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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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