+ <th>Raison du changement de nom</th>
+ </tr>
+ <tr>
+ <td class="rt">
+ <input type="radio" name="reason" checked="checked" value="époux/se" id="reason_ep" onclick="this.form.other_reason.value=''" /><label for="reason_ep">Nom d'épouse / d'époux</label><br />
+ {if $usage_old}
+ <input type="radio" name="reason" value="divorce" id="reason_div" onclick="this.form.other_reason.value=''" /><label for="reason_div">Divorce</label><br />
+ {/if}
+ <input type="radio" name="reason" value="raccourci" id="reason_rac" onclick="this.form.other_reason.value=''" /><label for="reason_rac">Nom d'état civil simplifié, le nom officiel étant trop long</label><br />
+ <input type="radio" name="reason" value="other" id="reason_oth" /><label for="reason_oth">Autre :</label><br />
+ <input type="text" name="other_reason" onfocus="document.getElementById('reason_oth').checked='checked'" size="60" />
+ </td>
+ </tr>
+ <tr>
+ <td class="center">
+ {if !$usage_old}
+ <input type="submit" name="submit" value="Faire la demande" />
+ {else}
+ <input type="submit" name="submit" value="Modifier" />
+ <input type="submit" name="submit" value="Supprimer" onClick="this.form.nom_usage.value=''" />
+ {/if}
+ </td>