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Submission: On February 29 via manual from FR — Scanned from FR
Submission: On February 29 via manual from FR — Scanned from FR
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<form id="hs-form-f4eb51b0-5dbb-445d-88ab-0ea7a54cfa4d-c047157c-238e-4743-bd2e-723052cd49ef" class="hs-form-f4eb51b0-5dbb-445d-88ab-0ea7a54cfa4d hs-form hs-form_theme-round" data-instance-id="c047157c-238e-4743-bd2e-723052cd49ef"
data-form-id="f4eb51b0-5dbb-445d-88ab-0ea7a54cfa4d" data-portal-id="2529003" lang="fr" data-test-id="hs-form-f4eb51b0-5dbb-445d-88ab-0ea7a54cfa4d-c047157c-238e-4743-bd2e-723052cd49ef">
<div class="hs-form__pagination-content-container">
<div class="hs-form__row">
<div class="hs-form__group">
<div data-hsfc-id="RichText" style="font-size: 14px; color: rgb(51, 71, 91);"><img src="https://page.gymlib.com/hubfs/Icons/logo_gymlib.png" style="max-width: 100%; max-height: 100%; display:block; margin-left:auto; margin-right:auto;"
data-img-aspect-ratio="3.8812351543942993" alt="logo_gymlib" width="300" data-img-width="300" data-img-height="77"></div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div data-hsfc-id="RichText" style="font-size: 14px; color: rgb(51, 71, 91);">
<p style="text-align: center;"><span style="font-size: 16px;">Délivrance d'un mandat de prélèvement SEPA avec Gymlib</span><br><br></p>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-email hs-email"><label id="email-label" for="email-input" class="hs-form__field__label" data-required="true"><span lang="fr">Votre Email</span><span
class="hs-form__field__label__required">*</span></label>
<div id="email-description" class="hs-form__field__description" lang="fr"><em>(adresse email sur laquelle vous avez reçu ce formulaire)</em></div><input id="email-input" class="hs-form__field__input" type="email" name="email"
required="" autocomplete="email" inputmode="email" aria-invalid="false" aria-required="true" value="">
</div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div data-hsfc-id="RichText" style="font-size: 14px; color: rgb(51, 71, 91);">
<p style="font-size: 16px;"><strong><br>Informations relatives à votre entreprise :</strong></p>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-ops_factu_nom_entreprise hs-ops_factu_nom_entreprise"><label id="0-2/ops_factu_nom_entreprise-label" for="0-2/ops_factu_nom_entreprise-input" class="hs-form__field__label"
data-required="true"><span lang="fr">Raison sociale de l'entreprise</span><span class="hs-form__field__label__required">*</span></label><input id="0-2/ops_factu_nom_entreprise-input" class="hs-form__field__input" type="text"
name="0-2/ops_factu_nom_entreprise" required="" inputmode="text" aria-invalid="false" aria-required="true" value=""></div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-ops_factu_adresse hs-ops_factu_adresse"><label id="0-2/ops_factu_adresse-label" for="0-2/ops_factu_adresse-input" class="hs-form__field__label" data-required="true"><span lang="fr">Adresse
postale</span><span class="hs-form__field__label__required">*</span></label><input id="0-2/ops_factu_adresse-input" class="hs-form__field__input" type="text" name="0-2/ops_factu_adresse" required="" inputmode="text"
aria-invalid="false" aria-required="true" value=""></div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-ops_factu_code_postal hs-ops_factu_code_postal"><label id="0-2/ops_factu_code_postal-label" for="0-2/ops_factu_code_postal-input" class="hs-form__field__label" data-required="true"><span
lang="fr">Code postal</span><span class="hs-form__field__label__required">*</span></label><input id="0-2/ops_factu_code_postal-input" class="hs-form__field__input" type="text" name="0-2/ops_factu_code_postal" required=""
inputmode="text" aria-invalid="false" aria-required="true" value=""></div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-ops_factu_ville hs-ops_factu_ville"><label id="0-2/ops_factu_ville-label" for="0-2/ops_factu_ville-input" class="hs-form__field__label" data-required="true"><span lang="fr">Ville</span><span
class="hs-form__field__label__required">*</span></label><input id="0-2/ops_factu_ville-input" class="hs-form__field__input" type="text" name="0-2/ops_factu_ville" required="" inputmode="text" aria-invalid="false"
aria-required="true" value=""></div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-ops_factu_pays hs-ops_factu_pays"><label id="0-2/ops_factu_pays-label" for="0-2/ops_factu_pays-input" class="hs-form__field__label" data-required="true"><span lang="fr">Pays</span><span
class="hs-form__field__label__required">*</span></label><input id="0-2/ops_factu_pays-input" class="hs-form__field__input" type="text" name="0-2/ops_factu_pays" required="" inputmode="text" aria-invalid="false" aria-required="true"
value=""></div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div data-hsfc-id="RichText" style="font-size: 14px; color: rgb(51, 71, 91);">
<p style="font-size: 16px;"><strong><br>Contact de facturation :</strong></p>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-ops_factu_contact_de_facturation_nom hs-ops_factu_contact_de_facturation_nom"><label id="0-2/ops_factu_contact_de_facturation_nom-label" for="0-2/ops_factu_contact_de_facturation_nom-input"
class="hs-form__field__label" data-required="true"><span lang="fr">Nom</span><span class="hs-form__field__label__required">*</span></label><input id="0-2/ops_factu_contact_de_facturation_nom-input" class="hs-form__field__input"
type="text" name="0-2/ops_factu_contact_de_facturation_nom" required="" inputmode="text" aria-invalid="false" aria-required="true" value=""></div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-ops_factu_contact_de_facturation_prenom hs-ops_factu_contact_de_facturation_prenom"><label id="0-2/ops_factu_contact_de_facturation_prenom-label"
for="0-2/ops_factu_contact_de_facturation_prenom-input" class="hs-form__field__label" data-required="true"><span lang="fr">Prénom</span><span class="hs-form__field__label__required">*</span></label><input
id="0-2/ops_factu_contact_de_facturation_prenom-input" class="hs-form__field__input" type="text" name="0-2/ops_factu_contact_de_facturation_prenom" required="" inputmode="text" aria-invalid="false" aria-required="true" value=""></div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-ops_factu_email_de_facturation hs-ops_factu_email_de_facturation"><label id="0-2/ops_factu_email_de_facturation-label" for="0-2/ops_factu_email_de_facturation-input" class="hs-form__field__label"
data-required="true"><span lang="fr">Email</span><span class="hs-form__field__label__required">*</span></label><input id="0-2/ops_factu_email_de_facturation-input" class="hs-form__field__input" type="text"
name="0-2/ops_factu_email_de_facturation" required="" inputmode="text" aria-invalid="false" aria-required="true" value=""></div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div data-hsfc-id="RichText" style="font-size: 14px; color: rgb(51, 71, 91);">
<p style="font-size: 16px;"><strong><br>Vos coordonnées bancaires :<br></strong><em><span style="font-size: 14px;">*données confidentielles et sécurisées par Gymlib</span></em></p>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-ops_factu_iban hs-ops_factu_iban"><label id="0-2/ops_factu_iban-label" for="0-2/ops_factu_iban-input" class="hs-form__field__label" data-required="true"><span lang="fr">IBAN</span><span
class="hs-form__field__label__required">*</span></label>
<div id="0-2/ops_factu_iban-description" class="hs-form__field__description" lang="fr">Identifiant international de compte bancaire (IBAN)</div><input id="0-2/ops_factu_iban-input" class="hs-form__field__input" type="text"
name="0-2/ops_factu_iban" required="" inputmode="text" aria-invalid="false" aria-required="true" value="">
</div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-ops_factu_bic hs-ops_factu_bic"><label id="0-2/ops_factu_bic-label" for="0-2/ops_factu_bic-input" class="hs-form__field__label" data-required="true"><span lang="fr">Code BIC</span><span
class="hs-form__field__label__required">*</span></label>
<div id="0-2/ops_factu_bic-description" class="hs-form__field__description" lang="fr">Bank Identify Number (BIC)</div><input id="0-2/ops_factu_bic-input" class="hs-form__field__input" type="text" name="0-2/ops_factu_bic" required=""
inputmode="text" aria-invalid="false" aria-required="true" value="">
</div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div data-hsfc-id="RichText" style="font-size: 14px; color: rgb(51, 71, 91);">
<p style="font-size: 16px;"><strong><br>Signature :</strong></p>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-date_de_delivrance_sepa hs-date_de_delivrance_sepa">
<div id="0-2/date_de_delivrance_sepa-label" class="hs-form__field__label" data-required="true"><span lang="fr">Date</span><span class="hs-form__field__label__required">*</span></div>
<div role="group" aria-invalid="false" aria-labelledby="0-2/date_de_delivrance_sepa-label"><label id="hs-form__date_input__dd-label"><span class="hs-form__visually-hidden">Day</span><input
id="0-2/date_de_delivrance_sepa-fragment-0-input" name="0-2/date_de_delivrance_sepa__DD" placeholder="DD" required="" aria-invalid="false" aria-required="true" maxlength="2"
class="hs-form__field__input hs-form__date_input__fragment hs-form__date_input__dd" type="text" pattern="[0-9]*" inputmode="numeric" aria-labelledby="hs-form__date_input__dd-label" value=""></label><span
class="hs-form__date_input__separator">/</span><label id="hs-form__date_input__mm-label"><span class="hs-form__visually-hidden">Month</span><input id="0-2/date_de_delivrance_sepa-fragment-2-input"
name="0-2/date_de_delivrance_sepa__MM" placeholder="MM" required="" aria-invalid="false" aria-required="true" maxlength="2" class="hs-form__field__input hs-form__date_input__fragment hs-form__date_input__mm" type="text"
pattern="[0-9]*" inputmode="numeric" aria-labelledby="hs-form__date_input__mm-label" value=""></label><span class="hs-form__date_input__separator">/</span><label id="hs-form__date_input__yyyy-label"><span
class="hs-form__visually-hidden">Year</span><input id="0-2/date_de_delivrance_sepa-fragment-4-input" name="0-2/date_de_delivrance_sepa__YYYY" placeholder="YYYY" required="" aria-invalid="false" aria-required="true" maxlength="4"
class="hs-form__field__input hs-form__date_input__fragment hs-form__date_input__yyyy" type="text" pattern="[0-9]*" inputmode="numeric" aria-labelledby="hs-form__date_input__yyyy-label" value=""></label></div>
</div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-lieu_delivrance_sepa hs-lieu_delivrance_sepa"><label id="0-2/lieu_delivrance_sepa-label" for="0-2/lieu_delivrance_sepa-input" class="hs-form__field__label" data-required="true"><span
lang="fr">Lieu</span><span class="hs-form__field__label__required">*</span></label><input id="0-2/lieu_delivrance_sepa-input" class="hs-form__field__input" type="text" name="0-2/lieu_delivrance_sepa" required="" inputmode="text"
aria-invalid="false" aria-required="true" value=""></div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div data-hsfc-id="RichText" style="font-size: 14px; color: rgb(51, 71, 91);">
<div style="font-size: 16px;">En signant ce formulaire de mandat, vous autorisez (A) Gymlib SAS à envoyer des instructions à votre banque pour débiter votre compte, et (B) votre banque à débiter votre compte conformément aux instructions de
Gymlib SAS. <br>Vous bénéficiez du droit d’être remboursé par votre banque selon les conditions décrites dans la convention que vous avez passée avec elle. Une demande de remboursement doit être présentée dans les 8 semaines suivant la
date de débit de votre compte pour un prélèvement autorisé.»</div>
</div>
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-ops_factu_validation_prelevement_sepa hs-ops_factu_validation_prelevement_sepa"><label id="0-2/ops_factu_validation_prelevement_sepa-label-1"
class="hs-form__field__label hs-form__field__checkbox__label"><input id="0-2/ops_factu_validation_prelevement_sepa-input-1" class="hs-form__field__input hs-form__field__checkbox__input" type="checkbox"
name="0-2/ops_factu_validation_prelevement_sepa" aria-invalid="false" aria-required="true" aria-labelledby="0-2/ops_factu_validation_prelevement_sepa-label-1" value=""><span class="hs-form__field__checkbox__label-text">J'ai pris
connaissance et accepte les conditions ci-dessus.</span><span class="hs-form__field__label__required">*</span></label></div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group"></div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__actions"><button type="submit" name="Soumettre" class="hs-form__actions__submit" lang="fr">Soumettre</button></div>
</div>
<div id="c047157c-238e-4743-bd2e-723052cd49ef-live-region-content" class="hs-form__visually-hidden" aria-live="polite"></div>
</form>Text Content
Skip to form Délivrance d'un mandat de prélèvement SEPA avec Gymlib Votre Email* (adresse email sur laquelle vous avez reçu ce formulaire) Informations relatives à votre entreprise : Raison sociale de l'entreprise* Adresse postale* Code postal* Ville* Pays* Contact de facturation : Nom* Prénom* Email* Vos coordonnées bancaires : *données confidentielles et sécurisées par Gymlib IBAN* Identifiant international de compte bancaire (IBAN) Code BIC* Bank Identify Number (BIC) Signature : Date* Day/Month/Year Lieu* En signant ce formulaire de mandat, vous autorisez (A) Gymlib SAS à envoyer des instructions à votre banque pour débiter votre compte, et (B) votre banque à débiter votre compte conformément aux instructions de Gymlib SAS. Vous bénéficiez du droit d’être remboursé par votre banque selon les conditions décrites dans la convention que vous avez passée avec elle. Une demande de remboursement doit être présentée dans les 8 semaines suivant la date de débit de votre compte pour un prélèvement autorisé.» J'ai pris connaissance et accepte les conditions ci-dessus.* Soumettre