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<html>
<head>
<meta http-equiv="Content-Language" content="de">
<meta http-equiv="Content-Type" content="text/html; charset=windows-1252">
<title>Kontaktformular</title>
</head>
<body>
<form action="http://www.ekiwi.de/tools/kontaktformular/formmail.php" method="POST" name="MyForm1">
<input type="hidden" name="redirect" value="http://www.ekiwi.de/tools/kontaktformular/danke.htm">
<input type="hidden" name="typemail" value="html">
<input type="hidden" name="crypt" value="0">
<input type="hidden" name="einleittext" value="">
<input type="hidden" name="admin1" value="">
<input type="hidden" name="admin2" value="">
<input type="hidden" name="subject" value="Kontaktformular"><input type="hidden" name="admin" value="pflegeagenturSENIOR24@gmx.at"> <div align="center">
<table border="0" cellpadding="3" cellspacing="2">
<tr>
<td colspan="2"><font face="Arial,helvetica" size="+1">Kontakt-Formular<br>
</font></td>
</tr>
<tr>
<td colspan="2"><font face="Arial,helvetica" size="-1">Mit diesem Fomular können Sie mit uns Kontakt aufnehmen.<br>
</font></td>
</tr>
<tr>
<td align="right" bgcolor="#E6E6E6"><font color="#000000" face="Arial,helvetica" size="-1">Name
:</font></td>
<td bgcolor="#E6E6E6"><input type="text" name="name" value size="20"></td>
</tr>
<tr>
<td align="right" bgcolor="#E6E6E6"><font color="#000000" face="Arial,helvetica" size="-1">
Ihre Emailadresse:</font></td>
<td bgcolor="#E6E6E6"><input type="text" name="email" value size="20"></td>
</tr>
<tr>
<td align="right" bgcolor="#E6E6E6"><font color="#000000" face="Arial,helvetica" size="-1">Straße:</font></td>
<td bgcolor="#E6E6E6"><input type="text" name="strasse" value size="20"></td>
</tr>
<tr>
<td align="right" bgcolor="#E6E6E6"><font color="#000000" face="Arial,helvetica" size="-1">Ort:</font></td>
<td bgcolor="#E6E6E6"><input type="text" name="ort" value size="20"></td>
</tr>
<tr>
<td align="right" bgcolor="#E6E6E6"><font color="#000000" face="Arial,helvetica" size="-1">Land:</font></td>
<td bgcolor="#E6E6E6"><input type="text" name="land" value size="20"></td>
</tr>
<tr>
<td align="right" bgcolor="#E6E6E6"><font color="#000000" face="Arial,helvetica" size="-1">Telefon-Nummer:</font></td>
<td bgcolor="#E6E6E6"><input type="text" name="tel" value size="20"></td>
</tr>
<tr>
<td align="right" bgcolor="#E6E6E6"><font color="#000000" face="Arial,helvetica" size="-1"></font></td>
<td bgcolor="#E6E6E6"><input type="text" name="" value size="20"></td>
</tr>
<tr>
<td align="right" valign="top" bgcolor="#E6E6E6"><strong><font color="#000000"><br>
</font><font color="#000000" face="Arial,helvetica" size="-1">Kommentar:</font></strong></td>
<td bgcolor="#E6E6E6"><textarea cols="30" rows="10" name="comment"></textarea></td>
</tr>
<tr>
<td colspan="2"><font face="Arial,helvetica"><input type="submit" name="next"
value="Abschicken"><input type="reset" name="next" value="Zurücksetzen"></font></td>
</tr>
</table>
</div>
</form>
</body>
</html>
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