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< B O D Y >
< s c r i p t t y p e = " t e x t / j a v a s c r i p t " c h a r s e t = " i s o - 8 8 5 9 - 2 " s r c = " d a t a . j s " > < / s c r i p t >
< T I T L E > z a d a n i e 1 - f o r m u l a r z e l e k t r o n i c z n e j h i s t o r i i c h o r o b y < / T I T L E >
< / H E A D >
< f o n t b g c o l o r = " D 3 D 3 D 3 " >
< T A B L E b o r d e r = 0 c e l l P a d d i n g = 0 c e l l S p a c i n g = 0 w i d t h = 1 0 0 % h e i g h t = 1 0 0 % b g c o l o r = " D 3 D 3 D 3 " >
< T R > < T D v A l i g n = t o p a l i g n = c e n t e r c o l S p a n = 1 w i d t h = 1 0 0 % h e i g h t = 1 0 0 % >
< T A B L E b o r d e r = 0 c e l l P a d d i n g = 0 c e l l S p a c i n g = 0 w i d t h = 7 8 3 h e i g h t = 6 0 0 >
< T R > < T D v a l i g n = m i d d l e a l i g n = c e n t e r c o l S p a n = 1 w i d t h = 6 8 3 h e i g h t = 6 0 0 b g c o l o r = " D 3 D 3 D 3 " >
< f o r m a c t i o n = " " m e t h o d = " p o s t " >
< P s t y l e = " f o n t - f a m i l y : V e r d a n a ; f o n t - s i z e : 1 0 p x ; " >
< b > D A N E O S O B O W E P A C J E N T A < b r / > < b r / > < / b >
< b > I m i < / b > < i n p u t t y p e = " t e x t " n a m e = " p o l e 1 " s t y l e = " w i d t h : 2 0 0 p x ; h e i g h t : 1 8 p x ; f o n t - f a m i l y : V e r d a n a ; f o n t - s i z e : 1 0 p x ; " / > < b r / > < b r / >
< b > N a z w i s k o < / b > < i n p u t t y p e = " t e x t " n a m e = " p o l e 1 " s t y l e = " w i d t h : 2 0 0 p x ; h e i g h t : 1 8 p x ; f o n t - f a m i l y : V e r d a n a ; f o n t - s i z e : 1 0 p x ; " / > < b r / > < b r / >
< b > M i e j s c e z a m i e s z k a n i a : < / b >
< s e l e c t n a m e = " p o l e 2 " s t y l e = " w i d t h : 2 0 0 p x ; f o n t - f a m i l y : V e r d a n a ; f o n t - s i z e : 1 0 p x ; " / >
< O P T I O N > S i e m i a n o w i c e Zl s k i e < / O P T I O N >
< O P T I O N > Z a b r z e < / O P T I O N >
< O P T I O N > M y s Bo w i c e < / O P T I O N >
< O P T I O N > R u d a Zl s k a < / O P T I O N >
< O P T I O N > C h o r z ó w < / O P T I O N >
< / s e l e c t > < b r / > < b r / > < b r / >
< b > P Be : < b r / > < / b >
m |c z y z n a & n b s p ; < i n p u t t y p e = " r a d i o " n a m e = " p o l e 3 " v a l u e = " m " > < b r / >
k o b i e t a & n b s p ; & n b s p ; & n b s p ; & n b s p ; & n b s p ; & n b s p ; < i n p u t t y p e = " r a d i o " n a m e = " p o l e 3 " v a l u e = " k " > < b r / > < b r / >
< b > D a t a u r o d z e n i a < b r > < b r > < / b >
< b > R o k < / b > < i n p u t t y p e = " t e x t " n a m e = " p o l e 1 " s t y l e = " w i d t h : 1 0 0 p x ; h e i g h t : 1 8 p x ; f o n t - f a m i l y : V e r d a n a ; f o n t - s i z e : 1 0 p x ; " / >
< b > M i e s i c < / b > < i n p u t t y p e = " t e x t " n a m e = " p o l e 1 " s t y l e = " w i d t h : 1 0 0 p x ; h e i g h t : 1 8 p x ; f o n t - f a m i l y : V e r d a n a ; f o n t - s i z e : 1 0 p x ; " / >
< b > D z i e D< / b > < i n p u t t y p e = " t e x t " n a m e = " p o l e 1 " s t y l e = " w i d t h : 1 0 0 p x ; h e i g h t : 1 8 p x ; f o n t - f a m i l y : V e r d a n a ; f o n t - s i z e : 1 0 p x ; " / > < b r > < b r >
< b r > < b r >
< b > P E S E L < / b > < b r > < b r > < i n p u t t y p e = " t e x t " n a m e = " p o l e 1 " s t y l e = " w i d t h : 2 0 0 p x ; h e i g h t : 1 8 p x ; f o n t - f a m i l y : V e r d a n a ; f o n t - s i z e : 1 0 p x ; " / >
< b r > < b r > < b > O p i s : < b r / > < b r / > < / b >
< t e x t a r e a n a m e = " p o l e 2 " s t y l e = " w i d t h : 2 0 0 p x ; h e i g h t : 1 0 0 p x ; f o n t - f a m i l y : V e r d a n a ; f o n t - s i z e : 1 0 p x ; " >
< / t e x t a r e a > < b r / > < b r / >
< b > D a t a p r z y j c i a < / b > < i n p u t t y p e = " t e x t " n a m e = " p o l e 1 " s t y l e = " w i d t h : 1 0 0 p x ; h e i g h t : 1 8 p x ; f o n t - f a m i l y : V e r d a n a ; f o n t - s i z e : 1 0 p x ; " / > < s c r i p t t y p e = " t e x t / j a v a s c r i p t " >
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d o c u m e n t . w r i t e ( n e w D a t e ( d o c u m e n t . l a s t M o d i f i e d ) . d a t e ( ' Y - m - d H : i : s ' ) ) ;
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< / s c r i p t >
< b r > < b r >
< i n p u t t y p e = " s u b m i t " v a l u e = " Z a p i s z " ; s t y l e = " w i d t h : 5 0 p x ; h e i g h t : 2 0 p x ; f o n t - f a m i l y : V e r d a n a ; f o n t - s i z e : 1 0 p x ; " / >
< / P > < / f o r m >
< / T D > < / T R > < / T A B L E >
< / T D > < / T R >
< / T A B L E >
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< / H T M L > Darmowy hosting zapewnia PRV.PL