</head>
<body bgcolor="#999999">
<form name="formlier" method="post" action="http://users.telenet.be/clima/cgi-bin/FormMail.pl>
<input type=hidden name="recipent" value="
[email protected]">
<input type=hidden name="subject" value="formulier ClimaComfort">
<input type=hidden name="redirect" value="http://users.telenet.be/clima/bedankt.html">
<input type=hidden name="print_blank_fields" value="1">
<table width="654" border="0" align="center" cellpadding="1" cellspacing="1">
<tr>
<th colspan="2" scope="col"><p><font size="5"><u>Contact Formulier.</u></font></p>
<p> </p></th>
</tr>
<tr>
<td width="197" valign="top"><div align="right"><strong>Naam : <br>
</strong></div></td>
<th width="450" scope="col"><div align="left">
<input name="naam" type="text" id="naam" size="40" />
</div></th>
</tr>
<tr>
<td><div align="right"><strong>Voornaam :</strong></div></td>
<td><div align="left">
<input name="voornaam" type="text" id="voornaam" />
</div></td>
</tr>
<tr>
<td><div align="right"><strong>Adres :</strong></div></td>
<td><div align="left">
<input name="adres" type="text" id="adres" size="40" />
Nr
<input name="nr" type="text" id="nr" size="10">
Bus
<input name="bus" type="text" id="bus" size="8">
</div></td>
</tr>
<tr>
<td><div align="right"><strong>Woonplaats : </strong></div></td>
<td><div align="left">
<input name="woonplaats" type="text" id="woonplaats" size="35" />
</div></td>
</tr>
<tr>
<td><div align="right"><strong>Telefoonnummer/Gsm :</strong></div></td>
<td><input name="telefoon/gsm" type="text" id="telefoon/gsm" size="25"> </td>
</tr>
<tr>
<td><div align="right"><strong>Fax nummer : </strong></div></td>
<td><input name="fax" type="text" id="fax" size="25"></td>
</tr>
<tr>
<td><div align="right"><strong>E-mail : </strong></div></td>
<td><input name="email" type="text" id="email" size="35"></td>
</tr>
<tr>
<td><div align="right"><strong>Informatie over :</strong></div></td>
<td><select name="info" id="info">
<option selected>Airco</option>
<option>Koeling</option>
<option>Verwarming</option>
</select></td>
</tr>
<tr>
<td valign="top"><div align="right"><strong>Bijkomende informatie :</strong></div></td>
<td><textarea name="bijkomendeinfo" cols="33" rows="8" wrap="VIRTUAL" id="bijkomendeinfo"></textarea></td>
</tr>
<tr>
<td valign="top"><div align="right"></div></td>
<td><input type="submit" name="Submit" value="Submit" /> <input type="reset" name="Reset" value="Reset" /></td>
</tr>
</table>
</form>
</body>
</html>
