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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">D&eacute;nomination sociale <span style="font-weight:600;">Company name</span> :</span></td>
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			<td>{% textinput_tag name=&quot;fe4918c7&quot; data_label=&quot;D&eacute;nomination soci&eacute;t&eacute;&quot; data_map_field=&quot;societe&quot; data_help=&quot;D&eacute;nomination sociale&quot; maxlength=&quot;100&quot; data_required_field=&quot;true&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td style="vertical-align: middle; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Immatricul&eacute;e au RCS de <span style="font-weight:600;">Place of RCS registration</span> :</span></td>
			<td style="vertical-align: middle; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Sous le num&eacute;ro <span style="font-weight:600;">RCS Number</span> :</span></td>
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			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;5b386f55&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;true&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;876a688c&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;true&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td style="vertical-align: middle; width: 22%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">au capital de <span style="font-weight:600;">capital of</span> :</span></td>
			<td>{% textinput_tag name=&quot;55cd98bd&quot; data_label=&quot;Capital social&quot; data_map_field=&quot;capital&quot; data_help=&quot;capital&quot; maxlength=&quot;70&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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<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 </span><span style="font-family:ITCAvantGardePro;"><span style="font-weight:600;">Represented in her/his capacity as Manager, by</span></span>&nbsp;<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">:</span>&nbsp;</p>

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			<td style="vertical-align: middle; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"><strong>&nbsp;</strong></span>{% select_tag name=&quot;87a7391fd&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;|; Monsieur / Mr|monsieur; Madame / Ms|madame;&quot; data_required_field=&quot;true&quot; data_bold_text=&quot;false&quot; %}&nbsp;<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Nom<span style="font-weight:600;">&nbsp;Last name</span> :</span></td>
			<td style="vertical-align: bottom; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Pr&eacute;nom&nbsp;<span style="font-weight:600;">First name</span> :</span></td>
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			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;d368006f&quot; data_label=&quot;Nom &quot; data_map_field=&quot;nom&quot; data_help=&quot;Nom du signataire &quot; maxlength=&quot;50&quot; data_required_field=&quot;true&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;ad756ce1&quot; data_label=&quot;Pr&eacute;nom &quot; data_map_field=&quot;prenom&quot; data_help=&quot;Pr&eacute;nom du signataire&quot; maxlength=&quot;50&quot; data_required_field=&quot;true&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td style="width: 68%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">dont le si&egrave;ge social est domicili&eacute; </span><span style="font-family:ITCAvantGardePro;"><span style="font-weight:600;">whose head office is domiciled&nbsp;</span></span><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">:</span></td>
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			<td style="width: 68%;">{% textinput_tag name=&quot;88cf7082&quot; data_label=&quot;Adresse postale du si&egrave;ge social&quot; data_map_field=&quot;adresse&quot; data_help=&quot;Adresse postale du si&egrave;ge social&quot; maxlength=&quot;100&quot; data_required_field=&quot;true&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td style="width: 20%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Code postal <span style="font-weight:600;">Zip code</span> :</span></td>
			<td style="width: 55%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Ville <span style="font-weight:600;">City</span> :</span></td>
			<td style="width: 25%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Pays <span style="font-weight:600;">Country</span> :</span></td>
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			<td style="width: 20%;">{% textinput_tag name=&quot;b5154f50&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;true&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 55%;">{% textinput_tag name=&quot;72230b87&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;true&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 25%;">{% textinput_tag name=&quot;72ba8a88&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;true&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Autres informations utiles <span style="font-weight:600;">Other useful information</span> :&nbsp;</span></td>
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			<td>{% textarea_tag name=&quot;201f4031&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; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td><span style="font-size:8px;"><span style="font-family: ITCAvantGardePro; font-weight: 200;"><em>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 /&nbsp;You have the possibility of registering on www.bloctel.gouv.fr to oppose any telephone canvassing in accordance with article L223-1 of the Consumer Code</em></span></span></td>
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Mode Simplifié

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"><strong>{{fe4918c7}}&nbsp;{{ae91c87b}}</strong> immatricul&eacute;e au <strong><em>RCS de&nbsp;Place of RCS registration&nbsp;</em>{{5b386f55}}</strong> sous le num&eacute;ro&nbsp;<em><strong>RCS Number</strong></em> <strong>{{876a688c}}</strong>, au capital de<em><strong>&nbsp;capital of</strong></em> <strong>{{55cd98bd}}</strong><br />
dont le si&egrave;ge social est domicili&eacute; <em><strong>whose head office is domiciled&nbsp;</strong></em><strong>{{88cf7082}} {{b5154f50}} {{72230b87}}</strong>, <strong>{{72ba8a88}}</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 <strong><em>Represented in her/his capacity as Manager, by :</em></strong>&nbsp;<strong>{{87a7391fd}}&nbsp;{{d368006f}} {{ad756ce1}}</strong><br />
&bull; email :<strong> {{c4f61172}}</strong>&nbsp;&bull;&nbsp;t&eacute;l&eacute;phone <em><strong>Phone number</strong></em> : <strong>{{86e4290d}}</strong></span></p>

<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Autres informations utiles <em><strong>Other useful information</strong></em>&nbsp;: <strong>{{201f4031}}</strong></span></p>

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