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bm/public_html/public/templates/subparts/kulturschrift_subscribe.html
2025-09-24 13:26:28 +02:00

63 lines
1.5 KiB
HTML

<h1>Bestellung der Kulturschrift</h1>
<!-- BEGINBLOCK FORM -->
<form action="{ACTION}" method="POST">
<table cellpadding="2" cellspacing="0">
<tr>
<td colspan="2">{ERRORS}</td>
</tr>
<tr>
<td width="100">Anrede:</td>
<td>
<select name="gender">
<option value="Herr" {GENDER_M}>Herr</option>
<option value="Frau" {GENDER_F}>Frau</option>
</select>
</td>
</tr>
<tr>
<td>Titel:</td>
<td><input type="text" name="acad" value="{ACAD}" /></td>
</tr>
<tr>
<td>Vorname*:</td>
<td><input type="text" name="firstname" value="{FIRSTNAME}" /></td>
</tr>
<tr>
<td>Nachname*:</td>
<td><input type="text" name="surname" value="{SURNAME}" /></td>
</tr>
<tr>
<td>E-Mail*:</td>
<td><input type="text" name="email" value="{EMAIL}" /></td>
</tr>
<tr>
<td>Stra&szlig;e:*</td>
<td><input type="text" name="street" value="{STREET}" /></td>
</tr>
<tr>
<td>PLZ*:</td>
<td><input type="text" name="zip" value="{ZIP}" maxlength="5" /></td>
</tr>
<tr>
<td>Ort*:</td>
<td><input type="text" name="city" value="{CITY}" /></td>
</tr>
<tr>
<td>Telefon:</td>
<td><input type="text" name="phone" value="{PHONE}" /></td>
</tr>
<tr>
<td>&nbsp;</td>
<td><small>Mit * markierte Felder m&uuml;ssen ausgef&uuml;llt werden!</small></td>
</tr>
<tr>
<td>&nbsp;</td>
<td><input type="submit" name="submit" value="bestellen" id="submit" /></td>
</tr>
</table>
</form>
<!-- ENDBLOCK FORM -->
<!-- BEGINBLOCK SUCCESS -->
<p>Ihre Bestellung wurde erfolgreich ausgef&uuml;hrt! Vielen Dank f&uuml;r Ihr Interesse!</p>
<!-- ENDBLOCK SUCCESS -->