npm - plac-micro-common - Versions diffs - 1.3.9 → 1.3.10 - Mend

plac-micro-common 1.3.9 → 1.3.10

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Files changed (10) hide show

package/dist/libs/pdf-form/pdf-form.lib.js CHANGED Viewed

@@ -34,58 +34,14 @@ var __importStar = (this && this.__importStar) || (function () {
 })();
 Object.defineProperty(exports, "__esModule", { value: true });
 exports.generateFormSIO = generateFormSIO;
-const fs = __importStar(require("fs"));
-const path = __importStar(require("path"));
+const khmer_os_font_1 = require("./fonts/khmer-os.font");
+const sio_form_en_template_1 = require("./templates/sio-form-en.template");
+const sio_form_kh_template_1 = require("./templates/sio-form-kh.template");
 const ejs = __importStar(require("ejs"));
-let cached_font_base64 = null;
-const cached_templates = {};
-function getAssetsRootPath() {
-    const shared_entry_path = require.resolve("plac-micro-common/shared");
-    const shared_dist_dir = path.dirname(shared_entry_path);
-    // shared entry = dist/shared/index.js
-    // assets root = dist/assets
-    return path.resolve(shared_dist_dir, "..", "assets");
-}
-function getFontBase64() {
-    if (!cached_font_base64) {
-        const font_path = path.join(getAssetsRootPath(), "fonts", "KhmerOS.ttf");
-        if (!fs.existsSync(font_path)) {
-            throw new Error([
-                "[generateFormSIO] Font not found",
-                `shared_entry: ${require.resolve("plac-micro-common/shared")}`,
-                `assets_root: ${getAssetsRootPath()}`,
-                `font_path: ${font_path}`,
-            ].join("\n"));
-        }
-        const font_buffer = fs.readFileSync(font_path);
-        cached_font_base64 = font_buffer.toString("base64");
-    }
-    return cached_font_base64;
-}
-function getTemplate(lang) {
-    if (!cached_templates[lang]) {
-        const template_path = lang === "en"
-            ? path.join(getAssetsRootPath(), "templates", "sio-form-en.ejs")
-            : path.join(getAssetsRootPath(), "templates", "sio-form-kh.ejs");
-        if (!fs.existsSync(template_path)) {
-            throw new Error([
-                "[generateFormSIO] Template not found",
-                `lang: ${lang}`,
-                `shared_entry: ${require.resolve("plac-micro-common/shared")}`,
-                `assets_root: ${getAssetsRootPath()}`,
-                `template_path: ${template_path}`,
-            ].join("\n"));
-        }
-        const template = fs.readFileSync(template_path, "utf8");
-        cached_templates[lang] = ejs.compile(template);
-    }
-    return cached_templates[lang];
-}
 async function generateFormSIO(data, lang) {
-    const template = getTemplate(lang);
-    const font_base64 = getFontBase64();
-    return template({
+    const template = lang === "en" ? sio_form_en_template_1.SIO_FORM_EN_TEMPLATE : sio_form_kh_template_1.SIO_FORM_KH_TEMPLATE;
+    return ejs.render(template, {
         ...data,
-        font_base64,
+        font_base64: khmer_os_font_1.KHMER_OS_FONT_BASE64,
     });
 }

package/dist/libs/pdf-form/templates/sio-form-en.template.d.ts ADDED Viewed

@@ -0,0 +1 @@

+ export declare const SIO_FORM_EN_TEMPLATE = "\n<!DOCTYPE html>\n<html lang=\"km\">\n <head>\n <meta charset=\"UTF-8\" />\n <meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0\" />\n <title>\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17A2\u17B6\u1799\u17BB\u1787\u17B8\u179C\u17B7\u178F</title>\n <style>\n /* \u2500\u2500 Khmer Font \u2500\u2500 */\n @font-face {\n font-family: 'Khmer OS';\n src: url('data:font/truetype;base64,<%= font_base64 %>') format('truetype');\n font-weight: normal;\n font-style: normal;\n }\n\n /* \u2500\u2500 Reset & Base \u2500\u2500 */\n *, *::before, *::after { box-sizing: border-box; margin: 0; padding: 0; }\n\n body {\n font-family: 'Khmer OS', sans-serif;\n font-size: 9pt;\n color: #1a1a1a;\n background: #fff;\n padding: 14mm 12mm;\n line-height: 1.5;\n -webkit-print-color-adjust: exact;\n print-color-adjust: exact;\n }\n\n /* \u2500\u2500 Logo & Header \u2500\u2500 */\n .logo {\n color: #005bac;\n font-size: 13pt;\n font-weight: bold;\n letter-spacing: 0.5px;\n margin-bottom: 4px;\n }\n\n .form-title {\n text-align: center;\n font-size: 11pt;\n font-weight: bold;\n margin-bottom: 10px;\n line-height: 1.6;\n }\n\n /* \u2500\u2500 Top Meta Row \u2500\u2500 */\n .meta-grid {\n display: grid;\n grid-template-columns: 1fr 1fr;\n gap: 4px 16px;\n margin-bottom: 8px;\n }\n\n .meta-row {\n display: flex;\n align-items: center;\n gap: 4px;\n border-bottom: 1px solid #333;\n padding-bottom: 2px;\n font-size: 8.5pt;\n }\n\n .meta-row span.label { white-space: nowrap; }\n .meta-row span.value { flex: 1; min-width: 0; }\n\n /* \u2500\u2500 Section Header \u2500\u2500 */\n .section-header {\n background-color: #005bac;\n color: #fff;\n text-align: center;\n font-weight: bold;\n font-size: 9pt;\n padding: 4px 8px;\n margin: 8px 0 6px;\n }\n\n /* \u2500\u2500 Field Row \u2500\u2500 */\n .field-row {\n display: flex;\n align-items: center;\n flex-wrap: wrap;\n gap: 4px 10px;\n margin-bottom: 5px;\n font-size: 8.5pt;\n }\n\n .field-row .label { white-space: nowrap; }\n\n .underline {\n border-bottom: 1px solid #333;\n min-width: 60px;\n display: inline-block;\n padding-bottom: 1px;\n }\n\n .underline.lg { min-width: 140px; }\n .underline.md { min-width: 90px; }\n .underline.sm { min-width: 50px; }\n .underline.xs { min-width: 30px; }\n .underline.full { flex: 1; min-width: 120px; }\n\n /* \u2500\u2500 Checkbox \u2500\u2500 */\n .cb-group { display: flex; align-items: center; gap: 12px; flex-wrap: wrap; }\n\n .cb-item {\n display: flex;\n align-items: center;\n gap: 4px;\n white-space: nowrap;\n }\n\n .cb-box {\n width: 11px;\n height: 11px;\n border: 1.2px solid #333;\n display: inline-flex;\n align-items: center;\n justify-content: center;\n font-size: 8pt;\n flex-shrink: 0;\n }\n\n .cb-box.checked::after { content: '\u2714'; color: #005bac; }\n\n /* \u2500\u2500 Table \u2500\u2500 */\n table {\n width: 100%;\n border-collapse: collapse;\n font-size: 8.5pt;\n margin-bottom: 6px;\n }\n\n th {\n background-color: #dce9f7;\n border: 1px solid #aac4e0;\n padding: 4px 6px;\n text-align: center;\n font-weight: bold;\n }\n\n td {\n border: 1px solid #aac4e0;\n padding: 4px 6px;\n text-align: center;\n min-height: 20px;\n }\n\n .td-empty { height: 20px; }\n\n /* \u2500\u2500 Note \u2500\u2500 */\n .note {\n font-size: 8pt;\n display: flex;\n justify-content: space-between;\n align-items: center;\n margin-top: 2px;\n }\n\n /* \u2500\u2500 Health Questions \u2500\u2500 */\n .health-q {\n font-size: 8.5pt;\n margin-bottom: 6px;\n line-height: 1.6;\n }\n\n .health-q .q-text { display: inline; }\n\n .detail-line {\n border-bottom: 1px solid #333;\n min-height: 14px;\n margin-top: 3px;\n width: 100%;\n }\n\n /* \u2500\u2500 Declaration \u2500\u2500 */\n .declaration {\n font-size: 8pt;\n line-height: 1.6;\n margin-bottom: 6px;\n }\n\n .declaration p { margin-bottom: 5px; }\n\n /* \u2500\u2500 Signature Row \u2500\u2500 */\n .sig-row {\n display: grid;\n grid-template-columns: 1fr 1fr;\n gap: 16px;\n margin-top: 10px;\n font-size: 8.5pt;\n }\n\n .sig-block { display: flex; flex-direction: column; gap: 6px; }\n\n .sig-line {\n border-bottom: 1px solid #333;\n min-height: 36px;\n margin-bottom: 4px;\n }\n\n /* \u2500\u2500 Page number \u2500\u2500 */\n .page-num {\n text-align: right;\n font-size: 7.5pt;\n color: #555;\n margin-bottom: 4px;\n }\n\n /* \u2500\u2500 Page break \u2500\u2500 */\n .page-break { page-break-before: always; }\n </style>\n </head>\n <body>\n\n \n <div class=\"page-num\">\u1791\u17C6\u1796\u17D0\u179A 1 \u1793\u17C3 2</div>\n\n <div class=\"logo\">PhillipLife</div>\n\n <div class=\"form-title\">\n \u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17A2\u17B6\u1799\u17BB\u1787\u17B8\u179C\u17B7\u178F<br/>\n \u179F\u1798\u17D2\u179A\u17B6\u1794\u17CB\u1791\u1798\u17D2\u179A\u1784\u17CB\u179F\u17B6\u1798\u1789\u17D2\u1789\u179F\u1798\u17D2\u179A\u17B6\u1794\u17CB\u17A2\u178F\u17B7\u1790\u17B7\u1787\u1793\u1787\u17C4\u1782\u1787\u17D0\u1799\u17A0\u17D2\u179C\u17B6\u1799\u1793\u17C2\u1793 (SIO)\n </div>\n\n \n <div class=\"meta-grid\">\n <div class=\"meta-row\">\n <span class=\"label\">\u1788\u17D2\u1798\u17C4\u17C7\u1793\u17B7\u1784\u179B\u17C1\u1781\u1780\u17BC\u178A\u179F\u17B6\u1781\u17B6</span>\n <span class=\"value underline full\"><%= branchName %> <%= branchCode %></span>\n </div>\n <div class=\"meta-row\">\n <span class=\"label\">\u1788\u17D2\u1798\u17C4\u17C7\u1793\u17B7\u1784\u179B\u17C1\u1781\u1780\u17BC\u178A\u1794\u17BB\u1782\u17D2\u1782\u179B\u17B7\u1780\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17CB</span>\n <span class=\"value underline full\"><%= insurerName %> <%= insurerCode %></span>\n </div>\n <div class=\"meta-row\">\n <span class=\"label\">\u1788\u17D2\u1798\u17C4\u17C7\u1793\u17B7\u1784\u179B\u17C1\u1781\u1780\u17BC\u178A\u1794\u17BB\u1782\u17D2\u1782\u179B\u17B7\u1780\u1792\u1793\u17B6\u1782\u17B6\u179A</span>\n <span class=\"value underline full\"><%= bankStaffName %> <%= bankStaffCode %></span>\n </div>\n <div class=\"meta-row\">\n <span class=\"label\">\u179B\u17C1\u1781\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6</span>\n <span class=\"value underline full\"><%= applicationNo %></span>\n </div>\n </div>\n\n \n <div class=\"section-header\">\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u17A2\u17C6\u1796\u17B8\u17A2\u17D2\u1793\u1780\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1796\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17CB</div>\n\n <div class=\"field-row\">\n <span class=\"label\">\u1788\u17D2\u1798\u17C4\u17C7\u1796\u17C1\u1789\u178A\u17BC\u1785\u1794\u1784\u17D2\u17A0\u17B6\u1789\u1793\u17C5\u1780\u17D2\u1793\u17BB\u1784\u17AF\u1780\u179F\u17B6\u179A\u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E \u1787\u17B6\u1797\u17B6\u179F\u17B6\u1781\u17D2\u1798\u17C2\u179A:</span>\n <span class=\"underline lg\"><%= fullNameKh %></span>\n <span class=\"label\">\u1787\u17B6\u1797\u17B6\u179F\u17B6\u17A2\u1784\u17CB\u1782\u17D2\u179B\u17C1\u179F</span>\n <span class=\"underline lg\"><%= fullNameEn %></span>\n <span class=\"label\">\u1797\u17C1\u1791:</span>\n <div class=\"cb-group\">\n <div class=\"cb-item\"><div class=\"cb-box <%= gender === 'male' ? 'checked' : '' %>\"></div><span>\u1794\u17D2\u179A\u17BB\u179F</span></div>\n <div class=\"cb-item\"><div class=\"cb-box <%= gender === 'female' ? 'checked' : '' %>\"></div><span>\u179F\u17D2\u179A\u17B8</span></div>\n </div>\n </div>\n\n <div class=\"field-row\">\n <span class=\"label\">\u179F\u17D2\u1790\u17B6\u1793\u1797\u17B6\u1796\u1782\u17D2\u179A\u17BD\u179F\u17B6\u179A:</span>\n <div class=\"cb-group\">\n <div class=\"cb-item\"><div class=\"cb-box <%= maritalStatus === 'single' ? 'checked' : '' %>\"></div><span>\u1793\u17C5\u17A1\u17B6\u179C</span></div>\n <div class=\"cb-item\"><div class=\"cb-box <%= maritalStatus === 'married' ? 'checked' : '' %>\"></div><span>\u179A\u17C0\u1794\u1780\u17B6\u179A</span></div>\n <div class=\"cb-item\"><div class=\"cb-box <%= maritalStatus === 'pregnant' ? 'checked' : '' %>\"></div><span>\u1796\u17C4\u17C7\u1798\u17D2\u178A\u17B6\u1799</span></div>\n </div>\n <span class=\"label\">\u178F\u17BD\u1793\u17B6\u1791\u17B8\u1793\u17B7\u1784\u1794\u17D2\u179A\u1797\u17C1\u1791\u1780\u17B6\u179A\u1784\u17B6\u179A:</span>\n <span class=\"underline md\"><%= occupation %></span>\n </div>\n\n <div class=\"field-row\">\n <span class=\"label\">\u17AF\u1780\u179F\u17B6\u179A\u1794\u1789\u17D2\u1785\u17B6\u1780\u17CB\u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E:</span>\n <div class=\"cb-group\">\n <div class=\"cb-item\"><div class=\"cb-box <%= idType === 'nid' ? 'checked' : '' %>\"></div><span>\u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E\u1794\u178E\u17D2\u178E</span></div>\n <div class=\"cb-item\"><div class=\"cb-box <%= idType === 'passport' ? 'checked' : '' %>\"></div><span>\u179B\u17B7\u1781\u17B7\u178F\u1786\u17D2\u179B\u1784\u178A\u17C2\u1793</span></div>\n <div class=\"cb-item\"><div class=\"cb-box <%= idType === 'birth' ? 'checked' : '' %>\"></div><span>\u179F\u17C6\u1794\u17BB\u178F\u17D2\u179A\u1780\u17C6\u178E\u17BE\u178F</span></div>\n </div>\n </div>\n\n <div class=\"field-row\">\n <span class=\"label\">\u1795\u17D2\u179F\u17C1\u1784\u1791\u17C0\u178F:</span>\n <span class=\"underline sm\"><%= idType === 'other' ? idNumber : '' %></span>\n <span class=\"label\">\u179B\u17C1\u1781\u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E:</span>\n <span class=\"underline md\"><%= idNumber %></span>\n <span class=\"label\">\u1790\u17D2\u1784\u17C3\u1781\u17C2\u1786\u17D2\u1793\u17B6\u17C6\u1780\u17C6\u178E\u17BE\u178F:</span>\n <span class=\"underline md\"><%= dob %></span>\n <span class=\"label\">\u17A2\u17B6\u1799\u17BB:</span>\n <span class=\"underline xs\"><%= age %></span>\n <span class=\"label\">\u179F\u1789\u17D2\u1787\u17B6\u178F\u17B7:</span>\n <span class=\"underline sm\"><%= nationality %></span>\n <span class=\"label\">\u179B\u17C1\u1781\u1791\u17BC\u179A\u179F\u17D0\u1796\u17D2\u1791:</span>\n <span class=\"underline md\"><%= phone %></span>\n </div>\n\n <div class=\"field-row\">\n <span class=\"label\">\u17A2\u17B6\u179F\u1799\u178A\u17D2\u178B\u17B6\u1793\u1794\u1785\u17D2\u1785\u17BB\u1794\u17D2\u1794\u1793\u17D2\u1793:</span>\n <span class=\"underline full\"><%= address %></span>\n </div>\n\n \n <div class=\"section-header\" style=\"background:#e8f0fb; color:#005bac; border:1px solid #aac4e0; font-size:8.5pt;\">\n \u179F\u17C1\u1785\u1780\u17D2\u178A\u17B8\u1794\u17D2\u179A\u1780\u17B6\u179F\u179F\u1798\u17D2\u179A\u17B6\u1794\u17CB\u1780\u17B6\u179A\u17A2\u1793\u17BB\u179C\u178F\u17D2\u178A FATCA\n </div>\n\n <div class=\"field-row\">\n \u17A2\u17D2\u1793\u1780\u179F\u17D2\u1793\u17BE\u179A\u179F\u17BB\u17C6\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17CB\u1798\u17B7\u1793\u1798\u17C2\u1793\u1787\u17B6\u1796\u179B\u179A\u178A\u17D2\u178B\u17A2\u17B6\u1798\u17C1\u179A\u17B7\u1780 \u17AC \u1787\u17B6\u1794\u17CB\u1796\u1793\u17D2\u1792\u179F\u17D2\u1793\u17B6\u1780\u17CB\u1793\u17C5\u17A2\u17B6\u1798\u17C1\u179A\u17B7\u1780 \u17AC \u1798\u17B6\u1793\u179F\u17B7\u1791\u17D2\u1792\u17B7\u1780\u17B6\u1793\u17CB Green Card \u1793\u17C4\u17C7\u1791\u17C1\u17D4\n </div>\n\n <div class=\"field-row\">\n <div class=\"cb-group\">\n <div class=\"cb-item\"><div class=\"cb-box <%= !isFatca ? 'checked' : '' %>\"></div><span>\u1798\u17B7\u1793\u1798\u17C2\u1793</span></div>\n <div class=\"cb-item\"><div class=\"cb-box <%= isFatca ? 'checked' : '' %>\"></div><span>\u1798\u17C2\u1793</span></div>\n </div>\n <span class=\"label\">US TIN:</span>\n <span class=\"underline md\"><%= usTin %></span>\n <span class=\"label\">\u179B\u17C1\u1781\u1780\u17BC\u178A\u179B\u17BE\u1780\u179B\u17C2\u1784 FATCA (\u1794\u17D2\u179A\u179F\u17B7\u1793\u1798\u17B6\u1793):</span>\n <span class=\"underline md\"><%= fatcaExemptCode %></span>\n </div>\n\n <div class=\"health-q\" style=\"font-size:7.8pt; color:#333;\">\n \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1780\u17B6\u179A\u1794\u1789\u17D2\u1785\u17B6\u1780\u17CB\u17A2\u17C7\u17A2\u17B6\u1784\u178E\u17B6\u1798\u17BD\u1799\u1798\u17B7\u1793\u178F\u17D2\u179A\u17B9\u1798\u178F\u17D2\u179A\u17BC\u179C \u1781\u17D2\u1789\u17BB\u17C6\u1793\u17B9\u1784\u1794\u17D2\u179A\u1782\u179B\u17CB\u1787\u17BC\u1793\u1793\u17BC\u179C\u17AF\u1780\u179F\u17B6\u179A\u1790\u17D2\u1798\u17B8\u1780\u17D2\u1793\u17BB\u1784\u179A\u1799\u17C7\u1796\u17C1\u179B \u17E3\u17E0\u1790\u17D2\u1784\u17C3\u17A0\u17BE\u1799\u17A2\u17C7\u17A2\u17B6\u1784\u1790\u17B6\u1781\u17D2\u1789\u17BB\u17C6\u1798\u17B7\u1793\u1787\u17B6\u1794\u17CB\u1796\u1793\u17D2\u1792\u1780\u17B6\u178F\u17CB\u1791\u17BB\u1780\u179A\u1794\u179F\u17CB\u179F\u17A0\u179A\u178A\u17D2\u178B\u17A2\u17B6\u1798\u17C1\u179A\u17B7\u1780\u1791\u17C1\u17D4\n </div>\n\n \n <div class=\"section-header\">\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u17A2\u17C6\u1796\u17B8\u1795\u179B\u17B7\u178F\u1795\u179B</div>\n\n <table>\n <thead>\n <tr>\n <th>\u1788\u17D2\u1798\u17C4\u17C7\u1795\u179B\u17B7\u178F\u1795\u179B \u1793\u17B7\u1784\u179A\u1799\u17C7\u1796\u17C1\u179B\u1792\u17B6\u1793\u17B6</th>\n <th>\u1791\u17B9\u1780\u1794\u17D2\u179A\u17B6\u1780\u17CB\u178F\u17D2\u179A\u17BC\u179C\u1792\u17B6\u1793\u17B6<br/>(\u178A\u17BB\u179B\u17D2\u179B\u17B6\u179A\u17A2\u179A\u17B6\u1798\u17C1\u179A\u17B7\u1780)</th>\n <th>\u179A\u1794\u17C0\u1794\u1794\u1784\u17CB\u1794\u17BB\u1796\u17D2\u179C\u179B\u17B6\u1797</th>\n <th>\u1794\u17BB\u1796\u17D2\u179C\u179B\u17B6\u1797\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17CB<br/>(\u178A\u17BB\u179B\u17D2\u179B\u17B6\u179A\u17A2\u179A\u17B6\u1798\u17C1\u179A\u17B7\u1780)</th>\n </tr>\n </thead>\n <tbody>\n <% if (products && products.length > 0) { %>\n <% products.forEach((p) => { %>\n <tr>\n <td><%= p.name || '' %></td>\n <td><%= p.sumAssured || '' %></td>\n <td><%= p.paymentMethod || '' %></td>\n <td><%= p.premium || '' %></td>\n </tr>\n <% }) %>\n <% } else { %>\n <tr>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n </tr>\n <tr>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n </tr>\n <% } %>\n </tbody>\n </table>\n\n <div class=\"field-row\">\n <span class=\"label\">\u179C\u17B7\u178C\u17B8\u179F\u17B6\u179F\u17D2\u179A\u17D2\u178A\u1794\u1784\u17CB\u1794\u17BB\u1796\u17D2\u179C\u179B\u17B6\u1797\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17CB:</span>\n <div class=\"cb-group\">\n <div class=\"cb-item\">\n <div class=\"cb-box <%= paymentVia === 'transfer' ? 'checked' : '' %>\"></div>\n <span>\u1780\u17B6\u179A\u1795\u17D2\u1791\u17C1\u179A\u1794\u17D2\u179A\u17B6\u1780\u17CB\u1785\u17BC\u179B\u1791\u17C5\u1780\u17D2\u1793\u17BB\u1784\u1782\u178E\u1793\u17B8\u179A\u1794\u179F\u17CB\u17A0\u17D2\u179C\u17B8\u179B\u17B8\u17A1\u17B6\u1799\u17A0\u17D2\u179C\u17CD \u178F\u17B6\u1798\u179A\u1799\u17C7\u178A\u17C3\u1782\u17BC\u179A\u179A\u1794\u179F\u17CB\u17A0\u17D2\u179C\u17B8\u179B\u17B8\u17A1\u17B6\u1799\u17A0\u17D2\u179C\u17CD</span>\n </div>\n <div class=\"cb-item\">\n <div class=\"cb-box <%= paymentVia === 'cash' ? 'checked' : '' %>\"></div>\n <span>\u178F\u17B6\u1798\u179A\u1799\u17C8\u178A\u17C3\u1782\u17BC\u179A\u1794\u179F\u17CB\u17A0\u17D2\u179C\u17B8\u179B\u17B8\u17A1\u17B6\u1799\u17A0\u17D2\u179C\u17CD</span>\n </div>\n </div>\n </div>\n\n \n <div class=\"section-header\">\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u17A2\u17C6\u1796\u17B8\u17A2\u17D2\u1793\u1780\u1791\u1791\u17BD\u179B\u1795\u179B</div>\n\n <table>\n <thead>\n <tr>\n <th>\u1788\u17D2\u1798\u17C4\u17C7\u1796\u17C1\u1789\u179A\u1794\u179F\u17CB\u17A2\u17D2\u1793\u1780\u1791\u1791\u17BD\u179B\u1795\u179B</th>\n <th>\u17A2\u17B6\u1799\u17BB</th>\n <th>\u1791\u17C6\u1793\u17B6\u1780\u17CB\u1791\u17C6\u1793\u1784</th>\n <th>\u179B\u17C1\u1781\u17A2\u178F\u17B7\u1790\u17B7\u1787\u1793/\u17AF\u1780\u179F\u17B6\u179A</th>\n <th>% \u1793\u17C3\u1780\u17B6\u179A\u1794\u17C2\u1784\u1785\u17C2\u1780</th>\n </tr>\n </thead>\n <tbody>\n <% if (beneficiaries && beneficiaries.length > 0) { %>\n <% beneficiaries.forEach((b) => { %>\n <tr>\n <td><%= b.fullName || '' %></td>\n <td><%= b.age || '' %></td>\n <td><%= b.relationship || '' %></td>\n <td><%= b.idNumber || '' %></td>\n <td><%= b.percentage || '' %></td>\n </tr>\n <% }) %>\n <% } else { %>\n <tr>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n </tr>\n <tr>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n </tr>\n <tr>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n <td class=\"td-empty\"></td>\n </tr>\n <% } %>\n </tbody>\n </table>\n\n <div class=\"note\">\n <span>\u1780\u178E\u178F\u17CB\u179F\u1798\u17D2\u1782\u17B6\u179B\u17CB\u17D6 \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1797\u17B6\u1782\u179A\u1799\u1798\u17B7\u1793\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1794\u1789\u17D2\u1787\u17B6\u1780\u17CB\u1785\u17C6\u1793\u17BD\u1793\u1791\u17B9\u1780\u1794\u17D2\u179A\u17B6\u1780\u17CB\u1793\u17B9\u1784\u178F\u17D2\u179A\u17BC\u179C\u1794\u17C2\u1784\u1785\u17C2\u1780\u179F\u17D2\u1798\u17BE\u17D7\u1782\u17D2\u1793\u17B6</span>\n <span>% \u179F\u179A\u17BB\u1794\u179F\u17D2\u1798\u17BE\u179A \u17E1\u17E0\u17E0%</span>\n </div>\n\n \n <div class=\"section-header\">\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u1796\u17B6\u1780\u17CB\u1796\u17D0\u1793\u17D2\u1791\u1793\u17B9\u1784\u179F\u17BB\u1781\u1797\u17B6\u1796\u179A\u1794\u179F\u17CB \u17A2\u17D2\u1793\u1780\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17CB</div>\n\n \n <div class=\"health-q\">\n <span class=\"q-text\">1) \u1780\u1798\u17D2\u1796\u179F\u17CB:</span>\n <span class=\"underline xs\"><%= height %></span> \u179F.\u1798\n <span class=\"q-text\" style=\"margin-left:8px;\">\u1791\u1798\u17D2\u1784\u1793\u17CB:</span>\n <span class=\"underline xs\"><%= weight %></span> \u1782.\u1780\n <span class=\"q-text\" style=\"margin-left:8px;\">\u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1796\u17B7\u179F\u17B6\u179A\u1794\u17B6\u179A\u17B8\u178A\u17C2\u179A\u17AC\u1791\u17C1?:</span>\n <div class=\"cb-group\" style=\"display:inline-flex; margin-left:4px;\">\n <div class=\"cb-item\"><div class=\"cb-box <%= !smokes ? 'checked' : '' %>\"></div><span>\u1798\u17B7\u1793\u1798\u17B6\u1793</span></div>\n <div class=\"cb-item\"><div class=\"cb-box <%= smokes ? 'checked' : '' %>\"></div><span>\u1798\u17B6\u1793</span></div>\n </div>\n <span class=\"underline xs\"><%= smokesCount %></span> \u1780\u17D2\u1793\u17BB\u1784\u1798\u17BD\u1799\u1790\u17D2\u1784\u17C3\n </div>\n\n \n <div class=\"health-q\">\n <span class=\"q-text\">2) \u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1796\u17B7\u179F\u17B6\u179A\u1782\u17D2\u179A\u17BF\u1784\u179F\u17D2\u179A\u179C\u17B9\u1784\u178A\u17C2\u179A\u17AC\u1791\u17C1?:</span>\n <div class=\"cb-group\" style=\"display:inline-flex; margin-left:4px;\">\n <div class=\"cb-item\"><div class=\"cb-box <%= !drinksAlcohol ? 'checked' : '' %>\"></div><span>\u1798\u17B7\u1793\u1798\u17B6\u1793</span></div>\n <div class=\"cb-item\"><div class=\"cb-box <%= drinksAlcohol ? 'checked' : '' %>\"></div><span>\u1798\u17B6\u1793</span></div>\n </div>\n <span class=\"underline xs\"><%= alcoholCount %></span> \u1780\u17D2\u1793\u17BB\u1784\u1798\u17BD\u1799\u179F\u1794\u17D2\u178A\u17B6\u17A0\u17CD\n </div>\n\n \n <div class=\"health-q\">\n <span class=\"q-text\">3) \u1780\u17D2\u1793\u17BB\u1784\u179A\u1799\u17C8\u1796\u17C1\u179B\u17E0\u17E2(\u1796\u17B8\u179A)\u1786\u17D2\u1793\u17B6\u17C6\u1785\u17BB\u1784\u1780\u17D2\u179A\u17C4\u1799\u1793\u17C1\u17C7\u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1792\u17D2\u179B\u17B6\u1794\u17CB\u1794\u17B6\u1793\u179F\u1798\u17D2\u179A\u17B6\u1780\u1780\u17D2\u1793\u17BB\u1784\u1798\u1793\u17D2\u1791\u17B8\u179A\u1796\u17C1\u1791\u17D2\u1799 \u1792\u17D2\u179B\u17B6\u1794\u17CB\u1794\u17B6\u1793\u1791\u1791\u17BD\u179B\u1780\u17B6\u179A\u179C\u17C7\u1780\u17B6\u178F\u17CB \u17AC\u1792\u17D2\u179B\u17B6\u1794\u17CB\u1791\u1791\u17BD\u179B\u1794\u17B6\u1793\u179B\u1791\u17D2\u1792\u1795\u179B\u1781\u17BB\u179F\u1794\u17D2\u179A\u1780\u17D2\u179A\u178F\u17B8\u17A2\u17C6\u1796\u17B8\u1780\u17B6\u179A\u179C\u17B7\u1797\u17B6\u1782\u1788\u17B6\u1798 \u1780\u17B6\u179A\u179C\u17B7\u1797\u17B6\u1782\u1791\u17B9\u1780\u1793\u17C4\u1798 \u1780\u17B6\u179A\u1790\u178F\u1780\u17B6\u17C6\u179A\u179F\u17D2\u1798\u17B8\u17A2\u17BB\u17B7\u1785 (X-ray) \u1798\u17C9\u17B6\u179F\u17CA\u17B8\u1793\u179C\u17B6\u179F\u17CB\u1785\u1784\u17D2\u179C\u17B6\u1780\u17CB\u1794\u17C1\u17C7\u178A\u17BC\u1784 \u17A2\u17C1\u1780\u17BC\u179F\u17B6\u179F\u17D2\u179A\u17D2\u178A\u179F\u17D2\u1780\u17C1\u1793 \u1780\u17B6\u179A\u1785\u17D2\u179A\u17B9\u1794\u179F\u17B6\u1785\u17CB\u1799\u1780\u1796\u17B7\u1793\u17B7\u178F\u17D2\u1799 \u17AC\u179B\u1791\u17D2\u1792\u1795\u179B\u179C\u17B7\u1797\u17B6\u1782\u1795\u17D2\u179F\u17C1\u1784\u17D7\u1791\u17C0\u178F\u178A\u17C2\u179B\u1798\u17B7\u1793\u1794\u17B6\u1793\u179A\u17C0\u1794\u179A\u17B6\u1794\u17CB\u1781\u17B6\u1784\u178A\u17BE\u1798\u1796\u17B8\u1782\u17D2\u179A\u17BC\u1796\u17C1\u1791\u17D2\u1799\u178A\u17C2\u179A\u17AC\u1791\u17C1?:</span>\n <div class=\"cb-group\" style=\"display:inline-flex; margin-left:4px;\">\n <div class=\"cb-item\"><div class=\"cb-box <%= !hospitalizedQ3 ? 'checked' : '' %>\"></div><span>\u1798\u17B7\u1793\u1798\u17B6\u1793</span></div>\n <div class=\"cb-item\"><div class=\"cb-box <%= hospitalizedQ3 ? 'checked' : '' %>\"></div><span>\u1798\u17B6\u1793</span></div>\n </div>\n\n <% if (hospitalizedQ3) { %>\n <div class=\"detail-line\"><%= hospitalizedQ3Detail %></div>\n <% } %>\n </div>\n\n \n <div class=\"page-break\"></div>\n <div class=\"page-num\">\u1791\u17C6\u1796\u17D0\u179A 2 \u1793\u17C3 2</div>\n\n \n <div class=\"health-q\">\n <span class=\"q-text\">4) \u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1792\u17D2\u179B\u17B6\u1794\u17CB\u1794\u17B6\u1793\u1792\u17D2\u179C\u17BE\u179A\u17C4\u1782\u179C\u17B7\u1793\u17B7\u1785\u17D2\u1786\u17D0\u1799 \u1796\u17B7\u1782\u17D2\u179A\u17C4\u17C7\u1787\u17C6\u1784\u17BA\u17AC\u1791\u1791\u17BD\u179B\u1780\u17B6\u179A\u1796\u17D2\u1799\u17B6\u1794\u17B6\u179B\u178A\u17BC\u1785\u1787\u17B6 \u179B\u17BE\u179F\u179F\u1798\u17D2\u1796\u17B6\u1792\u1788\u17B6\u1798 \u1791\u17B9\u1780\u1793\u17C4\u1798\u1795\u17D2\u17A2\u17C2\u1798 \u1787\u17C6\u1784\u17BA\u1794\u17C1\u17C7\u178A\u17BC\u1784 \u1785\u17BB\u1780\u1791\u17D2\u179A\u17BC\u1784 \u1787\u17C6\u1784\u17BA\u179F\u17BD\u178F \u1787\u17C6\u1784\u17BA\u1790\u17D2\u179B\u17BE\u1798 \u1787\u17C6\u1784\u17BA\u178F\u1798\u17D2\u179A\u1784\u1793\u17C4\u1798 \u1798\u17A0\u17B6\u179A\u17B8\u1780 \u1787\u17C6\u1784\u17BA\u178A\u17B6\u1785\u17CB\u179F\u179F\u17C3\u1788\u17B6\u1798\u1781\u17BD\u179A\u1780\u17D2\u1794\u17B6\u179B \u1787\u17C6\u1784\u17BA\u17A2\u17C1\u178A\u179F\u17CD \u1787\u17C6\u1784\u17BA\u1795\u17D2\u179B\u17BC\u179C\u1785\u17B7\u178F\u17D2\u178F \u1796\u17B7\u1780\u17B6\u179A\u1797\u17B6\u1796 \u17AC\u179A\u17B6\u1784\u1780\u17B6\u1799\u1798\u17B7\u1793\u1794\u17D2\u179A\u1780\u17D2\u179A\u178F\u17B8 \u1794\u17D2\u179A\u17BE\u1794\u17D2\u179A\u17B6\u179F\u17CB\u1790\u17D2\u1793\u17B6\u17C6\u1789\u17C0\u1793 \u17AC\u1789\u17C0\u1793\u179F\u17D2\u179A\u17B6 \u17AC\u1787\u17C6\u1784\u17BA\u1795\u17D2\u179F\u17C1\u1784\u1791\u17C0\u178F\u178A\u17C2\u179B\u1798\u17B7\u1793\u1794\u17B6\u1793\u179A\u17C0\u1794\u179A\u17B6\u1794\u17CB\u1781\u17B6\u1784\u179B\u17BE\u178A\u17C2\u179A\u17AC\u1791\u17C1?</span>\n <div class=\"cb-group\" style=\"display:inline-flex; margin-left:4px;\">\n <div class=\"cb-item\"><div class=\"cb-box <%= !diagnosedQ4 ? 'checked' : '' %>\"></div><span>\u1798\u17B7\u1793\u1798\u17B6\u1793</span></div>\n <div class=\"cb-item\"><div class=\"cb-box <%= diagnosedQ4 ? 'checked' : '' %>\"></div><span>\u1798\u17B6\u1793</span></div>\n </div>\n\n <% if (diagnosedQ4) { %>\n <div style=\"margin-top:4px; font-size:8pt;\">\u1794\u17BE\u1798\u17B6\u1793\u179F\u17BC\u1798\u1794\u1789\u17D2\u1787\u17B6\u1780\u17CB\u179B\u1798\u17D2\u17A2\u17B7\u178F\u1781\u17B6\u1784\u1780\u17D2\u179A\u17C4\u1798\u17D6</div>\n <div class=\"detail-line\"><%= diagnosedQ4Detail %></div>\n <% } %>\n </div>\n\n \n <div class=\"section-header\">\u179F\u17C1\u1785\u1780\u17D2\u178A\u17B8\u1794\u17D2\u179A\u1780\u17B6\u179F\u179A\u1794\u179F\u17CB\u17A2\u17D2\u1793\u1780\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17CB</div>\n\n <div class=\"declaration\">\n <p>1) \u1781\u17D2\u1789\u17BB\u17C6\u17A2\u1793\u17BB\u1789\u17D2\u1789\u17B6\u178F \u1793\u17B7\u1784\u1799\u179B\u17CB\u1796\u17D2\u179A\u1798\u17B2\u17D2\u1799\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u1794\u17D2\u179A\u17BE\u1794\u17D2\u179A\u17B6\u179F\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793 \u1793\u17B7\u1784\u1791\u17B7\u1793\u17D2\u1793\u1793\u17D0\u1799\u1791\u17B6\u17C6\u1784\u179F\u17D2\u179A\u17BB\u1784\u178A\u17C2\u179B\u1781\u17D2\u1789\u17BB\u17C6\u1794\u17B6\u1793\u1795\u17D2\u178A\u179B\u17CB\u1793\u17C5\u1780\u17D2\u1793\u17BB\u1784\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u179A\u1794\u179F\u17CB\u1781\u17D2\u1789\u17BB\u17C6\u1780\u17D2\u1793\u17BB\u1784\u1782\u17C4\u179B\u1794\u17C6\u178E\u1784 \u179F\u17D2\u179A\u1794\u178F\u17B6\u1798\u1785\u17D2\u1794\u17B6\u1794\u17CB \u178A\u17BC\u1785\u1787\u17B6 \u1780\u17B6\u179A\u1795\u17D2\u179F\u1796\u17D2\u179C\u1795\u17D2\u179F\u17B6\u1799\u1791\u17B8\u1795\u17D2\u179F\u17B6\u179A \u1780\u17B6\u179A\u179F\u17B7\u1780\u17D2\u179F\u17B6\u1791\u17B8\u1795\u17D2\u179F\u17B6\u179A \u1793\u17B7\u1784 \u1780\u17B6\u179A\u1794\u1798\u17D2\u179A\u17BE\u17A2\u178F\u17B7\u1790\u17B7\u1787\u1793\u178A\u17C4\u1799\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793 \u179F\u1798\u17D2\u1796\u17D0\u1793\u17D2\u1792\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793 \u17AC \u1787\u17B6\u178A\u17C3\u1782\u17BC\u1796\u17B6\u178E\u17B7\u1787\u17D2\u1787\u1780\u1798\u17D2\u1798\u179A\u1794\u179F\u17CB\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793 \u178A\u17C4\u1799\u1798\u17B7\u1793\u1785\u17B6\u17C6\u1794\u17B6\u1785\u17CB\u1798\u17B6\u1793\u1780\u17B6\u179A\u1799\u179B\u17CB\u1796\u17D2\u179A\u1798 \u1793\u17B7\u1784\u1787\u17BC\u1793\u178A\u17C6\u178E\u17B9\u1784\u1794\u1793\u17D2\u1790\u17C2\u1798\u1796\u17B8\u1781\u17D2\u1789\u17BB\u17C6\u17A1\u17BE\u1799\u17D4 \u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u1798\u17B7\u1793\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u17A2\u1793\u17BB\u1789\u17D2\u1789\u17B6\u178F\u17B2\u17D2\u1799\u1794\u1789\u17D2\u1785\u17C1\u1789\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u178E\u17B6\u1798\u17BD\u1799\u1791\u17C5\u1797\u17B6\u1782\u17B8\u1791\u17B8\u1794\u17B8\u178E\u17B6\u1798\u17BD\u1799 \u17AC\u1794\u17D2\u179A\u17BE\u1794\u17D2\u179A\u17B6\u179F\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u1793\u17C4\u17C7\u179F\u1798\u17D2\u179A\u17B6\u1794\u17CB\u1782\u17C4\u179B\u1794\u17C6\u178E\u1784\u1795\u17D2\u179F\u17C1\u1784\u1791\u17C0\u178F\u178A\u17C2\u179B\u1798\u17B7\u1793\u1791\u17B6\u1780\u17CB\u1791\u1784\u1793\u17B9\u1784\u1782\u17C4\u179B\u1794\u17C6\u178E\u1784\u1791\u17B6\u17C6\u1784\u17A1\u17B6\u1799\u1781\u17B6\u1784\u179B\u17BE\u17A1\u17BE\u1799 \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1782\u17D2\u1798\u17B6\u1793\u1780\u17B6\u179A\u1799\u179B\u17CB\u1796\u17D2\u179A\u1798\u1796\u17D2\u179A\u17C0\u1784\u1787\u17B6\u179B\u17B6\u1799\u179B\u1780\u17D2\u1781\u178E\u17CD\u17A2\u1780\u17D2\u179F\u179A\u1793\u17C4\u17C7\u17D4</p>\n <p>2) \u1781\u17D2\u1789\u17BB\u17C6\u179F\u17BC\u1798\u17A2\u17C7\u17A2\u17B6\u1784\u1790\u17B6\u1794\u17B6\u1793\u17A2\u17B6\u1793 \u1793\u17B7\u1784\u1799\u179B\u17CB\u179F\u17D2\u179A\u1794\u1793\u17BC\u179C\u1782\u17D2\u179A\u1794\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u1780\u17D2\u1793\u17BB\u1784\u17AF\u1780\u179F\u17B6\u179A\u1793\u17C1\u17C7\u17D4 \u1781\u17D2\u1789\u17BB\u17C6\u179F\u17BC\u1798\u1794\u17D2\u179A\u1780\u17B6\u179F\u1790\u17B6\u1782\u17D2\u179A\u1794\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u178A\u17C2\u179B\u1794\u17B6\u1793\u1795\u17D2\u178A\u179B\u17CB\u1793\u17C5\u1780\u17D2\u1793\u17BB\u1784\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1793\u17C1\u17C7 \u1796\u17B7\u178F\u1787\u17B6\u1798\u17B6\u1793\u1797\u17B6\u1796\u1796\u17C1\u1789\u179B\u17C1\u1789 \u1793\u17B7\u1784\u178F\u17D2\u179A\u17B9\u1798\u178F\u17D2\u179A\u17BC\u179C\u1796\u17B7\u178F\u1794\u17D2\u179A\u17B6\u1780\u178A\u1798\u17C2\u1793\u17D4</p>\n </div>\n\n \n <div class=\"sig-row\">\n <div class=\"sig-block\">\n <div>\u17A0\u178F\u17D2\u1790\u179B\u17C1\u1781\u17B6 \u17AC\u179F\u17D2\u1793\u17B6\u1798\u1798\u17C1\u178A\u17C3\u179A\u1794\u179F\u17CB\u17A2\u17D2\u1793\u1780\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784</div>\n <div class=\"sig-line\"></div>\n <div class=\"field-row\">\n <span class=\"label\">\u1788\u17D2\u1798\u17C4\u17C7</span>\n <span class=\"underline full\"><%= applicantSignatureName %></span>\n </div>\n <div class=\"field-row\">\n <span class=\"label\">\u1780\u17B6\u179B\u1794\u179A\u17B7\u1785\u17D2\u1786\u17C1\u1791</span>\n <span class=\"underline full\"><%= signatureDate %></span>\n </div>\n </div>\n <div class=\"sig-block\">\n <div>\u17A0\u178F\u17D2\u1790\u179B\u17C1\u1781\u17B6 \u17AC\u179F\u17D2\u1793\u17B6\u1798\u1798\u17C1\u178A\u17C3\u179A\u1794\u179F\u17CB\u179F\u17B6\u1780\u17D2\u179F\u17B8</div>\n <div class=\"sig-line\"></div>\n <div class=\"field-row\">\n <span class=\"label\">\u1788\u17D2\u1798\u17C4\u17C7</span>\n <span class=\"underline full\"><%= witnessName %></span>\n </div>\n <div class=\"field-row\">\n <span class=\"label\">\u1780\u17B6\u179B\u1794\u179A\u17B7\u1785\u17D2\u1786\u17C1\u1791</span>\n <span class=\"underline full\"><%= witnessDate %></span>\n </div>\n </div>\n </div>\n\n </body>\n</html>\n";