doneer.als.be
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2a00:1c98:1000:1023::4aad:3b9b
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Submitted URL: https://ymlps5.com/4f03fwbqeavaeqssbapaqsyadamhbyqy/click.php
Effective URL: https://doneer.als.be/
Submission: On May 21 via api from BE — Scanned from FR
Effective URL: https://doneer.als.be/
Submission: On May 21 via api from BE — Scanned from FR
Form analysis 2 forms found in the DOM
POST /
<form class="bg_default_theme BG_medium_size BG_Light " method="post" enctype="multipart/form-data" target="gform_ajax_frame_17" id="gform_17" action="/" novalidate="">
<div id="gf_progressbar_wrapper_17" class="gf_progressbar_wrapper">
<h3 class="gf_progressbar_title">Stap <span class="gf_step_current_page">1</span> van <span class="gf_step_page_count">3</span>
</h3>
<div class="gf_progressbar gf_progressbar_blue" aria-hidden="true">
<div class="gf_progressbar_percentage percentbar_blue percentbar_33" style="width:33%;"><span>33%</span></div>
</div>
</div>
<div class="gform_body gform-body">
<div id="gform_page_17_1" class="gform_page">
<div class="gform_page_fields">
<ul id="gform_fields_17" class="gform_fields right_label form_sublabel_below description_below">
<li id="field_17_" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><input type="hidden" class="sibg_form_init" value="gform_17" data-class="bg_default_theme, , BG_medium_size, BG_Light"
data-color="#0389ff" data-animation="None" is_rtl="false" is_ux="false" use_scroll="false" scroll_pad="50"></li>
<li id="field_17_19" class="gfield gf_list_2col gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Doel<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio BG_Icon" id="input_17_19">
<li class="gchoice gchoice_17_19_0">
<input name="input_19" type="radio" value="ALS Liga" checked="checked" id="choice_17_19_0">
<label for="choice_17_19_0" id="label_17_19_0">ALS Liga</label>
</li>
<li class="gchoice gchoice_17_19_1">
<input name="input_19" type="radio" value="MaMuze" id="choice_17_19_1">
<label for="choice_17_19_1" id="label_17_19_1">MaMuze</label>
</li>
<li class="gchoice gchoice_17_19_2">
<input name="input_19" type="radio" value="A Cure for ALS" id="choice_17_19_2">
<label for="choice_17_19_2" id="label_17_19_2">A Cure for ALS</label>
</li>
<li class="gchoice gchoice_17_19_3">
<input name="input_19" type="radio" value="Hulpmiddelen" id="choice_17_19_3">
<label for="choice_17_19_3" id="label_17_19_3">Hulpmiddelen</label>
</li>
</ul>
</div>
</li>
<li id="field_17_5" class="gfield gfield_price gfield_price_17_5 gfield_product_17_5 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_17_5">Bedrag in
EUR<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_product_price">
<input name="input_5" id="input_17_5" type="text" value="" class="small ginput_amount" placeholder="40" aria-required="true" aria-invalid="false">
</div>
</li>
<li id="field_17_6" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_17_6">Mededeling</label>
<div class="ginput_container ginput_container_text"><input name="input_6" id="input_17_6" type="text" value="" class="medium" aria-invalid="false"> </div>
</li>
<li id="field_17_1" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label gfield_label_before_complex">Naam<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name" id="input_17_1">
<span id="input_17_1_3_container" class="name_first">
<input type="text" name="input_1.3" id="input_17_1_3" value="" aria-required="true" aria-describedby="gfield_description_17_1">
<label for="input_17_1_3">Voornaam</label>
</span>
<span id="input_17_1_6_container" class="name_last">
<input type="text" name="input_1.6" id="input_17_1_6" value="" aria-required="true">
<label for="input_17_1_6">Naam</label>
</span>
</div>
<div class="gfield_description" id="gfield_description_17_1">zoals op eID</div>
</li>
<li id="field_17_2" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_17_2">Email<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_2" id="input_17_2" type="email" value="" class="medium" aria-required="true" aria-invalid="false">
</div>
</li>
</ul>
</div>
<div class="gform_page_footer right_label">
<input type="button" id="gform_next_button_17_24" class="gform_next_button button" value="Volgende"
onclick="jQuery("#gform_target_page_number_17").val("2"); jQuery("#gform_17").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_17").val("2"); jQuery("#gform_17").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_17_2" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_17_2" class="gform_fields right_label form_sublabel_below description_below">
<li id="field_17_7" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Fiscaal attest?<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio BG_Icon" id="input_17_7">
<li class="gchoice gchoice_17_7_0">
<input name="input_7" type="radio" value="Ja, ik bevestig dat ik een gift uit eigen middelen doe" id="choice_17_7_0">
<label for="choice_17_7_0" id="label_17_7_0">Ja, ik bevestig dat ik een gift uit eigen middelen doe</label>
</li>
<li class="gchoice gchoice_17_7_1">
<input name="input_7" type="radio" value="Nee" checked="checked" id="choice_17_7_1">
<label for="choice_17_7_1" id="label_17_7_1">Nee</label>
</li>
</ul>
</div>
<div class="gfield_description" id="gfield_description_17_7">Wenst u een fiscaal attest te ontvangen? Dit is mogelijk vanaf €40 </div>
</li>
<li id="field_17_8" class="gfield gsection field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;">
<h2 class="gsection_title">Informatie voor fiscaal attest</h2>
</li>
<li id="field_17_9" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label">Particulier of bedrijf?<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio BG_Icon" id="input_17_9">
<li class="gchoice gchoice_17_9_0">
<input name="input_9" type="radio" value="Particulier" checked="checked" id="choice_17_9_0" disabled="disabled">
<label for="choice_17_9_0" id="label_17_9_0">Particulier</label>
</li>
<li class="gchoice gchoice_17_9_1">
<input name="input_9" type="radio" value="Bedrijf" id="choice_17_9_1" disabled="disabled">
<label for="choice_17_9_1" id="label_17_9_1">Bedrijf</label>
</li>
</ul>
</div>
<div class="gfield_description" id="gfield_description_17_9">Doet u een gift als particulier of al bedrijf?</div>
</li>
<li id="field_17_3" class="gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label gfield_label_before_complex">Adres<span
class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container has_street has_city has_zip has_country ginput_container_address" id="input_17_3">
<span class="ginput_full address_line_1 ginput_address_line_1" id="input_17_3_1_container">
<input type="text" name="input_3.1" id="input_17_3_1" value="" aria-required="true" disabled="disabled">
<label for="input_17_3_1" id="input_17_3_1_label">straat + nummer</label>
</span><span class="ginput_left address_zip ginput_address_zip" id="input_17_3_5_container">
<input type="text" name="input_3.5" id="input_17_3_5" value="" aria-required="true" disabled="disabled">
<label for="input_17_3_5" id="input_17_3_5_label">Postcode</label>
</span><span class="ginput_right address_city ginput_address_city" id="input_17_3_3_container">
<input type="text" name="input_3.3" id="input_17_3_3" value="" aria-required="true" disabled="disabled">
<label for="input_17_3_3" id="input_17_3_3_label">Gemeente</label>
</span><input type="hidden" class="gform_hidden" name="input_3.4" id="input_17_3_4" value="" disabled="disabled"><span class="ginput_left address_country ginput_address_country" id="input_17_3_6_container">
<select name="input_3.6" id="input_17_3_6" aria-required="true" disabled="disabled">
<option value="">België</option>
<option value="Afghanistan">Afghanistan</option>
<option value="Aland-eilanden">Aland-eilanden</option>
<option value="Albanië">Albanië</option>
<option value="Algerije">Algerije</option>
<option value="Amerikaans Samoa">Amerikaans Samoa</option>
<option value="Amerikaanse Maagdeneilanden">Amerikaanse Maagdeneilanden</option>
<option value="Andorra">Andorra</option>
<option value="Angola">Angola</option>
<option value="Anguilla">Anguilla</option>
<option value="Antarctica">Antarctica</option>
<option value="Antigua en Barbuda">Antigua en Barbuda</option>
<option value="Argentinië">Argentinië</option>
<option value="Armenië">Armenië</option>
<option value="Aruba">Aruba</option>
<option value="Australië">Australië</option>
<option value="Azerbeidzjan">Azerbeidzjan</option>
<option value="Bahama's">Bahama's</option>
<option value="Bahrein">Bahrein</option>
<option value="Bangladesh">Bangladesh</option>
<option value="Barbados">Barbados</option>
<option value="België" selected="selected">België</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="Bonaire, Sint Eustatius en Saba">Bonaire, Sint Eustatius en Saba</option>
<option value="Bosnië en Herzegovina">Bosnië en Herzegovina</option>
<option value="Botswana">Botswana</option>
<option value="Bouvet eiland">Bouvet eiland</option>
<option value="Brazilië">Brazilië</option>
<option value="Brits-Indisch oceaan gebied">Brits-Indisch oceaan gebied</option>
<option value="Britse Maagdeneilanden">Britse Maagdeneilanden</option>
<option value="Brunei Darussalam">Brunei Darussalam</option>
<option value="Bulgarije">Bulgarije</option>
<option value="Burkina Faso">Burkina Faso</option>
<option value="Burundi">Burundi</option>
<option value="Cambodja">Cambodja</option>
<option value="Canada">Canada</option>
<option value="Centraal-Afrikaanse Republiek">Centraal-Afrikaanse Republiek</option>
<option value="Chili">Chili</option>
<option value="China">China</option>
<option value="Cocoseilanden">Cocoseilanden</option>
<option value="Colombia">Colombia</option>
<option value="Comoren">Comoren</option>
<option value="Congo, Democratische Republiek">Congo, Democratische Republiek</option>
<option value="Congo, Republiek">Congo, Republiek</option>
<option value="Cook eilanden">Cook eilanden</option>
<option value="Costa Rica">Costa Rica</option>
<option value="Cuba">Cuba</option>
<option value="Curaçao">Curaçao</option>
<option value="Cyprus">Cyprus</option>
<option value="Denemarken">Denemarken</option>
<option value="Djibouti">Djibouti</option>
<option value="Dominica">Dominica</option>
<option value="Dominicaanse Republiek">Dominicaanse Republiek</option>
<option value="Duitsland">Duitsland</option>
<option value="Ecuador">Ecuador</option>
<option value="Egypte">Egypte</option>
<option value="El Salvador">El Salvador</option>
<option value="Equatoriaal-Guinea">Equatoriaal-Guinea</option>
<option value="Eritrea">Eritrea</option>
<option value="Estland">Estland</option>
<option value="Ethiopië">Ethiopië</option>
<option value="Faeröer">Faeröer</option>
<option value="Falkland eilanden">Falkland eilanden</option>
<option value="Fiji">Fiji</option>
<option value="Filipijnen">Filipijnen</option>
<option value="Finland">Finland</option>
<option value="Frankrijk">Frankrijk</option>
<option value="Frans Guyana">Frans Guyana</option>
<option value="Frans-Polynesië">Frans-Polynesië</option>
<option value="Franse zuidelijke gebieden">Franse zuidelijke gebieden</option>
<option value="Gabon">Gabon</option>
<option value="Gambia">Gambia</option>
<option value="Georgië">Georgië</option>
<option value="Ghana">Ghana</option>
<option value="Gibraltar">Gibraltar</option>
<option value="Grenada">Grenada</option>
<option value="Griekenland">Griekenland</option>
<option value="Groenland">Groenland</option>
<option value="Guadeloupe">Guadeloupe</option>
<option value="Guam">Guam</option>
<option value="Guatemala">Guatemala</option>
<option value="Guernsey">Guernsey</option>
<option value="Guinee">Guinee</option>
<option value="Guinee-Bissau">Guinee-Bissau</option>
<option value="Guyana">Guyana</option>
<option value="Haïti">Haïti</option>
<option value="Heard en McDonaldeilanden">Heard en McDonaldeilanden</option>
<option value="Honduras">Honduras</option>
<option value="Hong Kong">Hong Kong</option>
<option value="Hongarije">Hongarije</option>
<option value="IJsland">IJsland</option>
<option value="Ierland">Ierland</option>
<option value="India">India</option>
<option value="Indonesië">Indonesië</option>
<option value="Irak">Irak</option>
<option value="Iran">Iran</option>
<option value="Israël">Israël</option>
<option value="Italië">Italië</option>
<option value="Ivoorkust">Ivoorkust</option>
<option value="Jamaica">Jamaica</option>
<option value="Japan">Japan</option>
<option value="Jersey">Jersey</option>
<option value="Jordanië">Jordanië</option>
<option value="Kaaimaneilanden">Kaaimaneilanden</option>
<option value="Kaapverdië">Kaapverdië</option>
<option value="Kameroen">Kameroen</option>
<option value="Kazachstan">Kazachstan</option>
<option value="Kenia">Kenia</option>
<option value="Kersteiland">Kersteiland</option>
<option value="Kirgizië">Kirgizië</option>
<option value="Kiribati">Kiribati</option>
<option value="Kleine eilanden van de Verenigde Staten">Kleine eilanden van de Verenigde Staten</option>
<option value="Koeweit">Koeweit</option>
<option value="Kroatië">Kroatië</option>
<option value="Lao Democratische Volksrepubliek">Lao Democratische Volksrepubliek</option>
<option value="Lesotho">Lesotho</option>
<option value="Letland">Letland</option>
<option value="Libanon">Libanon</option>
<option value="Liberia">Liberia</option>
<option value="Libië">Libië</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Litouwen">Litouwen</option>
<option value="Luxemburg">Luxemburg</option>
<option value="Macau">Macau</option>
<option value="Macedonië">Macedonië</option>
<option value="Madagaskar">Madagaskar</option>
<option value="Malawi">Malawi</option>
<option value="Maldiven">Maldiven</option>
<option value="Maleisië">Maleisië</option>
<option value="Mali">Mali</option>
<option value="Malta">Malta</option>
<option value="Man">Man</option>
<option value="Marokko">Marokko</option>
<option value="Marshalleilanden">Marshalleilanden</option>
<option value="Martinique">Martinique</option>
<option value="Mauritanië">Mauritanië</option>
<option value="Mauritius">Mauritius</option>
<option value="Mayotte">Mayotte</option>
<option value="Mexico">Mexico</option>
<option value="Micronesia">Micronesia</option>
<option value="Moldavië">Moldavië</option>
<option value="Monaco">Monaco</option>
<option value="Mongolië">Mongolië</option>
<option value="Montenegro">Montenegro</option>
<option value="Montserrat">Montserrat</option>
<option value="Mozambique">Mozambique</option>
<option value="Myanmar">Myanmar</option>
<option value="Namibië">Namibië</option>
<option value="Nauru">Nauru</option>
<option value="Nederland">Nederland</option>
<option value="Nepal">Nepal</option>
<option value="Nicaragua">Nicaragua</option>
<option value="Nieuw-Caledonië">Nieuw-Caledonië</option>
<option value="Nieuw-Zeeland">Nieuw-Zeeland</option>
<option value="Niger">Niger</option>
<option value="Nigeria">Nigeria</option>
<option value="Niue">Niue</option>
<option value="Noord-Korea">Noord-Korea</option>
<option value="Noordelijke Marianen">Noordelijke Marianen</option>
<option value="Noorwegen">Noorwegen</option>
<option value="Norfolk eiland">Norfolk eiland</option>
<option value="Oeganda">Oeganda</option>
<option value="Oekraïne">Oekraïne</option>
<option value="Oezbekistan">Oezbekistan</option>
<option value="Oman">Oman</option>
<option value="Oostenrijk">Oostenrijk</option>
<option value="Pakistan">Pakistan</option>
<option value="Palau">Palau</option>
<option value="Palestina, Staat">Palestina, Staat</option>
<option value="Panama">Panama</option>
<option value="Papoea-Nieuw-Guinea">Papoea-Nieuw-Guinea</option>
<option value="Paraguay">Paraguay</option>
<option value="Peru">Peru</option>
<option value="Pitcairn">Pitcairn</option>
<option value="Polen">Polen</option>
<option value="Portugal">Portugal</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Qatar">Qatar</option>
<option value="Roemenië">Roemenië</option>
<option value="Rusland">Rusland</option>
<option value="Rwanda">Rwanda</option>
<option value="Réunion">Réunion</option>
<option value="Saint Barthélemy">Saint Barthélemy</option>
<option value="Saint Kitts en Nevis">Saint Kitts en Nevis</option>
<option value="Saint Lucia">Saint Lucia</option>
<option value="Saint Pierre en Miquelon">Saint Pierre en Miquelon</option>
<option value="Saint Vincent en de Grenadines">Saint Vincent en de Grenadines</option>
<option value="Salomonseilanden">Salomonseilanden</option>
<option value="Samoa">Samoa</option>
<option value="San Marino">San Marino</option>
<option value="Sao Tomé en Principe">Sao Tomé en Principe</option>
<option value="Saoedi-Arabië">Saoedi-Arabië</option>
<option value="Senegal">Senegal</option>
<option value="Servië">Servië</option>
<option value="Seychellen">Seychellen</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapore">Singapore</option>
<option value="Sint Helena">Sint Helena</option>
<option value="Sint Maarten">Sint Maarten</option>
<option value="Sint Maarten">Sint Maarten</option>
<option value="Slovenië">Slovenië</option>
<option value="Slowakije">Slowakije</option>
<option value="Soedan">Soedan</option>
<option value="Somalië">Somalië</option>
<option value="Spanje">Spanje</option>
<option value="Sri Lanka">Sri Lanka</option>
<option value="Suriname">Suriname</option>
<option value="Svalbard en Jan Mayen eilanden">Svalbard en Jan Mayen eilanden</option>
<option value="Swaziland">Swaziland</option>
<option value="Syrië">Syrië</option>
<option value="Tadzjikistan">Tadzjikistan</option>
<option value="Taiwan">Taiwan</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 en Tobago">Trinidad en Tobago</option>
<option value="Tsjaad">Tsjaad</option>
<option value="Tsjechië">Tsjechië</option>
<option value="Tunesië">Tunesië</option>
<option value="Turkije">Turkije</option>
<option value="Turkmenistan">Turkmenistan</option>
<option value="Turks- en Caicoseilanden">Turks- en Caicoseilanden</option>
<option value="Tuvalu">Tuvalu</option>
<option value="Uruguay">Uruguay</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Vaticaanstad">Vaticaanstad</option>
<option value="Venezuela">Venezuela</option>
<option value="Verenigd Koninkrijk">Verenigd Koninkrijk</option>
<option value="Verenigde Arabische Emiraten">Verenigde Arabische Emiraten</option>
<option value="Verenigde Staten">Verenigde Staten</option>
<option value="Vietnam">Vietnam</option>
<option value="Wallis en Futuna">Wallis en Futuna</option>
<option value="Westelijke Sahara">Westelijke Sahara</option>
<option value="Wit-Rusland">Wit-Rusland</option>
<option value="Yemen">Yemen</option>
<option value="Zambia">Zambia</option>
<option value="Zimbabwe">Zimbabwe</option>
<option value="Zuid Soedan">Zuid Soedan</option>
<option value="Zuid-Afrika">Zuid-Afrika</option>
<option value="Zuid-Geogië">Zuid-Geogië</option>
<option value="Zuid-Korea">Zuid-Korea</option>
<option value="Zweden">Zweden</option>
<option value="Zwitserland">Zwitserland</option>
</select>
<label for="input_17_3_6" id="input_17_3_6_label">Land</label>
</span>
<div class="gf_clear gf_clear_complex"></div>
</div>
</li>
<li id="field_17_4" class="gfield field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label" for="input_17_4">Tel</label>
<div class="ginput_container ginput_container_phone"><input name="input_4" id="input_17_4" type="tel" value="" class="medium" aria-invalid="false" disabled="disabled"></div>
</li>
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class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_10" id="input_17_10" type="text" value="" class="medium" aria-required="true" aria-invalid="false" disabled="disabled"> </div>
</li>
<li id="field_17_11" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label" for="input_17_11">BTW nummer<span
class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_11" id="input_17_11" type="text" value="" class="medium" aria-required="true" aria-invalid="false" disabled="disabled"> </div>
</li>
<li id="field_17_12" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label" for="input_17_12">Nationaal nummer of geboortedatum<span
class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_12" id="input_17_12" type="text" value="" class="medium" aria-required="true" aria-invalid="false" disabled="disabled"> </div>
</li>
<li id="field_17_13" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label">Heeft u een officiële partner?<span
class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio BG_Icon" id="input_17_13">
<li class="gchoice gchoice_17_13_0">
<input name="input_13" type="radio" value="Ja, ik heb een officiële partner" id="choice_17_13_0" disabled="disabled">
<label for="choice_17_13_0" id="label_17_13_0">Ja, ik heb een officiële partner</label>
</li>
<li class="gchoice gchoice_17_13_1">
<input name="input_13" type="radio" value="Nee" checked="checked" id="choice_17_13_1" disabled="disabled">
<label for="choice_17_13_1" id="label_17_13_1">Nee</label>
</li>
</ul>
</div>
</li>
<li id="field_17_20" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label gfield_label_before_complex">Naam van de partner<span
class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name" id="input_17_20">
<span id="input_17_20_3_container" class="name_first">
<input type="text" name="input_20.3" id="input_17_20_3" value="" aria-required="true" aria-describedby="gfield_description_17_20" disabled="disabled">
<label for="input_17_20_3">Voornaam</label>
</span>
<span id="input_17_20_6_container" class="name_last">
<input type="text" name="input_20.6" id="input_17_20_6" value="" aria-required="true" disabled="disabled">
<label for="input_17_20_6">Naam</label>
</span>
</div>
<div class="gfield_description" id="gfield_description_17_20">zoals op eID</div>
</li>
</ul>
</div>
<div class="gform_page_footer right_label">
<input type="button" id="gform_previous_button_17_25" class="gform_previous_button button" value="Vorige"
onclick="jQuery("#gform_target_page_number_17").val("1"); jQuery("#gform_17").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_17").val("1"); jQuery("#gform_17").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_17_25"
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onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_17").val("3"); jQuery("#gform_17").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_17_3" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_17_3" class="gform_fields right_label form_sublabel_below description_below">
<li id="field_17_15" class="gfield gsection field_sublabel_below field_description_below gfield_visibility_visible">
<h2 class="gsection_title">Betaalmethode</h2>
</li>
<li id="field_17_16" class="gfield pronamic_pay_display_icons gf_list_2col gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_17_16">betaalmethode<span
class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_radio gfield_trigger_change">
<ul class="gfield_radio input_17_16">
<li class="gchoice_17_16_credit_card"><input type="radio" id="choice_17_16_credit_card" name="input_16" value="credit_card"> <label for="choice_17_16_credit_card"><img
src="https://cdn.wp-pay.org/jsdelivr.net/npm/@wp-pay/logos@1.6.8/dist/methods/credit-card/method-credit-card-640x360.svg" alt="Kredietkaart (VISA, Mastercard/maestro, American Express)"><span>Kredietkaart (VISA,
Mastercard/maestro, American Express)</span></label></li>
<li class="gchoice_17_16_bancontact"><input type="radio" id="choice_17_16_bancontact" name="input_16" value="bancontact"> <label for="choice_17_16_bancontact"><img
src="https://cdn.wp-pay.org/jsdelivr.net/npm/@wp-pay/logos@1.6.8/dist/methods/bancontact/method-bancontact-640x360.svg" alt="Bancontact (Payconiq)"><span>Bancontact (Payconiq)</span></label></li>
<li class="gchoice_17_16_kbc"><input type="radio" id="choice_17_16_kbc" name="input_16" value="kbc"> <label for="choice_17_16_kbc"><img
src="https://cdn.wp-pay.org/jsdelivr.net/npm/@wp-pay/logos@1.6.8/dist/methods/kbc/method-kbc-640x360.svg" alt="KBC/CBC-betaalknop"><span>KBC/CBC-betaalknop</span></label></li>
<li class="gchoice_17_16_belfius"><input type="radio" id="choice_17_16_belfius" name="input_16" value="belfius"> <label for="choice_17_16_belfius"><img
src="https://cdn.wp-pay.org/jsdelivr.net/npm/@wp-pay/logos@1.6.8/dist/methods/belfius/method-belfius-640x360.svg" alt="Belfius Direct Net"><span>Belfius Direct Net</span></label></li>
</ul>
</div>
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width: 50%;
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max-width: 100%;
width: 100%;
margin: 0;
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.gform_wrapper #field_17_16 .gfield_radio li input[type="radio"] {
display: none;
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.gform_wrapper #field_17_16 .gfield_radio {
width: 256px;
}
.gform_wrapper #field_17_16 .gfield_radio li {
text-align: center;
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margin: 0;
padding-bottom: 10px;
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border-radius: 4px;
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}
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margin: 10px auto;
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.gform_wrapper #field_17_16 .gfield_radio li span {
display: table-cell;
width: 127px;
height: 105px;
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vertical-align: bottom;
white-space: normal;
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background: #efefef;
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</li>
<li id="field_17_17" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label screen-reader-text gfield_label_before_complex"><span
class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_consent"><input name="input_17.1" id="input_17_17_1" type="checkbox" value="1" aria-required="true" aria-invalid="false"> <label class="gfield_consent_label" for="input_17_17_1">Ik ga akkoord
met de <a href="privacy-policy" role="link">privacy policy</a>.</label><input type="hidden" name="input_17.2" value="Ik ga akkoord met de <a href="privacy-policy">privacy policy</a>." class="gform_hidden"><input
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</li>
<li id="field_17_26" class="gfield gform_validation_container field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_17_26">Comments</label>
<div class="ginput_container"><input name="input_26" id="input_17_26" type="text" value="" autocomplete="new-password"></div>
<div class="gfield_description" id="gfield_description_17_26">Dit veld is bedoeld voor validatiedoeleinden en moet niet worden gewijzigd.</div>
</li>
</ul>
</div>
<div class="gform_page_footer right_label"><input type="submit" id="gform_previous_button_17" class="gform_previous_button button" value="Vorige"
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<input type="submit" id="gform_submit_button_17" class="gform_button button" value="Doneer"
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<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
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value="WyJ7XCIxNy4xXCI6XCJjYzQ1ZGJhM2I3NzMxYmU2N2UzNjI2Y2VhZTc1YmJmNVwiLFwiMTcuMlwiOlwiZDg1Nzc2ZGViMDk3Zjg5Y2U1OTU2YzQ4MTdjYTU1M2NcIixcIjE3LjNcIjpcImQ3OGUzOGFjOTNlMzdkYThlMDUzMjM5NGFkNDVkOWM0XCJ9IiwiNzE3NWJiYTk1MDUyYTk1ZjRmMjlhYTVhMDNlZjc1OGUiXQ==">
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<input type="hidden" class="gform_hidden" name="gform_source_page_number_17" id="gform_source_page_number_17" value="1">
<input type="hidden" name="gform_field_values" value="">
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Ik ga akkoord met de privacy policy.
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