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<table border="0" cellpadding="1" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="width: 70%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Bedrijfsnaam :</span></td>
			<td style="width: 30%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Bedrijfstype :</span></td>
		</tr>
		<tr>
			<td style="width: 70%;">{% textinput_tag name=&quot;fe4918c7&quot; data_label=&quot;Bedrijfsnaam&quot; data_map_field=&quot;societe&quot; data_help=&quot;Bedrijfsnaam&quot; maxlength=&quot;100&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 30%;">{% textinput_tag name=&quot;ae91c87b&quot; data_label=&quot;Type&quot; data_map_field=&quot;company_type&quot; data_help=&quot;SCI, SA, SARL...&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align: middle; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Ingeschreven bij :</span></td>
			<td style="vertical-align: middle; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Onder nummer :</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;5b386f55&quot; data_label=&quot;Locatie van inschrijving&quot; data_map_field=&quot;rcs_place&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;876a688c&quot; data_label=&quot;Nummer&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>

<table border="0" cellpadding="1" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align: middle; width: 15%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Met een kapitaal van :</span></td>
			<td>{% textinput_tag name=&quot;55cd98bd&quot; data_label=&quot;Maatschappelijk kapitaal&quot; data_map_field=&quot;capital&quot; data_help=&quot;Maatschappelijk kapitaal&quot; maxlength=&quot;70&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Vertegenwoordigd als bedrijfsleider, door :</span>&nbsp;</p>

<table border="0" cellpadding="1" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align: middle; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"><strong>&nbsp;</strong></span>{% select_tag name=&quot;87a7391fd&quot; data_label=&quot;Aanhef&quot; data_map_field=&quot;civilite&quot; data_help=&quot;Kies de aanhef&quot; data_choices=&quot;Aanhef|civilite; Meneer|Monsieur; Mevrouw|Madame;&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}&nbsp;<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Naam :</span></td>
			<td style="vertical-align: bottom; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Voornaam :</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;d368006f&quot; data_label=&quot;Achternaam&quot; data_map_field=&quot;nom&quot; data_help=&quot;Naam van de ondertekenaar&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;ad756ce1&quot; data_label=&quot;Voornaam&quot; data_map_field=&quot;prenom&quot; data_help=&quot;Voornaam van de ondertekenaar&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="width: 68%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Waarvan de maatschappelijke zetel is gevestigd :</span></td>
		</tr>
		<tr>
			<td style="width: 68%;">{% textinput_tag name=&quot;88cf7082&quot; data_label=&quot;Postadres van de maatschappelijke zetel&quot; data_map_field=&quot;adresse&quot; data_help=&quot;Postadres van de maatschappelijke zetel&quot; maxlength=&quot;100&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="width: 20%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Postcode :</span></td>
			<td style="width: 55%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Stad :</span></td>
			<td style="width: 25%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Land :</span></td>
		</tr>
		<tr>
			<td style="width: 20%;">{% textinput_tag name=&quot;b5154f50&quot; data_label=&quot;Postcode&quot; data_map_field=&quot;zipcode&quot; data_help=&quot;Postcode&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;72230b87&quot; data_label=&quot;Stad&quot; data_map_field=&quot;ville&quot; data_help=&quot;Stad&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;72ba8a88&quot; placeholder=&quot;Luxemburg&quot; data_label=&quot;Land&quot; data_map_field=&quot;pays&quot; data_help=&quot;Land&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<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;c4f61172&quot; data_label=&quot;E-mail van de ondertekenaar&quot; data_map_field=&quot;email&quot; data_help=&quot;E-mail van de ondertekenaar&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;86e4290d&quot; data_label=&quot;Tel van de ondertekenaar&quot; data_map_field=&quot;tel&quot; data_help=&quot;Tel van de ondertekenaar&quot; maxlength=&quot;25&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="2" style="width: 100%;">
	<tbody>
		<tr>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Andere nuttige informatie :&nbsp;</span></td>
		</tr>
		<tr>
			<td>{% textarea_tag name=&quot;201f4031&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Andere nuttige informatie&quot; data_map_field=&quot;comment&quot; data_help=&quot;Andere nuttige informatie&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

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