Code:
<!-- START Code DWFormgenerator -->
<style type="text/css">
body {
background-color: #ECECEC;
}
.fieldset {
width:90%;
text-align:left;
margin-bottom:10px;
}
.font-big {
font-family:Verdana, sans-serif;
font-size:14px; font-weight:bold;
color:#0003FF;
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.font-small {
font-family:Verdana, sans-serif;
font-size:10px; font-weight:normal;
color:#333333;
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.table {
background-color:#ECECEC;
width:90%;
}
.table2 {
background-color:#ECECEC;
width:100%;
}
.head {
background-color:#ECECEC;
}
.main {
background-color:#ECECEC;
font-family:Verdana, sans-serif;
font-size:12px; font-weight:normal;
color:#333333;
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.foot {
background-color:#ECECEC;
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.align {
text-align:right;
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.textarea {
background-color:#ECECEC;
color:#333333;
font-family : Verdana, Helvetica, sans-serif;
font-size:12px;
font-weight: normal;
border : 1px solid #CCCCCC;
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.input {
background-color:#ECECEC;
color:#333333;
font-family : Verdana, Helvetica, sans-serif;
border : 1px solid #CCCCCC;
font-size:12px;
}
.select {
background-color:#ECECEC;
color:#333333;
font-family : Verdana, Helvetica, sans-serif;
border : 1px solid #CCCCCC;
font-size:12px;
}
.textarea:hover, .textarea:focus, .input:hover, .input:focus, .select:hover, .select:focus {
border : 1px solid #000000;
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.button {
width: 130px;
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</style>
<link type="text/css" rel="stylesheet" href="http://www.dw-formmailer.de/compress/scripts_forms_css_calendar.php?ver=1.4" />
<script type="text/javascript" src="http://www.dw-formmailer.de/compress/scripts_forms_js_calendar.php?lng=de&dsg=orange&ver=1.5"></script>
<script type="text/javascript">
/* <![CDATA[ */
var tv=-1;
window.onLoad=page_tv();
function VerifyEmailAddress(EmailAddress) {
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var reg1str = "(@.*@)|(\\.\\.)|(@\\.)|(\\.@)|(^\\.)";
var reg2str = "^.+\\@(\\[?)[a-zA-Z0-9\\-\\.]+\\.([a-zA-Z]{2,4}|[0-9]{1,4})(\\]?)$";
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var chk;
function check_form(f,g) {
if (f.elements['Pfl od Fahr'].selectedIndex==0) {
alert("Bitte alle Pflichtfelder ausf\u00FCllen! \n(Produkt)");
f.elements['Pfl od Fahr'].focus();
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if (f.elements['Gerätetyp'].selectedIndex==0) {
alert("Bitte alle Pflichtfelder ausf\u00FCllen! \n(Maschinentyp)");
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alert("Bitte alle Pflichtfelder ausf\u00FCllen! \n(Firmenname)");
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alert("Bitte alle Pflichtfelder ausf\u00FCllen! \n(PLZ)");
f.elements['Händ_PLZ'].focus();
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f.elements['Händ_Ort'].focus();
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f.elements['absender_mail'].focus();
return false;
} else {
if (!VerifyEmailAddress(f.elements['absender_mail'].value)) {
alert("Bitte geben Sie eine g\u00FCltige E-Mail Adresse ein! \n(E-Mail Adresse)");
f.elements['absender_mail'].focus();
return false;
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alert("Bitte alle Pflichtfelder ausf\u00FCllen! \n(Name)");
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alert("Bitte alle Pflichtfelder ausf\u00FCllen! \n(PLZ)");
f.elements['Kun_PLZ'].focus();
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alert("Bitte alle Pflichtfelder ausf\u00FCllen! \n(Fahrgestell / Ger\u00E4te-Nr.)");
f.elements['Masch_GeräteNr'].focus();
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if (f.elements['Betriebs_Std'].value == '') {
alert("Bitte alle Pflichtfelder ausf\u00FCllen! \n(Betriebsstunden)");
f.elements['Betriebs_Std'].focus();
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chk=false;
for (var i=0;i<f.elements['Überg_Datum'].length;i++) {
if (f.elements['Überg_Datum'][i].value=='Tag' ||
f.elements['Überg_Datum'][i].value=='Monat' ||
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f.elements['Überg_Datum'][i].value=='') {
chk=true;
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alert("Bitte alle Pflichtfelder ausf\u00FCllen! \n(\u00DCbergabedatum)");
f.elements['Überg_Datum'][0].focus();
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alert("Bitte alle Pflichtfelder ausf\u00FCllen! \n(Ort)");
f.elements['Abs_Ort'].focus();
return false;
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alert("Bitte alle Pflichtfelder ausf\u00FCllen! \n(Name)");
f.elements['Abs_Name'].focus();
return false;
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alert("Bitte alle Pflichtfelder ausf\u00FCllen! \n(Datum)");
f.elements['Abs_Datum'][0].focus();
return false;
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if (!f.elements['Abs_AGB'].checked) {
alert("Bitte alle Pflichtfelder ausf\u00FCllen! \n(Garantiebedingungen)");
f.elements['Abs_AGB'].focus();
return false;
}
if (navigator.appName=="Microsoft Internet Explorer") {
for (i=0;i<f.length;i++) {
var e=f.elements[i];
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return true;
}
/* ]]> */
</script>
<form name="dwmailer" action="http://www.dw-formmailer.de/cgi-bin/dwmailer/dwmailer.pl" enctype="multipart/form-data" method="post" onsubmit="return check_form(this);">
<input type="hidden" name="page_tv" value="" />
<input type="hidden" name="page_tv_2" value="äöü" />
<input type="hidden" name="pflicht" value="Pfl od Fahr,Gerätetyp,Kunden_Nr,Haendler_Name,Händ_PLZ,Händ_Ort,Händ_Land,Händ_Ansprechp,Händ_Tel,Kun_Anred,Kun_Name,Kun_PLZ,Kun_Ort,Kun_Str,Kun_H_Nr,Masch_GeräteNr,Betriebs_Std,Überg_Datum,Abs_Ort,Abs_Name,Abs_Datum,Abs_AGB" />
<input type="hidden" name="empfaenger_mail" value="bmV0dGVycGF0cmlja0Btc24uY29t" />
<input type="hidden" name="page_background_color" value="#ECECEC" />
<input type="hidden" name="page_font_color" value="#333333" />
<input type="hidden" name="ip_infos" value="on" />
<input type="hidden" name="language" value="de" />
<div align="center">
<fieldset class="fieldset"><legend class="font-big">Geräteregistrierung</legend>
<table align="center" class="table" border="0" cellspacing="1" cellpadding="3">
<tr>
<td colspan="4" class="main">Das Übergabeprotokoll ersetzt die bisherigen Garantiekarten. Nachfolgende Felder entsprechend ausfüllen. Pflichtfelder sind mit \\\\\\\" * \\\\\\\" gekennzeichnet. Am Ende das Formular absenden. Sie erhalten per E-Mail eine Kopie des Übergabeprotokoll.</td>
</tr>
<tr>
<td class="main" width="25%"><div class="align">Produkt*</div></td>
<td class="main"><select class="select" size="1" name="Pfl od Fahr">
<option value="">Bitte wählen</option><option value="D0">D0</option><option value="D1">D1</option></select>
</td>
<td class="main" width="25%"><div class="align">Maschinentyp*</div></td>
<td class="main"><select class="select" size="1" name="Gerätetyp">
<option value="">Bitte wählen</option><option value="C1">C1</option><option value="C2">C2</option><option value="C3">C3</option><option value="C4">C4</option><option value="C5">C5</option><option value="C6">C6</option><option value="C7">C7</option><option value="C8">C8</option><option value="C9">C9</option><option value="C10">C10</option><option value="A1">A1</option><option value="A2">A2</option><option value="A3">A3</option><option value="A4">A4</option><option value="A5">A5</option><option value="A6">A6</option><option value="A7">A7</option><option value="A8">A8</option><option value="A9">A9</option><option value="A10">A10</option><option value="A11">A11</option><option value="A12">A12</option><option value="A13">A13</option><option value="B1">B1</option><option value="B2">B2</option><option value="B3">B3</option><option value="B4">B4</option><option value="B5">B5</option><option value="B6">B6</option><option value="B7">B7</option><option value="B8">B8</option><option value="B9">B9</option><option value="B10">B10</option><option value="B11">B11</option><option value="B12">B12</option><option value="B13">B13</option><option value="B14">B14</option><option value="B15">B15</option><option value="B16">B16</option><option value="B17">B17</option><option value="B18">B18</option><option value="B19">B19</option></select>
</td>
</tr>
</table>
</fieldset>
<fieldset class="fieldset">
<legend class="font-big">Händlerdaten</legend>
<table class="table" align="center" border="0" cellspacing="1" cellpadding="3">
<tr>
<td class="main" width="25%"><div class="align">Kundennummer*</div></td>
<td class="main"><input class="input" type="text" name="Kunden_Nr" size="35" maxlength="6" /></td>
<td class="main" width="25%"><div class="align">Firmenname*</div></td>
<td class="main"><input class="input" type="text" name="Haendler_Name" size="35" maxlength="35" /></td>
</tr>
<tr>
<td class="main" width="25%"><div class="align">PLZ*</div></td>
<td class="main"><input class="input" type="text" name="Händ_PLZ" size="35" maxlength="5" /></td>
<td class="main" width="25%"><div class="align">Ort*</div></td>
<td class="main"><input class="input" type="text" name="Händ_Ort" size="35" maxlength="35" /></td>
</tr>
<tr>
<td class="main" width="25%"><div class="align">Land*</div></td>
<td class="main"><select class="select" name="Händ_Land">
<option value="">Bitte wählen</option>
<option value="Afghanistan">Afghanistan</option><option value="Ägypten">Ägypten</option><option value="Åland">Åland</option><option value="Albanien">Albanien</option><option value="Algerien">Algerien</option><option value="Amerikanisch-Samoa">Amerikanisch-Samoa</option><option value="Amerikanische Jungferninseln">Amerikanische Jungferninseln</option><option value="Andorra">Andorra</option><option value="Angola">Angola</option><option value="Anguilla">Anguilla</option><option value="Antarktis">Antarktis</option><option value="Antigua und Barbuda">Antigua und Barbuda</option><option value="Äquatorialguinea">Äquatorialguinea</option><option value="Argentinien">Argentinien</option><option value="Armenien">Armenien</option><option value="Aruba">Aruba</option><option value="Ascension">Ascension</option><option value="Aserbaidschan">Aserbaidschan</option><option value="Äthiopien">Äthiopien</option><option value="Australien">Australien</option><option value="Bahamas">Bahamas</option><option value="Bahrain">Bahrain</option><option value="Bangladesch">Bangladesch</option><option value="Barbados">Barbados</option><option value="Belarus (Weißrussland)">Belarus (Weißrussland)</option><option value="Belgien">Belgien</option><option value="Belize">Belize</option><option value="Benin">Benin</option><option value="Bermuda">Bermuda</option><option value="Bhutan">Bhutan</option><option value="Bolivien">Bolivien</option><option value="Bosnien und Herzegowina">Bosnien und Herzegowina</option><option value="Botswana">Botswana</option><option value="Bouvetinsel">Bouvetinsel</option><option value="Brasilien">Brasilien</option><option value="Britische Jungferninseln">Britische Jungferninseln</option><option value="Britisches Territorium">Britisches Territorium</option><option value="Brunei Darussalam">Brunei Darussalam</option><option value="Bulgarien">Bulgarien</option><option value="Burkina Faso">Burkina Faso</option><option value="Burma (jetzt Myanmar)">Burma (jetzt Myanmar)</option><option value="Burundi">Burundi</option><option value="Ceuta Melilla">Ceuta Melilla</option><option value="Chile">Chile</option><option value="China, Volksrepublik">China, Volksrepublik</option><option value="Clipperton">Clipperton</option><option value="Cookinseln">Cookinseln</option><option value="Costa Rica">Costa Rica</option><option value="Côte d'Ivoire (Elfenbeinküste)">Côte d'Ivoire (Elfenbeinküste)</option><option value="Dänemark">Dänemark</option><option selected="selected" value="Deutschland">Deutschland</option><option value="Diego Garcia">Diego Garcia</option><option value="Dominica">Dominica</option><option value="Dominikanische Republik">Dominikanische Republik</option><option value="Dschibuti">Dschibuti</option><option value="Ecuador">Ecuador</option><option value="El Salvador">El Salvador</option><option value="Eritrea">Eritrea</option><option value="Estland">Estland</option><option value="Europäische Gemeinschaft">Europäische Gemeinschaft</option><option value="Europäische Union">Europäische Union</option><option value="Falklandinseln">Falklandinseln</option><option value="Färöer">Färöer</option><option value="Fidschi">Fidschi</option><option value="Finnland">Finnland</option><option value="Frankreich">Frankreich</option><option value="Französisch-Guayana">Französisch-Guayana</option><option value="Französisch-Polynesien">Französisch-Polynesien</option><option value="Franz. Süd- und Antarktisgebiete">Franz. Süd- und Antarktisgebiete</option><option value="Gabun">Gabun</option><option value="Gambia">Gambia</option><option value="Georgien">Georgien</option><option value="Ghana">Ghana</option><option value="Gibraltar">Gibraltar</option><option value="Grenada">Grenada</option><option value="Griechenland">Griechenland</option><option value="Grönland">Grönland</option><option value="Guadeloupe">Guadeloupe</option><option value="Guam">Guam</option><option value="Guatemala">Guatemala</option><option value="Guernsey (Kanalinsel)">Guernsey (Kanalinsel)</option><option value="Guinea">Guinea</option><option value="Guinea-Bissau">Guinea-Bissau</option><option value="Guyana">Guyana</option><option value="Haiti">Haiti</option><option value="Heard- und McDonald-Inseln">Heard- und McDonald-Inseln</option><option value="Honduras">Honduras</option><option value="Hongkong">Hongkong</option><option value="Indien">Indien</option><option value="Indonesien">Indonesien</option><option value="Insel Man">Insel Man</option><option value="Irak">Irak</option><option value="Iran">Iran</option><option value="Irland">Irland</option><option value="Island">Island</option><option value="Israel">Israel</option><option value="Italien">Italien</option><option value="Jamaika">Jamaika</option><option value="Japan">Japan</option><option value="Jemen">Jemen</option><option value="Jersey (Kanalinsel)">Jersey (Kanalinsel)</option><option value="Jordanien">Jordanien</option><option value="Kaimaninseln">Kaimaninseln</option><option value="Kambodscha">Kambodscha</option><option value="Kamerun">Kamerun</option><option value="Kanada">Kanada</option><option value="Kanarische Inseln">Kanarische Inseln</option><option value="Kap Verde">Kap Verde</option><option value="Kasachstan">Kasachstan</option><option value="Katar">Katar</option><option value="Kenia">Kenia</option><option value="Kirgisistan">Kirgisistan</option><option value="Kiribati">Kiribati</option><option value="Kokosinseln">Kokosinseln</option><option value="Kolumbien">Kolumbien</option><option value="Komoren">Komoren</option><option value="Kongo">Kongo</option><option value="Republik Kongo">Republik Kongo</option><option value="Korea (Nordkorea)">Korea (Nordkorea)</option><option value="Korea (Südkorea)">Korea (Südkorea)</option><option value="Kroatien">Kroatien</option><option value="Kuba">Kuba</option><option value="Kuwait">Kuwait</option><option value="Laos">Laos</option><option value="Lesotho">Lesotho</option><option value="Lettland">Lettland</option><option value="Libanon">Libanon</option><option value="Liberia">Liberia</option><option value="Libyen">Libyen</option><option value="Liechtenstein">Liechtenstein</option><option value="Litauen">Litauen</option><option value="Luxemburg">Luxemburg</option><option value="Macao">Macao</option><option value="Madagaskar">Madagaskar</option><option value="Malawi">Malawi</option><option value="Malaysia">Malaysia</option><option value="Malediven">Malediven</option><option value="Mali">Mali</option><option value="Malta">Malta</option><option value="Marokko">Marokko</option><option value="Marshallinseln">Marshallinseln</option><option value="Martinique">Martinique</option><option value="Mauretanien">Mauretanien</option><option value="Mauritius">Mauritius</option><option value="Mayotte">Mayotte</option><option value="Mazedonien">Mazedonien</option><option value="Mexiko">Mexiko</option><option value="Mikronesien">Mikronesien</option><option value="Moldawien">Moldawien</option><option value="Monaco">Monaco</option><option value="Mongolei">Mongolei</option><option value="Montenegro">Montenegro</option><option value="Montserrat">Montserrat</option><option value="Mosambik">Mosambik</option><option value="Myanmar (Burma)">Myanmar (Burma)</option><option value="Namibia">Namibia</option><option value="Nauru">Nauru</option><option value="Nepal">Nepal</option><option value="Neukaledonien">Neukaledonien</option><option value="Neuseeland">Neuseeland</option><option value="Neutrale Zone (Saudi-Arabien und Irak)">Neutrale Zone (Saudi-Arabien und Irak)</option><option value="Nicaragua">Nicaragua</option><option value="Niederlande">Niederlande</option><option value="Niederländische Antillen">Niederländische Antillen</option><option value="Niger">Niger</option><option value="Nigeria">Nigeria</option><option value="Niue">Niue</option><option value="Nördliche Marianen">Nördliche Marianen</option><option value="Norfolkinsel">Norfolkinsel</option><option value="Norwegen">Norwegen</option><option value="Oman">Oman</option><option value="Österreich">Österreich</option><option value="Osttimor">Osttimor</option><option value="Pakistan">Pakistan</option><option value="Palästinensische Autonomiegebiete">Palästinensische Autonomiegebiete</option><option value="Palau">Palau</option><option value="Panama">Panama</option><option value="Papua-Neuguinea">Papua-Neuguinea</option><option value="Paraguay">Paraguay</option><option value="Peru">Peru</option><option value="Philippinen">Philippinen</option><option value="Pitcairninseln">Pitcairninseln</option><option value="Polska">Polska</option><option value="Portugal">Portugal</option><option value="Puerto Rico">Puerto Rico</option><option value="Réunion">Réunion</option><option value="Ruanda">Ruanda</option><option value="Rumänien">Rumänien</option><option value="Russische Föderation">Russische Föderation</option><option value="Salomonen">Salomonen</option><option value="Saint-Barthélemy">Saint-Barthélemy</option><option value="Saint-Martin (franz. Teil)">Saint-Martin (franz. Teil)</option><option value="Sambia">Sambia</option><option value="Samoa">Samoa</option><option value="San Marino">San Marino</option><option value="São Tomé und Príncipe">São Tomé und Príncipe</option><option value="Saudi-Arabien">Saudi-Arabien</option><option value="Schweden">Schweden</option><option value="Schweiz">Schweiz</option><option value="Senegal">Senegal</option><option value="Serbien">Serbien</option><option value="Seychellen">Seychellen</option><option value="Sierra Leone">Sierra Leone</option><option value="Simbabwe">Simbabwe</option><option value="Singapur">Singapur</option><option value="Slowakei">Slowakei</option><option value="Slowenien">Slowenien</option><option value="Somalia">Somalia</option><option value="Spanien">Spanien</option><option value="Sri Lanka">Sri Lanka</option><option value="St. Helena">St. Helena</option><option value="St. Kitts und Nevis">St. Kitts und Nevis</option><option value="St. Lucia">St. Lucia</option><option value="Saint-Pierre und Miquelon">Saint-Pierre und Miquelon</option><option value="St. Vincent und die Grenadinen">St. Vincent und die Grenadinen</option><option value="Südafrika">Südafrika</option><option value="Sudan">Sudan</option><option value="Südgeorgien">Südgeorgien</option><option value="Suriname">Suriname</option><option value="Svalbard und Jan Mayen">Svalbard und Jan Mayen</option><option value="Swasiland">Swasiland</option><option value="Syrien, Arabische Republik">Syrien, Arabische Republik</option><option value="Tadschikistan">Tadschikistan</option><option value="Republik China (Taiwan)">Republik China (Taiwan)</option><option value="Tansania">Tansania</option><option value="Thailand">Thailand</option><option value="Togo">Togo</option><option value="Tokelau">Tokelau</option><option value="Tonga">Tonga</option><option value="Trinidad und Tobago">Trinidad und Tobago</option><option value="Tristan da Cunha">Tristan da Cunha</option><option value="Tschad">Tschad</option><option value="Tschechische Republik">Tschechische Republik</option><option value="Tunesien">Tunesien</option><option value="Türkei">Türkei</option><option value="Turkmenistan">Turkmenistan</option><option value="Turks- und Caicosinseln">Turks- und Caicosinseln</option><option value="Tuvalu">Tuvalu</option><option value="Russische Föderation">Russische Föderation</option><option value="Uganda">Uganda</option><option value="Ukraine">Ukraine</option><option value="Ungarn">Ungarn</option><option value="United States Minor Outlying Islands">United States Minor Outlying Islands</option><option value="Uruguay">Uruguay</option><option value="Usbekistan">Usbekistan</option><option value="Vanuatu">Vanuatu</option><option value="Vatikanstadt">Vatikanstadt</option><option value="Venezuela">Venezuela</option><option value="Vereinigte Arabische Emirate">Vereinigte Arabische Emirate</option><option value="United-States">United-States</option><option value="United-Kingdom">United-Kingdom</option><option value="Vietnam">Vietnam</option><option value="Wallis und Futuna">Wallis und Futuna</option><option value="Weihnachtsinsel">Weihnachtsinsel</option><option value="Westsahara">Westsahara</option><option value="Republik Kongo">Republik Kongo</option><option value="Zentralafrikanische Republik">Zentralafrikanische Republik</option><option value="Zypern">Zypern</option></select>
</td>
<td class="main" width="25%"><div class="align">Ansprechpartner*</div></td>
<td class="main"><input class="input" type="text" name="Händ_Ansprechp" size="35" maxlength="35" /></td>
</tr>
<tr>
<td class="main" width="25%"><div class="align">E-Mail Adresse*</div></td>
<td class="main"><input class="input" type="text" name="absender_mail" size="35" maxlength="35" /></td>
<td class="main" width="25%"><div class="align">Telefon*</div></td>
<td class="main"><input class="input" type="text" name="Händ_Tel" size="35" maxlength="35" /></td>
</tr>
</table>
</fieldset>
<fieldset class="fieldset">
<legend class="font-big">Kundendaten</legend>
<table class="table" align="center" border="0" cellspacing="1" cellpadding="3">
<tr>
<td class="main" width="25%"><div class="align">Anrede*</div></td>
<td class="main"><input type="radio" name="Kun_Anred" id="Kun_Anred_1" value="Herr" /><label for="Kun_Anred_1">Herr</label> <input type="radio" name="Kun_Anred" id="Kun_Anred_2" value="Frau" /><label for="Kun_Anred_2">Frau</label> <input type="radio" name="Kun_Anred" id="Kun_Anred_3" value="Firma" /><label for="Kun_Anred_3">Firma</label></td>
<td class="main" width="25%"><div class="align">Name*</div></td>
<td class="main"><input class="input" type="text" name="Kun_Name" size="35" maxlength="35" /></td>
</tr>
<tr>
<td class="main" width="25%"><div class="align">PLZ*</div></td>
<td class="main"><input class="input" type="text" name="Kun_PLZ" size="35" maxlength="5" /></td>
<td class="main" width="25%"><div class="align">Ort*</div></td>
<td class="main"><input class="input" type="text" name="Kun_Ort" size="35" maxlength="35" /></td>
</tr>
<tr>
<td class="main" width="25%"><div class="align">Straße*</div></td>
<td class="main"><input class="input" type="text" name="Kun_Str" size="35" maxlength="35" /></td>
<td class="main" width="25%"><div class="align">Haus-Nr.*</div></td>
<td class="main"><input class="input" type="text" name="Kun_H_Nr" size="35" maxlength="15" /></td>
</tr>
</table>
</fieldset>
<fieldset class="fieldset">
<legend class="font-big">Geräte / Fahrzeugdaten</legend>
<table class="table" align="center" border="0" cellspacing="1" cellpadding="3">
<tr>
<td class="main" width="25%"><div class="align">Fahrgestell / Geräte-Nr.*</div></td>
<td class="main"><input class="input" type="text" name="Masch_GeräteNr" size="35" maxlength="30" /></td>
<td class="main" width="25%"><div class="align">Betriebsstunden*</div></td>
<td class="main"><input class="input" type="text" name="Betriebs_Std" size="35" maxlength="6" /></td>
</tr>
<tr>
<td class="main" width="25%"><div class="align">Zubehör</div></td>
<td class="main"><input class="input" type="text" name="Zubehör" size="35" maxlength="35" /></td>
<td class="main" width="25%"><div class="align">Anbaugeräte</div></td>
<td class="main"><input class="input" type="text" name="Anbaugeräte" size="35" maxlength="35" /></td>
</tr>
</table>
</fieldset>
<fieldset class="fieldset">
<legend class="font-big">Übergaben</legend>
<table class="table" align="center" border="0" cellspacing="1" cellpadding="3">
<tr>
<td colspan="4" class="main"><b>Folgende Dokumente wurden dem Endkunden ausgehändigt sowie eine Geräteeinweisung und Übergabeinspektion durchgeführt</b></td>
</tr>
<tr>
<td class="main" align="right" width="25%"><input type="checkbox" name="Überg_Bedien" value="ON" /></td>
<td class="main">Bedienungsanleitungen</td>
<td class="main" align="right" width="25%"><input type="checkbox" name="Überg_Einweis" value="ON" /></td>
<td class="main">Geräteeinweisung</td>
</tr>
<tr>
<td class="main" align="right" width="25%"><input type="checkbox" name="Überg_Inspek" value="ON" /></td>
<td class="main">Übergabeinspektion</td>
<td class="main" width="25%"><div class="align">Sondervereinbarung</div></td>
<td class="main">(Restzeichen: <span id="count_1">1000</span>)<br />
<textarea class="textarea" name="Sonderver" id="Sonderver" cols="35" rows="2" onkeydown="rest(this,1000,'count_1',event)" onkeyup="rest(this,1000,'count_1',event)" onchange="rest(this,1000,'count_1',event)"></textarea></td>
</tr>
<tr>
<td class="main" align="right" width="25%"><input type="checkbox" name="Überg_Service" value="ON" /></td>
<td class="main">Serviceheft</td>
<td class="main" width="25%"><div class="align">Übergabedatum*</div></td>
<td class="main"><select class="select" size="1" name="Überg_Datum" id="Überg_Datum_day">
<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>
<option value="10.">10</option>
<option value="11.">11</option>
<option value="12.">12</option>
<option value="13.">13</option>
<option value="14.">14</option>
<option value="15.">15</option>
<option value="16.">16</option>
<option value="17.">17</option>
<option value="18.">18</option>
<option value="19.">19</option>
<option selected="selected" value="">Tag</option>
<option value="20.">20</option>
<option value="21.">21</option>
<option value="22.">22</option>
<option value="23.">23</option>
<option value="24.">24</option>
<option value="25.">25</option>
<option value="26.">26</option>
<option value="27.">27</option>
<option value="28.">28</option>
<option value="29.">29</option>
<option value="30.">30</option>
<option value="31.">31</option>
</select>
<select class="select" size="1" name="Überg_Datum" id="Überg_Datum_month">
<option value="Januar">Januar</option>
<option value="Februar">Februar</option>
<option value="März">März</option>
<option selected="selected" value="">Monat</option>
<option value="April">April</option>
<option value="Mai">Mai</option>
<option value="Juni">Juni</option>
<option value="Juli">Juli</option>
<option value="August">August</option>
<option value="September">September</option>
<option value="Oktober">Oktober</option>
<option value="November">November</option>
<option value="Dezember">Dezember</option>
</select>
<select class="select" size="1" name="Überg_Datum" id="Überg_Datum_year">
<option value="2042">2042</option><option value="2041">2041</option><option value="2040">2040</option><option value="2039">2039</option><option value="2038">2038</option><option value="2037">2037</option><option value="2036">2036</option><option value="2035">2035</option><option value="2034">2034</option><option value="2033">2033</option><option value="2032">2032</option><option value="2031">2031</option><option value="2030">2030</option><option value="2029">2029</option><option value="2028">2028</option><option value="2027">2027</option><option value="2026">2026</option><option value="2025">2025</option><option value="2024">2024</option><option value="2023">2023</option><option value="2022">2022</option><option value="2021">2021</option><option value="2020">2020</option><option value="2019">2019</option><option value="2018">2018</option><option value="2017">2017</option><option value="2016">2016</option><option value="2015">2015</option><option value="2014">2014</option><option value="2013">2013</option><option selected="selected" value="">Jahr</option><option value="2012">2012</option><option value="2011">2011</option><option value="2010">2010</option><option value="2009">2009</option><option value="2008">2008</option><option value="2007">2007</option><option value="2006">2006</option><option value="2005">2005</option><option value="2004">2004</option><option value="2003">2003</option><option value="2002">2002</option><option value="2001">2001</option><option value="2000">2000</option><option value="1999">1999</option><option value="1998">1998</option><option value="1997">1997</option><option value="1996">1996</option><option value="1995">1995</option><option value="1994">1994</option><option value="1993">1993</option><option value="1992">1992</option><option value="1991">1991</option><option value="1990">1990</option><option value="1989">1989</option><option value="1988">1988</option><option value="1987">1987</option><option value="1986">1986</option><option value="1985">1985</option><option value="1984">1984</option><option value="1983">1983</option><option value="1982">1982</option></select>
<a title="Kalender" href="javascript:;" onclick="kalender('Überg_Datum',this);"><img align="top" border="0" src="http://www.dw-formmailer.de/images/calendar.png" width="16" height="16" title="Kalender" alt="Kalender" /></a>
</td>
</tr>
</table>
</fieldset>
<fieldset class="fieldset">
<legend class="font-big">Formular senden und bestätigen</legend>
<table class="table" align="center" border="0" cellspacing="1" cellpadding="3">
<tr>
<td colspan="4" class="main"><b>Hiermit bestätige ich die wahrheitsgemäßen Angaben der übermittelten Daten</b></td>
</tr>
<tr>
<td class="main" width="25%"><div class="align">Ort*</div></td>
<td class="main"><input class="input" type="text" name="Abs_Ort" size="35" maxlength="35" /></td>
<td class="main" width="25%"><div class="align">Name*</div></td>
<td class="main"><input class="input" type="text" name="Abs_Name" size="35" maxlength="35" /></td>
</tr>
<tr>
<td class="main" width="25%"><div class="align">Datum*</div></td>
<td class="main"><select class="select" size="1" name="Abs_Datum" id="Abs_Datum_day">
<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>
<option value="10.">10</option>
<option value="11.">11</option>
<option value="12.">12</option>
<option value="13.">13</option>
<option value="14.">14</option>
<option value="15.">15</option>
<option value="16.">16</option>
<option value="17.">17</option>
<option value="18.">18</option>
<option value="19.">19</option>
<option selected="selected" value="">Tag</option>
<option value="20.">20</option>
<option value="21.">21</option>
<option value="22.">22</option>
<option value="23.">23</option>
<option value="24.">24</option>
<option value="25.">25</option>
<option value="26.">26</option>
<option value="27.">27</option>
<option value="28.">28</option>
<option value="29.">29</option>
<option value="30.">30</option>
<option value="31.">31</option>
</select>
<select class="select" size="1" name="Abs_Datum" id="Abs_Datum_month">
<option value="Januar">Januar</option>
<option value="Februar">Februar</option>
<option value="März">März</option>
<option selected="selected" value="">Monat</option>
<option value="April">April</option>
<option value="Mai">Mai</option>
<option value="Juni">Juni</option>
<option value="Juli">Juli</option>
<option value="August">August</option>
<option value="September">September</option>
<option value="Oktober">Oktober</option>
<option value="November">November</option>
<option value="Dezember">Dezember</option>
</select>
<select class="select" size="1" name="Abs_Datum" id="Abs_Datum_year">
<option value="2042">2042</option><option value="2041">2041</option><option value="2040">2040</option><option value="2039">2039</option><option value="2038">2038</option><option value="2037">2037</option><option value="2036">2036</option><option value="2035">2035</option><option value="2034">2034</option><option value="2033">2033</option><option value="2032">2032</option><option value="2031">2031</option><option value="2030">2030</option><option value="2029">2029</option><option value="2028">2028</option><option value="2027">2027</option><option value="2026">2026</option><option value="2025">2025</option><option value="2024">2024</option><option value="2023">2023</option><option value="2022">2022</option><option value="2021">2021</option><option value="2020">2020</option><option value="2019">2019</option><option value="2018">2018</option><option value="2017">2017</option><option value="2016">2016</option><option value="2015">2015</option><option value="2014">2014</option><option value="2013">2013</option><option selected="selected" value="">Jahr</option><option value="2012">2012</option><option value="2011">2011</option><option value="2010">2010</option><option value="2009">2009</option><option value="2008">2008</option><option value="2007">2007</option><option value="2006">2006</option><option value="2005">2005</option><option value="2004">2004</option><option value="2003">2003</option><option value="2002">2002</option><option value="2001">2001</option><option value="2000">2000</option><option value="1999">1999</option><option value="1998">1998</option><option value="1997">1997</option><option value="1996">1996</option><option value="1995">1995</option><option value="1994">1994</option><option value="1993">1993</option><option value="1992">1992</option><option value="1991">1991</option><option value="1990">1990</option><option value="1989">1989</option><option value="1988">1988</option><option value="1987">1987</option><option value="1986">1986</option><option value="1985">1985</option><option value="1984">1984</option><option value="1983">1983</option><option value="1982">1982</option></select>
<a title="Kalender" href="javascript:;" onclick="kalender('Abs_Datum',this);"><img align="top" border="0" src="http://www.dw-formmailer.de/images/calendar.png" width="16" height="16" title="Kalender" alt="Kalender" /></a>
</td>
<td class="main" width="25%"><div class="align">Garantiebedingungen*</div></td>
<td class="main"><input type="checkbox" name="Abs_AGB" id="Abs_AGB" value="ja" /> <span class="main"><a href="http://www.MyDomain.com/agb.html" target="_blank">AGB</a></span> <label for="Abs_AGB">gelesen und akzeptiert</label></td>
</tr>
<tr>
<td class="foot" colspan="4" align="center" height="25" width="100%"><input class="button" type="submit" value="Abschicken" /> <input class="button" type="reset" value="Zurücksetzen" /></td>
</tr>
<tr>
<td align="center" class="main" colspan="4" height="16" width="100%"><span class="font-small">Bitte füllen Sie alle mit * markierten Felder aus. (Pflichtfelder)</span></td>
</tr>
</table>
</fieldset>
</div>
</form>
<!-- END Code DWFormgenerator -->
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