<table width="100%" border="0" cellspacing="0">
  <tbody>
    <tr>
      <td colspan="4" align="center">
        <h2>
          POMIS-1 Report
        </h2>
      </td>
    </tr>
    <tr>
      <th width="20%">
        <div align="left">
          Branch Name &amp; Code
        </div>
      </th>
      <td class="align-left">
        <strong>:</strong> Uttara (085)
      </td>
      <th width="15%">
        <div align="left">
          Branch Address
        </div>
      </th>
      <td class="align-left">
        <strong>:</strong> Vill. Anowarbag, House no-79, P.O+P.S -
        Dakkhinkhan, Dist-Dhaka.
      </td>
    </tr>
    <tr>
      <th>
        <div align="left">
          Reporting Month
        </div>
      </th>
      <td class="align-left">
        <strong>:</strong> January,2017
      </td>
      <th>
        <div align="left">
          Print Date
        </div>
      </th>
      <td class="align-left">
        <strong>:</strong> 14-02-2017
      </td>
    </tr>
  </tbody>
</table>
<h2>
  01. Statement of Samity and Member
</h2>
<table width="100%" border="1" cellspacing="0" style=
"border: 1px solid #000000;">
  <tbody>
    <tr style="border: 1px solid #000000;">
      <th rowspan="2" colspan="2" style=
      "border: 1px solid #000000;">
        <div align="center">
          Component
        </div>
      </th>
      <th rowspan="2" width="50" style=
      "border: 1px solid #000000;">
        <div align="center">
          No. of Branch
        </div>
      </th>
      <th colspan="3" width="210" style=
      "border: 1px solid #000000;">
        <div align="center">
          No of Samity
        </div>
      </th>
      <th colspan="3" width="210" style=
      "border: 1px solid #000000;">
        <div align="center">
          No. of Member
        </div>
      </th>
    </tr>
    <tr>
      <th>
        <div align="center">
          Male
        </div>
      </th>
      <th>
        <div align="center">
          Female
        </div>
      </th>
      <th>
        <div align="center">
          Total
        </div>
      </th>
      <th>
        <div align="center">
          Male
        </div>
      </th>
      <th>
        <div align="center">
          Female
        </div>
      </th>
      <th>
        <div align="center">
          Total
        </div>
      </th>
    </tr>
    <tr>
      <th colspan="2">
        <div align="center">
          1
        </div>
      </th>
      <th>
        <div align="center">
          2
        </div>
      </th>
      <th>
        <div align="center">
          3
        </div>
      </th>
      <th>
        <div align="center">
          4
        </div>
      </th>
      <th>
        <div align="center">
          5=3+4
        </div>
      </th>
      <th>
        <div align="center">
          6
        </div>
      </th>
      <th>
        <div align="center">
          7
        </div>
      </th>
      <th>
        <div align="center">
          8=6+7
        </div>
      </th>
    </tr>
    <tr>
      <th rowspan="3">
        PKSF
      </th>
      <td>
        AGRO-(W)
      </td>
      <td>
        <div align="center">
          1
        </div>
      </td>
      <td>
        <div align="center">
          0
        </div>
      </td>
      <td>
        <div align="center">
          29
        </div>
      </td>
      <td>
        <div align="center">
          29
        </div>
      </td>
      <td>
        <div align="center">
          0
        </div>
      </td>
      <td>
        <div align="center">
          104
        </div>
      </td>
      <td>
        <div align="center">
          104
        </div>
      </td>
    </tr>
    <tr>
      <td>
        JAGO-W
      </td>
      <td>
        <div align="center">
          1
        </div>
      </td>
      <td>
        <div align="center">
          0
        </div>
      </td>
      <td>
        <div align="center">
          33
        </div>
      </td>
      <td>
        <div align="center">
          33
        </div>
      </td>
      <td>
        <div align="center">
          0
        </div>
      </td>
      <td>
        <div align="center">
          458
        </div>
      </td>
      <td>
        <div align="center">
          458
        </div>
      </td>
    </tr>
    <tr bgcolor="#A0A2A4">
      <th>
        Sub Total
      </th>
      <th>
        <div align="center">
          1
        </div>
      </th>
      <th>
        <div align="center">
          0
        </div>
      </th>
      <th>
        <div align="center">
          35
        </div>
      </th>
      <th>
        <div align="center">
          35
        </div>
      </th>
      <th>
        <div align="center">
          0
        </div>
      </th>
      <th>
        <div align="center">
          562
        </div>
      </th>
      <th>
        <div align="center">
          562
        </div>
      </th>
    </tr>
    <tr bgcolor="#A0A2A4">
      <th colspan="2">
        Grand Total
      </th>
      <th>
        <div align="center">
          1
        </div>
      </th>
      <th>
        <div align="center">
          0
        </div>
      </th>
      <th>
        <div align="center">
          35
        </div>
      </th>
      <th>
        <div align="center">
          35
        </div>
      </th>
      <th>
        <div align="center">
          0
        </div>
      </th>
      <th>
        <div align="center">
          562
        </div>
      </th>
      <th>
        <div align="center">
          562
        </div>
      </th>
    </tr>
    <tr bgcolor="#A0A2A4">
      <th colspan="2">
        Total Independent Branch
      </th>
      <th colspan="6">
        <div align="left">
          PKSF : 0
        </div>
      </th>
      <th>
        <div align="left">
          Total=0
        </div>
      </th>
    </tr>
  </tbody>
</table>
<p>
  <br />
</p>
<h2>
  02. Statement of Savings
</h2>
<table width="100%" border="1" cellspacing="0">
  <tbody>
    <tr>
      <th colspan="3" rowspan="2">
        <div align="center">
          Component
        </div>
      </th>
      <th colspan="2">
        <div align="center">
          Opening Balance
        </div>
      </th>
      <th colspan="2">
        <div align="center">
          Current Month Savings Collection
        </div>
      </th>
      <th colspan="2">
        <div align="center">
          Current Month Savings Refund
        </div>
      </th>
      <th colspan="3">
        <div align="center">
          Closing Balance
        </div>
      </th>
    </tr>
    <tr>
      <th>
        <div align="center">
          Male
        </div>
      </th>
      <th>
        <div align="center">
          Female
        </div>
      </th>
      <th>
        <div align="center">
          Male
        </div>
      </th>
      <th>
        <div align="center">
          Female
        </div>
      </th>
      <th>
        <div align="center">
          Male
        </div>
      </th>
      <th>
        <div align="center">
          Female
        </div>
      </th>
      <th>
        <div align="center">
          Male
        </div>
      </th>
      <th>
        <div align="center">
          Female
        </div>
      </th>
      <th>
        <div align="center">
          Total
        </div>
      </th>
    </tr>
    <tr>
      <th rowspan="8">
        PKSF
      </th>
      <th rowspan="4">
        AGRO-(W)
      </th>
      <td>
        GS
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          1,661,635.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          94,191.00<br />
          <u>48,647.00</u>*<br />
          <u>9,694.00</u>**<br />
          <u>9,694.00</u> (SPT)
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          44,643.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          1,711,183.00
        </div>
      </td>
      <td>
        <div align="right">
          1,711,183.00
        </div>
      </td>
    </tr>
    <tr>
      <td>
        VS
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          493,211.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          49,920.00<br />
          <u>11,045.00</u>*<br />
          <u>2,850.00</u>**<br />
          <u>2,850.00</u> (SPT)
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          75,767.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          467,364.00
        </div>
      </td>
      <td>
        <div align="right">
          467,364.00
        </div>
      </td>
    </tr>
    <tr>
      <td>
        UMSP
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          50,100.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          14,300.00<br />
          <u>2,800.00</u>*
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          64,400.00
        </div>
      </td>
      <td>
        <div align="right">
          64,400.00
        </div>
      </td>
    </tr>
    <tr bgcolor="#A0A2A4">
      <th align="right">
        Total:
      </th>
      <th>
        <div align="right">
          0.00
        </div>
      </th>
      <th>
        <div align="right">
          2,204,946.00
        </div>
      </th>
      <th>
        <div align="right">
          0.00
        </div>
      </th>
      <th>
        <div align="right">
          158,411.00
        </div>
      </th>
      <th>
        <div align="right">
          0.00
        </div>
      </th>
      <th>
        <div align="right">
          120,410.00
        </div>
      </th>
      <th>
        <div align="right">
          0.00
        </div>
      </th>
      <th>
        <div align="right">
          2,242,947.00
        </div>
      </th>
      <th>
        <div align="right">
          2,242,947.00
        </div>
      </th>
    </tr>
    <tr>
      <th rowspan="4">
        JAGO-W
      </th>
      <td>
        GS
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          1,947,631.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          173,310.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          192,380.00<br />
          <u>48,647.00</u>*<br />
          <u>9,694.00</u>**<br />
          <u>9,694.00</u> (SPT)
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          1,928,561.00
        </div>
      </td>
      <td>
        <div align="right">
          1,928,561.00
        </div>
      </td>
    </tr>
    <tr>
      <td>
        VS
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          627,286.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          105,890.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          119,886.00<br />
          <u>11,045.00</u>*<br />
          <u>2,850.00</u>**<br />
          <u>2,850.00</u> (SPT)
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          613,290.00
        </div>
      </td>
      <td>
        <div align="right">
          613,290.00
        </div>
      </td>
    </tr>
    <tr>
      <td>
        UMSP
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          14,100.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          4,700.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          2,800.00<br />
          <u>2,800.00</u>*
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          16,000.00
        </div>
      </td>
      <td>
        <div align="right">
          16,000.00
        </div>
      </td>
    </tr>
    <tr bgcolor="#A0A2A4">
      <th align="right">
        Total:
      </th>
      <th>
        <div align="right">
          0.00
        </div>
      </th>
      <th>
        <div align="right">
          2,589,017.00
        </div>
      </th>
      <th>
        <div align="right">
          0.00
        </div>
      </th>
      <th>
        <div align="right">
          283,900.00
        </div>
      </th>
      <th>
        <div align="right">
          0.00
        </div>
      </th>
      <th>
        <div align="right">
          315,066.00
        </div>
      </th>
      <th>
        <div align="right">
          0.00
        </div>
      </th>
      <th>
        <div align="right">
          2,557,851.00
        </div>
      </th>
      <th>
        <div align="right">
          2,557,851.00
        </div>
      </th>
    </tr>
    <tr bgcolor="#A0A2A4">
      <th rowspan="4">
        PKSF-Total
      </th>
      <td colspan="2" align="right">
        GS
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          3,609,266.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          267,501.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          237,023.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          3,639,744.00
        </div>
      </td>
      <td>
        <div align="right">
          3,639,744.00
        </div>
      </td>
    </tr>
    <tr bgcolor="#A0A2A4">
      <td colspan="2" align="right">
        VS
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          1,120,497.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          155,810.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          195,653.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          1,080,654.00
        </div>
      </td>
      <td>
        <div align="right">
          1,080,654.00
        </div>
      </td>
    </tr>
    <tr bgcolor="#A0A2A4">
      <td colspan="2" align="right">
        UMSP
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          64,200.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          19,000.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          2,800.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          80,400.00
        </div>
      </td>
      <td>
        <div align="right">
          80,400.00
        </div>
      </td>
    </tr>
    <tr bgcolor="#A0A2A4">
      <th colspan="2" align="right">
        Total:
      </th>
      <th>
        <div align="right">
          0.00
        </div>
      </th>
      <th>
        <div align="right">
          4,793,963.00
        </div>
      </th>
      <th>
        <div align="right">
          0.00
        </div>
      </th>
      <th>
        <div align="right">
          442,311.00
        </div>
      </th>
      <th>
        <div align="right">
          0.00
        </div>
      </th>
      <th>
        <div align="right">
          435,476.00
        </div>
      </th>
      <th>
        <div align="right">
          0.00
        </div>
      </th>
      <th>
        <div align="right">
          4,800,798.00
        </div>
      </th>
      <th>
        <div align="right">
          4,800,798.00
        </div>
      </th>
    </tr>
    <tr bgcolor="#A0A2A4">
      <th rowspan="4">
        PKSF-Total
      </th>
      <td colspan="2" align="right">
        GS
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          3,609,266.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          267,501.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          237,023.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          3,639,744.00
        </div>
      </td>
      <td>
        <div align="right">
          3,639,744.00
        </div>
      </td>
    </tr>
    <tr bgcolor="#A0A2A4">
      <td colspan="2" align="right">
        VS
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          1,120,497.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          155,810.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          195,653.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          1,080,654.00
        </div>
      </td>
      <td>
        <div align="right">
          1,080,654.00
        </div>
      </td>
    </tr>
    <tr bgcolor="#A0A2A4">
      <td colspan="2" align="right">
        UMSP
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          64,200.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          19,000.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          2,800.00
        </div>
      </td>
      <td>
        <div align="right">
          0.00
        </div>
      </td>
      <td>
        <div align="right">
          80,400.00
        </div>
      </td>
      <td>
        <div align="right">
          80,400.00
        </div>
      </td>
    </tr>
    <tr bgcolor="#A0A2A4">
      <th colspan="2" align="right">
        Total:
      </th>
      <th>
        <div align="right">
          0.00
        </div>
      </th>
      <th>
        <div align="right">
          4,793,963.00
        </div>
      </th>
      <th>
        <div align="right">
          0.00
        </div>
      </th>
      <th>
        <div align="right">
          442,311.00
        </div>
      </th>
      <th>
        <div align="right">
          0.00
        </div>
      </th>
      <th>
        <div align="right">
          435,476.00
        </div>
      </th>
      <th>
        <div align="right">
          0.00
        </div>
      </th>
      <th>
        <div align="right">
          4,800,798.00
        </div>
      </th>
      <th>
        <div align="right">
          4,800,798.00
        </div>
      </th>
    </tr>
    <tr>
      <th colspan="3" align="right">
        Grand Total(Male+Female)
      </th>
      <th colspan="2">
        <div align="right">
          4,793,963.00
        </div>
      </th>
      <th colspan="2">
        <div align="right">
          442,311.00
        </div>
      </th>
      <th colspan="2">
        <div align="right">
          435,476.00
        </div>
      </th>
      <th colspan="3">
        <div align="right">
          4,800,798.00
        </div>
      </th>
    </tr>
    <tr>
      <th colspan="3">
        Saving Interest Rate
      </th>
      <th colspan="9">
        <div align="center">
          PKSF=6.00%
        </div>
      </th>
    </tr>
  </tbody>
</table>
<p class="align-left" style="font-size:10px;text-align:left;">
  <br />
  <strong>* Product Transfer.</strong><br />
  <strong>* Samity Product Transfer.</strong><br />
  <strong>SPT - Samity Product Transfer</strong>
</p>
<p>
  <br />
</p>
<h2>
  03. Statement Of Member Admission, Cancellation, Deposit &amp;
  Attendance
</h2>
<table width="100%" border="1" cellspacing="0">
  <tbody>
    <tr>
      <th colspan="2" width="96">
        Component
      </th>
      <th>
        <div align="center">
          Total Member End of Last Month
        </div>
      </th>
      <th>
        <div align="center">
          New Member Admission (Current Month)
        </div>
      </th>
      <th>
        <div align="center">
          Member Cancellation (Current Month)
        </div>
      </th>
      <th>
        <div align="center">
          Total Member (End of Current Month)
        </div>
      </th>
      <th>
        <div align="center">
          Avg. No. of Savings Depositor
        </div>
      </th>
      <th>
        <div align="center">
          No. of Savings Withdrawal Member<br />
          <em>(Full+Partial)</em>
        </div>
      </th>
      <th>
        <div align="center">
          Average Attendance (Current Month)
        </div>
      </th>
    </tr>
    <tr>
      <th colspan="2" width="96">
        <div align="center">
          1
        </div>
      </th>
      <th>
        <div align="center">
          2
        </div>
      </th>
      <th>
        <div align="center">
          3
        </div>
      </th>
      <th>
        <div align="center">
          4
        </div>
      </th>
      <th>
        <div align="center">
          5=2+3-4
        </div>
      </th>
      <th>
        <div align="center">
          6
        </div>
      </th>
      <th>
        <div align="center">
          7
        </div>
      </th>
      <th>
        <div align="center">
          8
        </div>
      </th>
    </tr>
    <tr>
      <th rowspan="3">
        PKSF
      </th>
      <td width="96">
        AGRO-(W)
      </td>
      <td>
        <div align="center">
          101
        </div>
      </td>
      <td>
        <div align="center">
          6<br />
          ( 0 +6** )
        </div>
      </td>
      <td>
        <div align="center">
          3
        </div>
      </td>
      <td>
        <div align="center">
          104
        </div>
      </td>
      <td>
        <div align="center">
          79
        </div>
      </td>
      <td>
        <div align="center">
          ( 3 + 17 )= 20
        </div>
      </td>
      <td>
        <div align="center">
          0
        </div>
      </td>
    </tr>
    <tr>
      <td width="96">
        JAGO-W
      </td>
      <td>
        <div align="center">
          459
        </div>
      </td>
      <td>
        <div align="center">
          27
        </div>
      </td>
      <td>
        <div align="center">
          28<br />
          ( 22 +6** )
        </div>
      </td>
      <td>
        <div align="center">
          458
        </div>
      </td>
      <td>
        <div align="center">
          313
        </div>
      </td>
      <td>
        <div align="center">
          ( 22 + 75 )= 97
        </div>
      </td>
      <td>
        <div align="center">
          0
        </div>
      </td>
    </tr>
    <tr bgcolor="#A0A2A4">
      <th>
        <div align="left">
          Total
        </div>
      </th>
      <th>
        <div align="center">
          560
        </div>
      </th>
      <th>
        <div align="center">
          27 + 6**
        </div>
      </th>
      <th>
        <div align="center">
          25 + 6**
        </div>
      </th>
      <th>
        <div align="center">
          562
        </div>
      </th>
      <th>
        <div align="center">
          392
        </div>
      </th>
      <th>
        <div align="center">
          (25 + 92)= 117
        </div>
      </th>
      <th>
        <div align="center">
          0
        </div>
      </th>
    </tr>
    <tr bgcolor="#A0A2A4">
      <th colspan="2" width="96">
        <div align="left">
          Grand Total
        </div>
      </th>
      <th>
        <div align="center">
          560
        </div>
      </th>
      <th>
        <div align="center">
          27
        </div>
      </th>
      <th>
        <div align="center">
          25
        </div>
      </th>
      <th>
        <div align="center">
          562
        </div>
      </th>
      <th>
        <div align="center">
          392
        </div>
      </th>
      <th>
        <div align="center">
          (25 + 92 )= 117
        </div>
      </th>
      <th>
        <div align="center">
          0
        </div>
      </th>
    </tr>
  </tbody>
</table>
<p class="align-left" style="font-size:10px;text-align:left;">
  <br />
  <strong>Note :<br />
  * Double counting is avoided in all cases/Optional product no of
  borrowers.<br />
  ** Member Product Transfer.<br />
  *** Total Full Withdrawal Member.<br />
  <br />
  <br /></strong>
</p>
<div class="report-footer" border="0" align="center">
  <table id="report_footer_table" width="100%" border="0"
  cellspacing="0">
    <tbody>
      <tr>
        <td nowrap="nowrap">
          <strong>Prepared By</strong>
        </td>
        <td>
          <strong>:</strong>
        </td>
        <td>
          &nbsp;
        </td>
        <td nowrap="nowrap">
          <strong>Verified By</strong>
        </td>
        <td>
          <strong>:</strong>
        </td>
        <td>
          &nbsp;
        </td>
        <td nowrap="nowrap">
          <strong>Approved By</strong>
        </td>
        <td>
          <strong>:</strong>
        </td>
        <td>
          &nbsp;
        </td>
      </tr>
      <tr>
        <td>
          <strong>Signature</strong>
        </td>
        <td>
          <strong>:</strong>
        </td>
        <td width="33%">
          &nbsp;
        </td>
        <td>
          <strong>Signature</strong>
        </td>
        <td>
          <strong>:</strong>
        </td>
        <td width="33%">
          &nbsp;
        </td>
        <td>
          <strong>Signature</strong>
        </td>
        <td>
          <strong>:</strong>
        </td>
        <td width="33%">
          &nbsp;
        </td>
      </tr>
      <tr>
        <td>
          <strong>Designation</strong>
        </td>
        <td>
          <strong>:</strong>
        </td>
        <td>
          &nbsp;
        </td>
        <td>
          <strong>Designation</strong>
        </td>
        <td>
          <strong>:</strong>
        </td>
        <td>
          &nbsp;
        </td>
        <td>
          <strong>Designation</strong>
        </td>
        <td>
          <strong>:</strong>
        </td>
        <td>
          &nbsp;
        </td>
      </tr>
      <tr>
        <td></td>
        <td>
          &nbsp;
        </td>
        <td></td>
        <td>
          &nbsp;
        </td>
        <td></td>
        <td>
          &nbsp;
        </td>
      </tr>
    </tbody>
  </table>
</div>
