37 lines
869 B
PHTML
37 lines
869 B
PHTML
<input type="hidden" name="pp" value="1"/>
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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="naissance_nom"/>
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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"/>
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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"/>M.
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<input type="radio" name="civilite" value="Mme"/>Mme
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<input type="radio" name="civilite" 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" size="10" name="naissance_date"/> à <input type="text" name="naissance_lieu"/>
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<select name="nat">
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<option>-</option>
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<?php foreach($this->countries as $code => $lib) {?>
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<option value="<?=$code?>"><?=$lib?></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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