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<table border="1" cellpadding="0" cellspacing="0" style="width:100%; border-color:#A5644B">
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			<table border="0" cellpadding="2" cellspacing="2" style="width:100%; padding:10px ; padding-bottom:3px">
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						<td colspan="7" style="width: 15%;">INFORMATIONS D&Eacute;BITEUR&nbsp;Veuillez compl&eacute;ter les champs marqu&eacute;s *</td>
					</tr>
					<tr>
						<td style="width: 15%; border-color: rgb(165, 100, 75);">Titulaire du compte</td>
						<td style="width: 3%; text-align: right;">*</td>
						<td colspan="5" rowspan="1" style="width: 25%;">{% textarea_tag name=&quot;defbdd37&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Nom et pr&eacute;nom du d&eacute;biteur&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Nom et pr&eacute;nom du d&eacute;biteur&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
					</tr>
					<tr>
						<td style="width: 15%;">&nbsp;</td>
						<td style="width: 3%;">&nbsp;</td>
						<td colspan="5" rowspan="1" style="width: 25%;">Nom / Pr&eacute;nom du d&eacute;biteur</td>
					</tr>
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						<td style="width: 15%;">Votre adresse</td>
						<td style="width: 3%; text-align: right;">*</td>
						<td colspan="5" rowspan="1" style="width: 25%;">{% textarea_tag name=&quot;cf2d47f2&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Adresse du d&eacute;biteur&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Adresse du d&eacute;biteur&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
					</tr>
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						<td style="width: 15%;">&nbsp;</td>
						<td style="width: 3%;">&nbsp;</td>
						<td colspan="5" rowspan="1" style="width: 25%;">Num&eacute;ro et nom de la rue</td>
					</tr>
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						<td style="width: 15%;">&nbsp;</td>
						<td style="width: 3%; text-align: right;">*</td>
						<td colspan="3" rowspan="1" style="width: 25%;">{% textarea_tag name=&quot;f9e61f53&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Code postal et ville du d&eacute;biteur&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Code postal et ville du d&eacute;biteur&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
						<td style="width: 3%; text-align: right;">*</td>
						<td style="width: 25%;">{% textarea_tag name=&quot;ec952aa5&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Pays du d&eacute;biteur&quot; data_map_field=&quot;nomap&quot; placeholder=&quot;France&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
					</tr>
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						<td style="width: 15%;">&nbsp;</td>
						<td style="width: 3%;">&nbsp;</td>
						<td colspan="3" rowspan="1" style="width: 25%;">Code Postal / Ville</td>
						<td style="width: 3%;">&nbsp;</td>
						<td style="width: 25%;">Pays</td>
					</tr>
					<tr>
						<td colspan="1" rowspan="2" style="width: 15%;">Coordonn&eacute;es de 
						votre compte</td>
						<td style="width: 3%; text-align: right;">*</td>
						<td colspan="5" rowspan="1" style="width: 25%;">{% textarea_tag name=&quot;7d336534&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Num&eacute;ro d&rsquo;identification international du compte bancaire - IBAN (International Bank Account Number)&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Num&eacute;ro d&rsquo;identification international du compte bancaire - IBAN (International Bank Account Number)&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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						<td style="width: 3%;">&nbsp;</td>
						<td colspan="5" rowspan="1" style="width: 25%;">Num&eacute;ro d&rsquo;identification international du compte bancaire - IBAN (International Bank Account Number)</td>
					</tr>
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						<td style="width: 15%;">&nbsp;</td>
						<td style="width: 3%; text-align: right;">*</td>
						<td colspan="5" rowspan="1" style="width: 25%;">{% textarea_tag name=&quot;98088b40&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Code international d&rsquo;identification de votre banque - BIC (Bank Identifier Code)&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Code international d&rsquo;identification de votre banque - BIC (Bank Identifier Code)&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
					</tr>
					<tr>
						<td style="width: 15%;">&nbsp;</td>
						<td style="width: 3%;">&nbsp;</td>
						<td colspan="5" rowspan="1" style="width: 25%;">Code international d&rsquo;identification de votre banque - BIC (Bank Identifier Code)</td>
					</tr>
					<tr style="margin-top:25px">
						<td colspan="7" style="width: 15%; vertical-align: bottom;">Note : Vos droits concernant le pr&eacute;sent mandat sont expliqu&eacute;s dans un document que vous pouvez obtenir aupr&egrave;s de votre banque.</td>
					</tr>
				</tbody>
			</table>
			</td>
		</tr>
	</tbody>
</table>

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