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<table align="center" bgcolor="#ffffff" width="943">
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<td width="933" height="149" valign="top"><a href="index.html"><img src="img/logofiem.gif" width="490" height="147" border="0"></a>
<img src="img/logoenfants.jpg" width="415" height="106"> </td>
</tr>
<tr>
<td height="116" valign="top"> <p><span style="text-align:center; display:block" class="Style7">Bulletin
de Solidarité</span></p>
<p><span style="text-align:center; display:block" class="Style1">Imprimez
ce bulletin, après l'avoir rempli à l'écran et envoyez
le, avec votre don, à :</span></p>
<p><span style="text-align:center; display:block" class="Style4">FIEM -
11 rue Jean-Charles AMAT - 1202 Genève - Boîte Postale 163
- CH-1211 Geneve 21 Suisse</span> </p>
<p></p></td>
</tr>
<tr>
<td height="23" valign="top"><hr></td>
</tr>
<tr>
<td height="440" valign="top"><div align="left">
<p></p>
<form name="form" action="" method="post">
<table width="95%" border="0" cellspacing="0">
<!--DWLayoutTable-->
<tr>
<td width="56" height="13"></td>
<td width="9"></td>
<td width="277"></td>
<td width="19"></td>
<td width="91"></td>
<td width="46"></td>
<td width="376"></td>
<!--DWLayoutTable-->
<tr>
<td height="26"></td>
<td></td>
<td></td>
<td colspan="3" valign="top"><span class="Style8">*</span> <span class="Style1">Champs
obligatoires</span></td>
<td></td>
<tr>
<td height="14"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<tr>
<td height="24" colspan="2" valign="top"><span class="Style1"> Nom</span>
<span class="Style8">*</span></td>
<td colspan="4" valign="top"> <input name="nom" type="text" size="30">
</td>
<td> </td>
</tr>
<tr>
<td height="24" colspan="2" valign="top"><span class="Style1"> Prénom</span>
<span class="Style8">*</span></td>
<td colspan="4" valign="top"> <input name="prenom" type="text" size="30">
</td>
<td> </td>
</tr>
<tr>
<td height="104" colspan="2" valign="top"><span class="Style1">
Adresse</span> <span class="Style8">*</span></td>
<td colspan="4" valign="top"><textarea name="adresse" cols="40" rows="5">
</textarea>
</td>
<td> </td>
</tr>
<tr>
<td height="24" colspan="2" valign="top"><span class="Style1"> E-mail</span>
<span class="Style8">*</span></td>
<td colspan="4" valign="top"> <input name="email" type="text" size="30">
</td>
<td></td>
</tr>
<tr>
<td height="26" colspan="2" valign="top"><span class="Style1"> Pays</span>
</td>
<td colspan="4" valign="top"> <select name="pays">
<option value="Suisse">Suisse</option>
<option value="France">France</option>
<option value="Autres">Autres</option>
</select> Si autres, précisez :
<input name="precision" type="text" size="15"> </td>
<td></td>
</tr>
<tr>
<td height="78" colspan="2" valign="top"><span class="Style1"> Paiement</span>
<span class="Style8">*</span></td>
<td colspan="4" valign="top"> <p>chèque
<input type="radio" name="paiement" value="cheque" checked>
virement bancaire
<input type="radio" name="paiement" value="virement bancaire">
</p>
<p><span class="Style1">nb : Veuillez fournir un RIB ou un RIP
pour le virement bancaire.</span></p></td>
<td></td>
</tr>
<tr>
<td height="37" colspan="6" valign="top"><span class="Style1">Signature
obligatoire :</span> </td>
<td></td>
</tr>
<tr>
<td height="26" valign="top"> <input name="reset" type="reset" value="Effacer"></td>
<td> </td>
<td> </td>
<td> </td>
<td valign="top"> <input type="button" name="test" onClick="javascript:verifChamps()" value="Imprimer"></td>
<td> </td>
<td> </td>
</tr>
</table>
</form>
<p><span style="text-align:justify; display:block" class="Style1">Vous
recevrez ensuite un document servant comme preuve de paiement, à
fournir aux services fiscaux.</span></p>
</div></td>
</tr>
</table> |
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