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<html>
<head><title>Etude personnalis&eacute;e Pr&eacute;sence Individuelle</title>
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1">
</head>

<body bgcolor="#FFCCFF">
<form method="get" action="http://www.mutuelles-presence.fr/formpresencepart.php">
  <table border="0" align="center" width="640">
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        <table bgcolor="#ffccff" border="0" cellpadding="0" cellspacing="0" width="720">
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                  <td bgcolor="#ffccff"><a href="accpart.htm"><img src="images/fleche-tabind.gif" width="34" height="37" border="0"></a></td>
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                  <td><img name="etulogo" src="images/etu-logo.gif" width="110" height="110" border="0"></td>
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                  <td bgcolor="#ffccff"><img src="images/spacer.gif" width="1" height="1" border="0"></td>
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                  <td><img name="etuvieux" src="images/etu-fam.gif" width="162" height="182" border="0"></td>
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              <table bgcolor="#ffccff" border="0" cellpadding="0" cellspacing="0" width="335">
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                  <td> 
                    <table bgcolor="#ffccff" border="0" cellpadding="0" cellspacing="0" width="335">
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                        <td><img name="etupat" src="images/etu-pat.gif" width="213" height="145" border="0"></td>
                        <td bgcolor="#ffccff"><img src="images/spacer.gif" width="1" height="1" border="0"></td>
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                  <td><img name="etuslog" src="images/etu-slog.gif" width="335" height="55" border="0"></td>
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      </td>
    </tr>
    <tr align="center"> 
      <td valign="middle" bordercolor="#000000" width="360"> 
        <table border="1" cellspacing="0" cellpadding="0" bordercolor="#000000" height="230">
          <tr align="center"> 
            <td> 
              <table border="0" cellpadding="2" cellspacing="2" bordercolor="#000000" height="230" align="center">
                <tr> 
                  <td rowspan="2"><img src="images/etu-vous.gif" width="75" height="50"></td>
                  <td><font face="Arial, Helvetica, sans-serif" size="1">Nom :</font></td>
                  <td> 
                    <input type="text" name="Nom" size="25">
                  </td>
                </tr>
                <tr> 
                  <td><font face="Arial, Helvetica, sans-serif" size="1">Pr&eacute;nom 
                    :</font></td>
                  <td> 
                    <input type="text" name="Prenom" size="25">
                  </td>
                </tr>
                <tr> 
                  <td>&nbsp;</td>
                  <td><font face="Arial, Helvetica, sans-serif" size="1">Date 
                    de naissance :</font></td>
                  <td> 
                    <input type="text" name="Jn" size="2">
                    / 
                    <input type="text" name="Mn" size="2">
                    / 
                    <input type="text" name="An"" size="2">
                  </td>
                </tr>
                <tr> 
                  <td>&nbsp;</td>
                  <td><font face="Arial, Helvetica, sans-serif" size="1">Profession 
                    :</font></td>
                  <td> 
                    <input type="text" name="Profession" size="25">
                  </td>
                </tr>
                <tr> 
                  <td valign="middle" align="center"><font face="Arial, Helvetica, sans-serif" size="1">Vous 
                    &ecirc;tes :</font></td>
                  <td valign="middle" align="center"> 
                    <input type="radio" name="statut" value="Assure social">
                    <font face="Arial, Helvetica, sans-serif" size="1"><br>
                    Assur&eacute; social</font></td>
                  <td valign="middle" align="center"> 
                    <div align="center"> 
                      <input type="radio" name="statut" value="Travailleur independant">
                      <font face="Arial, Helvetica, sans-serif" size="1"><br>
                      Travailleur ind&eacute;pendant</font></div>
                  </td>
                </tr>
                <tr> 
                  <td valign="middle" colspan="3" align="center"><font face="Arial, Helvetica, sans-serif" size="1">N&deg; 
                    S.Sociale :</font> 
                    <input type="text" name="Sx" size="1">
                    <input type="text" name="Adn" size="2">
                    <input type="text" name="Mdn"" size="2">
                    <input type="text" name="Dp"" size="2">
                    <input type="text" name="C1"" size="3">
                    <input type="text" name="C2"" size="3">
                    <input type="text" name="Cl"" size="2">
                  </td>
                </tr>
              </table>
            </td>
          </tr>
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      </td>
      <td width="360" valign="middle"> 
        <table border="1" cellspacing="0" cellpadding="0" bordercolor="#000000" align="center">
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            <td> 
              <table border="0" cellpadding="2" cellspacing="2" bordercolor="#000000" height="230">
                <tr> 
                  <td rowspan="2"><img src="images/etu-conj.gif" width="75" height="50"></td>
                  <td><font face="Arial, Helvetica, sans-serif" size="1">Nom :</font></td>
                  <td> 
                    <input type="text" name="Nomc" size="25">
                  </td>
                </tr>
                <tr> 
                  <td><font face="Arial, Helvetica, sans-serif" size="1">Pr&eacute;nom 
                    :</font></td>
                  <td> 
                    <input type="text" name="Prenomc" size="25">
                  </td>
                </tr>
                <tr> 
                  <td>&nbsp;</td>
                  <td><font face="Arial, Helvetica, sans-serif" size="1"> Date 
                    de naissance:</font></td>
                  <td> 
                    <input type="text" name="Jnc" size="2">
                    / 
                    <input type="text" name="Mnc" size="2">
                    / 
                    <input type="text" name="Anc" size="2">
                  </td>
                </tr>
                <tr> 
                  <td>&nbsp;</td>
                  <td><font face="Arial, Helvetica, sans-serif" size="1">Profession 
                    :</font></td>
                  <td> 
                    <input type="text" name="Professionc" size="25">
                  </td>
                </tr>
                <tr> 
                  <td valign="middle" align="center"><font face="Arial, Helvetica, sans-serif" size="1">Vous 
                    &ecirc;tes :</font></td>
                  <td valign="middle" align="center"> 
                    <input type="radio" name="statutc" value="Assure social">
                    <br>
                    <font face="Arial, Helvetica, sans-serif" size="1"> Assur&eacute; 
                    social</font></td>
                  <td valign="middle" align="center"> 
                    <input type="radio" name="statutc" value="Travailleur independant">
                    <font face="Arial, Helvetica, sans-serif" size="1"><br>
                    Travailleur ind&eacute;pendant</font></td>
                </tr>
                <tr> 
                  <td valign="middle" colspan="3" align="center"><font face="Arial, Helvetica, sans-serif" size="1">N&deg; 
                    S. Sociale :</font> 
                    <input type="text" name="Sxc" size="1">
                    <input type="text" name="Adnc" size="2">
                    <input type="text" name="Mdnc"" size="2">
                    <input type="text" name="Dpc"" size="2">
                    <input type="text" name="C1c"" size="3">
                    <input type="text" name="C2c"" size="3">
                    <input type="text" name="Clc"" size="2">
                  </td>
                </tr>
              </table>
            </td>
          </tr>
        </table>
      </td>
    </tr>
    <tr> 
      <td colspan="2" height="72"> 
        <table width="100%" border="0" cellpadding="2" cellspacing="2">
          <tr> 
            <td width="85"><font face="Arial, Helvetica, sans-serif" size="1">Adresse 
              </font><font size="1">:</font></td>
            <td colspan="7"> 
              <div align="left"> 
                <input type="text" name="Adresse" size="80">
                <font face="Arial, Helvetica, sans-serif" size="1" color="#FF0000">* 
                obligatoire</font></div>
            </td>
          </tr>
          <tr> 
            <td width="85"><font face="Arial, Helvetica, sans-serif" size="1">CP 
              :</font></td>
            <td width="85"> 
              <div align="left"> 
                <input type="text" name="CP" size="5">
              </div>
            </td>
            <td width="85"><font face="Arial, Helvetica, sans-serif" size="1">Ville 
              :</font></td>
            <td width="250"> 
              <input type="text" name="Ville" size="35">
            </td>
            <td width="85"><font face="Arial, Helvetica, sans-serif" size="1">T&eacute;l 
              1 :</font></td>
            <td width="100"> 
              <div align="left"> 
                <input type="text" name="Tel" size="14">
              </div>
            </td>
            <td width="100"><font face="Arial, Helvetica, sans-serif" size="1">T&eacute;l 
              2 :</font></td>
            <td width="100"> 
              <div align="left"> 
                <input type="text" name="Tel2" size="14">
              </div>
            </td>
          </tr>
          <tr> 
            <td width="85"><font face="Arial, Helvetica, sans-serif" size="1">Email 
              </font><font size="1">:</font></td>
            <td colspan="7"> 
              <div align="left"> 
                <input type="text" name="EMAIL" size="80">
                <font face="Arial, Helvetica, sans-serif" size="1" color="#FF0000">* 
                obligatoire</font></div>
            </td>
          </tr>
        </table>
      </td>
    </tr>
    <tr> 
      <td height="25" colspan="2"> 
        <hr noshade size=2 color="#336633">
      </td>
    </tr>
    <tr> 
      <td width="357"> 
        <table width="100%" border="0" cellspacing="2" cellpadding="2" align="center">
          <tr> 
            <td colspan="4"><font face="Arial, Helvetica, sans-serif" size="1">&#149; 
              Enfants &agrave; charge</font></td>
          </tr>
          <tr> 
            <td width="55" valign="bottom"><font face="Arial, Helvetica, sans-serif" size="1">Pr&eacute;nom 
              :</font></td>
            <td width="130" valign="bottom"> 
              <div align="left"> 
                <input type="text" name="Penfant1" size="15">
              </div>
            </td>
            <td colspan="2" width="170"><font face="Arial, Helvetica, sans-serif" size="1">Date 
              de naissance :</font><font face="Arial, Helvetica, sans-serif"> 
              <br>
              <input type="text" name="Jne1" size="2">
              / 
              <input type="text" name="Mne1" size="2">
              / 
              <input type="text" name="Ane1" size="2">
              </font> </td>
          </tr>
          <tr> 
            <td width="55" valign="bottom"><font face="Arial, Helvetica, sans-serif" size="1">Pr&eacute;nom 
              :</font></td>
            <td width="130" valign="bottom"> 
              <div align="left"> 
                <input type="text" name="Penfant2" size="15">
              </div>
            </td>
            <td width="170" colspan="2"><font face="Arial, Helvetica, sans-serif" size="1">Date 
              de naissance :<br>
              </font> <font face="Arial, Helvetica, sans-serif"> 
              <input type="text" name="Jne2" size="2">
              / 
              <input type="text" name="Mne2" size="2">
              / 
              <input type="text" name="Ane2" size="2">
              </font> </td>
          </tr>
          <tr> 
            <td width="55" valign="bottom"><font face="Arial, Helvetica, sans-serif" size="1">Pr&eacute;nom 
              :</font></td>
            <td width="130" valign="bottom"> 
              <div align="left"> 
                <input type="text" name="Penfant3" size="15">
              </div>
            </td>
            <td width="170" colspan="2"><font face="Arial, Helvetica, sans-serif" size="1">Date 
              de naissance :<br>
              </font> <font face="Arial, Helvetica, sans-serif"> 
              <input type="text" name="Jne3" size="2">
              / 
              <input type="text" name="Mne3" size="2">
              / 
              <input type="text" name="Ane3" size="2">
              </font> </td>
          </tr>
          <tr> 
            <td width="55" valign="bottom"><font face="Arial, Helvetica, sans-serif" size="1">Pr&eacute;nom 
              :</font></td>
            <td width="130" valign="bottom"> 
              <div align="left"> 
                <input type="text" name="Penfant4" size="15">
              </div>
            </td>
            <td width="170" colspan="2"><font face="Arial, Helvetica, sans-serif" size="1">Date 
              de naissance :<br>
              </font> <font face="Arial, Helvetica, sans-serif"> 
              <input type="text" name="Jne4" size="2">
              / 
              <input type="text" name="Mne4" size="2">
              / 
              <input type="text" name="Ane4" size="2">
              </font> </td>
          </tr>
        </table>
        <br>
        <table width="100%" border="0" cellspacing="0" cellpadding="0">
          <tr> 
            <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="1">&#149; 
              Avez-vous une mutuelle actuellement ?<br>
              </font></td>
          </tr>
          <tr> 
            <td width="50%"><font face="Arial, Helvetica, sans-serif" size="1">oui 
              <input type="radio" name="avoirmut" value="OUI">
              </font></td>
            <td width="50%"><font face="Arial, Helvetica, sans-serif" size="1">non 
              <input type="radio" name="avoirmut" value="NON">
              </font></td>
          </tr>
          <tr> 
            <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="1"><br>
              Si oui, laquelle?</font></td>
          </tr>
          <tr> 
            <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="1"> 
              <input type="text" name="mutuactu" size="30">
              <br>
              <br>
              </font></td>
          </tr>
        </table>
        <table width="100%" border="0" cellspacing="0" cellpadding="0">
          <tr> 
            <td colspan="2" height="22"><font face="Arial, Helvetica, sans-serif" size="1">&#149; 
              En cas d'hospitalisation (maternit&eacute; comprise) choisirez-vous 
              plut&ocirc;t ?</font></td>
          </tr>
          <tr> 
            <td> 
              <input type="radio" name="hospitalisation" value="hopital">
              <font face="Arial, Helvetica, sans-serif" size="1"> l'h&ocirc;pital</font></td>
            <td> 
              <input type="radio" name="hospitalisation" value="clinique privee">
              <font face="Arial, Helvetica,
sans-serif" size="1"> une clinique priv&eacute;e </font></td>
          </tr>
          <tr> 
            <td colspan="2" height="22"><font face="Arial, Helvetica, sans-serif" size="1">Dans 
              ce cas, souhaitez-vous b&eacute;n&eacute;ficier d'une chambre particuli&egrave;re 
              ?</font></td>
          </tr>
          <tr> 
            <td width="50%"> 
              <input type="radio" name="chambre" value="OUI">
              <font face="Arial, Helvetica, sans-serif" size="1">Oui </font></td>
            <td width="50%"> 
              <input type="radio" name="chambre" value="NON">
              <font face="Arial, Helvetica, sans-serif" size="1">Non</font></td>
          </tr>
        </table>
        <br>
        <table width="100%" border="0" cellspacing="0" cellpadding="0">
          <tr> 
            <td colspan="3" height="22"><font face="Arial, Helvetica, sans-serif" size="1">&#149; 
              Vous arrive-t-il de consulter des sp&eacute;cialistes qui pratiquent 
              des d&eacute;passements d'honoraires ?<br>
              (Ex : dermatologue, ophtalmologiste, gyn&eacute;cologue, etc&#133;)</font></td>
          </tr>
          <tr align="left"> 
            <td width="33%"> 
              <div align="left">
                <input type="radio" name="specialiste" value="Fr&eacute;quemment">
                <font face="Arial, Helvetica, sans-serif"
size="1">Fr&eacute;quemment</font></div>
            </td>
            <td width="33%"> 
              <div align="left">
                <input type="radio" name="specialiste" value="Occasionnellement">
                <font face="Arial, Helvetica, sans-serif" size="1">Occasionnellement</font></div>
            </td>
            <td width="34%"> 
              <div align="left">
                <input type="radio" name="specialiste" value="Jamais">
                <font face="Arial, Helvetica, sans-serif" size="1">Jamais</font></div>
            </td>
          </tr>
        </table>
        <p>&nbsp;</p>
      </td>
      <td width="364"> 
        <table width="100%" border="0" cellspacing="2" cellpadding="2">
          <tr> 
            <td colspan="3" height="22"><font face="Arial, Helvetica, sans-serif" size="1">&#149; 
              En dentaire, pensez-vous avoir besoin d'un budget ?</font></td>
          </tr>
          <tr align="left"> 
            <td width="33%"> 
              <input name="dentaire" type="radio" value="Normal">
              <font face="Arial, Helvetica, sans-serif" size="1">Normal</font></td>
            <td width="33%"> 
              <input name="dentaire" type="radio" value="Important">
              <font face="Arial, Helvetica, sans-serif" size="1">Important</font></td>
            <td width="33%"> 
              <input name="dentaire" type="radio" value="Tr&egrave;s important">
              <font face="Arial, Helvetica, sans-serif" size="1">Tr&egrave;s important</font></td>
          </tr>
          <tr align="left"> 
            <td colspan="3"><font face="Arial, Helvetica, sans-serif" size="1">Pour 
              quels types de soins ?</font> 
              <input type="text" name="denactu" size="30">
            </td>
          </tr>
        </table>
        <br>
        <table border="0" cellspacing="2" cellpadding="2" width="100%">
          <tr> 
            <td colspan="2" height="22"><font face="Arial, Helvetica, sans-serif" size="1">&#149; 
              Envisagez-vous des soins d'orthodontie dans votre famille ?</font></td>
          </tr>
          <tr> 
            <td width="50%"> 
              <input type="radio" name="ortho" value="OUI">
              <font face="Arial, Helvetica, sans-serif" size="1"> Oui</font></td>
            <td width="50%"> 
              <input type="radio" name="ortho" value="NON">
              <font face="Arial, Helvetica, sans-serif" size="1"> Non</font></td>
          </tr>
        </table>
        <br>
        <table width="100%" border="0" cellspacing="2" cellpadding="2">
          <tr> 
            <td colspan="3" height="22"><font face="Arial, Helvetica, sans-serif" size="1">&#149; 
              Certaines personnes de votre famille ont-elles des probl&egrave;mes 
              de vue ?</font></td>
          </tr>
          <tr align="left"> 
            <td width="33%"> 
              <input type="checkbox" name="Lunettes" value="OUI">
              <font face="Arial, Helvetica, sans-serif" size="1">Lunettes</font></td>
            <td width="33%"> 
              <input type="checkbox" name="Lentilles" value="OUI">
              <font face="Arial, Helvetica, sans-serif" size="1">Lentilles</font></td>
            <td width="33%"> 
              <input type="checkbox" name="Verrespro" value="OUI">
              <font face="Arial, Helvetica, sans-serif" size="1">Verres progressifs</font></td>
          </tr>
        </table>
        <br>
        <table width="100%" border="0" cellspacing="0" cellpadding="0">
          <tr> 
            <td colspan="2" height="22"><font face="Arial, Helvetica, sans-serif" size="1">&#149; 
              Avez-vous des troubles auditifs qui n&eacute;cessitent un appareillage 
              ?</font></td>
          </tr>
          <tr> 
            <td width="50%"> 
              <input type="radio" name="pbauditif" value="OUI">
              <font face="Arial, Helvetica, sans-serif" size="1"> Oui</font></td>
            <td width="50%"> 
              <input type="radio" name="pbauditif" value="NON">
              <font face="Arial, Helvetica, sans-serif" size="1"> Non</font></td>
          </tr>
        </table>
        <br>
        <table width="100%" border="0" cellspacing="0" cellpadding="0">
          <tr> 
            <td colspan="2" height="22"><font face="Arial, Helvetica, sans-serif" size="1">&#149; 
              Questions particuli&egrave;res :</font></td>
          </tr>
          <tr> 
            <td colspan="2"> 
              <textarea name="questions" cols="40" rows="5"></textarea>
            </td>
          </tr>
        </table>
        <p>&nbsp;</p>
      </td>
    </tr>
    <tr> 
      <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="1">Votre 
        budget familial pour votre compl&eacute;mentaire sant&eacute; ? 
        <input type="text" name="budgcomp" size="40" value="" maxlength="80">
        </font></td>
    </tr>
    <tr> 
      <td colspan="2"> 
        <hr noshade size=2 color="#336633">
      </td>
    </tr>
    <tr> 
      <td colspan="2"> 
        <table width="600" border="0" cellspacing="1" cellpadding="2" align="center" bordercolor="#CC99CC">
          <tr align="center" valign="middle" bordercolor="#000000"> 
            <td rowspan="5" width="140"><font face="Arial, Helvetica, sans-serif" size="2"><b>GARANTIE 
              SANTE </b></font></td>
            <td width="80"><b><font face="Arial, Helvetica, sans-serif" size="2">Modules</font></b></td>
            <td width="80" bgcolor="#CC99CC"><b><font face="Arial, Helvetica, sans-serif" size="2">0</font></b></td>
            <td width="80" bgcolor="#FFFFCC"><b><font face="Arial, Helvetica, sans-serif" size="2">1</font></b></td>
            <td width="80" bgcolor="#FFFF99"><b><font face="Arial, Helvetica, sans-serif" size="2">2</font></b></td>
            <td width="80" bgcolor="#FFFF66"><b><font face="Arial, Helvetica, sans-serif" size="2">3</font></b></td>
          </tr>
          <tr align="center" valign="middle" bordercolor="#000000"> 
            <td width="80"><b><font face="Arial, Helvetica, sans-serif" size="1">Hospitalisation</font></b></td>
            <td width="80" bgcolor="#CC99CC"> <font face="Arial, Helvetica, sans-serif" size="1"><b>obligatoire</b></font></td>
            <td width="80" bgcolor="#FFFFCC"> 
              <input type="radio" name="hospi" value="1">
            </td>
            <td width="80" bgcolor="#FFFF99"> 
              <input type="radio" name="hospi" value="2">
            </td>
            <td width="80" bgcolor="#FFFF66"> 
              <input type="radio" name="hospi" value="3">
            </td>
          </tr>
          <tr align="center" valign="middle" bordercolor="#000000"> 
            <td width="80"><b><font face="Arial, Helvetica, sans-serif" size="1">Dentaire, 
              Optique, Paramedical</font></b></td>
            <td width="80" bgcolor="#CC99CC"> 
              <input type="radio" name="dentaire" value="0">
            </td>
            <td width="80" bgcolor="#FFFFCC"> 
              <input type="radio" name="dentaire" value="1">
            </td>
            <td width="80" bgcolor="#FFFF99"> 
              <input type="radio" name="dentaire" value="2">
            </td>
            <td width="80" bgcolor="#FFFF66"> 
              <input type="radio" name="dentaire" value="3">
            </td>
          </tr>
          <tr align="center" valign="middle" bordercolor="#000000"> 
            <td width="80"><b><font face="Arial, Helvetica, sans-serif" size="1">Medecine, 
              Pharmacie </font></b></td>
            <td width="80" bgcolor="#CC99CC"> 
              <input type="radio" name="medphar" value="0">
            </td>
            <td width="80" bgcolor="#FFFFCC"> 
              <input type="radio" name="medphar" value="1">
            </td>
            <td width="80" bgcolor="#FFFF99"> 
              <input type="radio" name="medphar" value="2">
            </td>
            <td width="80" bgcolor="#FFFF66"> 
              <input type="radio" name="medphar" value="3">
            </td>
          </tr>
          <tr align="center" valign="middle" bordercolor="#000000"> 
            <td width="80"> <font size="1"><b><font face="Arial, Helvetica, sans-serif">Prestations 
              Particuli&egrave;res </font> </b></font></td>
            <td width="80" bgcolor="#CC99CC"> 
              <input type="radio" name="particulier" value="0">
            </td>
            <td width="80" bgcolor="#FFFFCC"> 
              <input type="radio" name="particulier" value="1">
            </td>
            <td width="80" bgcolor="#FFFF99"> 
              <input type="radio" name="particulier" value="2">
            </td>
            <td width="80" bgcolor="#FFFF66"> 
              <input type="radio" name="particulier" value="3">
            </td>
          </tr>
        </table>
      </td>
    </tr>
    <tr align="center"> 
      <td height="30" valign="middle" colspan="2"><font face="Arial, Helvetica, sans-serif" size="1"> 
        </font> <br>
        <table width="600" border="0" cellspacing="0" cellpadding="0">
          <tr> 
            <td> 
              <div align="center"><font size="2" face="Arial, Helvetica, sans-serif"><b>GARANTIE 
                HOSPITALIERE </b></font></div>
            </td>
            <td> 
              <div align="center"><font face="Arial, Helvetica, sans-serif" size="1"> 
                <input type="radio" name="gh" value="16 euros">
                16 &euro;</font></div>
            </td>
            <td> 
              <div align="center"><font face="Arial, Helvetica, sans-serif" size="1"> 
                <input type="radio" name="gh" value="24 euros">
                24 &euro;</font></div>
            </td>
            <td> 
              <div align="center"><font face="Arial, Helvetica, sans-serif" size="1"> 
                <input type="radio" name="gh" value="32 euros">
                32 &euro; </font></div>
            </td>
            <td> 
              <div align="center"><font face="Arial, Helvetica, sans-serif" size="1"> 
                <input type="radio" name="gh" value="40 euros">
                40 &euro;</font></div>
            </td>
          </tr>
        </table>
        <br>
      </td>
    </tr>
    <tr align="center" valign="middle"> 
      <td colspan="2"> 
        <table width="390" border="0" cellspacing="0" cellpadding="0" align="center">
          <tr align="center" valign="middle"> 
            <td> 
              <input type="reset" value="Annuler" name="reset">
            </td>
            <td> 
              <INPUT TYPE="submit" VALUE="Envoyer">
            </td>
            <td> 
              <input type="button" name="Button" value="Retour" onClick="window.close()">
            </td>
          </tr>
        </table>
      </td>
    </tr>
  </table>
  </form>
</body>
</html>

Zerion Mini Shell 1.0