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<table border="0" cellpadding="1" cellspacing="5" style="width:100%;">
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">D&eacute;nomination sociale :</span></td>
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			<td>{% textinput_tag name=&quot;3ac347eb&quot; data_label=&quot;D&eacute;nomination sociale&quot; data_help=&quot;D&eacute;nomination sociale&quot; maxlength=&quot;100&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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</table>

<table border="0" cellpadding="1" cellspacing="5" style="width:100%;">
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			<td style="vertical-align: middle; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Immatricum&eacute;e au RCS de :</span></td>
			<td style="vertical-align: middle; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Sous le num&eacute;ro :</span></td>
		</tr>
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			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;3d3da87b&quot; data_label=&quot;Lieu RCS&quot; data_help=&quot;Lieu RCS&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;011e7cf8&quot; data_label=&quot;num&eacute;ro RCS&quot; data_help=&quot;num&eacute;ro RCS&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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</table>

<table border="0" cellpadding="1" cellspacing="5" style="width:100%;">
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	<p style="text-align: left;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Repr&eacute;sent&eacute;e par :</span></p>
	</caption>
	<tbody>
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			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;47bd4f60&quot; data_label=&quot;Nom et pr&eacute;nom du g&eacute;rant&quot; data_help=&quot;Nom et pr&eacute;nom du g&eacute;rant&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%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">en sa qualit&eacute; de G&eacute;rant,</span></td>
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</table>

<table border="0" cellpadding="1" cellspacing="5" style="width:100%;">
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			<td>{% textarea_tag name=&quot;aaea850d&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;personne morale&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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</table>

<table border="0" cellpadding="1" cellspacing="5" style="width:100%;">
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">dont le si&egrave;ge social est domicili&eacute; :&nbsp;</span></td>
		</tr>
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			<td>{% textarea_tag name=&quot;fcd770ac&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Adresse si&egrave;ge social&quot; data_help=&quot;Adresse si&egrave;ge social&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

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			<td style="vertical-align: middle; width: 7%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">E-mail :&nbsp;</span></td>
			<td style="width: 65%;">{% textinput_tag name=&quot;deb4fb51&quot; data_label=&quot;E mail bailleur&quot; data_help=&quot;E mail bailleur&quot; maxlength=&quot;65&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="vertical-align: middle; width: 5%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Tel :</span></td>
			<td style="vertical-align: middle; width: 20%;">{% textinput_tag name=&quot;b2f19aa9&quot; data_label=&quot;T&eacute;l&eacute;phone bailleur&quot; data_help=&quot;T&eacute;l&eacute;phone bailleur&quot; maxlength=&quot;22&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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</table>

<p style="text-align: justify;"><span style="font-size:8px;"><span style="font-family: ITCAvantGardePro; font-weight: 200;"><em>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.</em>&nbsp;</span></span></p>

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp;{% checkbox_tag name=&quot;a39f5ca9&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;fd1921cd&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%;">
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% textarea_tag name=&quot;fa32510c&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>
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<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%;">
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			<td style="width: 15%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% dateinput_tag name=&quot;079bc8c4&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; white-space: nowrap;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">fait &agrave;&nbsp;</span></td>
			<td style="width: 80%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% textinput_tag name=&quot;f147a53a&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>
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</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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