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<table border="0" cellpadding="1" cellspacing="2" style="width: 100%;">
	<tbody>
		<tr>
			<td style="vertical-align: bottom; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% select_tag name=&quot;4f020961&quot; data_label=&quot;Civilit&eacute;&quot; data_map_field=&quot;civilite&quot; data_help=&quot;Civilit&eacute;&quot; data_choices=&quot;Civilit&eacute;|civilite; Madame|madame; Monsieur|monsieur;&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}<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;199982c6&quot; data_label=&quot;Nom&quot; data_map_field=&quot;nom&quot; data_help=&quot;Nom &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;476293fd&quot; data_label=&quot;Pr&eacute;nom&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="1" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="width: 68%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Adresse :</span></td>
		</tr>
		<tr>
			<td style="width: 68%;">{% textinput_tag name=&quot;6769eae3&quot; data_label=&quot;Adresse postale&quot; data_map_field=&quot;adresse&quot; data_help=&quot;Adresse postale&quot; maxlength=&quot;100&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 :</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%;">{% numberinput_tag name=&quot;30b54018&quot; data_label=&quot;Code Postal&quot; data_map_field=&quot;zipcode&quot; data_help=&quot;Code Postal&quot; maxlength=&quot;8&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 55%;">{% textinput_tag name=&quot;123f5ca4&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;7a7c773b&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="1" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<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%;">&nbsp;<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Tel :&nbsp;&nbsp;</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 70%;">{% textinput_tag name=&quot;6c8cfb0a&quot; data_label=&quot;Email&quot; data_map_field=&quot;email&quot; data_help=&quot;Email&quot; maxlength=&quot;50&quot; relation_ids_list=&quot;79c77dc2&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;2669686c&quot; data_label=&quot;Tel&quot; data_map_field=&quot;tel&quot; data_help=&quot;Tel&quot; maxlength=&quot;25&quot; relation_ids_list=&quot;d39f50f4&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%; break-inside: avoid;">
	<tbody>
		<tr>
			<td style="width: 20%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Date de naissance :</span></td>
			<td style="width: 80%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Lieu de naissance :</span></td>
		</tr>
		<tr>
			<td style="width: 20%;">{% dateinput_tag name=&quot;7abc5256&quot; placeholder=&quot;jj/mm/aaaa&quot; data_map_field=&quot;date_naissance&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;true&quot; %}</td>
			<td style="width: 80%;">{% textinput_tag name=&quot;5f34688a&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>
		</tr>
	</tbody>
</table>

<p><span style="font-size:8px;"><span style="font-family: ITCAvantGardePro; font-weight: 200;"><em>Vous avez la possibilit&eacute; de vous inscrire sur www.bloctel.gouv.fr pour vous opposer &agrave; tout d&eacute;marchage t&eacute;l&eacute;phonique conform&eacute;ment &agrave; l&#39;article L223-1 du Code de la consommation.</em></span></span></p>

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"><em>Le garant signataire des pr&eacute;sentes s&#39;engage &agrave; informer le bailleur de toutes modifications de domicile</em></span></p>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="width: 25%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">situation maritale actuelle :</span></td>
			<td>{% radio_tag name=&quot;1fa947b8&quot; data_label=&quot;situation maritale actuelle&quot; data_map_field=&quot;nomap&quot; data_choices=&quot;c&eacute;libataire&nbsp; &nbsp;|c&eacute;libataire; pacs&eacute;&nbsp; &nbsp;|pacs&eacute;; mari&eacute;|mari&eacute;;&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="width: 21%; vertical-align: middle;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Si mari&eacute;, r&eacute;gime matrimonial :</span></td>
			<td style="width: 65%;">{% select_tag name=&quot;5aa46d14&quot; data_label=&quot;en cas de mariage :&quot; data_map_field=&quot;nomap&quot; data_choices=&quot;r&eacute;gime de la communaut&eacute; r&eacute;duite aux acqu&ecirc;ts|r&eacute;gime de la communaut&eacute; r&eacute;duite aux acqu&ecirc;ts; r&eacute;gime de la communaut&eacute; universelle|r&eacute;gime de la communaut&eacute; universelle; r&eacute;gime de la s&eacute;paration de biens|r&eacute;gime de la s&eacute;paration de biens; r&eacute;gime de la participation aux acqu&ecirc;ts|r&eacute;gime de la participation aux acqu&ecirc;ts;&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: 10%; vertical-align: middle;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Profession :</span></td>
			<td style="width: 35%;">{% textinput_tag name=&quot;6975922d&quot; data_label=&quot;profession&quot; data_map_field=&quot;job&quot; data_help=&quot;profession&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 20%; vertical-align: middle;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">situation professionnelle :</span></td>
			<td style="width: 30%;">{% textinput_tag name=&quot;a2c4af1b&quot; data_label=&quot;situation professionnelle&quot; data_map_field=&quot;nomap&quot; data_help=&quot;situation professionnelle&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<p>{% select_tag name=&quot;8640425a&quot; data_label=&quot;travailleur salari&eacute; ou non salari&eacute;&quot; data_map_field=&quot;nomap&quot; data_choices=&quot;travailleur salari&eacute;|travailleur salarie; travailleur non salari&eacute;|travailleur non salarie&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</p>

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