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			<td><font face="ITCAvantGardePro"><span style="font-size:18px"><b>ESTIMATION DU RISQUE DE BLANCHIMENT</b></span></font></td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Objet et nature de la mission, op&eacute;ration, relation d&#39;affaires :</span></td>
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			<td>{% textarea_tag name=&quot;a038b8e2&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;objet et nature de la mission, op&eacute;ration, relation d&#39;affaires&quot; data_map_field=&quot;nomap&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td style="vertical-align: bottom;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Risque de blanchiment :</span></td>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% radio_tag name=&quot;a5934090&quot; data_label=&quot;risque de blanchiment&quot; data_map_field=&quot;nomap&quot; data_choices=&quot;oui|oui; non|non;&quot; %}</span></td>
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			<td style="width: 30%; vertical-align: bottom;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Si oui, niveau de risque &eacute;valu&eacute; :</span></td>
			<td>{% select_tag name=&quot;6ac60d75&quot; data_label=&quot;niveau de risque &eacute;valu&eacute;&quot; data_map_field=&quot;nomap&quot; data_choices=&quot;faible|faible; moyen|moyen; &eacute;lev&eacute;|&eacute;lev&eacute;;&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Justification du niveau de risque :</span></td>
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			<td>{% textarea_tag name=&quot;ab5ce5f9&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Justification du niveau de risque&quot; data_map_field=&quot;nomap&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td><span class="titre_p" style="font-family:ITCAvantGardePro;font-size:18px;font-weight:900;">V&Eacute;RIFICATION DES DONN&Eacute;ES PERSONNELLES</span></td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% radio_tag name=&quot;6c2f22d1&quot; data_label=&quot;le client est pr&eacute;sent physiquement&quot; data_map_field=&quot;nomap&quot; data_choices=&quot;le client est pr&eacute;sent physiquement|le client est pr&eacute;sent physiquement;le client n&#39;est pas pr&eacute;sent physiquement|le client n&#39;est pas pr&eacute;sent physiquement;&quot; %}</span></td>
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			<td style="vertical-align: bottom; width: 40%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Date de validit&eacute; de la pi&egrave;ce d&#39;identit&eacute;</span></td>
			<td>{% dateinput_tag name=&quot;4a5ae136&quot; placeholder=&quot;jj/mm/aaaa&quot; data_label=&quot;date de validit&eacute; de la pi&egrave;ce d&#39;identit&eacute;&quot; data_map_field=&quot;nomap&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td style="vertical-align: bottom; width: 15%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Certification</span></td>
			<td style="width: 15%; vertical-align: bottom;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% radio_tag name=&quot;7f150250&quot; data_label=&quot;certification&quot; data_map_field=&quot;nomap&quot; data_choices=&quot;oui|oui;non|non;&quot; %}</span></td>
			<td style="vertical-align: bottom; width: 15%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&eacute;mise par :</span></td>
			<td>{% textinput_tag name=&quot;d6576e33&quot; data_label=&quot;certification &eacute;mise par&quot; data_map_field=&quot;nomap&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td style="vertical-align: bottom; width: 20%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Date de la certification</span></td>
			<td style="width: 70%;">{% dateinput_tag name=&quot;61747319&quot; data_label=&quot;date de la certification&quot; data_map_field=&quot;nomap&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td colspan="2" style="vertical-align: bottom; width: 15%;"><span class="titre_p" style="font-family:ITCAvantGardePro;font-size:18px;font-weight:900;">CONTR&Ocirc;LE PEP (Politically Exposed Person)</span></td>
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			<td style="vertical-align: bottom; width: 15%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">La personne est-elle un PEP ?</span></td>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% radio_tag name=&quot;816d73f1&quot; data_label=&quot;la personne est-elle un PEP ?&quot; data_map_field=&quot;nomap&quot; data_choices=&quot;oui|oui;non|non;&quot; %}</span></td>
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			<td colspan="2" style="width: 32%; vertical-align: bottom;"><span class="titre_p" style="font-family:ITCAvantGardePro;font-size:18px;font-weight:900;">IDENTIFICATION DES B&Eacute;N&Eacute;FICIAIRES EFFECTIFS (BE)</span></td>
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			<td style="width: 32%; vertical-align: bottom;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Les BE sont-ils identifi&eacute;s ?</span></td>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% radio_tag name=&quot;cca95ee0&quot; data_label=&quot;Les BE sont-ils identifi&eacute;s ?&quot; data_map_field=&quot;nomap&quot; data_choices=&quot;oui|oui;non|non;&quot; %}</span></td>
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			<td style="width: 32%; vertical-align: bottom;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">La d&eacute;claration de BE est-elle remplie ?</span></td>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% radio_tag name=&quot;4baf5701&quot; data_label=&quot;La d&eacute;claration de BE est-elle remplie ?&quot; data_map_field=&quot;nomap&quot; data_choices=&quot;oui|oui;non|non;&quot; %}</span></td>
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			<td style="width: 32%; vertical-align: bottom;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&Eacute;tabli &agrave; :</span></td>
			<td>{% textinput_tag name=&quot;84e60064&quot; data_label=&quot;de d&eacute;claration de BE a &eacute;t&eacute; &eacute;tabli &agrave;&quot; data_map_field=&quot;nomap&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td><span class="titre_p" style="font-family:ITCAvantGardePro;font-size:18px;font-weight:900;">OBSERVATIONS</span></td>
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			<td>{% textarea_tag name=&quot;edb7f360&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;observations&quot; data_map_field=&quot;nomap&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td style="width: 65%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Nom et pr&eacute;nom du professionnel responsable de l&#39;application de la loi LBC/FT :</span></td>
			<td style="width: 35px;">{% textinput_tag name=&quot;5889cf61&quot; data_label=&quot;Nom et pr&eacute;nom du professionnel responsable de l&#39;application de la loi LBC/FT&quot; data_map_field=&quot;nomap&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td style="width: 65%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Nom et pr&eacute;nom du professionnel :</span></td>
			<td style="width: 35px;">{% textinput_tag name=&quot;d461b625&quot; data_label=&quot;Nom et pr&eacute;nom du professionnel&quot; data_map_field=&quot;nomap&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td style="width: 65%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Mission pour le client termin&eacute;e le :</span></td>
			<td style="width: 35px;">{% dateinput_tag name=&quot;3558fc41&quot; data_label=&quot;Mission pour le client termin&eacute;e le&quot; data_map_field=&quot;nomap&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td style="width: 65%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&Eacute;tablissement/V&eacute;rification des donn&eacute;es le :</span></td>
			<td style="width: 35px;">{% dateinput_tag name=&quot;a96dbc58&quot; data_label=&quot;&Eacute;tablissement/V&eacute;rification des donn&eacute;es le&quot; data_map_field=&quot;nomap&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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