[paytium name="Blijvend in Actie korting termijn" description="Blijvend in Actie korting in termijnen" button_label="Aanmelden"] [paytium_subscription interval="1 months" times="2" /] [paytium_field type="email" label="Email" required="true" /] [paytium_field type="first name" label="Voornaam" required="true" /] [paytium_field type="last name" label="Achternaam" required="true" /] [paytium_field type="text" label="Adres" required="true" /] [paytium_field type="text" label="Postcode" required="true" /] [paytium_field type="text" label="Plaatsnaam" required="true" /] [paytium_field type="dropdown" label="Land" options="Belgie/Nederland/Anders" first_option="text" first_option_text="Eigen eerste selectie tekst"required="true" /] [paytium_field type="label" label="Eerste termijn €53 " amount="53" /] [paytium_total /] [paytium_field type="checkbox" label="Periodieke incasso" options="Hierbij geef ik toestemming om het resterende bedrag in 2 termijnen van mijn rekening te incasseren." required="false" /] [paytium_field type="terms" label="Ik accepteer de algemene voorwaarden" link="https://drive.google.com/file/d/1KANeYtivEHynhvp_5m69tubMnGGm8cPq/view?usp=share_link" required="true" /] [/paytium]