<h4>{TITLE}</h4>
<table border="0" width="60%" cellpadding="5" cellspacing="1">
<tr class="bg_medium"><td width="10%" align="center">{NUMBER_LABEL}</td><td>{INPUT_LABEL}</td><td>{VALUE_LABEL}</td></tr>
{OPTIONS}
</table><br /><br />
{BACK_BUTTON}&#160;{SAVE_BUTTON}
