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Reprise des signataires

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<table border="0" cellpadding="1" cellspacing="5" style="width:100%;">
	<tbody>
		<tr>
			<td style="width: 50%; vertical-align: bottom; text-align: left;">
			<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Civilit&eacute; : </span>{% select_tag name=&quot;871c169a&quot; data_label=&quot;Civilit&eacute; locataire&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; %}&nbsp;<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Nom :</span></p>
			</td>
			<td style="vertical-align: bottom; width: 50%; text-align: left;">
			<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Pr&eacute;nom :</span></p>
			</td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;79fc7ffa&quot; data_label=&quot;Nom du locataire&quot; data_map_field=&quot;nom&quot; data_help=&quot;Nom du locataire&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;5185aba3&quot; data_label=&quot;Pr&eacute;nom du locataire&quot; data_map_field=&quot;prenom&quot; data_help=&quot;Pr&eacute;nom du locataire&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="5" 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;25917887&quot; data_label=&quot;Adresse postale du locataire&quot; data_map_field=&quot;adresse&quot; data_help=&quot;Adresse postale du locataire&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;44e85bf2&quot; data_label=&quot;Code Postal du locataire&quot; data_map_field=&quot;zipcode&quot; data_help=&quot;Code Postal du locataire&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;214789e4&quot; data_label=&quot;Ville du locataire&quot; data_map_field=&quot;ville&quot; data_help=&quot;Ville du locataire&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;25037fe9&quot; placeholder=&quot;France&quot; data_label=&quot;Pays du locataire&quot; data_map_field=&quot;pays&quot; data_help=&quot;Pays du locataire&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="5" 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;f4f59f87&quot; data_label=&quot;Email du locataire&quot; data_map_field=&quot;email&quot; data_help=&quot;Email du locataire&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;f851d3d5&quot; data_label=&quot;T&eacute;l du locataire&quot; data_map_field=&quot;mobile&quot; data_help=&quot;T&eacute;l du locataire&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="5" style="break-inside:avoid;width:100%;">
	<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;43f29e92&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="width: 80%;">{% textinput_tag name=&quot;427a83e0&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_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="5" style="width:100%;">
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Autres informations utiles&nbsp;:</span></td>
		</tr>
		<tr>
			<td style="width: 80%;">
			<p>{% textarea_tag name=&quot;0782e38f&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; 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; %}</p>

<p><span style="font-weight:200;"><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></span></p>
			</td>
		</tr>
	</tbody>
</table>

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