document.write('<form method="post" action="http://16862.newsletter.onetwomax.de/">');
document.write('  <table align="center" cellspacing="1" cellpadding="1">');
document.write('    <tr>');
document.write('      <td align="center"><font color="#99CCFF" face="verdana" size="1"><b>Name</b></font></td>');
document.write('      <td align="center"><font color="#CCCCCC" face="verdana" size="1">');
document.write('        <input style=" border: 1px solid #CCCCCC; background-color: #000000; color: #CCCCCC; font-family: verdana;" type="text" name="user_input[id4]" value="" size="20">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="center"><font color="#99CCFF" face="Verdana" size="1"><b>E-Mail</b></font></td>');
document.write('      <td align="center"><font color="#CCCCCC" face="Verdana" size="1">');
document.write('        <input style=" border: 1px solid #CCCCCC; background-color: #000000; color: #CCCCCC; font-family: Verdana;" type="text" name="email" value="" size="20">');
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="add">');
document.write('        <input type="hidden" name="entry" value="16862">');
document.write('        <input type="submit" name="submit" value="Abschicken">');
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> Newsletter Script</font></td>');
document.write('    </tr>');
document.write('  </table>');
document.write('</form>');
document.write('');
