<!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.01//EN"> <html> <head> <style type="text/css"> #myshp_mail_form,body.myshp_block_inner {background: #fff !important;} .myshp_formMail{background: #fff; margin:0 25px; text-align: left;} .myshp_formMail_input{width:297px; font-family:Verdana, Arial, Helvetica, sans-serif; font-size:12px;} .myshp_formMail_em{font-size:11px;} </style> <title></title> </head> <body> <div class="clear"></div> <div class="myshp_formMail"> <br> <br> <table cellpadding="0" cellspacing="0" style="width:536px;"> <tr> <td width="304" valign="top" style="width:316;border-right: 2px solid #ccc;"> Heeft u een vraag of opmerking? Laat het ons weten via dit formulier en u ontvangt snel een reactie.</td> <td width="230" valign="top" style="padding-left:10px;"><p><strong>Leukepakjes.nl</strong><br> Oude Apeldoornseweg 41 - 45<br> 7333 NR Apeldoorn</p></td> </tr> </table> <br> <br> <h2> Uw vraag of opmerking: </h2> <textarea name="vraag" style="width:532px; height: 88px;font-family:Verdana, Arial, Helvetica, sans-serif; font-size:12px;"> </textarea> <br> <br> <h2> Uw contactgegevens: </h2> <em class="myshp_formMail_em">Velden met een * zijn verplicht.</em><br> <br> <table width="536" border="0" cellpadding="0" cellspacing="0"> <tr> <td valign="top"> Bedrijfsnaam </td> <td width="297" valign="top" height="60"><input type="text" class="myshp_formMail_input" name="Bedrijfsnaam"> <div style="padding-top:5px"> <input type="radio" name="de heer"> <label>de heer</label> </div> <div> <input type="radio" name="mevrouw"> <label>mevrouw</label> </div></td> </tr> <tr> <td height="30" valign="top"> Naam* </td> <td valign="top"><input type="text" class="myshp_formMail_input" name="Naam"> </td> </tr> <tr> <td height="30" valign="top"> Telefoonnummer* </td> <td valign="top"><input type="text" class="myshp_formMail_input" name="Telefoonnummer"> </td> </tr> <tr> <td height="30" valign="top"> E-mail* </td> <td valign="top"><input type="text" class="myshp_formMail_input" name="E-mail"> </td> </tr> <tr> <td height="30" valign="top"> Adres (straat en huisnummer) </td> <td valign="top"><input type="text" class="myshp_formMail_input" name="Adres"> </td> </tr> <tr> <td height="30" valign="top"> Postcode en plaats </td> <td valign="top"><input type="text" class="myshp_formMail_input" name="Postcode"> </td> </tr> <tr> <td colspan="2"><table width="100%" border="0"> <tr> <td width="10"><input type="checkbox" name="nieuws"> </td> <td><span>Ik wil graag nieuws en aanbiedingen ontvangen.</span> </td> </tr> <tr> <td>&nbsp;</td> <td><em class="myshp_formMail_em">Wij zullen uw e-mailadres <b><u>nooit</u></b> misbruiken. U kunt zich met &eacute;&eacute;n klik afmelden.</em> </td> </tr> </table></td> </tr> <tr> <td height="40" colspan="2" valign="bottom"><input type="submit" value="Versturen" name="versturen"> </td> </tr> </table> <br> </div> </div> <div class="clear"></div> </div> <div class="clear"></div> <div class="clear"></div> </body> </html>