altech.talassa.fr
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urlscan Pro
195.15.231.199
Public Scan
URL:
https://altech.talassa.fr/
Submission: On July 09 via api from US — Scanned from FR
Submission: On July 09 via api from US — Scanned from FR
Form analysis 1 forms found in the DOM
POST
<form method="post" action="" class="ipt_uif_validate_form ipt_fsqm_main_form" id="ipt_fsqm_form_8" autocomplete="on">
<input type="hidden" data-sayt-exclude="" name="action" id="action" value="ipt_fsqm_save_form">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_epoc" class="eform-epoc-value" value="1720541330">
<input type="hidden" class="ipt_fsqm_form_tab_pos" name="fsqm_form8_tab_pos" value="0" id="fsqm_form8_tab_pos">
<input type="hidden" id="ipt_fsqm_form_data_save" name="ipt_fsqm_form_data_save" value="aa258c476a" data-sayt-exclude=""> <input type="hidden" name="_wp_http_referer" value="/">
<input type="hidden" data-sayt-exclude="" name="form_id" value="8">
<div class="ipt-eform-width-restrain">
<div class="ipt-eform-content ">
<div id="ipt_fsqm_form_8_layout_0_inner" class="ipt-eform-layout-wrapper">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_main_heading_column">
<div class="ipt_uif_column_inner">
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][0][m_type]" id="ipt_fsqm_form_8_design_0_m_type" value="design" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][0][type]" id="ipt_fsqm_form_8_design_0_type" value="heading" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_heading" id="ipt_fsqm_form_8_design_0">
<div class="ipt_uif_column_inner">
<h4 class="ipt_uif_heading ipt_uif_divider ipt_uif_align_left ipt_uif_divider_no_icon">
<span class="ipt_uif_divider_text">
<span class="ipt_uif_divider_text_inner"> 1 – CHOIX DU PRESTATAIRE DU DÉPARTEMENT QUI INTERVIENDRA </span>
</span>
</h4>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][19][m_type]" id="ipt_fsqm_form_8_freetype_19_m_type" value="freetype" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][19][type]" id="ipt_fsqm_form_8_freetype_19_type" value="citychoice" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_citychoice" id="ipt_fsqm_form_8_freetype_19_wrap">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_question ipt_uif_question_full">
<div class="ipt_uif_question_content">
<div class="input-field">
<input class=" check_me ipt_uif_text" type="text" name="ipt_fsqm_form_8[freetype][19][value]" id="ipt_fsqm_form_8_freetype_19_value" value="">
<label for="ipt_fsqm_form_8_freetype_19_value">Code postal</label>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][1][m_type]" id="ipt_fsqm_form_8_design_1_m_type" value="design" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][1][type]" id="ipt_fsqm_form_8_design_1_type" value="heading" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_heading" id="ipt_fsqm_form_8_design_1">
<div class="ipt_uif_column_inner">
<h4 class="ipt_uif_heading ipt_uif_divider ipt_uif_align_left ipt_uif_divider_no_icon">
<span class="ipt_uif_divider_text">
<span class="ipt_uif_divider_text_inner"> 2 – VOS COORDONNÉES </span>
</span>
</h4>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][5][m_type]" id="ipt_fsqm_form_8_design_5_m_type" value="design" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][5][type]" id="ipt_fsqm_form_8_design_5_type" value="col_half" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_half ipt_uif_conditional ipt_uif_column_custom ipt_fsqm_container_col_half" id="ipt_fsqm_form_8_design_5">
<div class="ipt_uif_column_inner">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[pinfo][3][m_type]" id="ipt_fsqm_form_8_pinfo_3_m_type" value="pinfo" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[pinfo][3][type]" id="ipt_fsqm_form_8_pinfo_3_type" value="l_name" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_l_name" id="ipt_fsqm_form_8_pinfo_3">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_question ipt_uif_question_vertical ipt_uif_question_full">
<div class="ipt_uif_question_content">
<div class="input-field">
<input class=" check_me validate[required] ipt_uif_text" type="text" name="ipt_fsqm_form_8[pinfo][3][value]" id="ipt_fsqm_form_8_pinfo_3_value" maxlength="" value="">
<label for="ipt_fsqm_form_8_pinfo_3_value">Nom*</label>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][6][m_type]" id="ipt_fsqm_form_8_design_6_m_type" value="design" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][6][type]" id="ipt_fsqm_form_8_design_6_type" value="col_half" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_half ipt_uif_conditional ipt_uif_column_custom ipt_fsqm_container_col_half" id="ipt_fsqm_form_8_design_6">
<div class="ipt_uif_column_inner">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[pinfo][4][m_type]" id="ipt_fsqm_form_8_pinfo_4_m_type" value="pinfo" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[pinfo][4][type]" id="ipt_fsqm_form_8_pinfo_4_type" value="f_name" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_f_name" id="ipt_fsqm_form_8_pinfo_4">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_question ipt_uif_question_vertical ipt_uif_question_full">
<div class="ipt_uif_question_content">
<div class="input-field">
<input class=" check_me validate[required] ipt_uif_text" type="text" name="ipt_fsqm_form_8[pinfo][4][value]" id="ipt_fsqm_form_8_pinfo_4_value" maxlength="" value="">
<label for="ipt_fsqm_form_8_pinfo_4_value">Prénom*</label>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][7][m_type]" id="ipt_fsqm_form_8_design_7_m_type" value="design" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][7][type]" id="ipt_fsqm_form_8_design_7_type" value="col_half" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_half ipt_uif_conditional ipt_uif_column_custom ipt_fsqm_container_col_half" id="ipt_fsqm_form_8_design_7">
<div class="ipt_uif_column_inner">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][2][m_type]" id="ipt_fsqm_form_8_freetype_2_m_type" value="freetype" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][2][type]" id="ipt_fsqm_form_8_freetype_2_type" value="feedback_small" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small" id="ipt_fsqm_form_8_freetype_2">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_question ipt_uif_question_vertical ipt_uif_question_full">
<div class="ipt_uif_question_content">
<div class="input-field">
<input class=" check_me validate[required] ipt_uif_text" type="text" name="ipt_fsqm_form_8[freetype][2][value]" id="ipt_fsqm_form_8_freetype_2_value" maxlength="" value="">
<label for="ipt_fsqm_form_8_freetype_2_value">Adresse*</label>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][8][m_type]" id="ipt_fsqm_form_8_design_8_m_type" value="design" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][8][type]" id="ipt_fsqm_form_8_design_8_type" value="col_half" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_half ipt_uif_conditional ipt_uif_column_custom ipt_fsqm_container_col_half" id="ipt_fsqm_form_8_design_8">
<div class="ipt_uif_column_inner">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][5][m_type]" id="ipt_fsqm_form_8_freetype_5_m_type" value="freetype" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][5][type]" id="ipt_fsqm_form_8_freetype_5_type" value="feedback_small" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small" id="ipt_fsqm_form_8_freetype_5">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_question ipt_uif_question_vertical ipt_uif_question_full">
<div class="ipt_uif_question_content">
<div class="input-field">
<input class=" check_me validate[required] ipt_uif_text" type="text" name="ipt_fsqm_form_8[freetype][5][value]" id="ipt_fsqm_form_8_freetype_5_value" maxlength="" value="">
<label for="ipt_fsqm_form_8_freetype_5_value">Code postal*</label>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][9][m_type]" id="ipt_fsqm_form_8_design_9_m_type" value="design" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][9][type]" id="ipt_fsqm_form_8_design_9_type" value="col_half" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_half ipt_uif_conditional ipt_uif_column_custom ipt_fsqm_container_col_half" id="ipt_fsqm_form_8_design_9">
<div class="ipt_uif_column_inner">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][4][m_type]" id="ipt_fsqm_form_8_freetype_4_m_type" value="freetype" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][4][type]" id="ipt_fsqm_form_8_freetype_4_type" value="feedback_small" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small" id="ipt_fsqm_form_8_freetype_4">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_question ipt_uif_question_vertical ipt_uif_question_full">
<div class="ipt_uif_question_content">
<div class="input-field">
<input class=" check_me validate[required] ipt_uif_text" type="text" name="ipt_fsqm_form_8[freetype][4][value]" id="ipt_fsqm_form_8_freetype_4_value" maxlength="" value="">
<label for="ipt_fsqm_form_8_freetype_4_value">Ville*</label>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][10][m_type]" id="ipt_fsqm_form_8_design_10_m_type" value="design" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][10][type]" id="ipt_fsqm_form_8_design_10_type" value="col_half" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_half ipt_uif_conditional ipt_uif_column_custom ipt_fsqm_container_col_half" id="ipt_fsqm_form_8_design_10">
<div class="ipt_uif_column_inner">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][3][m_type]" id="ipt_fsqm_form_8_freetype_3_m_type" value="freetype" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][3][type]" id="ipt_fsqm_form_8_freetype_3_type" value="feedback_small" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small" id="ipt_fsqm_form_8_freetype_3">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_question ipt_uif_question_vertical ipt_uif_question_full">
<div class="ipt_uif_question_content">
<div class="input-field">
<input class=" check_me ipt_uif_text" type="text" name="ipt_fsqm_form_8[freetype][3][value]" id="ipt_fsqm_form_8_freetype_3_value" maxlength="" value="">
<label for="ipt_fsqm_form_8_freetype_3_value">Tél. fixe</label>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][11][m_type]" id="ipt_fsqm_form_8_design_11_m_type" value="design" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][11][type]" id="ipt_fsqm_form_8_design_11_type" value="col_half" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_half ipt_uif_conditional ipt_uif_column_custom ipt_fsqm_container_col_half" id="ipt_fsqm_form_8_design_11">
<div class="ipt_uif_column_inner">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][6][m_type]" id="ipt_fsqm_form_8_freetype_6_m_type" value="freetype" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][6][type]" id="ipt_fsqm_form_8_freetype_6_type" value="feedback_small" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small" id="ipt_fsqm_form_8_freetype_6">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_question ipt_uif_question_vertical ipt_uif_question_full">
<div class="ipt_uif_question_content">
<div class="input-field">
<input class=" check_me validate[required] ipt_uif_text" type="text" name="ipt_fsqm_form_8[freetype][6][value]" id="ipt_fsqm_form_8_freetype_6_value" maxlength="" value="">
<label for="ipt_fsqm_form_8_freetype_6_value">Tél. portable*</label>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][12][m_type]" id="ipt_fsqm_form_8_design_12_m_type" value="design" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][12][type]" id="ipt_fsqm_form_8_design_12_type" value="col_half" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_half ipt_uif_conditional ipt_uif_column_custom ipt_fsqm_container_col_half" id="ipt_fsqm_form_8_design_12">
<div class="ipt_uif_column_inner">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[pinfo][0][m_type]" id="ipt_fsqm_form_8_pinfo_0_m_type" value="pinfo" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[pinfo][0][type]" id="ipt_fsqm_form_8_pinfo_0_type" value="email" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_email" id="ipt_fsqm_form_8_pinfo_0">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_question ipt_uif_question_vertical ipt_uif_question_full">
<div class="ipt_uif_question_content">
<div class="input-field">
<input class=" check_me validate[required,custom[email]] ipt_uif_text" type="email" name="ipt_fsqm_form_8[pinfo][0][value]" id="ipt_fsqm_form_8_pinfo_0_value" value="">
<label for="ipt_fsqm_form_8_pinfo_0_value">Email*</label>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][2][m_type]" id="ipt_fsqm_form_8_design_2_m_type" value="design" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][2][type]" id="ipt_fsqm_form_8_design_2_type" value="heading" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_heading" id="ipt_fsqm_form_8_design_2">
<div class="ipt_uif_column_inner">
<h4 class="ipt_uif_heading ipt_uif_divider ipt_uif_align_left ipt_uif_divider_no_icon">
<span class="ipt_uif_divider_text">
<span class="ipt_uif_divider_text_inner"> 3 – COORDONNÉES DE VOTRE INSTALLATEUR </span>
</span>
</h4>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][13][m_type]" id="ipt_fsqm_form_8_design_13_m_type" value="design" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][13][type]" id="ipt_fsqm_form_8_design_13_type" value="col_half" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_half ipt_uif_conditional ipt_uif_column_custom ipt_fsqm_container_col_half" id="ipt_fsqm_form_8_design_13">
<div class="ipt_uif_column_inner">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][8][m_type]" id="ipt_fsqm_form_8_freetype_8_m_type" value="freetype" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][8][type]" id="ipt_fsqm_form_8_freetype_8_type" value="feedback_small" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small" id="ipt_fsqm_form_8_freetype_8">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_question ipt_uif_question_vertical ipt_uif_question_full">
<div class="ipt_uif_question_content">
<div class="input-field">
<input class=" check_me ipt_uif_text" type="text" name="ipt_fsqm_form_8[freetype][8][value]" id="ipt_fsqm_form_8_freetype_8_value" maxlength="" value="">
<label for="ipt_fsqm_form_8_freetype_8_value">Raison sociale</label>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][14][m_type]" id="ipt_fsqm_form_8_design_14_m_type" value="design" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][14][type]" id="ipt_fsqm_form_8_design_14_type" value="col_half" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_half ipt_uif_conditional ipt_uif_column_custom ipt_fsqm_container_col_half" id="ipt_fsqm_form_8_design_14">
<div class="ipt_uif_column_inner">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][9][m_type]" id="ipt_fsqm_form_8_freetype_9_m_type" value="freetype" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][9][type]" id="ipt_fsqm_form_8_freetype_9_type" value="feedback_small" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small" id="ipt_fsqm_form_8_freetype_9">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_question ipt_uif_question_vertical ipt_uif_question_full">
<div class="ipt_uif_question_content">
<div class="input-field">
<input class=" check_me ipt_uif_text" type="text" name="ipt_fsqm_form_8[freetype][9][value]" id="ipt_fsqm_form_8_freetype_9_value" maxlength="" value="">
<label for="ipt_fsqm_form_8_freetype_9_value">Nom</label>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][15][m_type]" id="ipt_fsqm_form_8_design_15_m_type" value="design" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][15][type]" id="ipt_fsqm_form_8_design_15_type" value="col_half" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_half ipt_uif_conditional ipt_uif_column_custom ipt_fsqm_container_col_half" id="ipt_fsqm_form_8_design_15">
<div class="ipt_uif_column_inner">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][10][m_type]" id="ipt_fsqm_form_8_freetype_10_m_type" value="freetype" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][10][type]" id="ipt_fsqm_form_8_freetype_10_type" value="feedback_small" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small" id="ipt_fsqm_form_8_freetype_10">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_question ipt_uif_question_vertical ipt_uif_question_full">
<div class="ipt_uif_question_content">
<div class="input-field">
<input class=" check_me ipt_uif_text" type="text" name="ipt_fsqm_form_8[freetype][10][value]" id="ipt_fsqm_form_8_freetype_10_value" maxlength="" value="">
<label for="ipt_fsqm_form_8_freetype_10_value">Prénom</label>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][16][m_type]" id="ipt_fsqm_form_8_design_16_m_type" value="design" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][16][type]" id="ipt_fsqm_form_8_design_16_type" value="col_half" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_half ipt_uif_conditional ipt_uif_column_custom ipt_fsqm_container_col_half" id="ipt_fsqm_form_8_design_16">
<div class="ipt_uif_column_inner">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][11][m_type]" id="ipt_fsqm_form_8_freetype_11_m_type" value="freetype" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][11][type]" id="ipt_fsqm_form_8_freetype_11_type" value="feedback_small" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small" id="ipt_fsqm_form_8_freetype_11">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_question ipt_uif_question_vertical ipt_uif_question_full">
<div class="ipt_uif_question_content">
<div class="input-field">
<input class=" check_me ipt_uif_text" type="text" name="ipt_fsqm_form_8[freetype][11][value]" id="ipt_fsqm_form_8_freetype_11_value" maxlength="" value="">
<label for="ipt_fsqm_form_8_freetype_11_value">Adresse</label>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][17][m_type]" id="ipt_fsqm_form_8_design_17_m_type" value="design" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][17][type]" id="ipt_fsqm_form_8_design_17_type" value="col_half" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_half ipt_uif_conditional ipt_uif_column_custom ipt_fsqm_container_col_half" id="ipt_fsqm_form_8_design_17">
<div class="ipt_uif_column_inner">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][12][m_type]" id="ipt_fsqm_form_8_freetype_12_m_type" value="freetype" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][12][type]" id="ipt_fsqm_form_8_freetype_12_type" value="feedback_small" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small" id="ipt_fsqm_form_8_freetype_12">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_question ipt_uif_question_vertical ipt_uif_question_full">
<div class="ipt_uif_question_content">
<div class="input-field">
<input class=" check_me ipt_uif_text" type="text" name="ipt_fsqm_form_8[freetype][12][value]" id="ipt_fsqm_form_8_freetype_12_value" maxlength="" value="">
<label for="ipt_fsqm_form_8_freetype_12_value">Code postal</label>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][19][m_type]" id="ipt_fsqm_form_8_design_19_m_type" value="design" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][19][type]" id="ipt_fsqm_form_8_design_19_type" value="col_half" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_half ipt_uif_conditional ipt_uif_column_custom ipt_fsqm_container_col_half" id="ipt_fsqm_form_8_design_19">
<div class="ipt_uif_column_inner">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][13][m_type]" id="ipt_fsqm_form_8_freetype_13_m_type" value="freetype" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][13][type]" id="ipt_fsqm_form_8_freetype_13_type" value="feedback_small" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small" id="ipt_fsqm_form_8_freetype_13">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_question ipt_uif_question_vertical ipt_uif_question_full">
<div class="ipt_uif_question_content">
<div class="input-field">
<input class=" check_me ipt_uif_text" type="text" name="ipt_fsqm_form_8[freetype][13][value]" id="ipt_fsqm_form_8_freetype_13_value" maxlength="" value="">
<label for="ipt_fsqm_form_8_freetype_13_value">Ville</label>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][18][m_type]" id="ipt_fsqm_form_8_design_18_m_type" value="design" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][18][type]" id="ipt_fsqm_form_8_design_18_type" value="col_half" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_half ipt_uif_conditional ipt_uif_column_custom ipt_fsqm_container_col_half" id="ipt_fsqm_form_8_design_18">
<div class="ipt_uif_column_inner">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][14][m_type]" id="ipt_fsqm_form_8_freetype_14_m_type" value="freetype" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][14][type]" id="ipt_fsqm_form_8_freetype_14_type" value="feedback_small" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small" id="ipt_fsqm_form_8_freetype_14">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_question ipt_uif_question_vertical ipt_uif_question_full">
<div class="ipt_uif_question_content">
<div class="input-field">
<input class=" check_me ipt_uif_text" type="text" name="ipt_fsqm_form_8[freetype][14][value]" id="ipt_fsqm_form_8_freetype_14_value" maxlength="" value="">
<label for="ipt_fsqm_form_8_freetype_14_value">Tél. fixe</label>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][20][m_type]" id="ipt_fsqm_form_8_design_20_m_type" value="design" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][20][type]" id="ipt_fsqm_form_8_design_20_type" value="col_half" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_half ipt_uif_conditional ipt_uif_column_custom ipt_fsqm_container_col_half" id="ipt_fsqm_form_8_design_20">
<div class="ipt_uif_column_inner">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][15][m_type]" id="ipt_fsqm_form_8_freetype_15_m_type" value="freetype" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][15][type]" id="ipt_fsqm_form_8_freetype_15_type" value="feedback_small" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small" id="ipt_fsqm_form_8_freetype_15">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_question ipt_uif_question_vertical ipt_uif_question_full">
<div class="ipt_uif_question_content">
<div class="input-field">
<input class=" check_me ipt_uif_text" type="text" name="ipt_fsqm_form_8[freetype][15][value]" id="ipt_fsqm_form_8_freetype_15_value" maxlength="" value="">
<label for="ipt_fsqm_form_8_freetype_15_value">Tél. portable</label>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][21][m_type]" id="ipt_fsqm_form_8_design_21_m_type" value="design" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][21][type]" id="ipt_fsqm_form_8_design_21_type" value="col_half" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_half ipt_uif_conditional ipt_uif_column_custom ipt_fsqm_container_col_half" id="ipt_fsqm_form_8_design_21">
<div class="ipt_uif_column_inner">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][16][m_type]" id="ipt_fsqm_form_8_freetype_16_m_type" value="freetype" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][16][type]" id="ipt_fsqm_form_8_freetype_16_type" value="feedback_small" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small" id="ipt_fsqm_form_8_freetype_16">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_question ipt_uif_question_vertical ipt_uif_question_full">
<div class="ipt_uif_question_content">
<div class="input-field">
<input class=" check_me ipt_uif_text" type="text" name="ipt_fsqm_form_8[freetype][16][value]" id="ipt_fsqm_form_8_freetype_16_value" maxlength="" value="">
<label for="ipt_fsqm_form_8_freetype_16_value">Email</label>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][3][m_type]" id="ipt_fsqm_form_8_design_3_m_type" value="design" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][3][type]" id="ipt_fsqm_form_8_design_3_type" value="heading" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_heading" id="ipt_fsqm_form_8_design_3">
<div class="ipt_uif_column_inner">
<h4 class="ipt_uif_heading ipt_uif_divider ipt_uif_align_left ipt_uif_divider_no_icon">
<span class="ipt_uif_divider_text">
<span class="ipt_uif_divider_text_inner"> 4 – VOTRE MATÉRIEL </span>
</span>
</h4>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][22][m_type]" id="ipt_fsqm_form_8_design_22_m_type" value="design" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][22][type]" id="ipt_fsqm_form_8_design_22_type" value="col_half" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_half ipt_uif_conditional ipt_uif_column_custom ipt_fsqm_container_col_half" id="ipt_fsqm_form_8_design_22">
<div class="ipt_uif_column_inner">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[mcq][1][m_type]" id="ipt_fsqm_form_8_mcq_1_m_type" value="mcq" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[mcq][1][type]" id="ipt_fsqm_form_8_mcq_1_type" value="checkbox" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_checkbox" id="ipt_fsqm_form_8_mcq_1">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_question ipt_uif_question_vertical ipt_uif_question_full">
<div class="ipt_uif_question_content">
<div class="ipt_uif_conditional_input">
<div class="ipt_uif_label_column column_1">
<input data-num="" type="checkbox" class="check_me validate[required] ipt_uif_checkbox filled-in " name="ipt_fsqm_form_8[mcq][1][options][]" id="ipt_fsqm_form_8_mcq_1_options__0" value="0">
<label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_1_options__0" data-labelcon=""> Adoucisseur </label>
</div>
<div class="ipt_uif_label_column column_1">
<input data-num="" type="checkbox" class="check_me validate[required] ipt_uif_checkbox filled-in " name="ipt_fsqm_form_8[mcq][1][options][]" id="ipt_fsqm_form_8_mcq_1_options__1" value="1">
<label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_1_options__1" data-labelcon=""> Osmoseur </label>
</div>
<div class="ipt_uif_label_column column_1">
<input data-num="" type="checkbox" class="check_me validate[required] ipt_uif_checkbox filled-in " name="ipt_fsqm_form_8[mcq][1][options][]" id="ipt_fsqm_form_8_mcq_1_options__2" value="2">
<label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_1_options__2" data-labelcon=""> Désinfection par ultra violet </label>
</div>
<div class="ipt_uif_label_column column_1">
<input data-num="" type="checkbox" class="check_me validate[required] ipt_uif_checkbox filled-in " name="ipt_fsqm_form_8[mcq][1][options][]" id="ipt_fsqm_form_8_mcq_1_options__3" value="3">
<label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_1_options__3" data-labelcon=""> Défériseur </label>
</div>
<div class="ipt_uif_label_column column_1">
<input data-num="" type="checkbox" class="check_me validate[required] ipt_uif_checkbox filled-in " name="ipt_fsqm_form_8[mcq][1][options][]" id="ipt_fsqm_form_8_mcq_1_options__4" value="4">
<label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_1_options__4" data-labelcon=""> Dénitrateur </label>
</div>
<div class="ipt_uif_label_column column_1">
<input data-num="" type="checkbox" class="check_me validate[required] ipt_uif_checkbox filled-in " name="ipt_fsqm_form_8[mcq][1][options][]" id="ipt_fsqm_form_8_mcq_1_options__5" value="5">
<label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_1_options__5" data-labelcon=""> Filtre à sable </label>
</div>
<div class="ipt_uif_label_column column_1">
<input data-num="" type="checkbox" class="check_me validate[required] ipt_uif_checkbox filled-in " name="ipt_fsqm_form_8[mcq][1][options][]" id="ipt_fsqm_form_8_mcq_1_options__6" value="6">
<label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_1_options__6" data-labelcon=""> Pompe doseuse </label>
</div>
<div class="ipt_uif_label_column column_1">
<input data-condid="ipt_fsqm_form_8_mcq_1_others_wrap" type="checkbox" class="check_me validate[required] ipt_uif_checkbox filled-in " name="ipt_fsqm_form_8[mcq][1][options][]" id="ipt_fsqm_form_8_mcq_1_options__others"
value="others">
<label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_1_options__others" data-labelcon=""> Autre </label>
</div>
<div class="clear-both"></div>
</div>
<div class="ipt_uif_box ipt_uif_question_others" id="ipt_fsqm_form_8_mcq_1_others_wrap">
<div class="input-field has-icon">
<input class=" check_me validate[required] ipt_uif_text" type="text" name="ipt_fsqm_form_8[mcq][1][others]" id="ipt_fsqm_form_8_mcq_1_others" value="">
<i title="" class=" ipt-icomoon-pen ipticm prefix"></i>
<label for="ipt_fsqm_form_8_mcq_1_others">Ecrire ici</label>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][23][m_type]" id="ipt_fsqm_form_8_design_23_m_type" value="design" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][23][type]" id="ipt_fsqm_form_8_design_23_type" value="col_half" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_half ipt_uif_conditional ipt_uif_column_custom ipt_fsqm_container_col_half" id="ipt_fsqm_form_8_design_23">
<div class="ipt_uif_column_inner">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][17][m_type]" id="ipt_fsqm_form_8_freetype_17_m_type" value="freetype" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][17][type]" id="ipt_fsqm_form_8_freetype_17_type" value="feedback_small" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small" id="ipt_fsqm_form_8_freetype_17">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_question ipt_uif_question_vertical ipt_uif_question_full">
<div class="ipt_uif_question_content">
<div class="input-field">
<input class=" check_me validate[required] ipt_uif_text" type="text" name="ipt_fsqm_form_8[freetype][17][value]" id="ipt_fsqm_form_8_freetype_17_value" maxlength="" value="">
<label for="ipt_fsqm_form_8_freetype_17_value">Modèle de l'appareil*</label>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][18][m_type]" id="ipt_fsqm_form_8_freetype_18_m_type" value="freetype" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][18][type]" id="ipt_fsqm_form_8_freetype_18_type" value="feedback_small" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small" id="ipt_fsqm_form_8_freetype_18">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_question ipt_uif_question_vertical ipt_uif_question_full">
<div class="ipt_uif_question_content">
<div class="input-field">
<input class=" check_me ipt_uif_text" type="text" name="ipt_fsqm_form_8[freetype][18][value]" id="ipt_fsqm_form_8_freetype_18_value" maxlength="" value="">
<label for="ipt_fsqm_form_8_freetype_18_value">N° de série indiqué</label>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][4][m_type]" id="ipt_fsqm_form_8_design_4_m_type" value="design" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][4][type]" id="ipt_fsqm_form_8_design_4_type" value="heading" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_heading" id="ipt_fsqm_form_8_design_4">
<div class="ipt_uif_column_inner">
<h4 class="ipt_uif_heading ipt_uif_divider ipt_uif_align_left ipt_uif_divider_no_icon">
<span class="ipt_uif_divider_text">
<span class="ipt_uif_divider_text_inner"> 5 – QUESTIONNAIRE À PROPROS DE VOTRE INSTALLATION </span>
</span>
</h4>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[mcq][2][m_type]" id="ipt_fsqm_form_8_mcq_2_m_type" value="mcq" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[mcq][2][type]" id="ipt_fsqm_form_8_mcq_2_type" value="radio" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_radio" id="ipt_fsqm_form_8_mcq_2">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_question ipt_uif_question_vertical">
<div class="ipt_uif_question_label">
<label class="ipt_uif_question_title ipt_uif_label" for="ipt_fsqm_form_8_mcq_2">1 – Présence d’un régulateur de pression réglé à 3 bars maxi. avant l’adoucisseur<span class="ipt_uif_question_required">*</span></label>
<div class="clear-both"></div>
</div>
<div class="ipt_uif_question_content">
<div class="ipt_uif_label_column column_random">
<input data-num="" type="radio" class="check_me validate[required] ipt_uif_radio with-gap" name="ipt_fsqm_form_8[mcq][2][options][]" id="ipt_fsqm_form_8_mcq_2_options__0" value="0">
<label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_2_options__0" data-labelcon=""> Oui </label>
</div>
<div class="ipt_uif_label_column column_random">
<input data-num="" type="radio" class="check_me validate[required] ipt_uif_radio with-gap" name="ipt_fsqm_form_8[mcq][2][options][]" id="ipt_fsqm_form_8_mcq_2_options__1" value="1">
<label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_2_options__1" data-labelcon=""> Non </label>
</div>
<div class="ipt_uif_label_column column_random">
<input data-num="" type="radio" class="check_me validate[required] ipt_uif_radio with-gap" name="ipt_fsqm_form_8[mcq][2][options][]" id="ipt_fsqm_form_8_mcq_2_options__2" value="2">
<label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_2_options__2" data-labelcon=""> Je ne sais pas </label>
</div>
<div class="clear-both"></div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[mcq][7][m_type]" id="ipt_fsqm_form_8_mcq_7_m_type" value="mcq" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[mcq][7][type]" id="ipt_fsqm_form_8_mcq_7_type" value="radio" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_radio" id="ipt_fsqm_form_8_mcq_7">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_question ipt_uif_question_vertical">
<div class="ipt_uif_question_label">
<label class="ipt_uif_question_title ipt_uif_label" for="ipt_fsqm_form_8_mcq_7">2 – Présence d’un clapet anti-retour anti-pollution (type EA) avant l’adoucisseur<span class="ipt_uif_question_required">*</span></label>
<div class="clear-both"></div>
</div>
<div class="ipt_uif_question_content">
<div class="ipt_uif_label_column column_random">
<input data-num="" type="radio" class="check_me validate[required] ipt_uif_radio with-gap" name="ipt_fsqm_form_8[mcq][7][options][]" id="ipt_fsqm_form_8_mcq_7_options__0" value="0">
<label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_7_options__0" data-labelcon=""> Oui </label>
</div>
<div class="ipt_uif_label_column column_random">
<input data-num="" type="radio" class="check_me validate[required] ipt_uif_radio with-gap" name="ipt_fsqm_form_8[mcq][7][options][]" id="ipt_fsqm_form_8_mcq_7_options__1" value="1">
<label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_7_options__1" data-labelcon=""> Non </label>
</div>
<div class="ipt_uif_label_column column_random">
<input data-num="" type="radio" class="check_me validate[required] ipt_uif_radio with-gap" name="ipt_fsqm_form_8[mcq][7][options][]" id="ipt_fsqm_form_8_mcq_7_options__2" value="2">
<label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_7_options__2" data-labelcon=""> Je ne sais pas </label>
</div>
<div class="clear-both"></div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[mcq][6][m_type]" id="ipt_fsqm_form_8_mcq_6_m_type" value="mcq" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[mcq][6][type]" id="ipt_fsqm_form_8_mcq_6_type" value="radio" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_radio" id="ipt_fsqm_form_8_mcq_6">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_question ipt_uif_question_vertical">
<div class="ipt_uif_question_label">
<label class="ipt_uif_question_title ipt_uif_label" for="ipt_fsqm_form_8_mcq_6">3 – Présence d’un clapet anti-retour simple contre les retours ECS ou groupe de sécurité sur chauffe-eau après l’adoucisseur<span
class="ipt_uif_question_required">*</span></label>
<div class="clear-both"></div>
</div>
<div class="ipt_uif_question_content">
<div class="ipt_uif_label_column column_random">
<input data-num="" type="radio" class="check_me validate[required] ipt_uif_radio with-gap" name="ipt_fsqm_form_8[mcq][6][options][]" id="ipt_fsqm_form_8_mcq_6_options__0" value="0">
<label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_6_options__0" data-labelcon=""> Oui </label>
</div>
<div class="ipt_uif_label_column column_random">
<input data-num="" type="radio" class="check_me validate[required] ipt_uif_radio with-gap" name="ipt_fsqm_form_8[mcq][6][options][]" id="ipt_fsqm_form_8_mcq_6_options__1" value="1">
<label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_6_options__1" data-labelcon=""> Non </label>
</div>
<div class="ipt_uif_label_column column_random">
<input data-num="" type="radio" class="check_me validate[required] ipt_uif_radio with-gap" name="ipt_fsqm_form_8[mcq][6][options][]" id="ipt_fsqm_form_8_mcq_6_options__2" value="2">
<label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_6_options__2" data-labelcon=""> Je ne sais pas </label>
</div>
<div class="clear-both"></div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[mcq][5][m_type]" id="ipt_fsqm_form_8_mcq_5_m_type" value="mcq" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[mcq][5][type]" id="ipt_fsqm_form_8_mcq_5_type" value="radio" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_radio" id="ipt_fsqm_form_8_mcq_5">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_question ipt_uif_question_vertical">
<div class="ipt_uif_question_label">
<label class="ipt_uif_question_title ipt_uif_label" for="ipt_fsqm_form_8_mcq_5">4 – Le tuyau de mise à l’égout est-il gravitaire et respecte-t-il une garde d’air?<span class="ipt_uif_question_required">*</span></label>
<div class="clear-both"></div>
</div>
<div class="ipt_uif_question_content">
<div class="ipt_uif_label_column column_random">
<input data-num="" type="radio" class="check_me validate[required] ipt_uif_radio with-gap" name="ipt_fsqm_form_8[mcq][5][options][]" id="ipt_fsqm_form_8_mcq_5_options__0" value="0">
<label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_5_options__0" data-labelcon=""> Oui </label>
</div>
<div class="ipt_uif_label_column column_random">
<input data-num="" type="radio" class="check_me validate[required] ipt_uif_radio with-gap" name="ipt_fsqm_form_8[mcq][5][options][]" id="ipt_fsqm_form_8_mcq_5_options__1" value="1">
<label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_5_options__1" data-labelcon=""> Non </label>
</div>
<div class="ipt_uif_label_column column_random">
<input data-num="" type="radio" class="check_me validate[required] ipt_uif_radio with-gap" name="ipt_fsqm_form_8[mcq][5][options][]" id="ipt_fsqm_form_8_mcq_5_options__2" value="2">
<label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_5_options__2" data-labelcon=""> Je ne sais pas </label>
</div>
<div class="clear-both"></div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[mcq][4][m_type]" id="ipt_fsqm_form_8_mcq_4_m_type" value="mcq" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[mcq][4][type]" id="ipt_fsqm_form_8_mcq_4_type" value="radio" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_radio" id="ipt_fsqm_form_8_mcq_4">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_question ipt_uif_question_vertical">
<div class="ipt_uif_question_label">
<label class="ipt_uif_question_title ipt_uif_label" for="ipt_fsqm_form_8_mcq_4">5 – Présence d’un robinet de puisage d’eau adoucie après l’adoucisseur (cuisine, évier, salle de bains)<span
class="ipt_uif_question_required">*</span></label>
<div class="clear-both"></div>
</div>
<div class="ipt_uif_question_content">
<div class="ipt_uif_label_column column_random">
<input data-num="" type="radio" class="check_me validate[required] ipt_uif_radio with-gap" name="ipt_fsqm_form_8[mcq][4][options][]" id="ipt_fsqm_form_8_mcq_4_options__0" value="0">
<label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_4_options__0" data-labelcon=""> Oui </label>
</div>
<div class="ipt_uif_label_column column_random">
<input data-num="" type="radio" class="check_me validate[required] ipt_uif_radio with-gap" name="ipt_fsqm_form_8[mcq][4][options][]" id="ipt_fsqm_form_8_mcq_4_options__1" value="1">
<label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_4_options__1" data-labelcon=""> Non </label>
</div>
<div class="ipt_uif_label_column column_random">
<input data-num="" type="radio" class="check_me validate[required] ipt_uif_radio with-gap" name="ipt_fsqm_form_8[mcq][4][options][]" id="ipt_fsqm_form_8_mcq_4_options__2" value="2">
<label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_4_options__2" data-labelcon=""> Je ne sais pas </label>
</div>
<div class="clear-both"></div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[mcq][3][m_type]" id="ipt_fsqm_form_8_mcq_3_m_type" value="mcq" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[mcq][3][type]" id="ipt_fsqm_form_8_mcq_3_type" value="radio" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_radio" id="ipt_fsqm_form_8_mcq_3">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_question ipt_uif_question_vertical">
<div class="ipt_uif_question_label">
<label class="ipt_uif_question_title ipt_uif_label" for="ipt_fsqm_form_8_mcq_3">6 – Raccordement électrique sur une prise murale normalisée<span class="ipt_uif_question_required">*</span></label>
<div class="clear-both"></div>
</div>
<div class="ipt_uif_question_content">
<div class="ipt_uif_label_column column_random">
<input data-num="" type="radio" class="check_me validate[required] ipt_uif_radio with-gap" name="ipt_fsqm_form_8[mcq][3][options][]" id="ipt_fsqm_form_8_mcq_3_options__0" value="0">
<label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_3_options__0" data-labelcon=""> Oui </label>
</div>
<div class="ipt_uif_label_column column_random">
<input data-num="" type="radio" class="check_me validate[required] ipt_uif_radio with-gap" name="ipt_fsqm_form_8[mcq][3][options][]" id="ipt_fsqm_form_8_mcq_3_options__1" value="1">
<label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_3_options__1" data-labelcon=""> Non </label>
</div>
<div class="ipt_uif_label_column column_random">
<input data-num="" type="radio" class="check_me validate[required] ipt_uif_radio with-gap" name="ipt_fsqm_form_8[mcq][3][options][]" id="ipt_fsqm_form_8_mcq_3_options__2" value="2">
<label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_3_options__2" data-labelcon=""> Je ne sais pas </label>
</div>
<div class="clear-both"></div>
<div class="clear-both"></div>
</div>
</div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[pinfo][1][m_type]" id="ipt_fsqm_form_8_pinfo_1_m_type" value="pinfo" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[pinfo][1][type]" id="ipt_fsqm_form_8_pinfo_1_type" value="s_checkbox" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_s_checkbox" id="ipt_fsqm_form_8_pinfo_1">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_label_column column_1">
<input type="checkbox" class="check_me validate[required] ipt_uif_checkbox filled-in ipt_uif_s_checkbox" name="ipt_fsqm_form_8[pinfo][1][value]" id="ipt_fsqm_form_8_pinfo_1_value_1" value="1">
<label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_pinfo_1_value_1" data-labelcon=""> Je reconnais que les informations saisies ci-dessus sont exactes et que mon installation est bien conforme aux règles de
l’art et aux codes de plomberie (DTU 60.1/60.11), d’électricité (norme C15-100) et d’hygiène. En cas de non-conformité de l’installation (points non facultatifs) ne permettant pas de mettre en service l’adoucisseur, l’appareil sera
isolé (vannes fermées) et bipassé. La seconde visite pour effectuer la mise en service sera facturée 55 euros HT. </label>
</div>
<div class="clear-both"></div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[pinfo][2][m_type]" id="ipt_fsqm_form_8_pinfo_2_m_type" value="pinfo" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[pinfo][2][type]" id="ipt_fsqm_form_8_pinfo_2_type" value="s_checkbox" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_s_checkbox" id="ipt_fsqm_form_8_pinfo_2">
<div class="ipt_uif_column_inner side_margin">
<div class="ipt_uif_label_column column_1">
<input type="checkbox" class="check_me validate[required] ipt_uif_checkbox filled-in ipt_uif_s_checkbox" name="ipt_fsqm_form_8[pinfo][2][value]" id="ipt_fsqm_form_8_pinfo_2_value_1" value="1">
<label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_pinfo_2_value_1" data-labelcon=""> En soumettant ce formulaire, j'accepte que les informations saisies soient exploitées dans le cadre de la relation
commerciale. </label>
</div>
<div class="clear-both"></div>
<div class="clear-both"></div>
</div>
</div>
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][24][m_type]" id="ipt_fsqm_form_8_design_24_m_type" value="design" class="ipt_fsqm_hf_m_type">
<input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][24][type]" id="ipt_fsqm_form_8_design_24_type" value="recaptcha" class="ipt_fsqm_hf_type">
<div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_recaptcha" id="ipt_fsqm_form_8_design_24">
<div class="ipt_uif_column_inner side_margin">
<input type="hidden" name="ipt_fsqm_form_8[design][24][recaptcha]" id="ipt_fsqm_form_8_design_24_recaptcha" value="">
<div class="eform-g-recaptcha" data-sitekey="6Ldto90mAAAAAAnlblvsfPdJd1Y_1Dc9sgZx4kd_" data-theme="light" data-type="image" data-size="normal">
<div style="width: 304px; height: 78px;">
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sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox allow-storage-access-by-user-activation"
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DEMANDE DE MISE EN SERVICE Javascript is disabled Javascript is disabled on your browser. Please enable it in order to use this form. Chargement 1 – CHOIX DU PRESTATAIRE DU DÉPARTEMENT QUI INTERVIENDRA Code postal 2 – VOS COORDONNÉES Nom* Prénom* Adresse* Code postal* Ville* Tél. fixe Tél. portable* Email* 3 – COORDONNÉES DE VOTRE INSTALLATEUR Raison sociale Nom Prénom Adresse Code postal Ville Tél. fixe Tél. portable Email 4 – VOTRE MATÉRIEL Adoucisseur Osmoseur Désinfection par ultra violet Défériseur Dénitrateur Filtre à sable Pompe doseuse Autre Ecrire ici Modèle de l'appareil* N° de série indiqué 5 – QUESTIONNAIRE À PROPROS DE VOTRE INSTALLATION 1 – Présence d’un régulateur de pression réglé à 3 bars maxi. avant l’adoucisseur* Oui Non Je ne sais pas 2 – Présence d’un clapet anti-retour anti-pollution (type EA) avant l’adoucisseur* Oui Non Je ne sais pas 3 – Présence d’un clapet anti-retour simple contre les retours ECS ou groupe de sécurité sur chauffe-eau après l’adoucisseur* Oui Non Je ne sais pas 4 – Le tuyau de mise à l’égout est-il gravitaire et respecte-t-il une garde d’air?* Oui Non Je ne sais pas 5 – Présence d’un robinet de puisage d’eau adoucie après l’adoucisseur (cuisine, évier, salle de bains)* Oui Non Je ne sais pas 6 – Raccordement électrique sur une prise murale normalisée* Oui Non Je ne sais pas Je reconnais que les informations saisies ci-dessus sont exactes et que mon installation est bien conforme aux règles de l’art et aux codes de plomberie (DTU 60.1/60.11), d’électricité (norme C15-100) et d’hygiène. En cas de non-conformité de l’installation (points non facultatifs) ne permettant pas de mettre en service l’adoucisseur, l’appareil sera isolé (vannes fermées) et bipassé. La seconde visite pour effectuer la mise en service sera facturée 55 euros HT. En soumettant ce formulaire, j'accepte que les informations saisies soient exploitées dans le cadre de la relation commerciale. Envoyer VOTRE FORMULAIRE A ÉTÉ ENVOYÉ Votre demande a bien été transmise, vous serez recontacté dans les plus brefs délais. Server Side Error We faced problems while connecting to the server or receiving data from the server. Please wait for a few seconds and try again. If the problem persists, then check your internet connectivity. If all other sites open fine, then please contact the administrator of this website with the following information. TextStatus: undefined HTTP Error: undefined Validation de vos informations Erreur Some error has occured. Notifications