<form id="subscribeform" method="post" action="http://005.frnl.de/box.php">
<table border="0" cellspacing="0" cellpadding="0">
<tr>
<td>Email</td>
<td><input name="email" type="text" id="email" /></td>
</tr>
<tr>
<td>Name</td>
<td><input name="name" type="text" id="name" /></td>
</tr>
<tr>
<td>Bitte den Text im Bild eingeben.</td>
<td><input type="text" name="captcha" /><img src="/http://005.frnl.de/randomimage.php" border=0 /></td>
</tr>
<tr>
  <td>Anrede</td>
  <td><input type='hidden' name='field[1742,0]' value='__--blank--__' /><label class='cFieldRadio' ><input type='radio' name='field[1742,0]' value='Herr' /> Herr</label><br /><label class='cFieldRadio' ><input type='radio' name='field[1742,0]' value='Frau' /> Frau</label><br /></td>
</tr>
<tr>
  <td>Vorname</td>
  <td><input type='text' name='field[1743,0]' value='Vorname' /></td>
</tr>
<tr>
  <td>Geburtsdatum</td>
  <td><input type='text' name='field[1745,0]' value='Geburtsdatum' /></td>
</tr>
<tr>
  <td>PLZ / Ort</td>
  <td><input type='text' name='field[1746,0]' value='PLZ / Ort' /></td>
</tr>
<tr>
  <td>Straße, Nr.</td>
  <td><input type='text' name='field[1747,0]' value='StraÃ?e, Nr.' /></td>
</tr>
<tr>
  <td>Kinder</td>
  <td><input type='hidden' name='field[1748,0]' value='__--blank--__' /><label class='cFieldRadio' ><input type='radio' name='field[1748,0]' value='Ja' /> Ja</label><br /><label class='cFieldRadio' ><input type='radio' name='field[1748,0]' value='Nein' /> Nein</label><br /></td>
</tr>
<tr>
  <td>in welchem Alter</td>
  <td><input type='text' name='field[1749,0]' value='in welchem Alter' /></td>
</tr>
<tr>
  <td>Telefon</td>
  <td><input type='text' name='field[1751,0]' value='' /></td>
</tr>
<tr>
  <td>Senden</td>
  <td><input type='hidden' name='field[1750,0]' value='unchecked' /><input type='checkbox' name='field[1750,0]' value='checked' /></td>
</tr>


<tr>
<td><div style="text-align:right">
<input name="p" type="hidden" id="p" value="753" />
<input name="funcml" type="hidden" value="add" />
    <input type="hidden" name="nlbox[1]" value="3156" />
</div></td>
<td>
<input type="submit" name="Speichern" value="Speichern" />
</td>
</tr>
</table>
</form>