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<table cellspacing="0" cellpadding="0" border="0"> <tbody> <tr> <td> </td> <td class="content_table"> <h1>Bestellen</h1> <div> <form action="form_mailer.php" method="post"> <table summary="Formulier voor escape mobility company"> <tbody> <tr> <td class="form_omschrijving">Organisation*</td> <td width="100"><input size="50" name="organisatie" /> </td> </tr> <tr> <td> </td> <td class="form_omschrijving"><input type="radio" name="geslacht" value="dhr" />Herr. <input type="radio" name="geslacht" value="mevr" />Frau </td> </tr> <tr> <td class="form_omschrijving">Name*</td> <td><input size="50" name="naam" /> </td> </tr> <tr> <td class="form_omschrijving">Initialen</td> <td width="100"><input size="50" name="voorletters" /> </td> </tr> <tr> <td class="form_omschrijving">Funktion</td> <td width="100"><input size="50" name="functie" /> </td> </tr> <tr> <td class="form_omschrijving">Straße und Hausnr.*</td> <td><input size="38" name="straat" /> <input size="6" name="huisnummer" /> </td> </tr> <tr> <td class="form_omschrijving">Postfach und Wohnort*</td> <td><input maxlength="12" size="6" name="postcode" /> <input size="38" name="plaats" /> </td> </tr> <tr> <td class="form_omschrijving"> </td> <td> </td> </tr> <tr> <td class="form_omschrijving">Postl.zahl</td> <td><input size="50" name="postbus" /> </td> </tr> <tr> <td class="form_omschrijving">Postfach und Wohnort</td> <td><input size="6" name="postcode_postbus" /> <input size="38" name="plaats_postbus" /> </td> </tr> <tr> <td class="form_omschrijving"> </td> <td> </td> </tr> <tr> <td class="form_omschrijving">E-mail*</td> <td><input size="50" name="email" /> </td> </tr> <tr> <td class="form_omschrijving">Telefon*</td> <td><input size="50" name="telefoon" /> </td> </tr> <tr> <td class="form_omschrijving">Fax</td> <td><input size="50" name="fax" /> </td> </tr> </tbody> </table> <table> <tbody> <tr> <td class="form_omschrijving">Typ</td> <td><select class="select_form_java" onchange="populate()" name="type"> <option value="16" selected="selected">---- Bitte wählen ---</option> <option value="17>Escape-Chair Comfort</option> <option value=">Escape-Chair StandardPLUS</option> <option value="19">Escape-Chair Standard</option> <option value="20">Escape-Chair Tragebügel</option> <option value="21">Escape-Stretcher</option> <option value="22">Escape-Training</option> <option value="23">Escape-Analysis</option> </select> </td> <td class="form_omschrijving">Anzahl<input size="10" name="aantal_type" /> </td> </tr> <tr> <td class="form_omschrijving">Zubehör</td> <td><select class="select_form_java" name="accessoires"> <option selected="selected">---- Bitte wählen ---</option> </select> </td> <td class="form_omschrijving">Anzahl<input size="10" name="aantal_accessoires" /> </td> </tr> <tr> <td class="form_omschrijving" colspan="3">Gerne machen wir Ihnen ein Angebot gemäß Ihren Wünschen und Anforderungen.<br /> Bitte versenden Sie dieses Formular und wir werden Sie in Kürze kontaktieren.<br /> </td> </tr> <tr> <td class="form_omschrijving" colspan="3"><input type="hidden" name="soort_formulier" value="bestelform" /> <input type="hidden" name="type_formulier" value="Ingevuld Bestelformulier" /> <input type="hidden" name="send_answer" value="Vielen Dank f?en Antrag. Wir werden uns so bald wie m?ch bei Ihnen melden." /> <input type="hidden" name="iddocument" value="fill_in_iddocument" /> <input type="image" src="images/versenden.jpg" /> </td> </tr> </tbody> </table> </form> </div> </td> </tr> </tbody> </table>
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