document.write('<form method="post" action="http://57753.newsletter.onetwomax.de/">');
document.write('  <table align="center" style="border: 1px solid #800000">');
document.write('    <tr>');
document.write('      <td><font color="#800000" face="Arial" size="4">Name</font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id4]" value="" size="50">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="#800000" face="Arial" size="4">E-Mail</font></td>');
document.write('      <td>');
document.write('        <input type="text" name="email" value="" size="50">');
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="add">');
document.write('        <input type="hidden" name="entry" value="57753">');
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('');