/*jslint nomen:false, debug:true, evil:true, vars:false, browser:true, forin:true, undef:false, white:false */
/**
* Includes a Form with javascript
* @param {Object} formId
* @param {Object} initialHeight
* @param {Object} iframeCode
*/
function FrameBuilder (formId, appendTo, initialHeight, iframeCode){
this.formId = formId;
this.initialHeight = initialHeight;
this.iframeCode = iframeCode;
this.frame = null;
this.timeInterval= 200;
this.appendTo = appendTo || false;
// initialize function for object
this.init = function(){
this.createFrame();
this.addFrameContent(this.iframeCode);
};
// Create the frame
this.createFrame = function(){
var htmlCode = "<"+"iframe src=\"\" allowtransparency=\"true\" frameborder=\"0\" name=\""+this.formId+"\" id=\""+this.formId+"\" style=\"width:100%; height:"+this.initialHeight+"px; border:none;\" scrolling=\"no\">";
if(this.appendTo === false){
document.write(htmlCode);
}else{
var tmp = document.createElement('div');
tmp.innerHTML = htmlCode;
var a = this.appendTo;
document.getElementById(a).appendChild(tmp.firstChild);
}
// also get the frame for future use.
this.frame = document.getElementById(this.formId);
// set the time on the on load event of the frame
this.addEvent(this.frame, 'load', this.bindMethod(this.setTimer, this));
};
// add event function for different browsers
this.addEvent = function( obj, type, fn ) {
if ( obj.attachEvent ) {
obj["e"+type+fn] = fn;
obj[type+fn] = function() { obj["e"+type+fn]( window.event ); };
obj.attachEvent( "on"+type, obj[type+fn] );
}
else{
obj.addEventListener( type, fn, false );
}
};
this.addFrameContent = function (string){
string = string.replace(new RegExp('src\\=\\"[^"]*captcha.php\"><\/scr'+'ipt>', 'gim'), 'src="http://api.recaptcha.net/js/recaptcha_ajax.js"><'+'div id="recaptcha_div"><'+'/div>'+
'<'+'style>#recaptcha_logo{ display:none;} #recaptcha_tagline{display:none;} #recaptcha_table{border:none !important;} .recaptchatable .recaptcha_image_cell, #recaptcha_table{ background-color:transparent !important; } <'+'/style>'+
'<'+'script defer="defer"> window.onload = function(){ Recaptcha.create("6Ld9UAgAAAAAAMon8zjt30tEZiGQZ4IIuWXLt1ky", "recaptcha_div", {theme: "clean",tabindex: 0,callback: function (){'+
'if (document.getElementById("uword")) { document.getElementById("uword").parentNode.removeChild(document.getElementById("uword")); } if (window["validate"] !== undefined) { if (document.getElementById("recaptcha_response_field")){ document.getElementById("recaptcha_response_field").onblur = function(){ validate(document.getElementById("recaptcha_response_field"), "Required"); } } } if (document.getElementById("recaptcha_response_field")){ document.getElementsByName("recaptcha_challenge_field")[0].setAttribute("name", "anum"); } if (document.getElementById("recaptcha_response_field")){ document.getElementsByName("recaptcha_response_field")[0].setAttribute("name", "qCap"); }}})'+
' }<'+'/script>');
string = string.replace(/(type="text\/javascript">)\s+(validate\(\"[^"]*"\);)/, '$1 jTime = setInterval(function(){if("validate" in window){$2clearTimeout(jTime);}}, 1000);');
var frameDocument = (this.frame.contentWindow) ? this.frame.contentWindow : (this.frame.contentDocument.document) ? this.frame.contentDocument.document : this.frame.contentDocument;
frameDocument.document.open();
frameDocument.document.write(string);
setTimeout( function(){
frameDocument.document.close();
try{
if('JotFormFrameLoaded' in window){
JotFormFrameLoaded();
}
}catch(e){}
},200);
};
this.setTimer = function(){
var self = this;
this.interval = setTimeout(function(){self.changeHeight();},this.timeInterval);
};
this.changeHeight = function (){
var actualHeight = this.getBodyHeight();
var currentHeight = this.getViewPortHeight();
if(actualHeight === undefined){
this.frame.style.height = "100%";
if(!this.frame.style.minHeight){
this.frame.style.minHeight = "300px";
}
}else if (Math.abs(actualHeight - currentHeight) > 18){
this.frame.style.height = (actualHeight)+"px";
}
this.setTimer();
};
this.bindMethod = function(method, scope) {
return function() {
method.apply(scope,arguments);
};
};
this.getBodyHeight = function (){
var height;
var scrollHeight;
var offsetHeight;
try{ // Prevent IE from throw errors
if (this.frame.contentWindow.document.height){
height = this.frame.contentWindow.document.height;
//Emre: to prevent "iframe height" problem (61059)
if (this.frame.contentWindow.document.body.scrollHeight){
height = scrollHeight = this.frame.contentWindow.document.body.scrollHeight;
}
if (this.frame.contentWindow.document.body.offsetHeight){
height = offsetHeight = this.frame.contentWindow.document.body.offsetHeight;
}
} else if (this.frame.contentWindow.document.body){
if (this.frame.contentWindow.document.body.scrollHeight){
height = scrollHeight = this.frame.contentWindow.document.body.scrollHeight;
}
if (this.frame.contentWindow.document.body.offsetHeight){
height = offsetHeight = this.frame.contentWindow.document.body.offsetHeight;
}
if (scrollHeight && offsetHeight){
height = Math.max(scrollHeight, offsetHeight);
}
}
}catch(e){ }
return height;
};
this.getViewPortHeight = function(){
var height = 0;
try{ // Prevent IE from throw errors
if (this.frame.contentWindow.window.innerHeight)
{
height = this.frame.contentWindow.window.innerHeight - 18;
}
else if ((this.frame.contentWindow.document.documentElement) &&
(this.frame.contentWindow.document.documentElement.clientHeight))
{
height = this.frame.contentWindow.document.documentElement.clientHeight;
}
else if ((this.frame.contentWindow.document.body) &&
(this.frame.contentWindow.document.body.clientHeight))
{
height = this.frame.contentWindow.document.body.clientHeight;
}
}catch(e){ }
return height;
};
this.init();
}
FrameBuilder.get = [];
var i90242456215 = new FrameBuilder("90242456215", false, "", "\n\n\n\n\nForm<\/title>\n<link href=\"http:\/\/max.jotfor.ms\/min\/g=formCss?3.0.2435\" rel=\"stylesheet\" type=\"text\/css\" \/>\n<style type=\"text\/css\">\n .form-label{\n width:150px !important;\n }\n .form-label-left{\n width:150px !important;\n }\n .form-line{\n padding:5px;\n }\n .form-label-right{\n width:150px !important;\n }\n body, html{\n margin:0;\n padding:0;\n background:#ffffff;\n }\n\n .form-all{\n margin:0px auto;\n padding-top:0px;\n width:690px;\n background:#ffffff;\n color:#333333 !important;\n font-family:Verdana;\n font-size:12px;\n }\n<\/style>\n\n<script src=\"http:\/\/max.jotfor.ms\/min\/g=jotform?3.0.2435\" type=\"text\/javascript\"><\/script>\n<script type=\"text\/javascript\">\n var jsTime = setInterval(function(){try{\n JotForm.jsForm = true;\n\n JotForm.init(function(){\n JotForm.description('input_54', '20');\n JotForm.description('input_55', '20');\n JotForm.description('input_52', '20');\n JotForm.description('input_51', '20');\n JotForm.totalCounter({\"input_33_100\":{\"price\":\"35\",\"quantityField\":\"input_33_quantity_100_0\"},\"input_33_101\":{\"price\":\"90\",\"quantityField\":\"input_33_quantity_101_0\"},\"input_33_102\":{\"price\":\"250\",\"quantityField\":\"input_33_quantity_102_0\"},\"input_33_103\":{\"price\":\"45\"},\"input_33_104\":{\"price\":\"125\"},\"input_33_105\":{\"price\":\"10\",\"quantityField\":\"input_33_quantity_105_0\"},\"input_33_106\":{\"price\":\"5\",\"quantityField\":\"input_33_quantity_106_0\"},\"input_33_109\":{\"price\":\"25\",\"quantityField\":\"input_33_quantity_109_0\"},\"input_33_110\":{\"price\":\"5\"},\"input_33_111\":{\"price\":\"3\",\"quantityField\":\"input_33_quantity_111_0\"},\"input_33_118\":{\"price\":\"10\",\"quantityField\":\"input_33_quantity_118_0\"},\"input_33_119\":{\"price\":\"5\",\"quantityField\":\"input_33_quantity_119_0\"}});\n JotForm.initCaptcha('input_50');\n });\n\n clearInterval(jsTime);\n }catch(e){}}, 1000);\n<\/script>\n<\/head>\n<body>\n<form class=\"jotform-form\" action=\"http:\/\/submit.jotform.com\/submit.php\" method=\"post\" name=\"form_90242456215\" id=\"90242456215\" accept-charset=\"utf-8\">\n <input type=\"hidden\" name=\"formID\" value=\"90242456215\" \/>\n <div class=\"form-all\">\n <ul class=\"form-section\">\n <li id=\"cid_35\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_35\" class=\"form-header\">\n 2012 Membership Application\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_64\">\n <label class=\"form-label-left\" id=\"label_64\" for=\"input_64\"> Click to edit <\/label>\n <div id=\"cid_64\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_64_0\" name=\"q64_clickTo[]\" value=\"Renewal\" \/>\n <label for=\"input_64_0\"> Renewal <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_64_1\" name=\"q64_clickTo[]\" value=\"New Member\" \/>\n <label for=\"input_64_1\"> New Member <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_2\">\n <label class=\"form-label-left\" id=\"label_2\" for=\"input_2\">\n Full Name:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_2\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_2\" name=\"q2_fullName\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_54\">\n <label class=\"form-label-left\" id=\"label_54\" for=\"input_54\"> Birth Date <\/label>\n <div id=\"cid_54\" class=\"form-input\"><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q54_birthDate[month]\" id=\"input_54_month\">\n <option> <\/option>\n <option value=\"January\"> January <\/option>\n <option value=\"February\"> February <\/option>\n <option value=\"March\"> March <\/option>\n <option value=\"April\"> April <\/option>\n <option value=\"May\"> May <\/option>\n <option value=\"June\"> June <\/option>\n <option value=\"July\"> July <\/option>\n <option value=\"August\"> August <\/option>\n <option value=\"September\"> September <\/option>\n <option value=\"October\"> October <\/option>\n <option value=\"November\"> November <\/option>\n <option value=\"December\"> December <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_54_month\" id=\"sublabel_month\"> Month <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q54_birthDate[day]\" id=\"input_54_day\">\n <option> <\/option>\n <option value=\"1\"> 1 <\/option>\n <option value=\"2\"> 2 <\/option>\n <option value=\"3\"> 3 <\/option>\n <option value=\"4\"> 4 <\/option>\n <option value=\"5\"> 5 <\/option>\n <option value=\"6\"> 6 <\/option>\n <option value=\"7\"> 7 <\/option>\n <option value=\"8\"> 8 <\/option>\n <option value=\"9\"> 9 <\/option>\n <option value=\"10\"> 10 <\/option>\n <option value=\"11\"> 11 <\/option>\n <option value=\"12\"> 12 <\/option>\n <option value=\"13\"> 13 <\/option>\n <option value=\"14\"> 14 <\/option>\n <option value=\"15\"> 15 <\/option>\n <option value=\"16\"> 16 <\/option>\n <option value=\"17\"> 17 <\/option>\n <option value=\"18\"> 18 <\/option>\n <option value=\"19\"> 19 <\/option>\n <option value=\"20\"> 20 <\/option>\n <option value=\"21\"> 21 <\/option>\n <option value=\"22\"> 22 <\/option>\n <option value=\"23\"> 23 <\/option>\n <option value=\"24\"> 24 <\/option>\n <option value=\"25\"> 25 <\/option>\n <option value=\"26\"> 26 <\/option>\n <option value=\"27\"> 27 <\/option>\n <option value=\"28\"> 28 <\/option>\n <option value=\"29\"> 29 <\/option>\n <option value=\"30\"> 30 <\/option>\n <option value=\"31\"> 31 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_54_day\" id=\"sublabel_day\"> Day <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q54_birthDate[year]\" id=\"input_54_year\">\n <option> <\/option>\n <option value=\"2016\"> 2016 <\/option>\n <option value=\"2015\"> 2015 <\/option>\n <option value=\"2014\"> 2014 <\/option>\n <option value=\"2013\"> 2013 <\/option>\n <option value=\"2012\"> 2012 <\/option>\n <option value=\"2011\"> 2011 <\/option>\n <option value=\"2010\"> 2010 <\/option>\n <option value=\"2009\"> 2009 <\/option>\n <option value=\"2008\"> 2008 <\/option>\n <option value=\"2007\"> 2007 <\/option>\n <option value=\"2006\"> 2006 <\/option>\n <option value=\"2005\"> 2005 <\/option>\n <option value=\"2004\"> 2004 <\/option>\n <option value=\"2003\"> 2003 <\/option>\n <option value=\"2002\"> 2002 <\/option>\n <option value=\"2001\"> 2001 <\/option>\n <option value=\"2000\"> 2000 <\/option>\n <option value=\"1999\"> 1999 <\/option>\n <option value=\"1998\"> 1998 <\/option>\n <option value=\"1997\"> 1997 <\/option>\n <option value=\"1996\"> 1996 <\/option>\n <option value=\"1995\"> 1995 <\/option>\n <option value=\"1994\"> 1994 <\/option>\n <option value=\"1993\"> 1993 <\/option>\n <option value=\"1992\"> 1992 <\/option>\n <option value=\"1991\"> 1991 <\/option>\n <option value=\"1990\"> 1990 <\/option>\n <option value=\"1989\"> 1989 <\/option>\n <option value=\"1988\"> 1988 <\/option>\n <option value=\"1987\"> 1987 <\/option>\n <option value=\"1986\"> 1986 <\/option>\n <option value=\"1985\"> 1985 <\/option>\n <option value=\"1984\"> 1984 <\/option>\n <option value=\"1983\"> 1983 <\/option>\n <option value=\"1982\"> 1982 <\/option>\n <option value=\"1981\"> 1981 <\/option>\n <option value=\"1980\"> 1980 <\/option>\n <option value=\"1979\"> 1979 <\/option>\n <option value=\"1978\"> 1978 <\/option>\n <option value=\"1977\"> 1977 <\/option>\n <option value=\"1976\"> 1976 <\/option>\n <option value=\"1975\"> 1975 <\/option>\n <option value=\"1974\"> 1974 <\/option>\n <option value=\"1973\"> 1973 <\/option>\n <option value=\"1972\"> 1972 <\/option>\n <option value=\"1971\"> 1971 <\/option>\n <option value=\"1970\"> 1970 <\/option>\n <option value=\"1969\"> 1969 <\/option>\n <option value=\"1968\"> 1968 <\/option>\n <option value=\"1967\"> 1967 <\/option>\n <option value=\"1966\"> 1966 <\/option>\n <option value=\"1965\"> 1965 <\/option>\n <option value=\"1964\"> 1964 <\/option>\n <option value=\"1963\"> 1963 <\/option>\n <option value=\"1962\"> 1962 <\/option>\n <option value=\"1961\"> 1961 <\/option>\n <option value=\"1960\"> 1960 <\/option>\n <option value=\"1959\"> 1959 <\/option>\n <option value=\"1958\"> 1958 <\/option>\n <option value=\"1957\"> 1957 <\/option>\n <option value=\"1956\"> 1956 <\/option>\n <option value=\"1955\"> 1955 <\/option>\n <option value=\"1954\"> 1954 <\/option>\n <option value=\"1953\"> 1953 <\/option>\n <option value=\"1952\"> 1952 <\/option>\n <option value=\"1951\"> 1951 <\/option>\n <option value=\"1950\"> 1950 <\/option>\n <option value=\"1949\"> 1949 <\/option>\n <option value=\"1948\"> 1948 <\/option>\n <option value=\"1947\"> 1947 <\/option>\n <option value=\"1946\"> 1946 <\/option>\n <option value=\"1945\"> 1945 <\/option>\n <option value=\"1944\"> 1944 <\/option>\n <option value=\"1943\"> 1943 <\/option>\n <option value=\"1942\"> 1942 <\/option>\n <option value=\"1941\"> 1941 <\/option>\n <option value=\"1940\"> 1940 <\/option>\n <option value=\"1939\"> 1939 <\/option>\n <option value=\"1938\"> 1938 <\/option>\n <option value=\"1937\"> 1937 <\/option>\n <option value=\"1936\"> 1936 <\/option>\n <option value=\"1935\"> 1935 <\/option>\n <option value=\"1934\"> 1934 <\/option>\n <option value=\"1933\"> 1933 <\/option>\n <option value=\"1932\"> 1932 <\/option>\n <option value=\"1931\"> 1931 <\/option>\n <option value=\"1930\"> 1930 <\/option>\n <option value=\"1929\"> 1929 <\/option>\n <option value=\"1928\"> 1928 <\/option>\n <option value=\"1927\"> 1927 <\/option>\n <option value=\"1926\"> 1926 <\/option>\n <option value=\"1925\"> 1925 <\/option>\n <option value=\"1924\"> 1924 <\/option>\n <option value=\"1923\"> 1923 <\/option>\n <option value=\"1922\"> 1922 <\/option>\n <option value=\"1921\"> 1921 <\/option>\n <option value=\"1920\"> 1920 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_54_year\" id=\"sublabel_year\"> Year <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_12\">\n <label class=\"form-label-left\" id=\"label_12\" for=\"input_12\"> AQHA Number <\/label>\n <div id=\"cid_12\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_12\" name=\"q12_aqhaNumber\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_14\">\n <label class=\"form-label-left\" id=\"label_14\" for=\"input_14\"> Expires: <\/label>\n <div id=\"cid_14\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_14\" name=\"q14_expires\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_3\">\n <label class=\"form-label-left\" id=\"label_3\" for=\"input_3\">\n E-mail:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_3\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_3\" name=\"q3_email\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_44\">\n <label class=\"form-label-left\" id=\"label_44\" for=\"input_44\"> Select One: <\/label>\n <div id=\"cid_44\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_44_0\" name=\"q44_selectOne\" value=\"Open\" \/>\n <label for=\"input_44_0\"> Open <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_44_1\" name=\"q44_selectOne\" value=\"Amateur\" \/>\n <label for=\"input_44_1\"> Amateur <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_44_2\" name=\"q44_selectOne\" value=\"Novice Amateur\" \/>\n <label for=\"input_44_2\"> Novice Amateur <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_44_3\" name=\"q44_selectOne\" value=\"Open Show Program\" \/>\n <label for=\"input_44_3\"> Open Show Program <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_9\">\n <label class=\"form-label-left\" id=\"label_9\" for=\"input_9\">\n Phone:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_9\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_9\" name=\"q9_phone\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_10\">\n <label class=\"form-label-left\" id=\"label_10\" for=\"input_10\">\n Address:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_10\" class=\"form-input\">\n <textarea id=\"input_10\" class=\"form-textarea validate[required]\" name=\"q10_address\" cols=\"30\" rows=\"2\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_0\">\n <label class=\"form-label-left\" id=\"label_0\" for=\"input_0\">\n City:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_0\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_0\" name=\"q0_city\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_11\">\n <label class=\"form-label-left\" id=\"label_11\" for=\"input_11\">\n State:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_11\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_11\" name=\"q11_state\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_7\">\n <label class=\"form-label-left\" id=\"label_7\" for=\"input_7\">\n Zip Code:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_7\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_7\" name=\"q7_zipCode\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_15\">\n <label class=\"form-label-left\" id=\"label_15\" for=\"input_15\"> Back No. Request: <\/label>\n <div id=\"cid_15\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_15\" name=\"q15_backNo\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_41\">\n <div id=\"cid_41\" class=\"form-input-wide\">\n <div id=\"text_41\" class=\"form-html\">\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_17\">\n <label class=\"form-label-left\" id=\"label_17\" for=\"input_17\"> Spouse Name <\/label>\n <div id=\"cid_17\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_17\" name=\"q17_spouseName\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_18\">\n <div id=\"cid_18\" class=\"form-input-wide\">\n <div id=\"text_18\" class=\"form-html\">\n (if family membership)\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_21\">\n <div id=\"cid_21\" class=\"form-input-wide\">\n <div id=\"text_21\" class=\"form-html\">\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_20\">\n <label class=\"form-label-left\" id=\"label_20\" for=\"input_20\"> Youth Name: <\/label>\n <div id=\"cid_20\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_20\" name=\"q20_youthName\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_55\">\n <label class=\"form-label-left\" id=\"label_55\" for=\"input_55\"> Birth Date <\/label>\n <div id=\"cid_55\" class=\"form-input\"><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q55_birthDate55[month]\" id=\"input_55_month\">\n <option> <\/option>\n <option value=\"January\"> January <\/option>\n <option value=\"February\"> February <\/option>\n <option value=\"March\"> March <\/option>\n <option value=\"April\"> April <\/option>\n <option value=\"May\"> May <\/option>\n <option value=\"June\"> June <\/option>\n <option value=\"July\"> July <\/option>\n <option value=\"August\"> August <\/option>\n <option value=\"September\"> September <\/option>\n <option value=\"October\"> October <\/option>\n <option value=\"November\"> November <\/option>\n <option value=\"December\"> December <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_55_month\" id=\"sublabel_month\"> Month <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q55_birthDate55[day]\" id=\"input_55_day\">\n <option> <\/option>\n <option value=\"1\"> 1 <\/option>\n <option value=\"2\"> 2 <\/option>\n <option value=\"3\"> 3 <\/option>\n <option value=\"4\"> 4 <\/option>\n <option value=\"5\"> 5 <\/option>\n <option value=\"6\"> 6 <\/option>\n <option value=\"7\"> 7 <\/option>\n <option value=\"8\"> 8 <\/option>\n <option value=\"9\"> 9 <\/option>\n <option value=\"10\"> 10 <\/option>\n <option value=\"11\"> 11 <\/option>\n <option value=\"12\"> 12 <\/option>\n <option value=\"13\"> 13 <\/option>\n <option value=\"14\"> 14 <\/option>\n <option value=\"15\"> 15 <\/option>\n <option value=\"16\"> 16 <\/option>\n <option value=\"17\"> 17 <\/option>\n <option value=\"18\"> 18 <\/option>\n <option value=\"19\"> 19 <\/option>\n <option value=\"20\"> 20 <\/option>\n <option value=\"21\"> 21 <\/option>\n <option value=\"22\"> 22 <\/option>\n <option value=\"23\"> 23 <\/option>\n <option value=\"24\"> 24 <\/option>\n <option value=\"25\"> 25 <\/option>\n <option value=\"26\"> 26 <\/option>\n <option value=\"27\"> 27 <\/option>\n <option value=\"28\"> 28 <\/option>\n <option value=\"29\"> 29 <\/option>\n <option value=\"30\"> 30 <\/option>\n <option value=\"31\"> 31 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_55_day\" id=\"sublabel_day\"> Day <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q55_birthDate55[year]\" id=\"input_55_year\">\n <option> <\/option>\n <option value=\"2016\"> 2016 <\/option>\n <option value=\"2015\"> 2015 <\/option>\n <option value=\"2014\"> 2014 <\/option>\n <option value=\"2013\"> 2013 <\/option>\n <option value=\"2012\"> 2012 <\/option>\n <option value=\"2011\"> 2011 <\/option>\n <option value=\"2010\"> 2010 <\/option>\n <option value=\"2009\"> 2009 <\/option>\n <option value=\"2008\"> 2008 <\/option>\n <option value=\"2007\"> 2007 <\/option>\n <option value=\"2006\"> 2006 <\/option>\n <option value=\"2005\"> 2005 <\/option>\n <option value=\"2004\"> 2004 <\/option>\n <option value=\"2003\"> 2003 <\/option>\n <option value=\"2002\"> 2002 <\/option>\n <option value=\"2001\"> 2001 <\/option>\n <option value=\"2000\"> 2000 <\/option>\n <option value=\"1999\"> 1999 <\/option>\n <option value=\"1998\"> 1998 <\/option>\n <option value=\"1997\"> 1997 <\/option>\n <option value=\"1996\"> 1996 <\/option>\n <option value=\"1995\"> 1995 <\/option>\n <option value=\"1994\"> 1994 <\/option>\n <option value=\"1993\"> 1993 <\/option>\n <option value=\"1992\"> 1992 <\/option>\n <option value=\"1991\"> 1991 <\/option>\n <option value=\"1990\"> 1990 <\/option>\n <option value=\"1989\"> 1989 <\/option>\n <option value=\"1988\"> 1988 <\/option>\n <option value=\"1987\"> 1987 <\/option>\n <option value=\"1986\"> 1986 <\/option>\n <option value=\"1985\"> 1985 <\/option>\n <option value=\"1984\"> 1984 <\/option>\n <option value=\"1983\"> 1983 <\/option>\n <option value=\"1982\"> 1982 <\/option>\n <option value=\"1981\"> 1981 <\/option>\n <option value=\"1980\"> 1980 <\/option>\n <option value=\"1979\"> 1979 <\/option>\n <option value=\"1978\"> 1978 <\/option>\n <option value=\"1977\"> 1977 <\/option>\n <option value=\"1976\"> 1976 <\/option>\n <option value=\"1975\"> 1975 <\/option>\n <option value=\"1974\"> 1974 <\/option>\n <option value=\"1973\"> 1973 <\/option>\n <option value=\"1972\"> 1972 <\/option>\n <option value=\"1971\"> 1971 <\/option>\n <option value=\"1970\"> 1970 <\/option>\n <option value=\"1969\"> 1969 <\/option>\n <option value=\"1968\"> 1968 <\/option>\n <option value=\"1967\"> 1967 <\/option>\n <option value=\"1966\"> 1966 <\/option>\n <option value=\"1965\"> 1965 <\/option>\n <option value=\"1964\"> 1964 <\/option>\n <option value=\"1963\"> 1963 <\/option>\n <option value=\"1962\"> 1962 <\/option>\n <option value=\"1961\"> 1961 <\/option>\n <option value=\"1960\"> 1960 <\/option>\n <option value=\"1959\"> 1959 <\/option>\n <option value=\"1958\"> 1958 <\/option>\n <option value=\"1957\"> 1957 <\/option>\n <option value=\"1956\"> 1956 <\/option>\n <option value=\"1955\"> 1955 <\/option>\n <option value=\"1954\"> 1954 <\/option>\n <option value=\"1953\"> 1953 <\/option>\n <option value=\"1952\"> 1952 <\/option>\n <option value=\"1951\"> 1951 <\/option>\n <option value=\"1950\"> 1950 <\/option>\n <option value=\"1949\"> 1949 <\/option>\n <option value=\"1948\"> 1948 <\/option>\n <option value=\"1947\"> 1947 <\/option>\n <option value=\"1946\"> 1946 <\/option>\n <option value=\"1945\"> 1945 <\/option>\n <option value=\"1944\"> 1944 <\/option>\n <option value=\"1943\"> 1943 <\/option>\n <option value=\"1942\"> 1942 <\/option>\n <option value=\"1941\"> 1941 <\/option>\n <option value=\"1940\"> 1940 <\/option>\n <option value=\"1939\"> 1939 <\/option>\n <option value=\"1938\"> 1938 <\/option>\n <option value=\"1937\"> 1937 <\/option>\n <option value=\"1936\"> 1936 <\/option>\n <option value=\"1935\"> 1935 <\/option>\n <option value=\"1934\"> 1934 <\/option>\n <option value=\"1933\"> 1933 <\/option>\n <option value=\"1932\"> 1932 <\/option>\n <option value=\"1931\"> 1931 <\/option>\n <option value=\"1930\"> 1930 <\/option>\n <option value=\"1929\"> 1929 <\/option>\n <option value=\"1928\"> 1928 <\/option>\n <option value=\"1927\"> 1927 <\/option>\n <option value=\"1926\"> 1926 <\/option>\n <option value=\"1925\"> 1925 <\/option>\n <option value=\"1924\"> 1924 <\/option>\n <option value=\"1923\"> 1923 <\/option>\n <option value=\"1922\"> 1922 <\/option>\n <option value=\"1921\"> 1921 <\/option>\n <option value=\"1920\"> 1920 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_55_year\" id=\"sublabel_year\"> Year <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_27\">\n <label class=\"form-label-left\" id=\"label_27\" for=\"input_27\"> AQHA Number <\/label>\n <div id=\"cid_27\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_27\" name=\"q27_aqhaNumber27\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_23\">\n <label class=\"form-label-left\" id=\"label_23\" for=\"input_23\"> Back No. Request: <\/label>\n <div id=\"cid_23\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_23\" name=\"q23_backNo23\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_46\">\n <label class=\"form-label-left\" id=\"label_46\" for=\"input_46\"> Please Select One: <\/label>\n <div id=\"cid_46\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_46_0\" name=\"q46_pleaseSelect\" value=\"Youth\" \/>\n <label for=\"input_46_0\"> Youth <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_46_1\" name=\"q46_pleaseSelect\" value=\"Novice Youth\" \/>\n <label for=\"input_46_1\"> Novice Youth <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li id=\"cid_58\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_58\" class=\"form-header\">\n ...\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_24\">\n <label class=\"form-label-left\" id=\"label_24\" for=\"input_24\"> Youth Name: <\/label>\n <div id=\"cid_24\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_24\" name=\"q24_youthName24\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_52\">\n <label class=\"form-label-left\" id=\"label_52\" for=\"input_52\"> Birth Date <\/label>\n <div id=\"cid_52\" class=\"form-input\"><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q52_birthDate52[month]\" id=\"input_52_month\">\n <option> <\/option>\n <option value=\"January\"> January <\/option>\n <option value=\"February\"> February <\/option>\n <option value=\"March\"> March <\/option>\n <option value=\"April\"> April <\/option>\n <option value=\"May\"> May <\/option>\n <option value=\"June\"> June <\/option>\n <option value=\"July\"> July <\/option>\n <option value=\"August\"> August <\/option>\n <option value=\"September\"> September <\/option>\n <option value=\"October\"> October <\/option>\n <option value=\"November\"> November <\/option>\n <option value=\"December\"> December <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_52_month\" id=\"sublabel_month\"> Month <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q52_birthDate52[day]\" id=\"input_52_day\">\n <option> <\/option>\n <option value=\"1\"> 1 <\/option>\n <option value=\"2\"> 2 <\/option>\n <option value=\"3\"> 3 <\/option>\n <option value=\"4\"> 4 <\/option>\n <option value=\"5\"> 5 <\/option>\n <option value=\"6\"> 6 <\/option>\n <option value=\"7\"> 7 <\/option>\n <option value=\"8\"> 8 <\/option>\n <option value=\"9\"> 9 <\/option>\n <option value=\"10\"> 10 <\/option>\n <option value=\"11\"> 11 <\/option>\n <option value=\"12\"> 12 <\/option>\n <option value=\"13\"> 13 <\/option>\n <option value=\"14\"> 14 <\/option>\n <option value=\"15\"> 15 <\/option>\n <option value=\"16\"> 16 <\/option>\n <option value=\"17\"> 17 <\/option>\n <option value=\"18\"> 18 <\/option>\n <option value=\"19\"> 19 <\/option>\n <option value=\"20\"> 20 <\/option>\n <option value=\"21\"> 21 <\/option>\n <option value=\"22\"> 22 <\/option>\n <option value=\"23\"> 23 <\/option>\n <option value=\"24\"> 24 <\/option>\n <option value=\"25\"> 25 <\/option>\n <option value=\"26\"> 26 <\/option>\n <option value=\"27\"> 27 <\/option>\n <option value=\"28\"> 28 <\/option>\n <option value=\"29\"> 29 <\/option>\n <option value=\"30\"> 30 <\/option>\n <option value=\"31\"> 31 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_52_day\" id=\"sublabel_day\"> Day <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q52_birthDate52[year]\" id=\"input_52_year\">\n <option> <\/option>\n <option value=\"2016\"> 2016 <\/option>\n <option value=\"2015\"> 2015 <\/option>\n <option value=\"2014\"> 2014 <\/option>\n <option value=\"2013\"> 2013 <\/option>\n <option value=\"2012\"> 2012 <\/option>\n <option value=\"2011\"> 2011 <\/option>\n <option value=\"2010\"> 2010 <\/option>\n <option value=\"2009\"> 2009 <\/option>\n <option value=\"2008\"> 2008 <\/option>\n <option value=\"2007\"> 2007 <\/option>\n <option value=\"2006\"> 2006 <\/option>\n <option value=\"2005\"> 2005 <\/option>\n <option value=\"2004\"> 2004 <\/option>\n <option value=\"2003\"> 2003 <\/option>\n <option value=\"2002\"> 2002 <\/option>\n <option value=\"2001\"> 2001 <\/option>\n <option value=\"2000\"> 2000 <\/option>\n <option value=\"1999\"> 1999 <\/option>\n <option value=\"1998\"> 1998 <\/option>\n <option value=\"1997\"> 1997 <\/option>\n <option value=\"1996\"> 1996 <\/option>\n <option value=\"1995\"> 1995 <\/option>\n <option value=\"1994\"> 1994 <\/option>\n <option value=\"1993\"> 1993 <\/option>\n <option value=\"1992\"> 1992 <\/option>\n <option value=\"1991\"> 1991 <\/option>\n <option value=\"1990\"> 1990 <\/option>\n <option value=\"1989\"> 1989 <\/option>\n <option value=\"1988\"> 1988 <\/option>\n <option value=\"1987\"> 1987 <\/option>\n <option value=\"1986\"> 1986 <\/option>\n <option value=\"1985\"> 1985 <\/option>\n <option value=\"1984\"> 1984 <\/option>\n <option value=\"1983\"> 1983 <\/option>\n <option value=\"1982\"> 1982 <\/option>\n <option value=\"1981\"> 1981 <\/option>\n <option value=\"1980\"> 1980 <\/option>\n <option value=\"1979\"> 1979 <\/option>\n <option value=\"1978\"> 1978 <\/option>\n <option value=\"1977\"> 1977 <\/option>\n <option value=\"1976\"> 1976 <\/option>\n <option value=\"1975\"> 1975 <\/option>\n <option value=\"1974\"> 1974 <\/option>\n <option value=\"1973\"> 1973 <\/option>\n <option value=\"1972\"> 1972 <\/option>\n <option value=\"1971\"> 1971 <\/option>\n <option value=\"1970\"> 1970 <\/option>\n <option value=\"1969\"> 1969 <\/option>\n <option value=\"1968\"> 1968 <\/option>\n <option value=\"1967\"> 1967 <\/option>\n <option value=\"1966\"> 1966 <\/option>\n <option value=\"1965\"> 1965 <\/option>\n <option value=\"1964\"> 1964 <\/option>\n <option value=\"1963\"> 1963 <\/option>\n <option value=\"1962\"> 1962 <\/option>\n <option value=\"1961\"> 1961 <\/option>\n <option value=\"1960\"> 1960 <\/option>\n <option value=\"1959\"> 1959 <\/option>\n <option value=\"1958\"> 1958 <\/option>\n <option value=\"1957\"> 1957 <\/option>\n <option value=\"1956\"> 1956 <\/option>\n <option value=\"1955\"> 1955 <\/option>\n <option value=\"1954\"> 1954 <\/option>\n <option value=\"1953\"> 1953 <\/option>\n <option value=\"1952\"> 1952 <\/option>\n <option value=\"1951\"> 1951 <\/option>\n <option value=\"1950\"> 1950 <\/option>\n <option value=\"1949\"> 1949 <\/option>\n <option value=\"1948\"> 1948 <\/option>\n <option value=\"1947\"> 1947 <\/option>\n <option value=\"1946\"> 1946 <\/option>\n <option value=\"1945\"> 1945 <\/option>\n <option value=\"1944\"> 1944 <\/option>\n <option value=\"1943\"> 1943 <\/option>\n <option value=\"1942\"> 1942 <\/option>\n <option value=\"1941\"> 1941 <\/option>\n <option value=\"1940\"> 1940 <\/option>\n <option value=\"1939\"> 1939 <\/option>\n <option value=\"1938\"> 1938 <\/option>\n <option value=\"1937\"> 1937 <\/option>\n <option value=\"1936\"> 1936 <\/option>\n <option value=\"1935\"> 1935 <\/option>\n <option value=\"1934\"> 1934 <\/option>\n <option value=\"1933\"> 1933 <\/option>\n <option value=\"1932\"> 1932 <\/option>\n <option value=\"1931\"> 1931 <\/option>\n <option value=\"1930\"> 1930 <\/option>\n <option value=\"1929\"> 1929 <\/option>\n <option value=\"1928\"> 1928 <\/option>\n <option value=\"1927\"> 1927 <\/option>\n <option value=\"1926\"> 1926 <\/option>\n <option value=\"1925\"> 1925 <\/option>\n <option value=\"1924\"> 1924 <\/option>\n <option value=\"1923\"> 1923 <\/option>\n <option value=\"1922\"> 1922 <\/option>\n <option value=\"1921\"> 1921 <\/option>\n <option value=\"1920\"> 1920 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_52_year\" id=\"sublabel_year\"> Year <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_28\">\n <label class=\"form-label-left\" id=\"label_28\" for=\"input_28\"> AQHA Number: <\/label>\n <div id=\"cid_28\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_28\" name=\"q28_aqhaNumber28\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_26\">\n <label class=\"form-label-left\" id=\"label_26\" for=\"input_26\"> Back No. Request: <\/label>\n <div id=\"cid_26\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_26\" name=\"q26_backNo26\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_47\">\n <label class=\"form-label-left\" id=\"label_47\" for=\"input_47\"> Please Select One <\/label>\n <div id=\"cid_47\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_47_0\" name=\"q47_pleaseSelect47\" value=\"Youth\" \/>\n <label for=\"input_47_0\"> Youth <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_47_1\" name=\"q47_pleaseSelect47\" value=\"Novice Youth\" \/>\n <label for=\"input_47_1\"> Novice Youth <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li id=\"cid_60\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_60\" class=\"form-header\">\n ...\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_29\">\n <label class=\"form-label-left\" id=\"label_29\" for=\"input_29\"> Youth Name: <\/label>\n <div id=\"cid_29\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_29\" name=\"q29_youthName29\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_51\">\n <label class=\"form-label-left\" id=\"label_51\" for=\"input_51\"> Birth Date <\/label>\n <div id=\"cid_51\" class=\"form-input\"><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q51_birthDate51[month]\" id=\"input_51_month\">\n <option> <\/option>\n <option value=\"January\"> January <\/option>\n <option value=\"February\"> February <\/option>\n <option value=\"March\"> March <\/option>\n <option value=\"April\"> April <\/option>\n <option value=\"May\"> May <\/option>\n <option value=\"June\"> June <\/option>\n <option value=\"July\"> July <\/option>\n <option value=\"August\"> August <\/option>\n <option value=\"September\"> September <\/option>\n <option value=\"October\"> October <\/option>\n <option value=\"November\"> November <\/option>\n <option value=\"December\"> December <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_51_month\" id=\"sublabel_month\"> Month <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q51_birthDate51[day]\" id=\"input_51_day\">\n <option> <\/option>\n <option value=\"1\"> 1 <\/option>\n <option value=\"2\"> 2 <\/option>\n <option value=\"3\"> 3 <\/option>\n <option value=\"4\"> 4 <\/option>\n <option value=\"5\"> 5 <\/option>\n <option value=\"6\"> 6 <\/option>\n <option value=\"7\"> 7 <\/option>\n <option value=\"8\"> 8 <\/option>\n <option value=\"9\"> 9 <\/option>\n <option value=\"10\"> 10 <\/option>\n <option value=\"11\"> 11 <\/option>\n <option value=\"12\"> 12 <\/option>\n <option value=\"13\"> 13 <\/option>\n <option value=\"14\"> 14 <\/option>\n <option value=\"15\"> 15 <\/option>\n <option value=\"16\"> 16 <\/option>\n <option value=\"17\"> 17 <\/option>\n <option value=\"18\"> 18 <\/option>\n <option value=\"19\"> 19 <\/option>\n <option value=\"20\"> 20 <\/option>\n <option value=\"21\"> 21 <\/option>\n <option value=\"22\"> 22 <\/option>\n <option value=\"23\"> 23 <\/option>\n <option value=\"24\"> 24 <\/option>\n <option value=\"25\"> 25 <\/option>\n <option value=\"26\"> 26 <\/option>\n <option value=\"27\"> 27 <\/option>\n <option value=\"28\"> 28 <\/option>\n <option value=\"29\"> 29 <\/option>\n <option value=\"30\"> 30 <\/option>\n <option value=\"31\"> 31 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_51_day\" id=\"sublabel_day\"> Day <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q51_birthDate51[year]\" id=\"input_51_year\">\n <option> <\/option>\n <option value=\"2016\"> 2016 <\/option>\n <option value=\"2015\"> 2015 <\/option>\n <option value=\"2014\"> 2014 <\/option>\n <option value=\"2013\"> 2013 <\/option>\n <option value=\"2012\"> 2012 <\/option>\n <option value=\"2011\"> 2011 <\/option>\n <option value=\"2010\"> 2010 <\/option>\n <option value=\"2009\"> 2009 <\/option>\n <option value=\"2008\"> 2008 <\/option>\n <option value=\"2007\"> 2007 <\/option>\n <option value=\"2006\"> 2006 <\/option>\n <option value=\"2005\"> 2005 <\/option>\n <option value=\"2004\"> 2004 <\/option>\n <option value=\"2003\"> 2003 <\/option>\n <option value=\"2002\"> 2002 <\/option>\n <option value=\"2001\"> 2001 <\/option>\n <option value=\"2000\"> 2000 <\/option>\n <option value=\"1999\"> 1999 <\/option>\n <option value=\"1998\"> 1998 <\/option>\n <option value=\"1997\"> 1997 <\/option>\n <option value=\"1996\"> 1996 <\/option>\n <option value=\"1995\"> 1995 <\/option>\n <option value=\"1994\"> 1994 <\/option>\n <option value=\"1993\"> 1993 <\/option>\n <option value=\"1992\"> 1992 <\/option>\n <option value=\"1991\"> 1991 <\/option>\n <option value=\"1990\"> 1990 <\/option>\n <option value=\"1989\"> 1989 <\/option>\n <option value=\"1988\"> 1988 <\/option>\n <option value=\"1987\"> 1987 <\/option>\n <option value=\"1986\"> 1986 <\/option>\n <option value=\"1985\"> 1985 <\/option>\n <option value=\"1984\"> 1984 <\/option>\n <option value=\"1983\"> 1983 <\/option>\n <option value=\"1982\"> 1982 <\/option>\n <option value=\"1981\"> 1981 <\/option>\n <option value=\"1980\"> 1980 <\/option>\n <option value=\"1979\"> 1979 <\/option>\n <option value=\"1978\"> 1978 <\/option>\n <option value=\"1977\"> 1977 <\/option>\n <option value=\"1976\"> 1976 <\/option>\n <option value=\"1975\"> 1975 <\/option>\n <option value=\"1974\"> 1974 <\/option>\n <option value=\"1973\"> 1973 <\/option>\n <option value=\"1972\"> 1972 <\/option>\n <option value=\"1971\"> 1971 <\/option>\n <option value=\"1970\"> 1970 <\/option>\n <option value=\"1969\"> 1969 <\/option>\n <option value=\"1968\"> 1968 <\/option>\n <option value=\"1967\"> 1967 <\/option>\n <option value=\"1966\"> 1966 <\/option>\n <option value=\"1965\"> 1965 <\/option>\n <option value=\"1964\"> 1964 <\/option>\n <option value=\"1963\"> 1963 <\/option>\n <option value=\"1962\"> 1962 <\/option>\n <option value=\"1961\"> 1961 <\/option>\n <option value=\"1960\"> 1960 <\/option>\n <option value=\"1959\"> 1959 <\/option>\n <option value=\"1958\"> 1958 <\/option>\n <option value=\"1957\"> 1957 <\/option>\n <option value=\"1956\"> 1956 <\/option>\n <option value=\"1955\"> 1955 <\/option>\n <option value=\"1954\"> 1954 <\/option>\n <option value=\"1953\"> 1953 <\/option>\n <option value=\"1952\"> 1952 <\/option>\n <option value=\"1951\"> 1951 <\/option>\n <option value=\"1950\"> 1950 <\/option>\n <option value=\"1949\"> 1949 <\/option>\n <option value=\"1948\"> 1948 <\/option>\n <option value=\"1947\"> 1947 <\/option>\n <option value=\"1946\"> 1946 <\/option>\n <option value=\"1945\"> 1945 <\/option>\n <option value=\"1944\"> 1944 <\/option>\n <option value=\"1943\"> 1943 <\/option>\n <option value=\"1942\"> 1942 <\/option>\n <option value=\"1941\"> 1941 <\/option>\n <option value=\"1940\"> 1940 <\/option>\n <option value=\"1939\"> 1939 <\/option>\n <option value=\"1938\"> 1938 <\/option>\n <option value=\"1937\"> 1937 <\/option>\n <option value=\"1936\"> 1936 <\/option>\n <option value=\"1935\"> 1935 <\/option>\n <option value=\"1934\"> 1934 <\/option>\n <option value=\"1933\"> 1933 <\/option>\n <option value=\"1932\"> 1932 <\/option>\n <option value=\"1931\"> 1931 <\/option>\n <option value=\"1930\"> 1930 <\/option>\n <option value=\"1929\"> 1929 <\/option>\n <option value=\"1928\"> 1928 <\/option>\n <option value=\"1927\"> 1927 <\/option>\n <option value=\"1926\"> 1926 <\/option>\n <option value=\"1925\"> 1925 <\/option>\n <option value=\"1924\"> 1924 <\/option>\n <option value=\"1923\"> 1923 <\/option>\n <option value=\"1922\"> 1922 <\/option>\n <option value=\"1921\"> 1921 <\/option>\n <option value=\"1920\"> 1920 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_51_year\" id=\"sublabel_year\"> Year <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_31\">\n <label class=\"form-label-left\" id=\"label_31\" for=\"input_31\"> AQHA Number: <\/label>\n <div id=\"cid_31\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_31\" name=\"q31_aqhaNumber31\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_32\">\n <label class=\"form-label-left\" id=\"label_32\" for=\"input_32\"> Back No. Request: <\/label>\n <div id=\"cid_32\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_32\" name=\"q32_backNo32\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_48\">\n <label class=\"form-label-left\" id=\"label_48\" for=\"input_48\"> Please Select One: <\/label>\n <div id=\"cid_48\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_48_0\" name=\"q48_pleaseSelect48\" value=\"Youth\" \/>\n <label for=\"input_48_0\"> Youth <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_48_1\" name=\"q48_pleaseSelect48\" value=\"Novice Youth\" \/>\n <label for=\"input_48_1\"> Novice Youth <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_38\">\n <div id=\"cid_38\" class=\"form-input-wide\">\n <div id=\"text_38\" class=\"form-html\">\n <\/div>\n <\/div>\n <\/li>\n <li id=\"cid_36\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_36\" class=\"form-header\">\n Please select appropriate options:\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_39\">\n <div id=\"cid_39\" class=\"form-input-wide\">\n <div id=\"text_39\" class=\"form-html\">\n (will total as you select)\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_49\">\n <div id=\"cid_49\" class=\"form-input-wide\">\n <div id=\"text_49\" class=\"form-html\">\n <p>\n <strong><span style=\"color: #ff0000;\">NOTE:<\/span>\n <\/strong>\n For Youth and Amateur Memberships\n <strong><span style=\"color: #ff0000;\">you MUST pay the Individual<\/span>\n <\/strong>\n <br \/>\n <strong><span style=\"color: #ff0000;\">Membership Fee in addition to the Youth or Amateur Membership fee<\/span>\n <\/strong>\n for\n <br \/>\n your points to count towards year-end awards.\n <\/p>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_33\">\n <label class=\"form-label-left\" id=\"label_33\" for=\"input_33\"> VQHA Membership: <\/label>\n <div id=\"cid_33\" class=\"form-input\"><span class=\"form-product-item\"><input class=\"form-checkbox\" type=\"checkbox\" id=\"input_33_100\" name=\"q33_vqhaMembership[][id]\" value=\"100\" \/>\n <label for=\"input_33_100\">\n Individual Membership - 1 year<span class=\"form-product-details\"><b>\n $<span id=\"\">35.00<\/span>\n USD\n <\/b><\/span>\n <\/label>\n <br \/>\n <br \/><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q33_vqhaMembership[special_100][item_0]\" id=\"input_33_quantity_100_0\">\n <option value=\"1\"> 1 <\/option>\n <option value=\"2\"> 2 <\/option>\n <option value=\"3\"> 3 <\/option>\n <option value=\"4\"> 4 <\/option>\n <option value=\"5\"> 5 <\/option>\n <option value=\"6\"> 6 <\/option>\n <option value=\"7\"> 7 <\/option>\n <option value=\"8\"> 8 <\/option>\n <option value=\"9\"> 9 <\/option>\n <option value=\"10\"> 10 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_33_quantity_100_0\"> Quantity <\/label><\/span><\/span>\n <br \/><span class=\"form-product-item\"><input class=\"form-checkbox\" type=\"checkbox\" id=\"input_33_101\" name=\"q33_vqhaMembership[][id]\" value=\"101\" \/>\n <label for=\"input_33_101\">\n Individual Membership - 3 years<span class=\"form-product-details\"><b>\n $<span id=\"\">90.00<\/span>\n USD\n <\/b><\/span>\n <\/label>\n <br \/>\n <br \/><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q33_vqhaMembership[special_101][item_0]\" id=\"input_33_quantity_101_0\">\n <option value=\"1\"> 1 <\/option>\n <option value=\"2\"> 2 <\/option>\n <option value=\"3\"> 3 <\/option>\n <option value=\"4\"> 4 <\/option>\n <option value=\"5\"> 5 <\/option>\n <option value=\"6\"> 6 <\/option>\n <option value=\"7\"> 7 <\/option>\n <option value=\"8\"> 8 <\/option>\n <option value=\"9\"> 9 <\/option>\n <option value=\"10\"> 10 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_33_quantity_101_0\"> Quantity <\/label><\/span><\/span>\n <br \/><span class=\"form-product-item\"><input class=\"form-checkbox\" type=\"checkbox\" id=\"input_33_102\" name=\"q33_vqhaMembership[][id]\" value=\"102\" \/>\n <label for=\"input_33_102\">\n Individual Life Membership<span class=\"form-product-details\"><b>\n $<span id=\"\">250.00<\/span>\n USD\n <\/b><\/span>\n <\/label>\n <br \/>\n <br \/><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q33_vqhaMembership[special_102][item_0]\" id=\"input_33_quantity_102_0\">\n <option value=\"1\"> 1 <\/option>\n <option value=\"2\"> 2 <\/option>\n <option value=\"3\"> 3 <\/option>\n <option value=\"4\"> 4 <\/option>\n <option value=\"5\"> 5 <\/option>\n <option value=\"6\"> 6 <\/option>\n <option value=\"7\"> 7 <\/option>\n <option value=\"8\"> 8 <\/option>\n <option value=\"9\"> 9 <\/option>\n <option value=\"10\"> 10 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_33_quantity_102_0\"> Quantity <\/label><\/span><\/span>\n <br \/><span class=\"form-product-item\"><input class=\"form-checkbox\" type=\"checkbox\" id=\"input_33_103\" name=\"q33_vqhaMembership[][id]\" value=\"103\" \/>\n <label for=\"input_33_103\">\n Family Membership - 1 year<span class=\"form-product-details\"><b>\n $<span id=\"\">45.00<\/span>\n USD\n <\/b><\/span>\n <\/label><\/span>\n <br \/><span class=\"form-product-item\"><input class=\"form-checkbox\" type=\"checkbox\" id=\"input_33_104\" name=\"q33_vqhaMembership[][id]\" value=\"104\" \/>\n <label for=\"input_33_104\">\n Family Membership - 3 years<span class=\"form-product-details\"><b>\n $<span id=\"\">125.00<\/span>\n USD\n <\/b><\/span>\n <\/label><\/span>\n <br \/><span class=\"form-product-item\"><input class=\"form-checkbox\" type=\"checkbox\" id=\"input_33_105\" name=\"q33_vqhaMembership[][id]\" value=\"105\" \/>\n <label for=\"input_33_105\">\n Amateur Membership - 1 year (see note above)<span class=\"form-product-details\"><b>\n $<span id=\"\">10.00<\/span>\n USD\n <\/b><\/span>\n <\/label>\n <br \/>\n <br \/><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q33_vqhaMembership[special_105][item_0]\" id=\"input_33_quantity_105_0\">\n <option value=\"1\"> 1 <\/option>\n <option value=\"2\"> 2 <\/option>\n <option value=\"3\"> 3 <\/option>\n <option value=\"4\"> 4 <\/option>\n <option value=\"5\"> 5 <\/option>\n <option value=\"6\"> 6 <\/option>\n <option value=\"7\"> 7 <\/option>\n <option value=\"8\"> 8 <\/option>\n <option value=\"9\"> 9 <\/option>\n <option value=\"10\"> 10 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_33_quantity_105_0\"> Quantity <\/label><\/span><\/span>\n <br \/><span class=\"form-product-item\"><input class=\"form-checkbox\" type=\"checkbox\" id=\"input_33_106\" name=\"q33_vqhaMembership[][id]\" value=\"106\" \/>\n <label for=\"input_33_106\">\n Youth Membership - 1 year (see note above)<span class=\"form-product-details\"><b>\n $<span id=\"\">5.00<\/span>\n USD\n <\/b><\/span>\n <\/label>\n <br \/>\n <br \/><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q33_vqhaMembership[special_106][item_0]\" id=\"input_33_quantity_106_0\">\n <option value=\"1\"> 1 <\/option>\n <option value=\"2\"> 2 <\/option>\n <option value=\"3\"> 3 <\/option>\n <option value=\"4\"> 4 <\/option>\n <option value=\"5\"> 5 <\/option>\n <option value=\"6\"> 6 <\/option>\n <option value=\"7\"> 7 <\/option>\n <option value=\"8\"> 8 <\/option>\n <option value=\"9\"> 9 <\/option>\n <option value=\"10\"> 10 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_33_quantity_106_0\"> Quantity <\/label><\/span><\/span>\n <br \/><span class=\"form-product-item\"><input class=\"form-checkbox\" type=\"checkbox\" id=\"input_33_109\" name=\"q33_vqhaMembership[][id]\" value=\"109\" \/>\n <label for=\"input_33_109\">\n Back Number - 1 year (benefits Amateur Association)<span class=\"form-product-details\"><b>\n $<span id=\"\">25.00<\/span>\n USD\n <\/b><\/span>\n <\/label>\n <br \/>\n <br \/><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q33_vqhaMembership[special_109][item_0]\" id=\"input_33_quantity_109_0\">\n <option value=\"1\"> 1 <\/option>\n <option value=\"2\"> 2 <\/option>\n <option value=\"3\"> 3 <\/option>\n <option value=\"4\"> 4 <\/option>\n <option value=\"5\"> 5 <\/option>\n <option value=\"6\"> 6 <\/option>\n <option value=\"7\"> 7 <\/option>\n <option value=\"8\"> 8 <\/option>\n <option value=\"9\"> 9 <\/option>\n <option value=\"10\"> 10 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_33_quantity_109_0\"> Quantity <\/label><\/span><\/span>\n <br \/><span class=\"form-product-item\"><input class=\"form-checkbox\" type=\"checkbox\" id=\"input_33_110\" name=\"q33_vqhaMembership[][id]\" value=\"110\" \/>\n <label for=\"input_33_110\">\n Newsletter via US Postal Service<span class=\"form-product-details\"><b>\n $<span id=\"\">5.00<\/span>\n USD\n <\/b><\/span>\n <\/label><\/span>\n <br \/><span class=\"form-product-item\"><input class=\"form-checkbox\" type=\"checkbox\" id=\"input_33_111\" name=\"q33_vqhaMembership[][id]\" value=\"111\" \/>\n <label for=\"input_33_111\">\n Additional VQHA Decal<span class=\"form-product-details\"><b>\n $<span id=\"\">3.00<\/span>\n USD\n <\/b><\/span>\n <\/label>\n <br \/>\n <br \/><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q33_vqhaMembership[special_111][item_0]\" id=\"input_33_quantity_111_0\">\n <option value=\"1\"> 1 <\/option>\n <option value=\"2\"> 2 <\/option>\n <option value=\"3\"> 3 <\/option>\n <option value=\"4\"> 4 <\/option>\n <option value=\"5\"> 5 <\/option>\n <option value=\"6\"> 6 <\/option>\n <option value=\"7\"> 7 <\/option>\n <option value=\"8\"> 8 <\/option>\n <option value=\"9\"> 9 <\/option>\n <option value=\"10\"> 10 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_33_quantity_111_0\"> Quantity <\/label><\/span><\/span>\n <br \/><span class=\"form-product-item\"><input class=\"form-checkbox\" type=\"checkbox\" id=\"input_33_118\" name=\"q33_vqhaMembership[][id]\" value=\"118\" \/>\n <label for=\"input_33_118\">\n Open Show All Breed - Adult<span class=\"form-product-details\"><b>\n $<span id=\"\">10.00<\/span>\n USD\n <\/b><\/span>\n <\/label>\n <br \/>\n <br \/><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q33_vqhaMembership[special_118][item_0]\" id=\"input_33_quantity_118_0\">\n <option value=\"1\"> 1 <\/option>\n <option value=\"2\"> 2 <\/option>\n <option value=\"3\"> 3 <\/option>\n <option value=\"4\"> 4 <\/option>\n <option value=\"5\"> 5 <\/option>\n <option value=\"6\"> 6 <\/option>\n <option value=\"7\"> 7 <\/option>\n <option value=\"8\"> 8 <\/option>\n <option value=\"9\"> 9 <\/option>\n <option value=\"10\"> 10 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_33_quantity_118_0\"> Quantity <\/label><\/span><\/span>\n <br \/><span class=\"form-product-item\"><input class=\"form-checkbox\" type=\"checkbox\" id=\"input_33_119\" name=\"q33_vqhaMembership[][id]\" value=\"119\" \/>\n <label for=\"input_33_119\">\n Open Show Program All-Breed - Youth<span class=\"form-product-details\"><b>\n $<span id=\"\">5.00<\/span>\n USD\n <\/b><\/span>\n <\/label>\n <br \/>\n <br \/><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" name=\"q33_vqhaMembership[special_119][item_0]\" id=\"input_33_quantity_119_0\">\n <option value=\"1\"> 1 <\/option>\n <option value=\"2\"> 2 <\/option>\n <option value=\"3\"> 3 <\/option>\n <option value=\"4\"> 4 <\/option>\n <option value=\"5\"> 5 <\/option>\n <option value=\"6\"> 6 <\/option>\n <option value=\"7\"> 7 <\/option>\n <option value=\"8\"> 8 <\/option>\n <option value=\"9\"> 9 <\/option>\n <option value=\"10\"> 10 <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_33_quantity_119_0\"> Quantity <\/label><\/span><\/span>\n <br \/>\n <br \/>\n <b>\n Total: <span>$<span id=\"payment_total\">0.00<\/span>\n USD<\/span>\n <\/b>\n <\/div>\n <\/li>\n <li id=\"cid_61\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_61\" class=\"form-header\">\n ...\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_45\">\n <div id=\"cid_45\" class=\"form-input-wide\">\n <div id=\"text_45\" class=\"form-html\">\n <p>\n Memberships run from January 1 to December 31 of current year.\n <br \/>\n If you do not join by January 1, memberships run from postmark\n <br \/>\n to December 31 of current year.\n <\/p>\n <\/div>\n <\/div>\n <\/li>\n <li id=\"cid_62\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_62\" class=\"form-header\">\n ...\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_40\">\n <div id=\"cid_40\" class=\"form-input-wide\">\n <div id=\"text_40\" class=\"form-html\">\n <p><span style=\"font-size: small;\">Please review the information above carefully before you click submit.\n <br \/>\n Clicking submit will take you to Google® Checkout where you can pay\n <br \/>\n online with a credit\/debit card. It's very safe and secure. If you have\n <br \/>\n Membership questions, please contact <span style=\"font-family: Geneva;\">Stephanie Cash via email at\n <br \/>\n <a href=\"mailto:lucascashshowhorses@yahoo.com?subject=VQHA Membership\">lucascashshowhorses@yahoo.com<\/a><\/span>\n . Thank you.<\/span>\n <\/p>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_50\">\n <label class=\"form-label-left\" id=\"label_50\" for=\"input_50\">\n Just so we know you're a person and not a computer<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_50\" class=\"form-input\">\n <div class=\"form-captcha\">\n <label for=\"input_50\"> <img alt=\"Captcha - Reload if it's not displayed\" id=\"input_50_captcha\" class=\"form-captcha-image\" style=\"background:url(http:\/\/www.jotform.com\/images\/loader-big.gif) no-repeat center;\" src=\"http:\/\/www.jotform.com\/images\/blank.gif\" width=\"150\" height=\"41\" \/> <\/label>\n <div style=\"white-space:nowrap;\">\n <input type=\"text\" id=\"input_50\" class=\"form-textbox validate[required]\" name=\"captcha\" style=\"width:130px;\" \/>\n <img src=\"http:\/\/www.jotform.com\/images\/reload.png\" alt=\"Reload\" align=\"absmiddle\" style=\"cursor:pointer\" onclick=\"JotForm.reloadCaptcha('input_50');\" \/>\n <input type=\"hidden\" name=\"captcha_id\" id=\"input_50_captcha_id\" value=\"0\">\n <\/div>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_63\">\n <div id=\"cid_63\" class=\"form-input-wide\">\n <div style=\"margin-left:156px\" class=\"form-buttons-wrapper\">\n <button id=\"input_63\" type=\"submit\" class=\"form-submit-button\">\n Submit Form\n <\/button>\n <\/div>\n <\/div>\n <\/li>\n <li style=\"display:none\">\n Should be Empty:\n <input type=\"text\" name=\"website\" value=\"\" \/>\n <\/li>\n <\/ul>\n <\/div>\n <input type=\"hidden\" id=\"simple_spc\" name=\"simple_spc\" value=\"90242456215\" \/>\n <script type=\"text\/javascript\">\n document.getElementById(\"si\" + \"mple\" + \"_spc\").value = \"90242456215-90242456215\";\n <\/script>\n<\/form><\/body>\n<\/html>\n");