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<table border="0" cellpadding="1" cellspacing="2" style="width: 100%;">
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			<td style="vertical-align: bottom; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% select_tag name=&quot;2a6cec09&quot; data_label=&quot;Aanhef&quot; data_map_field=&quot;civilite&quot; data_help=&quot;Aanhef&quot; data_choices=&quot;Aanhef|civilite; Mevrouw|madame; De heer|monsieur;&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}<strong>&nbsp;</strong>Naam:</span></td>
			<td style="vertical-align: bottom; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Voornaam:</span></td>
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			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;f1d9a812&quot; data_label=&quot;Naam ondertekenaar&quot; data_map_field=&quot;nom&quot; data_help=&quot;Naam ondertekenaar&quot; maxlength=&quot;50&quot; relation_ids_list=&quot;087a9c2a&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;e7d938b6&quot; data_label=&quot;Voornaam ondertekenaar&quot; data_map_field=&quot;prenom&quot; data_help=&quot;Voornaam ondertekenaar&quot; maxlength=&quot;50&quot; relation_ids_list=&quot;002cb93f&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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</table>

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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Adres:</span></td>
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			<td style="width: 68px;">{% textinput_tag name=&quot;109d7745&quot; data_label=&quot;Adres ondertekenaar&quot; data_map_field=&quot;adresse&quot; data_help=&quot;Adres ondertekenaar&quot; maxlength=&quot;100&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td style="width: 20%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Postcode:</span></td>
			<td style="width: 55%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Stad:</span></td>
			<td style="width: 25%;"><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200"><font face="ITCAvantGardePro">Land:</font></span></span></span></td>
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			<td style="width: 20%;">{% textinput_tag name=&quot;de0ac6cf&quot; data_label=&quot;Postcode&quot; data_map_field=&quot;zipcode&quot; data_help=&quot;Postcode&quot; maxlength=&quot;10&quot; relation_ids_list=&quot;f5e66571&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 55%;">{% textinput_tag name=&quot;729bba52&quot; data_label=&quot;Stad&quot; data_map_field=&quot;ville&quot; data_help=&quot;Stad&quot; maxlength=&quot;80&quot; relation_ids_list=&quot;ed0a66fe&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 25%;">{% textinput_tag name=&quot;4e0fc70a&quot; placeholder=&quot;Luxemburg&quot; data_label=&quot;Land van ondertekenaar&quot; data_map_field=&quot;pays&quot; data_help=&quot;Land van ondertekenaar&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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</table>

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			<td style="vertical-align: middle; width: 70%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">E-mail :&nbsp;</span></td>
			<td style="vertical-align: middle; width: 30%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp;Tel :&nbsp;&nbsp;</span></td>
		</tr>
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			<td style="vertical-align: middle; width: 70%;">{% textinput_tag name=&quot;70dab79e&quot; data_label=&quot;E-mail&quot; data_map_field=&quot;email&quot; data_help=&quot;E-mail &quot; maxlength=&quot;50&quot; relation_ids_list=&quot;4ce94e90&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;6dc1dd0c&quot; data_label=&quot;Tel&quot; data_map_field=&quot;tel&quot; data_help=&quot;Tel ondertekenaar&quot; maxlength=&quot;25&quot; relation_ids_list=&quot;983649b0&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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</table>

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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Beroep:</span></td>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Nationaliteit:</span></td>
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			<td>{% textinput_tag name=&quot;9bb31b8e&quot; data_label=&quot;Beroep &quot; data_map_field=&quot;job&quot; data_help=&quot;Beroep &quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td>{% textinput_tag name=&quot;1f8f2318&quot; data_label=&quot;Nationaliteit &quot; data_map_field=&quot;nationality&quot; data_help=&quot;Nationaliteit &quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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</table>

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			<td><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200"><font face="ITCAvantGardePro">Burgerlijke staat :&nbsp;</font>{% radio_tag name=&quot;d8242156f&quot; data_label=&quot;Burgerlijke staat&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Burgerlijke staat&quot; data_choices=&quot;Alleenstaand&nbsp;&nbsp;&nbsp; |C&eacute;libataire; Gehuwd&nbsp;&nbsp;&nbsp; |Mari&eacute;(e); Samenwonend&nbsp;&nbsp;&nbsp; |Pacs&eacute;(e); Gescheiden&nbsp;&nbsp;&nbsp; |Divorc&eacute;(e); Weduwe/Weduwnaar&nbsp;&nbsp;&nbsp; |Veuf(ve);&quot; %}</span></span></span></td>
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			<td><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">Detail burgerlijke staat:</span></span></span></td>
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			<td><span style="font-size:12px"><span style="font-family:ITCAvantGardePro"><span style="font-weight:200">{% textarea_tag name=&quot;dcb41cd9&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Detail burgerlijke staat&quot; data_map_field=&quot;family_situation&quot; data_help=&quot;Geef de datum en plaats van huwelijk op en het huwelijksstelsel. De datum en plaats van PACS-registratie&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></span></span></td>
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</table>

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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Andere nuttige informatie:</span></td>
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			<td>{% textarea_tag name=&quot;740db238&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Andere nuttige informatie&quot; data_map_field=&quot;comment&quot; data_help=&quot;Andere nuttige informatie&quot; relation_ids_list=&quot;1256,1728,1111,7056,6290,10507,525,1206,1728,2248,6286,8701,0782e38f&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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</table>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Handelend als :&nbsp;{% radio_tag name=&quot;a6c38d5e&quot; data_label=&quot;Hoedanigheid van de ondertekenaar&quot; data_map_field=&quot;nomap&quot; data_choices=&quot;Eigenaar(s)&nbsp;&nbsp;&nbsp; |propri&eacute;taire(s); Gemachtigde(n)&nbsp;&nbsp;&nbsp; |mandataire(s); Sterkmaker&nbsp;&nbsp;&nbsp; |porte-fort;&quot; %}</span></td>
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</table>

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