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<tr > <td width="150" class="left" > <label >Nom : <span class="required">*</span></label> </td> <td class="right" > <input type="text" size="20" name="q2 Nom" class="text" value="" id="q2" onblur="validate(this,'Required')" maxlength="100" maxsize="100" /> </td> </tr> <tr > <td width="150" class="left" > <label >Prenom :</label> </td> <td class="right" > <input type="text" size="20" name="q22 Prenom" class="text" value="" id="q22" maxlength="100" maxsize="100" /> </td> </tr> <tr > <td width="150" class="left" > <label >E-mail: <span class="required">*</span></label> </td> <td class="right" > <input type="text" size="20" name="q3 E-mail" class="text" value="" id="q3" onblur="validate(this,'Required')" maxlength="100" maxsize="100" /> </td> </tr> <tr > <td width="150" class="left" > <label >Phone:</label> </td> <td class="right" > <input type="text" size="20" name="q9 Phone" class="text" value="" id="q9" maxlength="100" maxsize="100" /> </td> </tr> <tr > <td width="150" class="left" valign="top" > <label>Address:</label> </td> <td class="right" > <textarea cols="30" rows="2" name="q10 Address" class="text" id="q10" ></textarea> </td> </tr> <tr > <td width="150" class="left" > <label >Zip code:</label> </td> <td class="right" > <input type="text" size="20" name="q7 Zipcode" class="text" value="" id="q7" maxlength="100" maxsize="100" /> </td> </tr> <tr > <td width="150" class="left" > <label >City: <span class="required">*</span></label> </td> <td class="right" > <input type="text" size="20" name="q0 City" class="text" value="" id="q0" onblur="validate(this,'Required')" maxlength="100" maxsize="100" /> </td> </tr> <tr > <td width="150" class="left" valign="top" > <label>State:</label> </td> <td class="right"> <select class="other" name="q8 State" id="q8" > <option></option> <option>Abkhazia</option> <option>Afghanistan</option> <option>United Kingdom Akrotiri and Dhekelia</option> <option>Aland</option> <option>Albania</option> <option>Algeria</option> <option>American Samoa</option> <option>Andorra</option> <option>Angola</option> <option>Anguilla</option> <option>Antigua and Barbuda</option> <option>Argentina Argentina</option> <option>Armenia</option> <option>Aruba</option> <option>United Kingdom Ascension Island</option> <option>Australia</option> <option>Austria</option> <option>Azerbaijan</option> <option>The Bahamas</option> <option>Bahrain</option> <option>Bangladesh</option> <option>Barbados</option> <option>Belarus</option> <option>Belgium</option> <option>Belize</option> <option>Benin</option> <option>Bermuda</option> <option>Bhutan</option> <option>Bolivia</option> <option>Bosnia and Herzegovina</option> <option>Botswana</option> <option>Brazil</option> <option>Brunei</option> <option>Bulgaria</option> <option>Burkina Faso</option> <option>Burundi</option> <option>Cambodia</option> <option>Cameroon</option> <option>Canada</option> <option>Cape Verde</option> <option>Cayman Islands</option> <option>Central African Republic</option> <option>Chad</option> <option>Chile</option> <option>People's Republic of China</option> <option>Republic of China</option> <option>Christmas Island</option> <option>Cocos (Keeling) Islands</option> <option>Colombia</option> <option>Comoros</option> <option>Congo</option> <option>Cook Islands</option> <option>Costa Rica</option> <option>CFFFDte d'Ivoire</option> <option>Croatia</option> <option>Cuba</option> <option>Cyprus</option> <option>Czech Republic</option> <option>Denmark</option> <option>Djibouti</option> <option>Dominica</option> <option>Dominican Republic</option> <option>Ecuador</option> <option>Egypt</option> <option>El Salvador</option> <option>Equatorial Guinea</option> <option>Eritrea</option> <option>Estonia</option> <option>Ethiopia</option> <option>Falkland Islands</option> <option>Faroe Islands</option> <option>Fiji</option> <option>Finland</option> <option>France</option> <option>French Polynesia</option> <option>Gabon</option> <option>The Gambia</option> <option>Georgia</option> <option>Germany</option> <option>Ghana</option> <option>Gibraltar</option> <option>Greece</option> <option>Greenland</option> <option>Grenada</option> <option>Guam</option> <option>Guatemala</option> <option>Guernsey</option> <option>Guinea</option> <option>Guinea-Bissau</option> <option>Guyana Guyana</option> <option>Haiti Haiti</option> <option>Honduras</option> <option>Hong Kong</option> <option>Hungary</option> <option>Iceland</option> <option>India</option> <option>Indonesia</option> <option>Iran</option> <option>Iraq</option> <option>Ireland</option> <option>Israel</option> <option>Italy</option> <option>Jamaica</option> <option>Japan</option> <option>Jersey</option> <option>Jordan</option> <option>Kazakhstan</option> <option>Kenya</option> <option>Kiribati</option> <option>North Korea</option> <option>South Korea</option> <option>Kosovo</option> <option>Kuwait</option> <option>Kyrgyzstan</option> <option>Laos</option> <option>Latvia</option> <option>Lebanon</option> <option>Lesotho</option> <option>Liberia</option> <option>Libya</option> <option>Liechtenstein</option> <option>Lithuania</option> <option>Luxembourg</option> <option>Macau</option> <option>Macedonia</option> <option>Madagascar</option> <option>Malawi</option> <option>Malaysia</option> <option>Maldives</option> <option>Mali</option> <option>Malta</option> <option>Marshall Islands</option> <option>Mauritania</option> <option>Mauritius</option> <option>Mayotte</option> <option>Mexico</option> <option>Micronesia</option> <option>Moldova</option> <option>Monaco</option> <option>Mongolia</option> <option>Montenegro</option> <option>Montserrat</option> <option>Morocco</option> <option>Mozambique</option> <option>Myanmar</option> <option>Nagorno-Karabakh</option> <option>Namibia</option> <option>Nauru</option> <option>Nepal</option> <option>Netherlands</option> <option>Netherlands Antilles</option> <option>New Caledonia</option> <option>New Zealand</option> <option>Nicaragua</option> <option>Niger</option> <option>Nigeria</option> <option>Niue</option> <option>Norfolk Island</option> <option>Turkish Republic of Northern Cyprus</option> <option>Northern Mariana</option> <option>Norway</option> <option>Pakistan</option> <option>Palau</option> <option>Palestine</option> <option>Panama</option> <option>Papua New Guinea</option> <option>Paraguay</option> <option>Peru</option> <option>Philippines</option> <option>Pitcairn Islands</option> <option>Poland</option> <option>Portugal</option> <option>Transnistria Pridnestrovie</option> <option>Puerto Rico</option> <option>Qatar</option> <option>Romania</option> <option>Russia</option> <option>Rwanda</option> <option>Saint Barthelemy</option> <option>Saint Helena</option> <option>Saint Kitts and Nevis</option> <option>Saint Lucia</option> <option>Saint Martin</option> <option>Saint Pierre and Miquelon</option> <option>Saint Vincent and the Grenadines</option> <option>Samoa</option> <option>San Marino</option> <option>SFFFDo TomFFFD and PrFFFDncipe</option> <option>Saudi Arabia</option> <option>Senegal</option> <option>Serbia</option> <option>Seychelles</option> <option>Sierra Leone</option> <option>Singapore</option> <option>Slovakia</option> <option>Slovenia</option> <option>Solomon Islands</option> <option>Somalia</option> <option>Somaliland</option> <option>South Africa</option> <option>South Ossetia</option> <option>Spain</option> <option>Sri Lanka</option> <option>Sudan</option> <option>Suriname</option> <option>Svalbard</option> <option>Swaziland</option> <option>Sweden</option> <option>Switzerland</option> <option>Syria</option> <option>Tajikistan</option> <option>Tanzania</option> <option>Thailand</option> <option>Timor-Leste</option> <option>Togo</option> <option>Tokelau</option> <option>Tonga</option> <option>Trinidad and Tobago</option> <option>Tristan da Cunha</option> <option>Tunisia</option> <option>Turkey</option> <option>Turkmenistan</option> <option>Turks and Caicos Islands</option> <option>Tuvalu</option> <option>Uganda</option> <option>Ukraine</option> <option>United Arab Emirates</option> <option>United Kingdom</option> <option>United States</option> <option>Uruguay</option> <option>Uzbekistan</option> <option>Vanuatu</option> <option>Vatican City</option> <option>Venezuela</option> <option>Vietnam</option> <option>British Virgin Islands</option> <option>US Virgin Islands</option> <option>Wallis and Futuna</option> <option>Western Sahara</option> <option>Yemen</option> <option>Zambia</option> <option>Zimbabwe</option> </select> </td> </tr> <tr > <td colspan="2" align='center'> <img width="240" height="161" src="" name="q12 Image" id="q12" alt="" /> </td> </tr> <tr > <td colspan="2" class="left" > Adhesion Via Paypal </td> </tr> <tr > <td width="150" class="left" valign="top" > <label>Adhesion à l'association BureauWiki</label> </td> <td class="right">
<input type="radio" class="other" name="q23 AdhesionlassociationBureauWiki[]" id="q237338395148001" onclick="sum(this);" value="73382636528" /><label class="left">adh 30 (€30) </label>
<input type="radio" class="other" name="q23 AdhesionlassociationBureauWiki[]" id="q237338395148002" onclick="sum(this);" value="73382636527" /><label class="left">adh 50 (€50) </label>
<input type="radio" class="other" name="q23 AdhesionlassociationBureauWiki[]" id="q237338395148003" onclick="sum(this);" value="73382637519" /><label class="left">adh 75 (€75) </label>
<input type="radio" class="other" name="q23 AdhesionlassociationBureauWiki[]" id="q237338395148004" onclick="sum(this);" value="73382637473" /><label class="left">adh 100 (€100) </label>
<input type="radio" class="other" name="q23 AdhesionlassociationBureauWiki[]" id="q237338395148005" onclick="sum(this);" value="73382638552" /><label class="left">adh 150 (€150) </label>
<input type="radio" class="other" name="q23 AdhesionlassociationBureauWiki[]" id="q237338395148006" onclick="sum(this);" value="73382639466" /><script type="text/javascript"><label class="left">adh 200 (€200) </label>
var price = Array(); var setup = Array(); price['73382636528'] = '30'; price['73382636527'] = '50'; price['73382637519'] = '75'; price['73382637473'] = '100'; price['73382638552'] = '150'; price['73382639466'] = '200';</script>
<input name="hid" type="hidden" id="hid" value="0" /> <div class="left" style="text-align:left;font-size:large; " id="res">Total : </div></td>
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