Mandate

Street number

Extension (bis, ter...)

Type of road (street, avenue...)

Street name

Postal code

Town

Country

Mandate and Mandatary

Gives mandate to

SIRET number, if applicable

To carry out on my behalf the administrative formalities related to the following registration operation

Brand

VIN number

Registration number (if applicable)

I am informed that to drive this vehicle I am required to insure it beforehand (articles L. 324-1 and L. 324-2 of the road code).

Yes, I understand

Done at

I object to the reuse of my personal data for commercial prospecting purposes.

Yes, I object

The (DD/MM/YYYY)