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| <form method="post" action="mailto:naturose.ma@gmail.com">
Nom: <input type="text" maxlength="40" name="name" style="width: 127px"> <br />
<br />
Tel:
<input type="text" maxlength="13" name="tel" style="width: 132px"><br /><br />
Quartier: <input type="text" maxlength="13" name="quartier" style="width: 136px"><br />
<br>
<B> <span style="color: #cc33ff; text-decoration: underline">Parapharmacie:</span></B><br>
<input type="checkbox" name="parapharmacie" value="Appetinate">
Appetinate <br>
<input type="checkbox" name="parapharmacie" value="Natudiab">
Natudiab<br>
<input type="checkbox" name="parapharmacie" value="Alharone">
Alharone<br>
<input type="checkbox" name="parapharmacie" value="vitarose">
Vitarose<br>
<input type="checkbox" name="parapharmacie" value="Finifumo">
Finifumo<br>
<input type="checkbox" name="parapharmacie" value="Biorelax">
Biorelax<br>
<input type="checkbox" name="parapharmacie" value="Phytodige">
Phytodige<br>
<input type="checkbox" name="parapharmacie" value="Revert">
Revert<br>
<input type="checkbox" name="parapharmacie" value="Jambio">
Jambio<br>
<br>
<--choiisir un element cosmetique---->
<B> <span style="color: #cc00ff; text-decoration: underline">Cosmetique:</span></B><br>
<input type="checkbox" name="cosmetique" value="lavebio">
Lavebio <br>
<input type="checkbox" name="cosmetique" value="Nogrino">
Nogrino<br>
<input type="checkbox" name="cosmetique" value="Rosargil">
Rosargil<br>
<input type="checkbox" name="cosmetique" value="Aloevero">
Aloevero<br>
<input type="checkbox" name="cosmetique" value="Dondor">
Dondor<br>
<input type="checkbox" name="cosmetique" value="Pronatur">
Pronatur<br>
<input type="checkbox" name="cosmetique" value="Romanticacorps">
Romantica<br>
<input type="checkbox" name="cosmetique" value="Romanticapieds">
Romantica<br>
<input type="checkbox" name="cosmetique" value="Romanticamains">
Romantica<br>
<input type="checkbox" name="cosmetique" value="bambabigpoitrine">
Bambabig<br>
<input type="checkbox" name="cosmetique" value="bambabigarriere">
Bambabig<br>
<input type="checkbox" name="cosmetique" value="visaclaireclaircissant">
Visaclair<br>
<input type="checkbox" name="cosmetique" value="visaclairantitache">
Visaclair<br>
<input type="checkbox" name="cosmetique" value="rosarosegenou">
Rosarose<br>
<input type="checkbox" name="cosmetique" value="Rosaroseapresepilation">
Rosarose<br>
<input type="checkbox" name="cosmetique" value="Rosaroseaisselles">
Rosarose<br>
<input type="checkbox" name="cosmetique" value="flamingo">
Flamingo<br>
<input type="checkbox" name="cosmetique" value="souribio">
Souribio<br>
<br>
<B> <span style="text-decoration: underline">Votre message:<br />
</span>
</B><br>
<textarea rows="5" wrap="physical" name="comments" style="width: 477px">
ecriver votre message ici
</textarea>
<br>
<br />
<input type="submit" value="envoyer">
<input type="reset" value="annuler">
<br>
</form> |