document.write('');
document.write('  <table align="center" bgcolor="#ffffff" cellspacing="5" cellpadding="5" style="border: 1px solid #ffffff">');
document.write('<form method="post" action="http://97240.formmailer.onetwomax.de/">');
document.write('    <tr>');
document.write('      <td><font size="3"><b>Bonita Dogs<br></b></font><font size="2"><i>Fragebogen zur Hundeadoption</i></font></td>');
document.write('      <td></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td colspan="2">Bitte tragen Sie Ihre Angaben ein...');
document.write('<BR>');
document.write('<BR>');
document.write('<BR>');
document.write('<BR>');
document.write('</td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="left"><b><i>Angaben zur Person</i></b></td>');
document.write('      <td></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Name</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id3]" value="" size="50">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Vormame</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id10]" value="" size="50">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Strasse</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id5]" value="" size="50">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>PLZ &amp; Ort</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id7]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>E-Mail</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id4]" value="" size="50">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Telefon Privat</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id33]" value="" size="30">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Telefon Handy</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id9]" value="" size="30">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Geburtsdatum</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id35]" value="" size="30">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Beruf</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id34]" value="" size="50">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="left"><b><i>Angaben zum Tier</i></b></td>');
document.write('      <td></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Name des Hundes</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id38]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Rasse</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id39]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Geschlecht</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id40]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td align="left"><b><i>Wohnsituation</i></b></td>');
document.write('      <td></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Ist ein Umzug in absehbarer Zeit geplant?</td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id42]" value="1" >');
document.write('        ja');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>&nbsp;</td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id43]" value="1" >');
document.write('        nein');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Ist die Tierhaltung gestattet?</td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id44]" value="1" >');
document.write('        ja');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>&nbsp;</td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id45]" value="1" >');
document.write('        nein');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Wie wohnen Sie?</td>');
document.write('      <td>');
document.write('        <select name="user_input[id46]">');
document.write('          <option value="0">Haus');
document.write('</option>');
document.write('          <option value="1">Wohnung');
document.write('</option>');
document.write('          <option value="2"></option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>&nbsp;</td>');
document.write('      <td>');
document.write('        <select name="user_input[id47]">');
document.write('          <option value="0">Eigentum');
document.write('</option>');
document.write('          <option value="1">Miete</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>&nbsp;</td>');
document.write('      <td>');
document.write('        <select name="user_input[id48]">');
document.write('          <option value="0">Stadt');
document.write('</option>');
document.write('          <option value="1">Land');
document.write('</option>');
document.write('          <option value="2">Randgebiet');
document.write('</option>');
document.write('          <option value="3">Kleinstadt</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Haben Sie einen Garten?</td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id49]" value="1" >');
document.write('        ja');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>&nbsp;</td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id50]" value="1" >');
document.write('        nein');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Hat Ihr Garten eine Zaun?</td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id51]" value="1" >');
document.write('        ja');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>&nbsp;</td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id52]" value="1" >');
document.write('        nein');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Wie hoch ist Ihr Zaun?</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id53]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td><b><i>Allgemeine Fragen</i></b></td>');
document.write('      <td></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Anzahl der Erwachsenen im Haushalt?</td>');
document.write('      <td>');
document.write('        <select name="user_input[id57]">');
document.write('          <option value="0">1');
document.write('</option>');
document.write('          <option value="1">2');
document.write('</option>');
document.write('          <option value="2">3');
document.write('</option>');
document.write('          <option value="3">4');
document.write('</option>');
document.write('          <option value="4">5');
document.write('</option>');
document.write('          <option value="5">mehr als 5</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Anzahl der Kinder im Haushalt?</td>');
document.write('      <td>');
document.write('        <select name="user_input[id58]">');
document.write('          <option value="0">0');
document.write('</option>');
document.write('          <option value="1">1');
document.write('</option>');
document.write('          <option value="2">2');
document.write('</option>');
document.write('          <option value="3">3');
document.write('</option>');
document.write('          <option value="4">4');
document.write('</option>');
document.write('          <option value="5">5');
document.write('</option>');
document.write('          <option value="6">mehr als 5</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Wie alt sind Ihre Kinder?</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id59]" value="" size="30">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Sind Alle mit der Tieranschaffung einverstanden?</td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id60]" value="1" >');
document.write('        ja');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>&nbsp;</td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id61]" value="1" >');
document.write('        nein');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Leben noch weitere Tiere in Ihrem Haushalt?</td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id62]" value="1" >');
document.write('        ja');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>&nbsp;</td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id64]" value="1" >');
document.write('        nein');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Welche &amp; Wie Viele?</td>');
document.write('      <td>');
document.write('        <textarea name="user_input[id63]" style="width:100%" rows="5"></textarea>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Hatten Sie vorher schon Haustiere?</td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id65]" value="1" >');
document.write('        ja');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>&nbsp;</td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id67]" value="1" >');
document.write('        nein');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Welche &amp; Wie Viele?</td>');
document.write('      <td>');
document.write('        <textarea name="user_input[id66]" style="width:100%" rows="5"></textarea>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Gehen Sie zur Hundeschule?</td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id68]" value="1" >');
document.write('        ja');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>&nbsp;</td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id69]" value="1" >');
document.write('        nein');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>&nbsp;</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id73]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Betreiben Sie Hundesport?</td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id70]" value="1" >');
document.write('        ja');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>&nbsp;</td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id71]" value="1" >');
document.write('        nein');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>&nbsp;</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id72]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Was ist Ihr Anschaffungsgrund?<br><font size="2"><i>Tierliebe, Wachhund usw.</i></font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id74]" value="" size="30">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Wo wird das Tier in Zunkunft leben?<br><font size="2"><i>Wohnung, Garten, Zwinger usw.</i></font></td>');
document.write('      <td>');
document.write('        <textarea name="user_input[id75]" style="width:100%" rows="5"></textarea>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Wie lange ist Ihr Tier am Tag allein?</td>');
document.write('      <td>');
document.write('        <select name="user_input[id76]">');
document.write('          <option value="0">nie');
document.write('</option>');
document.write('          <option value="1">1-3h tägl.');
document.write('</option>');
document.write('          <option value="2">4-6h tägl.');
document.write('</option>');
document.write('          <option value="3">mehr als 6h tägl.</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>&nbsp;</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id77]" value="" size="30">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Wer versorgt das Tier in Ihrer Abwesenheit?</td>');
document.write('      <td>');
document.write('        <select name="user_input[id78]">');
document.write('          <option value="0">Nachbarn');
document.write('</option>');
document.write('          <option value="1">Familienangehörige');
document.write('</option>');
document.write('          <option value="2">Freunde');
document.write('</option>');
document.write('          <option value="3">Tierpension');
document.write('</option>');
document.write('          <option value="4">Tiersitter</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>&nbsp;</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id79]" value="" size="30">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Wollen Sie Ihr Tier registrieren lassen?</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id80]" value="" size="20">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Welche Kosten haben Sie eingeplant?<br><font size="2"><i>Impfung, Futter, Steuer, Arznei, OP</i></font></td>');
document.write('      <td>');
document.write('        <textarea name="user_input[id81]" style="width:100%" rows="5"></textarea>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Kommt eine alternative Behandlung  in Frage?<br><font size="2"><i>z.B durch einen Tierheilpraktiker</i></font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id82]" value="" size="30">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Haben Sie sich ueber MKK informiert?<br><font size="2"><i>(Mittelmeerkrankheiten)</i></font></td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id83]" value="" size="30">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Moechten Sie noch weitere Infos dazu?</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id84]" value="" size="30">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Besteht Kontakt zu Artgenossen?</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id85]" value="" size="30">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Besteht in Ihrer Umgebung Anleinpflicht?</td>');
document.write('      <td>');
document.write('        <input type="text" name="user_input[id86]" value="" size="30">');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Zur Eingewoehnungsphase...</td>');
document.write('      <td></td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Wie lange koennten Sie sich frei nehmen?</td>');
document.write('      <td>');
document.write('        <select name="user_input[id87]">');
document.write('          <option value="0">gar nicht');
document.write('</option>');
document.write('          <option value="1">3 Tage');
document.write('</option>');
document.write('          <option value="2">5 Tage');
document.write('</option>');
document.write('          <option value="3">1 Woche');
document.write('</option>');
document.write('          <option value="4">2 Wochen');
document.write('</option>');
document.write('          <option value="5">mehr</option>');
document.write('        </select>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Sind Sie mit einer Nachkontrolle einverstanden?</td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id89]" value="1" >');
document.write('        ja');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>&nbsp;</td>');
document.write('      <td>');
document.write('        <input type="checkbox" name="user_input[id90]" value="1" >');
document.write('        nein');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Welche Erwartungen stellen Sie an das Tier?<br><font size="2"><i>Stubenreinheit, Angst, sonst.Probleme</i></font></td>');
document.write('      <td>');
document.write('        <textarea name="user_input[id91]" style="width:100%" rows="5"></textarea>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Anmerkung</td>');
document.write('      <td>');
document.write('        <textarea name="user_input[id92]" style="width:100%" rows="10"></textarea>');
document.write('      </td>');
document.write('    </tr>');
document.write('    <tr>');
document.write('      <td>Vielen Dank ...<br>Wir werden uns schnellstens mit Ihnen in Verbindung setzten...');
document.write('<BR>');
document.write('<BR>');
document.write('</td>');
document.write('      <td></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="send_mail">');
document.write('        <input type="hidden" name="entry" value="97240">');
document.write('        <input type="submit" name="submit" value="Abschicken">');
document.write('        <input type="reset" name="reset" value="Zur&uuml;cksetzen">');
document.write('      </td>');
document.write('    </tr>');
document.write('</form>');
document.write('  </table>');
document.write('');