1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64
|
<form action="" method="post" target="_new">
<table border="0" align="center" cellpadding="6">
<tr>
<td width="35%" align="right" class=forumheader2><label for="email">Email: </label></td>
<td width="65%" align="left" class=forumheader2><input name="email" type="text" id="email" size="35" maxlength="90" /></td>
</tr>
<tr>
<td align="right"><label for="name">Name: </label></td>
<td align="left"><input name="name" type="text" id="name" size="35" maxlength="90" /></td>
</tr>
<tr>
<td align="right">Phone: </td>
<td align="left"><input name="phone" type="text" id="phone" size="35" maxlength="12" /></td>
</tr>
<tr>
<td align="right">Budget : </td>
<td align="left"><p>
<label>
<input type="radio" name="budget" value="moin de 1000 DA" id="budget_0" />
moin de 1000 DA</label>
<br />
<label>
<input type="radio" name="budget" value="1000 -2500 DA" id="budget_1" />
1000 DA - 2500 DA</label>
<br />
<label>
<input type="radio" name="budget" value="2500 DA -5000 DA" id="budget_2" />
2500 DA - 5000 DA</label>
<br />
<label>
<input type="radio" name="budget" value="5000 DA - 10 000 DA" id="budget_3" />
5000 DA - 10 000 DA</label>
<br />
<label>
<input type="radio" name="budget" value="plus de 10 000 DA" id="budget_4" />
10 000 DA +</label>
<br />
</p></td>
</tr>
<tr>
<td align="right"><label for="travlers">Number of Travelers</label></td>
<td align="left"><select name="travlers" id="travlers">
<option>Chose....</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
</select></td>
</tr>
<tr>
<td align="right">Commentaires</td>
<td align="left"><textarea name="commentaires" id="commentaires" cols="25" rows="5"></textarea></td>
</tr>
<tr>
<td align="right"> </td>
<td align="left"><input name="newsletter" type="checkbox" id="newsletter" value="subscribme" />
<label for="newsletter">Subscrib to our FREE News Letter!</label></td>
</tr>
<tr>
<td align="right"><input type="reset" name="clear" id="clear" value="Effacer le formulaire" /></td>
<td align="left"><input type="submit" name="envoyer" id="envoyer" value="Envoyer l'Email" /></td>
</tr>
</table> |
Partager