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[et_pb_line_break_holder] --><link type="text/css" rel="stylesheet" href="https://cdn.jotfor.ms/themes/CSS/566a91c2977cdfcd478b4567.css?"/><!-- [et_pb_line_break_holder] --><style type="text/css"> .form-label-left{ width:150px !important; } .form-line{ padding-top:12px; padding-bottom:12px; } .form-label-right{ width:150px !important; } .form-all{ width:690px; color:#555 !important; font-family:"Lucida Grande", "Lucida Sans Unicode", "Lucida Sans", Verdana, sans-serif; font-size:14px; }<!-- [et_pb_line_break_holder] --></style> <style type="text/css" id="form-designer-style"> /* Injected CSS Code */<!-- [et_pb_line_break_holder] -->.form-label.form-label-auto { display: block; float: none; text-align: left; width: inherit; } /*__INSPECT_SEPERATOR__*/ /* Injected CSS Code */<!-- [et_pb_line_break_holder] --></style> <form class="jotform-form" action="https://submit.jotform.us/submit/71528460525153/" method="post" name="form_71528460525153" id="71528460525153" accept-charset="utf-8"> <input type="hidden" name="formID" value="71528460525153" /> <div class="form-all"> <ul class="form-section page-section"> <li class="form-line" data-type="control_fullname" id="id_3"> <label class="form-label form-label-top form-label-auto" id="label_3" for="first_3"> Name </label> <div id="cid_3" class="form-input-wide jf-required"> <div data-wrapper-react="true"> <span class="form-sub-label-container" style="vertical-align:top;"> <input type="text" id="first_3" name="q3_name[first]" class="form-textbox" size="10" value="" data-component="first" /> <label class="form-sub-label" for="first_3" id="sublabel_first" style="min-height:13px;"> First Name </label> </span> <span class="form-sub-label-container" style="vertical-align:top;"> <input type="text" id="last_3" name="q3_name[last]" class="form-textbox" size="15" value="" data-component="last" /> <label class="form-sub-label" for="last_3" id="sublabel_last" style="min-height:13px;"> Last Name </label> </span> </div> </div> </li> <li class="form-line" data-type="control_address" id="id_4"> <label class="form-label form-label-top form-label-auto" id="label_4" for="input_4_addr_line1"> Address </label> <div id="cid_4" class="form-input-wide jf-required"> <table summary="" class="form-address-table" cellpadding="0" cellspacing="0"> <tbody> <tr> <td colspan="2"> <span class="form-sub-label-container" style="vertical-align:top;"> <input type="text" id="input_4_addr_line1" name="q4_address[addr_line1]" class="form-textbox form-address-line" value="" data-component="address_line_1" /> <label class="form-sub-label" for="input_4_addr_line1" id="sublabel_4_addr_line1" style="min-height:13px;"> Street Address </label> </span> </td> </tr> <tr> <td colspan="2"> <span class="form-sub-label-container" style="vertical-align:top;"> <input type="text" id="input_4_addr_line2" name="q4_address[addr_line2]" class="form-textbox form-address-line" size="46" value="" data-component="address_line_2" /> <label class="form-sub-label" for="input_4_addr_line2" id="sublabel_4_addr_line2" style="min-height:13px;"> Street Address Line 2 </label> </span> </td> </tr> <tr> <td width="50%"> <span class="form-sub-label-container" style="vertical-align:top;"> <input type="text" id="input_4_city" name="q4_address[city]" class="form-textbox form-address-city" size="21" value="" data-component="city" /> <label class="form-sub-label" for="input_4_city" id="sublabel_4_city" style="min-height:13px;"> City </label> </span> </td> <td> <span class="form-sub-label-container" style="vertical-align:top;"> <input type="text" id="input_4_state" name="q4_address[state]" class="form-textbox form-address-state" size="22" value="" data-component="state" /> <label class="form-sub-label" for="input_4_state" id="sublabel_4_state" style="min-height:13px;"> State / Province </label> </span> </td> </tr> <tr> <td width="50%"> <span class="form-sub-label-container" style="vertical-align:top;"> <input type="text" id="input_4_postal" name="q4_address[postal]" class="form-textbox form-address-postal" size="10" value="" data-component="zip" /> <label class="form-sub-label" for="input_4_postal" id="sublabel_4_postal" style="min-height:13px;"> Postal / Zip Code </label> </span> </td> <td style="display:none;"> <span class="form-sub-label-container" style="vertical-align:top;"> <select class="form-dropdown form-address-country" name="q4_address[country]" id="input_4_country" data-component="country"> <option value=""> Please Select </option> <option value="United States"> United States </option> <option value="Afghanistan"> Afghanistan </option> <option value="Albania"> Albania </option> <option value="Algeria"> Algeria </option> <option value="American Samoa"> American Samoa </option> <option value="Andorra"> Andorra </option> <option value="Angola"> Angola </option> <option value="Anguilla"> Anguilla </option> <option value="Antigua and Barbuda"> Antigua and Barbuda </option> <option value="Argentina"> Argentina </option> <option value="Armenia"> Armenia </option> <option value="Aruba"> Aruba </option> <option value="Australia"> Australia </option> <option value="Austria"> Austria </option> <option value="Azerbaijan"> Azerbaijan </option> <option value="The Bahamas"> The Bahamas </option> <option value="Bahrain"> Bahrain </option> <option value="Bangladesh"> Bangladesh </option> <option value="Barbados"> Barbados </option> <option value="Belarus"> Belarus </option> <option value="Belgium"> Belgium </option> <option value="Belize"> Belize </option> <option value="Benin"> Benin </option> <option value="Bermuda"> Bermuda </option> <option value="Bhutan"> Bhutan </option> <option value="Bolivia"> Bolivia </option> <option value="Bosnia and Herzegovina"> Bosnia and Herzegovina </option> <option value="Botswana"> Botswana </option> <option value="Brazil"> Brazil </option> <option value="Brunei"> Brunei </option> <option value="Bulgaria"> Bulgaria </option> <option value="Burkina Faso"> Burkina Faso </option> <option value="Burundi"> Burundi </option> <option value="Cambodia"> Cambodia </option> <option value="Cameroon"> Cameroon </option> <option value="Canada"> Canada </option> <option value="Cape Verde"> Cape Verde </option> <option value="Cayman Islands"> Cayman Islands </option> <option value="Central African Republic"> Central African Republic </option> <option value="Chad"> Chad </option> <option value="Chile"> Chile </option> <option value="China"> China </option> <option value="Christmas Island"> Christmas Island </option> <option value="Cocos (Keeling) Islands"> Cocos (Keeling) Islands </option> <option value="Colombia"> Colombia </option> <option value="Comoros"> Comoros </option> <option value="Congo"> Congo </option> <option value="Cook Islands"> Cook Islands </option> <option value="Costa Rica"> Costa Rica </option> <option value="Cote d'Ivoire"> Cote d'Ivoire </option> <option value="Croatia"> Croatia </option> <option value="Cuba"> Cuba </option> <option value="Cyprus"> Cyprus </option> <option value="Czech Republic"> Czech Republic </option> <option value="Democratic Republic of the Congo"> Democratic Republic of the Congo </option> <option value="Denmark"> Denmark </option> <option value="Djibouti"> Djibouti </option> <option value="Dominica"> Dominica </option> <option value="Dominican Republic"> Dominican Republic </option> <option value="Ecuador"> Ecuador </option> <option value="Egypt"> Egypt </option> <option value="El Salvador"> El Salvador </option> <option value="Equatorial Guinea"> Equatorial Guinea </option> <option value="Eritrea"> Eritrea </option> <option value="Estonia"> Estonia </option> <option value="Ethiopia"> Ethiopia </option> <option value="Falkland Islands"> Falkland Islands </option> <option value="Faroe Islands"> Faroe Islands </option> <option value="Fiji"> Fiji </option> <option value="Finland"> Finland </option> <option value="France"> France </option> <option value="French Polynesia"> French Polynesia </option> <option value="Gabon"> Gabon </option> <option value="The Gambia"> The Gambia </option> <option value="Georgia"> Georgia </option> <option value="Germany"> Germany </option> <option value="Ghana"> Ghana </option> <option value="Gibraltar"> Gibraltar </option> <option value="Greece"> Greece </option> <option value="Greenland"> Greenland </option> <option value="Grenada"> Grenada </option> <option value="Guadeloupe"> Guadeloupe </option> <option value="Guam"> Guam </option> <option value="Guatemala"> Guatemala </option> <option value="Guernsey"> Guernsey </option> <option value="Guinea"> Guinea </option> <option value="Guinea-Bissau"> Guinea-Bissau </option> <option value="Guyana"> Guyana </option> <option value="Haiti"> Haiti </option> <option value="Honduras"> Honduras </option> <option value="Hong Kong"> Hong Kong </option> <option value="Hungary"> Hungary </option> <option value="Iceland"> Iceland </option> <option value="India"> India </option> <option value="Indonesia"> Indonesia </option> <option value="Iran"> Iran </option> <option value="Iraq"> Iraq </option> <option value="Ireland"> Ireland </option> <option value="Israel"> Israel </option> <option value="Italy"> Italy </option> <option value="Jamaica"> Jamaica </option> <option value="Japan"> Japan </option> <option value="Jersey"> Jersey </option> <option value="Jordan"> Jordan </option> <option value="Kazakhstan"> Kazakhstan </option> <option value="Kenya"> Kenya </option> <option value="Kiribati"> Kiribati </option> <option value="North Korea"> North Korea </option> <option value="South Korea"> South Korea </option> <option value="Kosovo"> Kosovo </option> <option value="Kuwait"> Kuwait </option> <option value="Kyrgyzstan"> Kyrgyzstan </option> <option value="Laos"> Laos </option> <option value="Latvia"> Latvia </option> <option value="Lebanon"> Lebanon </option> <option value="Lesotho"> Lesotho </option> <option value="Liberia"> Liberia </option> <option value="Libya"> Libya </option> <option value="Liechtenstein"> Liechtenstein </option> <option value="Lithuania"> Lithuania </option> <option value="Luxembourg"> Luxembourg </option> <option value="Macau"> Macau </option> <option value="Macedonia"> Macedonia </option> <option value="Madagascar"> Madagascar </option> <option value="Malawi"> Malawi </option> <option value="Malaysia"> Malaysia </option> <option value="Maldives"> Maldives </option> <option value="Mali"> Mali </option> <option value="Malta"> Malta </option> <option value="Marshall Islands"> Marshall Islands </option> <option value="Martinique"> Martinique </option> <option value="Mauritania"> Mauritania </option> <option value="Mauritius"> Mauritius </option> <option value="Mayotte"> Mayotte </option> <option value="Mexico"> Mexico </option> <option value="Micronesia"> Micronesia </option> <option value="Moldova"> Moldova </option> <option value="Monaco"> Monaco </option> <option value="Mongolia"> Mongolia </option> <option value="Montenegro"> Montenegro </option> <option value="Montserrat"> Montserrat </option> <option value="Morocco"> Morocco </option> <option value="Mozambique"> Mozambique </option> <option value="Myanmar"> Myanmar </option> <option value="Nagorno-Karabakh"> Nagorno-Karabakh </option> <option value="Namibia"> Namibia </option> <option value="Nauru"> Nauru </option> <option value="Nepal"> Nepal </option> <option value="Netherlands"> Netherlands </option> <option value="Netherlands Antilles"> Netherlands Antilles </option> <option value="New Caledonia"> New Caledonia </option> <option value="New Zealand"> New Zealand </option> <option value="Nicaragua"> Nicaragua </option> <option value="Niger"> Niger </option> <option value="Nigeria"> Nigeria </option> <option value="Niue"> Niue </option> <option value="Norfolk Island"> Norfolk Island </option> <option value="Turkish Republic of Northern Cyprus"> Turkish Republic of Northern Cyprus </option> <option value="Northern Mariana"> Northern Mariana </option> <option value="Norway"> Norway </option> <option value="Oman"> Oman </option> <option value="Pakistan"> Pakistan </option> <option value="Palau"> Palau </option> <option value="Palestine"> Palestine </option> <option value="Panama"> Panama </option> <option value="Papua New Guinea"> Papua New Guinea </option> <option value="Paraguay"> Paraguay </option> <option value="Peru"> Peru </option> <option value="Philippines"> Philippines </option> <option value="Pitcairn Islands"> Pitcairn Islands </option> <option value="Poland"> Poland </option> <option value="Portugal"> Portugal </option> <option value="Puerto Rico"> Puerto Rico </option> <option value="Qatar"> Qatar </option> <option value="Republic of the Congo"> Republic of the Congo </option> <option value="Romania"> Romania </option> <option value="Russia"> Russia </option> <option value="Rwanda"> Rwanda </option> <option value="Saint Barthelemy"> Saint Barthelemy </option> <option value="Saint Helena"> Saint Helena </option> <option value="Saint Kitts and Nevis"> Saint Kitts and Nevis </option> <option value="Saint Lucia"> Saint Lucia </option> <option value="Saint Martin"> Saint Martin </option> <option value="Saint Pierre and Miquelon"> Saint Pierre and Miquelon </option> <option value="Saint Vincent and the Grenadines"> Saint Vincent and the Grenadines </option> <option value="Samoa"> Samoa </option> <option value="San Marino"> San Marino </option> <option value="Sao Tome and Principe"> Sao Tome and Principe </option> <option value="Saudi Arabia"> Saudi Arabia </option> <option value="Senegal"> Senegal </option> <option value="Serbia"> Serbia </option> <option value="Seychelles"> Seychelles </option> <option value="Sierra Leone"> Sierra Leone </option> <option value="Singapore"> Singapore </option> <option value="Slovakia"> Slovakia </option> <option value="Slovenia"> Slovenia </option> <option value="Solomon Islands"> Solomon Islands </option> <option value="Somalia"> Somalia </option> <option value="Somaliland"> Somaliland </option> <option value="South Africa"> South Africa </option> <option value="South Ossetia"> South Ossetia </option> <option value="South Sudan"> South Sudan </option> <option value="Spain"> Spain </option> <option value="Sri Lanka"> Sri Lanka </option> <option value="Sudan"> Sudan </option> <option value="Suriname"> Suriname </option> <option value="Svalbard"> Svalbard </option> <option value="Swaziland"> Swaziland </option> <option value="Sweden"> Sweden </option> <option value="Switzerland"> Switzerland </option> <option value="Syria"> Syria </option> <option value="Taiwan"> Taiwan </option> <option value="Tajikistan"> Tajikistan </option> <option value="Tanzania"> Tanzania </option> <option value="Thailand"> Thailand </option> <option value="Timor-Leste"> Timor-Leste </option> <option value="Togo"> Togo </option> <option value="Tokelau"> Tokelau </option> <option value="Tonga"> Tonga </option> <option value="Transnistria Pridnestrovie"> Transnistria Pridnestrovie </option> <option value="Trinidad and Tobago"> Trinidad and Tobago </option> <option value="Tristan da Cunha"> Tristan da Cunha </option> <option value="Tunisia"> Tunisia </option> <option value="Turkey"> Turkey </option> <option value="Turkmenistan"> Turkmenistan </option> <option value="Turks and Caicos Islands"> Turks and Caicos Islands </option> <option value="Tuvalu"> Tuvalu </option> <option value="Uganda"> Uganda </option> <option value="Ukraine"> Ukraine </option> <option value="United Arab Emirates"> United Arab Emirates </option> <option value="United Kingdom"> United Kingdom </option> <option value="Uruguay"> Uruguay </option> <option value="Uzbekistan"> Uzbekistan </option> <option value="Vanuatu"> Vanuatu </option> <option value="Vatican City"> Vatican City </option> <option value="Venezuela"> Venezuela </option> <option value="Vietnam"> Vietnam </option> <option value="British Virgin Islands"> British Virgin Islands </option> <option value="Isle of Man"> Isle of Man </option> <option value="US Virgin Islands"> US Virgin Islands </option> <option value="Wallis and Futuna"> Wallis and Futuna </option> <option value="Western Sahara"> Western Sahara </option> <option value="Yemen"> Yemen </option> <option value="Zambia"> Zambia </option> <option value="Zimbabwe"> Zimbabwe </option> <option value="other"> Other </option> </select> <label class="form-sub-label" for="input_4_country" id="sublabel_4_country" style="min-height:13px;"> Country </label> </span> </td> </tr> </tbody> </table> </div> </li> <li class="form-line" data-type="control_email" id="id_5"> <label class="form-label form-label-top form-label-auto" id="label_5" for="input_5"> E-mail </label> <div id="cid_5" class="form-input-wide jf-required"> <input type="email" id="input_5" name="q5_email" class="form-textbox validate[Email]" size="30" value="" data-component="email" /> </div> </li> <li class="form-line" data-type="control_phone" id="id_6"> <label class="form-label form-label-top form-label-auto" id="label_6" for="input_6_area"> Phone Number </label> <div id="cid_6" class="form-input-wide jf-required"> <div data-wrapper-react="true"> <span class="form-sub-label-container" style="vertical-align:top;"> <input type="tel" id="input_6_area" name="q6_phoneNumber[area]" class="form-textbox" size="3" value="" data-component="areaCode" /> <span class="phone-separate"> - </span> <label class="form-sub-label" for="input_6_area" id="sublabel_area" style="min-height:13px;"> Area Code </label> </span> <span class="form-sub-label-container" style="vertical-align:top;"> <input type="tel" id="input_6_phone" name="q6_phoneNumber[phone]" class="form-textbox" size="8" value="" data-component="phone" /> <label class="form-sub-label" for="input_6_phone" id="sublabel_phone" style="min-height:13px;"> Phone Number </label> </span> </div> </div> </li> <li class="form-line" data-type="control_stripe" id="id_7"> <label class="form-label form-label-top form-label-auto" id="label_7" for="input_7"> My Products </label> <div id="cid_7" class="form-input-wide jf-required"> <div data-wrapper-react="true"> <div data-wrapper-react="true"> <input type="hidden" name="simple_fpc" data-payment_type="stripe" data-component="payment1" value="7" /> <input type="hidden" name="payment_total_checksum" id="payment_total_checksum" data-component="payment2" /> <span class="form-sub-label-container" style="vertical-align:top;"> <input type="text" class="form-textbox validate[Numeric]" id="input_7_donation" name="q7_myProducts[price]" value="" data-component="paymentDonation" /> USD <label class="form-sub-label" for="input_7_donation" style="min-height:13px;"> Description </label> </span> <hr/> </div> <table class="form-address-table payment-form-table" cellpadding="0" cellspacing="0"> <tbody> <tr> <th colspan="2" style="text-align:left;margin-top:20px;display:table;" id="ccTitle7"> Credit Card Details </th> </tr> <tr> <td width="50%"> <span class="form-sub-label-container" style="vertical-align:top;"> <label class="form-sub-label" for="input_7_cc_firstName" id="sublabel_cc_firstName" style="min-height:13px;margin:0 0 3px 0;"> First Name </label> <input type="text" id="input_7_cc_firstName" name="q7_myProducts[cc_firstName]" class="form-textbox cc_firstName" size="20" value="" data-component="cc_firstName" /> </span> </td> <td width="50%"> <span class="form-sub-label-container" style="vertical-align:top;"> <label class="form-sub-label" for="input_7_cc_lastName" id="sublabel_cc_lastName" style="min-height:13px;margin:0 0 3px 0;"> Last Name </label> <input type="text" id="input_7_cc_lastName" name="q7_myProducts[cc_lastName]" class="form-textbox cc_lastName" size="20" value="" data-component="cc_lastName" /> </span> </td> </tr> <tr> <td width="50%"> <span class="form-sub-label-container" style="vertical-align:top;"> <label class="form-sub-label" for="input_7_cc_number" id="sublabel_cc_number" style="min-height:13px;margin:0 0 3px 0;"> Credit Card Number </label> <input type="number" id="input_7_cc_number" name="q7_myProducts[cc_number]" class="form-textbox cc_number" autocomplete="off" size="20" value="" data-component="cc_number" /> </span> </td> <td width="50%"> <span class="form-sub-label-container" style="vertical-align:top;"> <label class="form-sub-label" for="input_7_cc_ccv" id="sublabel_cc_ccv" style="min-height:13px;margin:0 0 3px 0;"> Security Code </label> <input type="number" id="input_7_cc_ccv" name="q7_myProducts[cc_ccv]" class="form-textbox cc_ccv" autocomplete="off" style="width:52px;" value="" data-component="cc_ccv" /> </span> </td> </tr> <tr> <td width="50%"> <span class="form-sub-label-container" style="vertical-align:top;"> <label class="form-sub-label" for="input_7_cc_exp_month" id="sublabel_cc_exp_month" style="min-height:13px;margin:0 0 3px 0;"> Expiration Month </label> <select class="form-dropdown cc_exp_month" name="q7_myProducts[cc_exp_month]" id="input_7_cc_exp_month" data-component="cc_exp_month"> <option> </option> <option value="1"> January </option> <option value="2"> February </option> <option value="3"> March </option> <option value="4"> April </option> <option value="5"> May </option> <option value="6"> June </option> <option value="7"> July </option> <option value="8"> August </option> <option value="9"> September </option> <option value="10"> October </option> <option value="11"> November </option> <option value="12"> December </option> </select> </span> </td> <td width="50%"> <span class="form-sub-label-container" style="vertical-align:top;"> <label class="form-sub-label" for="input_7_cc_exp_year" id="sublabel_cc_exp_year" style="min-height:13px;margin:0 0 3px 0;"> Expiration Year </label> <select class="form-dropdown cc_exp_year" name="q7_myProducts[cc_exp_year]" id="input_7_cc_exp_year" data-component="cc_exp_year"> <option> </option> <option value="2017"> 2017 </option> <option value="2018"> 2018 </option> <option value="2019"> 2019 </option> <option value="2020"> 2020 </option> <option value="2021"> 2021 </option> <option value="2022"> 2022 </option> <option value="2023"> 2023 </option> <option value="2024"> 2024 </option> <option value="2025"> 2025 </option> <option value="2026"> 2026 </option> <option value="2027"> 2027 </option> <option value="2028"> 2028 </option> <option value="2029"> 2029 </option> <option value="2030"> 2030 </option> <option value="2031"> 2031 </option> <option value="2032"> 2032 </option> <option value="2033"> 2033 </option> <option value="2034"> 2034 </option> <option value="2035"> 2035 </option> <option value="2036"> 2036 </option> </select> </span> </td> </tr> </tbody> </table> </div> </div> </li> <li class="form-line" data-type="control_button" id="id_2"> <div id="cid_2" class="form-input-wide"> <div style="margin-left:156px;" class="form-buttons-wrapper"> <button id="input_2" type="submit" class="form-submit-button" data-component="button"> Submit </button> </div> </div> </li> <li 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