var qsProxy = {};
function FrameBuilder(formId,appendTo,initialHeight,iframeCode,title,embedStyleJSON){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.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\" allow=\"geolocation; microphone; camera\" 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){}},200);};this.setTimer=function(){var self=this;this.interval=setTimeout(this.changeHeight.bind(this),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+".","");}
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){if(this.frame.contentWindow.document.body.offsetHeight){height=offsetHeight=this.frame.contentWindow.document.body.offsetHeight;}
var formWrapper=this.frame.contentWindow.document.querySelector('.form-all');var margin=parseInt(getComputedStyle(formWrapper).marginTop,10);if(!isNaN(margin)){height+=margin;}}}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 i92197128021857=new FrameBuilder("92197128021857",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%2F92197128021857\" 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%2F92197128021857\" title=\"oEmbed Form\">\n<meta property=\"og:title\" content=\"TGFS Pre-Payment form\" >\n<meta property=\"og:url\" content=\"https:\/\/form.jotform.co\/92197128021857\" >\n<meta property=\"og:description\" content=\"Please click the link to complete this form.\">\n<meta name=\"slack-app-id\" content=\"AHNMASS8M\">\n<link rel=\"shortcut icon\" href=\"https:\/\/cdn.jotfor.ms\/favicon.ico\">\n<link rel=\"canonical\" href=\"https:\/\/form.jotform.co\/92197128021857\" \/>\n<meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0, maximum-scale=2.0, user-scalable=1\" \/>\n<meta name=\"HandheldFriendly\" content=\"true\" \/>\n<title>TGFS Pre-Payment form<\/title>\n<link href=\"https:\/\/cdn.jotfor.ms\/static\/formCss.css?3.3.13909\" rel=\"stylesheet\" type=\"text\/css\" \/>\n<link type=\"text\/css\" media=\"print\" rel=\"stylesheet\" href=\"https:\/\/cdn.jotfor.ms\/css\/printForm.css?3.3.13909\" \/>\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/cdn.jotfor.ms\/css\/styles\/nova.css?3.3.13909\" \/>\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/cdn.jotfor.ms\/themes\/CSS\/566a91c2977cdfcd478b4567.css?themeRevisionID=59fb4852cf3bfe589c6c6f21\"\/>\n<style type=\"text\/css\">\n    .form-label-left{\n        width:75px;\n    }\n    .form-line{\n        padding-top:12px;\n        padding-bottom:12px;\n    }\n    .form-label-right{\n        width:75px;\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:0px;\n        width:590px;\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: false;\n    }\n\n<\/style>\n\n<style type=\"text\/css\" id=\"form-designer-style\">\n    \/* Injected CSS Code *\/\n.form-label.form-label-auto {\n        \n      display: block;\n      float: none;\n      text-align: left;\n      width: 100%;\n    \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 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.supernova {\n      background-image: none;\n    }\n    #stage {\n      background-image: none;\n    }\n  \n    .form-all {\n      background-image: none;\n    }\n  \n  .ie-8 .form-all:before { display: none; }\n  .ie-8 {\n    margin-top: auto;\n    margin-top: initial;\n  }\n  \n  \/*PREFERENCES STYLE*\/\/*__INSPECT_SEPERATOR__*\/\n    \/* Injected CSS Code *\/\n<\/style>\n\n<script src=\"https:\/\/cdnjs.cloudflare.com\/ajax\/libs\/punycode\/1.4.1\/punycode.min.js\"><\/script>\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?3.3.13909\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/js.jotform.com\/vendor\/postMessage.js?3.3.13909\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/js.jotform.com\/WidgetsServer.js?v=1573932346854\" type=\"text\/javascript\"><\/script>\n<script type=\"text\/javascript\">\n var jsTime = setInterval(function(){try{\n   JotForm.jsForm = true;\n\n\tJotForm.init(function(){\n      setTimeout(function() {\n          $('input_30').hint('ex: myname@example.com');\n       }, 20);\n\n JotForm.calendarMonths = [\"January\",\"February\",\"March\",\"April\",\"May\",\"June\",\"July\",\"August\",\"September\",\"October\",\"November\",\"December\"];\n JotForm.calendarDays = [\"Sunday\",\"Monday\",\"Tuesday\",\"Wednesday\",\"Thursday\",\"Friday\",\"Saturday\",\"Sunday\"];\n JotForm.calendarOther = {\"today\":\"Today\"};\n var languageOptions = document.querySelectorAll('#langList li'); \n for(var langIndex = 0; langIndex < languageOptions.length; langIndex++) { \n   languageOptions[langIndex].on('click', function(e) { setTimeout(function(){ JotForm.setCalendar(\"156\", false, {\"days\":{\"monday\":true,\"tuesday\":true,\"wednesday\":true,\"thursday\":true,\"friday\":true,\"saturday\":true,\"sunday\":true},\"future\":true,\"past\":true,\"custom\":false,\"ranges\":false,\"start\":\"\",\"end\":\"\"}); }, 0); });\n } \n JotForm.setCalendar(\"156\", false, {\"days\":{\"monday\":true,\"tuesday\":true,\"wednesday\":true,\"thursday\":true,\"friday\":true,\"saturday\":true,\"sunday\":true},\"future\":true,\"past\":true,\"custom\":false,\"ranges\":false,\"start\":\"\",\"end\":\"\"});\n    \/*INIT-END*\/\n\t});\n\n   clearInterval(jsTime);\n }catch(e){}}, 1000);\n\n   JotForm.prepareCalculationsOnTheFly([null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{\"name\":\"name15\",\"qid\":\"15\",\"text\":\"Name\",\"type\":\"control_fullname\"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,{\"name\":\"email30\",\"qid\":\"30\",\"text\":\"E-mail\",\"type\":\"control_email\"},null,{\"name\":\"personalDetails\",\"qid\":\"32\",\"text\":\"Personal Details\",\"type\":\"control_head\"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{\"name\":\"submit\",\"qid\":\"61\",\"text\":\"Submit\",\"type\":\"control_button\"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{\"description\":\"\",\"name\":\"phoneNumber\",\"qid\":\"124\",\"text\":\"Phone Number\",\"type\":\"control_phone\"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{\"description\":\"\",\"name\":\"irdNumber\",\"qid\":\"155\",\"subLabel\":\"\",\"text\":\"IRD Number\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"dateOf156\",\"qid\":\"156\",\"text\":\"Date of birth\",\"type\":\"control_datetime\"},{\"description\":\"\",\"name\":\"contributionAmount\",\"qid\":\"157\",\"subLabel\":\"\",\"text\":\"Contribution Amount\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"haveYou\",\"qid\":\"158\",\"text\":\"Have you pre-arranged your funeral?\",\"type\":\"control_radio\"},null,null,{\"description\":\"\",\"name\":\"iAcknowledge161\",\"qid\":\"161\",\"text\":\"I acknowledge and confirm that...(select all)\",\"type\":\"control_checkbox\"},{\"description\":\"\",\"name\":\"signature\",\"qid\":\"162\",\"text\":\"Signature\",\"type\":\"control_checkbox\"},{\"description\":\"\",\"name\":\"address163\",\"qid\":\"163\",\"text\":\"Address\",\"type\":\"control_address\"},{\"name\":\"typeA\",\"qid\":\"164\",\"text\":\"\",\"type\":\"control_widget\"}]);\n   setTimeout(function() {\nJotForm.paymentExtrasOnTheFly([null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{\"name\":\"name15\",\"qid\":\"15\",\"text\":\"Name\",\"type\":\"control_fullname\"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,{\"name\":\"email30\",\"qid\":\"30\",\"text\":\"E-mail\",\"type\":\"control_email\"},null,{\"name\":\"personalDetails\",\"qid\":\"32\",\"text\":\"Personal Details\",\"type\":\"control_head\"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{\"name\":\"submit\",\"qid\":\"61\",\"text\":\"Submit\",\"type\":\"control_button\"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{\"description\":\"\",\"name\":\"phoneNumber\",\"qid\":\"124\",\"text\":\"Phone Number\",\"type\":\"control_phone\"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{\"description\":\"\",\"name\":\"irdNumber\",\"qid\":\"155\",\"subLabel\":\"\",\"text\":\"IRD Number\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"dateOf156\",\"qid\":\"156\",\"text\":\"Date of birth\",\"type\":\"control_datetime\"},{\"description\":\"\",\"name\":\"contributionAmount\",\"qid\":\"157\",\"subLabel\":\"\",\"text\":\"Contribution Amount\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"haveYou\",\"qid\":\"158\",\"text\":\"Have you pre-arranged your funeral?\",\"type\":\"control_radio\"},null,null,{\"description\":\"\",\"name\":\"iAcknowledge161\",\"qid\":\"161\",\"text\":\"I acknowledge and confirm that...(select all)\",\"type\":\"control_checkbox\"},{\"description\":\"\",\"name\":\"signature\",\"qid\":\"162\",\"text\":\"Signature\",\"type\":\"control_checkbox\"},{\"description\":\"\",\"name\":\"address163\",\"qid\":\"163\",\"text\":\"Address\",\"type\":\"control_address\"},{\"name\":\"typeA\",\"qid\":\"164\",\"text\":\"\",\"type\":\"control_widget\"}]);}, 20); \n<\/script>\n<\/head>\n<body>\n<form class=\"jotform-form\" action=\"https:\/\/submit.jotform.co\/submit\/92197128021857\/\" method=\"post\" name=\"form_92197128021857\" id=\"92197128021857\" accept-charset=\"utf-8\">\n  <input type=\"hidden\" name=\"formID\" value=\"92197128021857\" \/>\n  <input type=\"hidden\" id=\"JWTContainer\" value=\"\" \/>\n  <input type=\"hidden\" id=\"cardinalOrderNumber\" value=\"\" \/>\n  <div role=\"main\" class=\"form-all\">\n    <ul class=\"form-section page-section\">\n      <li id=\"cid_32\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h3 id=\"header_32\" class=\"form-header\" data-component=\"header\">\n              Personal Details\n            <\/h3>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_fullname\" id=\"id_15\">\n        <label class=\"form-label form-label-top\" id=\"label_15\" for=\"first_15\">\n          Name\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=\"text\" id=\"first_15\" name=\"q15_name15[first]\" class=\"form-textbox validate[required]\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_15 sublabel_15_first\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"first_15\" id=\"sublabel_15_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_15\" name=\"q15_name15[last]\" class=\"form-textbox validate[required]\" size=\"15\" value=\"\" data-component=\"last\" aria-labelledby=\"label_15 sublabel_15_last\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"last_15\" id=\"sublabel_15_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_email\" id=\"id_30\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_30\" for=\"input_30\">\n          E-mail\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_30\" class=\"form-input-wide jf-required\">\n          <input type=\"email\" id=\"input_30\" name=\"q30_email30\" class=\"form-textbox validate[required, Email]\" size=\"32\" value=\"\" placeholder=\"ex: myname@example.com\" data-component=\"email\" aria-labelledby=\"label_30\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_address\" id=\"id_163\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_163\" for=\"input_163_addr_line1\">\n          Address\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_163\" class=\"form-input-wide jf-required\">\n          <table summary=\"\" class=\"form-address-table\">\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_163_addr_line1\" name=\"q163_address163[addr_line1]\" class=\"form-textbox validate[required] form-address-line\" autoComplete=\"address-line1\" value=\"\" data-component=\"address_line_1\" aria-labelledby=\"label_163 sublabel_163_addr_line1\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_163_addr_line1\" id=\"sublabel_163_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_163_addr_line2\" name=\"q163_address163[addr_line2]\" class=\"form-textbox form-address-line\" autoComplete=\"address-line2\" size=\"46\" value=\"\" data-component=\"address_line_2\" aria-labelledby=\"label_163 sublabel_163_addr_line2\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_163_addr_line2\" id=\"sublabel_163_addr_line2\" style=\"min-height:13px\"> Street Address Line 2 <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td>\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_163_city\" name=\"q163_address163[city]\" class=\"form-textbox validate[required] form-address-city\" autoComplete=\"address-level2\" size=\"21\" value=\"\" data-component=\"city\" aria-labelledby=\"label_163 sublabel_163_city\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_163_city\" id=\"sublabel_163_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_163_state\" name=\"q163_address163[state]\" class=\"form-textbox validate[required] form-address-state\" autoComplete=\"address-level1\" size=\"22\" value=\"\" data-component=\"state\" aria-labelledby=\"label_163 sublabel_163_state\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_163_state\" id=\"sublabel_163_state\" style=\"min-height:13px\"> State \/ Province <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td>\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_163_postal\" name=\"q163_address163[postal]\" class=\"form-textbox form-address-postal\" autoComplete=\"postal-code\" size=\"10\" value=\"\" data-component=\"zip\" aria-labelledby=\"label_163 sublabel_163_postal\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_163_postal\" id=\"sublabel_163_postal\" style=\"min-height:13px\"> Postal \/ Zip Code <\/label>\n                  <\/span>\n                <\/td>\n                <td style=\"display:none\">\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <select class=\"form-dropdown validate[required] form-address-country noTranslate\" name=\"q163_address163[country]\" id=\"input_163_country\" data-component=\"country\" required=\"\" aria-labelledby=\"label_163 sublabel_163_country\" autoComplete=\"new-password\">\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=\"eSwatini\"> eSwatini <\/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_163_country\" id=\"sublabel_163_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_phone\" id=\"id_124\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_124\" for=\"input_124_area\">\n          Phone Number\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_124\" 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_124_area\" name=\"q124_phoneNumber[area]\" class=\"form-textbox validate[required]\" size=\"6\" value=\"\" data-component=\"areaCode\" aria-labelledby=\"label_124 sublabel_124_area\" required=\"\" \/>\n              <span class=\"phone-separate\" aria-hidden=\"true\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"input_124_area\" id=\"sublabel_124_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_124_phone\" name=\"q124_phoneNumber[phone]\" class=\"form-textbox validate[required]\" size=\"12\" value=\"\" data-component=\"phone\" aria-labelledby=\"label_124 sublabel_124_phone\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"input_124_phone\" id=\"sublabel_124_phone\" style=\"min-height:13px\"> Phone Number <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_datetime\" id=\"id_156\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_156\" for=\"lite_mode_156\">\n          Date of birth\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_156\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <div style=\"display:none\">\n              <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                <input type=\"tel\" class=\"form-textbox validate[required, limitDate]\" id=\"month_156\" name=\"q156_dateOf156[month]\" size=\"2\" data-maxlength=\"2\" value=\"\" required=\"\" aria-labelledby=\"label_156 sublabel_156_month\" \/>\n                <span class=\"date-separate\" aria-hidden=\"true\">\n                  \u00a0-\n                <\/span>\n                <label class=\"form-sub-label\" for=\"month_156\" id=\"sublabel_156_month\" style=\"min-height:13px\"> Month <\/label>\n              <\/span>\n              <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                <input type=\"tel\" class=\"form-textbox validate[required, limitDate]\" id=\"day_156\" name=\"q156_dateOf156[day]\" size=\"2\" data-maxlength=\"2\" value=\"\" required=\"\" aria-labelledby=\"label_156 sublabel_156_day\" \/>\n                <span class=\"date-separate\" aria-hidden=\"true\">\n                  \u00a0-\n                <\/span>\n                <label class=\"form-sub-label\" for=\"day_156\" id=\"sublabel_156_day\" style=\"min-height:13px\"> Day <\/label>\n              <\/span>\n              <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                <input type=\"tel\" class=\"form-textbox validate[required, limitDate]\" id=\"year_156\" name=\"q156_dateOf156[year]\" size=\"4\" data-maxlength=\"4\" value=\"\" required=\"\" aria-labelledby=\"label_156 sublabel_156_year\" \/>\n                <label class=\"form-sub-label\" for=\"year_156\" id=\"sublabel_156_year\" style=\"min-height:13px\"> Year <\/label>\n              <\/span>\n            <\/div>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" class=\"form-textbox validate[required, limitDate, validateLiteDate]\" id=\"lite_mode_156\" size=\"12\" data-maxlength=\"12\" data-age=\"\" value=\"\" required=\"\" data-format=\"mmddyyyy\" data-seperator=\"-\" placeholder=\"mm-dd-yyyy\" aria-labelledby=\"label_156 sublabel_156_litemode\" \/>\n              <img alt=\"Pick a Date\" id=\"input_156_pick\" src=\"https:\/\/cdn.jotfor.ms\/images\/calendar.png\" style=\"vertical-align:middle;margin-left:5px\" data-component=\"datetime\" aria-hidden=\"true\" \/>\n              <label class=\"form-sub-label\" for=\"lite_mode_156\" id=\"sublabel_156_litemode\" style=\"min-height:13px\"> Date <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <label class=\"form-sub-label\" for=\"input_156_pick\" style=\"border:0;clip:rect(0 0 0 0);height:1px;margin:-1px;overflow:hidden;padding:0;position:absolute;width:1px;white-space:nowrap\"> Date Picker Icon <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_155\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_155\" for=\"input_155\">\n          IRD Number\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_155\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_155\" name=\"q155_irdNumber\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_155\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_157\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_157\" for=\"input_157\">\n          Contribution Amount\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_157\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_157\" name=\"q157_contributionAmount\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_157\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_158\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_158\" for=\"input_158\">\n          Have you pre-arranged your funeral?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_158\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_158\" 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_158_0\" name=\"q158_haveYou\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_158_0\" for=\"input_158_0\"> Yes <\/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_158_1\" name=\"q158_haveYou\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_158_1\" for=\"input_158_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_checkbox\" id=\"id_161\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_161\" for=\"input_161\">\n          I acknowledge and confirm that...(select all)\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_161\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_161\" 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_161_0\" name=\"q161_iAcknowledge161[]\" value=\"Hereby apply to settle on Legacy Prepaid Funerals Limited as Trustee and establish with effect from the date of acceptance by the Trustee (the \u201cCommencement Date\u201d) a Client Funeral Trust for the purpose of contributing toward the payment of my funeral expenses in the event of my death (\u201cmy Fund\u201d).\" required=\"\" \/>\n              <label id=\"label_input_161_0\" for=\"input_161_0\"> Hereby apply to settle on Legacy Prepaid Funerals Limited as Trustee and establish with effect from the date of acceptance by the Trustee (the \u201cCommencement Date\u201d) a Client Funeral Trust for the purpose of contributing toward the payment of my funeral expenses in the event of my death (\u201cmy Fund\u201d). <\/label>\n            <\/span>\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_161_1\" name=\"q161_iAcknowledge161[]\" value=\"I have read the said terms and conditions of my Fund as set out in the Trust Deed establishing the Legacy Prepaid Funeral Trust (and any amendments thereto) (\u201cDeed\u201d) and this Application Form\" required=\"\" \/>\n              <label id=\"label_input_161_1\" for=\"input_161_1\"> I have read the said terms and conditions of my Fund as set out in the Trust Deed establishing the Legacy Prepaid Funeral Trust (and any amendments thereto) (\u201cDeed\u201d) and this Application Form <\/label>\n            <\/span>\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_161_2\" name=\"q161_iAcknowledge161[]\" value=\"My Contributions shall be held in a sub-trust account in the name of the Trustee and specifically identified as my Fund\" required=\"\" \/>\n              <label id=\"label_input_161_2\" for=\"input_161_2\"> My Contributions shall be held in a sub-trust account in the name of the Trustee and specifically identified as my Fund <\/label>\n            <\/span>\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_161_3\" name=\"q161_iAcknowledge161[]\" value=\"My Fund shall not be settled and established unless and until the Trustee accepts this Application Form together with my payment of the amount stipulated above\" required=\"\" \/>\n              <label id=\"label_input_161_3\" for=\"input_161_3\"> My Fund shall not be settled and established unless and until the Trustee accepts this Application Form together with my payment of the amount stipulated above <\/label>\n            <\/span>\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_161_4\" name=\"q161_iAcknowledge161[]\" value=\"I specifically acknowledge that all interest earned on money held in my Fund shall be paid to Legacy Trust after administration costs\" required=\"\" \/>\n              <label id=\"label_input_161_4\" for=\"input_161_4\"> I specifically acknowledge that all interest earned on money held in my Fund shall be paid to Legacy Trust after administration costs <\/label>\n            <\/span>\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_161_5\" name=\"q161_iAcknowledge161[]\" value=\"I specifically acknowledge that it has been explained to me that I will not be entitled to receive any income or any gains on my Fund, and the real purchasing power of my contribution(s) may be eroded over time due to inflation. I am satisfied with this arrangement in the knowledge that the surplus income earned on my Fund will be benefitting charitable purposes within the community through distribution to Legacy Trust\" required=\"\" \/>\n              <label id=\"label_input_161_5\" for=\"input_161_5\"> I specifically acknowledge that it has been explained to me that I will not be entitled to receive any income or any gains on my Fund, and the real purchasing power of my contribution(s) may be eroded over time due to inflation. I am satisfied with this arrangement in the knowledge that the surplus income earned on my Fund will be benefitting charitable purposes within the community through distribution to Legacy Trust <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_checkbox\" id=\"id_162\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_162\" for=\"input_162\">\n          Signature\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_162\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_162\" 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_162_0\" name=\"q162_signature[]\" value=\"In place of a signature, please select the checkbox. By doing so you acknowledge that all information submitted is true and correct to the best of your knowledge.\" required=\"\" \/>\n              <label id=\"label_input_162_0\" for=\"input_162_0\"> In place of a signature, please select the checkbox. By doing so you acknowledge that all information submitted is true and correct to the best of your knowledge. <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_widget\" id=\"id_164\">\n        <div id=\"cid_164\" class=\"\">\n          <div style=\"width:100%;text-align:Left\" data-component=\"widget-directEmbed\">\n            <div class=\"direct-embed-widgets google-analytics-widget \" data-type=\"direct-embed\" style=\"width:50px;min-height:50px\">\n              <div class=\"google_analytics_widget\">\n                <script>\n                var analyticsFormId = '{analyticsFormId}';\nvar analyticsAutoLink = '';\n(function(i, s, o, g, r, a, m)\n{\n  i['GoogleAnalyticsObject'] = r;\n  i[r] = i[r] ||\n  function()\n  {\n    (i[r].q = i[r].q || []).push(arguments)\n  }, i[r].l = 1 * new Date();\n  a = s.createElement(o), m = s.getElementsByTagName(o)[0];\n  a.async = 1;\n  a.src = g;\n  m.parentNode.insertBefore(a, m)\n})(window, document, 'script', '\/\/www.google-analytics.com\/analytics.js', 'ga');\n\nga('create', 'UA-84927146-1', 'auto', {\n  'allowLinker': true\n});\nga('send', 'pageview');\nif (window.analyticsAutoLink && analyticsAutoLink != '<empty>')\n{\n  analyticsAutoLink = analyticsAutoLink.replace(\/ \/g, '').split(\/[,\\n]\/g);\n  ga('require', 'linker');\n  ga('linker:autoLink', analyticsAutoLink);\n}\n                <\/script>\n                <script src=\"\/\/widgets.jotform.io\/googleanalytics\/scripts.js\" type=\"text\/javascript\"><\/script>\n              <\/div>\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_button\" id=\"id_61\">\n        <div id=\"cid_61\" class=\"form-input-wide\">\n          <div style=\"margin-left:156px\" class=\"form-buttons-wrapper \">\n            <button id=\"input_61\" type=\"submit\" class=\"form-submit-button\" data-component=\"button\">\n              Submit\n            <\/button>\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 = \"old_footer\";\n  <\/script>\n  <input type=\"hidden\" id=\"simple_spc\" name=\"simple_spc\" value=\"92197128021857\" \/>\n  <script type=\"text\/javascript\">\n  document.getElementById(\"si\" + \"mple\" + \"_spc\").value = \"92197128021857-92197128021857\";\n  <\/script>\n  <script src=\"https:\/\/cdn.jotfor.ms\/js\/widgetResizer.js?REV=3.3.13909\" type=\"text\/javascript\"><\/script>\n<\/form><\/body>\n<\/html>\n","TGFS Pre-Payment form",Array);(function(){window.handleIFrameMessage=function(e){if(!e.data||!e.data.split)return;var args=e.data.split(":");if(args[2]!="92197128021857"){return;}
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