document.write('<form method="post" action="http://44403.newsletter.onetwomax.de/">');
document.write('  <table>');
document.write('    <tr>');
document.write('      <td colspan="2"><font size="1"></font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="black" face="Verdana" size="1">E-Mail</font></td>');
document.write('      <td><font size="1">');
document.write('        <input type="text" name="email" value="" size="10">');
document.write('      </font></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><font color="black" face="Verdana" size="1">Name</font></td>');
document.write('      <td><font size="1">');
document.write('        <input type="text" name="user_input[id4]" value="" size="10">');
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="44403">');
document.write('        <input type="submit" name="submit" value="Abschicken">');
document.write('      </td>');
document.write('    </tr>');
document.write('  </table>');
document.write('</form>');
document.write('');