    <form name="newuser" action="<?=$SELF_PHP?>" method="POST">
      <input type="hidden" name="versnummer" value="<?=$versnummer?>" />
      <fieldset class="fieldset"><legend>Pers. Daten</legend>

        <div class="field">
          <label for="versnummer">Versichertennr.</label>
          <input type="text" name="versnummer" id="versnummer" value="<?=$versnummer?>" />
          <div class="clear"> </div>
        </div>

        <div class="field">
          <label for="rechtskreis">Rechtskreis</label>
          <input type="radio" id="ost" class="inputradio" name="rechtskreis" value="Ost" <?=($rechtskreis=='Ost')?'checked="checked"':''?>/> <label class="small" for="ost">Ost</label>
          <input type="radio" id="west" class="inputradio" name="rechtskreis" value="West" <?=($rechtskreis=='West'||$rechtskreis=='')?'checked="checked"':''?>/> <label class="small" for="west">West</label>
          <div class="clear"> </div>
        </div>

        <div class="field">
          <label for="mitgliedseit">Mitglied seit</label>
          <input type="text" id="mitgliedseit" name="mitgliedseit" value="<?=$mitgliedseit?>" />
          <script type="text/javascript">
            $(function() {
              $("#mitgliedseit").datepicker();});
          </script>
          <div class="clear"> </div>
        </div>

        <div class="field">
          <label for="versnummerfamilie">Familienversichert (Versnummer)</label>
          <input type="text" name="versnummerfamilie" id="versnummerfamilie" value="<?=$versnummerfamilie?>" />
          <div class="clear"> </div>
        </div>

        <div class="field">
          <label for="rechtskreisfamilie">Rechtskreis</label>
          <input type="radio" id="ost" class="inputradio" name="rechtskreisfamilie" value="Ost" <?=($rechtskreisfamilie=='Ost')?'checked="checked"':''?>/> <label class="small" for="ost">Ost</label>
          <input type="radio" id="west" class="inputradio" name="rechtskreisfamilie" value="West" <?=($rechtskreisfamilie=='West'||$rechtskreisfamilie=='')?'checked="checked"':''?>/> <label class="small" for="west">West</label>
          <div class="clear"> </div>
        </div>

        <div class="field">
          <label for="anrede">Anrede</label>
          <select class="inputgen" name="anrede">
            <option class="inputgen" value="Frau" <? if ($anrede == 'Frau') echo 'selected'; ?>>Frau</option>
            <option class="inputgen" value="Herrn" <? if ($anrede == 'Herrn') echo 'selected'; ?>>Herrn</option>
          </select>
          <div class="clear"> </div>
        </div>

        <div class="field">
          <label for="titel">Titel</label>
          <input type="text" name="titel" value="<?=$titel?>" />
          <div class="clear"> </div>
          <div class="clear"> </div>
        </div>

        <div class="field">
          <label for="name">Nachname</label>
          <input type="text" name="name" value="<?=$name?>" />
          <div class="clear"> </div>
        </div>

        <div class="field">
          <label for="vorname">Vorname</label>
          <input type="text" name="vorname" value="<?=$vorname?>" />
          <div class="clear"> </div>
        </div>

        <div class="field">
          <label for="strasse">Strasse</label>
          <input type="text" name="strasse" value="<?=$strasse?>" /></label>
          <div class="clear"> </div>
        </div>

        <div class="field">
          <label for="plz">PLZ</label>
          <input type="text" name="plz" value="<?=$plz?>" />
        </div>
          <div class="clear"> </div>
        <div class="field">
          <label for="ort">Ort</label>
          <input type="text" name="ort" value="<?=$ort?>" /></label>
        </div>

        <div class="field">
          <label for="land">Land</label>
          <select name="land">
<? foreach ($eucountries as $iso=>$country) { ?>
            <option value="<?=$country?>" <?=($country==$land)?'selected="selected"':''?>><?=$country?></option>
<? } ?></select>
          <div class="clear"> </div>
        </div>

        <div class="field">
          <label for="geburtsdatum">Geburtsdatum</label>
          <input type="text" id="geburtsdatum" name="geburtsdatum" value="<?=$geburtsdatum?>" /></label>
          <script type="text/javascript">
            $(function() {
              $("#geburtsdatum").datepicker();});
          </script>
          <div class="clear"> </div>
        </div>

        <div class="field">
          <label for="email">E-Mail</label>
          <input type="text" name="email" value="<?=$email?>" />
          <div class="clear"> </div>
        </div>

        <div class="field">
          <label for="auszugperemail">Kontoauszug</label>
          <select name="auszugperemail" id="auszugperemail">
              <option value="0"<?=($auszugperemail==0)?' selected="selected"':''?>>Kein Kontoauszug</option>
              <option value="1"<?=($auszugperemail==1)?' selected="selected"':''?>>Nur per Briefpost</option>
              <option value="2"<?=($auszugperemail==2)||($auszugperemail == '')?' selected="selected"':''?>>Nur Per EMail</option>
            </select>
          <div class="clear"> </div>
        </div>

        <div class="field">
          <label for="">&nbsp;</label>
          <input type="submit" value="Eintragen" />
          <div class="clear"> </div>
        </div>
      </fieldset>
    </form>
