{"id":1083,"date":"2024-10-22T06:24:26","date_gmt":"2024-10-22T04:24:26","guid":{"rendered":"https:\/\/ammd.themesawesome.com\/registre\/"},"modified":"2025-03-21T22:07:38","modified_gmt":"2025-03-21T21:07:38","slug":"registre","status":"publish","type":"page","link":"https:\/\/ammd.lu\/fr\/registre\/","title":{"rendered":"Register"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1083\" class=\"elementor elementor-1083 elementor-845\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-5dba860 e-flex e-con-boxed e-con e-parent\" data-id=\"5dba860\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-aa52cb6 elementor-widget elementor-widget-ammd_community_register_block\" data-id=\"aa52cb6\" data-element_type=\"widget\" data-widget_type=\"ammd_community_register_block.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<script type=\"text\/javascript\" src=\"https:\/\/cdn.jsdelivr.net\/jquery\/latest\/jquery.min.js\"><\/script>\n<script type=\"text\/javascript\" src=\"https:\/\/cdn.jsdelivr.net\/momentjs\/latest\/moment.min.js\"><\/script>\n<script type=\"text\/javascript\" src=\"https:\/\/cdn.jsdelivr.net\/npm\/daterangepicker\/daterangepicker.min.js\"><\/script>\n<link rel=\"stylesheet\" type=\"text\/css\" href=\"https:\/\/cdn.jsdelivr.net\/npm\/daterangepicker\/daterangepicker.css\" \/>\n\n<style>\n    .register-wrap {\n        max-width: 500px;\n        margin: auto;\n    }\n    .register-step {\n        font-family: 'Open Sans';\n    }\n    .register-step h2 {\n        font-size: 32px;\n        font-weight: 600;\n        line-height: 41.6px;\n        color: #2F2F2F;\n        margin-bottom: 0;\n    }\n    .register-step .form-contents {\n        margin-top: 30px;\n    }\n    .register-step p {\n        font-size: 18px;\n        font-weight: 400;\n        line-height: 27px;\n        color: #2F2F2F;\n    }\n    .register-step ul li {\n        font-size: 16px;\n        font-weight: 400;\n        line-height: 24px;\n        color: #676665;\n    }\n    .register-step ul li {\n        position: relative;\n        padding-left: 20px;\n        margin-bottom: 10px;\n    }\n    .register-step ul li:before {\n        left: 0;\n        top: 8px;\n        position: absolute;\n        content: '';\n        width: 7px;\n        height: 7px;\n        border-radius: 100%;\n        background-color: #6EC2CF;\n    }\n    .regis-btns {\n        margin-top: 30px;\n        display: flex;\n        flex-direction: column;\n        gap: 15px;\n    }\n    .regis-btns.register-prev {\n        flex-direction:row;\n    }\n    .regis-btns .btn {\n        height: 48px;\n        display: flex;\n        justify-content: center;\n        align-items: center;\n        font-size: 16px;\n        font-weight: 600;\n        line-height: 24px;\n        border-radius: 8px;\n        cursor: pointer;\n        border: 0;\n        outline: 0;\n        outline: none;\n    }\n    .regis-btns .btn.btn-prev{\n        width: 15%;\n        background-color: #E3E3E3;\n        color: #676665;\n    }\n    .regis-btns .btn.btn-next {\n        background-color: #6EC2CF;\n        color: #ffffff;\n        flex-grow:1;\n    }\n    .regis-btns .btn.btn-close {\n        background-color: #E3E3E3;\n        color: #676665;\n    }\n    .additional-req {\n        font-size: 14px;\n        font-weight: 600;\n        line-height: 21px;\n        color: #2363BB;\n    }\n    .step-2,\n    .step-3,\n    .step-4,\n    .step-5,\n    .step-6,\n    .step-7 {\n        display: none;\n    }\n    .form-contents label,\n    .form-item p {\n        font-size: 18px;\n        font-weight: 600;\n        line-height: 23.4px;\n        margin-bottom: 12px;\n    }\n    .form-contents label .mandatory, .form-item p .mandatory {\n        font-size: 16px;\n        font-weight: 600;\n        line-height: 20.8px;\n        color: #6EC2CF;\n    }\n    .form-contents .form-item {\n        margin-bottom: 15px;\n    }\n    .form-contents .form-item input,\n    .form-contents .form-item select {\n        border-color: #D5D5D5;\n        border-radius: 8px;\n        padding: 12px 15px;\n    }\n    .form-contents .form-item textarea {\n        border-color: #D5D5D5;\n        border-radius: 8px;\n        padding: 12px 15px;\n        height: 125px;\n    }\n    .sending-checkbox {\n        display: flex;\n    }\n    .sending-checkbox .checkitem {\n        width: 180px;\n        display: flex;\n        gap: 10px;\n        align-items: center;\n    }\n    .sending-checkbox .checkitem label {\n        font-size: 15px;\n        font-weight: 400;\n        line-height: 19.5px;\n        color: #676665;\n        margin-bottom: 0;\n    }\n    .aggreement {\n        gap: 12px;\n        align-items: start;\n    }\n    .aggreement input {\n        transform: scale(1.2);\n        margin-top: 3px;\n    }\n    .aggreement label {\n        font-size: 15px;\n        font-weight: 400;\n        line-height: 19.5px;\n        color: #676665;\n    }\n    .aggreement label a {\n        color: #6EC2CF;\n    }\n\n    \/* START CUSTOM CSS  FOR DATERANGEPICKER *\/\n    .daterangepicker {\n        width: 350px;\n    }\n\n    .daterangepicker select.monthselect{\n        width: 100%;\n        margin: 0;\n        margin-bottom: 8px;\n        border-radius: 8px;\n        border: 2px solid #676665;\n        padding: 8px 12px;\n        font-family: \"Open Sans\";\n        font-weight: bold;\n    }\n\n    .daterangepicker select.yearselect{\n        width: 100%;\n        margin: 0;\n        border-radius: 8px;\n        border: 2px solid #676665;\n        padding: 8px 12px;\n        font-family: \"Open Sans\";\n        font-weight: bold;\n    }\n\n    .daterangepicker .drp-buttons .btn{\n        background-color: #6EC2CF;\n        color: white;\n        border: 0;\n    }\n\n    .daterangepicker .drp-buttons .btn.cancelBtn,\n    .daterangepicker .drp-buttons .btn.cancelBtn:hover{\n        background-color: #676665;\n        border: 0;\n    }\n\n    .daterangepicker .drp-buttons .btn:hover{\n        background-color: #6EC2CF;\n        color: white;\n        border: 0;\n    }\n\n    input.error, select.error, textarea.error {\n        border: 2px solid red !important;\n    }\n\n    @media only screen and (max-width: 600px) {\n        .daterangepicker {\n            width: 95%;\n        }\n    }\n<\/style>\n\n<div class=\"register-wrap\">\n        <div class=\"register-content\">\n        <div class=\"register-step step-1\">\n            <h2>\n                Devenir membre de l&#039;AMMD            <\/h2>\n            <div class=\"form-contents\">\n                <p>\n                    Pour devenir membre de l&#039;AMMD, il faut \u00eatre titulaire d&#039;une autorisation d&#039;exercer la m\u00e9decine ou la m\u00e9decine dentaire au Grand-Duch\u00e9 de Luxembourg, avoir accompli toutes les formalit\u00e9s requises par la loi en rapport avec cette autorisation et exercer activement la profession.                <\/p>\n                <ul>\n                    <li>\n                        Repr\u00e9senter les professions m\u00e9dicales et dentaires \u00e0 tous les niveaux de d\u00e9cision dans le secteur des soins de sant\u00e9                    <\/li>\n                    <li>\n                        D\u00e9fendre les int\u00e9r\u00eats et les besoins des professions m\u00e9dicales et dentaires luxembourgeoises et promouvoir les meilleures pratiques m\u00e9dicales par le biais du Conseil scientifique, pr\u00e9sid\u00e9 par notre association                    <\/li>\n                    <li>\n                        D\u00e9fendre les int\u00e9r\u00eats des professions m\u00e9dicales et dentaires. A ce niveau, les objectifs de l&#039;association sont purement syndicaux.                    <\/li>\n                    <li>\n                        Repr\u00e9senter le corps m\u00e9dical luxembourgeois dans les organisations europ\u00e9ennes et internationales                    <\/li>\n                <\/ul>\n            <\/div>\n            <div class=\"regis-btns\">\n                <div class=\"btn btn-next\">\n                    Suivant                <\/div>\n                <!-- <div class=\"btn btn-close\">\n                    No, Thanks\n                <\/div> -->\n            <\/div>\n        <\/div>\n        <form action=\"\" method=\"post\">\n            <div class=\"register-step step-2\">\n                <h2>Informations sur l&#039;utilisateur<\/h2>\n                <div class=\"form-contents\">\n                    <div class=\"form-item\">\n                        <label for=\"username\">Nom d&#039;utilisateur <span class=\"mandatory\">*<\/span><\/label>\n                        <input id=\"username\" name=\"username\" type=\"text\" placeholder=\"Nom d&#039;utilisateur\" required >\n                    <\/div>\n                    <div class=\"form-item\">\n                        <label for=\"email\">Adresse e-mail <span class=\"mandatory\">*<\/span><\/label>\n                        <input id=\"email\" name=\"user_email\" type=\"email\" placeholder=\"Adresse e-mail\" required >\n                    <\/div>\n                    <!-- <div class=\"form-item\">\n                        <label for=\"password\">Password <span class=\"mandatory\">*<\/span><\/label>\n                        <input id=\"password\" name=\"password\" type=\"password\" placeholder=\"Password\" required >\n                    <\/div>\n                    <div class=\"form-item\">\n                        <label for=\"repeat_password\">Repeat Password <span class=\"mandatory\">*<\/span><\/label>\n                        <input id=\"repeat_password\" name=\"repeat_password\" type=\"password\" placeholder=\"Repeat Password\" required >\n                    <\/div> -->\n                <\/div>\n                <div class=\"regis-btns register-prev\">\n                    <div class=\"btn btn-prev\">\n                        <svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"24px\" height=\"24px\" viewBox=\"0 0 1024 1024\" class=\"icon\"><path fill=\"#000000\" d=\"M224 480h640a32 32 0 110 64H224a32 32 0 010-64z\"\/><path fill=\"#000000\" d=\"M237.248 512l265.408 265.344a32 32 0 01-45.312 45.312l-288-288a32 32 0 010-45.312l288-288a32 32 0 1145.312 45.312L237.248 512z\"\/><\/svg>\n                    <\/div>\n                    <div class=\"btn btn-next\">\n                        Suivant                    <\/div>\n                <\/div>\n            <\/div>\n            <div class=\"register-step step-3\">\n                <h2>Informations g\u00e9n\u00e9rales<\/h2>\n                <div class=\"form-contents\">\n                    <div class=\"form-item\">\n                        <label for=\"title\">Titre <span class=\"mandatory\">*<\/span><\/label>\n                        <!-- <input id=\"title\" name=\"title\" type=\"text\" placeholder=\"Title\" required > -->\n                        <select name=\"title\" id=\"title\">\n                            <option value=\"\">S\u00e9lectionner le titre<\/option>\n                            <option value=\"Mr\">Mr<\/option>\n                            <option value=\"Mrs\">Mme<\/option>\n                            <option value=\"Miss\">Mlle<\/option>\n                            <option value=\"Dr.\">Dr.<\/option>\n                            <option value=\"Sir\">Monsieur<\/option>\n                            <option value=\"Madam\">Madame<\/option>\n                        <\/select>\n                    <\/div>\n                    <!-- <div class=\"form-item\">\n                        <label for=\"name\">Name <span class=\"mandatory\">*<\/span><\/label>\n                        <input id=\"name\" name=\"name\" type=\"text\" placeholder=\"Name\" required >\n                    <\/div> -->\n                    <div class=\"form-item\">\n                        <label for=\"first_name\">Pr\u00e9nom <span class=\"mandatory\">*<\/span><\/label>\n                        <input id=\"first_name\" name=\"first_name\" type=\"text\" placeholder=\"Pr\u00e9nom\" required >\n                    <\/div>\n                    <div class=\"form-item\">\n                        <label for=\"last_name\">Nom <span class=\"mandatory\">*<\/span><\/label>\n                        <input id=\"last_name\" name=\"last_name\" type=\"text\" placeholder=\"Nom\" required >\n                    <\/div>\n                <\/div>\n                <div class=\"regis-btns register-prev\">\n                    <div class=\"btn btn-prev\">\n                        <svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"24px\" height=\"24px\" viewBox=\"0 0 1024 1024\" class=\"icon\"><path fill=\"#000000\" d=\"M224 480h640a32 32 0 110 64H224a32 32 0 010-64z\"\/><path fill=\"#000000\" d=\"M237.248 512l265.408 265.344a32 32 0 01-45.312 45.312l-288-288a32 32 0 010-45.312l288-288a32 32 0 1145.312 45.312L237.248 512z\"\/><\/svg>\n                    <\/div>\n                    <div class=\"btn btn-next\">\n                        Suivant                    <\/div>\n                <\/div>\n            <\/div>\n            <div class=\"register-step step-4\">\n            <h2>Informations g\u00e9n\u00e9rales<\/h2>\n                <div class=\"form-contents\">\n                    <div class=\"form-item\">\n                        <label for=\"speciality\">Sp\u00e9cialit\u00e9 <span class=\"mandatory\">*<\/span><\/label>\n                        <input id=\"speciality\" name=\"speciality\" type=\"text\" placeholder=\"Votre sp\u00e9cialit\u00e9\" required >\n                    <\/div>\n                    <div class=\"form-item\">\n                        <label for=\"birthdate\">Date de naissance <span class=\"mandatory\">*<\/span><\/label>\n                        <input id=\"birthdate\" name=\"birthdate\" type=\"text\" placeholder=\"JJ\/MM\/AAAA\" required >\n                    <\/div>\n                    <div class=\"form-item\">\n                        <label for=\"nationality\">Nationalit\u00e9 <span class=\"mandatory\">*<\/span><\/label>\n                        <input id=\"nationality\" name=\"nationality\" type=\"text\" placeholder=\"Votre nationalit\u00e9\" required >\n                    <\/div>\n                    <div class=\"form-item\">\n                        <label for=\"authorization_date\">Date d&#039;autorisation <span class=\"mandatory\">*<\/span><\/label>\n                        <input id=\"authorization_date\" name=\"authorization_date\" type=\"text\" placeholder=\"JJ\/MM\/AAAA\" required >\n                    <\/div>\n                    <div class=\"form-item\">\n                        <label for=\"installation_date\">Date d&#039;installation <span class=\"mandatory\">*<\/span><\/label>\n                        <input id=\"installation_date\" name=\"installation_date\" type=\"text\" placeholder=\"JJ\/MM\/AAAA\" required >\n                    <\/div>\n                <\/div>\n                <div class=\"regis-btns register-prev\">\n                    <div class=\"btn btn-prev\">\n                        <svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"24px\" height=\"24px\" viewBox=\"0 0 1024 1024\" class=\"icon\"><path fill=\"#000000\" d=\"M224 480h640a32 32 0 110 64H224a32 32 0 010-64z\"\/><path fill=\"#000000\" d=\"M237.248 512l265.408 265.344a32 32 0 01-45.312 45.312l-288-288a32 32 0 010-45.312l288-288a32 32 0 1145.312 45.312L237.248 512z\"\/><\/svg>\n                    <\/div>\n                    <div class=\"btn btn-next\">\n                        Suivant                    <\/div>\n                <\/div>\n            <\/div>\n            <div class=\"register-step step-5\">\n                <h2>Coordonn\u00e9es du cabinet<\/h2>\n                <span class=\"additional-req\">*Adresse au Luxembourg essentielle<\/span>\n                <div class=\"form-contents\">\n                    <div class=\"form-item\">\n                        <label for=\"office_address\">Adresse <span class=\"mandatory\">*<\/span><\/label>\n                        <input id=\"office_address\" name=\"office_address\" type=\"text\" placeholder=\"Adresse du cabinet\" required >\n                    <\/div>\n                    <div class=\"form-item\">\n                        <label for=\"office_zip\">ZIP\/Code postal <span class=\"mandatory\">*<\/span><\/label>\n                        <input id=\"office_zip\" name=\"office_zip\" type=\"text\" placeholder=\"Code postal du cabinet\" required >\n                    <\/div>\n                    <div class=\"form-item\">\n                        <label for=\"office_city\">Ville <span class=\"mandatory\">*<\/span><\/label>\n                        <input id=\"office_city\" name=\"office_city\" type=\"text\" placeholder=\"Ville\" required >\n                    <\/div>\n                    <div class=\"form-item\">\n                        <label for=\"office_telp\">T\u00e9l\u00e9phone<\/label>\n                        <input id=\"office_telp\" name=\"office_telp\" type=\"text\" placeholder=\"T\u00e9l\u00e9phone du cabinet\" >\n                    <\/div>\n                    <div class=\"form-item\">\n                        <label for=\"office_fax\">Fax<\/label>\n                        <input id=\"office_fax\" name=\"office_fax\" type=\"text\" placeholder=\"Fax du cabinet\" >\n                    <\/div>\n                    <!-- <div class=\"form-item\">\n                        <label for=\"office_email\">Email address <span class=\"mandatory\">*<\/span><\/label>\n                        <input id=\"office_email\" name=\"office_email\" type=\"email\" placeholder=\"Firm email address\" >\n                    <\/div> -->\n                <\/div>\n                <div class=\"regis-btns register-prev\">\n                    <div class=\"btn btn-prev\">\n                        <svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"24px\" height=\"24px\" viewBox=\"0 0 1024 1024\" class=\"icon\"><path fill=\"#000000\" d=\"M224 480h640a32 32 0 110 64H224a32 32 0 010-64z\"\/><path fill=\"#000000\" d=\"M237.248 512l265.408 265.344a32 32 0 01-45.312 45.312l-288-288a32 32 0 010-45.312l288-288a32 32 0 1145.312 45.312L237.248 512z\"\/><\/svg>\n                    <\/div>\n                    <div class=\"btn btn-next\">\n                        Suivant                    <\/div>\n                <\/div>\n            <\/div>\n            <div class=\"register-step step-6\">\n                <h2>Coordonn\u00e9es priv\u00e9es<\/h2>\n                <span class=\"additional-req\">*Adresse au Luxembourg essentielle<\/span>\n                <div class=\"form-contents\">\n                    <div class=\"form-item\">\n                        <label for=\"private_address\">Adresse <span class=\"mandatory\">*<\/span><\/label>\n                        <input id=\"private_address\" name=\"private_address\" type=\"text\" placeholder=\"Adresse priv\u00e9e\" required >\n                    <\/div>\n                    <div class=\"form-item\">\n                        <label for=\"private_zip\">ZIP\/Code postal <span class=\"mandatory\">*<\/span><\/label>\n                        <input id=\"private_zip\" name=\"private_zip\" type=\"text\" placeholder=\"Code postal\" required >\n                    <\/div>\n                    <div class=\"form-item\">\n                        <label for=\"private_city\">Ville <span class=\"mandatory\">*<\/span><\/label>\n                        <input id=\"private_city\" name=\"private_city\" type=\"text\" placeholder=\"Ville\" required >\n                    <\/div>\n                    <div class=\"form-item\">\n                        <label for=\"private_telp\">T\u00e9l\u00e9phone\/Mobile<\/label>\n                        <input id=\"private_telp\" name=\"private_telp\" type=\"text\" placeholder=\"T\u00e9l\u00e9phone priv\u00e9\/mobile\" >\n                    <\/div>\n                    <!-- <div class=\"form-item\">\n                        <label for=\"private_email\">Email address <span class=\"mandatory\">*<\/span><\/label>\n                        <input id=\"private_email\" name=\"private_email\" type=\"email\" placeholder=\"Email address\" >\n                    <\/div> -->\n                <\/div>\n                <div class=\"regis-btns register-prev\">\n                    <div class=\"btn btn-prev\">\n                        <svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"24px\" height=\"24px\" viewBox=\"0 0 1024 1024\" class=\"icon\"><path fill=\"#000000\" d=\"M224 480h640a32 32 0 110 64H224a32 32 0 010-64z\"\/><path fill=\"#000000\" d=\"M237.248 512l265.408 265.344a32 32 0 01-45.312 45.312l-288-288a32 32 0 010-45.312l288-288a32 32 0 1145.312 45.312L237.248 512z\"\/><\/svg>\n                    <\/div>\n                    <div class=\"btn btn-next\">\n                        Suivant                    <\/div>\n                <\/div>\n            <\/div>\n            <div class=\"register-step step-7\">\n                <h2>Derni\u00e8re \u00e9tape<\/h2>\n                <div class=\"form-contents\">\n                    <!-- <div class=\"form-item\">\n                        <p>Sending email <span class=\"mandatory\">*<\/span><\/p>\n                        <div class=\"sending-checkbox\">\n                            <div class=\"checkitem\">\n                                <input id=\"sending_email_office\" name=\"sending_email\" type=\"radio\" value=\"office\" >\n                                <label for=\"sending_email_office\">Office<\/label>\n                            <\/div>\n                            <div class=\"checkitem\">\n                                <input id=\"sending_email_private\" name=\"sending_email\" type=\"radio\" value=\"private\" >\n                                <label for=\"sending_email_private\">Private<\/label>\n                            <\/div>\n                        <\/div>\n                    <\/div> -->\n                    <div class=\"form-item\">\n                        <!-- <label for=\"message\">Enter your message <span class=\"mandatory\">*<\/span><\/label> -->\n                        <label for=\"message\">Message facultatif <\/label>\n                        <textarea id=\"message\" name=\"message\" placeholder=\"Laissez votre message...\" ><\/textarea>\n                    <\/div>\n                    <div class=\"form-item aggreement\" style=\"display:flex;\">\n                        <input id=\"accept_aggreement\" name=\"accept_aggreement\" type=\"checkbox\" value=\"aggreed\">\n                        <label for=\"accept_aggreement\">J&#039;accepte que les donn\u00e9es envoy\u00e9es par ce formulaire ne soient utilis\u00e9es que pour traiter ma demande. Le traitement des donn\u00e9es est soumis \u00e0 notre politique de confidentialit\u00e9.<\/label>\n                    <\/div>\n                <\/div>\n\t\t\t\t<div class=\"gglcptch gglcptch_v2\"><div id=\"gglcptch_recaptcha_3215795899\" class=\"gglcptch_recaptcha\"><\/div>\n\t\t\t\t<noscript>\n\t\t\t\t\t<div style=\"width: 302px;\">\n\t\t\t\t\t\t<div style=\"width: 302px; height: 422px; position: relative;\">\n\t\t\t\t\t\t\t<div style=\"width: 302px; height: 422px; position: absolute;\">\n\t\t\t\t\t\t\t\t<iframe src=\"https:\/\/www.google.com\/recaptcha\/api\/fallback?k=6LfcYGcrAAAAAG9b3cwqz4aGLNh76vWYZBdgHBj0\" frameborder=\"0\" scrolling=\"no\" style=\"width: 302px; height:422px; border-style: none;\"><\/iframe>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div style=\"border-style: none; bottom: 12px; left: 25px; margin: 0px; padding: 0px; right: 25px; background: #f9f9f9; border: 1px solid #c1c1c1; border-radius: 3px; height: 60px; width: 300px;\">\n\t\t\t\t\t\t\t<input type=\"hidden\" id=\"g-recaptcha-response\" name=\"g-recaptcha-response\" class=\"g-recaptcha-response\" style=\"width: 250px !important; height: 40px !important; border: 1px solid #c1c1c1 !important; margin: 10px 25px !important; padding: 0px !important; resize: none !important;\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/noscript><\/div>                <div class=\"regis-btns register-prev\">\n                    <div class=\"btn btn-prev\">\n                        <svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"24px\" height=\"24px\" viewBox=\"0 0 1024 1024\" class=\"icon\"><path fill=\"#000000\" d=\"M224 480h640a32 32 0 110 64H224a32 32 0 010-64z\"\/><path fill=\"#000000\" d=\"M237.248 512l265.408 265.344a32 32 0 01-45.312 45.312l-288-288a32 32 0 010-45.312l288-288a32 32 0 1145.312 45.312L237.248 512z\"\/><\/svg>\n                    <\/div>\n                    <button type=\"submit\" class=\"btn btn-next\" disabled id=\"submitForm\">\n                        Envoyer ma demande                    <\/button>\n                <\/div>\n            <\/div>\n            <input id=\"ammd-login-btn\" type=\"hidden\" name=\"ammd_register_nonce\" value=\"57fe71a9a5\"\/>\n            <input id=\"ammd-login-btn\" type=\"hidden\" name=\"ammd_login_nonce\" value=\"\"\/>\n        <\/form>\n    <\/div>\n<\/div>\n\n<script>\n(function( $ ) {\n\t'use strict';\n\n\t$(document).ready(function() {\n        \/\/ Function to validate the email format using regular expressions\n        function isValidEmail(email) {\n            const emailPattern = \/^[a-zA-Z0-9._-]+@[a-zA-Z0-9.-]+\\.[a-zA-Z]{2,6}$\/;\n            return emailPattern.test(email);\n        }\n\n        \/\/ Function to add error message under the input field\n        function showError(field, message) {\n            \/\/ Remove previous error message\n            $(field).next('.error-message').remove();\n            \/\/ Add error class and message\n   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