Admin - Plateforme Administration Editions Préference

Informations générales

Nom mobile

Nom de recherche

Paramètres de duplication

Contient un/plusieurs signataires

Reprise des signataires

Peut etre dupliqué

Nombre maximum de block

Texte du bouton 'ajouter'

Texte du bouton 'supprimer'

Ce block contient un

Contenu HTML

<table border="0" cellpadding="1" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align: middle; 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 signataire &quot; data_map_field=&quot;nom&quot; data_help=&quot;Nom du signataire, 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 signataire&quot; data_map_field=&quot;prenom&quot; data_help=&quot;Pr&eacute;nom du signataire &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: 20%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Date de naissance :</span></td>
			<td style="vertical-align: middle; width: 80%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Lieu de naissance :</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 20%;">{% 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>
			<td style="vertical-align: middle; width: 80%;">{% 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>
		</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;">T&eacute;l :&nbsp;&nbsp;</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 70%;">{% textinput_tag name=&quot;7a4b4c6f&quot; data_label=&quot;Email du signataire&quot; data_map_field=&quot;email&quot; data_help=&quot;Email du signataire&quot; maxlength=&quot;50&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;ed7c9998&quot; data_label=&quot;T&eacute;l du signataire&quot; data_map_field=&quot;tel&quot; data_help=&quot;T&eacute;l du signataire&quot; maxlength=&quot;25&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;109d7745&quot; data_label=&quot;Adresse postale du signataire&quot; data_map_field=&quot;adresse&quot; data_help=&quot;Adresse postale du signataire&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><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;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>{% 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 du signataire&quot; data_map_field=&quot;pays&quot; data_help=&quot;Pays du signataire&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;">Profession :</span></td>
		</tr>
		<tr>
			<td>{% textinput_tag name=&quot;38078f5b&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>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align: middle; 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; %}<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;322861a6&quot; data_label=&quot;Nom du signataire &quot; data_map_field=&quot;nom&quot; data_help=&quot;Nom du signataire, 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 signataire &quot; data_map_field=&quot;prenom&quot; data_help=&quot;Pr&eacute;nom du signataire &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: 20%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Date de naissance :</span></td>
			<td style="vertical-align: middle; width: 80%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Lieu de naissance :</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 20%;">{% 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>
			<td style="vertical-align: middle; width: 80%;">{% 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>
		</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;">T&eacute;l :&nbsp;&nbsp;</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 70%;">{% textinput_tag name=&quot;627736e1&quot; data_label=&quot;Email du signataire&quot; data_map_field=&quot;email&quot; data_help=&quot;Email du signataire&quot; maxlength=&quot;50&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;382a5e67&quot; data_label=&quot;T&eacute;l du signataire&quot; data_map_field=&quot;tel&quot; data_help=&quot;T&eacute;l du signataire&quot; maxlength=&quot;25&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;109d7745&quot; data_label=&quot;Adresse postale du signataire&quot; data_map_field=&quot;adresse&quot; data_help=&quot;Adresse postale du signataire&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><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;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>{% 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 du signataire&quot; data_map_field=&quot;pays&quot; data_help=&quot;Pays du signataire&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;">Profession :</span></td>
		</tr>
		<tr>
			<td>{% textinput_tag name=&quot;9e4ba3ae&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>
		</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;">Autres informations utiles :</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 70%;">{% textarea_tag name=&quot;f69daf9e&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; 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>

<table border="0" cellpadding="1" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td><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;</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="5" style="width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align: middle; width: 25%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Date et lieu de mariage&nbsp;: </span></td>
			<td>{% textinput_tag name=&quot;377a5647&quot; data_label=&quot;Date et lieu de mariage&quot; data_map_field=&quot;marriage_place_and_date&quot; data_help=&quot;Date et lieu de mariage&quot; maxlength=&quot;70&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 25%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">R&eacute;gime matrimonial &nbsp;:</span></td>
			<td>{% textinput_tag name=&quot;f24e2d99&quot; data_label=&quot;R&eacute;gime matrimonial&quot; data_map_field=&quot;matrimonial_regime&quot; data_help=&quot;R&eacute;gime matrimonial&quot; maxlength=&quot;70&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

Informations du bloc

Informations générales

Ce bloc est utilisé dans les documents suivants :

Paramètres de duplication

Contenu HTML

Mode Simplifié

Aperçu

Astuces