colspan="2">
<div align="left"><input type="text" size="40" name=
"Bank/Sitz"></div>
</td>
</tr>
<tr>
<td align="left">
<div align="right">Bankleitzahl</div>
</td>
<td> </td>
<td colspan="2">
<div align="left"><input type="text" size="40" name="BLZ"></div>
</td>
</tr>
<tr>
<td align="left">
<div align="right">Konto-Nr.</div>
</td>
<td> </td>
<td colspan="2">
<div align="left"><input type="text" size="40" name="Konto"></div>
</td>
</tr>
<tr>
<td colspan="4"> </td>
</tr>
</table>
</div>
<div id="Kreditkarte">
<table>
<tr>
<td align="left">
<div align="right">Kartenname</div>
</td>
<td> </td>
<td colspan="2">
<div align="left"><input type="text" size="40" name="Karte"></div>
</td>
</tr>
<tr>
<td align="left">
<div align="right">Karten-Nr.</div>
</td>
<td> </td>
<td colspan="2">
<div align="left"><input type="text" size="40" name="K-Nr"></div>
</td>
</tr>
<tr>
<td align="left">
<div align="right">gültig bis</div>
</td>
<td> </td>
<td colspan="2">
<div align="left"><input type="text" size="40" name="bis"></div>
</td>
</tr>
<tr>
<td colspan="4"> </td>
</tr>
</table>
</div>
<!--....-->
</div>
</td>
</tr>
<tr>
<td colspan="4"> </td>
</tr>
<tr>
<td width="118" height="70" align="left" valign="top">
<div align="right">Zusatz:</div>
</td>
<td width="1"> </td>
<td colspan="2" width="562">
<div align="left"><textarea cols="45" name="Nachricht" rows="3"
wrap="vitual"></textarea></div>
</td>
</tr>
<tr>
<td colspan="4">
<hr size="7" width="80%">
</td>
</tr>
<tr>
<td colspan="4" align="center">
<div align="center"><input type="Submit" value="Abschicken"> <input
type="reset" value="Verwerfen"></div>
</td>
</tr>
<tr>
<td colspan="4" align="center"> </td>
</tr>
</table>
</form>
</body>
</html>