<HEAD><TITLE>contact</TITLE></HEAD>
<BODY id=main_body class=c7>>>RECEIVERS>> service@cosdep-pelletkachels.be
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<H1 class=c1>contactformulier cosdep pelletkachels</H1>
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<UL>
<LI id=li_1><LABEL class=description for=element_1>Titel</LABEL>
<DIV><INPUT id=element_1 class="element text medium c2" name=element_1 maxLength=255></DIV>
<LI id=li_2><LABEL class=description for=element_2>Reden van contact</LABEL>
<DIV><TEXTAREA id=element_2 class="element textarea medium c3" name=element_2></TEXTAREA></DIV>
<LI id=li_3><LABEL class=description for=element_3>Naam</LABEL> <SPAN><INPUT id=element_3_1 class="element text" name=element_3_1 maxLength=255 size=8> <LABEL>voornaam</LABEL></SPAN> <SPAN><INPUT id=element_3_2 class="element text" name=element_3_2 maxLength=255 size=14> <LABEL>achternaam</LABEL></SPAN>
<LI id=li_5><LABEL class=description for=element_5>Gewenste tijd om u te contacteren</LABEL><SPAN><INPUT id=element_5_1 class="element text" name=element_5_1 maxLength=2 size=2> : uur</SPAN> <SPAN><SELECT id=element_5_4 class="element select c4" name=element_5_4> <OPTION selected value=AM>AM</OPTION> <OPTION value=PM>PM</OPTION></SELECT> <LABEL>AM/PM</LABEL></SPAN>
<LI id=li_6><LABEL class=description for=element_6>adres</LABEL>
<DIV><INPUT id=element_6_1 class="element text large" name=element_6_1> <LABEL for=element_6_1>Straatnaam</LABEL></DIV>
<DIV><INPUT id=element_6_2 class="element text large" name=element_6_2></DIV>
<DIV class=left><INPUT id=element_6_3 class="element text medium" name=element_6_3> <LABEL for=element_6_3>Gemeente</LABEL></DIV>
<DIV class=right><INPUT id=element_6_4 class="element text medium" name=element_6_4> <LABEL for=element_6_4>provincie</LABEL></DIV>
<DIV class=left><INPUT id=element_6_5 class="element text medium" name=element_6_5 maxLength=15> <LABEL for=element_6_5>Postcode</LABEL></DIV>
<DIV class=right><SELECT id=element_6_6 class="element select medium" name=element_6_6> <OPTION selected value=Afghanistan>Afghanistan</OPTION> <OPTION value=Albania>Albania</OPTION> <OPTION value=Algeria>Algeria</OPTION> <OPTION value=Andorra>Andorra</OPTION> <OPTION value="Antigua and Barbuda">Antigua and Barbuda</OPTION> <OPTION value=Argentina>Argentina</OPTION> <OPTION value=Armenia>Armenia</OPTION> <OPTION value=Australia>Australia</OPTION> <OPTION value=Austria>Austria</OPTION> <OPTION value=Azerbaijan>Azerbaijan</OPTION> <OPTION value=Bahamas>Bahamas</OPTION> <OPTION value=Bahrain>Bahrain</OPTION> <OPTION value=Bangladesh>Bangladesh</OPTION> <OPTION value=Barbados>Barbados</OPTION> <OPTION value=Belarus>Belarus</OPTION> <OPTION value=Belgium>Belgium</OPTION> <OPTION value=Belize>Belize</OPTION> <OPTION value=Benin>Benin</OPTION> <OPTION value=Bhutan>Bhutan</OPTION> <OPTION value=Bolivia>Bolivia</OPTION> <OPTION value="Bosnia and Herzegovina">Bosnia and Herzegovina</OPTION> <OPTION value=Botswana>Botswana</OPTION> <OPTION value=Brazil>Brazil</OPTION> <OPTION value=Brunei>Brunei</OPTION> <OPTION value=Bulgaria>Bulgaria</OPTION> <OPTION value="Burkina Faso">Burkina Faso</OPTION> <OPTION value=Burundi>Burundi</OPTION> <OPTION value=Cambodia>Cambodia</OPTION> <OPTION value=Cameroon>Cameroon</OPTION> <OPTION value=Canada>Canada</OPTION> <OPTION value="Cape Verde">Cape Verde</OPTION> <OPTION value="Central African Republic">Central African Republic</OPTION> <OPTION value=Chad>Chad</OPTION> <OPTION value=Chile>Chile</OPTION> <OPTION value=China>China</OPTION> <OPTION value=Colombia>Colombia</OPTION> <OPTION value=Comoros>Comoros</OPTION> <OPTION value=Congo>Congo</OPTION> <OPTION value="Costa Rica">Costa Rica</OPTION> <OPTION value="C�te d'Ivoire">C�te d'Ivoire</OPTION> <OPTION value=Croatia>Croatia</OPTION> <OPTION value=Cuba>Cuba</OPTION> <OPTION value=Cyprus>Cyprus</OPTION> <OPTION value="Czech Republic">Czech Republic</OPTION> <OPTION value=Denmark>Denmark</OPTION> <OPTION value=Djibouti>Djibouti</OPTION> <OPTION value=Dominica>Dominica</OPTION> <OPTION value="Dominican Republic">Dominican Republic</OPTION> <OPTION value="East Timor">East Timor</OPTION> <OPTION value=Ecuador>Ecuador</OPTION> <OPTION value=Egypt>Egypt</OPTION> <OPTION value="El Salvador">El Salvador</OPTION> <OPTION value="Equatorial Guinea">Equatorial Guinea</OPTION> <OPTION value=Eritrea>Eritrea</OPTION> <OPTION value=Estonia>Estonia</OPTION> <OPTION value=Ethiopia>Ethiopia</OPTION> <OPTION value=Fiji>Fiji</OPTION> <OPTION value=Finland>Finland</OPTION> <OPTION value=France>France</OPTION> <OPTION value=Gabon>Gabon</OPTION> <OPTION value=Gambia>Gambia</OPTION> <OPTION value=Georgia>Georgia</OPTION> <OPTION value=Germany>Germany</OPTION> <OPTION value=Ghana>Ghana</OPTION> <OPTION value=Greece>Greece</OPTION> <OPTION value=Grenada>Grenada</OPTION> <OPTION value=Guatemala>Guatemala</OPTION> <OPTION value=Guinea>Guinea</OPTION> <OPTION value=Guinea-Bissau>Guinea-Bissau</OPTION> <OPTION value=Guyana>Guyana</OPTION> <OPTION value=Haiti>Haiti</OPTION> <OPTION value=Honduras>Honduras</OPTION> <OPTION value="Hong Kong">Hong Kong</OPTION> <OPTION value=Hungary>Hungary</OPTION> <OPTION value=Iceland>Iceland</OPTION> <OPTION value=India>India</OPTION> <OPTION value=Indonesia>Indonesia</OPTION> <OPTION value=Iran>Iran</OPTION> <OPTION value=Iraq>Iraq</OPTION> <OPTION value=Ireland>Ireland</OPTION> <OPTION value=Israel>Israel</OPTION> <OPTION value=Italy>Italy</OPTION> <OPTION value=Jamaica>Jamaica</OPTION> <OPTION value=Japan>Japan</OPTION> <OPTION value=Jordan>Jordan</OPTION> <OPTION value=Kazakhstan>Kazakhstan</OPTION> <OPTION value=Kenya>Kenya</OPTION> <OPTION value=Kiribati>Kiribati</OPTION> <OPTION value="North Korea">North Korea</OPTION> <OPTION value="South Korea">South Korea</OPTION> <OPTION value=Kuwait>Kuwait</OPTION> <OPTION value=Kyrgyzstan>Kyrgyzstan</OPTION> <OPTION value=Laos>Laos</OPTION> <OPTION value=Latvia>Latvia</OPTION> <OPTION value=Lebanon>Lebanon</OPTION> <OPTION value=Lesotho>Lesotho</OPTION> <OPTION value=Liberia>Liberia</OPTION> <OPTION value=Libya>Libya</OPTION> <OPTION value=Liechtenstein>Liechtenstein</OPTION> <OPTION value=Lithuania>Lithuania</OPTION> <OPTION value=Luxembourg>Luxembourg</OPTION> <OPTION value=Macedonia>Macedonia</OPTION> <OPTION value=Madagascar>Madagascar</OPTION> <OPTION value=Malawi>Malawi</OPTION> <OPTION value=Malaysia>Malaysia</OPTION> <OPTION value=Maldives>Maldives</OPTION> <OPTION value=Mali>Mali</OPTION> <OPTION value=Malta>Malta</OPTION> <OPTION value="Marshall Islands">Marshall Islands</OPTION> <OPTION value=Mauritania>Mauritania</OPTION> <OPTION value=Mauritius>Mauritius</OPTION> <OPTION value=Mexico>Mexico</OPTION> <OPTION value=Micronesia>Micronesia</OPTION> <OPTION value=Moldova>Moldova</OPTION> <OPTION value=Monaco>Monaco</OPTION> <OPTION value=Mongolia>Mongolia</OPTION> <OPTION value=Montenegro>Montenegro</OPTION> <OPTION value=Morocco>Morocco</OPTION> <OPTION value=Mozambique>Mozambique</OPTION> <OPTION value=Myanmar>Myanmar</OPTION> <OPTION value=Namibia>Namibia</OPTION> <OPTION value=Nauru>Nauru</OPTION> <OPTION value=Nepal>Nepal</OPTION> <OPTION value=Netherlands>Netherlands</OPTION> <OPTION value="New Zealand">New Zealand</OPTION> <OPTION value=Nicaragua>Nicaragua</OPTION> <OPTION value=Niger>Niger</OPTION> <OPTION value=Nigeria>Nigeria</OPTION> <OPTION value=Norway>Norway</OPTION> <OPTION value=Oman>Oman</OPTION> <OPTION value=Pakistan>Pakistan</OPTION> <OPTION value=Palau>Palau</OPTION> <OPTION value=Panama>Panama</OPTION> <OPTION value="Papua New Guinea">Papua New Guinea</OPTION> <OPTION value=Paraguay>Paraguay</OPTION> <OPTION value=Peru>Peru</OPTION> <OPTION value=Philippines>Philippines</OPTION> <OPTION value=Poland>Poland</OPTION> <OPTION value=Portugal>Portugal</OPTION> <OPTION value="Puerto Rico">Puerto Rico</OPTION> <OPTION value=Qatar>Qatar</OPTION> <OPTION value=Romania>Romania</OPTION> <OPTION value=Russia>Russia</OPTION> <OPTION value=Rwanda>Rwanda</OPTION> <OPTION value="Saint Kitts and Nevis">Saint Kitts and Nevis</OPTION> <OPTION value="Saint Lucia">Saint Lucia</OPTION> <OPTION value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</OPTION> <OPTION value=Samoa>Samoa</OPTION> <OPTION value="San Marino">San Marino</OPTION> <OPTION value="Sao Tome and Principe">Sao Tome and Principe</OPTION> <OPTION value="Saudi Arabia">Saudi Arabia</OPTION> <OPTION value=Senegal>Senegal</OPTION> <OPTION value="Serbia and Montenegro">Serbia and Montenegro</OPTION> <OPTION value=Seychelles>Seychelles</OPTION> <OPTION value="Sierra Leone">Sierra Leone</OPTION> <OPTION value=Singapore>Singapore</OPTION> <OPTION value=Slovakia>Slovakia</OPTION> <OPTION value=Slovenia>Slovenia</OPTION> <OPTION value="Solomon Islands">Solomon Islands</OPTION> <OPTION value=Somalia>Somalia</OPTION> <OPTION value="South Africa">South Africa</OPTION> <OPTION value=Spain>Spain</OPTION> <OPTION value="Sri Lanka">Sri Lanka</OPTION> <OPTION value=Sudan>Sudan</OPTION> <OPTION value=Suriname>Suriname</OPTION> <OPTION value=Swaziland>Swaziland</OPTION> <OPTION value=Sweden>Sweden</OPTION> <OPTION value=Switzerland>Switzerland</OPTION> <OPTION value=Syria>Syria</OPTION> <OPTION value=Taiwan>Taiwan</OPTION> <OPTION value=Tajikistan>Tajikistan</OPTION> <OPTION value=Tanzania>Tanzania</OPTION> <OPTION value=Thailand>Thailand</OPTION> <OPTION value=Togo>Togo</OPTION> <OPTION value=Tonga>Tonga</OPTION> <OPTION value="Trinidad and Tobago">Trinidad and Tobago</OPTION> <OPTION value=Tunisia>Tunisia</OPTION> <OPTION value=Turkey>Turkey</OPTION> <OPTION value=Turkmenistan>Turkmenistan</OPTION> <OPTION value=Tuvalu>Tuvalu</OPTION> <OPTION value=Uganda>Uganda</OPTION> <OPTION value=Ukraine>Ukraine</OPTION> <OPTION value="United Arab Emirates">United Arab Emirates</OPTION> <OPTION value="United Kingdom">United Kingdom</OPTION> <OPTION value="United States">United States</OPTION> <OPTION value=Uruguay>Uruguay</OPTION> <OPTION value=Uzbekistan>Uzbekistan</OPTION> <OPTION value=Vanuatu>Vanuatu</OPTION> <OPTION value="Vatican City">Vatican City</OPTION> <OPTION value=Venezuela>Venezuela</OPTION> <OPTION value=Vietnam>Vietnam</OPTION> <OPTION value=Yemen>Yemen</OPTION> <OPTION value=Zambia>Zambia</OPTION> <OPTION value=Zimbabwe>Zimbabwe</OPTION></SELECT> <LABEL for=element_6_6>land</LABEL></DIV>
<LI class=section_break>
<P>Voor onze klanten</P>
<LI id=li_8><LABEL class=description for=element_8>serienummer pelletkachel</LABEL>
<DIV><INPUT id=element_8 class="element text medium c5" name=element_8 maxLength=255></DIV>
<LI id=li_9><LABEL class=description for=element_9>telefoonnummer</LABEL><SPAN><INPUT id=element_9_1 class="element text" name=element_9_1 maxLength=3 size=3> - <INPUT id=element_9_2 class="element text" name=element_9_2 maxLength=3 size=3></SPAN> <SPAN><INPUT id=element_9_3 class="element text" name=element_9_3 maxLength=4 size=4></SPAN>
<LI id=li_10><LABEL class=description for=element_10>Web Site</LABEL>
<DIV><INPUT id=element_10 class="element text medium c6" name=element_10 maxLength=255 value=http://www.cosdep-pelletkachels.be size=18></DIV>
<LI id=li_11><LABEL class=description for=element_11>Email</LABEL>
<DIV><INPUT id=element_11 class="element text medium" name=element_11 maxLength=255></DIV>
<LI id=li_12><LABEL class=description for=element_12>Upload a File</LABEL>
<DIV><INPUT id=element_12 class="element file" name=element_12 type=file></DIV>
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