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| <form id="monForm" action="index.php" method="post" name="contact" onSubmit="return fnVerif()">
<table cellpadding="0" cellspacing="1" border="0" width="408">
<tr>
<td class="label">Pays :</td>
<td><select name="pays"><option value="#" selected="selected">Sélectionner votre pays</option><option value="#" disabled="disabled">-----------------------</option><option value="France">France</option><option value="Belgique">Belgique</option><option value="Pays Bas">Pays Bas</option><option value="Espagne">Espagne</option></select></td>
</tr>
<tr>
<td class="label">Nom :</td>
<td width="300"><input type="text" size="22" name="nom" /></td>
</tr>
<tr>
<td class="label">Prénom :</td>
<td><input type="text" size="22" name="prenom" /></td>
</tr>
<tr>
<td class="label">E.mail :</td>
<td><input type="text" size="22" name="email" /></td>
</tr>
<tr>
<td class="label">Tél :</td>
<td><input type="text" size="22" name="telephone" /></td>
</tr>
<tr>
<td colspan="2"> </td>
</tr>
<tr>
<td class="label" valign="top">Vous êtes :</td>
<td nowrap="nowrap" class="label">
<input type="radio" name="typecontact" value="Magazine" /> Magazine<br />
<input type="radio" name="typecontact" value="Boutique" /> Boutique<br />
<input type="radio" name="typecontact" value="Multimarque" /> Multimarque
</td>
</tr>
<tr>
<td colspan="2"> </td>
</tr>
<tr>
<td class="label" valign="top" nowrap="nowrap">Choix de saison : </td>
<td nowrap="nowrap" class="label">
<input type="radio" name="saison" value="Été 08" /> Été 08<br />
<input type="radio" name="saison" value="Hiver 09" /> Hiver 09<br />
<input type="radio" name="saison" value="Été 09" /> Été 09
</td>
</tr>
<tr>
<td colspan="2"> </td>
</tr>
<tr>
<td class="label" valign="top">Marque :</td>
<td nowrap="nowrap" class="label">
<input type="checkbox" name="imagesikks[]" value="Women" /> Women<br />
<input type="checkbox" name="imagesikks[]" value="Men" /> Men<br />
<input type="checkbox" name="imagesikks[]" value="Very Girls" /> Very Girls<br />
<input type="checkbox" name="imagesikks[]" value="The Boys" /> The Boys<br />
<input type="checkbox" name="imagesikks[]" value="Baby" /> Baby<br />
<input type="checkbox" name="imagesikks[]" value="I.Code" /> I.Code<br />
<input type="checkbox" name="imagesikks[]" value="Private (Women Underwear)" /> Private (Women Underwear)
</td>
</tr>
<tr>
<td colspan="2"> </td>
</tr>
<tr>
<td class="label" valign="top">Type d'image :</td>
<td nowrap="nowrap" class="label">
<input type="checkbox" name="typeimage[]" value="Image" /> Image<br />
<input type="checkbox" name="typeimage[]" value="Logo" /> Logo<br />
<input type="checkbox" name="typeimage[]" value="Texte" /> Texte
</td>
</tr>
<tr>
<td colspan="2"> </td>
</tr>
<tr>
<td colspan="2" class="label">Merci de préciser en quelques mots l'utilisation<br />que vous souhaitez faire de ces images<br />et l'urgence de votre demande :</td>
</tr>
<tr>
<td colspan="2"><textarea rows="10" cols="45" name="message"></textarea></td>
</tr>
<tr>
<td colspan="2"> </td>
</tr>
<tr>
<td colspan="2"><input name="submit" src="/img/home/ok.gif" border="0" height="21" type="image" width="77"></td>
</tr>
</table>
</form> |
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