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| <!DOCTYPE html>
<html>
<form id="contact">
<div style="color: #ffff;"> * Champs Obligatoires </div>
<div style="color: #000;">
<div class="row">
<div class="col-md-12 col-sm-12">
<div class="row">
<div class="col-md-4 col-sm-4">
<div class="form-group">
<div class="libelle">Civilité*</div> <select name="titre">
<option value='0'>- </option>
<option value='5'>Docteur </option>
<option value='2'>Mademoiselle </option>
<option value='6'>Maître </option>
<option value='3'>Madame </option>
<option value='1'>Monsieur </option>
<option value='7'>Monsieur et Madame </option> </select>
</div>
</div>
</div>
<div class="row">
<div class="col-md-6 col-sm-6">
<div class="form-group">
<div class="libelle">Nom*</div>
<input type="text" name="nom" value="" minlength="2" required>
</div>
</div>
<div class="col-md-6 col-sm-6">
<div class="form-group">
<div class="libelle">Prénom*</div>
<input type="text" name="prenom" value="" minlength="2" required>
</div>
</div>
</div>
<div class="row">
<div class="col-md-6 col-sm-6">
<div class="form-group">
<div class="libelle">Email*</div>
<input type="text" name="email" value="" minlength="5" required>
</div>
</div>
<div class="col-md-6 col-sm-6">
<div class="form-group">
<div class="libelle">Téléphone*</div>
<input type="text" name="telephone" value="" minlength="10" required>
</div>
</div>
</div>
<div class="row">
<div class="col-md-5 col-sm-5">
<div class="form-group">
<div class="libelle">Adresse*</div>
<input type="text" name="adresse" minlength="10" required>
</div>
</div>
<div class="col-md-2 col-sm-2">
<div class="form-group">
<div class="libelle">CP* </div>
<input type="text" name="code_postal" minlength="5" required>
</div>
</div>
<div class="col-md-2 col-sm-2">
<div class="form-group">
<div class="libelle">Ville*</div>
<input type="text" name="ville_particulier" minlength="3" required>
</div>
</div>
<div class="col-md-3 col-sm-3">
<div class="form-group">
<div class="libelle">Date de naissance* </div> <input type="text" name="date_de_naissance_particulier" placeholder="JJ-MM-AAAA" required>
</div>
</div>
</div>
<div class="row">
<div class="col-md-4 col-sm-4">
<div class="form-group">
<div class="libelle">Catégorie Professionnelle*</div> <select name="profession" required>
<option value='0'>- </option> <option value='11'>Artisan-Commerçant</option><option value='24'>Assistante Maternelle</option><option value='20'>CDD</option><option value='13'>CDI non Cadre</option><option value='8'>CDI-Cadre</option><option value='21'>Congé Parental</option><option value='9'>Fonctionnaire (Titulaire)</option><option value='16'>Gérant- PDG</option><option value='19'>Intérimaire</option><option value='26'>Invalidité</option><option value='2'>Profession libérale</option><option value='4'>Retraité(e)</option><option value='25'>Sans Activité-Chomeur</option>
</select>
</div>
</div>
<div class="col-md-4 col-sm-4">
<div class="form-group">
<div class="libelle">Situation de Famille*</div> <select name="situation_de_famille_particulier" required>
<option value='0'>- </option><option value='1'>Célibataire</option><option value='2'>Concubinage</option><option value='3'>Divorce</option><option value='7'>Divorce et union libre</option><option value='4'>Marie(e)</option><option value='9'>Pacsé</option><option value='8'>Séparé(e), instance de divorce</option><option value='5'>Vnion libre</option><option value='6'>Veuf(ve)</option> </select>
</div>
</div>
<div class="col-md-4 col-sm-4">
<div class="form-group">
<div class="libelle">Type d'hébergement*</div> <select name="hebergement_particulier" required>
<option value='0'>- </option>
<option value='0'>-</option>
<option value='4'>Hebergement de fonction </option>
<option value='3'>Hebergement familial </option>
<option value='5'>Hebergement par l'employeur </option>
<option value='1'>Locataire </option>
<option value='6'>Locataire et proprietaire </option>
<option value='2'>Proprietaire </option>
<option value='7'>Sans effet </option> </select>
</div>
</div>
</div>
<div class="row">
<div class="col-md-3 col-sm-3">
<div class="form-group">
<center>
<div class="libelle"> Revenu mensuel total du ménage*</div>
</center> <input type="text" name="revenu_total_menage" required></div>
</div>
<div class="col-md-3 col-sm-3">
<div class="form-group">
<center>
<div class="libelle">Valeur de votre bien immobilier*</div>
</center>
<input type="text" name="valeur_bien_immobilier" required>
</div>
</div>
<div class="col-md-3 col-sm-3">
<div class="form-group">
<center>
<div class="libelle">Capital restant dû de votre pret* </div>
</center> <input type="text" name="krd_immo" required>
</div>
</div>
<div class="col-md-3 col-sm-3">
<div class="form-group">
<center>
<div class="libelle"> Montant des dettes et des crédits*</div>
</center> <input type="text" name="krd_total" required>
</div>
</div>
</div>
<center>
<div>
<p>Résumé de votre demande<br /><textarea name="resume_demande" rows="4" cols="50"></textarea> </p>
</div>
</center>
<center>
<div>
<input type="button" onclick="contact.submit()" name="submit" id="submit" value="envoyer" class="fusion-button button-flat button-round button-default button-1 button-large" />
</div>
</center>
</div>
</div>
</div>
</form>
<script src="https://jqueryvalidation.org/files/dist/jquery.validate.js"></script>
<script>
jQuery("#contact").validate({
submitHandler: function() {
jQuery("#contact").submit(function() {
jQuery.ajax({
type: 'POST',
url: 'demande1.php',
data:jQuery("#contact").serialize(),
dataType: 'json'
})
.done(function(data) {
alert(JSON.stringify("Votre Numero de dossier:" + data["dossier"]) + ", " +JSON.stringify(data["response"]));
window.location = 'https://remere1.nessiafly.com'
})
.fail(function(data) {
// just in case posting your form failed
alert(JSON.stringify(data['response']));
});
});
},
rules: {
email: {
required: true,
email: true
},
telephone: {
required: true,
number: true
},
code_postal: {
required: true,
number: true
}
}
});
jQuery.extend(jQuery.validator.messages, {
required: "Ce Champ est requis.",
remote: "Veuillez verifier ce champ.",
email: "Veuillez mettre une adresse email valide.",
url: "Please enter a valid URL.",
date: "Please enter a valid date.",
dateISO: "Please enter a valid date ( ISO ).",
number: "S'il vous plait, entrez un nombre valide.",
digits: "Merci de n'entrer que des chiffres.",
equalTo: "Entrez à nouveau la même valeur s'il vous plait.",
maxlength:jQuery.validator.format("Please enter no more than {0} characters."),
minlength:jQuery.validator.format("S'il vous plaît entrer au moins {0} caractères."),
rangelength:jQuery.validator.format("Please enter a value between {0} and {1} characters long."),
range:jQuery.validator.format("Please enter a value between {0} and {1}."),
max:jQuery.validator.format("Please enter a value less than or equal to {0}."),
min:jQuery.validator.format("S'il vous plaît entrer une valeur supérieure ou égale à {0}."),
step:jQuery.validator.format("Please enter a multiple of {0}.")
});
</script>
</html> |
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