102 lines
2.9 KiB
PHTML
102 lines
2.9 KiB
PHTML
<input type="hidden" name="pp" value="1"/>
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<div class="fieldgrp">
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<label>Nom</label>
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<div class="field">
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<input type="text" name="nom" value="<?=$this->nom?>"/>
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</div>
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</div>
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<div class="fieldgrp">
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<label>Nom d'usage</label>
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<div class="field">
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<input type="text" name="nom_usage" value="<?=$this->nom_usage?>"/>
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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" name="prenom" value="<?=$this->prenom?>"/>
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</div>
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</div>
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<div class="fieldgrp">
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<label>Civilité</label>
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<div class="field">
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<input type="radio" name="civilite" value="M"<?php if ($this->civilite==strtoupper('M')) echo ' checked'; ?>/>M.
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<input type="radio" name="civilite" value="Mme"<?php if ($this->civilite==strtoupper('Mme')) echo ' checked'; ?>/>Mme
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<input type="radio" name="civilite" value="Mlle"<?php if ($this->civilite==strtoupper('Mlle')) echo ' checked'; ?>/>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" size="10" name="naissance_date" value="<?=$this->naissance_date?>"/>
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à <input type="text" name="naissance_lieu" value="<?=$this->naissance_lieu?>"/>
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<select name="naissance_dept_pays">
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<option>-</option>
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<?php foreach($this->countries as $code => $item) {?>
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<?php $select = ''; if ($this->naissance_dept_pays==$code) $select = 'selected';?>
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<option value="<?=$code?>"<?=$select?>><?=$item['libPays']?></option>
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<?php }?>
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</select>
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</div>
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</div>
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<div class="fieldgrp">
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<label>Nationnalité</label>
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<select name="nat">
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<option>-</option>
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<?php foreach($this->countries as $code => $item) {?>
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<?php $select = ''; if ($this->nat==$code) $select = 'selected';?>
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<option value="<?=$code?>"<?=$select?>><?=$item['libPays']?></option>
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<?php }?>
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</select>
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</div>
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</div>
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<div class="fieldgrp">
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<label>Adresse</label>
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<div class="field">
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<input type="text" name="adresse_num" size="4" value="<?=$this->adresse_num?>"/>
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<input type="text" name="adresse_btq" size="1" value="<?=$this->adresse_btq?>"/>
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<input type="text" name="adresse_codvoie" size="4" value="<?=$this->adresse_codvoie?>"/>
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<input type="text" name="adresse_libvoie" size="32" value="<?=$this->adresse_libvoie?>"/>
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</div>
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</div>
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<div class="fieldgrp">
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<label>Adresse complément</label>
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<div class="field">
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<input type="text" name="adresse_comp" size="40" value="<?=$this->adresse_comp?>"/>
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</div>
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</div>
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<div class="fieldgrp">
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<label>CP</label>
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<div class="field">
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<input type="text" name="adresse_cp" value="<?=$this->adresse_cp?>"/>
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</div>
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</div>
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<div class="fieldgrp">
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<label>Ville</label>
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<div class="field">
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<input type="text" name="adresse_ville" value="<?=$this->adresse_ville?>"/>
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</div>
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</div>
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<div class="fieldgrp">
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<label>Pays</label>
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<div class="field">
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<select name="adresse_pays">
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<option value="">-</option>
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<?php foreach($this->countries as $code => $item) {?>
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<?php $select = ''; if ($this->adresse_pays==$code) $select = 'selected';?>
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<option value="<?=$code?>"<?=$select?>><?=$item['libPays']?></option>
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<?php }?>
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</select>
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</div>
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</div>
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