Untitled

<form name="liaise_7" id="liaise_7" onSubmit="return checkFieldsIn()" method="post" action="http://redirect2.mailingwork.de/addabo.php" enctype="multipart/form-data">

  <input type="hidden" id="extIn0" name="extdbfields[0][value][]" value="Website" />

  <input type="hidden" name="extdbfields[0][ID]" value="100005431" />

  <input type="hidden" name="formtype" value="eMail" />

  <input type="hidden" name="customerID" value="MzU2NQ%3D%3D" />

  <input type="hidden" name="Liste[1]" value="MTU5NDE%3D" />

  <input type="hidden" id="extIn1" name="extdbfields[1][value][]" value="ja" />

  <input type="hidden" name="extdbfields[1][ID]" value="100005432" />

  <input type="hidden" id="extIn2" name="extdbfields[2][value][]" value="<?php echo $_GET['betreuer']; ?>" />

  <input type="hidden" name="extdbfields[2][ID]" value="100007299" />

  <table width="500px">

    <tr>

      <td align="left">Vorname * </td>

      <td class="odd"><input class=text type='text' name="Vorname" id="stdIn2" value="" size='30' maxlength='255' /></td>

    </tr>

    <tr>

      <td align="left">Nachname * </td>

      <td class="odd"><input class=text type='text' name="Nachname" id="stdIn1" value="" size='30' maxlength='255' /></td>

    </tr>

    <tr>

      <td align="left">E-Mail * </td>

      <td class="odd"><input class=text type='text' name="eMail" id="stdIn0" value="" size='30' maxlength='255' /></td>

    </tr>

    <tr>

      <td align="left">Firma</td>

      <td class="odd"><input class=text type='text' name="Firma" id="stdIn11" value="" size='30' maxlength='255' /></td>

    </tr>

    <tr>

      <td align="left">Strasse</td>

      <td class="odd"><input class=text type='text' name="Strasse" id="stdIn7" value="" size='30' maxlength='255' /></td>

    </tr>

    <tr>

      <td align="left">Postleitzahl</td>

      <td class="odd"><input class=text type='text' name="Postleitzahl" id="stdIn9" value="" size='30' maxlength='255' /></td>

    </tr>

    <tr>

      <td align="left">Ort</td>

      <td class="odd"><input class=text type='text' name="Ort" id="stdIn10" value="" size='30' maxlength='255' /></td>

    </tr>

    <tr>

      <td align="left">Land</td>

      <td class="odd"><input class=text type='text' name="Land" id="stdIn12" value="" size='30' maxlength='255' /></td>

    </tr>

    <tr>

      <td align="left">Telefonnummer</td>

      <td class="odd"><input class=text type='text' name="Telefonnummer" id="stdIn14" value="" size='30' maxlength='255' /></td>

    </tr>

    <tr>

      <td align="left">Faxnummer</td>

      <td class="odd"><input class=text type='text' name="Faxnummer" id="stdIn18" value="" size='30' maxlength='255' /></td>

    </tr>

    <tr height="5px"><tr/>

  </table>

 

  <input type='submit' class='button' name='submit'  value='Ja, ich möchte mehr Informationen zum Thema Schluss mit Kaltakquise' /></td>

</form>