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Texte du bouton 'supprimer'

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<table style="width:100%; border:undefined">
	<tbody>
		<tr>
			<td style="vertical-align:middle; width:50%">{% select_tag name=&quot;2e0c7352a&quot; data_label=&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; %}<span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200"><strong>&nbsp;</strong>Nom :</span></span></span></td>
			<td style="vertical-align:middle; width:50%"><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">Pr&eacute;nom :</span></span></span></td>
		</tr>
		<tr>
			<td style="vertical-align:middle; width:50%">{% textinput_tag name=&quot;087a9c2aa&quot; data_label=&quot;Nom du mandant &quot; data_help=&quot;Nom du mandant &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;002cb93fa&quot; data_label=&quot;Pr&eacute;nom du mandant &quot; data_help=&quot;Nom du mandant&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
		<tr>
			<td style="vertical-align:middle; width:50%"><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">E-mail :&nbsp;</span></span></span></td>
			<td style="vertical-align:middle; width:50%">&nbsp;<span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">Tel :&nbsp;&nbsp;</span></span></span></td>
		</tr>
		<tr>
			<td style="vertical-align:middle; width:50%">{% textinput_tag name=&quot;bf7debbaf&quot; data_label=&quot;Email &quot; data_help=&quot;Email &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;d93d2bab8&quot; data_label=&quot;Tel &quot; data_help=&quot;Tel &quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
		<tr>
			<td colspan="2" style="vertical-align:middle; width:50%"><em><span style="font-size:8px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">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></span></em></td>
		</tr>
		<tr>
			<td style="vertical-align:middle; width:50%"><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">Profession&nbsp;:</span></span></span></td>
			<td style="vertical-align:middle; width:50%"><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">Nationalit&eacute;&nbsp;:</span></span></span></td>
		</tr>
		<tr>
			<td style="vertical-align:middle; width:50%">{% textinput_tag name=&quot;4803daab5&quot; data_label=&quot;Profession &quot; data_help=&quot;Profession &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;58a3b2eff&quot; data_label=&quot;Nationalit&eacute; &quot; data_help=&quot;Nationalit&eacute; &quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table style="width:100%; border:undefined">
	<tbody>
		<tr>
			<td style="text-align:left; vertical-align:middle; width:50%"><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">Date de naissance :&nbsp;</span></span></span></td>
			<td style="width:50%"><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">Lieu de Naissance :</span></span></span></td>
		</tr>
		<tr>
			<td style="text-align:left; vertical-align:middle; width:50%">{% dateinput_tag name=&quot;a2e342c52&quot; placeholder=&quot;jj/mm/aaaa&quot; data_label=&quot;Date de naissance &quot; data_help=&quot;Date de naissance&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width:50%">{% textinput_tag name=&quot;aed1d6001&quot; data_label=&quot;Lieu de naissance&quot; data_help=&quot;Lieu de naissance&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table style="width:100%; border:undefined">
	<tbody>
		<tr>
			<td><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">&nbsp;Adresse :</span></span></span><br />
			{% textarea_tag name=&quot;1ba1357bf&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Adresse mandant 1&quot; data_help=&quot;Adresse mandant 1&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<p><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">&nbsp;{% checkbox_tag name=&quot;b025a93fd&quot; data_label=&quot;R&eacute;sident fiscal&quot; data_help=&quot;R&eacute;sident fiscal&quot; %} Ayant la qualit&eacute; de r&eacute;sident au sens de la r&egrave;glementation fiscale.</span></span></span></p>

<p><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200"><font face="ITCAvantGardePro">&nbsp;Situation matrimoniale :&nbsp;</font>{% radio_tag name=&quot;ad824596f&quot; data_label=&quot;Situation matrimoniale Vendeur 1&quot; data_help=&quot;Situation matrimoniale&quot; data_choices=&quot;C&eacute;libataire|C&eacute;libataire; Mari&eacute;|Mari&eacute;; Pacs&eacute;|pacs&eacute;; Divoc&eacute;(e)|divorc&eacute;(e);Veuf(ve)|Veuf(ve);&quot; %} :</span></span></span></p>

<p><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">D&eacute;tail de la situation matrimoniale :&nbsp;</span></span></span></p>

<table style="width:100%; border:undefined">
	<tbody>
		<tr>
			<td><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">{% textarea_tag name=&quot;40546f9db&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;D&eacute;tail de la situation matrimoniale&quot; data_help=&quot;Indiquer la date&nbsp;le lieu de mariage et le r&eacute;gime matrimoniale.&nbsp;La date et lieu d&#39;enregistrement du pacs &quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></span></span></td>
		</tr>
	</tbody>
</table>

<p><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">&nbsp;{% checkbox_tag name=&quot;397cd023&quot; data_label=&quot;Ici pr&eacute;sent&quot; data_help=&quot;Ici pr&eacute;sent&quot; %}&nbsp; Ici pr&eacute;sent</span></span></span></p>

<p><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">&nbsp;{% checkbox_tag name=&quot;79be0de1&quot; data_label=&quot;non pr&eacute;sent &agrave; l&rsquo;acte&quot; data_help=&quot;non pr&eacute;sent &agrave; l&rsquo;acte&quot; %}&nbsp;Non pr&eacute;sent &agrave; l&rsquo;acte mais repr&eacute;sent&eacute; par :</span></span></span></p>

<table style="width:100%; border:undefined">
	<tbody>
		<tr>
			<td><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">{% textarea_tag name=&quot;4d02d745&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Repr&eacute;sent&eacute; par &quot; data_help=&quot;Repr&eacute;sent&eacute; par &quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></span></span></td>
		</tr>
	</tbody>
</table>

<p style="text-align:justify"><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">en vertu des pouvoirs qui lui ont &eacute;t&eacute; conf&eacute;r&eacute;s &agrave; cet effet aux termes d&rsquo;une procuration sous seing priv&eacute; en date du&nbsp;</span></span></span></p>

<table style="width:100%; border:undefined">
	<tbody>
		<tr>
			<td style="width:15%"><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">{% dateinput_tag name=&quot;252a40ef&quot; placeholder=&quot;jj/mm/aaaa&quot; data_label=&quot;Date de la procuration&quot; data_help=&quot;Date de la procuration&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></span></span></td>
			<td style="vertical-align:middle; width:5%"><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">fait &agrave;&nbsp;</span></span></span></td>
			<td><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">{% textinput_tag name=&quot;adc663fc&quot; data_label=&quot;Lieu de la procuration&quot; data_help=&quot;Lieu de la procuration&quot; maxlength=&quot;80&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></span></span></td>
		</tr>
	</tbody>
</table>

<p><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">dont l&rsquo;original est demeur&eacute; ci-annex&eacute;.</span></span></span></p>

<table border="0" cellpadding="1" cellspacing="5" style="width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align: middle; width: 50%;">{% select_tag name=&quot;56f6e0c64&quot; data_label=&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; %}<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"><strong>&nbsp;</strong>Nom :</span></td>
			<td style="vertical-align: middle; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Pr&eacute;nom :</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;ebf59fdf3&quot; data_label=&quot;Nom du mandant &quot; data_help=&quot;Nom du mandant &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;dc0f5d3a0&quot; data_label=&quot;Pr&eacute;nom du mandant &quot; data_help=&quot;Nom du mandant&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">E-mail :&nbsp;</span></td>
			<td style="vertical-align: middle; width: 50%;">&nbsp;<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Tel :&nbsp;&nbsp;</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;0f5f2d55a&quot; data_label=&quot;Email &quot; data_help=&quot;Email &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;d73f0a729&quot; data_label=&quot;Tel &quot; data_help=&quot;Tel &quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
		<tr>
			<td colspan="2" style="vertical-align: middle; width: 50%;"><em><span style="font-size:8px;"><span style="font-family: ITCAvantGardePro; font-weight: 200;">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></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Profession&nbsp;:</span></td>
			<td style="vertical-align: middle; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Nationalit&eacute;&nbsp;:</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;bb3b4fdfb&quot; data_label=&quot;Profession &quot; data_help=&quot;Profession &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;16c4fe073&quot; data_label=&quot;Nationalit&eacute; &quot; data_help=&quot;Nationalit&eacute; &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="5" style="width:100%;">
	<tbody>
		<tr>
			<td style="text-align: left; vertical-align: middle; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Date de naissance :&nbsp;</span></td>
			<td style="width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Lieu de Naissance :</span></td>
		</tr>
		<tr>
			<td style="text-align: left; vertical-align: middle; width: 50%;">{% dateinput_tag name=&quot;9b70f9345&quot; placeholder=&quot;jj/mm/aaaa&quot; data_label=&quot;Date de naissance &quot; data_help=&quot;Date de naissance&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 50%;">{% textinput_tag name=&quot;07cfed152&quot; data_label=&quot;Lieu de naissance&quot; data_help=&quot;Lieu de naissance&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="5" style="width:100%;">
	<tbody>
		<tr>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp;Adresse :</span><br />
			{% textarea_tag name=&quot;1b13f57bcf&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Adresse mandant 1&quot; data_help=&quot;Adresse mandant 1&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp;{% checkbox_tag name=&quot;e52fc6ab3&quot; data_label=&quot;R&eacute;sident fiscal&quot; data_help=&quot;R&eacute;sident fiscal&quot; %} Ayant la qualit&eacute; de r&eacute;sident au sens de la r&egrave;glementation fiscale.</span></p>

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"><font face="ITCAvantGardePro">&nbsp;Situation matrimoniale :&nbsp;</font>{% radio_tag name=&quot;d82f4596fc&quot; data_label=&quot;Situation matrimoniale Vendeur 1&quot; data_help=&quot;Situation matrimoniale&quot; data_choices=&quot;C&eacute;libataire|C&eacute;libataire; Mari&eacute;|Mari&eacute;; Pacs&eacute;|pacs&eacute;; Divoc&eacute;(e)|divorc&eacute;(e);Veuf(ve)|Veuf(ve);&quot; %} :</span></p>

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">D&eacute;tail de la situation matrimoniale :&nbsp;</span></p>

<table border="0" cellpadding="1" cellspacing="5" style="width:100%;">
	<tbody>
		<tr>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% textarea_tag name=&quot;4052f9db&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;D&eacute;tail de la situation matrimoniale&quot; data_help=&quot;Indiquer la date&nbsp;le lieu de mariage et le r&eacute;gime matrimoniale.&nbsp;La date et lieu d&#39;enregistrement du pacs &quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></td>
		</tr>
	</tbody>
</table>

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp;{% checkbox_tag name=&quot;21e6b1b2&quot; data_label=&quot;Ici pr&eacute;sent&quot; data_help=&quot;Ici pr&eacute;sent&quot; %}&nbsp; Ici pr&eacute;sent</span></p>

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp;{% checkbox_tag name=&quot;3269b7d9&quot; data_label=&quot;non pr&eacute;sent &agrave; l&rsquo;acte&quot; data_help=&quot;non pr&eacute;sent &agrave; l&rsquo;acte&quot; %}&nbsp;Non pr&eacute;sent &agrave; l&rsquo;acte mais repr&eacute;sent&eacute; par :</span></p>

<table border="0" cellpadding="1" cellspacing="5" style="width:100%;">
	<tbody>
		<tr>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% textarea_tag name=&quot;7aed721e&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Repr&eacute;sent&eacute; par &quot; data_help=&quot;Repr&eacute;sent&eacute; par &quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></td>
		</tr>
	</tbody>
</table>

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">en vertu des pouvoirs qui lui ont &eacute;t&eacute; conf&eacute;r&eacute;s &agrave; cet effet aux termes d&rsquo;une procuration sous seing priv&eacute; en date du&nbsp;</span></p>

<table border="0" cellpadding="1" cellspacing="5" style="width:100%;">
	<tbody>
		<tr>
			<td style="width: 15%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% dateinput_tag name=&quot;0eb74f6e&quot; placeholder=&quot;jj/mm/aaaa&quot; data_label=&quot;Date de la procuration&quot; data_help=&quot;Date de la procuration&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></td>
			<td style="vertical-align: middle; width: 5%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">fait &agrave;&nbsp;</span></td>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% textinput_tag name=&quot;811886de&quot; data_label=&quot;Lieu de la procuration&quot; data_help=&quot;Lieu de la procuration&quot; maxlength=&quot;80&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></td>
		</tr>
	</tbody>
</table>

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">dont l&rsquo;original est demeur&eacute; ci-annex&eacute;.</span></p>

<table cellspacing="5" style="border:undefined;width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align:middle; width:50%">{% select_tag name=&quot;56f6e0c641&quot; data_label=&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; %}<span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200"><strong>&nbsp;</strong>Nom :</span></span></span></td>
			<td style="vertical-align:middle; width:50%"><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">Pr&eacute;nom :</span></span></span></td>
		</tr>
		<tr>
			<td style="vertical-align:middle; width:50%">{% textinput_tag name=&quot;eb5f9fdf34&quot; data_label=&quot;Nom du mandant &quot; data_help=&quot;Nom du mandant &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;dc05fd3a00&quot; data_label=&quot;Pr&eacute;nom du mandant &quot; data_help=&quot;Nom du mandant&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
		<tr>
			<td style="vertical-align:middle; width:50%"><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">E-mail :&nbsp;</span></span></span></td>
			<td style="vertical-align:middle; width:50%">&nbsp;<span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">Tel :&nbsp;&nbsp;</span></span></span></td>
		</tr>
		<tr>
			<td style="vertical-align:middle; width:50%">{% textinput_tag name=&quot;0ff52d55aa&quot; data_label=&quot;Email &quot; data_help=&quot;Email &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;d73f0a729a&quot; data_label=&quot;Tel &quot; data_help=&quot;Tel &quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
		<tr>
			<td colspan="2" style="vertical-align:middle; width:50%"><em><span style="font-size:8px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">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></span></em></td>
		</tr>
		<tr>
			<td style="vertical-align:middle; width:50%"><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">Profession&nbsp;:</span></span></span></td>
			<td style="vertical-align:middle; width:50%"><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">Nationalit&eacute;&nbsp;:</span></span></span></td>
		</tr>
		<tr>
			<td style="vertical-align:middle; width:50%">{% textinput_tag name=&quot;bb3b4fdfba&quot; data_label=&quot;Profession &quot; data_help=&quot;Profession &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;16c4ef073a&quot; data_label=&quot;Nationalit&eacute; &quot; data_help=&quot;Nationalit&eacute; &quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table cellspacing="5" style="border:undefined;width:100%;">
	<tbody>
		<tr>
			<td style="text-align:left; vertical-align:middle; width:50%"><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">Date de naissance :&nbsp;</span></span></span></td>
			<td style="width:50%"><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">Lieu de Naissance :</span></span></span></td>
		</tr>
		<tr>
			<td style="text-align:left; vertical-align:middle; width:50%">{% dateinput_tag name=&quot;9b70f9345a&quot; placeholder=&quot;jj/mm/aaaa&quot; data_label=&quot;Date de naissance &quot; data_help=&quot;Date de naissance&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width:50%">{% textinput_tag name=&quot;07ced1f52a&quot; data_label=&quot;Lieu de naissance&quot; data_help=&quot;Lieu de naissance&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table cellspacing="5" style="border:undefined;width:100%;">
	<tbody>
		<tr>
			<td><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">&nbsp;Adresse :</span></span></span><br />
			{% textarea_tag name=&quot;1b135f7bcfa&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Adresse mandant 1&quot; data_help=&quot;Adresse mandant 1&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<p><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">&nbsp;{% checkbox_tag name=&quot;e52c6afb3a&quot; data_label=&quot;R&eacute;sident fiscal&quot; data_help=&quot;R&eacute;sident fiscal&quot; %} Ayant la qualit&eacute; de r&eacute;sident au sens de la r&egrave;glementation fiscale.</span></span></span></p>

<p><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200"><font face="ITCAvantGardePro">&nbsp;Situation matrimoniale :&nbsp;</font>{% radio_tag name=&quot;d824f596fca&quot; data_label=&quot;Situation matrimoniale Vendeur 1&quot; data_help=&quot;Situation matrimoniale&quot; data_choices=&quot;C&eacute;libataire|C&eacute;libataire; Mari&eacute;|Mari&eacute;; Pacs&eacute;|pacs&eacute;; Divoc&eacute;(e)|divorc&eacute;(e);Veuf(ve)|Veuf(ve);&quot; %} :</span></span></span></p>

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">D&eacute;tail de la situation matrimoniale :&nbsp;</span></p>

<table border="0" cellpadding="1" cellspacing="5" style="width:100%;">
	<tbody>
		<tr>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% textarea_tag name=&quot;40123f9db&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;D&eacute;tail de la situation matrimoniale&quot; data_help=&quot;Indiquer la date&nbsp;le lieu de mariage et le r&eacute;gime matrimoniale.&nbsp;La date et lieu d&#39;enregistrement du pacs &quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></td>
		</tr>
	</tbody>
</table>

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp;{% checkbox_tag name=&quot;6e6c9d1b&quot; data_label=&quot;Ici pr&eacute;sent&quot; data_help=&quot;Ici pr&eacute;sent&quot; %}&nbsp; Ici pr&eacute;sent</span></p>

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp;{% checkbox_tag name=&quot;49ca72a8&quot; data_label=&quot;non pr&eacute;sent &agrave; l&rsquo;acte&quot; data_help=&quot;non pr&eacute;sent &agrave; l&rsquo;acte&quot; %}&nbsp;Non pr&eacute;sent &agrave; l&rsquo;acte mais repr&eacute;sent&eacute; par :</span></p>

<table border="0" cellpadding="1" cellspacing="5" style="width:100%;">
	<tbody>
		<tr>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% textarea_tag name=&quot;bfde289e&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Repr&eacute;sent&eacute; par &quot; data_help=&quot;Repr&eacute;sent&eacute; par &quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="5" style="width:100%;">
	<tbody>
		<tr>
			<td style="width: 15%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% dateinput_tag name=&quot;0eb74f6e&quot; placeholder=&quot;jj/mm/aaaa&quot; data_label=&quot;Date de la procuration&quot; data_help=&quot;Date de la procuration&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></td>
			<td style="vertical-align: middle; width: 5%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">fait &agrave;&nbsp;</span></td>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% textinput_tag name=&quot;06f29639&quot; data_label=&quot;Lieu de la procuration&quot; data_help=&quot;Lieu de la procuration&quot; maxlength=&quot;80&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></td>
		</tr>
	</tbody>
</table>

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">dont l&rsquo;original est demeur&eacute; ci-annex&eacute;.</span></p>

<table cellspacing="5" style="border:undefined;width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align:middle; width:50%">{% select_tag name=&quot;a6c4f4a7a&quot; data_label=&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; %}<span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200"><strong>&nbsp;</strong>Nom :</span></span></span></td>
			<td style="vertical-align:middle; width:50%"><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">Pr&eacute;nom :</span></span></span></td>
		</tr>
		<tr>
			<td style="vertical-align:middle; width:50%">{% textinput_tag name=&quot;eb5fb9fdf3c&quot; data_label=&quot;Nom du mandant &quot; data_help=&quot;Nom du mandant &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;dc0f5d3ab0c&quot; data_label=&quot;Pr&eacute;nom du mandant &quot; data_help=&quot;Nom du mandant&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
		<tr>
			<td style="vertical-align:middle; width:50%"><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">E-mail :&nbsp;</span></span></span></td>
			<td style="vertical-align:middle; width:50%">&nbsp;<span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">Tel :&nbsp;&nbsp;</span></span></span></td>
		</tr>
		<tr>
			<td style="vertical-align:middle; width:50%">{% textinput_tag name=&quot;0f52d55fab&quot; data_label=&quot;Email &quot; data_help=&quot;Email &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;d7f30a729b&quot; data_label=&quot;Tel &quot; data_help=&quot;Tel &quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
		<tr>
			<td colspan="2" style="vertical-align:middle; width:50%"><em><span style="font-size:8px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">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></span></em></td>
		</tr>
		<tr>
			<td style="vertical-align:middle; width:50%"><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">Profession&nbsp;:</span></span></span></td>
			<td style="vertical-align:middle; width:50%"><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">Nationalit&eacute;&nbsp;:</span></span></span></td>
		</tr>
		<tr>
			<td style="vertical-align:middle; width:50%">{% textinput_tag name=&quot;bb3fb4dfba&quot; data_label=&quot;Profession &quot; data_help=&quot;Profession &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;16c4e0f73a&quot; data_label=&quot;Nationalit&eacute; &quot; data_help=&quot;Nationalit&eacute; &quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table cellspacing="5" style="border:undefined;width:100%;">
	<tbody>
		<tr>
			<td style="text-align:left; vertical-align:middle; width:50%"><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">Date de naissance :&nbsp;</span></span></span></td>
			<td style="width:50%"><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">Lieu de Naissance :</span></span></span></td>
		</tr>
		<tr>
			<td style="text-align:left; vertical-align:middle; width:50%">{% dateinput_tag name=&quot;9bf709345a&quot; placeholder=&quot;jj/mm/aaaa&quot; data_label=&quot;Date de naissance &quot; data_help=&quot;Date de naissance&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width:50%">{% textinput_tag name=&quot;07cefd152a&quot; data_label=&quot;Lieu de naissance&quot; data_help=&quot;Lieu de naissance&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table cellspacing="5" style="border:undefined;width:100%;">
	<tbody>
		<tr>
			<td><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">&nbsp;Adresse :</span></span></span><br />
			{% textarea_tag name=&quot;78ed8017&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Adresse mandant 4&quot; data_help=&quot;Adresse mandant 4&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<p><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">&nbsp;{% checkbox_tag name=&quot;e52c6fab3a&quot; data_label=&quot;R&eacute;sident fiscal&quot; data_help=&quot;R&eacute;sident fiscal&quot; %} Ayant la qualit&eacute; de r&eacute;sident au sens de la r&egrave;glementation fiscale.</span></span></span></p>

<p><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200"><font face="ITCAvantGardePro">&nbsp;Situation matrimoniale :&nbsp;</font>{% radio_tag name=&quot;d824f596fca&quot; data_label=&quot;Situation matrimoniale Vendeur 1&quot; data_help=&quot;Situation matrimoniale&quot; data_choices=&quot;C&eacute;libataire|C&eacute;libataire; Mari&eacute;|Mari&eacute;; Pacs&eacute;|pacs&eacute;; Divoc&eacute;(e)|divorc&eacute;(e);Veuf(ve)|Veuf(ve);&quot; %} :</span></span></span></p>

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">D&eacute;tail de la situation matrimoniale :&nbsp;</span></p>

<table border="0" cellpadding="1" cellspacing="5" style="width:100%;">
	<tbody>
		<tr>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% textarea_tag name=&quot;a8ba745c&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;D&eacute;tail de la situation matrimoniale&quot; data_help=&quot;Indiquer la date&nbsp;le lieu de mariage et le r&eacute;gime matrimoniale.&nbsp;La date et lieu d&#39;enregistrement du pacs &quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></td>
		</tr>
	</tbody>
</table>

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp;{% checkbox_tag name=&quot;3d018d48&quot; data_label=&quot;Ici pr&eacute;sent&quot; data_help=&quot;Ici pr&eacute;sent&quot; %}&nbsp; Ici pr&eacute;sent</span></p>

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp;{% checkbox_tag name=&quot;c281b670&quot; data_label=&quot;non pr&eacute;sent &agrave; l&rsquo;acte&quot; data_help=&quot;non pr&eacute;sent &agrave; l&rsquo;acte&quot; %}&nbsp;Non pr&eacute;sent &agrave; l&rsquo;acte mais repr&eacute;sent&eacute; par :</span></p>

<table border="0" cellpadding="1" cellspacing="5" style="width:100%;">
	<tbody>
		<tr>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% textarea_tag name=&quot;b46703fd&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Repr&eacute;sent&eacute; par &quot; data_help=&quot;Repr&eacute;sent&eacute; par &quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="5" style="width:100%;">
	<tbody>
		<tr>
			<td style="width: 15%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% dateinput_tag name=&quot;e201a1b2&quot; placeholder=&quot;jj/mm/aaaa&quot; data_label=&quot;Date de la procuration&quot; data_help=&quot;Date de la procuration&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></td>
			<td style="vertical-align: middle; width: 5%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">fait &agrave;&nbsp;</span></td>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% textinput_tag name=&quot;8ba30e59&quot; data_label=&quot;Lieu de la procuration&quot; data_help=&quot;Lieu de la procuration&quot; maxlength=&quot;80&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></td>
		</tr>
	</tbody>
</table>

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">dont l&rsquo;original est demeur&eacute; ci-annex&eacute;.</span></p>

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