<label class="labeltype1" for="Civilite{0}" style="margin-top:10px;">Civilité du {1} adulte <span class="red">*</span> :</label>
	<span class="spantype1" style="margin-top:10px;">
		<input ezsend="true" name="Civilite{0}" type="radio" id="Civilite{0}_1" checked="true" class="radio {required:true, messages:{required:'Merci d\'indiquer la civilité du {1} adulte.'}}" value="mme"> <label class="labelradio" for="Civilite{0}_1">Mme</label>
		<input ezsend="true" name="Civilite{0}" type="radio" id="Civilite{0}_2" class="radio {required:true, messages:{required:'Merci d\'indiquer la civilité du {1} adulte.'}}" value="mlle"> <label class="labelradio" for="Civilite{0}_2">Mlle</label>
		<input ezsend="true" name="Civilite{0}" type="radio" id="Civilite{0}_3" class="radio {required:true, messages:{required:'Merci d\'indiquer la civilité du {1} adulte.'}}" value="m"> <label class="labelradio" for="Civilite{0}_3">M</label>
		<input ezsend="true" name="Sexe{0}" type="text" id="Sexe{0}" style="display:none">
	</span>
  <span class="spacer"> </span>
    
  <label class="labeltype1" for="Jour{0}">Date de naissance du {1} adulte <span class="red">*</span> :</label>
  <span class="spantype1">
		<select class="selecttype1" ezsend="true" id="Jour{0}" name="Jour{0}">
			{3}
	  </select> 
	  <select class="selecttype1" ezsend="true" id="Mois{0}" name="Mois{0}">
			<option value="01">janvier</option>
			<option  value="02">février</option>
			<option  value="03">mars</option>
			<option  value="04">avril</option>
			<option  value="05">mai</option>
			<option  value="06">juin</option>
			<option  value="07">juillet</option>
			<option  value="08">août</option>
			<option  value="09">septembre</option>
			<option  value="10">octobre</option>
			<option  value="11">novembre</option>
			<option  value="12">décembre</option>
		</select> 
	  <select class="selecttype1" ezsend="true" id="Annee{0}" name="Annee{0}">
			{2}
	  </select>
  </span>
  <span class="spacer"> </span>

<label class="labeltype1" for="Regime{0}">Régime social du {1} adulte <span class="red">*</span> :</label>
  <span class="spantype1">
		<select ezsend="true" id="Regime{0}" name="Regime{0}" class="selecttype1 {required:true, messages:{required:'Champs obligatoire'}}">
			<option value="">Sélectionnez</option>
				<option value="S">Salarié</option>
			<option value="TNS">Travailleur non salarié</option>
			<option value="A">Travailleur agricole</option>
	  </select>
  </span>
  <span class="spacer"> </span>
          
  <label class="labeltype1" for="Profession{0}">Profession du {1} adulte <span class="red">*</span> :</label>
  <span class="spantype1">
    <select ezsend="true" id="Profession{0}" name="Profession{0}" class="selecttype1 {required:true, messages:{required:'Champs obligatoire'}}">
			<option value="">Sélectionnez</option>
			<option value="AC">Artisans commerçants</option>
			<option value="AG">Agriculteurs</option>
			<option value="CD">Cadres</option>
			<option value="CE">Chefs d'entreprise</option>
			<option value="CH">Chômeurs</option>
			<option value="CS">Cadres supérieurs</option>
			<option value="EM">Employés</option>
			<option value="ET">Etudiants</option>
			<option value="OV">Ouvriers</option>
			<option value="PI">Professions intermédiaires</option>
			<option value="PL">Profession libérale</option>
			<option value="RT">Retraités</option>
    </select>
	<input type="text" style="display:none;" ezsend="true" id="LibProfession1">
	<input type="text" style="display:none;" ezsend="true" id="LibProfession2">
  </span>
  <span class="spacer"> </span>

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