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<h1>Registrierung</h1>
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			<span class="text-fett">Lieferanschrift:</span>
			
			
					
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				<td colspan=2 class="text-color" align=right>Kunden-Art &nbsp;&nbsp;</TD>
			
				
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			  	  <input name="kind" type="radio" class="input" value="K"> Krankenhaus / Klinik &nbsp; <br>
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				  <input name="gender" type="radio" class="input" value="Herr"> Herr &nbsp;&nbsp;&nbsp;
				  <input name="gender" type="radio" class="input" value="Frau"> Frau	
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				Mit diesen Daten melden Sie sich in Zukunft bei uns an:	<td><td></td></tr>		
		
		
		
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			eMail-Adresse &nbsp;&nbsp;</TD>
				
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				Ihr Kennwort muss mindestens 6 Zeichen lang sein. </td><td></td></tr>	
				
				
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			Kennwort &nbsp;&nbsp;</TD>
				
			<td><input maxLength="15" size="28" name="passwd" type="password" class="input" value=""></td><td></td></tr>
	
	
	
		<tr height=8><td colspan=5></td></tr>
		
			<tr><td></td><td colspan=2 class="text-color" align=right>
			Wiederholung &nbsp;&nbsp;</TD>
			
			<td><input maxLength="15" size="28" name="passwd2" type="password" class="input" value=""></td><td></td></tr>

			
 
		<tr height=50><td colspan=5></td></tr>
		<tr><td></td><td colspan=3 class="text-grau">
			Die farblich gekennzeichneten Felder d&uuml;rfen nicht leer bleiben			
			</td></tr>
			
			
		<INPUT TYPE="hidden" NAME="phone2" VALUE= "">			
 		<INPUT TYPE="hidden" NAME="phone3" VALUE= "">
		
		
		<tr height=50><td colspan=5></td></tr>
		<tr valign=top>
			<td>
				
					<input name="datenschutz" type="checkbox" class="input" value="">
				
			</td>
			<td colspan=3 class="text">Ich bin damit einverstanden, dass meine Daten entsprechend den
				<a href="zpem_datenschutz.cfm?CFID=80667562-6e42-4e6a-b397-6b6a5fe75827&CFTOKEN=0&" style="color:000000;">Datenschutzbestimmungen</a> 
				gespeichert werden.	
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</table>
		
		
	
		
		
		
		


	
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	<tr height=0><td width="5%"></td><td width="15%"></td><td width="15%"></td><td width="60%"></td><td width="5%"></td></tr>
	<tr height=5><td colspan=5></td></tr>			
	<tr height=100 valign=center><td colspan=5 align=middle>
		<input type="submit" name="dummy" value=" weiter " class="button"></TD></TR>
</TABLE>
		
</form><!-- name:form_customer --><script>
lucee_form_21nz=new LuceeForms('form_customer',null);
lucee_form_21nz.addInput('kind',false,1,14,null,null,null,null,null,null,-1);
lucee_form_21nz.addInput('company1',false,0,14,null,null,null,null,null,null,40);
lucee_form_21nz.addInput('company2',false,0,14,null,null,null,null,null,null,40);
lucee_form_21nz.addInput('street',false,0,14,null,null,null,null,null,null,40);
lucee_form_21nz.addInput('number',false,0,14,null,null,null,null,null,null,6);
lucee_form_21nz.addInput('city',false,0,14,null,null,null,null,null,null,40);
lucee_form_21nz.addInput('country',false,0,14,null,null,null,null,null,null,2);
lucee_form_21nz.addInput('zipcode',false,0,14,null,null,null,null,null,null,15);
lucee_form_21nz.addInput('gender',false,1,14,null,null,null,null,null,null,-1);
lucee_form_21nz.addInput('title',false,0,14,null,null,null,null,null,null,40);
lucee_form_21nz.addInput('first_name',false,0,14,null,null,null,null,null,null,40);
lucee_form_21nz.addInput('last_name',false,0,14,null,null,null,null,null,null,40);
lucee_form_21nz.addInput('phone1',false,0,14,null,null,null,null,null,null,25);
lucee_form_21nz.addInput('email',false,0,14,null,null,null,null,null,null,70);
lucee_form_21nz.addInput('passwd',false,3,14,null,null,null,null,null,null,15);
lucee_form_21nz.addInput('passwd2',false,3,14,null,null,null,null,null,null,15);
lucee_form_21nz.addInput('datenschutz',false,2,14,null,null,null,null,null,null,-1);
</script>
		



	


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