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The question of developing a template with user fields in the SM ITSM

Good day all, on the project there is a task on creation of a template with the form of input of data from the user, transaction type is SMIN (ZMIN).

Standard function "Insert Text Template" is not enough. Need to have only lines and checkboxes in the form. For example:

System ERP [ ]

System BW [х]

System PI [х]

Is there any solution how to solve this task?

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