<html>
<head>
<meta http-equiv="Content-Type" content="text/html; charset=windows-1252">
<title>www.eine-heemkring.be ..:: Bestelllingen ::..</title>
<script language="javascript" type="text/javascript">
function totaal(){
var totaal = 0;
if(document.forms['bestellen'].CheckboxKleur.checked == true){
totaal += 25;
}
if(document.forms['bestellen'].CheckboxZwartWit.checked == true){
totaal += 20;
}
if(document.forms['bestellen'].CheckboxZichtkaarten.checked == true){
totaal += 25;
}
document.getElementById('totaal').innerHTML = "€ " + totaal + ",-";
}
</script>
<style type="text/css">
<!--
.tekst {
font-family: Arial, Helvetica, sans-serif;
font-size: 12px;
}
-->
</style>
</head>
<body>
<form method="post" action="" name="bestellen">
<table width="668" height="416" align="center">
<tr>
<td width="102" nowrap class="tekst"> <div align="right">Voornaam :</div></td>
<td width="554" nowrap class="tekst"> <input name="Voornaam" id="Voornaam" type="text" value=""
size="30" maxlength="30" >
(*)</td>
</tr>
<tr>
<td nowrap class="tekst"> <div align="right">Achternaam : </div></td>
<td nowrap class="tekst"> <input name="Achternaam" id="Achternaam" type="text" value=""
size="50" maxlength="50" >
(*)</td>
</tr>
<tr>
<td nowrap class="tekst"> <div align="right">Straat : </div></td>
<td nowrap class="tekst"> <input name="Straat" id="Straat" type="text" value="" size="50"
maxlength="50" >
(*) Huisnr :
<input name="nr" id="nummer" type="text" value="" size="4"
maxlength="4" >
(*) bus :
<input name="bus" id="bus" type="text" value="" size="2"
maxlength="2" > </td>
</tr>
<tr>
<td nowrap class="tekst"> <div align="right">Postnr : </div></td>
<td nowrap class="tekst"> <input name="Postnr" id="postnr" type="text" value="" size="4"
maxlength="4" >
(*) Gemeente :
<input name="Gemeente" id="Gemeente" type="text" value=""
size="35" maxlength="354" >
(*) </td>
</tr>
<tr>
<td nowrap class="tekst"> <div align="right">Provincie: </div></td>
<td nowrap class="tekst"> <select name="Provincie" id="Provincie">
<option value="Antwerpen">Antwerpen</option>
<option value="Limburg">Limburg</option>
<option value="Oost-Vlaanderen">Oost-Vlaanderen</option>
<option value="Vlaams Brabant">Vlaams Brabant</option>
<option value="West-Vlaanderen">West-Vlaanderen</option>
<option value="Hainaut">Hainaut</option>
<option value="Liège">Liège</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Namur">Namur</option>
<option value="Brabant-Wallon">Brabant-Wallon</option>
</select> </td>
</tr>
<tr>
<td nowrap class="tekst"> <div align="right">Telefoon : </div></td>
<td nowrap class="tekst"> <input name="tel" id="telefoon" type="text" value="" size="15"
maxlength="15">
GSM :
<input name="gsm" type="text" value="" size="15" maxlength="15"> </td>
</tr>
<tr>
<td nowrap class="tekst"> <div align="right">Email-adres : </div></td>
<td nowrap class="tekst"> <input name="mail" id="mail" type="text" value="" size="50"
maxlength="100"> </td>
</tr>
<tr>
<td height="39" nowrap class="tekst"> <div align="right">Websiteadres :
</div></td>
<td nowrap class="tekst"> <input type="text" name="firmasite" value="http://"
size="50"> </td>
</tr>
<br>
<br>
<tr>
<td colspan="2" nowrap class="tekst"><table width="100%" border="1">
<tr class="tekst">
<td width="48%"> <div align="right">150 jaar Fietel in kleur (25€)
<input name="CheckboxKleur" id="CheckboxKleur" type="Checkbox"
onClick="totaal();" value=false>
</div></td>
<td width="52%"> <div align="right">150 jaar Fietel in Zwart/Wit (20€)
<input name="CheckboxZwartWit" id="CheckboxZwartWit"
onClick="totaal();" type="Checkbox" value=false>
</div></td>
</tr>
<tr class="tekst">
<td> <div align="right">Zichtkaarten in aanbieding (25€)
<input name="CheckboxZichtkaarten" id="CheckboxZichtkaarten" type="Checkbox"
onClick="totaal();" value=false>
</div></td>
<td> </td>
</tr>
</table></td>
</tr>
<tr>
<td colspan="2" nowrap class="tekst"> <div align="right"></div>
</td>
</tr>
<tr bgcolor="#999999">
<td nowrap class="tekst"> <div align="right"><font color="#000000">Totaal
: </font></div></td>
<td nowrap class="tekst" id="totaal"><font color="#000000"><em>€ 0,-</em></font></td>
</tr>
<tr>
<td height="26" nowrap> </td>
<td nowrap><input type="submit" class="inputSubmit" value="Verstuur de bestelling">
<input name="Reset" type="reset" class="inputSubmit" value="Reset"> </td>
</tr>
</table>
</form>
</body>
</html>