SiliconValois: CampagneMassiveAdhésionOrganisation

Campagne Massive Adhésion Organisation

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<tr> <td class="midleft" width="10"> </td> <td class="midmid" valign="top"> <form action="

http://jotform.com/submit.php" method="post" name="q form 73385521486"> <input type="hidden" name="formID" value="73385521486" /> <div id="main"> <table width="520" cellpadding="5" cellspacing="0">

 <tr >
  <td width="150" class="left" >
   <label >Nom de l'organisation: <span class="required">*</span></label>
  </td>
  <td class="right" >
   <input type="text" size="20" name="q2 Nomdelorganisation" class="text" value="" id="q2"  onblur="validate(this,'Required')"  />
  </td>
 </tr>
 <tr >
  <td width="150" class="left" >
   <label >Forme Juridique :</label>
  </td>
  <td class="right" >
   <input type="text" size="20" name="q11 FormeJuridique" class="text" value="" id="q11"  />
  </td>
 </tr>
 <tr >
  <td width="150" class="left" >
   <label >Site Web :</label>
  </td>
  <td class="right" >
   <input type="text" size="20" name="q13 SiteWeb" class="text" value="" id="q13"  />
  </td>
 </tr>
 <tr >
  <td width="150" class="left" >
   <label >E-mail: <span class="required">*</span></label>
  </td>
  <td class="right" >
   <input type="text" size="20" name="q3 E-mail" class="text" value="" id="q3"  onblur="validate(this,'Required')"  />
  </td>
 </tr>
 <tr >
  <td width="150" class="left" >
   <label >Contact :</label>
  </td>
  <td class="right" >
   <input type="text" size="20" name="q12 Contact" class="text" value="" id="q12"  />
  </td>
 </tr>
 <tr >
  <td width="150" class="left" >
   <label >Phone:</label>
  </td>
  <td class="right" >
   <input type="text" size="20" name="q9 Phone" class="text" value="" id="q9"  />
  </td>
 </tr>
 <tr >
  <td width="150" class="left" valign="top"  >
   <label>Address:</label>
  </td>
  <td class="right" >
   <textarea cols="30" rows="2" name="q10 Address" class="text" id="q10" ></textarea>
  </td>
 </tr>
 <tr >
  <td width="150" class="left" >
   <label >City:</label>
  </td>
  <td class="right" >
   <input type="text" size="20" name="q0 City" class="text" value="" id="q0"  />
  </td>
 </tr>
 <tr >
  <td width="150" class="left" >
   <label >Zip code:</label>
  </td>
  <td class="right" >
   <input type="text" size="20" name="q7 Zipcode" class="text" value="" id="q7"  />
  </td>
 </tr>
 <tr >
  <td width="150" class="left"  valign="top" >
   <label>Pays:</label>
  </td>
  <td class="right">
   <select class="other" name="q4 Pays" id="q4" >
  <option></option>
    <option>Abkhazia</option>
    <option>Afghanistan</option>
    <option>United Kingdom Akrotiri and Dhekelia</option>
    <option>Aland</option>
    <option>Albania</option>
    <option>Algeria</option>
    <option>American Samoa</option>
    <option>Andorra</option>
    <option>Angola</option>
    <option>Anguilla</option>
    <option>Antigua and Barbuda</option>
    <option>Argentina Argentina</option>
    <option>Armenia</option>
    <option>Aruba</option>
    <option>United Kingdom Ascension Island</option>
    <option>Australia</option>
    <option>Austria</option>
    <option>Azerbaijan</option>
    <option>The Bahamas</option>
    <option>Bahrain</option>
    <option>Bangladesh</option>
    <option>Barbados</option>
    <option>Belarus</option>
    <option>Belgium</option>
    <option>Belize</option>
    <option>Benin</option>
    <option>Bermuda</option>
    <option>Bhutan</option>
    <option>Bolivia</option>
    <option>Bosnia and Herzegovina</option>
    <option>Botswana</option>
    <option>Brazil</option>
    <option>Brunei</option>
    <option>Bulgaria</option>
    <option>Burkina Faso</option>
    <option>Burundi</option>
    <option>Cambodia</option>
    <option>Cameroon</option>
    <option>Canada</option>
    <option>Cape Verde</option>
    <option>Cayman Islands</option>
    <option>Central African Republic</option>
    <option>Chad</option>
    <option>Chile</option>
    <option>People's Republic of China</option>
    <option>Republic of China</option>
    <option>Christmas Island</option>
    <option>Cocos (Keeling) Islands</option>
    <option>Colombia</option>
    <option>Comoros</option>
    <option>Congo</option>
    <option>Cook Islands</option>
    <option>Costa Rica</option>
    <option>CFFFDte d'Ivoire</option>
    <option>Croatia</option>
    <option>Cuba</option>
    <option>Cyprus</option>
    <option>Czech Republic</option>
    <option>Denmark</option>
    <option>Djibouti</option>
    <option>Dominica</option>
    <option>Dominican Republic</option>
    <option>Ecuador</option>
    <option>Egypt</option>
    <option>El Salvador</option>
    <option>Equatorial Guinea</option>
    <option>Eritrea</option>
    <option>Estonia</option>
    <option>Ethiopia</option>
    <option>Falkland Islands</option>
    <option>Faroe Islands</option>
    <option>Fiji</option>
    <option>Finland</option>
    <option>France</option>
    <option>French Polynesia</option>
    <option>Gabon</option>
    <option>The Gambia</option>
    <option>Georgia</option>
    <option>Germany</option>
    <option>Ghana</option>
    <option>Gibraltar</option>
    <option>Greece</option>
    <option>Greenland</option>
    <option>Grenada</option>
    <option>Guam</option>
    <option>Guatemala</option>
    <option>Guernsey</option>
    <option>Guinea</option>
    <option>Guinea-Bissau</option>
    <option>Guyana Guyana</option>
    <option>Haiti Haiti</option>
    <option>Honduras</option>
    <option>Hong Kong</option>
    <option>Hungary</option>
    <option>Iceland</option>
    <option>India</option>
    <option>Indonesia</option>
    <option>Iran</option>
    <option>Iraq</option>
    <option>Ireland</option>
    <option>Israel</option>
    <option>Italy</option>
    <option>Jamaica</option>
    <option>Japan</option>
    <option>Jersey</option>
    <option>Jordan</option>
    <option>Kazakhstan</option>
    <option>Kenya</option>
    <option>Kiribati</option>
    <option>North Korea</option>
    <option>South Korea</option>
    <option>Kosovo</option>
    <option>Kuwait</option>
    <option>Kyrgyzstan</option>
    <option>Laos</option>
    <option>Latvia</option>
    <option>Lebanon</option>
    <option>Lesotho</option>
    <option>Liberia</option>
    <option>Libya</option>
    <option>Liechtenstein</option>
    <option>Lithuania</option>
    <option>Luxembourg</option>
    <option>Macau</option>
    <option>Macedonia</option>
    <option>Madagascar</option>
    <option>Malawi</option>
    <option>Malaysia</option>
    <option>Maldives</option>
    <option>Mali</option>
    <option>Malta</option>
    <option>Marshall Islands</option>
    <option>Mauritania</option>
    <option>Mauritius</option>
    <option>Mayotte</option>
    <option>Mexico</option>
    <option>Micronesia</option>
    <option>Moldova</option>
    <option>Monaco</option>
    <option>Mongolia</option>
    <option>Montenegro</option>
    <option>Montserrat</option>
    <option>Morocco</option>
    <option>Mozambique</option>
    <option>Myanmar</option>
    <option>Nagorno-Karabakh</option>
    <option>Namibia</option>
    <option>Nauru</option>
    <option>Nepal</option>
    <option>Netherlands</option>
    <option>Netherlands Antilles</option>
    <option>New Caledonia</option>
    <option>New Zealand</option>
    <option>Nicaragua</option>
    <option>Niger</option>
    <option>Nigeria</option>
    <option>Niue</option>
    <option>Norfolk Island</option>
    <option>Turkish Republic of Northern Cyprus</option>
    <option>Northern Mariana</option>
    <option>Norway</option>
    <option>Pakistan</option>
    <option>Palau</option>
    <option>Palestine</option>
    <option>Panama</option>
    <option>Papua New Guinea</option>
    <option>Paraguay</option>
    <option>Peru</option>
    <option>Philippines</option>
    <option>Pitcairn Islands</option>
    <option>Poland</option>
    <option>Portugal</option>
    <option>Transnistria Pridnestrovie</option>
    <option>Puerto Rico</option>
    <option>Qatar</option>
    <option>Romania</option>
    <option>Russia</option>
    <option>Rwanda</option>
    <option>Saint Barthelemy</option>
    <option>Saint Helena</option>
    <option>Saint Kitts and Nevis</option>
    <option>Saint Lucia</option>
    <option>Saint Martin</option>
    <option>Saint Pierre and Miquelon</option>
    <option>Saint Vincent and the Grenadines</option>
    <option>Samoa</option>
    <option>San Marino</option>
    <option>SFFFDo TomFFFD and PrFFFDncipe</option>
    <option>Saudi Arabia</option>
    <option>Senegal</option>
    <option>Serbia</option>
    <option>Seychelles</option>
    <option>Sierra Leone</option>
    <option>Singapore</option>
    <option>Slovakia</option>
    <option>Slovenia</option>
    <option>Solomon Islands</option>
    <option>Somalia</option>
    <option>Somaliland</option>
    <option>South Africa</option>
    <option>South Ossetia</option>
    <option>Spain</option>
    <option>Sri Lanka</option>
    <option>Sudan</option>
    <option>Suriname</option>
    <option>Svalbard</option>
    <option>Swaziland</option>
    <option>Sweden</option>
    <option>Switzerland</option>
    <option>Syria</option>
    <option>Tajikistan</option>
    <option>Tanzania</option>
    <option>Thailand</option>
    <option>Timor-Leste</option>
    <option>Togo</option>
    <option>Tokelau</option>
    <option>Tonga</option>
    <option>Trinidad and Tobago</option>
    <option>Tristan da Cunha</option>
    <option>Tunisia</option>
    <option>Turkey</option>
    <option>Turkmenistan</option>
    <option>Turks and Caicos Islands</option>
    <option>Tuvalu</option>
    <option>Uganda</option>
    <option>Ukraine</option>
    <option>United Arab Emirates</option>
    <option>United Kingdom</option>
    <option>United States</option>
    <option>Uruguay</option>
    <option>Uzbekistan</option>
    <option>Vanuatu</option>
    <option>Vatican City</option>
    <option>Venezuela</option>
    <option>Vietnam</option>
    <option>British Virgin Islands</option>
    <option>US Virgin Islands</option>
    <option>Wallis and Futuna</option>
    <option>Western Sahara</option>
    <option>Yemen</option>
    <option>Zambia</option>
    <option>Zimbabwe</option>
   </select>
  </td>
 </tr>
 <tr >
  <td colspan="2" class="head" >
   Adhesion a l'association BureauWiki
  </td>
 </tr>
 <tr >
  <td width="150" class="left"  valign="top" >
   <label>Adhesion au BureauWiki</label>
  </td>
  <td class="right">
   <select class="other" name="q14 AdhesionauBureauWiki" id="q14" >
  <option></option>
    <option>200 euros</option>
    <option>500 euros</option>
    <option>1000 euros</option>
    <option>2000 euros</option>
   </select>
  </td>
 </tr>
 <tr >
  <td colspan="2" class="left" >
   Suite a l'adhesion, l'organisation recevra une copie des statuts sign�et une carte d'adh�on. Apr�r�ement elle recevra un recu en attestant.
  </td>
 </tr>
 <tr >
  <td width="150" class="left" > 

  </td>
  <td class="right">
  <input type="submit" class="btn" name="q1_" value="Submit" />
 </td>
 </tr>

</table> </div> </form> </td> <td class="midright" width="10"> </td> </tr> <tr>

 <td class="bottomleft" width="10" height="10"> </td>
 <td class="bottommid"> </td>
 <td class="bottomright" width="10" height="10"> </td>

</tr> </table> <script type="text/javascript"> validate("q form 73385521486"); </script> </html>

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Campagne Massive Adhésion Organisation

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