plac-micro-common 1.3.16 → 1.3.17
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.
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export declare const SIO_FORM_KH_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 <link rel=\"preconnect\" href=\"https://fonts.googleapis.com\">\n <link rel=\"preconnect\" href=\"https://fonts.gstatic.com\" crossorigin>\n <link href=\"https://fonts.googleapis.com/css2?family=Hanuman:wght@100..900&family=Moul&display=swap\" rel=\"stylesheet\">\n <style>\n body {\n font-family: \"Hanuman\", system-ui, sans-serif;\n font-size: 14px;\n line-height: 1.4;\n margin: 1rem;\n /* Reduced from 2rem */\n background: #fff;\n color: #000;\n }\n\n .space {\n width: 8px;\n }\n\n /* margin */\n .ml-4 {margin-left: 1rem; }\n .ml-8 {margin-left: 2rem; }\n\n .mr-4 {margin-right: 1rem; }\n .mr-8 {margin-right: 2rem; }\n\n .mt-4 {margin-top: 1rem; }\n .mt-8 {margin-top: 2rem; }\n\n .mb-4 {margin-bottom: 1rem; }\n .mb-8 {margin-bottom: 2rem; }\n\n /* alignment */\n .align-left { justify-content: flex-start !important; text-align: left; padding-left: 16px; }\n .align-right { justify-content: flex-end !important; text-align: right; padding-right: 16px; }\n .align-center { justify-content: center !important; text-align: center; }\n\n .space-height {\n height: 60px;\n align-items: center;\n }\n\n .signature-space {\n height: 100px;\n margin-top: 10px;\n }\n\n /* === Page header === */\n .page-header {\n margin-bottom: 0.5rem;\n page-break-inside: avoid;\n }\n\n .header-container {\n display: flex;\n flex-direction: column;\n align-items: center;\n }\n\n .title-logo {\n width: 125px;\n height: auto;\n }\n\n .title {\n font-weight: 700;\n font-size: 18px;\n line-height: 1;\n }\n\n .title-container {\n text-align: center;\n font-weight: 700;\n font-size: 16px;\n line-height: 1.4;\n margin: 0;\n }\n\n /* === Card Header === */\n .card-header {\n background-color: #0d6efd;\n color: white;\n text-align: center;\n padding: 0.1rem 0;\n border-radius: 6px 6px 0 0;\n font-size: 1rem;\n font-weight: bold;\n margin-bottom: 0.5rem;\n /* Reduced */\n -webkit-print-color-adjust: exact;\n print-color-adjust: exact;\n }\n\n /* === Form Text === */\n .form-container {\n display: flex;\n flex-wrap: wrap;\n margin: 0;\n padding: 0;\n gap: 0.5rem;\n }\n\n .form-item {\n display: flex;\n align-items: flex-start;\n flex-wrap: wrap;\n width: 100%;\n }\n\n .label,\n .question-label {\n word-wrap: break-word;\n white-space: normal;\n font-weight: 500;\n color: #444;\n }\n\n /* Underline for blanks */\n .underline {\n border-bottom: 1px dashed #000;\n flex: 1;\n min-width: 60px;\n min-height: 1em;\n display: inline-flex;\n align-items: center;\n justify-content: center;\n text-align: center;\n word-break: break-word;\n white-space: normal;\n -webkit-box-decoration-break: clone;\n box-decoration-break: clone;\n align-self: flex-end;\n color: #000;\n }\n\n /* size variants */\n .underline.xs { flex: none; width: 30px; min-width: unset; }\n .underline.sm { flex: none; width: 80px; min-width: unset; }\n .underline.md { flex: none; width: 180px; min-width: unset; }\n .underline.lg { flex: 2; }\n\n .underline.with-unit {\n flex: 1;\n min-width: 0;\n display: block;\n word-break: break-word;\n white-space: normal;\n border-bottom: none;\n line-height: 1.6em;\n text-align: left;\n padding-left: 4px;\n }\n\n .with-unit .value {\n display: inline;\n text-decoration: underline;\n text-decoration-style: dashed;\n text-decoration-color: #000; \n text-underline-offset: 3px; \n -webkit-box-decoration-break: clone;\n box-decoration-break: clone;\n vertical-align: baseline;\n }\n\n .unit {\n display: inline;\n white-space: nowrap;\n margin-left: 4px;\n text-decoration: none; \n }\n\n /* Checkbox labels */\n .checkbox-label {\n display: inline-flex;\n align-items: center;\n gap: 0.5rem;\n position: relative;\n cursor: pointer;\n padding-left: 0.2rem;\n user-select: none;\n }\n\n .checkbox-label::before {\n content: \"\";\n display: inline-flex;\n align-items: center;\n justify-content: center;\n width: 20px;\n height: 20px;\n border: 2px solid #555;\n border-radius: 3px;\n background-color: #fff;\n box-sizing: border-box;\n flex-shrink: 0;\n }\n\n .checkbox-label.checked::after {\n content: \"\u2714\";\n position: absolute;\n top: 50%;\n left: 0.2rem;\n width: 20px;\n height: 20px;\n display: flex;\n align-items: center;\n justify-content: center;\n font-size: 14px;\n color: #0d6efd;\n transform: translateY(-50%);\n pointer-events: none;\n }\n\n /* === Table data === */\n .table-container {\n margin: auto;\n margin-bottom: 4px;\n }\n\n table {\n width: 100%;\n border-collapse: collapse;\n }\n\n th,\n td {\n border: 1px solid #ccc;\n padding: 0;\n font-size: 14px;\n }\n\n .cell {\n min-height: 10px;\n padding: 4px 8px;\n display: flex;\n justify-content: center;\n text-align: center;\n }\n\n th {\n font-weight: 600;\n }\n\n /* === Print-specific: Footer with Page Numbers on the RIGHT === */\n @media print {\n body {\n margin: 0;\n padding-top: 10mm;\n }\n\n /* Make room for footer on the right side */\n @page {\n size: A4 portrait;\n margin: 15mm 15mm 20mm 10mm;\n /* increased right margin slightly for better spacing */\n\n @bottom-right {\n content: \"\u1791\u17C6\u1796\u17D0\u179A \" counter(page) \" \u1793\u17C3 \" counter(pages);\n font-size: 11px;\n color: #555;\n font-family: \"Battambang\", sans-serif;\n }\n }\n\n /* Increment page counter */\n body {\n counter-increment: page;\n }\n\n .page-header,\n .title-container,\n table {\n page-break-inside: avoid;\n }\n\n .card-header {\n -webkit-print-color-adjust: exact;\n print-color-adjust: exact;\n }\n }\n </style>\n </head>\n\n <body>\n <div class=\"page-header mb-8\">\n <img src=\"data:image/png;base64,<%= logo_base64 %>\" alt=\"Logo\" class=\"title-logo\" />\n <div class=\"title-container\">\n <h1 class=\"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</h1>\n <h1 class=\"title\">\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 </h1>\n </div>\n </div>\n\n <div class=\"form-container\">\n <div class=\"form-item\">\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=\"underline\">\n <%= branch_staff_app_info.branch_name %> / <%= branch_staff_app_info.branch_code %>\n </span>\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=\"underline\">\n <%= branch_staff_app_info.advisor_name %> / <%= branch_staff_app_info.advisor_code %>\n </span>\n </div>\n <div class=\"form-item\">\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=\"underline\">\n <%= branch_staff_app_info.bank_staff_name %> / <%= branch_staff_app_info.bank_staff_code %>\n </span>\n <span class=\"label\">\u179B\u17C1\u1781\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6</span>\n <span class=\"underline\">\n <%= branch_staff_app_info.application_no %>\n </span>\n </div>\n </div>\n\n <!-- Section 1 -->\n <div class=\"card-header mt-4\">\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u17A2\u17C6\u1796\u17B8\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=\"form-container\">\n <div class=\"form-item\">\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\"><%= 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\"><%= applicant_info.full_name %></span>\n </div>\n\n <div class=\"form-item\">\n <span class=\"label\">\u1797\u17C1\u1791:</span>\n <label class=\"checkbox-label <%= applicant_info.gender === 'M' ? 'checked' : '' %>\">\u1794\u17D2\u179A\u17BB\u179F</label>\n <label class=\"checkbox-label <%= applicant_info.gender === 'F' ? 'checked' : '' %>\">\u179F\u17D2\u179A\u17B8</label>\n\n <div class=\"ml-8\"></div>\n\n <div>\n <span class=\"label\">\u179F\u17D2\u1790\u17B6\u1793\u1797\u17B6\u1796\u1782\u17D2\u179A\u17BD\u179F\u17B6\u179A:</span>\n <label class=\"checkbox-label <%= applicant_info.marital_status === 'single' ? 'checked' : '' %>\">\n \u1793\u17C5\u179B\u17B8\u179C\n </label>\n <label class=\"checkbox-label <%= applicant_info.marital_status === 'married' ? 'checked' : '' %>\">\n \u179A\u17C0\u1794\u1780\u17B6\u179A\u17A0\u17BE\u1799\n </label>\n <label class=\"checkbox-label <%= applicant_info.marital_status === 'divorced' ? 'checked' : '' %>\">\n \u179B\u17C2\u1784\u179B\u17C7\n </label>\n <label class=\"checkbox-label <%= applicant_info.marital_status === 'widowed' ? 'checked' : '' %>\">\n \u1798\u17C1\u1798\u17C9\u17B6\u1799/\u1796\u17C4\u17C7\u1798\u17C9\u17B6\u1799\n </label>\n </div>\n </div>\n\n <div class=\"form-item\">\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 align-left\"><%= applicant_info.occupation %></span>\n </div>\n\n <div class=\"form-item\">\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 <label class=\"checkbox-label <%= applicant_info.identity_type === 'nid' ? 'checked' : '' %>\">\n \u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E\u1794\u178E\u17D2\u178E\n </label>\n <label class=\"checkbox-label <%= applicant_info.identity_type === 'passport' ? 'checked' : '' %>\">\n \u179B\u17B7\u1781\u17B7\u178F\u1786\u17D2\u179B\u1784\u178A\u17C2\u1793\n </label>\n <label class=\"checkbox-label <%= applicant_info.identity_type === 'birth' ? 'checked' : '' %>\">\n \u179F\u17C6\u1794\u17BB\u178F\u17D2\u179A\u1780\u17C6\u178E\u17BE\u178F\n </label>\n <label class=\"checkbox-label <%= applicant_info.identity_type === 'other' ? 'checked' : '' %>\">\n \u1795\u17D2\u179F\u17C1\u1784\u1791\u17C0\u178F:\n </label>\n\n\n <!-- other field stays separate since it has extra input -->\n <label class=\"underline\"><%= applicant_info.identity_other_description %></label>\n </div>\n\n <div class=\"form-item\">\n <span class=\"label\">\u179B\u17C1\u1781\u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E:</span>\n <span class=\"underline\"><%= 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\"><%= applicant_info.date_of_birth %></span>\n <span class=\"label\">\u17A2\u17B6\u1799\u17BB:</span>\n <span class=\"underline sm\"><%= applicant_info.age %></span>\n <span class=\"label\">\u179F\u1789\u17D2\u1785\u17B6\u178F\u17B7:</span>\n <span class=\"underline\"><%= applicant_info.nationality %></span>\n <span class=\"label\">\u179B\u17C1\u1781\u1791\u17BC\u179A\u179F\u17D0\u1796\u17D2\u1791:</span>\n <span class=\"underline\"><%= applicant_info.phone_number %></span>\n </div>\n\n <div class=\"form-item\">\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 align-left\"><%= applicant_info.current_address %></span>\n </div>\n\n\n </div>\n\n\n\n <div class=\"form-container\">\n <div class=\"form-item mt-4\">\n <span class=\"label\">\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</span>\n </div>\n <div class=\"form-item\">\n <span class=\"label\">\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\u17B6\u17A2\u17B6\u1798\u17C1\u179A\u17B7\u1780 \u17AC\n \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 </span>\n </div>\n <div class=\"form-item\">\n <label class=\"checkbox-label <%= fatca_info.is_fatca === false ? 'checked' : '' %>\">\u1798\u17B7\u1793\u1798\u17C2\u1793</label>\n <label class=\"checkbox-label <%= fatca_info.is_fatca === true ? 'checked' : '' %>\">\u1798\u17C2\u1793</label>\n <span class=\"label\">US TIN:</span>\n <span class=\"underline\"><%= 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\"><%= fatca_info.fatca_exempt_code %></span>\n </div>\n <div class=\"form-item\">\n <span class=\"label\">\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\n \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\n \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\n </span>\n </div>\n </div>\n\n\n\n <!-- Section 2 -->\n <div class=\"card-header mt-4\">\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u17A2\u17C6\u1796\u17B8\u1795\u179B\u17B7\u178F\u1795\u179B</div>\n <div class=\"table-container\">\n <table>\n <thead>\n <tr>\n <th><div class=\"cell\">\u1788\u17D2\u1798\u17C4\u17C7\u1795\u179B\u17B7\u178F\u1795\u179B \u1793\u17B7\u1784\u179A\u1799\u17C7\u1796\u17C1\u179B\u1792\u17B6\u1793\u17B6</div></th>\n <th><div class=\"cell\">\u1791\u17B9\u1780\u1794\u17D2\u179A\u17B6\u1780\u17CB\u178F\u17D2\u179A\u17BC\u179C\u1792\u17B6\u1793\u17B6(\u178A\u17BB\u179B\u17D2\u179B\u17B6\u179A\u17A2\u17B6\u1798\u17C1\u179A\u17B7\u1780)</div></th>\n <th><div class=\"cell\">\u179A\u1794\u17C0\u1794\u1794\u1784\u17CB\u1794\u17BB\u1796\u17D2\u179C\u179B\u17B6\u1797</div></th>\n <th>\n <div class=\"cell\">\u1794\u17BB\u1796\u17D2\u179C\u179B\u17B6\u1797\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17CB(\u178A\u17BB\u179B\u17D2\u179B\u17B6\u179A\u17A2\u17B6\u1798\u17C1\u179A\u17B7\u1780)</div>\n </th>\n </tr>\n </thead>\n <tbody>\n <% product_payment_info?.products?.forEach(function(product) { %>\n <tr>\n <td><div class=\"cell\"><%= product.name %> <%= product.term %></div></td>\n <td><div class=\"cell\"><%= product.sum_assured %></div></td>\n <td><div class=\"cell\"><%= product.payment_mode %></div></td>\n <td><div class=\"cell\"><%= product.premium %></div></td>\n </tr>\n <% }) %>\n </tbody>\n </table>\n </div>\n <div class=\"form-container\">\n <div class=\"form-item\">\n <span class=\"question-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 <label class=\"checkbox-label <%= product_payment_info.payment_method === 'transfer' ? 'checked' : '' %>\">\n \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\n </label>\n <label class=\"checkbox-label <%= product_payment_info.payment_method === 'partner' ? 'checked' : '' %>\">\n \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\n </label>\n </div>\n </div>\n\n <!-- Section 3 -->\n <div class=\"card-header mt-4\">\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u17A2\u17C6\u1796\u17B8\u17A2\u17D2\u1793\u1780\u1791\u1791\u17BD\u179B\u1795\u179B</div>\n <div class=\"table-container\">\n <table>\n <thead>\n <tr>\n <th><div class=\"cell\">\u1788\u17D2\u1798\u17C4\u17C7\u1796\u17C1\u1789\u179A\u1794\u179F\u17CB\u17A2\u17D2\u1793\u1780\u1791\u1791\u17BD\u179B\u1795\u179B</div></th>\n <th><div class=\"cell\">\u17A2\u17B6\u1799\u17BB</div></th>\n <th><div class=\"cell\">\u1791\u17C6\u1793\u17B6\u1780\u17CB\u1791\u17C6\u1793\u1784</div></th>\n <th><div class=\"cell\">\u179B\u17C1\u1781\u17A2\u178F\u1780\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E</div></th>\n <th><div class=\"cell\">% \u1793\u17C3\u1780\u17B6\u179A\u1794\u17C2\u1784\u1785\u17C2\u1780</div></th>\n </tr>\n </thead>\n <tbody>\n <% beneficiary_info?.forEach(function(beneficiary) { %>\n <tr>\n <td><div class=\"cell\"><%= beneficiary.full_name %></div></td>\n <td><div class=\"cell\"><%= beneficiary.age %></div></td>\n <td><div class=\"cell\"><%= beneficiary.relationship %></div></td>\n <td><div class=\"cell\"><%= beneficiary.id_number %></div></td>\n <td><div class=\"cell\"><%= beneficiary.percentage %></div></td>\n </tr>\n <% }) %>\n <tr>\n <td colspan=\"4\">\n <div class=\"cell\">\n \u1780\u178E\u178F\u17CB\u179F\u1798\u17D2\u1782\u17B6\u179B\u17CB\u17D6\n \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\n </div>\n </td>\n <td><div class=\"cell\">% \u179F\u179A\u17BB\u1794\u179F\u17D2\u1798\u17BE\u179A \u17E1\u17E0\u17E0%</div></td>\n </tr>\n </tbody>\n </table>\n </div>\n\n <!-- Section 4 -->\n <div class=\"card-header\">\n \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\n </div>\n\n <div class=\"form-container\">\n <!-- Question 1 -->\n <div class=\"form-item\">\n <span class=\"label\">1) \u1780\u1798\u17D2\u1796\u179F\u17CB:</span>\n <span class=\"underline sm\"><%= health_info.height %></span>\n <span class=\"label\">\u179F.\u1798</span>\n <div class=\"space\"></div>\n <span class=\"label\">\u1791\u1798\u17D2\u1784\u1793\u17CB:</span>\n <span class=\"underline sm\"><%= health_info.weight %></span>\n <span class=\"label\">\u1782.\u1780</span>\n <div class=\"space\"></div>\n <span class=\"question-label\">\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 <label class=\"checkbox-label <%= health_info.is_smoke === false ? 'checked' : '' %>\">\n \u1798\u17B7\u1793\u1798\u17B6\u1793\n </label>\n <label class=\"checkbox-label <%= health_info.is_smoke === true ? 'checked' : '' %>\">\n \u1798\u17B6\u1793\n </label>\n </div>\n\n <div class=\"form-item\">\n <span class=\"label\">\u1785\u17C6\u1793\u17BD\u1793\u17D6</span>\n <% if (health_info.smoke_detail) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\"><%= health_info.smoke_detail %></span>\n <span class=\"unit\">\u178A\u17BE\u1798\u1780\u17D2\u1793\u17BB\u1784\u1798\u17BD\u1799\u179F\u1794\u17D2\u178A\u17B6\u17A0\u17CD</span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n </div>\n </div>\n\n <div class=\"form-container\">\n <!-- Question 2 -->\n <div class=\"form-item\">\n <span class=\"question-label\">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 <label class=\"checkbox-label <%= health_info.is_drink_alcohol === false ? 'checked' : '' %>\">\n \u1798\u17B7\u1793\u1798\u17B6\u1793\n </label>\n <label class=\"checkbox-label <%= health_info.is_drink_alcohol === true ? 'checked' : '' %>\">\n \u1798\u17B6\u1793\n </label>\n </div>\n <div class=\"form-item\">\n <span class=\"label\">\u1785\u17C6\u1793\u17BD\u1793</span>\n <% if (health_info.drink_alcohol_detail) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\"><%= health_info.drink_alcohol_detail %></span>\n <span class=\"unit\">\u1780\u17D2\u1793\u17BB\u1784\u1798\u17BD\u1799\u1790\u17D2\u1784\u17C3</span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <span class=\"label\">\u1780\u17D2\u1793\u17BB\u1784\u1798\u17BD\u1799\u1790\u17D2\u1784\u17C3</span>\n <% } %>\n </div>\n </div>\n\n <div class=\"form-container\">\n <!-- Question 3 -->\n <span class=\"question-label\">\n 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\n \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\n \u1780\u17B6\u179A\u1790\u178F\u1780\u17B6\u17C6\u179A\u179F\u17D2\u1798\u17B8\u17A2\u17BB\u17B7\u1785 (X-ray) \u1798\u17C9\u17B6\u179F\u17BB\u17B7\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\n \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\n \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?:\n </span>\n <div class=\"form-item\">\n <label class=\"checkbox-label <%= health_info.is_hospitalized === false ? 'checked' : '' %>\">\n \u1798\u17B7\u1793\u1798\u17B6\u1793\n </label>\n <label class=\"checkbox-label <%= health_info.is_hospitalized === true ? 'checked' : '' %>\">\n \u1798\u17B6\u1793\n </label>\n </div>\n\n <div class=\"form-item\">\n <span class=\"label\">\u1794\u17BE\u1798\u17B6\u1793\u179F\u17BC\u1798\u1795\u17D2\u178A\u179B\u17CB\u1796\u17D0\u178F\u17CD\u1798\u17B6\u1793\u179B\u1798\u17D2\u17A2\u17B7\u178F\u17D6</span>\n <% if (health_info.hospitalized_detail) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\"><%= health_info.hospitalized_detail %></span>\n <span class=\"unit\">\u1780\u17D2\u1793\u17BB\u1784\u1798\u17BD\u1799\u1790\u17D2\u1784\u17C3</span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n </div>\n </div>\n\n <div class=\"form-container\">\n <!-- Question 4 -->\n <span class=\"question-label\">\n 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\n \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\n \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\n \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\n \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?\n </span>\n <div class=\"form-item\">\n <label class=\"checkbox-label <%= health_info.is_diagnosed === false ? 'checked' : '' %>\">\n \u1798\u17B7\u1793\u1798\u17B6\u1793\n </label>\n <label class=\"checkbox-label <%= health_info.is_diagnosed === true ? 'checked' : '' %>\">\n \u1798\u17B6\u1793\n </label>\n \n </div>\n <div class=\"form-item\">\n <span class=\"label\">\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</span>\n <% if (health_info.diagnosed_detail) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\"><%= health_info.diagnosed_detail %></span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n </div>\n </div>\n\n <!-- Section 5 -->\n <div class=\"card-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 <div class=\"form-container\">\n <div class=\"form-item\">\n <span class=\"label\"\n >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\n \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\n \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\n \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\n \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\n \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\n \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\n \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</span\n >\n </div>\n <div class=\"form-item\">\n <span class=\"label\">\n 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\n \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\n \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\n </span>\n </div>\n </div>\n <div class=\"table-container\">\n <table>\n <thead>\n <tr>\n <th style=\"width: 50%\">\n <div class=\"cell\">\n \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\n </div>\n <div class=\"signature-space\"></div>\n </th>\n <th style=\"width: 50%\">\n <div class=\"cell\">\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=\"signature-space\"></div>\n </th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>\n <div class=\"form-container space-height\">\n <div class=\"form-item\">\n <div class=\"space\"></div>\n <span class=\"label\">\u1788\u17D2\u1798\u17C4\u17C7</span>\n <% if (signature_info.applicant_name) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\"><%= signature_info.applicant_name %></span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n <div class=\"space\"></div> \n </div>\n </div>\n </td>\n <td>\n <div class=\"form-container space-height\">\n <div class=\"form-item\">\n <div class=\"space\"></div>\n <span class=\"label\">\u1788\u17D2\u1798\u17C4\u17C7</span>\n <% if (signature_info.witness_name) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\"><%= signature_info.witness_name %></span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n <div class=\"space\"></div> \n </div>\n </div>\n </td>\n </tr>\n <tr>\n <td>\n <div class=\"form-container space-height\">\n <div class=\"form-item\">\n <div class=\"space\"></div>\n <span class=\"label\">\u1780\u17B6\u179B\u1794\u179A\u17B7\u1785\u17D2\u1786\u17C1\u1791</span>\n <% if (signature_info.applicant_signature_date) { %>\n <span class=\"underline with-unit\" >\n <span class=\"value\"><%= signature_info.applicant_signature_date %></span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n <div class=\"space\"></div> \n </div>\n </div>\n </td>\n <td>\n <div class=\"form-container space-height\">\n <div class=\"form-item\">\n <div class=\"space\"></div>\n <span class=\"label\">\u1780\u17B6\u179B\u1794\u179A\u17B7\u1785\u17D2\u1786\u17C1\u1791</span>\n <% if (signature_info.witness_signature_date) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\"><%= signature_info.witness_signature_date %></span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n <div class=\"space\"></div> \n </div>\n </div>\n </td>\n </tr>\n </tbody>\n </table>\n </div>\n </body>\n</html>\n";
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export declare const SIO_FORM_KH_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 <link rel=\"preconnect\" href=\"https://fonts.googleapis.com\">\n <link rel=\"preconnect\" href=\"https://fonts.gstatic.com\" crossorigin>\n <link href=\"https://fonts.googleapis.com/css2?family=Hanuman:wght@100..900&family=Moul&display=swap\" rel=\"stylesheet\">\n <style>\n body {\n font-family: \"Hanuman\", system-ui, sans-serif;\n font-size: 14px;\n line-height: 1.4;\n margin: 1rem;\n /* Reduced from 2rem */\n background: #fff;\n color: #000;\n }\n\n .space {\n width: 8px;\n }\n\n /* margin */\n .ml-4 {margin-left: 1rem; }\n .ml-8 {margin-left: 2rem; }\n\n .mr-4 {margin-right: 1rem; }\n .mr-8 {margin-right: 2rem; }\n\n .mt-4 {margin-top: 1rem; }\n .mt-8 {margin-top: 2rem; }\n\n .mb-4 {margin-bottom: 1rem; }\n .mb-8 {margin-bottom: 2rem; }\n\n /* alignment */\n .align-left { justify-content: flex-start !important; text-align: left; padding-left: 16px; }\n .align-right { justify-content: flex-end !important; text-align: right; padding-right: 16px; }\n .align-center { justify-content: center !important; text-align: center; }\n\n .space-height {\n height: 60px;\n align-items: center;\n }\n\n .signature-space {\n height: 100px;\n margin-top: 10px;\n }\n\n /* === Page header === */\n .page-header {\n margin-bottom: 0.5rem;\n page-break-inside: avoid;\n }\n\n .header-container {\n display: flex;\n flex-direction: column;\n align-items: center;\n }\n\n .title-logo {\n width: 125px;\n height: auto;\n }\n\n .title {\n font-weight: 700;\n font-size: 18px;\n line-height: 1;\n }\n\n .title-container {\n text-align: center;\n font-weight: 700;\n font-size: 16px;\n line-height: 1.4;\n margin: 0;\n }\n\n /* === Card Header === */\n .card-header {\n background-color: #0d6efd;\n color: white;\n text-align: center;\n padding: 0.1rem 0;\n border-radius: 6px 6px 0 0;\n font-size: 1rem;\n font-weight: bold;\n margin-bottom: 0.5rem;\n /* Reduced */\n -webkit-print-color-adjust: exact;\n print-color-adjust: exact;\n }\n\n /* === Form Text === */\n .form-container {\n display: flex;\n flex-wrap: wrap;\n margin: 0;\n padding: 0;\n gap: 0.5rem;\n }\n\n .form-item {\n display: flex;\n align-items: flex-start;\n flex-wrap: wrap;\n width: 100%;\n }\n\n .label,\n .question-label {\n word-wrap: break-word;\n white-space: normal;\n font-weight: 500;\n color: #444;\n }\n\n /* Underline for blanks */\n .underline {\n border-bottom: 1px dashed #000;\n flex: 1;\n min-width: 60px;\n min-height: 1em;\n display: inline-flex;\n align-items: center;\n justify-content: center;\n text-align: center;\n word-break: break-word;\n white-space: normal;\n -webkit-box-decoration-break: clone;\n box-decoration-break: clone;\n align-self: flex-end;\n color: #000;\n }\n\n /* size variants */\n .underline.xs { flex: none; width: 30px; min-width: unset; }\n .underline.sm { flex: none; width: 80px; min-width: unset; }\n .underline.md { flex: none; width: 180px; min-width: unset; }\n .underline.lg { flex: 2; }\n\n .underline.with-unit {\n flex: 1;\n min-width: 0;\n display: block;\n word-break: break-word;\n white-space: normal;\n border-bottom: none;\n line-height: 1.6em;\n text-align: left;\n padding-left: 4px;\n }\n\n .with-unit .value {\n display: inline;\n text-decoration: underline;\n text-decoration-style: dashed;\n text-decoration-color: #000; \n text-underline-offset: 3px; \n -webkit-box-decoration-break: clone;\n box-decoration-break: clone;\n vertical-align: baseline;\n }\n\n .unit {\n display: inline;\n white-space: nowrap;\n margin-left: 4px;\n text-decoration: none; \n }\n\n /* Checkbox labels */\n .checkbox-label {\n display: inline-flex;\n align-items: center;\n gap: 0.5rem;\n position: relative;\n cursor: pointer;\n padding-left: 0.2rem;\n user-select: none;\n }\n\n .checkbox-label::before {\n content: \"\";\n display: inline-flex;\n align-items: center;\n justify-content: center;\n width: 20px;\n height: 20px;\n border: 2px solid #555;\n border-radius: 3px;\n background-color: #fff;\n box-sizing: border-box;\n flex-shrink: 0;\n }\n\n .checkbox-label.checked::after {\n content: \"\u2714\";\n position: absolute;\n top: 50%;\n left: 0.2rem;\n width: 20px;\n height: 20px;\n display: flex;\n align-items: center;\n justify-content: center;\n font-size: 14px;\n color: #0d6efd;\n transform: translateY(-50%);\n pointer-events: none;\n }\n\n /* === Table data === */\n .table-container {\n margin: auto;\n margin-bottom: 4px;\n }\n\n table {\n width: 100%;\n border-collapse: collapse;\n }\n\n th,\n td {\n border: 1px solid #ccc;\n padding: 0;\n font-size: 14px;\n }\n\n .cell {\n min-height: 10px;\n padding: 4px 8px;\n display: flex;\n justify-content: center;\n text-align: center;\n }\n\n th {\n font-weight: 600;\n }\n\n /* === Print-specific: Footer with Page Numbers on the RIGHT === */\n @media print {\n body {\n margin: 0;\n padding-top: 10mm;\n }\n\n /* Make room for footer on the right side */\n @page {\n size: A4 portrait;\n margin: 15mm 15mm 20mm 10mm;\n /* increased right margin slightly for better spacing */\n\n @bottom-right {\n content: \"\u1791\u17C6\u1796\u17D0\u179A \" counter(page) \" \u1793\u17C3 \" counter(pages);\n font-size: 11px;\n color: #555;\n font-family: \"Battambang\", sans-serif;\n }\n }\n\n /* Increment page counter */\n body {\n counter-increment: page;\n }\n\n .page-header,\n .title-container,\n table {\n page-break-inside: avoid;\n }\n\n .card-header {\n -webkit-print-color-adjust: exact;\n print-color-adjust: exact;\n }\n }\n </style>\n </head>\n\n <body>\n <div class=\"page-header mb-8\">\n <img src=\"data:image/png;base64,<%= logo_base64 %>\" alt=\"Logo\" class=\"title-logo\" />\n <div class=\"title-container\">\n <h1 class=\"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</h1>\n <h1 class=\"title\">\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 </h1>\n </div>\n </div>\n\n <div class=\"form-container\">\n <div class=\"form-item\">\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=\"underline\">\n <%= branch_staff_app_info.branch_name %> / <%= branch_staff_app_info.branch_code %>\n </span>\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=\"underline\">\n <%= branch_staff_app_info.advisor_name %> / <%= branch_staff_app_info.advisor_code %>\n </span>\n </div>\n <div class=\"form-item\">\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=\"underline\">\n <%= branch_staff_app_info.bank_staff_name %> / <%= branch_staff_app_info.bank_staff_code %>\n </span>\n <span class=\"label\">\u179B\u17C1\u1781\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6</span>\n <span class=\"underline\">\n <%= branch_staff_app_info.application_no %>\n </span>\n </div>\n </div>\n\n <!-- Section 1 -->\n <div class=\"card-header mt-4\">\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u17A2\u17C6\u1796\u17B8\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=\"form-container\">\n <div class=\"form-item\">\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\"><%= 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\"><%= applicant_info.full_name %></span>\n </div>\n\n <div class=\"form-item\">\n <span class=\"label\">\u1797\u17C1\u1791:</span>\n <label class=\"checkbox-label <%= applicant_info.gender === 'M' ? 'checked' : '' %>\">\u1794\u17D2\u179A\u17BB\u179F</label>\n <label class=\"checkbox-label <%= applicant_info.gender === 'F' ? 'checked' : '' %>\">\u179F\u17D2\u179A\u17B8</label>\n\n <div class=\"ml-8\"></div>\n\n <div>\n <span class=\"label\">\u179F\u17D2\u1790\u17B6\u1793\u1797\u17B6\u1796\u1782\u17D2\u179A\u17BD\u179F\u17B6\u179A:</span>\n <label class=\"checkbox-label <%= applicant_info.marital_status === 'single' ? 'checked' : '' %>\">\n \u1793\u17C5\u179B\u17B8\u179C\n </label>\n <label class=\"checkbox-label <%= applicant_info.marital_status === 'married' ? 'checked' : '' %>\">\n \u179A\u17C0\u1794\u1780\u17B6\u179A\u17A0\u17BE\u1799\n </label>\n <label class=\"checkbox-label <%= applicant_info.marital_status === 'divorced' ? 'checked' : '' %>\">\n \u179B\u17C2\u1784\u179B\u17C7\n </label>\n <label class=\"checkbox-label <%= applicant_info.marital_status === 'widowed' ? 'checked' : '' %>\">\n \u1798\u17C1\u1798\u17C9\u17B6\u1799/\u1796\u17C4\u17C7\u1798\u17C9\u17B6\u1799\n </label>\n </div>\n </div>\n\n <div class=\"form-item\">\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 align-left\"><%= applicant_info.occupation %></span>\n </div>\n\n <div class=\"form-item\">\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 <label class=\"checkbox-label <%= applicant_info.identity_type === 'nid' ? 'checked' : '' %>\">\n \u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E\u1794\u178E\u17D2\u178E\n </label>\n <label class=\"checkbox-label <%= applicant_info.identity_type === 'passport' ? 'checked' : '' %>\">\n \u179B\u17B7\u1781\u17B7\u178F\u1786\u17D2\u179B\u1784\u178A\u17C2\u1793\n </label>\n <label class=\"checkbox-label <%= applicant_info.identity_type === 'birth' ? 'checked' : '' %>\">\n \u179F\u17C6\u1794\u17BB\u178F\u17D2\u179A\u1780\u17C6\u178E\u17BE\u178F\n </label>\n <label class=\"checkbox-label <%= applicant_info.identity_type === 'other' ? 'checked' : '' %>\">\n \u1795\u17D2\u179F\u17C1\u1784\u1791\u17C0\u178F:\n </label>\n\n\n <!-- other field stays separate since it has extra input -->\n <label class=\"underline\"><%= applicant_info.identity_other_description %></label>\n </div>\n\n <div class=\"form-item\">\n <span class=\"label\">\u179B\u17C1\u1781\u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E:</span>\n <span class=\"underline\"><%= 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\"><%= 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\u1785\u17B6\u178F\u17B7:</span>\n <span class=\"underline\"><%= applicant_info.nationality %></span>\n <span class=\"label\">\u179B\u17C1\u1781\u1791\u17BC\u179A\u179F\u17D0\u1796\u17D2\u1791:</span>\n <span class=\"underline\"><%= applicant_info.phone_number %></span>\n </div>\n\n <div class=\"form-item\">\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 align-left\"><%= applicant_info.current_address %></span>\n </div>\n\n\n </div>\n\n\n\n <div class=\"form-container\">\n <div class=\"form-item mt-4\">\n <span class=\"label\">\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</span>\n </div>\n <div class=\"form-item\">\n <span class=\"label\">\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\u17B6\u17A2\u17B6\u1798\u17C1\u179A\u17B7\u1780 \u17AC\n \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 </span>\n </div>\n <div class=\"form-item\">\n <label class=\"checkbox-label <%= fatca_info.is_fatca === false ? 'checked' : '' %>\">\u1798\u17B7\u1793\u1798\u17C2\u1793</label>\n <label class=\"checkbox-label <%= fatca_info.is_fatca === true ? 'checked' : '' %>\">\u1798\u17C2\u1793</label>\n <span class=\"label\">US TIN:</span>\n <span class=\"underline\"><%= 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\"><%= fatca_info.fatca_exempt_code %></span>\n </div>\n <div class=\"form-item\">\n <span class=\"label\">\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\n \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\n \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\n </span>\n </div>\n </div>\n\n\n\n <!-- Section 2 -->\n <div class=\"card-header mt-4\">\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u17A2\u17C6\u1796\u17B8\u1795\u179B\u17B7\u178F\u1795\u179B</div>\n <div class=\"table-container\">\n <table>\n <thead>\n <tr>\n <th><div class=\"cell\">\u1788\u17D2\u1798\u17C4\u17C7\u1795\u179B\u17B7\u178F\u1795\u179B \u1793\u17B7\u1784\u179A\u1799\u17C7\u1796\u17C1\u179B\u1792\u17B6\u1793\u17B6</div></th>\n <th><div class=\"cell\">\u1791\u17B9\u1780\u1794\u17D2\u179A\u17B6\u1780\u17CB\u178F\u17D2\u179A\u17BC\u179C\u1792\u17B6\u1793\u17B6(\u178A\u17BB\u179B\u17D2\u179B\u17B6\u179A\u17A2\u17B6\u1798\u17C1\u179A\u17B7\u1780)</div></th>\n <th><div class=\"cell\">\u179A\u1794\u17C0\u1794\u1794\u1784\u17CB\u1794\u17BB\u1796\u17D2\u179C\u179B\u17B6\u1797</div></th>\n <th>\n <div class=\"cell\">\u1794\u17BB\u1796\u17D2\u179C\u179B\u17B6\u1797\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17CB(\u178A\u17BB\u179B\u17D2\u179B\u17B6\u179A\u17A2\u17B6\u1798\u17C1\u179A\u17B7\u1780)</div>\n </th>\n </tr>\n </thead>\n <tbody>\n <% product_payment_info?.products?.forEach(function(product) { %>\n <tr>\n <td><div class=\"cell\"><%= product.name %> <%= product.term %></div></td>\n <td><div class=\"cell\"><%= product.sum_assured %></div></td>\n <td><div class=\"cell\"><%= product.payment_mode %></div></td>\n <td><div class=\"cell\"><%= product.premium %></div></td>\n </tr>\n <% }) %>\n </tbody>\n </table>\n </div>\n <div class=\"form-container\">\n <div class=\"form-item\">\n <span class=\"question-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 <label class=\"checkbox-label <%= product_payment_info.payment_method === 'transfer_to_plac' ? 'checked' : '' %>\">\n \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\n </label>\n <label class=\"checkbox-label <%= product_payment_info.payment_method === 'other' ? 'checked' : '' %>\">\n \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\n </label>\n </div>\n </div>\n\n <!-- Section 3 -->\n <div class=\"card-header mt-4\">\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u17A2\u17C6\u1796\u17B8\u17A2\u17D2\u1793\u1780\u1791\u1791\u17BD\u179B\u1795\u179B</div>\n <div class=\"table-container\">\n <table>\n <thead>\n <tr>\n <th><div class=\"cell\">\u1788\u17D2\u1798\u17C4\u17C7\u1796\u17C1\u1789\u179A\u1794\u179F\u17CB\u17A2\u17D2\u1793\u1780\u1791\u1791\u17BD\u179B\u1795\u179B</div></th>\n <th><div class=\"cell\">\u17A2\u17B6\u1799\u17BB</div></th>\n <th><div class=\"cell\">\u1791\u17C6\u1793\u17B6\u1780\u17CB\u1791\u17C6\u1793\u1784</div></th>\n <th><div class=\"cell\">\u179B\u17C1\u1781\u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E</div></th>\n <th><div class=\"cell\">% \u1793\u17C3\u1780\u17B6\u179A\u1794\u17C2\u1784\u1785\u17C2\u1780</div></th>\n </tr>\n </thead>\n <tbody>\n <% beneficiary_info?.forEach(function(beneficiary) { %>\n <tr>\n <td><div class=\"cell\"><%= beneficiary.full_name %></div></td>\n <td><div class=\"cell\"><%= beneficiary.age %></div></td>\n <td><div class=\"cell\"><%= beneficiary.relationship %></div></td>\n <td><div class=\"cell\"><%= beneficiary.id_number %></div></td>\n <td><div class=\"cell\"><%= beneficiary.percentage %></div></td>\n </tr>\n <% }) %>\n <tr>\n <td colspan=\"4\">\n <div class=\"cell\">\n \u1780\u178E\u178F\u17CB\u179F\u1798\u17D2\u1782\u17B6\u179B\u17CB\u17D6\n \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\n </div>\n </td>\n <td><div class=\"cell\">% \u179F\u179A\u17BB\u1794\u179F\u17D2\u1798\u17BE\u179A \u17E1\u17E0\u17E0%</div></td>\n </tr>\n </tbody>\n </table>\n </div>\n\n <!-- Section 4 -->\n <div class=\"card-header\">\n \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\n </div>\n\n <!-- Question 1 -->\n <div class=\"form-container mt-4\">\n <div class=\"form-item\">\n <span class=\"label\">1) \u1780\u1798\u17D2\u1796\u179F\u17CB:</span>\n <span class=\"underline sm\"><%= health_info.height %></span>\n <span class=\"label\">\u179F.\u1798</span>\n <div class=\"space\"></div>\n <span class=\"label\">\u1791\u1798\u17D2\u1784\u1793\u17CB:</span>\n <span class=\"underline sm\"><%= health_info.weight %></span>\n <span class=\"label\">\u1782.\u1780</span>\n <div class=\"space\"></div>\n <span class=\"question-label\">\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 <label class=\"checkbox-label <%= health_info.is_smoke === false ? 'checked' : '' %>\">\n \u1798\u17B7\u1793\u1798\u17B6\u1793\n </label>\n <label class=\"checkbox-label <%= health_info.is_smoke === true ? 'checked' : '' %>\">\n \u1798\u17B6\u1793\n </label>\n </div>\n\n <div class=\"form-item\">\n <span class=\"label\">\u1785\u17C6\u1793\u17BD\u1793\u17D6</span>\n <% if (health_info.smoke_detail) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\"><%= health_info.smoke_detail %></span>\n <span class=\"unit\">\u178A\u17BE\u1798\u1780\u17D2\u1793\u17BB\u1784\u1798\u17BD\u1799\u179F\u1794\u17D2\u178A\u17B6\u17A0\u17CD</span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n </div>\n </div>\n\n <!-- Question 2 -->\n <div class=\"form-container mt-4\">\n <div class=\"form-item\">\n <span class=\"question-label\">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 <label class=\"checkbox-label <%= health_info.is_drink_alcohol === false ? 'checked' : '' %>\">\n \u1798\u17B7\u1793\u1798\u17B6\u1793\n </label>\n <label class=\"checkbox-label <%= health_info.is_drink_alcohol === true ? 'checked' : '' %>\">\n \u1798\u17B6\u1793\n </label>\n </div>\n <div class=\"form-item\">\n <span class=\"label\">\u1785\u17C6\u1793\u17BD\u1793</span>\n <% if (health_info.drink_alcohol_detail) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\"><%= health_info.drink_alcohol_detail %></span>\n <span class=\"unit\">\u1780\u17D2\u1793\u17BB\u1784\u1798\u17BD\u1799\u1790\u17D2\u1784\u17C3</span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <span class=\"label\">\u1780\u17D2\u1793\u17BB\u1784\u1798\u17BD\u1799\u1790\u17D2\u1784\u17C3</span>\n <% } %>\n </div>\n </div>\n\n <!-- Question 3 -->\n <div class=\"form-container mt-4\">\n <span class=\"question-label\">\n 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\n \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\n \u1780\u17B6\u179A\u1790\u178F\u1780\u17B6\u17C6\u179A\u179F\u17D2\u1798\u17B8\u17A2\u17BB\u17B7\u1785 (X-ray) \u1798\u17C9\u17B6\u179F\u17BB\u17B7\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\n \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\n \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?:\n </span>\n <div class=\"form-item\">\n <label class=\"checkbox-label <%= health_info.is_hospitalized === false ? 'checked' : '' %>\">\n \u1798\u17B7\u1793\u1798\u17B6\u1793\n </label>\n <label class=\"checkbox-label <%= health_info.is_hospitalized === true ? 'checked' : '' %>\">\n \u1798\u17B6\u1793\n </label>\n </div>\n\n <div class=\"form-item\">\n <span class=\"label\">\u1794\u17BE\u1798\u17B6\u1793\u179F\u17BC\u1798\u1795\u17D2\u178A\u179B\u17CB\u1796\u17D0\u178F\u17CD\u1798\u17B6\u1793\u179B\u1798\u17D2\u17A2\u17B7\u178F\u17D6</span>\n <% if (health_info.hospitalized_detail) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\"><%= health_info.hospitalized_detail %></span>\n <span class=\"unit\">\u1780\u17D2\u1793\u17BB\u1784\u1798\u17BD\u1799\u1790\u17D2\u1784\u17C3</span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n </div>\n </div>\n\n <!-- Question 4 -->\n <div class=\"form-container mt-4\"> \n <span class=\"question-label\">\n 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\n \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\n \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\n \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\n \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?\n </span>\n <div class=\"form-item\">\n <label class=\"checkbox-label <%= health_info.is_diagnosed === false ? 'checked' : '' %>\">\n \u1798\u17B7\u1793\u1798\u17B6\u1793\n </label>\n <label class=\"checkbox-label <%= health_info.is_diagnosed === true ? 'checked' : '' %>\">\n \u1798\u17B6\u1793\n </label>\n \n </div>\n <div class=\"form-item\">\n <span class=\"label\">\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</span>\n <% if (health_info.diagnosed_detail) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\"><%= health_info.diagnosed_detail %></span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n </div>\n </div>\n\n <!-- Section 5 -->\n <div class=\"card-header mt-8\">\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 <div class=\"form-container\">\n <div class=\"form-item\">\n <span class=\"label\"\n >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\n \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\n \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\n \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\n \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\n \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\n \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\n \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</span\n >\n </div>\n <div class=\"form-item\">\n <span class=\"label\">\n 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\n \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\n \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\n </span>\n </div>\n </div>\n <div class=\"table-container mt-4\">\n <table>\n <thead>\n <tr>\n <th style=\"width: 50%\">\n <div class=\"cell\">\n \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\n </div>\n <div class=\"signature-space\"></div>\n </th>\n <th style=\"width: 50%\">\n <div class=\"cell\">\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=\"signature-space\"></div>\n </th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>\n <div class=\"form-container space-height\">\n <div class=\"form-item\">\n <div class=\"space\"></div>\n <span class=\"label\">\u1788\u17D2\u1798\u17C4\u17C7</span>\n <% if (signature_info.applicant_name) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\"><%= signature_info.applicant_name %></span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n <div class=\"space\"></div> \n </div>\n </div>\n </td>\n <td>\n <div class=\"form-container space-height\">\n <div class=\"form-item\">\n <div class=\"space\"></div>\n <span class=\"label\">\u1788\u17D2\u1798\u17C4\u17C7</span>\n <% if (signature_info.witness_name) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\"><%= signature_info.witness_name %></span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n <div class=\"space\"></div> \n </div>\n </div>\n </td>\n </tr>\n <tr>\n <td>\n <div class=\"form-container space-height\">\n <div class=\"form-item\">\n <div class=\"space\"></div>\n <span class=\"label\">\u1780\u17B6\u179B\u1794\u179A\u17B7\u1785\u17D2\u1786\u17C1\u1791</span>\n <% if (signature_info.applicant_signature_date) { %>\n <span class=\"underline with-unit\" >\n <span class=\"value\"><%= signature_info.applicant_signature_date %></span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n <div class=\"space\"></div> \n </div>\n </div>\n </td>\n <td>\n <div class=\"form-container space-height\">\n <div class=\"form-item\">\n <div class=\"space\"></div>\n <span class=\"label\">\u1780\u17B6\u179B\u1794\u179A\u17B7\u1785\u17D2\u1786\u17C1\u1791</span>\n <% if (signature_info.witness_signature_date) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\"><%= signature_info.witness_signature_date %></span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n <div class=\"space\"></div> \n </div>\n </div>\n </td>\n </tr>\n </tbody>\n </table>\n </div>\n </body>\n</html>\n";
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@@ -389,7 +389,7 @@ exports.SIO_FORM_KH_TEMPLATE = `
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<span class="label">ថ្ងៃខែឆ្នាំកំណើត:</span>
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390
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<span class="underline"><%= applicant_info.date_of_birth %></span>
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<span class="label">អាយុ:</span>
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-
<span class="underline
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+
<span class="underline xs"><%= applicant_info.age %></span>
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<span class="label">សញ្ចាតិ:</span>
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<span class="underline"><%= applicant_info.nationality %></span>
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<span class="label">លេខទូរស័ព្ទ:</span>
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@@ -463,10 +463,10 @@ exports.SIO_FORM_KH_TEMPLATE = `
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<div class="form-container">
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<div class="form-item">
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<span class="question-label">វិធីសាស្រ្ដបង់បុព្វលាភធានារ៉ាប់រង់:</span>
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-
<label class="checkbox-label <%= product_payment_info.payment_method === '
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+
<label class="checkbox-label <%= product_payment_info.payment_method === 'transfer_to_plac' ? 'checked' : '' %>">
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467
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ការផ្ទេរប្រាក់ចូលទៅក្នុងគណនីរបស់ហ្វីលីឡាយហ្វ៍
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468
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</label>
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469
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-
<label class="checkbox-label <%= product_payment_info.payment_method === '
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469
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<label class="checkbox-label <%= product_payment_info.payment_method === 'other' ? 'checked' : '' %>">
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តាមរយះដៃគូររបស់ហ្វីលីឡាយហ្វ៍
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</label>
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</div>
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@@ -481,7 +481,7 @@ exports.SIO_FORM_KH_TEMPLATE = `
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481
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<th><div class="cell">ឈ្មោះពេញរបស់អ្នកទទួលផល</div></th>
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<th><div class="cell">អាយុ</div></th>
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<th><div class="cell">ទំនាក់ទំនង</div></th>
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484
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<th><div class="cell"
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484
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+
<th><div class="cell">លេខអត្តសញ្ញាណ</div></th>
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<th><div class="cell">% នៃការបែងចែក</div></th>
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</tr>
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</thead>
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@@ -513,8 +513,8 @@ exports.SIO_FORM_KH_TEMPLATE = `
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ព័ត៌មានពាក់ព័ន្ទនឹងសុខភាពរបស់ អ្នកស្នើសុំបណ្ណសន្យារ៉ាប់រង់
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</div>
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-
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-
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+
<!-- Question 1 -->
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517
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<div class="form-container mt-4">
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<div class="form-item">
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519
519
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<span class="label">1) កម្ពស់:</span>
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520
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<span class="underline sm"><%= health_info.height %></span>
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@@ -546,8 +546,8 @@ exports.SIO_FORM_KH_TEMPLATE = `
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546
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</div>
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</div>
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548
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549
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-
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550
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-
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549
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+
<!-- Question 2 -->
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550
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+
<div class="form-container mt-4">
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<div class="form-item">
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<span class="question-label">2) តើលោកអ្នកពិសារគ្រឿងស្រវឹងដែរឬទេ?:</span>
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<label class="checkbox-label <%= health_info.is_drink_alcohol === false ? 'checked' : '' %>">
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@@ -571,8 +571,8 @@ exports.SIO_FORM_KH_TEMPLATE = `
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</div>
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</div>
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-
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-
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+
<!-- Question 3 -->
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575
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+
<div class="form-container mt-4">
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<span class="question-label">
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3) ក្នុងរយៈពេល០២(ពីរ)ឆ្នាំចុងក្រោយនេះតើលោកអ្នកធ្លាប់បានសម្រាកក្នុងមន្ទីរពេទ្យធ្លាប់បានទទួលការវះកាត់
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578
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ឬធ្លាប់ទទួលបានលទ្ធផលខុសប្រក្រតីអំពី ការវិភាគឈាម ការវិភាគទឹកនោម
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@@ -602,8 +602,8 @@ exports.SIO_FORM_KH_TEMPLATE = `
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</div>
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</div>
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604
604
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605
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-
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606
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-
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605
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+
<!-- Question 4 -->
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606
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+
<div class="form-container mt-4">
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607
607
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<span class="question-label">
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608
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4) តើលោកអ្នកធ្លាប់បានធ្វើរោគវិនិច្ឆ័យ ពិគ្រោះជំងឺ ឬទទួលការព្យាបាលដូចជា
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609
609
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លើសសម្ពាធឈាម ទឹកនោមផ្អែម ជំងឺបេះដូង ចុកទ្រូង ជំងឺសួត ជំងឺថ្លើម
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|
@@ -633,7 +633,7 @@ exports.SIO_FORM_KH_TEMPLATE = `
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</div>
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634
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635
635
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<!-- Section 5 -->
|
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636
|
-
<div class="card-header">សេចក្ដីប្រកាសរបស់អ្នកស្នើសុំធានារ៉ាប់រង់</div>
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636
|
+
<div class="card-header mt-8">សេចក្ដីប្រកាសរបស់អ្នកស្នើសុំធានារ៉ាប់រង់</div>
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637
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<div class="form-container">
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638
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|
<div class="form-item">
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639
639
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<span class="label"
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|
@@ -655,7 +655,7 @@ exports.SIO_FORM_KH_TEMPLATE = `
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</span>
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656
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</div>
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657
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|
</div>
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658
|
-
<div class="table-container">
|
|
658
|
+
<div class="table-container mt-4">
|
|
659
659
|
<table>
|
|
660
660
|
<thead>
|
|
661
661
|
<tr>
|
|
@@ -1,7 +1,7 @@
|
|
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1
1
|
export type SIOGender = "M" | "F";
|
|
2
2
|
export type SIOMaritalStatus = "single" | "married" | "divorced" | "widowed";
|
|
3
3
|
export type SIOIdentityType = "nid" | "passport" | "birth" | "other";
|
|
4
|
-
export type SIOPaymentMethodType = "
|
|
4
|
+
export type SIOPaymentMethodType = "transfer_to_plac" | "other";
|
|
5
5
|
export interface ISIOBranchStaffAppInfo {
|
|
6
6
|
branch_name: string;
|
|
7
7
|
branch_code: string;
|