Editer le texte de cette page (date de la dernière modification: 20 Janvier, 2008 14:29 (diff))

Formulaire Adhésion

<html> <script src=" http://jotform.com/js/form.js?v2.0.502" type="text/javascript"></script> <style type="text/css"> html,body{height:100%; margin:0;} .tbmain{ 
 /* Changes on the form */
 background: white !important;
} .left{ 
  /* Changes on the form */
  color: black !important; 
  font-family: Verdana !important;
  font-size: 12px !important;
} td.left { 
   font-family: "Trebuchet MS";
   font-size: 11px;
   font-weight:bold;
   color:#ff5200;
   vertical-align: top;
   text-align: left;
} .pagebreak{ 
   font-family: "Trebuchet MS";
   font-size: 11px;
   font-weight:bold;
   color:black;
} td.right { 
   font-family: "Trebuchet MS";
   font-size: 11px;
   font-weight:normal;
   color:#333333;
   vertical-align: top;   
   text-align: left;
} .tbmain{ 
   height:100%;
   color:#333333;
   background:url() #ffffff top repeat-x;
} .head{ 
   font-family: "Trebuchet MS";
   font-size: large;
   font-weight: bold;
   color:#ff5200;
   vertical-align: top;
   text-align: left;
} .notvalid{ 
   border:2px red solid;
   font-family:"Trebuchet MS";
} .text{ 
   font-family: "Trebuchet MS";
   font-size: 11px;
   font-weight:normal;
   color:#333333;
   border:1px #cccccc solid;
   background:url() #f6f6f6 top repeat-x;
} select.other{ 
   font-family: "Trebuchet MS";
   font-size: 11px;
   font-weight:normal;
   color:#333333;
   border:1px #cccccc solid;
   background:url() #f6f6f6 top repeat-x;
} .btn{ 
   font-family: "Trebuchet MS";
   font-size: 11px;
   font-weight:normal;
   color:#333333;
   border:1px #c6c7ca solid;
   background: url() #e4e4e4 top repeat-x;
} span.required{ 
  font-size: 13px !important;
  color: red !important;
}

</style> <body> <table width="100%" cellpadding="2" cellspacing="0" class="tbmain"> <tr><td class="topleft" width="10" height="10"> </td> <td class="topmid"> </td> <td class="topright" width="10" height="10"> </td> 

  </tr>
<tr> <td class="midleft" width="10">   </td> <td class="midmid" valign="top"> <form action=" http://jotform.com/submit.php" target="_top" method="post" name="q form 80195223781"> <input type="hidden" name="formID" value="80195223781" /> <div id="main"> <table width="520" cellpadding="5" cellspacing="0"> 
 <tr >
  <td width="150" class="left" >
   <label >Prénom</label>
  </td>
  <td class="right" >
   <input type="text" size="20" name="q2 Prnom" class="text" value="" id="q2"  maxlength="100" maxsize="100" />
  </td>
 </tr>
 <tr >
  <td width="150" class="left" >
   <label >Nom</label>
  </td>
  <td class="right" >
   <input type="text" size="20" name="q12 Nom" class="text" value="" id="q12"  maxlength="100" maxsize="100" />
  </td>
 </tr>
 <tr >
  <td width="150" class="left" >
   <label >Adresse e-mail</label>
  </td>
  <td class="right" >
   <input type="text" size="20" name="q13 Adressee-mail" class="text" value="" id="q13"  maxlength="100" maxsize="100" />
  </td>
 </tr>
 <tr >
  <td width="150" class="left" valign="top"  >
   <label>Adresse</label>
  </td>
  <td class="right" >
   <textarea cols="30" rows="5" name="q10 Adresse" class="text" id="q10" ></textarea>
  </td>
 </tr>
 <tr >
  <td width="150" class="left" valign="top"  >
   <label>Adhesion Bureau Wiki via PayPal</label>
  </td>
  <td class="right">


   <input type="radio" class="other" name="q11 AdhesionBureauWikiviaPayPal[]" id="q118019522378101" onclick="sum(this);" value="80195750728" />


    <label class="left">10 (€10)
   </label>


   <input type="radio" class="other" name="q11 AdhesionBureauWikiviaPayPal[]" id="q118019522378102" onclick="sum(this);" value="80195751765" />


    <label class="left">30 (€30)
   </label>


   <input type="radio" class="other" name="q11 AdhesionBureauWikiviaPayPal[]" id="q118019522378103" onclick="sum(this);" value="80195751715" />


    <label class="left">50 (€50)
   </label>


   <input type="radio" class="other" name="q11 AdhesionBureauWikiviaPayPal[]" id="q118019522378104" onclick="sum(this);" value="80195752716" />


    <label class="left">75 (€75)
   </label>


   <input type="radio" class="other" name="q11 AdhesionBureauWikiviaPayPal[]" id="q118019522378105" onclick="sum(this);" value="80195752739" />


    <label class="left">100 (€100)
   </label>


   <input type="radio" class="other" name="q11 AdhesionBureauWikiviaPayPal[]" id="q118019522378106" onclick="sum(this);" value="80195753791" />


    <label class="left">150 (€150)
   </label>


   <input type="radio" class="other" name="q11 AdhesionBureauWikiviaPayPal[]" id="q118019522378107" onclick="sum(this);" value="80195753748" />


    <label class="left">200 (€200)
   </label>
<script type="text/javascript"> 
   var price = Array();
   var setup = Array();
   price['80195750728'] = '10';
   price['80195751765'] = '30';
   price['80195751715'] = '50';
   price['80195752716'] = '75';
   price['80195752739'] = '100';
   price['80195753791'] = '150';
   price['80195753748'] = '200';
</script> 
  <input name="hid" type="hidden" id="hid" value="0" />
  <div class="left" style="text-align:left;font-size:large;display:none" id="res">Total : </div>
</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 80195223781"); </script> </html>