TELETHON

telethon

<style>
<!--
div#miniform5 {  height:175px; background: url(http://bannieres.telethon.fr/mini-formulaires/bk-mini-form_10_190_175.gif) no-repeat; padding:0px 0 0 10px; font-family:arial, verdana, sans-serif;}
div#miniform5 table {   margin:77px 0 0 0 ; padding:0;}
div#miniform5  form {   margin:0px 0 0 0 ; padding:0;}
div#miniform5 label {  color: #000; font-size:12px; margin:0; padding:0;}
div#miniform5 input{  font-size:10px;   border:0;  margin:0; padding:0 1px; }
div#miniform5 input#email { width:104px;   }
div#miniform5 input#autreMontant { width:50px;    }
div#miniform5 input#valider {  height:auto; }
div#miniform5 span.euro{font-size:11px;padding: 2px 2px 0 0;}
-->
</style>
<div id="miniform5">
<form name="formulaire" method="post" action="http://don.telethon.fr" title="Faire un don en ligne.">
<input type="hidden" name="compteur" value="3" />
<input type="hidden" name="source_type" value="FOR" />
<input type="hidden" name="source_id" value="3216" />
<input type="hidden" name="campagne_id" value="telethon2008" />
<input type="hidden" name="campagne_element" value="190x175" />
<input type="hidden" name="xtor" value="AD-10000017-[telethon2008-190_175]-[3216]-[0]" />
<table cellspacing="0" cellpadding="0" border="0"><tr><td colspan="3"><label for="email"> E-Mail : </label><br /><input type="text"  name="email" id="email" title="Veuillez indiquer votre e-mail." value="Votre e-mail" onfocus="this.value='';" /></td></tr>
<tr><td width="58" height="38"><label for="autreMontant"> Montant : </label><br /><input type="text"  name="autreMontant" id="autreMontant" title="Veuillez indiquer le montant de votre don." value="Votre montant" onfocus="this.value='';" /><td valign="bottom" align="left"> <span class="euro">€</span></td><td width="35"valign="bottom" align="left" > <input type="image" id="valider" src="http://bannieres.telethon.fr/mini-formulaires/bt-mini-form_10_190_175.gif" value="Valider" alt="Valider votre don en ligne." /></td> </tr></table></form></div>