Canvassing request

To make your request, you can:

• Either download, complete and send by e-mail the PDF file below to the following address:
  or by post or to be delivered directly to the town hall reception.
• Either complete and send the online form.

The municipal department concerned will get back to you as soon as possible.

Online form

Last Name *Enter your name. Example: “Durand”.

First Name: *Enter your first name. Example: “Loïc”.

Name of company/association/etc. : *Enter the name of your company or association, etc.

Legal form :CompanyAssociationOther

SIRET: *Enter the SIRET number of the structure. (14 digits).

Kbis: *Enter your Kbis.

Address: *Enter the full mailing address. Example: “10 rue de Nîmes, 30200 Bagnols-sur-Cèze”.

PhoneEnter your landline. Example: "0301020304".

Phone: *Enter your mobile number. Example: "0601020304".

Email: *Enter your email address. Example "". You will receive a copy of your request.

Prospection

Sector or neighborhood:Indicate the canvassing area.

Purpose of canvassingIndicate the purpose of the canvassing.

Of : *Choose a start date. For example "06/07/2024" for July 6, 2024.

At : *Choose an end date. For example "07/07/2024" for July 7, 2024.

Canvasser(s)

Vehicle used:Indicate the make of the vehicle, its type.

Registration: *Indicate the vehicle registration number

Last NameIndicate the name of the direct seller.

First Name:Indicate the first name of the direct seller.

Sector:Indicate the canvassing area concerned.

Consent. *

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