SiliconValois: FormulaireAdhésion

Formulaire Adhésion

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Modifié: 1c1,207

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<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(

http://jotform.com/images/styles/style1_bg.gif) #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(

http://jotform.com/images/styles/style1_txt_bg.gif) #f6f6f6 top repeat-x;
}
select.other{
font-family: "Trebuchet MS";
font-size: 11px;
font-weight:normal;
color:#333333;
border:1px #cccccc solid;
background:url(

http://jotform.com/images/styles/style1_txt_bg.gif) #f6f6f6 top repeat-x;
}
.btn{
font-family: "Trebuchet MS";
font-size: 11px;
font-weight:normal;
color:#333333;
border:1px #c6c7ca solid;
background: url(

http://jotform.com/images/styles/style1_btn_bg.gif) #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>

<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="

 <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>

   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>

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