{"id":3376,"date":"2021-08-09T10:51:50","date_gmt":"2021-08-09T08:51:50","guid":{"rendered":"https:\/\/www.derma.swiss\/devenir-membre\/formulaire-dinscription\/"},"modified":"2022-03-22T15:18:21","modified_gmt":"2022-03-22T14:18:21","slug":"formulaire-dinscription","status":"publish","type":"page","link":"https:\/\/www.derma.swiss\/fr\/devenir-membre\/formulaire-dinscription\/","title":{"rendered":"Formulaire d&rsquo;inscription"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\">La demande compl\u00e8te, accompagn\u00e9e des documents correspondants, est examin\u00e9e par le comit\u00e9 de la SSDV et une d\u00e9cision est ensuite prise quant \u00e0 l&rsquo;admission.<\/p>\n\n<p class=\"wp-block-paragraph\">\n\n\n<form id=\"rcp_registration_form\" class=\"rcp_form \" method=\"POST\" enctype=\"multipart\/form-data\" action=\"https:\/\/www.derma.swiss\/fr\/wp-json\/wp\/v2\/pages\/3376\/\">\n\n    <fieldset class=\"\"><legend>Param\u00e8tres de recherche<\/legend><div class=\"input-group input-group--radio\"><label for=\"consider_skills_in_search\">Prendre en compte les comp\u00e9tences m\u00e9dicales dans la recherche de membres dans le tableau de bord * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><div class=\"radio-groups-wrapper\">\n        <div class=\"radio-group\">\n        <input type=\"radio\" checked id=\"consider_skills_in_search-1\" name=\"consider_skills_in_search\" value=\"1\" required  >\n        <label for=\"consider_skills_in_search-1\">Oui<\/label>\n    <\/div>\n        <div class=\"radio-group\">\n        <input type=\"radio\"  id=\"consider_skills_in_search-2\" name=\"consider_skills_in_search\" value=\"0\" required  >\n        <label for=\"consider_skills_in_search-2\">Non<\/label>\n    <\/div>\n    <\/div><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--radio\"><label for=\"consider_equipment_in_search\">Prendre en compte l'\u00e9quipement du cabinet dans la recherche de membres dans le tableau de bord * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><div class=\"radio-groups-wrapper\">\n        <div class=\"radio-group\">\n        <input type=\"radio\" checked id=\"consider_equipment_in_search-1\" name=\"consider_equipment_in_search\" value=\"1\" required  >\n        <label for=\"consider_equipment_in_search-1\">Oui<\/label>\n    <\/div>\n        <div class=\"radio-group\">\n        <input type=\"radio\"  id=\"consider_equipment_in_search-2\" name=\"consider_equipment_in_search\" value=\"0\" required  >\n        <label for=\"consider_equipment_in_search-2\">Non<\/label>\n    <\/div>\n    <\/div><\/div><div class=\"error-message\"><\/div><\/div><\/div><\/fieldset><fieldset class=\"\"><legend>Identification<\/legend><div class=\"input-group input-group--email\"><label for=\"rcp_user_email\">Adresse \u00e9lectronique * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"email\" id=\"rcp_user_email\" name=\"rcp_user_email\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\trequired\n\t\t\t><\/div><div class=\"error-message\"><\/div><p class=\"description\">Utilis\u00e9 pour se connecter.<\/p><\/div><\/div><div class=\"input-group input-group--password\"><label for=\"rcp_user_pass\">Mot de passe * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"password\" id=\"rcp_user_pass\" name=\"rcp_user_pass\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\trequired\n\t\t\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--password\"><label for=\"rcp_user_pass_confirm\">Confirmation du mot de passe * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"password\" id=\"rcp_user_pass_confirm\" name=\"rcp_user_pass_confirm\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\trequired\n\t\t\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--text\"><label for=\"gln_id\">N\u00b0 GLN <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"text\" id=\"gln_id\" name=\"gln_id\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\t\tminlength=\"13\"\n\t\t\t\tmaxlength=\"13\"\n\t\t\t\tpattern=\"[0-9]+\"\n\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--text\"><label for=\"fmh_id\">No FMH * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"text\" id=\"fmh_id\" name=\"fmh_id\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\trequired\n\t\t\t\t\t\tminlength=\"5\"\n\t\t\t\tmaxlength=\"6\"\n\t\t\t\tpattern=\"[0-9]+\"\n\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><\/fieldset><fieldset class=\"\"><legend>Donn\u00e9es personnelles<\/legend><div class=\"input-group input-group--select\"><label for=\"salutation\">Formule d'appel * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><select name=\"salutation\" id=\"salutation\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\trequired\n\t\t\t><option selected value=\"\">--Veuillez choisir--<\/option><option  selected  value=\"0\">Madame<\/option><option  value=\"1\">Monsieur<\/option><\/select><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--select\"><label for=\"title\">Titre <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><select name=\"title\" id=\"title\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t><option selected value=\"\">--Veuillez choisir--<\/option><option  selected  value=\"0\">Pas de titre<\/option><option  value=\"1\">Dr<\/option><option  value=\"2\">PD Dr<\/option><option  value=\"3\">Prof.<\/option><option  value=\"4\">Dr m\u00e9d.<\/option><option  value=\"5\">Prof. Dr m\u00e9d.<\/option><\/select><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--text\"><label for=\"first_name\">Pr\u00e9nom * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"text\" id=\"first_name\" name=\"first_name\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\trequired\n\t\t\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--text\"><label for=\"last_name\">Nom de famille * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"text\" id=\"last_name\" name=\"last_name\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\trequired\n\t\t\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--text\"><label for=\"additional_name\">Nom de c\u00e9libataire <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"text\" id=\"additional_name\" name=\"additional_name\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--date\"><label for=\"dob\">Date de naissance * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"text\" id=\"dob\" name=\"dob\" class=\"date\" value=\"23.10.2026\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\trequired\n\t\t\t\t\t\t\t\t\treadonly\n\t\t\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--select\"><label for=\"language\">Langue * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><select name=\"language\" id=\"language\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\trequired\n\t\t\t><option selected value=\"\">--Veuillez choisir--<\/option><option  value=\"de\">Allemand<\/option><option  value=\"fr\">Fran\u00e7ais<\/option><\/select><\/div><div class=\"error-message\"><\/div><\/div><\/div><\/fieldset><fieldset class=\"\"><legend>Adresse professionnelle<\/legend><div class=\"input-group input-group--radio\"><label for=\"use_private_address\">Gew\u00fcnschte Kontaktadresse * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><div class=\"radio-groups-wrapper\">\n        <div class=\"radio-group\">\n        <input type=\"radio\" checked id=\"use_private_address-1\" name=\"use_private_address\" value=\"0\" required  >\n        <label for=\"use_private_address-1\">Adresse professionnelle<\/label>\n    <\/div>\n        <div class=\"radio-group\">\n        <input type=\"radio\"  id=\"use_private_address-2\" name=\"use_private_address\" value=\"2\" required  >\n        <label for=\"use_private_address-2\">2. Gesch\u00e4ftsadresse<\/label>\n    <\/div>\n        <div class=\"radio-group\">\n        <input type=\"radio\"  id=\"use_private_address-3\" name=\"use_private_address\" value=\"1\" required  >\n        <label for=\"use_private_address-3\">Adresse priv\u00e9e<\/label>\n    <\/div>\n    <\/div><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--text\"><label for=\"work_clinic\">Nom de la clinique \/ du cabinet * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"text\" id=\"work_clinic\" name=\"work_clinic\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\trequired\n\t\t\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--text\"><label for=\"work_department\">D\u00e9partement <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"text\" id=\"work_department\" name=\"work_department\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--text\"><label for=\"work_street\">Rue * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"text\" id=\"work_street\" name=\"work_street\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\trequired\n\t\t\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--text\"><label for=\"work_zip\">Code postal * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"text\" id=\"work_zip\" name=\"work_zip\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\trequired\n\t\t\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--text\"><label for=\"work_place\">Lieu * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"text\" id=\"work_place\" name=\"work_place\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\trequired\n\t\t\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--select\"><label for=\"work_canton\">Canton * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><select name=\"work_canton\" id=\"work_canton\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\trequired\n\t\t\t><option selected value=\"\">--Veuillez choisir--<\/option><option  value=\"ag\">Aargau <\/option><option  value=\"ai\">Appenzell Innerrhoden <\/option><option  value=\"ar\">Appenzell Ausserrhoden<\/option><option  value=\"be\">Bern<\/option><option  value=\"bl\">Basel-Landschaft<\/option><option  value=\"bs\">Basel-Stadt<\/option><option  value=\"fr\">Freiburg<\/option><option  value=\"ge\">Genf<\/option><option  value=\"gl\">Glarus<\/option><option  value=\"gr\">Graub\u00fcnden <\/option><option  value=\"ju\">Jura<\/option><option  value=\"lu\">Luzern <\/option><option  value=\"ne\">Neuenburg<\/option><option  value=\"nw\">Nidwalden <\/option><option  value=\"ow\">Obwalden <\/option><option  value=\"sg\">St. Gallen<\/option><option  value=\"sh\">Schaffhausen<\/option><option  value=\"so\">Solothurn <\/option><option  value=\"sz\">Schwyz<\/option><option  value=\"tg\">Thurgau<\/option><option  value=\"ti\">Tessin <\/option><option  value=\"ur\">Uri<\/option><option  value=\"vd\">Waadt<\/option><option  value=\"vs\">Wallis<\/option><option  value=\"zg\">Zug <\/option><option  value=\"zh\">Z\u00fcrich<\/option><\/select><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--select\"><label for=\"work_country\">Pays * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><select name=\"work_country\" id=\"work_country\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\trequired\n\t\t\t><option selected value=\"\">--Veuillez choisir--<\/option><option  value=\"af\">\u0627\u0641\u063a\u0627\u0646\u0633\u062a\u0627\u0646<\/option><option  value=\"ax\">\u00c5land<\/option><option  value=\"al\">Shqip\u00ebria<\/option><option  value=\"dz\">\u0627\u0644\u062c\u0632\u0627\u0626\u0631<\/option><option  value=\"as\">American Samoa<\/option><option  value=\"ad\">Andorra<\/option><option  value=\"ao\">Angola<\/option><option  value=\"ai\">Anguilla<\/option><option  value=\"aq\">Antarctica<\/option><option  value=\"ag\">Antigua and Barbuda<\/option><option  value=\"ar\">Argentina<\/option><option  value=\"am\">\u0540\u0561\u0575\u0561\u057d\u057f\u0561\u0576<\/option><option  value=\"aw\">Aruba<\/option><option  value=\"au\">Australia<\/option><option  value=\"at\">\u00d6sterreich<\/option><option  value=\"az\">Az\u0259rbaycan<\/option><option  value=\"bs\">Bahamas<\/option><option  value=\"bh\">\u200f\u0627\u0644\u0628\u062d\u0631\u064a\u0646<\/option><option  value=\"bd\">Bangladesh<\/option><option  value=\"bb\">Barbados<\/option><option  value=\"by\">\u0411\u0435\u043b\u0430\u0440\u0443\u0301\u0441\u044c<\/option><option  value=\"be\">Belgi\u00eb<\/option><option  value=\"bz\">Belize<\/option><option  value=\"bj\">B\u00e9nin<\/option><option  value=\"bm\">Bermuda<\/option><option  value=\"bt\">\u02bcbrug-yul<\/option><option  value=\"bo\">Bolivia<\/option><option  value=\"bq\">Bonaire<\/option><option  value=\"ba\">Bosna i Hercegovina<\/option><option  value=\"bw\">Botswana<\/option><option  value=\"bv\">Bouvet\u00f8ya<\/option><option  value=\"br\">Brasil<\/option><option  value=\"io\">British Indian Ocean Territory<\/option><option  value=\"um\">United States Minor Outlying Islands<\/option><option  value=\"vg\">British Virgin Islands<\/option><option  value=\"vi\">Virgin Islands of the United States<\/option><option  value=\"bn\">Negara Brunei Darussalam<\/option><option  value=\"bg\">\u0411\u044a\u043b\u0433\u0430\u0440\u0438\u044f<\/option><option  value=\"bf\">Burkina Faso<\/option><option  value=\"bi\">Burundi<\/option><option  value=\"kh\">K\u00e2mp\u016dch\u00e9a<\/option><option  value=\"cm\">Cameroon<\/option><option  value=\"ca\">Canada<\/option><option  value=\"cv\">Cabo Verde<\/option><option  value=\"ky\">Cayman Islands<\/option><option  value=\"cf\">K\u00f6d\u00f6r\u00f6s\u00ease t\u00ee B\u00eaafr\u00eeka<\/option><option  value=\"td\">Tchad<\/option><option  value=\"cl\">Chile<\/option><option  value=\"cn\">\u4e2d\u56fd<\/option><option  value=\"cx\">Christmas Island<\/option><option  value=\"cc\">Cocos (Keeling) Islands<\/option><option  value=\"co\">Colombia<\/option><option  value=\"km\">Komori<\/option><option  value=\"cg\">R\u00e9publique du Congo<\/option><option  value=\"cd\">R\u00e9publique d\u00e9mocratique du Congo<\/option><option  value=\"ck\">Cook Islands<\/option><option  value=\"cr\">Costa Rica<\/option><option  value=\"hr\">Hrvatska<\/option><option  value=\"cu\">Cuba<\/option><option  value=\"cw\">Cura\u00e7ao<\/option><option  value=\"cy\">\u039a\u03cd\u03c0\u03c1\u03bf\u03c2<\/option><option  value=\"cz\">\u010cesk\u00e1 republika<\/option><option  value=\"dk\">Danmark<\/option><option  value=\"dj\">Djibouti<\/option><option  value=\"dm\">Dominica<\/option><option  value=\"do\">Rep\u00fablica Dominicana<\/option><option  value=\"ec\">Ecuador<\/option><option  value=\"eg\">\u0645\u0635\u0631\u200e<\/option><option  value=\"sv\">El Salvador<\/option><option  value=\"gq\">Guinea Ecuatorial<\/option><option  value=\"er\">\u12a4\u122d\u1275\u122b<\/option><option  value=\"ee\">Eesti<\/option><option  value=\"et\">\u12a2\u1275\u12ee\u1335\u12eb<\/option><option  value=\"fk\">Falkland Islands<\/option><option  value=\"fo\">F\u00f8royar<\/option><option  value=\"fj\">Fiji<\/option><option  value=\"fi\">Suomi<\/option><option  value=\"fr\">France<\/option><option  value=\"gf\">Guyane fran\u00e7aise<\/option><option  value=\"pf\">Polyn\u00e9sie fran\u00e7aise<\/option><option  value=\"tf\">Territoire des Terres australes et antarctiques fran\u00e7aises<\/option><option  value=\"ga\">Gabon<\/option><option  value=\"gm\">Gambia<\/option><option  value=\"ge\">\u10e1\u10d0\u10e5\u10d0\u10e0\u10d7\u10d5\u10d4\u10da\u10dd<\/option><option  value=\"de\">Deutschland<\/option><option  value=\"gh\">Ghana<\/option><option  value=\"gi\">Gibraltar<\/option><option  value=\"gr\">\u0395\u03bb\u03bb\u03ac\u03b4\u03b1<\/option><option  value=\"gl\">Kalaallit Nunaat<\/option><option  value=\"gd\">Grenada<\/option><option  value=\"gp\">Guadeloupe<\/option><option  value=\"gu\">Guam<\/option><option  value=\"gt\">Guatemala<\/option><option  value=\"gg\">Guernsey<\/option><option  value=\"gn\">Guin\u00e9e<\/option><option  value=\"gw\">Guin\u00e9-Bissau<\/option><option  value=\"gy\">Guyana<\/option><option  value=\"ht\">Ha\u00efti<\/option><option  value=\"hm\">Heard Island and McDonald Islands<\/option><option  value=\"va\">Sancta Sedes<\/option><option  value=\"hn\">Honduras<\/option><option  value=\"hk\">\u9999\u6e2f<\/option><option  value=\"hu\">Magyarorsz\u00e1g<\/option><option  value=\"is\">\u00cdsland<\/option><option  value=\"in\">\u092d\u093e\u0930\u0924<\/option><option  value=\"id\">Indonesia<\/option><option  value=\"ci\">C\u00f4te d'Ivoire<\/option><option  value=\"ir\">\u0627\u06cc\u0631\u0627\u0646<\/option><option  value=\"iq\">\u0627\u0644\u0639\u0631\u0627\u0642<\/option><option  value=\"ie\">\u00c9ire<\/option><option  value=\"im\">Isle of Man<\/option><option  value=\"il\">\u05d9\u05b4\u05e9\u05b0\u05c2\u05e8\u05b8\u05d0\u05b5\u05dc<\/option><option  value=\"it\">Italia<\/option><option  value=\"jm\">Jamaica<\/option><option  value=\"jp\">\u65e5\u672c<\/option><option  value=\"je\">Jersey<\/option><option  value=\"jo\">\u0627\u0644\u0623\u0631\u062f\u0646<\/option><option  value=\"kz\">\u049a\u0430\u0437\u0430\u049b\u0441\u0442\u0430\u043d<\/option><option  value=\"ke\">Kenya<\/option><option  value=\"ki\">Kiribati<\/option><option  value=\"kw\">\u0627\u0644\u0643\u0648\u064a\u062a<\/option><option  value=\"kg\">\u041a\u044b\u0440\u0433\u044b\u0437\u0441\u0442\u0430\u043d<\/option><option  value=\"la\">\u0eaa\u0e9b\u0e9b\u0ea5\u0eb2\u0ea7<\/option><option  value=\"lv\">Latvija<\/option><option  value=\"lb\">\u0644\u0628\u0646\u0627\u0646<\/option><option  value=\"ls\">Lesotho<\/option><option  value=\"lr\">Liberia<\/option><option  value=\"ly\">\u200f\u0644\u064a\u0628\u064a\u0627<\/option><option  value=\"li\">Liechtenstein<\/option><option  value=\"lt\">Lietuva<\/option><option  value=\"lu\">Luxembourg<\/option><option  value=\"mo\">\u6fb3\u9580<\/option><option  value=\"mk\">\u041c\u0430\u043a\u0435\u0434\u043e\u043d\u0438\u0458\u0430<\/option><option  value=\"mg\">Madagasikara<\/option><option  value=\"mw\">Malawi<\/option><option  value=\"my\">Malaysia<\/option><option  value=\"mv\">Maldives<\/option><option  value=\"ml\">Mali<\/option><option  value=\"mt\">Malta<\/option><option  value=\"mh\">M\u0327aje\u013c<\/option><option  value=\"mq\">Martinique<\/option><option  value=\"mr\">\u0645\u0648\u0631\u064a\u062a\u0627\u0646\u064a\u0627<\/option><option  value=\"mu\">Maurice<\/option><option  value=\"yt\">Mayotte<\/option><option  value=\"mx\">M\u00e9xico<\/option><option  value=\"fm\">Micronesia<\/option><option  value=\"md\">Moldova<\/option><option  value=\"mc\">Monaco<\/option><option  value=\"mn\">\u041c\u043e\u043d\u0433\u043e\u043b \u0443\u043b\u0441<\/option><option  value=\"me\">\u0426\u0440\u043d\u0430 \u0413\u043e\u0440\u0430<\/option><option  value=\"ms\">Montserrat<\/option><option  value=\"ma\">\u0627\u0644\u0645\u063a\u0631\u0628<\/option><option  value=\"mz\">Mo\u00e7ambique<\/option><option  value=\"mm\">Myanma<\/option><option  value=\"na\">Namibia<\/option><option  value=\"nr\">Nauru<\/option><option  value=\"np\">\u0928\u0947\u092a\u093e\u0932<\/option><option  value=\"nl\">Nederland<\/option><option  value=\"nc\">Nouvelle-Cal\u00e9donie<\/option><option  value=\"nz\">New Zealand<\/option><option  value=\"ni\">Nicaragua<\/option><option  value=\"ne\">Niger<\/option><option  value=\"ng\">Nigeria<\/option><option  value=\"nu\">Niu\u0113<\/option><option  value=\"nf\">Norfolk Island<\/option><option  value=\"kp\">\ubd81\ud55c<\/option><option  value=\"mp\">Northern Mariana Islands<\/option><option  value=\"no\">Norge<\/option><option  value=\"om\">\u0639\u0645\u0627\u0646<\/option><option  value=\"pk\">Pakistan<\/option><option  value=\"pw\">Palau<\/option><option  value=\"ps\">\u0641\u0644\u0633\u0637\u064a\u0646<\/option><option  value=\"pa\">Panam\u00e1<\/option><option  value=\"pg\">Papua Niugini<\/option><option  value=\"py\">Paraguay<\/option><option  value=\"pe\">Per\u00fa<\/option><option  value=\"ph\">Pilipinas<\/option><option  value=\"pn\">Pitcairn Islands<\/option><option  value=\"pl\">Polska<\/option><option  value=\"pt\">Portugal<\/option><option  value=\"pr\">Puerto Rico<\/option><option  value=\"qa\">\u0642\u0637\u0631<\/option><option  value=\"xk\">Republika e Kosov\u00ebs<\/option><option  value=\"re\">La R\u00e9union<\/option><option  value=\"ro\">Rom\u00e2nia<\/option><option  value=\"ru\">\u0420\u043e\u0441\u0441\u0438\u044f<\/option><option  value=\"rw\">Rwanda<\/option><option  value=\"bl\">Saint-Barth\u00e9lemy<\/option><option  value=\"sh\">Saint Helena<\/option><option  value=\"kn\">Saint Kitts and Nevis<\/option><option  value=\"lc\">Saint Lucia<\/option><option  value=\"mf\">Saint-Martin<\/option><option  value=\"pm\">Saint-Pierre-et-Miquelon<\/option><option  value=\"vc\">Saint Vincent and the Grenadines<\/option><option  value=\"ws\">Samoa<\/option><option  value=\"sm\">San Marino<\/option><option  value=\"st\">S\u00e3o Tom\u00e9 e Pr\u00edncipe<\/option><option  value=\"sa\">\u0627\u0644\u0639\u0631\u0628\u064a\u0629 \u0627\u0644\u0633\u0639\u0648\u062f\u064a\u0629<\/option><option  value=\"sn\">S\u00e9n\u00e9gal<\/option><option  value=\"rs\">\u0421\u0440\u0431\u0438\u0458\u0430<\/option><option  value=\"sc\">Seychelles<\/option><option  value=\"sl\">Sierra Leone<\/option><option  value=\"sg\">Singapore<\/option><option  value=\"sx\">Sint Maarten<\/option><option  value=\"sk\">Slovensko<\/option><option  value=\"si\">Slovenija<\/option><option  value=\"sb\">Solomon Islands<\/option><option  value=\"so\">Soomaaliya<\/option><option  value=\"za\">South Africa<\/option><option  value=\"gs\">South Georgia<\/option><option  value=\"kr\">\ub300\ud55c\ubbfc\uad6d<\/option><option  value=\"ss\">South Sudan<\/option><option  value=\"es\">Espa\u00f1a<\/option><option  value=\"lk\">\u015br\u012b la\u1e43k\u0101va<\/option><option  value=\"sd\">\u0627\u0644\u0633\u0648\u062f\u0627\u0646<\/option><option  value=\"sr\">Suriname<\/option><option  value=\"sj\">Svalbard og Jan Mayen<\/option><option  value=\"sz\">Swaziland<\/option><option  value=\"se\">Sverige<\/option><option  value=\"ch\">Schweiz<\/option><option  value=\"sy\">\u0633\u0648\u0631\u064a\u0627<\/option><option  value=\"tw\">\u81fa\u7063<\/option><option  value=\"tj\">\u0422\u043e\u04b7\u0438\u043a\u0438\u0441\u0442\u043e\u043d<\/option><option  value=\"tz\">Tanzania<\/option><option  value=\"th\">\u0e1b\u0e23\u0e30\u0e40\u0e17\u0e28\u0e44\u0e17\u0e22<\/option><option  value=\"tl\">Timor-Leste<\/option><option  value=\"tg\">Togo<\/option><option  value=\"tk\">Tokelau<\/option><option  value=\"to\">Tonga<\/option><option  value=\"tt\">Trinidad and Tobago<\/option><option  value=\"tn\">\u062a\u0648\u0646\u0633<\/option><option  value=\"tr\">T\u00fcrkiye<\/option><option  value=\"tm\">T\u00fcrkmenistan<\/option><option  value=\"tc\">Turks and Caicos Islands<\/option><option  value=\"tv\">Tuvalu<\/option><option  value=\"ug\">Uganda<\/option><option  value=\"ua\">\u0423\u043a\u0440\u0430\u0457\u043d\u0430<\/option><option  value=\"ae\">\u062f\u0648\u0644\u0629 \u0627\u0644\u0625\u0645\u0627\u0631\u0627\u062a \u0627\u0644\u0639\u0631\u0628\u064a\u0629 \u0627\u0644\u0645\u062a\u062d\u062f\u0629<\/option><option  value=\"gb\">United Kingdom<\/option><option  value=\"us\">United States<\/option><option  value=\"uy\">Uruguay<\/option><option  value=\"uz\">O\u2018zbekiston<\/option><option  value=\"vu\">Vanuatu<\/option><option  value=\"ve\">Venezuela<\/option><option  value=\"vn\">Vi\u1ec7t Nam<\/option><option  value=\"wf\">Wallis et Futuna<\/option><option  value=\"eh\">\u0627\u0644\u0635\u062d\u0631\u0627\u0621 \u0627\u0644\u063a\u0631\u0628\u064a\u0629<\/option><option  value=\"ye\">\u0627\u0644\u064a\u064e\u0645\u064e\u0646<\/option><option  value=\"zm\">Zambia<\/option><option  value=\"zw\">Zimbabwe<\/option><\/select><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--text\"><label for=\"work_phone\">T\u00e9l\u00e9phone \/ Mobile * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"text\" id=\"work_phone\" name=\"work_phone\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\trequired\n\t\t\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--text\"><label for=\"work_web\">Page d'accueil <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"text\" id=\"work_web\" name=\"work_web\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--email\"><label for=\"work_email\">Courriel professionnel * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"email\" id=\"work_email\" name=\"work_email\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\trequired\n\t\t\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><\/fieldset><fieldset class=\"\"><legend>2. Gesch\u00e4ftsadresse<\/legend><div class=\"input-group input-group--text\"><label for=\"work2_clinic\">Nom de la clinique \/ du cabinet <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"text\" id=\"work2_clinic\" name=\"work2_clinic\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--text\"><label for=\"work2_department\">D\u00e9partement <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"text\" id=\"work2_department\" name=\"work2_department\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--text\"><label for=\"work2_street\">Rue <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"text\" id=\"work2_street\" name=\"work2_street\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--text\"><label for=\"work2_zip\">Code postal <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"text\" id=\"work2_zip\" name=\"work2_zip\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--text\"><label for=\"work2_place\">Lieu <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"text\" id=\"work2_place\" name=\"work2_place\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--select\"><label for=\"work2_canton\">Canton <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><select name=\"work2_canton\" id=\"work2_canton\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t><option selected value=\"\">--Veuillez choisir--<\/option><option  value=\"ag\">Aargau <\/option><option  value=\"ai\">Appenzell Innerrhoden <\/option><option  value=\"ar\">Appenzell Ausserrhoden<\/option><option  value=\"be\">Bern<\/option><option  value=\"bl\">Basel-Landschaft<\/option><option  value=\"bs\">Basel-Stadt<\/option><option  value=\"fr\">Freiburg<\/option><option  value=\"ge\">Genf<\/option><option  value=\"gl\">Glarus<\/option><option  value=\"gr\">Graub\u00fcnden <\/option><option  value=\"ju\">Jura<\/option><option  value=\"lu\">Luzern <\/option><option  value=\"ne\">Neuenburg<\/option><option  value=\"nw\">Nidwalden <\/option><option  value=\"ow\">Obwalden <\/option><option  value=\"sg\">St. Gallen<\/option><option  value=\"sh\">Schaffhausen<\/option><option  value=\"so\">Solothurn <\/option><option  value=\"sz\">Schwyz<\/option><option  value=\"tg\">Thurgau<\/option><option  value=\"ti\">Tessin <\/option><option  value=\"ur\">Uri<\/option><option  value=\"vd\">Waadt<\/option><option  value=\"vs\">Wallis<\/option><option  value=\"zg\">Zug <\/option><option  value=\"zh\">Z\u00fcrich<\/option><\/select><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--select\"><label for=\"work2_country\">Pays <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><select name=\"work2_country\" id=\"work2_country\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t><option selected value=\"\">--Veuillez choisir--<\/option><option  value=\"af\">\u0627\u0641\u063a\u0627\u0646\u0633\u062a\u0627\u0646<\/option><option  value=\"ax\">\u00c5land<\/option><option  value=\"al\">Shqip\u00ebria<\/option><option  value=\"dz\">\u0627\u0644\u062c\u0632\u0627\u0626\u0631<\/option><option  value=\"as\">American Samoa<\/option><option  value=\"ad\">Andorra<\/option><option  value=\"ao\">Angola<\/option><option  value=\"ai\">Anguilla<\/option><option  value=\"aq\">Antarctica<\/option><option  value=\"ag\">Antigua and Barbuda<\/option><option  value=\"ar\">Argentina<\/option><option  value=\"am\">\u0540\u0561\u0575\u0561\u057d\u057f\u0561\u0576<\/option><option  value=\"aw\">Aruba<\/option><option  value=\"au\">Australia<\/option><option  value=\"at\">\u00d6sterreich<\/option><option  value=\"az\">Az\u0259rbaycan<\/option><option  value=\"bs\">Bahamas<\/option><option  value=\"bh\">\u200f\u0627\u0644\u0628\u062d\u0631\u064a\u0646<\/option><option  value=\"bd\">Bangladesh<\/option><option  value=\"bb\">Barbados<\/option><option  value=\"by\">\u0411\u0435\u043b\u0430\u0440\u0443\u0301\u0441\u044c<\/option><option  value=\"be\">Belgi\u00eb<\/option><option  value=\"bz\">Belize<\/option><option  value=\"bj\">B\u00e9nin<\/option><option  value=\"bm\">Bermuda<\/option><option  value=\"bt\">\u02bcbrug-yul<\/option><option  value=\"bo\">Bolivia<\/option><option  value=\"bq\">Bonaire<\/option><option  value=\"ba\">Bosna i Hercegovina<\/option><option  value=\"bw\">Botswana<\/option><option  value=\"bv\">Bouvet\u00f8ya<\/option><option  value=\"br\">Brasil<\/option><option  value=\"io\">British Indian Ocean Territory<\/option><option  value=\"um\">United States Minor Outlying Islands<\/option><option  value=\"vg\">British Virgin Islands<\/option><option  value=\"vi\">Virgin Islands of the United States<\/option><option  value=\"bn\">Negara Brunei Darussalam<\/option><option  value=\"bg\">\u0411\u044a\u043b\u0433\u0430\u0440\u0438\u044f<\/option><option  value=\"bf\">Burkina Faso<\/option><option  value=\"bi\">Burundi<\/option><option  value=\"kh\">K\u00e2mp\u016dch\u00e9a<\/option><option  value=\"cm\">Cameroon<\/option><option  value=\"ca\">Canada<\/option><option  value=\"cv\">Cabo Verde<\/option><option  value=\"ky\">Cayman Islands<\/option><option  value=\"cf\">K\u00f6d\u00f6r\u00f6s\u00ease t\u00ee B\u00eaafr\u00eeka<\/option><option  value=\"td\">Tchad<\/option><option  value=\"cl\">Chile<\/option><option  value=\"cn\">\u4e2d\u56fd<\/option><option  value=\"cx\">Christmas Island<\/option><option  value=\"cc\">Cocos (Keeling) Islands<\/option><option  value=\"co\">Colombia<\/option><option  value=\"km\">Komori<\/option><option  value=\"cg\">R\u00e9publique du Congo<\/option><option  value=\"cd\">R\u00e9publique d\u00e9mocratique du Congo<\/option><option  value=\"ck\">Cook Islands<\/option><option  value=\"cr\">Costa Rica<\/option><option  value=\"hr\">Hrvatska<\/option><option  value=\"cu\">Cuba<\/option><option  value=\"cw\">Cura\u00e7ao<\/option><option  value=\"cy\">\u039a\u03cd\u03c0\u03c1\u03bf\u03c2<\/option><option  value=\"cz\">\u010cesk\u00e1 republika<\/option><option  value=\"dk\">Danmark<\/option><option  value=\"dj\">Djibouti<\/option><option  value=\"dm\">Dominica<\/option><option  value=\"do\">Rep\u00fablica Dominicana<\/option><option  value=\"ec\">Ecuador<\/option><option  value=\"eg\">\u0645\u0635\u0631\u200e<\/option><option  value=\"sv\">El Salvador<\/option><option  value=\"gq\">Guinea Ecuatorial<\/option><option  value=\"er\">\u12a4\u122d\u1275\u122b<\/option><option  value=\"ee\">Eesti<\/option><option  value=\"et\">\u12a2\u1275\u12ee\u1335\u12eb<\/option><option  value=\"fk\">Falkland Islands<\/option><option  value=\"fo\">F\u00f8royar<\/option><option  value=\"fj\">Fiji<\/option><option  value=\"fi\">Suomi<\/option><option  value=\"fr\">France<\/option><option  value=\"gf\">Guyane fran\u00e7aise<\/option><option  value=\"pf\">Polyn\u00e9sie fran\u00e7aise<\/option><option  value=\"tf\">Territoire des Terres australes et antarctiques fran\u00e7aises<\/option><option  value=\"ga\">Gabon<\/option><option  value=\"gm\">Gambia<\/option><option  value=\"ge\">\u10e1\u10d0\u10e5\u10d0\u10e0\u10d7\u10d5\u10d4\u10da\u10dd<\/option><option  value=\"de\">Deutschland<\/option><option  value=\"gh\">Ghana<\/option><option  value=\"gi\">Gibraltar<\/option><option  value=\"gr\">\u0395\u03bb\u03bb\u03ac\u03b4\u03b1<\/option><option  value=\"gl\">Kalaallit Nunaat<\/option><option  value=\"gd\">Grenada<\/option><option  value=\"gp\">Guadeloupe<\/option><option  value=\"gu\">Guam<\/option><option  value=\"gt\">Guatemala<\/option><option  value=\"gg\">Guernsey<\/option><option  value=\"gn\">Guin\u00e9e<\/option><option  value=\"gw\">Guin\u00e9-Bissau<\/option><option  value=\"gy\">Guyana<\/option><option  value=\"ht\">Ha\u00efti<\/option><option  value=\"hm\">Heard Island and McDonald Islands<\/option><option  value=\"va\">Sancta Sedes<\/option><option  value=\"hn\">Honduras<\/option><option  value=\"hk\">\u9999\u6e2f<\/option><option  value=\"hu\">Magyarorsz\u00e1g<\/option><option  value=\"is\">\u00cdsland<\/option><option  value=\"in\">\u092d\u093e\u0930\u0924<\/option><option  value=\"id\">Indonesia<\/option><option  value=\"ci\">C\u00f4te d'Ivoire<\/option><option  value=\"ir\">\u0627\u06cc\u0631\u0627\u0646<\/option><option  value=\"iq\">\u0627\u0644\u0639\u0631\u0627\u0642<\/option><option  value=\"ie\">\u00c9ire<\/option><option  value=\"im\">Isle of Man<\/option><option  value=\"il\">\u05d9\u05b4\u05e9\u05b0\u05c2\u05e8\u05b8\u05d0\u05b5\u05dc<\/option><option  value=\"it\">Italia<\/option><option  value=\"jm\">Jamaica<\/option><option  value=\"jp\">\u65e5\u672c<\/option><option  value=\"je\">Jersey<\/option><option  value=\"jo\">\u0627\u0644\u0623\u0631\u062f\u0646<\/option><option  value=\"kz\">\u049a\u0430\u0437\u0430\u049b\u0441\u0442\u0430\u043d<\/option><option  value=\"ke\">Kenya<\/option><option  value=\"ki\">Kiribati<\/option><option  value=\"kw\">\u0627\u0644\u0643\u0648\u064a\u062a<\/option><option  value=\"kg\">\u041a\u044b\u0440\u0433\u044b\u0437\u0441\u0442\u0430\u043d<\/option><option  value=\"la\">\u0eaa\u0e9b\u0e9b\u0ea5\u0eb2\u0ea7<\/option><option  value=\"lv\">Latvija<\/option><option  value=\"lb\">\u0644\u0628\u0646\u0627\u0646<\/option><option  value=\"ls\">Lesotho<\/option><option  value=\"lr\">Liberia<\/option><option  value=\"ly\">\u200f\u0644\u064a\u0628\u064a\u0627<\/option><option  value=\"li\">Liechtenstein<\/option><option  value=\"lt\">Lietuva<\/option><option  value=\"lu\">Luxembourg<\/option><option  value=\"mo\">\u6fb3\u9580<\/option><option  value=\"mk\">\u041c\u0430\u043a\u0435\u0434\u043e\u043d\u0438\u0458\u0430<\/option><option  value=\"mg\">Madagasikara<\/option><option  value=\"mw\">Malawi<\/option><option  value=\"my\">Malaysia<\/option><option  value=\"mv\">Maldives<\/option><option  value=\"ml\">Mali<\/option><option  value=\"mt\">Malta<\/option><option  value=\"mh\">M\u0327aje\u013c<\/option><option  value=\"mq\">Martinique<\/option><option  value=\"mr\">\u0645\u0648\u0631\u064a\u062a\u0627\u0646\u064a\u0627<\/option><option  value=\"mu\">Maurice<\/option><option  value=\"yt\">Mayotte<\/option><option  value=\"mx\">M\u00e9xico<\/option><option  value=\"fm\">Micronesia<\/option><option  value=\"md\">Moldova<\/option><option  value=\"mc\">Monaco<\/option><option  value=\"mn\">\u041c\u043e\u043d\u0433\u043e\u043b \u0443\u043b\u0441<\/option><option  value=\"me\">\u0426\u0440\u043d\u0430 \u0413\u043e\u0440\u0430<\/option><option  value=\"ms\">Montserrat<\/option><option  value=\"ma\">\u0627\u0644\u0645\u063a\u0631\u0628<\/option><option  value=\"mz\">Mo\u00e7ambique<\/option><option  value=\"mm\">Myanma<\/option><option  value=\"na\">Namibia<\/option><option  value=\"nr\">Nauru<\/option><option  value=\"np\">\u0928\u0947\u092a\u093e\u0932<\/option><option  value=\"nl\">Nederland<\/option><option  value=\"nc\">Nouvelle-Cal\u00e9donie<\/option><option  value=\"nz\">New Zealand<\/option><option  value=\"ni\">Nicaragua<\/option><option  value=\"ne\">Niger<\/option><option  value=\"ng\">Nigeria<\/option><option  value=\"nu\">Niu\u0113<\/option><option  value=\"nf\">Norfolk Island<\/option><option  value=\"kp\">\ubd81\ud55c<\/option><option  value=\"mp\">Northern Mariana Islands<\/option><option  value=\"no\">Norge<\/option><option  value=\"om\">\u0639\u0645\u0627\u0646<\/option><option  value=\"pk\">Pakistan<\/option><option  value=\"pw\">Palau<\/option><option  value=\"ps\">\u0641\u0644\u0633\u0637\u064a\u0646<\/option><option  value=\"pa\">Panam\u00e1<\/option><option  value=\"pg\">Papua Niugini<\/option><option  value=\"py\">Paraguay<\/option><option  value=\"pe\">Per\u00fa<\/option><option  value=\"ph\">Pilipinas<\/option><option  value=\"pn\">Pitcairn Islands<\/option><option  value=\"pl\">Polska<\/option><option  value=\"pt\">Portugal<\/option><option  value=\"pr\">Puerto Rico<\/option><option  value=\"qa\">\u0642\u0637\u0631<\/option><option  value=\"xk\">Republika e Kosov\u00ebs<\/option><option  value=\"re\">La R\u00e9union<\/option><option  value=\"ro\">Rom\u00e2nia<\/option><option  value=\"ru\">\u0420\u043e\u0441\u0441\u0438\u044f<\/option><option  value=\"rw\">Rwanda<\/option><option  value=\"bl\">Saint-Barth\u00e9lemy<\/option><option  value=\"sh\">Saint Helena<\/option><option  value=\"kn\">Saint Kitts and Nevis<\/option><option  value=\"lc\">Saint Lucia<\/option><option  value=\"mf\">Saint-Martin<\/option><option  value=\"pm\">Saint-Pierre-et-Miquelon<\/option><option  value=\"vc\">Saint Vincent and the Grenadines<\/option><option  value=\"ws\">Samoa<\/option><option  value=\"sm\">San Marino<\/option><option  value=\"st\">S\u00e3o Tom\u00e9 e Pr\u00edncipe<\/option><option  value=\"sa\">\u0627\u0644\u0639\u0631\u0628\u064a\u0629 \u0627\u0644\u0633\u0639\u0648\u062f\u064a\u0629<\/option><option  value=\"sn\">S\u00e9n\u00e9gal<\/option><option  value=\"rs\">\u0421\u0440\u0431\u0438\u0458\u0430<\/option><option  value=\"sc\">Seychelles<\/option><option  value=\"sl\">Sierra Leone<\/option><option  value=\"sg\">Singapore<\/option><option  value=\"sx\">Sint Maarten<\/option><option  value=\"sk\">Slovensko<\/option><option  value=\"si\">Slovenija<\/option><option  value=\"sb\">Solomon Islands<\/option><option  value=\"so\">Soomaaliya<\/option><option  value=\"za\">South Africa<\/option><option  value=\"gs\">South Georgia<\/option><option  value=\"kr\">\ub300\ud55c\ubbfc\uad6d<\/option><option  value=\"ss\">South Sudan<\/option><option  value=\"es\">Espa\u00f1a<\/option><option  value=\"lk\">\u015br\u012b la\u1e43k\u0101va<\/option><option  value=\"sd\">\u0627\u0644\u0633\u0648\u062f\u0627\u0646<\/option><option  value=\"sr\">Suriname<\/option><option  value=\"sj\">Svalbard og Jan Mayen<\/option><option  value=\"sz\">Swaziland<\/option><option  value=\"se\">Sverige<\/option><option  value=\"ch\">Schweiz<\/option><option  value=\"sy\">\u0633\u0648\u0631\u064a\u0627<\/option><option  value=\"tw\">\u81fa\u7063<\/option><option  value=\"tj\">\u0422\u043e\u04b7\u0438\u043a\u0438\u0441\u0442\u043e\u043d<\/option><option  value=\"tz\">Tanzania<\/option><option  value=\"th\">\u0e1b\u0e23\u0e30\u0e40\u0e17\u0e28\u0e44\u0e17\u0e22<\/option><option  value=\"tl\">Timor-Leste<\/option><option  value=\"tg\">Togo<\/option><option  value=\"tk\">Tokelau<\/option><option  value=\"to\">Tonga<\/option><option  value=\"tt\">Trinidad and Tobago<\/option><option  value=\"tn\">\u062a\u0648\u0646\u0633<\/option><option  value=\"tr\">T\u00fcrkiye<\/option><option  value=\"tm\">T\u00fcrkmenistan<\/option><option  value=\"tc\">Turks and Caicos Islands<\/option><option  value=\"tv\">Tuvalu<\/option><option  value=\"ug\">Uganda<\/option><option  value=\"ua\">\u0423\u043a\u0440\u0430\u0457\u043d\u0430<\/option><option  value=\"ae\">\u062f\u0648\u0644\u0629 \u0627\u0644\u0625\u0645\u0627\u0631\u0627\u062a \u0627\u0644\u0639\u0631\u0628\u064a\u0629 \u0627\u0644\u0645\u062a\u062d\u062f\u0629<\/option><option  value=\"gb\">United Kingdom<\/option><option  value=\"us\">United States<\/option><option  value=\"uy\">Uruguay<\/option><option  value=\"uz\">O\u2018zbekiston<\/option><option  value=\"vu\">Vanuatu<\/option><option  value=\"ve\">Venezuela<\/option><option  value=\"vn\">Vi\u1ec7t Nam<\/option><option  value=\"wf\">Wallis et Futuna<\/option><option  value=\"eh\">\u0627\u0644\u0635\u062d\u0631\u0627\u0621 \u0627\u0644\u063a\u0631\u0628\u064a\u0629<\/option><option  value=\"ye\">\u0627\u0644\u064a\u064e\u0645\u064e\u0646<\/option><option  value=\"zm\">Zambia<\/option><option  value=\"zw\">Zimbabwe<\/option><\/select><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--text\"><label for=\"work2_phone\">T\u00e9l\u00e9phone \/ Mobile <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"text\" id=\"work2_phone\" name=\"work2_phone\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--text\"><label for=\"work2_web\">Page d'accueil <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"text\" id=\"work2_web\" name=\"work2_web\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--email\"><label for=\"work2_email\">Courriel professionnel <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"email\" id=\"work2_email\" name=\"work2_email\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><\/fieldset><fieldset class=\"\"><legend>Adresse priv\u00e9e<\/legend><div class=\"input-group input-group--text\"><label for=\"private_street\">Rue <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"text\" id=\"private_street\" name=\"private_street\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--text\"><label for=\"private_zip\">Code postal <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"text\" id=\"private_zip\" name=\"private_zip\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--text\"><label for=\"private_place\">Lieu <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"text\" id=\"private_place\" name=\"private_place\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--select\"><label for=\"private_canton\">Canton <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><select name=\"private_canton\" id=\"private_canton\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t><option selected value=\"\">--Veuillez choisir--<\/option><option  value=\"ag\">Aargau <\/option><option  value=\"ai\">Appenzell Innerrhoden <\/option><option  value=\"ar\">Appenzell Ausserrhoden<\/option><option  value=\"be\">Bern<\/option><option  value=\"bl\">Basel-Landschaft<\/option><option  value=\"bs\">Basel-Stadt<\/option><option  value=\"fr\">Freiburg<\/option><option  value=\"ge\">Genf<\/option><option  value=\"gl\">Glarus<\/option><option  value=\"gr\">Graub\u00fcnden <\/option><option  value=\"ju\">Jura<\/option><option  value=\"lu\">Luzern <\/option><option  value=\"ne\">Neuenburg<\/option><option  value=\"nw\">Nidwalden <\/option><option  value=\"ow\">Obwalden <\/option><option  value=\"sg\">St. Gallen<\/option><option  value=\"sh\">Schaffhausen<\/option><option  value=\"so\">Solothurn <\/option><option  value=\"sz\">Schwyz<\/option><option  value=\"tg\">Thurgau<\/option><option  value=\"ti\">Tessin <\/option><option  value=\"ur\">Uri<\/option><option  value=\"vd\">Waadt<\/option><option  value=\"vs\">Wallis<\/option><option  value=\"zg\">Zug <\/option><option  value=\"zh\">Z\u00fcrich<\/option><\/select><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--select\"><label for=\"private_country\">Pays <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><select name=\"private_country\" id=\"private_country\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t><option selected value=\"\">--Veuillez choisir--<\/option><option  value=\"af\">\u0627\u0641\u063a\u0627\u0646\u0633\u062a\u0627\u0646<\/option><option  value=\"ax\">\u00c5land<\/option><option  value=\"al\">Shqip\u00ebria<\/option><option  value=\"dz\">\u0627\u0644\u062c\u0632\u0627\u0626\u0631<\/option><option  value=\"as\">American Samoa<\/option><option  value=\"ad\">Andorra<\/option><option  value=\"ao\">Angola<\/option><option  value=\"ai\">Anguilla<\/option><option  value=\"aq\">Antarctica<\/option><option  value=\"ag\">Antigua and Barbuda<\/option><option  value=\"ar\">Argentina<\/option><option  value=\"am\">\u0540\u0561\u0575\u0561\u057d\u057f\u0561\u0576<\/option><option  value=\"aw\">Aruba<\/option><option  value=\"au\">Australia<\/option><option  value=\"at\">\u00d6sterreich<\/option><option  value=\"az\">Az\u0259rbaycan<\/option><option  value=\"bs\">Bahamas<\/option><option  value=\"bh\">\u200f\u0627\u0644\u0628\u062d\u0631\u064a\u0646<\/option><option  value=\"bd\">Bangladesh<\/option><option  value=\"bb\">Barbados<\/option><option  value=\"by\">\u0411\u0435\u043b\u0430\u0440\u0443\u0301\u0441\u044c<\/option><option  value=\"be\">Belgi\u00eb<\/option><option  value=\"bz\">Belize<\/option><option  value=\"bj\">B\u00e9nin<\/option><option  value=\"bm\">Bermuda<\/option><option  value=\"bt\">\u02bcbrug-yul<\/option><option  value=\"bo\">Bolivia<\/option><option  value=\"bq\">Bonaire<\/option><option  value=\"ba\">Bosna i Hercegovina<\/option><option  value=\"bw\">Botswana<\/option><option  value=\"bv\">Bouvet\u00f8ya<\/option><option  value=\"br\">Brasil<\/option><option  value=\"io\">British Indian Ocean Territory<\/option><option  value=\"um\">United States Minor Outlying Islands<\/option><option  value=\"vg\">British Virgin Islands<\/option><option  value=\"vi\">Virgin Islands of the United States<\/option><option  value=\"bn\">Negara Brunei Darussalam<\/option><option  value=\"bg\">\u0411\u044a\u043b\u0433\u0430\u0440\u0438\u044f<\/option><option  value=\"bf\">Burkina Faso<\/option><option  value=\"bi\">Burundi<\/option><option  value=\"kh\">K\u00e2mp\u016dch\u00e9a<\/option><option  value=\"cm\">Cameroon<\/option><option  value=\"ca\">Canada<\/option><option  value=\"cv\">Cabo Verde<\/option><option  value=\"ky\">Cayman Islands<\/option><option  value=\"cf\">K\u00f6d\u00f6r\u00f6s\u00ease t\u00ee B\u00eaafr\u00eeka<\/option><option  value=\"td\">Tchad<\/option><option  value=\"cl\">Chile<\/option><option  value=\"cn\">\u4e2d\u56fd<\/option><option  value=\"cx\">Christmas Island<\/option><option  value=\"cc\">Cocos (Keeling) Islands<\/option><option  value=\"co\">Colombia<\/option><option  value=\"km\">Komori<\/option><option  value=\"cg\">R\u00e9publique du Congo<\/option><option  value=\"cd\">R\u00e9publique d\u00e9mocratique du Congo<\/option><option  value=\"ck\">Cook Islands<\/option><option  value=\"cr\">Costa Rica<\/option><option  value=\"hr\">Hrvatska<\/option><option  value=\"cu\">Cuba<\/option><option  value=\"cw\">Cura\u00e7ao<\/option><option  value=\"cy\">\u039a\u03cd\u03c0\u03c1\u03bf\u03c2<\/option><option  value=\"cz\">\u010cesk\u00e1 republika<\/option><option  value=\"dk\">Danmark<\/option><option  value=\"dj\">Djibouti<\/option><option  value=\"dm\">Dominica<\/option><option  value=\"do\">Rep\u00fablica Dominicana<\/option><option  value=\"ec\">Ecuador<\/option><option  value=\"eg\">\u0645\u0635\u0631\u200e<\/option><option  value=\"sv\">El Salvador<\/option><option  value=\"gq\">Guinea Ecuatorial<\/option><option  value=\"er\">\u12a4\u122d\u1275\u122b<\/option><option  value=\"ee\">Eesti<\/option><option  value=\"et\">\u12a2\u1275\u12ee\u1335\u12eb<\/option><option  value=\"fk\">Falkland Islands<\/option><option  value=\"fo\">F\u00f8royar<\/option><option  value=\"fj\">Fiji<\/option><option  value=\"fi\">Suomi<\/option><option  value=\"fr\">France<\/option><option  value=\"gf\">Guyane fran\u00e7aise<\/option><option  value=\"pf\">Polyn\u00e9sie fran\u00e7aise<\/option><option  value=\"tf\">Territoire des Terres australes et antarctiques fran\u00e7aises<\/option><option  value=\"ga\">Gabon<\/option><option  value=\"gm\">Gambia<\/option><option  value=\"ge\">\u10e1\u10d0\u10e5\u10d0\u10e0\u10d7\u10d5\u10d4\u10da\u10dd<\/option><option  value=\"de\">Deutschland<\/option><option  value=\"gh\">Ghana<\/option><option  value=\"gi\">Gibraltar<\/option><option  value=\"gr\">\u0395\u03bb\u03bb\u03ac\u03b4\u03b1<\/option><option  value=\"gl\">Kalaallit Nunaat<\/option><option  value=\"gd\">Grenada<\/option><option  value=\"gp\">Guadeloupe<\/option><option  value=\"gu\">Guam<\/option><option  value=\"gt\">Guatemala<\/option><option  value=\"gg\">Guernsey<\/option><option  value=\"gn\">Guin\u00e9e<\/option><option  value=\"gw\">Guin\u00e9-Bissau<\/option><option  value=\"gy\">Guyana<\/option><option  value=\"ht\">Ha\u00efti<\/option><option  value=\"hm\">Heard Island and McDonald Islands<\/option><option  value=\"va\">Sancta Sedes<\/option><option  value=\"hn\">Honduras<\/option><option  value=\"hk\">\u9999\u6e2f<\/option><option  value=\"hu\">Magyarorsz\u00e1g<\/option><option  value=\"is\">\u00cdsland<\/option><option  value=\"in\">\u092d\u093e\u0930\u0924<\/option><option  value=\"id\">Indonesia<\/option><option  value=\"ci\">C\u00f4te d'Ivoire<\/option><option  value=\"ir\">\u0627\u06cc\u0631\u0627\u0646<\/option><option  value=\"iq\">\u0627\u0644\u0639\u0631\u0627\u0642<\/option><option  value=\"ie\">\u00c9ire<\/option><option  value=\"im\">Isle of Man<\/option><option  value=\"il\">\u05d9\u05b4\u05e9\u05b0\u05c2\u05e8\u05b8\u05d0\u05b5\u05dc<\/option><option  value=\"it\">Italia<\/option><option  value=\"jm\">Jamaica<\/option><option  value=\"jp\">\u65e5\u672c<\/option><option  value=\"je\">Jersey<\/option><option  value=\"jo\">\u0627\u0644\u0623\u0631\u062f\u0646<\/option><option  value=\"kz\">\u049a\u0430\u0437\u0430\u049b\u0441\u0442\u0430\u043d<\/option><option  value=\"ke\">Kenya<\/option><option  value=\"ki\">Kiribati<\/option><option  value=\"kw\">\u0627\u0644\u0643\u0648\u064a\u062a<\/option><option  value=\"kg\">\u041a\u044b\u0440\u0433\u044b\u0437\u0441\u0442\u0430\u043d<\/option><option  value=\"la\">\u0eaa\u0e9b\u0e9b\u0ea5\u0eb2\u0ea7<\/option><option  value=\"lv\">Latvija<\/option><option  value=\"lb\">\u0644\u0628\u0646\u0627\u0646<\/option><option  value=\"ls\">Lesotho<\/option><option  value=\"lr\">Liberia<\/option><option  value=\"ly\">\u200f\u0644\u064a\u0628\u064a\u0627<\/option><option  value=\"li\">Liechtenstein<\/option><option  value=\"lt\">Lietuva<\/option><option  value=\"lu\">Luxembourg<\/option><option  value=\"mo\">\u6fb3\u9580<\/option><option  value=\"mk\">\u041c\u0430\u043a\u0435\u0434\u043e\u043d\u0438\u0458\u0430<\/option><option  value=\"mg\">Madagasikara<\/option><option  value=\"mw\">Malawi<\/option><option  value=\"my\">Malaysia<\/option><option  value=\"mv\">Maldives<\/option><option  value=\"ml\">Mali<\/option><option  value=\"mt\">Malta<\/option><option  value=\"mh\">M\u0327aje\u013c<\/option><option  value=\"mq\">Martinique<\/option><option  value=\"mr\">\u0645\u0648\u0631\u064a\u062a\u0627\u0646\u064a\u0627<\/option><option  value=\"mu\">Maurice<\/option><option  value=\"yt\">Mayotte<\/option><option  value=\"mx\">M\u00e9xico<\/option><option  value=\"fm\">Micronesia<\/option><option  value=\"md\">Moldova<\/option><option  value=\"mc\">Monaco<\/option><option  value=\"mn\">\u041c\u043e\u043d\u0433\u043e\u043b \u0443\u043b\u0441<\/option><option  value=\"me\">\u0426\u0440\u043d\u0430 \u0413\u043e\u0440\u0430<\/option><option  value=\"ms\">Montserrat<\/option><option  value=\"ma\">\u0627\u0644\u0645\u063a\u0631\u0628<\/option><option  value=\"mz\">Mo\u00e7ambique<\/option><option  value=\"mm\">Myanma<\/option><option  value=\"na\">Namibia<\/option><option  value=\"nr\">Nauru<\/option><option  value=\"np\">\u0928\u0947\u092a\u093e\u0932<\/option><option  value=\"nl\">Nederland<\/option><option  value=\"nc\">Nouvelle-Cal\u00e9donie<\/option><option  value=\"nz\">New Zealand<\/option><option  value=\"ni\">Nicaragua<\/option><option  value=\"ne\">Niger<\/option><option  value=\"ng\">Nigeria<\/option><option  value=\"nu\">Niu\u0113<\/option><option  value=\"nf\">Norfolk Island<\/option><option  value=\"kp\">\ubd81\ud55c<\/option><option  value=\"mp\">Northern Mariana Islands<\/option><option  value=\"no\">Norge<\/option><option  value=\"om\">\u0639\u0645\u0627\u0646<\/option><option  value=\"pk\">Pakistan<\/option><option  value=\"pw\">Palau<\/option><option  value=\"ps\">\u0641\u0644\u0633\u0637\u064a\u0646<\/option><option  value=\"pa\">Panam\u00e1<\/option><option  value=\"pg\">Papua Niugini<\/option><option  value=\"py\">Paraguay<\/option><option  value=\"pe\">Per\u00fa<\/option><option  value=\"ph\">Pilipinas<\/option><option  value=\"pn\">Pitcairn Islands<\/option><option  value=\"pl\">Polska<\/option><option  value=\"pt\">Portugal<\/option><option  value=\"pr\">Puerto Rico<\/option><option  value=\"qa\">\u0642\u0637\u0631<\/option><option  value=\"xk\">Republika e Kosov\u00ebs<\/option><option  value=\"re\">La R\u00e9union<\/option><option  value=\"ro\">Rom\u00e2nia<\/option><option  value=\"ru\">\u0420\u043e\u0441\u0441\u0438\u044f<\/option><option  value=\"rw\">Rwanda<\/option><option  value=\"bl\">Saint-Barth\u00e9lemy<\/option><option  value=\"sh\">Saint Helena<\/option><option  value=\"kn\">Saint Kitts and Nevis<\/option><option  value=\"lc\">Saint Lucia<\/option><option  value=\"mf\">Saint-Martin<\/option><option  value=\"pm\">Saint-Pierre-et-Miquelon<\/option><option  value=\"vc\">Saint Vincent and the Grenadines<\/option><option  value=\"ws\">Samoa<\/option><option  value=\"sm\">San Marino<\/option><option  value=\"st\">S\u00e3o Tom\u00e9 e Pr\u00edncipe<\/option><option  value=\"sa\">\u0627\u0644\u0639\u0631\u0628\u064a\u0629 \u0627\u0644\u0633\u0639\u0648\u062f\u064a\u0629<\/option><option  value=\"sn\">S\u00e9n\u00e9gal<\/option><option  value=\"rs\">\u0421\u0440\u0431\u0438\u0458\u0430<\/option><option  value=\"sc\">Seychelles<\/option><option  value=\"sl\">Sierra Leone<\/option><option  value=\"sg\">Singapore<\/option><option  value=\"sx\">Sint Maarten<\/option><option  value=\"sk\">Slovensko<\/option><option  value=\"si\">Slovenija<\/option><option  value=\"sb\">Solomon Islands<\/option><option  value=\"so\">Soomaaliya<\/option><option  value=\"za\">South Africa<\/option><option  value=\"gs\">South Georgia<\/option><option  value=\"kr\">\ub300\ud55c\ubbfc\uad6d<\/option><option  value=\"ss\">South Sudan<\/option><option  value=\"es\">Espa\u00f1a<\/option><option  value=\"lk\">\u015br\u012b la\u1e43k\u0101va<\/option><option  value=\"sd\">\u0627\u0644\u0633\u0648\u062f\u0627\u0646<\/option><option  value=\"sr\">Suriname<\/option><option  value=\"sj\">Svalbard og Jan Mayen<\/option><option  value=\"sz\">Swaziland<\/option><option  value=\"se\">Sverige<\/option><option  value=\"ch\">Schweiz<\/option><option  value=\"sy\">\u0633\u0648\u0631\u064a\u0627<\/option><option  value=\"tw\">\u81fa\u7063<\/option><option  value=\"tj\">\u0422\u043e\u04b7\u0438\u043a\u0438\u0441\u0442\u043e\u043d<\/option><option  value=\"tz\">Tanzania<\/option><option  value=\"th\">\u0e1b\u0e23\u0e30\u0e40\u0e17\u0e28\u0e44\u0e17\u0e22<\/option><option  value=\"tl\">Timor-Leste<\/option><option  value=\"tg\">Togo<\/option><option  value=\"tk\">Tokelau<\/option><option  value=\"to\">Tonga<\/option><option  value=\"tt\">Trinidad and Tobago<\/option><option  value=\"tn\">\u062a\u0648\u0646\u0633<\/option><option  value=\"tr\">T\u00fcrkiye<\/option><option  value=\"tm\">T\u00fcrkmenistan<\/option><option  value=\"tc\">Turks and Caicos Islands<\/option><option  value=\"tv\">Tuvalu<\/option><option  value=\"ug\">Uganda<\/option><option  value=\"ua\">\u0423\u043a\u0440\u0430\u0457\u043d\u0430<\/option><option  value=\"ae\">\u062f\u0648\u0644\u0629 \u0627\u0644\u0625\u0645\u0627\u0631\u0627\u062a \u0627\u0644\u0639\u0631\u0628\u064a\u0629 \u0627\u0644\u0645\u062a\u062d\u062f\u0629<\/option><option  value=\"gb\">United Kingdom<\/option><option  value=\"us\">United States<\/option><option  value=\"uy\">Uruguay<\/option><option  value=\"uz\">O\u2018zbekiston<\/option><option  value=\"vu\">Vanuatu<\/option><option  value=\"ve\">Venezuela<\/option><option  value=\"vn\">Vi\u1ec7t Nam<\/option><option  value=\"wf\">Wallis et Futuna<\/option><option  value=\"eh\">\u0627\u0644\u0635\u062d\u0631\u0627\u0621 \u0627\u0644\u063a\u0631\u0628\u064a\u0629<\/option><option  value=\"ye\">\u0627\u0644\u064a\u064e\u0645\u064e\u0646<\/option><option  value=\"zm\">Zambia<\/option><option  value=\"zw\">Zimbabwe<\/option><\/select><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--text\"><label for=\"private_phone\">T\u00e9l\u00e9phone \/ Mobile <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"text\" id=\"private_phone\" name=\"private_phone\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--email\"><label for=\"private_email\">E-Mail <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><input type=\"email\" id=\"private_email\" name=\"private_email\" value=\"\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t><\/div><div class=\"error-message\"><\/div><\/div><\/div><\/fieldset><fieldset class=\"\"><legend>Formation<\/legend><div class=\"input-group input-group--textarea\"><label for=\"education\">\u00c9tudes * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><textarea id=\"education\" name=\"education\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\trequired\n\t\t\t><\/textarea><\/div><div class=\"error-message\"><\/div><p class=\"description\">Universit\u00e9 et lieu<\/p><\/div><\/div><div class=\"input-group input-group--select\"><label for=\"exam\">Examen d'\u00c9tat (ann\u00e9e) * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><select name=\"exam\" id=\"exam\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\trequired\n\t\t\t><option selected value=\"\">--Veuillez choisir--<\/option><option  value=\"2032\">2032<\/option><option  value=\"2031\">2031<\/option><option  value=\"2030\">2030<\/option><option  value=\"2029\">2029<\/option><option  value=\"2028\">2028<\/option><option  value=\"2027\">2027<\/option><option  value=\"2026\">2026<\/option><option  value=\"2025\">2025<\/option><option  value=\"2024\">2024<\/option><option  value=\"2023\">2023<\/option><option  value=\"2022\">2022<\/option><option  value=\"2021\">2021<\/option><option  value=\"2020\">2020<\/option><option  value=\"2019\">2019<\/option><option  value=\"2018\">2018<\/option><option  value=\"2017\">2017<\/option><option  value=\"2016\">2016<\/option><option  value=\"2015\">2015<\/option><option  value=\"2014\">2014<\/option><option  value=\"2013\">2013<\/option><option  value=\"2012\">2012<\/option><option  value=\"2011\">2011<\/option><option  value=\"2010\">2010<\/option><option  value=\"2009\">2009<\/option><option  value=\"2008\">2008<\/option><option  value=\"2007\">2007<\/option><option  value=\"2006\">2006<\/option><option  value=\"2005\">2005<\/option><option  value=\"2004\">2004<\/option><option  value=\"2003\">2003<\/option><option  value=\"2002\">2002<\/option><option  value=\"2001\">2001<\/option><option  value=\"2000\">2000<\/option><option  value=\"1999\">1999<\/option><option  value=\"1998\">1998<\/option><option  value=\"1997\">1997<\/option><option  value=\"1996\">1996<\/option><option  value=\"1995\">1995<\/option><option  value=\"1994\">1994<\/option><option  value=\"1993\">1993<\/option><option  value=\"1992\">1992<\/option><option  value=\"1991\">1991<\/option><option  value=\"1990\">1990<\/option><option  value=\"1989\">1989<\/option><option  value=\"1988\">1988<\/option><option  value=\"1987\">1987<\/option><option  value=\"1986\">1986<\/option><option  value=\"1985\">1985<\/option><option  value=\"1984\">1984<\/option><option  value=\"1983\">1983<\/option><option  value=\"1982\">1982<\/option><option  value=\"1981\">1981<\/option><option  value=\"1980\">1980<\/option><option  value=\"1979\">1979<\/option><option  value=\"1978\">1978<\/option><option  value=\"1977\">1977<\/option><option  value=\"1976\">1976<\/option><option  value=\"1975\">1975<\/option><option  value=\"1974\">1974<\/option><option  value=\"1973\">1973<\/option><option  value=\"1972\">1972<\/option><\/select><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--textarea\"><label for=\"dissertation\">Dissertation * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><textarea id=\"dissertation\" name=\"dissertation\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\trequired\n\t\t\t><\/textarea><\/div><div class=\"error-message\"><\/div><p class=\"description\">Titre, Universit\u00e9, Directeur de th\u00e8se \/ M\u00e8re<\/p><\/div><\/div><div class=\"input-group input-group--select\"><label for=\"title_year\">Obtention du titre de sp\u00e9cialiste en dermatologie et v\u00e9n\u00e9r\u00e9ologie (ann\u00e9e) <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><select name=\"title_year\" id=\"title_year\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t><option selected value=\"\">--Veuillez choisir--<\/option><option  value=\"2032\">2032<\/option><option  value=\"2031\">2031<\/option><option  value=\"2030\">2030<\/option><option  value=\"2029\">2029<\/option><option  value=\"2028\">2028<\/option><option  value=\"2027\">2027<\/option><option  value=\"2026\">2026<\/option><option  value=\"2025\">2025<\/option><option  value=\"2024\">2024<\/option><option  value=\"2023\">2023<\/option><option  value=\"2022\">2022<\/option><option  value=\"2021\">2021<\/option><option  value=\"2020\">2020<\/option><option  value=\"2019\">2019<\/option><option  value=\"2018\">2018<\/option><option  value=\"2017\">2017<\/option><option  value=\"2016\">2016<\/option><option  value=\"2015\">2015<\/option><option  value=\"2014\">2014<\/option><option  value=\"2013\">2013<\/option><option  value=\"2012\">2012<\/option><option  value=\"2011\">2011<\/option><option  value=\"2010\">2010<\/option><option  value=\"2009\">2009<\/option><option  value=\"2008\">2008<\/option><option  value=\"2007\">2007<\/option><option  value=\"2006\">2006<\/option><option  value=\"2005\">2005<\/option><option  value=\"2004\">2004<\/option><option  value=\"2003\">2003<\/option><option  value=\"2002\">2002<\/option><option  value=\"2001\">2001<\/option><option  value=\"2000\">2000<\/option><option  value=\"1999\">1999<\/option><option  value=\"1998\">1998<\/option><option  value=\"1997\">1997<\/option><option  value=\"1996\">1996<\/option><option  value=\"1995\">1995<\/option><option  value=\"1994\">1994<\/option><option  value=\"1993\">1993<\/option><option  value=\"1992\">1992<\/option><option  value=\"1991\">1991<\/option><option  value=\"1990\">1990<\/option><option  value=\"1989\">1989<\/option><option  value=\"1988\">1988<\/option><option  value=\"1987\">1987<\/option><option  value=\"1986\">1986<\/option><option  value=\"1985\">1985<\/option><option  value=\"1984\">1984<\/option><option  value=\"1983\">1983<\/option><option  value=\"1982\">1982<\/option><option  value=\"1981\">1981<\/option><option  value=\"1980\">1980<\/option><option  value=\"1979\">1979<\/option><option  value=\"1978\">1978<\/option><option  value=\"1977\">1977<\/option><option  value=\"1976\">1976<\/option><option  value=\"1975\">1975<\/option><option  value=\"1974\">1974<\/option><option  value=\"1973\">1973<\/option><option  value=\"1972\">1972<\/option><\/select><\/div><div class=\"error-message\"><\/div><\/div><\/div><\/fieldset><fieldset class=\"\"><legend>Comp\u00e9tences m\u00e9dicales<\/legend><div class=\"input-group input-group--checkbox\"><label for=\"degrees\">Titre de sp\u00e9cialiste * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><div class=\"checkbox-groups-wrapper required\">\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"degrees-1\" name=\"degrees[]\" value=\"0\"  >\n\t\t\t<label for=\"degrees-1\">FA Dermatologie<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"degrees-2\" name=\"degrees[]\" value=\"1\"  >\n\t\t\t<label for=\"degrees-2\">FA Allergologie et immunologie clinique<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"degrees-3\" name=\"degrees[]\" value=\"2\"  >\n\t\t\t<label for=\"degrees-3\">FA g\u00e9n\u00e9ral m\u00e9decine interne<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"degrees-4\" name=\"degrees[]\" value=\"3\"  >\n\t\t\t<label for=\"degrees-4\">FA Chirurgie plastique<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"degrees-5\" name=\"degrees[]\" value=\"4\"  >\n\t\t\t<label for=\"degrees-5\">FA Angiologie<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"degrees-6\" name=\"degrees[]\" value=\"5\"  >\n\t\t\t<label for=\"degrees-6\">Aucun<\/label>\n\t\t<\/div>\n\t\t\t\t<div class=\"checkbox-group custom\">\n\t\t\t<div class=\"custom-group\">\n\t\t\t\t<input type=\"checkbox\"  id=\"degrees-custom\" name=\"degrees[]\" value=\"-1\"  >\n\t\t\t\t<label for=\"degrees-custom\">Autre titre de sp\u00e9cialiste<\/label>\n\t\t\t<\/div>\n\t\t\t<input class=\"compact\" type=\"text\" name=\"degrees_custom\" value=\"\"  >\n\t\t<\/div>\n\t<\/div>\n<\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--checkbox\"><label for=\"certificates\">Certificat de comp\u00e9tence * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><div class=\"checkbox-groups-wrapper required\">\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"certificates-1\" name=\"certificates[]\" value=\"0\"  >\n\t\t\t<label for=\"certificates-1\">Traitement au laser de la peau et des muqueuses proches de la peau FMCH<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"certificates-2\" name=\"certificates[]\" value=\"1\"  >\n\t\t\t<label for=\"certificates-2\">Phl\u00e9bologie USGG<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"certificates-3\" name=\"certificates[]\" value=\"2\"  >\n\t\t\t<label for=\"certificates-3\">Radioth\u00e9rapie dermatologique SGDV<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"certificates-4\" name=\"certificates[]\" value=\"3\"  >\n\t\t\t<label for=\"certificates-4\">Ablation thermique endoveineuse des veines tronculaires pour la varicose USGG<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"certificates-5\" name=\"certificates[]\" value=\"4\"  >\n\t\t\t<label for=\"certificates-5\">Certificat d&#039;aptitude \u00e0 la pratique du laboratoire<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"certificates-6\" name=\"certificates[]\" value=\"5\"  >\n\t\t\t<label for=\"certificates-6\">Aucun<\/label>\n\t\t<\/div>\n\t\t\t\t<div class=\"checkbox-group custom\">\n\t\t\t<div class=\"custom-group\">\n\t\t\t\t<input type=\"checkbox\"  id=\"certificates-custom\" name=\"certificates[]\" value=\"-1\"  >\n\t\t\t\t<label for=\"certificates-custom\">Autre<\/label>\n\t\t\t<\/div>\n\t\t\t<input class=\"compact\" type=\"text\" name=\"certificates_custom\" value=\"\"  >\n\t\t<\/div>\n\t<\/div>\n<\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--checkbox\"><label for=\"specializations\">Sp\u00e9cialisation en droit priv\u00e9 * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><div class=\"checkbox-groups-wrapper required\">\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"specializations-1\" name=\"specializations[]\" value=\"0\"  >\n\t\t\t<label for=\"specializations-1\">Dermatopathologie<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"specializations-2\" name=\"specializations[]\" value=\"1\"  >\n\t\t\t<label for=\"specializations-2\">Aucun<\/label>\n\t\t<\/div>\n\t\t\t\t<div class=\"checkbox-group custom\">\n\t\t\t<div class=\"custom-group\">\n\t\t\t\t<input type=\"checkbox\"  id=\"specializations-custom\" name=\"specializations[]\" value=\"-1\"  >\n\t\t\t\t<label for=\"specializations-custom\">Autre<\/label>\n\t\t\t<\/div>\n\t\t\t<input class=\"compact\" type=\"text\" name=\"specializations_custom\" value=\"\"  >\n\t\t<\/div>\n\t<\/div>\n<\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--checkbox\"><label for=\"skin_procedure_recognitions\">Reconnaissance de l'utilisation de proc\u00e9dures de substitution de la peau * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><div class=\"checkbox-groups-wrapper required\">\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"skin_procedure_recognitions-1\" name=\"skin_procedure_recognitions[]\" value=\"0\"  >\n\t\t\t<label for=\"skin_procedure_recognitions-1\">Appligraf<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"skin_procedure_recognitions-2\" name=\"skin_procedure_recognitions[]\" value=\"1\"  >\n\t\t\t<label for=\"skin_procedure_recognitions-2\">Epifix<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"skin_procedure_recognitions-3\" name=\"skin_procedure_recognitions[]\" value=\"2\"  >\n\t\t\t<label for=\"skin_procedure_recognitions-3\">NuShield<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"skin_procedure_recognitions-4\" name=\"skin_procedure_recognitions[]\" value=\"3\"  >\n\t\t\t<label for=\"skin_procedure_recognitions-4\">Plaie Kerecis Omega3<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"skin_procedure_recognitions-5\" name=\"skin_procedure_recognitions[]\" value=\"4\"  >\n\t\t\t<label for=\"skin_procedure_recognitions-5\">EpiDex<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"skin_procedure_recognitions-6\" name=\"skin_procedure_recognitions[]\" value=\"5\"  >\n\t\t\t<label for=\"skin_procedure_recognitions-6\">Aucun<\/label>\n\t\t<\/div>\n\t\t<\/div>\n<\/div><div class=\"error-message\"><\/div><\/div><\/div><\/fieldset><fieldset class=\"\"><legend>\u00c9quipement du cabinet m\u00e9dical<\/legend><p class=\"fieldset-description\">A remplir uniquement par les m\u00e9decins \u00e9tablis.<\/p><div class=\"input-group input-group--radio\"><label for=\"ambulatory_surgeries\">Chirurgie ambulatoire (chirurgie certifi\u00e9e\/OP1) * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><div class=\"radio-groups-wrapper\">\n        <div class=\"radio-group\">\n        <input type=\"radio\" checked id=\"ambulatory_surgeries-1\" name=\"ambulatory_surgeries\" value=\"1\" required  >\n        <label for=\"ambulatory_surgeries-1\">Oui<\/label>\n    <\/div>\n        <div class=\"radio-group\">\n        <input type=\"radio\" checked id=\"ambulatory_surgeries-2\" name=\"ambulatory_surgeries\" value=\"0\" required  >\n        <label for=\"ambulatory_surgeries-2\">Non<\/label>\n    <\/div>\n    <\/div><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--radio\"><label for=\"photodynamic_therapy\">Th\u00e9rapie photodynamique * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><div class=\"radio-groups-wrapper\">\n        <div class=\"radio-group\">\n        <input type=\"radio\" checked id=\"photodynamic_therapy-1\" name=\"photodynamic_therapy\" value=\"1\" required  >\n        <label for=\"photodynamic_therapy-1\">Oui<\/label>\n    <\/div>\n        <div class=\"radio-group\">\n        <input type=\"radio\" checked id=\"photodynamic_therapy-2\" name=\"photodynamic_therapy\" value=\"0\" required  >\n        <label for=\"photodynamic_therapy-2\">Non<\/label>\n    <\/div>\n    <\/div><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--checkbox\"><label for=\"light_therapy\">La luminoth\u00e9rapie * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><div class=\"checkbox-groups-wrapper required\">\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"light_therapy-1\" name=\"light_therapy[]\" value=\"0\"  >\n\t\t\t<label for=\"light_therapy-1\">UVB nb<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"light_therapy-2\" name=\"light_therapy[]\" value=\"1\"  >\n\t\t\t<label for=\"light_therapy-2\">UVA<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"light_therapy-3\" name=\"light_therapy[]\" value=\"2\"  >\n\t\t\t<label for=\"light_therapy-3\">UVA1<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"light_therapy-4\" name=\"light_therapy[]\" value=\"3\"  >\n\t\t\t<label for=\"light_therapy-4\">PUVA (cr\u00e8me\/bain\/oral)<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"light_therapy-5\" name=\"light_therapy[]\" value=\"4\"  >\n\t\t\t<label for=\"light_therapy-5\">Laser \u00e0 excim\u00e8re<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"light_therapy-6\" name=\"light_therapy[]\" value=\"5\"  >\n\t\t\t<label for=\"light_therapy-6\">Luminoth\u00e9rapie pour tout le corps<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"light_therapy-7\" name=\"light_therapy[]\" value=\"6\"  >\n\t\t\t<label for=\"light_therapy-7\">Luminoth\u00e9rapie main\/pied<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"light_therapy-8\" name=\"light_therapy[]\" value=\"7\"  >\n\t\t\t<label for=\"light_therapy-8\">Aucun<\/label>\n\t\t<\/div>\n\t\t<\/div>\n<\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--radio\"><label for=\"radio_therapy\">Radioth\u00e9rapie * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><div class=\"radio-groups-wrapper\">\n        <div class=\"radio-group\">\n        <input type=\"radio\" checked id=\"radio_therapy-1\" name=\"radio_therapy\" value=\"1\" required  >\n        <label for=\"radio_therapy-1\">Oui<\/label>\n    <\/div>\n        <div class=\"radio-group\">\n        <input type=\"radio\" checked id=\"radio_therapy-2\" name=\"radio_therapy\" value=\"0\" required  >\n        <label for=\"radio_therapy-2\">Non<\/label>\n    <\/div>\n    <\/div><\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--checkbox\"><label for=\"laser_therapy\">Th\u00e9rapie au laser * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><div class=\"checkbox-groups-wrapper required\">\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"laser_therapy-1\" name=\"laser_therapy[]\" value=\"0\"  >\n\t\t\t<label for=\"laser_therapy-1\">Th\u00e9rapies laser ablatives\/chirurgicales (Co2, erbium, etc.)<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"laser_therapy-2\" name=\"laser_therapy[]\" value=\"1\"  >\n\t\t\t<label for=\"laser_therapy-2\">Th\u00e9rapie laser fractionn\u00e9e (Co2, erbium, etc.)<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"laser_therapy-3\" name=\"laser_therapy[]\" value=\"2\"  >\n\t\t\t<label for=\"laser_therapy-3\">Vases de th\u00e9rapie au laser (KTP, ND:YAG, laser \u00e0 colorant, etc.)<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"laser_therapy-4\" name=\"laser_therapy[]\" value=\"3\"  >\n\t\t\t<label for=\"laser_therapy-4\">\u00c9pilation au laser (alexandrite, diode, etc.)<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"laser_therapy-5\" name=\"laser_therapy[]\" value=\"4\"  >\n\t\t\t<label for=\"laser_therapy-5\">Tatouage\/Pigments (Nd:YAG d\u00e9clench\u00e9, pico, etc.)<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"laser_therapy-6\" name=\"laser_therapy[]\" value=\"5\"  >\n\t\t\t<label for=\"laser_therapy-6\">Laser endoluminal\/radiofr\u00e9quence pour phl\u00e9bectomie laser<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"laser_therapy-7\" name=\"laser_therapy[]\" value=\"6\"  >\n\t\t\t<label for=\"laser_therapy-7\">Laser vaginal<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"laser_therapy-8\" name=\"laser_therapy[]\" value=\"7\"  >\n\t\t\t<label for=\"laser_therapy-8\">Laser fractionn\u00e9 non-ablatif<\/label>\n\t\t<\/div>\n\t\t\t<div class=\"checkbox-group\">\n\t\t\t<input type=\"checkbox\"  id=\"laser_therapy-9\" name=\"laser_therapy[]\" value=\"8\"  >\n\t\t\t<label for=\"laser_therapy-9\">Aucun<\/label>\n\t\t<\/div>\n\t\t\t\t<div class=\"checkbox-group custom\">\n\t\t\t<div class=\"custom-group\">\n\t\t\t\t<input type=\"checkbox\"  id=\"laser_therapy-custom\" name=\"laser_therapy[]\" value=\"-1\"  >\n\t\t\t\t<label for=\"laser_therapy-custom\">Autre<\/label>\n\t\t\t<\/div>\n\t\t\t<input class=\"compact\" type=\"text\" name=\"laser_therapy_custom\" value=\"\"  >\n\t\t<\/div>\n\t<\/div>\n<\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--radio\"><label for=\"iontophorese\">Iontophor\u00e8se * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><div class=\"radio-groups-wrapper\">\n        <div class=\"radio-group\">\n        <input type=\"radio\" checked id=\"iontophorese-1\" name=\"iontophorese\" value=\"1\" required  >\n        <label for=\"iontophorese-1\">Oui<\/label>\n    <\/div>\n        <div class=\"radio-group\">\n        <input type=\"radio\" checked id=\"iontophorese-2\" name=\"iontophorese\" value=\"0\" required  >\n        <label for=\"iontophorese-2\">Non<\/label>\n    <\/div>\n    <\/div><\/div><div class=\"error-message\"><\/div><\/div><\/div><\/fieldset><fieldset class=\"\"><legend>Fichiers<\/legend><div class=\"input-group input-group--file\"><label for=\"photo\">Photo <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><template class=\"file-input\">\n    <div class=\"file-input\">\n                <input type=\"hidden\" name=\"photo[title][]\">\n        <input type=\"hidden\" name=\"photo[description][]\">\n                <input  name=\"photo[path][]\" type=\"file\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\t\taccept=\"image\/*\"\n\t>\n    <\/div>\n<\/template>\n<input type=\"hidden\" name=\"photo[title][]\">\n<input type=\"hidden\" name=\"photo[description][]\">\n<input name=\"photo[path][]\" type=\"file\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\t\taccept=\"image\/*\"\n\t>\n\n\n<\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--file\"><label for=\"cv\">CV complet * <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><template class=\"file-input\">\n    <div class=\"file-input\">\n                <input type=\"hidden\" name=\"cv[title][]\">\n        <input type=\"hidden\" name=\"cv[description][]\">\n                <input  name=\"cv[path][]\" type=\"file\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\trequired\n\t\t\t\t\t\taccept=\".pdf,.doc,.docx,.odt\"\n\t>\n    <\/div>\n<\/template>\n<input type=\"hidden\" name=\"cv[title][]\">\n<input type=\"hidden\" name=\"cv[description][]\">\n<input name=\"cv[path][]\" type=\"file\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\trequired\n\t\t\t\t\t\taccept=\".pdf,.doc,.docx,.odt\"\n\t>\n\n\n<\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--file\"><label for=\"recommendation\">Lettre de recommandation 1 <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><template class=\"file-input\">\n    <div class=\"file-input\">\n                <input type=\"hidden\" name=\"recommendation[title][]\">\n        <input type=\"hidden\" name=\"recommendation[description][]\">\n                <input  name=\"recommendation[path][]\" type=\"file\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\t\taccept=\".pdf,.doc,.docx,.odt\"\n\t>\n    <\/div>\n<\/template>\n<input type=\"hidden\" name=\"recommendation[title][]\">\n<input type=\"hidden\" name=\"recommendation[description][]\">\n<input name=\"recommendation[path][]\" type=\"file\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\t\taccept=\".pdf,.doc,.docx,.odt\"\n\t>\n\n\n<\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--file\"><label for=\"recommendation2\">Lettre de recommandation 2 <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><template class=\"file-input\">\n    <div class=\"file-input\">\n                <input type=\"hidden\" name=\"recommendation2[title][]\">\n        <input type=\"hidden\" name=\"recommendation2[description][]\">\n                <input  name=\"recommendation2[path][]\" type=\"file\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\t\taccept=\".pdf,.doc,.docx,.odt\"\n\t>\n    <\/div>\n<\/template>\n<input type=\"hidden\" name=\"recommendation2[title][]\">\n<input type=\"hidden\" name=\"recommendation2[description][]\">\n<input name=\"recommendation2[path][]\" type=\"file\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\t\taccept=\".pdf,.doc,.docx,.odt\"\n\t>\n\n\n<\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--file\"><label for=\"state_exam\">Examen d'\u00c9tat <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><template class=\"file-input\">\n    <div class=\"file-input\">\n                <input type=\"hidden\" name=\"state_exam[title][]\">\n        <input type=\"hidden\" name=\"state_exam[description][]\">\n                <input  name=\"state_exam[path][]\" type=\"file\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\t\taccept=\".pdf,.doc,.docx,.odt\"\n\t>\n    <\/div>\n<\/template>\n<input type=\"hidden\" name=\"state_exam[title][]\">\n<input type=\"hidden\" name=\"state_exam[description][]\">\n<input name=\"state_exam[path][]\" type=\"file\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\t\taccept=\".pdf,.doc,.docx,.odt\"\n\t>\n\n\n<\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--file\"><label for=\"professional_title\">Titre de sp\u00e9cialiste <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><template class=\"file-input\">\n    <div class=\"file-input\">\n                <input type=\"hidden\" name=\"professional_title[title][]\">\n        <input type=\"hidden\" name=\"professional_title[description][]\">\n                <input  name=\"professional_title[path][]\" type=\"file\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\t\taccept=\".pdf,.doc,.docx,.odt\"\n\t>\n    <\/div>\n<\/template>\n<input type=\"hidden\" name=\"professional_title[title][]\">\n<input type=\"hidden\" name=\"professional_title[description][]\">\n<input name=\"professional_title[path][]\" type=\"file\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\t\taccept=\".pdf,.doc,.docx,.odt\"\n\t>\n\n\n<\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--file\"><label for=\"mebeke_title\">MEBEKO-Anerkennung Arzttitel <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><template class=\"file-input\">\n    <div class=\"file-input\">\n                <input type=\"hidden\" name=\"mebeke_title[title][]\">\n        <input type=\"hidden\" name=\"mebeke_title[description][]\">\n                <input  name=\"mebeke_title[path][]\" type=\"file\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\t\taccept=\".pdf,.doc,.docx,.odt\"\n\t>\n    <\/div>\n<\/template>\n<input type=\"hidden\" name=\"mebeke_title[title][]\">\n<input type=\"hidden\" name=\"mebeke_title[description][]\">\n<input name=\"mebeke_title[path][]\" type=\"file\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\t\taccept=\".pdf,.doc,.docx,.odt\"\n\t>\n\n\n<\/div><div class=\"error-message\"><\/div><\/div><\/div><div class=\"input-group input-group--file\"><label for=\"mebeko_professional_title\">MEBEKO-Anerkennung Facharzttitel <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><template class=\"file-input\">\n    <div class=\"file-input\">\n                <input type=\"hidden\" name=\"mebeko_professional_title[title][]\">\n        <input type=\"hidden\" name=\"mebeko_professional_title[description][]\">\n                <input  name=\"mebeko_professional_title[path][]\" type=\"file\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\t\taccept=\".pdf,.doc,.docx,.odt\"\n\t>\n    <\/div>\n<\/template>\n<input type=\"hidden\" name=\"mebeko_professional_title[title][]\">\n<input type=\"hidden\" name=\"mebeko_professional_title[description][]\">\n<input name=\"mebeko_professional_title[path][]\" type=\"file\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t\t\t\taccept=\".pdf,.doc,.docx,.odt\"\n\t>\n\n\n<\/div><div class=\"error-message\"><\/div><p class=\"description\">Les personnes ayant obtenu leur dipl\u00f4me et leur formation postgradu\u00e9e de sp\u00e9cialiste dans l'Union europ\u00e9enne (UE\/AELE) sont pri\u00e9es de joindre leurs reconnaissances de titres, c'est-\u00e0-dire la reconnaissance du dipl\u00f4me et du titre de sp\u00e9cialiste en dermatologie et v\u00e9n\u00e9r\u00e9ologie d\u00e9livr\u00e9e par l'Office f\u00e9d\u00e9ral de la sant\u00e9 publique OFSP. <br><a href=\"https:\/\/www.bag.admin.ch\/bag\/fr\/home\/berufe-im-gesundheitswesen\/akkreditierung-gesundheitsberufe.html \">Formulaires pour l'obtention d'une reconnaissance de titre<\/a><\/p><\/div><\/div><\/fieldset><fieldset class=\"single-column\"><legend>Remarques<\/legend><div class=\"input-group input-group--textarea\"><label for=\"comments\">Remarques <\/label><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><textarea id=\"comments\" name=\"comments\" \t\t\tautocomplete=\"off\"\n\t\t\t\t\t><\/textarea><\/div><div class=\"error-message\"><\/div><p class=\"description\">Veuillez nous en informer : <br>\nSi vous souhaitez devenir membre de Swiss Young Dermatologists <br>\nSi vous \u00eates membre d'une soci\u00e9t\u00e9 r\u00e9gionale de dermatologie (veuillez indiquer le canton) <br>\nSi vous \u00eates membre d'un groupe de travail de la SSDV<\/p><\/div><\/div><\/fieldset><fieldset class=\"captcha\"><legend>Protection contre le spam<\/legend><div class=\"input-group input-group--html\"><div class=\"input-wrapper\"><div class=\"input-validation-wrapper\"><div class=\"g-recaptcha\" data-sitekey=\"6LdwySojAAAAAFIFxDfq8k4weswDDzDKcO5U8MZI\"><\/div><\/div><div class=\"error-message\"><\/div><\/div><\/div><\/fieldset>    \t<div class=\"rcp_registration_total\"><\/div>\n\t\n\n    \n    <fieldset>\n        <p id=\"rcp_submit_wrap\" class=\"input-group input-group--full-width\">\n            <input type=\"hidden\" name=\"rcp_level\" class=\"rcp_level\" value=\"1\" rel=\"0\"  \/>\n            <input type=\"hidden\" name=\"rcp_register_nonce\" value=\"02e4013498\" \/>\n            <input type=\"submit\" name=\"rcp_submit_registration\" id=\"rcp_submit\" class=\"btBtn btnFilledStyle btnAccentColor rcp-button\" value=\"S&#039;inscrire\" \/>\n        <\/p>\n    <\/fieldset>\n<\/form>\n<\/p>\n","protected":false},"excerpt":{"rendered":"<p>La demande compl\u00e8te, accompagn\u00e9e des documents correspondants, est examin\u00e9e par le comit\u00e9 de la SSDV et une d\u00e9cision est ensuite prise quant \u00e0 l&rsquo;admission.<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":3369,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"inline_featured_image":false,"_derma_icon_id":0,"_derma_icon_url":"","_derma_background_id":0,"_derma_background_url":"","_derma_header_text":"","_derma_member_only":false,"_derma_show_original_image":false,"_derma_menu_title":"","_derma_menu":"","_derma_background_color":"","_derma_narrow_congress_header":false,"_derma_is_full_width":false,"_derma_sliderimage1_id":0,"_derma_sliderimage1_url":"","_derma_sliderimage2_id":0,"_derma_sliderimage2_url":"","_derma_sliderimage3_id":0,"_derma_sliderimage3_url":"","_derma_slider_delay":3000,"_derma_slidertext1":"","_derma_slidertext2":"","_derma_slidertext3":"","_derma_sliderlink1":"","_derma_sliderlink2":"","_derma_sliderlink3":"","footnotes":""},"class_list":["post-3376","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the 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