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| <form name="inscription_membre" method="post" action="mailto:jmb@wanadoo.fr" enctype="text/plain">
<table width="635" border="1" align="center" cellspacing="0" bordercolor="#6600CC" bordercolordark="white" bordercolorlight="fuchsia">
<tr>
<td width="349" height="39">
<p align="center"><b><font face="Arial"><span style="font-size:12pt;">votre pseudo</span></font></b></p>
</td>
<td width="264" height="39">
<p align="center"><b><input name="pseudo" type="text"></b></p>
</td>
</tr>
<tr>
<td width="349">
<p align="center"><b><font face="Arial"><span style="font-size:12pt;">votre mot de passe</span></font></b></p>
</td>
<td width="264">
<p align="center"><b><input name="pass" type="password"></b></p>
</td>
</tr>
<tr>
<td width="349">
<p align="center"><b><font face="Arial"><span style="font-size:12pt;">confirmer votre mot de passe</span></font></b></p>
</td>
<td width="264">
<p align="center"><b><input name="repass" type="password"></b></p>
</td>
</tr>
<tr>
<td width="349">
<p align="center"><b><font face="Arial"><span style="font-size:12pt;">votre nom</span></font></b></p>
</td>
<td width="264">
<p align="center"><b><input name="nom" type="text"></b></p>
</td>
</tr>
<tr>
<td width="349">
<p align="center"><b><font face="Arial"><span style="font-size:12pt;">votre prénom</span></font></b></p>
</td>
<td width="264">
<p align="center"><b><input name="prenom" type="text"></b></p>
</td>
</tr>
<tr>
<td width="349">
<p align="center"><b><font face="Arial"><span style="font-size:12pt;">votre adresse</span></font></b></p>
</td>
<td width="264">
<p align="center"><b><input name="adresse" type="text"></b></p>
</td>
</tr>
<tr>
<td width="349">
<p align="center"><b><font face="Arial"><span style="font-size:12pt;">votre code postal</span></font></b></p>
</td>
<td width="264">
<p align="center"><b><input name="code" type="text"></b></p>
</td>
</tr>
<tr>
<td width="349">
<p align="center"><b><font face="Arial"><span style="font-size:12pt;">votre ville</span></font></b></p>
</td>
<td width="264">
<p align="center"><b><input name="ville" type="text"></b></p>
</td>
</tr>
<tr>
<td width="349">
<p align="center"><b><font face="Arial"><span style="font-size:12pt;">votre age</span></font></b></p>
</td>
<td width="264">
<p align="center"><b><input name="age" type="text"></b></p>
</td>
</tr>
<tr>
<td width="349">
<p align="center"><b><font face="Arial"><span style="font-size:12pt;">votre telephone</span></font></b></p>
</td>
<td width="264">
<p align="center"><b><input name="telephone" type="text"></b></p>
</td>
</tr>
<tr>
<td width="349">
<p align="center"><b><font face="Arial"><span style="font-size:12pt;">votre adresse email</span></font></b></p>
</td>
<td width="264">
<p align="center"><b><input name="zone_email" type="text" size="34"></b></p>
</td>
</tr>
<tr>
<td valign="top" width="349">
<p align="center"><b><font face="Arial"><span style="font-size:12pt;">votre adresse msn</span></font></b></p>
</td>
<td width="264">
<p align="center"><b><input name="msn" type="text" size="34"></b></p>
</td>
</tr>
<tr>
<td valign="top" width="349">
<p align="center"><b><font face="Arial"><span style="font-size:12pt;">votre adresse de site, book ou blog</span></font></b></p>
</td>
<td width="264">
<p align="center"><b><input name="site" type="text" size="34"></b></p>
</td>
</tr>
<tr>
<td valign="top" width="349">
<p align="center"> </p>
</td>
<td width="264"><div align="center">
<p align="center"><input type="reset" name="Reset" value="Effacer">
<input type="submit" name="envoi" value="Envoyer">
</p>
</div></td>
</tr>
</table>
</form> |
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