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<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"><em>Le cas &eacute;ch&eacute;ant,</em> repr&eacute;sent&eacute; par le mandataire gestionnaire :</span></p>

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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Nom ou raison social :</span></td>
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			<td>{% textarea_tag name=&quot;c44ddb93&quot; data_width=&quot;100&quot; rows=&quot;3&quot; data_label=&quot;Nom ou raison social du repr&eacute;sentant&quot; data_map_field=&quot;nom&quot; data_help=&quot;Nom ou raison social du repr&eacute;sentant&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;">Adresse du mandataire ainsi que l&rsquo;activit&eacute; exerc&eacute;e :</span></td>
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			<td>{% textarea_tag name=&quot;ee11a72a&quot; data_width=&quot;100&quot; rows=&quot;4&quot; data_label=&quot;Adresse du mandataire ainsi que l&rsquo;activit&eacute; exerc&eacute;e :&quot; data_map_field=&quot;adresse&quot; data_help=&quot;Adresse du mandataire ainsi que l&rsquo;activit&eacute; exerc&eacute;e :&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td style="vertical-align: middle; width: 70%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Adresse &eacute;lectronique (facultatif) <sup>(2)</sup> :</span></td>
			<td style="vertical-align: middle; width: 30%;">&nbsp;<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">T&eacute;l. (facultatif) <sup>(2)</sup> :&nbsp;&nbsp;</span></td>
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			<td style="vertical-align: middle; width: 70%;">{% textinput_tag name=&quot;c8dc7052&quot; data_label=&quot;Email du repr&eacute;sentant&quot; data_map_field=&quot;email&quot; data_help=&quot;Email du repr&eacute;sentant&quot; maxlength=&quot;50&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;9d621xx1&quot; data_label=&quot;T&eacute;l du repr&eacute;sentant&quot; data_map_field=&quot;tel&quot; data_help=&quot;T&eacute;l du repr&eacute;sentant&quot; maxlength=&quot;64&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td style="width: 30%; vertical-align: middle;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Num&eacute;ro de la carte professionnelle :</span></td>
			<td style="width: 20%;">{% textinput_tag name=&quot;65a32c3b&quot; data_label=&quot;Num&eacute;ro de la carte professionnelle :&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Num&eacute;ro de la carte professionnelle :&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 16%; vertical-align: middle;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">lieu de d&eacute;livrance :</span></td>
			<td style="width: 45%;">{% textinput_tag name=&quot;870c8bce&quot; data_label=&quot;lieu de d&eacute;livrance de la CP&quot; data_map_field=&quot;nomap&quot; data_help=&quot;lieu de d&eacute;livrance de la CP&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td style="vertical-align: middle; width: 25%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Nom et adresse du garant <sup>(3)</sup> :</span></td>
			<td style="width: 70%;">{% textinput_tag name=&quot;fcae3cea&quot; data_label=&quot;Nom et adresse du garant :&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Nom et adresse du garant :&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-family:ITCAvantGardePro;font-size:12px;font-weight:200;">M&eacute;diateur : Association MEDIMMOCONSO, 1 All&eacute;e du Parc de Mesemena - B&acirc;t A - CS 25222 - 44505 LA BAULE CEDEX<br />
Site internet : <a href="https://recevabilite-mediations.medimmoconso.fr/">https://medimmoconso.fr/adresser-une-reclamation/</a></span></p>

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