{"id":2712,"date":"2026-05-12T13:43:56","date_gmt":"2026-05-12T13:43:56","guid":{"rendered":"https:\/\/cma31.fr\/?page_id=2712"},"modified":"2026-05-12T13:44:29","modified_gmt":"2026-05-12T13:44:29","slug":"formulaire-de-contact","status":"publish","type":"page","link":"https:\/\/cma31.fr\/?page_id=2712","title":{"rendered":"Formulaire de contact"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"2712\" class=\"elementor elementor-2712\">\n\t\t\t\t<div class=\"elementor-element elementor-element-f3c5dfa e-flex e-con-boxed e-con e-parent\" data-id=\"f3c5dfa\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-856c982 elementor-widget elementor-widget-sureforms_form\" data-id=\"856c982\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"sureforms_form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t<div class=\"srfm-form-container srfm-form-container-2395 srfm-form-container-2395-elementor-856c982 srfm-bg-color\">\n\t\t\t<style>\n\t\t\t\t\/* Need to check and remove the input variables related to the Style Tab. *\/\n\t\t\t\t.srfm-form-container-2395-elementor-856c982 {\n\t\t\t\t\t\/* New test variables *\/\n\t\t\t\t\t--srfm-color-scheme-primary: var(--ast-global-color-0);\n\t\t\t\t\t--srfm-color-scheme-text-on-primary: #FFFFFF;\n\t\t\t\t\t--srfm-color-scheme-text: var(--ast-global-color-2);\n\t\t\t\t\t--srfm-quill-editor-color: var(--ast-global-color-0);\n\n\t\t\t\t\t--srfm-color-input-label: var(--ast-global-color-2);\n\t\t\t\t\t--srfm-color-input-description: hsl( from var(--ast-global-color-2) h s l \/ 0.65 );\n\t\t\t\t\t--srfm-color-input-placeholder: hsl( from var(--ast-global-color-2) h s l \/ 0.5 );\n\t\t\t\t\t--srfm-color-input-text: var(--ast-global-color-2);\n\t\t\t\t\t--srfm-color-input-prefix: hsl( from var(--ast-global-color-2) h s l \/ 0.65 );\n\t\t\t\t\t--srfm-color-input-background: hsl( from var(--ast-global-color-2) h s l \/ 0.02 );\n\t\t\t\t\t--srfm-color-input-background-hover: hsl( from var(--ast-global-color-2) h s l \/ 0.05 );\n\t\t\t\t\t--srfm-color-input-background-disabled: hsl( from var(--ast-global-color-2) h s l \/ 0.07 );\n\t\t\t\t\t--srfm-color-input-border: hsl( from var(--ast-global-color-2) h s l \/ 0.25 );\n\t\t\t\t\t--srfm-color-input-border-disabled: hsl( from var(--ast-global-color-2) h s l \/ 0.15 );\n\t\t\t\t\t--srfm-color-multi-choice-svg: hsl( from var(--ast-global-color-2) h s l \/ 0.7 );\n\t\t\t\t\t--srfm-color-input-border-hover: hsl( from var(--ast-global-color-0) h s l \/ 0.65 );\n\t\t\t\t\t--srfm-color-input-border-focus-glow: hsl( from var(--ast-global-color-0) h s l \/ 0.15 );\n\t\t\t\t\t--srfm-color-input-selected: hsl( from var(--ast-global-color-0) h s l \/ 0.1 );\n\t\t\t\t\t--srfm-btn-color-hover: hsl( from var(--ast-global-color-0) h s l \/ 0.9 );\n\t\t\t\t\t--srfm-btn-color-disabled: hsl( from var(--ast-global-color-0) h s l \/ 0.25 );\n\n\t\t\t\t\t\/* Dropdown Variables *\/\n\t\t\t\t\t--srfm-dropdown-input-background-hover: hsl( from var(--ast-global-color-2) h s l \/ 0.05 );\n\t\t\t\t\t--srfm-dropdown-option-background-hover: hsl( from var(--ast-global-color-2) h s l \/ 0.10 );\n\t\t\t\t\t--srfm-dropdown-option-background-selected: hsl( from var(--ast-global-color-2) h s l \/ 0.05 );\n\t\t\t\t\t--srfm-dropdown-option-selected-icon: hsl( from var(--ast-global-color-2) h s l \/ 0.65 );\n\t\t\t\t\t--srfm-dropdown-option-text-color: hsl( from var(--ast-global-color-2) h s l \/ 0.80 );\n\t\t\t\t\t--srfm-dropdown-option-selected-text: var(--ast-global-color-2);\n\t\t\t\t\t--srfm-dropdown-badge-background: hsl( from var(--ast-global-color-2) h s l \/ 0.05 );\n\t\t\t\t\t--srfm-dropdown-badge-background-hover: hsl( from var(--ast-global-color-2) h s l \/ 0.10 );\n\t\t\t\t\t--srfm-dropdown-menu-border-color: hsl( from var(--ast-global-color-2) h s l \/ 0.10 );\n\t\t\t\t\t--srfm-dropdown-placeholder-color: hsl( from var(--ast-global-color-2) h s l \/ 0.50 );\n\t\t\t\t\t--srfm-dropdown-icon-color: hsl( from var(--ast-global-color-2) h s l \/ 0.65 );\n\t\t\t\t\t--srfm-dropdown-icon-disabled: hsl( from var(--ast-global-color-2) h s l \/ 0.25 );\n\n\t\t\t\t\t\/* Background Control Variables *\/\n\t\t\t\t\t--srfm-instant-form-padding-top: 32px;--srfm-instant-form-padding-right: 32px;--srfm-instant-form-padding-bottom: 32px;--srfm-instant-form-padding-left: 32px;--srfm-instant-form-border-radius-top: 12px;--srfm-instant-form-border-radius-right: 12px;--srfm-instant-form-border-radius-bottom: 12px;--srfm-instant-form-border-radius-left: 12px;--srfm-form-padding-top: 0px;--srfm-form-padding-right: 0px;--srfm-form-padding-bottom: 0px;--srfm-form-padding-left: 0px;--srfm-form-border-radius-top: 0px;--srfm-form-border-radius-right: 0px;--srfm-form-border-radius-bottom: 0px;--srfm-form-border-radius-left: 0px;--srfm-bg-overlay-opacity: 1;\t\t\t\t\t--srfm-row-gap-between-blocks: 18px;--srfm-address-label-font-size: 16px;--srfm-address-label-line-height: 24px;--srfm-address-description-font-size: 14px;--srfm-address-description-line-height: 20px;--srfm-col-gap-between-fields: 16px;--srfm-row-gap-between-fields: 16px;--srfm-gap-below-address-label: 14px;--srfm-dropdown-font-size: 14px;--srfm-dropdown-gap-between-input-menu: 4px;--srfm-dropdown-badge-padding: 2px 6px;--srfm-dropdown-multiselect-font-size: 12px;--srfm-dropdown-multiselect-line-height: 16px;--srfm-dropdown-padding-right: 12px;--srfm-dropdown-padding-right-icon: calc( var( --srfm-dropdown-padding-right ) + 20px );--srfm-dropdown-multiselect-padding: 8px var( --srfm-dropdown-padding-right-icon ) 8px 8px;--srfm-input-height: 44px;--srfm-input-field-padding: 10px 12px;--srfm-input-field-font-size: 16px;--srfm-input-field-line-height: 24px;--srfm-input-field-margin-top: 6px;--srfm-input-field-margin-bottom: 6px;--srfm-checkbox-label-font-size: 16px;--srfm-checkbox-label-line-height: 24px;--srfm-checkbox-description-font-size: 14px;--srfm-checkbox-description-line-height: 20px;--srfm-check-ctn-width: 16px;--srfm-check-ctn-height: 16px;--srfm-check-svg-size: 10px;--srfm-checkbox-margin-top-frontend: 4px;--srfm-checkbox-margin-top-editor: 6px;--srfm-check-gap: 8px;--srfm-checkbox-description-margin-left: 24px;--srfm-flag-section-padding: 10px 0 10px 12px;--srfm-gap-between-icon-text: 8px;--srfm-label-font-size: 16px;--srfm-label-line-height: 24px;--srfm-description-font-size: 14px;--srfm-description-line-height: 20px;--srfm-btn-padding: 10px 14px;--srfm-btn-font-size: 16px;--srfm-btn-line-height: 24px;--srfm-multi-choice-horizontal-padding: 20px;--srfm-multi-choice-vertical-padding: 20px;--srfm-multi-choice-internal-option-gap: 8px;--srfm-multi-choice-vertical-svg-size: 40px;--srfm-multi-choice-horizontal-image-size: 24px;--srfm-multi-choice-vertical-image-size: 120px;--srfm-multi-choice-outer-padding: 2px;\t\t\t\t}\n\t\t\t<\/style>\n\t\t\t\t\t\t\t<h2 class=\"srfm-form-title\">Formulaire de contact<\/h2>\n\t\t\t\t\t\t\t\t<form method=\"post\" enctype=\"multipart\/form-data\" id=\"srfm-form-2395\" class=\"srfm-form \"\n\t\t\t\tform-id=\"2395\" after-submission=\"hide form\" message-type=\"same page\" success-url=\"\" ajaxurl=\"https:\/\/cma31.fr\/wp-admin\/admin-ajax.php\" data-submit-token=\"16f75e9bedaddbde60f82c304c99f2d3de16c316fbf1a262dd7c4f58f3cbec6d\"\n\t\t\t\t>\n\t\t\t\t\n\t\t\t\t<input type=\"hidden\" value=\"2395\" name=\"form-id\">\n\t\t\t\t<input type=\"hidden\" value=\"\" name=\"srfm-sender-email-field\" id=\"srfm-sender-email\">\n\t\t\t\t<input type=\"hidden\" value=\"\" id=\"srfm-page-break\">\n\t\t\t\t\t\t<p id=\"srfm-error-message\" class=\"srfm-common-error-message srfm-error-message srfm-head-error\" hidden>\t\t<span class=\"srfm-icon\" aria-hidden=\"true\">\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"20\" height=\"20\" fill=\"none\"><path d=\"M9.99935 18.3327C14.6017 18.3327 18.3327 14.6017 18.3327 9.99935C18.3327 5.39698 14.6017 1.66602 9.99935 1.66602C5.39698 1.66602 1.66602 5.39698 1.66602 9.99935C1.66602 14.6017 5.39698 18.3327 9.99935 18.3327Z\" stroke=\"currentColor\" stroke-width=\"1.5\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M10 6.66602V9.99935\" stroke=\"currentColor\" stroke-width=\"1.5\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M10 13.334H10.0083\" stroke=\"currentColor\" stroke-width=\"1.5\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<span class=\"srfm-error-content\">Une erreur s\u2019est produite lors de l\u2019envoi de votre formulaire. Veuillez r\u00e9essayer.<\/span><\/p>\n\t\t\t\t\t<div data-block-id=\"a2a54828\" class=\"srfm-block-single srfm-block srfm-input-block srf-input-a2a54828-block  srfm-block-width-100 srfm-slug-text-field 2395\" >\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-description\" id=\"srfm-description-a2a54828\">\n\t\t\t\t\t\tL'ID se retrouve au dos de votre carte de membre\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t<input class=\"srfm-input-common srfm-input-input\" type=\"text\" name=\"srfm-input-a2a54828-lbl-Vm90cmUgSUQgZg-text-field\" id=\"srfm-input-a2a54828-lbl-Vm90cmUgSUQgZg\"\n\t\t\t\t\taria-describedby='srfm-error-a2a54828 srfm-description-a2a54828'\t\t\t\t\tdata-required=\"true\" aria-required=\"true\" data-unique=\"false\" maxlength=\"100\" value=\"\"  placeholder=\"Votre ID f *\"  data-srfm-mask=\"none\"   \/>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-a2a54828\" data-error-msg=\"Ce champ est n\u00e9cessaire.\" data-unique-msg=\"La valeur doit \u00eatre unique.\">\n\t\t\t\t\t\tCe champ est n\u00e9cessaire.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\n\n\t\t\t<div data-block-id=\"8c4fa4ec\" class=\"srfm-block-single srfm-block srfm-input-block srf-input-8c4fa4ec-block  srfm-block-width-100 srfm-slug-phone-number 2395\" >\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t<input class=\"srfm-input-common srfm-input-input\" type=\"text\" name=\"srfm-input-8c4fa4ec-lbl-VMOpbMOpcGhvbmU-phone-number\" id=\"srfm-input-8c4fa4ec-lbl-VMOpbMOpcGhvbmU\"\n\t\t\t\t\taria-describedby='srfm-error-8c4fa4ec'\t\t\t\t\tdata-required=\"true\" aria-required=\"true\" data-unique=\"false\" maxlength=\"100\" value=\"\"  placeholder=\"T\u00e9l\u00e9phone *\"  data-srfm-mask=\"none\"   \/>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-8c4fa4ec\" data-error-msg=\"Ce champ est n\u00e9cessaire.\" data-unique-msg=\"La valeur doit \u00eatre unique.\">\n\t\t\t\t\t\tCe champ est n\u00e9cessaire.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\n\n\t\t<div data-block-id=\"b99788e9\" class=\"srfm-block-single srfm-block srfm-multi-choice-block srf-multi-choice-b99788e9-block  srfm-block-width-100 srfm-slug-votre-probleme-concerne 2395 srfm-checkbox-mode\">\n\t\t\t<fieldset>\n\t\t\t\t<input class=\"srfm-input-multi-choice-hidden\" data-required=\"true\" aria-required=\"true\"  name=\"srfm-input-multi-choice-b99788e9-lbl-Vm90cmUgcHJvYmzDqG1lIGNvbmNlcm5lIDo-votre-probleme-concerne\" type=\"hidden\" value=\"\"\/>\n\t\t\t\t<legend class=\"srfm-block-legend\">\n\t\t\t\t\t\t\t\t\t\tVotre probl\u00e8me concerne :\t\t\t\t\t\t\t\t\t\t\t<span class=\"srfm-required\" aria-hidden=\"true\"> *<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/legend>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-description\" id=\"srfm-description-b99788e9\">\n\t\t\t\t\t\tS\u00e9lectionner le probl\u00e8me qui vous concerne\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap srfm-choice-width-100 \">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-multi-choice-single\">\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\n\t\t\t\t\t\t\t\t\t\tid=\"srfm-multi-choice-b99788e9-0\"\n\t\t\t\t\t\t\t\t\t\tclass=\"srfm-input-multi-choice-single\" \t\t\t\t\t\t\t\t\t\taria-describedby=\"srfm-error-b99788e9 srfm-description-b99788e9\"\t\t\t\t\t\t\t\t\t\taria-required=\"true\"\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-content-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-option-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"srfm-option-image\" aria-hidden=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/cma31.fr\/wp-content\/uploads\/2026\/05\/cagire.jpeg\" alt=\"Cagire\" title=\"Formulaire de contact\">\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<!-- This label content is used in conditional logic and for storing values in a hidden input field as comma-separated values.\n\t\t\t\t\t\t\t\t\t\t\tThe markup should remain unchanged.\n\t\t\t\t\t\t\t\t\t\t\tIf you make any changes here, ensure the corresponding JavaScript value functionality and conditional logic are also updated. -->\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"srfm-multi-choice-b99788e9-0\" data-option-text=\"Indigestion\">Indigestion<\/label>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-icon-container\">\t\t<span class=\"srfm-icon srfm-multi-choice-icon\" aria-hidden=\"true\">\n\t\t\t<svg width=\"17\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M6.5 7.33366L8.5 9.33366L15.1667 2.66699\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M14.5 8V12.6667C14.5 13.0203 14.3595 13.3594 14.1095 13.6095C13.8594 13.8595 13.5203 14 13.1667 14H3.83333C3.47971 14 3.14057 13.8595 2.89052 13.6095C2.64048 13.3594 2.5 13.0203 2.5 12.6667V3.33333C2.5 2.97971 2.64048 2.64057 2.89052 2.39052C3.14057 2.14048 3.47971 2 3.83333 2H11.1667\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t\t\t<span class=\"srfm-icon srfm-multi-choice-icon-unchecked\" aria-hidden=\"true\">\n\t\t\t<svg width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.6667 2H3.33333C2.59695 2 2 2.59695 2 3.33333V12.6667C2 13.403 2.59695 14 3.33333 14H12.6667C13.403 14 14 13.403 14 12.6667V3.33333C14 2.59695 13.403 2 12.6667 2Z\" stroke=\"#1E1E1E\" stroke-opacity=\"0.7\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-multi-choice-single\">\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\n\t\t\t\t\t\t\t\t\t\tid=\"srfm-multi-choice-b99788e9-1\"\n\t\t\t\t\t\t\t\t\t\tclass=\"srfm-input-multi-choice-single\" \t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-content-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-option-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"srfm-option-image\" aria-hidden=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/cma31.fr\/wp-content\/uploads\/2026\/05\/usine.jpg\" alt=\"Usine\" title=\"Formulaire de contact\">\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<!-- This label content is used in conditional logic and for storing values in a hidden input field as comma-separated values.\n\t\t\t\t\t\t\t\t\t\t\tThe markup should remain unchanged.\n\t\t\t\t\t\t\t\t\t\t\tIf you make any changes here, ensure the corresponding JavaScript value functionality and conditional logic are also updated. -->\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"srfm-multi-choice-b99788e9-1\" data-option-text=\"Hantavirus\">Hantavirus<\/label>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-icon-container\">\t\t<span class=\"srfm-icon srfm-multi-choice-icon\" aria-hidden=\"true\">\n\t\t\t<svg width=\"17\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M6.5 7.33366L8.5 9.33366L15.1667 2.66699\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M14.5 8V12.6667C14.5 13.0203 14.3595 13.3594 14.1095 13.6095C13.8594 13.8595 13.5203 14 13.1667 14H3.83333C3.47971 14 3.14057 13.8595 2.89052 13.6095C2.64048 13.3594 2.5 13.0203 2.5 12.6667V3.33333C2.5 2.97971 2.64048 2.64057 2.89052 2.39052C3.14057 2.14048 3.47971 2 3.83333 2H11.1667\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t\t\t<span class=\"srfm-icon srfm-multi-choice-icon-unchecked\" aria-hidden=\"true\">\n\t\t\t<svg width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.6667 2H3.33333C2.59695 2 2 2.59695 2 3.33333V12.6667C2 13.403 2.59695 14 3.33333 14H12.6667C13.403 14 14 13.403 14 12.6667V3.33333C14 2.59695 13.403 2 12.6667 2Z\" stroke=\"#1E1E1E\" stroke-opacity=\"0.7\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-multi-choice-single\">\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\n\t\t\t\t\t\t\t\t\t\tid=\"srfm-multi-choice-b99788e9-2\"\n\t\t\t\t\t\t\t\t\t\tclass=\"srfm-input-multi-choice-single\" \t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-content-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-option-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<!-- This label content is used in conditional logic and for storing values in a hidden input field as comma-separated values.\n\t\t\t\t\t\t\t\t\t\t\tThe markup should remain unchanged.\n\t\t\t\t\t\t\t\t\t\t\tIf you make any changes here, ensure the corresponding JavaScript value functionality and conditional logic are also updated. -->\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"srfm-multi-choice-b99788e9-2\" data-option-text=\"La sauce n&#039;\u00e9tait pas la bonne\">La sauce n&#039;\u00e9tait pas la bonne<\/label>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-icon-container\">\t\t<span class=\"srfm-icon srfm-multi-choice-icon\" aria-hidden=\"true\">\n\t\t\t<svg width=\"17\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M6.5 7.33366L8.5 9.33366L15.1667 2.66699\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M14.5 8V12.6667C14.5 13.0203 14.3595 13.3594 14.1095 13.6095C13.8594 13.8595 13.5203 14 13.1667 14H3.83333C3.47971 14 3.14057 13.8595 2.89052 13.6095C2.64048 13.3594 2.5 13.0203 2.5 12.6667V3.33333C2.5 2.97971 2.64048 2.64057 2.89052 2.39052C3.14057 2.14048 3.47971 2 3.83333 2H11.1667\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t\t\t<span class=\"srfm-icon srfm-multi-choice-icon-unchecked\" aria-hidden=\"true\">\n\t\t\t<svg width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.6667 2H3.33333C2.59695 2 2 2.59695 2 3.33333V12.6667C2 13.403 2.59695 14 3.33333 14H12.6667C13.403 14 14 13.403 14 12.6667V3.33333C14 2.59695 13.403 2 12.6667 2Z\" stroke=\"#1E1E1E\" stroke-opacity=\"0.7\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-multi-choice-single\">\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\n\t\t\t\t\t\t\t\t\t\tid=\"srfm-multi-choice-b99788e9-3\"\n\t\t\t\t\t\t\t\t\t\tclass=\"srfm-input-multi-choice-single\" \t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-content-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-option-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<!-- This label content is used in conditional logic and for storing values in a hidden input field as comma-separated values.\n\t\t\t\t\t\t\t\t\t\t\tThe markup should remain unchanged.\n\t\t\t\t\t\t\t\t\t\t\tIf you make any changes here, ensure the corresponding JavaScript value functionality and conditional logic are also updated. -->\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"srfm-multi-choice-b99788e9-3\" data-option-text=\"Les frites n&#039;\u00e9taient pas assez cuitez\">Les frites n&#039;\u00e9taient pas assez cuitez<\/label>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-icon-container\">\t\t<span class=\"srfm-icon srfm-multi-choice-icon\" aria-hidden=\"true\">\n\t\t\t<svg width=\"17\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M6.5 7.33366L8.5 9.33366L15.1667 2.66699\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M14.5 8V12.6667C14.5 13.0203 14.3595 13.3594 14.1095 13.6095C13.8594 13.8595 13.5203 14 13.1667 14H3.83333C3.47971 14 3.14057 13.8595 2.89052 13.6095C2.64048 13.3594 2.5 13.0203 2.5 12.6667V3.33333C2.5 2.97971 2.64048 2.64057 2.89052 2.39052C3.14057 2.14048 3.47971 2 3.83333 2H11.1667\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t\t\t<span class=\"srfm-icon srfm-multi-choice-icon-unchecked\" aria-hidden=\"true\">\n\t\t\t<svg width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.6667 2H3.33333C2.59695 2 2 2.59695 2 3.33333V12.6667C2 13.403 2.59695 14 3.33333 14H12.6667C13.403 14 14 13.403 14 12.6667V3.33333C14 2.59695 13.403 2 12.6667 2Z\" stroke=\"#1E1E1E\" stroke-opacity=\"0.7\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-wrap\">\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-b99788e9\" data-error-msg=\"Ce champ est n\u00e9cessaire.\">\n\t\t\t\t\t\tCe champ est n\u00e9cessaire.\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t<\/fieldset>\n\t\t<\/div>\n\t\t\n\n\t\t\t<div data-block-id=\"dc50d175\" class=\"srfm-block-single srfm-block srfm-address-block srf-address-dc50d175-block  srfm-block-width-100 srfm-slug-srfm-address 2395\" data-slug=\"srfm-address\"\n\t\t\t\t\t\t>\n\t\t\t\t<fieldset>\n\t\t\t\t\t<legend class=\"srfm-block-legend\">\n\t\t\t\t\t\t\t\t\t\t\tAddress\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/legend>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t\t\n\t\t\t<div data-block-id=\"25e704c9\" class=\"srfm-block-single srfm-block srfm-input-block srf-input-25e704c9-block  srfm-block-width-50 srfm-slug-srfm-address-address-line-1 2395\" >\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t<input class=\"srfm-input-common srfm-input-input\" type=\"text\" name=\"srfm-input-25e704c9-lbl-QWRkcmVzcyBMaW5lIDE-srfm-address-address-line-1\" id=\"srfm-input-25e704c9-lbl-QWRkcmVzcyBMaW5lIDE\"\n\t\t\t\t\taria-describedby='srfm-error-25e704c9'\t\t\t\t\tdata-required=\"false\" aria-required=\"false\" data-unique=\"false\" maxlength=\"100\" value=\"\"  placeholder=\"Address Line 1\"  data-srfm-mask=\"none\"   \/>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-25e704c9\" data-error-msg=\"Ce champ est n\u00e9cessaire.\" data-unique-msg=\"La valeur doit \u00eatre unique.\">\n\t\t\t\t\t\tCe champ est n\u00e9cessaire.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\n\n\t\t\t<div data-block-id=\"16ead728\" class=\"srfm-block-single srfm-block srfm-input-block srf-input-16ead728-block  srfm-block-width-50 srfm-slug-srfm-address-address-line-2 2395\" >\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t<input class=\"srfm-input-common srfm-input-input\" type=\"text\" name=\"srfm-input-16ead728-lbl-QWRkcmVzcyBMaW5lIDI-srfm-address-address-line-2\" id=\"srfm-input-16ead728-lbl-QWRkcmVzcyBMaW5lIDI\"\n\t\t\t\t\taria-describedby='srfm-error-16ead728'\t\t\t\t\tdata-required=\"false\" aria-required=\"false\" data-unique=\"false\" maxlength=\"100\" value=\"\"  placeholder=\"Address Line 2\"  data-srfm-mask=\"none\"   \/>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-16ead728\" data-error-msg=\"Ce champ est n\u00e9cessaire.\" data-unique-msg=\"La valeur doit \u00eatre unique.\">\n\t\t\t\t\t\tCe champ est n\u00e9cessaire.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\n\n\t\t\t<div data-block-id=\"45e6d7fc\" class=\"srfm-block-single srfm-block srfm-input-block srf-input-45e6d7fc-block  srfm-block-width-50 srfm-slug-srfm-address-city 2395\" >\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t<input class=\"srfm-input-common srfm-input-input\" type=\"text\" name=\"srfm-input-45e6d7fc-lbl-Q2l0eQ-srfm-address-city\" id=\"srfm-input-45e6d7fc-lbl-Q2l0eQ\"\n\t\t\t\t\taria-describedby='srfm-error-45e6d7fc'\t\t\t\t\tdata-required=\"false\" aria-required=\"false\" data-unique=\"false\" maxlength=\"100\" value=\"\"  placeholder=\"City\"  data-srfm-mask=\"none\"   \/>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-45e6d7fc\" data-error-msg=\"Ce champ est n\u00e9cessaire.\" data-unique-msg=\"La valeur doit \u00eatre unique.\">\n\t\t\t\t\t\tCe champ est n\u00e9cessaire.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\n\n\t\t\t<div data-block-id=\"64b8163a\" class=\"srfm-block-single srfm-block srfm-input-block srf-input-64b8163a-block  srfm-block-width-50 srfm-slug-srfm-address-state 2395\" >\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t<input class=\"srfm-input-common srfm-input-input\" type=\"text\" name=\"srfm-input-64b8163a-lbl-U3RhdGU-srfm-address-state\" id=\"srfm-input-64b8163a-lbl-U3RhdGU\"\n\t\t\t\t\taria-describedby='srfm-error-64b8163a'\t\t\t\t\tdata-required=\"false\" aria-required=\"false\" data-unique=\"false\" maxlength=\"100\" value=\"\"  placeholder=\"State\"  data-srfm-mask=\"none\"   \/>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-64b8163a\" data-error-msg=\"Ce champ est n\u00e9cessaire.\" data-unique-msg=\"La valeur doit \u00eatre unique.\">\n\t\t\t\t\t\tCe champ est n\u00e9cessaire.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\n\n\t\t\t<div data-block-id=\"dc7faa27\" class=\"srfm-block-single srfm-block srfm-input-block srf-input-dc7faa27-block  srfm-block-width-50 srfm-slug-srfm-address-postal-code 2395\" >\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t<input class=\"srfm-input-common srfm-input-input\" type=\"text\" name=\"srfm-input-dc7faa27-lbl-UG9zdGFsIENvZGU-srfm-address-postal-code\" id=\"srfm-input-dc7faa27-lbl-UG9zdGFsIENvZGU\"\n\t\t\t\t\taria-describedby='srfm-error-dc7faa27'\t\t\t\t\tdata-required=\"false\" aria-required=\"false\" data-unique=\"false\" maxlength=\"100\" value=\"\"  placeholder=\"Postal Code\"  data-srfm-mask=\"none\"   \/>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-dc7faa27\" data-error-msg=\"Ce champ est n\u00e9cessaire.\" data-unique-msg=\"La valeur doit \u00eatre unique.\">\n\t\t\t\t\t\tCe champ est n\u00e9cessaire.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\n\n\t\t\t<div data-block-id=\"4f7a81f2\" class=\"srfm-block-single srfm-block srfm-dropdown-block srf-dropdown-4f7a81f2-block  srfm-block-width-50 srfm-slug-srfm-address-country 2395\">\n\t\t\t\t<fieldset>\n\t\t\t\t\t<input class=\"srfm-input-dropdown-hidden\" data-required=\"false\" aria-required=\"false\"  name=\"srfm-dropdown-1-4f7a81f2-lbl-Q291bnRyeQ-srfm-address-country\" type=\"hidden\" value=\"\"\/>\n\t\t\t\t\t<legend class=\"srfm-block-legend\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/legend>\n\t\t\t\t\t<div class=\"srfm-block-wrap srfm-dropdown-common-wrap\">\n\t\t\t\t\t\t\t\t\t\t<select\n\t\t\t\t\t\tclass=\"srfm-dropdown-common srfm-dropdown-input\"\n\t\t\t\t\t\taria-describedby='srfm-error-4f7a81f2'\t\t\t\tdata-required=\"false\" aria-required=\"false\"  name=\"srfm-dropdown-1-4f7a81f2-lbl-Q291bnRyeQ-srfm-address-country\" data-multiple=\"false\" data-searchable=\"true\"\n\t\t\t\t\t\t\t\t\t\t\t\ttabindex=\"0\" aria-hidden=\"true\">\n\t\t\t\t\t<option class=\"srfm-dropdown-placeholder\" value=\"\" disabled selected>Country<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Afghanistan\" data-icon=\"\"  >Afghanistan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Aland Islands\" data-icon=\"\"  >Aland Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Albania\" data-icon=\"\"  >Albania<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Algeria\" data-icon=\"\"  >Algeria<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"American Samoa\" data-icon=\"\"  >American Samoa<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Andorra\" data-icon=\"\"  >Andorra<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Angola\" data-icon=\"\"  >Angola<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Anguilla\" data-icon=\"\"  >Anguilla<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Antarctica\" data-icon=\"\"  >Antarctica<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Antigua and Barbuda\" data-icon=\"\"  >Antigua and Barbuda<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Argentina\" data-icon=\"\"  >Argentina<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Armenia\" data-icon=\"\"  >Armenia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Aruba\" data-icon=\"\"  >Aruba<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Australia\" data-icon=\"\"  >Australia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Austria\" data-icon=\"\"  >Austria<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Azerbaijan\" data-icon=\"\"  >Azerbaijan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Bahamas\" data-icon=\"\"  >Bahamas<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Bahrain\" data-icon=\"\"  >Bahrain<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Bangladesh\" data-icon=\"\"  >Bangladesh<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Barbados\" data-icon=\"\"  >Barbados<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Belarus\" data-icon=\"\"  >Belarus<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Belgium\" data-icon=\"\"  >Belgium<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Belize\" data-icon=\"\"  >Belize<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Benin\" data-icon=\"\"  >Benin<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Bermuda\" data-icon=\"\"  >Bermuda<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Bhutan\" data-icon=\"\"  >Bhutan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Bolivia, Plurinational State of\" data-icon=\"\"  >Bolivia, Plurinational State of<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Bosnia and Herzegovina\" data-icon=\"\"  >Bosnia and Herzegovina<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Botswana\" data-icon=\"\"  >Botswana<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Brazil\" data-icon=\"\"  >Brazil<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"British Indian Ocean Territory\" data-icon=\"\"  >British Indian Ocean Territory<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Brunei Darussalam\" data-icon=\"\"  >Brunei Darussalam<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Bulgaria\" data-icon=\"\"  >Bulgaria<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Burkina Faso\" data-icon=\"\"  >Burkina Faso<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Burundi\" data-icon=\"\"  >Burundi<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Cambodia\" data-icon=\"\"  >Cambodia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Cameroon\" data-icon=\"\"  >Cameroon<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Canada\" data-icon=\"\"  >Canada<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Cape Verde\" data-icon=\"\"  >Cape Verde<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Cayman Islands\" data-icon=\"\"  >Cayman Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Central African Republic\" data-icon=\"\"  >Central African Republic<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Chad\" data-icon=\"\"  >Chad<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Chile\" data-icon=\"\"  >Chile<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"China\" data-icon=\"\"  >China<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Christmas Island\" data-icon=\"\"  >Christmas Island<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Cocos (Keeling) Islands\" data-icon=\"\"  >Cocos (Keeling) Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Colombia\" data-icon=\"\"  >Colombia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Comoros\" data-icon=\"\"  >Comoros<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Congo\" data-icon=\"\"  >Congo<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Congo, The Democratic Republic of the Congo\" data-icon=\"\"  >Congo, The Democratic Republic of the Congo<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Cook Islands\" data-icon=\"\"  >Cook Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Costa Rica\" data-icon=\"\"  >Costa Rica<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Cote d&#039;Ivoire\" data-icon=\"\"  >Cote d&#039;Ivoire<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Croatia\" data-icon=\"\"  >Croatia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Cuba\" data-icon=\"\"  >Cuba<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Cyprus\" data-icon=\"\"  >Cyprus<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Czech Republic\" data-icon=\"\"  >Czech Republic<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Denmark\" data-icon=\"\"  >Denmark<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Djibouti\" data-icon=\"\"  >Djibouti<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Dominica\" data-icon=\"\"  >Dominica<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Dominican Republic\" data-icon=\"\"  >Dominican Republic<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Ecuador\" data-icon=\"\"  >Ecuador<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Egypt\" data-icon=\"\"  >Egypt<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"El Salvador\" data-icon=\"\"  >El Salvador<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Equatorial Guinea\" data-icon=\"\"  >Equatorial Guinea<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Eritrea\" data-icon=\"\"  >Eritrea<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Estonia\" data-icon=\"\"  >Estonia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Ethiopia\" data-icon=\"\"  >Ethiopia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Falkland Islands (Malvinas)\" data-icon=\"\"  >Falkland Islands (Malvinas)<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Faroe Islands\" data-icon=\"\"  >Faroe Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Fiji\" data-icon=\"\"  >Fiji<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Finland\" data-icon=\"\"  >Finland<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"France\" data-icon=\"\"  >France<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"French Guiana\" data-icon=\"\"  >French Guiana<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"French Polynesia\" data-icon=\"\"  >French Polynesia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Gabon\" data-icon=\"\"  >Gabon<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Gambia\" data-icon=\"\"  >Gambia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Georgia\" data-icon=\"\"  >Georgia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Germany\" data-icon=\"\"  >Germany<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Ghana\" data-icon=\"\"  >Ghana<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Gibraltar\" data-icon=\"\"  >Gibraltar<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Greece\" data-icon=\"\"  >Greece<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Greenland\" data-icon=\"\"  >Greenland<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Grenada\" data-icon=\"\"  >Grenada<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Guadeloupe\" data-icon=\"\"  >Guadeloupe<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Guam\" data-icon=\"\"  >Guam<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Guatemala\" data-icon=\"\"  >Guatemala<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Guernsey\" data-icon=\"\"  >Guernsey<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Guinea\" data-icon=\"\"  >Guinea<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Guinea-Bissau\" data-icon=\"\"  >Guinea-Bissau<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Guyana\" data-icon=\"\"  >Guyana<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Haiti\" data-icon=\"\"  >Haiti<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Holy See (Vatican City State)\" data-icon=\"\"  >Holy See (Vatican City State)<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Honduras\" data-icon=\"\"  >Honduras<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Hong Kong\" data-icon=\"\"  >Hong Kong<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Hungary\" data-icon=\"\"  >Hungary<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Iceland\" data-icon=\"\"  >Iceland<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"India\" data-icon=\"\"  >India<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Indonesia\" data-icon=\"\"  >Indonesia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Iran, Islamic Republic of Persian Gulf\" data-icon=\"\"  >Iran, Islamic Republic of Persian Gulf<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Iraq\" data-icon=\"\"  >Iraq<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Ireland\" data-icon=\"\"  >Ireland<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Isle of Man\" data-icon=\"\"  >Isle of Man<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Israel\" data-icon=\"\"  >Israel<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Italy\" data-icon=\"\"  >Italy<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Jamaica\" data-icon=\"\"  >Jamaica<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Japan\" data-icon=\"\"  >Japan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Jersey\" data-icon=\"\"  >Jersey<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Jordan\" data-icon=\"\"  >Jordan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Kazakhstan\" data-icon=\"\"  >Kazakhstan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Kenya\" data-icon=\"\"  >Kenya<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Kiribati\" data-icon=\"\"  >Kiribati<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Korea, Democratic People&#039;s Republic of Korea\" data-icon=\"\"  >Korea, Democratic People&#039;s Republic of Korea<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Korea, Republic of South Korea\" data-icon=\"\"  >Korea, Republic of South Korea<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Kuwait\" data-icon=\"\"  >Kuwait<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Kyrgyzstan\" data-icon=\"\"  >Kyrgyzstan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Laos\" data-icon=\"\"  >Laos<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Latvia\" data-icon=\"\"  >Latvia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Lebanon\" data-icon=\"\"  >Lebanon<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Lesotho\" data-icon=\"\"  >Lesotho<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Liberia\" data-icon=\"\"  >Liberia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Libyan Arab Jamahiriya\" data-icon=\"\"  >Libyan Arab Jamahiriya<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Liechtenstein\" data-icon=\"\"  >Liechtenstein<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Lithuania\" data-icon=\"\"  >Lithuania<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Luxembourg\" data-icon=\"\"  >Luxembourg<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Macao\" data-icon=\"\"  >Macao<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Macedonia\" data-icon=\"\"  >Macedonia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Madagascar\" data-icon=\"\"  >Madagascar<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Malawi\" data-icon=\"\"  >Malawi<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Malaysia\" data-icon=\"\"  >Malaysia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Maldives\" data-icon=\"\"  >Maldives<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Mali\" data-icon=\"\"  >Mali<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Malta\" data-icon=\"\"  >Malta<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Marshall Islands\" data-icon=\"\"  >Marshall Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Martinique\" data-icon=\"\"  >Martinique<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Mauritania\" data-icon=\"\"  >Mauritania<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Mauritius\" data-icon=\"\"  >Mauritius<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Mayotte\" data-icon=\"\"  >Mayotte<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Mexico\" data-icon=\"\"  >Mexico<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Micronesia, Federated States of Micronesia\" data-icon=\"\"  >Micronesia, Federated States of Micronesia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Moldova\" data-icon=\"\"  >Moldova<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Monaco\" data-icon=\"\"  >Monaco<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Mongolia\" data-icon=\"\"  >Mongolia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Montenegro\" data-icon=\"\"  >Montenegro<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Montserrat\" data-icon=\"\"  >Montserrat<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Morocco\" data-icon=\"\"  >Morocco<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Mozambique\" data-icon=\"\"  >Mozambique<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Myanmar\" data-icon=\"\"  >Myanmar<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Namibia\" data-icon=\"\"  >Namibia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Nauru\" data-icon=\"\"  >Nauru<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Nepal\" data-icon=\"\"  >Nepal<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Netherlands\" data-icon=\"\"  >Netherlands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Netherlands Antilles\" data-icon=\"\"  >Netherlands Antilles<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"New Caledonia\" data-icon=\"\"  >New Caledonia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"New Zealand\" data-icon=\"\"  >New Zealand<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Nicaragua\" data-icon=\"\"  >Nicaragua<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Niger\" data-icon=\"\"  >Niger<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Nigeria\" data-icon=\"\"  >Nigeria<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Niue\" data-icon=\"\"  >Niue<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Norfolk Island\" data-icon=\"\"  >Norfolk Island<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Northern Mariana Islands\" data-icon=\"\"  >Northern Mariana Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Norway\" data-icon=\"\"  >Norway<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Oman\" data-icon=\"\"  >Oman<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Pakistan\" data-icon=\"\"  >Pakistan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Palau\" data-icon=\"\"  >Palau<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Palestinian Territory, Occupied\" data-icon=\"\"  >Palestinian Territory, Occupied<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Panama\" data-icon=\"\"  >Panama<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Papua New Guinea\" data-icon=\"\"  >Papua New Guinea<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Paraguay\" data-icon=\"\"  >Paraguay<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Peru\" data-icon=\"\"  >Peru<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Philippines\" data-icon=\"\"  >Philippines<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Pitcairn\" data-icon=\"\"  >Pitcairn<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Poland\" data-icon=\"\"  >Poland<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Portugal\" data-icon=\"\"  >Portugal<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Puerto Rico\" data-icon=\"\"  >Puerto Rico<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Qatar\" data-icon=\"\"  >Qatar<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Romania\" data-icon=\"\"  >Romania<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Russia\" data-icon=\"\"  >Russia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Rwanda\" data-icon=\"\"  >Rwanda<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Reunion\" data-icon=\"\"  >Reunion<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Saint Barthelemy\" data-icon=\"\"  >Saint Barthelemy<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Saint Helena, Ascension and Tristan Da Cunha\" data-icon=\"\"  >Saint Helena, Ascension and Tristan Da Cunha<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Saint Kitts and Nevis\" data-icon=\"\"  >Saint Kitts and Nevis<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Saint Lucia\" data-icon=\"\"  >Saint Lucia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Saint Martin\" data-icon=\"\"  >Saint Martin<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Saint Pierre and Miquelon\" data-icon=\"\"  >Saint Pierre and Miquelon<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Saint Vincent and the Grenadines\" data-icon=\"\"  >Saint Vincent and the Grenadines<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Samoa\" data-icon=\"\"  >Samoa<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"San Marino\" data-icon=\"\"  >San Marino<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Sao Tome and Principe\" data-icon=\"\"  >Sao Tome and Principe<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Saudi Arabia\" data-icon=\"\"  >Saudi Arabia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Senegal\" data-icon=\"\"  >Senegal<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Serbia\" data-icon=\"\"  >Serbia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Seychelles\" data-icon=\"\"  >Seychelles<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Sierra Leone\" data-icon=\"\"  >Sierra Leone<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Singapore\" data-icon=\"\"  >Singapore<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Slovakia\" data-icon=\"\"  >Slovakia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Slovenia\" data-icon=\"\"  >Slovenia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Solomon Islands\" data-icon=\"\"  >Solomon Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Somalia\" data-icon=\"\"  >Somalia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"South Africa\" data-icon=\"\"  >South Africa<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"South Sudan\" data-icon=\"\"  >South Sudan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"South Georgia and the South Sandwich Islands\" data-icon=\"\"  >South Georgia and the South Sandwich Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Spain\" data-icon=\"\"  >Spain<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Sri Lanka\" data-icon=\"\"  >Sri Lanka<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Sudan\" data-icon=\"\"  >Sudan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Suriname\" data-icon=\"\"  >Suriname<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Svalbard and Jan Mayen\" data-icon=\"\"  >Svalbard and Jan Mayen<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Swaziland\" data-icon=\"\"  >Swaziland<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Sweden\" data-icon=\"\"  >Sweden<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Switzerland\" data-icon=\"\"  >Switzerland<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Syrian Arab Republic\" data-icon=\"\"  >Syrian Arab Republic<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Taiwan\" data-icon=\"\"  >Taiwan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Tajikistan\" data-icon=\"\"  >Tajikistan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Tanzania, United Republic of Tanzania\" data-icon=\"\"  >Tanzania, United Republic of Tanzania<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Thailand\" data-icon=\"\"  >Thailand<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Timor-Leste\" data-icon=\"\"  >Timor-Leste<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Togo\" data-icon=\"\"  >Togo<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Tokelau\" data-icon=\"\"  >Tokelau<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Tonga\" data-icon=\"\"  >Tonga<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Trinidad and Tobago\" data-icon=\"\"  >Trinidad and Tobago<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Tunisia\" data-icon=\"\"  >Tunisia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Turkey\" data-icon=\"\"  >Turkey<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Turkmenistan\" data-icon=\"\"  >Turkmenistan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Turks and Caicos Islands\" data-icon=\"\"  >Turks and Caicos Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Tuvalu\" data-icon=\"\"  >Tuvalu<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Uganda\" data-icon=\"\"  >Uganda<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Ukraine\" data-icon=\"\"  >Ukraine<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"United Arab Emirates\" data-icon=\"\"  >United Arab Emirates<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"United Kingdom\" data-icon=\"\"  >United Kingdom<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"United States\" data-icon=\"\"  >United States<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Uruguay\" data-icon=\"\"  >Uruguay<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Uzbekistan\" data-icon=\"\"  >Uzbekistan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Vanuatu\" data-icon=\"\"  >Vanuatu<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Venezuela, Bolivarian Republic of Venezuela\" data-icon=\"\"  >Venezuela, Bolivarian Republic of Venezuela<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Vietnam\" data-icon=\"\"  >Vietnam<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Virgin Islands, British\" data-icon=\"\"  >Virgin Islands, British<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Virgin Islands, U.S.\" data-icon=\"\"  >Virgin Islands, U.S.<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Wallis and Futuna\" data-icon=\"\"  >Wallis and Futuna<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Yemen\" data-icon=\"\"  >Yemen<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Zambia\" data-icon=\"\"  >Zambia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Zimbabwe\" data-icon=\"\"  >Zimbabwe<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/fieldset>\n\t\t\t<\/div>\n\t\t\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/fieldset>\n\t\t\t<\/div>\n\t\t\n\n\t\t\t<div data-block-id=\"dab69fea\" class=\"srfm-block-single srfm-block srfm-email-block srf-email-dab69fea-block  srfm-block-width-100 srfm-slug-email 2395 srfm-email-block-wrap\">\n\t\t\t\t<div class=\"srfm-email-block srf-email-dab69fea-block\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t\t\t<input class=\"srfm-input-common srfm-input-email\" type=\"email\" name=\"srfm-email-dab69fea-lbl-RW1haWw-email\" id=\"srfm-email-dab69fea-lbl-RW1haWw\"\n\t\t\t\t\t\taria-describedby='srfm-error-dab69fea'\t\t\t\t\t\tdata-required=\"true\" aria-required=\"true\" data-unique=\"false\" value=\"\"  placeholder=\"Email *\"   \/>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-message\" data-srfm-id=\"srfm-error-dab69fea\" data-error-msg=\"Ce champ est n\u00e9cessaire.\" data-unique-msg=\"La valeur doit \u00eatre unique.\">\n\t\t\t\t\t\tCe champ est n\u00e9cessaire.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t\n\n\t\t<div data-block-id=\"0a3fc3cd\" class=\"srfm-block-single srfm-block srfm-textarea-block srf-textarea-0a3fc3cd-block  srfm-block-width-100 2395\">\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-description\" id=\"srfm-description-0a3fc3cd\">\n\t\t\t\t\t\tRentrez-ici votre demande, je vous recontacterai pour la traiter.\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t<textarea\n\t\t\t\t\tclass=\"srfm-input-common srfm-input-textarea\"\n\t\t\t\t\tname=\"srfm-textarea-0a3fc3cd-lbl-TWVzc2FnZQ-message\"\n\t\t\t\t\tid=\"srfm-textarea-0a3fc3cd-lbl-TWVzc2FnZQ-7570\"\n\t\t\t\t\taria-describedby='srfm-error-0a3fc3cd srfm-description-0a3fc3cd'\t\t\t\t\tdata-required=\"false\" aria-required=\"false\"  rows=\"4\"   placeholder=\"Message\" \t\t\t\t\t\t\t\t\t\t\t\t\t\t\t><\/textarea>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\n\t\t\n\n\t\t<div data-block-id=\"8ce064c4\" class=\"srfm-block-single srfm-block srfm-multi-choice-block srf-multi-choice-8ce064c4-block  srfm-block-width-100 srfm-slug-type-de-prestation-demandee 2395 srfm-checkbox-mode\">\n\t\t\t<fieldset>\n\t\t\t\t<input class=\"srfm-input-multi-choice-hidden\" data-required=\"false\" aria-required=\"false\"  name=\"srfm-input-multi-choice-8ce064c4-lbl-VHlwZSBkZSBwcmVzdGF0aW9uIGRlbWFuZMOpZQ-type-de-prestation-demandee\" type=\"hidden\" value=\"\"\/>\n\t\t\t\t<legend class=\"srfm-block-legend\">\n\t\t\t\t\t\t\t\t\t\tType de prestation demand\u00e9e\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/legend>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-wrap srfm-choice-width-33-33 \">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-multi-choice-single\">\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\n\t\t\t\t\t\t\t\t\t\tid=\"srfm-multi-choice-8ce064c4-0\"\n\t\t\t\t\t\t\t\t\t\tclass=\"srfm-input-multi-choice-single\" \t\t\t\t\t\t\t\t\t\taria-describedby=\"srfm-error-8ce064c4\"\t\t\t\t\t\t\t\t\t\taria-required=\"false\"\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-content-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-option-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<!-- This label content is used in conditional logic and for storing values in a hidden input field as comma-separated values.\n\t\t\t\t\t\t\t\t\t\t\tThe markup should remain unchanged.\n\t\t\t\t\t\t\t\t\t\t\tIf you make any changes here, ensure the corresponding JavaScript value functionality and conditional logic are also updated. -->\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"srfm-multi-choice-8ce064c4-0\" data-option-text=\"Automobile\">Automobile<\/label>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-icon-container\">\t\t<span class=\"srfm-icon srfm-multi-choice-icon\" aria-hidden=\"true\">\n\t\t\t<svg width=\"17\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M6.5 7.33366L8.5 9.33366L15.1667 2.66699\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M14.5 8V12.6667C14.5 13.0203 14.3595 13.3594 14.1095 13.6095C13.8594 13.8595 13.5203 14 13.1667 14H3.83333C3.47971 14 3.14057 13.8595 2.89052 13.6095C2.64048 13.3594 2.5 13.0203 2.5 12.6667V3.33333C2.5 2.97971 2.64048 2.64057 2.89052 2.39052C3.14057 2.14048 3.47971 2 3.83333 2H11.1667\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t\t\t<span class=\"srfm-icon srfm-multi-choice-icon-unchecked\" aria-hidden=\"true\">\n\t\t\t<svg width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.6667 2H3.33333C2.59695 2 2 2.59695 2 3.33333V12.6667C2 13.403 2.59695 14 3.33333 14H12.6667C13.403 14 14 13.403 14 12.6667V3.33333C14 2.59695 13.403 2 12.6667 2Z\" stroke=\"#1E1E1E\" stroke-opacity=\"0.7\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-multi-choice-single\">\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\n\t\t\t\t\t\t\t\t\t\tid=\"srfm-multi-choice-8ce064c4-1\"\n\t\t\t\t\t\t\t\t\t\tclass=\"srfm-input-multi-choice-single\" \t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-content-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-option-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<!-- This label content is used in conditional logic and for storing values in a hidden input field as comma-separated values.\n\t\t\t\t\t\t\t\t\t\t\tThe markup should remain unchanged.\n\t\t\t\t\t\t\t\t\t\t\tIf you make any changes here, ensure the corresponding JavaScript value functionality and conditional logic are also updated. -->\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"srfm-multi-choice-8ce064c4-1\" data-option-text=\"Moto\">Moto<\/label>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-icon-container\">\t\t<span class=\"srfm-icon srfm-multi-choice-icon\" aria-hidden=\"true\">\n\t\t\t<svg width=\"17\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M6.5 7.33366L8.5 9.33366L15.1667 2.66699\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M14.5 8V12.6667C14.5 13.0203 14.3595 13.3594 14.1095 13.6095C13.8594 13.8595 13.5203 14 13.1667 14H3.83333C3.47971 14 3.14057 13.8595 2.89052 13.6095C2.64048 13.3594 2.5 13.0203 2.5 12.6667V3.33333C2.5 2.97971 2.64048 2.64057 2.89052 2.39052C3.14057 2.14048 3.47971 2 3.83333 2H11.1667\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t\t\t<span class=\"srfm-icon srfm-multi-choice-icon-unchecked\" aria-hidden=\"true\">\n\t\t\t<svg width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.6667 2H3.33333C2.59695 2 2 2.59695 2 3.33333V12.6667C2 13.403 2.59695 14 3.33333 14H12.6667C13.403 14 14 13.403 14 12.6667V3.33333C14 2.59695 13.403 2 12.6667 2Z\" stroke=\"#1E1E1E\" stroke-opacity=\"0.7\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-multi-choice-single\">\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\"\n\t\t\t\t\t\t\t\t\t\tid=\"srfm-multi-choice-8ce064c4-2\"\n\t\t\t\t\t\t\t\t\t\tclass=\"srfm-input-multi-choice-single\" \t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-block-content-wrap\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-option-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<!-- This label content is used in conditional logic and for storing values in a hidden input field as comma-separated values.\n\t\t\t\t\t\t\t\t\t\t\tThe markup should remain unchanged.\n\t\t\t\t\t\t\t\t\t\t\tIf you make any changes here, ensure the corresponding JavaScript value functionality and conditional logic are also updated. -->\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"srfm-multi-choice-8ce064c4-2\" data-option-text=\"V\u00e9lo\">V\u00e9lo<\/label>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-icon-container\">\t\t<span class=\"srfm-icon srfm-multi-choice-icon\" aria-hidden=\"true\">\n\t\t\t<svg width=\"17\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M6.5 7.33366L8.5 9.33366L15.1667 2.66699\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M14.5 8V12.6667C14.5 13.0203 14.3595 13.3594 14.1095 13.6095C13.8594 13.8595 13.5203 14 13.1667 14H3.83333C3.47971 14 3.14057 13.8595 2.89052 13.6095C2.64048 13.3594 2.5 13.0203 2.5 12.6667V3.33333C2.5 2.97971 2.64048 2.64057 2.89052 2.39052C3.14057 2.14048 3.47971 2 3.83333 2H11.1667\" stroke=\"#111C44\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t\t\t<span class=\"srfm-icon srfm-multi-choice-icon-unchecked\" aria-hidden=\"true\">\n\t\t\t<svg width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.6667 2H3.33333C2.59695 2 2 2.59695 2 3.33333V12.6667C2 13.403 2.59695 14 3.33333 14H12.6667C13.403 14 14 13.403 14 12.6667V3.33333C14 2.59695 13.403 2 12.6667 2Z\" stroke=\"#1E1E1E\" stroke-opacity=\"0.7\" stroke-width=\"1.25\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"srfm-error-wrap\"><\/div>\n\t\t\t<\/fieldset>\n\t\t<\/div>\n\t\t\n\n\t\t\t<div data-block-id=\"5730f6a8\" class=\"srfm-block-single srfm-block srfm-checkbox-block srf-checkbox-5730f6a8-block srfm-block-width-50 2395\">\n\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t\t<input class=\"srfm-input-common screen-reader-text srfm-input-checkbox\" id=\"srfm-checkbox-3595285915\"\n\t\t\t\t\t\taria-describedby='srfm-error-5730f6a8'\t\t\t\t\tname=\"srfm-checkbox-5730f6a8-lbl-UHJlc3RhdGlvbiBhdXRv-prestation-auto\" data-required=\"false\" aria-required=\"false\" type=\"checkbox\" \/>\n\t\t\t\t\t<label class=\"srfm-cbx\" for=\"srfm-checkbox-3595285915\">\n\t\t\t\t\t\t<span class=\"srfm-span-wrap\">\n\t\t\t\t\t\t\t<svg class=\"srfm-check-icon\" width=\"12px\" height=\"10px\" aria-hidden=\"true\">\n\t\t\t\t\t\t\t\t<use xlink:href=\"#srfm-checkbox-5730f6a8-check\"><\/use>\n\t\t\t\t\t\t\t<\/svg>\n\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t<span class=\"srfm-span-wrap srfm-block-label\">Prestation auto\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t\t\t<svg class=\"srfm-inline-svg\" aria-hidden=\"true\">\n\t\t\t\t\t\t<symbol id=\"srfm-checkbox-5730f6a8-check\" viewbox=\"0 0 12 10\">\n\t\t\t\t\t\t<polyline points=\"1.5 6 4.5 9 10.5 1\"><\/polyline>\n\t\t\t\t\t\t<\/symbol>\n\t\t\t\t\t<\/svg>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\n\n\t\t\t<div data-block-id=\"5374887f\" class=\"srfm-block-single srfm-block srfm-checkbox-block srf-checkbox-5374887f-block srfm-block-width-100 2395\">\n\t\t\t\t<div class=\"srfm-block-wrap\">\n\t\t\t\t\t<input class=\"srfm-input-common screen-reader-text srfm-input-checkbox\" id=\"srfm-checkbox-798149849\"\n\t\t\t\t\t\taria-describedby='srfm-error-5374887f'\t\t\t\t\tname=\"srfm-checkbox-5374887f-lbl-Q2hlY2tib3g-srfm-checkbox\" data-required=\"false\" aria-required=\"false\" type=\"checkbox\" \/>\n\t\t\t\t\t<label class=\"srfm-cbx\" for=\"srfm-checkbox-798149849\">\n\t\t\t\t\t\t<span class=\"srfm-span-wrap\">\n\t\t\t\t\t\t\t<svg class=\"srfm-check-icon\" width=\"12px\" height=\"10px\" aria-hidden=\"true\">\n\t\t\t\t\t\t\t\t<use xlink:href=\"#srfm-checkbox-5374887f-check\"><\/use>\n\t\t\t\t\t\t\t<\/svg>\n\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t<span class=\"srfm-span-wrap srfm-block-label\">Checkbox\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t\t\t<svg class=\"srfm-inline-svg\" aria-hidden=\"true\">\n\t\t\t\t\t\t<symbol id=\"srfm-checkbox-5374887f-check\" viewbox=\"0 0 12 10\">\n\t\t\t\t\t\t<polyline points=\"1.5 6 4.5 9 10.5 1\"><\/polyline>\n\t\t\t\t\t\t<\/symbol>\n\t\t\t\t\t<\/svg>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"srfm-error-wrap\">\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"srfm-captcha-container \">\n\n\t\t\t\t\t\t\t\t<p id=\"sitekey-error\" class=\"srfm-common-error-message srfm-error-message\">\n\t\t\t\t\t<span class=\"srfm-icon\" aria-hidden=\"true\">\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"20\" height=\"20\" fill=\"none\"><path d=\"M9.99935 18.3327C14.6017 18.3327 18.3327 14.6017 18.3327 9.99935C18.3327 5.39698 14.6017 1.66602 9.99935 1.66602C5.39698 1.66602 1.66602 5.39698 1.66602 9.99935C1.66602 14.6017 5.39698 18.3327 9.99935 18.3327Z\" stroke=\"currentColor\" stroke-width=\"1.5\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M10 6.66602V9.99935\" stroke=\"currentColor\" stroke-width=\"1.5\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M10 13.334H10.0083\" stroke=\"currentColor\" stroke-width=\"1.5\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t\t\t\t<span class=\"srfm-error-content\">\n\t\t\t\tLa cl\u00e9 Google reCAPTCHA de site est manquante. Veuillez contacter l\u2019administrateur de votre site.\t\t\t<\/span>\n\t\t<\/p>\n\t\t\t\t\t\t\t\t<div class=\"srfm-validation-error\" id=\"captcha-error\" style=\"display: none;\">Merci de confirmer que vous n\u2019\u00eates pas un robot.<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t<div class=\"srfm-submit-container \" style=\"\">\n\t\t\t\t\t\t<div style=\"width: ; text-align: left\" class=\"wp-block-button\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<button style=\"\" id=\"srfm-submit-btn\" class=\"srfm-btn-frontend srfm-button srfm-submit-button\"\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t>\n\t\t\t\t\t\t\t\t<div class=\"srfm-submit-wrap\">\n\t\t\t\t\t\t\t\t\tSoumettre\t\t\t\t\t\t\t\t<div class=\"srfm-loader\"><\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<\/button>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<p id=\"srfm-error-message\" class=\"srfm-common-error-message srfm-error-message srfm-footer-error\" hidden>\t\t<span class=\"srfm-icon\" aria-hidden=\"true\">\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"20\" height=\"20\" fill=\"none\"><path d=\"M9.99935 18.3327C14.6017 18.3327 18.3327 14.6017 18.3327 9.99935C18.3327 5.39698 14.6017 1.66602 9.99935 1.66602C5.39698 1.66602 1.66602 5.39698 1.66602 9.99935C1.66602 14.6017 5.39698 18.3327 9.99935 18.3327Z\" stroke=\"currentColor\" stroke-width=\"1.5\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M10 6.66602V9.99935\" stroke=\"currentColor\" stroke-width=\"1.5\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><path d=\"M10 13.334H10.0083\" stroke=\"currentColor\" stroke-width=\"1.5\" stroke-linecap=\"round\" stroke-linejoin=\"round\" \/><\/svg>\t\t<\/span>\n\t\t<span class=\"srfm-error-content\">Une erreur s\u2019est produite lors de l\u2019envoi de votre formulaire. Veuillez r\u00e9essayer.<\/span><\/p>\n\t\t\t\t\t<\/form>\n\t\t\t<div class=\"srfm-single-form srfm-success-box in-page\">\n\t\t\t\t<div aria-live=\"polite\" aria-atomic=\"true\" role=\"alert\" id=\"srfm-success-message-page-2395\" class=\"srfm-success-box-description\"><\/div>\n\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<style><\/style>\n\t\t<script><\/script>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Formulaire de contact Une erreur s\u2019est produite lors de l\u2019envoi de votre formulaire. Veuillez r\u00e9essayer. L&rsquo;ID se retrouve au dos de votre carte de membre Ce champ est n\u00e9cessaire. Ce champ est n\u00e9cessaire. Votre probl\u00e8me concerne : * S\u00e9lectionner le probl\u00e8me qui vous concerne Indigestion Hantavirus La sauce n&#039;\u00e9tait pas la bonne Les frites n&#039;\u00e9taient [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"site-sidebar-layout":"no-sidebar","site-content-layout":"page-builder","ast-site-content-layout":"full-width-container","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"disabled","ast-breadcrumbs-content":"","ast-featured-img":"disabled","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"class_list":["post-2712","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/cma31.fr\/index.php?rest_route=\/wp\/v2\/pages\/2712","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/cma31.fr\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/cma31.fr\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/cma31.fr\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/cma31.fr\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=2712"}],"version-history":[{"count":4,"href":"https:\/\/cma31.fr\/index.php?rest_route=\/wp\/v2\/pages\/2712\/revisions"}],"predecessor-version":[{"id":2716,"href":"https:\/\/cma31.fr\/index.php?rest_route=\/wp\/v2\/pages\/2712\/revisions\/2716"}],"wp:attachment":[{"href":"https:\/\/cma31.fr\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=2712"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}