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<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Non pr&eacute;sent &agrave; l&rsquo;acte mais repr&eacute;sent&eacute; par :&nbsp;</span></p>

<table border="0" cellpadding="1" cellspacing="5" style="width:100%;">
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			<td style="vertical-align: bottom; width: 50%; text-align: left;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% select_tag name=&quot;70247b57&quot; data_label=&quot;Civilit&eacute;&quot; data_map_field=&quot;nomap&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%; text-align: left;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Pr&eacute;nom :</span></td>
		</tr>
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			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;82534804&quot; data_label=&quot;Nom&quot; data_map_field=&quot;nomap&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;c1cac95b&quot; data_label=&quot;Pr&eacute;nom&quot; data_map_field=&quot;nomap&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>

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			<td style="width: 68%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Adresse :</span></td>
		</tr>
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			<td style="width: 68%;">{% textinput_tag name=&quot;bd410959&quot; data_label=&quot;Adresse postale&quot; data_map_field=&quot;nomap&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>

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			<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%;">{% textinput_tag name=&quot;381676c0&quot; data_label=&quot;Code Postal&quot; data_map_field=&quot;nomap&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;cc288093&quot; data_label=&quot;Ville&quot; data_map_field=&quot;nomap&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;0c24aecf&quot; placeholder=&quot;France&quot; data_label=&quot;Pays&quot; data_map_field=&quot;nomap&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>

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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%;">&nbsp;<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">T&eacute;l :&nbsp;&nbsp;</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 70%;">{% textinput_tag name=&quot;3f3941d1&quot; data_label=&quot;Email&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Email&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;f9fcfbe8&quot; data_label=&quot;T&eacute;l&quot; data_map_field=&quot;nomap&quot; data_help=&quot;T&eacute;l&quot; maxlength=&quot;25&quot; relation_ids_list=&quot;983649b0&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Autres informations utiles :</span></td>
		</tr>
		<tr>
			<td>{% textarea_tag name=&quot;3ed16f52&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Autres informations utiles&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Autres informations utiles&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

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			<td><span style="font-weight:100;"><em><span style="font-size:8px;"><span style="font-family: ITCAvantGardePro;">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.</span></span></em>&nbsp;</span></td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">en vertu des pouvoirs qui lui ont &eacute;t&eacute; conf&eacute;r&eacute;s &agrave; cet effet aux termes d&rsquo;une procuration sous seing priv&eacute; en date du</span></td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="5" style="width: 100%;">
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			<td style="width: 15%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% dateinput_tag name=&quot;079bc8c4&quot; placeholder=&quot;jj/mm/aaaa&quot; data_label=&quot;Date de la procuration&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Date de la procuration&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></td>
			<td style="vertical-align: middle; white-space: nowrap;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">fait &agrave;&nbsp;</span></td>
			<td style="width: 80%;"><span style="font-family: ITCAvantGardePro; font-size: 12px;">{% textinput_tag name=&quot;f147a53a&quot; data_label=&quot;Lieu de la procuration&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Lieu de la procuration&quot; maxlength=&quot;80&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></td>
		</tr>
	</tbody>
</table>

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">dont l&rsquo;original est demeur&eacute; ci-annex&eacute;.</span></p>

Mode Simplifié

<p style="text-align: justify;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Non pr&eacute;sent &agrave; l&rsquo;acte mais repr&eacute;sent&eacute; par :&nbsp;</span></p>

<p style="text-align: justify;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"><strong>{{70247b57}}&nbsp;{{82534804}} {{c1cac95b}}</strong> demeurant&nbsp;<strong>{{bd410959}}&nbsp;{{381676c0}} {{cc288093}}, {{0c24aecf}}</strong></span></p>

<p style="text-align: justify;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&bull; email :<strong>&nbsp;{{3f3941d1}}</strong> &bull; t&eacute;l&eacute;phone :&nbsp;<strong>{{f9fcfbe8}}</strong></span></p>

<p style="text-align: justify;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">en vertu des pouvoirs qui lui ont &eacute;t&eacute; conf&eacute;r&eacute;s &agrave; cet effet aux termes d&rsquo;une procuration sous seing priv&eacute; en date du <strong>{{079bc8c4}}</strong> fait &agrave;&nbsp;<strong>{{f147a53a}}&nbsp;</strong>dont l&rsquo;original est demeur&eacute; ci-annex&eacute;.</span></p>

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