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| <form method="POST" action="index.php?page=validation" target="_parent" class="commande">
<table width="80%" border="0" align="center">
<tr bgcolor="#C7D3D7">
<td width="187"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Nom / Prénom </font></td>
<td width="229"><div align="right">
<select name="Civilite" id="civilite">
<option value="M." selected>M.</option>
<option value="Me">Me</option>
<option value="Melle">Melle</option>
</select>
</div></td>
<td width="330"><div align="right">
<input name="Nom" type="text" id="nom" size="21" maxlength="50">
/ <input name="Prenom" type="text" id="nom" size="21" maxlength="50">
</div></td>
</tr>
<tr>
<td width="187"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Adresse</font></td>
<td colspan="2"><div align="right">
<input name="Adresse" type="text" id="adresse" size="50" maxlength="200">
</div></td>
</tr>
<tr bgcolor="#C7D3D7">
<td width="187"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Code postal / Ville</font></td>
<td colspan="2"><div align="right">
<input name="Code" type="text" id="code" size="21" maxlength="5">
/ <input name="Ville" type="text" id="ville" size="21" maxlength="50">
</div></td>
</tr>
<tr>
<td width="187"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Pays</font></td>
<td colspan="2"><div align="right">
<input name="Pays" type="text" id="pays" size="50" maxlength="30">
</div></td>
</tr>
<tr bgcolor="#C7D3D7">
<td width="187"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Téléphone</font></td>
<td colspan="2"><div align="right">
<input name="Telephone" type="text" id="telephone" size="10" maxlength="10">
</div></td>
</tr>
<tr>
<td width="187"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">E-Mail</font></td>
<td colspan="2"><div align="right">
<input name="Email" type="text" id="email" size="50" maxlength="50">
</div></td>
</tr>
<tr bgcolor="#C7D3D7">
<td width="187"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Référence
de la création</font></td>
<td colspan="2"><div align="right">
<select name="Reference" size="1">
<?php do { ?>
<option>
<?php echo $row_Liaison_tables['ref']; ?>
-
<?php echo $row_Liaison_tables['nom']; ?>
</option>
<?php } while ($row_Liaison_tables = mysql_fetch_assoc($Liaison_tables)); ?>
</select>
</div></td>
</tr>
<tr>
<td width="187"> </td>
<td colspan="2"><div align="right"></div></td>
</tr>
<tr>
<td> </td>
<td colspan="2"><div align="right">
<input name="Submit" type="submit" value="Envoyer la commande">
</div></td>
</tr>
</table>
<table width="760" border="0" align="center">
<tr>
<td><font size="1" face="Verdana, Arial, Helvetica, sans-serif"><u>Note</u>
: Tous les champs sont obligatoires.</font></td>
</tr>
</table>
<input type="hidden" name="MM_insert" value="form1">
</form> |
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