myaxafidelity.axa.be
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Submitted URL: https://eye.mail.myaxafidelity.axa.be/c?p=wAbNBFPDxBDQvNDF0NA0Ym5E49C14_rQpBI6KVPEENDG0I1K0NIF0JJO79CD_yjQxO4y0K3g2atodHRwczovL215YXhh...
Effective URL: https://myaxafidelity.axa.be/fr/smooth-register/c1eba5d6-37d4-4d19-9cfd-aae558055419?lang=fr&utm_source=Sarbacane&utm_medium=...
Submission: On October 19 via api from BE — Scanned from FR
Effective URL: https://myaxafidelity.axa.be/fr/smooth-register/c1eba5d6-37d4-4d19-9cfd-aae558055419?lang=fr&utm_source=Sarbacane&utm_medium=...
Submission: On October 19 via api from BE — Scanned from FR
Form analysis 1 forms found in the DOM
<form _ngcontent-axabe-c410="" novalidate="" class="ng-untouched ng-pristine ng-invalid">
<div _ngcontent-axabe-c410="" class="civility-inputs typo18 font-weight-bold"><cora-o-input _ngcontent-axabe-c410="" _nghost-axabe-c112="" class="ng-untouched ng-pristine ng-valid">
<div _ngcontent-axabe-c112="" class="row form-group has-feedback"><label _ngcontent-axabe-c112="" class="col-12" for="civility"> Civilité <span _ngcontent-axabe-c112="">*</span><!----></label><!---->
<div _ngcontent-axabe-c112="" class="col-12"><!----><!---->
<div _ngcontent-axabe-c112="" class="form-check form-check-inline"><input _ngcontent-axabe-c112="" class="form-check-input" id="civility-1" name="civility" type="radio" value="1"><label _ngcontent-axabe-c112="" class="form-check-label"
for="civility-1"> Monsieur </label></div>
<div _ngcontent-axabe-c112="" class="form-check form-check-inline"><input _ngcontent-axabe-c112="" class="form-check-input" id="civility-2" name="civility" type="radio" value="2"><label _ngcontent-axabe-c112="" class="form-check-label"
for="civility-2"> Madame </label></div><!----><!----><!----><!----><!----><!----><!---->
</div><!---->
</div><!----><!---->
</cora-o-input></div>
<div _ngcontent-axabe-c410="" class="typo18 font-weight-bold"><cora-o-input _ngcontent-axabe-c410="" _nghost-axabe-c112="" class="ng-untouched ng-pristine ng-valid">
<div _ngcontent-axabe-c112="" class="row form-group has-feedback"><label _ngcontent-axabe-c112="" class="col-12" for="firstname"> Prénom <span _ngcontent-axabe-c112="">*</span><!----></label><!---->
<div _ngcontent-axabe-c112="" class="col-12"><!----><!---->
<div _ngcontent-axabe-c112="" class="input-group"><!----><input _ngcontent-axabe-c112="" id="firstname" name="firstname" placeholder="Prénom" type="text" autocomplete="undefined" maxlength="80" minlength="0"
class="form-control"><!----><!----><!----><!----><!----></div><!----><!----><!----><!----><!----><!----><!----><!---->
</div><!---->
</div><!----><!---->
</cora-o-input><cora-o-input _ngcontent-axabe-c410="" _nghost-axabe-c112="" class="ng-untouched ng-pristine ng-valid">
<div _ngcontent-axabe-c112="" class="row form-group has-feedback"><label _ngcontent-axabe-c112="" class="col-12" for="lastname"> Nom <span _ngcontent-axabe-c112="">*</span><!----></label><!---->
<div _ngcontent-axabe-c112="" class="col-12"><!----><!---->
<div _ngcontent-axabe-c112="" class="input-group"><!----><input _ngcontent-axabe-c112="" id="lastname" name="lastname" placeholder="Nom" type="text" autocomplete="undefined" maxlength="80" minlength="0"
class="form-control"><!----><!----><!----><!----><!----></div><!----><!----><!----><!----><!----><!----><!----><!---->
</div><!---->
</div><!----><!---->
</cora-o-input></div><app-form-date-field _ngcontent-axabe-c410="" outputformat="YYYY-MM-DD" _nghost-axabe-c364="" class="ng-untouched ng-pristine ng-valid">
<div _ngcontent-axabe-c364="" class="row">
<div _ngcontent-axabe-c364="" class="col-12"><label _ngcontent-axabe-c364="" class="typo18 font-weight-bold">Date de naissance *</label></div>
</div>
<div _ngcontent-axabe-c364="" class="form-row align-items-center mb-xl-0 mb-sm-0 mb-3">
<div _ngcontent-axabe-c364="" class="col-4"><select _ngcontent-axabe-c364="" class="form-control" id="-day" name="-day">
<option _ngcontent-axabe-c364="">jj</option>
<option _ngcontent-axabe-c364="" value="01">01</option>
<option _ngcontent-axabe-c364="" value="02">02</option>
<option _ngcontent-axabe-c364="" value="03">03</option>
<option _ngcontent-axabe-c364="" value="04">04</option>
<option _ngcontent-axabe-c364="" value="05">05</option>
<option _ngcontent-axabe-c364="" value="06">06</option>
<option _ngcontent-axabe-c364="" value="07">07</option>
<option _ngcontent-axabe-c364="" value="08">08</option>
<option _ngcontent-axabe-c364="" value="09">09</option>
<option _ngcontent-axabe-c364="" value="10">10</option>
<option _ngcontent-axabe-c364="" value="11">11</option>
<option _ngcontent-axabe-c364="" value="12">12</option>
<option _ngcontent-axabe-c364="" value="13">13</option>
<option _ngcontent-axabe-c364="" value="14">14</option>
<option _ngcontent-axabe-c364="" value="15">15</option>
<option _ngcontent-axabe-c364="" value="16">16</option>
<option _ngcontent-axabe-c364="" value="17">17</option>
<option _ngcontent-axabe-c364="" value="18">18</option>
<option _ngcontent-axabe-c364="" value="19">19</option>
<option _ngcontent-axabe-c364="" value="20">20</option>
<option _ngcontent-axabe-c364="" value="21">21</option>
<option _ngcontent-axabe-c364="" value="22">22</option>
<option _ngcontent-axabe-c364="" value="23">23</option>
<option _ngcontent-axabe-c364="" value="24">24</option>
<option _ngcontent-axabe-c364="" value="25">25</option>
<option _ngcontent-axabe-c364="" value="26">26</option>
<option _ngcontent-axabe-c364="" value="27">27</option>
<option _ngcontent-axabe-c364="" value="28">28</option>
<option _ngcontent-axabe-c364="" value="29">29</option>
<option _ngcontent-axabe-c364="" value="30">30</option>
<option _ngcontent-axabe-c364="" value="31">31</option><!---->
</select></div>
<div _ngcontent-axabe-c364="" class="col-4"><select _ngcontent-axabe-c364="" class="form-control" id="-month" name="-month">
<option _ngcontent-axabe-c364="">mm</option>
<option _ngcontent-axabe-c364="" value="01">janvier</option>
<option _ngcontent-axabe-c364="" value="02">février</option>
<option _ngcontent-axabe-c364="" value="03">mars</option>
<option _ngcontent-axabe-c364="" value="04">avril</option>
<option _ngcontent-axabe-c364="" value="05">mai</option>
<option _ngcontent-axabe-c364="" value="06">juin</option>
<option _ngcontent-axabe-c364="" value="07">juillet</option>
<option _ngcontent-axabe-c364="" value="08">août</option>
<option _ngcontent-axabe-c364="" value="09">septembre</option>
<option _ngcontent-axabe-c364="" value="10">octobre</option>
<option _ngcontent-axabe-c364="" value="11">novembre</option>
<option _ngcontent-axabe-c364="" value="12">décembre</option><!---->
</select></div>
<div _ngcontent-axabe-c364="" class="col-4"><select _ngcontent-axabe-c364="" class="form-control" id="-year" name="-year">
<option _ngcontent-axabe-c364="">aaaa</option>
<option _ngcontent-axabe-c364="" value="1900">1900</option>
<option _ngcontent-axabe-c364="" value="1901">1901</option>
<option _ngcontent-axabe-c364="" value="1902">1902</option>
<option _ngcontent-axabe-c364="" value="1903">1903</option>
<option _ngcontent-axabe-c364="" value="1904">1904</option>
<option _ngcontent-axabe-c364="" value="1905">1905</option>
<option _ngcontent-axabe-c364="" value="1906">1906</option>
<option _ngcontent-axabe-c364="" value="1907">1907</option>
<option _ngcontent-axabe-c364="" value="1908">1908</option>
<option _ngcontent-axabe-c364="" value="1909">1909</option>
<option _ngcontent-axabe-c364="" value="1910">1910</option>
<option _ngcontent-axabe-c364="" value="1911">1911</option>
<option _ngcontent-axabe-c364="" value="1912">1912</option>
<option _ngcontent-axabe-c364="" value="1913">1913</option>
<option _ngcontent-axabe-c364="" value="1914">1914</option>
<option _ngcontent-axabe-c364="" value="1915">1915</option>
<option _ngcontent-axabe-c364="" value="1916">1916</option>
<option _ngcontent-axabe-c364="" value="1917">1917</option>
<option _ngcontent-axabe-c364="" value="1918">1918</option>
<option _ngcontent-axabe-c364="" value="1919">1919</option>
<option _ngcontent-axabe-c364="" value="1920">1920</option>
<option _ngcontent-axabe-c364="" value="1921">1921</option>
<option _ngcontent-axabe-c364="" value="1922">1922</option>
<option _ngcontent-axabe-c364="" value="1923">1923</option>
<option _ngcontent-axabe-c364="" value="1924">1924</option>
<option _ngcontent-axabe-c364="" value="1925">1925</option>
<option _ngcontent-axabe-c364="" value="1926">1926</option>
<option _ngcontent-axabe-c364="" value="1927">1927</option>
<option _ngcontent-axabe-c364="" value="1928">1928</option>
<option _ngcontent-axabe-c364="" value="1929">1929</option>
<option _ngcontent-axabe-c364="" value="1930">1930</option>
<option _ngcontent-axabe-c364="" value="1931">1931</option>
<option _ngcontent-axabe-c364="" value="1932">1932</option>
<option _ngcontent-axabe-c364="" value="1933">1933</option>
<option _ngcontent-axabe-c364="" value="1934">1934</option>
<option _ngcontent-axabe-c364="" value="1935">1935</option>
<option _ngcontent-axabe-c364="" value="1936">1936</option>
<option _ngcontent-axabe-c364="" value="1937">1937</option>
<option _ngcontent-axabe-c364="" value="1938">1938</option>
<option _ngcontent-axabe-c364="" value="1939">1939</option>
<option _ngcontent-axabe-c364="" value="1940">1940</option>
<option _ngcontent-axabe-c364="" value="1941">1941</option>
<option _ngcontent-axabe-c364="" value="1942">1942</option>
<option _ngcontent-axabe-c364="" value="1943">1943</option>
<option _ngcontent-axabe-c364="" value="1944">1944</option>
<option _ngcontent-axabe-c364="" value="1945">1945</option>
<option _ngcontent-axabe-c364="" value="1946">1946</option>
<option _ngcontent-axabe-c364="" value="1947">1947</option>
<option _ngcontent-axabe-c364="" value="1948">1948</option>
<option _ngcontent-axabe-c364="" value="1949">1949</option>
<option _ngcontent-axabe-c364="" value="1950">1950</option>
<option _ngcontent-axabe-c364="" value="1951">1951</option>
<option _ngcontent-axabe-c364="" value="1952">1952</option>
<option _ngcontent-axabe-c364="" value="1953">1953</option>
<option _ngcontent-axabe-c364="" value="1954">1954</option>
<option _ngcontent-axabe-c364="" value="1955">1955</option>
<option _ngcontent-axabe-c364="" value="1956">1956</option>
<option _ngcontent-axabe-c364="" value="1957">1957</option>
<option _ngcontent-axabe-c364="" value="1958">1958</option>
<option _ngcontent-axabe-c364="" value="1959">1959</option>
<option _ngcontent-axabe-c364="" value="1960">1960</option>
<option _ngcontent-axabe-c364="" value="1961">1961</option>
<option _ngcontent-axabe-c364="" value="1962">1962</option>
<option _ngcontent-axabe-c364="" value="1963">1963</option>
<option _ngcontent-axabe-c364="" value="1964">1964</option>
<option _ngcontent-axabe-c364="" value="1965">1965</option>
<option _ngcontent-axabe-c364="" value="1966">1966</option>
<option _ngcontent-axabe-c364="" value="1967">1967</option>
<option _ngcontent-axabe-c364="" value="1968">1968</option>
<option _ngcontent-axabe-c364="" value="1969">1969</option>
<option _ngcontent-axabe-c364="" value="1970">1970</option>
<option _ngcontent-axabe-c364="" value="1971">1971</option>
<option _ngcontent-axabe-c364="" value="1972">1972</option>
<option _ngcontent-axabe-c364="" value="1973">1973</option>
<option _ngcontent-axabe-c364="" value="1974">1974</option>
<option _ngcontent-axabe-c364="" value="1975">1975</option>
<option _ngcontent-axabe-c364="" value="1976">1976</option>
<option _ngcontent-axabe-c364="" value="1977">1977</option>
<option _ngcontent-axabe-c364="" value="1978">1978</option>
<option _ngcontent-axabe-c364="" value="1979">1979</option>
<option _ngcontent-axabe-c364="" value="1980">1980</option>
<option _ngcontent-axabe-c364="" value="1981">1981</option>
<option _ngcontent-axabe-c364="" value="1982">1982</option>
<option _ngcontent-axabe-c364="" value="1983">1983</option>
<option _ngcontent-axabe-c364="" value="1984">1984</option>
<option _ngcontent-axabe-c364="" value="1985">1985</option>
<option _ngcontent-axabe-c364="" value="1986">1986</option>
<option _ngcontent-axabe-c364="" value="1987">1987</option>
<option _ngcontent-axabe-c364="" value="1988">1988</option>
<option _ngcontent-axabe-c364="" value="1989">1989</option>
<option _ngcontent-axabe-c364="" value="1990">1990</option>
<option _ngcontent-axabe-c364="" value="1991">1991</option>
<option _ngcontent-axabe-c364="" value="1992">1992</option>
<option _ngcontent-axabe-c364="" value="1993">1993</option>
<option _ngcontent-axabe-c364="" value="1994">1994</option>
<option _ngcontent-axabe-c364="" value="1995">1995</option>
<option _ngcontent-axabe-c364="" value="1996">1996</option>
<option _ngcontent-axabe-c364="" value="1997">1997</option>
<option _ngcontent-axabe-c364="" value="1998">1998</option>
<option _ngcontent-axabe-c364="" value="1999">1999</option>
<option _ngcontent-axabe-c364="" value="2000">2000</option>
<option _ngcontent-axabe-c364="" value="2001">2001</option>
<option _ngcontent-axabe-c364="" value="2002">2002</option>
<option _ngcontent-axabe-c364="" value="2003">2003</option>
<option _ngcontent-axabe-c364="" value="2004">2004</option>
<option _ngcontent-axabe-c364="" value="2005">2005</option>
<option _ngcontent-axabe-c364="" value="2006">2006</option>
<option _ngcontent-axabe-c364="" value="2007">2007</option>
<option _ngcontent-axabe-c364="" value="2008">2008</option>
<option _ngcontent-axabe-c364="" value="2009">2009</option>
<option _ngcontent-axabe-c364="" value="2010">2010</option>
<option _ngcontent-axabe-c364="" value="2011">2011</option>
<option _ngcontent-axabe-c364="" value="2012">2012</option>
<option _ngcontent-axabe-c364="" value="2013">2013</option>
<option _ngcontent-axabe-c364="" value="2014">2014</option>
<option _ngcontent-axabe-c364="" value="2015">2015</option>
<option _ngcontent-axabe-c364="" value="2016">2016</option>
<option _ngcontent-axabe-c364="" value="2017">2017</option>
<option _ngcontent-axabe-c364="" value="2018">2018</option>
<option _ngcontent-axabe-c364="" value="2019">2019</option>
<option _ngcontent-axabe-c364="" value="2020">2020</option>
<option _ngcontent-axabe-c364="" value="2021">2021</option>
<option _ngcontent-axabe-c364="" value="2022">2022</option><!---->
</select></div>
</div>
</app-form-date-field>
<div _ngcontent-axabe-c410="" class="typo18 font-weight-bold mt-3"><cora-o-input _ngcontent-axabe-c410="" _nghost-axabe-c112="" class="ng-untouched ng-pristine ng-valid">
<div _ngcontent-axabe-c112="" class="row form-group has-feedback"><label _ngcontent-axabe-c112="" class="col-12" for="zipcode"> Code Postal <span _ngcontent-axabe-c112="">*</span><!----></label><!---->
<div _ngcontent-axabe-c112="" class="col-12"><!----><!---->
<div _ngcontent-axabe-c112="" class="input-group"><!----><input _ngcontent-axabe-c112="" id="zipcode" name="zipcode" placeholder="Code Postal" type="text" autocomplete="undefined" maxlength="5" minlength="0"
class="form-control"><!----><!----><!----><!----><!----></div><!----><!----><!----><!----><!----><!----><!----><!---->
</div><!---->
</div><!----><!---->
</cora-o-input></div>
<div _ngcontent-axabe-c410="" class="typo18 font-weight-bold"><cora-o-input _ngcontent-axabe-c410="" _nghost-axabe-c112="" class="ng-untouched ng-pristine ng-valid">
<div _ngcontent-axabe-c112="" class="row form-group has-feedback"><label _ngcontent-axabe-c112="" class="col-12" for="phone"> Téléphone (ex : 04XXXXXXXX) <!----></label><!---->
<div _ngcontent-axabe-c112="" class="col-12"><!----><!---->
<div _ngcontent-axabe-c112="" class="input-group"><!----><input _ngcontent-axabe-c112="" id="phone" name="phone" placeholder="Téléphone" type="text" autocomplete="undefined" maxlength="18" minlength="0"
class="form-control"><!----><!----><!----><!----><!----></div><!----><!----><!----><!----><!----><!----><!----><!---->
</div><!---->
</div><!----><!---->
</cora-o-input></div>
<div _ngcontent-axabe-c410="" class="typo18 font-weight-bold"><cora-o-input _ngcontent-axabe-c410="" _nghost-axabe-c112="" class="ng-untouched ng-pristine ng-valid">
<div _ngcontent-axabe-c112="" class="row form-group has-feedback"><label _ngcontent-axabe-c112="" class="col-12" for="email"> E-mail <span _ngcontent-axabe-c112="">*</span><!----></label><!---->
<div _ngcontent-axabe-c112="" class="col-12"><!----><!---->
<div _ngcontent-axabe-c112="" class="input-group"><!----><input _ngcontent-axabe-c112="" id="email" name="email" placeholder="E-mail" type="text" autocomplete="email" minlength="0" class="form-control"><!----><!----><!----><!----><!---->
</div><!----><!----><!----><!----><!----><!----><!----><!---->
</div><!---->
</div><!----><!---->
</cora-o-input></div>
<div _ngcontent-axabe-c410="" class="typo18 font-weight-bold"><cora-o-input _ngcontent-axabe-c410="" _nghost-axabe-c112="" class="ng-untouched ng-pristine ng-invalid">
<div _ngcontent-axabe-c112="" class="row form-group has-feedback"><label _ngcontent-axabe-c112="" class="col-12" for="password"> Choisissez votre mot de passe <span _ngcontent-axabe-c112="">*</span><!----></label><!---->
<div _ngcontent-axabe-c112="" class="col-12"><!----><!---->
<div _ngcontent-axabe-c112="" class="input-group"><!----><input _ngcontent-axabe-c112="" id="password" name="password" placeholder="Choisissez votre mot de passe" type="password" autocomplete="undefined" minlength="0"
class="form-control"><!----><!----><!---->
<div _ngcontent-axabe-c112="" class="input-group-append"><button _ngcontent-axabe-c112="" type="button" role="button" tabindex="-1"><i _ngcontent-axabe-c112="" class="fa fa-eye-slash"></i></button></div><!----><!---->
</div><!----><!----><!----><!----><!----><!----><!----><!---->
</div><!---->
</div><!----><!---->
</cora-o-input></div>
<div _ngcontent-axabe-c410="" class="typo18 font-weight-bold"><cora-o-input _ngcontent-axabe-c410="" _nghost-axabe-c112="" class="ng-untouched ng-pristine ng-invalid">
<div _ngcontent-axabe-c112="" class="row form-group has-feedback"><label _ngcontent-axabe-c112="" class="col-12" for="passwordConfirmation"> Confirmez votre mot de passe <span _ngcontent-axabe-c112="">*</span><!----></label><!---->
<div _ngcontent-axabe-c112="" class="col-12"><!----><!---->
<div _ngcontent-axabe-c112="" class="input-group"><!----><input _ngcontent-axabe-c112="" id="passwordConfirmation" name="passwordConfirmation" placeholder="Confirmez votre mot de passe" type="password" autocomplete="current-password"
minlength="0" class="form-control"><!----><!----><!---->
<div _ngcontent-axabe-c112="" class="input-group-append"><button _ngcontent-axabe-c112="" type="button" role="button" tabindex="-1"><i _ngcontent-axabe-c112="" class="fa fa-eye-slash"></i></button></div><!----><!---->
</div><!----><!----><!----><!----><!----><!----><!----><!---->
</div><!---->
</div><!----><!---->
</cora-o-input></div>
<div _ngcontent-axabe-c410="" class="typo18"><cora-o-input _ngcontent-axabe-c410="" _nghost-axabe-c112="" class="ng-untouched ng-pristine ng-valid">
<div _ngcontent-axabe-c112="" class="row form-group has-feedback"><!---->
<div _ngcontent-axabe-c112="" class="col-12 col-lg-8 col-md-7"><!----><!---->
<div _ngcontent-axabe-c112="" class="input-group form-check-inline"><!----><input _ngcontent-axabe-c112="" id="optIn" name="optIn" placeholder="" type="checkbox" autocomplete="undefined" value="0" minlength="0"
class="form-check-input"><!----><!----><!----><!----><label _ngcontent-axabe-c112="" for="optIn"> Je souhaite recevoir les newsletters et les offres MyAXA Fidelity. <!----></label><!----></div>
<!----><!----><!----><!----><!----><!----><!----><!---->
</div><!---->
</div><!----><!---->
</cora-o-input></div>
<div _ngcontent-axabe-c410="" class="typo18"><cora-o-input _ngcontent-axabe-c410="" _nghost-axabe-c112="" class="ng-untouched ng-pristine ng-valid">
<div _ngcontent-axabe-c112="" class="row form-group has-feedback"><!---->
<div _ngcontent-axabe-c112="" class="col-12 col-lg-8 col-md-7"><!----><!---->
<div _ngcontent-axabe-c112="" class="input-group form-check-inline"><!----><input _ngcontent-axabe-c112="" id="optIn-261" name="optIn261" placeholder="" type="checkbox" autocomplete="undefined" value="0" minlength="0"
class="form-check-input"><!----><!----><!----><!----><label _ngcontent-axabe-c112="" for="optIn-261"> Je souhaite recevoir les rappels personnalisés de ma boutique MyAXA Fidelity. <!----></label><!----></div>
<!----><!----><!----><!----><!----><!----><!----><!---->
</div><!---->
</div><!----><!---->
</cora-o-input></div><!---->
<div _ngcontent-axabe-c410="" class="row bloc_cgu_wrapper">
<div _ngcontent-axabe-c410="" class="col-xl-12">
<div _ngcontent-axabe-c410="" class="row typo18">
<div _ngcontent-axabe-c410="" class="col-1"><cora-o-input _ngcontent-axabe-c410="" _nghost-axabe-c112="" class="ng-untouched ng-pristine ng-invalid">
<div _ngcontent-axabe-c112="" class="row form-group has-feedback"><!---->
<div _ngcontent-axabe-c112="" class="col-12"><!----><!---->
<div _ngcontent-axabe-c112="" class="input-group form-check-inline"><!----><input _ngcontent-axabe-c112="" id="optInTerms" name="optInTerms" placeholder="" type="checkbox" autocomplete="undefined" value="false" minlength="0"
class="form-check-input"><!----><!----><!----><!----><label _ngcontent-axabe-c112="" for="optInTerms"> <!----></label><!----></div><!----><!----><!----><!----><!----><!----><!----><!---->
</div><!---->
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