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<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
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			<td colspan="5" style="width: 6%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">En partenariat avec :</span></td>
		</tr>
		<tr>
			<td colspan="4" rowspan="1" style="width: 6%;">{% textinput_tag name=&quot;e6d38bd1&quot; placeholder=&quot;A renseigner : nom ou raison sociale&quot; data_label=&quot;Nom de l&#39;agence&quot; data_map_field=&quot;nomap&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;true&quot; %}</td>
			<td rowspan="5" style="width: 20%; background-color: rgb(255, 255, 255); vertical-align: middle;">{% textarea_tag name=&quot;47868945xx&quot; data_width=&quot;100&quot; rows=&quot;9&quot; data_label=&quot;Ins&eacute;rer logo&quot; data_help=&quot;Ins&eacute;rer logo&quot; placeholder=&quot;logo&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
		<tr>
			<td colspan="4" style="width: 6%;">{% textinput_tag name=&quot;8b254931&quot;&nbsp; placeholder=&quot;A renseigner : enseigne partenaire&quot; data_label=&quot;Enseigne partenaire&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Enseigne&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
		<tr>
			<td colspan="4" style="width: 6%;">{% textinput_tag name=&quot;c1626b88&quot; placeholder=&quot;A renseigner : adresse partenaire&quot; data_label=&quot;Adresse agence partenaire&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Adresse agence partenaire&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
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			<td colspan="4" style="width: 6%;">{% textinput_tag name=&quot;8fe8046f&quot; placeholder=&quot;A renseigner : autres informations&quot; data_label=&quot;Autres informations partenaire&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Autres informations partenaire&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
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			<td style="width: 6%; vertical-align: bottom;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">E-mail :</span></td>
			<td style="width: 34%; vertical-align: bottom;">{% textinput_tag name=&quot;b30941cc&quot; value=&quot;INFO_CLIENT_email&quot; data_label=&quot;Email agence partenaire&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Email agence partenaire&quot; maxlength=&quot;60&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 4%; vertical-align: bottom;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp;Tel :</span></td>
			<td style="width: 36%; vertical-align: bottom;">{% textinput_tag name=&quot;79ccc413&quot; value=&quot;INFO_CLIENT_telephone&quot; data_label=&quot;T&eacute;l agence partenaire&quot; data_map_field=&quot;nomap&quot; maxlength=&quot;22&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<p style="text-align: justify;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"><span style="text-align: justify;">IL A &Eacute;T&Eacute; FAIT ET CONVENU CE QUI SUIT : Le mandant conf&egrave;re par les pr&eacute;sentes au mandataire, qui l&#39;accepte, mandat d&#39;administrer le(s) bien(s) suivant(s) tant activement que passivement.</span></span></p>

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