<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN" "http://www.w3.org/TR/html4/loose.dtd">
<html>
<head>
<meta http-equiv="Content-Type" content="text/html; charset=windows-1252">
<title></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;
}
document.getElementById('totaal').innerHTML = "€ " + totaal + ",-";
}
</script>
</head>
<body>
<form method="post" action="" name="bestellen">
<table>
<tr>
<td nowrap>Voornaam :</td>
<td nowrap><input name="Voornaam" id="Voornaam" type="text" value="" size="30" maxlength="30" > (*)</td>
</tr>
<tr>
<td nowrap>Achternaam : </td>
<td nowrap><input name="Achternaam" id="Achternaam" type="text" value="" size="50" maxlength="50" > (*)</td>
</tr>
<tr>
<td nowrap>Straat : </td>
<td nowrap><input name="Straat" id="Straat" type="text" value="" size="50" maxlength="50" > (*)</td>
</tr>
<tr>
<td nowrap>Huisnr : </td>
<td nowrap><input name="nr" id="nummer" type="text" value="" size="4" maxlength="4" > (*) </td>
</tr>
<tr>
<td nowrap>bus : </td>
<td nowrap><input name="bus" id="bus" type="text" value="" size="2" maxlength="2" > </td>
</tr>
<tr>
<td nowrap>Postnr : </td>
<td nowrap> <input name="Postnr" id="postnr" type="text" value="" size="4" maxlength="4" > (*)</td>
</tr>
<tr>
<td nowrap>Gemeente : </td>
<td nowrap> <input name="Gemeente" id="Gemeente" type="text" value="" size="35" maxlength="354" > (*) </td>
</tr>
<tr>
<td nowrap>Provincie: </td>
<td nowrap><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>
</td>
</tr>
<tr>
<td nowrap>Telefoon : </td>
<td nowrap><input name="tel" id="telefoon" type="text" value="" size="15" maxlength="15"> </td>
</tr>
<tr>
<td nowrap>GSM : </td>
<td nowrap><input name="gsm" type="text" value="" size="15" maxlength="15"> </td>
</tr>
<tr>
<td nowrap>Email-adres : </td>
<td nowrap><input name="mail" id="mail" type="text" value="" size="50" maxlength="100"> </td>
</tr>
<tr>
<td nowrap>Websiteadres: </td>
<td nowrap>Websiteadres: <input type="text" name="firmasite" value="http://" size="32"> <br>
na http websiteadres in typen! </td>
</tr>
<br><br>
<tr>
<td nowrap>Kleur 25Euro: </td>
<td nowrap><input name="CheckboxKleur" id="CheckboxKleur" type="Checkbox" onclick="totaal();" value=false> </td>
</tr>
<tr>
<td nowrap>Zwart/Wit 20Euro: </td>
<td nowrap><input name="CheckboxZwartWit" id="CheckboxZwartWit" onclick="totaal();" type="Checkbox" value=false> </td>
</tr>
<tr>
<td nowrap>Totaal : </td>
<td id="totaal" nowrap>€ 0,-</td>
</tr>
<tr>
<td nowrap> <input type="submit" class="inputSubmit" value="Registreer"> </td>
<td nowrap> <input name="Reset" type="reset" class="inputSubmit" value="Reset"> </td>
</tr>
</td>
</form>
</body>
</html>