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			<td><em><span style="font-weight:600;"><span style="font-family: ITCAvantGardePro; font-size: 12px;">(Personne morale)</span></span></em></td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">La soci&eacute;t&eacute; <em>(forme, d&eacute;nomination sociale)</em> :</span></td>
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			<td>{% textarea_tag name=&quot;4d05c59f&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;soci&eacute;t&eacute; (forme, d&eacute;nomination sociale)&quot; data_map_field=&quot;nomap&quot; data_help=&quot;soci&eacute;t&eacute; (forme, d&eacute;nomination sociale)&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Ayant son si&egrave;ge social &agrave; l&rsquo;adresse suivante :</span></td>
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			<td>{% textarea_tag name=&quot;25c10199&quot; data_width=&quot;100&quot; rows=&quot;0&quot; data_label=&quot;adresse si&egrave;ge social&quot; data_map_field=&quot;nomap&quot; data_help=&quot;adresse si&egrave;ge social&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Repr&eacute;sent&eacute;e par :&nbsp;</span>{% textinput_tag name=&quot;18a3a924&quot; data_label=&quot;repr&eacute;sentant du syndic&quot; data_map_field=&quot;nomap&quot; data_help=&quot;repr&eacute;sentant du syndic&quot; maxlength=&quot;90&quot; style=&quot;max-width:600px;min-width:600px;width:600px;&quot; fixedwidth=&quot;600&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">en qualit&eacute; de :&nbsp;&nbsp;</span>{% textinput_tag name=&quot;a6e44103&quot; data_label=&quot;qualit&eacute; du repr&eacute;sentant&quot; data_map_field=&quot;nomap&quot; data_help=&quot;qualit&eacute; du repr&eacute;sentant&quot; maxlength=&quot;35&quot; style=&quot;max-width:250px;min-width:250px;width:250px;&quot; fixedwidth=&quot;250&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Immatricul&eacute; (e) au registre du commerce et des soci&eacute;t&eacute;s de :&nbsp;&nbsp;{% textinput_tag name=&quot;7af96c96&quot; data_label=&quot;lieu immatriculation RCS&quot; data_map_field=&quot;nomap&quot; data_help=&quot;lieu immatriculation RCS&quot; maxlength=&quot;60&quot; style=&quot;max-width:400px;min-width:400px;width:400px;&quot; fixedwidth=&quot;400&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">sous le num&eacute;ro :&nbsp; {% textinput_tag name=&quot;ee21b798&quot; data_label=&quot;num&eacute;ro RCS&quot; data_map_field=&quot;nomap&quot; data_help=&quot;num&eacute;ro RCS&quot; maxlength=&quot;20&quot; style=&quot;max-width:150px;min-width:125px;width:125px;&quot; fixedwidth=&quot;150&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;true&quot; %}&nbsp; et dont le num&eacute;ro unique d&rsquo;identification est :&nbsp;&nbsp;{% textinput_tag name=&quot;a68a956f&quot; data_label=&quot;num&eacute;ro unique d&#39;identification RCS&quot; data_map_field=&quot;nomap&quot; data_help=&quot;num&eacute;ro unique d&#39;identification RCS&quot; maxlength=&quot;20&quot; style=&quot;max-width:150px;min-width:125px;width:125px;&quot; fixedwidth=&quot;150&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;true&quot; %}</span></td>
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<p style="text-align: justify;"><em><span style="font-weight:600;"><span style="font-family: ITCAvantGardePro; font-size: 12px;">Mentions propres au syndic soumis &agrave; la loi n&deg; 70-9 du 2 janvier 1970 modifi&eacute;e r&eacute;glementant les conditions d&rsquo;exercice des activit&eacute;s relatives &agrave; certaines op&eacute;rations portant sur les immeubles et les fonds de commerce :</span></span></em></p>

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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Titulaire de la carte professionnelle mention :&nbsp; </span>{% textinput_tag name=&quot;6b37db5f&quot; data_label=&quot;mention carte professionnelle&quot; data_map_field=&quot;nomap&quot; data_help=&quot;mention carte professionnelle&quot; maxlength=&quot;600&quot; style=&quot;max-width:250px;min-width:250px;width:250px;&quot; fixedwidth=&quot;250&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp; &nbsp;&nbsp;n&deg; :&nbsp;&nbsp;</span>{% textinput_tag name=&quot;95d8633e&quot; data_label=&quot;num&eacute;ro carte professionnelle&quot; data_map_field=&quot;nomap&quot; maxlength=&quot;50&quot; style=&quot;max-width:170px;min-width:170px;width:170px;&quot; fixedwidth=&quot;170&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">d&eacute;livr&eacute;e le :&nbsp; </span>{% dateinput_tag name=&quot;c74a16a8&quot; placeholder=&quot;jj/mm/aaaa&quot; data_label=&quot;date de d&eacute;livrance carte professionnelle&quot; data_map_field=&quot;nomap&quot; data_help=&quot;date de d&eacute;livrance carte professionnelle&quot; style=&quot;max-width:80px;min-width:80px;width:80px;&quot; fixedwidth=&quot;80&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;true&quot; %}<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp; par :&nbsp;&nbsp;</span>{% textinput_tag name=&quot;1edb0792&quot; data_label=&quot;organisme de d&eacute;livrance carte professionnelle&quot; data_map_field=&quot;nomap&quot; data_help=&quot;organisme de d&eacute;livrance carte professionnelle&quot; maxlength=&quot;600&quot; style=&quot;max-width:450px;min-width:450px;width:450px;&quot; fixedwidth=&quot;450&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Titulaire d&rsquo;un contrat d&rsquo;assurance responsabilit&eacute; civile professionnelle souscrit le :&nbsp;{% dateinput_tag name=&quot;fcd86927&quot; data_map_field=&quot;nomap&quot; data_label=&quot;date de souscription du contrat d&rsquo;assurance RCP&quot; data_help=&quot;date de souscription du contrat d&rsquo;assurance RCP&quot; style=&quot;max-width:80px;min-width:80px;width:80px;&quot; fixedwidth=&quot;80&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;true&quot; %}&nbsp;</span></p>

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">aupr&egrave;s de :&nbsp;&nbsp;{% textinput_tag name=&quot;68833979&quot; data_label=&quot;assureur&quot; data_map_field=&quot;nomap&quot; data_help=&quot;assureur&quot; maxlength=&quot;90&quot; style=&quot;max-width:500px;min-width:500px;width:500px;&quot; fixedwidth=&quot;500&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></p>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Titulaire d&rsquo;une garantie financi&egrave;re conform&eacute;ment &agrave; l&rsquo;article 3 de la loi du 2 janvier 1970 pr&eacute;cit&eacute;e, souscrite le :&nbsp;</span>{% dateinput_tag name=&quot;6c22d411&quot; placeholder=&quot;jj/mm/aaaa&quot; data_label=&quot;date de souscription garantie financi&egrave;re &quot; data_map_field=&quot;nomap&quot; data_help=&quot;date de souscription garantie financi&egrave;re &quot; style=&quot;max-width:70px;min-width:70px;width:70px;&quot; fixedwidth=&quot;70&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;true&quot; %}</td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">aupr&egrave;s de :&nbsp;&nbsp;</span>{% textinput_tag name=&quot;4f265451&quot; data_label=&quot;garantie financi&egrave;re souscrit aupr&egrave;s de&quot; data_map_field=&quot;nomap&quot; data_help=&quot;garantie financi&egrave;re souscrit aupr&egrave;s de&quot; maxlength=&quot;100&quot; style=&quot;max-width:650px;min-width:650px;width:650px;&quot; fixedwidth=&quot;650&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">dont l&rsquo;adresse est :</span></td>
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			<td>{% textarea_tag name=&quot;d89ffa0c&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;adresse de l&#39;organisme de garantie financi&egrave;re&quot; data_map_field=&quot;nomap&quot; data_help=&quot;adresse de l&#39;organisme de garantie financi&egrave;re&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Autres mentions obligatoires requises par la r&eacute;glementation applicable (le cas &eacute;ch&eacute;ant) :</span></td>
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			<td>{% textarea_tag name=&quot;d80e10a8&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;autres mentions obligatoires requises par la r&eacute;glementation applicable &quot; data_map_field=&quot;nomap&quot; data_help=&quot;autres mentions obligatoires requises par la r&eacute;glementation applicable &quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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