plac-micro-common 1.3.19 → 1.3.21

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Files changed (11) hide show
  1. package/dist/libs/pdf-form/templates/sio-form-en.template.d.ts +1 -1
  2. package/dist/libs/pdf-form/templates/sio-form-en.template.js +688 -527
  3. package/dist/types/general.type.d.ts +1 -0
  4. package/dist/types/general.type.js +1 -0
  5. package/dist/types/index.d.ts +1 -0
  6. package/dist/types/index.js +1 -0
  7. package/dist/types/pdf-form/index.d.ts +1 -2
  8. package/dist/types/pdf-form/index.js +0 -1
  9. package/dist/types/underwriting.type.d.ts +6 -0
  10. package/dist/types/underwriting.type.js +10 -0
  11. package/package.json +1 -1
package/dist/libs/pdf-form/templates/sio-form-en.template.js CHANGED
@@ -2,570 +2,731 @@
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  Object.defineProperty(exports, "__esModule", { value: true });
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  exports.SIO_FORM_EN_TEMPLATE = void 0;
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  exports.SIO_FORM_EN_TEMPLATE = `
5
- <!DOCTYPE html>
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- <html lang="km">
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- <head>
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- <meta charset="UTF-8" />
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- <meta name="viewport" content="width=device-width, initial-scale=1.0" />
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- <title>ពាក្យស្នើសុំធានារ៉ាប់រងអាយុជីវិត</title>
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- <style>
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- @font-face {
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- font-family: 'Khmer OS';
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- src: url('data:font/truetype;base64,<%= font_base64 %>') format('truetype');
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- font-weight: normal;
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- font-style: normal;
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- }
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-
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- *, *::before, *::after { box-sizing: border-box; margin: 0; padding: 0; }
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-
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- body {
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- font-family: 'Khmer OS', sans-serif;
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- font-size: 9pt;
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- color: #1a1a1a;
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- background: #fff;
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- padding: 14mm 12mm;
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- line-height: 1.5;
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- -webkit-print-color-adjust: exact;
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- print-color-adjust: exact;
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- }
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-
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- .logo {
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- color: #005bac;
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- font-size: 13pt;
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- font-weight: bold;
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- letter-spacing: 0.5px;
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- margin-bottom: 4px;
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- }
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-
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- .form-title {
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- text-align: center;
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- font-size: 11pt;
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- font-weight: bold;
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- margin-bottom: 10px;
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- line-height: 1.6;
46
- }
47
-
48
- .meta-grid {
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- display: grid;
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- grid-template-columns: 1fr 1fr;
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- gap: 4px 16px;
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- margin-bottom: 8px;
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- }
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-
55
- .meta-row {
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- display: flex;
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- align-items: center;
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- gap: 4px;
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- border-bottom: 1px solid #333;
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- padding-bottom: 2px;
61
- font-size: 8.5pt;
62
- }
63
-
64
- .meta-row span.label { white-space: nowrap; }
65
- .meta-row span.value { flex: 1; min-width: 0; }
66
-
67
- .section-header {
68
- background-color: #005bac;
69
- color: #fff;
70
- text-align: center;
71
- font-weight: bold;
72
- font-size: 9pt;
73
- padding: 4px 8px;
74
- margin: 8px 0 6px;
75
- }
76
-
77
- .field-row {
78
- display: flex;
79
- align-items: center;
80
- flex-wrap: wrap;
81
- gap: 4px 10px;
82
- margin-bottom: 5px;
83
- font-size: 8.5pt;
84
- }
85
-
86
- .field-row .label { white-space: nowrap; }
87
-
88
- .underline {
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- border-bottom: 1px solid #333;
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- min-width: 60px;
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- display: inline-block;
92
- padding-bottom: 1px;
93
- }
94
-
95
- .underline.lg { min-width: 140px; }
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- .underline.md { min-width: 90px; }
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- .underline.sm { min-width: 50px; }
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- .underline.xs { min-width: 30px; }
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- .underline.full { flex: 1; min-width: 120px; }
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-
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- .cb-group { display: flex; align-items: center; gap: 12px; flex-wrap: wrap; }
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-
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- .cb-item {
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- display: flex;
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- align-items: center;
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- gap: 4px;
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- white-space: nowrap;
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- }
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-
110
- .cb-box {
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- width: 11px;
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- height: 11px;
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- border: 1.2px solid #333;
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- display: inline-flex;
115
- align-items: center;
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- justify-content: center;
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- font-size: 8pt;
118
- flex-shrink: 0;
119
- }
120
-
121
- .cb-box.checked::after { content: '✔'; color: #005bac; }
122
-
123
- table {
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- width: 100%;
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- border-collapse: collapse;
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- font-size: 8.5pt;
127
- margin-bottom: 6px;
128
- }
129
-
130
- th {
131
- background-color: #dce9f7;
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- border: 1px solid #aac4e0;
133
- padding: 4px 6px;
134
- text-align: center;
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- font-weight: bold;
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- }
137
-
138
- td {
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- border: 1px solid #aac4e0;
140
- padding: 4px 6px;
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- text-align: center;
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- min-height: 20px;
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- }
144
-
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- .td-empty { height: 20px; }
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-
147
- .note {
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- font-size: 8pt;
149
- display: flex;
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- justify-content: space-between;
151
- align-items: center;
152
- margin-top: 2px;
153
- }
154
-
155
- .health-q {
156
- font-size: 8.5pt;
157
- margin-bottom: 6px;
158
- line-height: 1.6;
159
- }
160
-
161
- .health-q .q-text { display: inline; }
162
-
163
- .detail-line {
164
- border-bottom: 1px solid #333;
165
- min-height: 14px;
166
- margin-top: 3px;
167
- width: 100%;
168
- }
169
-
170
- .declaration {
171
- font-size: 8pt;
172
- line-height: 1.6;
173
- margin-bottom: 6px;
174
- }
175
-
176
- .declaration p { margin-bottom: 5px; }
177
-
178
- .sig-row {
179
- display: grid;
180
- grid-template-columns: 1fr 1fr;
181
- gap: 16px;
182
- margin-top: 10px;
183
- font-size: 8.5pt;
184
- }
185
-
186
- .sig-block { display: flex; flex-direction: column; gap: 6px; }
187
-
188
- .sig-line {
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- border-bottom: 1px solid #333;
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- min-height: 36px;
191
- margin-bottom: 4px;
192
- }
193
-
194
- .page-num {
195
- text-align: right;
196
- font-size: 7.5pt;
197
- color: #555;
198
- margin-bottom: 4px;
199
- }
200
-
201
- .page-break { page-break-before: always; }
202
- </style>
203
- </head>
204
- <body>
205
- <div class="page-num">ទំព័រ 1 នៃ 2</div>
206
-
207
- <div class="logo">PhillipLife</div>
208
-
209
- <div class="form-title">
210
- ពាក្យស្នើសុំធានារ៉ាប់រងអាយុជីវិត<br/>
211
- សម្រាប់ទម្រង់សាមញ្ញសម្រាប់អតិថិជនជោគជ័យហ្វាយនែន (SIO)
212
- </div>
213
-
214
- <div class="meta-grid">
215
- <div class="meta-row">
216
- <span class="label">ឈ្មោះនិងលេខកូដសាខា</span>
217
- <span class="value underline full">
218
- <%= branch_staff_app_info?.branch_name ?? '' %> / <%= branch_staff_app_info?.branch_code ?? '' %>
219
- </span>
220
- </div>
221
- <div class="meta-row">
222
- <span class="label">ឈ្មោះនិងលេខកូដបុគ្គលិកធានារ៉ាប់រង់</span>
223
- <span class="value underline full">
224
- <%= branch_staff_app_info?.advisor_name ?? '' %> / <%= branch_staff_app_info?.advisor_code ?? '' %>
225
- </span>
226
- </div>
227
- <div class="meta-row">
228
- <span class="label">ឈ្មោះនិងលេខកូដបុគ្គលិកធនាគារ</span>
229
- <span class="value underline full">
230
- <%= branch_staff_app_info?.bank_staff_name ?? '' %> / <%= branch_staff_app_info?.bank_staff_code ?? '' %>
231
- </span>
232
- </div>
233
- <div class="meta-row">
234
- <span class="label">លេខពាក្យស្នើសុំ</span>
235
- <span class="value underline full"><%= branch_staff_app_info?.application_no ?? '' %></span>
5
+ <!doctype html>
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+ <html lang="en">
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+ <head>
8
+ <meta charset="UTF-8" />
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+ <meta name="viewport" content="width=device-width, initial-scale=1.0" />
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+ <title>SIO Insurance Application Form</title>
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+ <link rel="preconnect" href="https://fonts.googleapis.com">
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+ <link rel="preconnect" href="https://fonts.gstatic.com" crossorigin>
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+ <link href="https://fonts.googleapis.com/css2?family=Hanuman:wght@100..900&family=Moul&display=swap" rel="stylesheet">
14
+ <style>
15
+ body {
16
+ font-family: "Hanuman", system-ui, sans-serif;
17
+ font-size: 14px;
18
+ line-height: 1.4;
19
+ margin: 1rem;
20
+ /* Reduced from 2rem */
21
+ background: #fff;
22
+ color: #000;
23
+ }
24
+
25
+ .space {
26
+ width: 8px;
27
+ }
28
+
29
+ /* margin */
30
+ .ml-4 {margin-left: 1rem; }
31
+ .ml-8 {margin-left: 2rem; }
32
+
33
+ .mr-4 {margin-right: 1rem; }
34
+ .mr-8 {margin-right: 2rem; }
35
+
36
+ .mt-4 {margin-top: 1rem; }
37
+ .mt-8 {margin-top: 2rem; }
38
+
39
+ .mb-4 {margin-bottom: 1rem; }
40
+ .mb-8 {margin-bottom: 2rem; }
41
+
42
+ /* alignment */
43
+ .align-left { justify-content: flex-start !important; text-align: left; padding-left: 16px; }
44
+ .align-right { justify-content: flex-end !important; text-align: right; padding-right: 16px; }
45
+ .align-center { justify-content: center !important; text-align: center; }
46
+
47
+ .space-height {
48
+ height: 60px;
49
+ align-items: center;
50
+ }
51
+
52
+ .signature-space {
53
+ height: 100px;
54
+ margin-top: 10px;
55
+ }
56
+
57
+ /* === Page header === */
58
+ .page-header {
59
+ margin-bottom: 0.5rem;
60
+ page-break-inside: avoid;
61
+ }
62
+
63
+ .header-container {
64
+ display: flex;
65
+ flex-direction: column;
66
+ align-items: center;
67
+ }
68
+
69
+ .title-logo {
70
+ width: 125px;
71
+ height: auto;
72
+ }
73
+
74
+ .title {
75
+ font-weight: 700;
76
+ font-size: 18px;
77
+ line-height: 1;
78
+ }
79
+
80
+ .title-container {
81
+ text-align: center;
82
+ font-weight: 700;
83
+ font-size: 16px;
84
+ line-height: 1.4;
85
+ margin: 0;
86
+ }
87
+
88
+ /* === Card Header === */
89
+ .card-header {
90
+ background-color: #0d6efd;
91
+ color: white;
92
+ text-align: center;
93
+ padding: 0.1rem 0;
94
+ border-radius: 6px 6px 0 0;
95
+ font-size: 1rem;
96
+ font-weight: bold;
97
+ margin-bottom: 0.5rem;
98
+ /* Reduced */
99
+ -webkit-print-color-adjust: exact;
100
+ print-color-adjust: exact;
101
+ }
102
+
103
+ /* === Form Text === */
104
+ .form-container {
105
+ display: flex;
106
+ flex-wrap: wrap;
107
+ margin: 0;
108
+ padding: 0;
109
+ gap: 0.5rem;
110
+ }
111
+
112
+ .form-item {
113
+ display: flex;
114
+ align-items: flex-start;
115
+ flex-wrap: wrap;
116
+ width: 100%;
117
+ }
118
+
119
+ .label,
120
+ .question-label {
121
+ word-wrap: break-word;
122
+ white-space: normal;
123
+ font-weight: 500;
124
+ color: #444;
125
+ }
126
+
127
+ /* Underline for blanks */
128
+ .underline {
129
+ border-bottom: 1px dashed #000;
130
+ flex: 1;
131
+ min-width: 60px;
132
+ min-height: 1em;
133
+ display: inline-flex;
134
+ align-items: center;
135
+ justify-content: center;
136
+ text-align: center;
137
+ word-break: break-word;
138
+ white-space: normal;
139
+ -webkit-box-decoration-break: clone;
140
+ box-decoration-break: clone;
141
+ align-self: flex-end;
142
+ color: #000;
143
+ }
144
+
145
+ /* size variants */
146
+ .underline.xs { flex: none; width: 30px; min-width: unset; }
147
+ .underline.sm { flex: none; width: 80px; min-width: unset; }
148
+ .underline.md { flex: none; width: 180px; min-width: unset; }
149
+ .underline.lg { flex: 2; }
150
+
151
+ .underline.with-unit {
152
+ flex: 1;
153
+ min-width: 0;
154
+ display: block;
155
+ word-break: break-word;
156
+ white-space: normal;
157
+ border-bottom: none;
158
+ line-height: 1.6em;
159
+ text-align: left;
160
+ padding-left: 4px;
161
+ }
162
+
163
+ .with-unit .value {
164
+ display: inline;
165
+ text-decoration: underline;
166
+ text-decoration-style: dashed;
167
+ text-decoration-color: #000;
168
+ text-underline-offset: 3px;
169
+ -webkit-box-decoration-break: clone;
170
+ box-decoration-break: clone;
171
+ vertical-align: baseline;
172
+ }
173
+
174
+ .unit {
175
+ display: inline;
176
+ white-space: nowrap;
177
+ margin-left: 4px;
178
+ text-decoration: none;
179
+ }
180
+
181
+ /* Checkbox labels */
182
+ .checkbox-label {
183
+ display: inline-flex;
184
+ align-items: center;
185
+ gap: 0.5rem;
186
+ position: relative;
187
+ cursor: pointer;
188
+ padding-left: 0.2rem;
189
+ user-select: none;
190
+ }
191
+
192
+ .checkbox-label::before {
193
+ content: "";
194
+ display: inline-flex;
195
+ align-items: center;
196
+ justify-content: center;
197
+ width: 20px;
198
+ height: 20px;
199
+ border: 2px solid #555;
200
+ border-radius: 3px;
201
+ background-color: #fff;
202
+ box-sizing: border-box;
203
+ flex-shrink: 0;
204
+ }
205
+
206
+ .checkbox-label.checked::after {
207
+ content: "✔";
208
+ position: absolute;
209
+ top: 50%;
210
+ left: 0.2rem;
211
+ width: 20px;
212
+ height: 20px;
213
+ display: flex;
214
+ align-items: center;
215
+ justify-content: center;
216
+ font-size: 14px;
217
+ color: #0d6efd;
218
+ transform: translateY(-50%);
219
+ pointer-events: none;
220
+ }
221
+
222
+ .page-break {
223
+ page-break-before: always;
224
+ }
225
+
226
+ /* === Table data === */
227
+ .table-container {
228
+ margin: auto;
229
+ margin-bottom: 4px;
230
+ }
231
+
232
+ table {
233
+ width: 100%;
234
+ border-collapse: collapse;
235
+ }
236
+
237
+ th,
238
+ td {
239
+ border: 1px solid #ccc;
240
+ padding: 0;
241
+ font-size: 14px;
242
+ }
243
+
244
+ .cell {
245
+ min-height: 10px;
246
+ padding: 4px 8px;
247
+ display: flex;
248
+ justify-content: center;
249
+ text-align: center;
250
+ }
251
+
252
+ th {
253
+ font-weight: 600;
254
+ }
255
+
256
+ /* === Print-specific: Footer with Page Numbers on the RIGHT === */
257
+ @media print {
258
+ body {
259
+ margin: 0;
260
+ padding-top: 10mm;
261
+ }
262
+
263
+ /* Make room for footer on the right side */
264
+ @page {
265
+ size: A4 portrait;
266
+ margin: 15mm 15mm 20mm 10mm;
267
+ /* increased right margin slightly for better spacing */
268
+
269
+ @bottom-right {
270
+ content: "ទំព័រ " counter(page) " នៃ " counter(pages);
271
+ font-size: 11px;
272
+ color: #555;
273
+ font-family: "Battambang", sans-serif;
274
+ }
275
+ }
276
+
277
+ /* Increment page counter */
278
+ body {
279
+ counter-increment: page;
280
+ }
281
+
282
+ .page-header,
283
+ .title-container,
284
+ table {
285
+ page-break-inside: avoid;
286
+ }
287
+
288
+ .card-header {
289
+ -webkit-print-color-adjust: exact;
290
+ print-color-adjust: exact;
291
+ }
292
+ }
293
+ </style>
294
+ </head>
295
+
296
+ <body>
297
+ <div class="page-header mb-8">
298
+ <img src="data:image/png;base64,<%= logo_base64 %>" alt="Logo" class="title-logo" />
299
+ <div class="title-container">
300
+ <h1 class="title">LIFE ASSURANCE APPLICATION FORM</h1>
301
+ <h1 class="title">
302
+ SIMPLIFY FORM FOR CHOKCHEY FINANCE PLC (SIO)
303
+ </h1>
304
+ </div>
236
305
  </div>
237
- </div>
238
-
239
- <div class="section-header">ព័ត៌មានអំពីអ្នកស្នើសុំពណ្ណសន្យារ៉ាប់រង់</div>
240
-
241
- <div class="field-row">
242
- <span class="label">ឈ្មោះពេញដូចបង្ហាញនៅក្នុងឯកសារអត្តសញ្ញាណ ជាភាសាខ្មែរ:</span>
243
- <span class="underline lg"><%= applicant_info?.full_name_kh ?? '' %></span>
244
- <span class="label">ជាភាសាអង់គ្លេស</span>
245
- <span class="underline lg"><%= applicant_info?.full_name ?? '' %></span>
246
- <span class="label">ភេទ:</span>
247
- <div class="cb-group">
248
- <div class="cb-item">
249
- <div class="cb-box <%= applicant_info?.gender === 'M' ? 'checked' : '' %>"></div>
250
- <span>ប្រុស</span>
306
+
307
+ <div class="form-container">
308
+ <div class="form-item">
309
+ <span class="label">Branch Name and Code:</span>
310
+ <span class="underline">
311
+ <%= branch_staff_app_info.branch_name %> / <%= branch_staff_app_info.branch_code %>
312
+ </span>
313
+ <span class="label">Advisor's Name and Code:</span>
314
+ <span class="underline">
315
+ <%= branch_staff_app_info.advisor_name %> / <%= branch_staff_app_info.advisor_code %>
316
+ </span>
251
317
  </div>
252
- <div class="cb-item">
253
- <div class="cb-box <%= applicant_info?.gender === 'F' ? 'checked' : '' %>"></div>
254
- <span>ស្រី</span>
318
+ <div class="form-item">
319
+ <span class="label">Bank staff's name and code:</span>
320
+ <span class="underline">
321
+ <%= branch_staff_app_info.bank_staff_name %> / <%= branch_staff_app_info.bank_staff_code %>
322
+ </span>
323
+ <span class="label">Application Number:</span>
324
+ <span class="underline">
325
+ <%= branch_staff_app_info.application_no %>
326
+ </span>
255
327
  </div>
256
328
  </div>
257
- </div>
258
-
259
- <div class="field-row">
260
- <span class="label">ស្ថានភាពគ្រួសារ:</span>
261
- <div class="cb-group">
262
- <div class="cb-item">
263
- <div class="cb-box <%= applicant_info?.marital_status === 'single' ? 'checked' : '' %>"></div>
264
- <span>នៅលីវ</span>
329
+
330
+ <!-- Section 1 -->
331
+ <div class="card-header mt-4">INFORMATION ABOUT THE APPLICANT</div>
332
+
333
+ <div class="form-container">
334
+ <div class="form-item">
335
+ <span class="label">Full Name as shown in identity documents: in KH Language:</span>
336
+ <span class="underline"><%= applicant_info.full_name_kh %></span>
337
+ <span class="label">EN Language:</span>
338
+ <span class="underline"><%= applicant_info.full_name %></span>
265
339
  </div>
266
- <div class="cb-item">
267
- <div class="cb-box <%= applicant_info?.marital_status === 'married' ? 'checked' : '' %>"></div>
268
- <span>រៀបការ</span>
340
+
341
+ <div class="form-item">
342
+ <span class="label">Gender:</span>
343
+ <label class="checkbox-label <%= applicant_info.gender === 'M' ? 'checked' : '' %>">M</label>
344
+ <label class="checkbox-label <%= applicant_info.gender === 'F' ? 'checked' : '' %>">F</label>
345
+
346
+ <div class="ml-8"></div>
347
+
348
+ <div>
349
+ <span class="label">Marital Status:</span>
350
+ <label class="checkbox-label <%= applicant_info.marital_status === 'single' ? 'checked' : '' %>">
351
+ Single
352
+ </label>
353
+ <label class="checkbox-label <%= applicant_info.marital_status === 'married' ? 'checked' : '' %>">
354
+ Married
355
+ </label>
356
+ <label class="checkbox-label <%= applicant_info.marital_status === 'divorced' ? 'checked' : '' %>">
357
+ Divorced
358
+ </label>
359
+ <label class="checkbox-label <%= applicant_info.marital_status === 'widowed' ? 'checked' : '' %>">
360
+ Widowed
361
+ </label>
362
+ </div>
269
363
  </div>
270
- <div class="cb-item">
271
- <div class="cb-box <%= applicant_info?.marital_status === 'divorced' ? 'checked' : '' %>"></div>
272
- <span>លែងលះ</span>
364
+
365
+ <div class="form-item">
366
+ <span class="label">Job Title and Nature of Work:</span>
367
+ <span class="underline align-left"><%= applicant_info.occupation %></span>
273
368
  </div>
274
- <div class="cb-item">
275
- <div class="cb-box <%= applicant_info?.marital_status === 'widowed' ? 'checked' : '' %>"></div>
276
- <span>មេម៉ាយ/ពោះម៉ាយ</span>
369
+
370
+ <div class="form-item">
371
+ <span class="label">Identity documents:</span>
372
+ <label class="checkbox-label <%= applicant_info.identity_type === 'nid' ? 'checked' : '' %>">
373
+ National ID Card
374
+ </label>
375
+ <label class="checkbox-label <%= applicant_info.identity_type === 'passport' ? 'checked' : '' %>">
376
+ Passport
377
+ </label>
378
+ <label class="checkbox-label <%= applicant_info.identity_type === 'birth' ? 'checked' : '' %>">
379
+ Birth Certificate
380
+ </label>
381
+ <label class="checkbox-label <%= applicant_info.identity_type === 'other' ? 'checked' : '' %>">
382
+ Others :
383
+ </label>
384
+
385
+
386
+ <!-- other field stays separate since it has extra input -->
387
+ <label class="underline"><%= applicant_info.identity_other_description %></label>
277
388
  </div>
389
+
390
+ <div class="form-item">
391
+ <span class="label">Identity #</span>
392
+ <span class="underline"><%= applicant_info.identity_no %></span>
393
+ <span class="label">DOB:</span>
394
+ <span class="underline"><%= applicant_info.date_of_birth %></span>
395
+ <span class="label">Age:</span>
396
+ <span class="underline xs"><%= applicant_info.age %></span>
397
+ <span class="label">Nationality:</span>
398
+ <span class="underline"><%= applicant_info.nationality %></span>
399
+ <span class="label">Phone #:</span>
400
+ <span class="underline"><%= applicant_info.phone_number %></span>
401
+ </div>
402
+
403
+ <div class="form-item">
404
+ <span class="label">Current Address:</span>
405
+ <span class="underline align-left"><%= applicant_info.current_address %></span>
406
+ </div>
407
+
408
+
278
409
  </div>
279
- <span class="label">តួនាទីនិងប្រភេទការងារ:</span>
280
- <span class="underline md"><%= applicant_info?.occupation ?? '' %></span>
281
- </div>
282
-
283
- <div class="field-row">
284
- <span class="label">ឯកសារបញ្ចាក់អត្តសញ្ញាណ:</span>
285
- <div class="cb-group">
286
- <div class="cb-item">
287
- <div class="cb-box <%= applicant_info?.identity_type === 'nid' ? 'checked' : '' %>"></div>
288
- <span>អត្តសញ្ញាណបណ្ណ</span>
410
+
411
+
412
+
413
+ <div class="form-container">
414
+ <div class="form-item mt-4">
415
+ <span class="label">Declaration on FATCA implementation</span>
289
416
  </div>
290
- <div class="cb-item">
291
- <div class="cb-box <%= applicant_info?.identity_type === 'passport' ? 'checked' : '' %>"></div>
292
- <span>លិខិតឆ្លងដែន</span>
417
+ <div class="form-item">
418
+ <span class="label">
419
+ The Policyholder is not USA citizen / USA resident for tax purpose or holding Green Card.
420
+ </span>
293
421
  </div>
294
- <div class="cb-item">
295
- <div class="cb-box <%= applicant_info?.identity_type === 'birth' ? 'checked' : '' %>"></div>
296
- <span>សំបុត្រកំណើត</span>
422
+ <div class="form-item">
423
+ <label class="checkbox-label <%= fatca_info.is_fatca === false ? 'checked' : '' %>">No</label>
424
+ <label class="checkbox-label <%= fatca_info.is_fatca === true ? 'checked' : '' %>">Yes</label>
425
+ <span class="label">US TIN #:</span>
426
+ <span class="underline"><%= fatca_info.us_tin_no %></span>
427
+ <span class="label">FATCA Exemption Code (If have):</span>
428
+ <span class="underline"><%= fatca_info.fatca_exempt_code %></span>
297
429
  </div>
298
- <div class="cb-item">
299
- <div class="cb-box <%= applicant_info?.identity_type === 'other' ? 'checked' : '' %>"></div>
300
- <span>ផ្សេងទៀត</span>
430
+ <div class="form-item">
431
+ <span class="label">
432
+ If any of the certifications I have provided are incorrect, I will submit a new document within 30 days, and I certify that I am not subject to U.S. withholding tax.
433
+ </span>
301
434
  </div>
302
435
  </div>
303
- </div>
304
-
305
- <div class="field-row">
306
- <span class="label">ផ្សេងទៀត:</span>
307
- <span class="underline sm"><%= applicant_info?.identity_type === 'other' ? (applicant_info?.identity_other_description ?? '') : '' %></span>
308
- <span class="label">លេខអត្តសញ្ញាណ:</span>
309
- <span class="underline md"><%= applicant_info?.identity_no ?? '' %></span>
310
- <span class="label">ថ្ងៃខែឆ្នាំកំណើត:</span>
311
- <span class="underline md"><%= applicant_info?.date_of_birth ?? '' %></span>
312
- <span class="label">អាយុ:</span>
313
- <span class="underline xs"><%= applicant_info?.age ?? '' %></span>
314
- <span class="label">សញ្ជាតិ:</span>
315
- <span class="underline sm"><%= applicant_info?.nationality ?? '' %></span>
316
- <span class="label">លេខទូរស័ព្ទ:</span>
317
- <span class="underline md"><%= applicant_info?.phone_number ?? '' %></span>
318
- </div>
319
-
320
- <div class="field-row">
321
- <span class="label">អាសយដ្ឋានបច្ចុប្បន្ន:</span>
322
- <span class="underline full"><%= applicant_info?.current_address ?? '' %></span>
323
- </div>
324
-
325
- <div class="section-header" style="background:#e8f0fb; color:#005bac; border:1px solid #aac4e0; font-size:8.5pt;">
326
- សេចក្ដីប្រកាសសម្រាប់ការអនុវត្ដ FATCA
327
- </div>
328
-
329
- <div class="field-row">
330
- អ្នកស្នើរសុំបណ្ណសន្យារ៉ាប់រង់មិនមែនជាពលរដ្ឋអាមេរិក ឬ ជាប់ពន្ធស្នាក់នៅអាមេរិក ឬ មានសិទ្ធិកាន់ Green Card នោះទេ។
331
- </div>
332
-
333
- <div class="field-row">
334
- <div class="cb-group">
335
- <div class="cb-item">
336
- <div class="cb-box <%= fatca_info?.is_fatca === false ? 'checked' : '' %>"></div>
337
- <span>មិនមែន</span>
338
- </div>
339
- <div class="cb-item">
340
- <div class="cb-box <%= fatca_info?.is_fatca === true ? 'checked' : '' %>"></div>
341
- <span>មែន</span>
436
+
437
+
438
+
439
+ <!-- Section 2 -->
440
+ <div class="card-header mt-4">INFORMATION ABOUT THE PRODUCT
441
+ </div>
442
+ <div class="table-container">
443
+ <table>
444
+ <thead>
445
+ <tr>
446
+ <th><div class="cell">NAME OF PRODUCT AND TERMS</div></th>
447
+ <th><div class="cell">SUM ASSURED (USD)</div></th>
448
+ <th><div class="cell">MODE OF PAYMENT</div></th>
449
+ <th>
450
+ <div class="cell">PREMIUM (USD)</div>
451
+ </th>
452
+ </tr>
453
+ </thead>
454
+ <tbody>
455
+ <% product_payment_info?.products?.forEach(function(product) { %>
456
+ <tr>
457
+ <td><div class="cell"><%= product.name %> <%= product.term %></div></td>
458
+ <td><div class="cell"><%= product.sum_assured %></div></td>
459
+ <td><div class="cell"><%= product.payment_mode %></div></td>
460
+ <td><div class="cell"><%= product.premium %></div></td>
461
+ </tr>
462
+ <% }) %>
463
+ </tbody>
464
+ </table>
465
+ </div>
466
+ <div class="form-container">
467
+ <div class="form-item">
468
+ <span class="question-label">Method of payment:</span>
469
+ <label class="checkbox-label <%= product_payment_info.payment_method === 'transfer_to_plac' ? 'checked' : '' %>">
470
+ Credit to Phillip Life Account
471
+ </label>
472
+ <label class="checkbox-label <%= product_payment_info.payment_method === 'other' ? 'checked' : '' %>">
473
+ Through Phillip Life's partner
474
+ </label>
342
475
  </div>
343
476
  </div>
344
- <span class="label">US TIN:</span>
345
- <span class="underline md"><%= fatca_info?.us_tin_no ?? '' %></span>
346
- <span class="label">លេខកូដលើកលែង FATCA (ប្រសិនមាន):</span>
347
- <span class="underline md"><%= fatca_info?.fatca_exempt_code ?? '' %></span>
348
- </div>
349
-
350
- <div class="health-q" style="font-size:7.8pt; color:#333;">
351
- ប្រសិនបើការបញ្ចាក់អះអាងណាមួយមិនត្រឹមត្រូវ ខ្ញុំនឹងប្រគល់ជូននូវឯកសារថ្មីក្នុងរយះពេល ៣០ថ្ងៃហើយអះអាងថាខ្ញុំមិនជាប់ពន្ធកាត់ទុករបស់សហរដ្ឋអាមេរិកទេ។
352
- </div>
353
-
354
- <div class="section-header">ព័ត៌មានអំពីផលិតផល</div>
355
-
356
- <table>
357
- <thead>
358
- <tr>
359
- <th>ឈ្មោះផលិតផល និងរយះពេលធានា</th>
360
- <th>ទឹកប្រាក់ត្រូវធានា<br/>(ដុល្លារអាមេរិក)</th>
361
- <th>របៀបបង់បុព្វលាភ</th>
362
- <th>បុព្វលាភធានារ៉ាប់រង់<br/>(ដុល្លារអាមេរិក)</th>
363
- </tr>
364
- </thead>
365
- <tbody>
366
- <% if (product_payment_info?.products && product_payment_info.products.length > 0) { %>
367
- <% product_payment_info.products.forEach((p) => { %>
477
+
478
+ <!-- Section 3 -->
479
+ <div class="card-header mt-4">INFORMATION ABOUT THE BENEFICIARY(IES)</div>
480
+ <div class="table-container">
481
+ <table>
482
+ <thead>
368
483
  <tr>
369
- <td><%= p.name ?? '' %> <%= p.term ? '(' + p.term + ')' : '' %></td>
370
- <td><%= p.sum_assured ?? '' %></td>
371
- <td><%= p.payment_mode ?? '' %></td>
372
- <td><%= p.premium ?? '' %></td>
484
+ <th><div class="cell">FULL NAME OF BENEFICIARY</div></th>
485
+ <th><div class="cell">AGE</div></th>
486
+ <th><div class="cell">RELATIONSHIP</div></th>
487
+ <th><div class="cell">IDENTITY NUMBER</div></th>
488
+ <th><div class="cell">% OF SHARE</div></th>
373
489
  </tr>
374
- <% }) %>
375
- <% } else { %>
376
- <tr>
377
- <td class="td-empty"></td>
378
- <td class="td-empty"></td>
379
- <td class="td-empty"></td>
380
- <td class="td-empty"></td>
381
- </tr>
382
- <tr>
383
- <td class="td-empty"></td>
384
- <td class="td-empty"></td>
385
- <td class="td-empty"></td>
386
- <td class="td-empty"></td>
387
- </tr>
388
- <% } %>
389
- </tbody>
390
- </table>
391
-
392
- <div class="field-row">
393
- <span class="label">វិធីសាស្រ្ដបង់បុព្វលាភធានារ៉ាប់រង់:</span>
394
- <div class="cb-group">
395
- <div class="cb-item">
396
- <div class="cb-box <%= product_payment_info?.payment_method === 'transfer' ? 'checked' : '' %>"></div>
397
- <span>ការផ្ទេរប្រាក់</span>
398
- </div>
399
- <div class="cb-item">
400
- <div class="cb-box <%= product_payment_info?.payment_method === 'cash' ? 'checked' : '' %>"></div>
401
- <span>សាច់ប្រាក់</span>
402
- </div>
403
- </div>
404
- </div>
405
-
406
- <div class="section-header">ព័ត៌មានអំពីអ្នកទទួលផល</div>
407
-
408
- <table>
409
- <thead>
410
- <tr>
411
- <th>ឈ្មោះពេញរបស់អ្នកទទួលផល</th>
412
- <th>អាយុ</th>
413
- <th>ទំនាក់ទំនង</th>
414
- <th>លេខអតិថិជន/ឯកសារ</th>
415
- <th>% នៃការបែងចែក</th>
416
- </tr>
417
- </thead>
418
- <tbody>
419
- <% if (beneficiary_info && beneficiary_info.length > 0) { %>
420
- <% beneficiary_info.forEach((b) => { %>
490
+ </thead>
491
+ <tbody>
492
+ <% beneficiary_info?.forEach(function(beneficiary) { %>
421
493
  <tr>
422
- <td><%= b.full_name ?? '' %></td>
423
- <td><%= b.age ?? '' %></td>
424
- <td><%= b.relationship ?? '' %></td>
425
- <td><%= b.id_number ?? '' %></td>
426
- <td><%= b.percentage ?? '' %></td>
494
+ <td><div class="cell"><%= beneficiary.full_name %></div></td>
495
+ <td><div class="cell"><%= beneficiary.age %></div></td>
496
+ <td><div class="cell"><%= beneficiary.relationship %></div></td>
497
+ <td><div class="cell"><%= beneficiary.id_number %></div></td>
498
+ <td><div class="cell"><%= beneficiary.percentage %></div></td>
427
499
  </tr>
428
- <% }) %>
429
- <% } else { %>
430
- <tr>
431
- <td class="td-empty"></td>
432
- <td class="td-empty"></td>
433
- <td class="td-empty"></td>
434
- <td class="td-empty"></td>
435
- <td class="td-empty"></td>
436
- </tr>
437
- <tr>
438
- <td class="td-empty"></td>
439
- <td class="td-empty"></td>
440
- <td class="td-empty"></td>
441
- <td class="td-empty"></td>
442
- <td class="td-empty"></td>
443
- </tr>
444
- <tr>
445
- <td class="td-empty"></td>
446
- <td class="td-empty"></td>
447
- <td class="td-empty"></td>
448
- <td class="td-empty"></td>
449
- <td class="td-empty"></td>
450
- </tr>
451
- <% } %>
452
- </tbody>
453
- </table>
454
-
455
- <div class="note">
456
- <span>កណត់សម្គាល់៖ ប្រសិនបើភាគរយមិនត្រូវបានបញ្ជាក់ចំនួនទឹកប្រាក់នឹងត្រូវបែងចែកស្មើៗគ្នា</span>
457
- <span>% សរុបស្មើរ ១០០%</span>
458
- </div>
459
-
460
- <div class="section-header">ព័ត៌មានពាក់ព័ន្ទនឹងសុខភាពរបស់ អ្នកស្នើសុំបណ្ណសន្យារ៉ាប់រង់</div>
461
-
462
- <div class="health-q">
463
- <span class="q-text">1) កម្ពស់:</span>
464
- <span class="underline xs"><%= health_info?.height ?? '' %></span> ស.ម
465
- <span class="q-text" style="margin-left:8px;">ទម្ងន់:</span>
466
- <span class="underline xs"><%= health_info?.weight ?? '' %></span> គ.ក
467
- <span class="q-text" style="margin-left:8px;">តើលោកអ្នកពិសារបារីដែរឬទេ?:</span>
468
- <div class="cb-group" style="display:inline-flex; margin-left:4px;">
469
- <div class="cb-item">
470
- <div class="cb-box <%= health_info?.is_smoke === false ? 'checked' : '' %>"></div>
471
- <span>មិនមាន</span>
472
- </div>
473
- <div class="cb-item">
474
- <div class="cb-box <%= health_info?.is_smoke === true ? 'checked' : '' %>"></div>
475
- <span>មាន</span>
476
- </div>
500
+ <% }) %>
501
+ <tr>
502
+ <td colspan="4">
503
+ <div class="cell">
504
+ Note:
505
+ If the percentage is not specified the amount will be shared equally
506
+ </div>
507
+ </td>
508
+ <td><div class="cell">% Total 100 %</div></td>
509
+ </tr>
510
+ </tbody>
511
+ </table>
512
+ </div>
513
+
514
+ <!-- Section 4 -->
515
+ <div class="page-break"></div>
516
+ <div class="card-header">
517
+ HEALTH RELATED QUESTIONS
477
518
  </div>
478
- <span class="underline xs"><%= health_info?.smoke_detail ?? '' %></span> ក្នុងមួយសប្ដាហ៍
479
- </div>
480
-
481
- <div class="health-q">
482
- <span class="q-text">2) តើលោកអ្នកពិសារគ្រឿងស្រវឹងដែរឬទេ?:</span>
483
- <div class="cb-group" style="display:inline-flex; margin-left:4px;">
484
- <div class="cb-item">
485
- <div class="cb-box <%= health_info?.is_drink_alcohol === false ? 'checked' : '' %>"></div>
486
- <span>មិនមាន</span>
519
+
520
+ <!-- Question 1 -->
521
+ <div class="form-container mt-4">
522
+ <div class="form-item">
523
+ <span class="label">1) Height:</span>
524
+ <span class="underline sm"><%= health_info.height %></span>
525
+ <span class="label">cm</span>
526
+ <div class="space"></div>
527
+ <span class="label">Weight:</span>
528
+ <span class="underline sm"><%= health_info.weight %></span>
529
+ <span class="label">Kg</span>
530
+ <div class="space"></div>
531
+ <span class="question-label">A) Do you smoke?</span>
532
+ <label class="checkbox-label <%= health_info.is_smoke === false ? 'checked' : '' %>">
533
+ No
534
+ </label>
535
+ <label class="checkbox-label <%= health_info.is_smoke === true ? 'checked' : '' %>">
536
+ Yes
537
+ </label>
487
538
  </div>
488
- <div class="cb-item">
489
- <div class="cb-box <%= health_info?.is_drink_alcohol === true ? 'checked' : '' %>"></div>
490
- <span>មាន</span>
539
+
540
+ <div class="form-item">
541
+ <span class="label">How many</span>
542
+ <% if (health_info.smoke_detail) { %>
543
+ <span class="underline with-unit">
544
+ <span class="value"><%= health_info.smoke_detail %></span>
545
+ <span class="unit">per day</span>
546
+ </span>
547
+ <% } else { %>
548
+ <span class="underline"></span>
549
+ <% } %>
491
550
  </div>
492
551
  </div>
493
- <span class="underline xs"><%= health_info?.drink_alcohol_detail ?? '' %></span> ក្នុងមួយសប្ដាហ៍
494
- </div>
495
-
496
- <div class="health-q">
497
- <span class="q-text">3) ក្នុងរយៈពេល០២(ពីរ)ឆ្នាំចុងក្រោយនេះតើលោកអ្នកធ្លាប់បានសម្រាកក្នុងមន្ទីរពេទ្យ ធ្លាប់បានទទួលការវះកាត់ ឬធ្លាប់ទទួលបានលទ្ធផលខុសប្រក្រតីអំពីការវិភាគឈាម ការវិភាគទឹកនោម ការថតកាំរស្មីអុិច (X-ray) ម៉ាស៊ីនវាស់ចង្វាក់បេះដូង អេកូសាស្រ្ដស្កេន ការច្រឹបសាច់យកពិនិត្យ ឬលទ្ធផលវិភាគផ្សេងៗទៀតដែលមិនបានរៀបរាប់ខាងដើមពីគ្រូពេទ្យដែរឬទេ?:</span>
498
- <div class="cb-group" style="display:inline-flex; margin-left:4px;">
499
- <div class="cb-item">
500
- <div class="cb-box <%= health_info?.is_hospitalized === false ? 'checked' : '' %>"></div>
501
- <span>មិនមាន</span>
552
+
553
+ <!-- Question 2 -->
554
+ <div class="form-container mt-4">
555
+ <div class="form-item">
556
+ <span class="question-label">2) Do you drink alcohol?</span>
557
+ <label class="checkbox-label <%= health_info.is_drink_alcohol === false ? 'checked' : '' %>">
558
+ No
559
+ </label>
560
+ <label class="checkbox-label <%= health_info.is_drink_alcohol === true ? 'checked' : '' %>">
561
+ Yes
562
+ </label>
502
563
  </div>
503
- <div class="cb-item">
504
- <div class="cb-box <%= health_info?.is_hospitalized === true ? 'checked' : '' %>"></div>
505
- <span>មាន</span>
564
+ <div class="form-item">
565
+ <span class="label">Please specify amount of drink per week</span>
566
+ <% if (health_info.drink_alcohol_detail) { %>
567
+ <span class="underline with-unit">
568
+ <span class="value"><%= health_info.drink_alcohol_detail %></span>
569
+ </span>
570
+ <% } else { %>
571
+ <span class="underline"></span>
572
+ <% } %>
506
573
  </div>
507
574
  </div>
508
575
 
509
- <% if (health_info?.is_hospitalized) { %>
510
- <div class="detail-line"><%= health_info?.hospitalized_detail ?? '' %></div>
511
- <% } %>
512
- </div>
513
-
514
- <div class="page-break"></div>
515
- <div class="page-num">ទំព័រ 2 នៃ 2</div>
516
-
517
- <div class="health-q">
518
- <span class="q-text">4) តើលោកអ្នកធ្លាប់បានធ្វើរោគវិនិច្ឆ័យ ពិគ្រោះជំងឺឬទទួលការព្យាបាលដូចជា លើសសម្ពាធឈាម ទឹកនោមផ្អែម ជំងឺបេះដូង ចុកទ្រូង ជំងឺសួត ជំងឺថ្លើម ជំងឺតម្រងនោម មហារីក ជំងឺដាច់សសៃឈាមខួរក្បាល ជំងឺអេដស៍ ជំងឺផ្លូវចិត្ត ពិការភាព ឬរាងកាយមិនប្រក្រតី ប្រើប្រាស់ថ្នាំញៀន ឬញៀនស្រា ឬជំងឺផ្សេងទៀតដែលមិនបានរៀបរាប់ខាងលើដែរឬទេ?</span>
519
- <div class="cb-group" style="display:inline-flex; margin-left:4px;">
520
- <div class="cb-item">
521
- <div class="cb-box <%= health_info?.is_diagnosed === false ? 'checked' : '' %>"></div>
522
- <span>មិនមាន</span>
576
+ <!-- Question 3 -->
577
+ <div class="form-container mt-4">
578
+ <span class="question-label">
579
+ 3) In the past 2 years, have you ever been hospitalized, undergone any surgical operation, or had abnormal results such as: Blood test, Urine test, X-ray, ECG, Ultrasound, Scan, Biopsy or any other test results.
580
+ </span>
581
+ <div class="form-item">
582
+ <label class="checkbox-label <%= health_info.is_hospitalized === false ? 'checked' : '' %>">
583
+ No
584
+ </label>
585
+ <label class="checkbox-label <%= health_info.is_hospitalized === true ? 'checked' : '' %>">
586
+ Yes
587
+ </label>
523
588
  </div>
524
- <div class="cb-item">
525
- <div class="cb-box <%= health_info?.is_diagnosed === true ? 'checked' : '' %>"></div>
526
- <span>មាន</span>
589
+
590
+ <div class="form-item">
591
+ <span class="label">provided more details:</span>
592
+ <% if (health_info.hospitalized_detail) { %>
593
+ <span class="underline with-unit">
594
+ <span class="value"><%= health_info.hospitalized_detail %></span>
595
+ </span>
596
+ <% } else { %>
597
+ <span class="underline"></span>
598
+ <% } %>
527
599
  </div>
528
600
  </div>
529
601
 
530
- <% if (health_info?.is_diagnosed) { %>
531
- <div style="margin-top:4px; font-size:8pt;">បើមានសូមបញ្ជាក់លម្អិតខាងក្រោម៖</div>
532
- <div class="detail-line"><%= health_info?.diagnosed_detail ?? '' %></div>
533
- <% } %>
534
- </div>
535
-
536
- <div class="section-header">សេចក្ដីប្រកាសរបស់អ្នកស្នើសុំធានារ៉ាប់រង់</div>
537
-
538
- <div class="declaration">
539
- <p>1) ខ្ញុំអនុញ្ញាត និងយល់ព្រមឲ្យក្រុមហ៊ុនប្រើប្រាស់ព័ត៌មាន និងទិន្នន័យទាំងស្រុងដែលខ្ញុំបានផ្ដល់នៅក្នុងពាក្យស្នើសុំរបស់ខ្ញុំក្នុងគោលបំណង ស្របតាមច្បាប់ ដូចជា ការផ្សព្វផ្សាយទីផ្សារ ការសិក្សាទីផ្សារ និង ការបម្រើអតិថិជនដោយក្រុមហ៊ុន សម្ព័ន្ធក្រុមហ៊ុន ឬ ជាដៃគូពាណិជ្ជកម្មរបស់ក្រុមហ៊ុន ដោយមិនចាំបាច់មានការយល់ព្រម និងជូនដំណឹងបន្ថែមពីខ្ញុំឡើយ។ ក្រុមហ៊ុនមិនត្រូវបានអនុញ្ញាតឲ្យបញ្ចេញព័ត៌មានណាមួយទៅភាគីទីបីណាមួយ ឬប្រើប្រាស់ព័ត៌មាននោះសម្រាប់គោលបំណងផ្សេងទៀតដែលមិនទាក់ទងនឹងគោលបំណងទាំងឡាយខាងលើឡើយ ប្រសិនបើគ្មានការយល់ព្រមព្រៀងជាលាយលក្ខណ៍អក្សរនោះ។</p>
540
- <p>2) ខ្ញុំសូមអះអាងថាបានអាន និងយល់ស្របនូវគ្រប់ព័ត៌មានក្នុងឯកសារនេះ។ ខ្ញុំសូមប្រកាសថាគ្រប់ព័ត៌មានដែលបានផ្ដល់នៅក្នុងពាក្យស្នើសុំនេះ ពិតជាមានភាពពេញលេញ និងត្រឹមត្រូវពិតប្រាកដមែន។</p>
541
- </div>
542
-
543
- <div class="sig-row">
544
- <div class="sig-block">
545
- <div>ហត្ថលេខា ឬស្នាមមេដៃរបស់អ្នកស្នើសុំធានារ៉ាប់រង</div>
546
- <div class="sig-line"></div>
547
- <div class="field-row">
548
- <span class="label">ឈ្មោះ</span>
549
- <span class="underline full"><%= signature_info?.applicant_name ?? '' %></span>
602
+ <!-- Question 4 -->
603
+ <div class="form-container mt-4">
604
+ <span class="question-label">
605
+ 4) Have you ever been diagnosed with, consulted a medical practitioner or been given treatment for any of the following conditions: Hypertension, Diabetes, Heart diseases, Chest pain, Lung diseases, Liver disease, Renal diseases, Cancer, Stroke, AIDS, Mental illness, Disability or Deformity, Drug or Alcohol Abuse or Any other diseases are not mentioned above.
606
+ </span>
607
+ <div class="form-item">
608
+ <label class="checkbox-label <%= health_info.is_diagnosed === false ? 'checked' : '' %>">
609
+ No
610
+ </label>
611
+ <label class="checkbox-label <%= health_info.is_diagnosed === true ? 'checked' : '' %>">
612
+ Yes
613
+ </label>
614
+
550
615
  </div>
551
- <div class="field-row">
552
- <span class="label">កាលបរិច្ឆេទ</span>
553
- <span class="underline full"><%= signature_info?.applicant_signature_date ?? '' %></span>
616
+ <div class="form-item">
617
+ <span class="label">if yes, please provided more details:</span>
618
+ <% if (health_info.diagnosed_detail) { %>
619
+ <span class="underline with-unit">
620
+ <span class="value"><%= health_info.diagnosed_detail %></span>
621
+ </span>
622
+ <% } else { %>
623
+ <span class="underline"></span>
624
+ <% } %>
554
625
  </div>
555
626
  </div>
556
- <div class="sig-block">
557
- <div>ហត្ថលេខា ឬស្នាមមេដៃរបស់សាក្សី</div>
558
- <div class="sig-line"></div>
559
- <div class="field-row">
560
- <span class="label">ឈ្មោះ</span>
561
- <span class="underline full"><%= signature_info?.witness_name ?? '' %></span>
627
+
628
+ <!-- Section 5 -->
629
+ <div class="card-header mt-8">DECLARATION BY THE APPLICANT</div>
630
+ <div class="form-container">
631
+ <div class="form-item">
632
+ <span class="label">
633
+ 1) I authorize and consent the Company to use all of my information provided in my application form for legal purposes such as marketing, market survey and customer service by company, affiliate, or business partner without my prior consent or notification. The Company shall not allow to disclose any information of any other purpose not related to the above-mentioned purpose without prior consent in writing.
634
+ </span>
562
635
  </div>
563
- <div class="field-row">
564
- <span class="label">កាលបរិច្ឆេទ</span>
565
- <span class="underline full"><%= signature_info?.witness_signature_date ?? '' %></span>
636
+ <div class="form-item">
637
+ <span class="label">
638
+ 2) I hereby confirm that I have read and understood all the information in this document. I declare that all the information provided in this application form is complete, accurate, and true.
639
+ </span>
566
640
  </div>
567
641
  </div>
568
- </div>
569
- </body>
642
+ <div class="table-container mt-4">
643
+ <table>
644
+ <thead>
645
+ <tr>
646
+ <th style="width: 50%">
647
+ <div class="cell">
648
+ Signature or Thumb print of the Applicant
649
+ </div>
650
+ <div class="signature-space"></div>
651
+ </th>
652
+ <th style="width: 50%">
653
+ <div class="cell">Signature or Thumb print of the witness</div>
654
+ <div class="signature-space"></div>
655
+ </th>
656
+ </tr>
657
+ </thead>
658
+ <tbody>
659
+ <tr>
660
+ <td>
661
+ <div class="form-container space-height">
662
+ <div class="form-item">
663
+ <div class="space"></div>
664
+ <span class="label">Name</span>
665
+ <% if (signature_info.applicant_name) { %>
666
+ <span class="underline with-unit">
667
+ <span class="value"><%= signature_info.applicant_name %></span>
668
+ </span>
669
+ <% } else { %>
670
+ <span class="underline"></span>
671
+ <% } %>
672
+ <div class="space"></div>
673
+ </div>
674
+ </div>
675
+ </td>
676
+ <td>
677
+ <div class="form-container space-height">
678
+ <div class="form-item">
679
+ <div class="space"></div>
680
+ <span class="label">Name</span>
681
+ <% if (signature_info.witness_name) { %>
682
+ <span class="underline with-unit">
683
+ <span class="value"><%= signature_info.witness_name %></span>
684
+ </span>
685
+ <% } else { %>
686
+ <span class="underline"></span>
687
+ <% } %>
688
+ <div class="space"></div>
689
+ </div>
690
+ </div>
691
+ </td>
692
+ </tr>
693
+ <tr>
694
+ <td>
695
+ <div class="form-container space-height">
696
+ <div class="form-item">
697
+ <div class="space"></div>
698
+ <span class="label">Date</span>
699
+ <% if (signature_info.applicant_signature_date) { %>
700
+ <span class="underline with-unit" >
701
+ <span class="value"><%= signature_info.applicant_signature_date %></span>
702
+ </span>
703
+ <% } else { %>
704
+ <span class="underline"></span>
705
+ <% } %>
706
+ <div class="space"></div>
707
+ </div>
708
+ </div>
709
+ </td>
710
+ <td>
711
+ <div class="form-container space-height">
712
+ <div class="form-item">
713
+ <div class="space"></div>
714
+ <span class="label">Date</span>
715
+ <% if (signature_info.witness_signature_date) { %>
716
+ <span class="underline with-unit">
717
+ <span class="value"><%= signature_info.witness_signature_date %></span>
718
+ </span>
719
+ <% } else { %>
720
+ <span class="underline"></span>
721
+ <% } %>
722
+ <div class="space"></div>
723
+ </div>
724
+ </div>
725
+ </td>
726
+ </tr>
727
+ </tbody>
728
+ </table>
729
+ </div>
730
+ </body>
570
731
  </html>
571
732
  `;