Cerfa No 11580 01
__DonationReceipt__
__FrenchArticle__
__DonationRef__
No:
__REF__
__DonationRecipient__
__Name__ :
__MAIN_INFO_SOCIETE_NOM__
__Address__ :
__MAIN_INFO_SOCIETE_ADDRESS__
__Zip__ :
__MAIN_INFO_SOCIETE_ZIP__
__Town__ :
__MAIN_INFO_SOCIETE_TOWN__
__Donor__
__Name__ :
__DONATOR_FIRSTNAME__ __DONATOR_LASTNAME__
__Address__ :
__DONATOR_ADDRESS__
__Zip__ :
__DONATOR_ZIP__
__Town__ :
__DONATOR_TOWN__
__IConfirmDonationReception__ :
__AMOUNT__ __CURRENCY__
__DatePayment__
: __DATE__
__PaymentMode__
: __PAYMENTMODE_LIB__
__ThankYou__
__Date__ __Signature__
__NOW__