<table class="freefield_bottom">
<tr>
	<td><strong>{TXT_DATE}</strong></td>
	<td>:</td>
	<td>{VALUE_DATE}</td>
	<td>&nbsp;</td>
	<td><strong>{TXT_SIGNATURE}</strong></td>
	<td>:</td>
	<td class="freefield_line"><img height="30px" border="0" src="{IMG_SPACER}" width="300px" /></td>
</tr>
</table>
