<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 - the online payment solution simplest and most secure line! ">

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

</form>