<select id="region">
<option>---</option>
<option value="1">Alsace</option>
<option value="2">Aquitaine</option>
<option value="3">Auvergne</option>
<option value="4">Basse Normandie</option>
<option value="5">Bourgogne</option>
<option value="6">Bretagne</option>
<option value="7">Centre</option>
<option value="8">Champagne Ardenne</option>
<option value="9">Corse</option>
<option value="10">Franche Comté</option>
<option value="11">Haute Normandie</option>
<option value="12">Ile de France</option>
<option value="13">Languedoc Roussillon</option>
<option value="14">Limousin</option>
<option value="15">Lorraine</option>
<option value="16">Midi-Pyrénées</option>
<option value="17">Nord Pas de Calais</option>
<option value="18">P.A.C.A</option>
<option value="19">Pays de la Loire</option>
<option value="20">Picardie</option>
<option value="21">Poitou Charente</option>
<option value="22">Rhone Alpes</option>
</select>

<select id="departement" disabled="disabled">
<option value="">--</option>
<option class="22" value="1">Ain</option>
<option class="20" value="2">Aisne</option>
<option class="3" value="3">Allier</option>
<option class="18" value="4">Alpes de haute provence</option>
<option class="18" value="5">Hautes alpes</option>
<option class="18" value="6">Alpes maritimes</option>
<option class="22" value="7">Ardèche</option>
<option class="8" value="8">Ardennes</option>
<option class="16" value="9">Ariège</option>
<option class="8" value="10">Aube</option>
<option class="13" value="11">Aude</option>
<option class="16" value="12">Aveyron</option>
<option class="18" value="13">Bouches du rhône</option>
<option class="4" value="14">Calvados</option>
<option class="3" value="15">Cantal</option>
<option class="21" value="16">Charente</option>
<option class="21" value="17">Charente maritime</option>
<option class="7" value="18">Cher</option>
<option class="14" value="19">Corrèze</option>
<option class="5" value="21">Côte d'or</option>
<option class="6" value="22">Côtes d'Armor</option>
<option class="14" value="23">Creuse</option>
<option class="2" value="24">Dordogne</option>
<option class="10" value="25">Doubs</option>
<option class="22" value="26">Drôme</option>
<option class="11" value="27">Eure</option>
<option class="7" value="28">Eure et Loir</option>
<option class="6" value="29">Finistère</option>
<option class="13" value="30">Gard</option>
<option class="16" value="31">Haute garonne</option>
<option class="16" value="32">Gers</option>
<option class="2" value="33">Gironde</option>
<option class="13" value="34">Hérault</option>
<option class="6" value="35">Ile et Vilaine</option>
<option class="7" value="36">Indre</option>
<option class="7" value="37">Indre et Loire</option>
<option class="22" value="38">Isère</option>
<option class="10" value="39">Jura</option>
<option class="2" value="40">Landes</option>
<option class="7" value="41">Loir et Cher</option>
<option class="22" value="42">Loire</option>
<option class="3" value="43">Haute loire</option>
<option class="19" value="44">Loire Atlantique</option>
<option class="7" value="45">Loiret</option>
<option class="16" value="46">Lot</option>
<option class="2" value="47">Lot et Garonne</option>
<option class="13" value="48">Lozère</option>
<option class="19" value="49">Maine et Loire</option>
<option class="4" value="50">Manche</option>
<option class="8" value="51">Marne</option>
<option class="8" value="52">Haute Marne</option>
<option class="19" value="53">Mayenne</option>
<option class="15" value="54">Meurthe et Moselle</option>
<option class="15" value="55">Meuse</option>
<option class="6" value="56">Morbihan</option>
<option class="15" value="57">Moselle</option>
<option class="5" value="58">Nièvre</option>
<option class="17" value="59">Nord</option>
<option class="20" value="60">Oise</option>
<option class="4" value="61">Orne</option>
<option class="17" value="62">Pas de Calais</option>
<option class="3" value="63">Puy de Dôme</option>
<option class="2" value="64">Pyrénées Atlantiques</option>
<option class="16" value="65">Hautes Pyrénées</option>
<option class="13" value="66">Pyrénées Orientales</option>
<option class="1" value="67">Bas Rhin</option>
<option class="1" value="68">Haut Rhin</option>
<option class="22" value="69">Rhône</option>
<option class="10" value="70">Haute Saône</option>
<option class="5" value="71">Saône et Loire</option>
<option class="19" value="72">Sarthe</option>
<option class="22" value="73">Savoie</option>
<option class="22" value="74">Haute Savoie</option>
<option class="12" value="75">Paris</option>
<option class="11" value="76">Seine Maritime</option>
<option class="12" value="77">Seine et Marne</option>
<option class="12" value="78">Yvelines</option>
<option class="21" value="79">Deux Sèvres</option>
<option class="20" value="80">Somme</option>
<option class="16" value="81">Tarn</option>
<option class="16" value="82">Tarn et Garonne</option>
<option class="18" value="83">Var</option>
<option class="18" value="84">Vaucluse</option>
<option class="19" value="85">Vendée</option>
<option class="21" value="86">Vienne</option>
<option class="14" value="87">Haute Vienne</option>
<option class="10" value="88">Vosge</option>
<option class="5" value="89">Yonne</option>
<option class="10" value="90">Territoire de Belfort</option>
<option class="12" value="91">Essonne</option>
<option class="12" value="92">Haut de seine</option>
<option class="12" value="93">Seine Saint Denis</option>
<option class="12" value="94">Val de Marne</option>
<option class="12" value="95">Val d'Oise</option>
<option class="9" value="2a">Corse du Sud</option>
<option class="9" value="2b">Haute Corse</option>
</select>

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