29 lines
574 B
PHTML
29 lines
574 B
PHTML
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<div class="fieldgrp">
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<label>Nom d'usage</label>
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<div class="field">
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<input type="text"/>
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</div>
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</div>
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<div class="fieldgrp">
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<label>Prénom(s)</label>
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<div class="field">
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<input type="text"/>
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</div>
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</div>
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<div class="fieldgrp">
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<label>Civilité</label>
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<div class="field">
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<input type="radio" name="" value="M."/> M.
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<input type="radio" name="" value="Mme"/>Mme
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<input type="radio" name="" value="Mlle"/>Mlle
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</div>
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</div>
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<div class="fieldgrp">
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<label>Né(e) le</label>
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<div class="field">
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<input type="text"/> à <input type="text"/> <select></select>
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</div>
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</div>
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