<?

	$voornaam_brdr = '';
	$achternaam_brdr = '';
	$email_brdr = '';
	$telefoon_brdr = '';
	$straat_nr_brdr = '';
	$postcode_brdr = '';
	$plaatsnaam_brdr = '';
	
	$type_0 = '';
	$type_1 = '';
	$type_2 = '';
	$type_3 = '';
	$type_4 = '';
	
	$el_bediening_ja = 'checked';
	$el_bediening_nee = '';
	
	$incl_installatie_ja = 'checked';
	$incl_installatie_nee = '';
	
	$verdieping_0 = 'checked';
	$verdieping_1 = '';
	$verdieping_2 = '';
	$verdieping_3 = '';
	
	$aanhef_dhr = '';
	$aanhef_mevr = '';
	
	$vorm_ja = 'checked';
	$vorm_nee = '';
	
	$land_nl = 'checked';
	$land_b = '';
	$land_de = '';
	$land_anders = '';
	
	$contact_email = '';
	$contact_telefoon = '';
	
	$display_proces = 'none';
	
	if (isset($_POST['aanvragen']))
	{
		// offerte
		$omschrijving 	= htmlentities(trim(strip_tags($_POST['omschrijving'])));

		$selType	= '';
		if (isset($_POST['type']))
		{
			$type = $_POST['type'];
			
			if (in_array('knikarmschermen', $_POST['type'])) { $type_0 = 'checked'; }
			if (in_array('markiezen', 		$_POST['type'])) { $type_1 = 'checked'; }
			if (in_array('rolluiken', 		$_POST['type'])) { $type_2 = 'checked'; }
			if (in_array('screens', 		$_POST['type'])) { $type_3 = 'checked'; }
			if (in_array('uitvalschermen', 	$_POST['type'])) { $type_4 = 'checked'; }
			
			foreach ($type as $typekeuze)
			{
				$selType .= $typekeuze . ', ';
			}
			
			$selType 	= substr($selType, 0, -2);
		}		
				
		$aantal 		= htmlentities(trim(strip_tags($_POST['aantal'])));
		$afmetingen 	= htmlentities(trim(strip_tags($_POST['afmetingen'])));
		$kleur 			= htmlentities(trim(strip_tags($_POST['kleur'])));
		
		$el_bediening 	= $_POST['el_bediening'];
		if (isset($_POST['el_bediening']))
		{
			if ($_POST['el_bediening'] == 'ja') 	{ $el_bediening_ja = 'checked'; }
			if ($_POST['el_bediening'] == 'nee') 	{ $el_bediening_ja = 'checked'; }
		}
		
		$incl_installatie = $_POST['incl_installatie'];
		if (isset($_POST['incl_installatie']))
		{
			if ($_POST['incl_installatie'] == 'ja') 	{ $incl_installatie_ja = 'checked'; }
			if ($_POST['incl_installatie'] == 'nee') 	{ $incl_installatie_ja = 'checked'; }
		}
		
		$selVerdieping = '';
		if (isset($_POST['verdieping']))
		{
			$verdieping 	= $_POST['verdieping'];
			
			if (in_array('begane_grond', 	$_POST['verdieping'])) { $verdieping_0 = 'checked'; }
			if (in_array('1e_verdieping', 	$_POST['verdieping'])) { $verdieping_1 = 'checked'; }
			if (in_array('2e_verdieping', 	$_POST['verdieping'])) { $verdieping_2 = 'checked'; }
			if (in_array('hoger', 			$_POST['verdieping'])) { $verdieping_3 = 'checked'; }
			
			foreach ($verdieping as $etage)
			{
				$selVerdieping .= $etage . ', ';
			}
			
			$selVerdieping 	= substr($selVerdieping, 0, -2);
			
			$selVerdieping = str_replace('begane_grond', 'Begane grond', $selVerdieping);
			$selVerdieping = str_replace('1e_verdieping', '1e verdieping', $selVerdieping);
			$selVerdieping = str_replace('2e_verdieping', '2e verdieping', $selVerdieping);
			$selVerdieping = str_replace('hoger', 'Hoger', $selVerdieping);
		}
		
		$opmerkingen 	= htmlentities(trim(strip_tags($_POST['opmerkingen'])));
		
		// persoonlijke gegevens
		$aanhef 		= $_POST['aanhef'];
		if (isset($_POST['aanhef']))
		{
			if ($_POST['aanhef'] == 'dhr') 	{ $aanhef_dhr = 'checked'; }
			if ($_POST['aanhef'] == 'mevr') { $aanhef_mevr = 'checked'; }
		}
		
		$voornaam 		= htmlentities(trim(strip_tags($_POST['voornaam'])));		// verplicht		
		$tussenvoegsel 	= htmlentities(trim(strip_tags($_POST['tussenvoegsel'])));
		$achternaam 	= htmlentities(trim(strip_tags($_POST['achternaam'])));		// verplicht	
		
		$vorm 			= $_POST['vorm']; // particulier of zakelijk
		if (isset($_POST['vorm']))
		{
			if ($_POST['vorm'] == 'particulier')	{ $vorm_ja = 'checked'; }
			if ($_POST['vorm'] == 'zakelijk') 		{ $vorm_nee = 'checked'; }
		}
		
		$bedrijfsnaam 	= htmlentities(trim(strip_tags($_POST['bedrijfsnaam'])));
		$email 			= trim(strip_tags($_POST['email']));						// verplicht
		$telefoon 		= htmlentities(trim(strip_tags($_POST['telefoon'])));		// verplicht
		$straat_nr 		= htmlentities(trim(strip_tags($_POST['straat_nr'])));		// verplicht		
		$postcode 		= htmlentities(trim(strip_tags($_POST['postcode'])));		// verplicht
		$plaatsnaam		= htmlentities(trim(strip_tags($_POST['plaatsnaam'])));		// verplicht		
		$provincie 		= htmlentities(trim(strip_tags($_POST['provincie'])));
		
		$land 			= $_POST['land'];
		if (isset($_POST['land']))
		{
			if ($_POST['land'] == 'nederland')	{ $land_nl = 'checked'; }
			if ($_POST['land'] == 'belgie') 	{ $land_b = 'checked'; }
			if ($_POST['land'] == 'duitsland')	{ $land_de = 'checked'; }
			if ($_POST['land'] == 'anders') 	{ $land_anders = 'checked'; }
		}
		
		$contactvorm 	= $_POST['contactvorm'];
		if (isset($_POST['contactvorm']))
		{
			if ($_POST['contactvorm'] == 'email')		{ $contact_email = 'checked'; }
			if ($_POST['contactvorm'] == 'telefoon') 	{ $contact_telefoon = 'checked'; }
		}
		
		$errors = array();
		
		$regex_voornaam = '/^[a-z -]+$/ismU';
		
		if (empty($voornaam) || strlen($voornaam) == 1 || preg_match($regex_voornaam, $voornaam) === 0)
		{
			$voornaam_brdr = 'border-color:#FF0000;';
			$errors[] = 'Geen geldige voornaam ingevuld!';
		}
		
		$regex_achternaam = '/^[a-z -]+$/ismU';
		
		if (empty($achternaam) || strlen($achternaam) == 1 || preg_match($regex_achternaam, $achternaam) === 0)
		{
			$achternaam_brdr = 'border-color:#FF0000;';
			$errors[] = 'Geen geldige achternaam ingevuld!';
		}
		
		function checkmail($mail) 
		{ 
			$email_host = explode("@", $mail); 
			$email_host = $email_host['1']; 
			$email_resolved = gethostbyname($email_host); 
		
			if ($email_resolved != $email_host && eregi("^[0-9a-z]([-_.~]?[0-9a-z])*@[0-9a-z]([-.]?[0-9a-z])*\\.[a-z]{2,4}$",$mail)) 
				$valid = 1; 
		
			return $valid; 
		}
		
		if (empty($email) || !checkmail($email))
		{
			$email_brdr = 'border-color:#FF0000;';
			$errors[] = 'Geen geldig e-mailadres ingevuld!';
		}
		
		if (empty($telefoon) || strlen($telefoon) != 10 || !ctype_digit($telefoon))
		{
			$telefoon_brdr = 'border-color:#FF0000;';
			$errors[] = 'Geen geldig telefoonnummer ingevuld!';
		}
		
		$regex_straat_nr = '/^[a-z0-9 -\']+$/ismU';
		
		if (empty($straat_nr) || strlen($straat_nr) < 4 || strlen($straat_nr) > 40 || preg_match($regex_straat_nr, $straat_nr) === 0)
		{
			$straat_nr_brdr = 'border-color:#FF0000;';
			$errors[] = 'Geen geldige straatnaam ingevuld!';
		}	
		
		$regex_postcode = '/^[1-9]{1}[0-9]{3}(\s|)[a-z]{2}$/ismU';
		
		if (empty($postcode) || strlen($postcode) < 6 || strlen($postcode) > 7 || preg_match($regex_postcode, $postcode) === 0)
		{
			$postcode_brdr = 'border-color:#FF0000;';
			$errors[] = 'Geen geldige postcode ingevuld!';
		}
		
		$regex_plaatsnaam = '/^[a-z -\']+$/ismU';
		
		if (empty($plaatsnaam) || strlen($plaatsnaam) < 3 || preg_match($regex_plaatsnaam, $plaatsnaam) === 0)
		{
			$plaatsnaam_brdr = 'border-color:#FF0000;';
			$errors[] = 'Geen geldige plaatsnaam ingevuld!';
		}
		
		if (count($errors) >= 1)
		{
			$display_proces = 'block';
			$proces			= 'proces_fout';
		}
		else
		{
			$display_proces = 'block';
			$proces			= 'proces_goed';
			
			// naam samenstellen
			if (!empty($tussenvoegsel))
			{
				$naam = $voornaam.' '.$tussenvoegsel.' '.$achternaam;
			}
			else
			{
				$naam = $voornaam.' '.$achternaam;
			}
			
			// bevestigingsemail sturen
			require_once('class.phpmailer.php');	
			$mail = new PHPMailer();
			$mail->IsHTML(true);
			$mail->From = 'info@johnszonwering.nl';
			$mail->FromName = $naam;				
			$mail->AddAddress('info@johnszonwering.nl', 'John\'s Zonwering');
			$mail->AddReplyTo($email, $voornaam);
			$mail->Subject = "Nieuwe offerte-aanvraag!";
				
			$body       	= file_get_contents('mailtje.html');
			$body       	= eregi_replace("[\]", '', $body);
			$body 			= str_replace("[datum]", date('d-m-Y'), $body);
			$body 			= str_replace("[omschrijving]", nl2br($omschrijving), $body);
			$body 			= str_replace("[type]", $selType, $body);
			$body 			= str_replace("[aantal]", $aantal, $body);
			$body 			= str_replace("[afmetingen]", nl2br($afmetingen), $body);
			$body 			= str_replace("[kleur]", $kleur, $body);
			$body 			= str_replace("[elektrische_bediening]", $el_bediening, $body);
			$body 			= str_replace("[inclusief_installatie]", $incl_installatie, $body);
			$body 			= str_replace("[verdieping]", $selVerdieping, $body);
			$body 			= str_replace("[opmerkingen]", nl2br($opmerkingen), $body);
			$body 			= str_replace("[aanhef]", $aanhef, $body);
			$body 			= str_replace("[voornaam]", $voornaam, $body);
			$body 			= str_replace("[tussenvoegsel]", $tussenvoegsel, $body);
			$body 			= str_replace("[achternaam]", $achternaam, $body);
			$body 			= str_replace("[vorm]", $vorm, $body);
			$body 			= str_replace("[bedrijfsnaam]", $bedrijfsnaam, $body);
			$body 			= str_replace("[email]", $email, $body);
			$body 			= str_replace("[telefoon]", $telefoon, $body);
			$body 			= str_replace("[straat_nr]", $straat_nr, $body);
			$body 			= str_replace("[postcode]", $postcode, $body);
			$body 			= str_replace("[plaatsnaam]", $plaatsnaam, $body);
			$body 			= str_replace("[provincie]", $provincie, $body);
			$body 			= str_replace("[land]", $land, $body);
			$body 			= str_replace("[contactvorm]", $contactvorm, $body);
				
			$mail->MsgHTML($body);
				
			if(!$mail->Send())
			{
				echo "Mailer Error: " . $mail->ErrorInfo;
			}
			else
			{
				echo "<meta http-equiv='Refresh' content='3;url=http://www.johnszonwering.nl'>";
			}			
		}			
	}

?>

<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1" />
<title>John's Zonwering / Offerte aanvragen.</title>
<style type="text/css">
<!--
body {
	margin-left: 0px;
	margin-top: 0px;
	margin-right: 0px;
	margin-bottom: 0px;
}
body {
	font-family: Lucida Sans;
	font-size: 10px;
	color: #1D2850;
}
.style5 {
	font-size: 24px;
	font-style: italic;
}
.style6 {
	color: #FF0000;
}
.style7 {color: #FF0000}

.form {
	font: normal 12px/24px Arial;
	color: #1D2850;
	margin-top: 20px;
	margin-bottom: 20px;
	}
#chckbx {
	float: left;
	width: auto;
	margin-right: 5px;
	height: auto;
}
#checkbox {
	float: left;
	margin-top: 2px;
	margin-right: 2px;
}
#radiobttn {
	float: left;
	margin-top: 1px;
	margin-right: 4px;
}
#titel {
	font: bold 16px/24px Arial;
	color: #0099FF;
}
.txtr {
	width: 500px;
	height: 120px;
	font: normal 12px/14px Arial;
	color: #333333;
	background: #FFFFFF;
	border: 1px solid #CCCCCC;
	padding: 6px 4px 6px 4px;
}
.txtr:focus {
	border: 1px solid #0099FF;
}
.txtfld {
	background: #FFFFFF;
	border: 1px solid #CCCCCC;
	height: 20px;
	padding-left: 4px;
	font: normal 12px/20px Arial;
	color: #333333;
}
.txtfld:focus {
	border: 1px solid #0099FF;
}
#proces_fout {
	width: 490px;
	background: #FFD9D9;
	border: 1px solid #FF6666;
	font: normal 12px/16px Arial;
	color: #FF0000;
	padding: 10px;
}
#proces_goed {
	width: 490px;
	background: #CAFFCA;
	border: 1px solid #93FF93;
	font: normal 12px/16px Arial;
	color: #008400;
	padding: 10px;
}
li {
	margin: 2px auto 2px 15px;
}
-->
</style>
</head>

<body>
<table width="100%" height="100%" border="0" cellpadding="0" cellspacing="0">
  <tr>
    <td align="center" valign="top" bgcolor="#E4E4E4"><table width="780" height="1000" border="0" cellpadding="0" cellspacing="0">
      <tr>
        <td align="center" valign="top" bgcolor="#FFFFFF"><img src="../img/header_offerte.jpg" width="800" height="270" /><br />
          <br />          
          <span class="style5">Offerte Formulier</span><span class="style6"><br />
          <br />
          Let op! Alle velden met een (*) zijn verplicht om in te vullen.</span><br />
          <table width="680" height="20" border="0" cellpadding="0" cellspacing="0" style="display: <? echo $display_proces; ?>;">
		  <tr>
		  <td height="20" align="left" valign="middle">&nbsp;</td>
		  </tr>
		  <tr>
		  <td align="left" valign="middle" id="<? echo $proces; ?>">
			<?
				if (count($errors) >= 1)
				{
					echo '<span style="font: bold 18px/24px Arial; color:#CE0000;">Oops.. er is iets mis gegaan</span><br>';
					foreach ($errors as $error)
					{
						echo '<li><b>'.$error.'</b></li>';
					}
				}
				else
				{
					echo '<span style="font: bold 18px/24px Arial; color:#009900;">Uw offerte-aanvraag is succesvol verzonden!</span>';
				}			  
		  	?>
			</td>
          </tr>
          </table>
          <table width="680" border="0" cellspacing="0" cellpadding="0" class="form">
		  <form action="" method="post">
			<tr>
              <td width="167" height="30" align="right" valign="top">&nbsp;</td>
              <td width="10" height="30" valign="top">&nbsp;</td>
              <td width="503" height="30" align="left" valign="top"><span id="titel">Uw aanvraag</span></td>
            </tr>
			<tr>
              <td width="167" height="140" align="right" valign="top">Omschrijving</td>
              <td width="10" height="140" valign="top">&nbsp;</td>
              <td width="503" height="140" align="left" valign="top"><textarea class="txtr" name="omschrijving"><? echo $omschrijving; ?></textarea></td>
            </tr>
            <tr>
              <td height="30" align="right" valign="top">Type</td>
              <td height="30" valign="top">&nbsp;</td>
              <td height="30" align="left" valign="top">
			  <div id="chckbx"><input name="type[]" type="checkbox" id="checkbox" <? echo $type_0; ?> value="knikarmschermen" />Knikarmschermen</div>
			  <div id="chckbx"><input name="type[]" type="checkbox" id="checkbox" <? echo $type_1; ?> value="markiezen" />Markiezen</div>
			  <div id="chckbx"><input name="type[]" type="checkbox" id="checkbox" <? echo $type_2; ?> value="rolluiken" />Rolluiken</div>
			  <div id="chckbx"><input name="type[]" type="checkbox" id="checkbox" <? echo $type_3; ?> value="screens" />Screens</div>
			  <div id="chckbx"><input name="type[]" type="checkbox" id="checkbox" <? echo $type_4; ?> value="uitvalschermen" />Uitvalschermen</div>			  </td>
            </tr>
            <tr>
              <td height="30" align="right" valign="top">Aantal</td>
              <td height="30" valign="top">&nbsp;</td>
              <td height="30" align="left" valign="top"><input type="text" class="txtfld" name="aantal" value="<? echo $aantal; ?>" style="width:50px;"/></td>
            </tr>
            <tr>
              <td height="140" align="right" valign="top">Afmetingen</td>
              <td height="140">&nbsp;</td>
              <td height="140" align="left" valign="top"><textarea class="txtr" name="afmetingen"><? echo $afmetingen; ?></textarea></td>
            </tr>
            <tr>
              <td height="30" align="right" valign="top">Kleur</td>
              <td height="30">&nbsp;</td>
              <td height="30" align="left" valign="top"><input type="text" class="txtfld" name="kleur" value="<? echo $kleur; ?>" style="width:100px;"/></td>
            </tr>
            <tr>
              <td height="30" align="right" valign="top">Elektrische bedieding </td>
              <td height="30">&nbsp;</td>
              <td height="30" align="left" valign="top">
			  <div id="chckbx"><input name="el_bediening" type="radio" value="ja" <? echo $el_bediening_ja; ?> id="radiobttn" />Ja</div>
			  <div id="chckbx"><input name="el_bediening" type="radio" value="nee" <? echo $el_bediening_nee; ?> id="radiobttn" />Nee</div></td>
            </tr>
            <tr>
              <td height="30" align="right" valign="top">Inclusief installatie </td>
              <td height="30">&nbsp;</td>
              <td height="30" align="left" valign="top">
			  <div id="chckbx"><input name="incl_installatie" type="radio" value="ja" <? echo $incl_installatie_ja; ?> id="radiobttn" />Ja</div>
			  <div id="chckbx"><input name="incl_installatie" type="radio" value="nee" <? echo $incl_installatie_nee; ?> id="radiobttn" />Nee</div>
			  </td>
            </tr>
            <tr>
              <td height="30" align="right" valign="top">Verdieping</td>
              <td height="30">&nbsp;</td>
              <td height="30" align="left" valign="top">
			  <div id="chckbx"><input name="verdieping[]" type="checkbox" id="checkbox" <? echo $verdieping_0; ?> value="begane_grond" />Begane grond</div>
			  <div id="chckbx"><input name="verdieping[]" type="checkbox" id="checkbox" <? echo $verdieping_1; ?> value="1e_verdieping" />1e verdieping</div>
			  <div id="chckbx"><input name="verdieping[]" type="checkbox" id="checkbox" <? echo $verdieping_2; ?> value="2e_verdieping" />2e verdieping</div>
			  <div id="chckbx"><input name="verdieping[]" type="checkbox" id="checkbox" <? echo $verdieping_3; ?> value="hoger" />Hoger</div>
			  </td>
            </tr>
            <tr>
              <td height="160" align="right" valign="top">Opmerkingen</td>
              <td height="160">&nbsp;</td>
              <td height="160" align="left" valign="top"><textarea class="txtr" name="opmerkingen"><? echo $opmerkingen; ?></textarea></td>
            </tr>
			<tr>
              <td height="30" align="right" valign="top">&nbsp;</td>
              <td height="30">&nbsp;</td>
              <td height="30" align="left" valign="top"><span id="titel">Uw gegevens</span></td>
            </tr>
            <tr>
              <td height="30" align="right" valign="top">Aanhef</td>
              <td height="30">&nbsp;</td>
              <td height="30" align="left" valign="top">
			  <div id="chckbx"><input name="aanhef" type="radio" value="dhr" <? echo $aanhef_dhr; ?> id="radiobttn" />Dhr.</div>
			  <div id="chckbx"><input name="aanhef" type="radio" value="mevr" <? echo $aanhef_mevr; ?> id="radiobttn" />Mevr.</div>
			  </td>
            </tr>
            <tr>
              <td height="30" align="right" valign="top">Voornaam <span class="style6">*</span></td>
              <td height="30">&nbsp;</td>
              <td height="30" align="left" valign="top">
			  <input type="text" class="txtfld" name="voornaam" style="width:200px; <? echo $voornaam_brdr; ?>" value="<? echo $voornaam; ?>"/>
			  </td>
            </tr>
            <tr>
              <td height="30" align="right" valign="top">tussenvoegsel</td>
              <td height="30">&nbsp;</td>
              <td height="30" align="left" valign="top">
			  <input type="text" class="txtfld" name="tussenvoegsel" style="width:50px;" value="<? echo $tussenvoegsel; ?>"/>
			  </td>
            </tr>
            <tr>
              <td height="30" align="right" valign="top">Achternaam <span class="style6">*</span></td>
              <td height="30">&nbsp;</td>
              <td height="30" align="left" valign="top">
			  <input type="text" class="txtfld" name="achternaam" style="width:200px; <? echo $achternaam_brdr; ?>" value="<? echo $achternaam; ?>"/>
			  </td>
            </tr>
            <tr>
              <td height="30" align="right" valign="top">Particulier</td>
              <td height="30">&nbsp;</td>
              <td height="30" align="left" valign="top">
			  <div id="chckbx"><input name="vorm" type="radio" value="particulier" <? echo $vorm_ja; ?> id="radiobttn" />Ja</div>
			  <div id="chckbx"><input name="vorm" type="radio" value="zakelijk" <? echo $vorm_nee; ?> id="radiobttn" />Nee, zakelijk</div>
			  </td>
            </tr>
            <tr>
              <td height="30" align="right" valign="top">Bedrijfsnaam</td>
              <td height="30">&nbsp;</td>
              <td height="30" align="left" valign="top">
			  <input type="text" class="txtfld" name="bedrijfsnaam" style="width:200px;" value="<? echo $bedrijfsnaam; ?>"/>
			  </td>
            </tr>
            <tr>
              <td height="30" align="right" valign="top">E-mail <span class="style6">*</span></td>
              <td height="30">&nbsp;</td>
              <td height="30" align="left" valign="top">
			  <input type="text" class="txtfld" name="email" style="width:200px; <? echo $email_brdr; ?>" value="<? echo $email; ?>"/>
			  </td>
            </tr>
            <tr>
              <td height="30" align="right" valign="top">Telefoon <span class="style6">*</span></td>
              <td height="30">&nbsp;</td>
              <td height="30" align="left" valign="top">
			  <input type="text" class="txtfld" name="telefoon" style="width:100px; <? echo $telefoon_brdr; ?>" value="<? echo $telefoon; ?>"/>
			  </td>
            </tr>
            <tr>
              <td height="30" align="right" valign="top">Straatnaam + huisnummer <span class="style6">*</span></td>
              <td height="30">&nbsp;</td>
              <td height="30" align="left" valign="top">
			  <input type="text" class="txtfld" name="straat_nr" style="width:200px; <? echo $straat_nr_brdr; ?>" value="<? echo $straat_nr; ?>"/>
			  </td>
            </tr>
            <tr>
              <td height="30" align="right" valign="top">Postcode <span class="style6">*</span></td>
              <td height="30">&nbsp;</td>
              <td height="30" align="left" valign="top">
			  <input type="text" class="txtfld" name="postcode" style="width:50px; <? echo $postcode_brdr; ?>" value="<? echo $postcode; ?>"/>
			  </td>
            </tr>
			<tr>
              <td height="30" align="right" valign="top">Plaatsnaam <span class="style6">*</span></td>
              <td height="30">&nbsp;</td>
              <td height="30" align="left" valign="top">
			  <input type="text" class="txtfld" name="plaatsnaam" style="width:200px; <? echo $plaatsnaam_brdr; ?>" value="<? echo $plaatsnaam; ?>"/>
			  </td>
            </tr>
            <tr>
              <td height="30" align="right" valign="top">Provincie</td>
              <td height="30">&nbsp;</td>
              <td height="30" align="left" valign="top">
			  <input type="text" class="txtfld" name="provincie" style="width:200px;" value="<? echo $provincie; ?>"/>
			  </td>
            </tr>
            <tr>
              <td height="30" align="right" valign="top">Land</td>
              <td height="30">&nbsp;</td>
              <td height="30" align="left" valign="top">
			  <div id="chckbx"><input name="land" type="radio" value="nederland" <? echo $land_nl; ?> id="radiobttn" />Nederland</div>
			  <div id="chckbx"><input name="land" type="radio" value="belgie" <? echo $land_b; ?> id="radiobttn" />Belgi�</div>
			  <div id="chckbx"><input name="land" type="radio" value="duitsland" <? echo $land_de; ?> id="radiobttn" />Duitsland</div>
			  <div id="chckbx"><input name="land" type="radio" value="anders" <? echo $land_anders; ?> id="radiobttn" />Anders</div>
			  </td>
            </tr>
            <tr>
              <td height="40" align="right" valign="top">Contacteer mij</td>
              <td height="40">&nbsp;</td>
              <td height="40" align="left" valign="top">
			  <div id="chckbx"><input name="contactvorm" type="radio" value="email" <? echo $contact_email; ?> id="radiobttn" />Per e-mail</div>
			  <div id="chckbx"><input name="contactvorm" type="radio" value="telefoon" <? echo $contact_telefoon; ?> id="radiobttn" />Per telefoon</div>
			  </td>
            </tr>
            <tr>
              <td height="22" align="right" valign="top">&nbsp;</td>
              <td height="22">&nbsp;</td>
              <td height="22" align="left" valign="top"><input type="submit" name="aanvragen" value="Offerte aanvragen"/></td>
            </tr>
			</form>
          </table>
		  </td>
      </tr>
    </table>
    </td>
  </tr>
</table>
</body>
</html>