independencecenter.org
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Submitted URL: https://u13778085.ct.sendgrid.net/ls/click?upn=6mFy9oubiMXZ3aDVSVZ1p5RVenj93mdxQArx6ZY-2FaXt0Ao9pNd4SgHEjdeBDMR8ogF5J0A-2B-2FIdeEj...
Effective URL: https://independencecenter.org/donation-form/?blm_aid=5260819
Submission: On December 18 via manual from US — Scanned from DE
Effective URL: https://independencecenter.org/donation-form/?blm_aid=5260819
Submission: On December 18 via manual from US — Scanned from DE
Form analysis
2 forms found in the DOMPOST
<form id="donation-form" class="donation-form" method="post" onsubmit="event.preventDefault(); collectPayment();">
<div class="errors hidden"></div>
<div class="section donation">
<h3>Donation</h3>
<div class="field radio 394240 required"><label for="394240"><input id="394240" name="donation-level" class="required" type="radio" value="1000" maxlength="255"><span class="label">$1,000.00 - Gift Amount</span></label></div>
<div class="field radio 394241 required"><label for="394241"><input id="394241" name="donation-level" class="required" type="radio" value="500" maxlength="255"><span class="label">$500.00 - Gift Amount</span></label></div>
<div class="field radio 394242 required"><label for="394242"><input id="394242" name="donation-level" class="required" type="radio" value="250" maxlength="255"><span class="label">$250.00 - Gift Amount</span></label></div>
<div class="field radio 394243 required"><label for="394243"><input id="394243" name="donation-level" class="required" type="radio" value="100" maxlength="255"><span class="label">$100.00 - Gift Amount</span></label></div>
<div class="field radio 394244 required"><label for="394244"><input id="394244" name="donation-level" class="required" type="radio" value="50" maxlength="255"><span class="label">$50.00 - Gift Amount</span></label></div>
<div class="field radio other-option required"><label for="other-option"><input id="other-option" name="donation-level" class="required" type="radio" maxlength="255"><span class="label">Other</span></label></div>
<div class="field text other-amount"><input id="other-amount" name="other-amount" class="otherAmount" type="text" placeholder="$0.00"></div>
</div>
<div class="section recurring">
<div class="field checkbox recurring"><label for="recurring"><input id="recurring" name="recurring" type="checkbox" maxlength="255"><span class="label">Show my support by making this a recurring donation</span></label></div>
<div class="field frequency required" style="display: none"><label for="frequency">Frequency<span class="required-star">*</span></label><select id="frequency" name="frequency" class="required">
<option value=""></option>
<option value="Weekly">Weekly</option>
<option value="Monthly" selected="">Monthly</option>
<option value="Quarterly">Quarterly</option>
<option value="Yearly">Yearly</option>
</select></div>
<div class="field date start-date required" style="display: none"><label for="start-date"><span class="label">Start Date</span><span class="required-star">*</span></label><input id="start-date" name="start-date" class="validDate required"
type="date" placeholder="mm/dd/yyyy"></div>
</div>
<div class="section contact">
<h3>Contact Information</h3>
<div class="field text first-name required"><label for="first-name"><span class="label">First Name</span><span class="required-star">*</span></label><input id="first-name" name="first-name" class="required" type="text"></div>
<div class="field text last-name required"><label for="last-name"><span class="label">Last Name</span><span class="required-star">*</span></label><input id="last-name" name="last-name" class="required" type="text"></div>
<div class="field email email-address required"><label for="email-address"><span class="label">Email</span><span class="required-star">*</span></label><input id="email-address" name="email-address" class="email required" type="email"
placeholder="someone@website.com"></div>
<div class="field tel phone-number"><label for="phone-number"><span class="label">Phone</span></label><input id="phone-number" name="phone-number" class="phoneUS" type="tel"></div>
</div>
<div class="section billing-address">
<h3>Billing Address</h3>
<div class="field country required"><label for="country">Country<span class="required-star">*</span></label><select id="country" name="country" class="required">
<option value=""></option>
<option value="AF">Afghanistan</option>
<option value="AX">Aland Islands</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AS">American Samoa</option>
<option value="AD">Andorra</option>
<option value="AO">Angola</option>
<option value="AI">Anguilla</option>
<option value="AQ">Antarctica</option>
<option value="AG">Antigua and Barbuda</option>
<option value="AR">Argentina</option>
<option value="AM">Armenia</option>
<option value="AW">Aruba</option>
<option value="AU">Australia</option>
<option value="AT">Austria</option>
<option value="AZ">Azerbaijan</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BD">Bangladesh</option>
<option value="BB">Barbados</option>
<option value="BY">Belarus</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BJ">Benin</option>
<option value="BM">Bermuda</option>
<option value="BT">Bhutan</option>
<option value="BO">Bolivia</option>
<option value="BA">Bosnia and Herzegovina</option>
<option value="BW">Botswana</option>
<option value="BV">Bouvet Island</option>
<option value="BR">Brazil</option>
<option value="IO">British Indian Ocean Territory</option>
<option value="BN">Brunei Darussalam</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="CV">Cape Verde</option>
<option value="KY">Cayman Islands</option>
<option value="CF">Central African Republic</option>
<option value="TD">Chad</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CX">Christmas Island</option>
<option value="CC">Cocos (Keeling) Islands</option>
<option value="CO">Colombia</option>
<option value="KM">Comoros</option>
<option value="CG">Congo</option>
<option value="CD">Democratic Republic of the Congo</option>
<option value="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="CI">Cote d'Ivoire</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CW">Curacao</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="GQ">Equatorial Guinea</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="SZ">Eswatini</option>
<option value="ET">Ethiopia</option>
<option value="FK">Falkland Islands (Malvinas)</option>
<option value="FO">Faroe Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="GF">French Guiana</option>
<option value="PF">French Polynesia</option>
<option value="TF">French Southern Territories</option>
<option value="GA">Gabon</option>
<option value="GM">Gambia</option>
<option value="GE">Georgia</option>
<option value="DE">Germany</option>
<option value="GH">Ghana</option>
<option value="GI">Gibraltar</option>
<option value="GR">Greece</option>
<option value="GL">Greenland</option>
<option value="GD">Grenada</option>
<option value="GP">Guadeloupe</option>
<option value="GU">Guam</option>
<option value="GT">Guatemala</option>
<option value="GG">Guernsey</option>
<option value="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard Island</option>
<option value="HN">Honduras</option>
<option value="HK">Hong Kong</option>
<option value="HU">Hungary</option>
<option value="IS">Iceland</option>
<option value="IN">India</option>
<option value="ID">Indonesia</option>
<option value="IR">Islamic Republic of Iran</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IM">Isle of Man</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JE">Jersey</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KP">Democratic People's Republic of Korea</option>
<option value="KR">Republic of Korea</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Lao People's Democratic Republic</option>
<option value="LV">Latvia</option>
<option value="LB">Lebanon</option>
<option value="LS">Lesotho</option>
<option value="LR">Liberia</option>
<option value="LY">Libya</option>
<option value="LI">Liechtenstein</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="MO">Macao</option>
<option value="MK">Macedonia</option>
<option value="MG">Madagascar</option>
<option value="MW">Malawi</option>
<option value="MY">Malaysia</option>
<option value="MV">Maldives</option>
<option value="ML">Mali</option>
<option value="MT">Malta</option>
<option value="MH">Marshall Islands</option>
<option value="MQ">Martinique</option>
<option value="MR">Mauritania</option>
<option value="MU">Mauritius</option>
<option value="YT">Mayotte</option>
<option value="MX">Mexico</option>
<option value="FM">Federated States of Micronesia</option>
<option value="MD">Republic of Moldova</option>
<option value="MC">Monaco</option>
<option value="MN">Mongolia</option>
<option value="ME">Montenegro</option>
<option value="MS">Montserrat</option>
<option value="MA">Morocco</option>
<option value="MZ">Mozambique</option>
<option value="MM">Myanmar</option>
<option value="NA">Namibia</option>
<option value="NR">Nauru</option>
<option value="NP">Nepal</option>
<option value="NL">Netherlands</option>
<option value="NC">New Caledonia</option>
<option value="NZ">New Zealand</option>
<option value="NI">Nicaragua</option>
<option value="NE">Niger</option>
<option value="NG">Nigeria</option>
<option value="NU">Niue</option>
<option value="NF">Norfolk Island</option>
<option value="MP">Northern Mariana Islands</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PK">Pakistan</option>
<option value="PW">Palau</option>
<option value="PS">State of Palestine</option>
<option value="PA">Panama</option>
<option value="PG">Papua New Guinea</option>
<option value="PY">Paraguay</option>
<option value="PE">Peru</option>
<option value="PH">Philippines</option>
<option value="PN">Pitcairn</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico</option>
<option value="QA">Qatar</option>
<option value="RE">Reunion</option>
<option value="RO">Romania</option>
<option value="RU">Russian Federation</option>
<option value="RW">Rwanda</option>
<option value="BL">Saint Barthelemy</option>
<option value="SH">Ascension and Tristan da Cunha Saint Helena</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="MF">Saint Martin (French part)</option>
<option value="PM">Saint Pierre and Miquelon</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</option>
<option value="ST">Sao Tome and Principe</option>
<option value="SA">Saudi Arabia</option>
<option value="SN">Senegal</option>
<option value="RS">Serbia</option>
<option value="SC">Seychelles</option>
<option value="SL">Sierra Leone</option>
<option value="SG">Singapore</option>
<option value="SX">Sint Maarten (Dutch part)</option>
<option value="SK">Slovakia</option>
<option value="SI">Slovenia</option>
<option value="SB">Solomon Islands</option>
<option value="SO">Somalia</option>
<option value="ZA">South Africa</option>
<option value="GS">South Georgia</option>
<option value="SS">South Sudan</option>
<option value="ES">Spain</option>
<option value="LK">Sri Lanka</option>
<option value="SD">Sudan</option>
<option value="SR">Suriname</option>
<option value="SJ">Svalbard and Jan Mayen</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syrian Arab Republic</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">United Republic of Tanzania</option>
<option value="TH">Thailand</option>
<option value="TL">Timor-Leste</option>
<option value="TG">Togo</option>
<option value="TK">Tokelau</option>
<option value="TO">Tonga</option>
<option value="TT">Trinidad and Tobago</option>
<option value="TN">Tunisia</option>
<option value="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks and Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom</option>
<option value="US" selected="">United States</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VA">Vatican City</option>
<option value="VE">Venezuela</option>
<option value="VN">Viet Nam</option>
<option value="VG">British Virgin Islands</option>
<option value="VI">U.S. Virgin Islands</option>
<option value="WF">Wallis and Futuna</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select></div>
<div class="field street-address required"><label for="street-address"><span class="label">Address</span><span class="required-star">*</span></label><textarea id="street-address" name="street-address" class="required"></textarea></div>
<div class="field text city required"><label for="city"><span class="label">City</span><span class="required-star">*</span></label><input id="city" name="city" class="required" type="text" data-us-label="City" data-bm-label="Parish"></div>
<div class="field state required"><label for="state">State<span class="required-star">*</span></label><select id="state" name="state" class="required">
<option value=""></option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AS">American Samoa</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="AE">Armed Forces Africa, Canada, Europe, Middle East</option>
<option value="AA">Armed Forces Americas (except Canada)</option>
<option value="AP">Armed Forces Pacific</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="GU">Guam</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="PR">Puerto Rico</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="VI">US Virgin Islands</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select></div>
<div class="field province required" style="display: none"><label for="province">Province<span class="required-star">*</span></label><select id="province" name="province" class="required">
<option value=""></option>
<option value="AB">Alberta</option>
<option value="BC">British Columbia</option>
<option value="MB">Manitoba</option>
<option value="NB">New Brunswick</option>
<option value="NL">Newfoundland and Labrador</option>
<option value="NT">Northwest Territories</option>
<option value="NS">Nova Scotia</option>
<option value="NU">Nunavut</option>
<option value="ON">Ontario</option>
<option value="PE">Prince Edward Island</option>
<option value="QC">Quebec</option>
<option value="SK">Saskatchewan</option>
<option value="YT">Yukon Territory</option>
</select></div>
<div class="field number zip-code required"><label for="zip-code"><span class="label">ZIP Code</span><span class="required-star">*</span></label><input id="zip-code" name="zip-code" class="zipcodeUS required" type="number" minlength="5"
maxlength="10"></div>
<div class="field text postal-code required" style="display: none"><label for="postal-code"><span class="label">Postal Code</span><span class="required-star">*</span></label><input id="postal-code" name="postal-code" class="required" type="text">
</div>
</div>
<div class="section custom-fields">
<h3>Additional Information</h3>
<div class="field text CustomTransactionField_218066946"><label for="CustomTransactionField_218066946">Is this a Tribute/Memorial Gift?</label><select id="CustomTransactionField_218066946" name="CustomTransactionField_218066946">
<option value=""></option>
<option value="218065923">Yes</option>
</select></div>
<div class="field text CustomTransactionField_218066944"><label for="CustomTransactionField_218066944">Tribute Kind</label><select id="CustomTransactionField_218066944" name="CustomTransactionField_218066944">
<option value=""></option>
<option value="218065922">In Honor Of</option>
<option value="218065921">In Memory Of</option>
</select></div>
<div class="field text CustomTransactionField_218066945"><label for="CustomTransactionField_218066945"><span class="label">Tribute Name</span></label><input id="CustomTransactionField_218066945" name="CustomTransactionField_218066945" type="text"
maxlength="255"></div>
</div>
<div class="section comment">
<div class="field text comment"><label for="comment"><span class="label">Comments</span></label><textarea id="comment" name="comment" type="text" value="Comments"></textarea></div>
</div>
<div class="section consent hidden">
<div class="field checkbox consent-all"><label for="consent-all"><input id="consent-all" name="consent-all" type="checkbox" maxlength="255"><span class="label">I would like to receive or continue receiving updates from Independence
Center</span></label></div>
<div class="field checkbox consent-email" style="display: none"><label for="consent-email"><input id="consent-email" name="consent-email" type="checkbox" checked="checked" maxlength="255"><span class="label">by email</span></label></div>
<div class="field checkbox consent-mail" style="display: none"><label for="consent-mail"><input id="consent-mail" name="consent-mail" type="checkbox" checked="checked" maxlength="255"><span class="label">by postal mail</span></label></div>
<div class="field checkbox consent-phone" style="display: none"><label for="consent-phone"><input id="consent-phone" name="consent-phone" type="checkbox" checked="checked" maxlength="255"><span class="label">by phone</span></label></div>
</div>
<div class="section true-impact">
<h3>Increase My Impact</h3>
<div class="field checkbox true-impact"><label for="true-impact"><input id="true-impact" name="true-impact" type="checkbox" maxlength="255"><span class="label">Yes! Add <span class="fee-amount">$0</span> to help offset bank fees</span></label>
</div>
</div>
<div class="section captcha"> <label id="noCaptchaResponseError" class="error noCaptchaResponseError" style="display: none">You must fill out the CAPTCHA</label>
<div id="captcha392192">
<div style="width: 304px; height: 78px;">
<div><iframe title="reCAPTCHA"
src="https://www.google.com/recaptcha/api2/anchor?ar=1&k=6LcWYTcdAAAAAOnuTaXn8bUBFhBTxvQiaQMmnLjn&co=aHR0cHM6Ly9pbmRlcGVuZGVuY2VjZW50ZXIub3JnOjQ0Mw..&hl=de&v=5qcenVbrhOy8zihcc2aHOWD4&size=normal&cb=qf9e1qttu82y"
width="304" height="78" role="presentation" name="a-y8gq68d3v3ho" frameborder="0" scrolling="no" sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox"></iframe>
</div><textarea id="g-recaptcha-response" name="g-recaptcha-response" class="g-recaptcha-response"
style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
</div><iframe style="display: none;"></iframe>
</div>
</div>
<div class="btn-group"> <input class="btn btn-submit btn-submit-donation" type="submit" value="Enter Payment" id="express-submit"> </div>
</form>
<form class="spreedly-form" accept-charset="UTF-8" id="spreedly-modal-form" onsubmit="return false;">
<div id="spreedly-frame-holder" class="spreedly-fields-holder ">
<fieldset class="spreedly-fs-name">
<div class="spreedly-field spreedly-field-name" id="spreedly-name-parent"> <label class="spreedly-label" for="spreedly-name" id="spreedly-name-label">Name</label> <input type="text" id="spreedly-name" name="full_name">
<i class="spreedly-icon-validation" id="spreedly-name-info-icon"></i> </div>
</fieldset>
<fieldset class="spreedly-fs-cc">
<legend class="spreedly-legend">Payment Details</legend>
<div class="spreedly-field spreedly-field-number spreedly-iframe-field" id="spreedly-number-parent" onclick="SpreedlyExpress.transferFocus("number");"> <label class="spreedly-label spreedly-iframe-label" id="spreedly-number-label"
for="spreedly-number">Credit Card Number</label>
<div id="spreedly-number" class="spreedly-iframe-input"><iframe sandbox="allow-scripts allow-same-origin" frameborder="0" width="100%" height="100%" scrolling="no" id="spreedly-number-frame-7248" name="spreedly-number-frame-7248"
src="https://core.spreedly.com/v1/embedded/number-frame-1.95.html?client=express"></iframe></div> <i class="spreedly-icon-cc"></i> <i class="spreedly-icon-validation" id="spreedly-number-info-icon"></i>
</div>
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LATEST NEWS INDEPENDENCE CENTER UNVEILS NEW ADA RAMP AND WELCOME CENTER July 7, 2022 FINANCIAL EXECUTIVES INTERNATIONAL (FEI) DONATES $5,000 TO INDEPENDENCE CENTER June 22, 2022 INDEPENDENCE CENTER BUILDS NEW ADA RAMP TO PROMOTE INCLUSION AND ACCESSIBILITY May 24, 2022 SCHEDULE A TOUR Come see first-hand how our programs and services restore lives FAQ Frequently Asked Questions SCHEDULE A SPEAKER Our member speakers are experts on living day to day with mental illnesses TESTIMONIALS What others say about Independence Center CONTACT Contact us CONTACT INFORMATION 4245 Forest Park Ave. St. Louis, MO 63108 Phone: 314-533-4245 Email: info@independencecenter.org CONTACT INFORMATION AFTER HOURS Crisis Hotline: (314) 469-0620 TTY Crisis Hotline for Hearing Impaired: (314) 469-3638 CONTACT INFORMATION Interact with us and stay up-to-date DOWNLOAD OUR MEDIA KIT Copyright © 2018 Independence Center. 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