document.writeln('<div id="pjWrapperNewsletter_theme3"><div class="container-fluid pjCfContainer nsl-form-container"><br><div class="panel panel-default pjCfForm"><div class="panel-heading pjCfFormHead"><strong class="pjCfFormTitle">Inscription à la liste de diffusion</strong></div><!-- /.panel-heading pjCfFormHead --><div class="panel-body pjCfFormBody"><form action="" method="post" id="nsl_subscribe_form_6494" name="nsl-subscribe-form_6494" class="form-horizontal nsl-form" novalidate="true" data-toggle="validator" role="form" ><div class="form-group"><label class="col-sm-3 control-label">Sélectionnez une liste</label><div class="col-sm-9"><select name="group_id" class="form-control nsl-select required" lang="Merci de sélectionner une liste"><option value="">-- Sélection--</option><option value="17">Mailing pétition</option><option value="16">Membres effectifs et adhérents - Revolht asbl</option><option value="5">Revolht Ath</option><option value="3">Revolht Braine-le-Comte</option><option value="11">Revolht Brugelette</option><option value="15">Revolht Celles</option><option value="6">Revolht Chièvres</option><option value="7">Revolht Courcelles</option><option value="8">Revolht Ecaussinnes</option><option value="9">Revolht Frasnes-lez-Anvaing</option><option value="4">Revolht Lens</option><option value="12">Revolht Leuze-en-Hainaut</option><option value="13">Revolht Mont-de-l"Enclus</option><option value="14">Revolht Pont-A-Celles</option><option value="10">Revolht Seneffe</option><option value="1">Revolht Soignies</option></select></div></div><div id="nsl_form_field_6494"><div class="form-group"><label for="inputPasswordConfirm" class="col-sm-3 control-label">&nbsp;</label><div class="col-sm-9"><span>Sélectionnez la liste à laquelle vous souhaitez vous abonner</span></div></div></div></form></div></div></div></div><script type="text/javascript">var stivaObj_6494 = new stivaNSL({subscribe_form_name: "nsl-subscribe-form_6494",subscribe_form_subscribe_name: "nsl_subscribe_form_subscribe_6494",check_email_url: "https://revolht.be/apps/newsletter/index.php?controller=pjFront&action=pjActionCheckEmail",check_captcha_url: "https://revolht.be/apps/newsletter/index.php?controller=pjFront&action=pjActionCheckCaptcha",subscribe_url: "https://revolht.be/apps/newsletter/index.php?controller=pjFront&action=pjActionFormSave",load_field_url: "https://revolht.be/apps/newsletter/index.php?controller=pjFront&action=pjActionLoadField",load_captcha_url: "https://revolht.be/apps/newsletter/index.php?controller=pjFront&action=pjActionCaptcha&rand=",index: "6494",group_id: "",validate: {"200":"List is missing.","201":"Renseignez le code visuel (captcha) svp","202":"Captcha cannot be empty.","203":"Le code visuel (captcha) est incorrect","204":"Il manque votre pr\u00e9nom ","205":"First name cannot be empty.","206":"Il manque le nom de famille","207":"Last name cannot be empty.","208":"Email is missing.","209":"Email cannot be empty.","210":"Email is not valid.","211":"Phone is missing.","212":"Phone cannot be empty.","213":"Website is missing.","214":"Website cannot be empty.","215":"Gender is missing.","216":"Gender cannot be empty.","217":"Age is missing.","218":"Age cannot be empty.","219":"Day is missing.","220":"Day cannot be empty.","221":"Month is missing.","222":"Month cannot be empty.","223":"Address is missing.","224":"Address cannot be empty.","225":"City is missing.","226":"City cannot be empty.","227":"Country is missing.","228":"Country cannot be empty.","229":"Il manque votre code postal","230":"Zip cannot be empty.","231":"Company name is missing.","232":"Company name cannot be empty.","233":"Year is missing.","234":"Year cannot be empty.","235":"State is missing.","236":"State cannot be empty.","birthday_invalid":"Birthday is invalid.","captcha_incorrect":"Le code visuel (captcha) est incorrect","email_invalid":"Email address is invalid.","email_used":"Cette adresse email est d\u00e9j\u00e0 utilis\u00e9e"},validation: {error_email_invalid: "Email address is invalid.",error_email_used: "Cette adresse email est déjà utilisée",error_birthday_invalid: "Birthday is invalid.",error_captcha_incorrect: "Le code visuel (captcha) est incorrect"},message: {info: "Subscription form is processing...",success: "Votre abonnement a bien &eacute;t&eacute; enregistr&eacute;",error: "Subscription form was failed to save."}});</script>');