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<table border="0" cellpadding="1" cellspacing="2" style="width:100%;">
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			<td style="width: 70%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Naam vennootschap:</span></td>
			<td style="width: 30%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Soort vennootschap:</span></td>
		</tr>
		<tr>
			<td style="width: 70%;">{% textinput_tag name=&quot;ab03824b&quot; data_label=&quot;Naam vennootschap&quot; data_map_field=&quot;societe&quot; data_help=&quot;Naam vennootschap&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;efb4a22a&quot; data_label=&quot;Soort&quot; data_map_field=&quot;nomap&quot; data_help=&quot;BV, NV, BVBA...&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%;">
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			<td style="vertical-align: middle; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Ingeschreven te:</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;66cded07&quot; data_label=&quot;Inschrijvingsplaats&quot; data_map_field=&quot;nomap&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;79bc8f8a&quot; data_label=&quot;Ondernemingsnummer&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Ondernemingsnummer KBO&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%;">
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			<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;c5dc6c9c&quot; data_label=&quot;Maatschappelijk kapitaal&quot; data_map_field=&quot;nomap&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 in zijn hoedanigheid van Bestuurder, door:</span>&nbsp;</p>

<table border="0" cellpadding="1" cellspacing="2" style="width:100%;">
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			<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;833391fd&quot; data_label=&quot;Aanhef&quot; data_help=&quot;Kies de aanhef&quot; data_choices=&quot;Aanhef|civilite; De heer|monsieur; Mevrouw|madame;&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; data_map_field=&quot;aanhef&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;087a9c2a&quot; data_label=&quot;Naam&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;002cb93f&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%;">
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			<td style="width: 68%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Waarvan de maatschappelijke zetel is gevestigd te:</span></td>
		</tr>
		<tr>
			<td style="width: 68%;">{% textinput_tag name=&quot;109d7745&quot; data_label=&quot;Postadres maatschappelijke zetel&quot; data_map_field=&quot;adresse&quot; data_help=&quot;Postadres 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%;">
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			<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;f5e66571&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;ed0a66fe&quot; data_label=&quot;Stad&quot; data_map_field=&quot;stad&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;4e0fc70a&quot; placeholder=&quot;Luxemburg&quot; data_label=&quot;Land&quot; data_map_field=&quot;land&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%;">
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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;">Tel:&nbsp;&nbsp;</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 70%;">{% textinput_tag name=&quot;385a4815&quot; data_label=&quot;E-mail ondertekenaar&quot; data_map_field=&quot;email&quot; data_help=&quot;E-mail 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;3f66c14a&quot; data_label=&quot;Tel ondertekenaar&quot; data_map_field=&quot;tel&quot; data_help=&quot;Tel ondertekenaar&quot; maxlength=&quot;25&quot; relation_ids_list=&quot;e98e647c&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%;">
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Andere nuttige informatie:&nbsp;</span></td>
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			<td>{% textarea_tag name=&quot;eda2bf89&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; relation_ids_list=&quot;1256,1728,1111,7056,6290,10507,525,1206,1728,2248,6286,8701&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%;">
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			<td style="vertical-align: middle; width: 20%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Andere vertegenwoordiger(s):</span></td>
			<td>{% select_tag name=&quot;900779a0&quot; data_label=&quot;Andere vertegenwoordiger(s)&quot; data_map_field=&quot;nomap&quot; data_help=&quot;andere vertegenwoordiger(s)&quot; data_choices=&quot;nee&nbsp; &nbsp;|non;ja&nbsp; &nbsp; |oui;&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

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