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	Calendar 2025-2026 - Chabad of the Berkshires
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			<h1 class="article-header__title js-article-title js-page-title">Calendar Ad Form</h1>
		
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<form class="userform-form" action="" method="post" name="form_6487145" id="6487145" accept-charset="utf-8"><input type="hidden" name="formID" value="6487145" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li class="form-line" id="id_66"><div id="cid_66" class="form-input-wide"> <img alt="" class="form-image" border="0" src="https://w2.chabad.org/media/images/1328/KNEk13286026.png" height="332.5" width="665" /> </div></li><li class="form-line" id="id_1"><div id="cid_1" class="form-input-wide"> <div id="text_1" class="form-html"><p>Dear Friend, <br />
<br />
Chabad of the Berkshires has launched our annual Calendar Campaign. The beautiful, colorful calendar for New Year 5786 corresponding to September 2025 – September 2026 will be distributed to over 5,000 homes and businesses throughout the Berkshires<br />
<br />
Please support the calendar campaign allowing us to distribute it widely, strengthening Jewish identity and community. <br />
<br />
There are several ways you can support the calendar campaign: <br />
1. <strong>Advertise your business</strong> – see below the various opportunities <br />
2. Place your <strong>families occasions</strong> on date of occurrence, i.e. birthdays, anniversaries and Yartzeits <br />
3. Join the Communal <strong>Greeting page</strong> wishing everyone a Shana Tova. <br />
<br />
The calendar will be sent in time for the High Holidays! <br />
<br />
Thank you for your participation and partnering with Chabad of the Berkshires for a bright Jewish future.</p>
</div> </div></li><li id="cid_3" class="form-input-wide"> <div class="form-header-group"><h2 id="header_3" class="form-header">Advertising Options</h2></div> </li><li class="form-line" id="id_62"><div class="form-label-left" id="label_62"><label for="input_62"> Large Calendar Page Banner Ad | 10.5" x 2" </label><label class="label-message" for="input_62"> </label></div><div id="cid_62" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_62_0" name="q62_input62[]" value="1 Months - $979" /><label id="label_input_62_0" for="input_62_0"><span>1 Months - $979</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_62_1" name="q62_input62[]" value="3 Months - $2700" /><label id="label_input_62_1" for="input_62_1"><span>3 Months - $2700</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_5"><div class="form-label-left" id="label_5"><label for="input_5"> Preferred Months: </label><label class="label-message" for="input_5"> </label></div><div id="cid_5" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_5" name="q5_preferredMonths" size="15" value="" /> </div></li><li class="form-line" id="id_64"><div class="form-label-left" id="label_64"><label for="input_64"> Calendar Covers | 10” x 7.5” </label><label class="label-message" for="input_64"> </label></div><div id="cid_64" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_64_0" name="q64_input64[]" value="Back Cover - $2500" /><label id="label_input_64_0" for="input_64_0"><span>Back Cover - $2500</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_64_1" name="q64_input64[]" value="Inside Back Cover - $1000" /><label id="label_input_64_1" for="input_64_1"><span>Inside Back Cover - $1000</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_65"><div class="form-label-left" id="label_65"><label for="input_65"> Advertsing Space in Centerfold </label><label class="label-message" for="input_65"> </label></div><div id="cid_65" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_65_0" name="q65_input65[]" value="Full Page - $979 (10.5” x 8”)" /><label id="label_input_65_0" for="input_65_0"><span>Full Page - $979 (10.5” x 8”)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_65_1" name="q65_input65[]" value="Half Page - $799 (5” x 4.5&quot;)" /><label id="label_input_65_1" for="input_65_1"><span>Half Page - $799 (5” x 4.5")</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_65_2" name="q65_input65[]" value="Business Card - $500 (3.5” x 2”)" /><label id="label_input_65_2" for="input_65_2"><span>Business Card - $500 (3.5” x 2”)</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_10"><div id="cid_10" class="form-input-wide"> <div id="text_10" class="form-html"><p><strong>Website Advertising</strong></p><p>Your ad will be displayed on Chabad’s website, calendar page. This displays info only and is not clickable. </p></div> </div></li><li class="form-line" id="id_12"><div class="form-label-left" id="label_12"><label for="input_12"> Please attach ad in space below. You can send your ad artwork separately </label><label class="label-message" for="input_12"> </label></div><div id="cid_12" class="form-input"> <textarea id="input_12" class="form-textarea" name="q12_pleaseAttach" cols="60" rows="6"></textarea> </div></li><li id="cid_14" class="form-input-wide"> <div class="form-header-group"><h2 id="header_14" class="form-header">Personal Greetings</h2></div> </li><li class="form-line" id="id_61"><div class="form-label-left" id="label_61"><label for="input_61"> Please include my family birthdays/yartzeits/anniversaries </label><label class="label-message" for="input_61"> </label></div><div id="cid_61" class="form-input"> <select class="form-dropdown" style="width:260px" id="input_61" name="q61_pleaseInclude"><option value="">Please Select Amount of Greetings</option><option value="1 Greeting - $26">1 Greeting - $26</option><option value="2 Greetings - $52">2 Greetings - $52</option><option value="3 Greetings - $78">3 Greetings - $78</option><option value="4 Greetings - $100">4 Greetings - $100</option><option value="5 Greetings - $125">5 Greetings - $125</option><option value="6 Greetings - $145">6 Greetings - $145</option></select> </div></li><li class="form-line" id="id_17"><div class="form-label-left" id="label_17"><label for="input_17"> Full Name #1 </label><label class="label-message" for="input_17"> </label></div><div id="cid_17" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q17_fullName17[first]" id="first_17" autocomplete="given-name" />  <label class="form-sub-label" for="first_17" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q17_fullName17[last]" id="last_17" autocomplete="family-name" />  <label class="form-sub-label" for="last_17" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_19"><div class="form-label-left" id="label_19"><label for="input_19"> Occasion </label><label class="label-message" for="input_19"> </label></div><div id="cid_19" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_19" name="q19_occasion19"><option value=""></option><option value="Anniversary">Anniversary</option><option value="Birthday">Birthday</option><option value="Yartzeit">Yartzeit</option></select> </div></li><li class="form-line" id="id_20"><div class="form-label-left" id="label_20"><label for="input_20"> Occasion Date </label><label class="label-message" for="input_20"> </label></div><div id="cid_20" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input class="form-textbox" id="month_20" name="q20_occasionDate[month]" type="tel" size="2" maxlength="2" value="07" />  <label class="form-sub-label" for="month_20" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input class="form-textbox" id="day_20" name="q20_occasionDate[day]" type="tel" size="2" maxlength="2" value="29" />  <label class="form-sub-label" for="day_20" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input class="form-textbox" id="year_20" name="q20_occasionDate[year]" type="tel" size="4" maxlength="4" value="2025" />  <label class="form-sub-label" for="year_20" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_20_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_20_pick"><span> </span></label></span></div></div> </div></li><li class="form-line" id="id_21"><div class="form-label-left" id="label_21"><label for="input_21"> Full Name #2 </label><label class="label-message" for="input_21"> </label></div><div id="cid_21" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q21_fullName21[first]" id="first_21" autocomplete="given-name" />  <label class="form-sub-label" for="first_21" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q21_fullName21[last]" id="last_21" autocomplete="family-name" />  <label class="form-sub-label" for="last_21" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_23"><div class="form-label-left" id="label_23"><label for="input_23"> Occasion </label><label class="label-message" for="input_23"> </label></div><div id="cid_23" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_23" name="q23_occasion23"><option value=""></option><option value="Anniversary">Anniversary</option><option value="Birthday">Birthday</option><option value="Yartzeit">Yartzeit</option></select> </div></li><li class="form-line" id="id_24"><div class="form-label-left" id="label_24"><label for="input_24"> Occasion Date </label><label class="label-message" for="input_24"> </label></div><div id="cid_24" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input class="form-textbox" id="month_24" name="q24_occasionDate24[month]" type="tel" size="2" maxlength="2" value="07" />  <label class="form-sub-label" for="month_24" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input class="form-textbox" id="day_24" name="q24_occasionDate24[day]" type="tel" size="2" maxlength="2" value="29" />  <label class="form-sub-label" for="day_24" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input class="form-textbox" id="year_24" name="q24_occasionDate24[year]" type="tel" size="4" maxlength="4" value="2025" />  <label class="form-sub-label" for="year_24" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_24_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_24_pick"><span> </span></label></span></div></div> </div></li><li class="form-line" id="id_26"><div class="form-label-left" id="label_26"><label for="input_26"> Full Name #3 </label><label class="label-message" for="input_26"> </label></div><div id="cid_26" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q26_fullName26[first]" id="first_26" autocomplete="given-name" />  <label class="form-sub-label" for="first_26" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q26_fullName26[last]" id="last_26" autocomplete="family-name" />  <label class="form-sub-label" for="last_26" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_37"><div class="form-label-left" id="label_37"><label for="input_37"> Occasion </label><label class="label-message" for="input_37"> </label></div><div id="cid_37" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_37" name="q37_occasion37"><option value=""></option><option value="Anniversary">Anniversary</option><option value="Birthday">Birthday</option><option value="Yartzeit">Yartzeit</option></select> </div></li><li class="form-line" id="id_40"><div class="form-label-left" id="label_40"><label for="input_40"> Occasion Date </label><label class="label-message" for="input_40"> </label></div><div id="cid_40" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input class="form-textbox" id="month_40" name="q40_occasionDate40[month]" type="tel" size="2" maxlength="2" value="07" />  <label class="form-sub-label" for="month_40" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input class="form-textbox" id="day_40" name="q40_occasionDate40[day]" type="tel" size="2" maxlength="2" value="29" />  <label class="form-sub-label" for="day_40" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input class="form-textbox" id="year_40" name="q40_occasionDate40[year]" type="tel" size="4" maxlength="4" value="2025" />  <label class="form-sub-label" for="year_40" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_40_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_40_pick"><span> </span></label></span></div></div> </div></li><li class="form-line" id="id_25"><div class="form-label-left" id="label_25"><label for="input_25"> Full Name #4 </label><label class="label-message" for="input_25"> </label></div><div id="cid_25" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q25_fullName25[first]" id="first_25" autocomplete="given-name" />  <label class="form-sub-label" for="first_25" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q25_fullName25[last]" id="last_25" autocomplete="family-name" />  <label class="form-sub-label" for="last_25" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_36"><div class="form-label-left" id="label_36"><label for="input_36"> Occasion </label><label class="label-message" for="input_36"> </label></div><div id="cid_36" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_36" name="q36_occasion36"><option value=""></option><option value="Anniversary">Anniversary</option><option value="Birthday">Birthday</option><option value="Yartzeit">Yartzeit</option></select> </div></li><li class="form-line" id="id_39"><div class="form-label-left" id="label_39"><label for="input_39"> Occasion Date </label><label class="label-message" for="input_39"> </label></div><div id="cid_39" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input class="form-textbox" id="month_39" name="q39_occasionDate39[month]" type="tel" size="2" maxlength="2" value="07" />  <label class="form-sub-label" for="month_39" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input class="form-textbox" id="day_39" name="q39_occasionDate39[day]" type="tel" size="2" maxlength="2" value="29" />  <label class="form-sub-label" for="day_39" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input class="form-textbox" id="year_39" name="q39_occasionDate39[year]" type="tel" size="4" maxlength="4" value="2025" />  <label class="form-sub-label" for="year_39" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_39_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_39_pick"><span> </span></label></span></div></div> </div></li><li class="form-line" id="id_28"><div class="form-label-left" id="label_28"><label for="input_28"> Full Name #5 </label><label class="label-message" for="input_28"> </label></div><div id="cid_28" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q28_fullName28[first]" id="first_28" autocomplete="given-name" />  <label class="form-sub-label" for="first_28" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q28_fullName28[last]" id="last_28" autocomplete="family-name" />  <label class="form-sub-label" for="last_28" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_35"><div class="form-label-left" id="label_35"><label for="input_35"> Occasion </label><label class="label-message" for="input_35"> </label></div><div id="cid_35" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_35" name="q35_occasion"><option value=""></option><option value="Anniversary">Anniversary</option><option value="Birthday">Birthday</option><option value="Yartzeit">Yartzeit</option></select> </div></li><li class="form-line" id="id_41"><div class="form-label-left" id="label_41"><label for="input_41"> Occasion Date </label><label class="label-message" for="input_41"> </label></div><div id="cid_41" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input class="form-textbox" id="month_41" name="q41_occasionDate41[month]" type="tel" size="2" maxlength="2" value="07" />  <label class="form-sub-label" for="month_41" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input class="form-textbox" id="day_41" name="q41_occasionDate41[day]" type="tel" size="2" maxlength="2" value="29" />  <label class="form-sub-label" for="day_41" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input class="form-textbox" id="year_41" name="q41_occasionDate41[year]" type="tel" size="4" maxlength="4" value="2025" />  <label class="form-sub-label" for="year_41" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_41_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_41_pick"><span> </span></label></span></div></div> </div></li><li class="form-line" id="id_27"><div class="form-label-left" id="label_27"><label for="input_27"> Full Name #6 </label><label class="label-message" for="input_27"> </label></div><div id="cid_27" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q27_fullName27[first]" id="first_27" autocomplete="given-name" />  <label class="form-sub-label" for="first_27" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q27_fullName27[last]" id="last_27" autocomplete="family-name" />  <label class="form-sub-label" for="last_27" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_34"><div class="form-label-left" id="label_34"><label for="input_34"> Occasion </label><label class="label-message" for="input_34"> </label></div><div id="cid_34" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_34" name="q34_occasion34"><option value=""></option><option value="Anniversary">Anniversary</option><option value="Birthday">Birthday</option><option value="Yartzeit">Yartzeit</option></select> </div></li><li class="form-line" id="id_38"><div class="form-label-left" id="label_38"><label for="input_38"> Occasion Date </label><label class="label-message" for="input_38"> </label></div><div id="cid_38" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input class="form-textbox" id="month_38" name="q38_occasionDate38[month]" type="tel" size="2" maxlength="2" value="07" />  <label class="form-sub-label" for="month_38" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input class="form-textbox" id="day_38" name="q38_occasionDate38[day]" type="tel" size="2" maxlength="2" value="29" />  <label class="form-sub-label" for="day_38" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input class="form-textbox" id="year_38" name="q38_occasionDate38[year]" type="tel" size="4" maxlength="4" value="2025" />  <label class="form-sub-label" for="year_38" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_38_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_38_pick"><span> </span></label></span></div></div> </div></li><li class="form-line" id="id_42"><div class="form-label-left" id="label_42"><label for="input_42">   </label><label class="label-message" for="input_42"> </label></div><div id="cid_42" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_42_0" name="q42_input42[]" value="Please convert my secular occasion to the corresponding Jewish Date" /><label id="label_input_42_0" for="input_42_0"><span>Please convert my secular occasion to the corresponding Jewish Date</span></label></span><span class="clearfix"></span></div> </div></li><li id="cid_47" class="form-input-wide"> <div class="form-header-group"><h2 id="header_47" class="form-header">Contact Information</h2></div> </li><li class="form-line" id="id_48"><div class="form-label-left" id="label_48"><label for="input_48"> Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_48"> </label></div><div id="cid_48" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q48_fullName48[first]" id="first_48" autocomplete="given-name" />  <label class="form-sub-label" for="first_48" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q48_fullName48[last]" id="last_48" autocomplete="family-name" />  <label class="form-sub-label" for="last_48" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_49"><div class="form-label-left" id="label_49"><label for="input_49"> Address </label><label class="label-message" for="input_49"> </label></div><div id="cid_49" class="form-input"> <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line" type="text" name="q49_address49[addr_line1]" id="input_49_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_49_addr_line1" id="sublabel_49_addr_line1">Street Address</label></span></td></tr><tr><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line no-validation" type="text" name="q49_address49[addr_line2]" id="input_49_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_49_addr_line2" id="sublabel_49_addr_line2">Street Address Line 2</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-city" type="text" name="q49_address49[city]" id="input_49_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_49_city" id="sublabel_49_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q49_address49[state]" id="input_49_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_49_state" id="sublabel_49_state">State / Province</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-postal" type="text" name="q49_address49[postal]" id="input_49_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_49_postal" id="sublabel_49_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q49_address49[country]" id="input_49_country" autocomplete="country-name"><option value="" selected="selected">Please Select</option><option value="United States">United States</option><option value="Afghanistan">Afghanistan</option><option value="Albania">Albania</option><option value="Algeria">Algeria</option><option value="American Samoa">American Samoa</option><option value="Andorra">Andorra</option><option value="Angola">Angola</option><option value="Anguilla">Anguilla</option><option value="Antigua and Barbuda">Antigua and Barbuda</option><option value="Argentina">Argentina</option><option value="Armenia">Armenia</option><option value="Aruba">Aruba</option><option value="Australia">Australia</option><option value="Austria">Austria</option><option value="Azerbaijan">Azerbaijan</option><option value="The Bahamas">The Bahamas</option><option value="Bahrain">Bahrain</option><option value="Bangladesh">Bangladesh</option><option value="Barbados">Barbados</option><option value="Belarus">Belarus</option><option value="Belgium">Belgium</option><option value="Belize">Belize</option><option value="Benin">Benin</option><option value="Bermuda">Bermuda</option><option value="Bhutan">Bhutan</option><option value="Bolivia">Bolivia</option><option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option><option value="Botswana">Botswana</option><option value="Brazil">Brazil</option><option value="Brunei">Brunei</option><option value="Bulgaria">Bulgaria</option><option value="Burkina Faso">Burkina Faso</option><option value="Burundi">Burundi</option><option value="Cambodia">Cambodia</option><option value="Cameroon">Cameroon</option><option value="Canada">Canada</option><option value="Cape Verde">Cape Verde</option><option value="Cayman Islands">Cayman Islands</option><option value="Central African Republic">Central African Republic</option><option value="Chad">Chad</option><option value="Chile">Chile</option><option value="People's Republic of China">People's Republic of China</option><option value="Republic of China">Republic of China</option><option value="Christmas Island">Christmas Island</option><option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option><option value="Colombia">Colombia</option><option value="Comoros">Comoros</option><option value="Congo">Congo</option><option value="Cook Islands">Cook Islands</option><option value="Costa Rica">Costa Rica</option><option value="Cote d'Ivoire">Cote d'Ivoire</option><option value="Croatia">Croatia</option><option value="Cuba">Cuba</option><option value="Cyprus">Cyprus</option><option value="Czech Republic">Czech Republic</option><option value="Denmark">Denmark</option><option value="Djibouti">Djibouti</option><option value="Dominica">Dominica</option><option value="Dominican Republic">Dominican Republic</option><option value="Ecuador">Ecuador</option><option value="Egypt">Egypt</option><option value="El Salvador">El Salvador</option><option value="Equatorial Guinea">Equatorial Guinea</option><option value="Eritrea">Eritrea</option><option value="Estonia">Estonia</option><option value="Eswatini">Eswatini</option><option value="Ethiopia">Ethiopia</option><option value="Falkland Islands">Falkland Islands</option><option value="Faroe Islands">Faroe Islands</option><option value="Fiji">Fiji</option><option value="Finland">Finland</option><option value="France">France</option><option value="French Polynesia">French Polynesia</option><option value="Gabon">Gabon</option><option value="The Gambia">The Gambia</option><option value="Georgia">Georgia</option><option value="Germany">Germany</option><option value="Ghana">Ghana</option><option value="Gibraltar">Gibraltar</option><option value="Greece">Greece</option><option value="Greenland">Greenland</option><option value="Grenada">Grenada</option><option value="Guadeloupe">Guadeloupe</option><option value="Guam">Guam</option><option value="Guatemala">Guatemala</option><option value="Guernsey">Guernsey</option><option value="Guinea">Guinea</option><option value="Guinea-Bissau">Guinea-Bissau</option><option value="Guyana">Guyana</option><option value="Haiti">Haiti</option><option value="Honduras">Honduras</option><option value="Hong Kong">Hong Kong</option><option value="Hungary">Hungary</option><option value="Iceland">Iceland</option><option value="India">India</option><option value="Indonesia">Indonesia</option><option value="Iran">Iran</option><option value="Iraq">Iraq</option><option value="Ireland">Ireland</option><option value="Israel">Israel</option><option value="Italy">Italy</option><option value="Jamaica">Jamaica</option><option value="Japan">Japan</option><option value="Jersey">Jersey</option><option value="Jordan">Jordan</option><option value="Kazakhstan">Kazakhstan</option><option value="Kenya">Kenya</option><option value="Kiribati">Kiribati</option><option value="North Korea">North Korea</option><option value="South Korea">South Korea</option><option value="Kosovo">Kosovo</option><option value="Kuwait">Kuwait</option><option value="Kyrgyzstan">Kyrgyzstan</option><option value="Laos">Laos</option><option value="Latvia">Latvia</option><option value="Lebanon">Lebanon</option><option value="Lesotho">Lesotho</option><option value="Liberia">Liberia</option><option value="Libya">Libya</option><option value="Liechtenstein">Liechtenstein</option><option value="Lithuania">Lithuania</option><option value="Luxembourg">Luxembourg</option><option value="Macau">Macau</option><option value="Macedonia">Macedonia</option><option value="Madagascar">Madagascar</option><option value="Malawi">Malawi</option><option value="Malaysia">Malaysia</option><option value="Maldives">Maldives</option><option value="Mali">Mali</option><option value="Malta">Malta</option><option value="Marshall Islands">Marshall Islands</option><option value="Martinique">Martinique</option><option value="Mauritania">Mauritania</option><option value="Mauritius">Mauritius</option><option value="Mayotte">Mayotte</option><option value="Mexico">Mexico</option><option value="Micronesia">Micronesia</option><option value="Moldova">Moldova</option><option value="Monaco">Monaco</option><option value="Mongolia">Mongolia</option><option value="Montenegro">Montenegro</option><option value="Montserrat">Montserrat</option><option value="Morocco">Morocco</option><option value="Mozambique">Mozambique</option><option value="Myanmar">Myanmar</option><option value="Namibia">Namibia</option><option value="Nauru">Nauru</option><option value="Nepal">Nepal</option><option value="Netherlands">Netherlands</option><option value="New Caledonia">New Caledonia</option><option value="New Zealand">New Zealand</option><option value="Nicaragua">Nicaragua</option><option value="Niger">Niger</option><option value="Nigeria">Nigeria</option><option value="Niue">Niue</option><option value="Norfolk Island">Norfolk Island</option><option value="Northern Mariana">Northern Mariana</option><option value="Norway">Norway</option><option value="Oman">Oman</option><option value="Pakistan">Pakistan</option><option value="Palau">Palau</option><option value="Panama">Panama</option><option value="Papua New Guinea">Papua New Guinea</option><option value="Paraguay">Paraguay</option><option value="Peru">Peru</option><option value="Philippines">Philippines</option><option value="Pitcairn Islands">Pitcairn Islands</option><option value="Poland">Poland</option><option value="Portugal">Portugal</option><option value="Puerto Rico">Puerto Rico</option><option value="Qatar">Qatar</option><option value="Romania">Romania</option><option value="Russia">Russia</option><option value="Rwanda">Rwanda</option><option value="Saint Barthelemy">Saint Barthelemy</option><option value="Saint Helena">Saint Helena</option><option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option><option value="Saint Lucia">Saint Lucia</option><option value="Saint Martin">Saint Martin</option><option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option><option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option><option value="Samoa">Samoa</option><option value="San Marino">San Marino</option><option value="Sao Tome and Principe">Sao Tome and Principe</option><option value="Saudi Arabia">Saudi Arabia</option><option value="Senegal">Senegal</option><option value="Serbia">Serbia</option><option value="Seychelles">Seychelles</option><option value="Sierra Leone">Sierra Leone</option><option value="Singapore">Singapore</option><option value="Slovakia">Slovakia</option><option value="Slovenia">Slovenia</option><option value="Solomon Islands">Solomon Islands</option><option value="Somalia">Somalia</option><option value="Somaliland">Somaliland</option><option value="South Africa">South Africa</option><option value="South Ossetia">South Ossetia</option><option value="Spain">Spain</option><option value="Sri Lanka">Sri Lanka</option><option value="Sudan">Sudan</option><option value="Suriname">Suriname</option><option value="Svalbard">Svalbard</option><option value="Sweden">Sweden</option><option value="Switzerland">Switzerland</option><option value="Syria">Syria</option><option value="Taiwan">Taiwan</option><option value="Tajikistan">Tajikistan</option><option value="Tanzania">Tanzania</option><option value="Thailand">Thailand</option><option value="Timor-Leste">Timor-Leste</option><option value="Togo">Togo</option><option value="Tokelau">Tokelau</option><option value="Tonga">Tonga</option><option value="Trinidad and Tobago">Trinidad and Tobago</option><option value="Tristan da Cunha">Tristan da Cunha</option><option value="Tunisia">Tunisia</option><option value="Turkey">Turkey</option><option value="Turkmenistan">Turkmenistan</option><option value="Turks and Caicos Islands">Turks and Caicos Islands</option><option value="Tuvalu">Tuvalu</option><option value="Uganda">Uganda</option><option value="Ukraine">Ukraine</option><option value="United Arab Emirates">United Arab Emirates</option><option value="United Kingdom">United Kingdom</option><option value="Uruguay">Uruguay</option><option value="Uzbekistan">Uzbekistan</option><option value="Vanuatu">Vanuatu</option><option value="Vatican City">Vatican City</option><option value="Venezuela">Venezuela</option><option value="Vietnam">Vietnam</option><option value="British Virgin Islands">British Virgin Islands</option><option value="US Virgin Islands">US Virgin Islands</option><option value="Wallis and Futuna">Wallis and Futuna</option><option value="Western Sahara">Western Sahara</option><option value="Yemen">Yemen</option><option value="Zambia">Zambia</option><option value="Zimbabwe">Zimbabwe</option><option value="other">Other</option></select>  <label class="form-sub-label" for="input_49_country" id="sublabel_49_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_50"><div class="form-label-left" id="label_50"><label for="input_50"> Phone Number </label><label class="label-message" for="input_50"> </label></div><div id="cid_50" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q50_phoneNumber50[area]" id="input_50_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_50_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q50_phoneNumber50[phone]" id="input_50_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_50_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_53"><div class="form-label-left" id="label_53"><label for="input_53"> E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_53"> </label></div><div id="cid_53" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_53" name="q53_email53" size="30" value="" autocomplete="email" /> </div></li><li id="cid_54" class="form-input-wide"> <div class="form-header-group"><h2 id="header_54" class="form-header">Payment Information</h2></div> </li><li class="form-line" id="id_55"><div class="form-label-left" id="label_55"><label for="input_55"> Total </label></div><div id="cid_55" class="form-input"> <div id="total_amount">$0.00 </div> </div></li><li class="form-line" id="id_56"><div class="form-label-left" id="label_56"><label for="input_56"> Payment<span class="form-required">*</span> </label><label class="label-message" for="input_56"> </label></div><div id="cid_56" class="form-input"> <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2" class="form-payment-methods form-multiple-column"><span class="form-radio-item"><input class="paymentMethod form-radio validate[required, paymentMethod] form-radio" type="radio" id="input_56_creditCard" name="q56_payment56[payment_method]" value="creditCard" onclick="BuildSource.creditCard(this)" /><label for="input_56_creditCard">Credit Card</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[required, paymentMethod] form-radio" type="radio" id="input_56_other" name="q56_payment56[payment_method]" value="other" onclick="BuildSource.other(this)" /><label for="input_56_other">Check/Pledge</label> </span></td></tr><tr class="credit_card hide"><th colspan="2">Credit Card</th></tr><tr class="credit_card hide"><td colspan="2" style="padding:0"><table cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"><span class="form-sub-label-container">  <label class="form-sub-label">We accept Visa, MasterCard, American Express, Discover</label></span><div class="cc-icons"><div class="cc-icon visa-icon"></div><div class="cc-icon mastercard-icon"></div><div class="cc-icon amex-icon"></div><div class="cc-icon discover-icon"></div></div><input type="hidden" name="q56_payment56[cc_type]" id="input_56_cc_type" value="" /></td></tr><tr><td><div class="cc-field-wrapper"><span class="form-sub-label-container"><input class="form-textbox form-creditcard js-cc-number validate[required, visible, creditcard]" type="text" name="q56_payment56[cc_number]" id="input_56_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_56_cc_number" id="sublabel_cc_number">Credit Card Number</label></span></div></td><td class="cc_ccv "><span class="form-sub-label-container"><input class="form-textbox validate[required, visible]" type="text" name="q56_payment56[cc_ccv]" id="input_56_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_56_cc_ccv" id="sublabel_cc_ccv">Security Code</label></span></td></tr><tr><td colspan="2" class="cc_name_on_card "><span class="form-sub-label-container"><input class="form-textbox validate[required, visible]" type="text" name="q56_payment56[cc_nameOnCard]" id="input_56_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_56_cc_nameOnCard" id="sublabel_cc_nameOnCard">Name on Card</label></span></td></tr><tr class="credit_card hide"><td colspan=""><span class="form-sub-label-container"><select class="form-textbox validate[required, visible]" name="q56_payment56[cc_exp_month]" id="input_56_cc_exp_month" autocomplete="cc-exp-month"><option></option><option value="1">1 - January</option><option value="2">2 - February</option><option value="3">3 - March</option><option value="4">4 - April</option><option value="5">5 - May</option><option value="6">6 - June</option><option value="7">7 - July</option><option value="8">8 - August</option><option value="9">9 - September</option><option value="10">10 - October</option><option value="11">11 - November</option><option value="12">12 - December</option></select>  <label class="form-sub-label" for="input_56_cc_exp_month" id="sublabel_cc_exp_month">Expiration Month</label></span></td><td><span class="form-sub-label-container"><select class="form-textbox validate[required, visible]" name="q56_payment56[cc_exp_year]" id="input_56_cc_exp_year" autocomplete="cc-exp-year"><option></option><option value="2025">2025</option><option value="2026">2026</option><option value="2027">2027</option><option value="2028">2028</option><option value="2029">2029</option><option value="2030">2030</option><option value="2031">2031</option><option value="2032">2032</option><option value="2033">2033</option><option value="2034">2034</option></select>  <label class="form-sub-label" for="input_56_cc_exp_year" id="sublabel_cc_exp_year">Expiration Year</label></span></td></tr></tbody></table></td></tr><tr class="other hide"><td colspan="2"></td></tr><tr class="billing_address hide"><th colspan="2">Billing Address</th></tr><tr class="billing_address hide"><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-line" type="text" name="q56_payment56[addr_line1]" id="input_56_addr_line1" autocomplete="billing address-line1" />  <label class="form-sub-label" for="input_56_addr_line1" id="sublabel_56_addr_line1">Street Address</label></span></td></tr><tr class="billing_address hide"><td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-city" type="text" name="q56_payment56[city]" id="input_56_city" autocomplete="billing address-level2" />  <label class="form-sub-label" for="input_56_city" id="sublabel_56_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q56_payment56[state]" id="input_56_state" autocomplete="billing address-level1" />  <label class="form-sub-label" for="input_56_state" id="sublabel_56_state">State / Province</label></span></td></tr><tr class="billing_address hide"><td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-postal" type="text" name="q56_payment56[postal]" id="input_56_postal" size="10" autocomplete="billing postal-code" />  <label class="form-sub-label" for="input_56_postal" id="sublabel_56_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q56_payment56[country]" id="input_56_country" autocomplete="billing country-name"><option value="" selected="selected">Please Select</option><option value="United States">United States</option><option value="Afghanistan">Afghanistan</option><option value="Albania">Albania</option><option value="Algeria">Algeria</option><option value="American Samoa">American Samoa</option><option value="Andorra">Andorra</option><option value="Angola">Angola</option><option value="Anguilla">Anguilla</option><option value="Antigua and Barbuda">Antigua and Barbuda</option><option value="Argentina">Argentina</option><option value="Armenia">Armenia</option><option value="Aruba">Aruba</option><option value="Australia">Australia</option><option value="Austria">Austria</option><option value="Azerbaijan">Azerbaijan</option><option value="The Bahamas">The Bahamas</option><option value="Bahrain">Bahrain</option><option value="Bangladesh">Bangladesh</option><option value="Barbados">Barbados</option><option value="Belarus">Belarus</option><option value="Belgium">Belgium</option><option value="Belize">Belize</option><option value="Benin">Benin</option><option value="Bermuda">Bermuda</option><option 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