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	Name *
	First name *
	Telephone
	E-mail *
	User *
	Password *
	Controller N° *
	Verification code *

	Company
		Company name *
		Siret number *
		Address *
		Post code *
		Town *
		Country *

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You have the right to access, correct and delete information about you (art. 34 of the law on information technology and individual freedom).