|-
| style="border:none; text-align: left; vertical-align:top; padding:0px; white-space:nowrap;" | <div style="margin-top:-5px;">{{{1}}}</div> || <div style="margin-top:-3px;">{{{2}}}</div> || colspan<div style="2margin-top:-3px;" >{{{3| }}}</div> || <div style="margin-top:-3px;"><small>{{{34| }}}</small></div>