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Je soussigné(e) Monsieur/Madame [nom, prénom], né(e) le [date de naissance] et demeurant à [adresse], agissant en tant que mandant, donne procuration à Monsieur/Madame [nom, prénom], né(e) le [date de naissance] et demeurant à [adresse], agissant en tant que mandataire.
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