<br><br><table id="paketmarketab" align="center">
<tr>
<td align="center">
<br>
<form action="" method="post">
[ERROR]
<h1>Paketmarken Drucker f&uuml;r [ZUSATZ]</h1>
<br>
<b>Empf&auml;nger</b>
<br>
<br>
<table>
<tr><td>


<table style="float:left;">
<tr><td>Name:</td><td><input type="text" size="36" value="[NAME]" name="name" id="name"><script type="text/javascript">document.getElementById("name").focus(); </script></td></tr>
<tr><td>Name 2:</td><td><input type="text" size="36" value="[NAME2]" name="name2"></td></tr>
<tr><td>p. Adr.:</td><td><input type="text" size="36" value="[NAME3]" name="name3"></td></tr>


<tr><td>Land:</td><td>[EPROO_SELECT_LAND]</td></tr>
<tr><td>PLZ/Ort:</td><td><input type="text" name="plz" size="5" value="[PLZ]">&nbsp;<input type="text" size="30" name="ort" value="[ORT]"></td></tr>
<tr><td>Strasse/Hausnummer:</td><td><input type="text" size="30" value="[STRASSE]" name="strasse">&nbsp;<input type="text" size="5" name="hausnummer" value="[HAUSNUMMER]"></td></tr>

<tr><td>E-Mail:</td><td><input type="text" size="36" value="[EMAIL]" name="email"></td></tr>
<tr><td>Telefon:</td><td><input type="text" size="36" value="[TELEFON]" name="telefon"></td></tr>
</table>


<table style="float:right;">
  [GEWICHT]
  <tr>
    <td>Höhe (in cm):</td>
    <td>
    <input type="text" size="10" value="[HEIGHT]" name="height">
    </td>
  </tr>
  <tr>
    <td>Breite (in cm):</td>
    <td>
    <input type="text" size="10" value="[WIDTH]" name="width">
    </td>
  </tr>
  <tr>
    <td>Länge (in cm):</td>
    <td>
    <input type="text" size="10" value="[LENGTH]" name="length">
    </td>
  </tr>
</table>

  <div style="clear:both"></div>
  <!--                                                              <br><br>
  <table align="center">
  <tr><td colspan="2"><b>Service</b></td></tr>
  <tr><td>Nachnahme:</td><td><input type="checkbox" name="nachnahme" value="1" [NACHNAHME]> (Betrag: [BETRAG] EUR)<input type="hidden" name="betrag" value="[BETRAG]"></td></tr>
  </table>-->

  <br><br>
  <center><input class="btnGreen" type="submit" value="Paketmarke drucken" name="drucken">&nbsp;
  [TRACKINGMANUELL]
  &nbsp;<input type="button" value="{|Andere Versandart auswählen|}" onclick="window.location.href='index.php?module=versanderzeugen&action=wechsel&id=[ID]'" name="anders">&nbsp;
  <!--<input type="button" value="Abbrechen">--></center>
</td></tr></table>
  </form>

<br><br>
</td></tr></table>