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SIGNATURE

<table border="0" cellpadding="10" cellspacing="10" style="height: 150px; width: 100%;">
	<tbody>
		<tr>
			<td colspan="2" style="width: 35%; vertical-align: top; text-align: center;">Responsable de la location</td>
			<td colspan="2" style="width: 40%; vertical-align: top; text-align: center;">Responsable interne de la proc&eacute;dure</td>
		</tr>
		<tr>
			<td colspan="2" style="width: 35%; vertical-align: top;">Nom, pr&eacute;nom :</td>
			<td colspan="2" style="width: 40%; vertical-align: top;">Nom, pr&eacute;nom :</td>
		</tr>
		<tr>
			<td colspan="2" style="width: 35%; vertical-align: top;">{% textarea_tag name=&quot;03f7e833&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Nom et pr&eacute;nom du responsable de la location&quot; data_map_field=&quot;nomap&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td colspan="2" style="width: 40%; vertical-align: top;">{% textarea_tag name=&quot;d1a19b30&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Nom et pr&eacute;nom du responsable interne de la proc&eacute;dure&quot; data_map_field=&quot;nomap&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
		<tr>
			<td style="width: 5%; vertical-align: bottom;">
			Fait le
			</td>
			<td style="vertical-align: top;">{% dateinput_tag name=&quot;6f5c7db3&quot; placeholder=&quot;jj/mm/aaaa&quot; data_label=&quot;Fait le&quot; data_map_field=&quot;nomap&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 5%; vertical-align: bottom;">
			Fait le
			</td>
			<td style="vertical-align: top;">{% dateinput_tag name=&quot;a02d12d5&quot; data_label=&quot;Fait le&quot; data_map_field=&quot;nomap&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
		<tr>
			<td colspan="2" style="width: 35%; height: 150px; background-color: rgb(247, 247, 247); vertical-align: top;">
			&nbsp;

&nbsp;

&nbsp;
			</td>
			<td colspan="2" style="width: 40%; height: 150px; background-color: rgb(247, 247, 247); vertical-align: top;">
			&nbsp;

&nbsp;

&nbsp;

&nbsp;
			</td>
		</tr>
	</tbody>
</table>

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