http://www.mfa.fr/ Auto, Habitation, Taxi, Loisir, Retraite, Santé, Crédit. fr SPIP - www.spip.net http://www.mfa.fr/IMG/siteon0.gif http://www.mfa.fr/ 87 265 http://www.mfa.fr/Formulaire-contact.html http://www.mfa.fr/Formulaire-contact.html 2009-04-29T16:56:15Z text/html fr admin - <a href="http://www.mfa.fr/-Formulaire-Contact-.html" rel="directory">1. Formulaire Contact</a> <div class='rss_texte'><a name='form7'></a> <div class='spip_forms form_7'> <div class='spip_descriptif titre_noir_12'></div> <form method='post' action='spip.php?page=backend&id_rubrique=35#form7' enctype='multipart/form-data'> <div> <input name='page' value='backend' type='hidden' /> <input name='id_rubrique' value='35' type='hidden' /> <input type='hidden' name='ajout_reponse' value='7' /> <input type='hidden' name='id_donnee' value='0' /> <input type='hidden' name='retour_form' value='' /> </div> <div id="form" style="display:none;"> <fieldset><legend>Formulaire contact</legend> <div class='spip_form_champ select_1'> <span class='spip_form_label'> <span class='label'>Vous êtes sociétaire MFA</span> <span class='spip_form_label_obligatoire'> [Obligatoire]</span> : </span> <div id='societaire'> <ul class='spip_form_choix_unique'> <li> <input type='radio' name='select_1' value='select_1_1' id='input-7-select_1_1' /> <label for='input-7-select_1_1'>Oui</label> </li> <li> <input type='radio' name='select_1' value='select_1_2' id='input-7-select_1_2' /> <label for='input-7-select_1_2'>Non</label> </li> </ul> </div> <span class='nettoyeur'> </span> </div> <div class='spip_form_champ ligne_3'> <span class='spip_form_label'> <label for="input-7-ligne_3">Numéro de sociétaire MFA</label> : </span> <div id='numSocietaire' class='hidden'><input type="text" name='ligne_3' id='input-7-ligne_3' value="" class=' ligne formo' size='40' /> </div> <span class='nettoyeur'> </span> </div> <div class='spip_form_champ select_5'> <span class='spip_form_label'> <span class='label'>Civilité</span> <span class='spip_form_label_obligatoire'> [Obligatoire]</span> : </span> <select name='select_5' id='input-7-select_5' class='fondl'> <option value=''></option> <option value='select_5_1' > M </option> <option value='select_5_2' > Mme </option> <option value='select_5_3' > Melle </option> </select> <span class='nettoyeur'> </span> </div> <div class='spip_form_champ ligne_1'> <span class='spip_form_label'> <label for="input-7-ligne_1">Nom</label> <span class='spip_form_label_obligatoire'> [Obligatoire]</span> : </span> <input type="text" name='ligne_1' id='input-7-ligne_1' value="" class=' ligne forml' size='40' /> <span class='nettoyeur'> </span> </div> <div class='spip_form_champ ligne_4'> <span class='spip_form_label'> <label for="input-7-ligne_4">Prénom</label> <span class='spip_form_label_obligatoire'> [Obligatoire]</span> : </span> <input type="text" name='ligne_4' id='input-7-ligne_4' value="" class=' ligne forml' size='40' /> <span class='nettoyeur'> </span> </div> <div class='spip_form_champ select_2'> <span class='spip_form_label'> <span class='label'>Mode de réponse</span> <span class='spip_form_label_obligatoire'> [Obligatoire]</span> : </span> <div id='modeReponse'> <select name='select_2' id='input-7-select_2' class='fondl'> <option value=''></option> <option value='select_2_1' > Courrier </option> <option value='select_2_2' > Mail </option> <option value='select_2_3' > Téléphone </option> </select> </div> <span class='nettoyeur'> </span> </div> <div class='spip_form_champ email_1'> <span class='spip_form_label'> <label for="input-7-email_1">Adresse e-mail</label> : </span> <span class='spip_form_label_details'>Veuillez entrer une adresse e-mail valide (de type vous@fournisseur.com).</span> <div id='mail' class='hidden'><input type="text" name='email_1' id='input-7-email_1' value="" class=' email formo' size='40' /> </div> <span class='nettoyeur'> </span> </div> <div class='spip_form_champ telephone_1'> <span class='spip_form_label'> <label for="input-7-telephone_1">Numéro de téléphone</label> : </span> <div id='telephone' class='hidden'><input type="text" name='telephone_1' id='input-7-telephone_1' value="" class=' telephone formo' size='40' /> </div> <span class='nettoyeur'> </span> </div> <div class='spip_form_champ select_3'> <span class='spip_form_label'> <span class='label'>A quel moment souhaitez-vous être rappelé ?</span> : </span> <div id='horaire' class='hidden'> <select name='select_3' id='input-7-select_3' class='fondo'> <option value=''></option> <option value='select_3_1' > matin </option> <option value='select_3_2' > après-midi </option> </select> </div> <span class='nettoyeur'> </span> </div> <div class='spip_form_champ ligne_5'> <span class='spip_form_label'> <label for="input-7-ligne_5">Adresse</label> : </span> <div id='adresse' class='hidden'><input type="text" name='ligne_5' id='input-7-ligne_5' value="" class=' ligne formo' size='40' /> </div> <span class='nettoyeur'> </span> </div> <div class='spip_form_champ ligne_6'> <span class='spip_form_label'> <label for="input-7-ligne_6">Complément</label> : </span> <div id='complement' class='hidden'><input type="text" name='ligne_6' id='input-7-ligne_6' value="" class=' ligne formo' size='40' /> </div> <span class='nettoyeur'> </span> </div> <div class='spip_form_champ code_postal_1'> <span class='spip_form_label'> <label for="input-7-code_postal_1">Code postal</label> <span class='spip_form_label_obligatoire'> [Obligatoire]</span> : </span> <div id='postalContact'><input type="text" name='code_postal_1' id='input-7-code_postal_1' value="" class=' code_postal forml' size='40' /> </div> <span class='nettoyeur'> </span> </div> <div class='spip_form_champ ligne_7'> <span class='spip_form_label'> <label for="input-7-ligne_7">Commune</label> : </span> <div id='commune' class='hidden'><input type="text" name='ligne_7' id='input-7-ligne_7' value="" class=' ligne formo' size='40' /> </div> <span class='nettoyeur'> </span> </div> <div class='spip_form_champ select_4'> <span class='spip_form_label'> <span class='label'>Mon besoin</span> <span class='spip_form_label_obligatoire'> [Obligatoire]</span> : </span> <div id='choixAppel'> <select name='select_4' id='input-7-select_4' class='fondl'> <option value=''></option> <option value='select_4_1' > Une information sur les assurances MFA </option> <option value='select_4_2' > Une information sur mon contrat </option> <option value='select_4_3' > Assurance d'un nouveau véhicule </option> <option value='select_4_4' > Assurance d'une nouvelle habitataion </option> <option value='select_4_5' > Une modification de mon contrat </option> <option value='select_4_6' > L'assistance MFA </option> <option value='select_4_7' > Le montant de ma cotisation </option> <option value='select_4_8' > Le paiement de mon assurance </option> <option value='select_4_9' > Mon bonus - malus </option> <option value='select_4_10' > Un courrier reçu </option> <option value='select_4_11' > Une réponse attendue </option> <option value='select_4_12' > Un sinistre automobile </option> <option value='select_4_13' > Un sinistre habitation </option> <option value='select_4_14' > Un sinistre autre </option> <option value='select_4_15' > Autre chose </option> </select> </div> <span class='nettoyeur'> </span> </div> <div class='spip_form_champ ligne_2'> <span class='spip_form_label'> <label for="input-7-ligne_2">Autre</label> : </span> <div id='autre' class='hidden'><input type="text" name='ligne_2' id='input-7-ligne_2' value="" class=' ligne formo' size='40' /> </div> <span class='nettoyeur'> </span> </div> <div class='spip_form_champ texte_1'> <span class='spip_form_label'> <label for="input-7-texte_1">Votre message</label> <span class='spip_form_label_obligatoire'> [Obligatoire]</span> : </span> <textarea name='texte_1' rows='10' class='forml ' cols='80' id='input-7-texte_1'></textarea> <span class='nettoyeur'> </span> </div> <div class='spip_form_champ email_2'> <span class='spip_form_label'> <label for="input-7-email_2">emailCommercial</label> : </span> <span class='spip_form_label_details'>Veuillez entrer une adresse e-mail valide (de type vous@fournisseur.com).</span> <div id='emailCommercial'><input type="text" name='email_2' id='input-7-email_2' value="" class=' email formo' size='40' /> </div> <span class='nettoyeur'> </span> </div> </fieldset> <p style='display:none;'><label for="nobotnobot-7">Veuillez laisser ce champ vide :</label> <input type="text" name="nobotnobot" id="nobotnobot-7" value="" size="10" /></p> <fieldset> <legend>Code de vérification</legend> <p><span class="spip_form_label"> <label for="captcha2">Recopiez, SVP, le code ci-dessous </label> <span class="spip_form_label_obligatoire">[Obligatoire]</span> : </span> <br /><img id="imgCaptcha" src="http://www.mfa.fr/plugins/captcha2/create_image.php?uri=&format=jpg" alt="captcha" style='max-width: 520px; max-height: 100000px' /><br /> <input type="text" class="forml" name="captcha2" id="captcha2" value="" size="10" /> </fieldset> <div style='text-align:center' class='spip_bouton'><input type="submit" name='Valider' value="Valider" /></div> <script src="http://www.mfa.fr/plugins/forms_et_tables_1_9_1/javascript/jtip.js" type="text/javascript"></script> <script type="text/javascript"><!-- //--></script> </div> </form> </div> <p class="spip"></form7></p></div> http://www.mfa.fr/Ecrivez-nous.html http://www.mfa.fr/Ecrivez-nous.html 2009-03-30T18:28:53Z text/html fr admin <br /><img src="http://www.mfa.fr/dist/puce.gif" width="8" height="11" alt="-" /> Envoyez un courrier à notre siège social : <br />MFA <br />Département relations sociétaires <br />6, rue Fournier <br />BP 311 <br />92111 CLICHY CEDEX <br />Remplissez le formulaire de contact : cliquez ici - <a href="http://www.mfa.fr/-Par-mail-ou-par-courrier-.html" rel="directory">Par mail ou par courrier</a> <div class='rss_texte'><p class="spip"><span class="verda10gris33bd">- Envoyez un courrier à notre siège social :</span></p> <blockquote> <p align="center">MFA<br />Département relations sociétaires<br />6, rue Fournier <br />BP 311 <br />92111 CLICHY CEDEX</p> </blockquote> <p class="spip">- Remplissez le formulaire de contact : <a href="http://www.mfa.fr/spip.php?article229">cliquez ici</a></p></div>