<div id="frontInterestedForm" class="col-xs-12"> <div class="med_valid"></div> <div class="med_content"> <div class="col-xs-12"> <h2>Intéressé par le produit</h2> </div> <div class="col-xs-12"> <p>Faites-nous part de votre intérêt pour ce produit et nous vous contacterons pour plus de détails..</p> </div> <form method="post" enctype="multipart/form-data" class="col-xs-12 med_form" action="https://palvac.com/module/interestedinproduct/form"> <div class="col-xs-12"> <div class="form-group col-xs-12"> <label class="form-control-label">Email <abbr>*</abbr></label> <input class="form-control" id="data_email" name="data_email" value="" /></div> <div class="form-group col-xs-12"> <label class="form-control-label">Nom <abbr>*</abbr></label> <input type="text" class="form-control" id="data_lastname" name="data_lastname" value="" /></div> <div class="form-group col-xs-12"> <label class="form-control-label">Société <abbr>*</abbr></label> <input type="text" class="form-control" id="data_company" name="data_company" value="" /></div> <div class="form-group col-xs-12"> <label class="form-control-label">Code postal <abbr>*</abbr></label> <input type="text" class="form-control" id="data_zipcode" name="data_zipcode" value="" /></div> <div class="form-group col-xs-12"> <label class="form-control-label">Numéro de téléphone <abbr>*</abbr></label> <input type="text" class="form-control" id="data_phone" name="data_phone" value="" /></div> <div class="form-group col-xs-12 last"> <label class="form-control-label">Votre message <abbr>*</abbr></label> <textarea class="form-control" id="data_message" name="data_message" rows="3" cols="22"></textarea></div> </div> <input type="hidden" id="ParentURL" name="ParentURL" value="" /><input type="hidden" id="id_product" name="id_product" value="231" /><input type="text" id="kikey" name="kikey" value="" /><input type="hidden" id="medFormKey" name="medFormKey" value="5f0b3f49d8af1f0b429f31e17010853a" /><div class="form-footer text-sm-left col-xs-12"> <button type="submit" id="submitInterestedInProduct" name="submitInterestedInProduct" class="btn btn-primary" disabled="disabled">Envoyer</button> <p><br /><abbr title="(Obligatoire)">*</abbr> : Les champs marqués d'un astérisque sont obligatoires. </p> </div> </form> </div> </div>
