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<table border="0" cellpadding="5" cellspacing="5" 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><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% select_tag name=&quot;866691fd&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;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>
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			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;ef701867&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;1f8ce236&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>
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</table>

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			<td style="width: 68%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Adres:</span></td>
		</tr>
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			<td style="width: 68%;">{% textinput_tag name=&quot;b5e126c9&quot; data_label=&quot;Postadres van de ondertekenaar&quot; data_map_field=&quot;adresse&quot; data_help=&quot;Postadres van de ondertekenaar&quot; maxlength=&quot;100&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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</table>

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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>
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			<td style="width: 20%;">{% textinput_tag name=&quot;6fa8b771&quot; data_label=&quot;Postcode van de ondertekenaar&quot; data_map_field=&quot;zipcode&quot; data_help=&quot;Postcode van de ondertekenaar&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;f7d5589a&quot; data_label=&quot;Stad van de ondertekenaar&quot; data_map_field=&quot;ville&quot; data_help=&quot;Stad van de ondertekenaar&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;0c600ba1&quot; placeholder=&quot;Luxemburg&quot; data_label=&quot;Land van de ondertekenaar&quot; data_map_field=&quot;pays&quot; data_help=&quot;Land van de ondertekenaar&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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</table>

<table border="0" cellpadding="1" cellspacing="5" 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>
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			<td style="vertical-align: middle; width: 70%;">{% textinput_tag name=&quot;80c95790&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;dfef57d2&quot; data_label=&quot;Telefoon van de ondertekenaar&quot; data_map_field=&quot;tel&quot; data_help=&quot;Telefoon van de ondertekenaar&quot; maxlength=&quot;25&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td style="vertical-align: middle; width: 70%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Geboorteplaats :</span></td>
			<td style="vertical-align: middle; width: 30%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Geboortedatum :</span></td>
		</tr>
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			<td style="vertical-align: middle; width: 70%;">{% textinput_tag name=&quot;46dde5c5&quot; data_label=&quot;Geboorteplaats:&quot; data_map_field=&quot;lieu_naissance&quot; data_help=&quot;Geboorteplaats:&quot; maxlength=&quot;80&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="vertical-align: middle; width: 30%;">{% dateinput_tag name=&quot;b0773fa7&quot; placeholder=&quot;dd/mm/jjjj&quot; data_label=&quot;Geboortedatum&quot; data_map_field=&quot;date_naissance&quot; data_help=&quot;Geboortedatum&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;true&quot; %}</td>
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</table>

<table border="0" cellpadding="1" cellspacing="5" 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;">Beroep :</span></td>
			<td style="vertical-align: middle; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Nationaliteit :</span></td>
		</tr>
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			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;61b57973&quot; data_label=&quot;Beroep&quot; data_map_field=&quot;job&quot; data_help=&quot;Beroep&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;9b260a78&quot; data_label=&quot;Nationaliteit&quot; data_map_field=&quot;nationality&quot; data_help=&quot;Nationaliteit&quot; maxlength=&quot;50&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;"><font face="ITCAvantGardePro">Burgerlijke staat: {% radio_tag name=&quot;d824696956f&quot; data_label=&quot;Burgerlijke staat&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Burgerlijke staat&quot; data_choices=&quot;Ongehuwd&nbsp; |Ongehuwd; Gehuwd&nbsp; |Gehuwd; Geregistreerd partnerschap&nbsp; |Geregistreerd partnerschap; Gescheiden&nbsp; |Gescheiden; Weduwe/Weduwnaar |Weduwe/Weduwnaar;&quot; %}</font></span></td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Gegevens over burgerlijke staat :</span></td>
		</tr>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% textarea_tag name=&quot;d5b6d4ed&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Gedetailleerde burgerlijke staat&quot; data_map_field=&quot;family_situation&quot; data_help=&quot;Vermeld de datum en plaats van het huwelijk en het huwelijksregime. Ook de datum en plaats van registratie van het geregistreerd partnerschap.&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></td>
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</table>

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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Andere nuttige informatie:</span></td>
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			<td>{% textarea_tag name=&quot;a8a19da6&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>
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</table>

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