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Je soussigné(e) Madame ou Monsieur (nom, prénom) né(e) le (date et lieu de naissance) et demeurant au (votre adresse actuelle) donne procuration à Madame ou Monsieur (nom, prénom du mandataire) demeurant (adresse du mandataire) né(e) le (date et lieu de naissance) pour (à choisir ou compléter).
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