Admin - Plateforme Administration Editions Préference

Contient un/plusieurs signataires

Reprise des signataires

Peut etre dupliqué

Nombre maximum de block

Texte du bouton 'ajouter'

Texte du bouton 'supprimer'

Ce block contient un

Contenu

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align: bottom; width: 50%;">{% select_tag name=&quot;871c169a&quot; data_label=&quot;Civilit&eacute; du signataire&quot; data_map_field=&quot;civilite&quot; data_help=&quot;Civilit&eacute;&quot; data_choices=&quot;Civilit&eacute;|civilite; Madame|madame; Monsieur|monsieur;&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;">Nom :</span></td>
			<td style="vertical-align: bottom; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp;Pr&eacute;nom :</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;79fc7ffa&quot; data_label=&quot;Nom du signataire&quot; data_map_field=&quot;nom&quot; data_help=&quot;Nom du signataire&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;5185aba3&quot; data_label=&quot;Pr&eacute;nom du signataire&quot; data_map_field=&quot;prenom&quot; data_help=&quot;Pr&eacute;nom du signataire&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="break-inside:avoid;width:100%;">
	<tbody>
		<tr>
			<td style="width: 20%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Date de naissance :</span></td>
			<td style="width: 80%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Lieu de naissance :</span></td>
		</tr>
		<tr>
			<td style="width: 20%;">{% dateinput_tag name=&quot;f014d7d1&quot; placeholder=&quot;jj/mm/aaaa&quot; data_label=&quot;Date de naissance&quot; data_map_field=&quot;date_naissance&quot; data_help=&quot;Date de naissance&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;true&quot; %}</td>
			<td style="width: 80%;">{% textinput_tag name=&quot;67fe78de&quot; data_label=&quot;Lieu de naissance&quot; data_map_field=&quot;lieu_naissance&quot; data_help=&quot;Lieu de naissance&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: 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;">T&eacute;l :&nbsp;&nbsp;</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 70%;">{% textinput_tag name=&quot;f4f59f87&quot; data_label=&quot;Email du signataire&quot; data_map_field=&quot;email&quot; data_help=&quot;Email du signataire&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;f851d3d5&quot; data_label=&quot;T&eacute;l du signataire&quot; data_map_field=&quot;tel&quot; data_help=&quot;T&eacute;l du signataire&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="2" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="width: 68%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Adresse :</span></td>
		</tr>
		<tr>
			<td style="width: 68%;">{% textinput_tag name=&quot;109d7745&quot; data_label=&quot;Adresse postale du signataire&quot; data_map_field=&quot;adresse&quot; data_help=&quot;Adresse postale du signataire&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="vertical-align: middle; width: 20%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Code postal :</span></td>
			<td style="vertical-align: middle; width: 55%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Ville :</span></td>
			<td style="vertical-align: middle; width: 25%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Pays :</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 20%;">{% textinput_tag name=&quot;44e85bf2&quot; data_label=&quot;Code Postal du signataire&quot; data_map_field=&quot;zipcode&quot; data_help=&quot;Code Postal du signataire&quot; maxlength=&quot;10&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="vertical-align: middle; width: 55%;">{% textinput_tag name=&quot;ed0a66fe&quot; data_label=&quot;Ville du signataire&quot; data_map_field=&quot;ville&quot; data_help=&quot;Ville du signataire&quot; maxlength=&quot;80&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="vertical-align: middle; width: 25%;">{% textinput_tag name=&quot;25037fe9&quot; placeholder=&quot;France&quot; data_label=&quot;Pays du signataire&quot; data_map_field=&quot;pays&quot; data_help=&quot;Pays du signataire&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: bottom; width: 50%;">{% select_tag name=&quot;bcc24a80&quot; data_label=&quot;Civilit&eacute; du signataire&quot; data_map_field=&quot;civilite&quot; data_help=&quot;Civilit&eacute;&quot; data_choices=&quot;Civilit&eacute;|civilite; Madame|madame; Monsieur|monsieur;&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;">Nom :</span></td>
			<td style="vertical-align: bottom; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp;Pr&eacute;nom :</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;e6c639a5&quot; data_label=&quot;Nom du signataire&quot; data_map_field=&quot;nom&quot; data_help=&quot;Nom du signataire&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;89a0a9f9&quot; data_label=&quot;Pr&eacute;nom du signataire&quot; data_map_field=&quot;prenom&quot; data_help=&quot;Pr&eacute;nom du signataire&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="break-inside:avoid;width:100%;">
	<tbody>
		<tr>
			<td style="width: 20%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Date de naissance :</span></td>
			<td style="width: 80%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Lieu de naissance :</span></td>
		</tr>
		<tr>
			<td style="width: 20%;">{% dateinput_tag name=&quot;272d5f9d&quot; placeholder=&quot;jj/mm/aaaa&quot; data_label=&quot;Date de naissance&quot; data_map_field=&quot;date_naissance&quot; data_help=&quot;Date de naissance&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;true&quot; %}</td>
			<td style="width: 80%;">{% textinput_tag name=&quot;a2914ec1&quot; data_label=&quot;Lieu de naissance&quot; data_map_field=&quot;lieu_naissance&quot; data_help=&quot;Lieu de naissance&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: 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;">T&eacute;l :&nbsp;&nbsp;</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 70%;">{% textinput_tag name=&quot;01a5a5db&quot; data_label=&quot;Email du signataire&quot; data_map_field=&quot;email&quot; data_help=&quot;Email du signataire&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;5ae0b27d&quot; data_label=&quot;T&eacute;l du signataire&quot; data_map_field=&quot;tel&quot; data_help=&quot;T&eacute;l du signataire&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="2" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="width: 68%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Adresse :</span></td>
		</tr>
		<tr>
			<td style="width: 68%;">{% textinput_tag name=&quot;109d7744&quot; data_label=&quot;Adresse postale du signataire&quot; data_map_field=&quot;adresse&quot; data_help=&quot;Adresse postale du signataire&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><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Autres informations utiles :</span></td>
		</tr>
		<tr>
			<td>{% textarea_tag name=&quot;0782e38f&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Autres informations utiles&quot; data_map_field=&quot;comment&quot; data_help=&quot;Autres informations utiles&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><em><span style="font-size:8px;"><span style="font-family: ITCAvantGardePro;">Vous avez la possibilit&eacute; de vous inscrire sur www.bloctel.gouv.fr pour vous opposer &agrave; tout d&eacute;marchage t&eacute;l&eacute;phonique conform&eacute;ment &agrave; l&#39;article L223-1 du Code de la consommation.</span></span></em>&nbsp;</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align: middle; width: 25%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Situation familiale&nbsp;: </span></td>
			<td>{% textinput_tag name=&quot;fef2f727&quot; data_label=&quot;Situation familiale&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Pacs&eacute;, ...&quot; maxlength=&quot;70&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

Mode Simplifié

<p style="text-align: justify;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"><strong>{{871c169a}}&nbsp;{{79fc7ffa}}&nbsp;{{5185aba3}} </strong>demeurant<strong> {{109d7745}}&nbsp;{{44e85bf2}}&nbsp;{{ed0a66fe}}</strong>, <strong>{{25037fe9}}</strong>,<br />
&bull; email : <strong>{{f4f59f87}}&nbsp;</strong>&bull;&nbsp;t&eacute;l&eacute;phone :&nbsp;<strong>{{f851d3d5}}&nbsp;</strong><br />
&bull; Lieu de naissance :&nbsp;<strong>{{67fe78de}}</strong>, le <strong>{{f014d7d1}}</strong></span></p>

<p style="text-align: justify;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"><strong>{{bcc24a80}}&nbsp;{{e6c639a5}}&nbsp;{{89a0a9f9}} </strong>demeurant <strong>{{109d7744}}&nbsp;{{44e85bf2}}&nbsp;{{ed0a66fe}}</strong>, <strong>{{25037fe9}}</strong>,<br />
&bull; Email : <strong>{{01a5a5db}}</strong>, t&eacute;l&eacute;phone :&nbsp;<strong>{{5ae0b27d}}&nbsp;</strong><br />
&bull; Lieu de naissance :&nbsp;<strong>{{a2914ec1}}</strong>, le <strong>{{272d5f9d}}</strong></span></p>

<p style="text-align: justify;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Situation familiale : <strong>{{fef2f727}}</strong><br />
Autres informations utiles :&nbsp;<strong>{{0782e38f}}</strong></span></p>

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