var qsProxy = {};
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);}
this.frame=document.getElementById(this.iframeDomId);if(tmp_is_ie===true){try{var iframe=this.frame;var doc=iframe.contentDocument?iframe.contentDocument:(iframe.contentWindow.document||iframe.document);doc.open();doc.write("");}
catch(err){this.frame.src="javascript:void((function(){document.open();document.domain=\'"+this.getBaseDomain()+"\';document.close();})())";}}
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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string=string.replace(new RegExp('src\\=\\"[^"]*captcha.php\"><\/scr'+'ipt>','gim'),'src="http://api.recaptcha.net/js/recaptcha_ajax.js"></scr'+'ipt><'+'div id="recaptcha_div"><'+'/div>'+'<'+'style>#recaptcha_logo{ display:none;} #recaptcha_tagline{display:none;} #recaptcha_table{border:none !important;} .recaptchatable .recaptcha_image_cell, #recaptcha_table{ background-color:transparent !important; } <'+'/style>'+'<'+'script defer="defer"> window.onload = function(){ Recaptcha.create("6Ld9UAgAAAAAAMon8zjt30tEZiGQZ4IIuWXLt1ky", "recaptcha_div", {theme: "clean",tabindex: 0,callback: function (){'+'if (document.getElementById("uword")) { document.getElementById("uword").parentNode.removeChild(document.getElementById("uword")); } if (window["validate"] !== undefined) { if (document.getElementById("recaptcha_response_field")){ document.getElementById("recaptcha_response_field").onblur = function(){ validate(document.getElementById("recaptcha_response_field"), "Required"); } } } if (document.getElementById("recaptcha_response_field")){ document.getElementsByName("recaptcha_challenge_field")[0].setAttribute("name", "anum"); } if (document.getElementById("recaptcha_response_field")){ document.getElementsByName("recaptcha_response_field")[0].setAttribute("name", "qCap"); }}})'+' }<'+'/script>');string=string.replace(/(type="text\/javascript">)\s+(validate\(\"[^"]*"\);)/,'$1 jTime = setInterval(function(){if("validate" in window){$2clearTimeout(jTime);}}, 1000);');if(string.match('#sublabel_litemode')){string=string.replace('class="form-all"','class="form-all" style="margin-top:0;"');}
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++;}
if(cc==0){buff+=chr;}}
if(cc==2){thn=thn.replace(buff+".","");}
return thn;}
this.changeHeight=function(){var actualHeight=this.getBodyHeight();var currentHeight=this.getViewPortHeight();if(actualHeight===undefined){this.frame.style.height=this.frameHeight;if(!this.frame.style.minHeight){this.frame.style.minHeight="300px";}}else if(Math.abs(actualHeight-currentHeight)>18){this.frame.style.height=(actualHeight)+"px";}
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;}
if(this.frame.contentWindow.document.body.offsetHeight){height=offsetHeight=this.frame.contentWindow.document.body.offsetHeight;}}else if(this.frame.contentWindow.document.body){var isChrome=/Chrome/.test(navigator.userAgent)&&/Google Inc/.test(navigator.vendor);if(this.frame.contentWindow.document.body.scrollHeight){height=scrollHeight=this.frame.contentWindow.document.body.scrollHeight;}
if(isChrome){height=scrollHeight=this.frame.contentWindow.document.height;}
if(this.frame.contentWindow.document.body.offsetHeight){height=offsetHeight=this.frame.contentWindow.document.body.offsetHeight;}
if(scrollHeight&&offsetHeight){height=Math.max(scrollHeight,offsetHeight);}}}catch(e){}
this.frameHeight=height;return height;};this.getViewPortHeight=function(){if(this.formSubmitted===1){return;}
var height=0;try{if(this.frame.contentWindow.window.innerHeight)
{height=this.frame.contentWindow.window.innerHeight-18;}
else if((this.frame.contentWindow.document.documentElement)&&(this.frame.contentWindow.document.documentElement.clientHeight))
{height=this.frame.contentWindow.document.documentElement.clientHeight;}
else if((this.frame.contentWindow.document.body)&&(this.frame.contentWindow.document.body.clientHeight))
{height=this.frame.contentWindow.document.body.clientHeight;}}catch(e){}
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 i62420697978875=new FrameBuilder("62420697978875",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%2F62420697978875\" 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%2F62420697978875\" title=\"oEmbed Form\">\n<meta property=\"og:title\" content=\"Payment\" >\n<meta property=\"og:url\" content=\"http:\/\/www.jotform.co\/form\/62420697978875\" >\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>Payment<\/title>\n<link href=\"https:\/\/cdn.jotfor.ms\/static\/formCss.css?3.3.4616\" rel=\"stylesheet\" type=\"text\/css\" \/>\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/cdn.jotfor.ms\/css\/styles\/nova.css?3.3.4616\" \/>\n<link type=\"text\/css\" media=\"print\" rel=\"stylesheet\" href=\"https:\/\/cdn.jotfor.ms\/css\/printForm.css?3.3.4616\" \/>\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:#f1c5c5;\n    }\n\n    .form-all{\n        margin:0px auto;\n        padding-top:0px;\n        width:590px;\n        color:#0b24f8 !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: #0b24f8;\n    }\n\n<\/style>\n\n<style type=\"text\/css\" id=\"form-designer-style\">\n    \/* Injected CSS Code *\/\n\/*PREFERENCES STYLE*\/\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 36px 12px 36px px;\n      margin-bottom: 12px 36px 12px 36px px;\n    }\n  \n    .form-all {\n      width: 590px;\n    }\n  \n    .form-label-left,\n    .form-label-right {\n      width: 150px\n    }\n  \n    .form-all {\n      font-family: 'Lucida Grande', 'Lucida Sans Unicode', 'Lucida Sans', Verdana, Tahoma, sans-serif, 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', 'Lucida Sans Unicode', 'Lucida Sans', Verdana, Tahoma, sans-serif, sans-serif;\n    }\n    .form-all .form-pagebreak-back-container,\n    .form-all .form-pagebreak-next-container {\n      font-family: 'Lucida Grande', 'Lucida Sans Unicode', 'Lucida Sans', Verdana, Tahoma, sans-serif, sans-serif;\n    }\n    .form-header-group {\n      font-family: 'Lucida Grande', 'Lucida Sans Unicode', 'Lucida Sans', Verdana, Tahoma, sans-serif, sans-serif;\n    }\n    .form-label {\n      font-family: 'Lucida Grande', 'Lucida Sans Unicode', 'Lucida Sans', Verdana, Tahoma, sans-serif, sans-serif;\n    }\n  \n    .form-all {\n      font-size: 14pxpx\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: 14pxpx\n    }\n    .form-all .form-pagebreak-back-container,\n    .form-all .form-pagebreak-next-container {\n      font-size: 14pxpx\n    }\n  \n    .supernova .form-all, .form-all {\n      background-color: #f1c5c5;\n      border: 1px solid transparent;\n    }\n  \n    .form-all {\n      color: #0b24f8;\n    }\n    .form-header-group .form-header {\n      color: #0b24f8;\n    }\n    .form-header-group .form-subHeader {\n      color: #0b24f8;\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: #0b24f8;\n    }\n  \n    .supernova {\n      background-color: undefined;\n    }\n    .supernova body {\n      background: transparent;\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: undefined;\n    }\n  \n    .supernova {\n      background-image: none;\n    }\n    #stage {\n      background-image: none;\n    }\n  \n    .form-all {\n      background-image: none;\n    }\n  \/*PREFERENCES STYLE*\/\/*__INSPECT_SEPERATOR__*\/\n    \/* Injected CSS Code *\/\n<\/style>\n\n<script src=\"https:\/\/cdn.jotfor.ms\/static\/prototype.forms.js\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn.jotfor.ms\/static\/jotform.forms.js?3.3.4616\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/js.jotform.com\/vendor\/postMessage.js?3.3.4616\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/js.jotform.com\/WidgetsServer.js?v=1518434776517\" type=\"text\/javascript\"><\/script>\n<script type=\"text\/javascript\">\n var jsTime = setInterval(function(){try{\n   JotForm.jsForm = true;\n\n   JotForm.setConditions([{\"action\":[{\"id\":\"action_1473334385080\",\"visibility\":\"ShowMultiple\",\"isError\":false,\"fields\":[\"18\",\"19\"]}],\"id\":\"1473334419787\",\"index\":\"0\",\"link\":\"Any\",\"priority\":\"0\",\"terms\":[{\"id\":\"term_1473334385080\",\"field\":\"9\",\"operator\":\"equals\",\"value\":\"Bill Payment\",\"isError\":false}],\"type\":\"field\"},{\"action\":[{\"id\":\"action_1472606590677\",\"visibility\":\"Show\",\"isError\":false,\"field\":\"16\"}],\"id\":\"1472606612324\",\"index\":\"1\",\"link\":\"Any\",\"priority\":\"1\",\"terms\":[{\"id\":\"term_1472606590677\",\"field\":\"9\",\"operator\":\"equals\",\"value\":\"Share Bill Payment\",\"isError\":false}],\"type\":\"field\"},{\"action\":[{\"id\":\"action_1472535593501\",\"visibility\":\"Show\",\"isError\":false,\"field\":\"12\"}],\"id\":\"1472535628252\",\"index\":\"2\",\"link\":\"Any\",\"priority\":\"2\",\"terms\":[{\"id\":\"term_1472535593501\",\"field\":\"9\",\"operator\":\"equals\",\"value\":\"Other 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id=\"subHeader_1\" class=\"form-subHeader\">\n              In our increasingly digital world we take our responsibilty to protect your privacy very seriously by applying strict security and privacy controls to the way handle your personal information.\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_10\">\n        <div id=\"cid_10\" class=\"form-input-wide\">\n          <div id=\"text_10\" class=\"form-html\" data-component=\"text\">\n            <p>Use this Form to pay your account or any extra shipping cost or eBay items sold pay by credit card................<\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_widget\" id=\"id_14\">\n        <div id=\"cid_14\" class=\"form-input-wide\">\n          <div style=\"width:100%;text-align:Left;\" data-component=\"widget-field\">\n            <iframe frameborder=\"0\" scrolling=\"no\" 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value=\"\" \/>\n              <input id=\"widget_settings_15\" class=\"form-hidden form-widget-settings\" type=\"hidden\" value=\"%5B%7B%22name%22%3A%22dateFormat%22%2C%22value%22%3A%22MM%2FDD%2FYYYY%20hh%3Amm%22%7D%2C%7B%22name%22%3A%22timeFormat%22%2C%22value%22%3A%2224hr%22%7D%2C%7B%22name%22%3A%22timeEnabled%22%2C%22value%22%3A%22Enabled%22%7D%2C%7B%22name%22%3A%22minuteInterval%22%2C%22value%22%3A%2230%22%7D%2C%7B%22name%22%3A%22emptyDefaultDate%22%2C%22value%22%3A%22Yes%22%7D%2C%7B%22name%22%3A%22fitToContent%22%2C%22value%22%3A%22Enabled%22%7D%5D\" data-version=\"2\" \/>\n            <\/div>\n            <script type=\"text\/javascript\">\n            setTimeout(function()\n{\n  var _cFieldFrame = document.getElementById(\"customFieldFrame_15\");\n  _cFieldFrame.onload = function()\n  {\n    widgetFrameLoaded(15, {\n      \"formID\": 62420697978875\n    })\n  };\n  _cFieldFrame.src = \"\/\/widgets.jotform.io\/datetimeSingle\/?qid=15&ref=\" + encodeURIComponent(window.location.protocol + \"\/\/\" + window.location.host);\n  _cFieldFrame.addClassName(\"custom-field-frame-rendered\");\n}, 0);\n            <\/script>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_paypalpro\" id=\"id_3\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_3\" for=\"input_3\">\n          Payment\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_3\" class=\"form-input jf-required\">\n          <div data-wrapper-react=\"true\">\n            <div data-wrapper-react=\"true\">\n              <input type=\"hidden\" name=\"simple_fpc\" data-payment_type=\"paypalpro\" data-component=\"payment1\" value=\"3\" \/>\n              <input type=\"hidden\" name=\"payment_total_checksum\" id=\"payment_total_checksum\" data-component=\"payment2\" \/>\n              <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                <input type=\"text\" class=\"form-textbox validate[required, Numeric]\" id=\"input_3_donation\" name=\"q3_payment[price]\" value=\"\" data-component=\"paymentDonation\" \/>\n                AUD\n                <label class=\"form-sub-label\" for=\"input_3_donation\" style=\"min-height:13px;\"> Amount <\/label>\n              <\/span>\n              <hr\/>\n            <\/div>\n            <table class=\"form-address-table payment-form-table\" style=\"border:0;\" cellpadding=\"4\" cellspacing=\"0\">\n              <tbody>\n                <tr>\n                  <th colspan=\"2\" style=\"text-align:left;\">\n                    Payment Method\n                  <\/th>\n                <\/tr>\n                <tr>\n                  <td style=\"min-width:50px;vertical-align:top;\" rowspan=\"2\">\n                    <input type=\"radio\" class=\"paymentTypeRadios\" id=\"input_3_paymentType_credit\" name=\"q3_payment[paymentType]\" value=\"credit\" \/>\n                    <label for=\"input_3_paymentType_credit\">\n                      <div style=\"display:inline-block;padding-right:4px;\">\n                        <img src=\"https:\/\/cdn.jotfor.ms\/images\/blank.gif\" class=\"paypalpro_img paypalpro_visa\" style=\"display:inline-block;vertical-align:middle;\" \/>\n                        <img src=\"https:\/\/cdn.jotfor.ms\/images\/blank.gif\" class=\"paypalpro_img paypalpro_mc\" style=\"display:inline-block;vertical-align:middle;\" \/>\n                        <img src=\"https:\/\/cdn.jotfor.ms\/images\/blank.gif\" class=\"paypalpro_img paypalpro_amex\" style=\"display:inline-block;vertical-align:middle;\" \/>\n                        <img src=\"https:\/\/cdn.jotfor.ms\/images\/blank.gif\" class=\"paypalpro_img paypalpro_dc\" style=\"display:inline-block;vertical-align:middle;\" \/>\n                      <\/div>\n                    <\/label>\n                  <\/td>\n                  <td style=\"padding-bottom:2px !important;text-align:left;vertical-align:top;\">\n                    <input type=\"radio\" class=\"paymentTypeRadios\" id=\"input_3_paymentType_express\" name=\"q3_payment[paymentType]\" checked=\"\" value=\"express\" \/>\n                    <label for=\"input_3_paymentType_express\"> <img style=\"vertical-align:middle;\" src=\"https:\/\/www.paypalobjects.com\/webstatic\/en_US\/i\/buttons\/pp-acceptance-small.png\" \/> <\/label>\n                  <\/td>\n                <\/tr>\n                <tr>\n                  <td style=\"vertical-align:top;\">\n                    <a style=\"font-size:9px;\" target=\"_blank\" href=\"https:\/\/www.paypal.com\/webapps\/mpp\/paypal-popup\">What is PayPal?<\/a>\n                  <\/td>\n                <\/tr>\n              <\/tbody>\n            <\/table>\n            <table style=\"display:none;border:0;\" id=\"creditCardTable\" class=\"form-address-table payment-form-table\" cellpadding=\"0\" cellspacing=\"0\">\n              <tbody>\n                <tr>\n                  <th colspan=\"2\" style=\"text-align:left;margin-top:20px;display:table;\" id=\"ccTitle3\">\n                    Credit Card\n                  <\/th>\n                <\/tr>\n                <tr>\n                  <td width=\"50%\">\n                    <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                      <label class=\"form-sub-label\" for=\"input_3_cc_firstName\" id=\"sublabel_cc_firstName\" style=\"min-height:13px;margin:0 0 3px 0;\"> First Name <\/label>\n                      <input type=\"text\" id=\"input_3_cc_firstName\" name=\"q3_payment[cc_firstName]\" class=\"form-textbox validate[required] cc_firstName\" size=\"20\" value=\"\" data-component=\"cc_firstName\" \/>\n                    <\/span>\n                  <\/td>\n                  <td width=\"50%\">\n                    <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                      <label class=\"form-sub-label\" for=\"input_3_cc_lastName\" id=\"sublabel_cc_lastName\" style=\"min-height:13px;margin:0 0 3px 0;\"> Last Name <\/label>\n                      <input type=\"text\" id=\"input_3_cc_lastName\" name=\"q3_payment[cc_lastName]\" class=\"form-textbox validate[required] cc_lastName\" size=\"20\" value=\"\" data-component=\"cc_lastName\" \/>\n                    <\/span>\n                  <\/td>\n                <\/tr>\n                <tr>\n                  <td width=\"50%\">\n                    <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                      <label class=\"form-sub-label\" for=\"input_3_cc_number\" id=\"sublabel_cc_number\" style=\"min-height:13px;margin:0 0 3px 0;\"> Credit Card Number <\/label>\n                      <input type=\"number\" id=\"input_3_cc_number\" name=\"q3_payment[cc_number]\" class=\"form-textbox validate[required] cc_number\" autocomplete=\"off\" size=\"20\" value=\"\" data-component=\"cc_number\" \/>\n                    <\/span>\n                  <\/td>\n                  <td width=\"50%\">\n                    <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                      <label class=\"form-sub-label\" for=\"input_3_cc_ccv\" id=\"sublabel_cc_ccv\" style=\"min-height:13px;margin:0 0 3px 0;\"> Security Code <\/label>\n                      <input type=\"number\" id=\"input_3_cc_ccv\" name=\"q3_payment[cc_ccv]\" class=\"form-textbox validate[required] cc_ccv\" autocomplete=\"off\" style=\"width:52px;\" value=\"\" data-component=\"cc_ccv\" \/>\n                    <\/span>\n                  <\/td>\n                <\/tr>\n                <tr>\n                  <td width=\"50%\">\n                    <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                      <label class=\"form-sub-label\" for=\"input_3_cc_exp_month\" id=\"sublabel_cc_exp_month\" style=\"min-height:13px;margin:0 0 3px 0;\"> Expiration Month <\/label>\n                      <select class=\"form-dropdown validate[required] cc_exp_month\" name=\"q3_payment[cc_exp_month]\" id=\"input_3_cc_exp_month\" data-component=\"cc_exp_month\">\n                        <option>  <\/option>\n                        <option value=\"January\"> January <\/option>\n                        <option value=\"February\"> February <\/option>\n                        <option value=\"March\"> March <\/option>\n                        <option value=\"April\"> April <\/option>\n                        <option value=\"May\"> May <\/option>\n                        <option value=\"June\"> June <\/option>\n                        <option value=\"July\"> July <\/option>\n                        <option value=\"August\"> August <\/option>\n                        <option value=\"September\"> September <\/option>\n                        <option value=\"October\"> October <\/option>\n                        <option value=\"November\"> November <\/option>\n                        <option value=\"December\"> December <\/option>\n                      <\/select>\n                    <\/span>\n                  <\/td>\n                  <td width=\"50%\">\n                    <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                      <label class=\"form-sub-label\" for=\"input_3_cc_exp_year\" id=\"sublabel_cc_exp_year\" style=\"min-height:13px;margin:0 0 3px 0;\"> Expiration Year <\/label>\n                      <select class=\"form-dropdown validate[required] cc_exp_year\" name=\"q3_payment[cc_exp_year]\" id=\"input_3_cc_exp_year\" data-component=\"cc_exp_year\">\n                        <option>  <\/option>\n                        <option value=\"2018\"> 2018 <\/option>\n                        <option value=\"2019\"> 2019 <\/option>\n                        <option value=\"2020\"> 2020 <\/option>\n                        <option value=\"2021\"> 2021 <\/option>\n                        <option value=\"2022\"> 2022 <\/option>\n                        <option value=\"2023\"> 2023 <\/option>\n                        <option value=\"2024\"> 2024 <\/option>\n                        <option value=\"2025\"> 2025 <\/option>\n                        <option value=\"2026\"> 2026 <\/option>\n                        <option value=\"2027\"> 2027 <\/option>\n                      <\/select>\n                    <\/span>\n                  <\/td>\n                <\/tr>\n                <tr>\n                  <th colspan=\"2\" style=\"text-align:left;margin-top:20px;display:table;\">\n                    Billing Address\n                  <\/th>\n                <\/tr>\n                <tr>\n                  <td colspan=\"2\">\n                    <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                      <input type=\"text\" id=\"input_3_addr_line1\" name=\"q3_payment[addr_line1]\" class=\"form-textbox validate[required] form-address-line\" value=\"\" data-component=\"addr_line1\" \/>\n                      <label class=\"form-sub-label\" for=\"input_3_addr_line1\" id=\"sublabel_3_addr_line1\" style=\"min-height:13px;\"> Street Address <\/label>\n                    <\/span>\n                  <\/td>\n                <\/tr>\n                <tr>\n                  <td colspan=\"2\">\n                    <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                      <input type=\"text\" id=\"input_3_addr_line2\" name=\"q3_payment[addr_line2]\" class=\"form-textbox form-address-line\" size=\"46\" value=\"\" data-component=\"addr_line2\" \/>\n                      <label class=\"form-sub-label\" for=\"input_3_addr_line2\" id=\"sublabel_3_addr_line2\" style=\"min-height:13px;\"> Street Address Line 2 <\/label>\n                    <\/span>\n                  <\/td>\n                <\/tr>\n                <tr>\n                  <td width=\"50%\">\n                    <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                      <input type=\"text\" id=\"input_3_city\" name=\"q3_payment[city]\" class=\"form-textbox validate[required] form-address-city\" size=\"21\" value=\"\" data-component=\"city\" \/>\n                      <label class=\"form-sub-label\" for=\"input_3_city\" id=\"sublabel_3_city\" style=\"min-height:13px;\"> City <\/label>\n                    <\/span>\n                  <\/td>\n                  <td>\n                    <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                      <input type=\"text\" id=\"input_3_state\" name=\"q3_payment[state]\" class=\"form-textbox validate[required] form-address-state\" size=\"22\" value=\"\" data-component=\"state\" \/>\n                      <label class=\"form-sub-label\" for=\"input_3_state\" id=\"sublabel_3_state\" style=\"min-height:13px;\"> State \/ Province <\/label>\n                    <\/span>\n        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   <option value=\"Austria\"> Austria <\/option>\n                        <option value=\"Azerbaijan\"> Azerbaijan <\/option>\n                        <option value=\"The Bahamas\"> The Bahamas <\/option>\n                        <option value=\"Bahrain\"> Bahrain <\/option>\n                        <option value=\"Bangladesh\"> Bangladesh <\/option>\n                        <option value=\"Barbados\"> Barbados <\/option>\n                        <option value=\"Belgium\"> Belgium <\/option>\n                        <option value=\"Belize\"> Belize <\/option>\n                        <option value=\"Benin\"> Benin <\/option>\n                        <option value=\"Bermuda\"> Bermuda <\/option>\n                        <option value=\"Bhutan\"> Bhutan <\/option>\n                        <option value=\"Bolivia\"> Bolivia <\/option>\n                        <option value=\"Bosnia and Herzegovina\"> Bosnia and Herzegovina <\/option>\n                        <option value=\"Botswana\"> Botswana <\/option>\n                        <option value=\"Brazil\"> Brazil <\/option>\n                        <option value=\"Brunei\"> Brunei <\/option>\n                        <option value=\"Bulgaria\"> Bulgaria <\/option>\n                        <option value=\"Burkina Faso\"> Burkina Faso <\/option>\n                        <option value=\"Burundi\"> Burundi <\/option>\n                        <option value=\"Cambodia\"> Cambodia <\/option>\n                        <option value=\"Cameroon\"> Cameroon <\/option>\n                        <option value=\"Canada\"> Canada <\/option>\n                        <option value=\"Cape Verde\"> Cape Verde <\/option>\n                        <option value=\"Cayman Islands\"> Cayman Islands <\/option>\n                        <option value=\"Central African Republic\"> Central African Republic <\/option>\n                        <option value=\"Chad\"> Chad <\/option>\n                        <option value=\"Chile\"> Chile <\/option>\n                        <option value=\"China\"> China <\/option>\n                        <option value=\"Christmas Island\"> Christmas Island <\/option>\n                        <option value=\"Cocos (Keeling) Islands\"> Cocos (Keeling) Islands <\/option>\n                        <option value=\"Colombia\"> Colombia <\/option>\n                        <option value=\"Comoros\"> Comoros <\/option>\n                        <option value=\"Congo\"> Congo <\/option>\n                        <option value=\"Cook Islands\"> Cook Islands <\/option>\n                        <option value=\"Costa Rica\"> Costa Rica <\/option>\n                        <option value=\"Croatia\"> Croatia <\/option>\n                        <option value=\"Cyprus\"> Cyprus <\/option>\n                        <option value=\"Czech Republic\"> Czech Republic <\/option>\n                        <option value=\"Denmark\"> Denmark <\/option>\n                        <option value=\"Djibouti\"> Djibouti <\/option>\n                        <option value=\"Dominica\"> Dominica <\/option>\n                        <option value=\"Dominican Republic\"> Dominican Republic <\/option>\n                        <option value=\"Ecuador\"> Ecuador <\/option>\n                        <option value=\"Egypt\"> Egypt <\/option>\n                        <option value=\"El Salvador\"> El Salvador <\/option>\n                        <option value=\"Equatorial Guinea\"> Equatorial Guinea <\/option>\n                        <option value=\"Eritrea\"> Eritrea <\/option>\n                        <option value=\"Estonia\"> Estonia <\/option>\n                        <option value=\"Ethiopia\"> Ethiopia <\/option>\n                        <option value=\"Falkland Islands\"> Falkland Islands <\/option>\n                        <option value=\"Faroe Islands\"> Faroe Islands <\/option>\n                        <option value=\"Fiji\"> Fiji <\/option>\n                        <option value=\"Finland\"> Finland <\/option>\n                        <option value=\"France\"> France <\/option>\n                        <option value=\"French Polynesia\"> French Polynesia <\/option>\n                        <option value=\"Gabon\"> Gabon <\/option>\n                        <option value=\"The Gambia\"> The Gambia <\/option>\n                        <option value=\"Georgia\"> Georgia <\/option>\n                        <option value=\"Germany\"> Germany <\/option>\n                        <option value=\"Ghana\"> Ghana <\/option>\n                        <option value=\"Gibraltar\"> Gibraltar <\/option>\n                        <option value=\"Greece\"> Greece <\/option>\n                        <option value=\"Greenland\"> Greenland <\/option>\n                        <option value=\"Grenada\"> Grenada <\/option>\n                        <option value=\"Guadeloupe\"> Guadeloupe <\/option>\n                        <option value=\"Guam\"> Guam <\/option>\n                        <option value=\"Guatemala\"> Guatemala <\/option>\n                        <option value=\"Guernsey\"> Guernsey <\/option>\n                        <option value=\"Guinea\"> Guinea <\/option>\n                        <option value=\"Guinea-Bissau\"> Guinea-Bissau <\/option>\n                        <option value=\"Guyana\"> Guyana <\/option>\n                        <option value=\"Haiti\"> Haiti <\/option>\n                        <option value=\"Honduras\"> Honduras <\/option>\n                        <option value=\"Hong Kong\"> Hong Kong <\/option>\n                        <option value=\"Hungary\"> Hungary <\/option>\n                        <option value=\"Iceland\"> Iceland <\/option>\n                        <option value=\"India\"> India <\/option>\n                        <option value=\"Indonesia\"> Indonesia <\/option>\n                        <option value=\"Iraq\"> Iraq <\/option>\n                        <option value=\"Ireland\"> Ireland <\/option>\n                        <option value=\"Israel\"> Israel <\/option>\n                        <option value=\"Italy\"> Italy <\/option>\n                        <option value=\"Jamaica\"> Jamaica <\/option>\n                        <option value=\"Japan\"> Japan <\/option>\n                        <option value=\"Jersey\"> Jersey <\/option>\n                        <option value=\"Jordan\"> Jordan <\/option>\n                        <option value=\"Kazakhstan\"> Kazakhstan <\/option>\n                        <option value=\"Kenya\"> Kenya <\/option>\n                        <option value=\"Kiribati\"> Kiribati <\/option>\n                        <option value=\"North Korea\"> North Korea <\/option>\n                        <option value=\"South Korea\"> South Korea <\/option>\n                        <option value=\"Kosovo\"> Kosovo <\/option>\n                        <option value=\"Kuwait\"> Kuwait <\/option>\n                        <option value=\"Kyrgyzstan\"> Kyrgyzstan <\/option>\n                        <option value=\"Laos\"> Laos <\/option>\n                        <option value=\"Latvia\"> Latvia <\/option>\n                        <option value=\"Lesotho\"> Lesotho <\/option>\n                        <option value=\"Liechtenstein\"> Liechtenstein <\/option>\n                        <option value=\"Lithuania\"> Lithuania <\/option>\n                        <option value=\"Luxembourg\"> Luxembourg <\/option>\n                        <option value=\"Macau\"> Macau <\/option>\n                        <option value=\"Macedonia\"> Macedonia <\/option>\n                        <option value=\"Madagascar\"> Madagascar <\/option>\n                        <option value=\"Malawi\"> Malawi <\/option>\n                        <option value=\"Malaysia\"> Malaysia <\/option>\n                        <option value=\"Maldives\"> Maldives <\/option>\n                        <option value=\"Mali\"> Mali <\/option>\n                        <option value=\"Malta\"> Malta <\/option>\n                        <option value=\"Marshall Islands\"> Marshall Islands <\/option>\n                        <option value=\"Martinique\"> Martinique <\/option>\n                        <option value=\"Mauritania\"> Mauritania <\/option>\n                        <option value=\"Mauritius\"> Mauritius <\/option>\n                        <option value=\"Mayotte\"> Mayotte <\/option>\n                        <option value=\"Mexico\"> Mexico <\/option>\n                        <option value=\"Micronesia\"> Micronesia <\/option>\n                        <option value=\"Moldova\"> Moldova <\/option>\n                        <option value=\"Monaco\"> Monaco <\/option>\n                        <option value=\"Mongolia\"> Mongolia <\/option>\n                        <option value=\"Montenegro\"> Montenegro <\/option>\n                        <option value=\"Montserrat\"> Montserrat <\/option>\n                        <option value=\"Morocco\"> Morocco <\/option>\n                        <option value=\"Mozambique\"> Mozambique <\/option>\n                        <option value=\"Myanmar\"> Myanmar <\/option>\n                        <option value=\"Nagorno-Karabakh\"> Nagorno-Karabakh <\/option>\n                        <option value=\"Namibia\"> Namibia <\/option>\n                        <option value=\"Nauru\"> Nauru <\/option>\n                        <option value=\"Nepal\"> Nepal <\/option>\n                        <option value=\"Netherlands\"> Netherlands <\/option>\n                        <option value=\"Netherlands Antilles\"> Netherlands Antilles <\/option>\n                        <option value=\"New Caledonia\"> New Caledonia <\/option>\n                        <option value=\"New Zealand\"> New Zealand <\/option>\n                        <option value=\"Nicaragua\"> Nicaragua <\/option>\n                        <option value=\"Niger\"> Niger <\/option>\n                        <option value=\"Nigeria\"> Nigeria <\/option>\n                        <option value=\"Niue\"> Niue <\/option>\n                        <option value=\"Norfolk Island\"> Norfolk Island <\/option>\n                        <option value=\"Turkish Republic of Northern Cyprus\"> Turkish Republic of Northern Cyprus <\/option>\n                        <option value=\"Northern Mariana\"> Northern Mariana <\/option>\n                        <option value=\"Norway\"> Norway <\/option>\n                        <option value=\"Oman\"> Oman <\/option>\n                        <option value=\"Pakistan\"> Pakistan <\/option>\n                        <option value=\"Palau\"> Palau <\/option>\n                        <option value=\"Palestine\"> Palestine <\/option>\n                        <option value=\"Panama\"> Panama <\/option>\n                        <option value=\"Papua New Guinea\"> Papua New Guinea <\/option>\n                        <option value=\"Paraguay\"> Paraguay <\/option>\n                        <option value=\"Peru\"> Peru <\/option>\n                        <option value=\"Philippines\"> Philippines <\/option>\n                        <option value=\"Pitcairn Islands\"> Pitcairn Islands <\/option>\n                        <option value=\"Poland\"> Poland <\/option>\n                        <option value=\"Portugal\"> Portugal <\/option>\n                        <option value=\"Puerto Rico\"> Puerto Rico <\/option>\n                        <option value=\"Qatar\"> Qatar <\/option>\n                        <option value=\"Republic of the Congo\"> Republic of the Congo <\/option>\n                        <option value=\"Romania\"> Romania <\/option>\n                        <option value=\"Russia\"> Russia <\/option>\n                        <option value=\"Rwanda\"> Rwanda <\/option>\n                        <option value=\"Saint Barthelemy\"> Saint Barthelemy <\/option>\n                        <option value=\"Saint Helena\"> Saint Helena <\/option>\n                        <option value=\"Saint Kitts and Nevis\"> Saint Kitts and Nevis <\/option>\n                        <option value=\"Saint Lucia\"> Saint Lucia <\/option>\n                        <option value=\"Saint Martin\"> Saint Martin <\/option>\n                        <option value=\"Saint Pierre and Miquelon\"> Saint Pierre and Miquelon <\/option>\n                        <option value=\"Saint Vincent and the Grenadines\"> Saint Vincent and the Grenadines <\/option>\n                        <option value=\"Samoa\"> Samoa <\/option>\n                        <option value=\"San Marino\"> San Marino <\/option>\n                        <option value=\"Sao Tome and Principe\"> Sao Tome and Principe <\/option>\n                        <option value=\"Saudi Arabia\"> Saudi Arabia <\/option>\n                        <option value=\"Senegal\"> Senegal <\/option>\n                        <option value=\"Serbia\"> Serbia <\/option>\n                        <option value=\"Seychelles\"> Seychelles <\/option>\n                        <option value=\"Sierra Leone\"> Sierra Leone <\/option>\n                        <option value=\"Singapore\"> Singapore <\/option>\n                        <option value=\"Slovakia\"> Slovakia <\/option>\n                        <option value=\"Slovenia\"> Slovenia <\/option>\n                        <option value=\"Solomon Islands\"> Solomon Islands <\/option>\n                        <option value=\"Somaliland\"> Somaliland <\/option>\n                        <option value=\"South Africa\"> South Africa <\/option>\n                        <option value=\"South Ossetia\"> South Ossetia <\/option>\n                        <option value=\"South Sudan\"> South Sudan <\/option>\n                        <option value=\"Spain\"> Spain <\/option>\n                        <option value=\"Sri Lanka\"> Sri Lanka <\/option>\n                        <option value=\"Sudan\"> Sudan <\/option>\n                        <option value=\"Suriname\"> Suriname <\/option>\n                        <option value=\"Svalbard\"> Svalbard <\/option>\n                        <option value=\"Swaziland\"> Swaziland <\/option>\n                        <option value=\"Sweden\"> Sweden <\/option>\n                        <option value=\"Switzerland\"> Switzerland <\/option>\n                        <option value=\"Taiwan\"> Taiwan <\/option>\n                        <option value=\"Tajikistan\"> Tajikistan <\/option>\n                        <option value=\"Tanzania\"> Tanzania <\/option>\n                        <option value=\"Thailand\"> Thailand <\/option>\n                        <option value=\"Timor-Leste\"> Timor-Leste <\/option>\n                        <option value=\"Togo\"> Togo <\/option>\n                        <option value=\"Tokelau\"> Tokelau <\/option>\n                        <option value=\"Tonga\"> Tonga <\/option>\n                        <option value=\"Transnistria Pridnestrovie\"> Transnistria Pridnestrovie <\/option>\n                        <option value=\"Trinidad and Tobago\"> Trinidad and Tobago <\/option>\n                        <option value=\"Tristan da Cunha\"> Tristan da Cunha <\/option>\n                        <option value=\"Tunisia\"> Tunisia <\/option>\n                        <option value=\"Turkey\"> Turkey <\/option>\n                        <option value=\"Turkmenistan\"> Turkmenistan <\/option>\n                        <option value=\"Turks and Caicos Islands\"> Turks and Caicos Islands <\/option>\n                        <option value=\"Tuvalu\"> Tuvalu <\/option>\n                        <option value=\"Uganda\"> Uganda <\/option>\n                        <option value=\"Ukraine\"> Ukraine <\/option>\n                        <option value=\"United Arab Emirates\"> United Arab Emirates <\/option>\n                        <option value=\"United Kingdom\"> United Kingdom <\/option>\n                        <option value=\"Uruguay\"> Uruguay <\/option>\n                        <option value=\"Uzbekistan\"> Uzbekistan <\/option>\n                        <option value=\"Vanuatu\"> Vanuatu <\/option>\n                        <option value=\"Vatican City\"> Vatican City <\/option>\n                        <option value=\"Venezuela\"> Venezuela <\/option>\n                        <option value=\"Vietnam\"> Vietnam <\/option>\n                        <option value=\"British Virgin Islands\"> British Virgin Islands <\/option>\n                        <option value=\"Isle of Man\"> Isle of Man <\/option>\n                        <option value=\"US Virgin Islands\"> US Virgin Islands <\/option>\n                        <option value=\"Wallis and Futuna\"> Wallis and Futuna <\/option>\n                        <option value=\"Western Sahara\"> Western Sahara <\/option>\n                        <option value=\"Yemen\"> Yemen <\/option>\n                        <option value=\"Zambia\"> Zambia <\/option>\n                        <option value=\"other\"> Other <\/option>\n                      <\/select>\n                      <label class=\"form-sub-label\" for=\"input_3_country\" id=\"sublabel_3_country\" style=\"min-height:13px;\"> Country <\/label>\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_fullname\" id=\"id_4\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_4\" for=\"first_4\">\n          Payer Name\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_4\" class=\"form-input jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input type=\"text\" id=\"first_4\" name=\"q4_payerName[first]\" class=\"form-textbox validate[required]\" size=\"10\" value=\"\" data-component=\"first\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"first_4\" id=\"sublabel_first\" style=\"min-height:13px;\"> First Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input type=\"text\" id=\"last_4\" name=\"q4_payerName[last]\" class=\"form-textbox validate[required]\" size=\"15\" value=\"\" data-component=\"last\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"last_4\" id=\"sublabel_last\" style=\"min-height:13px;\"> Last Name <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_phone\" id=\"id_13\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_13\" for=\"input_13_area\">\n          Phone Number\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_13\" class=\"form-input 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_13_area\" name=\"q13_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_13_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_13_phone\" name=\"q13_phoneNumber[phone]\" class=\"form-textbox validate[required]\" size=\"8\" value=\"\" data-component=\"phone\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"input_13_phone\" id=\"sublabel_phone\" style=\"min-height:13px;\"> Phone Number <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_email\" id=\"id_5\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_5\" for=\"input_5\"> Buyer E-mail <\/label>\n        <div id=\"cid_5\" class=\"form-input\">\n          <input type=\"email\" id=\"input_5\" name=\"q5_buyerEmail\" class=\"form-textbox validate[Email]\" size=\"32\" value=\"\" placeholder=\"ex: myname@example.com\" data-component=\"email\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_9\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_9\" for=\"input_9\">\n          Type of Payment\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_9\" class=\"form-input jf-required\">\n          <div class=\"form-single-column\" data-component=\"radio\">\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_9_0\" name=\"q9_typeOf\" value=\"Account Payment\" required=\"\" \/>\n              <label id=\"label_input_9_0\" for=\"input_9_0\"> Account Payment <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_9_1\" name=\"q9_typeOf\" value=\"Bill Payment\" required=\"\" \/>\n              <label id=\"label_input_9_1\" for=\"input_9_1\"> Bill Payment <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_9_2\" name=\"q9_typeOf\" value=\"Shipping Cost Payment\" required=\"\" \/>\n              <label id=\"label_input_9_2\" for=\"input_9_2\"> Shipping Cost Payment <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_9_3\" name=\"q9_typeOf\" value=\"eBay Sold Item Payment\" required=\"\" \/>\n              <label id=\"label_input_9_3\" for=\"input_9_3\"> eBay Sold Item Payment <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_9_4\" name=\"q9_typeOf\" value=\"Share Bill Payment\" required=\"\" \/>\n              <label id=\"label_input_9_4\" for=\"input_9_4\"> Share Bill Payment <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_9_5\" name=\"q9_typeOf\" value=\"Other Payment\" required=\"\" \/>\n              <label id=\"label_input_9_5\" for=\"input_9_5\"> Other Payment <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required form-field-hidden\" style=\"display:none;\" data-type=\"control_textbox\" id=\"id_8\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_8\" for=\"input_8\">\n          Account No. or Invoice Number\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_8\" class=\"form-input jf-required\">\n          <input type=\"text\" id=\"input_8\" name=\"q8_accountNo\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"20\" value=\"\" placeholder=\" \" data-component=\"textbox\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_dropdown\" id=\"id_18\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_18\" for=\"input_18\"> Bill Type <\/label>\n        <div id=\"cid_18\" class=\"form-input\">\n          <select class=\"form-dropdown\" id=\"input_18\" name=\"q18_billType\" style=\"width:150px;\" data-component=\"dropdown\">\n            <option value=\"\">  <\/option>\n            <option value=\"Job Offer Payment\"> Job Offer Payment <\/option>\n            <option value=\"Contract Fee Payment\"> Contract Fee Payment <\/option>\n            <option value=\"Invoice Payment\"> Invoice Payment <\/option>\n            <option value=\"Printing &amp; Advertising Payment\"> Printing &amp; Advertising Payment <\/option>\n            <option value=\"Service and Repair Payment\"> Service and Repair Payment <\/option>\n            <option value=\"Service Cleaning Payment\"> Service Cleaning Payment <\/option>\n            <option value=\"Subcontractor Fee Payment\"> Subcontractor Fee Payment <\/option>\n            <option value=\"Subscription Payment\"> Subscription Payment <\/option>\n            <option value=\"Hiring Equipment Payment\"> Hiring Equipment Payment <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required form-field-hidden\" style=\"display:none;\" data-type=\"control_textbox\" id=\"id_19\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_19\" for=\"input_19\">\n          Bill Number\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_19\" class=\"form-input jf-required\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n            <input type=\"text\" id=\"input_19\" name=\"q19_billNumber\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"40\" value=\"\" placeholder=\" \" data-component=\"textbox\" required=\"\" \/>\n            <label class=\"form-sub-label\" for=\"input_19\" style=\"min-height:13px;\"> eg. Job Offer No, Invoice No, Reference No <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required form-field-hidden\" style=\"display:none;\" data-type=\"control_textbox\" id=\"id_7\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_7\" for=\"input_7\">\n          eBay Item Nubmer\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_7\" class=\"form-input jf-required\">\n          <input type=\"text\" id=\"input_7\" name=\"q7_ebayItem7\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"20\" value=\"\" placeholder=\" \" data-component=\"textbox\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required form-field-hidden\" style=\"display:none;\" data-type=\"control_textbox\" id=\"id_12\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_12\" for=\"input_12\">\n          Reason for Payment\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_12\" class=\"form-input jf-required\">\n          <input type=\"text\" id=\"input_12\" name=\"q12_reasonFor\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"50\" value=\"\" placeholder=\"Donation, Service Fee, Subscription, etc.\" data-component=\"textbox\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required form-field-hidden\" style=\"display:none;\" data-type=\"control_widget\" id=\"id_16\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_16\" for=\"input_16\">\n          Share Bill Number or Document\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_16\" class=\"form-input jf-required\">\n          <div style=\"width:100%;text-align:Left;\" data-component=\"widget-field\">\n            <iframe frameborder=\"0\" scrolling=\"no\" allowtransparency=\"true\" data-type=\"iframe\" class=\"custom-field-frame\" id=\"customFieldFrame_16\" src=\"\" style=\"border:none;width:300px;height:70px;\" data-width=\"300\" data-height=\"70\">\n            <\/iframe>\n            <div class=\"widget-inputs-wrapper\">\n              <input id=\"input_16\" class=\"form-hidden form-widget widget-required \" type=\"hidden\" name=\"q16_shareBill\" value=\"\" \/>\n              <input id=\"widget_settings_16\" class=\"form-hidden form-widget-settings\" type=\"hidden\" value=\"%5B%7B%22name%22%3A%22existing%22%2C%22value%22%3A%221%22%7D%2C%7B%22name%22%3A%22buttontext%22%2C%22value%22%3A%22Add%20More%22%7D%2C%7B%22name%22%3A%22size%22%2C%22value%22%3A%2225%22%7D%2C%7B%22name%22%3A%22theme%22%2C%22value%22%3A%22Default%22%7D%5D\" data-version=\"2\" \/>\n            <\/div>\n            <script type=\"text\/javascript\">\n            setTimeout(function()\n{\n  var _cFieldFrame = document.getElementById(\"customFieldFrame_16\");\n  _cFieldFrame.onload = function()\n  {\n    widgetFrameLoaded(16, {\n      \"formID\": 62420697978875\n    })\n  };\n  _cFieldFrame.src = \"\/\/widgets.jotform.io\/dynamicFields\/?qid=16&ref=\" + encodeURIComponent(window.location.protocol + \"\/\/\" + window.location.host);\n  _cFieldFrame.addClassName(\"custom-field-frame-rendered\");\n}, 0);\n            <\/script>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required form-field-hidden\" style=\"display:none;\" data-type=\"control_address\" id=\"id_6\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_6\" for=\"input_6_addr_line1\">\n          Shipping Address\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_6\" class=\"form-input jf-required\">\n          <table summary=\"\" class=\"form-address-table\" cellpadding=\"0\" cellspacing=\"0\">\n            <tbody>\n              <tr>\n                <td colspan=\"2\">\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                    <input type=\"text\" id=\"input_6_addr_line1\" name=\"q6_shippingAddress[addr_line1]\" class=\"form-textbox validate[required] form-address-line\" value=\"\" data-component=\"address_line_1\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_6_addr_line1\" id=\"sublabel_6_addr_line1\" style=\"min-height:13px;\"> Street Address <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td colspan=\"2\">\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                    <input type=\"text\" id=\"input_6_addr_line2\" name=\"q6_shippingAddress[addr_line2]\" class=\"form-textbox form-address-line\" size=\"46\" value=\"\" data-component=\"address_line_2\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_6_addr_line2\" id=\"sublabel_6_addr_line2\" style=\"min-height:13px;\"> Street Address Line 2 <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td width=\"50%\">\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                    <input type=\"text\" id=\"input_6_city\" name=\"q6_shippingAddress[city]\" class=\"form-textbox validate[required] form-address-city\" size=\"21\" value=\"\" data-component=\"city\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_6_city\" id=\"sublabel_6_city\" style=\"min-height:13px;\"> City <\/label>\n                  <\/span>\n                <\/td>\n                <td>\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                    <input type=\"text\" id=\"input_6_state\" name=\"q6_shippingAddress[state]\" class=\"form-textbox validate[required] form-address-state\" size=\"22\" value=\"\" data-component=\"state\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_6_state\" id=\"sublabel_6_state\" style=\"min-height:13px;\"> State \/ Province <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td width=\"50%\">\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                    <input type=\"text\" id=\"input_6_postal\" name=\"q6_shippingAddress[postal]\" class=\"form-textbox form-address-postal\" size=\"10\" value=\"\" data-component=\"zip\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_6_postal\" id=\"sublabel_6_postal\" style=\"min-height:13px;\"> Postal \/ Zip Code <\/label>\n                  <\/span>\n                <\/td>\n                <td>\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                    <select class=\"form-dropdown validate[required] form-address-country\" name=\"q6_shippingAddress[country]\" id=\"input_6_country\" data-component=\"country\" required=\"\">\n                      <option value=\"\"> Please Select <\/option>\n                      <option value=\"United States\"> United States <\/option>\n                      <option value=\"Afghanistan\"> Afghanistan <\/option>\n                      <option value=\"Albania\"> Albania <\/option>\n                      <option value=\"Algeria\"> Algeria <\/option>\n                      <option value=\"American Samoa\"> American Samoa <\/option>\n                      <option value=\"Andorra\"> Andorra <\/option>\n                      <option value=\"Angola\"> Angola <\/option>\n                      <option value=\"Anguilla\"> Anguilla <\/option>\n                      <option value=\"Antigua and Barbuda\"> Antigua and Barbuda <\/option>\n                      <option value=\"Argentina\"> Argentina <\/option>\n                      <option value=\"Armenia\"> Armenia <\/option>\n                      <option value=\"Aruba\"> Aruba <\/option>\n                      <option value=\"Australia\"> Australia <\/option>\n                      <option value=\"Austria\"> Austria <\/option>\n                      <option value=\"Azerbaijan\"> Azerbaijan <\/option>\n                      <option value=\"The Bahamas\"> The Bahamas <\/option>\n                      <option value=\"Bahrain\"> Bahrain <\/option>\n                      <option value=\"Bangladesh\"> Bangladesh <\/option>\n                      <option value=\"Barbados\"> Barbados <\/option>\n                      <option value=\"Belarus\"> Belarus <\/option>\n                      <option value=\"Belgium\"> Belgium <\/option>\n                      <option value=\"Belize\"> Belize <\/option>\n                      <option value=\"Benin\"> Benin <\/option>\n                      <option value=\"Bermuda\"> Bermuda <\/option>\n                      <option value=\"Bhutan\"> Bhutan <\/option>\n                      <option value=\"Bolivia\"> Bolivia <\/option>\n                      <option value=\"Bosnia and Herzegovina\"> Bosnia and Herzegovina <\/option>\n                      <option value=\"Botswana\"> Botswana <\/option>\n                      <option value=\"Brazil\"> Brazil <\/option>\n                      <option value=\"Brunei\"> Brunei <\/option>\n                      <option value=\"Bulgaria\"> Bulgaria <\/option>\n                      <option value=\"Burkina Faso\"> Burkina Faso <\/option>\n                      <option value=\"Burundi\"> Burundi <\/option>\n                      <option value=\"Cambodia\"> Cambodia <\/option>\n                      <option value=\"Cameroon\"> Cameroon <\/option>\n                      <option value=\"Canada\"> Canada <\/option>\n                      <option value=\"Cape Verde\"> Cape Verde <\/option>\n                      <option value=\"Cayman Islands\"> Cayman Islands <\/option>\n                      <option value=\"Central African Republic\"> Central African Republic <\/option>\n                      <option value=\"Chad\"> Chad <\/option>\n                      <option value=\"Chile\"> Chile <\/option>\n                      <option value=\"China\"> China <\/option>\n                      <option value=\"Christmas Island\"> Christmas Island <\/option>\n                      <option value=\"Cocos (Keeling) Islands\"> Cocos (Keeling) Islands <\/option>\n                      <option value=\"Colombia\"> Colombia <\/option>\n                      <option value=\"Comoros\"> Comoros <\/option>\n                      <option value=\"Congo\"> Congo <\/option>\n                      <option value=\"Cook Islands\"> Cook Islands <\/option>\n                      <option value=\"Costa Rica\"> Costa Rica <\/option>\n                      <option value=\"Cote d&#x27;Ivoire\"> Cote d&#x27;Ivoire <\/option>\n                      <option value=\"Croatia\"> Croatia <\/option>\n                      <option value=\"Cuba\"> Cuba <\/option>\n                      <option value=\"Cyprus\"> Cyprus <\/option>\n                      <option value=\"Czech Republic\"> Czech Republic <\/option>\n                      <option value=\"Democratic Republic of the Congo\"> Democratic Republic of the Congo <\/option>\n                      <option value=\"Denmark\"> Denmark <\/option>\n                      <option value=\"Djibouti\"> Djibouti <\/option>\n                      <option value=\"Dominica\"> Dominica <\/option>\n                      <option value=\"Dominican Republic\"> Dominican Republic <\/option>\n                      <option value=\"Ecuador\"> Ecuador <\/option>\n                      <option value=\"Egypt\"> Egypt <\/option>\n                      <option value=\"El Salvador\"> El Salvador <\/option>\n                      <option value=\"Equatorial Guinea\"> Equatorial Guinea <\/option>\n                      <option value=\"Eritrea\"> Eritrea <\/option>\n                      <option value=\"Estonia\"> Estonia <\/option>\n                      <option value=\"Ethiopia\"> Ethiopia <\/option>\n                      <option value=\"Falkland Islands\"> Falkland Islands <\/option>\n                      <option value=\"Faroe Islands\"> Faroe Islands <\/option>\n                      <option value=\"Fiji\"> Fiji <\/option>\n                      <option value=\"Finland\"> Finland <\/option>\n                      <option value=\"France\"> France <\/option>\n                      <option value=\"French Polynesia\"> French Polynesia <\/option>\n                      <option value=\"Gabon\"> Gabon <\/option>\n                      <option value=\"The Gambia\"> The Gambia <\/option>\n                      <option value=\"Georgia\"> Georgia <\/option>\n                      <option value=\"Germany\"> Germany <\/option>\n                      <option value=\"Ghana\"> Ghana <\/option>\n                      <option value=\"Gibraltar\"> Gibraltar <\/option>\n                      <option value=\"Greece\"> Greece <\/option>\n                      <option value=\"Greenland\"> Greenland <\/option>\n                      <option value=\"Grenada\"> Grenada <\/option>\n                      <option value=\"Guadeloupe\"> Guadeloupe <\/option>\n                      <option value=\"Guam\"> Guam <\/option>\n                      <option value=\"Guatemala\"> Guatemala <\/option>\n                      <option value=\"Guernsey\"> Guernsey <\/option>\n                      <option value=\"Guinea\"> Guinea <\/option>\n                      <option value=\"Guinea-Bissau\"> Guinea-Bissau <\/option>\n                      <option value=\"Guyana\"> Guyana <\/option>\n                      <option value=\"Haiti\"> Haiti <\/option>\n                      <option value=\"Honduras\"> Honduras <\/option>\n                      <option value=\"Hong Kong\"> Hong Kong <\/option>\n                      <option value=\"Hungary\"> Hungary <\/option>\n                      <option value=\"Iceland\"> Iceland <\/option>\n                      <option value=\"India\"> India <\/option>\n                      <option value=\"Indonesia\"> Indonesia <\/option>\n                      <option value=\"Iran\"> Iran <\/option>\n                      <option value=\"Iraq\"> Iraq <\/option>\n                      <option value=\"Ireland\"> Ireland <\/option>\n                      <option value=\"Israel\"> Israel <\/option>\n                      <option value=\"Italy\"> Italy <\/option>\n                      <option value=\"Jamaica\"> Jamaica <\/option>\n                      <option value=\"Japan\"> Japan <\/option>\n                      <option value=\"Jersey\"> Jersey <\/option>\n                      <option value=\"Jordan\"> Jordan <\/option>\n                      <option value=\"Kazakhstan\"> Kazakhstan <\/option>\n                      <option value=\"Kenya\"> Kenya <\/option>\n                      <option value=\"Kiribati\"> Kiribati <\/option>\n                      <option value=\"North Korea\"> North Korea <\/option>\n                      <option value=\"South Korea\"> South Korea <\/option>\n                      <option value=\"Kosovo\"> Kosovo <\/option>\n                      <option value=\"Kuwait\"> Kuwait <\/option>\n                      <option value=\"Kyrgyzstan\"> Kyrgyzstan <\/option>\n                      <option value=\"Laos\"> Laos <\/option>\n                      <option value=\"Latvia\"> Latvia <\/option>\n                      <option value=\"Lebanon\"> Lebanon <\/option>\n                      <option value=\"Lesotho\"> Lesotho <\/option>\n                      <option value=\"Liberia\"> Liberia <\/option>\n                      <option value=\"Libya\"> Libya <\/option>\n                      <option value=\"Liechtenstein\"> Liechtenstein <\/option>\n                      <option value=\"Lithuania\"> Lithuania <\/option>\n                      <option value=\"Luxembourg\"> Luxembourg <\/option>\n                      <option value=\"Macau\"> Macau <\/option>\n                      <option value=\"Macedonia\"> Macedonia <\/option>\n                      <option value=\"Madagascar\"> Madagascar <\/option>\n                      <option value=\"Malawi\"> Malawi <\/option>\n                      <option value=\"Malaysia\"> Malaysia <\/option>\n                      <option value=\"Maldives\"> Maldives <\/option>\n                      <option value=\"Mali\"> Mali <\/option>\n                      <option value=\"Malta\"> Malta <\/option>\n                      <option value=\"Marshall Islands\"> Marshall Islands <\/option>\n                      <option value=\"Martinique\"> Martinique <\/option>\n                      <option value=\"Mauritania\"> Mauritania <\/option>\n                      <option value=\"Mauritius\"> Mauritius <\/option>\n                      <option value=\"Mayotte\"> Mayotte <\/option>\n                      <option value=\"Mexico\"> Mexico <\/option>\n                      <option value=\"Micronesia\"> Micronesia <\/option>\n                      <option value=\"Moldova\"> Moldova <\/option>\n                      <option value=\"Monaco\"> Monaco <\/option>\n                      <option value=\"Mongolia\"> Mongolia <\/option>\n                      <option value=\"Montenegro\"> Montenegro <\/option>\n                      <option value=\"Montserrat\"> Montserrat <\/option>\n                      <option value=\"Morocco\"> Morocco <\/option>\n                      <option value=\"Mozambique\"> Mozambique <\/option>\n                      <option value=\"Myanmar\"> Myanmar <\/option>\n                      <option value=\"Nagorno-Karabakh\"> Nagorno-Karabakh <\/option>\n                      <option value=\"Namibia\"> Namibia <\/option>\n                      <option value=\"Nauru\"> Nauru <\/option>\n                      <option value=\"Nepal\"> Nepal <\/option>\n                      <option value=\"Netherlands\"> Netherlands <\/option>\n                      <option value=\"Netherlands Antilles\"> Netherlands Antilles <\/option>\n                      <option value=\"New Caledonia\"> New Caledonia <\/option>\n                      <option value=\"New Zealand\"> New Zealand <\/option>\n                      <option value=\"Nicaragua\"> Nicaragua <\/option>\n                      <option value=\"Niger\"> Niger <\/option>\n                      <option value=\"Nigeria\"> Nigeria <\/option>\n                      <option value=\"Niue\"> Niue <\/option>\n                      <option value=\"Norfolk Island\"> Norfolk Island <\/option>\n                      <option value=\"Turkish Republic of Northern Cyprus\"> Turkish Republic of Northern Cyprus <\/option>\n                      <option value=\"Northern Mariana\"> Northern Mariana <\/option>\n                      <option value=\"Norway\"> Norway <\/option>\n                      <option value=\"Oman\"> Oman <\/option>\n                      <option value=\"Pakistan\"> Pakistan <\/option>\n                      <option value=\"Palau\"> Palau <\/option>\n                      <option value=\"Palestine\"> Palestine <\/option>\n                      <option value=\"Panama\"> Panama <\/option>\n                      <option value=\"Papua New Guinea\"> Papua New Guinea <\/option>\n                      <option value=\"Paraguay\"> Paraguay <\/option>\n                      <option value=\"Peru\"> Peru <\/option>\n                      <option value=\"Philippines\"> Philippines <\/option>\n                      <option value=\"Pitcairn Islands\"> Pitcairn Islands <\/option>\n                      <option value=\"Poland\"> Poland <\/option>\n                      <option value=\"Portugal\"> Portugal <\/option>\n                      <option value=\"Puerto Rico\"> Puerto Rico <\/option>\n                      <option value=\"Qatar\"> Qatar <\/option>\n                      <option value=\"Republic of the Congo\"> Republic of the Congo <\/option>\n                      <option value=\"Romania\"> Romania <\/option>\n                      <option value=\"Russia\"> Russia <\/option>\n                      <option value=\"Rwanda\"> Rwanda <\/option>\n                      <option value=\"Saint Barthelemy\"> Saint Barthelemy <\/option>\n                      <option value=\"Saint Helena\"> Saint Helena <\/option>\n                      <option value=\"Saint Kitts and Nevis\"> Saint Kitts and Nevis <\/option>\n                      <option value=\"Saint Lucia\"> Saint Lucia <\/option>\n                      <option value=\"Saint Martin\"> Saint Martin <\/option>\n                      <option value=\"Saint Pierre and Miquelon\"> Saint Pierre and Miquelon <\/option>\n                      <option value=\"Saint Vincent and the Grenadines\"> Saint Vincent and the Grenadines <\/option>\n                      <option value=\"Samoa\"> Samoa <\/option>\n                      <option value=\"San Marino\"> San Marino <\/option>\n                      <option value=\"Sao Tome and Principe\"> Sao Tome and Principe <\/option>\n                      <option value=\"Saudi Arabia\"> Saudi Arabia <\/option>\n                      <option value=\"Senegal\"> Senegal <\/option>\n                      <option value=\"Serbia\"> Serbia <\/option>\n                      <option value=\"Seychelles\"> Seychelles <\/option>\n                      <option value=\"Sierra Leone\"> Sierra Leone <\/option>\n                      <option value=\"Singapore\"> Singapore <\/option>\n                      <option value=\"Slovakia\"> Slovakia <\/option>\n                      <option value=\"Slovenia\"> Slovenia <\/option>\n                      <option value=\"Solomon Islands\"> Solomon Islands <\/option>\n                      <option value=\"Somalia\"> Somalia <\/option>\n                      <option value=\"Somaliland\"> Somaliland <\/option>\n                      <option value=\"South Africa\"> South Africa <\/option>\n                      <option value=\"South Ossetia\"> South Ossetia <\/option>\n                      <option value=\"South Sudan\"> South Sudan <\/option>\n                      <option value=\"Spain\"> Spain <\/option>\n                      <option value=\"Sri Lanka\"> Sri Lanka <\/option>\n                      <option value=\"Sudan\"> Sudan <\/option>\n                      <option value=\"Suriname\"> Suriname <\/option>\n                      <option value=\"Svalbard\"> Svalbard <\/option>\n                      <option value=\"Swaziland\"> Swaziland <\/option>\n                      <option value=\"Sweden\"> Sweden <\/option>\n                      <option value=\"Switzerland\"> Switzerland <\/option>\n                      <option value=\"Syria\"> Syria <\/option>\n                      <option value=\"Taiwan\"> Taiwan <\/option>\n                      <option value=\"Tajikistan\"> Tajikistan <\/option>\n                      <option value=\"Tanzania\"> Tanzania <\/option>\n                      <option value=\"Thailand\"> Thailand <\/option>\n                      <option value=\"Timor-Leste\"> Timor-Leste <\/option>\n                      <option value=\"Togo\"> Togo <\/option>\n                      <option value=\"Tokelau\"> Tokelau <\/option>\n                      <option value=\"Tonga\"> Tonga <\/option>\n                      <option value=\"Transnistria Pridnestrovie\"> Transnistria Pridnestrovie <\/option>\n                      <option value=\"Trinidad and Tobago\"> Trinidad and Tobago <\/option>\n                      <option value=\"Tristan da Cunha\"> Tristan da Cunha <\/option>\n                      <option value=\"Tunisia\"> Tunisia <\/option>\n                      <option value=\"Turkey\"> Turkey <\/option>\n                      <option value=\"Turkmenistan\"> Turkmenistan <\/option>\n                      <option value=\"Turks and Caicos Islands\"> Turks and Caicos Islands <\/option>\n                      <option value=\"Tuvalu\"> Tuvalu <\/option>\n                      <option value=\"Uganda\"> Uganda <\/option>\n                      <option value=\"Ukraine\"> Ukraine <\/option>\n                      <option value=\"United Arab Emirates\"> United Arab Emirates <\/option>\n                      <option value=\"United Kingdom\"> United Kingdom <\/option>\n                      <option value=\"Uruguay\"> Uruguay <\/option>\n                      <option value=\"Uzbekistan\"> Uzbekistan <\/option>\n                      <option value=\"Vanuatu\"> Vanuatu <\/option>\n                      <option value=\"Vatican City\"> Vatican City <\/option>\n                      <option value=\"Venezuela\"> Venezuela <\/option>\n                      <option value=\"Vietnam\"> Vietnam <\/option>\n                      <option value=\"British Virgin Islands\"> British Virgin Islands <\/option>\n                      <option value=\"Isle of Man\"> Isle of Man <\/option>\n                      <option value=\"US Virgin Islands\"> US Virgin Islands <\/option>\n                      <option value=\"Wallis and Futuna\"> Wallis and Futuna <\/option>\n                      <option value=\"Western Sahara\"> Western Sahara <\/option>\n                      <option value=\"Yemen\"> Yemen <\/option>\n                      <option value=\"Zambia\"> Zambia <\/option>\n                      <option value=\"Zimbabwe\"> Zimbabwe <\/option>\n                      <option value=\"other\"> Other <\/option>\n                    <\/select>\n                    <label class=\"form-sub-label\" for=\"input_6_country\" id=\"sublabel_6_country\" style=\"min-height:13px;\"> Country <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n            <\/tbody>\n          <\/table>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_captcha\" id=\"id_11\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_11\" for=\"input_11\">\n          Enter the message as it's shown\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_11\" class=\"form-input jf-required\">\n          <div class=\"form-captcha\" data-component=\"captcha\">\n            <label for=\"input_11\"> <img alt=\"Captcha - Reload if not displayed\" id=\"input_11_captcha\" class=\"form-captcha-image\" style=\"background:url(https:\/\/cdn.jotfor.ms\/images\/loader-big.gif) no-repeat center;\" src=\"https:\/\/cdn.jotfor.ms\/images\/blank.gif\" width=\"150\" height=\"41\" \/> <\/label>\n            <div style=\"white-space:nowrap;\">\n              <input type=\"text\" id=\"input_11\" class=\"form-textbox validate[required]\" name=\"captcha\" style=\"width:130px;\" required=\"\" \/>\n              <img src=\"https:\/\/cdn.jotfor.ms\/images\/reload.png\" alt=\"Reload\" style=\"cursor:pointer;vertical-align:middle;\" id=\"input_11_reload\" \/>\n              <input type=\"hidden\" name=\"captcha_id\" id=\"input_11_captcha_id\" value=\"0\" \/>\n            <\/div>\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 class=\"form-line\" data-type=\"control_text\" id=\"id_17\">\n        <div id=\"cid_17\" class=\"form-input-wide\">\n          <div id=\"text_17\" class=\"form-html\" data-component=\"text\">\n            <p>* We may charge you a payment processing fee on any payments you make using a credit card and PayPal (subject to certain limited exceptions). Currently, the amount of the fee is 2.6% (including GST) of the total payment amount for Visa and MasterCard. Diners and American Express not accepted. Any payment processing fee you incur will be included in your next GBCS Tax Invoice.<\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li style=\"display:none\">\n        Should be Empty:\n        <input type=\"text\" name=\"website\" value=\"\" \/>\n      <\/li>\n    <\/ul>\n  <\/div>\n  <script>\n  JotForm.showJotFormPowered = \"0\";\n  <\/script>\n  <input type=\"hidden\" id=\"simple_spc\" name=\"simple_spc\" value=\"62420697978875\" \/>\n  <script type=\"text\/javascript\">\n  document.getElementById(\"si\" + \"mple\" + \"_spc\").value = \"62420697978875-62420697978875\";\n  <\/script>\n  <script src=\"https:\/\/cdn.jotfor.ms\/js\/widgetResizer.js?REV=3.3.4616\" type=\"text\/javascript\"><\/script>\n<\/form><\/body>\n<\/html>\n","Payment",Array,0);(function(){window.handleIFrameMessage=function(e){if(!e.data||!e.data.split)return;var args=e.data.split(":");var iframe=document.getElementById("62420697978875");if(!iframe){return};switch(args[0]){case"scrollIntoView":if(!("nojump"in FrameBuilder.get)){iframe.scrollIntoView();}
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