diff --git a/src/app/form/form.component.html b/src/app/form/form.component.html
index 2b11b64d3bd955218b9b29025c09e4151079e14f..ff8043be8e9fafcfb9d48ba179d796f2754d151e 100644
--- a/src/app/form/form.component.html
+++ b/src/app/form/form.component.html
@@ -305,24 +305,6 @@
 
           <li><span>les horaires d’ouverture</span></li>
 
-          <li><span>la liste des ateliers que vous dispensez (optionnel)</span></li>
-        </ul>
-      </div>
-      <div>
-        <ul>
-          <li><span>les coordonnées de votre structure</span></li>
-
-          <li><span>les horaires d’ouverture</span></li>
-
-          <li><span>la liste des ateliers que vous dispensez (optionnel)</span></li>
-        </ul>
-      </div>
-      <div>
-        <ul>
-          <li><span>les coordonnées de votre structure</span></li>
-
-          <li><span>les horaires d’ouverture</span></li>
-
           <li><span>la liste des ateliers que vous dispensez (optionnel)</span></li>
         </ul>
       </div>
@@ -331,18 +313,31 @@
       <div *ngIf="currentPage == 2" class="page">
         <h3>Qui êtes-vous ?</h3>
         <p>Ces informations ne seront pas visibles sur la plateforme</p>
-        <div class="form-group">
+        <div class="form-group" fxLayout="column">
           <label for="surname">Nom</label>
-          <input type="text" (input)="setValidationsForm()" formControlName="surname" class="form-control" />
+          <div fxLayout="row" fxLayoutGap="13px">
+            <input type="text" (input)="setValidationsForm()" formControlName="surname" class="form-control" />
+            <img *ngIf="accountForm.get('surname').valid" src="../../assets/form/checked.svg" alt="logo checked" />
+          </div>
+        </div>
+        <div class="form-group" fxLayout="column">
+          <label for="name">Prénom</label>
+          <div fxLayout="row" fxLayoutGap="13px">
+            <input type="text" (input)="setValidationsForm()" formControlName="name" class="form-control" />
+            <img *ngIf="accountForm.get('name').valid" src="../../assets/form/checked.svg" alt="logo checked" />
+          </div>
         </div>
-        <div class="form-group">
+        <div class="form-group" fxLayout="column">
           <label for="phone">Téléphone</label>
-          <input
-            type="text"
-            formControlName="phone"
-            class="form-control"
-            (input)="modifyPhoneInput(accountForm, 'phone', $event.target.value)"
-          />
+          <div fxLayout="row" fxLayoutGap="13px">
+            <input
+              type="text"
+              formControlName="phone"
+              class="form-control phone"
+              (input)="modifyPhoneInput(accountForm, 'phone', $event.target.value)"
+            />
+            <img *ngIf="accountForm.get('phone').valid" src="../../assets/form/checked.svg" alt="logo checked" />
+          </div>
         </div>
       </div>
     </form>
diff --git a/src/app/form/form.component.scss b/src/app/form/form.component.scss
index de317e588fc05712803423baca460fb952cd2f70..07934258b5d7896fedcb2270bd9dad49b20d682a 100644
--- a/src/app/form/form.component.scss
+++ b/src/app/form/form.component.scss
@@ -173,3 +173,20 @@
     min-width: 26px;
   }
 }
+.form-group {
+  margin-bottom: 26px;
+}
+input {
+  margin-top: 4px;
+  background: $grey-6;
+  padding: 8px;
+  height: 40px;
+  border: 1px solid $grey-4;
+  box-sizing: border-box;
+  border-radius: 4px;
+  width: 296px;
+  @include cn-regular-14;
+  &.phone {
+    width: 205px;
+  }
+}
diff --git a/src/app/form/form.component.ts b/src/app/form/form.component.ts
index c61887530b0ec5c32879f57ed9273ff38759747d..1cb1ffce263418d5411c594cb557b5fa5db9efe4 100644
--- a/src/app/form/form.component.ts
+++ b/src/app/form/form.component.ts
@@ -304,7 +304,12 @@ export class FormComponent implements OnInit {
   public setValidationsForm(): void {
     this.pagesValidation[0] = { valid: true };
     this.pagesValidation[1] = { valid: true };
-    this.pagesValidation[2] = { valid: this.accountForm.get('surname').valid && this.accountForm.get('phone').valid };
+    this.pagesValidation[2] = {
+      valid:
+        this.accountForm.get('surname').valid &&
+        this.accountForm.get('name').valid &&
+        this.accountForm.get('phone').valid,
+    };
     this.updatePageValid();
   }
 
diff --git a/src/assets/form/checked.svg b/src/assets/form/checked.svg
new file mode 100644
index 0000000000000000000000000000000000000000..991694b27aee6ebb7e16c88850251638d0e014f1
--- /dev/null
+++ b/src/assets/form/checked.svg
@@ -0,0 +1,4 @@
+<svg width="26" height="26" viewBox="0 0 26 26" fill="none" xmlns="http://www.w3.org/2000/svg">
+<circle cx="13" cy="13" r="13" fill="#47C562"/>
+<path d="M8 13.8182L11.8889 17L18 10" stroke="white" stroke-width="3" stroke-linecap="round" stroke-linejoin="round"/>
+</svg>