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Fiche de renseignement de l'astreint·e
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ORPC
Broye-Vully
Gros-de-Vaud
Jura-Nord Vaudois
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Nom
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Prénom
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Rue, n°
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Ville
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NPA
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Téléphone
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E-mail
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Relation bancaire
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Nom de la banque
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IBAN
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Titulaire du compte
Si personne différente de l'astreint·e
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