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&nbsp;

Formulaire de r&eacute;tractation

Withdrawal form

(Articles L.221-18 &agrave; L.221-28 du Code de la consommation)&nbsp;(Articles L.221-18 to L.221-28 of the French Consumer Code) 
			(&Agrave; compl&eacute;ter et renvoyer au Mandataire uniquement si vous souhaitez vous r&eacute;tracter du contrat)&nbsp;(To be completed and returned to the Agent only if you wish to withdraw from the agreement)

&nbsp;

&Agrave; l&#39;attention de&nbsp;For the attention of :&nbsp;

<table align="center" border="0" cellpadding="0" cellspacing="0" style="width:99%;">
				<tbody>
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						<td style="width: 32%; vertical-align: middle;">Nom du consultant Name of consultant :</td>
						<td style="width: 65%; vertical-align: middle;">{% textinput_tag name=&quot;49X63fa2&quot; value=&quot;INFO_CLIENT_nom_prenom&quot; data_label=&quot;Nom du consultant&nbsp;&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Nom et pr&eacute;nom&quot; maxlength=&quot;70&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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				</tbody>
			</table>

<table align="center" border="0" cellpadding="0" cellspacing="0" style="width:99%;">
				<tbody>
					<tr>
						<td style="width: 28%; vertical-align: middle;">Nom&nbsp;de l&#39;agence&nbsp;Agency name :</td>
						<td style="vertical-align: middle;">{% textinput_tag name=&quot;d35bec23&quot; value=&quot;INFO_CLIENT_enseigne&quot; data_label=&quot;Nom&nbsp;de l&#39;agence&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Nom&nbsp;de l&#39;agence&quot; maxlength=&quot;90&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
					</tr>
				</tbody>
			</table>

<table align="center" border="0" cellpadding="0" cellspacing="0" style="width:99%;">
				<tbody>
					<tr>
						<td style="width: 26%; vertical-align: middle;">Adresse compl&egrave;te Full address :</td>
						<td style="vertical-align: middle;">{% textinput_tag name=&quot;4da373f6&quot; value=&quot;INFO_CLIENT_adresse&quot; data_label=&quot;Adresse compl&egrave;te&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Adresse compl&egrave;te&quot; maxlength=&quot;100&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
					</tr>
				</tbody>
			</table>

<table align="center" border="0" cellpadding="0" cellspacing="0" style="width: 99%;">
				<tbody>
					<tr>
						<td style="width: 30%; vertical-align: middle;">T&eacute;l&nbsp;Tel. :&nbsp;{% textinput_tag name=&quot;1593ca42&quot; value=&quot;INFO_CLIENT_telephone&quot; data_label=&quot;T&eacute;l&eacute;phone de l&#39;agence&quot; data_map_field=&quot;nomap&quot; data_help=&quot;T&eacute;l&eacute;phone de l&#39;agence&quot; maxlength=&quot;20&quot; style=&quot;max-width:150px;min-width:150px;width:150px;&quot; fixedwidth=&quot;150&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
						<td style="width: 12%; text-align: right; vertical-align: middle;">E-mail Email :&nbsp;</td>
						<td style="vertical-align: middle;">{% textinput_tag name=&quot;ecb11cb4&quot; value=&quot;INFO_CLIENT_email&quot; data_label=&quot;E-mail de l&#39;agence&quot; data_map_field=&quot;nomap&quot; data_help=&quot;E-mail de l&#39;agence&quot; maxlength=&quot;100&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
					</tr>
				</tbody>
			</table>

&nbsp;

Je / nous(*) vous notifie / notifions(*) par la pr&eacute;sente ma / notre(*) r&eacute;tractation du contrat de mandat :

I / we(*) hereby notify you of my / our(*) withdrawal from the agency agreement:

Command&eacute; le&nbsp;Ordered on :&nbsp;..................................&nbsp; &nbsp;&nbsp;Enregistr&eacute; sous le num&eacute;ro Registered under number :&nbsp;................................

Adresse du lieu&nbsp;Location address :

..............................................................................................................................................................................

Nom du / des(*) consommateur(s) Mandant(s)&nbsp;Name(s) of consumer Principal/Principals(*) :

Adresse&nbsp;du / des(*) consommateur(s) Mandant(s)&nbsp;Address(es) of consumer Principal/Principals(*) :

Le On&nbsp;......................................................&nbsp; &Agrave; In&nbsp;................................................................................................

<table align="center" border="0" cellpadding="0" cellspacing="0" style="width:99%;">
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						<td font-size:14px="" style="background-color: rgb(234, 227, 222);padding:20px;&gt;
						&lt;p&gt;&lt;span style=">Signature(s)

&nbsp;

du/des (*) consommateurs Mandant(s)&nbsp;of the consumer Principal/Principals(*)&nbsp;:

&nbsp;
						</td>
					</tr>
				</tbody>
			</table>

(*) Rayez la mention inutile&nbsp;(*) Cross out as appropriate&nbsp;
			</td>
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	</tbody>
</table>

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