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0 2px #252d5b0a,0 4px 8px 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[class].sm\:rtl\:ml-0{margin-left:0}[class].sm\:mt-0{margin-top:0}[class].sm\:mb-0{margin-bottom:0}[class].sm\:ml-2{margin-left:.5rem}[class].sm\:mr-2{margin-right:.5rem}[class].sm\:mb-2{margin-bottom:.5rem}[class].sm\:mt-3{margin-top:.75rem}[class].sm\:my-4{margin-top:1rem;margin-bottom:1rem}[class].sm\:ml-4{margin-left:1rem}[class].sm\:mr-4,[dir=rtl] [class].sm\:rtl\:mr-4{margin-right:1rem}[class].sm\:-mx-7{margin-left:-1.75rem;margin-right:-1.75rem}[class].sm\:mt-20{margin-top:5rem}[class].sm\:mb-20{margin-bottom:5rem}[class].sm\:ml-2\.5{margin-left:.625rem}[class].sm\:m-auto{margin:auto}[class].sm\:mx-auto{margin-left:auto;margin-right:auto}[class].sm\:ml-auto{margin-left:auto}[dir=rtl] [class].sm\:rtl\:mr-auto{margin-right:auto}}@media only screen and (min-width:48rem){[dir=rtl] [class].md\:rtl\:border-l-0{border-left-width:0}[class].md\:border-l{border-left-width:1px}[dir=rtl] [class].md\:rtl\:border-r{border-right-width:1px}[class].md\:border-b{border-bottom-width:1px}[class].md\:relative{position:relative}[class].md\:px-0{padding-left:0;padding-right:0}[class].md\:pl-0{padding-left:0}[class].md\:pr-0,[dir=rtl] [class].md\:rtl\:pr-0{padding-right:0}[class].md\:p-3{padding:.75rem}[class].md\:px-3{padding-left:.75rem;padding-right:.75rem}[class].md\:py-3{padding-top:.75rem;padding-bottom:.75rem}[class].md\:pl-3{padding-left:.75rem}[class].md\:pr-3{padding-right:.75rem}[class].md\:px-4{padding-left:1rem;padding-right:1rem}[class].md\:pt-4{padding-top:1rem}[class].md\:pb-4{padding-bottom:1rem}[class].md\:pl-4{padding-left:1rem}[class].md\:pr-4{padding-right:1rem}[class].md\:px-5{padding-left:1.25rem;padding-right:1.25rem}[class].md\:p-6{padding:1.5rem}[class].md\:py-6{padding-top:1.5rem;padding-bottom:1.5rem}[class].md\:pb-6{padding-bottom:1.5rem}[class].md\:px-8{padding-left:2rem;padding-right:2rem}[class].md\:py-8{padding-top:2rem;padding-bottom:2rem}[class].md\:pr-8{padding-right:2rem}[class].md\:px-10{padding-left:2.5rem;padding-right:2.5rem}[class].md\:pb-10{padding-bottom:2.5rem}[class].md\:pt-12{padding-top:3rem}[class].md\:pt-16{padding-top:4rem}[class].md\:pr-20{padding-right:5rem}[class].md\:pb-24{padding-bottom:6rem}[class].md\:px-32{padding-left:8rem;padding-right:8rem}[class].md\:pb-32{padding-bottom:8rem}[class].md\:pb-40{padding-bottom:10rem}[dir=rtl] [class].md\:rtl\:pl-60{padding-left:15rem}[class].md\:pr-60{padding-right:15rem}[class].md\:text-sm{font-size:.875rem;line-height:1.125rem}[class].md\:text-md{font-size:1rem;line-height:1.25rem}[class].md\:text-lg{font-size:1.125rem;line-height:1.375rem}[class].md\:text-xl{font-size:1.25rem;line-height:1.5rem}[class].md\:text-2xl{font-size:1.5rem;line-height:1.75rem}[class].md\:text-3xl{font-size:1.75rem;line-height:2rem}[class].md\:text-4xl{font-size:2rem;line-height:2.5rem}[class].md\:line-height-xl{line-height:1.5rem}[class].md\:line-height-3xl{line-height:2rem}[class].md\:line-height-4xl{line-height:2.5rem}[class].md\:justify-center{justify-content:center}[class].md\:justify-start{justify-content:flex-start}[class].md\:justify-end{justify-content:flex-end}[class].md\:justify-between{justify-content:space-between}[class].md\:justify-around{justify-content:space-around}[class].md\:justify-evenly{justify-content:space-evenly}[class].md\:justify-self-auto{justify-self:auto}[class].md\:justify-self-start{justify-self:start}[class].md\:justify-self-end{justify-self:end}[class].md\:justify-self-center{justify-self:center}[class].md\:justify-self-stretch{justify-self:stretch}[class].md\:self-auto{align-self:auto}[class].md\:self-center{align-self:center}[class].md\:self-start{align-self:flex-start}[class].md\:self-end{align-self:flex-end}[class].md\:self-stretch{align-self:stretch}[class].md\:self-baseline{align-self:baseline}[class].md\:items-center{align-items:center}[class].md\:items-start{align-items:flex-start}[class].md\:items-end{align-items:flex-end}[class].md\:items-stretch{align-items:stretch}[class].md\:items-baseline{align-items:baseline}[class].md\:min-h-10{min-height:2.5rem}[class].md\:min-h-12{min-height:3rem}[class].md\:min-h-16{min-height:4rem}[class].md\:min-h-24{min-height:6rem}[class].md\:min-h-36{min-height:9rem}[class].md\:min-w-40{min-width:10rem}[class].md\:min-w-68{min-width:17rem}[class].md\:min-w-76{min-width:19rem}[class].md\:min-h-120{min-height:30rem}[class].md\:min-h-sm{min-height:40rem}[class].md\:min-w-md{min-width:48rem}[class].md\:max-w-20{max-width:5rem}[class].md\:max-w-56{max-width:14rem}[class].md\:max-w-92{max-width:23rem}[class].md\:max-h-sm{max-height:40rem}[class].md\:max-w-md{max-width:48rem}[class].md\:max-w-xl{max-width:80rem}[class].md\:max-w-3\/5{max-width:60%}[class].md\:cols-none{grid-template-columns:repeat(none,minmax(0,1fr))}[class].md\:cols-1{grid-template-columns:repeat(1,minmax(0,1fr))}[class].md\:cols-2{grid-template-columns:repeat(2,minmax(0,1fr))}[class].md\:cols-3{grid-template-columns:repeat(3,minmax(0,1fr))}[class].md\:cols-4{grid-template-columns:repeat(4,minmax(0,1fr))}[class].md\:cols-5{grid-template-columns:repeat(5,minmax(0,1fr))}[class].md\:cols-6{grid-template-columns:repeat(6,minmax(0,1fr))}[class].md\:cols-7{grid-template-columns:repeat(7,minmax(0,1fr))}[class].md\:cols-8{grid-template-columns:repeat(8,minmax(0,1fr))}[class].md\:cols-9{grid-template-columns:repeat(9,minmax(0,1fr))}[class].md\:cols-10{grid-template-columns:repeat(10,minmax(0,1fr))}[class].md\:cols-11{grid-template-columns:repeat(11,minmax(0,1fr))}[class].md\:cols-12{grid-template-columns:repeat(12,minmax(0,1fr))}[class].md\:col-start-auto{grid-column-start:auto}[class].md\:col-end-auto{grid-column-end:auto}[class].md\:col-start-1{grid-column-start:1}[class].md\:col-end-1{grid-column-end:1}[class].md\:col-start-2{grid-column-start:2}[class].md\:col-end-2{grid-column-end:2}[class].md\:col-start-3{grid-column-start:3}[class].md\:col-end-3{grid-column-end:3}[class].md\:col-start-4{grid-column-start:4}[class].md\:col-end-4{grid-column-end:4}[class].md\:col-start-5{grid-column-start:5}[class].md\:col-end-5{grid-column-end:5}[class].md\:col-start-6{grid-column-start:6}[class].md\:col-end-6{grid-column-end:6}[class].md\:col-start-7{grid-column-start:7}[class].md\:col-end-7{grid-column-end:7}[class].md\:col-start-8{grid-column-start:8}[class].md\:col-end-8{grid-column-end:8}[class].md\:col-start-9{grid-column-start:9}[class].md\:col-end-9{grid-column-end:9}[class].md\:col-start-10{grid-column-start:10}[class].md\:col-end-10{grid-column-end:10}[class].md\:col-start-11{grid-column-start:11}[class].md\:col-end-11{grid-column-end:11}[class].md\:col-start-12{grid-column-start:12}[class].md\:col-end-12{grid-column-end:12}[class].md\:row-start-auto{grid-row-start:auto}[class].md\:row-end-auto{grid-row-end:auto}[class].md\:row-start-1{grid-row-start:1}[class].md\:row-end-1{grid-row-end:1}[class].md\:row-start-2{grid-row-start:2}[class].md\:row-end-2{grid-row-end:2}[class].md\:row-start-3{grid-row-start:3}[class].md\:row-end-3{grid-row-end:3}[class].md\:row-start-4{grid-row-start:4}[class].md\:row-end-4{grid-row-end:4}[class].md\:row-start-5{grid-row-start:5}[class].md\:row-end-5{grid-row-end:5}[class].md\:row-start-6{grid-row-start:6}[class].md\:row-end-6{grid-row-end:6}[class].md\:row-start-7{grid-row-start:7}[class].md\:row-end-7{grid-row-end:7}[class].md\:row-start-8{grid-row-start:8}[class].md\:row-end-8{grid-row-end:8}[class].md\:row-start-9{grid-row-start:9}[class].md\:row-end-9{grid-row-end:9}[class].md\:row-start-10{grid-row-start:10}[class].md\:row-end-10{grid-row-end:10}[class].md\:row-start-11{grid-row-start:11}[class].md\:row-end-11{grid-row-end:11}[class].md\:row-start-12{grid-row-start:12}[class].md\:row-end-12{grid-row-end:12}[class].md\:gap-0{gap:0}[class].md\:gap-2{gap:.5rem}[class].md\:gap-4{gap:1rem}[class].md\:gap-5{gap:1.25rem}[class].md\:gap-16{gap:4rem}[class].md\:gap-20{gap:5rem}[class].md\:flex-row{flex-direction:row}[class].md\:flex-col{flex-direction:column}[class].md\:flex-row-reverse{flex-direction:row-reverse}[class].md\:flex-col-reverse{flex-direction:column-reverse}[class].md\:shrink-0{flex-shrink:0}[class].md\:shrink-1{flex-shrink:1}[class].md\:grow-0{flex-grow:0}[class].md\:grow-1{flex-grow:1}[class].md\:flex-wrap{flex-wrap:wrap}[class].md\:flex-nowrap{flex-wrap:nowrap}[class].md\:order-first{order:-9999}[class].md\:order-last{order:9999}[class].md\:order-none{order:0}[class].md\:inline-flex{display:inline-flex}[class].md\:block{display:block}[class].md\:flex{display:flex}[class].md\:hidden{display:none}[class].md\:inline{display:inline}[class].md\:hiddenjf{display:none}[class].md\:font-bold{font-weight:700}[class].md\:h-8{height:2rem}[class].md\:h-12{height:3rem}[class].md\:w-12{width:3rem}[class].md\:h-14{height:3.5rem}[class].md\:w-14{width:3.5rem}[class].md\:h-16{height:4rem}[class].md\:w-24{width:6rem}[class].md\:w-52{width:13rem}[class].md\:h-64{height:16rem}[class].md\:h-68{height:17rem}[class].md\:w-68{width:17rem}[class].md\:h-120{height:30rem}[class].md\:w-120{width:30rem}[class].md\:h-auto{height:auto}[class].md\:w-auto{width:auto}[class].md\:w-2\/6{width:33.333333%}[class].md\:h-full{height:100%}[class].md\:w-full{width:100%}[class].md\:h-70vh{height:70vh}[class].md\:basis-80{flex-basis:20rem}[class].md\:basis-92{flex-basis:23rem}[class].md\:top-0{top:0}[class].md\:right-0{right:0}[class].md\:right-3{right:.75rem}[class].md\:right-6{right:1.5rem}[class].md\:bottom-9{bottom:2.25rem}[class].md\:top-18{top:4.5rem}[class].md\:top-1\/2{top:50%}[class].md\:left-auto{left:auto}[class].md\:bottom-auto{bottom:auto}[class].md\:radius-none{border-radius:0}[class].md\:radius-tr-none{border-top-right-radius:0}[class].md\:radius-bl-none{border-bottom-left-radius:0}[class].md\:radius-r-md,[class].md\:radius-tr-md{border-top-right-radius:.375rem}[class].md\:radius-r-md{border-bottom-right-radius:.375rem}[class].md\:radius-bl-md{border-bottom-left-radius:.375rem}[class].md\:radius-tl-lg{border-top-left-radius:.5rem}[class].md\:radius-tr-lg{border-top-right-radius:.5rem}[class].md\:radius-bl-lg{border-bottom-left-radius:.5rem}[dir=rtl] [class].md\:rtl\:left-0{left:0}[dir=rtl] [class].md\:rtl\:right-auto{right:auto}[class].md\:-translate-y-1\/2{--translate-y:-50%}[class].md\:ml-0{margin-left:0}[class].md\:mr-0{margin-right:0}[class].md\:mt-0{margin-top:0}[class].md\:mb-0{margin-bottom:0}[class].md\:mb-1{margin-bottom:.25rem}[class].md\:mb-2{margin-bottom:.5rem}[class].md\:ml-3{margin-left:.75rem}[class].md\:mt-4{margin-top:1rem}[class].md\:mb-4{margin-bottom:1rem}[class].md\:mb-5{margin-bottom:1.25rem}[class].md\:-mb-5{margin-bottom:-1.25rem}[class].md\:mt-6{margin-top:1.5rem}[class].md\:mb-6{margin-bottom:1.5rem}[class].md\:mb-7{margin-bottom:1.75rem}[class].md\:my-8{margin-top:2rem;margin-bottom:2rem}[class].md\:mb-8{margin-bottom:2rem}[class].md\:-mt-8{margin-top:-2rem}[class].md\:mx-10{margin-left:2.5rem;margin-right:2.5rem}[class].md\:ml-10{margin-left:2.5rem}[class].md\:mr-10{margin-right:2.5rem}[class].md\:mb-12{margin-bottom:3rem}[class].md\:mt-18{margin-top:4.5rem}[class].md\:-mt-24{margin-top:-6rem}}@media only screen and (min-width:64rem){[class].lg\:border-t-0{border-top-width:0}[class].lg\:border{border-width:1px}[class].lg\:absolute{position:absolute}[class].lg\:relative{position:relative}[class].lg\:fixed{position:fixed}[class].lg\:static{position:static}[class].lg\:py-0{padding-top:0;padding-bottom:0}[class].lg\:p-2{padding:.5rem}[class].lg\:px-2{padding-left:.5rem;padding-right:.5rem}[class].lg\:px-3{padding-left:.75rem;padding-right:.75rem}[class].lg\:py-3{padding-top:.75rem;padding-bottom:.75rem}[class].lg\:px-4{padding-left:1rem;padding-right:1rem}[class].lg\:px-5{padding-left:1.25rem;padding-right:1.25rem}[class].lg\:pb-6{padding-bottom:1.5rem}[class].lg\:p-8{padding:2rem}[class].lg\:px-8{padding-left:2rem;padding-right:2rem}[class].lg\:py-8{padding-top:2rem;padding-bottom:2rem}[class].lg\:px-12{padding-left:3rem;padding-right:3rem}[class].lg\:pt-12{padding-top:3rem}[class].lg\:px-16{padding-left:4rem;padding-right:4rem}[class].lg\:pb-16{padding-bottom:4rem}[class].lg\:pr-16{padding-right:4rem}[class].lg\:text-xs{font-size:.75rem;line-height:1rem}[class].lg\:text-sm{font-size:.875rem;line-height:1.125rem}[class].lg\:text-md{font-size:1rem;line-height:1.25rem}[class].lg\:text-3xl{font-size:1.75rem;line-height:2rem}[class].lg\:text-4xl{font-size:2rem;line-height:2.5rem}[class].lg\:text-6xl{font-size:2.5rem;line-height:2.875rem}[class].lg\:text-7xl{font-size:3rem;line-height:3.25rem}[class].lg\:line-height-xl{line-height:1.5rem}[class].lg\:line-height-4xl{line-height:2.5rem}[class].lg\:justify-center{justify-content:center}[class].lg\:justify-start{justify-content:flex-start}[class].lg\:justify-end{justify-content:flex-end}[class].lg\:justify-between{justify-content:space-between}[class].lg\:justify-around{justify-content:space-around}[class].lg\:justify-evenly{justify-content:space-evenly}[class].lg\:justify-self-auto{justify-self:auto}[class].lg\:justify-self-start{justify-self:start}[class].lg\:justify-self-end{justify-self:end}[class].lg\:justify-self-center{justify-self:center}[class].lg\:justify-self-stretch{justify-self:stretch}[class].lg\:self-auto{align-self:auto}[class].lg\:self-center{align-self:center}[class].lg\:self-start{align-self:flex-start}[class].lg\:self-end{align-self:flex-end}[class].lg\:self-stretch{align-self:stretch}[class].lg\:self-baseline{align-self:baseline}[class].lg\:items-center{align-items:center}[class].lg\:items-start{align-items:flex-start}[class].lg\:items-end{align-items:flex-end}[class].lg\:items-stretch{align-items:stretch}[class].lg\:items-baseline{align-items:baseline}[class].lg\:min-h-56{min-height:14rem}[class].lg\:min-w-92{min-width:23rem}[class].lg\:min-w-120{min-width:30rem}[class].lg\:min-h-sm{min-height:40rem}[class].lg\:min-h-md{min-height:48rem}[class].lg\:min-w-1\/3{min-width:33.333333%}[class].lg\:max-w-72{max-width:18rem}[class].lg\:max-h-80{max-height:20rem}[class].lg\:max-w-88{max-width:22rem}[class].lg\:max-w-sm{max-width:40rem}[class].lg\:max-w-1\/2{max-width:50%}[class].lg\:max-w-1\/3{max-width:33.333333%}[class].lg\:cols-none{grid-template-columns:repeat(none,minmax(0,1fr))}[class].lg\:cols-1{grid-template-columns:repeat(1,minmax(0,1fr))}[class].lg\:cols-2{grid-template-columns:repeat(2,minmax(0,1fr))}[class].lg\:cols-3{grid-template-columns:repeat(3,minmax(0,1fr))}[class].lg\:cols-4{grid-template-columns:repeat(4,minmax(0,1fr))}[class].lg\:cols-5{grid-template-columns:repeat(5,minmax(0,1fr))}[class].lg\:cols-6{grid-template-columns:repeat(6,minmax(0,1fr))}[class].lg\:cols-7{grid-template-columns:repeat(7,minmax(0,1fr))}[class].lg\:cols-8{grid-template-columns:repeat(8,minmax(0,1fr))}[class].lg\:cols-9{grid-template-columns:repeat(9,minmax(0,1fr))}[class].lg\:cols-10{grid-template-columns:repeat(10,minmax(0,1fr))}[class].lg\:cols-11{grid-template-columns:repeat(11,minmax(0,1fr))}[class].lg\:cols-12{grid-template-columns:repeat(12,minmax(0,1fr))}[class].lg\:col-start-auto{grid-column-start:auto}[class].lg\:col-end-auto{grid-column-end:auto}[class].lg\:col-start-1{grid-column-start:1}[class].lg\:col-end-1{grid-column-end:1}[class].lg\:col-start-2{grid-column-start:2}[class].lg\:col-end-2{grid-column-end:2}[class].lg\:col-start-3{grid-column-start:3}[class].lg\:col-end-3{grid-column-end:3}[class].lg\:col-start-4{grid-column-start:4}[class].lg\:col-end-4{grid-column-end:4}[class].lg\:col-start-5{grid-column-start:5}[class].lg\:col-end-5{grid-column-end:5}[class].lg\:col-start-6{grid-column-start:6}[class].lg\:col-end-6{grid-column-end:6}[class].lg\:col-start-7{grid-column-start:7}[class].lg\:col-end-7{grid-column-end:7}[class].lg\:col-start-8{grid-column-start:8}[class].lg\:col-end-8{grid-column-end:8}[class].lg\:col-start-9{grid-column-start:9}[class].lg\:col-end-9{grid-column-end:9}[class].lg\:col-start-10{grid-column-start:10}[class].lg\:col-end-10{grid-column-end:10}[class].lg\:col-start-11{grid-column-start:11}[class].lg\:col-end-11{grid-column-end:11}[class].lg\:col-start-12{grid-column-start:12}[class].lg\:col-end-12{grid-column-end:12}[class].lg\:row-sta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32px 64px -12px 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<body>
<form class="jotform-form" onsubmit="return typeof testSubmitFunction !== 'undefined' && testSubmitFunction();" action="https://submit.jotform.com/submit/243335566634562" method="post" name="form_243335566634562" id="243335566634562" accept-charset="utf-8" autocomplete="on" novalidate="true"><input type="hidden" name="formID" value="243335566634562"><input type="hidden" id="JWTContainer" value=""><input type="hidden" id="cardinalOrderNumber" value=""><input type="hidden" id="jsExecutionTracker" name="jsExecutionTracker" value="build-date-1732909540974=>init-started:1733270576991=>validator-called:1733270577087=>validator-mounted-false:1733270577088=>init-complete:1733270577092"><input type="hidden" id="submitSource" name="submitSource" value="mounted"><input type="hidden" id="buildDate" name="buildDate" value="1732909540974"><input type="hidden" name="uploadServerUrl" value="https://upload.jotform.com/upload"><input type="hidden" name="eventObserver" value="1">
<div id="formCoverLogo" style="margin-bottom:32px" class="form-cover-wrapper form-has-cover form-page-cover-image-align-center">
<div class="form-page-cover-image-wrapper" style="max-width:752px"><img src="https://www.jotform.com/uploads/victoriahamberg221/form_files/IMG_7561.674a199fdaf9a5.41369763.jpeg" class="form-page-cover-image" width="700" height="140" aria-label="Form Logo" style="aspect-ratio:700/140"></div>
</div>
<div role="main" class="form-all">
<ul class="form-section page-section" role="presentation">
<li id="cid_1" class="form-input-wide" data-type="control_head" data-css-selector="id_1">
<div class="form-header-group header-large">
<div class="header-text httac htvam">
<h1 id="header_1" class="form-header" data-component="header">ANTHONY V. PLUNKETT SUGARBABY REGISTRATION PAYROLL FORM </h1>
</div>
</div>
</li>
<li class="form-line" data-type="control_fullname" id="id_3" data-css-selector="id_3"><label class="form-label form-label-top form-label-auto" id="label_3" for="first_3" aria-hidden="false"> Name </label>
<div id="cid_3" class="form-input-wide" data-layout="full">
<div data-wrapper-react="true"><span class="form-sub-label-container" style="vertical-align:top" data-input-type="first"><input type="text" id="first_3" name="q3_name[first]" class="form-textbox" data-defaultvalue="" autocomplete="section-input_3 given-name" size="10" data-component="first" aria-labelledby="label_3 sublabel_3_first" value=""><label class="form-sub-label" for="first_3" id="sublabel_3_first" style="min-height:13px">First Name</label></span><span class="form-sub-label-container" style="vertical-align:top" data-input-type="last"><input type="text" id="last_3" name="q3_name[last]" class="form-textbox" data-defaultvalue="" autocomplete="section-input_3 family-name" size="15" data-component="last" aria-labelledby="label_3 sublabel_3_last" value=""><label class="form-sub-label" for="last_3" id="sublabel_3_last" style="min-height:13px">Last Name</label></span></div>
</div>
</li>
<li class="form-line" data-type="control_datetime" id="id_4" data-css-selector="id_4"><label class="form-label form-label-top form-label-auto" id="label_4" for="lite_mode_4" aria-hidden="false"> Date Of Birth </label>
<div id="cid_4" class="form-input-wide" data-layout="half">
<div data-wrapper-react="true">
<div style="display:none"><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[limitDate]" id="month_4" name="q4_dateOf[month]" type="tel" size="2" data-maxlength="2" data-age="" maxlength="2" autocomplete="off" aria-labelledby="label_4 sublabel_4_month" value="" inputmode="numeric"><span class="date-separate" aria-hidden="true"> -</span><label class="form-sub-label" for="month_4" id="sublabel_4_month" style="min-height:13px">Month</label></span><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[limitDate]" id="day_4" name="q4_dateOf[day]" type="tel" size="2" data-maxlength="2" data-age="" maxlength="2" autocomplete="off" aria-labelledby="label_4 sublabel_4_day" value="" inputmode="numeric"><span class="date-separate" aria-hidden="true"> -</span><label class="form-sub-label" for="day_4" id="sublabel_4_day" style="min-height:13px">Day</label></span><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[limitDate]" id="year_4" name="q4_dateOf[year]" type="tel" size="4" data-maxlength="4" data-age="" maxlength="4" autocomplete="off" aria-labelledby="label_4 sublabel_4_year" value=""><label class="form-sub-label" for="year_4" id="sublabel_4_year" style="min-height:13px">Year</label></span></div><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[limitDate, validateLiteDate]" id="lite_mode_4" type="text" size="12" data-maxlength="12" data-age="" data-format="mmddyyyy" data-seperator="-" placeholder="MM-DD-YYYY" data-placeholder="MM-DD-YYYY" autocomplete="off" aria-labelledby="label_4 sublabel_4_litemode" value="" inputmode="numeric"><button type="button" class=" newDefaultTheme-dateIcon focusable icon-liteMode" id="input_4_pick" data-component="datetime" aria-hidden="false" data-allow-time="No" data-version="v2" aria-label="Choose Date" role="button" tabindex="0" aria-haspopup="dialog" aria-expanded="false"></button><label class="form-sub-label" for="lite_mode_4" id="sublabel_4_litemode" style="min-height:13px">Date</label></span>
</div>
</div>
</li>
<li class="form-line" data-type="control_phone" id="id_5" data-css-selector="id_5"><label class="form-label form-label-top form-label-auto" id="label_5" for="input_5_full"> Phone Number </label>
<div id="cid_5" class="form-input-wide" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="tel" id="input_5_full" name="q5_phoneNumber[full]" data-type="mask-number" class="mask-phone-number form-textbox validate[Fill Mask]" data-defaultvalue="" autocomplete="section-input_5 tel-national" style="width:310px" data-masked="true" placeholder="(000) 000-0000" data-component="phone" aria-labelledby="label_5 sublabel_5_masked" value="" inputmode="text" maskvalue="(###) ###-####"><label class="form-sub-label" for="input_5_full" id="sublabel_5_masked" style="min-height:13px">Please enter a valid phone number.</label></span> </div>
</li>
<li class="form-line" data-type="control_email" id="id_6" data-css-selector="id_6"><label class="form-label form-label-top form-label-auto" id="label_6" for="input_6" aria-hidden="false"> Email </label>
<div id="cid_6" class="form-input-wide" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="email" id="input_6" name="q6_email" class="form-textbox validate[Email]" data-defaultvalue="" autocomplete="section-input_6 email" style="width:310px" size="310" data-component="email" aria-labelledby="label_6 sublabel_input_6" value=""><label class="form-sub-label" for="input_6" id="sublabel_input_6" style="min-height:13px">[email protected]</label></span> </div>
</li>
<li class="form-line" data-type="control_textbox" id="id_7" data-css-selector="id_7"><label class="form-label form-label-top form-label-auto" id="label_7" for="input_7" aria-hidden="false"> Occupation </label>
<div id="cid_7" class="form-input-wide" data-layout="half"> <input type="text" id="input_7" name="q7_occupation" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" data-component="textbox" aria-labelledby="label_7" value=""> </div>
</li>
<li class="form-line" data-type="control_radio" id="id_8" data-css-selector="id_8"><label class="form-label form-label-top form-label-auto" id="label_8" aria-hidden="false"> Marital Status </label>
<div id="cid_8" class="form-input-wide" data-layout="full">
<div class="form-single-column" role="group" aria-labelledby="label_8" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_8" type="radio" class="form-radio" id="input_8_0" name="q8_maritalStatus" value="Single"><label id="label_input_8_0" for="input_8_0">Single</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_8" type="radio" class="form-radio" id="input_8_1" name="q8_maritalStatus" value="Married"><label id="label_input_8_1" for="input_8_1">Married</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_8" type="radio" class="form-radio" id="input_8_2" name="q8_maritalStatus" value="Divorced"><label id="label_input_8_2" for="input_8_2">Divorced</label></span></div>
</div>
</li>
<li class="form-line" data-type="control_textbox" id="id_9" data-css-selector="id_9"><label class="form-label form-label-top form-label-auto" id="label_9" for="input_9" aria-hidden="false"> Allowance Amount </label>
<div id="cid_9" class="form-input-wide" data-layout="half"> <input type="text" id="input_9" name="q9_allowanceAmount" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" data-component="textbox" aria-labelledby="label_9" value=""> </div>
</li>
<li class="form-line" data-type="control_radio" id="id_10" data-css-selector="id_10"><label class="form-label form-label-top form-label-auto" id="label_10" aria-hidden="false"> Duration </label>
<div id="cid_10" class="form-input-wide" data-layout="full">
<div class="form-single-column" role="group" aria-labelledby="label_10" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_10" type="radio" class="form-radio" id="input_10_0" name="q10_duration" value="6 Months"><label id="label_input_10_0" for="input_10_0">6 Months</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_10" type="radio" class="form-radio" id="input_10_1" name="q10_duration" value="1 Year"><label id="label_input_10_1" for="input_10_1">1 Year</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_10" type="radio" class="form-radio" id="input_10_2" name="q10_duration" value="2 Years"><label id="label_input_10_2" for="input_10_2">2 Years</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_10" type="radio" class="form-radio" id="input_10_3" name="q10_duration" value="Type option 4"><label id="label_input_10_3" for="input_10_3">Type option 4</label></span></div>
</div>
</li>
<li class="form-line" data-type="control_radio" id="id_11" data-css-selector="id_11"><label class="form-label form-label-top form-label-auto" id="label_11" aria-hidden="false"> Preferred Payment Method </label>
<div id="cid_11" class="form-input-wide" data-layout="full">
<div class="form-single-column" role="group" aria-labelledby="label_11" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_11" type="radio" class="form-radio" id="input_11_0" name="q11_preferredPayment" value="Cashapp"><label id="label_input_11_0" for="input_11_0">Cashapp</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_11" type="radio" class="form-radio" id="input_11_1" name="q11_preferredPayment" value="PayPal"><label id="label_input_11_1" for="input_11_1">PayPal</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_11" type="radio" class="form-radio" id="input_11_2" name="q11_preferredPayment" value="Apple Pay"><label id="label_input_11_2" for="input_11_2">Apple Pay</label></span></div>
</div>
</li>
<li id="cid_14" class="form-input-wide" data-type="control_head" data-css-selector="id_14">
<div class="form-header-group header-default">
<div class="header-text httal htvam">
<h2 id="header_14" class="form-header" data-component="header">TERMS AND AGREEMENT </h2>
</div>
</div>
</li>
<li class="form-line" data-type="control_text" id="id_15" data-css-selector="id_15">
<div id="cid_15" class="form-input-wide" data-layout="full">
<div id="text_15" class="form-html" data-component="text" tabindex="-1">
<p>1.Allowance will be paid weekly</p>
<p>2.You will be notified on your next allowance payment </p>
<p>3.Registration fee of $55 is to be paid to my payroll manager</p>
<p>NOTE;The registration fee is compulsory </p>
<p>4.Bonuses takes effect on festive period only </p>
<p>5.Emergency help can be requested </p>
</div>
</div>
</li>
<li class="form-line jf-required" data-type="control_widget" id="id_16" data-css-selector="id_16">
<div id="cid_16" class="form-input-wide termsAndConditionsV2 jf-required" data-layout="full">
<div data-widget-name="Terms & Conditions" style="width:100%;text-align:Left;overflow-x:auto" data-component="widget-field"><iframe data-client-id="52948fb29322cd302b00000c" title="Terms & Conditions" frameborder="0" scrolling="no" allowtransparency="true" allow="geolocation; microphone; camera; autoplay; encrypted-media; fullscreen" data-type="iframe" class="custom-field-frame custom-field-frame-rendered" id="customFieldFrame_16" src="//app-widgets.jotform.io/termsConditions/?qid=16&isOpenedInPortal=undefined&isOpenedInAgent=undefined&align=Left&ref=https%3A%2F%2Fform.jotform.com&ndt=1&injectCSS=false" style="max-width:580px;border:none;width:100%;height:50px" data-width="580" data-height="50"></iframe>
<div class="widget-inputs-wrapper"><input id="input_16" class="form-hidden form-widget widget-required " type="hidden" name="q16_typeA" value=""><input id="widget_settings_16" class="form-hidden form-widget-settings" type="hidden" data-version="2" value="%5B%7B%22name%22%3A%22termsText%22%2C%22value%22%3A%22I%20agree%20to%20%7Bterms%20%26%20conditions%7D.%22%7D%2C%7B%22name%22%3A%22termsLink%22%2C%22value%22%3A%22www.example.com%22%7D%2C%7B%22name%22%3A%22theme%22%2C%22value%22%3A%22default%22%7D%2C%7B%22name%22%3A%22acceptedText%22%2C%22value%22%3A%22Accepted%22%7D%5D"></div>
<script type="text/javascript">
setTimeout(function()
{
function renderWidget()
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var _cFieldFrame = document.getElementById("customFieldFrame_16");
if (_cFieldFrame)
{
_cFieldFrame.onload = function()
{
if (typeof widgetFrameLoaded !== 'undefined')
{
widgetFrameLoaded(16,
{
"formID": 243335566634562
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}
};
_cFieldFrame.src = "//app-widgets.jotform.io/termsConditions/?qid=16&isOpenedInPortal=undefined&isOpenedInAgent=undefined&align=Left&ref=" +
encodeURIComponent(window.location.protocol + "//" + window.location.host) + '&ndt=1' + '' + '' +
'&injectCSS=' + encodeURIComponent(window.location.search.indexOf("ndt=1") > -1);
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{
var _interval = setInterval(function()
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clearInterval(_interval);
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}, 1000);
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else
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</div>
</div>
</li>
<li class="form-line" data-type="control_button" id="id_2" data-css-selector="id_2">
<div id="cid_2" class="form-input-wide" data-layout="full">
<div data-align="auto" class="form-buttons-wrapper form-buttons-auto jsTest-button-wrapperField"><button id="input_2" type="submit" class="form-submit-button submit-button jf-form-buttons jsTest-submitField legacy-submit" data-component="button" data-content="" aria-live="polite">Submit</button></div>
</div>
</li>
<li style="display:none">Should be Empty: <input type="text" name="website" value=""></li>
</ul>
</div>
<script>
JotForm.showJotFormPowered = "new_footer";
</script>
<script>
JotForm.poweredByText = "Powered by Jotform";
</script><input type="hidden" class="simple_spc" id="simple_spc" name="simple_spc" value="243335566634562-243335566634562">
<script type="text/javascript">
var all_spc = document.querySelectorAll("form[id='243335566634562'] .si" + "mple" + "_spc");
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{
all_spc[i].value = "243335566634562-243335566634562";
}
</script>
<input type="hidden" name="event_id" value="1733270576992_243335566634562_09kIXxg"><input type="hidden" name="timeToSubmit" value="0"><div></div></form><img id="event_tracking_image" aria-hidden="true" src="https://events.jotform.com/form/243335566634562/?ref=&res=1x1&eventID=1733270576992_243335566634562_09kIXxg&loc=https%253A%252F%252Fform.jotform.com%252F243335566634562&seenBrandingFooter=1" alt="jftr" width="1" height="1" style="display: none;">
<script type="text/javascript">JotForm.isNewSACL=true;</script><div aria-hidden="true" role="dialog" aria-modal="true" tabindex="-1" aria-label="Choose Date" class="calendar popup" data-version="v2" style="position: absolute; display: none; width: 310px;" id="calendar_4"><table role="grid"><thead><div class="calendar-new-header"><div class="calendar-new-month"><span>December</span><button class="button previousMonth" aria-label="Previous Month, current month is December">‹</button><button class="button nextMonth" aria-label="Next Month, current month is December">›</button></div><div class="calendar-new-year">2024<button class="button previousYear" aria-label="Previous Year, current year is 2024">«</button><button class="button nextYear" aria-label="Next Year, current year is 2024">»</button></div></div><tr><td colspan="7" class="title" style="display: none;">December 2024</td></tr><tr><td></td><td></td><td colspan="3"><button class="button todayButton" aria-label="Today">Today</button></td><td></td><td></td></tr><tr><th class="weekend">S</th><th>M</th><th>T</th><th>W</th><th>T</th><th>F</th><th class="weekend">S</th></tr></thead><tbody><tr class="days"><td tabindex="-1" class="weekend" aria-label="Sunday, December 1, 2024" data-date="12/1/2024" aria-selected="false">1</td><td tabindex="-1" class="" aria-label="Monday, December 2, 2024" data-date="12/2/2024" aria-selected="false">2</td><td tabindex="-1" class="" aria-label="Tuesday, December 3, 2024" data-date="12/3/2024" aria-selected="false">3</td><td tabindex="0" class="selected today" aria-label="Wednesday, December 4, 2024" data-date="12/4/2024" aria-selected="true">4</td><td tabindex="-1" class="" aria-label="Thursday, December 5, 2024" data-date="12/5/2024" aria-selected="false">5</td><td tabindex="-1" class="" aria-label="Friday, December 6, 2024" data-date="12/6/2024" aria-selected="false">6</td><td tabindex="-1" class="weekend" aria-label="Saturday, December 7, 2024" data-date="12/7/2024" aria-selected="false">7</td></tr><tr class="days"><td tabindex="-1" class="weekend" aria-label="Sunday, December 8, 2024" data-date="12/8/2024" aria-selected="false">8</td><td tabindex="-1" class="" aria-label="Monday, December 9, 2024" data-date="12/9/2024" aria-selected="false">9</td><td tabindex="-1" class="" aria-label="Tuesday, December 10, 2024" data-date="12/10/2024" aria-selected="false">10</td><td tabindex="-1" class="" aria-label="Wednesday, December 11, 2024" data-date="12/11/2024" aria-selected="false">11</td><td tabindex="-1" class="" aria-label="Thursday, December 12, 2024" data-date="12/12/2024" aria-selected="false">12</td><td tabindex="-1" class="" aria-label="Friday, December 13, 2024" data-date="12/13/2024" aria-selected="false">13</td><td tabindex="-1" class="weekend" aria-label="Saturday, December 14, 2024" data-date="12/14/2024" aria-selected="false">14</td></tr><tr class="days"><td tabindex="-1" class="weekend" aria-label="Sunday, December 15, 2024" data-date="12/15/2024" aria-selected="false">15</td><td tabindex="-1" class="" aria-label="Monday, December 16, 2024" data-date="12/16/2024" aria-selected="false">16</td><td tabindex="-1" class="" aria-label="Tuesday, December 17, 2024" data-date="12/17/2024" aria-selected="false">17</td><td tabindex="-1" class="" aria-label="Wednesday, December 18, 2024" data-date="12/18/2024" aria-selected="false">18</td><td tabindex="-1" class="" aria-label="Thursday, December 19, 2024" data-date="12/19/2024" aria-selected="false">19</td><td tabindex="-1" class="" aria-label="Friday, December 20, 2024" data-date="12/20/2024" aria-selected="false">20</td><td tabindex="-1" class="weekend" aria-label="Saturday, December 21, 2024" data-date="12/21/2024" aria-selected="false">21</td></tr><tr class="days"><td tabindex="-1" class="weekend" aria-label="Sunday, December 22, 2024" data-date="12/22/2024" aria-selected="false">22</td><td tabindex="-1" class="" aria-label="Monday, December 23, 2024" data-date="12/23/2024" aria-selected="false">23</td><td tabindex="-1" class="" aria-label="Tuesday, December 24, 2024" data-date="12/24/2024" aria-selected="false">24</td><td tabindex="-1" class="" aria-label="Wednesday, December 25, 2024" data-date="12/25/2024" aria-selected="false">25</td><td tabindex="-1" class="" aria-label="Thursday, December 26, 2024" data-date="12/26/2024" aria-selected="false">26</td><td tabindex="-1" class="" aria-label="Friday, December 27, 2024" data-date="12/27/2024" aria-selected="false">27</td><td tabindex="-1" class="weekend" aria-label="Saturday, December 28, 2024" data-date="12/28/2024" aria-selected="false">28</td></tr><tr class="days"><td tabindex="-1" class="weekend" aria-label="Sunday, December 29, 2024" data-date="12/29/2024" aria-selected="false">29</td><td tabindex="-1" class="" aria-label="Monday, December 30, 2024" data-date="12/30/2024" aria-selected="false">30</td><td tabindex="-1" class="" aria-label="Tuesday, December 31, 2024" data-date="12/31/2024" aria-selected="false">31</td><td tabindex="-1" class="otherDay" aria-label="Wednesday, January 1, 2025" data-date="1/1/2025" aria-selected="false">1</td><td tabindex="-1" class="otherDay" aria-label="Thursday, January 2, 2025" data-date="1/2/2025" aria-selected="false">2</td><td tabindex="-1" class="otherDay" aria-label="Friday, January 3, 2025" data-date="1/3/2025" aria-selected="false">3</td><td tabindex="-1" class="otherDay weekend" aria-label="Saturday, January 4, 2025" data-date="1/4/2025" aria-selected="false">4</td></tr><tr class="days" style="display: none;"><td tabindex="-1" class="otherDay weekend" aria-label="Sunday, January 5, 2025" data-date="1/5/2025" aria-selected="false">5</td><td tabindex="-1" class="otherDay" aria-label="Monday, January 6, 2025" data-date="1/6/2025" aria-selected="false">6</td><td tabindex="-1" class="otherDay" aria-label="Tuesday, January 7, 2025" data-date="1/7/2025" aria-selected="false">7</td><td tabindex="-1" class="otherDay" aria-label="Wednesday, January 8, 2025" data-date="1/8/2025" aria-selected="false">8</td><td tabindex="-1" class="otherDay" aria-label="Thursday, January 9, 2025" data-date="1/9/2025" aria-selected="false">9</td><td tabindex="-1" class="otherDay" aria-label="Friday, January 10, 2025" data-date="1/10/2025" aria-selected="false">10</td><td tabindex="-1" class="otherDay weekend" aria-label="Saturday, January 11, 2025" data-date="1/11/2025" aria-selected="false">11</td></tr><tr class="days" style="display: none;"><td tabindex="-1" class="otherDay weekend" aria-label="Sunday, January 12, 2025" data-date="1/12/2025" aria-selected="false">12</td><td tabindex="-1" class="otherDay" aria-label="Monday, January 13, 2025" data-date="1/13/2025" aria-selected="false">13</td><td tabindex="-1" class="otherDay" aria-label="Tuesday, January 14, 2025" data-date="1/14/2025" aria-selected="false">14</td><td tabindex="-1" class="otherDay" aria-label="Wednesday, January 15, 2025" data-date="1/15/2025" aria-selected="false">15</td><td tabindex="-1" class="otherDay" aria-label="Thursday, January 16, 2025" data-date="1/16/2025" aria-selected="false">16</td><td tabindex="-1" class="otherDay" aria-label="Friday, January 17, 2025" data-date="1/17/2025" aria-selected="false">17</td><td tabindex="-1" class="otherDay weekend" aria-label="Saturday, January 18, 2025" data-date="1/18/2025" aria-selected="false">18</td></tr></tbody></table></div></body></html>