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<html>
<head>
<title>Bestellschein</title>
<meta name="author" content="Alex">
</head>
<body text="#000000" bgcolor="#FFFFFF" link="#FF0000" alink="#FF0000" vlink="#FF0000">
<h1 align="center">Bestellschein</h1>
<form method="post" action="mailto:
[email protected]">
<P></P>
<table width="50%" border="0" cellpadding="0" cellspacing="2">
<tr>
<th colspan=2><font size="+2">Persöhnliche Daten</font></th>
</tr>
<tr>
<td></td>
<td><select name="Geschlecht" size="1">
<option value="Herr">Herr</option>
<option selected value="Frau">Frau</option>
</select><br></td></td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>Name:
<td><input name="Name" size=15><br></td></td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>Vorname:</td>
<td><input name="Vorname" size=15><br></td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>Adresse</td>
<td>
Straße/Hausnummer:<br>
Ort: <br>
PLZ: <br>
Land: <br>
</td>
<td>
<input name="Straße" size=15><br>
<input name="Ort" size=15><br>
<input name="PLZ" size=5><br>
<select name="Land" size=1>
<option selected value="Deutschland">Deutschland</option>
<option value="Schweitz">Schweitz</option>
<option value="östereichich">Östereich</option>
</select>
</td>
<td>
</tr>
<tr>
<td>E-Mail:</td>
<td><input name="e-mail" size=15</td>
<td> </td>
<td> </td>
</tr>
<tr>
<th colspan=2><font size="+2">Produkte</font></th>
</tr>
<tr>
<th colspan=2><p align="left"><input type="checkbox" name="produkte" value="V3 Komfort-Blinkrelais für ÿTasteramerturen" checked>V3 Komfort-Blinkrelais für Tasteramerturen </p></th>
<th colspan=2><select name="Anzahl" size=1>
<option selected value="0">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option></select>
</tr>
<tr>
<th colspan=2><p align="left"><input type="checkbox" name="produkte" value="Fernlichtrelais für Tasteramerturen(Stromstoß)" checked>Fernlichtrelais für Tasteramerturen(Stromstoß)</p>
<th colspan=2><select name="Anzahl" size=1>
<option selected value="0">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option></select></tr>
<tr>
<th colspan=2><p align="left"><input type="checkbox" name="produkte" value="Minirelais" checked>Minirelais</p>
<th colspan=2><select name="Anzahl" size=1>
<option selected value="0">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option></select></tr>
<tr>
<th colspan=2><p align="left"><input type="checkbox" name="produkte" value="Mikrorelais" checked>Mikrorelais</p>
<th colspan=2><select name="Anzahl" size=1>
<option selected value="0">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option></select></tr>
<tr>
<th colspan=2><p align="left"><input type="checkbox" name="produkte" value="All-in-One Mini Blinkrelais Modul" checked>All-in-One Mini Blinkrelais Modul</p>
<th colspan=2><select name="Anzahl" size=1>
<option select value="0">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
</select></tr>
<tr>
<th colspan=2><font size="+2"><b>Bezahlart</b></font></th>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<th colspan=2><font size="+2"><b>Versand</b></font></th>
</tr>
<tr>
<th colspan=2><input type="radio" name="Versandt" value="versichert"checked>versicherter Versand deutschlandweit im Paket(5.00Euro)</th>
</tr>
<tr>
<th colspan=2><input type="radio" name="Versandt" value="unversicherter">Unversicherter Versand deutschlandweit im Brief (2.50 Euro)</th>
</tr>
</table>
<p></p>
<input type="submit" value="Abschicken">
<input type="reset" value="Eingaben löschen">
</form>
</body>
</html>