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Current File : /home/meir5web/public_html/f/form_inc_yoni.php
				<?php
				if(empty($_GET['don'])) $_GET['don']='ponctuel';
				$list_formulaire=array();
				$don = $_GET['don'];
				if ($don!=''){
				if ($don=='ponctuel') echo "<h2><font color='#0066FF'>Don ponctuel :</font></h2>";
			//	else if ($don=='abonnement') echo "<h2><font color='#0066FF'>Don par abonnement p&eacute;riodique :</font></h2>";
				else if ($don=='manif') echo "<h2><font color='#0066FF'>Gala ou manifestation :</font></h2>";
				?>
				
                    <form action="/stripe/public/checkout.php#top" method="POST" name="validation" id="validation"
            ONSUBMIT="return  verif_form();">
			<input type="hidden" name="type_don" value="<?=$don?>" />
                      <div align="center"><a name="form"></a><span class="textRed">* Champs obligatoire</span><br><span class="textRed">Les informations renseign&eacute;es ci-dessous, seront utilis&eacute;es dans le CERFA.</span><br>
                      </div>
                      <table width="100%" border="0" align="center" cellpadding="0" cellspacing="0">
                        <tr>
                          <td><div align="center"><span class="text1"></span>
                          </div>
                            <table width="100%" border="0" cellpadding="2" cellspacing="2" class="text1">
                              
                              <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="text1"><div align="right" class="headerNewsHP"> <span class="textRed">*</span>Titre : </div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><select name="titre" id="form_titre" class="headerNewsHP">
                                    <option value="Mr">Mr </option>
                                    <option value="Mme">Mme </option>
                                    <option value="Mlle">Melle </option>
                                    <option value="Mr & Mme">Mr & Mme </option>
                                  </select>
								  <?php $list_formulaire[]='titre'; ?>
                                    <b>
                                    <input name="MPreffers" type="hidden"  id="MPreffers" 
							value="<? echo $MPreffers; ?>" >
							<input name="MPbanner" type="hidden"  id="MPbanner" 
							value="<? echo $MPbanner; ?>" >
                                  </b> </td>
                              </tr>
                              <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> <span class="textRed">*</span>Nom: </div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <input name="nom" id="form_nom" type="text" class="headerNewsHP" value="<?php echo $_COOKIE['nom'] ?>">
                                </b>
								<?php $list_formulaire[]='nom'; ?>
								</td>
                              </tr>
							  <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> <span class="textRed">*</span>Pr&eacute;nom: </div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <input name="prenom" id="form_prenom" type="text" class="headerNewsHP" value="<?php echo $_COOKIE['prenom'] ?>">
								  <?php $list_formulaire[]='prenom'; ?>
                                </b></td>
                              </tr>
							   <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> <span class="textRed">*</span>Adresse: </div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <input  name="adresse" id="form_adresse" type="text" class="headerNewsHP" value="<?php echo $_COOKIE['adresse'] ?>" maxlength="50">
                                </b>
								<?php $list_formulaire[]='adresse'; ?>
								</td>
                              </tr>
							   <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> <span class="textRed">*</span>Code postal: </div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <input name="cp" id="form_cp" type="text" class="headerNewsHP" value="<?php echo $_COOKIE['cp'] ?>" size="10" maxlength="10">
                                </b>
								<?php $list_formulaire[]='cp'; ?>
								</td>
                              </tr>
							   <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> <span class="textRed">*</span>Ville: </div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <input  name="ville" id="form_ville" type="text" class="headerNewsHP" value="<?php echo $_COOKIE['ville'] ?>" maxlength="50">
                                </b>
								<?php $list_formulaire[]='ville'; ?>
								</td>
                              </tr>
							   <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> <span class="textRed">*</span>Pays: </div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <input name="pays" id="form_pays" type="text" class="headerNewsHP" value="<?php echo $_COOKIE['pays'] ?>" size="10" maxlength="20">
								  <?php $list_formulaire[]='pays'; ?>
                                </b></td>
                              </tr>
							  <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> T&eacute;l&eacute;phone: </div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <input name="tel" id="form_tel" type="text" class="headerNewsHP" value="<?php echo $_COOKIE['tel'] ?>" size="10" maxlength="20">
								  <?php //$list_formulaire[]='tel'; ?>
                                </b></td>
                              </tr>
							   <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> Portable: </div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <input name="portable" id="form_portable" type="text" class="headerNewsHP" value="<?php echo $_COOKIE['portable'] ?>" size="10" maxlength="20">
								  <?php //$list_formulaire[]='portable'; ?>
                                </b></td>
                              </tr>
                              <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> <span class="textRed">*</span>E-mail:</div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <input name="email" id="email" type="text" class="headerNewsHP" onChange="javascript:this.value=this.value.toLowerCase();" value="<?php echo $_COOKIE['email'] ?>">
								  <?php $list_formulaire[]='email'; ?>
                                </b></td>
                              </tr>
							  </table>
                 <?
					
					if ($don=='ponctuel'){
					?>
 <!--Don ponctuel-->
						 </font>
						  <table width="100%" border="0" cellpadding="2" cellspacing="2" class="text1"> 
     <?php            /*        <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> <span class="textRed">*</span>Occasion: </div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <select name="occasion" id="form_occasion" class="headerNewsHP">
                                    <option value="Pourim: Micheté enfant 10€">Pourim: Michet&eacute; enfant 10&euro;</option>
                                    <option value="Pessah: Carte magnétique 60€">Pessah: Carte magn&eacute;tique 60&euro;</option>
                                    <option value="Autre">Autre</option>
                                  </select>
								  <?php $list_formulaire[]='occasion'; ?>
                                </b></td>
                              </tr> */
?>
							  <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> <span class="textRed">*</span>Montant en EUROS: </div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <input name="montant" id="form_montant" type="text" class="headerNewsHP" onChange="javascript:this.value=this.value.toLowerCase();" value="<?php echo $_COOKIE['montant'] ?>">
                                <?php $list_formulaire[]='montant'; ?>
								</b></td>
                              </tr>
							  <?php /*
							  <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> <span class="textRed">*</span>Date :</div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <input name="date" id="form_date" type="text" class="headerNewsHP" onChange="javascript:this.value=this.value.toLowerCase();" value="<?php echo $_COOKIE['date'] ?>">
								  <?php $list_formulaire[]='date'; ?>
                                </b></td>
                              </tr>
							  */
							  ?>
							  <tr><td colspan="2"><br>Un cerfa vous sera envoy&eacute; d&egrave;s validation du paiement.<br>Merci de v&eacute;rifier la validit&eacute; des informations renseign&eacute;es ci-dessus.</td></tr>
							  </table>

	<?}
	else if ($don=='abonnement'){?>
	 <!--Don abonnement-->
	<br><br>
				 
						 </font>
						  <table width="100%" border="0" cellpadding="2" cellspacing="2" class="text1"> 
                              <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right">P&eacute;riodicit&eacute; :  <span class="textRed">*</span></div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <select name="periodicite" id="form_periodicite" class="headerNewsHP">
                                    <option>Choisir la p&eacute;riodicit&eacute;</option>
                                    <option>Mensuelle</option>
                                    <option>Trimestrielle</option>
                                  </select>
								  <?php $list_formulaire[]='periodicite'; ?>
                                </b></td>
                              </tr>
							  <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> <span class="textRed">*</span>Dur&eacute;e : </div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                   <select name="duree" id="form_duree" class="headerNewsHP">
                                    <option>Choisir la dur&eacute;e</option>
                                    <option>Indetermin&eacute;e</option>
                                    <option>D&eacute;termin&eacute;e</option>
                                  </select>
								  <?php $list_formulaire[]='duree'; ?>
                                </b></td>
                              </tr>
							  <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> <span class="textRed">*</span>Montant en EUROS :</div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <input name="montant" id="form_montant" type="text" class="headerNewsHP" onChange="javascript:this.value=this.value.toLowerCase();" value="<?php echo $_COOKIE['montant'] ?>">€
								  <?php $list_formulaire[]='montant'; ?>
                                </b></td>
                              </tr>
							   <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> <span class="textRed">*</span>A partir du mois de : </div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
								<?php $list_formulaire[]='du_mois'; ?>
                                   <select name="du_mois" id="form_du_mois" class="headerNewsHP">
                                    <option>Choisir le mois</option>
                                    <option>Janvier</option>
                                    <option>F&eacute;vrier</option>
                                    <option>Mars</option>
                                    <option>Avril</option>
                                    <option>Mai</option>
                                    <option>Juin</option>
                                    <option>Juillet</option>
                                    <option>Ao&ucirc;t</option>
                                    <option>Septembre</option>
                                    <option>Octobre</option>
                                    <option>Novembre</option>
                                    <option>D&eacute;cembre</option>
                                  </select>
                                </b></td>
                              </tr>
							  <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> <span class="textRed">*</span>Choisir le jour:  </div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
								<?php $list_formulaire[]='du_jour'; ?>
                                   <select name="du_jour" id="form_du_jour" class="headerNewsHP">
                                    <option>Choisir le jour</option>
                                    <?for ($i=1;$i<32;$i++) echo "<option>".$i."</option>";?>
                                  </select>
                                </b></td>
                              </tr>
							  <tr><td colspan="2">Un cerfa du montant total reçu vous sera envoy&eacute; &agrave; la fin de chaque ann&eacute;e civile.</td></tr>
							  </table>		
<?}
else if ($don=='manif') echo "<h2><font color='#0066FF'>Gala ou manifestation :</font></h2>";
?>
<br><br>
							  <!--Info complementaire:adresse expedition-->
							  <table width="100%" border="0" cellpadding="2" cellspacing="2" class="text1">
                           
							  <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"colspan="2">Autre adresse d'exp&eacute;dition &agrave; pr&eacute;ciser:</td>
                              </tr>
							  
                              <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> <span class="textRed"></span>Nom: </div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <input name="nom_autre" id="form_nom_autre" type="text" class="headerNewsHP" value="<?php echo $_COOKIE['nom2'] ?>">
								  <?php // $list_formulaire[]='nom_autre'; ?>
                                </b></td>
                              </tr>
							  
							  <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> <span class="textRed"></span>Pr&eacute;nom: </div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <input name="prenom_autre" id="form_prenom_autre" type="text" class="headerNewsHP" value="<?php echo $_COOKIE['prenom2'] ?>">
								  <?php // $list_formulaire[]='prenom_autre'; ?>
                                </b></td>
                              </tr>
							   <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> <span class="textRed"></span>Adresse: </div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <input  name="adresse_autre" id="form_adresse_autre" type="text" class="headerNewsHP" value="<?php echo $_COOKIE['adresse2'] ?>" maxlength="50">
								  <?php // $list_formulaire[]='adresse_autre'; ?>
                                </b></td>
                              </tr>
							   <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> <span class="textRed"></span>Code postal: </div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <input name="cp_autre" id="form_cp_autre" type="text" class="headerNewsHP" value="<?php echo $_COOKIE['cp2'] ?>" size="10" maxlength="10">
								  <?php // $list_formulaire[]='cp_autre'; ?>
                                </b></td>
                              </tr>
							   <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> <span class="textRed"></span>Ville: </div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <input  name="ville_autre" id="form_ville_autre" type="text" class="headerNewsHP" value="<?php echo $_COOKIE['ville2'] ?>" maxlength="50">
								  <?php // $list_formulaire[]='ville_autre'; ?>
                                </b></td>
                              </tr>
							  </table>
							  <!--Fin Info complementaire-->
							 
						 <table width="100%" border="0" cellpadding="2" cellspacing="2" class="text1">
						 <tr><td colspan="2" align="center"><br>Choix de la Carte<br></td></tr>
						 <tr><td colspan="2" align="center">
						 <table><tr><td><input type="image" name="cb" src="f/logo_cb.jpg"></td><td><input type="image" name="visa" src="f/logo_visa.jpg"></td><td><input type="image" name="mastercard" src="f/logo_mastercard.jpg"></td></tr></table><br><br>

<div align="center"><span class="textRed" style="font-size:24px;"><b>ATTENTION : Apres avoir cliqu&eacute; sur une des cartes, veuillez patienter quelques secondes et ne pas cliquer de suite sur le bouton bleu "Valider le paiement"</b></span><br><br>
                      </div>

						 <u>Renseignements relatifs au don:</u><br>
							 Un accus&eacute; de r&eacute;ception vous parviendra automatiquement apr&egrave;s validation du paiement.  <br><br>
						 </td></tr>
						 <!--<tr>
                                <td width="50%"><div align="right">
                                    <input type="reset" name="clear" value="effacer" class="frame">
                                </div></td>
                                <td width="50%"><input type=submit value="envoyer" class="frame">                                </td>
                              </tr>-->
                          </table>
                            <span class="headerNewsHP"><b>
                            <script>
							function verif_form1()
							{
							if(<?php $script=''; 
							foreach($list_formulaire as $id)
								$script.= ' !document.getElementById("form_'.$id.'").value ||';
							echo substr($script,0,-2);
							?>)
								{
								alert('Vous devez remplir tout les champs obligatoire.');
								return false;
								}
							}
							
							function verif_form()
							{
							<?php $script=''; 
							foreach($list_formulaire as $id)
								{
								echo 'if(!document.getElementById("form_'.$id.'").value) {';
								echo 'alert(\'Vous devez remplir tout les champs obligatoire ('.$id.').\');';
								echo 'return false; } ';
								}
							?>
							}
							</script>
                            </b></span></td>
                        </tr>
                      </table>
                    </form>
					<?}?>

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