<form action="Offerteverstuurd.php" method="POST" target="_self">
<div id="CollapsiblePanel1" class="CollapsiblePanel">
<div class="CollapsiblePanelTab"><strong>Uw persoonsgegevens</strong></div>
<div class="CollapsiblePanelContent"><table width="100%" border="0" cellpadding="0" cellspacing="1">
<tr >
<td align="left" valign="top" > </td>
<td align="left" valign="top" > </td>
</tr>
<tr >
<td align="left" valign="top" >Offerte aanvraag voor :</td>
<td align="left" valign="top" ><input name="Offerte" type="text"
style=" border-bottom:double #6F0024; border-left:1px; border-right:1px; border-top:1px size=" size="50" maxlength="30"/></td>
</tr>
<tr >
<td align="left" valign="top" > </td>
<td align="left" valign="top" ><input type="radio" checked="checked" value="Dhr" name="Aanhef" />
Dhr.
<input type="radio" value="Mevr" name="Aanhef" />
Mevr.</td>
</tr>
<tr >
<td width="315" align="left" valign="top" >Voor-& achternaam</td>
<td width="454" align="left" valign="top" ><input name="Voornaam" type="text" size="20" maxlength="30"/> <input name="Achternaam" type="text" size="41" maxlength="30"/></td>
</tr>
<tr >
<td align="left" valign="top">Adres (pc, stad, straat , nr.)</td>
<td align="left"><textarea name="Adres" cols="52" rows="2" id="Adres" ></textarea></td>
</tr>
<tr >
<td align="left">Land</td>
<td align="left"><select name="Land" size="1" >
<option value="" selected="selected">Land</option>
<option value="Nederland">Nederland</option>
<option value="Belgie">Belgie</option>
<option value="ander">ander</option>
</select>
<input name="Land" type="text" size="52" maxlength="25"/></td>
</tr>
<tr >
<td align="left">Telefoon </td>
<td align="left"><input name="Telefoon" type="text" size="67" maxlength="30"/></td>
</tr>
<tr >
<td align="left" valign="top"> Mobiel</td>
<td align="left" valign="top"><input name="Mobiel" type="text" id="Mobiel" size="67" maxlength="20"/></td>
</tr>
<tr >
<td align="left">E-Mail </td>
<td align="left"><input name="email" size="67" maxlength="40"/></td>
</tr>
<tr >
<td align="left" valign="top">Evt. noodnummers thuisblijvers:
</td>
<td align="left" valign="top"><input name="noodnummer" type="text" size="67" maxlength="30"/></td>
</tr>
</table><br />
<br />
<div id="CollapsiblePanel2" class="CollapsiblePanel">
<div class="CollapsiblePanelTab" tabindex="0">Uw reisgegevens</div>
<div class="CollapsiblePanelContent"><table width="100%" border="0" cellpadding="0" cellspacing="1">
<tr >
<td colspan="2" align="center" valign="top" ></td>
</tr>
<tr >
<td align="left" valign="top">Wilt u een offerte incl. vlucht ?</td>
<td width="449" align="left" valign="top" ><input name="vlucht" type="radio" value="ja" />
Ja,
vanaf
<select name="Vertrekluchthaven" >
<option selected="selected">kies a.u.b.</option>
<option value="Amsterdam Schiphol">Amsterdam Schiphol</option>
<option value="Brussel Zaventem">Brussel Zaventem</option>
<option value="Düsseldorf">Düsseldorf</option>
<option value="Münster-Osnabrück">Münster-Osnabrück</option>
</select>
naar
<input name="Luchthaven" type="text" size="19" />
<br />
<input name="vlucht" type="radio" value="nee" />
Nee</td>
</tr>
<tr >
<td align="left" valign="top">Gewenste Periode :</td>
<td align="left" valign="top" >van:
<input name="van" type="text" id="van" size="19" />
<select name="van2" size="1" id="van2" >
<option value="" selected="selected">+/- dagen</option>
<option value="+/- 1dagen">+/- 1 dag</option>
<option value="+/- 2 dagen">+/- 2 dagen</option>
<option value="+/- 3 dagen">+/- 3 dagen</option>
<option value="+/- 4 dagen">+/- 4 dagen</option>
</select>
<span class="style18"><br />
</span>tot:
<input name="tot" type="text" id="tot" size="19" />
<select name="tot2" size="1" id="tot2" >
<option value="" selected="selected">+/- dagen</option>
<option value="+/- 1dagen">+/- 1 dag</option>
<option value="+/- 2 dagen">+/- 2 dagen</option>
<option value="+/- 3 dagen">+/- 3 dagen</option>
<option value="+/- 4 dagen">+/- 4 dagen</option>
</select></td>
</tr>
<tr >
<td align="left">Wilt u een transfer v.a. de luchthaven/ <span class="style18"><br />
</span>haven naar de accommodatie v.v.?</td>
<td align="left"><input name="transfer" type="radio" value="Nee" />
Nee
<input name="transfer" type="radio" value="Ja" />
Ja</td>
</tr>
<tr >
<td width="301" align="left">Reisdeelnemers
:</td>
<td align="left"><select name="Reisdeelnemer1" size="1" id="van3" >
<option value="Mvr.">Mvr.</option>
<option value="Dhr.">Dhr.</option>
</select>
<input name="Reisdeelnemer1" type="text" value="Naam " size="19" />
<input name="Reisdeelnemer1" type="text" value="voorletters " size="8" />
&
<input name="Reisdeelnemer1" type="text" value="geb. datum" size="11" maxlength="11" /></td>
</tr>
<tr >
<td width="301" rowspan="2" align="left" valign="top" ><em>Vul a.u.b. de namen uitsluitend
in zoals<br />
vermeld
in uw paspoort !</em></td>
<td align="left" valign="top" ><select name="Reisdeelnemer2" size="1" id="Reisdeelnemer" >
<option value="Mvr.">Mvr.</option>
<option value="Dhr.">Dhr.</option>
</select>
<input name="Reisdeelnemer2" type="text" value="Naam " size="19" />
<input name="Reisdeelnemer2" type="text" value="voorletters " size="8" />
&
<input name="Reisdeelnemer2" type="text" value="geb. datum" size="11" maxlength="11" /></td>
</tr>
<tr >
<td align="left" valign="top" ><select name="Reisdeelnemer3" size="1" id="Reisdeelnemer2" >
<option value="Mvr.">Mvr.</option>
<option value="Dhr.">Dhr.</option>
</select>
<input name="Reisdeelnemer3" type="text" value="Naam " size="19" />
<input name="Reisdeelnemer3" type="text" value="voorletters " size="8" />
&
<input name="Reisdeelnemer3" type="text" value="geb. datum" size="11" maxlength="11" /></td>
</tr>
<tr >
<td width="301" align="left" valign="top" ></td>
<td align="left" valign="top" ><select name="Reisdeelnemer4" size="1" id="Reisdeelnemer3" >
<option value="Mvr.">Mvr.</option>
<option value="Dhr.">Dhr.</option>
</select>
<input name="Reisdeelnemer4" type="text" value="Naam " size="19" />
<input name="Reisdeelnemer4" type="text" value="voorletters " size="8" />
&
<input name="Reisdeelnemer4" type="text" value="geb. datum" size="11" maxlength="11" /></td>
</tr>
<tr >
<td align="left" valign="top" ></td>
<td align="left" valign="top" ><select name="Reisdeelnemer5" size="1" id="Reisdeelnemer4" >
<option value="Mvr.">Mvr.</option>
<option value="Dhr.">Dhr.</option>
</select>
<input name="Reisdeelnemer5" type="text" value="Naam " size="19" />
<input name="Reisdeelnemer5" type="text" value="voorletters " size="8" />
&
<input name="Reisdeelnemer5" type="text" value="geb. datum" size="11" maxlength="11" /></td>
</tr>
<tr >
<td align="left" valign="top" ></td>
<td align="left" valign="top" ><select name="Reisdeelnemer6" size="1" id="Reisdeelnemer5" >
<option value="Mvr.">Mvr.</option>
<option value="Dhr.">Dhr.</option>
</select>
<input name="Reisdeelnemer6" type="text" value="Naam " size="19" />
<input name="Reisdeelnemer6" type="text" value="voorletters " size="8" />
&
<input name="Reisdeelnemer6" type="text" value="geb. datum" size="11" maxlength="11" /></td>
</tr>
<tr >
<td align="left" valign="top" > </td>
<td align="left" valign="top" > </td>
</tr>
</table></div>
</div>
<input type="submit" value="Offerte aanvraag versturen" name="submit"></div>
</div></form>