{literal} 
<script type="text/javascript">
    jQuery(document).ready(function(){
	    jQuery("#l{/literal}{$_module.idlinker}{literal}-form").validationEngine();
		//Anti-Robot
		jQuery("#testBot_d").val("imNotBot");
		jQuery.ajax({
		type: "GET",
		url: "modules/{/literal}{$_module.namemodule}{literal}/captcha/rand.php",
		})
		.done(function( text ) {
		  jQuery("#l{/literal}{$_module.idlinker}{literal}-txtCaptcha").val(text);
		  var newstr=text;
		   jQuery("#l{/literal}{$_module.idlinker}{literal}-imgCaptcha").attr("src", 'modules/{/literal}{$_module.namemodule}{literal}/captcha/image.php?str='+newstr);
		});	 

		jQuery("#l{/literal}{$_module.idlinker}{literal}-Captcha").click(function() {
		  jQuery.ajax({
		  type: "GET",
		  url: "modules/{/literal}{$_module.namemodule}{literal}/captcha/rand.php",
		  })
		  .done(function( text ) {
			  jQuery("#l{/literal}{$_module.idlinker}{literal}-txtCaptcha").val(text);
			  var newstr=text;
			   jQuery("#l{/literal}{$_module.idlinker}{literal}-imgCaptcha").attr("src", 'modules/{/literal}{$_module.namemodule}{literal}/captcha/image.php?str='+newstr);
		  });	 
		});
	});

</script> 
{/literal}

{if $_vars.result && $_vars.result=='sent'}
	<div class="res_success">
    	<p>{$_config.text_success}</p>
        {if !empty($_vars.sentjs)}{$_vars.sentjs}{/if}
    </div>
    
{elseif $_vars.result && $_vars.result=='notsent'}
	<div class="res_error">
        <p>{$_config.text_error}</p>
    </div>
    
{/if}
 
 {if !isset($_vars.result) || $_vars.result!='sent'}


<form method="post" action="" id="l{$_module.idlinker}-form" enctype="multipart/form-data">
<table width="100%">
    {if $_config.text_submit_wait}
    <tr>
      <td colspan="2"><h3>{$_config.text_submit_wait}</h3></td>
    </tr>
    {/if}
    <tr>
      <td valign="top" class="label"><label for="l{$_module.idlinker}-nom" id="la{$_module.idlinker}-nom">{$_config.field_nom} *</label></td>
      <td valign="top"><input type="text" name="lkr{$_module.idlinker}-nom" id="l{$_module.idlinker}-nom"  class="validate[required,minSize[3],maxSize[100]] text-input" /></td>
</tr>

    <tr>
      <td valign="top"><label for="l{$_module.idlinker}-prenom" id="la{$_module.idlinker}-prenom">{$_config.field_prenom}</label></td>
      <td valign="top"><input type="text" name="lkr{$_module.idlinker}-prenom" id="l{$_module.idlinker}-prenom" class="text-input" /></td>
    </tr>
    <tr>
      <td valign="top"><label for="l{$_module.idlinker}-adresse" id="la{$_module.idlinker}-adresse">{$_config.field_adresse}</label></td>
      <td valign="top"><input type="text" name="lkr{$_module.idlinker}-adresse" id="l{$_module.idlinker}-adresse" class="text-input" /></td>
    </tr>
    <tr>
      <td valign="top"><label for="l{$_module.idlinker}-cp" id="la{$_module.idlinker}-cp">{$_config.field_cp} </label></td>
      <td valign="top"><input type="text" name="lkr{$_module.idlinker}-cp" id="l{$_module.idlinker}-cp" class="validate[minSize[5],custom[number]] text-input" /></td>
    </tr>
    <tr>
      <td valign="top"><label for="l{$_module.idlinker}-ville" id="la{$_module.idlinker}-ville">{$_config.field_ville} </label></td>
      <td valign="top"><input type="text" name="lkr{$_module.idlinker}-ville" id="l{$_module.idlinker}-ville" class="text-input"/></td>
    </tr>
    <tr>
      <td valign="top"><label for="l{$_module.idlinker}-telephone" id="la{$_module.idlinker}-telephone">{$_config.field_tel}</label></td>
      <td valign="top"><input type="text" name="lkr{$_module.idlinker}-telephone" id="l{$_module.idlinker}-telephone" class="validate[custom[phone]] text-input" /></td>
    </tr>
    <tr>
      <td valign="top"><label for="l{$_module.idlinker}-email" id="la{$_module.idlinker}-email">{$_config.field_mail} *{if $_config.field_mail_info!=''}<br />
          <span class="info">{$_config.field_mail_info}</span>{/if}</label></td>
      <td valign="top"><input type="text" name="lkr{$_module.idlinker}-email" id="l{$_module.idlinker}-email" class="validate[required,custom[email]] text-input" /></td>
    </tr>
    {if $_config.besoin1!='' || $_config.besoin2!='' || $_config.besoin3!='' || $_config.besoin4!='' || $_config.besoin5!=''}
    <tr>
        <td height="235" valign="top">
        <label for="l{$_module.idlinker}-besoin" id="la{$_module.idlinker}-besoin">{$_config.field_besoin}</label>
        </td>       
         <td valign="top">
        {if $_config.besoin1!='' }<input type="checkbox" value="{$_config.besoin1}" name="lkr{$_module.idlinker}-besoin[]" class="validate[minCheckbox[1]] checkbox"/><label>{$_config.besoin1}</label><br />{/if}
        {if $_config.besoin2!='' }<input type="checkbox" value="{$_config.besoin2}" name="lkr{$_module.idlinker}-besoin[]" class="validate[minCheckbox[1]] checkbox"/><label>{$_config.besoin2}</label><br />{/if}
        {if $_config.besoin3!='' }<input type="checkbox" value="{$_config.besoin3}" name="lkr{$_module.idlinker}-besoin[]" class="validate[minCheckbox[1]] checkbox"/><label>{$_config.besoin3}</label><br />{/if}
        {if $_config.besoin4!='' }<input type="checkbox" value="{$_config.besoin4}" name="lkr{$_module.idlinker}-besoin[]" class="validate[minCheckbox[1]] checkbox"/><label>{$_config.besoin4}</label><br />{/if}
        {if $_config.besoin5!='' }<input type="checkbox" value="{$_config.besoin5}" name="lkr{$_module.idlinker}-besoin[]" class="validate[minCheckbox[1]] checkbox"/><label>{$_config.besoin5}</label><br />{/if}
        {if $_config.besoin6!='' }<input type="checkbox" value="{$_config.besoin6}" name="lkr{$_module.idlinker}-besoin[]" class="validate[minCheckbox[1]] checkbox"/><label>{$_config.besoin6}</label><br />{/if}
        {if $_config.besoin7!='' }<input type="checkbox" value="{$_config.besoin7}" name="lkr{$_module.idlinker}-besoin[]" class="validate[minCheckbox[1]] checkbox"/><label>{$_config.besoin7}</label><br />{/if}
        {if $_config.besoin8!='' }<input type="checkbox" value="{$_config.besoin8}" name="lkr{$_module.idlinker}-besoin[]" class="validate[minCheckbox[1]] checkbox"/><label>{$_config.besoin8}</label><br />{/if}
        {if $_config.besoin9!='' }<input type="checkbox" value="{$_config.besoin9}" name="lkr{$_module.idlinker}-besoin[]" class="validate[minCheckbox[1]] checkbox"/><label>{$_config.besoin9}</label><br />{/if}
        {if $_config.besoin10!='' }<input type="checkbox" value="{$_config.besoin10}" name="lkr{$_module.idlinker}-besoin[]" class="validate[minCheckbox[1]] checkbox"/><label>{$_config.besoin10}</label><br />{/if}
         
         </td>
    </tr>
{/if}
	
    <tr>
       <td valign="top">
       <label for="l{$_module.idlinker}-file" id="la{$_module.idlinker}-file">T&eacute;l&eacute;charger le scan de l'ordonnance </label></td>
       <td>
      	 <input id="file" type="file" name="file" class="validate[checkFileType[doc|docx|DOC|DOCX|xls|XLS|xlsx|XLSX|txt|TXT|pdf|jpg|jpeg|png|JPG|PDF|JPEG|PNG]]" />
	    </td>
    </tr>

    <tr>
      <td colspan="2"><label for="l{$_module.idlinker}-message" id="la{$_module.idlinker}-message">{$_config.field_message} *</label></td>
    </tr>
    <tr>
      <td colspan="2"><textarea name="lkr{$_module.idlinker}-message" id="l{$_module.idlinker}-message" class="validate[required,minSize[5],maxSize[500]] text-input"></textarea></td>
    </tr>

    <tr>
      <td valign="top"><label for="l{$_module.idlinker}-txtInput" id="la{$_module.idlinker}-txtInput">{$_config.field_control}{if $_config.field_control_info != ''}<br />
          <span class="info">{$_config.field_control_info}{/if}</span></label></td>
      <td valign="top">
      <img src="modules/{$_module.namemodule}/captcha/image.php" alt="Captcha" border="0" id="l{$_module.idlinker}-imgCaptcha"/> 
      <img src="modules/{$_module.namemodule}/captcha/reload.png" alt="Reload" border="0" id="l{$_module.idlinker}-Captcha" style="cursor:pointer; width:30px; margin-bottom:5px;"/>
      <input name="lkr{$_module.idlinker}-txtCaptcha" id="l{$_module.idlinker}-txtCaptcha" type="hidden" value="{php} echo $_SESSION['devis_Captcha']; {/php}" /><br />
      <input type="text" id="l{$_module.idlinker}-txtInput" class="validate[required,equals[l{$_module.idlinker}-txtCaptcha]] text-input" />
      <input type="hidden" name="adresse" value=""/>
	  <input type="hidden" id="testBot_d" name="botOrNotBo_d" value="imBot" />
      </td>
    </tr>
  </table>
  <br clear="all" />
  <br clear="all" />
  <div class="box_submit">
    <input type="submit" value="{$_config.text_submit}" class="submit" />
    <input type="hidden" name="lkr{$_module.idlinker}-action" value="submit_Devis" />
  </div>
  <span class="require">* {$_config.text_required}</span> 
</form>
{/if}