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						<td><span style="font-family: ITCAvantGardePro; font-size: 12px;">Le &nbsp;</span>{% dateinput_tag name=&quot;db8c7ec4&quot; placeholder=&quot;jj/mm/aaaa&quot; data_label=&quot;Date de signature du mandat&quot; data_map_field=&quot;sign_date&quot; data_help=&quot;Date de signature du mandat&quot; style=&quot;max-width:80px;min-width:80px;width:80px;&quot; fixedwidth=&quot;80&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;true&quot; %}<span style="font-family: ITCAvantGardePro; font-size: 12px;"> &nbsp; &Agrave;&nbsp;</span>{% textinput_tag name=&quot;09d5e02e&quot; data_label=&quot;Lieu de signature du mandat&quot; data_map_field=&quot;sign_place&quot; data_help=&quot;Lieu de signature du mandat&quot; maxlength=&quot;75&quot; style=&quot;max-width:500px;min-width:500px;width:500px;&quot; fixedwidth=&quot;500&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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						<p><span style="font-size:14px;"><em><span style="font-family:Garamond;"><strong>Le&nbsp;Cr&eacute;ancier</strong></span></em></span></p>

<p><span style="font-weight:600;"><span style="font-family: ITCAvantGardePro; font-size: 12px;">SAS JUNOT CARIOCA</span></span><br />
						<span style="font-weight:600;"><span style="font-family: ITCAvantGardePro; font-size: 12px;">23 bis, avenue Junot<br />
						75018 Paris<br />
						France</span></span></p>
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						<p><span style="font-size:14px;"><em><span style="font-family:Garamond;"><strong>Le D&eacute;biteur&nbsp;</strong></span></em></span></p>

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						<td style="width: 10%; vertical-align: middle; padding: 8px; background-color: rgb(234, 227, 222); text-align: right;">{% textinput_tag name=&quot;0fe123c3&quot; data_label=&quot;Nombre de mots ray&eacute;s&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Nombre de mots ray&eacute;s&quot; maxlength=&quot;4&quot; style=&quot;max-width:25px;min-width:25px;width:25px;&quot; fixedwidth=&quot;25&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;true&quot; %}<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp;mots*,&nbsp; </span>{% textinput_tag name=&quot;2d91d152&quot; data_label=&quot;Nombre de lignes ray&eacute;s&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Nombre de lignes ray&eacute;s&quot; maxlength=&quot;4&quot; style=&quot;max-width:25px;min-width:25px;width:25px;&quot; fixedwidth=&quot;25&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;true&quot; %}<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp;lignes*,&nbsp;</span>{% textinput_tag name=&quot;5828b57a&quot; data_label=&quot;Nombre de chiffres ray&eacute;s&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Nombre de chiffres ray&eacute;s&quot; maxlength=&quot;4&quot; style=&quot;max-width:25px;min-width:25px;width:25px;&quot; fixedwidth=&quot;25&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;true&quot; %}<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"> chiffres*&nbsp; <span style="color:#ffffff;"><span style="font-weight:900;">|</span></span>&nbsp; *Ray&eacute;s comme nuls</span></td>
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