{"id":606,"date":"2024-01-14T13:47:07","date_gmt":"2024-01-14T12:47:07","guid":{"rendered":"https:\/\/www.francecoag.org\/registration-request\/"},"modified":"2025-03-07T16:31:38","modified_gmt":"2025-03-07T15:31:38","slug":"registration-request","status":"publish","type":"page","link":"https:\/\/www.francecoag.org\/en\/space-pro\/registration-request\/","title":{"rendered":"Sign up"},"content":{"rendered":"\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f927-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"927\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/606#wpcf7-f927-o1\" method=\"post\" class=\"wpcf7-form init cf7mls-no-scroll cf7mls-no-moving-animation\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"927\" \/><input type=\"hidden\" 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\/>\n<\/fieldset>\n<p>*these fields are required\n<\/p>\n<p><label> Name*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" autocomplete=\"name\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span><br \/>\n<\/label>\n<\/p>\n<p><label> First name*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-surname\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" autocomplete=\"name\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-surname\" \/><\/span><br \/>\n<\/label>\n<\/p>\n<p><label>Professional email*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" autocomplete=\"email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span><br \/>\n<\/label>\n<\/p>\n<p><label>Mobile phone<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-telport\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"your-telport\" \/><\/span><br \/>\n<\/label>\n<\/p>\n<p><label> Institution*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"menu-institution\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"menu-institution\"><option value=\"\"><\/option><option value=\"Publique\">Publique<\/option><option value=\"Priv\u00e9e\">Priv\u00e9e<\/option><\/select><\/span><br \/>\n<\/label>\n<\/p>\n<div data-id=\"group-institution-publique\" data-orig_data_id=\"group-institution-publique\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t<p><label>Establishment name*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-nom-etablissement-publique\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-nom-etablissement-publique\" \/><\/span><br \/>\n<\/label>\n\t<\/p>\n\t<p><label>Establishment department*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-service-etablissement-publique\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-service-etablissement-publique\" \/><\/span><br \/>\n<\/label>\n\t<\/p>\n\t<p><label>Fonction*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"fonction-publique\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"fonction-publique\"><option value=\"\"><\/option><option value=\"Clinicien\">Clinicien<\/option><option value=\"Participant hors clinicien\">Participant hors clinicien<\/option><\/select><\/span><br \/>\n<\/label>\n\t<\/p>\n\t<p><label>CPE\/CPS card number*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"numero-carte-cpe-cps\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"numero-carte-cpe-cps\" \/><\/span><br \/>\n<\/label>\n\t<\/p>\n<\/div>\n<div data-id=\"group-institution-prive\" data-orig_data_id=\"group-institution-prive\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t<p><label>Type of institution*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"menu-institution-prive\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"menu-institution-prive\"><option value=\"\"><\/option><option value=\"Entreprise\">Entreprise<\/option><option value=\"Association\">Association<\/option><\/select><\/span><br \/>\n<\/label>\n\t<\/p>\n\t<div data-id=\"group-entreprise\" data-orig_data_id=\"group-entreprise\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<p><label>Company name*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-nom-entreprise\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-nom-entreprise\" \/><\/span><br \/>\n<\/label>\n\t\t<\/p>\n\t\t<p><label>Siren identifier*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-numero-siren-prive\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-numero-siren-prive\" \/><\/span><br \/>\n<\/label>\n\t\t<\/p>\n\t\t<p><label>Fonction*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-fonction-prive\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-fonction-prive\" \/><\/span><br \/>\n<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div data-id=\"group-association\" data-orig_data_id=\"group-association\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<p><label>Name of association*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-nom-association\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-nom-association\" \/><\/span><br \/>\n<\/label>\n\t\t<\/p>\n\t\t<p><label>RNA number*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-numero-rna-association\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-numero-rna-association\" \/><\/span><br \/>\n<\/label>\n\t\t<\/p>\n\t\t<p><label>Fonction*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-fonction-association\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-fonction-association\" \/><\/span><br \/>\n<\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<p><div id=\"cf7sr-69f1d9222f4ed\" class=\"cf7sr-g-hcaptcha\" data-theme=\"light\" data-size=\"normal\" data-sitekey=\"2c929026-ad14-42d8-b222-52eae9428c84\"><\/div><span class=\"wpcf7-form-control-wrap cf7sr-hcaptcha\" data-name=\"cf7sr-hcaptcha\"><input type=\"hidden\" name=\"cf7sr-hcaptcha\" value=\"\" class=\"wpcf7-form-control\"><\/span>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Send\" \/>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":593,"menu_order":44,"comment_status":"closed","ping_status":"closed","template":"page-sidebar.php","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-606","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.5 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Sign up - FranceCoag<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" 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