<form id="moduleFormContact" name="moduleFormContact" method="post" title="{{ 'label.contactez_nous'|trans }}">
    <fieldset>
        <legend>{{ 'label.form_votre_message'|trans }}</legend>
        <div class="well"><p class="mb-0"><strong>{{ 'label.form_mention-obligatoire'|trans }}</strong></p></div>
        {% if disableMotif is defined and disableMotif == false and themes is defined and themes is iterable and themes|length >0 %}
            <div class="form-group">
                <label for="theme">{{ 'label.theme'|trans }} <abbr tabindex="0" title="{{ 'label.obligatoire'|trans }}">*</abbr></label>
                <select class="form-control selectpicker" id="theme" name="theme">
                    <option value="-1">{{ 'label.choose_theme'|trans }}</option>
                    {% for theme in themes %}
                        <option value="{{ theme.id }}">{{ theme.nom }}</option>
                    {% endfor %}
                </select>
            </div>
        {% endif %}

        <div class="form-group">
            <label for="sujet">{{ 'label.sujet'|trans }}</label>
            <input class="form-control" name="sujet" type="text" id="sujet"/>
        </div>

        <div class="form-group">
            <label for="message">{{ 'label.message'|trans }} <abbr tabindex="0" title="{{ 'label.obligatoire'|trans }}">*</abbr></label>
            <textarea id="message" rows="5" class="form-control" name="message"></textarea>
        </div>


    </fieldset>

    <fieldset>
        <legend>{{ 'label.vos_coordonnees'|trans }}</legend>
        <div class="well"><p class="mb-0"><strong>{{ 'label.form_mention-obligatoire'|trans }}</strong></p></div>

        <div class="row">
            <div class="form-group col-md-2">
                <label for="civilite">{{ 'label.civilite'|trans }}</label>
                <select class="form-control selectpicker" id="civilite" name="civilite" autocomplete="honorific-prefix">
                    <option value="mme" selected>{{ 'label.civilite.mme'|trans }}</option>
                    <option value="m">{{ 'label.civilite.mr'|trans }}</option>
                </select>
            </div>

            <div class="form-group col-md-5">
                <label for="nom">{{ 'label.nom'|trans }} <abbr tabindex="0" title="{{ 'label.obligatoire'|trans }}">*</abbr></label>
                <input class="form-control" name="nom" type="text" id="nom" required autocomplete="family-name"/>
            </div>

            <div class="form-group col-md-5">
                <label for="prenom">{{ 'label.prenom'|trans }}</label>
                <input class="form-control" name="prenom" type="text" id="prenom" autocomplete="given-name"/>
            </div>
        </div>
        <div class="form-group">
            <label for="adresse">{{ 'label.adresse'|trans }}</label>
            <input class="form-control" name="adresse" type="text" id="adresse" autocomplete="address-line1"/>
        </div>


        <div class="row">
            <div class="form-group col-md-3">
                <label class="control-label" for="cp">{{ 'label.cp'|trans }}</label>
                <input class="form-control" name="cp" type="number" id="cp" autocomplete="postal-code"/>
            </div>
            <div class="form-group col-md-9">
                <label class="control-label" for="ville">{{ 'label.ville'|trans }}</label>
                <input class="form-control" name="ville" type="text" id="ville" autocomplete="address-level2" />
            </div>
        </div>

        <div class="row">
            <div class="form-group col-md-6">
                <label class="control-label" for="telephone">{{ 'label.phone'|trans }}</label>
                <input class="form-control" name="telephone" type="text" id="telephone" autocomplete="tel-national"/>
            </div>
            <div class="form-group col-md-6">
                <label class="control-label" for="mail">{{ 'label.mailadress'|trans }} <abbr tabindex="0" title="{{ 'label.obligatoire'|trans }}">*</abbr> <small>{{ 'label.exemplemail'|trans }}</small></label>
                <input class="form-control" name="mail" type="email" id="mail" required autocomplete="email"/>
            </div>
        </div>

        {{ GetRgpdForModule(6)|raw}}

    </fieldset>
    
    <div class="row">
        <div class="col-sm-6">{{ CaptchaService.getHtmlCaptcha|raw }}</div>
        <div class="col-sm-6">
            <input type="button" id="moduleContactSubmit" class="btn btn-primary btn-lg btn-block submit" value="{{ 'label.envoyer'|trans }}">
        </div>
    </div>

</form>