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function FrameBuilder(formId,appendTo,initialHeight,iframeCode,title,embedStyleJSON,isSmartEmbedEnabled){this.formId=formId;this.initialHeight=initialHeight;this.iframeCode=iframeCode;this.frame=null;this.timeInterval=200;this.appendTo=appendTo||false;this.formSubmitted=0;this.frameMinWidth='100%';this.defaultHeight='';this.isSmartEmbedEnabled=isSmartEmbedEnabled===1;this.init=function(){this.embedURLHash=this.getMD5(window.location.href);if(embedStyleJSON&&(embedStyleJSON[this.embedURLHash]&&embedStyleJSON[this.embedURLHash]['inlineStyle']['embedWidth'])){this.frameMinWidth=embedStyleJSON[this.embedURLHash]['inlineStyle']['embedWidth']+'px';}
if(embedStyleJSON&&(embedStyleJSON[this.embedURLHash])){if(embedStyleJSON[this.embedURLHash]['inlineStyle']&&embedStyleJSON[this.embedURLHash]['inlineStyle']['embedHeight']){this.defaultHeight='data-frameHeight="'+embedStyleJSON[this.embedURLHash]['inlineStyle']['embedHeight']+'"';}}
this.createFrame();this.addFrameContent(this.iframeCode);};this.createFrame=function(){var tmp_is_ie=!!window.ActiveXObject;this.iframeDomId=document.getElementById(this.formId)?this.formId+'_'+new Date().getTime():this.formId;var htmlCode="<"+"iframe title=\""+title.replace(/[\\"']/g,'\\$&').replace(/&amp;/g,'&')+"\" src=\"\" allowtransparency=\"true\" allowfullscreen=\"true\" name=\""+this.formId+"\" id=\""+this.iframeDomId+"\" style=\"width: 10px; min-width:"+this.frameMinWidth+"; display: block; overflow: hidden; height:"+this.initialHeight+"px; border: none;\" scrolling=\"no\""+this.defaultHeight+"></if"+"rame>";if(this.appendTo===false){document.write(htmlCode);}else{var tmp=document.createElement('div');tmp.innerHTML=htmlCode;var a=this.appendTo;document.getElementById(a).appendChild(tmp.firstChild);}
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this.addEvent(this.frame,'load',this.bindMethod(this.setTimer,this));var self=this;if(window.chrome!==undefined){this.frame.onload=function(){try{var doc=this.contentWindow.document;var _jotform=this.contentWindow.JotForm;if(doc!==undefined){var form=doc.getElementById(""+self.iframeDomId);self.addEvent(form,"submit",function(){if(_jotform.validateAll()){self.formSubmitted=1;}});}}catch(e){}}}};this.addEvent=function(obj,type,fn){if(obj.attachEvent){obj["e"+type+fn]=fn;obj[type+fn]=function(){obj["e"+type+fn](window.event);};obj.attachEvent("on"+type,obj[type+fn]);}
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var iframe=this.frame;var doc=iframe.contentDocument?iframe.contentDocument:(iframe.contentWindow.document||iframe.document);doc.open();doc.write(string);setTimeout(function(){doc.close();try{if('JotFormFrameLoaded'in window){JotFormFrameLoaded();}}catch(e){console.log("error on frame loading",e);}},200);};this.setTimer=function(){var self=this;this.interval=setTimeout(function(){self.changeHeight();},this.timeInterval);};this.getBaseDomain=function(){var thn=window.location.hostname;var cc=0;var buff="";for(var i=0;i<thn.length;i++){var chr=thn.charAt(i);if(chr=="."){cc++;}
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if(cc==2){thn=thn.replace(buff+".","");}
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this.setTimer();};this.bindMethod=function(method,scope){return function(){method.apply(scope,arguments);};};this.frameHeight=0;this.getBodyHeight=function(){if(this.formSubmitted===1){return;}
var height;var scrollHeight;var offsetHeight;try{if(this.frame.contentWindow.document.height){height=this.frame.contentWindow.document.height;if(this.frame.contentWindow.document.body.scrollHeight){height=scrollHeight=this.frame.contentWindow.document.body.scrollHeight;}
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if(isChrome){height=scrollHeight=this.frame.contentWindow.document.height;}
if(this.frame.contentWindow.document.body.offsetHeight){height=offsetHeight=this.frame.contentWindow.document.body.offsetHeight;}
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var height=0;try{if(this.frame.contentWindow.window.innerHeight)
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{height=this.frame.contentWindow.document.documentElement.clientHeight;}
else if((this.frame.contentWindow.document.body)&&(this.frame.contentWindow.document.body.clientHeight))
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return height;};this.getMD5=function(s){function L(k,d){return(k<<d)|(k>>>(32-d))}function K(G,k){var I,d,F,H,x;F=(G&2147483648);H=(k&2147483648);I=(G&1073741824);d=(k&1073741824);x=(G&1073741823)+(k&1073741823);if(I&d){return(x^2147483648^F^H)}if(I|d){if(x&1073741824){return(x^3221225472^F^H)}else{return(x^1073741824^F^H)}}else{return(x^F^H)}}function r(d,F,k){return(d&F)|((~d)&k)}function q(d,F,k){return(d&k)|(F&(~k))}function p(d,F,k){return(d^F^k)}function n(d,F,k){return(F^(d|(~k)))}function u(G,F,aa,Z,k,H,I){G=K(G,K(K(r(F,aa,Z),k),I));return K(L(G,H),F)}function f(G,F,aa,Z,k,H,I){G=K(G,K(K(q(F,aa,Z),k),I));return K(L(G,H),F)}function D(G,F,aa,Z,k,H,I){G=K(G,K(K(p(F,aa,Z),k),I));return K(L(G,H),F)}function t(G,F,aa,Z,k,H,I){G=K(G,K(K(n(F,aa,Z),k),I));return K(L(G,H),F)}function e(G){var Z;var F=G.length;var x=F+8;var k=(x-(x%64))/64;var I=(k+1)*16;var aa=Array(I-1);var d=0;var H=0;while(H<F){Z=(H-(H%4))/4;d=(H%4)*8;aa[Z]=(aa[Z]|(G.charCodeAt(H)<<d));H++}Z=(H-(H%4))/4;d=(H%4)*8;aa[Z]=aa[Z]|(128<<d);aa[I-2]=F<<3;aa[I-1]=F>>>29;return aa}function B(x){var k="",F="",G,d;for(d=0;d<=3;d++){G=(x>>>(d*8))&255;F="0"+G.toString(16);k=k+F.substr(F.length-2,2)}return k}function J(k){k=k.replace(/rn/g,"n");var d="";for(var F=0;F<k.length;F++){var x=k.charCodeAt(F);if(x<128){d+=String.fromCharCode(x)}else{if((x>127)&&(x<2048)){d+=String.fromCharCode((x>>6)|192);d+=String.fromCharCode((x&63)|128)}else{d+=String.fromCharCode((x>>12)|224);d+=String.fromCharCode(((x>>6)&63)|128);d+=String.fromCharCode((x&63)|128)}}}return d}var C=Array();var P,h,E,v,g,Y,X,W,V;var S=7,Q=12,N=17,M=22;var A=5,z=9,y=14,w=20;var o=4,m=11,l=16,j=23;var U=6,T=10,R=15,O=21;s=J(s);C=e(s);Y=1732584193;X=4023233417;W=2562383102;V=271733878;for(P=0;P<C.length;P+=16){h=Y;E=X;v=W;g=V;Y=u(Y,X,W,V,C[P+0],S,3614090360);V=u(V,Y,X,W,C[P+1],Q,3905402710);W=u(W,V,Y,X,C[P+2],N,606105819);X=u(X,W,V,Y,C[P+3],M,3250441966);Y=u(Y,X,W,V,C[P+4],S,4118548399);V=u(V,Y,X,W,C[P+5],Q,1200080426);W=u(W,V,Y,X,C[P+6],N,2821735955);X=u(X,W,V,Y,C[P+7],M,4249261313);Y=u(Y,X,W,V,C[P+8],S,1770035416);V=u(V,Y,X,W,C[P+9],Q,2336552879);W=u(W,V,Y,X,C[P+10],N,4294925233);X=u(X,W,V,Y,C[P+11],M,2304563134);Y=u(Y,X,W,V,C[P+12],S,1804603682);V=u(V,Y,X,W,C[P+13],Q,4254626195);W=u(W,V,Y,X,C[P+14],N,2792965006);X=u(X,W,V,Y,C[P+15],M,1236535329);Y=f(Y,X,W,V,C[P+1],A,4129170786);V=f(V,Y,X,W,C[P+6],z,3225465664);W=f(W,V,Y,X,C[P+11],y,643717713);X=f(X,W,V,Y,C[P+0],w,3921069994);Y=f(Y,X,W,V,C[P+5],A,3593408605);V=f(V,Y,X,W,C[P+10],z,38016083);W=f(W,V,Y,X,C[P+15],y,3634488961);X=f(X,W,V,Y,C[P+4],w,3889429448);Y=f(Y,X,W,V,C[P+9],A,568446438);V=f(V,Y,X,W,C[P+14],z,3275163606);W=f(W,V,Y,X,C[P+3],y,4107603335);X=f(X,W,V,Y,C[P+8],w,1163531501);Y=f(Y,X,W,V,C[P+13],A,2850285829);V=f(V,Y,X,W,C[P+2],z,4243563512);W=f(W,V,Y,X,C[P+7],y,1735328473);X=f(X,W,V,Y,C[P+12],w,2368359562);Y=D(Y,X,W,V,C[P+5],o,4294588738);V=D(V,Y,X,W,C[P+8],m,2272392833);W=D(W,V,Y,X,C[P+11],l,1839030562);X=D(X,W,V,Y,C[P+14],j,4259657740);Y=D(Y,X,W,V,C[P+1],o,2763975236);V=D(V,Y,X,W,C[P+4],m,1272893353);W=D(W,V,Y,X,C[P+7],l,4139469664);X=D(X,W,V,Y,C[P+10],j,3200236656);Y=D(Y,X,W,V,C[P+13],o,681279174);V=D(V,Y,X,W,C[P+0],m,3936430074);W=D(W,V,Y,X,C[P+3],l,3572445317);X=D(X,W,V,Y,C[P+6],j,76029189);Y=D(Y,X,W,V,C[P+9],o,3654602809);V=D(V,Y,X,W,C[P+12],m,3873151461);W=D(W,V,Y,X,C[P+15],l,530742520);X=D(X,W,V,Y,C[P+2],j,3299628645);Y=t(Y,X,W,V,C[P+0],U,4096336452);V=t(V,Y,X,W,C[P+7],T,1126891415);W=t(W,V,Y,X,C[P+14],R,2878612391);X=t(X,W,V,Y,C[P+5],O,4237533241);Y=t(Y,X,W,V,C[P+12],U,1700485571);V=t(V,Y,X,W,C[P+3],T,2399980690);W=t(W,V,Y,X,C[P+10],R,4293915773);X=t(X,W,V,Y,C[P+1],O,2240044497);Y=t(Y,X,W,V,C[P+8],U,1873313359);V=t(V,Y,X,W,C[P+15],T,4264355552);W=t(W,V,Y,X,C[P+6],R,2734768916);X=t(X,W,V,Y,C[P+13],O,1309151649);Y=t(Y,X,W,V,C[P+4],U,4149444226);V=t(V,Y,X,W,C[P+11],T,3174756917);W=t(W,V,Y,X,C[P+2],R,718787259);X=t(X,W,V,Y,C[P+9],O,3951481745);Y=K(Y,h);X=K(X,E);W=K(W,v);V=K(V,g)}var i=B(Y)+B(X)+B(W)+B(V);return i.toLowerCase()};this.init();}
FrameBuilder.get=qsProxy||[];var i32538643990867=new FrameBuilder("32538643990867",false,"","<!DOCTYPE HTML PUBLIC \"-\/\/W3C\/\/DTD HTML 4.01\/\/EN\" \"http:\/\/www.w3.org\/TR\/html4\/strict.dtd\">\n<html class=\"supernova\"><head>\n<meta http-equiv=\"Content-Type\" content=\"text\/html; charset=utf-8\" \/>\n<link rel=\"alternate\" type=\"application\/json+oembed\" href=\"https:\/\/www.jotform.com\/oembed\/?format=json&amp;url=http%3A%2F%2Fwww.jotform.com%2Fform%2F32538643990867\" title=\"oEmbed Form\"><link rel=\"alternate\" type=\"text\/xml+oembed\" href=\"https:\/\/www.jotform.com\/oembed\/?format=xml&amp;url=http%3A%2F%2Fwww.jotform.com%2Fform%2F32538643990867\" title=\"oEmbed Form\">\n<meta property=\"og:title\" content=\"Opticare Account Application Form\" >\n<meta property=\"og:url\" content=\"http:\/\/www.jotform.co\/form\/32538643990867\" >\n<meta property=\"og:description\" content=\"Please click the link to complete this form.\">\n<link rel=\"shortcut icon\" href=\"https:\/\/cdn.jotfor.ms\/favicon.ico\">\n<meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0, maximum-scale=1.0, user-scalable=0\" \/>\n<meta name=\"HandheldFriendly\" content=\"true\" \/>\n<title>Opticare Account Application Form<\/title>\n<link href=\"https:\/\/cdn.jotfor.ms\/static\/formCss.css?3.3.4645\" rel=\"stylesheet\" type=\"text\/css\" \/>\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/cdn.jotfor.ms\/css\/styles\/nova.css?3.3.4645\" \/>\n<link type=\"text\/css\" media=\"print\" rel=\"stylesheet\" href=\"https:\/\/cdn.jotfor.ms\/css\/printForm.css?3.3.4645\" \/>\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/cdn.jotfor.ms\/themes\/CSS\/566a91c2977cdfcd478b4567.css?\"\/>\n<style type=\"text\/css\">\n    .form-label-left{\n        width:150px;\n    }\n    .form-line{\n        padding-top:12px;\n        padding-bottom:12px;\n    }\n    .form-label-right{\n        width:150px;\n    }\n    body, html{\n        margin:0;\n        padding:0;\n        background:#fff;\n    }\n\n    .form-all{\n        margin:0px auto;\n        padding-top:20px;\n        width:1000px;\n        color:#555 !important;\n        font-family:\"Lucida Grande\", \"Lucida Sans Unicode\", \"Lucida Sans\", Verdana, sans-serif;\n        font-size:14px;\n    }\n    .form-radio-item label, .form-checkbox-item label, .form-grading-label, .form-header{\n        color: #363E45;\n    }\n\n<\/style>\n\n<style type=\"text\/css\" id=\"form-designer-style\">\n    \/* Injected CSS Code *\/\n\/*PREFERENCES STYLE*\/\n    .form-all {\n      font-family: Lucida Grande, sans-serif;\n    }\n    .form-all .qq-upload-button,\n    .form-all .form-submit-button,\n    .form-all .form-submit-reset,\n    .form-all .form-submit-print {\n      font-family: Lucida Grande, sans-serif;\n    }\n    .form-all .form-pagebreak-back-container,\n    .form-all .form-pagebreak-next-container {\n      font-family: Lucida Grande, sans-serif;\n    }\n    .form-header-group {\n      font-family: Lucida Grande, sans-serif;\n    }\n    .form-label {\n      font-family: Lucida Grande, sans-serif;\n    }\n  \n    .form-label.form-label-auto {\n      \n    display: inline-block;\n    float: left;\n    text-align: left;\n  \n    }\n  \n    .form-line {\n      margin-top: 12px;\n      margin-bottom: 12px;\n    }\n  \n    .form-all {\n      width: 1000px;\n    }\n  \n    .form-label-left,\n    .form-label-right {\n      width: 150px\n    }\n  \n    .form-all {\n      font-size: 14px\n    }\n    .form-all .qq-upload-button,\n    .form-all .qq-upload-button,\n    .form-all .form-submit-button,\n    .form-all .form-submit-reset,\n    .form-all .form-submit-print {\n      font-size: 14px\n    }\n    .form-all .form-pagebreak-back-container,\n    .form-all .form-pagebreak-next-container {\n      font-size: 14px\n    }\n  \n    .supernova {\n      background-color: #f5f5f5;\n    }\n    .supernova body {\n      background: transparent;\n    }\n  \n    .supernova .form-all, .form-all {\n      background-color: #fff;\n      border: 1px solid transparent;\n    }\n  \n    .form-all {\n      color: #555;\n    }\n    .form-header-group .form-header {\n      color: #555;\n    }\n    .form-header-group .form-subHeader {\n      color: #555;\n    }\n    .form-label-top,\n    .form-label-left,\n    .form-label-right,\n    .form-html,\n    .form-checkbox-item label,\n    .form-radio-item label {\n      color: #555;\n    }\n    .form-sub-label {\n      color: #6f6f6f;\n    }\n  \n    .form-textbox,\n    .form-textarea,\n    .form-radio-other-input,\n    .form-checkbox-other-input,\n    .form-captcha input,\n    .form-spinner input {\n      background-color: #fff;\n    }\n  \n    .form-line-error {\n      overflow: hidden;\n      .transition(none; 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class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_6\" name=\"q6_abn\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"18\" value=\"\" placeholder=\" \" data-component=\"textbox\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-2\" data-type=\"control_textbox\" id=\"id_7\">\n        <label class=\"form-label form-label-top\" id=\"label_7\" for=\"input_7\"> ACN <\/label>\n        <div id=\"cid_7\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_7\" name=\"q7_acn\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"18\" value=\"\" placeholder=\" \" data-component=\"textbox\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-3 jf-required\" data-type=\"control_textbox\" id=\"id_8\">\n        <label class=\"form-label form-label-top\" id=\"label_8\" for=\"input_8\">\n          Registered Office\n          <span class=\"form-required\">\n            *\n 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class=\"form-textbox validate[required]\" size=\"3\" value=\"\" data-component=\"areaCode\" required=\"\" \/>\n              <span class=\"phone-separate\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"input_21_area\" id=\"sublabel_area\" style=\"min-height:13px;\"> Area Code <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input type=\"tel\" id=\"input_21_phone\" name=\"q21_phoneNumber21[phone]\" class=\"form-textbox validate[required]\" size=\"8\" value=\"\" data-component=\"phone\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"input_21_phone\" id=\"sublabel_phone\" style=\"min-height:13px;\"> Phone Number <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-2 jf-required\" data-type=\"control_phone\" id=\"id_22\">\n        <label class=\"form-label form-label-top\" id=\"label_22\" for=\"input_22_area\">\n          Fax Number\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_22\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input type=\"tel\" id=\"input_22_area\" name=\"q22_faxNumber[area]\" class=\"form-textbox validate[required]\" size=\"3\" value=\"\" data-component=\"areaCode\" required=\"\" \/>\n              <span class=\"phone-separate\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"input_22_area\" id=\"sublabel_area\" style=\"min-height:13px;\"> Area Code <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input type=\"tel\" id=\"input_22_phone\" name=\"q22_faxNumber[phone]\" class=\"form-textbox validate[required]\" size=\"8\" value=\"\" data-component=\"phone\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"input_22_phone\" id=\"sublabel_phone\" style=\"min-height:13px;\"> Phone Number <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-3 jf-required\" data-type=\"control_email\" id=\"id_23\">\n        <label class=\"form-label form-label-top\" id=\"label_23\" for=\"input_23\">\n          E-mail\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_23\" class=\"form-input-wide jf-required\">\n          <input type=\"email\" id=\"input_23\" name=\"q23_email\" class=\"form-textbox validate[required, Email]\" size=\"26\" value=\"\" placeholder=\"ex: myname@example.com\" data-component=\"email\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li id=\"cid_13\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_13\" class=\"form-header\" data-component=\"header\">\n              Accounts Postal Address Details\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-4 jf-required\" data-type=\"control_textbox\" id=\"id_14\">\n        <label class=\"form-label form-label-top\" id=\"label_14\" for=\"input_14\">\n          Accounts Contact Person\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_14\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_14\" name=\"q14_accountsContact14\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"40\" value=\"\" placeholder=\" \" data-component=\"textbox\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-5 jf-required\" data-type=\"control_phone\" id=\"id_15\">\n        <label class=\"form-label form-label-top\" id=\"label_15\" for=\"input_15_area\">\n          Phone Number\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_15\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input type=\"tel\" id=\"input_15_area\" name=\"q15_phoneNumber[area]\" class=\"form-textbox validate[required]\" size=\"3\" value=\"\" data-component=\"areaCode\" required=\"\" \/>\n              <span class=\"phone-separate\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"input_15_area\" id=\"sublabel_area\" style=\"min-height:13px;\"> Area Code <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input type=\"tel\" id=\"input_15_phone\" name=\"q15_phoneNumber[phone]\" class=\"form-textbox validate[required]\" size=\"8\" value=\"\" data-component=\"phone\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"input_15_phone\" id=\"sublabel_phone\" style=\"min-height:13px;\"> Phone Number <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1 form-line-column-clear jf-required\" data-type=\"control_textbox\" id=\"id_9\">\n        <label class=\"form-label form-label-top\" id=\"label_9\" for=\"input_9\">\n          Address\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_9\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_9\" name=\"q9_address\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"40\" value=\"\" placeholder=\" \" data-component=\"textbox\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-2 jf-required\" data-type=\"control_textbox\" id=\"id_10\">\n        <label class=\"form-label form-label-top\" id=\"label_10\" for=\"input_10\">\n          Suburb\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_10\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_10\" name=\"q10_suburb\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"30\" value=\"\" placeholder=\" \" data-component=\"textbox\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1 form-line-column-clear jf-required\" data-type=\"control_dropdown\" id=\"id_11\">\n        <label class=\"form-label form-label-top\" id=\"label_11\" for=\"input_11\">\n          State\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_11\" class=\"form-input-wide jf-required\">\n          <select class=\"form-dropdown validate[required]\" id=\"input_11\" name=\"q11_state11\" style=\"width:265px;\" data-component=\"dropdown\" required=\"\">\n            <option value=\"\">  <\/option>\n            <option value=\"NSW\"> NSW <\/option>\n            <option value=\"NT\"> NT <\/option>\n            <option value=\"QLD\"> QLD <\/option>\n            <option value=\"SA\"> SA <\/option>\n            <option value=\"TAS\"> TAS <\/option>\n            <option value=\"VIC\"> VIC <\/option>\n            <option value=\"WA\"> WA <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-2 jf-required\" data-type=\"control_textbox\" id=\"id_12\">\n        <label class=\"form-label form-label-top\" id=\"label_12\" for=\"input_12\">\n          Postcode\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_12\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_12\" name=\"q12_postcode12\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"20\" value=\"\" placeholder=\" \" data-component=\"textbox\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li id=\"cid_16\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_16\" class=\"form-header\" data-component=\"header\">\n              Accounts Delivery Address Details\n            <\/h2>\n            <div id=\"subHeader_16\" class=\"form-subHeader\">\n              (Leave blank if same as postal address)\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-3\" data-type=\"control_textbox\" id=\"id_17\">\n        <label class=\"form-label form-label-top\" id=\"label_17\" for=\"input_17\"> Address <\/label>\n        <div id=\"cid_17\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_17\" name=\"q17_address17\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"40\" value=\"\" placeholder=\" \" data-component=\"textbox\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-4\" data-type=\"control_textbox\" id=\"id_18\">\n        <label class=\"form-label form-label-top\" id=\"label_18\" for=\"input_18\"> Suburb <\/label>\n        <div id=\"cid_18\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_18\" name=\"q18_suburb18\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"30\" value=\"\" placeholder=\" \" data-component=\"textbox\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1 form-line-column-clear\" data-type=\"control_dropdown\" id=\"id_19\">\n        <label class=\"form-label form-label-top\" id=\"label_19\" for=\"input_19\"> State <\/label>\n        <div id=\"cid_19\" class=\"form-input-wide\">\n          <select class=\"form-dropdown\" id=\"input_19\" name=\"q19_state19\" style=\"width:265px;\" data-component=\"dropdown\">\n            <option value=\"\">  <\/option>\n            <option value=\"NSW\"> NSW <\/option>\n            <option value=\"NT\"> NT <\/option>\n            <option value=\"QLD\"> QLD <\/option>\n            <option value=\"SA\"> SA <\/option>\n            <option value=\"TAS\"> TAS <\/option>\n            <option value=\"VIC\"> VIC <\/option>\n            <option value=\"WA\"> WA <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-2\" data-type=\"control_textbox\" id=\"id_20\">\n        <label class=\"form-label form-label-top\" id=\"label_20\" for=\"input_20\"> Postcode <\/label>\n        <div id=\"cid_20\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_20\" name=\"q20_postcode20\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" placeholder=\" \" data-component=\"textbox\" \/>\n        <\/div>\n      <\/li>\n      <li id=\"cid_24\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_24\" class=\"form-header\" data-component=\"header\">\n              Trade References:\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-3 jf-required\" data-type=\"control_textbox\" id=\"id_25\">\n        <label class=\"form-label form-label-top\" id=\"label_25\" for=\"input_25\">\n          1. Name\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_25\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_25\" name=\"q25_1Name25\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"25\" value=\"\" placeholder=\" \" data-component=\"textbox\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-4 jf-required\" data-type=\"control_phone\" id=\"id_26\">\n        <label class=\"form-label form-label-top\" id=\"label_26\" for=\"input_26_area\">\n          Phone Number\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_26\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input type=\"tel\" id=\"input_26_area\" name=\"q26_phoneNumber26[area]\" class=\"form-textbox validate[required]\" size=\"3\" value=\"\" data-component=\"areaCode\" required=\"\" \/>\n              <span class=\"phone-separate\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"input_26_area\" id=\"sublabel_area\" style=\"min-height:13px;\"> Area Code <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input type=\"tel\" id=\"input_26_phone\" name=\"q26_phoneNumber26[phone]\" class=\"form-textbox validate[required]\" size=\"8\" value=\"\" data-component=\"phone\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"input_26_phone\" id=\"sublabel_phone\" style=\"min-height:13px;\"> Phone Number <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-5 jf-required\" data-type=\"control_phone\" id=\"id_27\">\n        <label class=\"form-label form-label-top\" id=\"label_27\" for=\"input_27_area\">\n          Fax Number\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_27\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input type=\"tel\" id=\"input_27_area\" name=\"q27_faxNumber27[area]\" class=\"form-textbox validate[required]\" size=\"3\" value=\"\" data-component=\"areaCode\" required=\"\" \/>\n              <span class=\"phone-separate\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"input_27_area\" id=\"sublabel_area\" style=\"min-height:13px;\"> Area Code <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input type=\"tel\" id=\"input_27_phone\" name=\"q27_faxNumber27[phone]\" class=\"form-textbox validate[required]\" size=\"8\" value=\"\" data-component=\"phone\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"input_27_phone\" id=\"sublabel_phone\" style=\"min-height:13px;\"> Phone Number <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1 form-line-column-clear jf-required\" data-type=\"control_textbox\" id=\"id_28\">\n        <label class=\"form-label form-label-top\" id=\"label_28\" for=\"input_28\">\n          2. Name\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_28\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_28\" name=\"q28_2Name\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"25\" value=\"\" placeholder=\" \" data-component=\"textbox\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-2 jf-required\" data-type=\"control_phone\" id=\"id_29\">\n        <label class=\"form-label form-label-top\" id=\"label_29\" for=\"input_29_area\">\n          Phone Number\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_29\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input type=\"tel\" id=\"input_29_area\" name=\"q29_phoneNumber29[area]\" class=\"form-textbox validate[required]\" size=\"3\" value=\"\" data-component=\"areaCode\" required=\"\" \/>\n              <span class=\"phone-separate\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"input_29_area\" id=\"sublabel_area\" style=\"min-height:13px;\"> Area Code <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input type=\"tel\" id=\"input_29_phone\" name=\"q29_phoneNumber29[phone]\" class=\"form-textbox validate[required]\" size=\"8\" value=\"\" data-component=\"phone\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"input_29_phone\" id=\"sublabel_phone\" style=\"min-height:13px;\"> Phone Number <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-3 jf-required\" data-type=\"control_phone\" id=\"id_30\">\n        <label class=\"form-label form-label-top\" id=\"label_30\" for=\"input_30_area\">\n          Fax Number\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_30\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input type=\"tel\" id=\"input_30_area\" name=\"q30_faxNumber30[area]\" class=\"form-textbox validate[required]\" size=\"3\" value=\"\" data-component=\"areaCode\" required=\"\" \/>\n              <span class=\"phone-separate\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"input_30_area\" id=\"sublabel_area\" style=\"min-height:13px;\"> Area Code <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input type=\"tel\" id=\"input_30_phone\" name=\"q30_faxNumber30[phone]\" class=\"form-textbox validate[required]\" size=\"8\" value=\"\" data-component=\"phone\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"input_30_phone\" id=\"sublabel_phone\" style=\"min-height:13px;\"> Phone Number <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_31\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_31\" class=\"form-header\" data-component=\"header\">\n              Terms of agreement\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_43\">\n        <div id=\"cid_43\" class=\"form-input-wide\">\n          <div id=\"text_43\" class=\"form-html\" data-component=\"text\">\n            <table cellpadding=\"5\">\n              <tbody>\n                <tr>\n                  <td valign=\"top\">\n                    <span style=\"font-size:medium;\">\n                      1.\n                    <\/span>\n                  <\/td>\n                  <td>\n                    <span style=\"font-size:medium;\">\n                      That the terms of payment are strictly net, with payment due in full by the 26th day of the month following the invoice date.\n                    <\/span>\n                  <\/td>\n                <\/tr>\n                <tr>\n                  <td valign=\"top\">\n                    <span style=\"font-size:medium;\">\n                      2.\n                    <\/span>\n                  <\/td>\n                  <td>\n                    <span style=\"font-size:medium;\">\n                      If extended credit is granted on overdue accounts a handling fee of 2.5% of the overdue balance, as at the end of each month, will be charged and accumulated to the account.\n                    <\/span>\n                  <\/td>\n                <\/tr>\n                <tr>\n                  <td valign=\"top\">\n                    <span style=\"font-size:medium;\">\n                      3.\n                    <\/span>\n                  <\/td>\n                  <td>\n                    <span style=\"font-size:medium;\">\n                      That all information given is true and correct.\n                    <\/span>\n                  <\/td>\n                <\/tr>\n                <tr>\n                  <td valign=\"top\">\n                    <span style=\"font-size:medium;\">\n                      4.\n                    <\/span>\n                  <\/td>\n                  <td>\n                    <span style=\"font-size:medium;\">\n                      That should any changes take place affecting the legal entity, structure or management control of the applicant, company or partnership then Opticare Pty Ltd will be notified accordingly.\n                    <\/span>\n                  <\/td>\n                <\/tr>\n                <tr>\n                  <td valign=\"top\">\n                    <span style=\"font-size:medium;\">\n                      5.\n                    <\/span>\n                  <\/td>\n                  <td>\n                    <span style=\"font-size:medium;\">\n                      That all expenses incurred in obtaining or attempting to obtain payment of overdue amounts will be a charge against debtor\/s.\n                    <\/span>\n                  <\/td>\n                <\/tr>\n                <tr>\n                  <td valign=\"top\">\n                    <span style=\"font-size:medium;\">\n                      6.\n                    <\/span>\n                  <\/td>\n                  <td>\n                    <span style=\"font-size:medium;\">\n                      That Opticare Pty Ltd may withdraw credit facilities without prior notice.\n                    <\/span>\n                  <\/td>\n                <\/tr>\n                <tr>\n                  <td valign=\"top\">\n                    <span style=\"font-size:medium;\">\n                      7.\n                    <\/span>\n                  <\/td>\n                  <td>\n                    <span style=\"font-size:medium;\">\n                      Acceptance of this application by Opticare Pty Ltd will be indicated by the provision of credit.\n                    <\/span>\n                  <\/td>\n                <\/tr>\n                <tr>\n                  <td valign=\"top\">\n                    <span style=\"font-size:medium;\">\n                      8.\n                    <\/span>\n                  <\/td>\n                  <td>\n                    <span style=\"font-size:medium;\">\n                      The terms and conditions in the supplied Opticare price List are considered to be incorporated in this application.\n                    <\/span>\n                  <\/td>\n                <\/tr>\n              <\/tbody>\n            <\/table>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_checkbox\" id=\"id_35\">\n        <label class=\"form-label form-label-top\" id=\"label_35\" for=\"input_35_0\">\n          Please tick the box to confirm agreement\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_35\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\" data-component=\"checkbox\">\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_35_0\" name=\"q35_pleaseTick[]\" value=\"I accept the above terms and conditions\" required=\"\" \/>\n              <label id=\"label_input_35_0\" for=\"input_35_0\"> I accept the above terms and conditions <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1 jf-required\" data-type=\"control_textbox\" id=\"id_36\">\n        <label class=\"form-label form-label-top\" id=\"label_36\" for=\"input_36\">\n          Name\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_36\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_36\" name=\"q36_name\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"40\" value=\"\" placeholder=\" \" data-component=\"textbox\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-2 jf-required\" data-type=\"control_textbox\" id=\"id_37\">\n        <label class=\"form-label form-label-top\" id=\"label_37\" for=\"input_37\">\n          Position\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_37\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_37\" name=\"q37_position\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"40\" value=\"\" placeholder=\" \" data-component=\"textbox\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-3 jf-required\" data-type=\"control_textbox\" id=\"id_39\">\n        <label class=\"form-label form-label-top\" id=\"label_39\" for=\"input_39\">\n          Home Address\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_39\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_39\" name=\"q39_homeAddress\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"40\" value=\"\" placeholder=\" \" data-component=\"textbox\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-4 jf-required\" data-type=\"control_phone\" id=\"id_40\">\n        <label class=\"form-label form-label-top\" id=\"label_40\" for=\"input_40_area\">\n          Home Phone\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_40\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input type=\"tel\" id=\"input_40_area\" name=\"q40_homePhone[area]\" class=\"form-textbox validate[required]\" size=\"3\" value=\"\" data-component=\"areaCode\" required=\"\" \/>\n              <span class=\"phone-separate\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"input_40_area\" id=\"sublabel_area\" style=\"min-height:13px;\"> Area Code <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input type=\"tel\" id=\"input_40_phone\" name=\"q40_homePhone[phone]\" class=\"form-textbox validate[required]\" size=\"8\" value=\"\" data-component=\"phone\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"input_40_phone\" id=\"sublabel_phone\" style=\"min-height:13px;\"> Phone Number <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-5 jf-required\" data-type=\"control_datetime\" id=\"id_41\">\n        <label class=\"form-label form-label-top\" id=\"label_41\" for=\"day_41\">\n          Date\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_41\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input class=\"currentDate form-textbox validate[required, limitDate]\" id=\"day_41\" name=\"q41_date[day]\" type=\"tel\" size=\"2\" data-maxlength=\"2\" value=\"13\" required=\"\" \/>\n              <span class=\"date-separate\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"day_41\" id=\"sublabel_day\" style=\"min-height:13px;\"> Day <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input class=\"form-textbox validate[required, limitDate]\" id=\"month_41\" name=\"q41_date[month]\" type=\"tel\" size=\"2\" data-maxlength=\"2\" value=\"02\" required=\"\" \/>\n              <span class=\"date-separate\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"month_41\" id=\"sublabel_month\" style=\"min-height:13px;\"> Month <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input class=\"form-textbox validate[required, limitDate]\" id=\"year_41\" name=\"q41_date[year]\" type=\"tel\" size=\"4\" data-maxlength=\"4\" value=\"2018\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"year_41\" id=\"sublabel_year\" style=\"min-height:13px;\"> Year <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <img class=\"showAutoCalendar\" alt=\"Pick a Date\" id=\"input_41_pick\" src=\"https:\/\/cdn.jotfor.ms\/images\/calendar.png\" style=\"vertical-align:middle;\" data-component=\"datetime\" \/>\n              <label class=\"form-sub-label\" for=\"input_41_pick\" style=\"min-height:13px;\">  <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_42\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_42\" class=\"form-header\" data-component=\"header\">\n              Directors\/Proprietors Guarantee\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_34\">\n        <div id=\"cid_34\" class=\"form-input-wide\">\n          <div id=\"text_34\" class=\"form-html\" data-component=\"text\">\n            <p><span style=\"font-size:medium;\">I guarantee to be personally answerable and responsible to Opticare Pty Ltd for the due payment by the said account as detailed on this application for all goods and services as the vendor may heretofore have supplied or which the vendor may hereafter supply.<\/span><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1 jf-required\" data-type=\"control_checkbox\" id=\"id_44\">\n        <label class=\"form-label form-label-top\" id=\"label_44\" for=\"input_44_0\">\n          Please tick the box to confirm agreement\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_44\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\" data-component=\"checkbox\">\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_44_0\" name=\"q44_pleaseTick44[]\" value=\"I accept the above terms and conditions\" required=\"\" \/>\n              <label id=\"label_input_44_0\" for=\"input_44_0\"> I accept the above terms and conditions <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-2 jf-required\" data-type=\"control_datetime\" id=\"id_45\">\n        <label class=\"form-label form-label-top\" id=\"label_45\" for=\"day_45\">\n          Dated\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_45\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input class=\"currentDate form-textbox validate[required, limitDate]\" id=\"day_45\" name=\"q45_dated[day]\" type=\"tel\" size=\"2\" data-maxlength=\"2\" value=\"13\" required=\"\" \/>\n              <span class=\"date-separate\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"day_45\" id=\"sublabel_day\" style=\"min-height:13px;\"> Day <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input class=\"form-textbox validate[required, limitDate]\" id=\"month_45\" name=\"q45_dated[month]\" type=\"tel\" size=\"2\" data-maxlength=\"2\" value=\"02\" required=\"\" \/>\n              <span class=\"date-separate\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"month_45\" id=\"sublabel_month\" style=\"min-height:13px;\"> Month <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input class=\"form-textbox validate[required, limitDate]\" id=\"year_45\" name=\"q45_dated[year]\" type=\"tel\" size=\"4\" data-maxlength=\"4\" value=\"2018\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"year_45\" id=\"sublabel_year\" style=\"min-height:13px;\"> Year <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <img class=\"showAutoCalendar\" alt=\"Pick a Date\" id=\"input_45_pick\" src=\"https:\/\/cdn.jotfor.ms\/images\/calendar.png\" style=\"vertical-align:middle;\" data-component=\"datetime\" \/>\n              <label class=\"form-sub-label\" for=\"input_45_pick\" style=\"min-height:13px;\">  <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_46\">\n        <label class=\"form-label form-label-top\" id=\"label_46\" for=\"input_46\"> Guarantor (Name) <\/label>\n        <div id=\"cid_46\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_46\" name=\"q46_guarantorname\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"40\" value=\"\" placeholder=\" \" data-component=\"textbox\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1 jf-required\" data-type=\"control_textbox\" id=\"id_47\">\n        <label class=\"form-label form-label-top\" id=\"label_47\" for=\"input_47\">\n          Home Address\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_47\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_47\" name=\"q47_homeAddress47\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"40\" value=\"\" placeholder=\" \" data-component=\"textbox\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-2 jf-required\" data-type=\"control_phone\" id=\"id_48\">\n        <label class=\"form-label form-label-top\" id=\"label_48\" for=\"input_48_area\">\n          Home Phone\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_48\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input type=\"tel\" id=\"input_48_area\" name=\"q48_homePhone48[area]\" class=\"form-textbox validate[required]\" size=\"3\" value=\"\" data-component=\"areaCode\" required=\"\" \/>\n              <span class=\"phone-separate\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"input_48_area\" id=\"sublabel_area\" style=\"min-height:13px;\"> Area Code <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input type=\"tel\" id=\"input_48_phone\" name=\"q48_homePhone48[phone]\" class=\"form-textbox validate[required]\" size=\"8\" value=\"\" data-component=\"phone\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"input_48_phone\" id=\"sublabel_phone\" style=\"min-height:13px;\"> Phone Number <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-3 jf-required\" data-type=\"control_checkbox\" id=\"id_50\">\n        <label class=\"form-label form-label-top\" id=\"label_50\" for=\"input_50_0\">\n          Witness Acceptance\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_50\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\" data-component=\"checkbox\">\n            <span class=\"form-checkbox-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_50_0\" name=\"q50_witnessAcceptance[]\" value=\"I confirm I have witnessed the completion of  this form and all information is true and correct\" required=\"\" \/>\n              <label id=\"label_input_50_0\" for=\"input_50_0\"> I confirm I have witnessed the completion of this form and all information is true and correct <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1 form-line-column-clear jf-required\" data-type=\"control_textbox\" id=\"id_49\">\n        <label class=\"form-label form-label-top\" id=\"label_49\" for=\"input_49\">\n          Witness (Name)\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_49\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_49\" name=\"q49_witnessname\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"40\" value=\"\" placeholder=\" \" data-component=\"textbox\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-2 jf-required\" data-type=\"control_datetime\" id=\"id_51\">\n        <label class=\"form-label form-label-top\" id=\"label_51\" for=\"day_51\">\n          Dated\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_51\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input class=\"currentDate form-textbox validate[required, limitDate]\" id=\"day_51\" name=\"q51_dated51[day]\" type=\"tel\" size=\"2\" data-maxlength=\"2\" value=\"13\" required=\"\" \/>\n              <span class=\"date-separate\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"day_51\" id=\"sublabel_day\" style=\"min-height:13px;\"> Day <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input class=\"form-textbox validate[required, limitDate]\" id=\"month_51\" name=\"q51_dated51[month]\" type=\"tel\" size=\"2\" data-maxlength=\"2\" value=\"02\" required=\"\" \/>\n              <span class=\"date-separate\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"month_51\" id=\"sublabel_month\" style=\"min-height:13px;\"> Month <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input class=\"form-textbox validate[required, limitDate]\" id=\"year_51\" name=\"q51_dated51[year]\" type=\"tel\" size=\"4\" data-maxlength=\"4\" value=\"2018\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"year_51\" id=\"sublabel_year\" style=\"min-height:13px;\"> Year <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <img class=\"showAutoCalendar\" alt=\"Pick a Date\" id=\"input_51_pick\" src=\"https:\/\/cdn.jotfor.ms\/images\/calendar.png\" style=\"vertical-align:middle;\" data-component=\"datetime\" \/>\n              <label class=\"form-sub-label\" for=\"input_51_pick\" style=\"min-height:13px;\">  <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_52\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_52\" class=\"form-header\" data-component=\"header\">\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_button\" id=\"id_2\">\n        <div id=\"cid_2\" class=\"form-input-wide\">\n          <div style=\"margin-left:156px;\" class=\"form-buttons-wrapper\">\n            <button id=\"input_2\" type=\"submit\" class=\"form-submit-button\" data-component=\"button\">\n              Submit\n            <\/button>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li style=\"clear:both\">\n      <\/li>\n      <li style=\"display:none\">\n        Should be Empty:\n        <input type=\"text\" name=\"website\" value=\"\" \/>\n      <\/li>\n    <\/ul>\n  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