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<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;">{% select_tag name=&quot;a6e3a684&quot; data_label=&quot;Geslacht&quot; data_map_field=&quot;civilite&quot; data_help=&quot;Kies het geslacht&quot; data_choices=&quot;Geslacht|civilite; Meneer|Monsieur; Mevrouw|Madame;&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %} 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;3a83994c&quot; data_label=&quot;Naam van de ondertekenaar &quot; data_map_field=&quot;nom&quot; data_help=&quot;Naam van de ondertekenaar, geef de meisjesnaam indien van toepassing&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;863d332e&quot; data_label=&quot;Voornaam van de ondertekenaar&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="vertical-align: middle; width: 20%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Geboortedatum :</span></td>
			<td style="vertical-align: middle; width: 80%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Geboorteplaats :</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 20%;">{% dateinput_tag name=&quot;2bf3b2e6&quot; placeholder=&quot;jj/mm/aaaa&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>
			<td style="vertical-align: middle; width: 80%;">{% textinput_tag name=&quot;0ce6ad00&quot; data_label=&quot;Geboorteplaats&quot; data_map_field=&quot;geboorteplaats&quot; data_help=&quot;Geboorteplaats&quot; maxlength=&quot;80&quot; data_ancien_ids=&quot;21911&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="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&nbsp;:</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;6981f7df&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;e3bc61fb&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>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="2" 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%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp;Tel :&nbsp;&nbsp;</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 70%;">{% textinput_tag name=&quot;236c0e3e&quot; data_label=&quot;E-mailadres van ondertekenaar&quot; data_map_field=&quot;email&quot; data_help=&quot;E-mailadres van 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;713d4f5d&quot; data_label=&quot;Telefoonnummer van ondertekenaar&quot; data_map_field=&quot;tel&quot; data_help=&quot;Telefoonnummer van 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 style="width: 68%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Adres :</span></td>
		</tr>
		<tr>
			<td style="width: 68%;">{% textinput_tag name=&quot;d88aeeaf&quot; data_label=&quot;Postadres van ondertekenaar&quot; data_map_field=&quot;adresse&quot; data_help=&quot;Postadres van ondertekenaar&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;b60aee67&quot; data_label=&quot;Postcode van ondertekenaar&quot; data_map_field=&quot;zipcode&quot; data_help=&quot;Postcode van 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;b7f2a81a&quot; data_label=&quot;Stad van ondertekenaar&quot; data_map_field=&quot;ville&quot; data_help=&quot;Stad van 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;a17ab43c&quot; placeholder=&quot;Luxemburg&quot; data_label=&quot;Land van ondertekenaar&quot; data_map_field=&quot;pays&quot; data_help=&quot;Land van 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="vertical-align: middle; width: 50%;">{% select_tag name=&quot;25732082&quot; data_label=&quot;Aanhef&quot; data_map_field=&quot;civilite&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; %} Naam:</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;0f5254e4&quot; data_label=&quot;Achternaam van ondertekenaar&quot; data_map_field=&quot;nom&quot; data_help=&quot;Achternaam van ondertekenaar, geef de meisjesnaam indien van toepassing&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;f1341fab&quot; data_label=&quot;Voornaam van ondertekenaar&quot; data_map_field=&quot;prenom&quot; data_help=&quot;Voornaam van 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="vertical-align: middle; width: 20%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Geboortedatum :</span></td>
			<td style="vertical-align: middle; width: 80%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Geboorteplaats :</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 20%;">{% dateinput_tag name=&quot;74aed1f2&quot; placeholder=&quot;jj/mm/aaaa&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>
			<td style="vertical-align: middle; width: 80%;">{% textinput_tag name=&quot;0252dbb6&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>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="2" 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;">Beroep&nbsp;:</span></td>
			<td style="vertical-align: middle; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Nationaliteit&nbsp;:</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;8d8075c9&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;1f8af9ec&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>
		</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%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp;Tel :&nbsp;&nbsp;</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 70%;">{% textinput_tag name=&quot;a0c53b54&quot; data_label=&quot;E-mailadres van ondertekenaar&quot; data_map_field=&quot;email&quot; data_help=&quot;E-mailadres van 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;586d0391&quot; data_label=&quot;Telefoonnummer van ondertekenaar&quot; data_map_field=&quot;tel&quot; data_help=&quot;Telefoonnummer van 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 style="width: 68%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Adres :</span></td>
		</tr>
		<tr>
			<td style="width: 68%;">{% textinput_tag name=&quot;d88aeeaf&quot; data_label=&quot;Postadres van ondertekenaar&quot; data_map_field=&quot;adresse&quot; data_help=&quot;Postadres van ondertekenaar&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;b60aee67&quot; data_label=&quot;Postcode van ondertekenaar&quot; data_map_field=&quot;zipcode&quot; data_help=&quot;Postcode van 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;b7f2a81a&quot; data_label=&quot;Stad van ondertekenaar&quot; data_map_field=&quot;ville&quot; data_help=&quot;Stad van 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;a17ab43c&quot; placeholder=&quot;Luxemburg&quot; data_label=&quot;Land van ondertekenaar&quot; data_map_field=&quot;pays&quot; data_help=&quot;Land van 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><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Andere nuttige informatie&nbsp;:</span></td>
		</tr>
		<tr>
			<td>{% textarea_tag name=&quot;efb904ff&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%;">
	<tbody>
		<tr>
			<td style="vertical-align: middle; width: 25%;">
			<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Datum en plaats van huwelijk:</span></p>
			</td>
			<td>{% textinput_tag name=&quot;5d003cd3&quot; data_label=&quot;Datum en plaats van huwelijk&quot; data_map_field=&quot;marriage_place_and_date&quot; data_help=&quot;Datum en plaats van huwelijk&quot; maxlength=&quot;70&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
		<tr>
			<td style="vertical-align: top; width: 25%;">
			<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Huwelijksvermogensstelsel:</span></p>
			</td>
			<td style="vertical-align: top;">{% textarea_tag name=&quot;d95f186e&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Huwelijksvermogensstelsel&quot; data_map_field=&quot;matrimonial_regime&quot; data_help=&quot;Huwelijksvermogensstelsel&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

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