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document.write('  <table>');
document.write('<form method="post" action="http://113689.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td colspan="2">Online Mitgliedsantrag des FC Bayern Fan Club Holledau e.V.</td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td colspan="2">mit * gekennzeichnete Felder müssen ausgefüllt  werden</td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Name *</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id3]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Vorname *</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id7]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Strasse *</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id8]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>PLZ *</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id15]" value="" size="5" maxlength="2">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Ort *</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id10]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Tel *</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id11]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>E-Mail *</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id4]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Antrag als *</td>');
document.write('      <td>');
document.write('        <select name="user_input[id14]">');
document.write('          <option value="0">Einzelmitglied / 10,- Euro Jahresbeitrag');
document.write('</option>');
document.write('          <option value="1">Kinder / Jugendliche bis 16 LJH / 3,- Euro Jahresbeitrag');
document.write('</option>');
document.write('          <option value="2">Familienmitglied / 18,- Euro Jahresbeitrag</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Satzung zur Kenntnis genommen *</td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id16]" value="1" >');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Bemerkung</td>');
document.write('      <td>');
document.write('        <textarea name="user_input[id17]" style="width:100%" rows="5"></textarea>');
document.write('      </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="113689">');
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('');