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Registrazione al sito | Formulazioni Farmalabor | Portale dedicato ai professionisti della Galenica
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class="fas fa-times"></i></a> </div> </div> </div> </div> </div> </section> </header> <form id="form" style="background-image: url(assets/images/pattern-ordine.png);" method="post" action="registrazione.html"> <div class="container bg-white mt-3"> <div class="row"> <div class="col-12 text-registrazione mt-4"> Registrazione al sito </div> <div class="col-12 mt-1 text-compilaform"> <p>Compila il form sottostante per effettuare la registrazione</p> </div> </div> <div class="row mt-4 mt-lg-5 mb-1"> <div class="col-12 text-campiobbligatori"> *Campi Obbligatori </div> </div> <div class="row"> <div class="col-12 col-lg-6 text-left"> <span class="text-dati">Dati personali</span> <div class="row mt-3"> <div class="col-4 text-form mt-2"> <label>Nome*</label> </div> <div class="col-8"> <input type="text" name="nome" class="form-control" aria-label="Nome" required> </div> </div> <div class="row mt-3"> <div class="col-4 text-form mt-2"> <label>Cognome*</label> </div> <div class="col-8"> <input type="text" name="cognome" class="form-control" aria-label="Cognome" required> </div> </div> <div class="row mt-3"> <div class="col-4 text-form mt-2"> <label>Ragione sociale*</label> </div> <div class="col-8"> <input type="text" name="ragionesociale" class="form-control" aria-label="Ragione sociale" required> </div> </div> <div class="row mt-3"> <div class="col-4 text-form mt-2"> <label>P.Iva*</label> </div> <div class="col-8"> <input type="text" class="form-control" minlength="11" maxlength="16" name="piva" aria-label="P.Iva" required> </div> </div> <div class="row mt-3"> <div class="col-4 text-form mt-2"> <label>Codice fiscale</label> </div> <div class="col-8"> <input type="text" name="cf" maxlength="16" minlength="16" class="form-control" aria-label="Codice fiscale"> </div> </div> <div class="row mt-3"> <div class="col-4 text-form mt-2"> <label>Cellulare*</label> </div> <div class="col-8"> <input type="text" name="cellulare" class="form-control" aria-label="Cellulare" required> </div> </div> <div class="row mt-3"> <div class="col-4 text-form mt-2"> <label>Fax</label> </div> <div class="col-8"> <input type="text" name="fax" class="form-control" aria-label="Fax"> </div> </div> <div class="row mt-3"> <div class="col-4 text-form mt-2"> <label>Responsabile Acquisti</label> </div> <div class="col-8"> <input type="text" name="resp_acquisti" class="form-control" aria-label="Responsabile Acquisti"> </div> </div> <div class="row mt-3"> <div class="col-4 text-form mt-2"> <label>Codice sdi*</label> </div> <div class="col-8"> <input type="text" name="codice_sdi" class="form-control" aria-label="Codice sdi" required> </div> </div> <div class="row mt-3 d-none"> <div class="col-4 text-form mt-2"> <label>Seleziona un codice per la fatturazione*</label> </div> <div class="col-8"> <select name="codice_sam" class="form-control" required disabled> </select> </div> </div> <div class="row mt-3"> <div class="col-4 text-form mt-2"> <label>Pec</label> </div> <div class="col-8"> <input type="email" name="pec" class="form-control" aria-label="pec"> </div> </div> <div class="row mt-3"> <div class="col-4 text-form mt-2"> <label>Iban </label> </div> <div class="col-8"> <input type="text" name="iban" maxlength="27" class="form-control" aria-label="Iban"> </div> </div> <!-- <div class="row mt-3"> <div class="col-4 text-form mt-2"> Codice SDI* </div> <div class="col-4"> <input type="text" class="form-control" aria-label="codice sdi"> </div> <div class="col-2 text-form mt-2"> Split Payments </div> <div class="col-1"> <input type="text" class="form-control" aria-label="si"> </div> <div class="col-1"> <input type="text" class="form-control" aria-label="no"> </div> </div> --> <div class="row mt-3"> <div class="col-4 text-form mt-2"> <label>Tipo di attività *</label> </div> <div class="col-8"> <div class="input-group"> <select class="custom-select" name="typeID" id="inputGroupSelect01" required> <option selected>Seleziona</option><option value="70">Farmacia</option><option value="72">Parafarmacia</option><option value="1936">Altro specificare</option></select> </div> </div> </div> <div class="row mt-3 other-choice d-none"> <div class="col-4 text-form mt-2"> <label>Tipo di attività<br>(Altro specificare)</label> </div> <div class="col-8"> <input type="text" name="tipo_attivita_altro" class="form-control" aria-label="Tipo di attività"> </div> </div> <div class="row mt-3"> <div class="col-4 text-form mt-2"> <label>Posizione</label> </div> <div class="col-8"> <div class="input-group"> <select class="custom-select" name="posizioneID" id="inputGroupSelect02"> <option value="" selected>Seleziona</option><option value="2047">Titolare</option><option value="2048">Collaboratore</option><option value="2050">Specializzando</option></select> </div> </div> </div> <div class="row mt-3"> <div class="col-4 text-form mt-2"> <label>Hai mai partecipato a un corso del nostro Campus?*</label> </div> <div class="col-8 mt-1"> <span class="radio inline"> <input type="radio" id="corso_si" value="1" name="part_corso" required> <label for="corso_si" class=""></label> <span style="font-size: 12px;">Si</span> </span> <span class="radio inline ml-2"> <input type="radio" id="corso_no" value="0" name="part_corso" required> <label for="corso_no"></label> <span style="font-size: 12px;">No</span> </span> </div> </div> <div class="row mt-3"> <div class="col-4 text-form mt-2"> <label>La tua farmacia fa parte della nostra RFR*</label> </div> <div class="col-8 mt-1"> <span class="radio inline"> <input type="radio" id="rfr_si" value="1" name="rfr" required> <label for="rfr_si" class=""></label> <span style="font-size: 12px;">Si</span> </span> <span class="radio inline ml-2"> <input type="radio" id="rfr_no" value="0" name="rfr" required> <label for="rfr_no"></label> <span style="font-size: 12px;">No</span> </span> </div> </div> </div> <div class="col-12 col-lg-6 text-left mt-5 mt-lg-0"> <span class="text-dati">Sede legale</span> <div class="row mt-3"> <div class="col-4 text-form mt-2"> <label>Indirizzo*</label> </div> <div class="col-8"> <input type="text" name="indirizzo_legale" class="form-control" aria-label="Indirizzo Sede legale" required> </div> </div> <div class="row mt-3"> <div class="col-4 text-form mt-2"> <label>Città*/Cap*</label> </div> <div class="col-5"> <input type="text" class="form-control" name="citta_legale" aria-label="Città" required> </div> <div class="col-3"> <input type="text" name="cap_legale" maxlength="5" class="form-control" aria-label="Cap" required> </div> </div> <div class="row mt-3 mb-5"> <div class="col-4 text-form mt-2"> <label>Provincia*</label> </div> <div class="col-8"> <div class="input-group"> <select name="provinciaID_legale" class="form-control" required><option value="">Scegli una provincia*</option><option value="1">Agrigento</option><option value="2">Alessandria</option><option value="3">Ancona</option><option value="4">Aosta</option><option value="7">Arezzo</option><option value="5">Ascoli-Piceno</option><option value="8">Asti</option><option value="9">Avellino</option><option value="10">Bari</option><option value="18">Barletta-Andria-Trani</option><option value="13">Belluno</option><option value="14">Benevento</option><option value="11">Bergamo</option><option value="12">Biella</option><option value="15">Bologna</option><option value="19">Bolzano</option><option value="17">Brescia</option><option value="16">Brindisi</option><option value="20">Cagliari</option><option value="24">Caltanissetta</option><option value="21">Campobasso</option><option value="109">CARBONIA-IGLESIAS </option><option value="22">Caserta</option><option value="29">Catania</option><option value="30">Catanzaro</option><option value="23">Chieti</option><option value="26">Como</option><option value="28">Cosenza</option><option value="27">Cremona</option><option value="43">Crotone</option><option value="25">Cuneo</option><option value="31">Enna</option><option value="123">Estero</option><option value="36">Fermo</option><option value="33">Ferrara</option><option value="35">Firenze</option><option value="34">Foggia</option><option value="32">Forli-Cesena</option><option value="37">Frosinone</option><option value="38">Genova</option><option value="39">Gorizia</option><option value="40">Grosseto</option><option value="41">Imperia</option><option value="42">Isernia</option><option value="6">L'Aquila</option><option value="86">La Spezia</option><option value="48">Latina</option><option value="45">Lecce</option><option value="44">Lecco</option><option value="46">Livorno</option><option value="47">Lodi</option><option value="49">Lucca</option><option value="51">Macerata</option><option value="54">Mantova</option><option value="56">Massa-Carrara</option><option value="57">Matera</option><option value="108">MEDIO CAMPIDANO</option><option value="52">Messina</option><option value="53">Milano</option><option value="55">Modena</option><option value="50">Monza-Brianza</option><option value="58">Napoli</option><option value="59">Novara</option><option value="60">Nuoro</option><option value="110">OGLIASTRA </option><option value="107">Olbia-Tempio </option><option value="61">Oristano</option><option value="64">Padova</option><option value="62">Palermo</option><option value="70">Parma</option><option value="73">Pavia</option><option value="66">Perugia</option><option value="72">Pesaro-Urbino</option><option value="65">Pescara</option><option value="63">Piacenza</option><option value="67">Pisa</option><option value="71">Pistoia</option><option value="68">Pordenone</option><option value="74">Potenza</option><option value="69">Prato</option><option value="78">Ragusa</option><option value="75">Ravenna</option><option value="76">Reggio Calabria</option><option value="77">Reggio Emilia</option><option value="79">Rieti</option><option value="80">Rimini</option><option value="82">Roma</option><option value="81">Rovigo</option><option value="83">Salerno</option><option value="88">Sassari</option><option value="89">Savona</option><option value="84">Siena</option><option value="87">Siracusa</option><option value="85">Sondrio</option><option value="90">Taranto</option><option value="91">Teramo</option><option value="95">Terni</option><option value="93">Torino</option><option value="94">Trapani</option><option value="92">Trento</option><option value="97">Treviso</option><option value="96">Trieste</option><option value="98">Udine</option><option value="99">Varese</option><option value="102">Venezia</option><option value="100">Verbania</option><option value="101">Vercelli</option><option value="104">Verona</option><option value="106">Vibo-Valentia</option><option value="103">Vicenza</option><option value="105">Viterbo</option></select> </div> </div> </div> <span class="text-dati">Microdistribuzione</span> <div class="row mt-3"> <div class="col-4 text-form mt-2"> <label class="text-nowrap">Utilizzi la microdistribuzione?*</label> </div> <div class="col-8 mt-1"> <span class="radio inline"> <input type="radio" id="microdistribuzione_si" value="1" name="microdistribuzione" required> <label for="microdistribuzione_si" class=""></label> <span style="font-size: 12px;">Si</span> </span> <span class="radio inline ml-2"> <input type="radio" id="microdistribuzione_no" value="0" name="microdistribuzione" required> <label for="microdistribuzione_no"></label> <span style="font-size: 12px;">No</span> </span> </div> </div> <div class="distributor-choice d-none"> <div class="row mt-3"> <div class="col-4 text-form mt-2"> <label>Seleziona un distributore</label> </div> <div class="col-8 mt-1"> <span class="radio inline"> <input type="radio" id="distributore_2054" value="ADM" name="distributoreID" disabled> <label for="distributore_2054" class=""></label> <span style="font-size: 12px;">FarmaAlvarion S.r.l </span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2056" value="ASCA" name="distributoreID" disabled> <label for="distributore_2056" class=""></label> <span style="font-size: 12px;">S.I.M.A. SPA</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2057" value="ASCG" name="distributoreID" disabled> <label for="distributore_2057" class=""></label> <span style="font-size: 12px;">ALLIANCE HEALTH CARE ITALIA DISTRIBUZIONE S.p.A. *** CAMPOGALLIANO</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2058" value="ASCT" name="distributoreID" disabled> <label for="distributore_2058" class=""></label> <span style="font-size: 12px;">ALLIANCE HEALTH CARE ITALIA DISTRIBUZIONE S.p.A. *** BELPASSO</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2059" value="ASFG" name="distributoreID" disabled> <label for="distributore_2059" class=""></label> <span style="font-size: 12px;">ALLIANCE HEALTH CARE ITALIA DISTRIBUZIONE S.p.A. *** FOGGIA</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2060" value="ASFI" name="distributoreID" disabled> <label for="distributore_2060" class=""></label> <span style="font-size: 12px;">ALLIANCE HEALTH CARE ITALIA DISTRIBUZIONE S.p.A. *** FIRENZE</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2061" value="ASFL" name="distributoreID" disabled> <label for="distributore_2061" class=""></label> <span style="font-size: 12px;">FARM.ALARICO S.P.A.</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2062" value="ASGE" name="distributoreID" disabled> <label for="distributore_2062" class=""></label> <span style="font-size: 12px;">DI.FAR S.P.A.</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2063" value="ASGI" name="distributoreID" disabled> <label for="distributore_2063" class=""></label> <span style="font-size: 12px;">ALLIANCE HEALTH CARE ITALIA DISTRIBUZIONE S.p.A. *** ROMA</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2064" value="ASNA" name="distributoreID" disabled> <label for="distributore_2064" class=""></label> <span style="font-size: 12px;">ALLIANCE HEALTH CARE ITALIA DISTRIBUZIONE S.p.A. *** NAPOLI</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2065" value="ASPA" name="distributoreID" disabled> <label for="distributore_2065" class=""></label> <span style="font-size: 12px;">ALLIANCE HEALTH CARE ITALIA DISTRIBUZIONE S.p.A. *** PALERMO</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2066" value="ASPI" name="distributoreID" disabled> <label for="distributore_2066" class=""></label> <span style="font-size: 12px;">ALLIANCE HEALTH CARE ITALIA DISTRIBUZIONE S.p.A. *** PISA</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2067" value="ASPZ" name="distributoreID" disabled> <label for="distributore_2067" class=""></label> <span style="font-size: 12px;">ALLIANCE HEALTH CARE ITALIA DISTRIBUZIONE S.p.A. *** POTENZA</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2068" value="ASRC" name="distributoreID" disabled> <label for="distributore_2068" class=""></label> <span style="font-size: 12px;">ALLIANCE HEALTH CARE ITALIA DISTRIBUZIONE S.p.A. *** REGGIO CALABRIA</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2069" value="ASSA" name="distributoreID" disabled> <label for="distributore_2069" class=""></label> <span style="font-size: 12px;">ALLIANCE HEALTH CARE ITALIA DISTRIBUZIONE S.p.A. *** SALERNO</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2070" value="ASTR" name="distributoreID" disabled> <label for="distributore_2070" class=""></label> <span style="font-size: 12px;">ALLIANCE HEALTH CARE ITALIA DISTRIBUZIONE S.p.A. *** ORVIETO</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2071" value="ASVA" name="distributoreID" disabled> <label for="distributore_2071" class=""></label> <span style="font-size: 12px;">ALLIANCE HEALTH CARE ITALIA DISTRIBUZIONE S.p.A. *** VASTO</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2072" value="ASVM" name="distributoreID" disabled> <label for="distributore_2072" class=""></label> <span style="font-size: 12px;">ALLIANCE HEALTH CARE ITALIA DISTRIBUZIONE S.p.A. *** VIMERCATE</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2073" value="CEF" name="distributoreID" disabled> <label for="distributore_2073" class=""></label> <span style="font-size: 12px;">COOPERATIVA ESERCENTI FARMACIA S.C.R.L.</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2074" value="CMFD" name="distributoreID" disabled> <label for="distributore_2074" class=""></label> <span style="font-size: 12px;">COMIFAR DISTRIBUZIONE S.P.A.</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2075" value="CMFM" name="distributoreID" disabled> <label for="distributore_2075" class=""></label> <span style="font-size: 12px;">SPEM S.p.A.</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2076" value="DMB" name="distributoreID" disabled> <label for="distributore_2076" class=""></label> <span style="font-size: 12px;">DM BARONE FARMACEUTICI SPA</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2077" value="FMC" name="distributoreID" disabled> <label for="distributore_2077" class=""></label> <span style="font-size: 12px;">FARMACENTRO SERVIZI E LOGISTICA SOCIET√Ä COOPERATIVA (UMB)</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2078" value="FRS" name="distributoreID" disabled> <label for="distributore_2078" class=""></label> <span style="font-size: 12px;">SAFAR DISTRIBUZIONE MEDICINALI ABRUZZO</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2079" value="FRV" name="distributoreID" disabled> <label for="distributore_2079" class=""></label> <span style="font-size: 12px;">FARVIMA MED.SPA CASANDRINO</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2080" value="FSC" name="distributoreID" disabled> <label for="distributore_2080" class=""></label> <span style="font-size: 12px;">FARLA SOC.COOP</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2081" value="G" name="distributoreID" disabled> <label for="distributore_2081" class=""></label> <span style="font-size: 12px;">GUACCI SPA</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2082" value="SFD" name="distributoreID" disabled> <label for="distributore_2082" class=""></label> <span style="font-size: 12px;">SOFAD S.R.L.</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2083" value="SFMA2" name="distributoreID" disabled> <label for="distributore_2083" class=""></label> <span style="font-size: 12px;">SO.FARMA.MORRA S.p.A. ***MERCOGLIANO*** </span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2084" value="SFMAP" name="distributoreID" disabled> <label for="distributore_2084" class=""></label> <span style="font-size: 12px;">SO.FARMA.MORRA S.P.A. ***ACQUAVIVA PICENA***</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2085" value="SFMBA" name="distributoreID" disabled> <label for="distributore_2085" class=""></label> <span style="font-size: 12px;">SO.FARMA.MORRA S.P.A. ***TRIGGIANO***</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2086" value="SFMBO" name="distributoreID" disabled> <label for="distributore_2086" class=""></label> <span style="font-size: 12px;">SO.FARMA.MORRA S.P.A. ***MINERBIO**</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2087" value="SFMFO" name="distributoreID" disabled> <label for="distributore_2087" class=""></label> <span style="font-size: 12px;">SO.FARMA.MORRA S.P.A. ***FORLI***</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2088" value="SFMGE" name="distributoreID" disabled> <label for="distributore_2088" class=""></label> <span style="font-size: 12px;">COFARM SPA *** SO.FARMA.MORRA S.P.A. ***</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2089" value="SFML2" name="distributoreID" disabled> <label for="distributore_2089" class=""></label> <span style="font-size: 12px;">SO.FARMA.MORRA S.P.A. ***CAPANNORI***</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2090" value="SFMMC" name="distributoreID" disabled> <label for="distributore_2090" class=""></label> <span style="font-size: 12px;">SO.FARMA.MORRA S.P.A. ***MARCELLINARA***</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2091" value="SFMME" name="distributoreID" disabled> <label for="distributore_2091" class=""></label> <span style="font-size: 12px;">SO.FARMA.MORRA S.P.A. ***TORREGROTTA***</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2092" value="SFMNL" name="distributoreID" disabled> <label for="distributore_2092" class=""></label> <span style="font-size: 12px;">SO.FARMA.MORRA S.P.A. ***NOLA***</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2093" value="SFMPA" name="distributoreID" disabled> <label for="distributore_2093" class=""></label> <span style="font-size: 12px;">SO.FARMA.MORRA S.P.A. ***PALERMO***</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2094" value="SFMPL" name="distributoreID" disabled> <label for="distributore_2094" class=""></label> <span style="font-size: 12px;">SO.FARMA.MORRA S.P.A. ***POLLENZA***</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2095" value="SFMRM" name="distributoreID" disabled> <label for="distributore_2095" class=""></label> <span style="font-size: 12px;">SO.FARMA.MORRA S.P.A. ***ROMA***</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2096" value="SFMTA" name="distributoreID" disabled> <label for="distributore_2096" class=""></label> <span style="font-size: 12px;">SO.FARMA.MORRA S.P.A. ***NEWCOTAFARTI***</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2097" value="SFMTO" name="distributoreID" disabled> <label for="distributore_2097" class=""></label> <span style="font-size: 12px;">UFM - UNIONE FARMACEUTICA MI. TO. SRL **TORINO ***</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2098" value="SFMUM" name="distributoreID" disabled> <label for="distributore_2098" class=""></label> <span style="font-size: 12px;">UFM - UNIONE FARMACEUTICA MI. TO. SRL ** MILANO ***</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2099" value="U" name="distributoreID" disabled> <label for="distributore_2099" class=""></label> <span style="font-size: 12px;">UNICO S.p.A.</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2100" value="UFR" name="distributoreID" disabled> <label for="distributore_2100" class=""></label> <span style="font-size: 12px;">UNIFARMA DISTRIBUZIONE S.p.A.</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2101" value="V" name="distributoreID" disabled> <label for="distributore_2101" class=""></label> <span style="font-size: 12px;">VIM FARMACEUTICI</span> </span> </div> </div><div class="row mt-3"> <div class="col-4 text-form mt-2"> <label></label> </div> <div class="col-8 "> <span class="radio inline"> <input type="radio" id="distributore_2102" value="ASBR" name="distributoreID" disabled> <label for="distributore_2102" class=""></label> <span style="font-size: 12px;">ALLIANCE HEALTH CARE ITALIA DISTRIBUZIONE S.p.A. *** BRINDISI</span> </span> </div> </div> </div> <span class="text-dati d-block mt-5">Dati per la consegna</span> <div class="row mt-3"> <div class="col-4 text-form mt-2"> <label>Indirizzo di spedizione*</label> </div> <div class="col-8"> <input type="text" class="form-control" name="indirizzo" aria-label="Indirizzo di spedizione" required> </div> </div> <div class="row mt-3"> <div class="col-4 text-form mt-2"> <label>Città*/Cap*</label> </div> <div class="col-5"> <input type="text" class="form-control" name="citta" aria-label="Città" required> </div> <div class="col-3"> <input type="text" name="cap" maxlength="5" class="form-control" aria-label="Cap" required> </div> </div> <div class="row mt-3 mb-3"> <div class="col-4 text-form mt-2"> <label>Provincia*</label> </div> <div class="col-8"> <div class="input-group"> <select name="provinciaID" class="form-control" required><option value="">Scegli una provincia*</option><option value="1">Agrigento</option><option value="2">Alessandria</option><option value="3">Ancona</option><option value="4">Aosta</option><option value="7">Arezzo</option><option value="5">Ascoli-Piceno</option><option value="8">Asti</option><option value="9">Avellino</option><option value="10">Bari</option><option value="18">Barletta-Andria-Trani</option><option value="13">Belluno</option><option value="14">Benevento</option><option value="11">Bergamo</option><option value="12">Biella</option><option value="15">Bologna</option><option value="19">Bolzano</option><option value="17">Brescia</option><option value="16">Brindisi</option><option value="20">Cagliari</option><option value="24">Caltanissetta</option><option value="21">Campobasso</option><option value="109">CARBONIA-IGLESIAS </option><option value="22">Caserta</option><option value="29">Catania</option><option value="30">Catanzaro</option><option value="23">Chieti</option><option value="26">Como</option><option value="28">Cosenza</option><option value="27">Cremona</option><option value="43">Crotone</option><option value="25">Cuneo</option><option value="31">Enna</option><option value="123">Estero</option><option value="36">Fermo</option><option value="33">Ferrara</option><option value="35">Firenze</option><option value="34">Foggia</option><option value="32">Forli-Cesena</option><option value="37">Frosinone</option><option value="38">Genova</option><option value="39">Gorizia</option><option value="40">Grosseto</option><option value="41">Imperia</option><option value="42">Isernia</option><option value="6">L'Aquila</option><option value="86">La Spezia</option><option value="48">Latina</option><option value="45">Lecce</option><option value="44">Lecco</option><option value="46">Livorno</option><option value="47">Lodi</option><option value="49">Lucca</option><option value="51">Macerata</option><option value="54">Mantova</option><option value="56">Massa-Carrara</option><option value="57">Matera</option><option value="108">MEDIO CAMPIDANO</option><option value="52">Messina</option><option value="53">Milano</option><option value="55">Modena</option><option value="50">Monza-Brianza</option><option value="58">Napoli</option><option value="59">Novara</option><option value="60">Nuoro</option><option value="110">OGLIASTRA </option><option value="107">Olbia-Tempio </option><option value="61">Oristano</option><option value="64">Padova</option><option value="62">Palermo</option><option value="70">Parma</option><option value="73">Pavia</option><option value="66">Perugia</option><option value="72">Pesaro-Urbino</option><option value="65">Pescara</option><option value="63">Piacenza</option><option value="67">Pisa</option><option value="71">Pistoia</option><option value="68">Pordenone</option><option value="74">Potenza</option><option value="69">Prato</option><option value="78">Ragusa</option><option value="75">Ravenna</option><option value="76">Reggio Calabria</option><option value="77">Reggio Emilia</option><option value="79">Rieti</option><option value="80">Rimini</option><option value="82">Roma</option><option value="81">Rovigo</option><option value="83">Salerno</option><option value="88">Sassari</option><option value="89">Savona</option><option value="84">Siena</option><option value="87">Siracusa</option><option value="85">Sondrio</option><option value="90">Taranto</option><option value="91">Teramo</option><option value="95">Terni</option><option value="93">Torino</option><option value="94">Trapani</option><option value="92">Trento</option><option value="97">Treviso</option><option value="96">Trieste</option><option value="98">Udine</option><option value="99">Varese</option><option value="102">Venezia</option><option value="100">Verbania</option><option value="101">Vercelli</option><option value="104">Verona</option><option value="106">Vibo-Valentia</option><option value="103">Vicenza</option><option value="105">Viterbo</option></select> </div> </div> </div> </div> <div class="col-12 col-lg-6 text-left mt-3 mt-lg-3"> <div class="col-12 text-dati mt-4 nopadding-form">Dati per accedere al portale</div> <div class="row mt-3"> <div class="col-4 text-form mt-2"> <label>Email*</label> </div> <div class="col-8"> <input type="text" class="form-control" name="email" aria-label="email" required> </div> </div> <div class="row mt-3"> <div class="col-4 text-form mt-2"> <label>Password*</label> </div> <div class="col-8"> <input type="password" class="form-control" name="password" aria-label="password" required> </div> </div> <div class="row mt-3"> <div class="col-4 text-form mt-2"> <label>Ripeti 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</strong></p> </div> <span class="price price-plane">FREE</span> <div class="for-input"> <input name="abbonamentoID" value="235" type="radio" required /> Seleziona </div> </div> </div><div class="col-12 col-md-6 col-lg-3 mb-3 mb-lg-0 pricing-item silver"> <div class="item"> <div class="title"> <h3>SILVER</h3> </div> <div class="price"><p>Contributo annuale €19,90 + IVA</p></div> <div class="description"> <p> </p> <p><strong>Accesso GRATUITO al sistema ordini WEB </strong></p> <p><strong>Download GRATUITO di n.5 formulazioni/settimana</strong></p> <p><strong>Download GRATUITO di n.1 formulazione per ogni ordine di importo maggiore di € 200,00</strong></p> <p><strong>Sessione GRATUITA di n.1 consulenza/mese</strong></p> <p> </p> </div> <span class="price price-plane">€ 19,90 + IVA</span> <div class="for-input"> <input name="abbonamentoID" value="234" type="radio" required /> Seleziona </div> </div> </div><div class="col-12 col-md-6 col-lg-3 mb-3 mb-lg-0 pricing-item gold"> <div class="item"> <div class="title"> <h3>GOLD</h3> </div> <div class="price"><p>Contributo annuale € 49,90 + IVA</p></div> <div class="description"> <p> </p> <p><strong>Accesso GRATUITO al sistema ordini WEB </strong></p> <p><strong>Download illimitati GRATUITI</strong></p> <p><strong>Sessione GRATUITA di n.4 consulenze/mese</strong></p> <p><em>Iscrizione GRATUITA al Comitato Tecnico Formulazioni FARMALABOR</em></p> <p> </p> </div> <span class="price price-plane">€ 49,90 + IVA</span> <div class="for-input"> <input name="abbonamentoID" value="233" type="radio" required /> Seleziona </div> </div> </div><div class="col-12 col-md-6 col-lg-3 mb-3 mb-lg-0 pricing-item rfr d-none"> <div class="item"> <div class="title"> <h3>RFR</h3> </div> <div class="price"><p><span style="text-decoration:line-through;font-size:12px;">FREE</span><br/>FREE</p></div> <div class="description"> <p> </p> <p><strong>Tutti gli aderenti alla </strong><strong>RETE FARMACISTI RICERCATORI accedono gratuitamente al piano 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Questi cookie permettono di avere delle informazioni riguardo il numero dei visitatori, il bounce rate, le sorgenti di traffico, ecc., ma non permettono di identificare l’utente né di profilarlo.</p> </div> <div class="table-list-cookie"> <div class="inner-table"> <div class="row-list header no-mobile"> <div class="width-20 width-mobile-30"><p>Nome</p> </div> <div class="width-20 no-mobile"><p>Fornitore</p> </div> <div class="width-30 width-mobile-40"><p>Descrizione</p> </div> <div class="width-20 width-mobile-30"><p>Scadenza</p> </div> <div class="width-10 no-mobile"><p>Tipo</p> </div> </div><div class="row-list body"> <div class="width-20 width-mobile-100"> <h5 class="only-mobile">Nome</h5> <p>_ga</p> </div> <div class="width-20 width-mobile-100"> <h5 class="only-mobile">Fornitore</h5> <p>formulazioni. farmalabor.it</p> </div> <div class="width-30 width-mobile-100"> <h5 class="only-mobile">Descrizione</h5> <p>Registra un ID univoco utilizzato per generare dati statistici su come il visitatore utilizza il sito internet. </p> </div> <div class="width-20 width-mobile-100"> <h5 class="only-mobile">Scadenza</h5> <p>2 Anni</p> </div> <div class="width-10 width-mobile-100"> <h5 class="only-mobile">Tipo</h5> <p>HTTP</p> </div> </div><div class="row-list body"> <div class="width-20 width-mobile-100"> <h5 class="only-mobile">Nome</h5> <p>_ga_ 0KD894XJ70</p> </div> <div class="width-20 width-mobile-100"> <h5 class="only-mobile">Fornitore</h5> <p>formulazioni. farmalabor.it</p> </div> <div class="width-30 width-mobile-100"> <h5 class="only-mobile">Descrizione</h5> <p>Questo cookie è installato da Google Analytics. </p> </div> <div class="width-20 width-mobile-100"> <h5 class="only-mobile">Scadenza</h5> <p>2 Anni</p> </div> <div class="width-10 width-mobile-100"> <h5 class="only-mobile">Tipo</h5> <p>HTTP</p> </div> </div><div class="row-list body"> <div class="width-20 width-mobile-100"> <h5 class="only-mobile">Nome</h5> <p>_gid</p> </div> <div class="width-20 width-mobile-100"> <h5 class="only-mobile">Fornitore</h5> <p>formulazioni. farmalabor.it</p> </div> <div class="width-30 width-mobile-100"> <h5 class="only-mobile">Descrizione</h5> <p>Registra un ID univoco utilizzato per generare dati statistici su come il visitatore utilizza il sito internet. </p> </div> <div class="width-20 width-mobile-100"> <h5 class="only-mobile">Scadenza</h5> <p>1 Giorno</p> </div> <div class="width-10 width-mobile-100"> <h5 class="only-mobile">Tipo</h5> <p>HTTP</p> </div> </div><div class="row-list body"> <div class="width-20 width-mobile-100"> <h5 class="only-mobile">Nome</h5> <p>_gat _gtag</p> </div> <div class="width-20 width-mobile-100"> <h5 class="only-mobile">Fornitore</h5> <p>formulazioni. farmalabor.it</p> </div> <div class="width-30 width-mobile-100"> <h5 class="only-mobile">Descrizione</h5> <p>Utilizzato da Google Analytics al fine di fornire informazioni agli operatori del sito Web e migliorare l'esperienza di navigazione del cliente. </p> </div> <div class="width-20 width-mobile-100"> <h5 class="only-mobile">Scadenza</h5> <p>1 minuto</p> </div> <div class="width-10 width-mobile-100"> <h5 class="only-mobile">Tipo</h5> <p>HTTP</p> </div> </div></div></div> </li> </ul> </li><li> <a href="#"><i class="fa fa-angle-right"></i>Cookie Funzionali</a> <div class="status-cookie-item"> <p>Non attivi</p> <div class="switch-option" data-text-inactive="Non attivi" data-text-active="Attivi"> <input type="checkbox" class="checkbox-cookie" name="cookie_f" value="1" /> <span class="switcher"></span> </div> </div> <ul> <li> <div class="description"> <p>Aiutano a svolgere determinate funzionalità come la condivisione del contenuto del sito Web su piattaforme di social media, la raccolta di feedback e altre funzionalità di terze parti.</p> </div> <div class="table-list-cookie"> <div class="inner-table"> <div class="row-list header no-mobile"> <div class="width-20 width-mobile-30"><p>Nome</p> </div> <div class="width-20 no-mobile"><p>Fornitore</p> </div> <div class="width-30 width-mobile-40"><p>Descrizione</p> </div> <div class="width-20 width-mobile-30"><p>Scadenza</p> </div> <div class="width-10 no-mobile"><p>Tipo</p> </div> </div><div class="row-list body"> <div class="width-20 width-mobile-100"> <h5 class="only-mobile">Nome</h5> <p>__zlcmid</p> </div> <div class="width-20 width-mobile-100"> <h5 class="only-mobile">Fornitore</h5> <p>formulazioni. farmalabor.it</p> </div> <div class="width-30 width-mobile-100"> <h5 class="only-mobile">Descrizione</h5> <p>Cookie impostato da Zopim per aiutare a identificare la sessione di chat di un utente tra i caricamenti della pagina. </p> </div> <div class="width-20 width-mobile-100"> <h5 class="only-mobile">Scadenza</h5> <p>1 anno</p> </div> <div class="width-10 width-mobile-100"> <h5 class="only-mobile">Tipo</h5> <p>HTTP</p> </div> </div><div class="row-list body"> <div class="width-20 width-mobile-100"> <h5 class="only-mobile">Nome</h5> <p>__cfruid</p> </div> <div class="width-20 width-mobile-100"> <h5 class="only-mobile">Fornitore</h5> <p>zendesk.com</p> </div> <div class="width-30 width-mobile-100"> <h5 class="only-mobile">Descrizione</h5> <p>Cloudflare imposta questo cookie per identificare il traffico web affidabile. </p> </div> <div class="width-20 width-mobile-100"> <h5 class="only-mobile">Scadenza</h5> <p>sessione</p> </div> <div class="width-10 width-mobile-100"> <h5 class="only-mobile">Tipo</h5> <p>HTTP</p> </div> </div><div class="row-list body"> <div class="width-20 width-mobile-100"> <h5 class="only-mobile">Nome</h5> <p>AWSALBCORS</p> </div> <div class="width-20 width-mobile-100"> <h5 class="only-mobile">Fornitore</h5> <p>widget-mediator.zopim.com</p> </div> <div class="width-30 width-mobile-100"> <h5 class="only-mobile">Descrizione</h5> <p>Questo cookie è gestito da Amazon Web Services e viene utilizzato per il bilanciamento del carico. </p> </div> <div class="width-20 width-mobile-100"> <h5 class="only-mobile">Scadenza</h5> <p>7 Giorni</p> </div> 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