Admin - Plateforme Administration Editions Préference

Contient un/plusieurs signataires

Reprise des signataires

Peut etre dupliqué

Nombre maximum de block

Texte du bouton 'ajouter'

Texte du bouton 'supprimer'

Ce block contient un

Contenu

<table style="width:100%; border:undefined">
	<tbody>
		<tr>
			<td style="vertical-align:middle; width:50%">{% select_tag name=&quot;ada3ee6b&quot; data_label=&quot;Civilit&eacute;&quot; data_map_field=&quot;nomap&quot; data_choices=&quot;Title|civilite; Misses|madame; Mister|monsieur;&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}<span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200"><strong>&nbsp;</strong>Last name:</span></span></span></td>
			<td style="vertical-align:middle; width:50%"><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">First name:</span></span></span></td>
		</tr>
		<tr>
			<td style="vertical-align:middle; width:50%">{% textinput_tag name=&quot;cb794f0b&quot; data_label=&quot;Nom&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Nom&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;59ab66fd&quot; data_label=&quot;Pr&eacute;nom&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Pr&eacute;nom&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
		<tr>
			<td style="vertical-align:middle; width:50%"><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">E-mail:&nbsp;</span></span></span></td>
			<td style="vertical-align:middle; width:50%"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp;Phone number:&nbsp;&nbsp;</span></td>
		</tr>
		<tr>
			<td style="vertical-align:middle; width:50%">{% textinput_tag name=&quot;8a9b23ae&quot; data_label=&quot;Email &quot; data_map_field=&quot;nomap&quot; data_help=&quot;Email &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;17918168&quot; data_label=&quot;Tel &quot; data_map_field=&quot;nomap&quot; data_help=&quot;Tel &quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
		<tr>
			<td style="vertical-align:middle; width:50%"><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">Profession:</span></span></span></td>
			<td style="vertical-align:middle; width:50%"><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">Nationality:</span></span></span></td>
		</tr>
		<tr>
			<td style="vertical-align:middle; width:50%">{% textinput_tag name=&quot;57eb599b&quot; data_label=&quot;Profession &quot; data_map_field=&quot;nomap&quot; data_help=&quot;Profession &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;0a0eee39&quot; data_label=&quot;Nationalit&eacute; &quot; data_map_field=&quot;nomap&quot; data_help=&quot;Nationalit&eacute; &quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="2" cellspacing="2" style="border:undefined;width:100%;">
	<tbody>
		<tr>
			<td style="text-align:left; vertical-align:middle; width:50%"><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">Date of birth:</span></span></span></td>
			<td style="width:50%"><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">Place of birth:</span></span></span></td>
		</tr>
		<tr>
			<td style="text-align:left; vertical-align:middle; width:50%">{% dateinput_tag name=&quot;6f2be7d0&quot; placeholder=&quot;jj/mm/aaaa&quot; data_label=&quot;Date de naissance &quot; data_map_field=&quot;nomap&quot; data_help=&quot;Date de naissance&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width:50%">{% textinput_tag name=&quot;66fc193f&quot; data_label=&quot;Lieu de naissance&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Lieu de naissance&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Address:</span></td>
		</tr>
		<tr>
			<td>{% textinput_tag name=&quot;c2d5d4e1&quot; data_label=&quot;Adresse&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Adresse&quot; maxlength=&quot;100&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="width: 20%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Zip code:</span></td>
			<td style="width: 55%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">City:</span></td>
			<td style="width: 25%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Country:</span></td>
		</tr>
		<tr>
			<td style="width: 20%;">{% textinput_tag name=&quot;45eff651&quot; data_label=&quot;Code postal&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Code postal&quot; maxlength=&quot;10&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 55%;">{% textinput_tag name=&quot;43994700&quot; data_label=&quot;Ville&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Ville&quot; maxlength=&quot;80&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 25%;">{% textinput_tag name=&quot;f6b125b1&quot; placeholder=&quot;France&quot; data_label=&quot;Pays&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Pays&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Reason for third party intervention:</span></p>

<table border="0" cellpadding="1" cellspacing="1" style="width:100%;">
	<tbody>
		<tr>
			<td>{% textarea_tag name=&quot;2e22be67&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Motif de d&#39;intervention du tiers&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Motif de d&#39;intervention du tiers&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
		<tr>
			<td><em><span style="font-size:8px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">You have the possibility of registering on www.bloctel.gouv.fr to oppose any telephone canvassing in accordance with article L223-1 of the Consumer Code</span></span></span></em></td>
		</tr>
	</tbody>
</table>

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