document.write('<form method="post" action="http://25996.newsletter.onetwomax.de/">');
document.write('  <table align="center">');
document.write('    <tr>');
document.write('      <td colspan="2"><font color="#CC0000" face="Arial" size="2"><b>mit * gekennzeichnete Felder müssen ausgefüllt werden</b></font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#CC0000" face="Arial" size="2"><b>Name *</b></font></td>');
document.write('      <td><font color="#CC0000" face="Arial" size="2"><b>');
document.write('        <input style=" color: #CC0000; font-family: Arial; font-weight: bold;" type="text" name="user_input[id4]" value="" size="30">');
document.write('      </b></font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#CC0000" face="Arial" size="2"><b>E-Mail *</b></font></td>');
document.write('      <td><font color="#CC0000" face="Arial" size="2"><b>');
document.write('        <input style=" color: #CC0000; font-family: Arial; font-weight: bold;" type="text" name="email" value="" size="30">');
document.write('      </b></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="25996">');
document.write('        <input type="submit" name="submit" value="Abschicken">');
document.write('      </td>');
document.write('    </tr>');
document.write('  </table>');
document.write('</form>');
document.write('');