
<form action="/pay/form" method="post">

	<p>

		<label>* Firstname LASTNAME</label>

		<input type="text" name="contact" required />

	</p>

	<p>

		<label>Email</label>

		<input type="email" name="email" placeholder="adress@mail.com" />

	</p>

	<p>

		<label>Phone</label>

		<input type="tel" name="tel" placeholder="04--------" />

	</p>

	<p>

		<label>* Object</label>

		<input type="text" name="objet" required />

	</p>

	<p>

		<label>* Amount (€)</label>

		<input type="number" name="amount" min="10" placeholder="00000,00" step=".01" required />

	</p>
	<p>
		<input type="checkbox" name="case" required />

		<label>* No data will be saved by, and after you send this form. I accept the <a href="https://notaem.notaires.fr/politique-de-confidentialite/#formulaire/" target="blank">Confidentiality Policy</a> by clicking on Save transaction</label>

	</p>

	<input type="hidden" name="url_return" value="https://notaem.notaires.fr/en/online-payment/" />

	<p><input type="submit" value="Save transaction" /></p>



</form>

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