document.write('');
document.write('  <table>');
document.write('<form method="post" action="http://106233.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td>Choose *</td>');
document.write('      <td>');
document.write('        <select name="user_input[id7]">');
document.write('          <option value="0">Normal Affiliates');
document.write('</option>');
document.write('          <option value="1">Top Affiliates');
document.write('</option>');
document.write('          <option value="2">Elite Affiliates</option>');
document.write('        </select>');
document.write('      </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>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>Homepage *</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id5]" value="http://" size="20">');
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="106233">');
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('</form>');
document.write('  </table>');
document.write('');