document.write('<form method="post" action="http://60593.newsletter.onetwomax.de/">');
document.write('  <table>');
document.write('    <tr>');
document.write('      <td colspan="2">Juicy News</td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td colspan="2">mit * gekennzeichnete Felder muessen ausgefuellt werden</td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><b>E-Mail *</b></td>');
document.write('      <td>');
document.write('        <input type="text" name="email" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><b>Name *</b></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id4]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td colspan="2" align="center" valign="middle">');
document.write('        <input type="hidden" name="mq" value="\'">');
document.write('        <input type="hidden" name="action" value="add">');
document.write('        <input type="hidden" name="entry" value="60593">');
document.write('        <input type="submit" name="submit" value="Abschicken">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td colspan="2" align="center"><font size="-2">Powered by <a href="http://www.onetwomax.de" target="_blank">OneTwoMax</a> Newsletter Script</font></td>');
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document.write('</form>');
document.write('');