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<p><span style="font-weight:800;"><strong><span style="font-family: ITCAvantGardePro; font-size: 12px;">ENTRE LES SOUSSIGNES</span></strong></span></p>

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"><span style="font-weight:900;">Le mandataire</span>, titulaire du mandat d&#39;origine :</span><br />
{% textarea_tag name=&quot;bb12b7b6&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Le mandataire&quot; data_help=&quot;Le mandataire titulaire du mandat&quot; data_ancien_ids=&quot;1256&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</p>

<table border="0" cellpadding="1" cellspacing="1" style="width:100%;">
	<tbody>
		<tr>
			<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;b46bbb8e&quot; data_label=&quot;E-mail du mandataire&quot; data_help=&quot;E-mail mandataire&quot; maxlength=&quot;70&quot; data_ancien_ids=&quot;7743&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;2abcdbd5&quot; data_label=&quot;T&eacute;l&eacute;phone du mandataire&quot; data_help=&quot;T&eacute;l&eacute;phone mandataire&quot; maxlength=&quot;22&quot; data_ancien_ids=&quot;7766&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;"><span style="font-weight:900;">Le d&eacute;l&eacute;gataire</span>, b&eacute;n&eacute;ficiaire de la d&eacute;l&eacute;gation :</span></p>

<table border="0" cellpadding="1" cellspacing="1" style="width:100%;">
	<tbody>
		<tr>
			<td>{% textarea_tag name=&quot;97c645a5&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Le d&eacute;l&eacute;gataire&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: 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;0c6cbb6c&quot; data_label=&quot;E-mail d&eacute;l&eacute;gataire&quot; data_help=&quot;E-mail du d&eacute;l&eacute;gataire&quot; maxlength=&quot;70&quot; data_ancien_ids=&quot;7851&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;f99113ec&quot; data_label=&quot;T&eacute;l&eacute;phone du d&eacute;l&eacute;gataire&quot; data_help=&quot;T&eacute;l&eacute;phone d&eacute;l&eacute;gataire&quot; maxlength=&quot;22&quot; data_ancien_ids=&quot;7874&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;">Tous deux r&eacute;guli&egrave;rement titulaires d&rsquo;une carte professionnelle conform&eacute;ment &agrave; la loi n&deg; 70/9 du 2 janvier 1970.</span>&nbsp;</p>

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