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<p>{% select_tag name=&quot;cf6f81dc&quot; data_label=&quot;type de travailleur non salari&eacute;&quot; data_map_field=&quot;nomap&quot; data_help=&quot;type de travailleur non salari&eacute;&quot; data_choices=&quot;commer&ccedil;ant|commer&ccedil;ant; artisan|artisan; profession lib&eacute;rale|profession lib&eacute;rale; travailleur ind&eacute;pendant|travailleur ind&eacute;pendant;&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</p>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="width: 25%;">{% select_tag name=&quot;cf6f81dc&quot; data_label=&quot;type de num&eacute;ro professionnel&quot; data_map_field=&quot;nomap&quot; data_choices=&quot;n&deg; d&#39;immatriculation au RCS|1;n&deg; d&#39;enregistrement au r&eacute;pertoire des m&eacute;tiers|2;n&deg; de carte professionnelle|3;&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 75%;">{% textinput_tag name=&quot;87defc13&quot; data_label=&quot;num&eacute;ro professionnel&quot; data_map_field=&quot;rcs_num&quot; data_help=&quot;num&eacute;ro professionnel&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: 25%;">{% select_tag name=&quot;cf6f81dc&quot; data_map_field=&quot;nomap&quot; data_choices=&quot;ville d&#39;immatriculation|1;ville d&#39;enregistrement|2;date et lieu de d&eacute;livrance de la carte|3;&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 75%;">{% textinput_tag name=&quot;4ac88928&quot; data_label=&quot;lieu et date de d&eacute;livrance&quot; data_map_field=&quot;rcs_place&quot; data_help=&quot;lieu et date de d&eacute;livrance&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="1" style="width:100%;">
	<tbody>
		<tr>
			<td colspan="2" style="vertical-align: middle; width: 45%;"><span style="font-size:18px;"><span style="font-family: ITCAvantGardePro; font-weight: 200;">Revenus</span></span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 45%;">
			<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Moyenne du revenu imposable des 12 derniers mois :</span></p>
			</td>
			<td style="width: 55%;">{% textinput_tag name=&quot;c142f139&quot; data_map_field=&quot;nomap&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>
			<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Dernier revenu fiscal de r&eacute;f&eacute;rence :</span></p>
			</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="width: 27%; vertical-align: middle;">
			<ul>
				<li><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">ann&eacute;e du revenu consid&eacute;r&eacute; :</span></li>
			</ul>
			</td>
			<td style="width: 15px;">{% textinput_tag name=&quot;9f464d95&quot; data_label=&quot;ann&eacute;e du dernier avis fiscal&quot; data_map_field=&quot;nomap&quot; data_help=&quot;ann&eacute;e du dernier avis fiscal&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 15%; vertical-align: middle;">
			<ul>
				<li><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">montant :</span></li>
			</ul>
			</td>
			<td style="width: 30%;">{% textinput_tag name=&quot;2b93fec4&quot; data_label=&quot;montant du dernier avis fiscal&quot; data_map_field=&quot;nomap&quot; data_help=&quot;montant du dernier avis fiscal&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="4" style="break-inside:avoid;width:100%;">
	<caption>
	<p style="text-align: left;">&nbsp;</p>
	</caption>
	<tbody>
		<tr>
			<td colspan="3" style="width: 33%;"><span style="font-family:ITCAvantGardePro;"><span style="font-weight:200;"><span style="font-size:18px;"><span class="titre_p">Pi&egrave;ces &agrave; fournir</span></span></span></span></td>
		</tr>
		<tr>
			<td style="width: 33%;">{% checkbox_tag name=&quot;90029611&quot; data_label=&quot;Pi&egrave;ce d&rsquo;identit&eacute;&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Pi&egrave;ce d&rsquo;identit&eacute;&quot; data_ancien_ids=&quot;6376&quot; %}<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp; pi&egrave;ce d&rsquo;identit&eacute;</span></td>
			<td style="width: 33%;">{% checkbox_tag name=&quot;aebcb6b3&quot; data_label=&quot;Justificatif de domicile&quot; data_map_field=&quot;nomap&quot; data_help=&quot;justificatif de domicile&quot; data_ancien_ids=&quot;6353&quot; %}<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp; justificatif de domicile</span></td>
			<td style="width: 33%;">{% checkbox_tag name=&quot;37ec799f&quot; data_label=&quot;Trois derniers bulletins de salaire&nbsp;&quot; data_map_field=&quot;nomap&quot; data_help=&quot;trois derniers bulletins de salaire&nbsp;&quot; data_ancien_ids=&quot;6331&quot; %}<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp; trois derniers bulletins de salaire&nbsp;</span></td>
		</tr>
		<tr>
			<td style="width: 33%;">{% checkbox_tag name=&quot;ec432cf0&quot; data_label=&quot;Justificatif des autres revenus&quot; data_map_field=&quot;nomap&quot; data_help=&quot;justificatif des autres revenus&quot; %}<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp; justificatif des autres revenus</span></td>
			<td style="width: 33%;">{% checkbox_tag name=&quot;4bfa48ab&quot; data_label=&quot;Dernier avis d&rsquo;imposition sur le revenu&quot; data_map_field=&quot;nomap&quot; data_help=&quot;dernier avis d&rsquo;imposition sur le revenu&quot; data_ancien_ids=&quot;6420&quot; %}<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp; dernier avis d&rsquo;imposition sur le revenu</span></td>
			<td style="width: 33%;">&nbsp;</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="width: 5%;">{% checkbox_tag name=&quot;a7ceb4eb&quot; data_label=&quot;justificatif d&#39;immatriculation professionnelle&quot; data_map_field=&quot;nomap&quot; data_help=&quot;justificatif d&#39;immatriculation professionnelle&quot; %}</td>
			<td style="width: 95%;">{% select_tag name=&quot;485f3fe8&quot; data_label=&quot;immatriculation professionnelle&quot; data_map_field=&quot;nomap&quot; data_help=&quot;immatriculation professionnelle&quot; data_choices=&quot;copie de la carte professionnelle|copie de la carte professionnelle; extrait d&#39;immatriculation au RCS de moins de 3 mois|extrait d&#39;immatriculation au RCS de moins de 3 mois; extrait D1 original du r&eacute;pertoire de moins de 3 mois|extrait D1 original du r&eacute;pertoire de moins de 3 mois; copie du certificat d&#39;identification de l&#39;INSEE avec num&eacute;ros d&#39;identification|copie du certificat d&#39;identification de l&#39;INSEE avec num&eacute;ros d&#39;identification; autre pi&egrave;ce r&eacute;cente attestant de l&#39;activit&eacute; pour les autres professionnels|autre pi&egrave;ce r&eacute;cente attestant de l&#39;activit&eacute; pour les autres professionnels;&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 colspan="2" style="width: 20%; vertical-align: middle;"><span class="titre_p" style="font-family:ITCAvantGardePro;font-size:18px;font-weight:900;">G&eacute;rant de soci&eacute;t&eacute; (non salari&eacute;)</span></td>
		</tr>
		<tr>
			<td style="width: 20%; vertical-align: middle;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">D&eacute;nomination sociale :</span></td>
			<td>{% textinput_tag name=&quot;c0cf97b7&quot; data_label=&quot;D&eacute;nomination sociale&quot; data_map_field=&quot;societe&quot; data_help=&quot;nom de la soci&eacute;t&eacute; figurant sur le Kbis&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%; vertical-align: middle;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Forme juridique :</span></td>
			<td style="width: 15%;">{% select_tag name=&quot;d2b280ff&quot; data_label=&quot;Forme juridique&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Forme juridique&quot; data_choices=&quot;SARL ou EURL|SARL ou EURL; SAS ou SASU|SAS ou SASU; SCI|SCI; Autre|Autre;&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 15%; vertical-align: middle;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">si autre :</span></td>
			<td style="width: 55%;">{% textinput_tag name=&quot;d902bea7&quot; data_label=&quot;autre forme juridique&quot; data_map_field=&quot;nomap&quot; data_help=&quot;autre forme juridique&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;">Num&eacute;ro de SIREN :</span></td>
			<td>{% numberinput_tag name=&quot;21eeb648&quot; data_label=&quot;Num&eacute;ro de SIREN&quot; data_map_field=&quot;rcs_num&quot; data_help=&quot;9 chiffres du num&eacute;ro SIREN&quot; maxlength=&quot;9&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="vertical-align: middle;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Ville d&#39;immatriculation :</span></td>
			<td>{% textinput_tag name=&quot;16295b49&quot; data_label=&quot;Ville d&#39;immatriculation de la soci&eacute;t&eacute;&quot; data_map_field=&quot;rcs_place&quot; data_help=&quot;Ville d&#39;immatriculation de la soci&eacute;t&eacute;&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="1" style="width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align: middle; width: 45%;">
			<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Moyenne du revenu imposable des 12 derniers mois :</span></p>
			</td>
			<td style="width: 55%;">{% textinput_tag name=&quot;fc2f3856&quot; data_map_field=&quot;nomap&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: 27%; vertical-align: middle;">
			<ul>
				<li><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">ann&eacute;e du revenu consid&eacute;r&eacute; :</span></li>
			</ul>
			</td>
			<td style="width: 15px;">{% textinput_tag name=&quot;580633a9&quot; data_label=&quot;ann&eacute;e du dernier avis fiscal&quot; data_map_field=&quot;nomap&quot; data_help=&quot;ann&eacute;e du dernier avis fiscal&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 15%; vertical-align: middle;">
			<ul>
				<li><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">montant :</span></li>
			</ul>
			</td>
			<td style="width: 30%;">{% textinput_tag name=&quot;3885f2e7&quot; data_label=&quot;montant du dernier avis fiscal&quot; data_map_field=&quot;nomap&quot; data_help=&quot;montant du dernier avis fiscal&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="4" style="break-inside:avoid;width:100%;">
	<caption>
	<p style="text-align: left;">&nbsp;</p>
	</caption>
	<tbody>
		<tr>
			<td colspan="3" style="width: 33%;"><span style="font-family:ITCAvantGardePro;"><span style="font-size:18px;"><span style="font-weight:200;"><span class="titre_p">Pi&egrave;ces &agrave; fournir</span></span></span></span></td>
		</tr>
		<tr>
			<td style="width: 33%;">{% checkbox_tag name=&quot;4b11d6d3&quot; data_label=&quot;Pi&egrave;ce d&rsquo;identit&eacute;&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Pi&egrave;ce d&rsquo;identit&eacute;&quot; data_ancien_ids=&quot;6376&quot; %}<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp; pi&egrave;ce d&rsquo;identit&eacute;</span></td>
			<td style="width: 33%;">{% checkbox_tag name=&quot;8e001fcd&quot; data_label=&quot;Justificatif de domicile&quot; data_map_field=&quot;nomap&quot; data_help=&quot;justificatif de domicile&quot; data_ancien_ids=&quot;6353&quot; %}<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp; justificatif de domicile</span></td>
			<td style="width: 33%;">{% checkbox_tag name=&quot;ba7f1e57&quot; data_label=&quot;Dernier avis d&rsquo;imposition sur le revenu&quot; data_map_field=&quot;nomap&quot; data_help=&quot;dernier avis d&rsquo;imposition sur le revenu&quot; data_ancien_ids=&quot;6420&quot; %}<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp; dernier avis d&rsquo;imposition sur le revenu</span></td>
		</tr>
		<tr>
			<td style="width: 33%;">{% checkbox_tag name=&quot;d8c0e492&quot; data_label=&quot;Extrait Kbis du RCS de moins de 3 mois&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Extrait Kbis du RCS de moins de 3 mois&quot; %}<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp;extrait Kbis du RCS de moins de 3 mois</span></td>
			<td style="width: 33%;">{% checkbox_tag name=&quot;7e879b26&quot; data_label=&quot;Attestation de ressources pour l&#39;exercice en cours d&eacute;livr&eacute;e par l&#39;expert-comptable&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Attestation de ressources pour l&#39;exercice en cours d&eacute;livr&eacute;e par l&#39;expert-comptable&quot; data_ancien_ids=&quot;6331&quot; %}<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp; attestation de ressources pour l&#39;exercice en cours d&eacute;livr&eacute;e par l&#39;expert-comptable</span></td>
		</tr>
	</tbody>
</table>

<p>{% checkbox_tag name=&quot;6d4a372a&quot; data_label=&quot;Intervention du conjoint en cas de cautionnement donn&eacute; par une personne physique mari&eacute;e sous un r&eacute;gime communautaire&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Intervention du conjoint en cas de cautionnement donn&eacute; par une personne physique mari&eacute;e sous un r&eacute;gime communautaire&quot; %}<strong> </strong><span style="font-weight:900;"><strong><span style="font-family: ITCAvantGardePro; font-size: 12px;">intervention du conjoint en cas de cautionnement donn&eacute; par une personne physique mari&eacute;e sous un r&eacute;gime communautaire</span></strong></span></p>

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