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| <table id="defaultform" cellspacing="0" cellpadding="0">
<tbody>
<tr>
<td>Société </td>
<td><input maxlength="60" name="Company" />
</td>
</tr>
<tr>
<td>Prénom </td>
<td><input maxlength="60" name="Firstname" />
* </td>
</tr>
<tr>
<td>Nom de Famille</td>
<td><input maxlength="60" name="Lastname" />
*</td>
</tr>
<tr>
<td>eMail </td>
<td><input onblur="Validate_Email(this);" maxlength="50" name="EMail" />
*</td>
</tr>
<tr>
<td>Téléphone </td>
<td><input maxlength="30" name="Phone" />
*</td>
</tr>
<tr>
<td>Pays </td>
<td><select name="Country">
<option selected="selected"></option>
<option value="DE">Germany</option>
<option value="AT">Austria</option>
<option value="CH">Switzerland</option>
<option value="GB">United Kingdom</option>
<option value="AF">Afghanistan</option>
<option value="AL">Albania</option>
<option value="CZ">Algeria</option>
<option value="AS">American Samoa</option>
<option value="AD">Andorra</option>
<option value="AO">Angola</option>
<option value="AI">Anguilla</option>
<option value="AQ">Antarktis</option>
<option value="AG">Antigua and Barbuda</option>
<option value="AR">Argentine Republic</option>
<option value="AM">Armenia</option>
<option value="AW">Aruba</option>
<option value="AU">Australia</option>
<option value="AZ">Azerbaijani Republic</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BD">Bangladesh</option>
<option value="BB">Barbados</option>
<option value="BY">Belarus</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BJ">Benin</option>
<option value="BM">Bermuda</option>
<option value="BT">Bhutan</option>
<option value="BO">Bolivia</option>
<option value="BA">Bosnia and Herzegovina</option>
<option value="BW">Botswana</option>
<option value="BR">Brazil</option>
<option value="VG">British Virgin Islands</option>
<option value="BN">Brunei Darussalam</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="CV">Cape Verde</option>
<option value="KY">Cayman Islands</option>
<option value="CF">Central African Republic</option>
<option value="TD">Chad</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CX">Christmas Islands</option>
<option value="CO">Colombia</option>
<option value="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="CI">Côte d´Ivoire</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="KP">Democratic Peoples Republic of Korea</option>
<option value="CD">Democratic Republic of Congo</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="GQ">Equatorial Guinea</option>
<option value="ER">Eritrea</option>
<option value="EE">Estland</option>
<option value="ET">Ethiopia</option>
<option value="FK">Falkland Islands</option>
<option value="FO">Faroe Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="PF">French Polynesia</option>
<option value="GA">Gabun</option>
<option value="GM">Gambia</option>
<option value="GE">Georgia</option>
<option value="GH">Ghana</option>
<option value="GI">Gibraltar</option>
<option value="GR">Greece</option>
<option value="GL">Greenland</option>
<option value="GD">Grenada</option>
<option value="Gu">Guam</option>
<option value="GT">Guatemala</option>
<option value="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HN">Honduras</option>
<option value="HK">Hongkong</option>
<option value="HU">Hungary</option>
<option value="IS">Iceland</option>
<option value="IN">India</option>
<option value="ID">Indonesia</option>
<option value="IR">Iran</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JA">Japan</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KR">Korea</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyz Republic</option>
<option value="LA">Lao Peoples Democratic Republic</option>
<option value="LB">Lebanon</option>
<option value="LS">Lesotho</option>
<option value="LV">Lettland</option>
<option value="LR">Liberia</option>
<option value="LY">Libya</option>
<option value="LI">Liechtenstein</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="MO">Macau</option>
<option value="MG">Madagascar</option>
<option value="MW">Malawi</option>
<option value="MY">Malaysia</option>
<option value="MV">Maledives</option>
<option value="ML">Mali</option>
<option value="MT">Malta</option>
<option value="MH">Marshall Islands</option>
<option value="MR">Mauretania</option>
<option value="MU">Mauritius</option>
<option value="YT">Mayotte</option>
<option value="MX">Mexico</option>
<option value="FM">Micronesia</option>
<option value="MN">Mongolia</option>
<option value="MS">Montserrat</option>
<option value="MA">Morocco</option>
<option value="MZ">Mozambique</option>
<option value="MM">Myanmar</option>
<option value="NA">Namibia</option>
<option value="NR">Nauru</option>
<option value="NP">Nepal</option>
<option value="NL">Netherlands</option>
<option value="AN">Netherlands Antilles</option>
<option value="NC">New Caledonia</option>
<option value="NZ">New Zealand</option>
<option value="NI">Nicaragua</option>
<option value="NE">Niger</option>
<option value="NG">Nigeria</option>
<option value="NU">Niue</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PK">Pakistan</option>
<option value="PW">Palau</option>
<option value="PA">Panama</option>
<option value="PG">Papua New Guinea</option>
<option value="PY">Paraguay</option>
<option value="PE">Peru</option>
<option value="PH">Philippines</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="RO">Romania</option>
<option value="SU">Russia</option>
<option value="RU">Russian Federation</option>
<option value="RW">Rwandese Republic</option>
<option value="SH">Saint Helena</option>
<option value="LC">Saint Lucia</option>
<option value="PM">Saint Pierre and Miquelon</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="SM">San Marino</option>
<option value="SA">Saudi Arabia</option>
<option value="SN">Senegal</option>
<option value="SC">Seychelles</option>
<option value="SL">Sierra Leone</option>
<option value="SG">Singapore</option>
<option value="SK">Slovak Republic</option>
<option value="SI">Slovenia</option>
<option value="SB">Solomon Islands</option>
<option value="SO">Somalia Democratic Republic</option>
<option value="ZA">South Africa</option>
<option value="ES">Spain</option>
<option value="LK">Sri Lanka</option>
<option value="SD">Sudan</option>
<option value="SR">Suriname</option>
<option value="SZ">Swaziland</option>
<option value="SE">Sweden</option>
<option value="SY">Syrian Arab Republic</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania</option>
<option value="TH">Thailand</option>
<option value="TG">Togolese Republic</option>
<option value="TK">Tokelau</option>
<option value="TO">Tonga</option>
<option value="TT">Trinidad and Tobago</option>
<option value="TN">Tunesia</option>
<option value="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks und Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="US">United States of America</option>
<option value="VI">United States Virgin Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VA">Vatican City State</option>
<option value="VE">Venezuela</option>
<option value="VN">Vietnam</option>
<option value="WF">Wallis and Futuna</option>
<option value="WS">Western Samoa</option>
<option value="YE">Yemen</option>
<option value="YU">Yugoslavia</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select>
*</td>
</tr>
<tr>
<td colspan="2"></td>
</tr>
</tbody>
</table>
</div>
<div>
<table cellspacing="0" cellpadding="0">
<tbody>
<tr>
<td> </td>
<td><table>
<tbody>
<tr>
<td width="103"><input type="radio" value="Sofort" name="strRueckruf" />
Maintenant </td>
</tr>
<tr>
<td><input type="radio" value="Am" name="strRueckruf" />
(ou) ce jour </td>
<td width="374"><input name="strDate" />
à
<input name="strTime" />
(heure).</td>
</tr>
<tr>
<td colspan="2">J'ai les questions suivantes : </td>
</tr>
<tr>
<td colspan="2"><textarea id="strNote" name="strNote" cols="32"></textarea>
</td>
</tr>
</tbody>
</table></td>
</tr>
</tbody>
</table>
</div>
<div>
<table id="frmToolbar2" cellspacing="0" cellpadding="0">
<tbody>
<tr>
<td></td>
<td><input type="hidden" value="15" name="t" />
<input type="hidden" value="callback" name="Origin" />
<input name="submit" type="submit" value="SEND" />
</td>
</tr>
</tbody>
</table> |
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