<script type='text/javascript' src='http://m10.mailplus.nl/genericservice/code/servlet/js-lib/calendar/calendar.js'></script>
<script type='text/javascript' src='http://m10.mailplus.nl/genericservice/code/servlet/js-lib/calendar/lang/calendar-nl.js'></script>
<script type='text/javascript' src='http://m10.mailplus.nl/genericservice/code/servlet/js-lib/calendar/calendar-setup.js'></script>
<link rel='stylesheet' type='text/css' media='all' href='http://m10.mailplus.nl/genericservice/code/servlet/js-lib/calendar/skins/aqua/theme.css' title='Aqua' />
<link rel='stylesheet' type='text/css' media='all' href='http://m10.mailplus.nl/genericservice/code/servlet/js-lib/calendar/calendar-win2k-cold-1.css' title='win2k-cold-1' />
<script type='text/javascript'>function setRedBorder(id){ var elem = document.getElementById(id); if (elem && elem.style) { elem.style.border = '1px solid red';} } </script>
<script type='text/javascript'>function setHiddenBorder(id){ var elem = document.getElementById(id); if (elem && elem.style) { elem.style.border = '';} } </script>
<form method="post" action="http://m10.mailplus.nl/genericservice/code/servlet/Redirect" enctype="application/x-www-form-urlencoded" name="form1001" id="form1001" onsubmit="return checkFormform1001(this);">
<script type="text/javascript">
function checkFormform1001(myForm) {
try {
    var errorMessage = 'Het formulier kon niet worden verzonden om de volgende reden(en):\n\n';
    var errorFound = false;

     setHiddenBorder('field1003TD');
    if (myForm.field1003 != null) {
        if (myForm.field1003.value == '') {
            errorMessage = errorMessage + '- Geen waarde ingevuld voor E-mailadres.\n';
            errorFound = true;
            setRedBorder('field1003TD');
        } else {
            emailAddress = myForm.field1003.value;
            if (emailAddress.search(/^[a-z0-9!#$%&'*+/=?^_`{|}~-]+(?:\.[a-z0-9!#$%&''*+/=?^_`{|}~-]+)*@(?:[a-z0-9](?:[a-z0-9-]*[a-z0-9])?\.)+[a-z0-9](?:[a-z0-9-]*[a-z0-9])?/i) == -1) {
                errorMessage = errorMessage + '- Ongeldig waarde ingevuld voor E-mailadres.\n';
                setRedBorder('field1003TD');
                errorFound = true;
            }
        }
    }
var field1182Checked = false;
for (i = 0; i < 3; i++) {
     if (document.getElementById('field1182_'+ i).checked) {
         field1182Checked = true; 
     }
}
        if (!field1182Checked) {
    ;    setRedBorder('field1182TD');
            errorMessage = errorMessage + '- Geen waarde ingevuld voor Ik ben geïnteresseerd in:.\n';
            errorFound = true;
    }
         else { setHiddenBorder('field1182TD'); }
var field1182Value = 0;for (i = 0; i < 3; i++) {
     if (document.getElementById('field1182_'+ i).checked) {
         var bitValue = parseInt(document.getElementById('field1182_'+ i).value);
         field1182Value |= bitValue     } 
} 
document.getElementById('field1182').value = field1182Value;
    
    if (errorFound) {
        alert(errorMessage);
        return false;
    }
    
    return true;
} catch (err) {
    return false;
}
}
</script>
<table class="mpFormTable" border="0" cellpadding="0" cellspacing="0">
<tr class="mpFormRow">

    <td class="mpFormLabel">E-mailadres *</td></tr>
<tr class="mpFormRow">
    <td class="mpFormField" id="field1003TD"><input type="text" name="field1003" value="">
</td>
</tr>
<tr class="mpFormRow">
    <td class="mpFormLabel">Voornaam</td></tr>
<tr class="mpFormRow">
    <td class="mpFormField" id="field1005TD"><input type="text" name="field1005" value="">
</td>
</tr>

<tr class="mpFormRow">
    <td class="mpFormLabel">Tussenvoegsel</td></tr>
<tr class="mpFormRow">
    <td class="mpFormField" id="field1183TD"><input type="text" name="field1183" value="">
</td>
</tr>
<tr class="mpFormRow">
    <td class="mpFormLabel">Achternaam</td></tr>
<tr class="mpFormRow">
    <td class="mpFormField" id="field1001TD"><input type="text" name="field1001" value="">
</td>

</tr>
<tr class="mpFormRow">
    <td class="mpFormLabel">Geslacht</td></tr>
<tr class="mpFormRow">
    <td class="mpFormField" id="field1002TD"><table class="mpRadioButtonTable" border="0" cellpadding="0" cellspacing="0">
<tr><td class="mpRadioButtonInput"><input type="radio" name="field1002" id="field1002"value="M"></td><td class="mpRadioButtonText">Man</td></tr>
<tr><td class="mpRadioButtonInput"><input type="radio" name="field1002" id="field1002"value="F"></td><td class="mpRadioButtonText">Vrouw</td></tr>
</table>
</td>
</tr>
<tr class="mpFormRow">
    <td class="mpFormLabel">Ja, ik ontvang graag: *</td></tr>

<tr class="mpFormRow">
    <td class="mpFormField" id="field1182TD"><table class="mpCheckBoxTable" border="0" cellpadding="0" cellspacing="0">
<tr><td class="mpCheckBoxInput"><input type="checkbox" name="field1182_0" id="field1182_0" value="1"></td><td class="mpCheckBoxLabel">Nieuwsbrief Algemeen</td></tr>
<tr><td class="mpCheckBoxInput"><input type="checkbox" name="field1182_1" id="field1182_1" value="2"></td><td class="mpCheckBoxLabel">Nieuwsbrief Gezin</td></tr>
<tr><td class="mpCheckBoxInput"><input type="checkbox" name="field1182_2" id="field1182_2" value="16"></td><td class="mpCheckBoxLabel">Nieuwsbrief Heartbeat Businessclub</td></tr>
</table>
</td>
</tr>

<tr><td class="submitCell" colspan="2"><input type="submit" value="Aanmelden"></td></tr></table>
<script language='javascript'>
    if (document.getElementById('form1001').field1003 != null) {
     document.getElementById('form1001').field1003.focus();
}
</script><input type="hidden" name="encId" id="encId" value="{encId}">
<input type="hidden" name="serviceInstanceId" id="serviceInstanceId" value="31001772">

<input type="hidden" name="okLink" id="okLink" value="www.stichtingheartbeat.nl">
<input type="hidden" name="redir" id="redir" value="formAdmin">
<input type="hidden" name="formEncId" id="formEncId" value="x6CRNkKYknCc7Xn">
<input type="hidden" name="field1182" id="field1182" value="">

</form>