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<span class="style4"><b><font  color=#00ff00>Ẻ�ͺ��� Online</font></b><br>
<font color="ffff00">��չ��Թ�����ò�Ԫҡ�� ���駷�� 3 ��Шӻ� �.�. 2551<br>
�ѹ�ظ��� 21 - 22 �ѹ����ʺ�� ��͹ ���Ҥ� 2552<br>
� �Ҥ���Ԩ����С���֡�ҵ�����ͧ ���稾��෾�ѵ��Ҫ�ش� � ����Է�������չ��Թ�����ò</font></span>
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<td colspan=4><strong>�͹��� 1 �����ż��ͺ </strong></td>
</tr>
<tr bgcolor="f0f0f0">
  <td width="31%" bgcolor="#FFFFCC"><div align="left">1. �� </div></td>
  <td width="21%" bgcolor="#FFFFCC"><input name="sex" type="radio" id="sex" value="1" />
    ˭ԧ</td>
  <td width="21%" bgcolor="#FFFFCC"><input name="sex" type="radio" id="sex" value="2" />
    ���</td>
  <td width="27%" bgcolor="#FFFFCC">&nbsp;</td>
</tr>
<tr bgcolor="f0f0f0">
  <td bgcolor="#FFFFCC">
    <div align="left"></div>
  <td bgcolor="#FFFFCC">
  <td colspan="2" bgcolor="#FFFFCC">
  <tr bgcolor="f0f0f0">
  <td>
    <div align="left">2. ���� </div>
  <td><input name="age1" type="text" id="age1" size="5" maxlength="2" /> 
    �� 
  <td>&nbsp;</td>
  <td>
  <tr bgcolor="f0f0f0">
    <td>  
      <div align="left"></div>
    <td>
    <td colspan="2">&nbsp;</td>
  <tr bgcolor="f0f0f0">
    <td bgcolor="#FFFFCC"><div align="left">3. ʶҹ�Ҿ�Ѩ�غѹ </div></td>
    <td bgcolor="#FFFFCC"><input name="status1" type="radio" id="status1" value="1" />
      �Ҩ����</td>
    <td bgcolor="#FFFFCC"><input name="status1" type="radio" id="radio4" value="2" />
      ���˹�ҷ��</td>
    <td bgcolor="#FFFFCC"><input name="status1" type="radio" id="radio5" value="3" />
      ���Ե / �ѡ�֡�� </td>
  </tr>
  <tr bgcolor="f0f0f0">
    <td colspan="4" bgcolor="#FFFFCC">&nbsp;</td>
  </tr>
  <tr bgcolor="f0f0f0">
    <td colspan="4"><div align="left">4. �������/͹ء�����ý��� 
        <em class="style13">(�óշ���ҹ�繡������/͹ء���������½��� ����ö�ͺ���ҡ���� 1 ���) </em></div>      </td>
    </tr>
  <tr bgcolor="f0f0f0">
    <td class="style13" ><div align="left"><span class="style13">
      <input name="commit1" type="checkbox" id="commit1" value="1" />
    </span><span class="style15"> ��С�����ý����ӹ�¡��</span></div></td>
    <td colspan="3" class="style13"><label>
      <div align="left"><span class="style13">
        <input name="commit7" type="checkbox" id="commit7" value="1" />
        </span><span class="style15">    ��С�����ô��Թ�ҹ</span></div>
    </label></td>
    </tr>
  <tr bgcolor="f0f0f0">
  <td class="style13"><div align="left" class="style2">
    <input name="commit2" type="checkbox" id="commit2" value="1" />
    <span class="style15">���͹ء�����ý����Ԫҡ��    </span></div>
  <td colspan="3" class="style13"><div align="left"><span class="style13">
    <input name="commit8" type="checkbox" id="commit8" value="1" />
  </span><span class="style15">    ���͹ء�����ý���ŧ����¹</span></div></td>
    </tr>
    
  <tr bgcolor="f0f0f0">
  <td class="style13"><div align="left" class="style2">
    <input name="commit3" type="checkbox" id="commit3" value="1" />
    <span class="style15">���͹ء�����ý��¾Ըա����е�͹�Ѻ    </span></div>
  <td colspan="3" class="style15"><div align="left" class="style2">
    <input name="commit9" type="checkbox" id="commit9" value="1" />
    
    <span class="style15">���͹ء�����ý��»�Ъ�����ѹ��    </span></div>
  <tr bgcolor="f0f0f0">
    <td class="style13"><div align="left" class="style2">
      <input name="commit4" type="checkbox" id="commit4" value="1" />
      <span class="style15">���͹ء�����ý���ʶҹ��� �ҹ��˹�</span>    </div>
    <td colspan="3" class="style15"><div align="left" class="style2">
      <input name="commit10" type="checkbox" id="commit10" value="1" />
      
      <span class="style15">���͹ء�����ý��¡���Թ      </span></div>
    <tr bgcolor="f0f0f0">
    <td class="style13"><div align="left" class="style2">
      <input name="commit5" type="checkbox" id="commit5" value="1" /> 
      <span class="style15">���͹ء�����ý����ʵ��ȹٻ�ó�</span>    </div>
    <td colspan="3" class="style15"><div align="left" class="style2">
      <input name="commit11" type="checkbox" id="commit11" value="1" />
      
      <span class="style15">���͹ء�����ý��¨Ѵ����§      </span></div>
    <tr bgcolor="f0f0f0">
    <td class="style13"><div align="left" class="style2">
      <input name="commit6" type="checkbox" id="commit6" value="1" />
      <span class="style15">���͹ء�����ý��»����Թ��      </span></div>
    <td colspan="3" class="style15"><div align="left" class="style2">
      <input name="commit12" type="checkbox" id="commit12" value="1" />
      <span class="style15">���͹ء�����ý��¹Է��ȡ�á�èѴ��Ъ��      </span></div>
    <tr bgcolor="f0f0f0">
    <td>  
    <td>  
    <td colspan="2">&nbsp;</td>
  <tr bgcolor="f0f0f0">
    <td>  
    <td>  
    <td colspan="2">&nbsp;</td>
  </table>
<td bgcolor=#ffffff width=5><IMG src="bar10000.gif" width=5 height=5 hspace=0 vspace=0 border=0><BR></td>
<td bgcolor=#6e9966 width=1><IMG src="bar10000.gif" width=1 height=1 hspace=0 vspace=0 border=0><BR></td>
</tr>
<tr valign=top><td height="10" colspan=5 bgcolor=#ffffff><IMG src="bar20000.gif" width="100%" height=10 hspace=0 vspace=0 border=0></td>
</tr>
<tr valign=top>
  <td height="10" colspan=5 bgcolor=#ffffff>&nbsp;</td>
</tr>
<tr valign=top>
  <td height="10" colspan=5 bgcolor=#ffffff><table width="750" border="0" align="center" cellpadding="0" cellspacing="0">
    <tr valign="top">
      <td colspan="5" bgcolor="#6e9966" align="center"><img src="bar30000.gif" width="9" height="18" hspace="0" vspace="0" border="0" align="left" /><img src="bar10000.gif" width="100" height="3" hspace="0" vspace="0" border="0" /> <br />
      <span class="style4"><br />
          <span class="style8"><font color="ffff00">�����Դ�������ǡѺ�Ҿ����ͧ��èѴ��Ъ��</font></span> </span><br /></td>
    </tr>
    <tr valign="top">
      <td width="1" height="270" bgcolor="#6e9966"><img src="bar10000.gif" width="1" height="1" hspace="0" vspace="0" border="0" /></td>
      <td bgcolor="#ffffff" width="5"><img src="bar10000.gif" width="5" height="5" hspace="0" vspace="0" border="0" /></td>
      <td ><img src="bar10000.gif" width="100%" height="10" hspace="0" vspace="0" border="0" /><br />
          <table width="100%" cellspacing="0">
            
            <tr>
              <td width="63%" bgcolor="#CC99FF"><div align="center"><strong>��¡�û����Թ</strong></div></td>
              <td width="9%" bgcolor="#CC99FF"><div align="center" class="style9">�ҡ����ش</div></td>
              <td width="10%" bgcolor="#CC99FF"><div align="center" class="style9">��͹��ҧ�ҡ</div></td>
              <td width="9%" bgcolor="#CC99FF"><div align="center" class="style9">��͹��ҧ����</div></td>
              <td width="9%" bgcolor="#CC99FF"><div align="center" class="style9">���·���ش</div></td>
            </tr>
            <tr>
              <td bgcolor="#F6F6F9"><div align="left">1. ��������������ǹ����Ѻ�Դ�ͺ </div></td>
              <td bgcolor="#F6F6F9"><div align="center" class="style2">
                  <input name="s31" type="radio" value="4" />
              </div></td>
              <td bgcolor="#F6F6F9"><div align="center" class="style2">
                <input name="s31" type="radio" value="3" />
              </div></td>
              <td bgcolor="#F6F6F9"><div align="center" class="style2">
                <input name="s31" type="radio" value="2" />
              </div></td>
              <td bgcolor="#F6F6F9"><div align="center" class="style2">
                <input name="s31" type="radio" value="1" />
              </div></td>
            </tr>
            <tr>
              <td bgcolor="#CCCCCC"><div align="left">2. ������������С���������š�û�Ъ�������ҧ��С������ </div></td>
              <td bgcolor="#CCCCCC"><div align="center">
                  <input name="s32" type="radio" value="4" />
              </div></td>
              <td bgcolor="#CCCCCC"><div align="center">
                  <input name="s32" type="radio" value="3" />
              </div></td>
              <td bgcolor="#CCCCCC"><div align="center">
                  <input name="s32" type="radio" value="2" />
              </div></td>
              <td bgcolor="#CCCCCC"><div align="center">
                  <input name="s32" type="radio" value="1" />
              </div></td>
            </tr>
            <tr>
              <td bgcolor="#F6F6F9"><div align="left">3. ���������������á�͹��û�Ъ�� </div></td>
              <td bgcolor="#F6F6F9"><div align="center">
                  <input name="s33" type="radio" value="4" />
              </div></td>
              <td bgcolor="#F6F6F9"><div align="center">
                  <input name="s33" type="radio" value="3" />
              </div></td>
              <td bgcolor="#F6F6F9"><div align="center">
                  <input name="s33" type="radio" value="2" />
              </div></td>
              <td bgcolor="#F6F6F9"><div align="center">
                  <input name="s33" type="radio" value="1" />
              </div></td>
            </tr>
            <tr>
              <td bgcolor="#CCCCCC"><div align="left">4. ��õԴ��ͻ���ҹ�ҹ�����ҧ��С�����ý��µ�ҧ � </div></td>
              <td bgcolor="#CCCCCC"><div align="center">
                  <input name="s34" type="radio" value="4" />
              </div></td>
              <td bgcolor="#CCCCCC"><div align="center">
                  <input name="s34" type="radio" value="3" />
              </div></td>
              <td bgcolor="#CCCCCC"><div align="center">
                  <input name="s34" type="radio" value="2" />
              </div></td>
              <td bgcolor="#CCCCCC"><div align="center">
                  <input name="s34" type="radio" value="1" />
              </div></td>
            </tr>
            <tr>
              <td bgcolor="#F6F6F9"><div align="left">5.��������§�ͧ��Ѿ�ҡ�ʹѺʹع㹡�èѴ�ҹ (�� ������ҳ �ؤ�ҡ�) </div></td>
              <td bgcolor="#F6F6F9"><div align="center" class="style2">
                  <input name="s35" type="radio" value="4" />
              </div></td>
              <td bgcolor="#F6F6F9"><div align="center" class="style2">
                  <input name="s35" type="radio" value="3" />
              </div></td>
              <td bgcolor="#F6F6F9"><div align="center" class="style2">
                  <input name="s35" type="radio" value="2" />
              </div></td>
              <td bgcolor="#F6F6F9"><div align="center" class="style2">
                  <input name="s35" type="radio" value="1" />
              </div></td>
            </tr>
            <tr>
              <td bgcolor="#CCCCCC"><div align="left">6. ���������������ͧ͢��С������ </div></td>
              <td bgcolor="#CCCCCC"><div align="center">
                  <input name="s36" type="radio" value="4" />
              </div></td>
              <td bgcolor="#CCCCCC"><div align="center">
                  <input name="s36" type="radio" value="3" />
              </div></td>
              <td bgcolor="#CCCCCC"><div align="center">
                  <input name="s36" type="radio" value="2" />
              </div></td>
              <td bgcolor="#CCCCCC"><div align="center">
                  <input name="s36" type="radio" value="1" />
              </div></td>
            </tr>
          </table>
          <div align="left"><br />
              <br />
              <strong>����ʹ����������</strong><br />
                <textarea name="comments3" cols="130" rows="5" style="color: red; background-color: #FFCCFF"></textarea>
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    </tr>
    <tr valign="top">
      <td height="10" colspan="5" bgcolor="#ffffff"><img src="bar20000.gif" width="100%" height="10" hspace="0" vspace="0" border="0" /></td>
    </tr>
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    <font size=5 color="blue">�͢ͺ�س����������������㹡�õͺẺ�ͺ���㹤��駹��    </font></span>
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