/*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 i93065343500 = new FrameBuilder("93065343500", 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:white;\n }\n\n .form-all{\n margin:0px auto;\n padding-top:0px;\n width:520px;\n background:white;\n color:black !important;\n font-family:Verdana;\n font-size:11px;\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.setConditions([{\"action\":{\"field\":\"38\",\"visibility\":\"Show\"},\"link\":\"Any\",\"terms\":[{\"field\":\"37\",\"operator\":\"equals\",\"value\":\"Yes\"}],\"type\":\"field\"}]);\n JotForm.init(function(){\n JotForm.setCalendar(\"30\");\n $('input_127').hint('ex: myname@example.com');\n $('input_128').hint('ex: myname@example.com');\n JotForm.setCalendar(\"47\");\n JotForm.setCalendar(\"49\");\n JotForm.setCalendar(\"54\");\n JotForm.setCalendar(\"55\");\n JotForm.setCalendar(\"60\");\n JotForm.setCalendar(\"68\");\n JotForm.setCalendar(\"69\");\n JotForm.setCalendar(\"73\");\n JotForm.setCalendar(\"74\");\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\" enctype=\"multipart\/form-data\" name=\"form_93065343500\" id=\"93065343500\" accept-charset=\"utf-8\">\n <input type=\"hidden\" name=\"formID\" value=\"93065343500\" \/>\n <div class=\"form-all\">\n <ul class=\"form-section\">\n <li id=\"cid_8\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_8\" class=\"form-header\">\n Thank you for taking your time to complete the Leadership Spokane Program application\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_10\">\n <div id=\"cid_10\" class=\"form-input-wide\">\n <div id=\"text_10\" class=\"form-html\">\n <p class=\"MsoNormal\"><span style=\"line-height: 115%;\">The Online Application process should take between 20-30 minutes to complete. We suggest that you complete the essay questions and have a photo ready to upload prior to beginning the online process. Please do not use the back and forward browser button as this may invalidate your form submission. If you have difficulty during the submission process, do not hesitate to contact the Leadership Spokane Office at (509) 321-3645 or\n <a href=\"mailto:Leadership@leadershipspokane.org\"><span style=\"color: windowtext;\">Leadership@leadershipspokane.org<\/span><\/a>\n for additional assistance. Please note that your online application is not complete until all of the forms noted below have been submitted to our office. ** Completed applications are due by 16 April 2012. <\/span>\n <\/p>\n <\/div>\n <\/div>\n <\/li>\n <li id=\"cid_11\" class=\"form-input-wide\">\n <div class=\"form-pagebreak\">\n <div class=\"form-pagebreak-back-container form-label-left\">\n <button type=\"button\" class=\"form-pagebreak-back\" id=\"form-pagebreak-back_11\">\n Back\n <\/button>\n <\/div>\n <div class=\"form-pagebreak-next-container\">\n <button type=\"button\" class=\"form-pagebreak-next\" id=\"form-pagebreak-next_11\">\n Next\n <\/button>\n <\/div>\n <\/div>\n <\/li>\n <\/ul>\n <ul class=\"form-section\" style=\"display:none;\">\n <li class=\"form-line\" id=\"id_7\">\n <div id=\"cid_7\" class=\"form-input-wide\">\n <div id=\"text_7\" class=\"form-html\">\n Please enter your full name and date to continue with your Leadership Spokane Application.\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_132\">\n <label class=\"form-label-left\" id=\"label_132\" for=\"input_132\">\n Enter your Full Name to continue<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_132\" class=\"form-input\"><span class=\"form-sub-label-container\"><input class=\"form-textbox validate[required]\" type=\"text\" size=\"10\" name=\"q132_enterYour132[first]\" id=\"first_132\" \/>\n <label class=\"form-sub-label\" for=\"first_132\" id=\"sublabel_first\"> First Name <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox validate[required]\" type=\"text\" size=\"15\" name=\"q132_enterYour132[last]\" id=\"last_132\" \/>\n <label class=\"form-sub-label\" for=\"last_132\" id=\"sublabel_last\"> Last Name <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_30\">\n <label class=\"form-label-left\" id=\"label_30\" for=\"input_30\"> Date <\/label>\n <div id=\"cid_30\" class=\"form-input\"><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"month_30\" name=\"q30_date[month]\" type=\"text\" size=\"2\" maxlength=\"2\" value=\"02\" \/><span class=\"date-separate\"> -<\/span>\n <label class=\"form-sub-label\" for=\"month_30\" id=\"sublabel_month\"> Month <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"day_30\" name=\"q30_date[day]\" type=\"text\" size=\"2\" maxlength=\"2\" value=\"10\" \/><span class=\"date-separate\"> -<\/span>\n <label class=\"form-sub-label\" for=\"day_30\" id=\"sublabel_day\"> Day <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"year_30\" name=\"q30_date[year]\" type=\"text\" size=\"4\" maxlength=\"4\" value=\"2012\" \/>\n <label class=\"form-sub-label\" for=\"year_30\" id=\"sublabel_year\"> Year <\/label><\/span><span class=\"form-sub-label-container\"><div id=\"at_30\">\n at\n <\/div>\n <label class=\"form-sub-label\" for=\"at_30\">     <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"hour_30\" name=\"q30_date[hour]\" type=\"text\" size=\"2\" maxlength=\"2\" value=\"01\" \/><span class=\"date-separate\"> \/<\/span>\n <label class=\"form-sub-label\" for=\"hour_30\" id=\"sublabel_hour\"> Hour <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"min_30\" name=\"q30_date[min]\" type=\"text\" size=\"2\" maxlength=\"2\" value=\"58\" \/>\n <label class=\"form-sub-label\" for=\"min_30\" id=\"sublabel_minutes\"> Minutes <\/label><\/span><span class=\"form-sub-label-container\"><select class=\"form-dropdown\" id=\"ampm_30\" name=\"q30_date[ampm]\">\n <option value=\"AM\"> AM <\/option>\n <option value=\"PM\"> PM <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"ampm_30\">     <\/label><\/span><span class=\"form-sub-label-container\"><img alt=\"Pick a Date\" id=\"input_30_pick\" src=\"http:\/\/www.jotform.com\/images\/calendar.png\" align=\"absmiddle\" \/>\n <label class=\"form-sub-label\" for=\"input_30_pick\">     <\/label><\/span>\n <\/div>\n <\/li>\n <li id=\"cid_148\" class=\"form-input-wide\">\n <div class=\"form-pagebreak\">\n <div class=\"form-pagebreak-back-container form-label-left\">\n <button type=\"button\" class=\"form-pagebreak-back\" id=\"form-pagebreak-back_148\">\n Back\n <\/button>\n <\/div>\n <div class=\"form-pagebreak-next-container\">\n <button type=\"button\" class=\"form-pagebreak-next\" id=\"form-pagebreak-next_148\">\n Next\n <\/button>\n <\/div>\n <\/div>\n <\/li>\n <\/ul>\n <ul class=\"form-section\" style=\"display:none;\">\n <li id=\"cid_21\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_21\" class=\"form-header\">\n Leadership Spokane Application\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_131\">\n <label class=\"form-label-left\" id=\"label_131\" for=\"input_131\">\n Full Name<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_131\" class=\"form-input\"><span class=\"form-sub-label-container\"><input class=\"form-textbox\" type=\"text\" name=\"q131_fullName[prefix]\" size=\"4\" id=\"pre_131\" \/>\n <label class=\"form-sub-label\" for=\"pre_131\" id=\"sublabel_prefix\"> Prefix <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox validate[required]\" type=\"text\" size=\"10\" name=\"q131_fullName[first]\" id=\"first_131\" \/>\n <label class=\"form-sub-label\" for=\"first_131\" id=\"sublabel_first\"> First Name <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox\" type=\"text\" size=\"10\" name=\"q131_fullName[middle]\" id=\"middle_131\" \/>\n <label class=\"form-sub-label\" for=\"middle_131\" id=\"sublabel_middle\"> Middle Name <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox validate[required]\" type=\"text\" size=\"15\" name=\"q131_fullName[last]\" id=\"last_131\" \/>\n <label class=\"form-sub-label\" for=\"last_131\" id=\"sublabel_last\"> Last Name <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_22\">\n <div id=\"cid_22\" class=\"form-input-wide\">\n <div id=\"text_22\" class=\"form-html\">\n Please complete each section fully. Incomplete applications will not be considered.\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_23\">\n <label class=\"form-label-left\" id=\"label_23\" for=\"input_23\">\n Preferred Name<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_23\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_23\" name=\"q23_preferredName\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_147\">\n <label class=\"form-label-left\" id=\"label_147\" for=\"input_147\">\n Business Phone<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_147\" class=\"form-input\"><span class=\"form-sub-label-container\"><input class=\"form-textbox validate[required]\" type=\"tel\" name=\"q147_businessPhone[area]\" id=\"input_147_area\" size=\"3\">\n -\n <label class=\"form-sub-label\" for=\"input_147_area\" id=\"sublabel_area\"> Area Code <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox validate[required]\" type=\"tel\" name=\"q147_businessPhone[phone]\" id=\"input_147_phone\" size=\"8\">\n <label class=\"form-sub-label\" for=\"input_147_phone\" id=\"sublabel_phone\"> Phone Number <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_126\">\n <label class=\"form-label-left\" id=\"label_126\" for=\"input_126\">\n Home Phone<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_126\" class=\"form-input\"><span class=\"form-sub-label-container\"><input class=\"form-textbox validate[required]\" type=\"tel\" name=\"q126_homePhone126[area]\" id=\"input_126_area\" size=\"3\">\n -\n <label class=\"form-sub-label\" for=\"input_126_area\" id=\"sublabel_area\"> Area Code <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox validate[required]\" type=\"tel\" name=\"q126_homePhone126[phone]\" id=\"input_126_phone\" size=\"8\">\n <label class=\"form-sub-label\" for=\"input_126_phone\" id=\"sublabel_phone\"> Phone Number <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_146\">\n <label class=\"form-label-left\" id=\"label_146\" for=\"input_146\"> Cell Phone <\/label>\n <div id=\"cid_146\" class=\"form-input\"><span class=\"form-sub-label-container\"><input class=\"form-textbox\" type=\"tel\" name=\"q146_cellPhone146[area]\" id=\"input_146_area\" size=\"3\">\n -\n <label class=\"form-sub-label\" for=\"input_146_area\" id=\"sublabel_area\"> Area Code <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox\" type=\"tel\" name=\"q146_cellPhone146[phone]\" id=\"input_146_phone\" size=\"8\">\n <label class=\"form-sub-label\" for=\"input_146_phone\" id=\"sublabel_phone\"> Phone Number <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_120\">\n <label class=\"form-label-left\" id=\"label_120\" for=\"input_120\">\n Preferred Phone Number:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_120\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_120_0\" name=\"q120_preferredPhone120[]\" value=\"Business\" \/>\n <label for=\"input_120_0\"> Business <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_120_1\" name=\"q120_preferredPhone120[]\" value=\"Home\" \/>\n <label for=\"input_120_1\"> Home <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_120_2\" name=\"q120_preferredPhone120[]\" value=\"Cell\" \/>\n <label for=\"input_120_2\"> Cell <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_127\">\n <label class=\"form-label-left\" id=\"label_127\" for=\"input_127\">\n E-mail<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_127\" class=\"form-input\">\n <input type=\"email\" class=\"form-textbox validate[required, Email]\" id=\"input_127\" name=\"q127_email\" size=\"30\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_128\">\n <label class=\"form-label-left\" id=\"label_128\" for=\"input_128\"> Alternate E-mail <\/label>\n <div id=\"cid_128\" class=\"form-input\">\n <input type=\"email\" class=\"form-textbox validate[Email]\" id=\"input_128\" name=\"q128_alternateEmail128\" size=\"30\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_119\">\n <label class=\"form-label-left\" id=\"label_119\" for=\"input_119\">\n Preferred Email:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_119\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_119_0\" name=\"q119_preferredEmail[]\" value=\"Email\" \/>\n <label for=\"input_119_0\"> Email <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_119_1\" name=\"q119_preferredEmail[]\" value=\"Alternate Email\" \/>\n <label for=\"input_119_1\"> Alternate Email <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_129\">\n <label class=\"form-label-left\" id=\"label_129\" for=\"input_129\"> Business Address <\/label>\n <div id=\"cid_129\" class=\"form-input\">\n <table summary=\"\" class=\"form-address-table\" border=\"0\" cellpadding=\"0\" cellspacing=\"0\">\n <tr>\n <td colspan=\"2\"><span class=\"form-sub-label-container\"><input class=\"form-textbox form-address-line\" type=\"text\" name=\"q129_businessAddress129[addr_line1]\" id=\"input_129_addr_line1\" \/>\n <label class=\"form-sub-label\" for=\"input_129_addr_line1\" id=\"sublabel_addr_line1\"> Street Address <\/label><\/span>\n <\/td>\n <\/tr>\n <tr>\n <td colspan=\"2\"><span class=\"form-sub-label-container\"><input class=\"form-textbox form-address-line\" type=\"text\" name=\"q129_businessAddress129[addr_line2]\" id=\"input_129_addr_line2\" size=\"46\" \/>\n <label class=\"form-sub-label\" for=\"input_129_addr_line2\" id=\"sublabel_addr_line2\"> Street Address Line 2 <\/label><\/span>\n <\/td>\n <\/tr>\n <tr>\n <td width=\"50%\"><span class=\"form-sub-label-container\"><input class=\"form-textbox form-address-city\" type=\"text\" name=\"q129_businessAddress129[city]\" id=\"input_129_city\" size=\"21\" \/>\n <label class=\"form-sub-label\" for=\"input_129_city\" id=\"sublabel_city\"> City <\/label><\/span>\n <\/td>\n <td><span class=\"form-sub-label-container\"><input class=\"form-textbox form-address-state\" type=\"text\" name=\"q129_businessAddress129[state]\" id=\"input_129_state\" size=\"22\" \/>\n <label class=\"form-sub-label\" for=\"input_129_state\" id=\"sublabel_state\"> State \/ Province <\/label><\/span>\n <\/td>\n <\/tr>\n <tr>\n <td width=\"50%\"><span class=\"form-sub-label-container\"><input class=\"form-textbox form-address-postal\" type=\"text\" name=\"q129_businessAddress129[postal]\" id=\"input_129_postal\" size=\"10\" \/>\n <label class=\"form-sub-label\" for=\"input_129_postal\" id=\"sublabel_postal\"> Postal \/ Zip Code <\/label><\/span>\n <\/td>\n <td><span class=\"form-sub-label-container\"><select class=\"form-dropdown form-address-country\" name=\"q129_businessAddress129[country]\" id=\"input_129_country\">\n <option selected> Please Select <\/option>\n <option value=\"United States\"> United States <\/option>\n <option value=\"Abkhazia\"> Abkhazia <\/option>\n <option value=\"Afghanistan\"> Afghanistan <\/option>\n <option value=\"Albania\"> Albania <\/option>\n <option value=\"Algeria\"> Algeria <\/option>\n <option value=\"American Samoa\"> American Samoa <\/option>\n <option value=\"Andorra\"> Andorra <\/option>\n <option value=\"Angola\"> Angola <\/option>\n <option value=\"Anguilla\"> Anguilla <\/option>\n <option value=\"Antigua and Barbuda\"> Antigua and Barbuda <\/option>\n <option value=\"Argentina\"> Argentina <\/option>\n <option value=\"Armenia\"> Armenia <\/option>\n <option value=\"Aruba\"> Aruba <\/option>\n <option value=\"Australia\"> Australia <\/option>\n <option value=\"Austria\"> Austria <\/option>\n <option value=\"Azerbaijan\"> Azerbaijan <\/option>\n <option value=\"The Bahamas\"> The Bahamas <\/option>\n <option value=\"Bahrain\"> Bahrain <\/option>\n <option value=\"Bangladesh\"> Bangladesh <\/option>\n <option value=\"Barbados\"> Barbados <\/option>\n <option value=\"Belarus\"> Belarus <\/option>\n <option value=\"Belgium\"> Belgium <\/option>\n <option value=\"Belize\"> Belize <\/option>\n <option value=\"Benin\"> Benin <\/option>\n <option value=\"Bermuda\"> Bermuda <\/option>\n <option value=\"Bhutan\"> Bhutan <\/option>\n <option value=\"Bolivia\"> Bolivia <\/option>\n <option value=\"Bosnia and Herzegovina\"> Bosnia and Herzegovina <\/option>\n <option value=\"Botswana\"> Botswana <\/option>\n <option value=\"Brazil\"> Brazil <\/option>\n <option value=\"Brunei\"> Brunei <\/option>\n <option value=\"Bulgaria\"> Bulgaria <\/option>\n <option value=\"Burkina Faso\"> Burkina Faso <\/option>\n <option value=\"Burundi\"> Burundi <\/option>\n <option value=\"Cambodia\"> Cambodia <\/option>\n <option value=\"Cameroon\"> Cameroon <\/option>\n <option value=\"Canada\"> Canada <\/option>\n <option value=\"Cape Verde\"> Cape Verde <\/option>\n <option value=\"Cayman Islands\"> Cayman Islands <\/option>\n <option value=\"Central African Republic\"> Central African Republic <\/option>\n <option value=\"Chad\"> Chad <\/option>\n <option value=\"Chile\"> Chile <\/option>\n <option value=\"People's Republic of China\"> People's Republic of China <\/option>\n <option value=\"Republic of China\"> Republic of China <\/option>\n <option value=\"Christmas Island\"> Christmas Island <\/option>\n <option value=\"Cocos (Keeling) Islands\"> Cocos (Keeling) Islands <\/option>\n <option value=\"Colombia\"> Colombia <\/option>\n <option value=\"Comoros\"> Comoros <\/option>\n <option value=\"Congo\"> Congo <\/option>\n <option value=\"Cook Islands\"> Cook Islands <\/option>\n <option value=\"Costa Rica\"> Costa Rica <\/option>\n <option value=\"Cote d'Ivoire\"> Cote d'Ivoire <\/option>\n <option value=\"Croatia\"> Croatia <\/option>\n <option value=\"Cuba\"> Cuba <\/option>\n <option value=\"Cyprus\"> Cyprus <\/option>\n <option value=\"Czech Republic\"> Czech Republic <\/option>\n <option value=\"Denmark\"> Denmark <\/option>\n <option value=\"Djibouti\"> Djibouti <\/option>\n <option value=\"Dominica\"> Dominica <\/option>\n <option value=\"Dominican Republic\"> Dominican Republic <\/option>\n <option value=\"Ecuador\"> Ecuador <\/option>\n <option value=\"Egypt\"> Egypt <\/option>\n <option value=\"El Salvador\"> El Salvador <\/option>\n <option value=\"Equatorial Guinea\"> Equatorial Guinea <\/option>\n <option value=\"Eritrea\"> Eritrea <\/option>\n <option value=\"Estonia\"> Estonia <\/option>\n <option value=\"Ethiopia\"> Ethiopia <\/option>\n <option value=\"Falkland Islands\"> Falkland Islands <\/option>\n <option value=\"Faroe Islands\"> Faroe Islands <\/option>\n <option value=\"Fiji\"> Fiji <\/option>\n <option value=\"Finland\"> Finland <\/option>\n <option value=\"France\"> France <\/option>\n <option value=\"French Polynesia\"> French Polynesia <\/option>\n <option value=\"Gabon\"> Gabon <\/option>\n <option value=\"The Gambia\"> The Gambia <\/option>\n <option value=\"Georgia\"> Georgia <\/option>\n <option value=\"Germany\"> Germany <\/option>\n <option value=\"Ghana\"> Ghana <\/option>\n <option value=\"Gibraltar\"> Gibraltar <\/option>\n <option value=\"Greece\"> Greece <\/option>\n <option value=\"Greenland\"> Greenland <\/option>\n <option value=\"Grenada\"> Grenada <\/option>\n <option value=\"Guadeloupe\"> Guadeloupe <\/option>\n <option value=\"Guam\"> Guam <\/option>\n <option value=\"Guatemala\"> Guatemala <\/option>\n <option value=\"Guernsey\"> Guernsey <\/option>\n <option value=\"Guinea\"> Guinea <\/option>\n <option value=\"Guinea-Bissau\"> Guinea-Bissau <\/option>\n <option value=\"Guyana\"> Guyana <\/option>\n <option value=\"Haiti\"> Haiti <\/option>\n <option value=\"Honduras\"> Honduras <\/option>\n <option value=\"Hong Kong\"> Hong Kong <\/option>\n <option value=\"Hungary\"> Hungary <\/option>\n <option value=\"Iceland\"> Iceland <\/option>\n <option value=\"India\"> India <\/option>\n <option value=\"Indonesia\"> Indonesia <\/option>\n <option value=\"Iran\"> Iran <\/option>\n <option value=\"Iraq\"> Iraq <\/option>\n <option value=\"Ireland\"> Ireland <\/option>\n <option value=\"Israel\"> Israel <\/option>\n <option value=\"Italy\"> Italy <\/option>\n <option value=\"Jamaica\"> Jamaica <\/option>\n <option value=\"Japan\"> Japan <\/option>\n <option value=\"Jersey\"> Jersey <\/option>\n <option value=\"Jordan\"> Jordan <\/option>\n <option value=\"Kazakhstan\"> Kazakhstan <\/option>\n <option value=\"Kenya\"> Kenya <\/option>\n <option value=\"Kiribati\"> Kiribati <\/option>\n <option value=\"North Korea\"> North Korea <\/option>\n <option value=\"South Korea\"> South Korea <\/option>\n <option value=\"Kosovo\"> Kosovo <\/option>\n <option value=\"Kuwait\"> Kuwait <\/option>\n <option value=\"Kyrgyzstan\"> Kyrgyzstan <\/option>\n <option value=\"Laos\"> Laos <\/option>\n <option value=\"Latvia\"> Latvia <\/option>\n <option value=\"Lebanon\"> Lebanon <\/option>\n <option value=\"Lesotho\"> Lesotho <\/option>\n <option value=\"Liberia\"> Liberia <\/option>\n <option value=\"Libya\"> Libya <\/option>\n <option value=\"Liechtenstein\"> Liechtenstein <\/option>\n <option value=\"Lithuania\"> Lithuania <\/option>\n <option value=\"Luxembourg\"> Luxembourg <\/option>\n <option value=\"Macau\"> Macau <\/option>\n <option value=\"Macedonia\"> Macedonia <\/option>\n <option value=\"Madagascar\"> Madagascar <\/option>\n <option value=\"Malawi\"> Malawi <\/option>\n <option value=\"Malaysia\"> Malaysia <\/option>\n <option value=\"Maldives\"> Maldives <\/option>\n <option value=\"Mali\"> Mali <\/option>\n <option value=\"Malta\"> Malta <\/option>\n <option value=\"Marshall Islands\"> Marshall Islands <\/option>\n <option value=\"Martinique\"> Martinique <\/option>\n <option value=\"Mauritania\"> Mauritania <\/option>\n <option value=\"Mauritius\"> Mauritius <\/option>\n <option value=\"Mayotte\"> Mayotte <\/option>\n <option value=\"Mexico\"> Mexico <\/option>\n <option value=\"Micronesia\"> Micronesia <\/option>\n <option value=\"Moldova\"> Moldova <\/option>\n <option value=\"Monaco\"> Monaco <\/option>\n <option value=\"Mongolia\"> Mongolia <\/option>\n <option value=\"Montenegro\"> Montenegro <\/option>\n <option value=\"Montserrat\"> Montserrat <\/option>\n <option value=\"Morocco\"> Morocco <\/option>\n <option value=\"Mozambique\"> Mozambique <\/option>\n <option value=\"Myanmar\"> Myanmar <\/option>\n <option value=\"Nagorno-Karabakh\"> Nagorno-Karabakh <\/option>\n <option value=\"Namibia\"> Namibia <\/option>\n <option value=\"Nauru\"> Nauru <\/option>\n <option value=\"Nepal\"> Nepal <\/option>\n <option value=\"Netherlands\"> Netherlands <\/option>\n <option value=\"Netherlands Antilles\"> Netherlands Antilles <\/option>\n <option value=\"New Caledonia\"> New Caledonia <\/option>\n <option value=\"New Zealand\"> New Zealand <\/option>\n <option value=\"Nicaragua\"> Nicaragua <\/option>\n <option value=\"Niger\"> Niger <\/option>\n <option value=\"Nigeria\"> Nigeria <\/option>\n <option value=\"Niue\"> Niue <\/option>\n <option value=\"Norfolk Island\"> Norfolk Island <\/option>\n <option value=\"Turkish Republic of Northern Cyprus\"> Turkish Republic of Northern Cyprus <\/option>\n <option value=\"Northern Mariana\"> Northern Mariana <\/option>\n <option value=\"Norway\"> Norway <\/option>\n <option value=\"Oman\"> Oman <\/option>\n <option value=\"Pakistan\"> Pakistan <\/option>\n <option value=\"Palau\"> Palau <\/option>\n <option value=\"Palestine\"> Palestine <\/option>\n <option value=\"Panama\"> Panama <\/option>\n <option value=\"Papua New Guinea\"> Papua New Guinea <\/option>\n <option value=\"Paraguay\"> Paraguay <\/option>\n <option value=\"Peru\"> Peru <\/option>\n <option value=\"Philippines\"> Philippines <\/option>\n <option value=\"Pitcairn Islands\"> Pitcairn Islands <\/option>\n <option value=\"Poland\"> Poland <\/option>\n <option value=\"Portugal\"> Portugal <\/option>\n <option value=\"Puerto Rico\"> Puerto Rico <\/option>\n <option value=\"Qatar\"> Qatar <\/option>\n <option value=\"Romania\"> Romania <\/option>\n <option value=\"Russia\"> Russia <\/option>\n <option value=\"Rwanda\"> Rwanda <\/option>\n <option value=\"Saint Barthelemy\"> Saint Barthelemy <\/option>\n <option value=\"Saint Helena\"> Saint Helena <\/option>\n <option value=\"Saint Kitts and Nevis\"> Saint Kitts and Nevis <\/option>\n <option value=\"Saint Lucia\"> Saint Lucia <\/option>\n <option value=\"Saint Martin\"> Saint Martin <\/option>\n <option value=\"Saint Pierre and Miquelon\"> Saint Pierre and Miquelon <\/option>\n <option value=\"Saint Vincent and the Grenadines\"> Saint Vincent and the Grenadines <\/option>\n <option value=\"Samoa\"> Samoa <\/option>\n <option value=\"San Marino\"> San Marino <\/option>\n <option value=\"Sao Tome and Principe\"> Sao Tome and Principe <\/option>\n <option value=\"Saudi Arabia\"> Saudi Arabia <\/option>\n <option value=\"Senegal\"> Senegal <\/option>\n <option value=\"Serbia\"> Serbia <\/option>\n <option value=\"Seychelles\"> Seychelles <\/option>\n <option value=\"Sierra Leone\"> Sierra Leone <\/option>\n <option value=\"Singapore\"> Singapore <\/option>\n <option value=\"Slovakia\"> Slovakia <\/option>\n <option value=\"Slovenia\"> Slovenia <\/option>\n <option value=\"Solomon Islands\"> Solomon Islands <\/option>\n <option value=\"Somalia\"> Somalia <\/option>\n <option value=\"Somaliland\"> Somaliland <\/option>\n <option value=\"South Africa\"> South Africa <\/option>\n <option value=\"South Ossetia\"> South Ossetia <\/option>\n <option value=\"Spain\"> Spain <\/option>\n <option value=\"Sri Lanka\"> Sri Lanka <\/option>\n <option value=\"Sudan\"> Sudan <\/option>\n <option value=\"Suriname\"> Suriname <\/option>\n <option value=\"Svalbard\"> Svalbard <\/option>\n <option value=\"Swaziland\"> Swaziland <\/option>\n <option value=\"Sweden\"> Sweden <\/option>\n <option value=\"Switzerland\"> Switzerland <\/option>\n <option value=\"Syria\"> Syria <\/option>\n <option value=\"Taiwan\"> Taiwan <\/option>\n <option value=\"Tajikistan\"> Tajikistan <\/option>\n <option value=\"Tanzania\"> Tanzania <\/option>\n <option value=\"Thailand\"> Thailand <\/option>\n <option value=\"Timor-Leste\"> Timor-Leste <\/option>\n <option value=\"Togo\"> Togo <\/option>\n <option value=\"Tokelau\"> Tokelau <\/option>\n <option value=\"Tonga\"> Tonga <\/option>\n <option value=\"Transnistria Pridnestrovie\"> Transnistria Pridnestrovie <\/option>\n <option value=\"Trinidad and Tobago\"> Trinidad and Tobago <\/option>\n <option value=\"Tristan da Cunha\"> Tristan da Cunha <\/option>\n <option value=\"Tunisia\"> Tunisia <\/option>\n <option value=\"Turkey\"> Turkey <\/option>\n <option value=\"Turkmenistan\"> Turkmenistan <\/option>\n <option value=\"Turks and Caicos Islands\"> Turks and Caicos Islands <\/option>\n <option value=\"Tuvalu\"> Tuvalu <\/option>\n <option value=\"Uganda\"> Uganda <\/option>\n <option value=\"Ukraine\"> Ukraine <\/option>\n <option value=\"United Arab Emirates\"> United Arab Emirates <\/option>\n <option value=\"United Kingdom\"> United Kingdom <\/option>\n <option value=\"Uruguay\"> Uruguay <\/option>\n <option value=\"Uzbekistan\"> Uzbekistan <\/option>\n <option value=\"Vanuatu\"> Vanuatu <\/option>\n <option value=\"Vatican City\"> Vatican City <\/option>\n <option value=\"Venezuela\"> Venezuela <\/option>\n <option value=\"Vietnam\"> Vietnam <\/option>\n <option value=\"British Virgin Islands\"> British Virgin Islands <\/option>\n <option value=\"US Virgin Islands\"> US Virgin Islands <\/option>\n <option value=\"Wallis and Futuna\"> Wallis and Futuna <\/option>\n <option value=\"Western Sahara\"> Western Sahara <\/option>\n <option value=\"Yemen\"> Yemen <\/option>\n <option value=\"Zambia\"> Zambia <\/option>\n <option value=\"Zimbabwe\"> Zimbabwe <\/option>\n <option value=\"other\"> Other <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_129_country\" id=\"sublabel_country\"> Country <\/label><\/span>\n <\/td>\n <\/tr>\n <\/table>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_130\">\n <label class=\"form-label-left\" id=\"label_130\" for=\"input_130\"> Home Address <\/label>\n <div id=\"cid_130\" class=\"form-input\">\n <table summary=\"\" class=\"form-address-table\" border=\"0\" cellpadding=\"0\" cellspacing=\"0\">\n <tr>\n <td colspan=\"2\"><span class=\"form-sub-label-container\"><input class=\"form-textbox form-address-line\" type=\"text\" name=\"q130_homeAddress[addr_line1]\" id=\"input_130_addr_line1\" \/>\n <label class=\"form-sub-label\" for=\"input_130_addr_line1\" id=\"sublabel_addr_line1\"> Street Address <\/label><\/span>\n <\/td>\n <\/tr>\n <tr>\n <td colspan=\"2\"><span class=\"form-sub-label-container\"><input class=\"form-textbox form-address-line\" type=\"text\" name=\"q130_homeAddress[addr_line2]\" id=\"input_130_addr_line2\" size=\"46\" \/>\n <label class=\"form-sub-label\" for=\"input_130_addr_line2\" id=\"sublabel_addr_line2\"> Street Address Line 2 <\/label><\/span>\n <\/td>\n <\/tr>\n <tr>\n <td width=\"50%\"><span class=\"form-sub-label-container\"><input class=\"form-textbox form-address-city\" type=\"text\" name=\"q130_homeAddress[city]\" id=\"input_130_city\" size=\"21\" \/>\n <label class=\"form-sub-label\" for=\"input_130_city\" id=\"sublabel_city\"> City <\/label><\/span>\n <\/td>\n <td><span class=\"form-sub-label-container\"><input class=\"form-textbox form-address-state\" type=\"text\" name=\"q130_homeAddress[state]\" id=\"input_130_state\" size=\"22\" \/>\n <label class=\"form-sub-label\" for=\"input_130_state\" id=\"sublabel_state\"> State \/ Province <\/label><\/span>\n <\/td>\n <\/tr>\n <tr>\n <td width=\"50%\"><span class=\"form-sub-label-container\"><input class=\"form-textbox form-address-postal\" type=\"text\" name=\"q130_homeAddress[postal]\" id=\"input_130_postal\" size=\"10\" \/>\n <label class=\"form-sub-label\" for=\"input_130_postal\" id=\"sublabel_postal\"> Postal \/ Zip Code <\/label><\/span>\n <\/td>\n <td><span class=\"form-sub-label-container\"><select class=\"form-dropdown form-address-country\" name=\"q130_homeAddress[country]\" id=\"input_130_country\">\n <option selected> Please Select <\/option>\n <option value=\"United States\"> United States <\/option>\n <option value=\"Abkhazia\"> Abkhazia <\/option>\n <option value=\"Afghanistan\"> Afghanistan <\/option>\n <option value=\"Albania\"> Albania <\/option>\n <option value=\"Algeria\"> Algeria <\/option>\n <option value=\"American Samoa\"> American Samoa <\/option>\n <option value=\"Andorra\"> Andorra <\/option>\n <option value=\"Angola\"> Angola <\/option>\n <option value=\"Anguilla\"> Anguilla <\/option>\n <option value=\"Antigua and Barbuda\"> Antigua and Barbuda <\/option>\n <option value=\"Argentina\"> Argentina <\/option>\n <option value=\"Armenia\"> Armenia <\/option>\n <option value=\"Aruba\"> Aruba <\/option>\n <option value=\"Australia\"> Australia <\/option>\n <option value=\"Austria\"> Austria <\/option>\n <option value=\"Azerbaijan\"> Azerbaijan <\/option>\n <option value=\"The Bahamas\"> The Bahamas <\/option>\n <option value=\"Bahrain\"> Bahrain <\/option>\n <option value=\"Bangladesh\"> Bangladesh <\/option>\n <option value=\"Barbados\"> Barbados <\/option>\n <option value=\"Belarus\"> Belarus <\/option>\n <option value=\"Belgium\"> Belgium <\/option>\n <option value=\"Belize\"> Belize <\/option>\n <option value=\"Benin\"> Benin <\/option>\n <option value=\"Bermuda\"> Bermuda <\/option>\n <option value=\"Bhutan\"> Bhutan <\/option>\n <option value=\"Bolivia\"> Bolivia <\/option>\n <option value=\"Bosnia and Herzegovina\"> Bosnia and Herzegovina <\/option>\n <option value=\"Botswana\"> Botswana <\/option>\n <option value=\"Brazil\"> Brazil <\/option>\n <option value=\"Brunei\"> Brunei <\/option>\n <option value=\"Bulgaria\"> Bulgaria <\/option>\n <option value=\"Burkina Faso\"> Burkina Faso <\/option>\n <option value=\"Burundi\"> Burundi <\/option>\n <option value=\"Cambodia\"> Cambodia <\/option>\n <option value=\"Cameroon\"> Cameroon <\/option>\n <option value=\"Canada\"> Canada <\/option>\n <option value=\"Cape Verde\"> Cape Verde <\/option>\n <option value=\"Cayman Islands\"> Cayman Islands <\/option>\n <option value=\"Central African Republic\"> Central African Republic <\/option>\n <option value=\"Chad\"> Chad <\/option>\n <option value=\"Chile\"> Chile <\/option>\n <option value=\"People's Republic of China\"> People's Republic of China <\/option>\n <option value=\"Republic of China\"> Republic of China <\/option>\n <option value=\"Christmas Island\"> Christmas Island <\/option>\n <option value=\"Cocos (Keeling) Islands\"> Cocos (Keeling) Islands <\/option>\n <option value=\"Colombia\"> Colombia <\/option>\n <option value=\"Comoros\"> Comoros <\/option>\n <option value=\"Congo\"> Congo <\/option>\n <option value=\"Cook Islands\"> Cook Islands <\/option>\n <option value=\"Costa Rica\"> Costa Rica <\/option>\n <option value=\"Cote d'Ivoire\"> Cote d'Ivoire <\/option>\n <option value=\"Croatia\"> Croatia <\/option>\n <option value=\"Cuba\"> Cuba <\/option>\n <option value=\"Cyprus\"> Cyprus <\/option>\n <option value=\"Czech Republic\"> Czech Republic <\/option>\n <option value=\"Denmark\"> Denmark <\/option>\n <option value=\"Djibouti\"> Djibouti <\/option>\n <option value=\"Dominica\"> Dominica <\/option>\n <option value=\"Dominican Republic\"> Dominican Republic <\/option>\n <option value=\"Ecuador\"> Ecuador <\/option>\n <option value=\"Egypt\"> Egypt <\/option>\n <option value=\"El Salvador\"> El Salvador <\/option>\n <option value=\"Equatorial Guinea\"> Equatorial Guinea <\/option>\n <option value=\"Eritrea\"> Eritrea <\/option>\n <option value=\"Estonia\"> Estonia <\/option>\n <option value=\"Ethiopia\"> Ethiopia <\/option>\n <option value=\"Falkland Islands\"> Falkland Islands <\/option>\n <option value=\"Faroe Islands\"> Faroe Islands <\/option>\n <option value=\"Fiji\"> Fiji <\/option>\n <option value=\"Finland\"> Finland <\/option>\n <option value=\"France\"> France <\/option>\n <option value=\"French Polynesia\"> French Polynesia <\/option>\n <option value=\"Gabon\"> Gabon <\/option>\n <option value=\"The Gambia\"> The Gambia <\/option>\n <option value=\"Georgia\"> Georgia <\/option>\n <option value=\"Germany\"> Germany <\/option>\n <option value=\"Ghana\"> Ghana <\/option>\n <option value=\"Gibraltar\"> Gibraltar <\/option>\n <option value=\"Greece\"> Greece <\/option>\n <option value=\"Greenland\"> Greenland <\/option>\n <option value=\"Grenada\"> Grenada <\/option>\n <option value=\"Guadeloupe\"> Guadeloupe <\/option>\n <option value=\"Guam\"> Guam <\/option>\n <option value=\"Guatemala\"> Guatemala <\/option>\n <option value=\"Guernsey\"> Guernsey <\/option>\n <option value=\"Guinea\"> Guinea <\/option>\n <option value=\"Guinea-Bissau\"> Guinea-Bissau <\/option>\n <option value=\"Guyana\"> Guyana <\/option>\n <option value=\"Haiti\"> Haiti <\/option>\n <option value=\"Honduras\"> Honduras <\/option>\n <option value=\"Hong Kong\"> Hong Kong <\/option>\n <option value=\"Hungary\"> Hungary <\/option>\n <option value=\"Iceland\"> Iceland <\/option>\n <option value=\"India\"> India <\/option>\n <option value=\"Indonesia\"> Indonesia <\/option>\n <option value=\"Iran\"> Iran <\/option>\n <option value=\"Iraq\"> Iraq <\/option>\n <option value=\"Ireland\"> Ireland <\/option>\n <option value=\"Israel\"> Israel <\/option>\n <option value=\"Italy\"> Italy <\/option>\n <option value=\"Jamaica\"> Jamaica <\/option>\n <option value=\"Japan\"> Japan <\/option>\n <option value=\"Jersey\"> Jersey <\/option>\n <option value=\"Jordan\"> Jordan <\/option>\n <option value=\"Kazakhstan\"> Kazakhstan <\/option>\n <option value=\"Kenya\"> Kenya <\/option>\n <option value=\"Kiribati\"> Kiribati <\/option>\n <option value=\"North Korea\"> North Korea <\/option>\n <option value=\"South Korea\"> South Korea <\/option>\n <option value=\"Kosovo\"> Kosovo <\/option>\n <option value=\"Kuwait\"> Kuwait <\/option>\n <option value=\"Kyrgyzstan\"> Kyrgyzstan <\/option>\n <option value=\"Laos\"> Laos <\/option>\n <option value=\"Latvia\"> Latvia <\/option>\n <option value=\"Lebanon\"> Lebanon <\/option>\n <option value=\"Lesotho\"> Lesotho <\/option>\n <option value=\"Liberia\"> Liberia <\/option>\n <option value=\"Libya\"> Libya <\/option>\n <option value=\"Liechtenstein\"> Liechtenstein <\/option>\n <option value=\"Lithuania\"> Lithuania <\/option>\n <option value=\"Luxembourg\"> Luxembourg <\/option>\n <option value=\"Macau\"> Macau <\/option>\n <option value=\"Macedonia\"> Macedonia <\/option>\n <option value=\"Madagascar\"> Madagascar <\/option>\n <option value=\"Malawi\"> Malawi <\/option>\n <option value=\"Malaysia\"> Malaysia <\/option>\n <option value=\"Maldives\"> Maldives <\/option>\n <option value=\"Mali\"> Mali <\/option>\n <option value=\"Malta\"> Malta <\/option>\n <option value=\"Marshall Islands\"> Marshall Islands <\/option>\n <option value=\"Martinique\"> Martinique <\/option>\n <option value=\"Mauritania\"> Mauritania <\/option>\n <option value=\"Mauritius\"> Mauritius <\/option>\n <option value=\"Mayotte\"> Mayotte <\/option>\n <option value=\"Mexico\"> Mexico <\/option>\n <option value=\"Micronesia\"> Micronesia <\/option>\n <option value=\"Moldova\"> Moldova <\/option>\n <option value=\"Monaco\"> Monaco <\/option>\n <option value=\"Mongolia\"> Mongolia <\/option>\n <option value=\"Montenegro\"> Montenegro <\/option>\n <option value=\"Montserrat\"> Montserrat <\/option>\n <option value=\"Morocco\"> Morocco <\/option>\n <option value=\"Mozambique\"> Mozambique <\/option>\n <option value=\"Myanmar\"> Myanmar <\/option>\n <option value=\"Nagorno-Karabakh\"> Nagorno-Karabakh <\/option>\n <option value=\"Namibia\"> Namibia <\/option>\n <option value=\"Nauru\"> Nauru <\/option>\n <option value=\"Nepal\"> Nepal <\/option>\n <option value=\"Netherlands\"> Netherlands <\/option>\n <option value=\"Netherlands Antilles\"> Netherlands Antilles <\/option>\n <option value=\"New Caledonia\"> New Caledonia <\/option>\n <option value=\"New Zealand\"> New Zealand <\/option>\n <option value=\"Nicaragua\"> Nicaragua <\/option>\n <option value=\"Niger\"> Niger <\/option>\n <option value=\"Nigeria\"> Nigeria <\/option>\n <option value=\"Niue\"> Niue <\/option>\n <option value=\"Norfolk Island\"> Norfolk Island <\/option>\n <option value=\"Turkish Republic of Northern Cyprus\"> Turkish Republic of Northern Cyprus <\/option>\n <option value=\"Northern Mariana\"> Northern Mariana <\/option>\n <option value=\"Norway\"> Norway <\/option>\n <option value=\"Oman\"> Oman <\/option>\n <option value=\"Pakistan\"> Pakistan <\/option>\n <option value=\"Palau\"> Palau <\/option>\n <option value=\"Palestine\"> Palestine <\/option>\n <option value=\"Panama\"> Panama <\/option>\n <option value=\"Papua New Guinea\"> Papua New Guinea <\/option>\n <option value=\"Paraguay\"> Paraguay <\/option>\n <option value=\"Peru\"> Peru <\/option>\n <option value=\"Philippines\"> Philippines <\/option>\n <option value=\"Pitcairn Islands\"> Pitcairn Islands <\/option>\n <option value=\"Poland\"> Poland <\/option>\n <option value=\"Portugal\"> Portugal <\/option>\n <option value=\"Puerto Rico\"> Puerto Rico <\/option>\n <option value=\"Qatar\"> Qatar <\/option>\n <option value=\"Romania\"> Romania <\/option>\n <option value=\"Russia\"> Russia <\/option>\n <option value=\"Rwanda\"> Rwanda <\/option>\n <option value=\"Saint Barthelemy\"> Saint Barthelemy <\/option>\n <option value=\"Saint Helena\"> Saint Helena <\/option>\n <option value=\"Saint Kitts and Nevis\"> Saint Kitts and Nevis <\/option>\n <option value=\"Saint Lucia\"> Saint Lucia <\/option>\n <option value=\"Saint Martin\"> Saint Martin <\/option>\n <option value=\"Saint Pierre and Miquelon\"> Saint Pierre and Miquelon <\/option>\n <option value=\"Saint Vincent and the Grenadines\"> Saint Vincent and the Grenadines <\/option>\n <option value=\"Samoa\"> Samoa <\/option>\n <option value=\"San Marino\"> San Marino <\/option>\n <option value=\"Sao Tome and Principe\"> Sao Tome and Principe <\/option>\n <option value=\"Saudi Arabia\"> Saudi Arabia <\/option>\n <option value=\"Senegal\"> Senegal <\/option>\n <option value=\"Serbia\"> Serbia <\/option>\n <option value=\"Seychelles\"> Seychelles <\/option>\n <option value=\"Sierra Leone\"> Sierra Leone <\/option>\n <option value=\"Singapore\"> Singapore <\/option>\n <option value=\"Slovakia\"> Slovakia <\/option>\n <option value=\"Slovenia\"> Slovenia <\/option>\n <option value=\"Solomon Islands\"> Solomon Islands <\/option>\n <option value=\"Somalia\"> Somalia <\/option>\n <option value=\"Somaliland\"> Somaliland <\/option>\n <option value=\"South Africa\"> South Africa <\/option>\n <option value=\"South Ossetia\"> South Ossetia <\/option>\n <option value=\"Spain\"> Spain <\/option>\n <option value=\"Sri Lanka\"> Sri Lanka <\/option>\n <option value=\"Sudan\"> Sudan <\/option>\n <option value=\"Suriname\"> Suriname <\/option>\n <option value=\"Svalbard\"> Svalbard <\/option>\n <option value=\"Swaziland\"> Swaziland <\/option>\n <option value=\"Sweden\"> Sweden <\/option>\n <option value=\"Switzerland\"> Switzerland <\/option>\n <option value=\"Syria\"> Syria <\/option>\n <option value=\"Taiwan\"> Taiwan <\/option>\n <option value=\"Tajikistan\"> Tajikistan <\/option>\n <option value=\"Tanzania\"> Tanzania <\/option>\n <option value=\"Thailand\"> Thailand <\/option>\n <option value=\"Timor-Leste\"> Timor-Leste <\/option>\n <option value=\"Togo\"> Togo <\/option>\n <option value=\"Tokelau\"> Tokelau <\/option>\n <option value=\"Tonga\"> Tonga <\/option>\n <option value=\"Transnistria Pridnestrovie\"> Transnistria Pridnestrovie <\/option>\n <option value=\"Trinidad and Tobago\"> Trinidad and Tobago <\/option>\n <option value=\"Tristan da Cunha\"> Tristan da Cunha <\/option>\n <option value=\"Tunisia\"> Tunisia <\/option>\n <option value=\"Turkey\"> Turkey <\/option>\n <option value=\"Turkmenistan\"> Turkmenistan <\/option>\n <option value=\"Turks and Caicos Islands\"> Turks and Caicos Islands <\/option>\n <option value=\"Tuvalu\"> Tuvalu <\/option>\n <option value=\"Uganda\"> Uganda <\/option>\n <option value=\"Ukraine\"> Ukraine <\/option>\n <option value=\"United Arab Emirates\"> United Arab Emirates <\/option>\n <option value=\"United Kingdom\"> United Kingdom <\/option>\n <option value=\"Uruguay\"> Uruguay <\/option>\n <option value=\"Uzbekistan\"> Uzbekistan <\/option>\n <option value=\"Vanuatu\"> Vanuatu <\/option>\n <option value=\"Vatican City\"> Vatican City <\/option>\n <option value=\"Venezuela\"> Venezuela <\/option>\n <option value=\"Vietnam\"> Vietnam <\/option>\n <option value=\"British Virgin Islands\"> British Virgin Islands <\/option>\n <option value=\"US Virgin Islands\"> US Virgin Islands <\/option>\n <option value=\"Wallis and Futuna\"> Wallis and Futuna <\/option>\n <option value=\"Western Sahara\"> Western Sahara <\/option>\n <option value=\"Yemen\"> Yemen <\/option>\n <option value=\"Zambia\"> Zambia <\/option>\n <option value=\"Zimbabwe\"> Zimbabwe <\/option>\n <option value=\"other\"> Other <\/option>\n <\/select>\n <label class=\"form-sub-label\" for=\"input_130_country\" id=\"sublabel_country\"> Country <\/label><\/span>\n <\/td>\n <\/tr>\n <\/table>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_33\">\n <label class=\"form-label-left\" id=\"label_33\" for=\"input_33\"> Preferred Mail to Address <\/label>\n <div id=\"cid_33\" 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_33_0\" name=\"q33_preferredMail[]\" value=\"Home\" \/>\n <label for=\"input_33_0\"> Home <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_33_1\" name=\"q33_preferredMail[]\" value=\"Business\" \/>\n <label for=\"input_33_1\"> Business <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_34\">\n <label class=\"form-label-left\" id=\"label_34\" for=\"input_34\">\n T-Shirt Size<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_34\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_34_0\" name=\"q34_tshirtSize\" value=\"SM\" \/>\n <label for=\"input_34_0\"> SM <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_34_1\" name=\"q34_tshirtSize\" value=\"M\" \/>\n <label for=\"input_34_1\"> M <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_34_2\" name=\"q34_tshirtSize\" value=\"L\" \/>\n <label for=\"input_34_2\"> L <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_34_3\" name=\"q34_tshirtSize\" value=\"XL\" \/>\n <label for=\"input_34_3\"> XL <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_34_4\" name=\"q34_tshirtSize\" value=\"XXL\" \/>\n <label for=\"input_34_4\"> XXL <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_34_5\" name=\"q34_tshirtSize\" value=\"XXXL\" \/>\n <label for=\"input_34_5\"> XXXL <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_35\">\n <label class=\"form-label-left\" id=\"label_35\" for=\"input_35\">\n Number of Years you've been in Spokane<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_35\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required, Numeric]\" id=\"input_35\" name=\"q35_numberOf\" size=\"5\" maxlength=\"2\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_36\">\n <label class=\"form-label-left\" id=\"label_36\" for=\"input_36\">\n What accommodations do you need to participate fully in the program? (Enter NA for Not Applicable)<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_36\" class=\"form-input\">\n <textarea id=\"input_36\" class=\"form-textarea validate[required]\" name=\"q36_whatAccommodations\" cols=\"50\" rows=\"5\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_37\">\n <label class=\"form-label-left\" id=\"label_37\" for=\"input_37\"> Do you have dietary restrictions? <\/label>\n <div id=\"cid_37\" 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_37_0\" name=\"q37_doYou\" value=\"Yes\" \/>\n <label for=\"input_37_0\"> Yes <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-radio-item\" style=\"clear:left;\"><input type=\"radio\" class=\"form-radio\" id=\"input_37_1\" name=\"q37_doYou\" value=\"No\" \/>\n <label for=\"input_37_1\"> No <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_38\">\n <label class=\"form-label-left\" id=\"label_38\" for=\"input_38\"> If Yes, please Specify. <\/label>\n <div id=\"cid_38\" class=\"form-input\">\n <textarea id=\"input_38\" class=\"form-textarea\" name=\"q38_ifYes\" cols=\"40\" rows=\"3\"><\/textarea>\n <\/div>\n <\/li>\n <li id=\"cid_40\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_40\" class=\"form-header\">\n EDUCATION\/TRAINING\n <\/h2>\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 College(s), advance degrees, or training\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_51\">\n <div id=\"cid_51\" class=\"form-input-wide\">\n <div id=\"text_51\" class=\"form-html\">\n Enter Name of Most Recent School Attended.\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_45\">\n <label class=\"form-label-left\" id=\"label_45\" for=\"input_45\"> School Name <\/label>\n <div id=\"cid_45\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_45\" name=\"q45_schoolName\" size=\"50\" 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\"> Date From <\/label>\n <div id=\"cid_47\" class=\"form-input\"><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"month_47\" name=\"q47_dateFrom[month]\" type=\"text\" size=\"2\" maxlength=\"2\" value=\"02\" \/><span class=\"date-separate\"> -<\/span>\n <label class=\"form-sub-label\" for=\"month_47\" id=\"sublabel_month\"> Month <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"day_47\" name=\"q47_dateFrom[day]\" type=\"text\" size=\"2\" maxlength=\"2\" value=\"10\" \/><span class=\"date-separate\"> -<\/span>\n <label class=\"form-sub-label\" for=\"day_47\" id=\"sublabel_day\"> Day <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"year_47\" name=\"q47_dateFrom[year]\" type=\"text\" size=\"4\" maxlength=\"4\" value=\"2012\" \/>\n <label class=\"form-sub-label\" for=\"year_47\" id=\"sublabel_year\"> Year <\/label><\/span><span class=\"form-sub-label-container\"><img alt=\"Pick a Date\" id=\"input_47_pick\" src=\"http:\/\/www.jotform.com\/images\/calendar.png\" align=\"absmiddle\" \/>\n <label class=\"form-sub-label\" for=\"input_47_pick\">     <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_49\">\n <label class=\"form-label-left\" id=\"label_49\" for=\"input_49\"> Date To <\/label>\n <div id=\"cid_49\" class=\"form-input\"><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"month_49\" name=\"q49_dateTo[month]\" type=\"text\" size=\"2\" maxlength=\"2\" value=\"02\" \/><span class=\"date-separate\"> -<\/span>\n <label class=\"form-sub-label\" for=\"month_49\" id=\"sublabel_month\"> Month <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"day_49\" name=\"q49_dateTo[day]\" type=\"text\" size=\"2\" maxlength=\"2\" value=\"10\" \/><span class=\"date-separate\"> -<\/span>\n <label class=\"form-sub-label\" for=\"day_49\" id=\"sublabel_day\"> Day <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"year_49\" name=\"q49_dateTo[year]\" type=\"text\" size=\"4\" maxlength=\"4\" value=\"2012\" \/>\n <label class=\"form-sub-label\" for=\"year_49\" id=\"sublabel_year\"> Year <\/label><\/span><span class=\"form-sub-label-container\"><img alt=\"Pick a Date\" id=\"input_49_pick\" src=\"http:\/\/www.jotform.com\/images\/calendar.png\" align=\"absmiddle\" \/>\n <label class=\"form-sub-label\" for=\"input_49_pick\">     <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_48\">\n <label class=\"form-label-left\" id=\"label_48\" for=\"input_48\"> Degree\/Major <\/label>\n <div id=\"cid_48\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_48\" name=\"q48_degreemajor\" size=\"45\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_52\">\n <div id=\"cid_52\" class=\"form-input-wide\">\n <div id=\"text_52\" class=\"form-html\">\n Enter Name of Second School Attended.\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_53\">\n <label class=\"form-label-left\" id=\"label_53\" for=\"input_53\"> School Name <\/label>\n <div id=\"cid_53\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_53\" name=\"q53_schoolName53\" size=\"50\" 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\"> Date From <\/label>\n <div id=\"cid_54\" class=\"form-input\"><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"month_54\" name=\"q54_dateFrom54[month]\" type=\"text\" size=\"2\" maxlength=\"2\" value=\"02\" \/><span class=\"date-separate\"> -<\/span>\n <label class=\"form-sub-label\" for=\"month_54\" id=\"sublabel_month\"> Month <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"day_54\" name=\"q54_dateFrom54[day]\" type=\"text\" size=\"2\" maxlength=\"2\" value=\"10\" \/><span class=\"date-separate\"> -<\/span>\n <label class=\"form-sub-label\" for=\"day_54\" id=\"sublabel_day\"> Day <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"year_54\" name=\"q54_dateFrom54[year]\" type=\"text\" size=\"4\" maxlength=\"4\" value=\"2012\" \/>\n <label class=\"form-sub-label\" for=\"year_54\" id=\"sublabel_year\"> Year <\/label><\/span><span class=\"form-sub-label-container\"><img alt=\"Pick a Date\" id=\"input_54_pick\" src=\"http:\/\/www.jotform.com\/images\/calendar.png\" align=\"absmiddle\" \/>\n <label class=\"form-sub-label\" for=\"input_54_pick\">     <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_55\">\n <label class=\"form-label-left\" id=\"label_55\" for=\"input_55\"> Date To <\/label>\n <div id=\"cid_55\" class=\"form-input\"><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"month_55\" name=\"q55_dateTo55[month]\" type=\"text\" size=\"2\" maxlength=\"2\" value=\"02\" \/><span class=\"date-separate\"> -<\/span>\n <label class=\"form-sub-label\" for=\"month_55\" id=\"sublabel_month\"> Month <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"day_55\" name=\"q55_dateTo55[day]\" type=\"text\" size=\"2\" maxlength=\"2\" value=\"10\" \/><span class=\"date-separate\"> -<\/span>\n <label class=\"form-sub-label\" for=\"day_55\" id=\"sublabel_day\"> Day <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"year_55\" name=\"q55_dateTo55[year]\" type=\"text\" size=\"4\" maxlength=\"4\" value=\"2012\" \/>\n <label class=\"form-sub-label\" for=\"year_55\" id=\"sublabel_year\"> Year <\/label><\/span><span class=\"form-sub-label-container\"><img alt=\"Pick a Date\" id=\"input_55_pick\" src=\"http:\/\/www.jotform.com\/images\/calendar.png\" align=\"absmiddle\" \/>\n <label class=\"form-sub-label\" for=\"input_55_pick\">     <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_56\">\n <label class=\"form-label-left\" id=\"label_56\" for=\"input_56\"> Degree\/Major <\/label>\n <div id=\"cid_56\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_56\" name=\"q56_degreemajor56\" size=\"45\" maxlength=\"100\" \/>\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 EMPLOYMENT\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_59\">\n <label class=\"form-label-left\" id=\"label_59\" for=\"input_59\">\n Present Employer (Enter Self Employed if Self Employed)<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_59\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_59\" name=\"q59_presentEmployer\" size=\"50\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_60\">\n <label class=\"form-label-left\" id=\"label_60\" for=\"input_60\">\n Date of Hire<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_60\" class=\"form-input\"><span class=\"form-sub-label-container\"><input class=\"form-textbox validate[required]\" id=\"month_60\" name=\"q60_dateOf[month]\" type=\"text\" size=\"2\" maxlength=\"2\" value=\"02\" \/><span class=\"date-separate\"> -<\/span>\n <label class=\"form-sub-label\" for=\"month_60\" id=\"sublabel_month\"> Month <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox validate[required]\" id=\"day_60\" name=\"q60_dateOf[day]\" type=\"text\" size=\"2\" maxlength=\"2\" value=\"10\" \/><span class=\"date-separate\"> -<\/span>\n <label class=\"form-sub-label\" for=\"day_60\" id=\"sublabel_day\"> Day <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox validate[required]\" id=\"year_60\" name=\"q60_dateOf[year]\" type=\"text\" size=\"4\" maxlength=\"4\" value=\"2012\" \/>\n <label class=\"form-sub-label\" for=\"year_60\" id=\"sublabel_year\"> Year <\/label><\/span><span class=\"form-sub-label-container\"><img alt=\"Pick a Date\" id=\"input_60_pick\" src=\"http:\/\/www.jotform.com\/images\/calendar.png\" align=\"absmiddle\" \/>\n <label class=\"form-sub-label\" for=\"input_60_pick\">     <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_61\">\n <label class=\"form-label-left\" id=\"label_61\" for=\"input_61\">\n Type of Organization<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_61\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_61_0\" name=\"q61_typeOf[]\" value=\"Corporation\" \/>\n <label for=\"input_61_0\"> Corporation <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_61_1\" name=\"q61_typeOf[]\" value=\"Education\" \/>\n <label for=\"input_61_1\"> Education <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_61_2\" name=\"q61_typeOf[]\" value=\"Financial Institution\" \/>\n <label for=\"input_61_2\"> Financial Institution <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_61_3\" name=\"q61_typeOf[]\" value=\"Government\" \/>\n <label for=\"input_61_3\"> Government <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_61_4\" name=\"q61_typeOf[]\" value=\"Healthcare\" \/>\n <label for=\"input_61_4\"> Healthcare <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_61_5\" name=\"q61_typeOf[]\" value=\"Insurance\" \/>\n <label for=\"input_61_5\"> Insurance <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_61_6\" name=\"q61_typeOf[]\" value=\"Legal\" \/>\n <label for=\"input_61_6\"> Legal <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_61_7\" name=\"q61_typeOf[]\" value=\"Military\" \/>\n <label for=\"input_61_7\"> Military <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_61_8\" name=\"q61_typeOf[]\" value=\"Non-Profit\" \/>\n <label for=\"input_61_8\"> Non-Profit <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_61_9\" name=\"q61_typeOf[]\" value=\"Self-Employed\" \/>\n <label for=\"input_61_9\"> Self-Employed <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_61_10\" name=\"q61_typeOf[]\" value=\"Arts\" \/>\n <label for=\"input_61_10\"> Arts <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_61_11\" name=\"q61_typeOf[]\" value=\"Other\" \/>\n <label for=\"input_61_11\"> Other <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_62\">\n <label class=\"form-label-left\" id=\"label_62\" for=\"input_62\"> Your Job Title <\/label>\n <div id=\"cid_62\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_62\" name=\"q62_yourJob\" size=\"45\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_63\">\n <label class=\"form-label-left\" id=\"label_63\" for=\"input_63\">\n Brief description of responsibilities:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_63\" class=\"form-input\">\n <textarea id=\"input_63\" class=\"form-textarea validate[required]\" name=\"q63_briefDescription\" cols=\"50\" rows=\"4\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_64\">\n <div id=\"cid_64\" class=\"form-input-wide\">\n <div id=\"text_64\" class=\"form-html\">\n List previous employers, beginning with the most recent. Include active military duty.\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_66\">\n <div id=\"cid_66\" class=\"form-input-wide\">\n <div id=\"text_66\" class=\"form-html\">\n First Employer\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_65\">\n <label class=\"form-label-left\" id=\"label_65\" for=\"input_65\"> Name <\/label>\n <div id=\"cid_65\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_65\" name=\"q65_name\" size=\"45\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_67\">\n <label class=\"form-label-left\" id=\"label_67\" for=\"input_67\"> Title\/Responsibility <\/label>\n <div id=\"cid_67\" class=\"form-input\">\n <textarea id=\"input_67\" class=\"form-textarea\" name=\"q67_titleresponsibility\" cols=\"45\" rows=\"4\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_68\">\n <label class=\"form-label-left\" id=\"label_68\" for=\"input_68\"> Date From <\/label>\n <div id=\"cid_68\" class=\"form-input\"><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"month_68\" name=\"q68_dateFrom68[month]\" type=\"text\" size=\"2\" maxlength=\"2\" value=\"02\" \/><span class=\"date-separate\"> -<\/span>\n <label class=\"form-sub-label\" for=\"month_68\" id=\"sublabel_month\"> Month <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"day_68\" name=\"q68_dateFrom68[day]\" type=\"text\" size=\"2\" maxlength=\"2\" value=\"10\" \/><span class=\"date-separate\"> -<\/span>\n <label class=\"form-sub-label\" for=\"day_68\" id=\"sublabel_day\"> Day <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"year_68\" name=\"q68_dateFrom68[year]\" type=\"text\" size=\"4\" maxlength=\"4\" value=\"2012\" \/>\n <label class=\"form-sub-label\" for=\"year_68\" id=\"sublabel_year\"> Year <\/label><\/span><span class=\"form-sub-label-container\"><img alt=\"Pick a Date\" id=\"input_68_pick\" src=\"http:\/\/www.jotform.com\/images\/calendar.png\" align=\"absmiddle\" \/>\n <label class=\"form-sub-label\" for=\"input_68_pick\">     <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_69\">\n <label class=\"form-label-left\" id=\"label_69\" for=\"input_69\"> Date To <\/label>\n <div id=\"cid_69\" class=\"form-input\"><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"month_69\" name=\"q69_dateTo69[month]\" type=\"text\" size=\"2\" maxlength=\"2\" value=\"02\" \/><span class=\"date-separate\"> -<\/span>\n <label class=\"form-sub-label\" for=\"month_69\" id=\"sublabel_month\"> Month <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"day_69\" name=\"q69_dateTo69[day]\" type=\"text\" size=\"2\" maxlength=\"2\" value=\"10\" \/><span class=\"date-separate\"> -<\/span>\n <label class=\"form-sub-label\" for=\"day_69\" id=\"sublabel_day\"> Day <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"year_69\" name=\"q69_dateTo69[year]\" type=\"text\" size=\"4\" maxlength=\"4\" value=\"2012\" \/>\n <label class=\"form-sub-label\" for=\"year_69\" id=\"sublabel_year\"> Year <\/label><\/span><span class=\"form-sub-label-container\"><img alt=\"Pick a Date\" id=\"input_69_pick\" src=\"http:\/\/www.jotform.com\/images\/calendar.png\" align=\"absmiddle\" \/>\n <label class=\"form-sub-label\" for=\"input_69_pick\">     <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_70\">\n <div id=\"cid_70\" class=\"form-input-wide\">\n <div id=\"text_70\" class=\"form-html\">\n Second Employer\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_71\">\n <label class=\"form-label-left\" id=\"label_71\" for=\"input_71\"> Name <\/label>\n <div id=\"cid_71\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_71\" name=\"q71_name71\" size=\"45\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_72\">\n <label class=\"form-label-left\" id=\"label_72\" for=\"input_72\"> Title\/Responsibility <\/label>\n <div id=\"cid_72\" class=\"form-input\">\n <textarea id=\"input_72\" class=\"form-textarea\" name=\"q72_titleresponsibility72\" cols=\"45\" rows=\"4\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_73\">\n <label class=\"form-label-left\" id=\"label_73\" for=\"input_73\"> Date From <\/label>\n <div id=\"cid_73\" class=\"form-input\"><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"month_73\" name=\"q73_dateFrom73[month]\" type=\"text\" size=\"2\" maxlength=\"2\" value=\"02\" \/><span class=\"date-separate\"> -<\/span>\n <label class=\"form-sub-label\" for=\"month_73\" id=\"sublabel_month\"> Month <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"day_73\" name=\"q73_dateFrom73[day]\" type=\"text\" size=\"2\" maxlength=\"2\" value=\"10\" \/><span class=\"date-separate\"> -<\/span>\n <label class=\"form-sub-label\" for=\"day_73\" id=\"sublabel_day\"> Day <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"year_73\" name=\"q73_dateFrom73[year]\" type=\"text\" size=\"4\" maxlength=\"4\" value=\"2012\" \/>\n <label class=\"form-sub-label\" for=\"year_73\" id=\"sublabel_year\"> Year <\/label><\/span><span class=\"form-sub-label-container\"><img alt=\"Pick a Date\" id=\"input_73_pick\" src=\"http:\/\/www.jotform.com\/images\/calendar.png\" align=\"absmiddle\" \/>\n <label class=\"form-sub-label\" for=\"input_73_pick\">     <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_74\">\n <label class=\"form-label-left\" id=\"label_74\" for=\"input_74\"> Date To <\/label>\n <div id=\"cid_74\" class=\"form-input\"><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"month_74\" name=\"q74_dateTo74[month]\" type=\"text\" size=\"2\" maxlength=\"2\" value=\"02\" \/><span class=\"date-separate\"> -<\/span>\n <label class=\"form-sub-label\" for=\"month_74\" id=\"sublabel_month\"> Month <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"day_74\" name=\"q74_dateTo74[day]\" type=\"text\" size=\"2\" maxlength=\"2\" value=\"10\" \/><span class=\"date-separate\"> -<\/span>\n <label class=\"form-sub-label\" for=\"day_74\" id=\"sublabel_day\"> Day <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"year_74\" name=\"q74_dateTo74[year]\" type=\"text\" size=\"4\" maxlength=\"4\" value=\"2012\" \/>\n <label class=\"form-sub-label\" for=\"year_74\" id=\"sublabel_year\"> Year <\/label><\/span><span class=\"form-sub-label-container\"><img alt=\"Pick a Date\" id=\"input_74_pick\" src=\"http:\/\/www.jotform.com\/images\/calendar.png\" align=\"absmiddle\" \/>\n <label class=\"form-sub-label\" for=\"input_74_pick\">     <\/label><\/span>\n <\/div>\n <\/li>\n <li id=\"cid_81\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_81\" class=\"form-header\">\n ACCOMPLISHMENTS & INVOLVEMENTS\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_80\">\n <div id=\"cid_80\" class=\"form-input-wide\">\n <div id=\"text_80\" class=\"form-html\">\n This section will allow us to know you more. in no more than 500 words, answer the following questions. Use N\/A if the section does not apply to you.\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_76\">\n <label class=\"form-label-left\" id=\"label_76\" for=\"input_76\">\n What do you consider your highest career achievement to date?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_76\" class=\"form-input\">\n <textarea id=\"input_76\" class=\"form-textarea validate[required]\" name=\"q76_whatDo\" cols=\"50\" rows=\"8\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_77\">\n <label class=\"form-label-left\" id=\"label_77\" for=\"input_77\">\n Business\/Professional Affiliations:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_77\" class=\"form-input\">\n <textarea id=\"input_77\" class=\"form-textarea validate[required]\" name=\"q77_businessprofessionalAffiliations\" cols=\"50\" rows=\"8\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_78\">\n <label class=\"form-label-left\" id=\"label_78\" for=\"input_78\">\n Community Involvement and major roles:<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_78\" class=\"form-input\">\n <textarea id=\"input_78\" class=\"form-textarea validate[required]\" name=\"q78_communityInvolvement\" cols=\"50\" rows=\"8\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_79\">\n <label class=\"form-label-left\" id=\"label_79\" for=\"input_79\">\n What do you consider to be your most important community service accomplishment to date? Why?<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_79\" class=\"form-input\">\n <textarea id=\"input_79\" class=\"form-textarea validate[required]\" name=\"q79_whatDo79\" cols=\"50\" rows=\"8\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_82\">\n <label class=\"form-label-left\" id=\"label_82\" for=\"input_82\"> What is your Meyer-Briggs personality type? (You can determine this by taking a brief test at <\/label>\n <div id=\"cid_82\" class=\"form-input\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_82\" name=\"q82_whatIs\" size=\"20\" maxlength=\"100\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_145\">\n <div id=\"cid_145\" class=\"form-input-wide\">\n <div id=\"text_145\" class=\"form-html\">\n http:\/\/www.humanmetrics.com\/cgi-win\/JTypes2.asp\n <\/div>\n <\/div>\n <\/li>\n <li id=\"cid_86\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_86\" class=\"form-header\">\n ESSAY QUESTIONS\n <\/h2>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_84\">\n <div id=\"cid_84\" class=\"form-input-wide\">\n <div id=\"text_84\" class=\"form-html\">\n In the next page, you will have the opportunity to upload your essays. Please not the essays must be saved in word processor format, or .pdf formats.\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_87\">\n <div id=\"cid_87\" class=\"form-input-wide\">\n <div id=\"text_87\" class=\"form-html\">\n Below are the list of Essay Questions you must include in your essay. Please answer them to the best of your ability. Limit your essays to no more than two pages total.\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_88\">\n <div id=\"cid_88\" class=\"form-input-wide\">\n <div id=\"text_88\" class=\"form-html\">\n 1. What do you think is the most significant challenge OR opportunity facing the greater Spokane region today?\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_89\">\n <div id=\"cid_89\" class=\"form-input-wide\">\n <div id=\"text_89\" class=\"form-html\">\n 2. What approach would you take to address this issue?\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_90\">\n <div id=\"cid_90\" class=\"form-input-wide\">\n <div id=\"text_90\" class=\"form-html\">\n 3. What specific skills, knowledge or connections do you hope to gain from participating in Leadership Spokane?\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_93\">\n <label class=\"form-label-left\" id=\"label_93\" for=\"input_93\">\n Attach your Essay<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_93\" class=\"form-input\">\n <input class=\"form-upload validate[required]\" type=\"file\" id=\"input_93\" name=\"q93_attachYour\" file-accept=\"doc, pdf, docx\" file-maxsize=\"7000\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_121\">\n <label class=\"form-label-left\" id=\"label_121\" for=\"input_121\">\n Attach your Photo<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_121\" class=\"form-input\">\n <input class=\"form-upload validate[required]\" type=\"file\" id=\"input_121\" name=\"q121_attachYour121\" file-accept=\"jpg, jpeg, gif, png\" file-maxsize=\"10000\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_117\">\n <div id=\"cid_117\" class=\"form-input-wide\">\n <div id=\"text_117\" class=\"form-html\">\n You are almost done.\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_118\">\n <label class=\"form-label-left\" id=\"label_118\" for=\"input_118\">\n By clicking the submit button below, I affirm that the information entered in my Leadership Spokane application is true to the best of my knowledge. I understand that my application is not complete until I submit the additional forms located at www. www.leadershipspokane.org\/apply-now\/application-forms.<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_118\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_118_0\" name=\"q118_byClicking118[]\" value=\"I Agree\" \/>\n <label for=\"input_118_0\"> I Agree <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_1\">\n <div id=\"cid_1\" class=\"form-input-wide\">\n <div style=\"margin-left:156px\" class=\"form-buttons-wrapper\">\n <button id=\"input_1\" type=\"submit\" class=\"form-submit-button\">\n Submit\n <\/button>\n <\/div>\n <\/div>\n <\/li>\n <li style=\"display:none\">\n Should be Empty:\n <input type=\"text\" name=\"website\" value=\"\" \/>\n <\/li>\n <\/ul>\n <\/div>\n <input type=\"hidden\" id=\"simple_spc\" name=\"simple_spc\" value=\"93065343500\" \/>\n <script type=\"text\/javascript\">\n document.getElementById(\"si\" + \"mple\" + \"_spc\").value = \"93065343500-93065343500\";\n <\/script>\n<\/form><\/body>\n<\/html>\n");