Andreas Hnida
d5867d2a7d
Some checks failed
Build and Deploy Hugo Site / buildAndDeploy (push) Failing after 43s
99 lines
3.8 KiB
Markdown
99 lines
3.8 KiB
Markdown
+++
|
|
date = '2024-02-21T13:22:03Z'
|
|
draft = false
|
|
title = 'Zusatzmodule Freiberufliche'
|
|
translationKey = 'zusatzmodule-freiberufliche'
|
|
bestellformular = true
|
|
+++
|
|
|
|
{{% section %}} {{% aligncenter %}}
|
|
|
|
#### Formulaire de commande
|
|
|
|
## VeruA \*\* Facturation et Administration
|
|
|
|
### infirmiers indépendants module supplementaire
|
|
|
|
<br>
|
|
|
|
---
|
|
|
|
<br>
|
|
|
|
{{% /aligncenter %}}
|
|
|
|
<form action="/php/ajaxmail.php" method="POST" id="bestellformular">
|
|
<input type="hidden" name="formularart" value="Zusatzmodule Freiberufliche">
|
|
<div>
|
|
<label class="hidden" for="gender">Sexe</label>
|
|
<select id="gender" name="gender" required >
|
|
<option value="weiblich">Madame</option>
|
|
<option value="männlich">Monsieur</option>
|
|
<option value="divers">Divers</option>
|
|
</select>
|
|
</div>
|
|
<div>
|
|
<label for="sprache">Langue</label>
|
|
<select id="sprache" name="sprache" required >
|
|
<option value="deutsch">Allemand</option>
|
|
<option value="franzoesisch">Français</option>
|
|
</select>
|
|
</div>
|
|
<div>
|
|
<label for="name">Nom</label>
|
|
<input type="text" id="name" name="name" required >
|
|
</div>
|
|
<div>
|
|
<label for="vorname">Prénom</label>
|
|
<input type="text" id="vorname" name="vorname" required >
|
|
</div>
|
|
<div>
|
|
<input type="text" id="hobbies" name="hobbies" autocomplete="off">
|
|
</div>
|
|
<div>
|
|
<label for="strasse">Rue et numéro d'huis</label>
|
|
<input type="text" id="strasse" name="strasse" required >
|
|
</div>
|
|
<div>
|
|
<input type="text" id="age" name="age" autocomplete="off">
|
|
</div>
|
|
<div>
|
|
<label for="plz_ort">NPAI Localité</label>
|
|
<input type="text" id="plz_ort" name="plz_ort" required >
|
|
</div>
|
|
<div>
|
|
<label for="telefon">Téléphone</label>
|
|
<input type="text" id="telefon" name="telefon" required >
|
|
</div>
|
|
<div>
|
|
<label for="email">E-mail</label>
|
|
<input type="email" id="email" name="email" required >
|
|
</div>
|
|
<div>
|
|
<input type="verify_email" id="verify_email" name="verify_email" autocomplete="off">
|
|
</div>
|
|
<div id="zsr-tooltip" data-tooltip="Veuillez entrer un numéro RCC valide ou 'demandé'.">
|
|
<label for="zsr_nummer">Nr. RCC</label>
|
|
<input type="text" id="zsr_nummer" name="zsr_nummer" required >
|
|
</div>
|
|
<div><br><br>
|
|
<h5>Quelles extensions souhaitez-vous ajouter ?</h5><br>
|
|
<div id="checkbox-group">
|
|
<input type="checkbox" id="zusatzmodul-materialverwaltung" name="zusatzmodul-materialverwaltung" value="Ja">
|
|
<label for="zusatzmodul-materialverwaltung">Module complémentaire gestion du matériel pour 260 CHF</label>
|
|
<br>
|
|
<input type="checkbox" id="zusatzmodul-qr-code" name="zusatzmodul-qr-code" value="Ja">
|
|
<label for="zusatzmodul-qr-code">Module complémentaire code QR pour 36.00 CHF par an, frais de désactivation uniques par instance 50.00 CHF</label>
|
|
<br>
|
|
<input type="checkbox" id="zusatzmodul-perigon" name="zusatzmodul-perigon" value="Ja">
|
|
<label for="zusatzmodul-perigon">Module complémentaire Perigon, frais de désactivation uniques 50.00 CHF</label>
|
|
</div>
|
|
<center class="w-full">
|
|
{{< captcha >}}
|
|
<button id="bestellformular-btn" type="submit" class="submitbutton text-white mx-auto submit-after-valid-captcha" >Commander avec obligation de paiement</button>
|
|
|
|
<p><div id="notification" class="bg-blue-500 text-white rounded invisible opacity-0 hidden">Notification</div></p>
|
|
</center>
|
|
</form>
|
|
|
|
{{% /section %}}
|