<form method= »post » id=’basicForm’ action=’https://agglochaumont.digitalebox.fr/newsletter/subscribe’><div id= »form-messages »></div><input type=’hidden’ name=’isConcern’ value=’1′><label style= »font-size: 12px; font-weight: normal; color: #696969; » required for= » »>Prénom</label><br> <input type= »text » name= »firstName » value= » » required style= »width: 100%; height: 30px; color: #696969; margin-top: 2px; padding: 0px 10px; max-width: 250px; margin-bottom: 10px; border: solid 1px #ccc; -webkit-border-radius: 5px; -moz-border-radius: 5px; border-radius: 5px; -webkit-box-shadow: 0px 0px 2px 0px #ccc; -moz-box-shadow: 0px 0px 2px 0px #ccc; box-shadow: 0px 0px 2px 0px #ccc; font-family: 'Helvetica Neue', Arial, Lucida Grande, sans-serif; »><br><label style= »font-size: 12px; font-weight: normal; color: #696969; » required for= » »>Nom</label><br> <input type= »text » name= »lastName » value= » » required style= »width: 100%; height: 30px; color: #696969; margin-top: 2px; padding: 0px 10px; max-width: 250px; margin-bottom: 10px; border: solid 1px #ccc; -webkit-border-radius: 5px; -moz-border-radius: 5px; border-radius: 5px; -webkit-box-shadow: 0px 0px 2px 0px #ccc; -moz-box-shadow: 0px 0px 2px 0px #ccc; box-shadow: 0px 0px 2px 0px #ccc; font-family: 'Helvetica Neue', Arial, Lucida Grande, sans-serif; »><br><label style= »font-size: 12px; font-weight: normal; color: #696969; » required for= » »>Email</label><br> <input type= »email » name= »email » value= » » placeholder= »ex: john@abc.com » required style= »width: 100%; height: 30px; color: #696969; margin-top: 2px; padding: 0px 10px; max-width: 250px; margin-bottom: 10px; border: solid 1px #ccc; -webkit-border-radius: 5px; -moz-border-radius: 5px; border-radius: 5px; -webkit-box-shadow: 0px 0px 2px 0px #ccc; -moz-box-shadow: 0px 0px 2px 0px #ccc; box-shadow: 0px 0px 2px 0px #ccc; font-family: 'Helvetica Neue', Arial, Lucida Grande, sans-serif; »><br><label style= »font-size: 12px; font-weight: normal; color: #696969; » required for= » »>Mobile No</label><br> <input type= »text » name= »mobile » value= » » placeholder= »ex: +330610882049″ required style= »width: 100%; height: 30px; color: #696969; margin-top: 2px; padding: 0px 10px; max-width: 250px; margin-bottom: 10px; border: solid 1px #ccc; -webkit-border-radius: 5px; -moz-border-radius: 5px; border-radius: 5px; -webkit-box-shadow: 0px 0px 2px 0px #ccc; -moz-box-shadow: 0px 0px 2px 0px #ccc; box-shadow: 0px 0px 2px 0px #ccc; font-family: 'Helvetica Neue', Arial, Lucida Grande, sans-serif; »><br><label style= »font-size: 12px; font-weight: normal; color: #696969; » for= » »>Organisme</label><br> <input type= »text » name= »CustomValue[3][fieldValue] » value= » » style= »width: 100%; height: 30px; color: #696969; margin-top: 2px; padding: 0px 10px; max-width: 250px; margin-bottom: 10px; border: solid 1px #ccc; -webkit-border-radius: 5px; -moz-border-radius: 5px; border-radius: 5px; -webkit-box-shadow: 0px 0px 2px 0px #ccc; -moz-box-shadow: 0px 0px 2px 0px #ccc; box-shadow: 0px 0px 2px 0px #ccc; font-family: 'Helvetica Neue', Arial, Lucida Grande, sans-serif; »><br><label style= »font-size: 12px; font-weight: normal; color: #696969; » for= » »>Profession</label><br> <input type= »text » name= »CustomValue[2][fieldValue] » value= » » style= »width: 100%; height: 30px; color: #696969; margin-top: 2px; padding: 0px 10px; max-width: 250px; margin-bottom: 10px; border: solid 1px #ccc; -webkit-border-radius: 5px; -moz-border-radius: 5px; border-radius: 5px; -webkit-box-shadow: 0px 0px 2px 0px #ccc; -moz-box-shadow: 0px 0px 2px 0px #ccc; box-shadow: 0px 0px 2px 0px #ccc; font-family: 'Helvetica Neue', Arial, Lucida Grande, sans-serif; »><br><br><input type= »checkbox » name= »concern » value= »1″ required style= »color: #696969; margin-top: 2px; padding: 0px 10px;margin-bottom: 10px; -webkit-border-radius: 5px; -moz-border-radius: 5px; border-radius: 5px; font-family: 'Helvetica Neue', Arial, Lucida Grande, sans-serif; »><label style= »font-size: 14px; font-weight: bold; color: #696969; » for= » »>En envoyant ce formulaire vous confirmez donner les informations ci-dessus et votre consentement.</label><br><br> <div id= »botdetect-captcha » data-captchastylename= »jqueryBasicCaptcha »></div>
<label>
<span style= »font-size: 12px; font-weight: normal; color: #696969; »>’Saisir les caractères'</span>
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required
style= »width: 100%; height: 30px; color: #696969; margin-top: 2px; padding: 0px 10px; max-width: 250px; margin-bottom: 10px; border: solid 1px #ccc; -webkit-border-radius: 5px; -moz-border-radius: 5px; border-radius: 5px; -webkit-box-shadow: 0px 0px 2px 0px #ccc; -moz-box-shadow: 0px 0px 2px 0px #ccc; box-shadow: 0px 0px 2px 0px #ccc; font-family: ‘Helvetica Neue’, Arial, Lucida Grande, sans-serif; »
><br><br><input type=’hidden’ id=’formActionUrl’ value=’https://agglochaumont.digitalebox.fr/newsletter/subscribe’><input type=’hidden’ id=’siteBaseUrl’ value=’https://agglochaumont.digitalebox.fr’><input type=’hidden’ name=’formId’ value=’NQ==’><input type=’hidden’ name=’callBackUrl’ value=’https://www.agglo-chaumont.fr’><!– Redirect URL ex: http://www.google.com, if not set redirects to client page –>
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