| class="textfield" style="width: 15%" | [[File:{{{1}}}.png|center]] | class="textfield" style="text-align: center; width: 15%" | [[|]] | class="textfield" style="text-align: center; width: 5%" | | class="textfield" style="text-align: center; width: 5%" | | class="textfield" style="text-align: center; width: 5%" | | class="textfield" style="text-align: center; width: 55%" | |- align="center"