<link href="//fonts.googleapis.com/css?family=Open+Sans" class="google-fonts" rel="stylesheet"><link href="//fonts.googleapis.com/css?family=Indie+Flower" class="google-fonts" rel="stylesheet"><link href="//forms.autorespond.eu/forms/ar5forms.css" rel="stylesheet"><style type="text/css">.arformSUBSCR_1515851475876 {font-family:Arial; font-size:16px; line-height:24px;font-weight:normal;font-style:normal;border:0px solid #c0c0c0;border-radius:8px;color:c91b29;display: block;background-color:ffffff;}@media only screen and ( min-width: 1405px ) { }@media only screen and ( min-width: 1100px ) and ( max-width: 1405px) { }@media only screen and ( min-width: 981px ) and ( max-width: 1100px ) { }@media only screen and ( min-width: 768px ) and ( max-width: 980px ) {}@media only screen and ( min-width: 480px ) and ( max-width: 767px ) {}@media only screen and ( max-width: 479px ) {}.arformSUBSCR_1515851475876 label.ar_req::after { content: " *"; padding-right:4px; }.arformSUBSCR_1515851475876 label { color: c91b29;font-family:Arial; font-size:16px; line-height:24px;font-weight:normal;font-style:normal;}.arformSUBSCR_1515851475876 .help { color: #605050;font-family:Open Sans; font-size:10px; line-height:14px;font-weight:normal;font-style:normal;}.ar-short { max-width: 200px!important; }.ar-inline-margin { margin-right:1em; }</style><div class="ar5" style="width:100%;"><div class="arformSUBSCR_1515851475876"><form action="https://www.e-act.nl/ah/action" method="POST" accept-charset="UTF-8" class="form-horizontal" style="margin-left: 50px; margin-right: 1em; padding-top:1em; padding-bottom:1em;"><input type="hidden" name="admin_id" value="2394"/><input type="hidden" name="trigger_code" value="SUBSCR_1515851475876"/><input type="hidden" name="confirm" value="false"/><div class="form-group"><label for="relation_firstName" class="control-label col-sm-3 text-left">Voornaam </label><div class="col-sm-9"><input type="text" style="width:70%;" class="form-control" id="relation_firstName" name="relation_firstName" placeholder="" value=""/></div></div><div class="form-group"><label for="relation_lastName" class="control-label col-sm-3 text-left">Achternaam </label><div class="col-sm-9"><input type="text" style="width:70%;" class="form-control" id="relation_lastName" name="relation_lastName" placeholder="" value=""/></div></div><div class="form-group"><label for="relation_email" class="control-label col-sm-3 text-left ar_req">E-mailadres </label><div class="col-sm-9"><input type="email" style="width:70%;" class="form-control" id="relation_email" name="relation_email" placeholder="" value=""/></div></div><div class="form-group"><div class="col-sm-offset-3 col-sm-9 text-left"><button title="klik hier" type="submit" onclick="return checkSUBSCR_1515851475876(this.form);" class="btn" style="padding:17px;border:0px solid #c00000;border-radius:4px;color:#FFFFFF!important;font-family:Open Sans; font-size:26px; line-height:28px;font-weight:bold;font-style:normal;background-color:#cd58a7!important;">AANVRAGEN</button></div></div><div class="emailField" style="display:none!important;">dit veld niet invullen s.v.p.<input type="text" name="emailaddress"/></div></form></div></div><script type="text/javascript"><!-- [et_pb_line_break_holder] --> function checkSUBSCR_1515851475876(form) {<!-- [et_pb_line_break_holder] --> var missing = false;<!-- [et_pb_line_break_holder] --> var missingFields = '';<!-- [et_pb_line_break_holder] --> for (i=0; i<form.elements.length; i++) {<!-- [et_pb_line_break_holder] --> if (form.elements[i].name === 'relation_email') {<!-- [et_pb_line_break_holder] --> if (form.elements[i].value === '') {<!-- [et_pb_line_break_holder] --> missing = true;<!-- [et_pb_line_break_holder] --> missingFields = missingFields + '\nE-mailadres';<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> if (missing) {<!-- [et_pb_line_break_holder] --> alert('De onderstaande velden moeten zijn ingevuld:\n' + missingFields);<!-- [et_pb_line_break_holder] --> return false;<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> return true;<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --></script><!-- [et_pb_line_break_holder] -->