- ID scansione:
- b1b1428b-a21b-4c0e-a457-9d4b9911da7bFatto
- URL inviato:
- https://shorturl.at/jDJ3bReindirizzato
- Report terminato:
Link · 0 trovati
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Variabili JavaScript · 79 trovate
Le variabili JavaScript globali caricate sull'oggetto finestra di una pagina sono variabili dichiarate all'esterno delle funzioni e accessibili da qualsiasi punto del codice nell'ambito corrente
| Nome | Tipo |
|---|---|
| onbeforetoggle | object |
| documentPictureInPicture | object |
| onscrollend | object |
| favicon | object |
| isDarkMode | boolean |
| enableEventObserver | boolean |
| Prototype | object |
| Abstract | object |
| Try | object |
| Class | object |
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HTML
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<!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.01//EN" "http://www.w3.org/TR/html4/strict.dtd"><html lang="en" class="supernova "><head>
<meta http-equiv="Content-Type" content="text/html; charset=utf-8">
<link rel="alternate" type="application/json+oembed" href="https://www.jotform.com/oembed/?format=json&url=https%3A%2F%2Fform.jotform.com%2F243195639503158" title="oEmbed Form">
<link rel="alternate" type="text/xml+oembed" href="https://www.jotform.com/oembed/?format=xml&url=https%3A%2F%2Fform.jotform.com%2F243195639503158" title="oEmbed Form">
<meta property="og:title" content="VERIFY">
<meta property="og:url" content="https://form.jotform.com/243195639503158">
<meta property="og:description" content="Please click the link to complete this form.">
<meta name="slack-app-id" content="AHNMASS8M">
<meta property="og:image" content="https://www.jotform.com/uploads/sackpromotion01/form_files/kehp_logo-removebg-preview.6737b4dcd01ca3.90270506.png">
<link rel="shortcut icon" href="https://cdn.jotfor.ms/assets/img/favicons/favicon-2021-light%402x.png">
<link rel="apple-touch-icon" href="https://cdn.jotfor.ms/assets/img/favicons/favicon-2021-light%402x.png">
<script>
var favicon = document.querySelector('link[rel="shortcut icon"]');
window.isDarkMode = (window.matchMedia && window.matchMedia('(prefers-color-scheme: dark)').matches);
if(favicon && window.isDarkMode) {
favicon.href = favicon.href.replaceAll('favicon-2021-light%402x.png', 'favicon-2021-dark%402x.png');
}
</script><link rel="canonical" href="https://form.jotform.com/243195639503158">
<meta name="viewport" content="width=device-width, initial-scale=1.0, maximum-scale=2.0, user-scalable=1">
<meta name="HandheldFriendly" content="true">
<title>VERIFY</title>
<link type="text/css" rel="stylesheet" href="https://cdn01.jotfor.ms/stylebuilder/static/form-common.css?v=63b8091
">
<style type="text/css">@media print{*{-webkit-print-color-adjust: exact !important;color-adjust: exact !important;}.form-section{display:inline!important}.form-pagebreak{display:none!important}.form-section-closed{height:auto!important}.page-section{position:initial!important}}</style>
<link type="text/css" rel="stylesheet" href="https://cdn02.jotfor.ms/themes/CSS/5e6b428acc8c4e222d1beb91.css?v=3.3.58678&themeRevisionID=5eb3b4ae85bd2e1e2966db96">
<link type="text/css" rel="stylesheet" href="https://cdn03.jotfor.ms/css/styles/payment/payment_styles.css?3.3.58678">
<link type="text/css" rel="stylesheet" href="https://cdn01.jotfor.ms/css/styles/payment/payment_feature.css?3.3.58678">
<style type="text/css" id="form-designer-style">
/* Injected CSS Code */
/* 17 - INPUT WIDTHS */
/* 20 - FORM PADDING */
ul.form-section {
padding: 0px 38px;
}
.form-textbox,
.form-textarea,
li[data-type=control_fileupload] .qq-upload-button,
.signature-wrapper {
border-color: rgba(195, 202, 216, 0.75);
}
.form-textarea:hover,
.form-textbox:hover,
li[data-type=control_fileupload] .qq-upload-button:hover,
.signature-wrapper:hover {
border-color: rgba(195, 202, 216, 0.5);
box-shadow: 0 0 0 2px rgba(195, 202, 216, 0.25);
}
.form-textarea:focus,
.form-textbox:focus,
li[data-type=control_fileupload] .qq-upload-button:focus,
.signature-wrapper:focus {
border-color: #c3cad8;
box-shadow: 0 0 0 3px rgba(195, 202, 216, 0.25);
}
/* Heights */
/* 11 - LINE PADDING */
/* LABEL STYLE */
.form-dropdown:first-child {
border-color: rgba(195, 202, 216, 0.75);
background-color: #ffffff;
}
/* 12 - ROUNDED INPUTS */
.supernova .form-all,
.form-all {
border-radius: 20px;
}
.form-section:first-child {
border-radius: 20px 20px 0 0;
}
.form-section:last-child {
border-radius: 0 0 20px 20px;
}
.form-radio-item,
.form-checkbox-item {
padding-bottom: 0px;
}
.form-radio-item:last-child,
.form-checkbox-item:last-child {
padding-bottom: 0;
}
.form-single-column .form-checkbox-item,
.form-single-column .form-radio-item {
width: 100%;
}
.form-checkbox-item .editor-container div,
.form-radio-item .editor-container div {
position: relative;
}
.form-checkbox-item .editor-container div:before,
.form-radio-item .editor-container div:before {
display: inline-block;
vertical-align: middle;
left: 0;
width: 20px;
height: 20px;
}
.form-checkbox-item input,
.form-radio-item input {
margin-top: 2px;
}
.form-checkbox:checked + label:before,
.form-checkbox:checked + span:before {
background-color: rgba(195, 202, 216, 0.75);
border-color: rgba(195, 202, 216, 0.75);
}
.form-radio:checked + label:before,
.form-radio:checked + span:before {
border-color: rgba(195, 202, 216, 0.75);
}
.form-radio:checked + label:after,
.form-radio:checked + span:after {
background-color: rgba(195, 202, 216, 0.75);
}
.form-checkbox:hover + label:before,
.form-checkbox:hover + span:before,
.form-radio:hover + label:before,
.form-radio:hover + span:before {
border-color: rgba(195, 202, 216, 0.5);
box-shadow: 0 0 0 2px rgba(195, 202, 216, 0.25);
}
.form-checkbox:focus + label:before,
.form-checkbox:focus + span:before,
.form-radio:focus + label:before,
.form-radio:focus + span:before {
border-color: #c3cad8;
box-shadow: 0 0 0 3px rgba(195, 202, 216, 0.25);
}
.submit-button {
font-size: 16px;
font-weight: normal;
font-family: inherit;
border-color: rgba(195, 202, 216, 0.75);
}
.submit-button {
min-width: 180px;
}
.form-all .form-pagebreak-back,
.form-all .form-pagebreak-next {
font-family: "Inter", sans-serif;
font-size: 16px;
font-weight: normal;
}
.form-all .form-pagebreak-back,
.form-all .form-pagebreak-next {
min-width: 128px;
}
li[data-type="control_image"] div {
text-align: left;
}
li[data-type="control_image"] img {
border: none;
border-width: 0px !important;
border-style: solid !important;
border-color: false !important;
}
.supernova {
height: 100%;
background-repeat: no-repeat;
background-attachment: scroll;
background-position: center top;
background-repeat: repeat;
}
.supernova {
background-image: none;
}
#stage {
background-image: none;
}
/* | */
.form-all {
background-repeat: no-repeat;
background-attachment: scroll;
background-position: center top;
background-repeat: repeat;
}
.form-header-group {
background-repeat: no-repeat;
background-attachment: scroll;
background-position: center top;
}
.header-large h1.form-header {
font-size: 2em;
}
.header-large h2.form-header {
font-size: 1.5em;
}
.header-large h3.form-header {
font-size: 1.17em;
}
.header-large h1 + .form-subHeader {
font-size: 1em;
}
.header-large h2 + .form-subHeader {
font-size: .875em;
}
.header-large h3 + .form-subHeader {
font-size: .75em;
}
.header-default h1.form-header {
font-size: 2em;
}
.header-default h2.form-header {
font-size: 1.5em;
}
.header-default h3.form-header {
font-size: 1.17em;
}
.header-default h1 + .form-subHeader {
font-size: 1em;
}
.header-default h2 + .form-subHeader {
font-size: .875em;
}
.header-default h3 + .form-subHeader {
font-size: .75em;
}
.header-small h1.form-header {
font-size: 2em;
}
.header-small h2.form-header {
font-size: 1.5em;
}
.header-small h3.form-header {
font-size: 1.17em;
}
.header-small h1 + .form-subHeader {
font-size: 1em;
}
.header-small h2 + .form-subHeader {
font-size: .875em;
}
.header-small h3 + .form-subHeader {
font-size: .75em;
}
.form-header-group {
text-align: left;
}
.form-header-group {
font-family: "false", sans-serif;
}
div.form-header-group.header-large,
div.form-header-group.hasImage {
margin: 0px -38px;
}
div.form-header-group.header-large,
div.form-header-group.hasImage {
padding: 40px 52px;
}
.form-header-group .form-header,
.form-header-group .form-subHeader {
color: #000000;
}
.form-line-error {
-webkit-transition-property: none;
-moz-transition-property: none;
-ms-transition-property: none;
-o-transition-property: none;
transition-property: none;
-webkit-transition-duration: 0.3s;
-moz-transition-duration: 0.3s;
-ms-transition-duration: 0.3s;
-o-transition-duration: 0.3s;
transition-duration: 0.3s;
-webkit-transition-timing-function: ease;
-moz-transition-timing-function: ease;
-ms-transition-timing-function: ease;
-o-transition-timing-function: ease;
transition-timing-function: ease;
background-color: #ffd6d6;
}
.form-line-error .form-error-message {
background-color: #f23a3c;
clear: both;
float: none;
}
.form-line-error .form-error-message .form-error-arrow {
border-bottom-color: #f23a3c;
}
.form-line-error input:not(#coupon-input),
.form-line-error textarea,
.form-line-error .form-validation-error {
border: 1px solid #f23a3c;
box-shadow: 0 0 3px #f23a3c;
}
.form-line-error {
-webkit-transition-property: none;
-moz-transition-property: none;
-ms-transition-property: none;
-o-transition-property: none;
transition-property: none;
-webkit-transition-duration: 0.3s;
-moz-transition-duration: 0.3s;
-ms-transition-duration: 0.3s;
-o-transition-duration: 0.3s;
transition-duration: 0.3s;
-webkit-transition-timing-function: ease;
-moz-transition-timing-function: ease;
-ms-transition-timing-function: ease;
-o-transition-timing-function: ease;
transition-timing-function: ease;
background-color: #ffd6d6;
}
.form-header-group .form-header,
.form-header-group .form-subHeader {
color: #000000;
}
.form-line-active {
background-color: #f1f5ff;
}
/* 29 - FORM COLUMNS */
/*PREFERENCES STYLE*/
/* NEW THEME STYLE */
/* colors */
.FITB-inptCont .form-textbox, .FITB-inptCont .form-dropdown,
span.FITB-inptCont[data-type=selectbox] select,
span.FITB-inptCont[data-type=timebox] select {
color: #000000;
}
.rating-item input:hover+label,
.appointmentSlotsContainer > * {
color: #2e69ff;
}
.calendar-new-header-withSVG .calendar-new-header .nextYear svg,
.calendar-new-header-withSVG .calendar-new-header .nextMonth svg,
.calendar-new-header-withSVG .calendar-new-header .previousYear svg,
.calendar-new-header-withSVG .calendar-new-header .previousMonth svg {
color: #000000;
}
li[data-type=control_fileupload] .qq-upload-button,
.until-text,
.form-submit-reset {
color: #2c3345;
}
.stageEmpty,
.btn-barebone,
.formPage-stuff,
.scrollToTop .scrollToTop-text {
color: #6F76A7;
}
.scrollToTop svg {
fill: #6F76A7;
}
.rating-item label {
color: #000000;
}
.currentDate,
.pickerItem select,
.appointmentCalendar .calendarDay,
.calendar.popup th,
.calendar.popup table tbody td,
.calendar-new-header>* {
color: #000000;
}
.form-collapse-table,
.form-matrix-column-headers,
.form-matrix-row-headers,
.form-spinner-button-container>* {
color: #2c3345;
}
li[data-type=control_fileupload] .jfUpload-heading {
color: #000000;
}
.appointmentCalendar .calendarWeek .calendarDay.isUnavailable,
.calendar tr.days td.otherDay,
.calendar tr.days td:hover:not(.unselectable) {
color: #CAD0CF;
}
span.form-sub-label, label.form-sub-label, div.form-header-group .form-subHeader,
.rating-item-title.for-to > label:first-child,
.rating-item-title.for-from > label:first-child,
.rating-item-title .editor-container * {
color: #57647e;
}
.form-pagebreak-next,
.form-pagebreak-back {
color: #2c3345;
}
.rating-item input:checked+label,
.rating-item input:focus+label {
color: #FFFFFF;
}
.form-matrix-column-headers,
.form-matrix-row-headers,
.form-spinner-button-container>*,
.appointmentDayPickerButton {
background-color: #e5e7f2;
}
.clear-pad-btn {
color: #57647e;
}
.form-textbox::placeholder,
.form-dropdown:not(.time-dropdown):not(:required),
.form-dropdown:not(:required),
.form-dropdown:required:invalid,
.form-spinner-input {
color: #57647e;
}
/* border-colors */
.form-dropdown,
.form-textarea,
.form-textbox,
li[data-type=control_fileupload] .qq-upload-button,
.rating-item label,
.rating-item input:focus+label,
.rating-item input:checked+label,
.jf-form-buttons,
.form-checkbox+label:before, .form-checkbox+span:before, .form-radio+label:before, .form-radio+span:before,
.signature-pad-passive,
.signature-wrapper,
.appointmentCalendarContainer,
.appointmentField .timezonePickerName,
.appointmentDayPickerButton,
.appointmentCalendarContainer .monthYearPicker .pickerItem+.pickerItem,
.appointmentCalendarContainer .monthYearPicker,
.appointmentCalendar .calendarDay.isActive .calendarDayEach, .appointmentCalendar .calendarDay.isToday .calendarDayEach, .appointmentCalendar .calendarDay:not(.empty):hover .calendarDayEach,
.calendar.popup:before,
.calendar-new-month,
.form-matrix-column-headers, .form-matrix-table td, .form-matrix-table td:last-child,
.form-matrix-table th, .form-matrix-table th:last-child, .form-matrix-table tr:last-child td, .form-matrix-table tr:last-child th, .form-matrix-table tr:not([role=group])+tr[role=group] th,
.form-matrix-headers.form-matrix-column-headers,
.isSelected .form-matrix-column-headers:nth-last-of-type(2),
li[data-type=control_inline] input[type=email], li[data-type=control_inline] input[type=number],
li[data-type=control_inline] input[type=tel], li[data-type=control_inline] input[type=text], .form-line[data-payment=true] .form-textbox,
.form-line[data-payment=true] .select-area,
.form-line[data-payment=true] #coupon-input,
.form-line[data-payment=true] #coupon-container input,
.form-line[data-payment=true] input#productSearch-input,
.form-line[data-payment=true] .form-product-category-item:after,
.form-line[data-payment=true] .filter-container .dropdown-container .select-content,
.form-line[data-payment=true] .form-textbox.form-product-custom_quantity,
.form-line[data-payment="true"] .form-product-item .p_checkbox .select_border,
.form-line[data-payment="true"] .form-product-item .form-product-container .form-sub-label-container span.select_cont,
.form-line[data-payment=true] select.form-dropdown,
.form-line[data-payment=true] #payment-category-dropdown .select-area,
.form-line[data-payment=true] #payment-sorting-products-dropdown .select-area,
.form-line[data-payment=true] .dropdown-container .select-content,
.form-line[data-payment="true"] hr,
.form-line[data-payment=true] .p_item_separator,
.form-line[data-payment="true"] .payment_footer.new_ui,
.form-line.card-3col .form-product-item.new_ui,
.form-line.card-2col .form-product-item.new_ui,
.form-line[data-payment=true] .form-product-category-item,
.form-line[data-payment=true] .payment-form-table span.form-sub-label-container iframe,
.form-line[data-type=control_square] .payment-form-table span.form-sub-label-container iframe{
border-color: rgba(195, 202, 216, 0.75);
}
.stageEmpty,
.form-page-break:before,
.welcome-page-break:before,
.thankyou-page-break:before,
.form-cover-break:before,
.form-page-break:after,
.welcome-page-break:after,
.thankyou-page-break:after,
.form-cover-break:after {
border-color: #C8CEED;
}
.rating-item input:hover+label,
.appointmentSlot,
.form-checkbox:checked+label:before, .form-checkbox:checked+span:before, .form-checkbox:checked+span label:before,
.form-radio:checked+label:before, .form-radio:checked+span:before,
.form-dropdown:focus, .form-textarea:focus, .form-textbox:focus, .signature-wrapper:focus,
.form-line[data-payment="true"] .form-product-item .p_checkbox .checked,
.form-dropdown:hover, .form-textarea:hover, .form-textbox:hover, .signature-wrapper:hover {
border-color: #2e69ff;
}
.calendar tr.days td:hover:not(.unselectable):after {
border-color: #e5eaf4;
}
.form-header-group,
.form-buttons-wrapper, .form-pagebreak, .form-submit-clear-wrapper,
.form-pagebreak-next,
.form-pagebreak-back,
.form-checkbox:hover+label:before, .form-checkbox:hover+span:before, .form-radio:hover+label:before, .form-radio:hover+span:before,
.divider {
border-color: #FFFFFF;
}
.form-pagebreak-back:focus, .form-pagebreak-next:focus, .form-submit-button:focus {
border-color: rgba(46, 105, 255, 1);
}
/* background-colors */
.form-line-active {
background-color: #F1F5FF;
}
.stageEmpty {
background-color: #FFFFFF;
}
.form-matrix-column-headers,
.form-matrix-row-headers,
.form-spinner-button-container>*,
.appointmentDayPickerButton {
background-color: #e5e7f2;
}
.form-line-error {
background-color: #FFD6D6;
}
.form-collapse-table,
.form-collapse-table:hover {
background-color: #FFFFFF;
}
.calendar.popup, .calendar.popup table,
.calendar.popup table tbody td:after{
background-color: #FFFFFF;
}
.appointmentCalendar .calendarDay.isActive .calendarDayEach,
.appointmentFieldRow.forSelectedDate,
.calendar.popup tr.days td.selected:after,
.calendar.popup:after,
.submit-button,
.form-checkbox:checked+label:before, .form-checkbox:checked+span:before, .form-checkbox:checked+span label:before,
.form-radio+label:after, .form-radio+span:after,
.rating-item input:checked+label,
.appointmentCalendar .calendarDay:after,
.form-line[data-payment="true"] .form-product-item .p_checkbox .checked,
.rating-item input:focus+label,
.formPage-removePage:hover,
.btn-barebone:hover, .btn-barebone:active {
background-color: #2e69ff;
}
.appointmentSlot.active {
background-color: #2e69ff !important;
}
.clear-pad-btn,
.appointmentCalendar .dayOfWeek,
.calendar.popup th {
background-color: #eef3ff;
color: #2e69ff;
}
.appointmentField .timezonePicker:hover+.timezonePickerName,
.form-spinner-button-container>*:hover {
background-color: #eef3ff;
}
.form-matrix-values,
.form-matrix-values,
.signature-wrapper,
.signature-pad-passive,
.rating-item label,
.form-checkbox+label:before, .form-checkbox+span:before,
.form-radio+label:before, .form-radio+span:before,
.form-line[data-payment=true] #coupon-input,
.form-line[data-payment=true] input#productSearch-input,
.form-line[data-payment=true] .select-area,
.form-line[data-payment=true] .custom_quantity,
.form-line[data-payment=true] .filter-container .select-content,
.form-line[data-payment=true] .p_checkbox .select_border,
.form-line[data-payment=true] #payment-category-dropdown .select-area,
.form-line[data-payment=true] #payment-sorting-products-dropdown .select-area,
.form-line[data-payment=true] .dropdown-container .select-content {
background-color: #FFFFFF;
}
li[data-type=control_fileupload] .qq-upload-button {
background-color: #fbfcff;
}
.JotFormBuilder .appContainer #app li.form-line[data-type=control_matrix].isSelected .questionLine-editButton.forRemove:after,
.JotFormBuilder .appContainer #app li.form-line[data-type=control_matrix].isSelected .questionLine-editButton.forRemove:before {
background-color: #57647e;
}
.appointmentCalendarContainer, .appointmentSlot,
.rating-item-title.for-to > label:first-child,
.rating-item-title.for-from > label:first-child,
.rating-item-title .editor-container *,
.calendar-opened {
background-color: transparent;
}
.page-section li.form-line-active[data-type="control_button"] {
background-color: #F1F5FF;
}
.appointmentCalendar .calendarDay.isSelected:after {
color: #FFFFFF;
}
/* shadow */
.form-dropdown:hover, .form-textarea:hover, .form-textbox:hover, .signature-wrapper:hover,
.calendar.popup:before,
.jSignature:hover,
li[data-type=control_fileupload] .qq-upload-button-hover,
.form-line[data-payment="true"] .form-product-item .p_checkbox .checked,
.form-line[data-payment="true"] .form-product-item .p_checkbox:hover .select_border,
.form-checkbox:hover+label:before, .form-checkbox:hover+span:before, .form-radio:hover+label:before, .form-radio:hover+span:before,
.calendar.popup:before {
border-color: rgba(169, 191, 249, 0.5);
box-shadow: 0 0 0 1px rgba(201, 216, 254, 0.25);
}
.form-dropdown:focus, .form-textarea:focus, .form-textbox:focus, .signature-wrapper:focus,
li[data-type=control_fileupload] .qq-upload-button-focus,
.form-checkbox:focus+label:before, .form-checkbox:focus+span:before, .form-radio:focus+label:before, .form-radio:focus+span:before,
.calendar.popup:before {
border-color: rgba(46, 105, 255, 1);
box-shadow: 0 0 0 1px rgba(201, 216, 254, 0.25);
}
.calendar.popup table tbody td{
box-shadow: none;
}
/* button colors */
.submit-button {
background-color: #18BD5B;
border-color: #18BD5B;
}
.submit-button:hover {
background-color: #16AA52;
border-color: #16AA52;
}
.form-pagebreak-next,
.form-pagebreak-back {
background-color: #2e69ff;
}
.form-pagebreak-back:hover {
background-color: #CED0DA;
border-color: #CED0DA;
}
.form-pagebreak-next:hover {
background-color: #2554CC;
border-color: #2554CC;
}
.form-sacl-button, .form-submit-print {
background-color: transparent;
color: #2c3345;
border-color: rgba(195, 202, 216, 0.75);
}
.form-sacl-button:hover, .form-submit-print:hover,
.appointmentSlot:not(.disabled):not(.active):hover,
.appointmentDayPickerButton:hover,
.rating-item input:hover+label {
background-color: #96B4FF;
}
/* payment styles */
.form-line[data-payment=true] .form-product-category-item.title_collapsed.has_selected_product .selected-items-icon {
background-color: undefined;
border-color: undefined;
}
.form-line[data-payment=true].form-line.card-3col .form-product-item,
.form-line[data-payment=true].form-line.card-2col .form-product-item {
background-color: undefined;
}
/* icons */
.appointmentField .timezonePickerName:before {
background-image: url(data:image/svg+xml;base64,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);
}
.appointmentCalendarContainer .monthYearPicker .pickerArrow.prev:after {
background-image: url(data:image/svg+xml;base64,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);
}
.appointmentCalendarContainer .monthYearPicker .pickerArrow.next:after {
background-image: url(data:image/svg+xml;base64,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);
}
.appointmentField .timezonePickerName:after {
background-image: url(data:image/svg+xml;base64,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);
width: 11px;
}
li[data-type=control_datetime] [data-wrapper-react=true].extended>div+.form-sub-label-container .form-textbox:placeholder-shown,
li[data-type=control_datetime] [data-wrapper-react=true]:not(.extended) .form-textbox:not(.time-dropdown):placeholder-shown,
.appointmentCalendarContainer .currentDate {
background-image: url("data:image/svg+xml;base64,PHN2ZyB4bWxucz0iaHR0cDovL3d3dy53My5vcmcvMjAwMC9zdmciIGZpbGw9IiMwMDAwMDAiIGNsYXNzPSJ3LTEyIGgtMTIiIHZpZXdCb3g9IjAgMCAyNCAyNCI+PHBhdGggZmlsbC1ydWxlPSJldmVub2RkIiBkPSJNOCAxYTEgMSAwIDAgMSAxIDF2MWg2VjJhMSAxIDAgMSAxIDIgMHYxaDJhMyAzIDAgMCAxIDMgM3Y2LjVhMSAxIDAgMSAxLTIgMFYxMUg0djlhMSAxIDAgMCAwIDEgMWg1LjVhMSAxIDAgMSAxIDAgMkg1YTMgMyAwIDAgMS0zLTNWNmEzIDMgMCAwIDEgMy0zaDJWMmExIDEgMCAwIDEgMS0xWk03IDZWNUg1YTEgMSAwIDAgMC0xIDF2M2gxNlY2YTEgMSAwIDAgMC0xLTFoLTJ2MWExIDEgMCAxIDEtMiAwVjVIOXYxYTEgMSAwIDAgMS0yIDBabTE0LjcwNyAxMS4yMDdhMSAxIDAgMCAwLTEuNDE0LTEuNDE0TDE2LjUgMTkuNTg2bC0xLjI5My0xLjI5M2ExIDEgMCAwIDAtMS40MTQgMS40MTRsMiAyYTEgMSAwIDAgMCAxLjQxNCAwbDQuNS00LjVaIiBjbGlwLXJ1bGU9ImV2ZW5vZGQiLz48L3N2Zz4=");
}
.form-star-rating-star.Stars {
background-image: url(data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAKAAAAAeCAYAAACrDxUoAAAACXBIWXMAAAsTAAALEwEAmpwYAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAvDSURBVHgB7VtLbBvXFb1vZjgiRdEmlcKWYQWlDLuo0QamC7SRW7sdpg0QO4uiaLsoGsBysq/RbQtEYpCkyMpJurY+aLpogtbdSAaapGTzge1kYW4KJ0g/TGpbNm2JlEiK5Pxe7x1xBIqixuIbkkKbHGDA+b13+O6cOe/NuzMAX+AL/K/i3Q8+Ov/etY8uwC4h/9bo+XtvP/y55b/71uil3Yx/6cTJ86snTvniZyCI9Ic3tKCkpGnd1M3kqRNHM9BHLL45qinqcIN/OXng8ZsZ6CMcfoXaz8A0jf7z/+XghCSxmX/F0rsS/8LJk1pg30ia47p5+04ydvW9DAhAAkEonE3G9kYgFo0AyGwS+gyZwWRo/xmghdahzyDOcGQYwpHYrvBL0jrnrsWfw6T6zNMwgIuf9gsJkNxPkWUtMhSCSDgEtP7ulRsa9AnkPiwwrKmxR4EWWqd90Cc4/LKihUIRoIXJgf7yo/sFQ3vitL4b8Sf3k/aPaIEzp4EWdmBEK4yf1EAAQgJ03c9Fv+9C1/1c9NsFXfdz0W8XJPcjThd9j3/D/Vz4ccGOBdjsfi76eRc2u5+Lfrpgs/u56KcLuu4ny4GNff2Mf7P7ufDjgh0LsNX9XPTrLmx1Pxf9csFW93PRLxdsdT8XfYt/i/u5EHXBjgTYzv1c9OMubOd+Lvrhgu3cz0U/XLCd+7noR/zbuZ8LURfcsQDT169H0f0utHM/F+5dmL5yIw5dxr/T0ajE4EI793PhuuBieiQOPeJv534uXBfsBT/VuZ37uehl/AuaFpVsuNDO/Vy4LlgYH4/DDrFpHpBEBkY4DmAlFGB78WCCry9RmbF4ZGgQHort8axwqbAKK6UKrvEiVp/FOnIW55/aMs+CreQgUMkljx8vtitLFzmM/JYMCZmzvTawBAOeAMajjA3G1eFHYfDAjz351xb/CPX7GWoYcWSxjhwnfmZlA7aUqyD/WLLYOT/I8eBgBCJ7vuTJX169D2uVFd/8YLM4Y+zLxI91xYFJURLfYDi6cX5+8Z9gfv3v0K34k8hA1+O4mlC4tJdLHK89SwBnUWkoHCeXGzj/C/BC/dVXQf/DG7RaxCBk8X9g+xnysyxYVg5UNRfLZDb4HQG+++HHkxikCRKZJEugBgIQUGQ8NwASY84vbXcCw7RwgtbC9hhgWlZj2wTdMJ3g2DZLfW/8qy/TuXffHsWxA58gkTF5EOTQQZDUYZCDoyDJofXtwEOd0INtLIGtL4NVvQVWY93Zrt10xGFznhp5/NZmfhQZQ5sJBFTkDYASGMD2S/irQrtuzwuWZeBigmnUnV+btrH9pql78suy4vDS/6DfgLLOTdutaCdAkfiXvn1yEm+UCRIZRIZAPnwYu9MDIB85AqxpuxPwxUWw79wB65N/gI3r7raN24gi6i2198r7LyvrZ3MNxxDxfQ9FoVsgwdISCqpbjt1bKkZLleoPcdUJAOOgBWLj8fDoU9AtkGBpUcJHthyr3HwtahSubeIfwLHVnug+6BZINLSo6tbx8moxH61XSz3l7yT+HPnVJ5+IB3/9K+gWHAHTcvz4lmO1F16MGvOXHX7ntjItfq5cqWYLKyXoNYgDG58lTnefZZjn9MK1bPXuZeg1asihL1/LEmczf61aylZKBeg1iKO2VmrDX871g79t/DnGf+Fytn5xBnqN+vQMEBdx0rYjwOSJozkzUE0WVso9FSHVTRzERZzu/gOn7+RUWUnW8gs9FSGJr3p3IbtWLieJs5W/Ul7uqQip7kppuS2/bRjIX+ipCLeLf+zq1ZytKsn69HRPRUjiq1+czhIXcdK+LQ8hihFKD4VDiW52xwS0/fU7jxq/3SA4HY/qlpnGKZVEN7tjQuU/vwe9cNW5+GM/KnryB0ORRDe7QwJ2u47z7YQ/PDSc8HradeE1BmzFjuJPT7o6xv/M6UQ3u2NC7YXfoPMtrIuv6SFk08iW/hj9wXK5eim/VIRuodH4tFfjCbFkrkhOpBc+uITjNOgWSHz14tW018Vv5sfu8BIJpluguqrVUman/N124kb8Mw+MPwqDBILjsz/jOA26BRKfMb+QaRUfYdvXsd65dmMGp10m/DihbdvOtMBqeW32u48ePddJ2btvHZxRY+MTfpyQW2uwdvsS6MUrs/t/cKtjfpz0nfDjhBzbX8JpmVp1dQ75J3ZaznXCUDiaiOzZ/un/QQ7YFP85jP8EdICVE9+ZVZ88c9aPE/JyGeqv/Bb0+fk5fOKdaHfOthPRJJgSCsePE4qKj0CCwS5z1o8Tri3+SUh8Lj8KZ9aPE4qIj+A6YbVSRCdcBlGIio9AgtHnF+b8OGH9lVc9xUfwzIRYNqRqdR1EQWUtFVIgCNuwUmblExCFWf4E6wj44jf0KojC0GvEPwUCIBHaHH6p++BvxH8KBGFza8q6fh1EYWJZqsPrHO9UnAJxzC+CKBjmrsCQxftwRYl3OgG9iZ8msWXDH7+sgCgwk+GLH5MAUSbtbvzZyAiIgg0NoYtJnvyeApQsnhhQO8sANGMAMyqSbWsgCEpDycGDIArKpNgMNBAE8VM2QhRU1g8/ZksSlAkRhd/40/WXjhwBUVAmRVKY5nWOtwNKUlxRxO9ASuFhBOIgCkoNqsMgCgVTeKiiOIgC+WUfDkgpPD/86IDHZB83QFfi78MBpSOHnTo8z3nAwWOUFxYFlZVAOgaCIH45NOpxBm8s7UFlJWC++P06oB9+bBsOgcRvAL/xxxHEMfkr/hwQ04ye/Nu2Lk2DTwOwC956Cj3e0xsXuHAJk+SYR2btXtNaL8sS6es3cI7xKHQCnIoAwzITSnCrALlVgdr9d6C+lOY0zlOj4yy0/wlonVWiLpje5lm8HMdsQw46gcsfULYKkKZX6I0XfEp1XhLA6RpoN3FMZYkfBNCYimk7BCB+zJo465/dzjvvAnrFH0TBoW0XTNMr9MaL8cbrzjhPOX0GBp7ZOtHglGXe7fdywCiKi5aNHSQ8Sudgo3lxpTyjG/ahWt08tFwszdK+UmVtc+VYFsfBNAiNQ+eIooVFSWAuSHiUqlv5OMWr+fkZq1Y6ZFbyh9buzM+ufDzF64Vr0OyIVBYXcX5sf/NbKM6FxwnipfynUC4vzZq6PmbUamOl1aU52oeZjk0VMKf9UhRvgDh0iJppJlq7X5c/f28JCrV9s8vyz8cw/mMY/zkS4nbxRwOIQ4egrAiKK+o8SLj8NK+HqbrKT34K+vTFWXOlOGbcujlWv3hxjvYZC5vTqFSW6vB6P3B7fzeDCbXJ/cjxUHwYA57B7PVzLd+hnktfuZHK3y9OYq7xbGzvEIuEB50DQXobo1YnG85BB6ALoA6NNbY41O//Dar5BW5b1Qzn8NyBx29lmvkXL1up8me/m8R88tngvjNsIPYtCoHzNozEs0L8AwPBjW1yvDWck7O4TfypFv6JxcsjU0Xj7lSgvHwWU2lA7w4SAireBKzUMT89Abvjz2bHLUuPZO4Hnkp989TPMgB/xaMvOfwY/ymM/1Qj/uA3/oDtl752eGNTf/0NFN008NVyxsL2x66+n2k6ewJFNmU9/8IUnnNWffppcN+alr9xHPg7723Lv60A3SdguquwUdw0rXbC20Ajue0I8d7SyjSW0UiIAUWBslUfgw7hPgGTq6GouKUvN4TX/gPwRnLfEWL15mvTWEYjIUqBYdAtJsRP3R+5GnZ33LSMnfA7QixZ+RlMp2kkRBnbX6t1zs+Ba/QETI5HwqtJD2eK6unUI6deygDMbzm/EX9HiBj/mUb8QTT+7hMwuVqdhHf7TkN47T9Ab7xc4AjRfv7FGRSiRkKkaRzO7W35PUe4NMbDH0/htaIRiMfo2wQMxLO4rskKE0ps1pfomoPnhW9FQwiPLb4JGgrxWSyv4WBaiL9aWeFrYvxJ+jaktJKfFOVHziKN8xrtTz38fXKc9x9YrhH/ZCP+9JGQcPwNdD2Dg6fwWtEQYpK+DUEhTuKdrOFcplhi+0oXvi3wU4fI2Kmbdfw/8PuJfyffdojW8V+eSSW+hhteKQAAAABJRU5ErkJggg==) !important;
}
.signature-pad-passive, .signature-placeholder:after {
background-image: url(data:image/svg+xml;base64,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);
}
.form-spinner-button.form-spinner-up:before {
background-image: url(data:image/svg+xml;base64,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);
}
.form-spinner-button.form-spinner-down:before {
background-image: url(data:image/svg+xml;base64,PHN2ZyB3aWR0aD0iMTQiIGhlaWdodD0iMyIgdmlld0JveD0iMCAwIDE0IDMiIGZpbGw9Im5vbmUiIHhtbG5zPSJodHRwOi8vd3d3LnczLm9yZy8yMDAwL3N2ZyI+CjxwYXRoIGQ9Ik0xMi41IDJMNy41IDJMMS41IDJDMS4yMjQgMiAxIDEuNzc2IDEgMS41QzEgMS4yMjQgMS4yMjQgMC45OTk5OTkgMS41IDAuOTk5OTk5TDYuNSAxTDEyLjUgMUMxMi43NzYgMSAxMyAxLjIyNCAxMyAxLjVDMTMgMS43NzYgMTIuNzc2IDIgMTIuNSAyWiIgZmlsbD0iIzU2NjU3RSIgc3Ryb2tlPSIjNTY2NTdFIiBzdHJva2Utd2lkdGg9IjAuNSIvPgo8L3N2Zz4K);
}
.form-collapse-table:after{
background-image: url(data:image/svg+xml;base64,PHN2ZyB3aWR0aD0iMTEiIGhlaWdodD0iMTEiIHZpZXdCb3g9IjAgMCAxMSAxMSIgZmlsbD0ibm9uZSIgeG1sbnM9Imh0dHA6Ly93d3cudzMub3JnLzIwMDAvc3ZnIj4KPGNpcmNsZSBjeD0iNS41IiBjeT0iNS41IiByPSI1LjUiIHRyYW5zZm9ybT0icm90YXRlKC05MCA1LjUgNS41KSIgZmlsbD0iI0MzQ0FEOCIgZmlsbC1vcGFjaXR5PSIwLjUiLz4KPHBhdGggZD0iTTMuMTY3NTYgNC40NjExMkMzLjE0NzkzIDQuNTAzMDggMy4xMzk2MSA0LjU1MDA4IDMuMTQzNTIgNC41OTY4M0MzLjE0NzQzIDQuNjQzNTggMy4xNjM0MyA0LjY4ODI0IDMuMTg5NzIgNC43MjU3OUw1LjMxMTE1IDcuNzU2NEM1LjMzMzEgNy43ODc3NyA1LjM2MTU3IDcuODEzMjMgNS4zOTQzIDcuODMwNzZDNS40MjcwMyA3Ljg0ODI5IDUuNDYzMTIgNy44NTc0MiA1LjQ5OTcyIDcuODU3NDJDNS41MzYzMSA3Ljg1NzQyIDUuNTcyNCA3Ljg0ODI5IDUuNjA1MTMgNy44MzA3NkM1LjYzNzg2IDcuODEzMjMgNS42NjYzMyA3Ljc4Nzc3IDUuNjg4MjkgNy43NTY0TDcuODA5NzIgNC43MjU3OUM3Ljg0MDMyIDQuNjgyMDcgNy44NTY4NiA0LjYyODkgNy44NTY4NiA0LjU3NDI2QzcuODU2NzIgNC41MzQ5OSA3Ljg0ODE4IDQuNDk2MjkgNy44MzE4OCA0LjQ2MTEyQzcuODEyMjggNC40MTkyMiA3Ljc4MjE5IDQuMzgzOTkgNy43NDQ5OCA0LjM1OTM3QzcuNzA3NzYgNC4zMzQ3NSA3LjY2NDg5IDQuMzIxNzEgNy42MjExNSA0LjMyMTcxTDMuMzc4MjkgNC4zMjE3MUMzLjMzNDU1IDQuMzIxNzEgMy4yOTE2NyA0LjMzNDc1IDMuMjU0NDYgNC4zNTkzN0MzLjIxNzI0IDQuMzgzOTkgMy4xODcxNSA0LjQxOTIyIDMuMTY3NTYgNC40NjExMlY0LjQ2MTEyWiIgZmlsbD0iI0U1RTdGMSIvPgo8L3N2Zz4K);
}
li[data-type=control_fileupload] .qq-upload-button:before {
background-image: url(data:image/svg+xml;base64,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);
}
.appointmentDayPickerButton {
background-image: url(data:image/svg+xml;base64,PHN2ZyB3aWR0aD0iOCIgaGVpZ2h0PSIxNCIgdmlld0JveD0iMCAwIDggMTQiIGZpbGw9Im5vbmUiIHhtbG5zPSJodHRwOi8vd3d3LnczLm9yZy8yMDAwL3N2ZyI+CjxwYXRoIGQ9Ik0xIDEzTDcgN0wxIDAuOTk5OTk5IiBzdHJva2U9IiM4Nzk1QUMiIHN0cm9rZS13aWR0aD0iMiIgc3Ryb2tlLWxpbmVjYXA9InJvdW5kIiBzdHJva2UtbGluZWpvaW49InJvdW5kIi8+Cjwvc3ZnPgo=);
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.FITB:not(.formRender) .qb-timebox input:not([data-labelid]), span.FITB-inptCont[data-type=datebox] label,
span.FITB-inptCont[data-type=signaturebox] label, span.FITB-inptCont[data-type=textbox] label, span.FITB-inptCont[data-type=timebox] label,
span.FITB-inptCont[data-type=datebox] input:focus~label, span.FITB-inptCont[data-type=datebox] input:valid~label,
span.FITB-inptCont[data-type=signaturebox] input:focus~label, span.FITB-inptCont[data-type=signaturebox] input:valid~label,
span.FITB-inptCont[data-type=textbox] input:focus~label, span.FITB-inptCont[data-type=textbox] input:valid~label,
span.FITB-inptCont[data-type=timebox] input:focus~label, span.FITB-inptCont[data-type=timebox] input:valid~label {
color: #57647e;
}
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.form-all {
font-family: Inter, sans-serif;
}
.form-label.form-label-auto {
display: block;
float: none;
text-align: left;
width: 100%;
}
.form-line {
margin-top: 12px;
margin-bottom: 12px;
padding-top: 0;
padding-bottom: 0;
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.form-all {
max-width: 700px;
width: 100%;
}
.form-label.form-label-left,
.form-label.form-label-right,
.form-label.form-label-left.form-label-auto,
.form-label.form-label-right.form-label-auto {
width: 230px;
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.form-all {
font-size: 16px
}
.supernova .form-all, .form-all {
background-color: #FFFFFF;
}
.form-all {
color: #000000;
}
.form-header-group .form-header {
color: #000000;
}
.form-header-group .form-subHeader {
color: #000000;
}
.form-label-top,
.form-label-left,
.form-label-right,
.form-html,
.form-checkbox-item label,
.form-radio-item label,
span.FITB .qb-checkbox-label,
span.FITB .qb-radiobox-label,
span.FITB .form-radio label,
span.FITB .form-checkbox label,
[data-blotid][data-type=checkbox] [data-labelid],
[data-blotid][data-type=radiobox] [data-labelid],
span.FITB-inptCont[data-type=checkbox] label,
span.FITB-inptCont[data-type=radiobox] label {
color: #000000;
}
.form-sub-label {
color: #1a1a1a;
}
.supernova {
background-color: #F3F3FE;
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.supernova body {
background: transparent;
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.form-textbox,
.form-textarea,
.form-dropdown,
.form-radio-other-input,
.form-checkbox-other-input,
.form-captcha input,
.form-spinner input {
background-color: #FFFFFF;
}
.supernova {
background-repeat: no-repeat;
background-size:auto;
background-attachment: scroll;
background-position: center top;
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background-image: none;
}
.form-all {
background-image: none;
}
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JotForm.newPaymentUI = true;
JotForm.originalLanguage = "en";
JotForm.isFormViewTrackingAllowed = true;
JotForm.replaceTagTest = true;
JotForm.uploadServerURL = "https://upload.jotform.com/upload";
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JotForm.calendarOther = {"today":"Today"};
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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\: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-10{gap:2.5rem}[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-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\:mb-16{margin-bottom:4rem}[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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jfa-spin-loader{to{transform:rotate(1turn)}}@keyframes jfa-zoom-in{0%{opacity:0;transform:scale3d(.3,.3,.3)}50%{opacity:1}}@keyframes jfa-zoom-out{0%{opacity:1}50%{opacity:0;transform:scale3d(.3,.3,.3)}to{opacity:0;pointer-events:none}}.anim{animation-duration:.5s;animation-fill-mode:forwards}.bounce{animation-name:jfa-bounce;transform-origin:center 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.logo{min-width:2rem;max-width:4rem;font-size:.75rem;-o-object-fit:contain;object-fit:contain;width:auto;height:2rem}.jfGovernmentWarningBanner .warning-text{-webkit-margin-before:0;margin-block-start:0;-webkit-margin-after:0;margin-block-end:0;font-size:.875rem;line-height:1.125rem;color:#0a1551;text-wrap:pretty}.jfGovernmentWarningBanner .read-more{border:none;font-size:.875rem;line-height:1.125rem;padding-inline:0;background-color:rgba(0,0,0,0);padding-block:0;-webkit-appearance:none;appearance:none;font-weight:500;cursor:pointer;text-decoration:underline;color:#0066c3}.jfGovernmentWarningBanner .close-button{-webkit-appearance:none;appearance:none;border:none;background-color:#dadef3}</style></head>
<body>
<form class="jotform-form" onsubmit="return typeof testSubmitFunction !== 'undefined' && testSubmitFunction();" action="https://submit.jotform.com/submit/243195639503158" method="post" name="form_243195639503158" id="243195639503158" accept-charset="utf-8" autocomplete="on" novalidate="true"><input type="hidden" name="formID" value="243195639503158"><input type="hidden" id="JWTContainer" value=""><input type="hidden" id="cardinalOrderNumber" value=""><input type="hidden" id="jsExecutionTracker" name="jsExecutionTracker" value="build-date-1731966335522=>init-started:1731966336223=>validator-called:1731966336337=>validator-mounted-false:1731966336338=>init-complete:1731966336349"><input type="hidden" id="submitSource" name="submitSource" value="mounted"><input type="hidden" id="buildDate" name="buildDate" value="1731966335522"><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:700px"><img src="https://www.jotform.com/uploads/sackpromotion01/form_files/kehp_logo-removebg-preview.6737b4dcd01ca3.90270506.png" class="form-page-cover-image" width="190" height="178" aria-label="Form Logo" style="aspect-ratio:190/178"></div>
</div>
<div role="main" class="form-all">
<ul class="form-section page-section">
<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 httal htvam">
<h1 id="header_1" class="form-header" data-component="header">VERIFY</h1>
</div>
</div>
</li>
<li class="form-line jf-required" 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"> Full Name<span class="form-required">*</span> </label>
<div id="cid_3" class="form-input-wide jf-required" 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_fullName3[first]" class="form-textbox validate[required]" data-defaultvalue="" autocomplete="section-input_3 given-name" size="10" data-component="first" aria-labelledby="label_3 sublabel_3_first" required="" 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_fullName3[last]" class="form-textbox validate[required]" data-defaultvalue="" autocomplete="section-input_3 family-name" size="15" data-component="last" aria-labelledby="label_3 sublabel_3_last" required="" 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 jf-required" data-type="control_address" id="id_4" data-css-selector="id_4"><label class="form-label form-label-top form-label-auto" id="label_4" for="input_4_addr_line1" aria-hidden="false"> Address<span class="form-required">*</span> </label>
<div id="cid_4" class="form-input-wide jf-required" data-layout="full">
<div summary="" class="form-address-table jsTest-addressField">
<div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-street-line jsTest-address-lineField"><span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_4_addr_line1" name="q4_address4[addr_line1]" class="form-textbox validate[required] form-address-line" data-defaultvalue="" autocomplete="section-input_4 address-line1" data-component="address_line_1" aria-labelledby="label_4 sublabel_4_addr_line1" required="" value="" maxlength="100"><label class="form-sub-label" for="input_4_addr_line1" id="sublabel_4_addr_line1" style="min-height:13px">Street Address</label></span></span></div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-street-line jsTest-address-lineField"><span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_4_addr_line2" name="q4_address4[addr_line2]" class="form-textbox form-address-line" data-defaultvalue="" autocomplete="section-input_4 address-line2" data-component="address_line_2" aria-labelledby="label_4 sublabel_4_addr_line2" value="" maxlength="100"><label class="form-sub-label" for="input_4_addr_line2" id="sublabel_4_addr_line2" style="min-height:13px">Street Address Line 2</label></span></span></div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-city-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_4_city" name="q4_address4[city]" class="form-textbox validate[required] form-address-city" data-defaultvalue="" autocomplete="section-input_4 address-level2" data-component="city" aria-labelledby="label_4 sublabel_4_city" required="" value="" maxlength="60"><label class="form-sub-label" for="input_4_city" id="sublabel_4_city" style="min-height:13px">City</label></span></span><span class="form-address-line form-address-state-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_4_state" name="q4_address4[state]" class="form-textbox validate[required] form-address-state" data-defaultvalue="" autocomplete="section-input_4 address-level1" data-component="state" aria-labelledby="label_4 sublabel_4_state" required="" value="" maxlength="60"><label class="form-sub-label" for="input_4_state" id="sublabel_4_state" style="min-height:13px">State / Province</label></span></span></div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-zip-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_4_postal" name="q4_address4[postal]" class="form-textbox validate[required] form-address-postal" data-defaultvalue="" autocomplete="section-input_4 postal-code" data-component="zip" aria-labelledby="label_4 sublabel_4_postal" required="" value="" maxlength="20"><label class="form-sub-label" for="input_4_postal" id="sublabel_4_postal" style="min-height:13px">Postal / Zip Code</label></span></span></div>
</div>
</div>
</li>
<li class="form-line form-line-column form-col-1 jf-required" 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<span class="form-required">*</span> </label>
<div id="cid_5" class="form-input-wide jf-required" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="tel" id="input_5_full" name="q5_phoneNumber5[full]" data-type="mask-number" class="mask-phone-number form-textbox validate[required, 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" required="" value="" inputmode="text" maskvalue="(###) ###-####"></span> </div>
</li>
<li class="form-line form-line-column form-col-2" 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"> E-mail </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_email6" class="form-textbox validate[Email]" data-defaultvalue="" autocomplete="section-input_6 email" style="width:310px" size="310" placeholder="ex: [email protected]" 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_divider" id="id_16" data-css-selector="id_16">
<div id="cid_16" class="form-input-wide" data-layout="full">
<div class="divider" data-component="divider" style="border-bottom-width:1px;border-bottom-style:solid;border-color:#FFFFFF;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px"></div>
</div>
</li>
<li class="form-line jf-required" data-type="control_datetime" id="id_31" data-css-selector="id_31"><label class="form-label form-label-top form-label-auto" id="label_31" for="lite_mode_31" aria-hidden="false"> Date Of Birth<span class="form-required">*</span> </label>
<div id="cid_31" class="form-input-wide jf-required" 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[required, limitDate]" id="month_31" name="q31_date[month]" type="tel" size="2" data-maxlength="2" data-age="" maxlength="2" required="" autocomplete="off" aria-labelledby="label_31 sublabel_31_month" value="" inputmode="numeric"><span class="date-separate" aria-hidden="true"> -</span><label class="form-sub-label" for="month_31" id="sublabel_31_month" style="min-height:13px">Month</label></span><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[required, limitDate]" id="day_31" name="q31_date[day]" type="tel" size="2" data-maxlength="2" data-age="" maxlength="2" required="" autocomplete="off" aria-labelledby="label_31 sublabel_31_day" value="" inputmode="numeric"><span class="date-separate" aria-hidden="true"> -</span><label class="form-sub-label" for="day_31" id="sublabel_31_day" style="min-height:13px">Day</label></span><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[required, limitDate]" id="year_31" name="q31_date[year]" type="tel" size="4" data-maxlength="4" data-age="" maxlength="4" required="" autocomplete="off" aria-labelledby="label_31 sublabel_31_year" value=""><label class="form-sub-label" for="year_31" id="sublabel_31_year" style="min-height:13px">Year</label></span></div><span class="form-sub-label-container" style="vertical-align:top"><input class="form-textbox validate[required, limitDate, validateLiteDate]" id="lite_mode_31" type="text" size="12" data-maxlength="12" data-age="" required="" data-format="mmddyyyy" data-seperator="-" placeholder="MM-DD-YYYY" data-placeholder="MM-DD-YYYY" autocomplete="off" aria-labelledby="label_31" value="" inputmode="numeric"><img class=" newDefaultTheme-dateIcon icon-liteMode" alt="Pick a Date" id="input_31_pick" src="https://cdn.jotfor.ms/images/calendar.png" 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"><label class="form-sub-label is-empty" for="lite_mode_31" id="sublabel_31_litemode" style="min-height:13px"></label></span>
</div>
</div>
</li>
<li class="form-line" data-type="control_divider" id="id_29" data-css-selector="id_29">
<div id="cid_29" class="form-input-wide" data-layout="full">
<div class="divider" data-component="divider" style="border-bottom-width:1px;border-bottom-style:solid;border-color:#FFFFFF;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px"></div>
</div>
</li>
<li class="form-line form-line-column form-col-1 jf-required" 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"> SSN<span class="form-required">*</span> </label>
<div id="cid_9" class="form-input-wide jf-required" data-layout="half"> <input type="text" id="input_9" name="q9_ssn" data-type="input-textbox" class="form-textbox validate[required, Numeric, minCharLimit]" data-defaultvalue="" style="width:310px" size="310" maxlength="9" data-minlength="9" placeholder=" 111-11-1111" data-component="textbox" aria-labelledby="label_9" required="" value=""> </div>
</li>
<li class="form-line" data-type="control_button" id="id_25" data-css-selector="id_25">
<div id="cid_25" class="form-input-wide" data-layout="full">
<div data-align="auto" class="form-buttons-wrapper form-buttons-auto jsTest-button-wrapperField"><button id="input_25" type="submit" class="form-submit-button form-submit-button-navy-700 submit-button jf-form-buttons jsTest-submitField legacy-submit" data-component="button" data-content="" aria-live="polite">Submit</button></div>
</div>
</li>
<li style="clear:both"></li>
<li style="display:none">Should be Empty: <input type="text" name="website" value=""></li>
</ul>
</div>
<script>
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JotForm.poweredByText = "Powered by Jotform";
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<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: 284px;" id="calendar_31"><table role="grid"><thead><div class="calendar-new-header"><div class="calendar-new-month"><span>November</span><button class="button previousMonth" aria-label="Previous Month, current month is November">‹</button><button class="button nextMonth" aria-label="Next Month, current month is November">›</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;">November 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="otherDay weekend" aria-label="Sunday, October 27, 2024" data-date="10/27/2024" aria-selected="false">27</td><td tabindex="-1" class="otherDay" aria-label="Monday, October 28, 2024" data-date="10/28/2024" aria-selected="false">28</td><td tabindex="-1" class="otherDay" aria-label="Tuesday, October 29, 2024" data-date="10/29/2024" aria-selected="false">29</td><td tabindex="-1" class="otherDay" aria-label="Wednesday, October 30, 2024" data-date="10/30/2024" aria-selected="false">30</td><td tabindex="-1" class="otherDay" aria-label="Thursday, October 31, 2024" data-date="10/31/2024" aria-selected="false">31</td><td tabindex="-1" class="" aria-label="Friday, November 1, 2024" data-date="11/1/2024" aria-selected="false">1</td><td tabindex="-1" class="weekend" aria-label="Saturday, November 2, 2024" data-date="11/2/2024" aria-selected="false">2</td></tr><tr class="days"><td tabindex="-1" class="weekend" aria-label="Sunday, November 3, 2024" data-date="11/3/2024" aria-selected="false">3</td><td tabindex="-1" class="" aria-label="Monday, November 4, 2024" data-date="11/4/2024" aria-selected="false">4</td><td tabindex="-1" class="" aria-label="Tuesday, November 5, 2024" data-date="11/5/2024" aria-selected="false">5</td><td tabindex="-1" class="" aria-label="Wednesday, November 6, 2024" data-date="11/6/2024" aria-selected="false">6</td><td tabindex="-1" class="" aria-label="Thursday, November 7, 2024" data-date="11/7/2024" aria-selected="false">7</td><td tabindex="-1" class="" aria-label="Friday, November 8, 2024" data-date="11/8/2024" aria-selected="false">8</td><td tabindex="-1" class="weekend" aria-label="Saturday, November 9, 2024" data-date="11/9/2024" aria-selected="false">9</td></tr><tr class="days"><td tabindex="-1" class="weekend" aria-label="Sunday, November 10, 2024" data-date="11/10/2024" aria-selected="false">10</td><td tabindex="-1" class="" aria-label="Monday, November 11, 2024" data-date="11/11/2024" aria-selected="false">11</td><td tabindex="-1" class="" aria-label="Tuesday, November 12, 2024" data-date="11/12/2024" aria-selected="false">12</td><td tabindex="-1" class="" aria-label="Wednesday, November 13, 2024" data-date="11/13/2024" aria-selected="false">13</td><td tabindex="-1" class="" aria-label="Thursday, November 14, 2024" data-date="11/14/2024" aria-selected="false">14</td><td tabindex="-1" class="" aria-label="Friday, November 15, 2024" data-date="11/15/2024" aria-selected="false">15</td><td tabindex="-1" class="weekend" aria-label="Saturday, November 16, 2024" data-date="11/16/2024" aria-selected="false">16</td></tr><tr class="days"><td tabindex="-1" class="weekend" aria-label="Sunday, November 17, 2024" data-date="11/17/2024" aria-selected="false">17</td><td tabindex="0" class="selected today" aria-label="Monday, November 18, 2024" data-date="11/18/2024" aria-selected="true">18</td><td tabindex="-1" class="" aria-label="Tuesday, November 19, 2024" data-date="11/19/2024" aria-selected="false">19</td><td tabindex="-1" class="" aria-label="Wednesday, November 20, 2024" data-date="11/20/2024" aria-selected="false">20</td><td tabindex="-1" class="" aria-label="Thursday, November 21, 2024" data-date="11/21/2024" aria-selected="false">21</td><td tabindex="-1" class="" aria-label="Friday, November 22, 2024" data-date="11/22/2024" aria-selected="false">22</td><td tabindex="-1" class="weekend" aria-label="Saturday, November 23, 2024" data-date="11/23/2024" aria-selected="false">23</td></tr><tr class="days"><td tabindex="-1" class="weekend" aria-label="Sunday, November 24, 2024" data-date="11/24/2024" aria-selected="false">24</td><td tabindex="-1" class="" aria-label="Monday, November 25, 2024" data-date="11/25/2024" aria-selected="false">25</td><td tabindex="-1" class="" aria-label="Tuesday, November 26, 2024" data-date="11/26/2024" aria-selected="false">26</td><td tabindex="-1" class="" aria-label="Wednesday, November 27, 2024" data-date="11/27/2024" aria-selected="false">27</td><td tabindex="-1" class="" aria-label="Thursday, November 28, 2024" data-date="11/28/2024" aria-selected="false">28</td><td tabindex="-1" class="" aria-label="Friday, November 29, 2024" data-date="11/29/2024" aria-selected="false">29</td><td tabindex="-1" class="weekend" aria-label="Saturday, November 30, 2024" data-date="11/30/2024" aria-selected="false">30</td></tr><tr class="days" style="display: none;"><td tabindex="-1" class="otherDay weekend" aria-label="Sunday, December 1, 2024" data-date="12/1/2024" aria-selected="false">1</td><td tabindex="-1" class="otherDay" aria-label="Monday, December 2, 2024" data-date="12/2/2024" aria-selected="false">2</td><td tabindex="-1" class="otherDay" aria-label="Tuesday, December 3, 2024" data-date="12/3/2024" aria-selected="false">3</td><td tabindex="-1" class="otherDay" aria-label="Wednesday, December 4, 2024" data-date="12/4/2024" aria-selected="false">4</td><td tabindex="-1" class="otherDay" aria-label="Thursday, December 5, 2024" data-date="12/5/2024" aria-selected="false">5</td><td tabindex="-1" class="otherDay" aria-label="Friday, December 6, 2024" data-date="12/6/2024" aria-selected="false">6</td><td tabindex="-1" class="otherDay weekend" aria-label="Saturday, December 7, 2024" data-date="12/7/2024" aria-selected="false">7</td></tr><tr class="days" style="display: none;"><td tabindex="-1" class="otherDay weekend" aria-label="Sunday, December 8, 2024" data-date="12/8/2024" aria-selected="false">8</td><td tabindex="-1" class="otherDay" aria-label="Monday, December 9, 2024" data-date="12/9/2024" aria-selected="false">9</td><td tabindex="-1" class="otherDay" aria-label="Tuesday, December 10, 2024" data-date="12/10/2024" aria-selected="false">10</td><td tabindex="-1" class="otherDay" aria-label="Wednesday, December 11, 2024" data-date="12/11/2024" aria-selected="false">11</td><td tabindex="-1" class="otherDay" aria-label="Thursday, December 12, 2024" data-date="12/12/2024" aria-selected="false">12</td><td tabindex="-1" class="otherDay" aria-label="Friday, December 13, 2024" data-date="12/13/2024" aria-selected="false">13</td><td tabindex="-1" class="otherDay weekend" aria-label="Saturday, December 14, 2024" data-date="12/14/2024" aria-selected="false">14</td></tr></tbody></table></div></body></html>