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<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;">D&eacute;nomination sociale&nbsp; :</span></td>
			<td style="width: 68%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Type de soci&eacute;t&eacute; :</span></td>
		</tr>
		<tr>
			<td style="width: 68%;">{% textinput_tag name=&quot;16b4acc2&quot; data_label=&quot;d&eacute;nomination sociale&quot; data_map_field=&quot;societe&quot; data_help=&quot;d&eacute;nomination sociale&quot; maxlength=&quot;100&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 68%;">{% textinput_tag name=&quot;2312094e&quot; data_label=&quot;Type&quot; data_map_field=&quot;company_type&quot; data_help=&quot;SCI, SA, SARL...&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%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Soci&eacute;t&eacute; repr&eacute;sent&eacute;e par :</span></td>
			<td style="vertical-align: middle; width: 50%;">&nbsp;</td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% select_tag name=&quot;2e0c7352&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; Monsieur|monsieur; Madame|madame; Repr&eacute;sentant l&eacute;gal|representant l&eacute;gal;&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}<strong>&nbsp;</strong>Nom :</span></td>
			<td style="vertical-align: middle; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Pr&eacute;noms :</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;087x9c2b&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;cdae3297&quot; data_label=&quot;Pr&eacute;nom du d&eacute;l&eacute;gataire&quot; data_map_field=&quot;prenom&quot; data_help=&quot;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 si&egrave;ge social :</span></td>
		</tr>
		<tr>
			<td style="width: 68%;">{% textinput_tag name=&quot;b1c99e59&quot; data_label=&quot;Adresse postale du si&egrave;ge social&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;ba2ab48b&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;ea2f77b3&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;2277e3c1&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;">T&eacute;l :&nbsp;&nbsp;</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 70%;">{% textinput_tag name=&quot;da85546d&quot; data_label=&quot;Email&quot; data_map_field=&quot;email&quot; data_help=&quot;Email &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;f992da9d&quot; data_label=&quot;T&eacute;l&quot; data_map_field=&quot;mobile&quot; data_help=&quot;T&eacute;l&quot; maxlength=&quot;15&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><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">TVA&nbsp;intracommunautaire&nbsp;:&nbsp;</span>{% textinput_tag name=&quot;9ba308fc&quot; placeholder=&quot;TVA intracommunautaire&quot; data_label=&quot;TVA intracommunautaire&quot; data_map_field=&quot;vat_number&quot; maxlength=&quot;20&quot; style=&quot;max-width:160px;min-width:160px;width:160px;&quot; fixedwidth=&quot;160&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><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Immatricul&eacute;e au RCS de :</span></td>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Sous le num&eacute;ro :</span></td>
		</tr>
		<tr>
			<td>{% textinput_tag name=&quot;66cded07&quot; data_label=&quot;Lieu d&#39;immatriculation RCS&quot; data_map_field=&quot;rcs_place&quot; data_help=&quot;Lieu RCS&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td>{% textinput_tag name=&quot;79bc8f8a&quot; data_label=&quot;Num&eacute;ro RCS&quot; data_map_field=&quot;rcs_num&quot; data_help=&quot;Num&eacute;ro RCS&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><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">N&deg; de CPI :</span></td>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">D&eacute;livr&eacute; par :</span></td>
		</tr>
		<tr>
			<td>{% textinput_tag name=&quot;dff13da5&quot; data_label=&quot;n&deg; de CPI&quot; data_map_field=&quot;nomap&quot; data_help=&quot;n&deg; de CPI&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td>{% textinput_tag name=&quot;a14c3f96&quot; data_label=&quot;CPI d&eacute;livr&eacute;e par&quot; data_map_field=&quot;nomap&quot; data_help=&quot;CPI d&eacute;livr&eacute;e par&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><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Garantie financi&egrave;re :</span></td>
		</tr>
		<tr>
			<td>{% textarea_tag name=&quot;faaebeba&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Garantie financi&egrave;re&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Garantie financi&egrave;re&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;">Autres informations utiles :</span></td>
		</tr>
		<tr>
			<td>{% textarea_tag name=&quot;5000bc42&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Autres informations utiles&quot; data_map_field=&quot;comment&quot; data_help=&quot;Autres informations utiles&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

Mode Simplifié

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"><strong>{{</strong><span style="font-weight:600;">16b4acc2</span><strong>}}&nbsp;{{</strong><span style="font-weight:600;">2312094e</span><strong>}}</strong><br />
dont le si&egrave;ge social est domicili&eacute; <strong>&nbsp;{{</strong><span style="font-weight:600;">b1c99e59</span><strong>}} {{</strong><span style="font-weight:600;">ba2ab48b</span><strong>}} {{</strong><span style="font-weight:600;">ea2f77b3</span><strong>}}</strong>, <strong>{{</strong><span style="font-weight:600;">2277e3c1</span><strong>}}</strong></span></p>

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Repr&eacute;sent&eacute;e en sa qualit&eacute; de G&eacute;rant, par :&nbsp;<strong>{{</strong><span style="font-weight:600;">2e0c7352</span><strong>}}&nbsp;{{087x9c2b</strong></span><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"><strong>}} {{cdae3297</strong></span><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"><strong>}}</strong><br />
Email : <strong>{{</strong><span style="font-weight:600;">da85546d</span><strong>}}</strong>, t&eacute;l&eacute;phone : <strong>{{</strong><span style="font-weight:600;">f992da9d</span><strong>}}</strong></span></p>

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">TVA intracommunautaire :&nbsp;<strong>{{9ba308fc}}</strong><br />
Immatricul&eacute;e au RCS de&nbsp;<strong>{{66cded07}} </strong>sous le num&eacute;ro<strong>&nbsp;{{79bc8f8a}}</strong><br />
N&deg; de CPI&nbsp;<strong>{{dff13da5}} </strong>d&eacute;livr&eacute;e par&nbsp;<strong>{{a14c3f96}}</strong><br />
Garantie financi&egrave;re :&nbsp;<strong>{{faaebeba</strong></span><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"><strong>}}</strong></span></p>

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Autres informations utiles : <strong>{{</strong><span style="font-weight:600;">5000bc42</span><strong>}}</strong></span></p>

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