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<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"><span style="font-weight:600;">Le (les) consommateur(s)</span>, nom et pr&eacute;nom :</span><br />
{% textarea_tag name=&quot;13b56f6c&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Nom et pr&eacute;nom du ou des consommateur(s)&quot; data_help=&quot;Nom et pr&eacute;nom consommateur(s)&quot; data_ancien_ids=&quot;1111&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</p>

<table border="0" cellpadding="1" cellspacing="1" style="width:100%;">
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			<td style="vertical-align: middle; width: 5%; white-space: nowrap;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">E-mail :&nbsp;</span></td>
			<td style="vertical-align: middle; width: 70%;">{% textinput_tag name=&quot;4ce94e90&quot; data_label=&quot;E-mail du consommateur&quot; data_help=&quot;E-mail consommateur&quot; maxlength=&quot;70&quot; data_ancien_ids=&quot;5092&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="vertical-align: middle; width: 5%; text-align: left;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp; Tel :&nbsp;</span></td>
			<td style="vertical-align: middle; width: 20%;">{% textinput_tag name=&quot;983649b0&quot; data_label=&quot;T&eacute;l&eacute;phone duconsommateur&quot; data_help=&quot;T&eacute;l&eacute;phone consommateur&quot; maxlength=&quot;22&quot; data_ancien_ids=&quot;5118&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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<p><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></p>

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Adresse</span><br />
{% textarea_tag name=&quot;083bf91b&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Adresse du consommateur&quot; data_help=&quot;Adresse consommateur&quot; data_ancien_ids=&quot;1748&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</p>

<p style="text-align: justify;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Votre interlocuteur exerce l&#39;activit&eacute; d&#39;entremise sur les immeubles et fonds de commerce, conform&eacute;ment &agrave; la loi n&deg; 70-9 du 2 janvier 1970, dite &quot;loi Hoguet&quot; et au d&eacute;cret n&deg;72-678 du 20 juillet 1972, consultables sur le site www.legifrance.gouv.fr.&nbsp;</span></p>

<p style="text-align: justify;"><span style="font-weight:600;"><span style="font-family: ITCAvantGardePro; font-size: 12px;">Le service propos&eacute; consiste en : </span></span></p>

<p style="text-align: justify;">{% checkbox_tag name=&quot;6c4a7c6d&quot; data_label=&quot;Service propos&eacute; : Vente d&#39;un bien&quot; data_help=&quot;Vente d&#39;un bien&quot; data_ancien_ids=&quot;3577&quot; %}<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp;vente d&#39;un bien &nbsp; &nbsp;</span>{% checkbox_tag name=&quot;0747effd&quot; data_label=&quot;Location d&#39;un bien&quot; data_help=&quot;Location d&#39;un bien&quot; data_ancien_ids=&quot;3553&quot; %}<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"> location d&#39;un bien &nbsp; &nbsp;</span>{% checkbox_tag name=&quot;a9a346d7&quot; data_label=&quot;Gestion d&#39;un bien&quot; data_help=&quot;Gestion d&#39;un bien&quot; data_ancien_ids=&quot;3408&quot; %}<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"> gestion d&#39;un bien &nbsp; &nbsp;</span>{% checkbox_tag name=&quot;09d89efd&quot; data_label=&quot;Recherche d&#39;un bien&quot; data_help=&quot;Recherche d&#39;un bien&quot; data_ancien_ids=&quot;3456&quot; %}<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"> recherche d&#39;un bien</span></p>

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			<td style="vertical-align: top; width: 3%;">{% checkbox_tag name=&quot;9fc928e5&quot; data_label=&quot;Autre service propos&eacute;&quot; data_help=&quot;Service propos&eacute;&quot; data_ancien_ids=&quot;3601&quot; %}</td>
			<td style="vertical-align: top;">{% textarea_tag name=&quot;a27be5d9&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;intitul&eacute; du service propos&eacute;&quot; data_help=&quot;Service propos&eacute;&quot; data_ancien_ids=&quot;1771&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td style="width: 16%; vertical-align: middle;"><span style="font-weight:600;"><span style="font-family: ITCAvantGardePro; font-size: 12px;">Dur&eacute;e du mandat :</span></span></td>
			<td style="width: 20%;">{% textinput_tag name=&quot;38b10423&quot; data_label=&quot;Dur&eacute;e mandat&quot; data_help=&quot;Dur&eacute;e mandat&quot; maxlength=&quot;20&quot; data_ancien_ids=&quot;3650&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;true&quot; %}</td>
			<td style="white-space: nowrap; vertical-align: middle;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp;&nbsp;Comprenant une 1<sup>&egrave;re </sup>p&eacute;riode irr&eacute;vocable de :</span></td>
			<td style="vertical-align: middle;">{% textinput_tag name=&quot;1f605eab&quot; data_label=&quot;Dur&eacute;e de la p&eacute;riode irr&eacute;vocable&quot; data_help=&quot;Dur&eacute;e p&eacute;riode irr&eacute;vocable&quot; maxlength=&quot;20&quot; data_ancien_ids=&quot;3687&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;true&quot; %}</td>
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<p style="text-align: justify;"><span style="font-weight:600;"><span style="font-family: ITCAvantGardePro; font-size: 12px;">Modalit&eacute;s de d&eacute;nonciation : </span></span></p>

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			<td style="white-space: nowrap; width: 65%; vertical-align: middle;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">par lettre recommand&eacute;e avec demande d&#39;avis de r&eacute;ception (LRAR), avec un pr&eacute;avis de :</span></td>
			<td style="width: 35%;">{% textinput_tag name=&quot;6fc80378&quot; data_label=&quot;Dur&eacute;e du pr&eacute;avis &quot; data_help=&quot;Dur&eacute;e pr&eacute;avis &quot; maxlength=&quot;20&quot; data_ancien_ids=&quot;3765&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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<p style="text-align: justify;"><span style="font-weight:600;"><span style="font-family: ITCAvantGardePro; font-size: 12px;">Honoraires,&nbsp;</span></span><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">en cas de pleine r&eacute;ussite de la mission confi&eacute;e, selon tarif de l&#39;agence :</span><br />
{% textarea_tag name=&quot;5429942a&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Honoraires en cas de pleine r&eacute;ussite de la mission&quot; data_help=&quot;Honoraires,&nbsp;en cas de pleine r&eacute;ussite de la mission confi&eacute;e&quot; data_ancien_ids=&quot;3740&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</p>

<p style="text-align: justify;"><span style="font-weight:600;"><span style="font-family: ITCAvantGardePro; font-size: 12px;">Modalit&eacute;s de r&egrave;glement,&nbsp;</span></span><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">ch&egrave;que ou virement.</span></p>

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