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Contenu

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Not present but represented by:</span></p>

<table border="0" cellpadding="1" cellspacing="5" style="width:100%;">
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			<td style="vertical-align: bottom; width: 50%; text-align: left;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% select_tag name=&quot;3b3f8632&quot; data_label=&quot;Civilit&eacute;&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Civilit&eacute;&quot; data_choices=&quot;Title|civilite; Misses|madame; Mister|monsieur;&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}<strong>&nbsp;</strong>Last name:</span></td>
			<td style="vertical-align: bottom; width: 50%; text-align: left;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">First name:</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;70fefbfc&quot; data_label=&quot;Nom&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Nom&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;38a690ae&quot; data_label=&quot;Pr&eacute;nom&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Pr&eacute;nom&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="width: 68%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Address:</span></td>
		</tr>
		<tr>
			<td style="width: 68%;">{% textinput_tag name=&quot;e3dd99c2&quot; data_label=&quot;Adresse postale&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Adresse postale&quot; maxlength=&quot;100&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

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			<td style="vertical-align: middle; width: 20%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Zip code:</span></td>
			<td style="width: 55%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">City:</span></td>
			<td style="width: 25%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Country:</span></td>
		</tr>
		<tr>
			<td style="width: 20%;">{% textinput_tag name=&quot;bc947c64&quot; data_label=&quot;Code Postal&quot; data_map_field=&quot;nomap&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: 55%;">{% textinput_tag name=&quot;e9da784c&quot; data_label=&quot;Ville&quot; data_map_field=&quot;nomap&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;93b6ed72&quot; placeholder=&quot;France&quot; data_label=&quot;Pays&quot; data_map_field=&quot;nomap&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="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;">Phone number:&nbsp;&nbsp;</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 70%;">{% textinput_tag name=&quot;4bb4a92e&quot; data_label=&quot;Email&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Email&quot; maxlength=&quot;50&quot; relation_ids_list=&quot;4ce94e90&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;a3b9c6fb&quot; data_label=&quot;T&eacute;l&quot; data_map_field=&quot;nomap&quot; data_help=&quot;T&eacute;l&quot; maxlength=&quot;25&quot; relation_ids_list=&quot;983649b0&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;">Other useful information:</span></td>
		</tr>
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			<td>{% textarea_tag name=&quot;6332743f&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Autres informations utiles&quot; data_map_field=&quot;nomap&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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			<td><span style="font-weight:100;"><em><span style="font-size:8px;"><span style="font-family: ITCAvantGardePro;">You have the possibility of registering on www.bloctel.gouv.fr to oppose any telephone canvassing in accordance with article L223-1 of the Consumer Code</span></span></em></span></td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">by virtue of the powers granted to them for this purpose under the terms of a private power of attorney dated</span></td>
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			<td style="width: 15%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% dateinput_tag name=&quot;c5bea8ef&quot; placeholder=&quot;jj/mm/aaaa&quot; data_label=&quot;Date de la procuration&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Date de la procuration&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></td>
			<td style="vertical-align: middle; white-space: nowrap;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">signed in</span></td>
			<td style="width: 80%;"><span style="font-family: ITCAvantGardePro; font-size: 12px;">{% textinput_tag name=&quot;288677c2&quot; data_label=&quot;Lieu de la procuration&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Lieu de la procuration&quot; maxlength=&quot;80&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></td>
		</tr>
	</tbody>
</table>

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">the original of which is attached hereto.</span></p>

Mode Simplifié

<p style="text-align: justify;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Non pr&eacute;sent &agrave; l&rsquo;acte mais repr&eacute;sent&eacute; par :&nbsp;</span></p>

<p style="text-align: justify;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"><strong>{{3b3f8632}}&nbsp;{{70fefbfc}} {{38a690ae}},</strong> demeurant&nbsp;<strong>{{e3dd99c2}}&nbsp;{{bc947c64}} {{e9da784c}}</strong>,&nbsp;<strong>{{93b6ed72}}</strong></span></p>

<p style="text-align: justify;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&bull; email :&nbsp;<strong>{{4bb4a92e}}&nbsp;&bull;</strong>&nbsp;t&eacute;l&eacute;phone : <strong>{{fa3b9c6fb}}</strong></span></p>

<p style="text-align: justify;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Autres informations utiles : <strong>&nbsp;{{6332743f}}</strong></span></p>

<p style="text-align: justify;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">en vertu des pouvoirs qui lui ont &eacute;t&eacute; conf&eacute;r&eacute;s &agrave; cet effet aux termes d&rsquo;une procuration sous seing priv&eacute; en date du <strong>{{c5bea8ef}}</strong> fait &agrave;&nbsp;<strong>{{288677c2}}</strong>&nbsp;dont l&#39;original est demeur&eacute; ci-annex&eacute;.</span></p>

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