{"id":21221,"date":"2026-02-25T08:08:16","date_gmt":"2026-02-25T07:08:16","guid":{"rendered":"https:\/\/www.hck-mikronaehrstoffe.ch\/donnees-de-base\/"},"modified":"2026-03-09T13:34:05","modified_gmt":"2026-03-09T12:34:05","slug":"donnees-de-base","status":"publish","type":"page","link":"https:\/\/www.hck-mikronaehrstoffe.ch\/fr\/donnees-de-base\/","title":{"rendered":"Donn\u00e9es de base"},"content":{"rendered":"<section class=\"l-section wpb_row height_medium\"><div class=\"l-section-h i-cf\"><div class=\"g-cols vc_row via_grid cols_1-2-1 laptops-cols_inherit tablets-cols_inherit mobiles-cols_1 valign_top type_default stacking_default\"><div class=\"wpb_column vc_column_container\"><div class=\"vc_column-inner\"><\/div><\/div><div class=\"wpb_column vc_column_container\"><div class=\"vc_column-inner\"><div class=\"wpb_text_column\"><div class=\"wpb_wrapper\"><h5 style=\"text-align: center;\">Afin que nous puissions traiter votre inscription pour le nouveau FAS, veuillez remplir enti\u00e8rement le formulaire suivant.<\/h5>\n<\/div><\/div><div class=\"w-separator size_medium\"><\/div><div class=\"wpb_text_column\"><div class=\"wpb_wrapper\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-21610 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-21610\" data-uid=\"6ad2e1d28c26a\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-21610\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-21610 forminator-design--default  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"21610\"\n\t\t\t\tenctype=\"multipart\/form-data\" data-color-option=\"default\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"6ad2e1d28c26a\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_6ad2e1d28c26a\" id=\"forminator-field-name-2_6ad2e1d28c26a-label\" class=\"forminator-label\">Entreprise<\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"p. ex. Max Mustermann\" id=\"forminator-field-name-2_6ad2e1d28c26a\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-3\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-3_6ad2e1d28c26a\" id=\"forminator-field-name-3_6ad2e1d28c26a-label\" class=\"forminator-label\">Pr\u00e9nom<\/label><input type=\"text\" name=\"name-3\" value=\"\" placeholder=\"p. ex. Max Mustermann\" id=\"forminator-field-name-3_6ad2e1d28c26a\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_6ad2e1d28c26a\" id=\"forminator-field-name-1_6ad2e1d28c26a-label\" class=\"forminator-label\">Nom<\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"p. ex. Max Mustermann\" id=\"forminator-field-name-1_6ad2e1d28c26a\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-1-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-street_address_6ad2e1d28c26a\" id=\"forminator-field-address-1-street_address_6ad2e1d28c26a-label\" class=\"forminator-label\">Rue et num\u00e9ro<\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"p. ex. Rue Principale 123\" id=\"forminator-field-address-1-street_address_6ad2e1d28c26a\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-1-city\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-city_6ad2e1d28c26a\" id=\"forminator-field-address-1-city_6ad2e1d28c26a-label\" class=\"forminator-label\">Ville<\/label><input type=\"text\" name=\"address-1-city\" placeholder=\"p. ex. Berlin\" id=\"forminator-field-address-1-city_6ad2e1d28c26a\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-level2\" value=\"\" \/><\/div><\/div><div id=\"address-1-state\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-state_6ad2e1d28c26a\" id=\"forminator-field-address-1-state_6ad2e1d28c26a-label\" class=\"forminator-label\">Canton\/Province<\/label><input type=\"text\" name=\"address-1-state\" placeholder=\"p. ex. Bavi\u00e8re\" id=\"forminator-field-address-1-state_6ad2e1d28c26a\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-level1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-1-zip\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-zip_6ad2e1d28c26a\" id=\"forminator-field-address-1-zip_6ad2e1d28c26a-label\" class=\"forminator-label\">NPA \/ Code postal<\/label><input type=\"text\" name=\"address-1-zip\" placeholder=\"p. ex. 2000\" id=\"forminator-field-address-1-zip_6ad2e1d28c26a\" class=\"forminator-input\" autocomplete=\"postal-code\" value=\"\" \/><\/div><\/div><div id=\"address-1-country\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-21610__field--address-1-country_6ad2e1d28c26a\" id=\"forminator-field-21610__field--address-1-country_6ad2e1d28c26a-label\" class=\"forminator-label\">Pays<\/label><select name=\"address-1-country\" id=\"forminator-field-21610__field--address-1-country_6ad2e1d28c26a\" class=\"forminator-select2\" data-search=\"true\" data-placeholder=\"S\u00e9lectionner un pays\" autocomplete=\"country-name\" data-default-value=\"\"><option value=\"\" data-country-code=\"\" selected=\"selected\"><\/option><option value=\"Afghanistan\" data-country-code=\"AF\" >Afghanistan<\/option><option value=\"Afrique du Sud\" data-country-code=\"ZA\" >Afrique du Sud<\/option><option value=\"Albanie\" data-country-code=\"AL\" >Albanie<\/option><option value=\"Alg\u00e9rie\" data-country-code=\"DZ\" >Alg\u00e9rie<\/option><option value=\"Allemagne\" data-country-code=\"DE\" >Allemagne<\/option><option value=\"Andorre\" data-country-code=\"AD\" >Andorre<\/option><option value=\"Angola\" data-country-code=\"AO\" >Angola<\/option><option value=\"Anguilla\" data-country-code=\"AI\" >Anguilla<\/option><option value=\"Antarctique\" data-country-code=\"AQ\" >Antarctique<\/option><option value=\"Antigua &amp; Barbuda\" data-country-code=\"AG\" >Antigua &amp; Barbuda<\/option><option value=\"Arabie saoudite\" data-country-code=\"SA\" >Arabie saoudite<\/option><option value=\"Argentine\" data-country-code=\"AR\" >Argentine<\/option><option value=\"Arm\u00e9nie\" data-country-code=\"AM\" >Arm\u00e9nie<\/option><option value=\"Aruba\" data-country-code=\"AW\" >Aruba<\/option><option value=\"Ascension Island\" data-country-code=\"AC\" >Ascension Island<\/option><option value=\"Australie\" data-country-code=\"AU\" >Australie<\/option><option value=\"Autriche\" data-country-code=\"AT\" >Autriche<\/option><option value=\"Azerba\u00efdjan\" data-country-code=\"AZ\" >Azerba\u00efdjan<\/option><option value=\"Bahamas\" data-country-code=\"BS\" >Bahamas<\/option><option value=\"Bahre\u00efn\" data-country-code=\"BH\" >Bahre\u00efn<\/option><option value=\"Bangladesh\" data-country-code=\"BD\" >Bangladesh<\/option><option value=\"Barbade\" data-country-code=\"BB\" >Barbade<\/option><option value=\"Belgique\" data-country-code=\"BE\" >Belgique<\/option><option value=\"Bermudes\" data-country-code=\"BM\" >Bermudes<\/option><option value=\"Bhoutan\" data-country-code=\"BT\" >Bhoutan<\/option><option value=\"Bi\u00e9lorussie\" data-country-code=\"BY\" >Bi\u00e9lorussie<\/option><option value=\"Bolivie\" data-country-code=\"BO\" >Bolivie<\/option><option value=\"Bosnie-Herz\u00e9govine\" data-country-code=\"BA\" >Bosnie-Herz\u00e9govine<\/option><option value=\"Botswana\" data-country-code=\"BW\" >Botswana<\/option><option value=\"British Virgin Islands\" data-country-code=\"VG\" >British Virgin Islands<\/option><option value=\"Brunei\" data-country-code=\"BN\" >Brunei<\/option><option value=\"Br\u00e9sil\" data-country-code=\"BR\" >Br\u00e9sil<\/option><option value=\"Bulgarie\" data-country-code=\"BG\" >Bulgarie<\/option><option value=\"Burkina Faso\" data-country-code=\"BF\" >Burkina Faso<\/option><option value=\"Burundi\" data-country-code=\"BI\" >Burundi<\/option><option value=\"B\u00e9lize\" data-country-code=\"BZ\" >B\u00e9lize<\/option><option value=\"B\u00e9nin\" data-country-code=\"BJ\" >B\u00e9nin<\/option><option value=\"Cambodge\" data-country-code=\"KH\" >Cambodge<\/option><option value=\"Cameroun\" data-country-code=\"CM\" >Cameroun<\/option><option value=\"Canada\" data-country-code=\"CA\" >Canada<\/option><option value=\"Cap Vert\" data-country-code=\"CV\" >Cap Vert<\/option><option value=\"Caribbean Netherlands\" data-country-code=\"BQ\" >Caribbean Netherlands<\/option><option value=\"Chili\" data-country-code=\"CL\" >Chili<\/option><option value=\"China\" data-country-code=\"CN\" >China<\/option><option value=\"Chypre\" data-country-code=\"CY\" >Chypre<\/option><option value=\"Cit\u00e9 du Vatican\" data-country-code=\"VA\" >Cit\u00e9 du Vatican<\/option><option value=\"Colombie\" data-country-code=\"CO\" >Colombie<\/option><option value=\"Comores\" data-country-code=\"KM\" >Comores<\/option><option value=\"Congo, R\u00e9publique du\" data-country-code=\"CG\" >Congo, R\u00e9publique du<\/option><option value=\"Congo, R\u00e9publique d\u00e9mocratique du\" data-country-code=\"CD\" >Congo, R\u00e9publique d\u00e9mocratique du<\/option><option value=\"Costa Rica\" data-country-code=\"CR\" >Costa Rica<\/option><option value=\"Croatie\" data-country-code=\"HR\" >Croatie<\/option><option value=\"Cuba\" data-country-code=\"CU\" >Cuba<\/option><option value=\"Cura\u00e7ao\" data-country-code=\"CW\" >Cura\u00e7ao<\/option><option value=\"Czechia\" data-country-code=\"CZ\" >Czechia<\/option><option value=\"C\u00f4te d\u2019Ivoire\" data-country-code=\"CI\" >C\u00f4te d\u2019Ivoire<\/option><option value=\"Danemark\" data-country-code=\"DK\" >Danemark<\/option><option value=\"Djibouti\" data-country-code=\"DJ\" >Djibouti<\/option><option value=\"Dominique\" data-country-code=\"DM\" >Dominique<\/option><option value=\"Espagne\" data-country-code=\"ES\" >Espagne<\/option><option value=\"Estonie\" data-country-code=\"EE\" >Estonie<\/option><option value=\"Eswatini\" data-country-code=\"SZ\" >Eswatini<\/option><option value=\"Fidji\" data-country-code=\"FJ\" >Fidji<\/option><option value=\"Finlande\" data-country-code=\"FI\" >Finlande<\/option><option value=\"France\" data-country-code=\"FR\" >France<\/option><option value=\"Gabon\" data-country-code=\"GA\" >Gabon<\/option><option value=\"Gambie\" data-country-code=\"GM\" >Gambie<\/option><option value=\"Ghana\" data-country-code=\"GH\" >Ghana<\/option><option value=\"Gibraltar\" data-country-code=\"GI\" >Gibraltar<\/option><option value=\"Grenade\" data-country-code=\"GD\" >Grenade<\/option><option value=\"Groenland\" data-country-code=\"GL\" >Groenland<\/option><option value=\"Gr\u00e8ce\" data-country-code=\"GR\" >Gr\u00e8ce<\/option><option value=\"Guadeloupe\" data-country-code=\"GP\" >Guadeloupe<\/option><option value=\"Guam\" data-country-code=\"GU\" >Guam<\/option><option value=\"Guat\u00e9mala\" data-country-code=\"GT\" >Guat\u00e9mala<\/option><option value=\"Guernesey\" data-country-code=\"GG\" >Guernesey<\/option><option value=\"Guin\u00e9e\" data-country-code=\"GN\" >Guin\u00e9e<\/option><option value=\"Guin\u00e9e \u00e9quatoriale\" data-country-code=\"GQ\" >Guin\u00e9e \u00e9quatoriale<\/option><option value=\"Guin\u00e9e-Bissau\" data-country-code=\"GW\" >Guin\u00e9e-Bissau<\/option><option value=\"Guyana\" data-country-code=\"GY\" >Guyana<\/option><option value=\"Guyane fran\u00e7aise\" data-country-code=\"GF\" >Guyane fran\u00e7aise<\/option><option value=\"G\u00e9orgie\" data-country-code=\"GE\" >G\u00e9orgie<\/option><option value=\"G\u00e9orgie du Sud et Sandwich du Sud\" data-country-code=\"GS\" >G\u00e9orgie du Sud et Sandwich du Sud<\/option><option value=\"Ha\u00efti\" data-country-code=\"HT\" >Ha\u00efti<\/option><option value=\"Honduras\" data-country-code=\"HN\" >Honduras<\/option><option value=\"Hong Kong SAR China\" data-country-code=\"HK\" >Hong Kong SAR China<\/option><option value=\"Hongrie\" data-country-code=\"HU\" >Hongrie<\/option><option value=\"Inde\" data-country-code=\"IN\" >Inde<\/option><option value=\"Indon\u00e9sie\" data-country-code=\"ID\" >Indon\u00e9sie<\/option><option value=\"Iran\" data-country-code=\"IR\" >Iran<\/option><option value=\"Iraq\" data-country-code=\"IQ\" >Iraq<\/option><option value=\"Irlande\" data-country-code=\"IE\" >Irlande<\/option><option value=\"Islande\" data-country-code=\"IS\" >Islande<\/option><option value=\"Isle of Man\" data-country-code=\"IM\" >Isle of Man<\/option><option value=\"Isra\u00ebl\" data-country-code=\"IL\" >Isra\u00ebl<\/option><option value=\"Italie\" data-country-code=\"IT\" >Italie<\/option><option value=\"Jama\u00efque\" data-country-code=\"JM\" >Jama\u00efque<\/option><option value=\"Japon\" data-country-code=\"JP\" >Japon<\/option><option value=\"Jersey\" data-country-code=\"JE\" >Jersey<\/option><option value=\"Jordanie\" data-country-code=\"JO\" >Jordanie<\/option><option value=\"Kazakhstan\" data-country-code=\"KZ\" >Kazakhstan<\/option><option value=\"Kenya\" data-country-code=\"KE\" >Kenya<\/option><option value=\"Kirghizistan\" data-country-code=\"KG\" >Kirghizistan<\/option><option value=\"Kiribati\" data-country-code=\"KI\" >Kiribati<\/option><option value=\"Kosovo\" data-country-code=\"XK\" >Kosovo<\/option><option value=\"Kowe\u00eft\" data-country-code=\"KW\" >Kowe\u00eft<\/option><option value=\"Lesotho\" data-country-code=\"LS\" >Lesotho<\/option><option value=\"Lettonie\" data-country-code=\"LV\" >Lettonie<\/option><option value=\"Liban\" data-country-code=\"LB\" >Liban<\/option><option value=\"Libye\" data-country-code=\"LY\" >Libye<\/option><option value=\"Lib\u00e9ria\" data-country-code=\"LR\" >Lib\u00e9ria<\/option><option value=\"Liechtenstein\" data-country-code=\"LI\" >Liechtenstein<\/option><option value=\"Lituanie\" data-country-code=\"LT\" >Lituanie<\/option><option value=\"Luxembourg\" data-country-code=\"LU\" >Luxembourg<\/option><option value=\"Macao SAR China\" data-country-code=\"MO\" >Macao SAR China<\/option><option value=\"Mac\u00e9doine du Nord\" data-country-code=\"MK\" >Mac\u00e9doine du Nord<\/option><option value=\"Madagascar\" data-country-code=\"MG\" >Madagascar<\/option><option value=\"Malaisie\" data-country-code=\"MY\" >Malaisie<\/option><option value=\"Malawi\" data-country-code=\"MW\" >Malawi<\/option><option value=\"Maldives\" data-country-code=\"MV\" >Maldives<\/option><option value=\"Mali\" data-country-code=\"ML\" >Mali<\/option><option value=\"Malte\" data-country-code=\"MT\" >Malte<\/option><option value=\"Maroc\" data-country-code=\"MA\" >Maroc<\/option><option value=\"Martinique\" data-country-code=\"MQ\" >Martinique<\/option><option value=\"Mauritanie\" data-country-code=\"MR\" >Mauritanie<\/option><option value=\"Mayotte\" data-country-code=\"YT\" >Mayotte<\/option><option value=\"Mexique\" data-country-code=\"MX\" >Mexique<\/option><option value=\"Micron\u00e9sie\" data-country-code=\"FM\" >Micron\u00e9sie<\/option><option value=\"Moldavie\" data-country-code=\"MD\" >Moldavie<\/option><option value=\"Monaco\" data-country-code=\"MC\" >Monaco<\/option><option value=\"Mongolie\" data-country-code=\"MN\" >Mongolie<\/option><option value=\"Montserrat\" data-country-code=\"MS\" >Montserrat<\/option><option value=\"Mont\u00e9n\u00e9gro\" data-country-code=\"ME\" >Mont\u00e9n\u00e9gro<\/option><option value=\"Mozambique\" data-country-code=\"MZ\" >Mozambique<\/option><option value=\"Myanmar\" data-country-code=\"MM\" >Myanmar<\/option><option value=\"Namibie\" data-country-code=\"NA\" >Namibie<\/option><option value=\"Nauru\" data-country-code=\"NR\" >Nauru<\/option><option value=\"Nicaragua\" data-country-code=\"NI\" >Nicaragua<\/option><option value=\"Niger\" data-country-code=\"NE\" >Niger<\/option><option value=\"Nig\u00e9ria\" data-country-code=\"NG\" >Nig\u00e9ria<\/option><option value=\"Niu\u00e9\" data-country-code=\"NU\" >Niu\u00e9<\/option><option value=\"North Korea\" data-country-code=\"KP\" >North Korea<\/option><option value=\"Norv\u00e8ge\" data-country-code=\"NO\" >Norv\u00e8ge<\/option><option value=\"Nouvelle-Cal\u00e9donie\" data-country-code=\"NC\" >Nouvelle-Cal\u00e9donie<\/option><option value=\"Nouvelle-Z\u00e9lande\" data-country-code=\"NZ\" >Nouvelle-Z\u00e9lande<\/option><option value=\"N\u00e9pal\" data-country-code=\"NP\" >N\u00e9pal<\/option><option value=\"Oman\" data-country-code=\"OM\" >Oman<\/option><option value=\"Ouganda\" data-country-code=\"UG\" >Ouganda<\/option><option value=\"Ouzb\u00e9kistan\" data-country-code=\"UZ\" >Ouzb\u00e9kistan<\/option><option value=\"Pakistan\" data-country-code=\"PK\" >Pakistan<\/option><option value=\"Palaos\" data-country-code=\"PW\" >Palaos<\/option><option value=\"Palestinian Territories\" data-country-code=\"PS\" >Palestinian Territories<\/option><option value=\"Panama\" data-country-code=\"PA\" >Panama<\/option><option value=\"Papouasie-Nouvelle-Guin\u00e9e\" data-country-code=\"PG\" >Papouasie-Nouvelle-Guin\u00e9e<\/option><option value=\"Paraguay\" data-country-code=\"PY\" >Paraguay<\/option><option value=\"Pays-Bas\" data-country-code=\"NL\" >Pays-Bas<\/option><option value=\"Philippines\" data-country-code=\"PH\" >Philippines<\/option><option value=\"Pologne\" data-country-code=\"PL\" >Pologne<\/option><option value=\"Polyn\u00e9sie fran\u00e7aise\" data-country-code=\"PF\" >Polyn\u00e9sie fran\u00e7aise<\/option><option value=\"Porto Rico\" data-country-code=\"PR\" >Porto Rico<\/option><option value=\"Portugal\" data-country-code=\"PT\" >Portugal<\/option><option value=\"P\u00e9rou\" data-country-code=\"PE\" >P\u00e9rou<\/option><option value=\"Qatar\" data-country-code=\"QA\" >Qatar<\/option><option value=\"Roumanie\" data-country-code=\"RO\" >Roumanie<\/option><option value=\"Royaume-Uni\" data-country-code=\"GB\" >Royaume-Uni<\/option><option value=\"Russie\" data-country-code=\"RU\" >Russie<\/option><option value=\"Rwanda\" data-country-code=\"RW\" >Rwanda<\/option><option value=\"R\u00e9publique centrafricaine\" data-country-code=\"CF\" >R\u00e9publique centrafricaine<\/option><option value=\"R\u00e9publique dominicaine\" data-country-code=\"DO\" >R\u00e9publique dominicaine<\/option><option value=\"R\u00e9publique d\u00e9mocratique populaire du Laos\" data-country-code=\"LA\" >R\u00e9publique d\u00e9mocratique populaire du Laos<\/option><option value=\"R\u00e9union\" data-country-code=\"RE\" >R\u00e9union<\/option><option value=\"Sahara occidental\" data-country-code=\"EH\" >Sahara occidental<\/option><option value=\"Saint-Kitts-et-Nevis\" data-country-code=\"KN\" >Saint-Kitts-et-Nevis<\/option><option value=\"Saint-Marin\" data-country-code=\"SM\" >Saint-Marin<\/option><option value=\"Saint-Martin (royaume des Pays-Bas)\" data-country-code=\"SX\" >Saint-Martin (royaume des Pays-Bas)<\/option><option value=\"Saint-Vincent-et-les-Grenadines\" data-country-code=\"VC\" >Saint-Vincent-et-les-Grenadines<\/option><option value=\"Sainte-H\u00e9l\u00e8ne\" data-country-code=\"SH\" >Sainte-H\u00e9l\u00e8ne<\/option><option value=\"Sainte-Lucie\" data-country-code=\"LC\" >Sainte-Lucie<\/option><option value=\"Salvador\" data-country-code=\"SV\" >Salvador<\/option><option value=\"Samoa\" data-country-code=\"WS\" >Samoa<\/option><option value=\"Samoa am\u00e9ricaines\" data-country-code=\"AS\" >Samoa am\u00e9ricaines<\/option><option value=\"Serbie\" data-country-code=\"RS\" >Serbie<\/option><option value=\"Seychelles\" data-country-code=\"SC\" >Seychelles<\/option><option value=\"Sierra Leone\" data-country-code=\"SL\" >Sierra Leone<\/option><option value=\"Singapour\" data-country-code=\"SG\" >Singapour<\/option><option value=\"Slovaquie\" data-country-code=\"SK\" >Slovaquie<\/option><option value=\"Slov\u00e9nie\" data-country-code=\"SI\" >Slov\u00e9nie<\/option><option value=\"Somalie\" data-country-code=\"SO\" >Somalie<\/option><option value=\"Soudan\" data-country-code=\"SD\" >Soudan<\/option><option value=\"South Korea\" data-country-code=\"KR\" >South Korea<\/option><option value=\"South Sudan\" data-country-code=\"SS\" >South Sudan<\/option><option value=\"Sri Lanka\" data-country-code=\"LK\" >Sri Lanka<\/option><option value=\"St. Barth\u00e9lemy\" data-country-code=\"BL\" >St. Barth\u00e9lemy<\/option><option value=\"St. Martin\" data-country-code=\"MF\" >St. Martin<\/option><option value=\"St. Pierre &amp; Miquelon\" data-country-code=\"PM\" >St. Pierre &amp; Miquelon<\/option><option value=\"Suisse\" data-country-code=\"CH\" >Suisse<\/option><option value=\"Suriname\" data-country-code=\"SR\" >Suriname<\/option><option value=\"Su\u00e8de\" data-country-code=\"SE\" >Su\u00e8de<\/option><option value=\"Svalbard et Jan Mayen\" data-country-code=\"SJ\" >Svalbard et Jan Mayen<\/option><option value=\"Syrie\" data-country-code=\"SY\" >Syrie<\/option><option value=\"S\u00e3o Tom\u00e9 &amp; Pr\u00edncipe\" data-country-code=\"ST\" >S\u00e3o Tom\u00e9 &amp; Pr\u00edncipe<\/option><option value=\"S\u00e9n\u00e9gal\" data-country-code=\"SN\" >S\u00e9n\u00e9gal<\/option><option value=\"Tadjikistan\" data-country-code=\"TJ\" >Tadjikistan<\/option><option value=\"Taiwan\" data-country-code=\"TW\" >Taiwan<\/option><option value=\"Tanzanie\" data-country-code=\"TZ\" >Tanzanie<\/option><option value=\"Tchad\" data-country-code=\"TD\" >Tchad<\/option><option value=\"Terres australes et antarctiques fran\u00e7aises\" data-country-code=\"TF\" >Terres australes et antarctiques fran\u00e7aises<\/option><option value=\"Territoire britannique de l\u2019oc\u00e9an Indien\" data-country-code=\"IO\" >Territoire britannique de l\u2019oc\u00e9an Indien<\/option><option value=\"Tha\u00eflande\" data-country-code=\"TH\" >Tha\u00eflande<\/option><option value=\"Timor-Leste\" data-country-code=\"TL\" >Timor-Leste<\/option><option value=\"Togo\" data-country-code=\"TG\" >Togo<\/option><option value=\"Tokelau\" data-country-code=\"TK\" >Tokelau<\/option><option value=\"Tonga\" data-country-code=\"TO\" >Tonga<\/option><option value=\"Trinidad &amp; Tobago\" data-country-code=\"TT\" >Trinidad &amp; Tobago<\/option><option value=\"Tunisie\" data-country-code=\"TN\" >Tunisie<\/option><option value=\"Turkm\u00e9nistan\" data-country-code=\"TM\" >Turkm\u00e9nistan<\/option><option value=\"Turks &amp; Caicos Islands\" data-country-code=\"TC\" >Turks &amp; Caicos Islands<\/option><option value=\"Turquie\" data-country-code=\"TR\" >Turquie<\/option><option value=\"Tuvalu\" data-country-code=\"TV\" >Tuvalu<\/option><option value=\"U.S. Virgin Islands\" data-country-code=\"VI\" >U.S. Virgin Islands<\/option><option value=\"Ukraine\" data-country-code=\"UA\" >Ukraine<\/option><option value=\"Uruguay\" data-country-code=\"UY\" >Uruguay<\/option><option value=\"Vanuatu\" data-country-code=\"VU\" >Vanuatu<\/option><option value=\"Vietnam\" data-country-code=\"VN\" >Vietnam<\/option><option value=\"V\u00e9n\u00e9zu\u00e9la\" data-country-code=\"VE\" >V\u00e9n\u00e9zu\u00e9la<\/option><option value=\"Yemen\" data-country-code=\"YE\" >Yemen<\/option><option value=\"Zambie\" data-country-code=\"ZM\" >Zambie<\/option><option value=\"Zimbabwe\" data-country-code=\"ZW\" >Zimbabwe<\/option><option value=\"\u00c9gypte\" data-country-code=\"EG\" >\u00c9gypte<\/option><option value=\"\u00c9mirats arabes unis\" data-country-code=\"AE\" >\u00c9mirats arabes unis<\/option><option value=\"\u00c9quateur\" data-country-code=\"EC\" >\u00c9quateur<\/option><option value=\"\u00c9rythr\u00e9e\" data-country-code=\"ER\" >\u00c9rythr\u00e9e<\/option><option value=\"\u00c9tats-Unis d\u2019Am\u00e9rique (USA)\" data-country-code=\"US\" >\u00c9tats-Unis d\u2019Am\u00e9rique (USA)<\/option><option value=\"\u00c9thiopie\" data-country-code=\"ET\" >\u00c9thiopie<\/option><option value=\"\u00cele Bouvet\" data-country-code=\"BV\" >\u00cele Bouvet<\/option><option value=\"\u00cele Christmas\" data-country-code=\"CX\" >\u00cele Christmas<\/option><option value=\"\u00cele Heard et \u00eele Mcdonald\" data-country-code=\"HM\" >\u00cele Heard et \u00eele Mcdonald<\/option><option value=\"\u00cele Maurice\" data-country-code=\"MU\" >\u00cele Maurice<\/option><option value=\"\u00cele Norfolk\" data-country-code=\"NF\" >\u00cele Norfolk<\/option><option value=\"\u00celes Ca\u00efmans\" data-country-code=\"KY\" >\u00celes Ca\u00efmans<\/option><option value=\"\u00celes Cocos\" data-country-code=\"CC\" >\u00celes Cocos<\/option><option value=\"\u00celes Cook\" data-country-code=\"CK\" >\u00celes Cook<\/option><option value=\"\u00celes Falkland\" data-country-code=\"FK\" >\u00celes Falkland<\/option><option value=\"\u00celes F\u00e9ro\u00e9\" data-country-code=\"FO\" >\u00celes F\u00e9ro\u00e9<\/option><option value=\"\u00celes Mariannes du Nord\" data-country-code=\"MP\" >\u00celes Mariannes du Nord<\/option><option value=\"\u00celes Marshall\" data-country-code=\"MH\" >\u00celes Marshall<\/option><option value=\"\u00celes Pitcairn\" data-country-code=\"PN\" >\u00celes Pitcairn<\/option><option value=\"\u00celes Salomon\" data-country-code=\"SB\" >\u00celes Salomon<\/option><option value=\"\u00celes Wallis et Futuna\" data-country-code=\"WF\" >\u00celes Wallis et Futuna<\/option><option value=\"\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis\" data-country-code=\"UM\" >\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis<\/option><\/select><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_6ad2e1d28c26a\" id=\"forminator-field-email-1_6ad2e1d28c26a-label\" class=\"forminator-label\">Adresse e-mail<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"p. ex. max@mustermann.de\" id=\"forminator-field-email-1_6ad2e1d28c26a\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_6ad2e1d28c26a\" id=\"forminator-field-phone-1_6ad2e1d28c26a-label\" class=\"forminator-label\">T\u00e9l\u00e9phone<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"p. ex. : +49 123 4567 89\" id=\"forminator-field-phone-1_6ad2e1d28c26a\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-1-6ad2e1d28c26a-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-1-6ad2e1d28c26a-label\" class=\"forminator-label\">Comment avez-vous entendu parler de nous ?<\/span><label id=\"forminator-field-checkbox-1-1-6ad2e1d28c26a-label\" for=\"forminator-field-checkbox-1-1-6ad2e1d28c26a\" class=\"forminator-checkbox\" title=\"Annonce\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"one\" id=\"forminator-field-checkbox-1-1-6ad2e1d28c26a\" aria-labelledby=\"forminator-field-checkbox-1-1-6ad2e1d28c26a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Annonce<\/span><\/label><label id=\"forminator-field-checkbox-1-2-6ad2e1d28c26a-label\" for=\"forminator-field-checkbox-1-2-6ad2e1d28c26a\" class=\"forminator-checkbox\" title=\"Internet\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"two\" id=\"forminator-field-checkbox-1-2-6ad2e1d28c26a\" aria-labelledby=\"forminator-field-checkbox-1-2-6ad2e1d28c26a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Internet<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_6ad2e1d28c26a\" id=\"forminator-field-text-1_6ad2e1d28c26a-label\" class=\"forminator-label\">Recommand\u00e9 par \/ Autre :<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"p. ex. texte d\u2019exemple\" id=\"forminator-field-text-1_6ad2e1d28c26a\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-2\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-2-6ad2e1d28c26a-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-2-6ad2e1d28c26a-label\" class=\"forminator-label\">Secteur<\/span><label id=\"forminator-field-checkbox-2-1-6ad2e1d28c26a-label\" for=\"forminator-field-checkbox-2-1-6ad2e1d28c26a\" class=\"forminator-checkbox\" title=\"(10) M\u00e9decin, dentiste avec autorisation professionnelle \/ d\u2019exercer, y compris autorisation de remise directe SD (CH uniquement)\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"one\" id=\"forminator-field-checkbox-2-1-6ad2e1d28c26a\" aria-labelledby=\"forminator-field-checkbox-2-1-6ad2e1d28c26a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">(10) M\u00e9decin, dentiste avec autorisation professionnelle \/ d\u2019exercer, y compris autorisation de remise directe SD (CH uniquement)<\/span><\/label><label id=\"forminator-field-checkbox-2-2-6ad2e1d28c26a-label\" for=\"forminator-field-checkbox-2-2-6ad2e1d28c26a\" class=\"forminator-checkbox\" title=\"(20) M\u00e9decin, dentiste, chiropraticien avec autorisation professionnelle \/ d\u2019exercer\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"two\" id=\"forminator-field-checkbox-2-2-6ad2e1d28c26a\" aria-labelledby=\"forminator-field-checkbox-2-2-6ad2e1d28c26a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">(20) M\u00e9decin, dentiste, chiropraticien avec autorisation professionnelle \/ d\u2019exercer<\/span><\/label><label id=\"forminator-field-checkbox-2-3-6ad2e1d28c26a-label\" for=\"forminator-field-checkbox-2-3-6ad2e1d28c26a\" class=\"forminator-checkbox\" title=\"(30) Professionnels de sant\u00e9 tels que naturopathes, naturopathes dipl\u00f4m\u00e9s, conseillers en nutrition, coachs sant\u00e9, m\u00e9decins en m\u00e9decine naturelle, praticiens en sant\u00e9 naturelle\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Sonstiges\" id=\"forminator-field-checkbox-2-3-6ad2e1d28c26a\" aria-labelledby=\"forminator-field-checkbox-2-3-6ad2e1d28c26a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">(30) Professionnels de sant\u00e9 tels que naturopathes, naturopathes dipl\u00f4m\u00e9s, conseillers en nutrition, coachs sant\u00e9, m\u00e9decins en m\u00e9decine naturelle, praticiens en sant\u00e9 naturelle<\/span><\/label><label id=\"forminator-field-checkbox-2-4-6ad2e1d28c26a-label\" for=\"forminator-field-checkbox-2-4-6ad2e1d28c26a\" class=\"forminator-checkbox\" title=\"(40) Pharmacie avec autorisation de commerce de d\u00e9tail pour la pharmacie (CH) resp. autorisation d\u2019exploitation de pharmacie (DE\/UE)\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"(40)-Apotheke-mit-Detailhandelsbewilligung-f\u00fcr-die-Apotheke-(CH)-resp.-Apothekenbetriebserlaubnis-(DE-EU)\" id=\"forminator-field-checkbox-2-4-6ad2e1d28c26a\" aria-labelledby=\"forminator-field-checkbox-2-4-6ad2e1d28c26a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">(40) Pharmacie avec autorisation de commerce de d\u00e9tail pour la pharmacie (CH) resp. autorisation d\u2019exploitation de pharmacie (DE\/UE)<\/span><\/label><label id=\"forminator-field-checkbox-2-5-6ad2e1d28c26a-label\" for=\"forminator-field-checkbox-2-5-6ad2e1d28c26a\" class=\"forminator-checkbox\" title=\"(50) Droguerie avec autorisation d\u2019exploitation (CH uniquement)\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"(50)-Drogerie-mit-Betriebsbewilligung-(nur-CH)\" id=\"forminator-field-checkbox-2-5-6ad2e1d28c26a\" aria-labelledby=\"forminator-field-checkbox-2-5-6ad2e1d28c26a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">(50) Droguerie avec autorisation d\u2019exploitation (CH uniquement)<\/span><\/label><label id=\"forminator-field-checkbox-2-6-6ad2e1d28c26a-label\" for=\"forminator-field-checkbox-2-6-6ad2e1d28c26a\" class=\"forminator-checkbox\" title=\"(60) Entreprise pharmaceutique avec autorisation de fabrication \/ de commerce de m\u00e9dicaments (toutes cat\u00e9gories)\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"(60)-Pharmaunternehmen-mit-Herstell---Handelsbewilligung-f\u00fcr-Arzneimittel-(alle-Kategorien)\" id=\"forminator-field-checkbox-2-6-6ad2e1d28c26a\" aria-labelledby=\"forminator-field-checkbox-2-6-6ad2e1d28c26a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">(60) Entreprise pharmaceutique avec autorisation de fabrication \/ de commerce de m\u00e9dicaments (toutes cat\u00e9gories)<\/span><\/label><label id=\"forminator-field-checkbox-2-7-6ad2e1d28c26a-label\" for=\"forminator-field-checkbox-2-7-6ad2e1d28c26a\" class=\"forminator-checkbox\" title=\"(70) Autre commerce sans m\u00e9dicaments, p. ex. commerce alimentaire \u2013 aucune autorisation requise\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"(70)-Sonstiger-Handel-ohne-Arzneimittel,-z.B.-Lebensmittelhandel-\u2013-keine-Bewilligung-erforderlich\" id=\"forminator-field-checkbox-2-7-6ad2e1d28c26a\" aria-labelledby=\"forminator-field-checkbox-2-7-6ad2e1d28c26a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">(70) Autre commerce sans m\u00e9dicaments, p. ex. commerce alimentaire \u2013 aucune autorisation requise<\/span><\/label><label id=\"forminator-field-checkbox-2-8-6ad2e1d28c26a-label\" for=\"forminator-field-checkbox-2-8-6ad2e1d28c26a\" class=\"forminator-checkbox\" title=\"(90) Client commercial Paramediform \u2013 aucune autorisation requise\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"(90)-Paramediform-Gesch\u00e4ftskunde-\u2013-keine-Bewilligung-erforderlich\" id=\"forminator-field-checkbox-2-8-6ad2e1d28c26a\" aria-labelledby=\"forminator-field-checkbox-2-8-6ad2e1d28c26a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">(90) Client commercial Paramediform \u2013 aucune autorisation requise<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-3\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-3-6ad2e1d28c26a-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-3-6ad2e1d28c26a-label\" class=\"forminator-label\">Publication sur les sites web de Hepart AG (Hepart &amp; HCK). En tant que revendeur, je d\u00e9clare accepter d\u2019\u00eatre publiquement visible sur la page d\u2019accueil de Hepart AG dans le moteur de recherche par code postal en tant que partenaire de distribution et membre du r\u00e9seau Hepart.<\/span><label id=\"forminator-field-checkbox-3-1-6ad2e1d28c26a-label\" for=\"forminator-field-checkbox-3-1-6ad2e1d28c26a\" class=\"forminator-checkbox\" title=\"Oui\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"one\" id=\"forminator-field-checkbox-3-1-6ad2e1d28c26a\" aria-labelledby=\"forminator-field-checkbox-3-1-6ad2e1d28c26a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Oui<\/span><\/label><label id=\"forminator-field-checkbox-3-2-6ad2e1d28c26a-label\" for=\"forminator-field-checkbox-3-2-6ad2e1d28c26a\" class=\"forminator-checkbox\" title=\"Non\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"two\" id=\"forminator-field-checkbox-3-2-6ad2e1d28c26a\" aria-labelledby=\"forminator-field-checkbox-3-2-6ad2e1d28c26a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Non<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-4\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-4-6ad2e1d28c26a-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-4-6ad2e1d28c26a-label\" class=\"forminator-label\">Je souhaite appara\u00eetre dans les domaines suivants :<\/span><label id=\"forminator-field-checkbox-4-1-6ad2e1d28c26a-label\" for=\"forminator-field-checkbox-4-1-6ad2e1d28c26a\" class=\"forminator-checkbox\" title=\"HCK\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"one\" id=\"forminator-field-checkbox-4-1-6ad2e1d28c26a\" aria-labelledby=\"forminator-field-checkbox-4-1-6ad2e1d28c26a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">HCK<\/span><\/label><label id=\"forminator-field-checkbox-4-2-6ad2e1d28c26a-label\" for=\"forminator-field-checkbox-4-2-6ad2e1d28c26a\" class=\"forminator-checkbox\" title=\"IABC\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"two\" id=\"forminator-field-checkbox-4-2-6ad2e1d28c26a\" aria-labelledby=\"forminator-field-checkbox-4-2-6ad2e1d28c26a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">IABC<\/span><\/label><label id=\"forminator-field-checkbox-4-3-6ad2e1d28c26a-label\" for=\"forminator-field-checkbox-4-3-6ad2e1d28c26a\" class=\"forminator-checkbox\" title=\"Provisan\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Provisan\" id=\"forminator-field-checkbox-4-3-6ad2e1d28c26a\" aria-labelledby=\"forminator-field-checkbox-4-3-6ad2e1d28c26a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Provisan<\/span><\/label><label id=\"forminator-field-checkbox-4-4-6ad2e1d28c26a-label\" for=\"forminator-field-checkbox-4-4-6ad2e1d28c26a\" class=\"forminator-checkbox\" title=\"HRV\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"HRV\" id=\"forminator-field-checkbox-4-4-6ad2e1d28c26a\" aria-labelledby=\"forminator-field-checkbox-4-4-6ad2e1d28c26a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">HRV<\/span><\/label><label id=\"forminator-field-checkbox-4-5-6ad2e1d28c26a-label\" for=\"forminator-field-checkbox-4-5-6ad2e1d28c26a\" class=\"forminator-checkbox\" title=\"EPD\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"EPD\" id=\"forminator-field-checkbox-4-5-6ad2e1d28c26a\" aria-labelledby=\"forminator-field-checkbox-4-5-6ad2e1d28c26a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">EPD<\/span><\/label><label id=\"forminator-field-checkbox-4-6-6ad2e1d28c26a-label\" for=\"forminator-field-checkbox-4-6-6ad2e1d28c26a\" class=\"forminator-checkbox\" title=\"Medical Wellness Coach\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Medical-Wellness-Coach\" id=\"forminator-field-checkbox-4-6-6ad2e1d28c26a\" aria-labelledby=\"forminator-field-checkbox-4-6-6ad2e1d28c26a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Medical Wellness Coach<\/span><\/label><label id=\"forminator-field-checkbox-4-7-6ad2e1d28c26a-label\" for=\"forminator-field-checkbox-4-7-6ad2e1d28c26a\" class=\"forminator-checkbox\" title=\"ColonConcept\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"ColonConcept\" id=\"forminator-field-checkbox-4-7-6ad2e1d28c26a\" aria-labelledby=\"forminator-field-checkbox-4-7-6ad2e1d28c26a-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">ColonConcept<\/span><\/label><label id=\"forminator-field-checkbox-4-8-6ad2e1d28c26a-label\" for=\"forminator-field-checkbox-4-8-6ad2e1d28c26a\" class=\"forminator-checkbox\" title=\"ColorBox12\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"ColorBox12\" id=\"forminator-field-checkbox-4-8-6ad2e1d28c26a\" aria-labelledby=\"forminator-field-checkbox-4-8-6ad2e1d28c26a-label\" 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tabindex=\"-1\"><button id=\"forminator-field-upload-1_6ad2e1d28c26a_button\" class=\"forminator-button forminator-button-upload\" data-id=\"forminator-field-upload-1_6ad2e1d28c26a\">Choisissez un fichier<\/button><span data-empty-text=\"Aucun fichier s\u00e9lectionn\u00e9\">Aucun fichier s\u00e9lectionn\u00e9<\/span><button class=\"forminator-button-delete\" style=\"display: none;\"><i class=\"forminator-icon-close\" aria-hidden=\"true\"><\/i><span class=\"forminator-screen-reader-only\">Supprimer le fichier t\u00e9l\u00e9vers\u00e9<\/span><\/button><\/div><span id=\"forminator-field-upload-1_6ad2e1d28c26a-description\" class=\"forminator-description\">Nous vous prions de t\u00e9l\u00e9charger avec ce formulaire une copie de votre autorisation (d\u2019exercice, de commerce, d\u2019exploitation, de fabrication, etc.).<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-5\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" 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