28 lines
778 B
PHTML
28 lines
778 B
PHTML
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<link href="/themes/default/styles/formdialog.css" media="all" rel="stylesheet" type="text/css" />
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<div id="survForm">
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<form id="frmSurv" name="frmSurv" action="#" method="post">
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<div class="fieldgrp">
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<label class="StyleInfoLib">Votre référence</label>
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<div class="field">
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<input class="longfield" name="ref" type="text" value="" size="10"/></div>
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</div>
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<div class="fieldgrp">
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<label class="StyleInfoLib">Votre encours (€)</label>
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<div class="field">
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<input class="longfield" name="encours" type="text" value="" size="10"/></div>
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</div>
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<div class="fieldgrp">
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<label class="StyleInfoLib">Adresse email du destinataire</label>
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<div class="field">
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<input class="longfield" name="email" type="text" value="<?=$this->email?>" size="20"/>
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</div>
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</div>
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</form>
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</div>
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