51 lines
2.0 KiB
HTML
51 lines
2.0 KiB
HTML
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<!DOCTYPE html>
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<html lang="fr">
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<head>
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<meta charset="utf-8">
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<title>Mutualité</title>
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</head>
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<body>
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<form method="post" action=".">
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<label for="champ1">Nom</label>
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<input id="champ1" name="nom" type="text" required placeholder="Votre nom"> <br>
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<label for="champ2">Nombre d'enfants</label>
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<select id="nombre enfants" name="nombre enfants" required aria-placeholder="nombre d'enfants">
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<option value="1" selected>1</option>
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<option value="2">2</option>
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<option value="3">3</option>
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<option value="4">4</option>
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<option value="5">5</option>
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<option value="6">6</option>
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</select> <br>
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<label for="champ3">Rue</label>
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<input id="champ3" name="Rue" type="text"> <br>
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<label for="champ4">Numéro de maison</label>
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<input id="champ4" name="Numéro de maison" type="number"> <br>
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<label for="champ5">Indication de la boîte/appartement</label>
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<input id="champ5" name="Indication de la boîte/appartement" type="text"> <br>
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<label for="champ6">le code postal</label>
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<input id="champ6" name="le code postal" type="number"> <br>
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<label for="champ7">la localité</label>
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<input id="champ7" name="la localité" type="text"> <br>
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<label for="champ8">la province de Belgique</label>
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<input id="champ8" name="la province de Belgique" type="text"> <br>
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<label for="champ9">la description de la situation familiale</label>
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<textarea id="champ9" cols="40" rows="3"></textarea><br>
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<label for="champ10">le livret de famille</label>
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<input id="champ10" type="file" name="le livret de famille" accept=".pdf, .docx"><br>
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<input type="button" value="Aide"><br>
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<input type="submit" name="Soumettre" value="Soumettre le formulaire">
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</form>
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</body>
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