plac-micro-common 1.3.95 → 1.3.96
This diff represents the content of publicly available package versions that have been released to one of the supported registries. The information contained in this diff is provided for informational purposes only and reflects changes between package versions as they appear in their respective public registries.
- package/dist/libs/pdf-form/templates/receipt.template.d.ts +1 -1
- package/dist/libs/pdf-form/templates/receipt.template.js +224 -210
- package/dist/libs/pdf-form/templates/sio-form-kh.template.d.ts +1 -1
- package/dist/libs/pdf-form/templates/sio-form-kh.template.js +845 -657
- package/dist/libs/pdf-form/templates/uw-form.template.d.ts +1 -1
- package/dist/libs/pdf-form/templates/uw-form.template.js +1551 -1533
- package/package.json +1 -1
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@@ -4,748 +4,936 @@ exports.SIO_FORM_KH_TEMPLATE = void 0;
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exports.SIO_FORM_KH_TEMPLATE = `
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<!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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<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">
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<style>
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body {
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font-family: "Hanuman", system-ui, sans-serif;
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font-size: 12px;
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line-height: 1.4;
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margin: 1rem;
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/* Reduced from 2rem */
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background: #fff;
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color: #000;
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}
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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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<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">
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<style>
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body {
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font-family: "Hanuman", system-ui, sans-serif;
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font-size: 12px;
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line-height: 1.4;
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margin: 1rem;
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/* Reduced from 2rem */
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background: #fff;
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color: #000;
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}
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.space {
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width: 8px;
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}
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/* margin */
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.ml-4 {
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margin-left: 1rem;
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}
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.ml-8 {
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margin-left: 2rem;
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}
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.mr-4 {
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margin-right: 1rem;
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}
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.mr-8 {
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margin-right: 2rem;
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}
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.mt-4 {
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margin-top: 1rem;
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}
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.mt-8 {
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margin-top: 2rem;
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}
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.mb-4 {
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margin-bottom: 1rem;
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}
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.mb-8 {
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margin-bottom: 2rem;
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}
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/* alignment */
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.align-left {
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justify-content: flex-start !important;
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text-align: left;
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padding-left: 16px;
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}
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.align-right {
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justify-content: flex-end !important;
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text-align: right;
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padding-right: 16px;
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}
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.align-center {
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justify-content: center !important;
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text-align: center;
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}
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.space-height {
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height: 60px;
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align-items: center;
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}
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.signature-space {
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height: 100px;
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margin-top: 10px;
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}
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/* === Page header === */
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.page-header {
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margin-bottom: 0.5rem;
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page-break-inside: avoid;
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}
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.header-container {
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display: flex;
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flex-direction: column;
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align-items: center;
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}
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.title-logo {
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width: 125px;
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height: auto;
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}
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.title {
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font-weight: 700;
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font-size: 14px;
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line-height: 1;
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}
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.title-container {
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text-align: center;
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font-weight: 700;
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font-size: 14px;
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line-height: 1.4;
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margin: 0;
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}
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/* === Card Header === */
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.card-header {
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background-color: #0d6efd;
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color: white;
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text-align: center;
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padding: 0.1rem 0;
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border-radius: 6px 6px 0 0;
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font-weight: bold;
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margin-bottom: 0.5rem;
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/* Reduced */
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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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/* === Form Text === */
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.form-container {
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display: flex;
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flex-wrap: wrap;
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margin: 0;
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padding: 0;
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gap: 0.5rem;
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}
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.form-item {
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display: flex;
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align-items: flex-start;
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flex-wrap: wrap;
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width: 100%;
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}
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.label,
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.question-label {
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word-wrap: break-word;
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white-space: normal;
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font-weight: 500;
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color: #444;
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}
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/* Underline for blanks */
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.underline {
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border-bottom: 1px dashed #000;
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flex: 1;
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min-width: 60px;
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min-height: 1em;
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display: inline-flex;
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align-items: center;
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justify-content: center;
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text-align: center;
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word-break: break-word;
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white-space: normal;
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-webkit-box-decoration-break: clone;
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box-decoration-break: clone;
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align-self: flex-end;
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color: #000;
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}
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/* size variants */
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.underline.xs {
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flex: none;
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width: 30px;
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min-width: unset;
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}
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.underline.sm {
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flex: none;
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width: 80px;
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min-width: unset;
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}
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.underline.md {
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flex: none;
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width: 180px;
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min-width: unset;
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}
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.underline.lg {
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flex: 2;
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}
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.underline.with-unit {
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flex: 1;
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min-width: 0;
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display: block;
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word-break: break-word;
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white-space: normal;
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border-bottom: none;
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line-height: 1.6em;
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text-align: left;
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padding-left: 4px;
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}
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.with-unit .value {
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display: inline;
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text-decoration: underline;
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text-decoration-style: dashed;
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text-decoration-color: #000;
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text-underline-offset: 3px;
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-webkit-box-decoration-break: clone;
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box-decoration-break: clone;
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vertical-align: baseline;
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}
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.unit {
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display: inline;
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white-space: nowrap;
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margin-left: 4px;
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text-decoration: none;
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}
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/* Checkbox labels */
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.checkbox-label {
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display: inline-flex;
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align-items: center;
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gap: 0.5rem;
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position: relative;
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cursor: pointer;
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padding-left: 0.2rem;
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user-select: none;
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}
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.checkbox-label::before {
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content: "";
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display: inline-flex;
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align-items: center;
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justify-content: center;
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width: 20px;
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height: 20px;
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border: 2px solid #555;
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border-radius: 3px;
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background-color: #fff;
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box-sizing: border-box;
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flex-shrink: 0;
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}
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.checkbox-label.checked::after {
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content: "";
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position: absolute;
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top: 45%;
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left: calc(0.2rem + 7px);
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width: 6px;
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height: 12px;
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border: solid #0d6efd;
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border-width: 0 2px 2px 0;
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box-sizing: border-box;
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transform: translateY(-50%) rotate(45deg);
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pointer-events: none;
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}
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.page-break {
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page-break-before: always;
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}
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/* === Table data === */
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.table-container {
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margin: auto;
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margin-bottom: 4px;
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}
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table {
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width: 100%;
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border-collapse: collapse;
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}
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th,
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td {
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border: 1px solid #ccc;
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padding: 0;
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}
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.cell {
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min-height: 10px;
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padding: 4px 8px;
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display: flex;
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justify-content: center;
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text-align: center;
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}
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th {
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font-weight: 600;
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}
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/* === Print-specific: Footer with Page Numbers on the RIGHT === */
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@media print {
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body {
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margin: 0;
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padding-top: 10mm;
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}
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/*
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/* alignment */
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.align-left { justify-content: flex-start !important; text-align: left; padding-left: 16px; }
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.align-right { justify-content: flex-end !important; text-align: right; padding-right: 16px; }
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.align-center { justify-content: center !important; text-align: center; }
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.space-height {
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height: 60px;
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align-items: center;
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/* Make room for footer on the right side */
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@page {
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size: A4 portrait;
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margin: 15mm 15mm 20mm 10mm;
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/* increased right margin slightly for better spacing */
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@bottom-right {
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content: "ទំព័រ " counter(page) " នៃ " counter(pages);
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font-size: 11px;
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color: #555;
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font-family: "Battambang", sans-serif;
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/* Increment page counter */
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body {
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counter-increment: page;
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table {
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.title {
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margin: 0;
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}
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/* === Card Header === */
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.card-header {
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background-color: #0d6efd;
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color: white;
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border-radius: 6px 6px 0 0;
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font-weight: bold;
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margin-bottom: 0.5rem;
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/* Reduced */
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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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flex-wrap: wrap;
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width: 100%;
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}
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.label,
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.question-label {
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word-wrap: break-word;
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white-space: normal;
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font-weight: 500;
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color: #444;
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}
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|
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|
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/* Underline for blanks */
|
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|
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.underline {
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|
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border-bottom: 1px dashed #000;
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|
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flex: 1;
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min-width: 60px;
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min-height: 1em;
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text-align: center;
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word-break: break-word;
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white-space: normal;
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-webkit-box-decoration-break: clone;
|
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box-decoration-break: clone;
|
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align-self: flex-end;
|
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|
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color: #000;
|
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|
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}
|
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143
|
-
|
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144
|
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/* size variants */
|
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|
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.underline.xs { flex: none; width: 30px; min-width: unset; }
|
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146
|
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.underline.sm { flex: none; width: 80px; min-width: unset; }
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.underline.md { flex: none; width: 180px; min-width: unset; }
|
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|
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.underline.lg { flex: 2; }
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|
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|
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|
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.underline.with-unit {
|
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|
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flex: 1;
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|
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min-width: 0;
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153
|
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display: block;
|
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|
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word-break: break-word;
|
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155
|
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white-space: normal;
|
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156
|
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border-bottom: none;
|
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157
|
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line-height: 1.6em;
|
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158
|
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text-align: left;
|
|
159
|
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padding-left: 4px;
|
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160
|
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}
|
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161
|
-
|
|
162
|
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.with-unit .value {
|
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163
|
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display: inline;
|
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164
|
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text-decoration: underline;
|
|
165
|
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text-decoration-style: dashed;
|
|
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|
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text-decoration-color: #000;
|
|
167
|
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text-underline-offset: 3px;
|
|
168
|
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-webkit-box-decoration-break: clone;
|
|
169
|
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box-decoration-break: clone;
|
|
170
|
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vertical-align: baseline;
|
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171
|
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}
|
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172
|
-
|
|
173
|
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.unit {
|
|
174
|
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display: inline;
|
|
175
|
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white-space: nowrap;
|
|
176
|
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margin-left: 4px;
|
|
177
|
-
text-decoration: none;
|
|
178
|
-
}
|
|
179
|
-
|
|
180
|
-
/* Checkbox labels */
|
|
181
|
-
.checkbox-label {
|
|
182
|
-
display: inline-flex;
|
|
183
|
-
align-items: center;
|
|
184
|
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gap: 0.5rem;
|
|
185
|
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position: relative;
|
|
186
|
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cursor: pointer;
|
|
187
|
-
padding-left: 0.2rem;
|
|
188
|
-
user-select: none;
|
|
189
|
-
}
|
|
190
|
-
|
|
191
|
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.checkbox-label::before {
|
|
192
|
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content: "";
|
|
193
|
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display: inline-flex;
|
|
194
|
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align-items: center;
|
|
195
|
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justify-content: center;
|
|
196
|
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width: 20px;
|
|
197
|
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height: 20px;
|
|
198
|
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border: 2px solid #555;
|
|
199
|
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border-radius: 3px;
|
|
200
|
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background-color: #fff;
|
|
201
|
-
box-sizing: border-box;
|
|
202
|
-
flex-shrink: 0;
|
|
203
|
-
}
|
|
204
|
-
|
|
205
|
-
.checkbox-label.checked::after {
|
|
206
|
-
content: "";
|
|
207
|
-
position: absolute;
|
|
208
|
-
top: 45%;
|
|
209
|
-
left: calc(0.2rem + 7px);
|
|
210
|
-
width: 6px;
|
|
211
|
-
height: 12px;
|
|
212
|
-
border: solid #0d6efd;
|
|
213
|
-
border-width: 0 2px 2px 0;
|
|
214
|
-
box-sizing: border-box;
|
|
215
|
-
transform: translateY(-50%) rotate(45deg);
|
|
216
|
-
pointer-events: none;
|
|
217
|
-
}
|
|
218
|
-
|
|
219
|
-
.page-break {
|
|
220
|
-
page-break-before: always;
|
|
221
|
-
}
|
|
222
|
-
|
|
223
|
-
/* === Table data === */
|
|
224
|
-
.table-container {
|
|
225
|
-
margin: auto;
|
|
226
|
-
margin-bottom: 4px;
|
|
227
|
-
}
|
|
228
|
-
|
|
229
|
-
table {
|
|
230
|
-
width: 100%;
|
|
231
|
-
border-collapse: collapse;
|
|
232
|
-
}
|
|
233
|
-
|
|
234
|
-
th,
|
|
235
|
-
td {
|
|
236
|
-
border: 1px solid #ccc;
|
|
237
|
-
padding: 0;
|
|
238
|
-
}
|
|
239
|
-
|
|
240
|
-
.cell {
|
|
241
|
-
min-height: 10px;
|
|
242
|
-
padding: 4px 8px;
|
|
243
|
-
display: flex;
|
|
244
|
-
justify-content: center;
|
|
245
|
-
text-align: center;
|
|
246
|
-
}
|
|
247
|
-
|
|
248
|
-
th {
|
|
249
|
-
font-weight: 600;
|
|
250
|
-
}
|
|
251
|
-
|
|
252
|
-
/* === Print-specific: Footer with Page Numbers on the RIGHT === */
|
|
253
|
-
@media print {
|
|
254
|
-
body {
|
|
255
|
-
margin: 0;
|
|
256
|
-
padding-top: 10mm;
|
|
257
|
-
}
|
|
258
|
-
|
|
259
|
-
/* Make room for footer on the right side */
|
|
260
|
-
@page {
|
|
261
|
-
size: A4 portrait;
|
|
262
|
-
margin: 15mm 15mm 20mm 10mm;
|
|
263
|
-
/* increased right margin slightly for better spacing */
|
|
264
|
-
|
|
265
|
-
@bottom-right {
|
|
266
|
-
content: "ទំព័រ " counter(page) " នៃ " counter(pages);
|
|
267
|
-
font-size: 11px;
|
|
268
|
-
color: #555;
|
|
269
|
-
font-family: "Battambang", sans-serif;
|
|
270
|
-
}
|
|
271
|
-
}
|
|
272
|
-
|
|
273
|
-
/* Increment page counter */
|
|
274
|
-
body {
|
|
275
|
-
counter-increment: page;
|
|
276
|
-
}
|
|
277
|
-
|
|
278
|
-
.page-header,
|
|
279
|
-
.title-container,
|
|
280
|
-
table {
|
|
281
|
-
page-break-inside: avoid;
|
|
282
|
-
}
|
|
283
|
-
|
|
284
|
-
.card-header {
|
|
285
|
-
-webkit-print-color-adjust: exact;
|
|
286
|
-
print-color-adjust: exact;
|
|
287
|
-
}
|
|
288
|
-
}
|
|
289
|
-
</style>
|
|
290
|
-
</head>
|
|
291
|
-
|
|
292
|
-
<body>
|
|
293
|
-
<div class="page-header mb-8">
|
|
294
|
-
<img src="data:image/png;base64,<%= logo_base64 %>" alt="Logo" class="title-logo" />
|
|
295
|
-
<div class="title-container">
|
|
296
|
-
<h1 class="title">ពាក្យស្នើសុំធានារ៉ាប់រងអាយុជីវិត</h1>
|
|
297
|
-
<h1 class="title">
|
|
298
|
-
សម្រាប់ទម្រង់សាមញ្ញសម្រាប់អតិថិជនជោគជ័យហ្វាយនែន (SIO)
|
|
299
|
-
</h1>
|
|
300
|
-
</div>
|
|
339
|
+
}
|
|
340
|
+
</style>
|
|
341
|
+
</head>
|
|
342
|
+
|
|
343
|
+
<body>
|
|
344
|
+
<div class="page-header mb-8">
|
|
345
|
+
<img src="data:image/png;base64,<%= logo_base64 %>" alt="Logo" class="title-logo" />
|
|
346
|
+
<div class="title-container">
|
|
347
|
+
<h1 class="title">ពាក្យស្នើសុំធានារ៉ាប់រងអាយុជីវិត</h1>
|
|
348
|
+
<h1 class="title">
|
|
349
|
+
សម្រាប់ទម្រង់សាមញ្ញសម្រាប់អតិថិជនជោគជ័យហ្វាយនែន (SIO)
|
|
350
|
+
</h1>
|
|
301
351
|
</div>
|
|
352
|
+
</div>
|
|
302
353
|
|
|
303
|
-
|
|
304
|
-
|
|
305
|
-
|
|
306
|
-
|
|
307
|
-
|
|
308
|
-
|
|
309
|
-
|
|
310
|
-
|
|
311
|
-
|
|
312
|
-
|
|
313
|
-
</div>
|
|
314
|
-
<div class="form-item">
|
|
315
|
-
<span class="label">ឈ្មោះនិងលេខកូដបុគ្គលិកធនាគារ</span>
|
|
316
|
-
<span class="underline">
|
|
317
|
-
<%= branch_staff_app_info.bank_staff_name %> / <%= branch_staff_app_info.bank_staff_code %>
|
|
318
|
-
</span>
|
|
319
|
-
<span class="label">លេខពាក្យស្នើសុំ</span>
|
|
320
|
-
<span class="underline">
|
|
321
|
-
<%= branch_staff_app_info.application_no %>
|
|
322
|
-
</span>
|
|
323
|
-
</div>
|
|
354
|
+
<div class="form-container">
|
|
355
|
+
<div class="form-item">
|
|
356
|
+
<span class="label">ឈ្មោះនិងលេខកូដសាខា</span>
|
|
357
|
+
<span class="underline">
|
|
358
|
+
<%= branch_staff_app_info.branch_name %> / <%= branch_staff_app_info.branch_code %>
|
|
359
|
+
</span>
|
|
360
|
+
<span class="label">ឈ្មោះនិងលេខកូដបុគ្គលិកធានារ៉ាប់រង់</span>
|
|
361
|
+
<span class="underline">
|
|
362
|
+
<%= branch_staff_app_info.advisor_name %> / <%= branch_staff_app_info.advisor_code %>
|
|
363
|
+
</span>
|
|
324
364
|
</div>
|
|
365
|
+
<div class="form-item">
|
|
366
|
+
<span class="label">ឈ្មោះនិងលេខកូដបុគ្គលិកធនាគារ</span>
|
|
367
|
+
<span class="underline">
|
|
368
|
+
<%= branch_staff_app_info.bank_staff_name %> / <%= branch_staff_app_info.bank_staff_code %>
|
|
369
|
+
</span>
|
|
370
|
+
<span class="label">លេខពាក្យស្នើសុំ</span>
|
|
371
|
+
<span class="underline">
|
|
372
|
+
<%= branch_staff_app_info.application_no %>
|
|
373
|
+
</span>
|
|
374
|
+
</div>
|
|
375
|
+
</div>
|
|
325
376
|
|
|
326
|
-
|
|
327
|
-
|
|
377
|
+
<!-- Section 1 -->
|
|
378
|
+
<div class="card-header mt-4">ព័ត៌មានអំពីអ្នកស្នើសុំបណ្ណសន្យារ៉ាប់រង់</div>
|
|
328
379
|
|
|
329
|
-
|
|
330
|
-
|
|
331
|
-
|
|
332
|
-
|
|
333
|
-
|
|
334
|
-
|
|
335
|
-
|
|
380
|
+
<div class="form-container">
|
|
381
|
+
<div class="form-item">
|
|
382
|
+
<span class="label">ឈ្មោះពេញដូចបង្ហាញនៅក្នុងឯកសារអត្តសញ្ញាណ ជាភាសាខ្មែរ:</span>
|
|
383
|
+
<span class="underline">
|
|
384
|
+
<%= applicant_info.full_name_kh %>
|
|
385
|
+
</span>
|
|
386
|
+
<span class="label">ជាភាសាអង់គ្លេស</span>
|
|
387
|
+
<span class="underline">
|
|
388
|
+
<%= applicant_info.full_name %>
|
|
389
|
+
</span>
|
|
390
|
+
</div>
|
|
336
391
|
|
|
337
|
-
|
|
338
|
-
|
|
339
|
-
|
|
340
|
-
|
|
341
|
-
|
|
342
|
-
<div class="ml-8"></div>
|
|
343
|
-
|
|
344
|
-
<div>
|
|
345
|
-
<span class="label">ស្ថានភាពគ្រួសារ:</span>
|
|
346
|
-
<label class="checkbox-label <%= applicant_info.marital_status === 'single' ? 'checked' : '' %>">
|
|
347
|
-
នៅលីវ
|
|
348
|
-
</label>
|
|
349
|
-
<label class="checkbox-label <%= applicant_info.marital_status === 'married' ? 'checked' : '' %>">
|
|
350
|
-
រៀបការហើយ
|
|
351
|
-
</label>
|
|
352
|
-
<label class="checkbox-label <%= applicant_info.marital_status === 'divorced' ? 'checked' : '' %>">
|
|
353
|
-
លែងលះ
|
|
354
|
-
</label>
|
|
355
|
-
<label class="checkbox-label <%= applicant_info.marital_status === 'widowed' ? 'checked' : '' %>">
|
|
356
|
-
មេម៉ាយ/ពោះម៉ាយ
|
|
357
|
-
</label>
|
|
358
|
-
</div>
|
|
359
|
-
</div>
|
|
392
|
+
<div class="form-item">
|
|
393
|
+
<span class="label">ភេទ:</span>
|
|
394
|
+
<label class="checkbox-label <%= applicant_info.gender === 'M' ? 'checked' : '' %>">ប្រុស</label>
|
|
395
|
+
<label class="checkbox-label <%= applicant_info.gender === 'F' ? 'checked' : '' %>">ស្រី</label>
|
|
360
396
|
|
|
361
|
-
<div class="
|
|
362
|
-
<span class="label">តួនាទី និងប្រភេទការងារ:</span>
|
|
363
|
-
<span class="underline align-left"><%= applicant_info.occupation %></span>
|
|
364
|
-
</div>
|
|
397
|
+
<div class="ml-8"></div>
|
|
365
398
|
|
|
366
|
-
<div
|
|
367
|
-
<span class="label"
|
|
368
|
-
<label class="checkbox-label <%= applicant_info.
|
|
369
|
-
|
|
399
|
+
<div>
|
|
400
|
+
<span class="label">ស្ថានភាពគ្រួសារ:</span>
|
|
401
|
+
<label class="checkbox-label <%= applicant_info.marital_status === 'single' ? 'checked' : '' %>">
|
|
402
|
+
នៅលីវ
|
|
370
403
|
</label>
|
|
371
|
-
<label class="checkbox-label <%= applicant_info.
|
|
372
|
-
|
|
404
|
+
<label class="checkbox-label <%= applicant_info.marital_status === 'married' ? 'checked' : '' %>">
|
|
405
|
+
រៀបការហើយ
|
|
373
406
|
</label>
|
|
374
|
-
<label class="checkbox-label <%= applicant_info.
|
|
375
|
-
|
|
407
|
+
<label class="checkbox-label <%= applicant_info.marital_status === 'divorced' ? 'checked' : '' %>">
|
|
408
|
+
លែងលះ
|
|
376
409
|
</label>
|
|
377
|
-
<label class="checkbox-label <%= applicant_info.
|
|
378
|
-
|
|
410
|
+
<label class="checkbox-label <%= applicant_info.marital_status === 'widowed' ? 'checked' : '' %>">
|
|
411
|
+
មេម៉ាយ/ពោះម៉ាយ
|
|
379
412
|
</label>
|
|
380
|
-
|
|
381
|
-
|
|
382
|
-
<!-- other field stays separate since it has extra input -->
|
|
383
|
-
<label class="underline"><%= applicant_info.identity_other_description %></label>
|
|
384
|
-
</div>
|
|
385
|
-
|
|
386
|
-
<div class="form-item">
|
|
387
|
-
<span class="label">លេខអត្តសញ្ញាណ:</span>
|
|
388
|
-
<span class="underline"><%= applicant_info.identity_no %></span>
|
|
389
|
-
<span class="label">ថ្ងៃខែឆ្នាំកំណើត:</span>
|
|
390
|
-
<span class="underline"><%= applicant_info.date_of_birth %></span>
|
|
391
|
-
<span class="label">អាយុ:</span>
|
|
392
|
-
<span class="underline xs"><%= applicant_info.age %></span>
|
|
393
|
-
<span class="label">សញ្ចាតិ:</span>
|
|
394
|
-
<span class="underline"><%= applicant_info.nationality %></span>
|
|
395
|
-
<span class="label">លេខទូរស័ព្ទ:</span>
|
|
396
|
-
<span class="underline"><%= applicant_info.phone_number %></span>
|
|
397
413
|
</div>
|
|
414
|
+
</div>
|
|
398
415
|
|
|
399
|
-
|
|
400
|
-
|
|
401
|
-
|
|
402
|
-
|
|
416
|
+
<div class="form-item">
|
|
417
|
+
<span class="label">តួនាទី និងប្រភេទការងារ:</span>
|
|
418
|
+
<span class="underline align-left">
|
|
419
|
+
<%= applicant_info.occupation %>
|
|
420
|
+
</span>
|
|
421
|
+
</div>
|
|
403
422
|
|
|
423
|
+
<div class="form-item">
|
|
424
|
+
<span class="label">ឯកសារបញ្ចាក់អត្តសញ្ញាណ:</span>
|
|
425
|
+
<label class="checkbox-label <%= applicant_info.identity_type === 'nid' ? 'checked' : '' %>">
|
|
426
|
+
អត្តសញ្ញាណបណ្ណ
|
|
427
|
+
</label>
|
|
428
|
+
<label class="checkbox-label <%= applicant_info.identity_type === 'passport' ? 'checked' : '' %>">
|
|
429
|
+
លិខិតឆ្លងដែន
|
|
430
|
+
</label>
|
|
431
|
+
<label class="checkbox-label <%= applicant_info.identity_type === 'birth' ? 'checked' : '' %>">
|
|
432
|
+
សំបុត្រកំណើត
|
|
433
|
+
</label>
|
|
434
|
+
<label class="checkbox-label <%= applicant_info.identity_type === 'other' ? 'checked' : '' %>">
|
|
435
|
+
ផ្សេងទៀត:
|
|
436
|
+
</label>
|
|
437
|
+
|
|
438
|
+
|
|
439
|
+
<!-- other field stays separate since it has extra input -->
|
|
440
|
+
<label class="underline">
|
|
441
|
+
<%= applicant_info.identity_other_description %>
|
|
442
|
+
</label>
|
|
443
|
+
</div>
|
|
404
444
|
|
|
445
|
+
<div class="form-item">
|
|
446
|
+
<span class="label">លេខអត្តសញ្ញាណ:</span>
|
|
447
|
+
<span class="underline">
|
|
448
|
+
<%= applicant_info.identity_no %>
|
|
449
|
+
</span>
|
|
450
|
+
<span class="label">ថ្ងៃខែឆ្នាំកំណើត:</span>
|
|
451
|
+
<span class="underline">
|
|
452
|
+
<%= applicant_info.date_of_birth %>
|
|
453
|
+
</span>
|
|
454
|
+
<span class="label">អាយុ:</span>
|
|
455
|
+
<span class="underline xs">
|
|
456
|
+
<%= applicant_info.age %>
|
|
457
|
+
</span>
|
|
458
|
+
<span class="label">សញ្ចាតិ:</span>
|
|
459
|
+
<span class="underline">
|
|
460
|
+
<%= applicant_info.nationality %>
|
|
461
|
+
</span>
|
|
462
|
+
<span class="label">លេខទូរស័ព្ទ:</span>
|
|
463
|
+
<span class="underline">
|
|
464
|
+
<%= applicant_info.phone_number %>
|
|
465
|
+
</span>
|
|
405
466
|
</div>
|
|
406
467
|
|
|
468
|
+
<div class="form-item">
|
|
469
|
+
<span class="label">អាសយដ្ឋានបច្ចុប្បន្ន:</span>
|
|
470
|
+
<span class="underline align-left">
|
|
471
|
+
<%= applicant_info.current_address %>
|
|
472
|
+
</span>
|
|
473
|
+
</div>
|
|
407
474
|
|
|
408
475
|
|
|
409
|
-
|
|
410
|
-
<div class="form-item mt-4">
|
|
411
|
-
<span class="label">សេចក្ដីប្រកាសសម្រាប់ការអនុវត្ដ FATCA</span>
|
|
412
|
-
</div>
|
|
413
|
-
<div class="form-item">
|
|
414
|
-
<span class="label">អ្នកស្នើរសុំបណ្ណសន្យារ៉ាប់រង់មិនមែនជាពលរដ្ឋាអាមេរិក ឬ
|
|
415
|
-
ជាប់ពន្ធស្នាក់នៅអាមេរិក ឬ មានសិទ្ធិកាន់ Green Card នោះទេ។
|
|
416
|
-
</span>
|
|
417
|
-
</div>
|
|
418
|
-
<div class="form-item">
|
|
419
|
-
<label class="checkbox-label <%= fatca_info.is_fatca === false ? 'checked' : '' %>">មិនមែន</label>
|
|
420
|
-
<label class="checkbox-label <%= fatca_info.is_fatca === true ? 'checked' : '' %>">មែន</label>
|
|
421
|
-
<div class="ml-4">
|
|
422
|
-
<span class="label">US TIN:</span>
|
|
423
|
-
<span class="underline"><%= fatca_info.us_tin_no %></span>
|
|
424
|
-
<span class="label">លេខកូដលើកលែង FATCA (ប្រសិនមាន):</span>
|
|
425
|
-
<span class="underline"><%= fatca_info.fatca_exempt_code %></span>
|
|
426
|
-
</div>
|
|
427
|
-
</div>
|
|
428
|
-
<div class="form-item mt-4">
|
|
429
|
-
<span class="label">
|
|
430
|
-
ប្រសិនបើការបញ្ចាក់អះអាងណាមួយមិនត្រឹមត្រូវ
|
|
431
|
-
ខ្ញុំនឹងប្រគល់ជូននូវឯកសារថ្មីក្នុងរយះពេល ៣០ថ្ងៃ
|
|
432
|
-
ហើយអះអាងថាខ្ញុំមិនជាប់ពន្ធកាត់ទុករបស់សហរដ្ឋអាមេរិកទេ
|
|
433
|
-
</span>
|
|
434
|
-
</div>
|
|
435
|
-
</div>
|
|
476
|
+
</div>
|
|
436
477
|
|
|
437
478
|
|
|
438
479
|
|
|
439
|
-
|
|
440
|
-
<div class="
|
|
441
|
-
|
|
442
|
-
<table>
|
|
443
|
-
<thead>
|
|
444
|
-
<tr>
|
|
445
|
-
<th><div class="cell">ឈ្មោះផលិតផល និងរយះពេលធានា</div></th>
|
|
446
|
-
<th><div class="cell">ទឹកប្រាក់ត្រូវធានា(ដុល្លារអាមេរិក)</div></th>
|
|
447
|
-
<th><div class="cell">របៀបបង់បុព្វលាភ</div></th>
|
|
448
|
-
<th>
|
|
449
|
-
<div class="cell">បុព្វលាភធានារ៉ាប់រង់(ដុល្លារអាមេរិក)</div>
|
|
450
|
-
</th>
|
|
451
|
-
</tr>
|
|
452
|
-
</thead>
|
|
453
|
-
<tbody>
|
|
454
|
-
<% product_payment_info?.products?.forEach(function(product) { %>
|
|
455
|
-
<tr>
|
|
456
|
-
<td><div class="cell"><%= product.name %> <%= product.term %></div></td>
|
|
457
|
-
<td><div class="cell"><%= product.sum_assured %></div></td>
|
|
458
|
-
<td><div class="cell"><%= product.payment_mode %></div></td>
|
|
459
|
-
<td><div class="cell"><%= product.premium %></div></td>
|
|
460
|
-
</tr>
|
|
461
|
-
<% }) %>
|
|
462
|
-
</tbody>
|
|
463
|
-
</table>
|
|
480
|
+
<div class="form-container">
|
|
481
|
+
<div class="form-item mt-4">
|
|
482
|
+
<span class="label">សេចក្ដីប្រកាសសម្រាប់ការអនុវត្ដ FATCA</span>
|
|
464
483
|
</div>
|
|
465
|
-
<div class="form-
|
|
466
|
-
<
|
|
467
|
-
|
|
468
|
-
|
|
469
|
-
|
|
470
|
-
|
|
471
|
-
|
|
472
|
-
|
|
473
|
-
|
|
484
|
+
<div class="form-item">
|
|
485
|
+
<span class="label">អ្នកស្នើរសុំបណ្ណសន្យារ៉ាប់រង់មិនមែនជាពលរដ្ឋាអាមេរិក ឬ
|
|
486
|
+
ជាប់ពន្ធស្នាក់នៅអាមេរិក ឬ មានសិទ្ធិកាន់ Green Card នោះទេ។
|
|
487
|
+
</span>
|
|
488
|
+
</div>
|
|
489
|
+
<div class="form-item">
|
|
490
|
+
<label class="checkbox-label <%= fatca_info.is_fatca === false ? 'checked' : '' %>">មិនមែន</label>
|
|
491
|
+
<label class="checkbox-label <%= fatca_info.is_fatca === true ? 'checked' : '' %>">មែន</label>
|
|
492
|
+
<div class="ml-4">
|
|
493
|
+
<span class="label">US TIN:</span>
|
|
494
|
+
<span class="underline">
|
|
495
|
+
<%= fatca_info.us_tin_no %>
|
|
496
|
+
</span>
|
|
497
|
+
<span class="label">លេខកូដលើកលែង FATCA (ប្រសិនមាន):</span>
|
|
498
|
+
<span class="underline">
|
|
499
|
+
<%= fatca_info.fatca_exempt_code %>
|
|
500
|
+
</span>
|
|
474
501
|
</div>
|
|
475
502
|
</div>
|
|
476
|
-
|
|
477
|
-
|
|
478
|
-
|
|
479
|
-
|
|
480
|
-
|
|
481
|
-
|
|
482
|
-
|
|
483
|
-
|
|
484
|
-
|
|
485
|
-
|
|
486
|
-
|
|
487
|
-
|
|
488
|
-
|
|
489
|
-
|
|
490
|
-
|
|
491
|
-
|
|
503
|
+
<div class="form-item mt-4">
|
|
504
|
+
<span class="label">
|
|
505
|
+
ប្រសិនបើការបញ្ចាក់អះអាងណាមួយមិនត្រឹមត្រូវ
|
|
506
|
+
ខ្ញុំនឹងប្រគល់ជូននូវឯកសារថ្មីក្នុងរយះពេល ៣០ថ្ងៃ
|
|
507
|
+
ហើយអះអាងថាខ្ញុំមិនជាប់ពន្ធកាត់ទុករបស់សហរដ្ឋអាមេរិកទេ
|
|
508
|
+
</span>
|
|
509
|
+
</div>
|
|
510
|
+
</div>
|
|
511
|
+
|
|
512
|
+
|
|
513
|
+
|
|
514
|
+
<!-- Section 2 -->
|
|
515
|
+
<div class="card-header mt-4">ព័ត៌មានអំពីផលិតផល</div>
|
|
516
|
+
<div class="table-container">
|
|
517
|
+
<table>
|
|
518
|
+
<thead>
|
|
519
|
+
<tr>
|
|
520
|
+
<th>
|
|
521
|
+
<div class="cell">ឈ្មោះផលិតផល និងរយះពេលធានា</div>
|
|
522
|
+
</th>
|
|
523
|
+
<th>
|
|
524
|
+
<div class="cell">ទឹកប្រាក់ត្រូវធានា(ដុល្លារអាមេរិក)</div>
|
|
525
|
+
</th>
|
|
526
|
+
<th>
|
|
527
|
+
<div class="cell">របៀបបង់បុព្វលាភ</div>
|
|
528
|
+
</th>
|
|
529
|
+
<th>
|
|
530
|
+
<div class="cell">បុព្វលាភធានារ៉ាប់រង់(ដុល្លារអាមេរិក)</div>
|
|
531
|
+
</th>
|
|
532
|
+
</tr>
|
|
533
|
+
</thead>
|
|
534
|
+
<tbody>
|
|
535
|
+
<% product_payment_info?.products?.forEach(function(product) { %>
|
|
492
536
|
<tr>
|
|
493
|
-
<td
|
|
494
|
-
|
|
495
|
-
|
|
496
|
-
|
|
497
|
-
|
|
537
|
+
<td>
|
|
538
|
+
<div class="cell">
|
|
539
|
+
<%= product.name %>
|
|
540
|
+
<%= product.term %>
|
|
541
|
+
</div>
|
|
542
|
+
</td>
|
|
543
|
+
<td>
|
|
544
|
+
<div class="cell">
|
|
545
|
+
<%= product.sum_assured %>
|
|
546
|
+
</div>
|
|
547
|
+
</td>
|
|
548
|
+
<td>
|
|
549
|
+
<div class="cell">
|
|
550
|
+
<%= product.payment_mode %>
|
|
551
|
+
</div>
|
|
552
|
+
</td>
|
|
553
|
+
<td>
|
|
554
|
+
<div class="cell">
|
|
555
|
+
<%= product.premium %>
|
|
556
|
+
</div>
|
|
557
|
+
</td>
|
|
498
558
|
</tr>
|
|
499
559
|
<% }) %>
|
|
560
|
+
</tbody>
|
|
561
|
+
</table>
|
|
562
|
+
</div>
|
|
563
|
+
<div class="form-container">
|
|
564
|
+
<div class="form-item">
|
|
565
|
+
<span class="question-label">វិធីសាស្រ្ដបង់បុព្វលាភធានារ៉ាប់រង់:</span>
|
|
566
|
+
<label class="checkbox-label <%= product_payment_info.payment_method === 'transfer_to_plac' ? 'checked' : '' %>">
|
|
567
|
+
ការផ្ទេរប្រាក់ចូលទៅក្នុងគណនីរបស់ហ្វីលីឡាយហ្វ៍
|
|
568
|
+
</label>
|
|
569
|
+
<label class="checkbox-label <%= product_payment_info.payment_method === 'other' ? 'checked' : '' %>">
|
|
570
|
+
តាមរយះដៃគូររបស់ហ្វីលីឡាយហ្វ៍
|
|
571
|
+
</label>
|
|
572
|
+
</div>
|
|
573
|
+
</div>
|
|
574
|
+
|
|
575
|
+
<div class="card-header mt-4">ព័ត៌មានអំពីកម្ចី</div>
|
|
576
|
+
<div class="table-container">
|
|
577
|
+
<table>
|
|
578
|
+
<thead>
|
|
579
|
+
<tr>
|
|
580
|
+
<th>
|
|
581
|
+
<div class="cell">ចំនួនទឹកប្រាក់កម្ចី</div>
|
|
582
|
+
</th>
|
|
583
|
+
<th>
|
|
584
|
+
<div class="cell">រយៈពេលកម្ចី</div>
|
|
585
|
+
</th>
|
|
586
|
+
<th>
|
|
587
|
+
<div class="cell">ប្រភេទកម្ចី</div>
|
|
588
|
+
</th>
|
|
589
|
+
</tr>
|
|
590
|
+
</thead>
|
|
591
|
+
<tbody>
|
|
592
|
+
<tr>
|
|
593
|
+
<td>
|
|
594
|
+
<div class="cell">
|
|
595
|
+
<%= loan_info.loan_amount %>
|
|
596
|
+
</div>
|
|
597
|
+
</td>
|
|
598
|
+
<td>
|
|
599
|
+
<div class="cell">
|
|
600
|
+
<%= loan_info.loan_duration %>
|
|
601
|
+
</div>
|
|
602
|
+
</td>
|
|
603
|
+
<td>
|
|
604
|
+
<div class="cell">
|
|
605
|
+
<%= loan_info.loan_type %>
|
|
606
|
+
</div>
|
|
607
|
+
</td>
|
|
608
|
+
</tr>
|
|
609
|
+
</tbody>
|
|
610
|
+
</table>
|
|
611
|
+
</div>
|
|
612
|
+
|
|
613
|
+
|
|
614
|
+
<!-- Section 3 -->
|
|
615
|
+
<div class="card-header mt-4">ព័ត៌មានអំពីអ្នកទទួលផល</div>
|
|
616
|
+
<div class="table-container">
|
|
617
|
+
<table>
|
|
618
|
+
<thead>
|
|
619
|
+
<tr>
|
|
620
|
+
<th style="align-items: flex-start; text-align: left; padding-left: 8px;">
|
|
621
|
+
<div>ឈ្មោះពេញរបស់អ្នកទទួលផល</div>
|
|
622
|
+
</th>
|
|
623
|
+
<th>
|
|
624
|
+
<div class="cell">អាយុ</div>
|
|
625
|
+
</th>
|
|
626
|
+
<th>
|
|
627
|
+
<div class="cell">ទំនាក់ទំនង</div>
|
|
628
|
+
</th>
|
|
629
|
+
<th>
|
|
630
|
+
<div class="cell">លេខអត្តសញ្ញាណ</div>
|
|
631
|
+
</th>
|
|
632
|
+
<th>
|
|
633
|
+
<div class="cell">ការបែងចែកសំណង</div>
|
|
634
|
+
</th>
|
|
635
|
+
</tr>
|
|
636
|
+
</thead>
|
|
637
|
+
<tbody>
|
|
638
|
+
<% beneficiary_info?.forEach(function(beneficiary) { %>
|
|
500
639
|
<tr>
|
|
501
|
-
<td
|
|
640
|
+
<td style="align-items: flex-start; text-align: left; padding-left: 8px;">
|
|
641
|
+
<div>
|
|
642
|
+
<%= beneficiary.full_name %>
|
|
643
|
+
</div>
|
|
644
|
+
</td>
|
|
645
|
+
<td>
|
|
646
|
+
<div class="cell">
|
|
647
|
+
<%= beneficiary.age %>
|
|
648
|
+
</div>
|
|
649
|
+
</td>
|
|
650
|
+
<td>
|
|
502
651
|
<div class="cell">
|
|
503
|
-
|
|
504
|
-
|
|
652
|
+
<%= beneficiary.relationship %>
|
|
653
|
+
</div>
|
|
654
|
+
</td>
|
|
655
|
+
<td>
|
|
656
|
+
<div class="cell">
|
|
657
|
+
<%= beneficiary.id_number %>
|
|
658
|
+
</div>
|
|
659
|
+
</td>
|
|
660
|
+
<td>
|
|
661
|
+
<div class="cell">
|
|
662
|
+
<%= beneficiary.percentage %>
|
|
505
663
|
</div>
|
|
506
664
|
</td>
|
|
507
|
-
<td><div class="cell">% សរុបស្មើរ ១០០%</div></td>
|
|
508
665
|
</tr>
|
|
509
|
-
|
|
510
|
-
|
|
511
|
-
|
|
512
|
-
|
|
513
|
-
|
|
514
|
-
|
|
515
|
-
|
|
516
|
-
|
|
666
|
+
<% }) %>
|
|
667
|
+
<tr>
|
|
668
|
+
<td colspan="5">
|
|
669
|
+
<div class="cell" style="text-align: left; padding-left: 8px;">
|
|
670
|
+
ក្រុមហ៊ុន នឹងទូរទាត់សំណងទៅកាន់អ្នកទទួលផលចម្បងជាមុនសិន
|
|
671
|
+
មុននឹងទូទាត់សំណងដែលនៅសល់ទៅកាន់អ្នកទទួលផលបន្ទាប់ដែលបានកំណត់ដោយអ្នកស្នើសុំធានារ៉ាប់រង
|
|
672
|
+
ឬទាយាទរបស់អ្នកត្រូវបានធានារ៉ាប់រងក្នុងករណិមិនមានការតែងតាំងអ្នកទទួលផល។
|
|
673
|
+
</div>
|
|
674
|
+
</td>
|
|
675
|
+
<!-- <td>
|
|
676
|
+
<div class="cell">% សរុបស្មើរ ១០០%</div>
|
|
677
|
+
</td> -->
|
|
678
|
+
</tr>
|
|
679
|
+
</tbody>
|
|
680
|
+
</table>
|
|
681
|
+
</div>
|
|
682
|
+
|
|
683
|
+
<!-- Section 4 -->
|
|
684
|
+
<div class="page-break"></div>
|
|
685
|
+
<div class="card-header">
|
|
686
|
+
ព័ត៌មានពាក់ព័ន្ទនឹងសុខភាពរបស់ អ្នកស្នើសុំបណ្ណសន្យារ៉ាប់រង់
|
|
687
|
+
</div>
|
|
688
|
+
|
|
689
|
+
<!-- Question 1 -->
|
|
690
|
+
<div class="form-container">
|
|
691
|
+
<div class="form-item">
|
|
692
|
+
<span class="label">1) កម្ពស់:</span>
|
|
693
|
+
<span class="underline sm">
|
|
694
|
+
<%= health_info.height %>
|
|
695
|
+
</span>
|
|
696
|
+
<span class="label">ស.ម</span>
|
|
697
|
+
<div class="space"></div>
|
|
698
|
+
<span class="label">ទម្ងន់:</span>
|
|
699
|
+
<span class="underline sm">
|
|
700
|
+
<%= health_info.weight %>
|
|
701
|
+
</span>
|
|
702
|
+
<span class="label">គ.ក</span>
|
|
703
|
+
<div class="space"></div>
|
|
704
|
+
<span class="question-label">តើលោកអ្នកពិសារបារីដែរឬទេ?:</span>
|
|
705
|
+
<label class="checkbox-label <%= health_info.is_smoke === false ? 'checked' : '' %>">
|
|
706
|
+
មិនមាន
|
|
707
|
+
</label>
|
|
708
|
+
<label class="checkbox-label <%= health_info.is_smoke === true ? 'checked' : '' %>">
|
|
709
|
+
មាន
|
|
710
|
+
</label>
|
|
517
711
|
</div>
|
|
518
712
|
|
|
519
|
-
|
|
520
|
-
|
|
521
|
-
|
|
522
|
-
<span class="
|
|
523
|
-
|
|
524
|
-
|
|
525
|
-
<div class="space"></div>
|
|
526
|
-
<span class="label">ទម្ងន់:</span>
|
|
527
|
-
<span class="underline sm"><%= health_info.weight %></span>
|
|
528
|
-
<span class="label">គ.ក</span>
|
|
529
|
-
<div class="space"></div>
|
|
530
|
-
<span class="question-label">តើលោកអ្នកពិសារបារីដែរឬទេ?:</span>
|
|
531
|
-
<label class="checkbox-label <%= health_info.is_smoke === false ? 'checked' : '' %>">
|
|
532
|
-
មិនមាន
|
|
533
|
-
</label>
|
|
534
|
-
<label class="checkbox-label <%= health_info.is_smoke === true ? 'checked' : '' %>">
|
|
535
|
-
មាន
|
|
536
|
-
</label>
|
|
537
|
-
</div>
|
|
538
|
-
|
|
539
|
-
<div class="form-item mb-4">
|
|
540
|
-
<span class="label">ចំនួន៖</span>
|
|
541
|
-
<% if (health_info.smoke_detail) { %>
|
|
542
|
-
<span class="underline with-unit">
|
|
543
|
-
<span class="value"><%= health_info.smoke_detail %></span>
|
|
544
|
-
<span class="unit">ដើមក្នុងមួយសប្ដាហ៍</span>
|
|
713
|
+
<div class="form-item mb-4">
|
|
714
|
+
<span class="label">ចំនួន៖</span>
|
|
715
|
+
<% if (health_info.smoke_detail) { %>
|
|
716
|
+
<span class="underline with-unit">
|
|
717
|
+
<span class="value">
|
|
718
|
+
<%= health_info.smoke_detail %>
|
|
545
719
|
</span>
|
|
720
|
+
<span class="unit">ដើមក្នុងមួយសប្ដាហ៍</span>
|
|
721
|
+
</span>
|
|
546
722
|
<% } else { %>
|
|
547
723
|
<span class="underline"></span>
|
|
548
|
-
|
|
549
|
-
</div>
|
|
724
|
+
<% } %>
|
|
550
725
|
</div>
|
|
551
|
-
|
|
552
|
-
|
|
553
|
-
|
|
554
|
-
|
|
555
|
-
|
|
556
|
-
|
|
557
|
-
|
|
558
|
-
|
|
559
|
-
|
|
560
|
-
|
|
561
|
-
|
|
562
|
-
</
|
|
563
|
-
|
|
564
|
-
|
|
565
|
-
|
|
566
|
-
|
|
567
|
-
|
|
568
|
-
|
|
726
|
+
</div>
|
|
727
|
+
|
|
728
|
+
<!-- Question 2 -->
|
|
729
|
+
<div class="form-container">
|
|
730
|
+
<div class="form-item">
|
|
731
|
+
<span class="question-label">2) តើលោកអ្នកពិសារគ្រឿងស្រវឹងដែរឬទេ?:</span>
|
|
732
|
+
<label class="checkbox-label <%= health_info.is_drink_alcohol === false ? 'checked' : '' %>">
|
|
733
|
+
មិនមាន
|
|
734
|
+
</label>
|
|
735
|
+
<label class="checkbox-label <%= health_info.is_drink_alcohol === true ? 'checked' : '' %>">
|
|
736
|
+
មាន
|
|
737
|
+
</label>
|
|
738
|
+
</div>
|
|
739
|
+
<div class="form-item mb-4">
|
|
740
|
+
<span class="label">ចំនួន</span>
|
|
741
|
+
<% if (health_info.drink_alcohol_detail) { %>
|
|
742
|
+
<span class="underline with-unit">
|
|
743
|
+
<span class="value">
|
|
744
|
+
<%= health_info.drink_alcohol_detail %>
|
|
569
745
|
</span>
|
|
746
|
+
<span class="unit">ក្នុងមួយថ្ងៃ</span>
|
|
747
|
+
</span>
|
|
570
748
|
<% } else { %>
|
|
571
749
|
<span class="underline"></span>
|
|
572
750
|
<span class="label">ក្នុងមួយថ្ងៃ</span>
|
|
573
|
-
|
|
574
|
-
|
|
751
|
+
<% } %>
|
|
752
|
+
</div>
|
|
753
|
+
</div>
|
|
754
|
+
|
|
755
|
+
<!-- Question 3 -->
|
|
756
|
+
<div class="form-container">
|
|
757
|
+
<span class="question-label">
|
|
758
|
+
3) ក្នុងរយៈពេល០២(ពីរ)ឆ្នាំចុងក្រោយនេះតើលោកអ្នកធ្លាប់បានសម្រាកក្នុងមន្ទីរពេទ្យធ្លាប់បានទទួលការវះកាត់
|
|
759
|
+
ឬធ្លាប់ទទួលបានលទ្ធផលខុសប្រក្រតីអំពី ការវិភាគឈាម ការវិភាគទឹកនោម
|
|
760
|
+
ការថតកាំរស្មីអុិច (X-ray) ម៉ាសុិនវាស់ចង្វាក់បេះដូង អេកូសាស្រ្ដ
|
|
761
|
+
ស្កេនការច្រឹបសាច់យកពិនិត្យ
|
|
762
|
+
ឬលទ្ធផលវិភាគផ្សេងៗទៀតដែលមិនបានរៀបរាប់ខាងដើមពីគ្រូពេទ្យដែរឬទេ?:
|
|
763
|
+
</span>
|
|
764
|
+
<div class="form-item">
|
|
765
|
+
<label class="checkbox-label <%= health_info.is_hospitalized === false ? 'checked' : '' %>">
|
|
766
|
+
មិនមាន
|
|
767
|
+
</label>
|
|
768
|
+
<label class="checkbox-label <%= health_info.is_hospitalized === true ? 'checked' : '' %>">
|
|
769
|
+
មាន
|
|
770
|
+
</label>
|
|
575
771
|
</div>
|
|
576
772
|
|
|
577
|
-
|
|
578
|
-
|
|
579
|
-
|
|
580
|
-
|
|
581
|
-
|
|
582
|
-
|
|
583
|
-
ស្កេនការច្រឹបសាច់យកពិនិត្យ
|
|
584
|
-
ឬលទ្ធផលវិភាគផ្សេងៗទៀតដែលមិនបានរៀបរាប់ខាងដើមពីគ្រូពេទ្យដែរឬទេ?:
|
|
585
|
-
</span>
|
|
586
|
-
<div class="form-item">
|
|
587
|
-
<label class="checkbox-label <%= health_info.is_hospitalized === false ? 'checked' : '' %>">
|
|
588
|
-
មិនមាន
|
|
589
|
-
</label>
|
|
590
|
-
<label class="checkbox-label <%= health_info.is_hospitalized === true ? 'checked' : '' %>">
|
|
591
|
-
មាន
|
|
592
|
-
</label>
|
|
593
|
-
</div>
|
|
594
|
-
|
|
595
|
-
<div class="form-item mb-4">
|
|
596
|
-
<span class="label">បើមានសូមផ្ដល់ព័ត៍មានលម្អិត៖</span>
|
|
597
|
-
<% if (health_info.hospitalized_detail) { %>
|
|
598
|
-
<span class="underline with-unit">
|
|
599
|
-
<span class="value"><%= health_info.hospitalized_detail %></span>
|
|
600
|
-
<span class="unit">ក្នុងមួយថ្ងៃ</span>
|
|
773
|
+
<div class="form-item mb-4">
|
|
774
|
+
<span class="label">បើមានសូមផ្ដល់ព័ត៍មានលម្អិត៖</span>
|
|
775
|
+
<% if (health_info.hospitalized_detail) { %>
|
|
776
|
+
<span class="underline with-unit">
|
|
777
|
+
<span class="value">
|
|
778
|
+
<%= health_info.hospitalized_detail %>
|
|
601
779
|
</span>
|
|
780
|
+
<span class="unit">ក្នុងមួយថ្ងៃ</span>
|
|
781
|
+
</span>
|
|
602
782
|
<% } else { %>
|
|
603
783
|
<span class="underline"></span>
|
|
604
|
-
|
|
605
|
-
</div>
|
|
784
|
+
<% } %>
|
|
606
785
|
</div>
|
|
786
|
+
</div>
|
|
787
|
+
|
|
788
|
+
<!-- Question 4 -->
|
|
789
|
+
<div class="form-container">
|
|
790
|
+
<span class="question-label">
|
|
791
|
+
4) តើលោកអ្នកធ្លាប់បានធ្វើរោគវិនិច្ឆ័យ ពិគ្រោះជំងឺ ឬទទួលការព្យាបាលដូចជា
|
|
792
|
+
លើសសម្ពាធឈាម ទឹកនោមផ្អែម ជំងឺបេះដូង ចុកទ្រូង ជំងឺសួត ជំងឺថ្លើម
|
|
793
|
+
ជំងឺតម្រងនោម មហារីក ជំងឺដាច់សសៃឈាមខួរក្បាល ជំងឺអេដស៍ ជំងឺផ្លូវចិត្ត
|
|
794
|
+
ពិការភាព ឬរាងកាយមិនប្រក្រតី ប្រើប្រាស់ថ្នាំញៀន ឬញៀនស្រា
|
|
795
|
+
ឬជំងឺផ្សេងទៀតដែលមិនបានរៀបរាប់ខាងលើដែរឬទេ?
|
|
796
|
+
</span>
|
|
797
|
+
<div class="form-item">
|
|
798
|
+
<label class="checkbox-label <%= health_info.is_diagnosed === false ? 'checked' : '' %>">
|
|
799
|
+
មិនមាន
|
|
800
|
+
</label>
|
|
801
|
+
<label class="checkbox-label <%= health_info.is_diagnosed === true ? 'checked' : '' %>">
|
|
802
|
+
មាន
|
|
803
|
+
</label>
|
|
607
804
|
|
|
608
|
-
|
|
609
|
-
<div class="form-
|
|
610
|
-
<span class="
|
|
611
|
-
|
|
612
|
-
|
|
613
|
-
|
|
614
|
-
|
|
615
|
-
ឬជំងឺផ្សេងទៀតដែលមិនបានរៀបរាប់ខាងលើដែរឬទេ?
|
|
616
|
-
</span>
|
|
617
|
-
<div class="form-item">
|
|
618
|
-
<label class="checkbox-label <%= health_info.is_diagnosed === false ? 'checked' : '' %>">
|
|
619
|
-
មិនមាន
|
|
620
|
-
</label>
|
|
621
|
-
<label class="checkbox-label <%= health_info.is_diagnosed === true ? 'checked' : '' %>">
|
|
622
|
-
មាន
|
|
623
|
-
</label>
|
|
624
|
-
|
|
625
|
-
</div>
|
|
626
|
-
<div class="form-item mb-4">
|
|
627
|
-
<span class="label">បើមានសូមបញ្ជាក់លម្អិតខាងក្រោម៖</span>
|
|
628
|
-
<% if (health_info.diagnosed_detail) { %>
|
|
629
|
-
<span class="underline with-unit">
|
|
630
|
-
<span class="value"><%= health_info.diagnosed_detail %></span>
|
|
805
|
+
</div>
|
|
806
|
+
<div class="form-item mb-4">
|
|
807
|
+
<span class="label">បើមានសូមបញ្ជាក់លម្អិតខាងក្រោម៖</span>
|
|
808
|
+
<% if (health_info.diagnosed_detail) { %>
|
|
809
|
+
<span class="underline with-unit">
|
|
810
|
+
<span class="value">
|
|
811
|
+
<%= health_info.diagnosed_detail %>
|
|
631
812
|
</span>
|
|
813
|
+
</span>
|
|
632
814
|
<% } else { %>
|
|
633
815
|
<span class="underline"></span>
|
|
634
|
-
|
|
635
|
-
</div>
|
|
816
|
+
<% } %>
|
|
636
817
|
</div>
|
|
637
|
-
|
|
638
|
-
|
|
639
|
-
|
|
640
|
-
|
|
641
|
-
|
|
642
|
-
|
|
643
|
-
|
|
644
|
-
|
|
645
|
-
|
|
646
|
-
|
|
647
|
-
|
|
648
|
-
|
|
649
|
-
|
|
650
|
-
|
|
651
|
-
>
|
|
652
|
-
</div>
|
|
653
|
-
<div class="form-item">
|
|
654
|
-
<span class="label">
|
|
655
|
-
2) ខ្ញុំសូមអះអាងថាបានអាន និងយល់ស្របនូវគ្រប់ព័ត៌មានក្នុងឯកសារនេះ។
|
|
656
|
-
ខ្ញុំសូមប្រកាសថាគ្រប់ព័ត៌មានដែលបានផ្ដល់នៅក្នុងពាក្យស្នើសុំនេះ
|
|
657
|
-
ពិតជាមានភាពពេញលេញ និងត្រឹមត្រូវពិតប្រាកដមែន។
|
|
658
|
-
</span>
|
|
659
|
-
</div>
|
|
818
|
+
</div>
|
|
819
|
+
|
|
820
|
+
<!-- Section 5 -->
|
|
821
|
+
<div class="card-header mt-8">សេចក្ដីប្រកាសរបស់អ្នកស្នើសុំធានារ៉ាប់រង់</div>
|
|
822
|
+
<div class="form-container">
|
|
823
|
+
<div class="form-item">
|
|
824
|
+
<span class="label">1) ខ្ញុំអនុញ្ញាត និងយល់ព្រមឲ្យក្រុមហ៊ុនប្រើប្រាស់ព័ត៌មាន
|
|
825
|
+
និងទិន្នន័យទាំងស្រុងដែលខ្ញុំបានផ្ដល់នៅក្នុងពាក្យស្នើសុំរបស់ខ្ញុំ
|
|
826
|
+
ក្នុងគោលបំណង ស្របតាមច្បាប់ដូចជាការផ្សព្វផ្សាយទីផ្សារ ការសិក្សាទីផ្សារ
|
|
827
|
+
និង ការបម្រើអតិថិជនដោយក្រុមហ៊ុន សម្ព័ន្ធក្រុមហ៊ុន ឬ ជាដៃគូ
|
|
828
|
+
ពាណិជ្ជកម្មរបស់ក្រុមហ៊ុនដោយមិនចាំបាច់មានការយល់ព្រម
|
|
829
|
+
និងជូនដំណឹងបន្ថែមពីខ្ញុំឡើយ។ ក្រុមហ៊ុនមិនត្រូវបានអនុញ្ញាតឲ្យបញ្ចេញ
|
|
830
|
+
ព័ត៌មានណាមួយទៅភាគីទីបីណាមួយឬប្រើប្រាស់ព័ត៌មាននោះសម្រាប់គោលបំណងផ្សេងទៀតដែលមិនទាក់ទងនឹងគោលបំណង
|
|
831
|
+
ទាំងឡាយខាងលើឡើយ ប្រសិនបើគ្មានការយល់ព្រមព្រៀងជាលាយលក្ខណ៍អក្សរនោះ។</span>
|
|
660
832
|
</div>
|
|
661
|
-
<div class="
|
|
662
|
-
<
|
|
663
|
-
|
|
664
|
-
|
|
665
|
-
|
|
666
|
-
|
|
667
|
-
|
|
668
|
-
|
|
669
|
-
|
|
670
|
-
|
|
671
|
-
|
|
672
|
-
|
|
673
|
-
|
|
674
|
-
|
|
675
|
-
|
|
676
|
-
|
|
677
|
-
|
|
678
|
-
|
|
679
|
-
|
|
680
|
-
|
|
681
|
-
|
|
682
|
-
|
|
683
|
-
|
|
684
|
-
|
|
685
|
-
|
|
686
|
-
|
|
833
|
+
<div class="form-item">
|
|
834
|
+
<span class="label">
|
|
835
|
+
2) ខ្ញុំសូមអះអាងថាបានអាន និងយល់ស្របនូវគ្រប់ព័ត៌មានក្នុងឯកសារនេះ។
|
|
836
|
+
ខ្ញុំសូមប្រកាសថាគ្រប់ព័ត៌មានដែលបានផ្ដល់នៅក្នុងពាក្យស្នើសុំនេះ
|
|
837
|
+
ពិតជាមានភាពពេញលេញ និងត្រឹមត្រូវពិតប្រាកដមែន។
|
|
838
|
+
</span>
|
|
839
|
+
</div>
|
|
840
|
+
</div>
|
|
841
|
+
<div class="table-container mt-4">
|
|
842
|
+
<table>
|
|
843
|
+
<thead>
|
|
844
|
+
<tr>
|
|
845
|
+
<th style="width: 50%">
|
|
846
|
+
<div class="cell">
|
|
847
|
+
ហត្ថលេខា ឬស្នាមមេដៃរបស់អ្នកស្នើសុំធានារ៉ាប់រង
|
|
848
|
+
</div>
|
|
849
|
+
<div class="signature-space"></div>
|
|
850
|
+
</th>
|
|
851
|
+
<th style="width: 50%">
|
|
852
|
+
<div class="cell">ហត្ថលេខា ឬស្នាមមេដៃរបស់សាក្សី</div>
|
|
853
|
+
<div class="signature-space"></div>
|
|
854
|
+
</th>
|
|
855
|
+
</tr>
|
|
856
|
+
</thead>
|
|
857
|
+
<tbody>
|
|
858
|
+
<tr>
|
|
859
|
+
<td>
|
|
860
|
+
<div class="form-container space-height">
|
|
861
|
+
<div class="form-item">
|
|
862
|
+
<div class="space"></div>
|
|
863
|
+
<span class="label">ឈ្មោះ</span>
|
|
864
|
+
<% if (signature_info.applicant_name) { %>
|
|
865
|
+
<span class="underline with-unit">
|
|
866
|
+
<span class="value">
|
|
867
|
+
<%= signature_info.applicant_name %>
|
|
687
868
|
</span>
|
|
869
|
+
</span>
|
|
688
870
|
<% } else { %>
|
|
689
871
|
<span class="underline"></span>
|
|
690
|
-
|
|
691
|
-
|
|
692
|
-
</div>
|
|
872
|
+
<% } %>
|
|
873
|
+
<div class="space"></div>
|
|
693
874
|
</div>
|
|
694
|
-
</
|
|
695
|
-
|
|
696
|
-
|
|
697
|
-
|
|
698
|
-
|
|
699
|
-
|
|
700
|
-
|
|
701
|
-
|
|
702
|
-
|
|
875
|
+
</div>
|
|
876
|
+
</td>
|
|
877
|
+
<td>
|
|
878
|
+
<div class="form-container space-height">
|
|
879
|
+
<div class="form-item">
|
|
880
|
+
<div class="space"></div>
|
|
881
|
+
<span class="label">ឈ្មោះ</span>
|
|
882
|
+
<% if (signature_info.witness_name) { %>
|
|
883
|
+
<span class="underline with-unit">
|
|
884
|
+
<span class="value">
|
|
885
|
+
<%= signature_info.witness_name %>
|
|
703
886
|
</span>
|
|
887
|
+
</span>
|
|
704
888
|
<% } else { %>
|
|
705
889
|
<span class="underline"></span>
|
|
706
|
-
|
|
707
|
-
|
|
708
|
-
</div>
|
|
890
|
+
<% } %>
|
|
891
|
+
<div class="space"></div>
|
|
709
892
|
</div>
|
|
710
|
-
</
|
|
711
|
-
</
|
|
712
|
-
|
|
713
|
-
|
|
714
|
-
|
|
715
|
-
|
|
716
|
-
|
|
717
|
-
|
|
718
|
-
|
|
719
|
-
|
|
720
|
-
|
|
893
|
+
</div>
|
|
894
|
+
</td>
|
|
895
|
+
</tr>
|
|
896
|
+
<tr>
|
|
897
|
+
<td>
|
|
898
|
+
<div class="form-container space-height">
|
|
899
|
+
<div class="form-item">
|
|
900
|
+
<div class="space"></div>
|
|
901
|
+
<span class="label">កាលបរិច្ឆេទ</span>
|
|
902
|
+
<% if (signature_info.applicant_signature_date) { %>
|
|
903
|
+
<span class="underline with-unit">
|
|
904
|
+
<span class="value">
|
|
905
|
+
<%= signature_info.applicant_signature_date %>
|
|
721
906
|
</span>
|
|
907
|
+
</span>
|
|
722
908
|
<% } else { %>
|
|
723
909
|
<span class="underline"></span>
|
|
724
|
-
|
|
725
|
-
|
|
726
|
-
</div>
|
|
910
|
+
<% } %>
|
|
911
|
+
<div class="space"></div>
|
|
727
912
|
</div>
|
|
728
|
-
</
|
|
729
|
-
|
|
730
|
-
|
|
731
|
-
|
|
732
|
-
|
|
733
|
-
|
|
734
|
-
|
|
735
|
-
|
|
736
|
-
|
|
913
|
+
</div>
|
|
914
|
+
</td>
|
|
915
|
+
<td>
|
|
916
|
+
<div class="form-container space-height">
|
|
917
|
+
<div class="form-item">
|
|
918
|
+
<div class="space"></div>
|
|
919
|
+
<span class="label">កាលបរិច្ឆេទ</span>
|
|
920
|
+
<% if (signature_info.witness_signature_date) { %>
|
|
921
|
+
<span class="underline with-unit">
|
|
922
|
+
<span class="value">
|
|
923
|
+
<%= signature_info.witness_signature_date %>
|
|
737
924
|
</span>
|
|
925
|
+
</span>
|
|
738
926
|
<% } else { %>
|
|
739
927
|
<span class="underline"></span>
|
|
740
|
-
|
|
741
|
-
|
|
742
|
-
</div>
|
|
928
|
+
<% } %>
|
|
929
|
+
<div class="space"></div>
|
|
743
930
|
</div>
|
|
744
|
-
</
|
|
745
|
-
</
|
|
746
|
-
</
|
|
747
|
-
</
|
|
748
|
-
</
|
|
749
|
-
</
|
|
931
|
+
</div>
|
|
932
|
+
</td>
|
|
933
|
+
</tr>
|
|
934
|
+
</tbody>
|
|
935
|
+
</table>
|
|
936
|
+
</div>
|
|
937
|
+
</body>
|
|
750
938
|
</html>
|
|
751
939
|
`;
|