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<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align: bottom; width: 50%;">{% select_tag name=&quot;833391fc&quot; data_label=&quot;Civilit&eacute; &quot; data_map_field=&quot;civilite&quot; data_help=&quot;Choisissez la civilit&eacute;&quot; data_choices=&quot;Civilit&eacute;|civilite; Monsieur|monsieur; Madame|madame;&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"><strong>&nbsp;</strong>Nom :</span></td>
			<td style="vertical-align: bottom; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Pr&eacute;nom :</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;087a9c2a&quot; data_label=&quot;Nom du mandant &quot; data_map_field=&quot;nom&quot; data_help=&quot;Nom du mandant, indiquer le nom de jeune fille le cas &eacute;ch&eacute;ant&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;002cb93f&quot; data_label=&quot;Pr&eacute;nom du mandant (Monsieur)&quot; data_map_field=&quot;prenom&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>
	</tbody>
</table>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="width: 70%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Lieu de naissance :</span></td>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Date de naissance :</span></td>
		</tr>
		<tr>
			<td>{% textinput_tag name=&quot;67fe78de&quot; data_label=&quot;Lieu de naissance&quot; data_map_field=&quot;lieu_naissance&quot; data_help=&quot;Lieu de naissance&quot; maxlength=&quot;80&quot; data_ancien_ids=&quot;21911&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td>{% dateinput_tag name=&quot;f014d7d1&quot; placeholder=&quot;jj/mm/aaaa&quot; data_label=&quot;Date de naissance&quot; data_map_field=&quot;date_naissance&quot; data_help=&quot;Date de naissance&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;true&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align: bottom; width: 50%;">{% select_tag name=&quot;d1c10b0a&quot; data_label=&quot;Civilit&eacute; &quot; data_map_field=&quot;civilite&quot; data_help=&quot;Choisissez la civilit&eacute;&quot; data_choices=&quot;Civilit&eacute;|civilite; Monsieur|monsieur; Madame|madame;&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}&nbsp;<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp;Nom :</span></td>
			<td style="vertical-align: bottom; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Pr&eacute;nom :</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;322861a6&quot; data_label=&quot;Nom du mandant (Madame)&quot; data_map_field=&quot;nom&quot; data_help=&quot;Nom du mandant, indiquer le nom de jeune fille le cas &eacute;ch&eacute;ant&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;ac7e9636&quot; data_label=&quot;Pr&eacute;nom du mandant &quot; data_map_field=&quot;prenom&quot; data_help=&quot;Nom du mandant&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;">&nbsp;Adresse commune :</span></td>
		</tr>
		<tr>
			<td>{% textinput_tag name=&quot;109d7745&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Adresse mandant&quot; data_map_field=&quot;adresse&quot; data_help=&quot;Adresse mandant&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;">Code postal :</span></td>
			<td style="width: 55%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Ville :&nbsp;</span></td>
			<td style="width: 25%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Pays :</span></td>
		</tr>
		<tr>
			<td style="width: 20%;">{% textinput_tag name=&quot;fa407fde&quot; data_label=&quot;Code Postal&quot; data_map_field=&quot;zipcode&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;12099384&quot; data_label=&quot;Ville&quot; data_map_field=&quot;ville&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;4e0fc70a&quot; placeholder=&quot;France&quot; data_label=&quot;Pays&quot; data_map_field=&quot;pays&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>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="width: 70%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Lieu de naissance :</span></td>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Date de naissance :</span></td>
		</tr>
		<tr>
			<td>{% textinput_tag name=&quot;412d69a0&quot; data_label=&quot;Lieu de naissance&quot; data_map_field=&quot;lieu_naissance&quot; data_help=&quot;Lieu de naissance&quot; maxlength=&quot;80&quot; data_ancien_ids=&quot;21911&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td>{% dateinput_tag name=&quot;af71a231&quot; placeholder=&quot;jj/mm/aaaa&quot; data_label=&quot;Date de naissance&quot; data_map_field=&quot;date_naissance&quot; data_help=&quot;Date de naissance&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;true&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="width: 100%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Autres informations utiles :&nbsp;</span></td>
		</tr>
		<tr>
			<td style="width: 100%;">{% textarea_tag name=&quot;eda2bf89&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Autres informations utiles&quot; data_map_field=&quot;comment&quot; data_help=&quot;Autres informations utiles&quot; relation_ids_list=&quot;1256,1728,1111,7056,6290,10507,525,1206,1728,2248,6286,8701&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

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