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<p><span style="color:#000000;"><span style="font-size:16px;"><span class="titre_p" style="font-family: ITCAvantGardePro; font-weight: 900;">IDENTIT&Eacute; DE L&rsquo;AGENT IMMOBILIER ET/OU DE SA SOCI&Eacute;T&Eacute; :&nbsp;&nbsp;</span></span></span></p>

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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Nom de l&rsquo;agent immobilier et/ou de la soci&eacute;t&eacute; :</span></td>
		</tr>
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			<td>{% textinput_tag name=&quot;fe4918c7&quot; data_label=&quot;Nom de l&rsquo;agent immobilier et/ou de la soci&eacute;t&eacute; :<br />
			&quot; data_map_field=&quot;societe&quot; data_help=&quot;Nom de l&rsquo;agent immobilier et/ou de la soci&eacute;t&eacute; :<br />
			&quot; maxlength=&quot;100&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">D&eacute;nomination commerciale&nbsp; :</span></td>
		</tr>
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			<td>{% textinput_tag name=&quot;fe4918c8&quot; data_label=&quot;D&eacute;nomination commerciale&nbsp;&quot; data_map_field=&quot;nomap&quot; data_help=&quot;D&eacute;nomination commerciale&quot; maxlength=&quot;100&quot; data_align_text=&quot;left&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Num&eacute;ro d&rsquo;entreprise :</span></td>
		</tr>
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			<td>{% textinput_tag name=&quot;876a688c&quot; data_label=&quot;Num&eacute;ro d&rsquo;entreprise&quot; data_map_field=&quot;rcs_num&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Adresse :</span></td>
		</tr>
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			<td>{% textinput_tag name=&quot;88cf7082&quot; data_label=&quot;Adresse postale du si&egrave;ge social&quot; data_map_field=&quot;adresse&quot; data_help=&quot;Adresse postale du si&egrave;ge social&quot; maxlength=&quot;100&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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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: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Ville :</span></td>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Pays :</span></td>
		</tr>
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			<td style="width: 20%;">{% textinput_tag name=&quot;b5154f50&quot; data_label=&quot;Code Postal&quot; data_map_field=&quot;zipcode&quot; data_help=&quot;Code Postal&quot; maxlength=&quot;10&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 50%;">{% textinput_tag name=&quot;72230b87&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>{% textinput_tag name=&quot;72ba8a88&quot; placeholder=&quot;Belgique&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>
		</tr>
	</tbody>
</table>

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			<td style="text-align: justify;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">E-mail :&nbsp;</span></td>
			<td style="text-align: justify;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp;T&eacute;l :&nbsp;&nbsp;</span></td>
		</tr>
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			<td style="text-align: justify;">{% textinput_tag name=&quot;c4f61172&quot; data_label=&quot;Email du signataire&quot; data_map_field=&quot;email&quot; data_help=&quot;Email du signataire&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="text-align: justify;">{% textinput_tag name=&quot;86e4290d&quot; data_label=&quot;T&eacute;l du signataire&quot; data_map_field=&quot;tel&quot; data_help=&quot;T&eacute;l du signataire&quot; maxlength=&quot;25&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

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			<td style="text-align: justify;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">! Si elle diff&egrave;re de l&#39;adresse fournie ci-dessus, il faut mentionner ici &eacute;galement l&#39;adresse g&eacute;ographique/mail/t&eacute;l&eacute;phone du si&egrave;ge commercial de l&#39;entreprise et, le cas &eacute;ch&eacute;ant, l&rsquo;adresse de l&#39;entreprise pour le compte de laquelle elle agit, &agrave; laquelle le consommateur peut adresser une &eacute;ventuelle r&eacute;clamation.</span></td>
		</tr>
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			<td>{% textarea_tag name=&quot;201f4031&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; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

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