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  1. <table border=0 width=100%>
  2. <tr>
  3. <td><h4>Informations compte</h4></td>
  4. </tr>
  5. <tr>
  6. <td>Civilité :</td>
  7. <td>
  8. <select name="civilite">
  9. <option selected="selected" value="2">Madame&nbsp;&nbsp;</option>
  10. <option value="3">Mademoiselle&nbsp;&nbsp;</option>
  11. <option value="1">Monsieur&nbsp;&nbsp;</option>
  12. </select>
  13. </td>
  14. <td>Nom :</td> <td><input name ="nom" type ="text"></td>
  15. </tr>
  16. <tr>
  17. <td>Prénom :</td> <td><input name ="prenom" type ="text"></td>
  18. <td>Naissance :</td>
  19. <td>
  20. <select name="jour" >
  21. <option value="1">1</option>
  22. <option value="2">2</option>
  23. <option value="3">3</option>
  24. <option value="4">4</option>
  25. <option value="5">5</option>
  26. <option value="6">6</option>
  27. <option value="7">7</option>
  28. <option value="8">8</option>
  29. <option value="9">9</option>
  30. <option value="10">10</option>
  31. <option value="11">11</option>
  32. <option value="12">12</option>
  33. <option value="13">13</option>
  34. <option value="14">14</option>
  35. <option value="15">15</option>
  36. <option value="16">16</option>
  37. <option value="17">17</option>
  38. <option value="18">18</option>
  39. <option value="19">19</option>
  40. <option value="20">20</option>
  41. <option value="21">21</option>
  42. <option value="22">22</option>
  43. <option value="23">23</option>
  44. <option value="24">24</option>
  45. <option value="25">25</option>
  46. <option value="26">26</option>
  47. <option value="27">27</option>
  48. <option value="28">28</option>
  49. <option value="29">29</option>
  50. <option value="30">30</option>
  51. <option value="31">31</option>
  52. </select>
  53. <select name="mois" >
  54. <option value="1">janvier</option>
  55. <option value="2">f&eacute;vrier</option>
  56. <option value="3">mars</option>
  57. <option value="4">avril</option>
  58. <option value="5">mai</option>
  59. <option value="6">juin</option>
  60. <option value="7">juillet</option>
  61. <option value="8">ao&ucirc;t</option>
  62. <option value="9">septembre</option>
  63. <option value="10">octobre</option>
  64. <option value="11">novembre</option>
  65. <option value="12">d&eacute;cembre</option>
  66. </select>
  67. <select name="annee" >
  68. <option value="1950">1950</option>
  69. <option value="1951">1951</option>
  70. <option value="1952">1952</option>
  71. <option value="1953">1953</option>
  72. <option value="1954">1954</option>
  73. <option value="1955">1955</option>
  74. <option value="1956">1956</option>
  75. <option value="1957">1957</option>
  76. <option value="1958">1958</option>
  77. <option value="1959">1959</option>
  78. <option value="1960">1960</option>
  79. <option value="1961">1961</option>
  80. <option value="1962">1962</option>
  81. <option value="1963">1963</option>
  82. <option value="1964">1964</option>
  83. <option value="1965">1965</option>
  84. <option value="1966">1966</option>
  85. <option value="1967">1967</option>
  86. <option value="1968">1968</option>
  87. <option value="1969">1969</option>
  88. <option value="1970">1970</option>
  89. <option value="1971">1971</option>
  90. <option value="1972">1972</option>
  91. <option value="1973">1973</option>
  92. <option value="1974">1974</option>
  93. <option value="1975">1975</option>
  94. <option value="1976">1976</option>
  95. <option value="1977">1977</option>
  96. <option value="1978">1978</option>
  97. <option value="1979">1979</option>
  98. <option value="1980">1980</option>
  99. <option value="1981">1981</option>
  100. <option value="1982">1982</option>
  101. <option value="1983">1983</option>
  102. <option value="1984">1984</option>
  103. <option value="1985">1985</option>
  104. <option value="1986">1986</option>
  105. <option value="1987">1987</option>
  106. <option value="1988">1988</option>
  107. <option value="1989">1989</option>
  108. <option value="1990">1990</option>
  109. <option value="1991">1991</option>
  110. <option value="1992">1992</option>
  111. <option value="1993">1993</option>
  112. <option value="1994">1994</option>
  113. <option value="1995">1995</option>
  114. </select>
  115. </td>
  116. </tr>
  117. <tr>
  118. <td>Code Postal :</td> <td><input name ="cp" type ="text"></td>
  119. <td>Pays :</td>
  120. <td>
  121. <select name="pays" >
  122. <option value="24">Afghanistan</option>
  123. <option value="25">Afrique du Sud</option>
  124. <option value="26">Albanie</option>
  125. <option value="27">Algérie</option>
  126. <option value="4">Allemagne</option>
  127. <option value="28">Andorre</option>
  128. <option value="29">Angola</option>
  129. <option value="30">Anguilla</option>
  130. <option value="32">Antigua-et-Barbuda</option>
  131. <option value="33">Antilles néerlandaises</option>
  132. <option value="34">Arabie Saoudite</option>
  133. <option value="35">Argentine</option>
  134. <option value="36">Arménie</option>
  135. <option value="37">Aruba</option>
  136. <option value="38">Australie</option>
  137. <option value="39">Autorité Palestinienne</option>
  138. <option value="5">Autriche</option>
  139. <option value="40">Azerbaïdjan</option>
  140. <option value="41">Bahamas</option>
  141. <option value="42">Bahreïn</option>
  142. <option value="43">Bangladesh</option>
  143. <option value="44">Barbade</option>
  144. <option value="2">Belgique</option>
  145. <option value="45">Belize</option>
  146. <option value="46">Bénin</option>
  147. <option value="47">Bermudes</option>
  148. <option value="48">Bhoutan</option>
  149. <option value="49">Biélorussie</option>
  150. <option value="50">Bolivie</option>
  151. <option value="51">Bosnie-Herzégovine</option>
  152. <option value="52">Botswana</option>
  153. <option value="54">Brésil</option>
  154. <option value="55">Brunei</option>
  155. <option value="56">Bulgarie</option>
  156. <option value="57">Burkina Faso</option>
  157. <option value="58">Burundi</option>
  158. <option value="59">Caïmans (îles)</option>
  159. <option value="60">Cambodge</option>
  160. <option value="61">Cameroun</option>
  161. <option value="62">Canada</option>
  162. <option value="64">Chili</option>
  163. <option value="65">Chine</option>
  164. <option value="6">Chypre</option>
  165. <option value="69">Colombie</option>
  166. <option value="70">Comores</option>
  167. <option value="71">Congo</option>
  168. <option value="72">Congo (RDC)</option>
  169. <option value="73">Cook (îles)</option>
  170. <option value="74">Corée</option>
  171. <option value="75">Corée du Nord</option>
  172. <option value="76">Costa Rica</option>
  173. <option value="77">Côte D'Ivoire</option>
  174. <option value="78">Croatie (Hrvatska)</option>
  175. <option value="79">Cuba</option>
  176. <option value="7">Danemark</option>
  177. <option value="81">Djibouti</option>
  178. <option value="82">Dominique</option>
  179. <option value="83">Égypte</option>
  180. <option value="84">Émirats arabes unis</option>
  181. <option value="85">Équateur</option>
  182. <option value="86">Érythrée</option>
  183. <option value="8">Espagne</option>
  184. <option value="87">Estonie</option>
  185. <option value="88">États-Unis</option>
  186. <option value="89">Éthiopie</option>
  187. <option value="91">Féroé (îles)</option>
  188. <option value="92">Fidji (îles)</option>
  189. <option value="9">Finlande</option>
  190. <option value="1" selected="selected">France</option>
  191. <option value="93">Gabon</option>
  192. <option value="94">Gambie</option>
  193. <option value="95">Géorgie</option>
  194. <option value="97">Ghana</option>
  195. <option value="98">Gibraltar</option>
  196. <option value="10">Grèce</option>
  197. <option value="99">Grenade</option>
  198. <option value="100">Groenland</option>
  199. <option value="101">Guadeloupe</option>
  200. <option value="102">Guam</option>
  201. <option value="103">Guatemala</option>
  202. <option value="104">Guernsey</option>
  203. <option value="105">Guinée</option>
  204. <option value="106">Guinée équatoriale</option>
  205. <option value="107">Guinée-Bissau</option>
  206. <option value="108">Guyane</option>
  207. <option value="109">Guyane française</option>
  208. <option value="110">Haïti</option>
  209. <option value="112">Honduras</option>
  210. <option value="183">Hong Kong</option>
  211. <option value="113">Hongrie</option>
  212. <option value="115">Île de Man</option>
  213. <option value="116">Inde</option>
  214. <option value="117">Indonésie</option>
  215. <option value="118">Irak</option>
  216. <option value="119">Iran</option>
  217. <option value="11">Irlande</option>
  218. <option value="120">Islande</option>
  219. <option value="121">Israël</option>
  220. <option value="12">Italie</option>
  221. <option value="122">Jamaïque</option>
  222. <option value="123">Japon</option>
  223. <option value="124">Jersey</option>
  224. <option value="125">Jordanie</option>
  225. <option value="126">Kazakhstan</option>
  226. <option value="127">Kenya</option>
  227. <option value="128">Kirghizistan</option>
  228. <option value="129">Kiribati</option>
  229. <option value="130">Koweït</option>
  230. <option value="131">La Réunion</option>
  231. <option value="132">Laos</option>
  232. <option value="133">Lesotho</option>
  233. <option value="13">Lettonie</option>
  234. <option value="134">Liban</option>
  235. <option value="135">Libéria</option>
  236. <option value="136">Libye</option>
  237. <option value="137">Liechtenstein</option>
  238. <option value="14">Lituanie</option>
  239. <option value="3">Luxembourg</option>
  240. <option value="184">Macao</option>
  241. <option value="138">Madagascar</option>
  242. <option value="139">Malaisie</option>
  243. <option value="140">Malawi</option>
  244. <option value="141">Maldives</option>
  245. <option value="142">Mali</option>
  246. <option value="143">Malouines (îles)</option>
  247. <option value="15">Malte</option>
  248. <option value="145">Maroc</option>
  249. <option value="146">Marshall (îles)</option>
  250. <option value="147">Martinique</option>
  251. <option value="148">Maurice</option>
  252. <option value="149">Mauritanie</option>
  253. <option value="150">Mayotte</option>
  254. <option value="151">Mexique</option>
  255. <option value="152">Micronésie</option>
  256. <option value="153">Moldavie</option>
  257. <option value="154">Monaco</option>
  258. <option value="155">Mongolie</option>
  259. <option value="156">Montserrat</option>
  260. <option value="157">Mozambique</option>
  261. <option value="158">Myanmar</option>
  262. <option value="159">Namibie</option>
  263. <option value="160">Nauru</option>
  264. <option value="161">Népal</option>
  265. <option value="162">Nicaragua</option>
  266. <option value="163">Niger</option>
  267. <option value="164">Nigéria</option>
  268. <option value="165">Niue</option>
  269. <option value="16">Norvège</option>
  270. <option value="167">Nouvelle-Calédonie</option>
  271. <option value="168">Nouvelle-Zélande</option>
  272. <option value="169">Oman</option>
  273. <option value="170">Ouganda</option>
  274. <option value="171">Ouzbékistan</option>
  275. <option value="172">Pakistan</option>
  276. <option value="173">Palau</option>
  277. <option value="174">Panama</option>
  278. <option value="175">Papouasie-Nouvelle-Guinée</option>
  279. <option value="176">Paraguay</option>
  280. <option value="17">Pays-Bas</option>
  281. <option value="177">Pérou</option>
  282. <option value="178">Philippines</option>
  283. <option value="18">Pologne</option>
  284. <option value="180">Polynésie française</option>
  285. <option value="181">Porto Rico</option>
  286. <option value="19">Portugal</option>
  287. <option value="182">Qatar</option>
  288. <option value="185">République centrafricaine</option>
  289. <option value="186">République dominicaine</option>
  290. <option value="20">République Tchèque</option>
  291. <option value="187">Roumanie</option>
  292. <option value="21">Royaume-Uni</option>
  293. <option value="188">Russie</option>
  294. <option value="189">Rwanda</option>
  295. <option value="193">Saint-Marin</option>
  296. <option value="196">Salomon (îles)</option>
  297. <option value="197">Salvador</option>
  298. <option value="198">Samoa</option>
  299. <option value="201">Sénégal</option>
  300. <option value="202">Seychelles</option>
  301. <option value="203">Sierra Leone</option>
  302. <option value="204">Singapour</option>
  303. <option value="22">Slovaquie</option>
  304. <option value="23">Slovénie</option>
  305. <option value="205">Somalie</option>
  306. <option value="206">Soudan</option>
  307. <option value="207">Sri Lanka</option>
  308. <option value="208">Suède</option>
  309. <option value="209">Suisse</option>
  310. <option value="210">Surinam</option>
  311. <option value="212">Swaziland</option>
  312. <option value="213">Syrie</option>
  313. <option value="214">Tadjikistan</option>
  314. <option value="215">Taïwan</option>
  315. <option value="216">Tanzanie</option>
  316. <option value="217">Tchad</option>
  317. <option value="219">Territoires britanniques de l'Océan Indien</option>
  318. <option value="220">Thaïlande</option>
  319. <option value="222">Togo</option>
  320. <option value="223">Tokelau</option>
  321. <option value="224">Tonga</option>
  322. <option value="227">Tunisie</option>
  323. <option value="228">Turkménistan</option>
  324. <option value="230">Turquie</option>
  325. <option value="231">Tuvalu</option>
  326. <option value="232">Ukraine</option>
  327. <option value="233">Uruguay</option>
  328. <option value="234">Vanuatu</option>
  329. <option value="235">Venezuela</option>
  330. <option value="238">Vietnam</option>
  331. <option value="240">Yémen</option>
  332. <option value="241">Yougoslavie</option>
  333. <option value="242">Zambie</option>
  334. <option value="243">Zimbabwe</option>
  335. </select>
  336. </td>
  337. </tr>
  338. <tr>
  339. <td>Type d'étude :</td>
  340. <td>
  341. <select name="etude">
  342. <option selected="selected" value='1'>Ecole de commerce</option>
  343. <option value='2'>Ecole d'ing&eacute;nieurs</option>
  344. <option value='3'>Universit&eacute;</option>
  345. <option value='4'>Autre</option>
  346. </select>
  347. </td>
  348. <td>Niv. d'études :</td>
  349. <td>
  350. <select name="niveau">
  351. <option selected="selected" value='0'>---------</option>
  352. <option value='1'>BAC + 1</option>
  353. <option value='2'>BAC + 2</option>
  354. <option value='3'>BAC + 3</option>
  355. <option value='4'>BAC + 4</option>
  356. <option value='5'>BAC + 5</option>
  357. <option value='6'>BAC > 5</option>
  358. </select>
  359. </td>
  360. </tr>
  361. </table>
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