<link href="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css"> <script src="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/js/bootstrap.min.js"></script> <script src="//code.jquery.com/jquery-1.11.1.min.js"></script> <!------ Include the above in your HEAD tag ----------> <form class="form-horizontal"> <fieldset> <!-- Form Name --> <legend><center><h2>VOUS</h2></center></legend> <legend><center>VOTRE SITUATION FAMILIALE ET PROFESSIONNELLE</center></legend> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="nomPrenom">Nom, Prénom</label> <div class="col-md-4"> <input id="nomPrenom" name="nomPrenom" type="text" placeholder="" class="form-control input-md"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="dateNaiss">Date de naissance</label> <div class="col-md-4"> <input id="dateNaiss" name="dateNaiss" type="text" placeholder="" class="form-control input-md"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="Nationalite">Nationalité</label> <div class="col-md-4"> <input id="Nationalite" name="Nationalite" type="text" placeholder="" class="form-control input-md"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="residenceFisc">Résidence fiscale</label> <div class="col-md-4"> <input id="residenceFisc" name="residenceFisc" type="text" placeholder="" class="form-control input-md"> </div> </div> <!-- Multiple Radios --> <div class="form-group"> <label class="col-md-4 control-label" for="situatFami">Situation familiale</label> <div class="col-md-4"> <div class="radio"> <label for="situatFami-0"> <input type="radio" name="situatFami" id="situatFami-0" value="1" checked="checked"> Célibataire </label> </div> <div class="radio"> <label for="situatFami-1"> <input type="radio" name="situatFami" id="situatFami-1" value="2"> Marié(e) (préciser ci-dessous le nom du conjoint) </label> <input id="nomCJ1" name="nomCJ1" type="text" placeholder="Nom du conjoint" class="form-control input-md"> </div> <div class="radio"> <label for="situatFami-2"> <input type="radio" name="situatFami" id="situatFami-2" value="3"> Pacsé(e) (préciser ci-dessous le nom du conjoint) </label> <input id="nomCJ2" name="nomCJ2" type="text" placeholder="Nom du conjoint" class="form-control input-md"> </div> <div class="radio"> <label for="situatFami-3"> <input type="radio" name="situatFami" id="situatFami-3" value="4"> Divorcé(e) </label> </div> <div class="radio"> <label for="situatFami-4"> <input type="radio" name="situatFami" id="situatFami-4" value="5"> Veuf(ve) </label> </div> <div class="radio"> <label for="situatFami-5"> <input type="radio" name="situatFami" id="situatFami-5" value="6"> Autre (à préciser) </label> <input id="SituFamAutre" name="SituFamAutre" type="text" placeholder="Autre" class="form-control input-md"> </div> </div> </div> <!-- Multiple Radios --> <div class="form-group"> <label class="col-md-4 control-label" for="regimeMatri">Régime matrimonial</label> <div class="col-md-4"> <div class="radio"> <label for="regimeMatri-0"> <input type="radio" name="regimeMatri" id="regimeMatri-0" value="1" checked="checked"> Communauté réduite aux acquêts </label> </div> <div class="radio"> <label for="regimeMatri-1"> <input type="radio" name="regimeMatri" id="regimeMatri-1" value="2"> Communauté universelle </label> </div> <div class="radio"> <label for="regimeMatri-2"> <input type="radio" name="regimeMatri" id="regimeMatri-2" value="3"> Communauté de meubles et acquêts </label> </div> <div class="radio"> <label for="regimeMatri-3"> <input type="radio" name="regimeMatri" id="regimeMatri-3" value="4"> Séparation de biens pure et simple </label> </div> <div class="radio"> <label for="regimeMatri-4"> <input type="radio" name="regimeMatri" id="regimeMatri-4" value="5"> Séparation de biens avec Société d'acquêts </label> </div> <div class="radio"> <label for="regimeMatri-5"> <input type="radio" name="regimeMatri" id="regimeMatri-5" value="6"> Participation aux acquêts </label> </div> <div class="radio"> <label for="regimeMatri-6"> <input type="radio" name="regimeMatri" id="regimeMatri-6" value="7"> Cluases particulières (avantages matrimoniaux) </label> </div> <div class="radio"> <label for="regimeMatri-7"> <input type="radio" name="regimeMatri" id="regimeMatri-7" value="8"> Régime de droit étranger </label> </div> <div class="radio"> <label for="regimeMatri-8"> <input type="radio" name="regimeMatri" id="regimeMatri-8" value="9"> Autre (à préciser) </label> </div> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="autreRegimeMatri"></label> <div class="col-md-4"> <input id="autreRegimeMatri" name="autreRegimeMatri" type="text" placeholder="" class="form-control input-md"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="textinput">Personnes à charge</label> <div class="col-md-4"> <table class="table table-bordered table-hover"> <tr> <td> <label>Nom, prénom</label> </td> <td> <label>Date de naissance</label> </td> <td> <label>Mineur/Majeur/Majeur protégé</label> </td> </tr> <tr> <td> <input id="persAcharge1" name="persAcharge1" type="text" placeholder="" class="form-control input-md"> </td> <td> <input id="dateNaiss1" name="dateNaiss1" type="text" placeholder="" class="form-control input-md"> </td> <td> <input id="MinMaj1" name="MinMaj1" type="text" placeholder="" class="form-control input-md"> </td> </tr> <tr> <td> <input id="persAcharge2" name="persAcharge2" type="text" placeholder="" class="form-control input-md"> </td> <td> <input id="dateNaiss2" name="dateNaiss2" type="text" placeholder="" class="form-control input-md"> </td> <td> <input id="MinMaj2" name="MinMaj2" type="text" placeholder="" class="form-control input-md"> </td> </tr> <tr> <td> <input id="persAcharge3" name="persAcharge3" type="text" placeholder="" class="form-control input-md"> </td> <td> <input id="dateNaiss3" name="dateNaiss3" type="text" placeholder="" class="form-control input-md"> </td> <td> <input id="MinMaj3" name="MinMaj3" type="text" placeholder="" class="form-control input-md"> </td> </tr> <tr> <td> <input id="persAcharge4" name="persAcharge4" type="text" placeholder="" class="form-control input-md"> </td> <td> <input id="dateNaiss4" name="dateNaiss4" type="text" placeholder="" class="form-control input-md"> </td> <td> <input id="MinMaj4" name="MinMaj4" type="text" placeholder="" class="form-control input-md"> </td> </tr> <tr> <td> <input id="persAcharge5" name="persAcharge5" type="text" placeholder="" class="form-control input-md"> </td> <td> <input id="dateNaiss5" name="dateNaiss5" type="text" placeholder="" class="form-control input-md"> </td> <td> <input id="MinMaj5" name="MinMaj5" type="text" placeholder="" class="form-control input-md"> </td> </tr> </table> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="textinput">Votre situation professionnelle</label> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="profession">Profession</label> <div class="col-md-4"> <input id="profession" name="profession" type="text" placeholder="" class="form-control input-md"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="sectActiv">Secteur d'activité</label> <div class="col-md-4"> <input id="sectActiv" name="sectActiv" type="text" placeholder="" class="form-control input-md"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="nomEmploy">Nom de l'employeur si salarié</label> <div class="col-md-4"> <input id="nomEmploy" name="nomEmploy" type="text" placeholder="" class="form-control input-md"> </div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="depRetraite">Horizon de départ à la retraite</label> <div class="col-md-4"> <label class="radio-inline" for="depRetraite-0"> <input type="radio" name="depRetraite" id="depRetraite-0" value="1" checked="checked"> moins de 5 ans </label> <label class="radio-inline" for="depRetraite-1"> <input type="radio" name="depRetraite" id="depRetraite-1" value="2"> de 5 à 10 ans </label> <label class="radio-inline" for="depRetraite-2"> <input type="radio" name="depRetraite" id="depRetraite-2" value="3"> plus de 10 ans </label> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="textinput">La situation professionnelle de votre conjoint/partenaire</label> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="profession">Profession</label> <div class="col-md-4"> <input id="profession" name="profession" type="text" placeholder="" class="form-control input-md"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="sectActiv">Secteur d'activité</label> <div class="col-md-4"> <input id="sectActiv" name="sectActiv" type="text" placeholder="" class="form-control input-md"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="nomEmploy">Nom de l'employeur si salarié</label> <div class="col-md-4"> <input id="nomEmploy" name="nomEmploy" type="text" placeholder="" class="form-control input-md"> </div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="depRetraite">Horizon de départ à la retraite</label> <div class="col-md-4"> <label class="radio-inline" for="depRetraite-0"> <input type="radio" name="depRetraite" id="depRetraite-0" value="1" checked="checked"> moins de 5 ans </label> <label class="radio-inline" for="depRetraite-1"> <input type="radio" name="depRetraite" id="depRetraite-1" value="2"> de 5 à 10 ans </label> <label class="radio-inline" for="depRetraite-2"> <input type="radio" name="depRetraite" id="depRetraite-2" value="3"> plus de 10 ans </label> </div> </div> </fieldset> </form>