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<table border="0" cellpadding="1" cellspacing="1" style="width:100%;">
	<tbody>
		<tr>
			<td colspan="2" style="vertical-align: top; width: 12%;"><span style="font-weight:600;"><span style="font-family: ITCAvantGardePro; font-size: 12px;">Par Virement :</span></span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 12%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Emis par :&nbsp;</span></td>
			<td style="vertical-align: top; width: 85%;">{% textarea_tag name=&quot;7bd8df43&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Nom de l&#39;&eacute;metteur du virement&quot; data_map_field=&quot;nomap&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="1" style="width:100%;">
	<tbody>
		<tr>
			<td style="width: 20%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Montant du virement :</span></td>
			<td>{% textinput_tag name=&quot;43d8addf&quot; data_label=&quot;Montant du virement :&quot; data_map_field=&quot;nomap&quot; maxlength=&quot;70&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="1" style="width:100%;">
	<tbody>
		<tr>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Agence bancaire :&nbsp;</span></td>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">R&eacute;f&eacute;rence du virement :</span></td>
		</tr>
		<tr>
			<td>{% textinput_tag name=&quot;e3ba7273&quot; data_label=&quot;Agence bancaire&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Agence bancaire&quot; maxlength=&quot;45&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td>{% textinput_tag name=&quot;895d9397&quot; data_label=&quot;R&eacute;f&eacute;rence du virement&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Num&eacute;ro du ch&egrave;que&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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