plac-micro-common 1.3.10 → 1.3.11
This diff represents the content of publicly available package versions that have been released to one of the supported registries. The information contained in this diff is provided for informational purposes only and reflects changes between package versions as they appear in their respective public registries.
- package/dist/libs/pdf-form/templates/sio-form-en.template.d.ts +1 -1
- package/dist/libs/pdf-form/templates/sio-form-en.template.js +542 -504
- package/dist/libs/pdf-form/templates/sio-form-kh.template.d.ts +1 -1
- package/dist/libs/pdf-form/templates/sio-form-kh.template.js +134 -96
- package/package.json +1 -1
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export declare const SIO_FORM_EN_TEMPLATE = "\n<!DOCTYPE html>\n<html lang=\"km\">\n <head>\n <meta charset=\"UTF-8\" />\n <meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0\" />\n <title>\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17A2\u17B6\u1799\u17BB\u1787\u17B8\u179C\u17B7\u178F</title>\n <style>\n /* \u2500\u2500 Khmer Font \u2500\u2500 */\n @font-face {\n font-family: 'Khmer OS';\n src: url('data:font/truetype;base64,<%= font_base64 %>') format('truetype');\n font-weight: normal;\n font-style: normal;\n }\n\n /* \u2500\u2500 Reset & Base \u2500\u2500 */\n *, *::before, *::after { box-sizing: border-box; margin: 0; padding: 0; }\n\n body {\n font-family: 'Khmer OS', sans-serif;\n font-size: 9pt;\n color: #1a1a1a;\n background: #fff;\n padding: 14mm 12mm;\n line-height: 1.5;\n -webkit-print-color-adjust: exact;\n print-color-adjust: exact;\n }\n\n /* \u2500\u2500 Logo & Header \u2500\u2500 */\n .logo {\n color: #005bac;\n font-size: 13pt;\n font-weight: bold;\n letter-spacing: 0.5px;\n margin-bottom: 4px;\n }\n\n .form-title {\n text-align: center;\n font-size: 11pt;\n font-weight: bold;\n margin-bottom: 10px;\n line-height: 1.6;\n }\n\n /* \u2500\u2500 Top Meta Row \u2500\u2500 */\n .meta-grid {\n display: grid;\n grid-template-columns: 1fr 1fr;\n gap: 4px 16px;\n margin-bottom: 8px;\n }\n\n .meta-row {\n display: flex;\n align-items: center;\n gap: 4px;\n border-bottom: 1px solid #333;\n padding-bottom: 2px;\n font-size: 8.5pt;\n }\n\n .meta-row span.label { white-space: nowrap; }\n .meta-row span.value { flex: 1; min-width: 0; }\n\n /* \u2500\u2500 Section Header \u2500\u2500 */\n .section-header {\n background-color: #005bac;\n color: #fff;\n text-align: center;\n font-weight: bold;\n font-size: 9pt;\n padding: 4px 8px;\n margin: 8px 0 6px;\n }\n\n /* \u2500\u2500 Field Row \u2500\u2500 */\n .field-row {\n display: flex;\n align-items: center;\n flex-wrap: wrap;\n gap: 4px 10px;\n margin-bottom: 5px;\n font-size: 8.5pt;\n }\n\n .field-row .label { white-space: nowrap; }\n\n .underline {\n border-bottom: 1px solid #333;\n min-width: 60px;\n display: inline-block;\n padding-bottom: 1px;\n }\n\n .underline.lg { min-width: 140px; }\n .underline.md { min-width: 90px; }\n .underline.sm { min-width: 50px; }\n .underline.xs { min-width: 30px; }\n .underline.full { flex: 1; min-width: 120px; }\n\n /* \u2500\u2500 Checkbox \u2500\u2500 */\n .cb-group { display: flex; align-items: center; gap: 12px; flex-wrap: wrap; }\n\n .cb-item {\n display: flex;\n align-items: center;\n gap: 4px;\n white-space: nowrap;\n }\n\n .cb-box {\n width: 11px;\n height: 11px;\n border: 1.2px solid #333;\n display: inline-flex;\n align-items: center;\n justify-content: center;\n font-size: 8pt;\n flex-shrink: 0;\n }\n\n .cb-box.checked::after { content: '\u2714'; color: #005bac; }\n\n /* \u2500\u2500 Table \u2500\u2500 */\n table {\n width: 100%;\n border-collapse: collapse;\n font-size: 8.5pt;\n margin-bottom: 6px;\n }\n\n th {\n background-color: #dce9f7;\n border: 1px solid #aac4e0;\n padding: 4px 6px;\n text-align: center;\n font-weight: bold;\n }\n\n td {\n border: 1px solid #aac4e0;\n padding: 4px 6px;\n text-align: center;\n min-height: 20px;\n }\n\n .td-empty { height: 20px; }\n\n /* \u2500\u2500 Note \u2500\u2500 */\n .note {\n font-size: 8pt;\n display: flex;\n justify-content: space-between;\n align-items: center;\n margin-top: 2px;\n }\n\n /* \u2500\u2500 Health Questions \u2500\u2500 */\n .health-q {\n font-size: 8.5pt;\n margin-bottom: 6px;\n line-height: 1.6;\n }\n\n .health-q .q-text { display: inline; }\n\n .detail-line {\n border-bottom: 1px solid #333;\n min-height: 14px;\n margin-top: 3px;\n width: 100%;\n }\n\n /* \u2500\u2500 Declaration \u2500\u2500 */\n .declaration {\n font-size: 8pt;\n line-height: 1.6;\n margin-bottom: 6px;\n }\n\n .declaration p { margin-bottom: 5px; }\n\n /* \u2500\u2500 Signature Row \u2500\u2500 */\n .sig-row {\n display: grid;\n grid-template-columns: 1fr 1fr;\n gap: 16px;\n margin-top: 10px;\n font-size: 8.5pt;\n }\n\n .sig-block { display: flex; flex-direction: column; gap: 6px; }\n\n .sig-line {\n border-bottom: 1px solid #333;\n min-height: 36px;\n margin-bottom: 4px;\n }\n\n /* \u2500\u2500 Page number \u2500\u2500 */\n .page-num {\n text-align: right;\n font-size: 7.5pt;\n color: #555;\n margin-bottom: 4px;\n }\n\n /* \u2500\u2500 Page break \u2500\u2500 */\n .page-break { page-break-before: always; }\n </style>\n </head>\n <body>\n\n <!-- PAGE 1 -->\n <div class=\"page-num\">\u1791\u17C6\u1796\u17D0\u179A 1 \u1793\u17C3 2</div>\n\n <div class=\"logo\">PhillipLife</div>\n\n <div class=\"form-title\">\n \u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17A2\u17B6\u1799\u17BB\u1787\u17B8\u179C\u17B7\u178F<br/>\n \u179F\u1798\u17D2\u179A\u17B6\u1794\u17CB\u1791\u1798\u17D2\u179A\u1784\u17CB\u179F\u17B6\u1798\u1789\u17D2\u1789\u179F\u1798\u17D2\u179A\u17B6\u1794\u17CB\u17A2\u178F\u17B7\u1790\u17B7\u1787\u1793\u1787\u17C4\u1782\u1787\u17D0\u1799\u17A0\u17D2\u179C\u17B6\u1799\u1793\u17C2\u1793 (SIO)\n </div>\n\n <!-- Meta -->\n <div class=\"meta-grid\">\n <div class=\"meta-row\">\n <span class=\"label\">\u1788\u17D2\u1798\u17C4\u17C7\u1793\u17B7\u1784\u179B\u17C1\u1781\u1780\u17BC\u178A\u179F\u17B6\u1781\u17B6</span>\n <span class=\"value underline full\"><%= branchName %> <%= branchCode %></span>\n </div>\n <div class=\"meta-row\">\n <span class=\"label\">\u1788\u17D2\u1798\u17C4\u17C7\u1793\u17B7\u1784\u179B\u17C1\u1781\u1780\u17BC\u178A\u1794\u17BB\u1782\u17D2\u1782\u179B\u17B7\u1780\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17CB</span>\n <span class=\"value underline full\"><%= insurerName %> <%= insurerCode %></span>\n </div>\n <div class=\"meta-row\">\n <span class=\"label\">\u1788\u17D2\u1798\u17C4\u17C7\u1793\u17B7\u1784\u179B\u17C1\u1781\u1780\u17BC\u178A\u1794\u17BB\u1782\u17D2\u1782\u179B\u17B7\u1780\u1792\u1793\u17B6\u1782\u17B6\u179A</span>\n <span class=\"value underline full\"><%= bankStaffName %> <%= bankStaffCode %></span>\n </div>\n <div class=\"meta-row\">\n <span class=\"label\">\u179B\u17C1\u1781\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6</span>\n <span class=\"value underline full\"><%= applicationNo %></span>\n </div>\n </div>\n\n <!-- Section: Applicant -->\n <div class=\"section-header\">\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u17A2\u17C6\u1796\u17B8\u17A2\u17D2\u1793\u1780\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1796\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17CB</div>\n\n <div class=\"field-row\">\n <span class=\"label\">\u1788\u17D2\u1798\u17C4\u17C7\u1796\u17C1\u1789\u178A\u17BC\u1785\u1794\u1784\u17D2\u17A0\u17B6\u1789\u1793\u17C5\u1780\u17D2\u1793\u17BB\u1784\u17AF\u1780\u179F\u17B6\u179A\u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E \u1787\u17B6\u1797\u17B6\u179F\u17B6\u1781\u17D2\u1798\u17C2\u179A:</span>\n <span class=\"underline lg\"><%= fullNameKh %></span>\n <span class=\"label\">\u1787\u17B6\u1797\u17B6\u179F\u17B6\u17A2\u1784\u17CB\u1782\u17D2\u179B\u17C1\u179F</span>\n <span class=\"underline lg\"><%= fullNameEn %></span>\n <span class=\"label\">\u1797\u17C1\u1791:</span>\n <div class=\"cb-group\">\n <div class=\"cb-item\"><div class=\"cb-box <%= gender === 'male' ? 'checked' : '' %>\"></div><span>\u1794\u17D2\u179A\u17BB\u179F</span></div>\n <div class=\"cb-item\"><div class=\"cb-box <%= gender === 'female' ? 'checked' : '' %>\"></div><span>\u179F\u17D2\u179A\u17B8</span></div>\n </div>\n </div>\n\n <div class=\"field-row\">\n <span class=\"label\">\u179F\u17D2\u1790\u17B6\u1793\u1797\u17B6\u1796\u1782\u17D2\u179A\u17BD\u179F\u17B6\u179A:</span>\n <div class=\"cb-group\">\n <div class=\"cb-item\"><div class=\"cb-box <%= maritalStatus === 'single' ? 'checked' : '' %>\"></div><span>\u1793\u17C5\u17A1\u17B6\u179C</span></div>\n <div class=\"cb-item\"><div class=\"cb-box <%= maritalStatus === 'married' ? 'checked' : '' %>\"></div><span>\u179A\u17C0\u1794\u1780\u17B6\u179A</span></div>\n <div class=\"cb-item\"><div class=\"cb-box <%= maritalStatus === 'pregnant' ? 'checked' : '' %>\"></div><span>\u1796\u17C4\u17C7\u1798\u17D2\u178A\u17B6\u1799</span></div>\n </div>\n <span class=\"label\">\u178F\u17BD\u1793\u17B6\u1791\u17B8\u1793\u17B7\u1784\u1794\u17D2\u179A\u1797\u17C1\u1791\u1780\u17B6\u179A\u1784\u17B6\u179A:</span>\n <span class=\"underline md\"><%= occupation %></span>\n </div>\n\n <div class=\"field-row\">\n <span class=\"label\">\u17AF\u1780\u179F\u17B6\u179A\u1794\u1789\u17D2\u1785\u17B6\u1780\u17CB\u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E:</span>\n <div class=\"cb-group\">\n <div class=\"cb-item\"><div class=\"cb-box <%= idType === 'nid' ? 'checked' : '' %>\"></div><span>\u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E\u1794\u178E\u17D2\u178E</span></div>\n <div class=\"cb-item\"><div class=\"cb-box <%= idType === 'passport' ? 'checked' : '' %>\"></div><span>\u179B\u17B7\u1781\u17B7\u178F\u1786\u17D2\u179B\u1784\u178A\u17C2\u1793</span></div>\n <div class=\"cb-item\"><div class=\"cb-box <%= idType === 'birth' ? 'checked' : '' %>\"></div><span>\u179F\u17C6\u1794\u17BB\u178F\u17D2\u179A\u1780\u17C6\u178E\u17BE\u178F</span></div>\n </div>\n </div>\n\n <div class=\"field-row\">\n <span class=\"label\">\u1795\u17D2\u179F\u17C1\u1784\u1791\u17C0\u178F:</span>\n <span class=\"underline sm\"><%= idType === 'other' ? idNumber : '' %></span>\n <span class=\"label\">\u179B\u17C1\u1781\u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E:</span>\n <span class=\"underline md\"><%= idNumber %></span>\n <span class=\"label\">\u1790\u17D2\u1784\u17C3\u1781\u17C2\u1786\u17D2\u1793\u17B6\u17C6\u1780\u17C6\u178E\u17BE\u178F:</span>\n <span class=\"underline md\"><%= dob %></span>\n <span class=\"label\">\u17A2\u17B6\u1799\u17BB:</span>\n <span class=\"underline xs\"><%= age %></span>\n <span class=\"label\">\u179F\u1789\u17D2\u1787\u17B6\u178F\u17B7:</span>\n <span class=\"underline sm\"><%= nationality %></span>\n <span class=\"label\">\u179B\u17C1\u1781\u1791\u17BC\u179A\u179F\u17D0\u1796\u17D2\u1791:</span>\n <span class=\"underline md\"><%= phone %></span>\n </div>\n\n <div class=\"field-row\">\n <span class=\"label\">\u17A2\u17B6\u179F\u1799\u178A\u17D2\u178B\u17B6\u1793\u1794\u1785\u17D2\u1785\u17BB\u1794\u17D2\u1794\u1793\u17D2\u1793:</span>\n <span class=\"underline full\"><%= address %></span>\n </div>\n\n <!-- FATCA -->\n <div class=\"section-header\" style=\"background:#e8f0fb; color:#005bac; border:1px solid #aac4e0; font-size:8.5pt;\">\n \u179F\u17C1\u1785\u1780\u17D2\u178A\u17B8\u1794\u17D2\u179A\u1780\u17B6\u179F\u179F\u1798\u17D2\u179A\u17B6\u1794\u17CB\u1780\u17B6\u179A\u17A2\u1793\u17BB\u179C\u178F\u17D2\u178A FATCA\n </div>\n\n <div class=\"field-row\">\n \u17A2\u17D2\u1793\u1780\u179F\u17D2\u1793\u17BE\u179A\u179F\u17BB\u17C6\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17CB\u1798\u17B7\u1793\u1798\u17C2\u1793\u1787\u17B6\u1796\u179B\u179A\u178A\u17D2\u178B\u17A2\u17B6\u1798\u17C1\u179A\u17B7\u1780 \u17AC \u1787\u17B6\u1794\u17CB\u1796\u1793\u17D2\u1792\u179F\u17D2\u1793\u17B6\u1780\u17CB\u1793\u17C5\u17A2\u17B6\u1798\u17C1\u179A\u17B7\u1780 \u17AC \u1798\u17B6\u1793\u179F\u17B7\u1791\u17D2\u1792\u17B7\u1780\u17B6\u1793\u17CB Green Card \u1793\u17C4\u17C7\u1791\u17C1\u17D4\n </div>\n\n <div class=\"field-row\">\n <div class=\"cb-group\">\n <div class=\"cb-item\"><div class=\"cb-box <%= !isFatca ? 'checked' : '' %>\"></div><span>\u1798\u17B7\u1793\u1798\u17C2\u1793</span></div>\n <div class=\"cb-item\"><div class=\"cb-box <%= isFatca ? 'checked' : '' %>\"></div><span>\u1798\u17C2\u1793</span></div>\n </div>\n <span class=\"label\">US TIN:</span>\n <span class=\"underline md\"><%= usTin %></span>\n <span class=\"label\">\u179B\u17C1\u1781\u1780\u17BC\u178A\u179B\u17BE\u1780\u179B\u17C2\u1784 FATCA (\u1794\u17D2\u179A\u179F\u17B7\u1793\u1798\u17B6\u1793):</span>\n <span class=\"underline md\"><%= fatcaExemptCode %></span>\n </div>\n\n <div class=\"health-q\" style=\"font-size:7.8pt; color:#333;\">\n \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1780\u17B6\u179A\u1794\u1789\u17D2\u1785\u17B6\u1780\u17CB\u17A2\u17C7\u17A2\u17B6\u1784\u178E\u17B6\u1798\u17BD\u1799\u1798\u17B7\u1793\u178F\u17D2\u179A\u17B9\u1798\u178F\u17D2\u179A\u17BC\u179C \u1781\u17D2\u1789\u17BB\u17C6\u1793\u17B9\u1784\u1794\u17D2\u179A\u1782\u179B\u17CB\u1787\u17BC\u1793\u1793\u17BC\u179C\u17AF\u1780\u179F\u17B6\u179A\u1790\u17D2\u1798\u17B8\u1780\u17D2\u1793\u17BB\u1784\u179A\u1799\u17C7\u1796\u17C1\u179B \u17E3\u17E0\u1790\u17D2\u1784\u17C3\u17A0\u17BE\u1799\u17A2\u17C7\u17A2\u17B6\u1784\u1790\u17B6\u1781\u17D2\u1789\u17BB\u17C6\u1798\u17B7\u1793\u1787\u17B6\u1794\u17CB\u1796\u1793\u17D2\u1792\u1780\u17B6\u178F\u17CB\u1791\u17BB\u1780\u179A\u1794\u179F\u17CB\u179F\u17A0\u179A\u178A\u17D2\u178B\u17A2\u17B6\u1798\u17C1\u179A\u17B7\u1780\u1791\u17C1\u17D4\n </div>\n\n <!-- Section: Product -->\n <div class=\"section-header\">\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u17A2\u17C6\u1796\u17B8\u1795\u179B\u17B7\u178F\u1795\u179B</div>\n\n <table>\n <thead>\n <tr>\n <th>\u1788\u17D2\u1798\u17C4\u17C7\u1795\u179B\u17B7\u178F\u1795\u179B \u1793\u17B7\u1784\u179A\u1799\u17C7\u1796\u17C1\u179B\u1792\u17B6\u1793\u17B6</th>\n <th>\u1791\u17B9\u1780\u1794\u17D2\u179A\u17B6\u1780\u17CB\u178F\u17D2\u179A\u17BC\u179C\u1792\u17B6\u1793\u17B6<br/>(\u178A\u17BB\u179B\u17D2\u179B\u17B6\u179A\u17A2\u179A\u17B6\u1798\u17C1\u179A\u17B7\u1780)</th>\n <th>\u179A\u1794\u17C0\u1794\u1794\u1784\u17CB\u1794\u17BB\u1796\u17D2\u179C\u179B\u17B6\u1797</th>\n <th>\u1794\u17BB\u1796\u17D2\u179C\u179B\u17B6\u1797\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17CB<br/>(\u178A\u17BB\u179B\u17D2\u179B\u17B6\u179A\u17A2\u179A\u17B6\u1798\u17C1\u179A\u17B7\u1780)</th>\n </tr>\n </thead>\n <tbody>\n <% if (products && products.length > 0) { %>\n <% products.forEach((p) => { %>\n <tr>\n <td><%= p.name || '' %></td>\n <td><%= p.sumAssured || '' %></td>\n <td><%= p.paymentMethod || '' %></td>\n <td><%= p.premium || '' %></td>\n </tr>\n <% }) %>\n <% } else { %>\n <tr>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n </tr>\n <tr>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n </tr>\n <% } %>\n </tbody>\n </table>\n\n <div class=\"field-row\">\n <span class=\"label\">\u179C\u17B7\u178C\u17B8\u179F\u17B6\u179F\u17D2\u179A\u17D2\u178A\u1794\u1784\u17CB\u1794\u17BB\u1796\u17D2\u179C\u179B\u17B6\u1797\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17CB:</span>\n <div class=\"cb-group\">\n <div class=\"cb-item\">\n <div class=\"cb-box <%= paymentVia === 'transfer' ? 'checked' : '' %>\"></div>\n <span>\u1780\u17B6\u179A\u1795\u17D2\u1791\u17C1\u179A\u1794\u17D2\u179A\u17B6\u1780\u17CB\u1785\u17BC\u179B\u1791\u17C5\u1780\u17D2\u1793\u17BB\u1784\u1782\u178E\u1793\u17B8\u179A\u1794\u179F\u17CB\u17A0\u17D2\u179C\u17B8\u179B\u17B8\u17A1\u17B6\u1799\u17A0\u17D2\u179C\u17CD \u178F\u17B6\u1798\u179A\u1799\u17C7\u178A\u17C3\u1782\u17BC\u179A\u179A\u1794\u179F\u17CB\u17A0\u17D2\u179C\u17B8\u179B\u17B8\u17A1\u17B6\u1799\u17A0\u17D2\u179C\u17CD</span>\n </div>\n <div class=\"cb-item\">\n <div class=\"cb-box <%= paymentVia === 'cash' ? 'checked' : '' %>\"></div>\n <span>\u178F\u17B6\u1798\u179A\u1799\u17C8\u178A\u17C3\u1782\u17BC\u179A\u1794\u179F\u17CB\u17A0\u17D2\u179C\u17B8\u179B\u17B8\u17A1\u17B6\u1799\u17A0\u17D2\u179C\u17CD</span>\n </div>\n </div>\n </div>\n\n <!-- Section: Beneficiaries -->\n <div class=\"section-header\">\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u17A2\u17C6\u1796\u17B8\u17A2\u17D2\u1793\u1780\u1791\u1791\u17BD\u179B\u1795\u179B</div>\n\n <table>\n <thead>\n <tr>\n <th>\u1788\u17D2\u1798\u17C4\u17C7\u1796\u17C1\u1789\u179A\u1794\u179F\u17CB\u17A2\u17D2\u1793\u1780\u1791\u1791\u17BD\u179B\u1795\u179B</th>\n <th>\u17A2\u17B6\u1799\u17BB</th>\n <th>\u1791\u17C6\u1793\u17B6\u1780\u17CB\u1791\u17C6\u1793\u1784</th>\n <th>\u179B\u17C1\u1781\u17A2\u178F\u17B7\u1790\u17B7\u1787\u1793/\u17AF\u1780\u179F\u17B6\u179A</th>\n <th>% \u1793\u17C3\u1780\u17B6\u179A\u1794\u17C2\u1784\u1785\u17C2\u1780</th>\n </tr>\n </thead>\n <tbody>\n <% if (beneficiaries && beneficiaries.length > 0) { %>\n <% beneficiaries.forEach((b) => { %>\n <tr>\n <td><%= b.fullName || '' %></td>\n <td><%= b.age || '' %></td>\n <td><%= b.relationship || '' %></td>\n <td><%= b.idNumber || '' %></td>\n <td><%= b.percentage || '' %></td>\n </tr>\n <% }) %>\n <% } else { %>\n <tr>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n </tr>\n <tr>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n </tr>\n <tr>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n </tr>\n <% } %>\n </tbody>\n </table>\n\n <div class=\"note\">\n <span>\u1780\u178E\u178F\u17CB\u179F\u1798\u17D2\u1782\u17B6\u179B\u17CB\u17D6 \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1797\u17B6\u1782\u179A\u1799\u1798\u17B7\u1793\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1794\u1789\u17D2\u1787\u17B6\u1780\u17CB\u1785\u17C6\u1793\u17BD\u1793\u1791\u17B9\u1780\u1794\u17D2\u179A\u17B6\u1780\u17CB\u1793\u17B9\u1784\u178F\u17D2\u179A\u17BC\u179C\u1794\u17C2\u1784\u1785\u17C2\u1780\u179F\u17D2\u1798\u17BE\u17D7\u1782\u17D2\u1793\u17B6</span>\n <span>% \u179F\u179A\u17BB\u1794\u179F\u17D2\u1798\u17BE\u179A \u17E1\u17E0\u17E0%</span>\n </div>\n\n <!-- Section: Health -->\n <div class=\"section-header\">\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u1796\u17B6\u1780\u17CB\u1796\u17D0\u1793\u17D2\u1791\u1793\u17B9\u1784\u179F\u17BB\u1781\u1797\u17B6\u1796\u179A\u1794\u179F\u17CB \u17A2\u17D2\u1793\u1780\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17CB</div>\n\n <!-- Q1 -->\n <div class=\"health-q\">\n <span class=\"q-text\">1) \u1780\u1798\u17D2\u1796\u179F\u17CB:</span>\n <span class=\"underline xs\"><%= height %></span> \u179F.\u1798\n <span class=\"q-text\" style=\"margin-left:8px;\">\u1791\u1798\u17D2\u1784\u1793\u17CB:</span>\n <span class=\"underline xs\"><%= weight %></span> \u1782.\u1780\n <span class=\"q-text\" style=\"margin-left:8px;\">\u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1796\u17B7\u179F\u17B6\u179A\u1794\u17B6\u179A\u17B8\u178A\u17C2\u179A\u17AC\u1791\u17C1?:</span>\n <div class=\"cb-group\" style=\"display:inline-flex; margin-left:4px;\">\n <div class=\"cb-item\"><div class=\"cb-box <%= !smokes ? 'checked' : '' %>\"></div><span>\u1798\u17B7\u1793\u1798\u17B6\u1793</span></div>\n <div class=\"cb-item\"><div class=\"cb-box <%= smokes ? 'checked' : '' %>\"></div><span>\u1798\u17B6\u1793</span></div>\n </div>\n <span class=\"underline xs\"><%= smokesCount %></span> \u1780\u17D2\u1793\u17BB\u1784\u1798\u17BD\u1799\u1790\u17D2\u1784\u17C3\n </div>\n\n <!-- Q2 -->\n <div class=\"health-q\">\n <span class=\"q-text\">2) \u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1796\u17B7\u179F\u17B6\u179A\u1782\u17D2\u179A\u17BF\u1784\u179F\u17D2\u179A\u179C\u17B9\u1784\u178A\u17C2\u179A\u17AC\u1791\u17C1?:</span>\n <div class=\"cb-group\" style=\"display:inline-flex; margin-left:4px;\">\n <div class=\"cb-item\"><div class=\"cb-box <%= !drinksAlcohol ? 'checked' : '' %>\"></div><span>\u1798\u17B7\u1793\u1798\u17B6\u1793</span></div>\n <div class=\"cb-item\"><div class=\"cb-box <%= drinksAlcohol ? 'checked' : '' %>\"></div><span>\u1798\u17B6\u1793</span></div>\n </div>\n <span class=\"underline xs\"><%= alcoholCount %></span> \u1780\u17D2\u1793\u17BB\u1784\u1798\u17BD\u1799\u179F\u1794\u17D2\u178A\u17B6\u17A0\u17CD\n </div>\n\n <!-- Q3 -->\n <div class=\"health-q\">\n <span class=\"q-text\">3) \u1780\u17D2\u1793\u17BB\u1784\u179A\u1799\u17C8\u1796\u17C1\u179B\u17E0\u17E2(\u1796\u17B8\u179A)\u1786\u17D2\u1793\u17B6\u17C6\u1785\u17BB\u1784\u1780\u17D2\u179A\u17C4\u1799\u1793\u17C1\u17C7\u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1792\u17D2\u179B\u17B6\u1794\u17CB\u1794\u17B6\u1793\u179F\u1798\u17D2\u179A\u17B6\u1780\u1780\u17D2\u1793\u17BB\u1784\u1798\u1793\u17D2\u1791\u17B8\u179A\u1796\u17C1\u1791\u17D2\u1799 \u1792\u17D2\u179B\u17B6\u1794\u17CB\u1794\u17B6\u1793\u1791\u1791\u17BD\u179B\u1780\u17B6\u179A\u179C\u17C7\u1780\u17B6\u178F\u17CB \u17AC\u1792\u17D2\u179B\u17B6\u1794\u17CB\u1791\u1791\u17BD\u179B\u1794\u17B6\u1793\u179B\u1791\u17D2\u1792\u1795\u179B\u1781\u17BB\u179F\u1794\u17D2\u179A\u1780\u17D2\u179A\u178F\u17B8\u17A2\u17C6\u1796\u17B8\u1780\u17B6\u179A\u179C\u17B7\u1797\u17B6\u1782\u1788\u17B6\u1798 \u1780\u17B6\u179A\u179C\u17B7\u1797\u17B6\u1782\u1791\u17B9\u1780\u1793\u17C4\u1798 \u1780\u17B6\u179A\u1790\u178F\u1780\u17B6\u17C6\u179A\u179F\u17D2\u1798\u17B8\u17A2\u17BB\u17B7\u1785 (X-ray) \u1798\u17C9\u17B6\u179F\u17CA\u17B8\u1793\u179C\u17B6\u179F\u17CB\u1785\u1784\u17D2\u179C\u17B6\u1780\u17CB\u1794\u17C1\u17C7\u178A\u17BC\u1784 \u17A2\u17C1\u1780\u17BC\u179F\u17B6\u179F\u17D2\u179A\u17D2\u178A\u179F\u17D2\u1780\u17C1\u1793 \u1780\u17B6\u179A\u1785\u17D2\u179A\u17B9\u1794\u179F\u17B6\u1785\u17CB\u1799\u1780\u1796\u17B7\u1793\u17B7\u178F\u17D2\u1799 \u17AC\u179B\u1791\u17D2\u1792\u1795\u179B\u179C\u17B7\u1797\u17B6\u1782\u1795\u17D2\u179F\u17C1\u1784\u17D7\u1791\u17C0\u178F\u178A\u17C2\u179B\u1798\u17B7\u1793\u1794\u17B6\u1793\u179A\u17C0\u1794\u179A\u17B6\u1794\u17CB\u1781\u17B6\u1784\u178A\u17BE\u1798\u1796\u17B8\u1782\u17D2\u179A\u17BC\u1796\u17C1\u1791\u17D2\u1799\u178A\u17C2\u179A\u17AC\u1791\u17C1?:</span>\n <div class=\"cb-group\" style=\"display:inline-flex; margin-left:4px;\">\n <div class=\"cb-item\"><div class=\"cb-box <%= !hospitalizedQ3 ? 'checked' : '' %>\"></div><span>\u1798\u17B7\u1793\u1798\u17B6\u1793</span></div>\n <div class=\"cb-item\"><div class=\"cb-box <%= hospitalizedQ3 ? 'checked' : '' %>\"></div><span>\u1798\u17B6\u1793</span></div>\n </div>\n\n <% if (hospitalizedQ3) { %>\n <div class=\"detail-line\"><%= hospitalizedQ3Detail %></div>\n <% } %>\n </div>\n\n <!-- PAGE 2 -->\n <div class=\"page-break\"></div>\n <div class=\"page-num\">\u1791\u17C6\u1796\u17D0\u179A 2 \u1793\u17C3 2</div>\n\n <!-- Q4 -->\n <div class=\"health-q\">\n <span class=\"q-text\">4) \u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1792\u17D2\u179B\u17B6\u1794\u17CB\u1794\u17B6\u1793\u1792\u17D2\u179C\u17BE\u179A\u17C4\u1782\u179C\u17B7\u1793\u17B7\u1785\u17D2\u1786\u17D0\u1799 \u1796\u17B7\u1782\u17D2\u179A\u17C4\u17C7\u1787\u17C6\u1784\u17BA\u17AC\u1791\u1791\u17BD\u179B\u1780\u17B6\u179A\u1796\u17D2\u1799\u17B6\u1794\u17B6\u179B\u178A\u17BC\u1785\u1787\u17B6 \u179B\u17BE\u179F\u179F\u1798\u17D2\u1796\u17B6\u1792\u1788\u17B6\u1798 \u1791\u17B9\u1780\u1793\u17C4\u1798\u1795\u17D2\u17A2\u17C2\u1798 \u1787\u17C6\u1784\u17BA\u1794\u17C1\u17C7\u178A\u17BC\u1784 \u1785\u17BB\u1780\u1791\u17D2\u179A\u17BC\u1784 \u1787\u17C6\u1784\u17BA\u179F\u17BD\u178F \u1787\u17C6\u1784\u17BA\u1790\u17D2\u179B\u17BE\u1798 \u1787\u17C6\u1784\u17BA\u178F\u1798\u17D2\u179A\u1784\u1793\u17C4\u1798 \u1798\u17A0\u17B6\u179A\u17B8\u1780 \u1787\u17C6\u1784\u17BA\u178A\u17B6\u1785\u17CB\u179F\u179F\u17C3\u1788\u17B6\u1798\u1781\u17BD\u179A\u1780\u17D2\u1794\u17B6\u179B \u1787\u17C6\u1784\u17BA\u17A2\u17C1\u178A\u179F\u17CD \u1787\u17C6\u1784\u17BA\u1795\u17D2\u179B\u17BC\u179C\u1785\u17B7\u178F\u17D2\u178F \u1796\u17B7\u1780\u17B6\u179A\u1797\u17B6\u1796 \u17AC\u179A\u17B6\u1784\u1780\u17B6\u1799\u1798\u17B7\u1793\u1794\u17D2\u179A\u1780\u17D2\u179A\u178F\u17B8 \u1794\u17D2\u179A\u17BE\u1794\u17D2\u179A\u17B6\u179F\u17CB\u1790\u17D2\u1793\u17B6\u17C6\u1789\u17C0\u1793 \u17AC\u1789\u17C0\u1793\u179F\u17D2\u179A\u17B6 \u17AC\u1787\u17C6\u1784\u17BA\u1795\u17D2\u179F\u17C1\u1784\u1791\u17C0\u178F\u178A\u17C2\u179B\u1798\u17B7\u1793\u1794\u17B6\u1793\u179A\u17C0\u1794\u179A\u17B6\u1794\u17CB\u1781\u17B6\u1784\u179B\u17BE\u178A\u17C2\u179A\u17AC\u1791\u17C1?</span>\n <div class=\"cb-group\" style=\"display:inline-flex; margin-left:4px;\">\n <div class=\"cb-item\"><div class=\"cb-box <%= !diagnosedQ4 ? 'checked' : '' %>\"></div><span>\u1798\u17B7\u1793\u1798\u17B6\u1793</span></div>\n <div class=\"cb-item\"><div class=\"cb-box <%= diagnosedQ4 ? 'checked' : '' %>\"></div><span>\u1798\u17B6\u1793</span></div>\n </div>\n\n <% if (diagnosedQ4) { %>\n <div style=\"margin-top:4px; font-size:8pt;\">\u1794\u17BE\u1798\u17B6\u1793\u179F\u17BC\u1798\u1794\u1789\u17D2\u1787\u17B6\u1780\u17CB\u179B\u1798\u17D2\u17A2\u17B7\u178F\u1781\u17B6\u1784\u1780\u17D2\u179A\u17C4\u1798\u17D6</div>\n <div class=\"detail-line\"><%= diagnosedQ4Detail %></div>\n <% } %>\n </div>\n\n <!-- Declaration -->\n <div class=\"section-header\">\u179F\u17C1\u1785\u1780\u17D2\u178A\u17B8\u1794\u17D2\u179A\u1780\u17B6\u179F\u179A\u1794\u179F\u17CB\u17A2\u17D2\u1793\u1780\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17CB</div>\n\n <div class=\"declaration\">\n <p>1) \u1781\u17D2\u1789\u17BB\u17C6\u17A2\u1793\u17BB\u1789\u17D2\u1789\u17B6\u178F \u1793\u17B7\u1784\u1799\u179B\u17CB\u1796\u17D2\u179A\u1798\u17B2\u17D2\u1799\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u1794\u17D2\u179A\u17BE\u1794\u17D2\u179A\u17B6\u179F\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793 \u1793\u17B7\u1784\u1791\u17B7\u1793\u17D2\u1793\u1793\u17D0\u1799\u1791\u17B6\u17C6\u1784\u179F\u17D2\u179A\u17BB\u1784\u178A\u17C2\u179B\u1781\u17D2\u1789\u17BB\u17C6\u1794\u17B6\u1793\u1795\u17D2\u178A\u179B\u17CB\u1793\u17C5\u1780\u17D2\u1793\u17BB\u1784\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u179A\u1794\u179F\u17CB\u1781\u17D2\u1789\u17BB\u17C6\u1780\u17D2\u1793\u17BB\u1784\u1782\u17C4\u179B\u1794\u17C6\u178E\u1784 \u179F\u17D2\u179A\u1794\u178F\u17B6\u1798\u1785\u17D2\u1794\u17B6\u1794\u17CB \u178A\u17BC\u1785\u1787\u17B6 \u1780\u17B6\u179A\u1795\u17D2\u179F\u1796\u17D2\u179C\u1795\u17D2\u179F\u17B6\u1799\u1791\u17B8\u1795\u17D2\u179F\u17B6\u179A \u1780\u17B6\u179A\u179F\u17B7\u1780\u17D2\u179F\u17B6\u1791\u17B8\u1795\u17D2\u179F\u17B6\u179A \u1793\u17B7\u1784 \u1780\u17B6\u179A\u1794\u1798\u17D2\u179A\u17BE\u17A2\u178F\u17B7\u1790\u17B7\u1787\u1793\u178A\u17C4\u1799\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793 \u179F\u1798\u17D2\u1796\u17D0\u1793\u17D2\u1792\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793 \u17AC \u1787\u17B6\u178A\u17C3\u1782\u17BC\u1796\u17B6\u178E\u17B7\u1787\u17D2\u1787\u1780\u1798\u17D2\u1798\u179A\u1794\u179F\u17CB\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793 \u178A\u17C4\u1799\u1798\u17B7\u1793\u1785\u17B6\u17C6\u1794\u17B6\u1785\u17CB\u1798\u17B6\u1793\u1780\u17B6\u179A\u1799\u179B\u17CB\u1796\u17D2\u179A\u1798 \u1793\u17B7\u1784\u1787\u17BC\u1793\u178A\u17C6\u178E\u17B9\u1784\u1794\u1793\u17D2\u1790\u17C2\u1798\u1796\u17B8\u1781\u17D2\u1789\u17BB\u17C6\u17A1\u17BE\u1799\u17D4 \u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u1798\u17B7\u1793\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u17A2\u1793\u17BB\u1789\u17D2\u1789\u17B6\u178F\u17B2\u17D2\u1799\u1794\u1789\u17D2\u1785\u17C1\u1789\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u178E\u17B6\u1798\u17BD\u1799\u1791\u17C5\u1797\u17B6\u1782\u17B8\u1791\u17B8\u1794\u17B8\u178E\u17B6\u1798\u17BD\u1799 \u17AC\u1794\u17D2\u179A\u17BE\u1794\u17D2\u179A\u17B6\u179F\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u1793\u17C4\u17C7\u179F\u1798\u17D2\u179A\u17B6\u1794\u17CB\u1782\u17C4\u179B\u1794\u17C6\u178E\u1784\u1795\u17D2\u179F\u17C1\u1784\u1791\u17C0\u178F\u178A\u17C2\u179B\u1798\u17B7\u1793\u1791\u17B6\u1780\u17CB\u1791\u1784\u1793\u17B9\u1784\u1782\u17C4\u179B\u1794\u17C6\u178E\u1784\u1791\u17B6\u17C6\u1784\u17A1\u17B6\u1799\u1781\u17B6\u1784\u179B\u17BE\u17A1\u17BE\u1799 \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1782\u17D2\u1798\u17B6\u1793\u1780\u17B6\u179A\u1799\u179B\u17CB\u1796\u17D2\u179A\u1798\u1796\u17D2\u179A\u17C0\u1784\u1787\u17B6\u179B\u17B6\u1799\u179B\u1780\u17D2\u1781\u178E\u17CD\u17A2\u1780\u17D2\u179F\u179A\u1793\u17C4\u17C7\u17D4</p>\n <p>2) \u1781\u17D2\u1789\u17BB\u17C6\u179F\u17BC\u1798\u17A2\u17C7\u17A2\u17B6\u1784\u1790\u17B6\u1794\u17B6\u1793\u17A2\u17B6\u1793 \u1793\u17B7\u1784\u1799\u179B\u17CB\u179F\u17D2\u179A\u1794\u1793\u17BC\u179C\u1782\u17D2\u179A\u1794\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u1780\u17D2\u1793\u17BB\u1784\u17AF\u1780\u179F\u17B6\u179A\u1793\u17C1\u17C7\u17D4 \u1781\u17D2\u1789\u17BB\u17C6\u179F\u17BC\u1798\u1794\u17D2\u179A\u1780\u17B6\u179F\u1790\u17B6\u1782\u17D2\u179A\u1794\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u178A\u17C2\u179B\u1794\u17B6\u1793\u1795\u17D2\u178A\u179B\u17CB\u1793\u17C5\u1780\u17D2\u1793\u17BB\u1784\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1793\u17C1\u17C7 \u1796\u17B7\u178F\u1787\u17B6\u1798\u17B6\u1793\u1797\u17B6\u1796\u1796\u17C1\u1789\u179B\u17C1\u1789 \u1793\u17B7\u1784\u178F\u17D2\u179A\u17B9\u1798\u178F\u17D2\u179A\u17BC\u179C\u1796\u17B7\u178F\u1794\u17D2\u179A\u17B6\u1780\u178A\u1798\u17C2\u1793\u17D4</p>\n </div>\n\n <!-- Signatures -->\n <div class=\"sig-row\">\n <div class=\"sig-block\">\n <div>\u17A0\u178F\u17D2\u1790\u179B\u17C1\u1781\u17B6 \u17AC\u179F\u17D2\u1793\u17B6\u1798\u1798\u17C1\u178A\u17C3\u179A\u1794\u179F\u17CB\u17A2\u17D2\u1793\u1780\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784</div>\n <div class=\"sig-line\"></div>\n <div class=\"field-row\">\n <span class=\"label\">\u1788\u17D2\u1798\u17C4\u17C7</span>\n <span class=\"underline full\"><%= applicantSignatureName %></span>\n </div>\n <div class=\"field-row\">\n <span class=\"label\">\u1780\u17B6\u179B\u1794\u179A\u17B7\u1785\u17D2\u1786\u17C1\u1791</span>\n <span class=\"underline full\"><%= signatureDate %></span>\n </div>\n </div>\n <div class=\"sig-block\">\n <div>\u17A0\u178F\u17D2\u1790\u179B\u17C1\u1781\u17B6 \u17AC\u179F\u17D2\u1793\u17B6\u1798\u1798\u17C1\u178A\u17C3\u179A\u1794\u179F\u17CB\u179F\u17B6\u1780\u17D2\u179F\u17B8</div>\n <div class=\"sig-line\"></div>\n <div class=\"field-row\">\n <span class=\"label\">\u1788\u17D2\u1798\u17C4\u17C7</span>\n <span class=\"underline full\"><%= witnessName %></span>\n </div>\n <div class=\"field-row\">\n <span class=\"label\">\u1780\u17B6\u179B\u1794\u179A\u17B7\u1785\u17D2\u1786\u17C1\u1791</span>\n <span class=\"underline full\"><%= witnessDate %></span>\n </div>\n </div>\n </div>\n\n </body>\n</html>\n";
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+
export declare const SIO_FORM_EN_TEMPLATE = "\n<!DOCTYPE html>\n<html lang=\"km\">\n<head>\n <meta charset=\"UTF-8\" />\n <meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0\" />\n <title>\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17A2\u17B6\u1799\u17BB\u1787\u17B8\u179C\u17B7\u178F</title>\n <style>\n @font-face {\n font-family: 'Khmer OS';\n src: url('data:font/truetype;base64,<%= font_base64 %>') format('truetype');\n font-weight: normal;\n font-style: normal;\n }\n\n *, *::before, *::after { box-sizing: border-box; margin: 0; padding: 0; }\n\n body {\n font-family: 'Khmer OS', sans-serif;\n font-size: 9pt;\n color: #1a1a1a;\n background: #fff;\n padding: 14mm 12mm;\n line-height: 1.5;\n -webkit-print-color-adjust: exact;\n print-color-adjust: exact;\n }\n\n .logo {\n color: #005bac;\n font-size: 13pt;\n font-weight: bold;\n letter-spacing: 0.5px;\n margin-bottom: 4px;\n }\n\n .form-title {\n text-align: center;\n font-size: 11pt;\n font-weight: bold;\n margin-bottom: 10px;\n line-height: 1.6;\n }\n\n .meta-grid {\n display: grid;\n grid-template-columns: 1fr 1fr;\n gap: 4px 16px;\n margin-bottom: 8px;\n }\n\n .meta-row {\n display: flex;\n align-items: center;\n gap: 4px;\n border-bottom: 1px solid #333;\n padding-bottom: 2px;\n font-size: 8.5pt;\n }\n\n .meta-row span.label { white-space: nowrap; }\n .meta-row span.value { flex: 1; min-width: 0; }\n\n .section-header {\n background-color: #005bac;\n color: #fff;\n text-align: center;\n font-weight: bold;\n font-size: 9pt;\n padding: 4px 8px;\n margin: 8px 0 6px;\n }\n\n .field-row {\n display: flex;\n align-items: center;\n flex-wrap: wrap;\n gap: 4px 10px;\n margin-bottom: 5px;\n font-size: 8.5pt;\n }\n\n .field-row .label { white-space: nowrap; }\n\n .underline {\n border-bottom: 1px solid #333;\n min-width: 60px;\n display: inline-block;\n padding-bottom: 1px;\n }\n\n .underline.lg { min-width: 140px; }\n .underline.md { min-width: 90px; }\n .underline.sm { min-width: 50px; }\n .underline.xs { min-width: 30px; }\n .underline.full { flex: 1; min-width: 120px; }\n\n .cb-group { display: flex; align-items: center; gap: 12px; flex-wrap: wrap; }\n\n .cb-item {\n display: flex;\n align-items: center;\n gap: 4px;\n white-space: nowrap;\n }\n\n .cb-box {\n width: 11px;\n height: 11px;\n border: 1.2px solid #333;\n display: inline-flex;\n align-items: center;\n justify-content: center;\n font-size: 8pt;\n flex-shrink: 0;\n }\n\n .cb-box.checked::after { content: '\u2714'; color: #005bac; }\n\n table {\n width: 100%;\n border-collapse: collapse;\n font-size: 8.5pt;\n margin-bottom: 6px;\n }\n\n th {\n background-color: #dce9f7;\n border: 1px solid #aac4e0;\n padding: 4px 6px;\n text-align: center;\n font-weight: bold;\n }\n\n td {\n border: 1px solid #aac4e0;\n padding: 4px 6px;\n text-align: center;\n min-height: 20px;\n }\n\n .td-empty { height: 20px; }\n\n .note {\n font-size: 8pt;\n display: flex;\n justify-content: space-between;\n align-items: center;\n margin-top: 2px;\n }\n\n .health-q {\n font-size: 8.5pt;\n margin-bottom: 6px;\n line-height: 1.6;\n }\n\n .health-q .q-text { display: inline; }\n\n .detail-line {\n border-bottom: 1px solid #333;\n min-height: 14px;\n margin-top: 3px;\n width: 100%;\n }\n\n .declaration {\n font-size: 8pt;\n line-height: 1.6;\n margin-bottom: 6px;\n }\n\n .declaration p { margin-bottom: 5px; }\n\n .sig-row {\n display: grid;\n grid-template-columns: 1fr 1fr;\n gap: 16px;\n margin-top: 10px;\n font-size: 8.5pt;\n }\n\n .sig-block { display: flex; flex-direction: column; gap: 6px; }\n\n .sig-line {\n border-bottom: 1px solid #333;\n min-height: 36px;\n margin-bottom: 4px;\n }\n\n .page-num {\n text-align: right;\n font-size: 7.5pt;\n color: #555;\n margin-bottom: 4px;\n }\n\n .page-break { page-break-before: always; }\n </style>\n</head>\n<body>\n <div class=\"page-num\">\u1791\u17C6\u1796\u17D0\u179A 1 \u1793\u17C3 2</div>\n\n <div class=\"logo\">PhillipLife</div>\n\n <div class=\"form-title\">\n \u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17A2\u17B6\u1799\u17BB\u1787\u17B8\u179C\u17B7\u178F<br/>\n \u179F\u1798\u17D2\u179A\u17B6\u1794\u17CB\u1791\u1798\u17D2\u179A\u1784\u17CB\u179F\u17B6\u1798\u1789\u17D2\u1789\u179F\u1798\u17D2\u179A\u17B6\u1794\u17CB\u17A2\u178F\u17B7\u1790\u17B7\u1787\u1793\u1787\u17C4\u1782\u1787\u17D0\u1799\u17A0\u17D2\u179C\u17B6\u1799\u1793\u17C2\u1793 (SIO)\n </div>\n\n <div class=\"meta-grid\">\n <div class=\"meta-row\">\n <span class=\"label\">\u1788\u17D2\u1798\u17C4\u17C7\u1793\u17B7\u1784\u179B\u17C1\u1781\u1780\u17BC\u178A\u179F\u17B6\u1781\u17B6</span>\n <span class=\"value underline full\">\n <%= branch_staff_app_info?.branch_name ?? '' %> / <%= branch_staff_app_info?.branch_code ?? '' %>\n </span>\n </div>\n <div class=\"meta-row\">\n <span class=\"label\">\u1788\u17D2\u1798\u17C4\u17C7\u1793\u17B7\u1784\u179B\u17C1\u1781\u1780\u17BC\u178A\u1794\u17BB\u1782\u17D2\u1782\u179B\u17B7\u1780\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17CB</span>\n <span class=\"value underline full\">\n <%= branch_staff_app_info?.advisor_name ?? '' %> / <%= branch_staff_app_info?.advisor_code ?? '' %>\n </span>\n </div>\n <div class=\"meta-row\">\n <span class=\"label\">\u1788\u17D2\u1798\u17C4\u17C7\u1793\u17B7\u1784\u179B\u17C1\u1781\u1780\u17BC\u178A\u1794\u17BB\u1782\u17D2\u1782\u179B\u17B7\u1780\u1792\u1793\u17B6\u1782\u17B6\u179A</span>\n <span class=\"value underline full\">\n <%= branch_staff_app_info?.bank_staff_name ?? '' %> / <%= branch_staff_app_info?.bank_staff_code ?? '' %>\n </span>\n </div>\n <div class=\"meta-row\">\n <span class=\"label\">\u179B\u17C1\u1781\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6</span>\n <span class=\"value underline full\"><%= branch_staff_app_info?.application_no ?? '' %></span>\n </div>\n </div>\n\n <div class=\"section-header\">\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u17A2\u17C6\u1796\u17B8\u17A2\u17D2\u1793\u1780\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1796\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17CB</div>\n\n <div class=\"field-row\">\n <span class=\"label\">\u1788\u17D2\u1798\u17C4\u17C7\u1796\u17C1\u1789\u178A\u17BC\u1785\u1794\u1784\u17D2\u17A0\u17B6\u1789\u1793\u17C5\u1780\u17D2\u1793\u17BB\u1784\u17AF\u1780\u179F\u17B6\u179A\u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E \u1787\u17B6\u1797\u17B6\u179F\u17B6\u1781\u17D2\u1798\u17C2\u179A:</span>\n <span class=\"underline lg\"><%= applicant_info?.full_name_kh ?? '' %></span>\n <span class=\"label\">\u1787\u17B6\u1797\u17B6\u179F\u17B6\u17A2\u1784\u17CB\u1782\u17D2\u179B\u17C1\u179F</span>\n <span class=\"underline lg\"><%= applicant_info?.full_name ?? '' %></span>\n <span class=\"label\">\u1797\u17C1\u1791:</span>\n <div class=\"cb-group\">\n <div class=\"cb-item\">\n <div class=\"cb-box <%= applicant_info?.gender === 'M' ? 'checked' : '' %>\"></div>\n <span>\u1794\u17D2\u179A\u17BB\u179F</span>\n </div>\n <div class=\"cb-item\">\n <div class=\"cb-box <%= applicant_info?.gender === 'F' ? 'checked' : '' %>\"></div>\n <span>\u179F\u17D2\u179A\u17B8</span>\n </div>\n </div>\n </div>\n\n <div class=\"field-row\">\n <span class=\"label\">\u179F\u17D2\u1790\u17B6\u1793\u1797\u17B6\u1796\u1782\u17D2\u179A\u17BD\u179F\u17B6\u179A:</span>\n <div class=\"cb-group\">\n <div class=\"cb-item\">\n <div class=\"cb-box <%= applicant_info?.marital_status === 'single' ? 'checked' : '' %>\"></div>\n <span>\u1793\u17C5\u179B\u17B8\u179C</span>\n </div>\n <div class=\"cb-item\">\n <div class=\"cb-box <%= applicant_info?.marital_status === 'married' ? 'checked' : '' %>\"></div>\n <span>\u179A\u17C0\u1794\u1780\u17B6\u179A</span>\n </div>\n <div class=\"cb-item\">\n <div class=\"cb-box <%= applicant_info?.marital_status === 'divorced' ? 'checked' : '' %>\"></div>\n <span>\u179B\u17C2\u1784\u179B\u17C7</span>\n </div>\n <div class=\"cb-item\">\n <div class=\"cb-box <%= applicant_info?.marital_status === 'widowed' ? 'checked' : '' %>\"></div>\n <span>\u1798\u17C1\u1798\u17C9\u17B6\u1799/\u1796\u17C4\u17C7\u1798\u17C9\u17B6\u1799</span>\n </div>\n </div>\n <span class=\"label\">\u178F\u17BD\u1793\u17B6\u1791\u17B8\u1793\u17B7\u1784\u1794\u17D2\u179A\u1797\u17C1\u1791\u1780\u17B6\u179A\u1784\u17B6\u179A:</span>\n <span class=\"underline md\"><%= applicant_info?.occupation ?? '' %></span>\n </div>\n\n <div class=\"field-row\">\n <span class=\"label\">\u17AF\u1780\u179F\u17B6\u179A\u1794\u1789\u17D2\u1785\u17B6\u1780\u17CB\u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E:</span>\n <div class=\"cb-group\">\n <div class=\"cb-item\">\n <div class=\"cb-box <%= applicant_info?.identity_type === 'nid' ? 'checked' : '' %>\"></div>\n <span>\u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E\u1794\u178E\u17D2\u178E</span>\n </div>\n <div class=\"cb-item\">\n <div class=\"cb-box <%= applicant_info?.identity_type === 'passport' ? 'checked' : '' %>\"></div>\n <span>\u179B\u17B7\u1781\u17B7\u178F\u1786\u17D2\u179B\u1784\u178A\u17C2\u1793</span>\n </div>\n <div class=\"cb-item\">\n <div class=\"cb-box <%= applicant_info?.identity_type === 'birth' ? 'checked' : '' %>\"></div>\n <span>\u179F\u17C6\u1794\u17BB\u178F\u17D2\u179A\u1780\u17C6\u178E\u17BE\u178F</span>\n </div>\n <div class=\"cb-item\">\n <div class=\"cb-box <%= applicant_info?.identity_type === 'other' ? 'checked' : '' %>\"></div>\n <span>\u1795\u17D2\u179F\u17C1\u1784\u1791\u17C0\u178F</span>\n </div>\n </div>\n </div>\n\n <div class=\"field-row\">\n <span class=\"label\">\u1795\u17D2\u179F\u17C1\u1784\u1791\u17C0\u178F:</span>\n <span class=\"underline sm\"><%= applicant_info?.identity_type === 'other' ? (applicant_info?.identity_other_description ?? '') : '' %></span>\n <span class=\"label\">\u179B\u17C1\u1781\u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E:</span>\n <span class=\"underline md\"><%= applicant_info?.identity_no ?? '' %></span>\n <span class=\"label\">\u1790\u17D2\u1784\u17C3\u1781\u17C2\u1786\u17D2\u1793\u17B6\u17C6\u1780\u17C6\u178E\u17BE\u178F:</span>\n <span class=\"underline md\"><%= applicant_info?.date_of_birth ?? '' %></span>\n <span class=\"label\">\u17A2\u17B6\u1799\u17BB:</span>\n <span class=\"underline xs\"><%= applicant_info?.age ?? '' %></span>\n <span class=\"label\">\u179F\u1789\u17D2\u1787\u17B6\u178F\u17B7:</span>\n <span class=\"underline sm\"><%= applicant_info?.nationality ?? '' %></span>\n <span class=\"label\">\u179B\u17C1\u1781\u1791\u17BC\u179A\u179F\u17D0\u1796\u17D2\u1791:</span>\n <span class=\"underline md\"><%= applicant_info?.phone_number ?? '' %></span>\n </div>\n\n <div class=\"field-row\">\n <span class=\"label\">\u17A2\u17B6\u179F\u1799\u178A\u17D2\u178B\u17B6\u1793\u1794\u1785\u17D2\u1785\u17BB\u1794\u17D2\u1794\u1793\u17D2\u1793:</span>\n <span class=\"underline full\"><%= applicant_info?.current_address ?? '' %></span>\n </div>\n\n <div class=\"section-header\" style=\"background:#e8f0fb; color:#005bac; border:1px solid #aac4e0; font-size:8.5pt;\">\n \u179F\u17C1\u1785\u1780\u17D2\u178A\u17B8\u1794\u17D2\u179A\u1780\u17B6\u179F\u179F\u1798\u17D2\u179A\u17B6\u1794\u17CB\u1780\u17B6\u179A\u17A2\u1793\u17BB\u179C\u178F\u17D2\u178A FATCA\n </div>\n\n <div class=\"field-row\">\n \u17A2\u17D2\u1793\u1780\u179F\u17D2\u1793\u17BE\u179A\u179F\u17BB\u17C6\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17CB\u1798\u17B7\u1793\u1798\u17C2\u1793\u1787\u17B6\u1796\u179B\u179A\u178A\u17D2\u178B\u17A2\u17B6\u1798\u17C1\u179A\u17B7\u1780 \u17AC \u1787\u17B6\u1794\u17CB\u1796\u1793\u17D2\u1792\u179F\u17D2\u1793\u17B6\u1780\u17CB\u1793\u17C5\u17A2\u17B6\u1798\u17C1\u179A\u17B7\u1780 \u17AC \u1798\u17B6\u1793\u179F\u17B7\u1791\u17D2\u1792\u17B7\u1780\u17B6\u1793\u17CB Green Card \u1793\u17C4\u17C7\u1791\u17C1\u17D4\n </div>\n\n <div class=\"field-row\">\n <div class=\"cb-group\">\n <div class=\"cb-item\">\n <div class=\"cb-box <%= fatca_info?.is_fatca === false ? 'checked' : '' %>\"></div>\n <span>\u1798\u17B7\u1793\u1798\u17C2\u1793</span>\n </div>\n <div class=\"cb-item\">\n <div class=\"cb-box <%= fatca_info?.is_fatca === true ? 'checked' : '' %>\"></div>\n <span>\u1798\u17C2\u1793</span>\n </div>\n </div>\n <span class=\"label\">US TIN:</span>\n <span class=\"underline md\"><%= fatca_info?.us_tin_no ?? '' %></span>\n <span class=\"label\">\u179B\u17C1\u1781\u1780\u17BC\u178A\u179B\u17BE\u1780\u179B\u17C2\u1784 FATCA (\u1794\u17D2\u179A\u179F\u17B7\u1793\u1798\u17B6\u1793):</span>\n <span class=\"underline md\"><%= fatca_info?.fatca_exempt_code ?? '' %></span>\n </div>\n\n <div class=\"health-q\" style=\"font-size:7.8pt; color:#333;\">\n \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1780\u17B6\u179A\u1794\u1789\u17D2\u1785\u17B6\u1780\u17CB\u17A2\u17C7\u17A2\u17B6\u1784\u178E\u17B6\u1798\u17BD\u1799\u1798\u17B7\u1793\u178F\u17D2\u179A\u17B9\u1798\u178F\u17D2\u179A\u17BC\u179C \u1781\u17D2\u1789\u17BB\u17C6\u1793\u17B9\u1784\u1794\u17D2\u179A\u1782\u179B\u17CB\u1787\u17BC\u1793\u1793\u17BC\u179C\u17AF\u1780\u179F\u17B6\u179A\u1790\u17D2\u1798\u17B8\u1780\u17D2\u1793\u17BB\u1784\u179A\u1799\u17C7\u1796\u17C1\u179B \u17E3\u17E0\u1790\u17D2\u1784\u17C3\u17A0\u17BE\u1799\u17A2\u17C7\u17A2\u17B6\u1784\u1790\u17B6\u1781\u17D2\u1789\u17BB\u17C6\u1798\u17B7\u1793\u1787\u17B6\u1794\u17CB\u1796\u1793\u17D2\u1792\u1780\u17B6\u178F\u17CB\u1791\u17BB\u1780\u179A\u1794\u179F\u17CB\u179F\u17A0\u179A\u178A\u17D2\u178B\u17A2\u17B6\u1798\u17C1\u179A\u17B7\u1780\u1791\u17C1\u17D4\n </div>\n\n <div class=\"section-header\">\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u17A2\u17C6\u1796\u17B8\u1795\u179B\u17B7\u178F\u1795\u179B</div>\n\n <table>\n <thead>\n <tr>\n <th>\u1788\u17D2\u1798\u17C4\u17C7\u1795\u179B\u17B7\u178F\u1795\u179B \u1793\u17B7\u1784\u179A\u1799\u17C7\u1796\u17C1\u179B\u1792\u17B6\u1793\u17B6</th>\n <th>\u1791\u17B9\u1780\u1794\u17D2\u179A\u17B6\u1780\u17CB\u178F\u17D2\u179A\u17BC\u179C\u1792\u17B6\u1793\u17B6<br/>(\u178A\u17BB\u179B\u17D2\u179B\u17B6\u179A\u17A2\u17B6\u1798\u17C1\u179A\u17B7\u1780)</th>\n <th>\u179A\u1794\u17C0\u1794\u1794\u1784\u17CB\u1794\u17BB\u1796\u17D2\u179C\u179B\u17B6\u1797</th>\n <th>\u1794\u17BB\u1796\u17D2\u179C\u179B\u17B6\u1797\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17CB<br/>(\u178A\u17BB\u179B\u17D2\u179B\u17B6\u179A\u17A2\u17B6\u1798\u17C1\u179A\u17B7\u1780)</th>\n </tr>\n </thead>\n <tbody>\n <% if (product_payment_info?.products && product_payment_info.products.length > 0) { %>\n <% product_payment_info.products.forEach((p) => { %>\n <tr>\n <td><%= p.name ?? '' %> <%= p.term ? '(' + p.term + ')' : '' %></td>\n <td><%= p.sum_assured ?? '' %></td>\n <td><%= p.payment_mode ?? '' %></td>\n <td><%= p.premium ?? '' %></td>\n </tr>\n <% }) %>\n <% } else { %>\n <tr>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n </tr>\n <tr>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n </tr>\n <% } %>\n </tbody>\n </table>\n\n <div class=\"field-row\">\n <span class=\"label\">\u179C\u17B7\u1792\u17B8\u179F\u17B6\u179F\u17D2\u179A\u17D2\u178A\u1794\u1784\u17CB\u1794\u17BB\u1796\u17D2\u179C\u179B\u17B6\u1797\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17CB:</span>\n <div class=\"cb-group\">\n <div class=\"cb-item\">\n <div class=\"cb-box <%= product_payment_info?.payment_method === 'transfer' ? 'checked' : '' %>\"></div>\n <span>\u1780\u17B6\u179A\u1795\u17D2\u1791\u17C1\u179A\u1794\u17D2\u179A\u17B6\u1780\u17CB</span>\n </div>\n <div class=\"cb-item\">\n <div class=\"cb-box <%= product_payment_info?.payment_method === 'cash' ? 'checked' : '' %>\"></div>\n <span>\u179F\u17B6\u1785\u17CB\u1794\u17D2\u179A\u17B6\u1780\u17CB</span>\n </div>\n </div>\n </div>\n\n <div class=\"section-header\">\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u17A2\u17C6\u1796\u17B8\u17A2\u17D2\u1793\u1780\u1791\u1791\u17BD\u179B\u1795\u179B</div>\n\n <table>\n <thead>\n <tr>\n <th>\u1788\u17D2\u1798\u17C4\u17C7\u1796\u17C1\u1789\u179A\u1794\u179F\u17CB\u17A2\u17D2\u1793\u1780\u1791\u1791\u17BD\u179B\u1795\u179B</th>\n <th>\u17A2\u17B6\u1799\u17BB</th>\n <th>\u1791\u17C6\u1793\u17B6\u1780\u17CB\u1791\u17C6\u1793\u1784</th>\n <th>\u179B\u17C1\u1781\u17A2\u178F\u17B7\u1790\u17B7\u1787\u1793/\u17AF\u1780\u179F\u17B6\u179A</th>\n <th>% \u1793\u17C3\u1780\u17B6\u179A\u1794\u17C2\u1784\u1785\u17C2\u1780</th>\n </tr>\n </thead>\n <tbody>\n <% if (beneficiary_info && beneficiary_info.length > 0) { %>\n <% beneficiary_info.forEach((b) => { %>\n <tr>\n <td><%= b.full_name ?? '' %></td>\n <td><%= b.age ?? '' %></td>\n <td><%= b.relationship ?? '' %></td>\n <td><%= b.id_number ?? '' %></td>\n <td><%= b.percentage ?? '' %></td>\n </tr>\n <% }) %>\n <% } else { %>\n <tr>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n </tr>\n <tr>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n </tr>\n <tr>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n </tr>\n <% } %>\n </tbody>\n </table>\n\n <div class=\"note\">\n <span>\u1780\u178E\u178F\u17CB\u179F\u1798\u17D2\u1782\u17B6\u179B\u17CB\u17D6 \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1797\u17B6\u1782\u179A\u1799\u1798\u17B7\u1793\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1794\u1789\u17D2\u1787\u17B6\u1780\u17CB\u1785\u17C6\u1793\u17BD\u1793\u1791\u17B9\u1780\u1794\u17D2\u179A\u17B6\u1780\u17CB\u1793\u17B9\u1784\u178F\u17D2\u179A\u17BC\u179C\u1794\u17C2\u1784\u1785\u17C2\u1780\u179F\u17D2\u1798\u17BE\u17D7\u1782\u17D2\u1793\u17B6</span>\n <span>% \u179F\u179A\u17BB\u1794\u179F\u17D2\u1798\u17BE\u179A \u17E1\u17E0\u17E0%</span>\n </div>\n\n <div class=\"section-header\">\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u1796\u17B6\u1780\u17CB\u1796\u17D0\u1793\u17D2\u1791\u1793\u17B9\u1784\u179F\u17BB\u1781\u1797\u17B6\u1796\u179A\u1794\u179F\u17CB \u17A2\u17D2\u1793\u1780\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17CB</div>\n\n <div class=\"health-q\">\n <span class=\"q-text\">1) \u1780\u1798\u17D2\u1796\u179F\u17CB:</span>\n <span class=\"underline xs\"><%= health_info?.height ?? '' %></span> \u179F.\u1798\n <span class=\"q-text\" style=\"margin-left:8px;\">\u1791\u1798\u17D2\u1784\u1793\u17CB:</span>\n <span class=\"underline xs\"><%= health_info?.weight ?? '' %></span> \u1782.\u1780\n <span class=\"q-text\" style=\"margin-left:8px;\">\u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1796\u17B7\u179F\u17B6\u179A\u1794\u17B6\u179A\u17B8\u178A\u17C2\u179A\u17AC\u1791\u17C1?:</span>\n <div class=\"cb-group\" style=\"display:inline-flex; margin-left:4px;\">\n <div class=\"cb-item\">\n <div class=\"cb-box <%= health_info?.is_smoke === false ? 'checked' : '' %>\"></div>\n <span>\u1798\u17B7\u1793\u1798\u17B6\u1793</span>\n </div>\n <div class=\"cb-item\">\n <div class=\"cb-box <%= health_info?.is_smoke === true ? 'checked' : '' %>\"></div>\n <span>\u1798\u17B6\u1793</span>\n </div>\n </div>\n <span class=\"underline xs\"><%= health_info?.smoke_detail ?? '' %></span> \u1780\u17D2\u1793\u17BB\u1784\u1798\u17BD\u1799\u179F\u1794\u17D2\u178A\u17B6\u17A0\u17CD\n </div>\n\n <div class=\"health-q\">\n <span class=\"q-text\">2) \u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1796\u17B7\u179F\u17B6\u179A\u1782\u17D2\u179A\u17BF\u1784\u179F\u17D2\u179A\u179C\u17B9\u1784\u178A\u17C2\u179A\u17AC\u1791\u17C1?:</span>\n <div class=\"cb-group\" style=\"display:inline-flex; margin-left:4px;\">\n <div class=\"cb-item\">\n <div class=\"cb-box <%= health_info?.is_drink_alcohol === false ? 'checked' : '' %>\"></div>\n <span>\u1798\u17B7\u1793\u1798\u17B6\u1793</span>\n </div>\n <div class=\"cb-item\">\n <div class=\"cb-box <%= health_info?.is_drink_alcohol === true ? 'checked' : '' %>\"></div>\n <span>\u1798\u17B6\u1793</span>\n </div>\n </div>\n <span class=\"underline xs\"><%= health_info?.drink_alcohol_detail ?? '' %></span> \u1780\u17D2\u1793\u17BB\u1784\u1798\u17BD\u1799\u179F\u1794\u17D2\u178A\u17B6\u17A0\u17CD\n </div>\n\n <div class=\"health-q\">\n <span class=\"q-text\">3) \u1780\u17D2\u1793\u17BB\u1784\u179A\u1799\u17C8\u1796\u17C1\u179B\u17E0\u17E2(\u1796\u17B8\u179A)\u1786\u17D2\u1793\u17B6\u17C6\u1785\u17BB\u1784\u1780\u17D2\u179A\u17C4\u1799\u1793\u17C1\u17C7\u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1792\u17D2\u179B\u17B6\u1794\u17CB\u1794\u17B6\u1793\u179F\u1798\u17D2\u179A\u17B6\u1780\u1780\u17D2\u1793\u17BB\u1784\u1798\u1793\u17D2\u1791\u17B8\u179A\u1796\u17C1\u1791\u17D2\u1799 \u1792\u17D2\u179B\u17B6\u1794\u17CB\u1794\u17B6\u1793\u1791\u1791\u17BD\u179B\u1780\u17B6\u179A\u179C\u17C7\u1780\u17B6\u178F\u17CB \u17AC\u1792\u17D2\u179B\u17B6\u1794\u17CB\u1791\u1791\u17BD\u179B\u1794\u17B6\u1793\u179B\u1791\u17D2\u1792\u1795\u179B\u1781\u17BB\u179F\u1794\u17D2\u179A\u1780\u17D2\u179A\u178F\u17B8\u17A2\u17C6\u1796\u17B8\u1780\u17B6\u179A\u179C\u17B7\u1797\u17B6\u1782\u1788\u17B6\u1798 \u1780\u17B6\u179A\u179C\u17B7\u1797\u17B6\u1782\u1791\u17B9\u1780\u1793\u17C4\u1798 \u1780\u17B6\u179A\u1790\u178F\u1780\u17B6\u17C6\u179A\u179F\u17D2\u1798\u17B8\u17A2\u17BB\u17B7\u1785 (X-ray) \u1798\u17C9\u17B6\u179F\u17CA\u17B8\u1793\u179C\u17B6\u179F\u17CB\u1785\u1784\u17D2\u179C\u17B6\u1780\u17CB\u1794\u17C1\u17C7\u178A\u17BC\u1784 \u17A2\u17C1\u1780\u17BC\u179F\u17B6\u179F\u17D2\u179A\u17D2\u178A\u179F\u17D2\u1780\u17C1\u1793 \u1780\u17B6\u179A\u1785\u17D2\u179A\u17B9\u1794\u179F\u17B6\u1785\u17CB\u1799\u1780\u1796\u17B7\u1793\u17B7\u178F\u17D2\u1799 \u17AC\u179B\u1791\u17D2\u1792\u1795\u179B\u179C\u17B7\u1797\u17B6\u1782\u1795\u17D2\u179F\u17C1\u1784\u17D7\u1791\u17C0\u178F\u178A\u17C2\u179B\u1798\u17B7\u1793\u1794\u17B6\u1793\u179A\u17C0\u1794\u179A\u17B6\u1794\u17CB\u1781\u17B6\u1784\u178A\u17BE\u1798\u1796\u17B8\u1782\u17D2\u179A\u17BC\u1796\u17C1\u1791\u17D2\u1799\u178A\u17C2\u179A\u17AC\u1791\u17C1?:</span>\n <div class=\"cb-group\" style=\"display:inline-flex; margin-left:4px;\">\n <div class=\"cb-item\">\n <div class=\"cb-box <%= health_info?.is_hospitalized === false ? 'checked' : '' %>\"></div>\n <span>\u1798\u17B7\u1793\u1798\u17B6\u1793</span>\n </div>\n <div class=\"cb-item\">\n <div class=\"cb-box <%= health_info?.is_hospitalized === true ? 'checked' : '' %>\"></div>\n <span>\u1798\u17B6\u1793</span>\n </div>\n </div>\n\n <% if (health_info?.is_hospitalized) { %>\n <div class=\"detail-line\"><%= health_info?.hospitalized_detail ?? '' %></div>\n <% } %>\n </div>\n\n <div class=\"page-break\"></div>\n <div class=\"page-num\">\u1791\u17C6\u1796\u17D0\u179A 2 \u1793\u17C3 2</div>\n\n <div class=\"health-q\">\n <span class=\"q-text\">4) \u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1792\u17D2\u179B\u17B6\u1794\u17CB\u1794\u17B6\u1793\u1792\u17D2\u179C\u17BE\u179A\u17C4\u1782\u179C\u17B7\u1793\u17B7\u1785\u17D2\u1786\u17D0\u1799 \u1796\u17B7\u1782\u17D2\u179A\u17C4\u17C7\u1787\u17C6\u1784\u17BA\u17AC\u1791\u1791\u17BD\u179B\u1780\u17B6\u179A\u1796\u17D2\u1799\u17B6\u1794\u17B6\u179B\u178A\u17BC\u1785\u1787\u17B6 \u179B\u17BE\u179F\u179F\u1798\u17D2\u1796\u17B6\u1792\u1788\u17B6\u1798 \u1791\u17B9\u1780\u1793\u17C4\u1798\u1795\u17D2\u17A2\u17C2\u1798 \u1787\u17C6\u1784\u17BA\u1794\u17C1\u17C7\u178A\u17BC\u1784 \u1785\u17BB\u1780\u1791\u17D2\u179A\u17BC\u1784 \u1787\u17C6\u1784\u17BA\u179F\u17BD\u178F \u1787\u17C6\u1784\u17BA\u1790\u17D2\u179B\u17BE\u1798 \u1787\u17C6\u1784\u17BA\u178F\u1798\u17D2\u179A\u1784\u1793\u17C4\u1798 \u1798\u17A0\u17B6\u179A\u17B8\u1780 \u1787\u17C6\u1784\u17BA\u178A\u17B6\u1785\u17CB\u179F\u179F\u17C3\u1788\u17B6\u1798\u1781\u17BD\u179A\u1780\u17D2\u1794\u17B6\u179B \u1787\u17C6\u1784\u17BA\u17A2\u17C1\u178A\u179F\u17CD \u1787\u17C6\u1784\u17BA\u1795\u17D2\u179B\u17BC\u179C\u1785\u17B7\u178F\u17D2\u178F \u1796\u17B7\u1780\u17B6\u179A\u1797\u17B6\u1796 \u17AC\u179A\u17B6\u1784\u1780\u17B6\u1799\u1798\u17B7\u1793\u1794\u17D2\u179A\u1780\u17D2\u179A\u178F\u17B8 \u1794\u17D2\u179A\u17BE\u1794\u17D2\u179A\u17B6\u179F\u17CB\u1790\u17D2\u1793\u17B6\u17C6\u1789\u17C0\u1793 \u17AC\u1789\u17C0\u1793\u179F\u17D2\u179A\u17B6 \u17AC\u1787\u17C6\u1784\u17BA\u1795\u17D2\u179F\u17C1\u1784\u1791\u17C0\u178F\u178A\u17C2\u179B\u1798\u17B7\u1793\u1794\u17B6\u1793\u179A\u17C0\u1794\u179A\u17B6\u1794\u17CB\u1781\u17B6\u1784\u179B\u17BE\u178A\u17C2\u179A\u17AC\u1791\u17C1?</span>\n <div class=\"cb-group\" style=\"display:inline-flex; margin-left:4px;\">\n <div class=\"cb-item\">\n <div class=\"cb-box <%= health_info?.is_diagnosed === false ? 'checked' : '' %>\"></div>\n <span>\u1798\u17B7\u1793\u1798\u17B6\u1793</span>\n </div>\n <div class=\"cb-item\">\n <div class=\"cb-box <%= health_info?.is_diagnosed === true ? 'checked' : '' %>\"></div>\n <span>\u1798\u17B6\u1793</span>\n </div>\n </div>\n\n <% if (health_info?.is_diagnosed) { %>\n <div style=\"margin-top:4px; font-size:8pt;\">\u1794\u17BE\u1798\u17B6\u1793\u179F\u17BC\u1798\u1794\u1789\u17D2\u1787\u17B6\u1780\u17CB\u179B\u1798\u17D2\u17A2\u17B7\u178F\u1781\u17B6\u1784\u1780\u17D2\u179A\u17C4\u1798\u17D6</div>\n <div class=\"detail-line\"><%= health_info?.diagnosed_detail ?? '' %></div>\n <% } %>\n </div>\n\n <div class=\"section-header\">\u179F\u17C1\u1785\u1780\u17D2\u178A\u17B8\u1794\u17D2\u179A\u1780\u17B6\u179F\u179A\u1794\u179F\u17CB\u17A2\u17D2\u1793\u1780\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17CB</div>\n\n <div class=\"declaration\">\n <p>1) \u1781\u17D2\u1789\u17BB\u17C6\u17A2\u1793\u17BB\u1789\u17D2\u1789\u17B6\u178F \u1793\u17B7\u1784\u1799\u179B\u17CB\u1796\u17D2\u179A\u1798\u17B2\u17D2\u1799\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u1794\u17D2\u179A\u17BE\u1794\u17D2\u179A\u17B6\u179F\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793 \u1793\u17B7\u1784\u1791\u17B7\u1793\u17D2\u1793\u1793\u17D0\u1799\u1791\u17B6\u17C6\u1784\u179F\u17D2\u179A\u17BB\u1784\u178A\u17C2\u179B\u1781\u17D2\u1789\u17BB\u17C6\u1794\u17B6\u1793\u1795\u17D2\u178A\u179B\u17CB\u1793\u17C5\u1780\u17D2\u1793\u17BB\u1784\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u179A\u1794\u179F\u17CB\u1781\u17D2\u1789\u17BB\u17C6\u1780\u17D2\u1793\u17BB\u1784\u1782\u17C4\u179B\u1794\u17C6\u178E\u1784 \u179F\u17D2\u179A\u1794\u178F\u17B6\u1798\u1785\u17D2\u1794\u17B6\u1794\u17CB \u178A\u17BC\u1785\u1787\u17B6 \u1780\u17B6\u179A\u1795\u17D2\u179F\u1796\u17D2\u179C\u1795\u17D2\u179F\u17B6\u1799\u1791\u17B8\u1795\u17D2\u179F\u17B6\u179A \u1780\u17B6\u179A\u179F\u17B7\u1780\u17D2\u179F\u17B6\u1791\u17B8\u1795\u17D2\u179F\u17B6\u179A \u1793\u17B7\u1784 \u1780\u17B6\u179A\u1794\u1798\u17D2\u179A\u17BE\u17A2\u178F\u17B7\u1790\u17B7\u1787\u1793\u178A\u17C4\u1799\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793 \u179F\u1798\u17D2\u1796\u17D0\u1793\u17D2\u1792\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793 \u17AC \u1787\u17B6\u178A\u17C3\u1782\u17BC\u1796\u17B6\u178E\u17B7\u1787\u17D2\u1787\u1780\u1798\u17D2\u1798\u179A\u1794\u179F\u17CB\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793 \u178A\u17C4\u1799\u1798\u17B7\u1793\u1785\u17B6\u17C6\u1794\u17B6\u1785\u17CB\u1798\u17B6\u1793\u1780\u17B6\u179A\u1799\u179B\u17CB\u1796\u17D2\u179A\u1798 \u1793\u17B7\u1784\u1787\u17BC\u1793\u178A\u17C6\u178E\u17B9\u1784\u1794\u1793\u17D2\u1790\u17C2\u1798\u1796\u17B8\u1781\u17D2\u1789\u17BB\u17C6\u17A1\u17BE\u1799\u17D4 \u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u1798\u17B7\u1793\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u17A2\u1793\u17BB\u1789\u17D2\u1789\u17B6\u178F\u17B2\u17D2\u1799\u1794\u1789\u17D2\u1785\u17C1\u1789\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u178E\u17B6\u1798\u17BD\u1799\u1791\u17C5\u1797\u17B6\u1782\u17B8\u1791\u17B8\u1794\u17B8\u178E\u17B6\u1798\u17BD\u1799 \u17AC\u1794\u17D2\u179A\u17BE\u1794\u17D2\u179A\u17B6\u179F\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u1793\u17C4\u17C7\u179F\u1798\u17D2\u179A\u17B6\u1794\u17CB\u1782\u17C4\u179B\u1794\u17C6\u178E\u1784\u1795\u17D2\u179F\u17C1\u1784\u1791\u17C0\u178F\u178A\u17C2\u179B\u1798\u17B7\u1793\u1791\u17B6\u1780\u17CB\u1791\u1784\u1793\u17B9\u1784\u1782\u17C4\u179B\u1794\u17C6\u178E\u1784\u1791\u17B6\u17C6\u1784\u17A1\u17B6\u1799\u1781\u17B6\u1784\u179B\u17BE\u17A1\u17BE\u1799 \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1782\u17D2\u1798\u17B6\u1793\u1780\u17B6\u179A\u1799\u179B\u17CB\u1796\u17D2\u179A\u1798\u1796\u17D2\u179A\u17C0\u1784\u1787\u17B6\u179B\u17B6\u1799\u179B\u1780\u17D2\u1781\u178E\u17CD\u17A2\u1780\u17D2\u179F\u179A\u1793\u17C4\u17C7\u17D4</p>\n <p>2) \u1781\u17D2\u1789\u17BB\u17C6\u179F\u17BC\u1798\u17A2\u17C7\u17A2\u17B6\u1784\u1790\u17B6\u1794\u17B6\u1793\u17A2\u17B6\u1793 \u1793\u17B7\u1784\u1799\u179B\u17CB\u179F\u17D2\u179A\u1794\u1793\u17BC\u179C\u1782\u17D2\u179A\u1794\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u1780\u17D2\u1793\u17BB\u1784\u17AF\u1780\u179F\u17B6\u179A\u1793\u17C1\u17C7\u17D4 \u1781\u17D2\u1789\u17BB\u17C6\u179F\u17BC\u1798\u1794\u17D2\u179A\u1780\u17B6\u179F\u1790\u17B6\u1782\u17D2\u179A\u1794\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u178A\u17C2\u179B\u1794\u17B6\u1793\u1795\u17D2\u178A\u179B\u17CB\u1793\u17C5\u1780\u17D2\u1793\u17BB\u1784\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1793\u17C1\u17C7 \u1796\u17B7\u178F\u1787\u17B6\u1798\u17B6\u1793\u1797\u17B6\u1796\u1796\u17C1\u1789\u179B\u17C1\u1789 \u1793\u17B7\u1784\u178F\u17D2\u179A\u17B9\u1798\u178F\u17D2\u179A\u17BC\u179C\u1796\u17B7\u178F\u1794\u17D2\u179A\u17B6\u1780\u178A\u1798\u17C2\u1793\u17D4</p>\n </div>\n\n <div class=\"sig-row\">\n <div class=\"sig-block\">\n <div>\u17A0\u178F\u17D2\u1790\u179B\u17C1\u1781\u17B6 \u17AC\u179F\u17D2\u1793\u17B6\u1798\u1798\u17C1\u178A\u17C3\u179A\u1794\u179F\u17CB\u17A2\u17D2\u1793\u1780\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784</div>\n <div class=\"sig-line\"></div>\n <div class=\"field-row\">\n <span class=\"label\">\u1788\u17D2\u1798\u17C4\u17C7</span>\n <span class=\"underline full\"><%= signature_info?.applicant_name ?? '' %></span>\n </div>\n <div class=\"field-row\">\n <span class=\"label\">\u1780\u17B6\u179B\u1794\u179A\u17B7\u1785\u17D2\u1786\u17C1\u1791</span>\n <span class=\"underline full\"><%= signature_info?.applicant_signature_date ?? '' %></span>\n </div>\n </div>\n <div class=\"sig-block\">\n <div>\u17A0\u178F\u17D2\u1790\u179B\u17C1\u1781\u17B6 \u17AC\u179F\u17D2\u1793\u17B6\u1798\u1798\u17C1\u178A\u17C3\u179A\u1794\u179F\u17CB\u179F\u17B6\u1780\u17D2\u179F\u17B8</div>\n <div class=\"sig-line\"></div>\n <div class=\"field-row\">\n <span class=\"label\">\u1788\u17D2\u1798\u17C4\u17C7</span>\n <span class=\"underline full\"><%= signature_info?.witness_name ?? '' %></span>\n </div>\n <div class=\"field-row\">\n <span class=\"label\">\u1780\u17B6\u179B\u1794\u179A\u17B7\u1785\u17D2\u1786\u17C1\u1791</span>\n <span class=\"underline full\"><%= signature_info?.witness_signature_date ?? '' %></span>\n </div>\n </div>\n </div>\n</body>\n</html>\n";
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