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<p style="text-align: justify;"><span class="titre_p" style="font-family:ITCAvantGardePro;font-size:18px;font-weight:900;">CAUTION SIGNATAIRE DU PR&Eacute;SENT ENGAGEMENT<br />
<span style="font-weight:600;"><span style="font-size: 12px;">Je soussign&eacute;(e),</span></span></span></p>

<table cellpadding="1" cellspacing="1" style="width: 100%;">
	<caption>
	<p style="text-align: left;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Nom et Pr&eacute;noms :</span></p>
	</caption>
	<tbody>
		<tr>
			<td>{% textarea_tag name=&quot;2b24ea76&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Nom et Pr&eacute;noms : &quot; data_help=&quot;Nom et Pr&eacute;noms : &quot; data_ancien_ids=&quot;5833&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="1" style="width: 100%; break-inside: avoid;">
	<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;7abc5256&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;true&quot; %}</td>
			<td style="width: 80%;">{% textinput_tag name=&quot;5f34688a&quot; data_label=&quot;Lieu de 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="1" cellspacing="1" style="width: 100%;">
	<caption>
	<p style="text-align: left;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Domicile :</span></p>
	</caption>
	<tbody>
		<tr>
			<td>{% textarea_tag name=&quot;1838fbe1&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Domicile :&quot; data_help=&quot;Domicile :&quot; data_ancien_ids=&quot;21964&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="1" style="width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align: middle; width: 6%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">E-mail :</span></td>
			<td style="width: 65%;">{% textinput_tag name=&quot;79c77dc2&quot; data_label=&quot;E-mail du garant&quot; data_help=&quot;e-mail du garant&quot; maxlength=&quot;65&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="vertical-align: middle; width: 4%;">&nbsp;<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">T&eacute;l :</span></td>
			<td style="width: 25%;">{% textinput_tag name=&quot;d39f50f4&quot; data_label=&quot;T&eacute;l&eacute;phone du&nbsp; garant&quot; data_help=&quot;tel garant&quot; maxlength=&quot;25&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<p><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></span></span></p>

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