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<table border="0" cellpadding="1" cellspacing="2" style="width: 100%;">
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			<td style="vertical-align: middle; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% select_tag name=&quot;f1e5b497&quot; data_label=&quot;Civilit&eacute; du propr&eacute;taire&quot; data_map_field=&quot;civilite&quot; data_help=&quot;Civilit&eacute; du propr&eacute;taire&quot; data_choices=&quot;Civilit&eacute;|civilite; Madame|madame; Monsieur|monsieur;&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}<strong>&nbsp;</strong>Nom :</span></td>
			<td style="vertical-align: middle; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Pr&eacute;nom :</span></td>
		</tr>
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			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;bfd751be&quot; data_label=&quot;Nom du propr&eacute;taire&quot; data_map_field=&quot;nom&quot; data_help=&quot;Nom du propr&eacute;taire&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;d7a0d998&quot; data_label=&quot;Pr&eacute;nom du propr&eacute;taire&quot; data_map_field=&quot;prenom&quot; data_help=&quot;Pr&eacute;nom du propr&eacute;taire&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td style="width: 68%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Adresse :</span></td>
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			<td style="width: 68%;">{% textinput_tag name=&quot;56874f6f&quot; data_label=&quot;Adresse postale du propri&eacute;taire&quot; data_map_field=&quot;adresse&quot; data_help=&quot;Adresse postale du propri&eacute;taire&quot; maxlength=&quot;100&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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</table>

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			<td style="width: 20%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Code postal :</span></td>
			<td style="width: 55%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Ville :</span></td>
			<td style="width: 25%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Pays :</span></td>
		</tr>
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			<td style="width: 20%;">{% numberinput_tag name=&quot;0702d1d6&quot; data_label=&quot;Code Postal&quot; data_map_field=&quot;zipcode&quot; data_help=&quot;Code Postal&quot; maxlength=&quot;8&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 55%;">{% textinput_tag name=&quot;8d3afb81&quot; data_label=&quot;Ville&quot; data_map_field=&quot;ville&quot; data_help=&quot;Ville&quot; maxlength=&quot;80&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 25%;">{% textinput_tag name=&quot;328077ae&quot; placeholder=&quot;France&quot; data_label=&quot;Pays&quot; data_map_field=&quot;pays&quot; data_help=&quot;Pays&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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</table>

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			<td style="vertical-align: middle; width: 70%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">E-mail :&nbsp;</span></td>
			<td style="vertical-align: middle; width: 30%;">&nbsp;<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Tel :&nbsp;&nbsp;</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 70%;">{% textinput_tag name=&quot;3d7a16a9&quot; data_label=&quot;Email&quot; data_map_field=&quot;email&quot; data_help=&quot;Email &quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="vertical-align: middle; width: 30%;">{% textinput_tag name=&quot;39f7b810&quot; data_label=&quot;Tel&quot; data_map_field=&quot;mobile&quot; data_help=&quot;T&eacute;l&eacute;phone mobile&quot; maxlength=&quot;15&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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</table>

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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Autres informations utiles :</span></td>
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			<td>{% textarea_tag name=&quot;3b6fb8ee&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Autres informations utiles&quot; data_map_field=&quot;comment&quot; data_help=&quot;Autres informations utiles&quot; relation_ids_list=&quot;1256,1728,1111,7056,6290,10507,525,1206,1728,2248,6286,8701&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td><span style="font-weight:100;"><em><span style="font-size:8px;"><span style="font-family: ITCAvantGardePro;">Vous avez la possibilit&eacute; de vous inscrire sur www.bloctel.gouv.fr pour vous opposer &agrave; tout d&eacute;marchage t&eacute;l&eacute;phonique conform&eacute;ment &agrave; l&#39;article L223-1 du Code de la consommation.</span></span></em>&nbsp;</span></td>
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<p style="text-align: justify;"><span style="font-family: ITCAvantGardePro; font-size: 12px; text-align: justify;">Nous vous prions de bien vouloir trouver ci-apr&egrave;s les coordonn&eacute;es de personnes &agrave; qui nous avons pr&eacute;sent&eacute; les biens que vous nous avez confi&eacute;s &agrave; la vente ou &agrave; la location.</span></p>

<p style="text-align: justify;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Nous ne manquerons pas de vous informer du suivi.<br />
De notre c&ocirc;t&eacute;, nous vous remercions de nous signaler tout contact que vous pourriez avoir avec ces personnes, conform&eacute;ment au mandat.</span></p>

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			<td><span style="font-weight:900;"><span style="font-family: ITCAvantGardePro; font-size: 12px;"><span class="titre_p">Observations &eacute;ventuelles :</span></span></span></td>
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			<td>{% textarea_tag name=&quot;f928ab18&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Observations &eacute;ventuelles&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Observations &eacute;ventuelles&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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