<form action="https://www.paypal.com/cgi-bin/webscr" method="post" target="_top">

<input type="hidden" name="cmd" value="_s-xclick">

<input type="hidden" name="hosted_button_id" value="5M8BMRU697WEU">

<table>

<tr><td><input type="hidden" name="on0" value="EDILIC Adhesion">EDILIC Adhesion</td></tr><tr><td><input type="text" name="os0" maxlength="200"></td></tr>

</table>

<input type="image" src="https://www.paypalobjects.com/fr_CA/i/btn/btn_buynowCC_LG.gif" border="0" name="submit" alt="PayPal - la solution de paiement en ligne la plus simple et la plus sécurisée !">

<img alt="" border="0" src="https://www.paypalobjects.com/fr_CA/i/scr/pixel.gif" width="1" height="1">

</form>