<!--<!-- [et_pb_line_break_holder] -->Do not modify the NAME value of any of the INPUT fields<!-- [et_pb_line_break_holder] -->the FORM action, or any of the hidden fields (eg. input type=hidden).<!-- [et_pb_line_break_holder] -->These are all required for this form to function correctly.<!-- [et_pb_line_break_holder] -->--><!-- [et_pb_line_break_holder] --><span style="color: #ffffff; font-family: inherit;"><!-- [et_pb_line_break_holder] --><meta http-equiv="Content-Type" content="text/html; charset=UTF-8"><meta charset="UTF-8"><meta name="viewport" content="width=device-width"><link rel="shortcut icon" href="favicon.ico" type="image/vnd.microsoft.icon"/><link rel="icon" href="favicon.ico" type="image/vnd.microsoft.icon"/><script src="https://www.google.com/recaptcha/api.js"></script><!-- [et_pb_line_break_holder] --><style type="text/css"><!-- [et_pb_line_break_holder] --> @media only screen and (max-width:640px) {<!-- [et_pb_line_break_holder] --> .iconneqt-form2 table {<!-- [et_pb_line_break_holder] --> margin:0 auto;<!-- [et_pb_line_break_holder] --> display:table !important;<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> .iconneqt-form2 tr {<!-- [et_pb_line_break_holder] --> padding-bottom:5px;<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> .iconneqt-form2 td {<!-- [et_pb_line_break_holder] --> display:block;<!-- [et_pb_line_break_holder] --> clear:both;<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> .iconneqt-form2 table tr td:last-child {<!-- [et_pb_line_break_holder] --> padding-bottom:20px;<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --></style><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><form method="post" action="https://crm01.iconneqt.nl/form.php?form=677" accept-charset="UTF-8" id="frmSS677" class="iconneqt-form2" onsubmit="return CheckForm677(this);" enctype="multipart/form-data"><!-- [et_pb_line_break_holder] --> <table border="0"><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td>Emailadres:<span class="required">*</span> <!-- [et_pb_line_break_holder] --></td><!-- [et_pb_line_break_holder] --> <td><input type="text" name="email" value=""/></td><!-- [et_pb_line_break_holder] --></tr><tr><!-- [et_pb_line_break_holder] --> <td>Organisatienaam:<span class="required">*</span> <!-- [et_pb_line_break_holder] --></td><!-- [et_pb_line_break_holder] --> <td><input required="required" type="text" name="CustomFields[1503]" id="CustomFields_1503_677" value="" size='20'/></td><!-- [et_pb_line_break_holder] --></tr><tr><!-- [et_pb_line_break_holder] --> <td>Voornaam:<span class="required">*</span> <!-- [et_pb_line_break_holder] --></td><!-- [et_pb_line_break_holder] --> <td><input required="required" type="text" name="CustomFields[1492]" id="CustomFields_1492_677" value=""/></td><!-- [et_pb_line_break_holder] --></tr><tr><!-- [et_pb_line_break_holder] --> <td>Achternaam:<span class="required">*</span> <!-- [et_pb_line_break_holder] --></td><!-- [et_pb_line_break_holder] --> <td><input required="required" type="text" name="CustomFields[1493]" id="CustomFields_1493_677" value="" size='20'/></td><!-- [et_pb_line_break_holder] --></tr><input type="hidden" name="format" value="h" /><tr><!-- [et_pb_line_break_holder] --> <td></td><!-- [et_pb_line_break_holder] --> <td><div class="recaptcha" style="heigth:70px"><div class="g-recaptcha" data-sitekey="6LfZsA0UAAAAAGrdId_m5EySKKa9ZpYna-6Uh-UT"></div></div></td><!-- [et_pb_line_break_holder] --></tr><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td></td><!-- [et_pb_line_break_holder] --> <td><!-- [et_pb_line_break_holder] --> <input type="submit" value="Verzenden" /><!-- [et_pb_line_break_holder] --> <br/><!-- [et_pb_line_break_holder] --> </td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> </table><!-- [et_pb_line_break_holder] --></form><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><script type="text/javascript"><!-- [et_pb_line_break_holder] -->// <![CDATA[<!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> function CheckMultiple677(frm, name) {<!-- [et_pb_line_break_holder] --> for (var i = 0; i < frm.length; i++)<!-- [et_pb_line_break_holder] --> {<!-- [et_pb_line_break_holder] --> fldObj = frm.elements[i];<!-- [et_pb_line_break_holder] --> fldId = fldObj.id;<!-- [et_pb_line_break_holder] --> if (fldId) {<!-- [et_pb_line_break_holder] --> var fieldnamecheck=fldObj.id.indexOf(name);<!-- [et_pb_line_break_holder] --> if (fieldnamecheck != -1) {<!-- [et_pb_line_break_holder] --> if (fldObj.checked) {<!-- [et_pb_line_break_holder] --> return true;<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> return false;<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> function CheckForm677(f) {<!-- [et_pb_line_break_holder] --> var email_re = /[a-z0-9!#$%&'*+\/=?^_`{|}~-]+(?:\.[a-z0-9!#$%&'*+\/=?^_`{|}~-]+)*@(?:[a-z0-9](?:[a-z0-9-]*[a-z0-9])?\.)+[a-z0-9](?:[a-z0-9-]*[a-z0-9])?/i;<!-- [et_pb_line_break_holder] --> if (!email_re.test(f.email.value)) {<!-- [et_pb_line_break_holder] --> alert("Vul je emailadres in. Bedankt.");<!-- [et_pb_line_break_holder] --> f.email.focus();<!-- [et_pb_line_break_holder] --> return false;<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> var response = grecaptcha.getResponse();<!-- [et_pb_line_break_holder] --> if (response.length == 0){<!-- [et_pb_line_break_holder] --> alert("Voer de reCAPTCHA in om te bevestigen dat je geen robot bent.");<!-- [et_pb_line_break_holder] --> return false;<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> var fname="CustomFields_1503_677",<!-- [et_pb_line_break_holder] --> fld=document.getElementById(fname);<!-- [et_pb_line_break_holder] --> if(fld.value==""){alert("Vul hier een waarde in voor het kenmerkveld Organisatienaam");fld.focus();return false;}<!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> var fname="CustomFields_1492_677",<!-- [et_pb_line_break_holder] --> fld=document.getElementById(fname);<!-- [et_pb_line_break_holder] --> if(fld.value==""){alert("Vul hier een waarde in voor het kenmerkveld Voornaam");fld.focus();return false;}<!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> var fname="CustomFields_1493_677",<!-- [et_pb_line_break_holder] --> fld=document.getElementById(fname);<!-- [et_pb_line_break_holder] --> if(fld.value==""){alert("Vul hier een waarde in voor het kenmerkveld Achternaam");fld.focus();return false;}<!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> return true;<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> function newCookie(name, value) {<!-- [et_pb_line_break_holder] --> var expire = new Date;<!-- [et_pb_line_break_holder] --> expire.setTime(expire.getTime() + 864E5);<!-- [et_pb_line_break_holder] --> expire = "; expires=" + expire.toGMTString();<!-- [et_pb_line_break_holder] --> document.cookie = name + "=" + value + expire + "; path=/";<!-- [et_pb_line_break_holder] --> };<!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> function readCookie(name) {<!-- [et_pb_line_break_holder] --> name += "=";<!-- [et_pb_line_break_holder] --> if (-1 == document.cookie.indexOf(name)) { return null; }<!-- [et_pb_line_break_holder] --> for (var d = document.cookie.split(";"), c = 0; c < d.length; ++c) {<!-- [et_pb_line_break_holder] --> for (var a = d[c]; " " == a.charAt(0);) {<!-- [et_pb_line_break_holder] --> a = a.substring(1, a.length);<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> if (0 == a.indexOf(name)) { return a.substring(name.length, a.length); }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> return null;<!-- [et_pb_line_break_holder] --> };<!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> function loadForm(form) {<!-- [et_pb_line_break_holder] --> for (var i = 0; i < form.elements.length; ++i) {<!-- [et_pb_line_break_holder] --> if (form.elements[i].type == "submit") {<!-- [et_pb_line_break_holder] --> form.elements[i].onclick = function() {<!-- [et_pb_line_break_holder] --> saveForm(form);<!-- [et_pb_line_break_holder] --> };<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> else {<!-- [et_pb_line_break_holder] --> var checker = form.elements[i].type == 'checkbox' || form.elements[i].type == 'radio';<!-- [et_pb_line_break_holder] --> var name = checker ? form.elements[i].id : form.elements[i].name;<!-- [et_pb_line_break_holder] --> if (name != '') {<!-- [et_pb_line_break_holder] --> if (name != 'captcha') {<!-- [et_pb_line_break_holder] --> value = readCookie(name);<!-- [et_pb_line_break_holder] --> if (value != null) {<!-- [et_pb_line_break_holder] --> if (checker) {<!-- [et_pb_line_break_holder] --> form.elements[i].checked = value == 'true';<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> else if (!form.elements[i].getAttribute('readonly')) {<!-- [et_pb_line_break_holder] --> form.elements[i].value = value;<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> function saveForm(form) {<!-- [et_pb_line_break_holder] --> for (var i = 0; i < form.elements.length; ++i) {<!-- [et_pb_line_break_holder] --> var checker = form.elements[i].type == 'checkbox' || form.elements[i].type == 'radio';<!-- [et_pb_line_break_holder] --> var name = checker ? form.elements[i].id : form.elements[i].name;<!-- [et_pb_line_break_holder] --> var value = checker ? form.elements[i].checked : form.elements[i].value;<!-- [et_pb_line_break_holder] --> if (name != '') {<!-- [et_pb_line_break_holder] --> if (name != 'captcha') {<!-- [et_pb_line_break_holder] --> newCookie(name, value);<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> } loadForm(document.getElementById("frmSS677"));<!-- [et_pb_line_break_holder] -->// ]]><!-- [et_pb_line_break_holder] --></script><!-- [et_pb_line_break_holder] --><style type="text/css">.disabled{color:#efebd8}</style>