63 lines
1.5 KiB
HTML
63 lines
1.5 KiB
HTML
<h1>Bestellung der Kulturschrift</h1>
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<!-- BEGINBLOCK FORM -->
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<form action="{ACTION}" method="POST">
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<table cellpadding="2" cellspacing="0">
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<tr>
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<td colspan="2">{ERRORS}</td>
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</tr>
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<tr>
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<td width="100">Anrede:</td>
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<td>
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<select name="gender">
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<option value="Herr" {GENDER_M}>Herr</option>
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<option value="Frau" {GENDER_F}>Frau</option>
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</select>
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</td>
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</tr>
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<tr>
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<td>Titel:</td>
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<td><input type="text" name="acad" value="{ACAD}" /></td>
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</tr>
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<tr>
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<td>Vorname*:</td>
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<td><input type="text" name="firstname" value="{FIRSTNAME}" /></td>
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</tr>
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<tr>
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<td>Nachname*:</td>
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<td><input type="text" name="surname" value="{SURNAME}" /></td>
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</tr>
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<tr>
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<td>E-Mail*:</td>
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<td><input type="text" name="email" value="{EMAIL}" /></td>
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</tr>
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<tr>
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<td>Straße:*</td>
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<td><input type="text" name="street" value="{STREET}" /></td>
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</tr>
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<tr>
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<td>PLZ*:</td>
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<td><input type="text" name="zip" value="{ZIP}" maxlength="5" /></td>
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</tr>
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<tr>
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<td>Ort*:</td>
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<td><input type="text" name="city" value="{CITY}" /></td>
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</tr>
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<tr>
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<td>Telefon:</td>
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<td><input type="text" name="phone" value="{PHONE}" /></td>
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</tr>
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<tr>
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<td> </td>
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<td><small>Mit * markierte Felder müssen ausgefüllt werden!</small></td>
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</tr>
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<tr>
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<td> </td>
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<td><input type="submit" name="submit" value="bestellen" id="submit" /></td>
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</tr>
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</table>
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</form>
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<!-- ENDBLOCK FORM -->
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<!-- BEGINBLOCK SUCCESS -->
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<p>Ihre Bestellung wurde erfolgreich ausgeführt! Vielen Dank für Ihr Interesse!</p>
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<!-- ENDBLOCK SUCCESS --> |