From: <Opgeslagen met Windows Internet Explorer 7>
Subject: Bestelling
Date: Sat, 22 Dec 2007 18:31:43 +0100
MIME-Version: 1.0
Content-Type: text/html;
	charset="iso-8859-1"
Content-Transfer-Encoding: quoted-printable
Content-Location: http://www.formgenerator.nl/forms/form_ysqw5l.html
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<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN">
<HTML><HEAD><TITLE>Bestelling</TITLE>
<META http-equiv=3DContent-Type content=3D"text/html; =
charset=3Diso-8859-1">
<SCRIPT language=3DJavaScript><!--=0A=

	function validate() =0A=

	{=0A=

    if ((document.formgenerator.voornaam.value.length > 0) && =
(document.formgenerator.achternaam.value.length > 0)&& =
(document.formgenerator.adres.value.length > 0)&& =
(document.formgenerator.postcode.value.length > 0)&& =
(document.formgenerator.woonplaats.value.length > 0)&& =
(document.formgenerator.telefoon.value.length > 0)&& =
(document.formgenerator.emailafzender.value.length > 0)&& =
(document.formgenerator.extra_veld_1.value.length > 0)&& =
(document.formgenerator.extra_veld_2.value.length > 0))=0A=

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	else=0A=
=20
		{=0A=

	alert('Vul alle verplichte velden in, deze zijn te herkennen aan \' * =
\' ');=0A=

	return false;  =0A=

    	}=0A=

	}=0A=

	//--></SCRIPT>

<META content=3D"MSHTML 6.00.6000.16587" name=3DGENERATOR></HEAD>
<BODY>
<FORM name=3Dformgenerator onsubmit=3D"return validate()"=20
action=3Dhttp://www.formgenerator.nl/script/sendmail.php3 =
method=3Dpost><INPUT=20
type=3Dhidden value=3Dinfo@ergowijs.com name=3Dstd_adres[0]> <INPUT =
type=3Dhidden=20
value=3D1 name=3Dstd_adres_teller> <INPUT type=3Dhidden=20
value=3Dwww.ergowijs.com/bedankt.htm name=3Dthankyoupage> <INPUT =
type=3Dhidden=20
value=3DBoekbestelling name=3Dsubject>=20
<TABLE cellPadding=3D0 width=3D"100%" celspacing=3D"0">
  <TBODY>
  <TR>
    <TD>Bedrijfsnaam:</TD>
    <TD><INPUT name=3Dbedrijfsnaam></TD></TR>
  <TR>
    <TD>Voornaam:*</TD>
    <TD><INPUT name=3Dvoornaam></TD></TR>
  <TR>
    <TD>Achternaam:*</TD>
    <TD><INPUT name=3Dachternaam></TD></TR>
  <TR>
    <TD>Geslacht:</TD>
    <TD><SELECT name=3Dgeslacht><OPTION value=3D"" selected>Maak uw=20
        keuze</OPTION><OPTION value=3Dman>Man</OPTION><OPTION=20
        value=3Dvrouw>Vrouw</OPTION></SELECT></TD></TR>
  <TR>
    <TD>Adres:*</TD>
    <TD><INPUT name=3Dadres></TD></TR>
  <TR>
    <TD>Postcode:*</TD>
    <TD><INPUT name=3Dpostcode></TD></TR>
  <TR>
    <TD>Woonplaats:*</TD>
    <TD><INPUT name=3Dwoonplaats></TD></TR>
  <TR>
    <TD>Telefoon:*</TD>
    <TD><INPUT name=3Dtelefoon></TD></TR>
  <TR>
    <TD>Email:*</TD>
    <TD><INPUT name=3Demailafzender></TD></TR>
  <TR>
    <TD>Land*</TD>
    <TD><INPUT name=3Dextra_veld_1><INPUT type=3Dhidden value=3DLand=20
      name=3Dextra_veld_naam[1]></TD></TR>
  <TR>
    <TD>Aantal boeken "Gezocht: effectieve ergotherapie"*</TD>
    <TD><INPUT name=3Dextra_veld_2><INPUT type=3Dhidden value=3DAantal=20
      name=3Dextra_veld_naam[2]></TD></TR><INPUT type=3Dhidden value=3D3 =

  name=3Dextra_veld_teller> </TBODY></TABLE></TABLE>
<TABLE cellPadding=3D0 width=3D"100%" celspacing=3D"0">
  <TBODY>
  <TR>
    <TD><B></B></TD><INPUT type=3Dhidden name=3Dgroep_naam[1]><INPUT =
type=3Dhidden=20
    name=3Dgroep_email[1]></TR><INPUT type=3Dhidden value=3D97=20
  name=3Dgroep_interesses[1]><INPUT type=3Dhidden value=3D1=20
name=3Dgroep_teller></TBODY></TABLE><INPUT type=3Dhidden value=3Dlogi935 =

name=3Dlogin><BR><INPUT type=3Dsubmit value=3Dverstuur> </FORM><!-- =
Begin Formgenerator Footer -->
<DIV id=3Did style=3D"Z-INDEX: 10; VISIBILITY: hidden; WIDTH: 744px; =
HEIGHT: 12px">
<TABLE cellSpacing=3D0 cellPadding=3D0 width=3D"100%" border=3D0>
  <TBODY>
  <TR>
    <TD bgColor=3D#ffffcc><B>Let op: </B>Laat de "<B>powered by</B>" =
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formulier niet=20
      zichtbaar. <B>Attention: </B>Do not delete the<B> "powered by" =
</B>link at=20
      the bottom of this form, Formgenerator will check if this link is =
on your=20
      form before processing. If you delete the link your form will not=20
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