<p>Senden Sie mir zusätzlich gedruckte Informationen.</p> <form method="POST" action="https://secure.nns.ch/chl/fomail.php" accept-charset="ISO-8859-1"> <!-- <input type="hidden" name="recipient" value="info@puklla.ch"> --> <input type="hidden" name="recipient" value="info@puklla.ch"> <input type="hidden" name="subject" value="Info Bestellung"> <input type="hidden" name="type" value="plain"> <input type="hidden" name="redirect" value="http://puklla.ch/de/danke.infos.php"> <TABLE BORDER="0" WIDTH="100%" CELLSPACING="4" CELLPADDING="0"> <TR> <TD><b>Name</b></TD> </TR> <TR> <TD align="left"><IMG SRC="gfx/dot.gif" ALT="" WIDTH="10" HEIGHT="1" HSPACE="0" VSPACE="0" BORDER="0" ALIGN="left"><input type="text" name="Name" size="40"><br><br></TD> </TR> <TR> <TD><b>Vorname</b></TD> </TR> <TR> <TD align="left"><IMG SRC="gfx/dot.gif" ALT="" WIDTH="10" HEIGHT="1" HSPACE="0" VSPACE="0" BORDER="0" ALIGN="left"><input type="text" name="Vorname" size="40"><br><br></TD> </TR> <TR> <TD><b>Strasse / Nummer </b></TD> </TR> <TR> <TD align="left"><IMG SRC="gfx/dot.gif" ALT="" WIDTH="10" HEIGHT="1" HSPACE="0" VSPACE="0" BORDER="0" ALIGN="left"><input type="text" name="StrasseNr." size="40"><br><br></TD> </TR> <TR> <TD><b>PLZ / Ort</b></TD> </TR> <TR> <TD align="left"><IMG SRC="gfx/dot.gif" ALT="" WIDTH="10" HEIGHT="1" HSPACE="0" VSPACE="0" BORDER="0" ALIGN="left"><input type="text" name="PLZOrt" size="40"><br><br></TD> </TR> <TR> <TD><b>E-Mail</b></TD> </TR> <TR> <TD align="left"><IMG SRC="gfx/dot.gif" ALT="" WIDTH="10" HEIGHT="1" HSPACE="0" VSPACE="0" BORDER="0" ALIGN="left"><input type="text" name="replyto" size="40"><br><br></TD> <TR> <TD><b>Bemerkungen</b></TD> </TR> <TR> <TD align="left"><IMG SRC="gfx/dot.gif" ALT="" WIDTH="10" HEIGHT="1" HSPACE="0" VSPACE="0" BORDER="0" ALIGN="left"><textarea name="Bemerkungen" cols="38" rows="6"></textarea><br><br></TD> </TR> <TD align="left"><IMG SRC="gfx/dot.gif" ALT="" WIDTH="10" HEIGHT="1" HSPACE="0" VSPACE="0" BORDER="0" ALIGN="left"> <INPUT TYPE="submit" VALUE="Senden" NAME=""></TD> </TR> </TABLE> </form>
