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行政执法文书样本

2017-08-04 来源:体育局
 

 

立案审批表
 

案件来源
 
案  由
 
当事人
公民
姓名
 
性别
 
  
 
住址
 
联系电话
 
单位
名称
 
法定代表人(负责人)
 
地址
 
联系电话
 
案情及
立案理由
 
承办人
意 见
 
 
 
        签名:       执法证编号:
     年  月  日
承办机构意见
 
 
             签名:
     年  月  日
行政机关负责人
审批意见
 
 
             签名:
     年  月  日

 
 
 
询 问 笔 录
                                                                          
                                                                  
                                                     
              
                                   
                                 
                                                                 
                                                                           
                                                                            
                               
                                  
                  
                                          
 
 
                            检查(勘验)笔录
                                                                                       
                                                     
          
                                          
                                                                               
                                                                                   
                                                                   
                                                                             
                                                                              
                                                                             
                                                                             
                                                                              
                                                                                               
             
                                
              [     ]                                                           
                                

 
 
 
                       
             
 
 
 
                                     
                                                
 
 
抽样取证物品处理通知书
       
                             
 (行政机关名称)[     ]                            
 
 
                           
                 
                                                         
 
                                                              
 
 
 
 
 
先行登记保存证据通知书
   
                         
                                        
                                                              
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
            [    ]                                         
 
 
 
                  
               
                         
                         
 
 
 
行政处罚事先告知书
   
                       
                    
 
 
 
 
 
 
 
 
                                               时间:                   分至      
地点:                                                                        
陈述(申辩)人:                  身份证号:                             
工作单位:                            电话:                              
住址:                                邮编:                             
与本案关系:                                                              
记录人:                        工作单位:                               
陈述(申辩)的目的:                                                     
                                                                         
陈述(申辩)的事实和理由:                                                
                                                                         
                                                                         
                                                                         
                                                                           
                                                                         
                                                                         
                                                                          
 陈述(申辩)人签字:                          记录人:              
                                                                
                                                       
 
 
 
 
 
行政处罚听证告知书
 
   
                       
                    
 
 
 
 
 
 
   
 
                                         
 
 
              
               
 
 
 
行政处罚听证通知书
      
 
                            
 
                                                           
2
3.
4.
                
 
 
 
 
 
                                             
 
 
 
 
 
 
听 证 笔 录
 
               
                     
                                                
                                                       
                                                      
                                                                            
                            
                            
                                                                                       
                                                                    
                                                                                                             
 
                                        当事人申辩质证的主要内容:                                                 
                                                                           
                                                                           
                                                                           
                                                                           
争论焦点问题:                                                             
                                                                           
                                                                           
主持人意见和建议:                                                         
                                                                           
                                                                          
                                                                           
               
       听证主持人签名:                
        员:                  
                                                                    
 
 
 
调查终结报告
 
案件调查的来源、调查经过(概括交代案件由来,包括案件来源、登记时间、立案时间和批准立案的机关等;调查经过,包括办案人员的组成、调查方式、调查时间等)。
当事人的基本情况。
当事人违法事实和相关证据记录(当事人实施违法行为的具体事实包括其从事违法行为的时间、地点、目的、手段、情节、违法所得、危害后果等,要客观真实,所描述的事实必须得到相关证据的支持)。
违反法律规定的行为和行政处罚的法律依据及行政处罚自由裁量规则依据(对当事人的违法行为进行定性,引用法律条文要具体到条、款、项、目以及结合当地的自由裁量规则进行裁量的内容)。
案件调查机构的处理建议(办案机构提出的对案件当事人的具体处罚意见,包括明确的行政处罚的种类和幅度)。
 
 
                         
                               
 
 
 
 
 
 
 
 
案 件 集 体 讨 论 笔 录
 
            
                      
                                                                   
                                                                                          
                                                                           
                                                   
                                                                           
                                                                           
                                                   
                                                                            
                                                                           
                                               
 
 
 
 
案件处理内部审批表(通用)
 
 
 
 
 
 
 
                      
 
 
  
 [     ]                           
                            x x x
21560 
             
 
                     
                                       
 
 
 
责令(限期)改正通知书
     
                      
                      
根据   有关规定,本机关于            日对你单位(你)           进行了检查,发现存在以下问题:
                                                                      
                                                                      
                                                                      
依据《中华人民共和国行政处罚法》第二十三条和                     
                                         
                                         
 
 
 
           
 
   
 
         
当事人名称或姓名:                         性别:   身份证号:            
法定代表人或负责人姓名:           职务:         地址:                      
你(单位)于      年 月 日    时,在       (违法地点)                (行为方式) 的行为,违反了      (法律依据名称条款)   的规定,事实确凿。本机关执法人员当场向你(你们)告知了违法事实、依据和依法享有的权利。    并听取了你(你们)的陈述申辩(或:对此,你(你们)未作陈述申辩)     。现依据   (法律依据条款)                         ,本机关决定对你(单位)处以下行政处罚:
1.警告; 2.罚款人民币                元整(大写)。 ¥:           
缴纳罚款方式:(1)当场收缴。    (2)要求你(单位)自收到本决定书之日起15日内将罚款交至     (××路×号××××银行)      。账号:0000000000户名:    (×××专户)   逾期缴纳罚款的,依据《中华人民共和国行政处罚法》第五十一条第(一)项的规定,每日按罚款数额的3%加处罚款。
如你(单位)不服本行政处罚决定,可以自收到本决定书之日起60日内向 (同级人民政府名称)(上一级行政机关名称) 申请行政复议;也可以自收到本决定书之日起3个月内直接向 (×××人民法院) 起诉。
执法人员签名及执法证号:                                                     
行政机关名称(印章)
     
 
 
 
行政违法案件移送函
 
                            
 
                          
                           
                                                                        
                                                                            
   
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LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 38.55pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 31.4pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" width=42> <div style="TEXT-ALIGN: center; LINE-HEIGHT: 24pt;" align=center>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 38.55pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 33.7pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=45> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD></TR> <TR style="HEIGHT: 38.3pt;"> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 38.3pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 25.8pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=34> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 38.3pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 60.75pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=81> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 38.3pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 62.85pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=84> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 38.3pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 198pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=264> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 38.3pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 36pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=48> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 38.3pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 31.4pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" width=42> <div style="TEXT-ALIGN: center; LINE-HEIGHT: 24pt;" align=center>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 38.3pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 33.7pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=45> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD></TR> <TR style="HEIGHT: 38.1pt;"> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 38.1pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 25.8pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=34> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 38.1pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 60.75pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=81> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 38.1pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 62.85pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=84> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 38.1pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 198pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=264> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 38.1pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 36pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=48> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 38.1pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 31.4pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" width=42> <div style="TEXT-ALIGN: center; LINE-HEIGHT: 24pt;" align=center>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 38.1pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 33.7pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=45> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD></TR> <TR style="HEIGHT: 37.95pt;"> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 37.95pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 25.8pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=34> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 37.95pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 60.75pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=81> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 37.95pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 62.85pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=84> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 37.95pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 198pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=264> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 37.95pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 36pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=48> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 37.95pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 31.4pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" width=42> <div style="TEXT-ALIGN: center; LINE-HEIGHT: 24pt;" align=center>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 37.95pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 33.7pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=45> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD></TR> <TR style="HEIGHT: 39.15pt;"> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 39.15pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 25.8pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=34> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 39.15pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 60.75pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=81> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 39.15pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 62.85pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=84> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 39.15pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 198pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=264> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 39.15pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 36pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=48> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 39.15pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 31.4pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" width=42> <div style="TEXT-ALIGN: center; LINE-HEIGHT: 24pt;" align=center>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 39.15pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 33.7pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=45> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD></TR> <TR style="HEIGHT: 35.7pt;"> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 35.7pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 25.8pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=34> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 35.7pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 60.75pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=81> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 35.7pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 62.85pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=84> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 35.7pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 198pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=264> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 35.7pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 36pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=48> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 35.7pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 31.4pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" width=42> <div style="TEXT-ALIGN: center; LINE-HEIGHT: 24pt;" align=center>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 35.7pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 33.7pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=45> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD></TR> <TR style="HEIGHT: 33.05pt;"> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 33.05pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 25.8pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=34> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 33.05pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 60.75pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=81> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 33.05pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 62.85pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=84> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 33.05pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 198pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=264> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 33.05pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 36pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=48> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 33.05pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 31.4pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" width=42> <div style="TEXT-ALIGN: center; LINE-HEIGHT: 24pt;" align=center>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 33.05pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 33.7pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=45> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD></TR> <TR style="HEIGHT: 39.05pt;"> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 39.05pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 25.8pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=34> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 39.05pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 60.75pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=81> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 39.05pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 62.85pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=84> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 39.05pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 198pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=264> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 39.05pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 36pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=48> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 39.05pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 31.4pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" width=42> <div style="TEXT-ALIGN: center; LINE-HEIGHT: 24pt;" align=center>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 39.05pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 33.7pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=45> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD></TR> <TR style="HEIGHT: 29.8pt;"> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 29.8pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 25.8pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=34> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 29.8pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 60.75pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=81> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 29.8pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 62.85pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=84> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 29.8pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 198pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=264> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 29.8pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 36pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=48> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 29.8pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 31.4pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" width=42> <div style="TEXT-ALIGN: center; LINE-HEIGHT: 24pt;" align=center>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 29.8pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 33.7pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=45> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD></TR> <TR style="HEIGHT: 30.25pt;"> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 30.25pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 25.8pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=34> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 30.25pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 60.75pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=81> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 30.25pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 62.85pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=84> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 30.25pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 198pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=264> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 30.25pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 36pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=48> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 30.25pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 31.4pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" width=42> <div style="TEXT-ALIGN: center; LINE-HEIGHT: 24pt;" align=center>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 30.25pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 33.7pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=45> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD></TR> <TR style="HEIGHT: 30.65pt;"> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 30.65pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 25.8pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=34> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 30.65pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 60.75pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=81> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 30.65pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 62.85pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=84> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 30.65pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 198pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=264> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 30.65pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 36pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=48> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 30.65pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 31.4pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" width=42> <div style="TEXT-ALIGN: center; LINE-HEIGHT: 24pt;" align=center>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 30.65pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 33.7pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=45> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD></TR> <TR style="HEIGHT: 26.5pt;"> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 26.5pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 25.8pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=34> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 26.5pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 60.75pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=81> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 26.5pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 62.85pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=84> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 26.5pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 198pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=264> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 26.5pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 36pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=48> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 26.5pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 31.4pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" width=42> <div style="TEXT-ALIGN: center; LINE-HEIGHT: 24pt;" align=center>&nbsp;</div></TD> <TD style="BORDER-TOP: #d4d0c8; HEIGHT: 26.5pt; BORDER-RIGHT: windowtext 1pt solid; WIDTH: 33.7pt; BORDER-BOTTOM: windowtext 1pt solid; PADDING-BOTTOM: 0cm; PADDING-TOP: 0cm; PADDING-LEFT: 5.4pt; BORDER-LEFT: #d4d0c8; PADDING-RIGHT: 5.4pt; BACKGROUND-COLOR: transparent;" vAlign=top width=45> <div style="TEXT-ALIGN: left; LINE-HEIGHT: 24pt;" align=left>&nbsp;</div></TD></TR></TBODY></TABLE> <div>&nbsp;</div> <div>&nbsp;</div>