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<table border="0" cellpadding="1" cellspacing="2" style="width: 100%;">
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			<td style="vertical-align: bottom; width: 50%; text-align: left;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% select_tag name=&quot;2e0c7352&quot; data_label=&quot;Civilit&eacute; du propri&eacute;taire&quot; data_help=&quot;Civilit&eacute; du propri&eacute;taire&quot; data_choices=&quot;Civilit&eacute;|civilite; Madame|madame; Monsieur|monsieur;&quot; relation_ids_list=&quot;2a6cec09&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}<strong>&nbsp;</strong>Nom :</span></td>
			<td style="vertical-align: bottom; width: 50%; text-align: left;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Pr&eacute;nom :</span></td>
		</tr>
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			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;087a9c2a&quot; data_label=&quot;Nom du propri&eacute;taire&quot; data_help=&quot;Nom du propri&eacute;taire &quot; maxlength=&quot;50&quot; relation_ids_list=&quot;f1d9a812&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;002cb93f&quot; data_label=&quot;Pr&eacute;nom du propri&eacute;taire&quot; data_help=&quot;Nom du propri&eacute;taire&quot; maxlength=&quot;50&quot; relation_ids_list=&quot;e7d938b6&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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</table>

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			<td style="width: 68%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Adresse postale :</span></td>
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			<td style="width: 68%;">{% textinput_tag name=&quot;109d7745&quot; data_label=&quot;Adresse postale du propri&eacute;taire&quot; data_help=&quot;Adresse postale du propri&eacute;taire&quot; maxlength=&quot;100&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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</table>

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			<td style="width: 20%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Code postal :</span></td>
			<td style="width: 55%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Ville :</span></td>
			<td style="width: 25%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Pays :</span></td>
		</tr>
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			<td style="width: 20%;">{% numberinput_tag name=&quot;f5e66571&quot; data_label=&quot;Code Postal du propri&eacute;taire&quot; data_help=&quot;Code Postal&quot; maxlength=&quot;8&quot; relation_ids_list=&quot;de0ac6cf&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 55%;">{% textinput_tag name=&quot;ed0a66fe&quot; data_label=&quot;Ville du propri&eacute;taire&quot; data_help=&quot;Ville du propri&eacute;taire&quot; maxlength=&quot;80&quot; relation_ids_list=&quot;729bba52&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 25%;">{% textinput_tag name=&quot;4e0fc70a&quot; placeholder=&quot;France&quot; data_label=&quot;Pays du propri&eacute;taire&quot; data_help=&quot;Pays du propri&eacute;taire&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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</table>

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			<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>
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			<td style="vertical-align: middle; width: 70%;">{% textinput_tag name=&quot;385a4815&quot; data_label=&quot;Email du propri&eacute;taire&quot; data_help=&quot;Email &quot; maxlength=&quot;50&quot; relation_ids_list=&quot;70dab79e&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;e98e647c&quot; data_label=&quot;T&eacute;l du propri&eacute;taire&quot; data_help=&quot;T&eacute;l du propri&eacute;taire&quot; maxlength=&quot;15&quot; relation_ids_list=&quot;6dc1dd0c&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<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>
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<table border="0" cellpadding="1" cellspacing="1" 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;">{% checkbox_tag name=&quot;ae628a77&quot; data_label=&quot;c&eacute;libataire&quot; data_help=&quot;c&eacute;libataire&quot; %}&nbsp;c&eacute;libataire&nbsp; &nbsp;&nbsp;{% checkbox_tag name=&quot;bfa4d45d&quot; data_label=&quot;pacs&eacute;(s)&quot; data_help=&quot;pacs&eacute;(s)&quot; %}&nbsp;pacs&eacute;(s)&nbsp; &nbsp; {% checkbox_tag name=&quot;1b57defb&quot; data_label=&quot;mari&eacute;(s)&quot; data_help=&quot;mari&eacute;(s)&quot; %}&nbsp;mari&eacute;(s), r&eacute;gime matrimonial :</span></td>
			<td style="width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% textinput_tag name=&quot;f84e5a83&quot; data_label=&quot;R&eacute;gime matrimoniale&quot; data_help=&quot;R&eacute;gime matrimoniale&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></td>
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</table>

<table border="0" cellpadding="1" cellspacing="1" style="width:100%;">
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			<td style="vertical-align: middle; width: 30%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% checkbox_tag name=&quot;2f15cd8f&quot; data_label=&quot;divorc&eacute; non remari&eacute;&quot; data_help=&quot;divorc&eacute; non remari&eacute;&quot; %}&nbsp;divorc&eacute; non remari&eacute;&nbsp; &nbsp; {% checkbox_tag name=&quot;1dcadb09&quot; data_label=&quot;veuf&quot; data_help=&quot;veuf&quot; %}&nbsp;veuf&nbsp; &nbsp; &nbsp;{% checkbox_tag name=&quot;7c7f2f49&quot; data_label=&quot;autre &quot; data_help=&quot;autre&quot; %}</span></td>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% textinput_tag name=&quot;50542876&quot; data_label=&quot;Autre &quot; data_help=&quot;Autre&quot; maxlength=&quot;70&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></td>
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</table>

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