act.alz.org
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Submitted URL: https://act.alz.org/site/R?i=-r0SiZcgCWKr-SVZVQF9UUPC9b2f_FFm7t551gaLKnhnOnDTTX7P7g
Effective URL: https://act.alz.org/site/Donation2?df_id=60528&mfc_pref=T&60528.donation=form1&autologin=true&s_subsrc=EM01P
Submission: On December 31 via manual from US — Scanned from FI
Effective URL: https://act.alz.org/site/Donation2?df_id=60528&mfc_pref=T&60528.donation=form1&autologin=true&s_subsrc=EM01P
Submission: On December 31 via manual from US — Scanned from FI
Form analysis 1 forms found in the DOM
Name: process — POST https://act.alz.org/site/Donation2
<form name="process" id="ProcessForm" action="https://act.alz.org/site/Donation2" method="post" onsubmit="return checkDoubleClick();" novalidate="novalidate">
<div class="donation-form-container responsive">
<script type="text/javascript">
<!--
function reloadPage() {
window.location.reload(true);
}
function testAjax() {
var xmlHttp = null;
// Opera 8.0+, Firefox, Chrome, Safari
try {
xmlHttp = new XMLHttpRequest();
} catch (e) {
// Internet Explorer Browsers
try {
xmlHttp = new ActiveXObject("Msxml2.XMLHTTP");
} catch (e) {
try {
xmlHttp = new ActiveXObject("Microsoft.XMLHTTP");
} catch (e) {
return false;
}
}
}
xmlHttp.open('POST', 'AjaxHelper;jsessionid=00000000.app20109b?NONCE_TOKEN=994519A348CB53A5E4ABF369F409918F', true);
xmlHttp.send();
}
addOnLoadHandler(testAjax);
//
-->
</script>
<div class="donation-form-content">
<script>
document.body.addEventListener("keypress", function(event) {
if (event.keyCode === 13) {
event.preventDefault();
var button = document.getElementById("pstep_finish");
if (!button) {
button = document.getElementById("pstep_next");
}
if (!button) {
button = document.getElementById("pstep_finish_validate");
}
if (button) {
button.click();
}
}
});
</script>
<input type="hidden" name="user_donation_amt" id="user_donation_amt" value="100">
<input type="hidden" name="company_min_matching_amt" id="company_min_matching_amt" value="">
<input type="hidden" name="currency_locale" id="currency_locale" value="en_US">
<input type="hidden" name="user_additional_amount" id="user_additional_amount" value="">
<input type="hidden" name="cc_available" id="cc_available" value="false">
<input type="hidden" name="debit_available" id="debit_available" value="false">
<input type="hidden" name="paypal_available" id="paypal_available" value="false">
<input type="hidden" name="wallets_available" id="wallets_available" value="false">
<input type="hidden" name="primary_color" id="primary_color" value="">
<input type="hidden" name="application_name" id="application_name" value="Luminate">
<input type="hidden" name="secondary_color" id="secondary_color" value="">
<input type="hidden" name="font_color" id="font_color" value="">
<input type="hidden" name="font_family" id="font_family" value="">
<input type="hidden" name="secure_url" id="secure_url" value="https://act.alz.org/site/">
<input type="hidden" name="is_admin_app" id="is_admin_app" value="F">
<input type="hidden" name="environment_id" id="environment_id" value="">
<input type="hidden" name="merchant_account_configuration_id" id="merchant_account_configuration_id" value="">
<input type="hidden" name="pco_javascript_location" id="pco_javascript_location" value="">
<input type="hidden" name="pco_language_locale" id="pco_language_locale" value="en_US">
<input type="hidden" name="pco_environment_zone" id="pco_environment_zone" value="p-usa01">
<div class="form-row">
<div class="html-caption-container">
<p class="source-code-field">src field source <input id="s_src" name="s_src" type="text"></p>
<p class="aff-code-field">affiliate code field <input id="gift_affiliation_input" name="gift_affiliation_input" value="" size="30" maxlength="255"></p>
<script>
$(document).ready(function($) {
if (/Android|webOS|iPhone|iPad|iPod|BlackBerry|IEMobile|Opera Mini/i.test(navigator.userAgent)) {
// true for mobile device
console.log("mobile device");
window.location.href = "SPageServer?pagename=digital_wallet_donations&df_id=60528&cybba=false"
} else {
// false for not mobile device
console.log("not mobile device");
}
});
</script>
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
</div>
</div>
<h2 class="section-header-container"> Gift Amount </h2>
<div id="level_standard_row">
<div class="don-standard-levels form-row">
<div class="levels-label">
</div>
<div id="level_standard_row" class="form-row form-donation-level">
<div class="form-content">
<span class="field-required"></span> <span class="aural-only">Field Is Required</span>
<span class="FormLabelText">A monthly gift shows your commitment to care, support, and research.</span>
<div class="donation-level-general-ask">
</div>
<div class="donation-levels">
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded141229" value="141229" onclick="evalMatchingGift('$50.00');
updateDonorCoverAmount('$50.00');">
<script type="text/javascript">
document.addEventListener('DOMContentLoaded', function() {
var radio = document.getElementById('level_standardexpanded141229');
if (radio && radio.checked) {
Y.use('jquery-noconflict', function() {
evalMatchingGift('$50.00');
updateDonorCoverAmount('$50.00');
});
}
});
</script>
</div>
<label for="level_standardexpanded141229" onclick="">
<div class="donation-level-amount-container"> $50</div>
</label>
<input type="hidden" name="level_standardexpanded141229dynamicAmount" id="level_standardexpanded141229dynamicAmount" value="5000">
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_141229expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded141231" value="141231" checked="checked" onclick="evalMatchingGift('$100.00');
updateDonorCoverAmount('$100.00');">
<script type="text/javascript">
document.addEventListener('DOMContentLoaded', function() {
var radio = document.getElementById('level_standardexpanded141231');
if (radio && radio.checked) {
Y.use('jquery-noconflict', function() {
evalMatchingGift('$100.00');
updateDonorCoverAmount('$100.00');
});
}
});
</script>
</div>
<label for="level_standardexpanded141231" onclick="" class="active">
<div class="donation-level-amount-container"> $100</div>
</label>
<input type="hidden" name="level_standardexpanded141231dynamicAmount" id="level_standardexpanded141231dynamicAmount" value="10000">
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_141231expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded141228" value="141228" onclick="evalMatchingGift('$250.00');
updateDonorCoverAmount('$250.00');">
<script type="text/javascript">
document.addEventListener('DOMContentLoaded', function() {
var radio = document.getElementById('level_standardexpanded141228');
if (radio && radio.checked) {
Y.use('jquery-noconflict', function() {
evalMatchingGift('$250.00');
updateDonorCoverAmount('$250.00');
});
}
});
</script>
</div>
<label for="level_standardexpanded141228" onclick="">
<div class="donation-level-amount-container"> $250</div>
</label>
<input type="hidden" name="level_standardexpanded141228dynamicAmount" id="level_standardexpanded141228dynamicAmount" value="25000">
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_141228expandedsubmit" value="true">
</div>
</div>
<div class="donation-level-container other-amount-container">
<div class="form-content">
<div class="donation-level-input-container form-input">
<div class="donation-level-label-input-container">
<input type="radio" name="level_standardexpanded" id="level_standardexpanded141230" value="141230" onclick="evalMatchingGift(document.getElementById('level_standardexpanded141230amount').value);
updateDonorCoverAmount(document.getElementById('level_standardexpanded141230amount').value);">
<script type="text/javascript">
document.addEventListener('DOMContentLoaded', function() {
var radio = document.getElementById('level_standardexpanded141230');
if (radio && radio.checked) {
Y.use('jquery-noconflict', function() {
evalMatchingGift(document.getElementById('level_standardexpanded141230amount').value);
updateDonorCoverAmount(document.getElementById('level_standardexpanded141230amount').value);
});
}
});
</script>
</div>
<label for="level_standardexpanded141230" onclick="" style="display: none;">
<div class="donation-level-label-container"> Your Best Gift </div>
</label>
<div class="donation-level-user-entered">
<label for="level_standardexpanded141230amount"><span class="aural-only">Enter amount</span></label>
<input type="text" name="level_standardexpanded141230amount" id="level_standardexpanded141230amount" value="" size="12" maxlength="50"
onfocus="var el = document.getElementById ('level_standardexpanded141230');if (el) el.click(); fire_obs_comp_event('level_standardexpanded141230amount', this, event);evalMatchingGift(value); "
onchange="fire_obs_comp_event('level_standardexpanded141230amount', this, event);evalMatchingGift(value);updateDonorCoverAmount(value);"
onkeyup="fire_obs_comp_event('level_standardexpanded141230amount', this, event);evalMatchingGift(value);updateDonorCoverAmount(value);"
onblur="fire_obs_comp_event('level_standardexpanded141230amount', this);updateDonorCoverAmount(value);" placeholder="Other Amount">
</div>
</div>
<input type="hidden" name="level_standardexpandedsubmit" id="level_standard_141230expandedsubmit" value="true">
</div>
</div>
</div>
</div>
<script type="text/javascript">
Y.use("jquery-ui", function(Y) {
jQuery(function() {
// subscribe observables
jQuery('div.donation-level-element-container').find('input[type="radio"]').each(function() {
var syncAction = function(obj) {
if (obj.is(':checked')) {
obj.closest('div.donation-level-container').addClass('selected');
} else {
obj.closest('div.donation-level-container').removeClass('selected');
};
return arguments.callee;
}(jQuery(this));
jQuery(this).click(function() {
jQuery('div.donation-level-container').removeClass('selected');
syncAction(jQuery(this));
});
});
});
});
</script><noscript> </noscript>
</div>
<div class="levels-gift-aid">
</div>
<input type="hidden" name="level_standardsubmit" id="level_standardsubmit" value="true">
<script type="text/javascript">
function updateDonorCoverAmount(gift) {
var currencyLocale = getLevelCurrencyLocale();
var tempGift = parseCurrency(gift, currencyLocale) / 100;
if (currencyLocale !== 'fr_CA') {
gift = tempGift;
}
if (isNaN(tempGift) || tempGift === 0) {
gift = '';
}
var amountHidden = document.getElementById('user_donation_amt');
if (amountHidden !== null) {
amountHidden.value = gift;
}
jQuery('#level_standardname').val(gift);
jQuery('#user_donation_amt').val(gift);
if (typeof updateAmount !== "undefined") {
updateAmount(gift);
}
};
function getLevelCurrencyLocale() {
var element = document.getElementById('currency_locale');
if (element) {
return element.value;
}
return 'en_US';
}
function evalMatchingGift(gift) {}
</script><noscript> </noscript>
</div>
<div class="donation-level-container-generic-repeat form-input">
<div class="generic-repeat-label-checkbox-container">
<input type="checkbox" name="level_standardauto_repeatname" id="level_standardauto_repeatname" onclick="fire_obs_comp_event('level_standardauto_repeat', this);" onkeypress="fire_obs_comp_event('level_standardauto_repeat', this);">
<input type="hidden" name="recurring_checkbox_name" id="recurring_checkbox_name" value="level_standardauto_repeatname">
<label for="level_standardauto_repeatname"> Make this a monthly gift </label>
</div>
<input type="hidden" name="level_standardauto_repeatsubmit" id="level_standardauto_repeatsubmit" value="true">
</div>
<script type="text/javascript">
// subscribe listeners to make an ajax call to the server to calculate the total amount
Y.use('jquery-noconflict', function() {
var fetchAmountFunc = function() {
// find all the select, textarea, input, etc... and format them into key=val pairs.
var params = jQuery('#level_standard_row :input').serialize();
// parse the path and append the key/value pairs above to the url
var url = 'https://act.alz.org/site/Donation2?idb=131988973&level_standardajaxfetch=true&df_id=60528&mfc_pref=T&60528.donation=form1&level_standardtotalcalculateBtn=true';
var index = url.indexOf("?");
var path = url.substring(0, index);
var args = url.substring(index + 1, url.length);
args += '&' + params;
var recurringGiftTermsContainer = jQuery('#recurring_gift_terms_acceptance_message_container');
if (recurringGiftTermsContainer && recurringGiftTermsContainer.length > 0) {
jQuery.ajax(path, {
data: args,
success: function(data) {
jQuery('#recurring_gift_terms_acceptance_message_container').trigger("recurringTermsChange");
}
});
}
};
jQuery('#level_standard_row :input[type=text]').blur(function() {
fetchAmountFunc();
});
jQuery('#level_standard_row input:checkbox, #level_standard_row input:radio').click(function() {
fetchAmountFunc();
});
jQuery('#level_standard_row select').change(function() {
fetchAmountFunc();
});
// call it on page load
fetchAmountFunc();
});
</script><noscript> </noscript>
</div>
<div class="form-row">
<div class="html-caption-container">
<br>
<p><strong>Thank you for your generous gift.</strong></p>
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
<!-- <div class="monthlyToggle ">
<label>Is this a monthly gift?</label>
<div class="btn-group">
<label id="monthlyYesLabelID" class="btn btn-primary" for="monthlyYes">
<input id="monthlyYes" class="radioButton" name="level_standardauto_repeatnameV" type="radio" value="true" /> Yes
</label>
<label id="monthlyNoLabelID" class="btn btn-primary active" for="monthlyNo">
<input id="monthlyNo" class="radioButton" name="level_standardauto_repeatnameV" type="radio" value="false" /> No
</label> -->
<!-- <input id="level_standardauto_repeatname" class="checkbox " name="level_standardauto_repeatname" type="checkbox" /> -->
<!-- </div>
</div> -->
</div>
</div>
<h2 class="section-header-container"> Is this a tribute gift? </h2>
<div id="tribute_show_honor_fields_row" class="form-row form-checkbox">
<div class="form-content">
<input type="checkbox" name="tribute_show_honor_fieldsname" id="tribute_show_honor_fieldsname" onclick="fire_obs_comp_event('tribute_show_honor_fields', this);">
<label for="tribute_show_honor_fieldsname">Yes, this is an honor or memorial gift</label>
<input type="hidden" name="tribute_show_honor_fieldssubmit" id="tribute_show_honor_fieldssubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('tribute_show_honor_fields', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('tribute_show_honor_fields_row', _display);
this.disable_submit_flag(_hidden);
}
comp.set = function(_value) {
if (document.getElementById('tribute_show_honor_fieldsname')) {
document.getElementById('tribute_show_honor_fieldsname').checked = _value;
this.fireEvent();
}
}
comp.get = function() {
if (document.getElementById('tribute_show_honor_fieldsname')) {
return document.getElementById('tribute_show_honor_fieldsname').checked;
}
}
comp.clear = function() {
this.set(false);
}
</script><noscript> </noscript>
</div>
</div>
<div id="honoreeInfo">
<div class="form-row">
<div class="html-caption-container">
<p class="tribute-disclaimer"><em>In Memory Of: honors an individual who has passed away<br>In Honor Of: marks a special occasion for a friend or family member</em> </p>
</div>
</div>
<div id="tribute_type_row" class="form-row form-selectlist" style="display: none;">
<div class="form-content">
<label class="FormLabel" for="tribute_type">Honor Gift Type:</label>
<select name="tribute_type" id="tribute_type" size="1" data-select2-id="tribute_type" tabindex="-1" class="select2-hidden-accessible" aria-hidden="true">
<option data-select2-id="2"></option>
<option value="tribute_type_value1">In Memory of</option>
<option value="tribute_type_value2">In Honor of</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" data-select2-id="1" style="width: 100%;"><span class="selection"><span class="select2-selection select2-selection--single" role="combobox"
aria-haspopup="true" aria-expanded="false" tabindex="0" aria-labelledby="select2-tribute_type-container"><span class="select2-selection__rendered" id="select2-tribute_type-container" role="textbox" aria-readonly="true"
title=""></span><span class="select2-selection__arrow" role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
<noscript><br>Required</noscript>
<input type="hidden" name="tribute_typesubmit_skip" id="tribute_typesubmit" value="true">
<noscript> </noscript>
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
<p><em>Please specify name of individual you would like to honor or memorialize.</em> </p>
</div>
</div>
<div id="tribute_honoree_name_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<label for="tribute_honoree_namename">Honoree Name:</label>
<input type="text" name="tribute_honoree_namename" id="tribute_honoree_namename" value="" maxlength="50">
<input type="hidden" name="tribute_honoree_namesubmit_skip" id="tribute_honoree_namesubmit" value="true">
<noscript> </noscript>
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
<div id="tribute_show_honor_notif"><input id="tribute_show_honor_notif_fieldsname" type="checkbox" name="s_honoreeSendNotif" value="Yes">
<label for="tribute_show_honor_notif_fieldsname">Yes, please send a notification to someone about this gift.</label>
</div>
</div>
</div>
<div id="honoreeNotifInfo">
<div class="form-row">
<div class="html-caption-container">
<h2 class="section-header-container">Notification Information</h2>
<p><em>If you would like us to notify someone of this gift, please provide full name and address for the individual that you want to be notified. </em></p>
</div>
</div>
<div id="tribute_notify_recip_name_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<label for="tribute_notify_recip_namename">Full Name:</label>
<input type="text" name="tribute_notify_recip_namename" id="tribute_notify_recip_namename" value="" maxlength="70">
<input type="hidden" name="tribute_notify_recip_namesubmit_skip" id="tribute_notify_recip_namesubmit" value="true">
<noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_street1_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<label for="tribute_notify_recip_street1name">Street 1:</label>
<input type="text" name="tribute_notify_recip_street1name" id="tribute_notify_recip_street1name" value="" maxlength="50">
<input type="hidden" name="tribute_notify_recip_street1submit_skip" id="tribute_notify_recip_street1submit" value="true">
<noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_street2_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<label for="tribute_notify_recip_street2name">Street 2:</label>
<input type="text" name="tribute_notify_recip_street2name" id="tribute_notify_recip_street2name" value="" maxlength="50">
<input type="hidden" name="tribute_notify_recip_street2submit_skip" id="tribute_notify_recip_street2submit" value="true">
<noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_city_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<label for="tribute_notify_recip_cityname">City:</label>
<input type="text" name="tribute_notify_recip_cityname" id="tribute_notify_recip_cityname" value="" maxlength="50">
<input type="hidden" name="tribute_notify_recip_citysubmit_skip" id="tribute_notify_recip_citysubmit" value="true">
<noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_state_row" class="form-row form-selectlist" style="display: none;">
<div class="form-content">
<label class="FormLabel" for="tribute_notify_recip_state">State/Province:</label>
<select name="tribute_notify_recip_state" id="tribute_notify_recip_state" size="1" onchange="fire_obs_comp_event('tribute_notify_recip_state', this)" data-select2-id="tribute_notify_recip_state" tabindex="-1"
class="select2-hidden-accessible" aria-hidden="true">
<option data-select2-id="4"></option>
<option value="AK">AK - Alaska</option>
<option value="AL">AL - Alabama</option>
<option value="AR">AR - Arkansas</option>
<option value="AZ">AZ - Arizona</option>
<option value="CA">CA - California</option>
<option value="CO">CO - Colorado</option>
<option value="CT">CT - Connecticut</option>
<option value="DC">DC - District of Columbia</option>
<option value="DE">DE - Delaware</option>
<option value="FL">FL - Florida</option>
<option value="GA">GA - Georgia</option>
<option value="HI">HI - Hawaii</option>
<option value="IA">IA - Iowa</option>
<option value="ID">ID - Idaho</option>
<option value="IL">IL - Illinois</option>
<option value="IN">IN - Indiana</option>
<option value="KS">KS - Kansas</option>
<option value="KY">KY - Kentucky</option>
<option value="LA">LA - Louisiana</option>
<option value="MA">MA - Massachusetts</option>
<option value="MD">MD - Maryland</option>
<option value="ME">ME - Maine</option>
<option value="MI">MI - Michigan</option>
<option value="MN">MN - Minnesota</option>
<option value="MO">MO - Missouri</option>
<option value="MS">MS - Mississippi</option>
<option value="MT">MT - Montana</option>
<option value="NC">NC - North Carolina</option>
<option value="ND">ND - North Dakota</option>
<option value="NE">NE - Nebraska</option>
<option value="NH">NH - New Hampshire</option>
<option value="NJ">NJ - New Jersey</option>
<option value="NM">NM - New Mexico</option>
<option value="NV">NV - Nevada</option>
<option value="NY">NY - New York</option>
<option value="OH">OH - Ohio</option>
<option value="OK">OK - Oklahoma</option>
<option value="OR">OR - Oregon</option>
<option value="PA">PA - Pennsylvania</option>
<option value="RI">RI - Rhode Island</option>
<option value="SC">SC - South Carolina</option>
<option value="SD">SD - South Dakota</option>
<option value="TN">TN - Tennessee</option>
<option value="TX">TX - Texas</option>
<option value="UT">UT - Utah</option>
<option value="VA">VA - Virginia</option>
<option value="VT">VT - Vermont</option>
<option value="WA">WA - Washington</option>
<option value="WI">WI - Wisconsin</option>
<option value="WV">WV - West Virginia</option>
<option value="WY">WY - Wyoming</option>
<option value="AS">AS - American Samoa</option>
<option value="FM">FM - Federated States of Micronesia</option>
<option value="GU">GU - Guam</option>
<option value="MH">MH - Marshall Islands</option>
<option value="MP">MP - Northern Mariana Islands</option>
<option value="PR">PR - Puerto Rico</option>
<option value="PW">PW - Palau</option>
<option value="VI">VI - Virgin Islands</option>
<option value="AA">AA - Armed Forces Americas</option>
<option value="AE">AE - Armed Forces</option>
<option value="AP">AP - Armed Forces Pacific</option>
<option value="AB">AB - Alberta</option>
<option value="BC">BC - British Columbia</option>
<option value="MB">MB - Manitoba</option>
<option value="NB">NB - New Brunswick</option>
<option value="NL">NL - Newfoundland and Labrador</option>
<option value="NS">NS - Nova Scotia</option>
<option value="NT">NT - Northwest Territories</option>
<option value="NU">NU - Nunavut</option>
<option value="ON">ON - Ontario</option>
<option value="PE">PE - Prince Edward Island</option>
<option value="QC">QC - Quebec</option>
<option value="SK">SK - Saskatchewan</option>
<option value="YT">YT - Yukon</option>
<option value="None">None</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" data-select2-id="3" style="width: 100%;"><span class="selection"><span class="select2-selection select2-selection--single" role="combobox"
aria-haspopup="true" aria-expanded="false" tabindex="0" aria-labelledby="select2-tribute_notify_recip_state-container"><span class="select2-selection__rendered" id="select2-tribute_notify_recip_state-container" role="textbox"
aria-readonly="true" title=""></span><span class="select2-selection__arrow" role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
<noscript><br>Required</noscript>
<input type="hidden" name="tribute_notify_recip_statesubmit_skip" id="tribute_notify_recip_statesubmit" value="true">
<noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_zip_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<label for="tribute_notify_recip_zipname">ZIP/Postal Code:</label>
<input type="text" name="tribute_notify_recip_zipname" id="tribute_notify_recip_zipname" value="" maxlength="50">
<input type="hidden" name="tribute_notify_recip_zipsubmit_skip" id="tribute_notify_recip_zipsubmit" value="true">
<noscript> </noscript>
</div>
</div>
<div id="tribute_notify_recip_country_row" class="form-row form-selectlist" style="display: none;">
<div class="form-content">
<label class="FormLabel" for="tribute_notify_recip_country">Notification Recipient Country:</label>
<select name="tribute_notify_recip_country" id="tribute_notify_recip_country" size="1" onchange="fire_obs_comp_event('tribute_notify_recip_country', this)" data-select2-id="tribute_notify_recip_country" tabindex="-1"
class="select2-hidden-accessible" aria-hidden="true">
<option></option>
<option selected="selected" value="United States" data-select2-id="6">United States</option>
<option value="Afghanistan">Afghanistan</option>
<option value="Aland Islands">Aland Islands</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="Antarctica">Antarctica</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="Bahamas">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="Bonaire, Sint Eustatios and Saba">Bonaire, Sint Eustatios and Saba</option>
<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
<option value="Botswana">Botswana</option>
<option value="Bouvet Island">Bouvet Island</option>
<option value="Brazil">Brazil</option>
<option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
<option value="Brunei Darussalam">Brunei Darussalam</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="China">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="Curacao">Curacao</option>
<option value="Cyprus">Cyprus</option>
<option value="Czech Republic">Czech Republic</option>
<option value="Democratic People's Republic of Korea">Democratic People's Republic of Korea</option>
<option value="The Democratic Republic of the Congo">The Democratic Republic of the Congo</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="Ethiopia">Ethiopia</option>
<option value="Falkland Islands (Malvinas)">Falkland Islands (Malvinas)</option>
<option value="Faroe Islands">Faroe Islands</option>
<option value="Federated States of Micronesia">Federated States of Micronesia</option>
<option value="Fiji">Fiji</option>
<option value="Finland">Finland</option>
<option value="The Former Yugoslav Republic of Macedonia">The Former Yugoslav Republic of Macedonia</option>
<option value="France">France</option>
<option value="French Guiana">French Guiana</option>
<option value="French Polynesia">French Polynesia</option>
<option value="French Southern Territories">French Southern Territories</option>
<option value="Gabon">Gabon</option>
<option value="Gambia">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="Heard Island and McDonald Islands">Heard Island and McDonald Islands</option>
<option value="Holy See (Vatican City State)">Holy See (Vatican City State)</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="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Islamic Republic of Iran">Islamic Republic of Iran</option>
<option value="Isle of Man">Isle of Man</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="Kuwait">Kuwait</option>
<option value="Kyrgyzstan">Kyrgyzstan</option>
<option value="Laos People's Democratic Republic">Laos People's Democratic Republic</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="Macao">Macao</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="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 Islands">Northern Mariana Islands</option>
<option value="Norway">Norway</option>
<option value="Oman">Oman</option>
<option value="Pakistan">Pakistan</option>
<option value="Palau">Palau</option>
<option value="Palestinian Territory, Occupied">Palestinian Territory, Occupied</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">Pitcairn</option>
<option value="Plurinational State of Bolivia">Plurinational State of Bolivia</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="Republic of Korea">Republic of Korea</option>
<option value="Republic of Moldova">Republic of Moldova</option>
<option value="Reunion">Reunion</option>
<option value="Romania">Romania</option>
<option value="Russian Federation">Russian Federation</option>
<option value="Rwanda">Rwanda</option>
<option value="Saint Barthelemy">Saint Barthelemy</option>
<option value="Saint Helena, Ascension and Tristan da Cunha">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
<option value="Saint Lucia">Saint Lucia</option>
<option value="Saint Martin (French)">Saint Martin (French)</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="S. Georgia & S. Sandwich Isls.">S. Georgia & S. Sandwich Isls.</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapore">Singapore</option>
<option value="Sint Maarten (Dutch)">Sint Maarten (Dutch)</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="South Africa">South Africa</option>
<option value="South Sudan">South Sudan</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 and Jan Mayen">Svalbard and Jan Mayen</option>
<option value="Swaziland">Swaziland</option>
<option value="Sweden">Sweden</option>
<option value="Switzerland">Switzerland</option>
<option value="Syrian Arab Republic">Syrian Arab Republic</option>
<option value="Taiwan">Taiwan</option>
<option value="Tajikistan">Tajikistan</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="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="United Republic of Tanzania">United Republic of Tanzania</option>
<option value="Uruguay">Uruguay</option>
<option value="USA Minor Outlying Islands">USA Minor Outlying Islands</option>
<option value="Uzbekistan">Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Venezuela">Venezuela</option>
<option value="Viet Nam">Viet Nam</option>
<option value="Virgin Islands (British)">Virgin Islands (British)</option>
<option value="Virgin Islands (USA)">Virgin Islands (USA)</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>
</select><span class="select2 select2-container select2-container--default" dir="ltr" data-select2-id="5" style="width: 100%;"><span class="selection"><span class="select2-selection select2-selection--single" role="combobox"
aria-haspopup="true" aria-expanded="false" tabindex="0" aria-labelledby="select2-tribute_notify_recip_country-container"><span class="select2-selection__rendered" id="select2-tribute_notify_recip_country-container" role="textbox"
aria-readonly="true" title="United States">United States</span><span class="select2-selection__arrow" role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper"
aria-hidden="true"></span></span>
<noscript><br>Required</noscript>
<input type="hidden" name="tribute_notify_recip_countrysubmit_skip" id="tribute_notify_recip_countrysubmit" value="true">
<noscript> </noscript>
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
<p><em>Enter message that you would like the individual to receive (e.g. "Congratulations on your 50th anniversary!").</em></p>
</div>
</div>
<div id="tribute_message_body_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<label for="tribute_message_bodyname">Message Body:</label>
<textarea cols="50" rows="4" name="tribute_message_bodyname" id="tribute_message_bodyname" maxlength="250"></textarea>
<p><em>Character count: <span class="counter-tribute_message_bodyname">250</span></em></p>
<input type="hidden" name="tribute_message_bodysubmit_skip" id="tribute_message_bodysubmit" value="true">
<noscript> </noscript>
</div>
</div>
<div id="tribute_message_closing_row" class="form-row form-text" style="display: none;">
<div class="form-content">
<label for="tribute_message_closingname">Message Closing/Signature:</label>
<input type="text" name="tribute_message_closingname" id="tribute_message_closingname" value="" maxlength="50">
<p><em>Character count: <span class="counter-tribute_message_closingname">50</span></em></p>
<input type="hidden" name="tribute_message_closingsubmit_skip" id="tribute_message_closingsubmit" value="true">
<noscript> </noscript>
</div>
</div>
</div>
</div>
<input type="hidden" name="tribute_notify_recip_titlehidden" id="tribute_notify_recip_titlehidden" value="">
<h2 class="section-header-container non-tribute-row"> Your Information </h2>
<div id="billing_first_name_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="billing_first_namename">First Name:</label>
<input type="text" name="billing_first_namename" id="billing_first_namename" value="" maxlength="50">
<input type="hidden" name="billing_first_namesubmit" id="billing_first_namesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_first_name', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_first_name_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_last_name_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="billing_last_namename">Last Name:</label>
<input type="text" name="billing_last_namename" id="billing_last_namename" value="" maxlength="50">
<input type="hidden" name="billing_last_namesubmit" id="billing_last_namesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_last_name', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_last_name_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="donor_email_address_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="donor_email_addressname">Email Address:</label>
<input type="text" name="donor_email_addressname" id="donor_email_addressname" value="" maxlength="255">
<input type="hidden" name="donor_email_addresssubmit" id="donor_email_addresssubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('donor_email_address', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_email_address_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_addr_street1_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="billing_addr_street1name">Street 1:</label>
<input type="text" name="billing_addr_street1name" id="billing_addr_street1name" value="" maxlength="50">
<input type="hidden" name="billing_addr_street1submit" id="billing_addr_street1submit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_street1', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_street1_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_addr_street2_row" class="form-row form-text">
<div class="form-content">
<label for="billing_addr_street2name">Street 2:</label>
<input type="text" name="billing_addr_street2name" id="billing_addr_street2name" value="" maxlength="50">
<input type="hidden" name="billing_addr_street2submit" id="billing_addr_street2submit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_street2', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_street2_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_addr_zip_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="billing_addr_zipname">ZIP/Postal Code:</label>
<input type="text" name="billing_addr_zipname" id="billing_addr_zipname" value="" maxlength="50">
<input type="hidden" name="billing_addr_zipsubmit" id="billing_addr_zipsubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_zip', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_zip_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_addr_city_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="billing_addr_cityname">City:</label>
<input type="text" name="billing_addr_cityname" id="billing_addr_cityname" value="" maxlength="50">
<input type="hidden" name="billing_addr_citysubmit" id="billing_addr_citysubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_city', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_city_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_addr_state_row" class="form-row form-selectlist">
<div class="form-content">
<span class="field-required"></span>
<label class="FormLabel" for="billing_addr_state">State</label>
<select name="billing_addr_state" id="billing_addr_state" size="1" onchange="fire_obs_comp_event('billing_addr_state', this)" data-select2-id="billing_addr_state" tabindex="-1" class="select2-hidden-accessible" aria-hidden="true">
<option data-select2-id="8"></option>
<option value="AK">AK - Alaska</option>
<option value="AL">AL - Alabama</option>
<option value="AR">AR - Arkansas</option>
<option value="AZ">AZ - Arizona</option>
<option value="CA">CA - California</option>
<option value="CO">CO - Colorado</option>
<option value="CT">CT - Connecticut</option>
<option value="DC">DC - District of Columbia</option>
<option value="DE">DE - Delaware</option>
<option value="FL">FL - Florida</option>
<option value="GA">GA - Georgia</option>
<option value="HI">HI - Hawaii</option>
<option value="IA">IA - Iowa</option>
<option value="ID">ID - Idaho</option>
<option value="IL">IL - Illinois</option>
<option value="IN">IN - Indiana</option>
<option value="KS">KS - Kansas</option>
<option value="KY">KY - Kentucky</option>
<option value="LA">LA - Louisiana</option>
<option value="MA">MA - Massachusetts</option>
<option value="MD">MD - Maryland</option>
<option value="ME">ME - Maine</option>
<option value="MI">MI - Michigan</option>
<option value="MN">MN - Minnesota</option>
<option value="MO">MO - Missouri</option>
<option value="MS">MS - Mississippi</option>
<option value="MT">MT - Montana</option>
<option value="NC">NC - North Carolina</option>
<option value="ND">ND - North Dakota</option>
<option value="NE">NE - Nebraska</option>
<option value="NH">NH - New Hampshire</option>
<option value="NJ">NJ - New Jersey</option>
<option value="NM">NM - New Mexico</option>
<option value="NV">NV - Nevada</option>
<option value="NY">NY - New York</option>
<option value="OH">OH - Ohio</option>
<option value="OK">OK - Oklahoma</option>
<option value="OR">OR - Oregon</option>
<option value="PA">PA - Pennsylvania</option>
<option value="RI">RI - Rhode Island</option>
<option value="SC">SC - South Carolina</option>
<option value="SD">SD - South Dakota</option>
<option value="TN">TN - Tennessee</option>
<option value="TX">TX - Texas</option>
<option value="UT">UT - Utah</option>
<option value="VA">VA - Virginia</option>
<option value="VT">VT - Vermont</option>
<option value="WA">WA - Washington</option>
<option value="WI">WI - Wisconsin</option>
<option value="WV">WV - West Virginia</option>
<option value="WY">WY - Wyoming</option>
<option value="AS">AS - American Samoa</option>
<option value="FM">FM - Federated States of Micronesia</option>
<option value="GU">GU - Guam</option>
<option value="MH">MH - Marshall Islands</option>
<option value="MP">MP - Northern Mariana Islands</option>
<option value="PR">PR - Puerto Rico</option>
<option value="PW">PW - Palau</option>
<option value="VI">VI - Virgin Islands</option>
<option value="AA">AA - Armed Forces Americas</option>
<option value="AE">AE - Armed Forces</option>
<option value="AP">AP - Armed Forces Pacific</option>
<option value="AB">AB - Alberta</option>
<option value="BC">BC - British Columbia</option>
<option value="MB">MB - Manitoba</option>
<option value="NB">NB - New Brunswick</option>
<option value="NL">NL - Newfoundland and Labrador</option>
<option value="NS">NS - Nova Scotia</option>
<option value="NT">NT - Northwest Territories</option>
<option value="NU">NU - Nunavut</option>
<option value="ON">ON - Ontario</option>
<option value="PE">PE - Prince Edward Island</option>
<option value="QC">QC - Quebec</option>
<option value="SK">SK - Saskatchewan</option>
<option value="YT">YT - Yukon</option>
<option value="None">None</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" data-select2-id="7" style="width: 100%;"><span class="selection"><span class="select2-selection select2-selection--single" role="combobox"
aria-haspopup="true" aria-expanded="false" tabindex="0" aria-labelledby="select2-billing_addr_state-container"><span class="select2-selection__rendered" id="select2-billing_addr_state-container" role="textbox" aria-readonly="true"
title=""></span><span class="select2-selection__arrow" role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('billing_addr_state', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_state_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="billing_addr_statesubmit" id="billing_addr_statesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_state', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_state_row', _display);
this.disable_submit_flag(_hidden);
}
function billing_addr_state_listChanged(_evt) {
var e = _evt ? _evt : event; // IE vs. Mozilla event model
if (e) {
var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model
fire_obs_comp_event('billing_addr_state', src);
}
}
var el = document.getElementById('billing_addr_state');
if (el) {
Utils.addEvent(el, 'change', billing_addr_state_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<div id="billing_addr_country_row" class="form-row form-selectlist">
<div class="form-content">
<span class="field-required"></span>
<label class="FormLabel" for="billing_addr_country">Country:</label>
<select name="billing_addr_country" id="billing_addr_country" size="1" onchange="fire_obs_comp_event('billing_addr_country', this)" data-select2-id="billing_addr_country" tabindex="-1" class="select2-hidden-accessible" aria-hidden="true">
<option></option>
<option selected="selected" value="United States" data-select2-id="10">United States</option>
<option value="Afghanistan">Afghanistan</option>
<option value="Aland Islands">Aland Islands</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="Antarctica">Antarctica</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="Bahamas">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="Bonaire, Sint Eustatios and Saba">Bonaire, Sint Eustatios and Saba</option>
<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
<option value="Botswana">Botswana</option>
<option value="Bouvet Island">Bouvet Island</option>
<option value="Brazil">Brazil</option>
<option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
<option value="Brunei Darussalam">Brunei Darussalam</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="China">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="Curacao">Curacao</option>
<option value="Cyprus">Cyprus</option>
<option value="Czech Republic">Czech Republic</option>
<option value="Democratic People's Republic of Korea">Democratic People's Republic of Korea</option>
<option value="The Democratic Republic of the Congo">The Democratic Republic of the Congo</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="Ethiopia">Ethiopia</option>
<option value="Falkland Islands (Malvinas)">Falkland Islands (Malvinas)</option>
<option value="Faroe Islands">Faroe Islands</option>
<option value="Federated States of Micronesia">Federated States of Micronesia</option>
<option value="Fiji">Fiji</option>
<option value="Finland">Finland</option>
<option value="The Former Yugoslav Republic of Macedonia">The Former Yugoslav Republic of Macedonia</option>
<option value="France">France</option>
<option value="French Guiana">French Guiana</option>
<option value="French Polynesia">French Polynesia</option>
<option value="French Southern Territories">French Southern Territories</option>
<option value="Gabon">Gabon</option>
<option value="Gambia">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="Heard Island and McDonald Islands">Heard Island and McDonald Islands</option>
<option value="Holy See (Vatican City State)">Holy See (Vatican City State)</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="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Islamic Republic of Iran">Islamic Republic of Iran</option>
<option value="Isle of Man">Isle of Man</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="Kuwait">Kuwait</option>
<option value="Kyrgyzstan">Kyrgyzstan</option>
<option value="Laos People's Democratic Republic">Laos People's Democratic Republic</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="Macao">Macao</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="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 Islands">Northern Mariana Islands</option>
<option value="Norway">Norway</option>
<option value="Oman">Oman</option>
<option value="Pakistan">Pakistan</option>
<option value="Palau">Palau</option>
<option value="Palestinian Territory, Occupied">Palestinian Territory, Occupied</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">Pitcairn</option>
<option value="Plurinational State of Bolivia">Plurinational State of Bolivia</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="Republic of Korea">Republic of Korea</option>
<option value="Republic of Moldova">Republic of Moldova</option>
<option value="Reunion">Reunion</option>
<option value="Romania">Romania</option>
<option value="Russian Federation">Russian Federation</option>
<option value="Rwanda">Rwanda</option>
<option value="Saint Barthelemy">Saint Barthelemy</option>
<option value="Saint Helena, Ascension and Tristan da Cunha">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
<option value="Saint Lucia">Saint Lucia</option>
<option value="Saint Martin (French)">Saint Martin (French)</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="S. Georgia & S. Sandwich Isls.">S. Georgia & S. Sandwich Isls.</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapore">Singapore</option>
<option value="Sint Maarten (Dutch)">Sint Maarten (Dutch)</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="South Africa">South Africa</option>
<option value="South Sudan">South Sudan</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 and Jan Mayen">Svalbard and Jan Mayen</option>
<option value="Swaziland">Swaziland</option>
<option value="Sweden">Sweden</option>
<option value="Switzerland">Switzerland</option>
<option value="Syrian Arab Republic">Syrian Arab Republic</option>
<option value="Taiwan">Taiwan</option>
<option value="Tajikistan">Tajikistan</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="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="United Republic of Tanzania">United Republic of Tanzania</option>
<option value="Uruguay">Uruguay</option>
<option value="USA Minor Outlying Islands">USA Minor Outlying Islands</option>
<option value="Uzbekistan">Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Venezuela">Venezuela</option>
<option value="Viet Nam">Viet Nam</option>
<option value="Virgin Islands (British)">Virgin Islands (British)</option>
<option value="Virgin Islands (USA)">Virgin Islands (USA)</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>
</select><span class="select2 select2-container select2-container--default" dir="ltr" data-select2-id="9" style="width: 100%;"><span class="selection"><span class="select2-selection select2-selection--single" role="combobox"
aria-haspopup="true" aria-expanded="false" tabindex="0" aria-labelledby="select2-billing_addr_country-container"><span class="select2-selection__rendered" id="select2-billing_addr_country-container" role="textbox" aria-readonly="true"
title="United States">United States</span><span class="select2-selection__arrow" role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('billing_addr_country', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_country_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="billing_addr_countrysubmit" id="billing_addr_countrysubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('billing_addr_country', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('billing_addr_country_row', _display);
this.disable_submit_flag(_hidden);
}
function billing_addr_country_listChanged(_evt) {
var e = _evt ? _evt : event; // IE vs. Mozilla event model
if (e) {
var src = e.target ? e.target : e.srcElement; // IE vs. Mozilla event model
fire_obs_comp_event('billing_addr_country', src);
}
}
var el = document.getElementById('billing_addr_country');
if (el) {
Utils.addEvent(el, 'change', billing_addr_country_listChanged);
}
</script><noscript> </noscript>
</div>
</div>
<div id="donor_phone_row" class="form-row form-text">
<div class="form-content">
<label for="donor_phonename">Phone Number: (Optional)</label>
<input type="text" name="donor_phonename" id="donor_phonename" value="" maxlength="50">
<input type="hidden" name="donor_phonesubmit" id="donor_phonesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('donor_phone', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_phone_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
<p style="font-size:16px; line-height:22px !important; color: #808285;"><em style="font-size:15px; line-height:18px !important; color: #808285;">By entering your mobile number, you will be opted in to receive text message updates from the
Alzheimer's Association and stay involved in the fight to end Alzheimer's. You will be able to opt-out of these messages at any time. <a href="https://www.alz.org/security-and-privacy-policy" target="_blank">Privacy Policy</a><br></em>
</p>
</div>
</div>
<div class="form-row form-checkbox" id="donor_email_opt_in_Row">
<div class="form-content">
<span class="check-box-form-label-text"></span>
<input type="checkbox" name="donor_email_opt_inname" id="donor_email_opt_inname" checked="checked" onclick="fire_obs_comp_event('donor_email_opt_in', this);">
<label for="donor_email_opt_inname"> Yes, I would like to receive email from the Alzheimer's Association </label>
<script type="text/javascript">
var comp = new ObservableComponent('donor_email_opt_in', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('donor_email_opt_in_Row', _display);
this.disable_submit_flag(_hidden);
}
comp.set = function(_value) {
if (document.getElementById('donor_email_opt_inname')) {
document.getElementById('donor_email_opt_inname').checked = _value;
this.fireEvent();
}
}
comp.get = function() {
if (document.getElementById('donor_email_opt_inname')) return document.getElementById('donor_email_opt_inname').checked;
}
comp.clear = function() {
this.set(false);
}
</script><noscript> </noscript>
<input type="hidden" name="donor_email_opt_insubmit" id="donor_email_opt_insubmit" value="true">
</div>
</div>
<div class="form-row">
<div class="html-caption-container">
<!-- fake email interest container -->
<div id="emailInterestContainer">
<div class="form-row">
<div class="html-caption-container">
</div>
</div>
<table border="0">
<tbody>
<tr class="FormRow" id="checkbox_array_Row" style="padding-bottom:5px">
<td class="requiredIndicator"> </td>
<td class="FormLabel">
<div class="FormLabel" title="For checkbox_arrayname">
<span class="CheckBoxFormLabelText">Email Interests:</span>
<span class="FormElementHiddenInfoLabel">You may periodically receive email from us regarding the interests you select.</span>
<img src="../images/Spacer.gif" width="1px" height="1px" alt="You may periodically receive email from us regarding the interests you select. Required">
</div>
</td>
<td class="FormInput">
<table width="100%" cellspacing="0" cellpadding="0">
<tbody>
<tr>
<td>
<input type="checkbox" class="ButtonInput" name="box1062" id="box1062" checked="checked">
<label class="CheckboxLabel" for="box1062">Yes, I would like to receive the Alzheimer's Association weekly e-news updates.</label>
</td>
</tr>
</tbody>
</table>
</td>
<td class="holdsErrorMsgTable">
<table border="0" class="holdsErrorMsg" cellspacing="0" cellpadding="0">
<tbody>
<tr class="holdsErrorMsg">
<td class="FormMsgIcon">
<img src="../images/error.gif" width="16px" height="16px" alt="Warning" class="HiddenErrorImage" style="display: none;">
<div class="InfoImage2" style="visibility: hidden;"><img src="../images/info.gif" title="Information Cue" alt="Information Cue" width="16" height="16"></div>
</td>
<td class="FormInfoMsg" width="100%">
<div class="FormMsgText"></div>
<script type="text/javascript">
<!--
// currently the checkbox array does not support component functions
//
// var comp = new ObservableComponent ('checkbox_array', 'name');
//
// comp.hide = function(_hidden)
// {
// var _display = _hidden ? 'none' : '';
// set_display ('checkbox_array_Row', _display);
// this.disable_submit_flag (_hidden);
// }
//
// comp.set = function (_value)
// {
// if (document.getElementById('checkbox_arrayname')) {
// document.getElementById('checkbox_arrayname').checked = _value;
// this.fireEvent();
// }
// }
//
// comp.get = function()
// {
// if (document.getElementById('checkbox_arrayname'))
// return document.getElementById('checkbox_arrayname').checked;
// }
//
// comp.clear = function()
// {
// this.set(false);
// }
// observe_component ('null', new ComponentEnabler ('checkbox_array'));
//
-->
</script><noscript> </noscript>
<noscript>You may periodically receive email from us regarding the interests you select.<br>
</noscript>
<div class="InfoMessage2" style="visibility: hidden;">You may periodically receive email from us regarding the interests you select.</div>
</td>
</tr>
</tbody>
</table>
<input type="hidden" name="checkbox_arraysubmit" id="checkbox_arraysubmit" value="true">
</td>
</tr>
</tbody>
</table>
</div>
<!-- closing fake email interest container from previous caption -->
</div>
</div>
<h2 class="section-header-container"> Payment Information </h2>
<div class="payment-type-element-container">
<div class="payment-type-selection-container payment-field-container">
<h3 style="display: none;">Payment Information</h3>
<div id="responsive_payment_typepay_typeradio_row" class="form-row">
<div class="form-content">
<div class="payment-type-selections" id="responsive_payment_typepay_typeradio_payment_types">
<span class="internal-payment"><span class="payment-type-option selected"><input type="radio" name="responsive_payment_typepay_typeradio" id="responsive_payment_typepay_typeradiocredit" value="credit" checked="checked"
onclick="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);" onkeypress="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);"><label
for="responsive_payment_typepay_typeradiocredit"><a href="javascript:void(0);" class="payment-type-label">Credit Card</a></label>
<script type="text/javascript">
var comp = new ObservableRadioComponent('responsive_payment_typepay_typeradio', 'name');
</script><noscript> </noscript>
</span></span>
<span class="external-payment"><span class="payment-type-option"><input type="radio" name="responsive_payment_typepay_typeradio" id="responsive_payment_typepay_typeradiopaypal" value="paypal"
onclick="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);" onkeypress="fire_obs_comp_event('responsive_payment_typepay_typeradio', this);"><label
for="responsive_payment_typepay_typeradiopaypal"><a href="javascript:void(0);" class="payment-type-label"><img src="../images/payment/paypal-logo.png" alt="Pay with Paypal"></a></label>
<script type="text/javascript">
var comp = new ObservableRadioComponent('responsive_payment_typepay_typeradio', 'name');
</script><noscript> </noscript>
</span></span>
</div>
<input type="hidden" name="responsive_payment_typepay_typeradiosubmit" id="responsive_payment_typepay_typeradiosubmit" value="true">
<script type="text/javascript">
Y.use("jquery-ui", function(Y) {
jQuery(function() {
// subscribe observable for payment type options
jQuery('.payment-type-option').each(function() {
var syncAction = function(obj) {
if (obj.hasClass('selected')) {
var radioGroupName = obj.find('input').attr('name');
obj.find('input').prop('checked', true);
fire_obs_comp_event(radioGroupName, obj.find('input').get());
}
return arguments.callee;
}(jQuery(this));
jQuery(this).click(function() {
jQuery('.payment-type-option').removeClass('selected');
jQuery(this).addClass('selected');
syncAction(jQuery(this));
var selectedValue = jQuery(this).find('input').val();
if (selectedValue == 'paypal' || selectedValue == 'amazon') {
// open up a boxinator dialog
jQuery(document).trigger('redirect-external');
jQuery('#btn_next').click();
}
});
});
});
});
var comp = new ObservableRadioComponent('responsive_payment_typepay_typeradio', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typepay_typeradio_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
</div>
<div id="payment_cc_container" class="payment-field-container">
<h3 style="display: none;">Credit Card Information:</h3>
<div id="responsive_payment_typecc_type_row" class="form-row form-radio-array">
<div class="form-content">
<fieldset>
<legend>Credit Card Type:</legend>
<ul class="radio-array-list">
<li class="tender-row ">
<img src="../images/diners_sm.gif" alt="Diners Club" name="responsive_payment_typecc_type_Diners_Club" id="responsive_payment_typecc_type_Diners_Club">
</li>
<li class="tender-row ">
<img src="../images/discovercard_sm.gif" alt="Discover" name="responsive_payment_typecc_type_Discover" id="responsive_payment_typecc_type_Discover">
</li>
<li class="tender-row ">
<img src="../images/amex_small.gif" alt="American Express" name="responsive_payment_typecc_type_American_Express" id="responsive_payment_typecc_type_American_Express">
</li>
<li class="tender-row ">
<img src="../images/mastercd_small.gif" alt="MasterCard" name="responsive_payment_typecc_type_MasterCard" id="responsive_payment_typecc_type_MasterCard">
</li>
<li class="tender-row ">
<img src="../images/visa_small.gif" alt="Visa" name="responsive_payment_typecc_type_Visa" id="responsive_payment_typecc_type_Visa">
</li>
</ul>
</fieldset>
<input type="hidden" name="responsive_payment_typecc_typesubmit" id="responsive_payment_typecc_typesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableRadioComponent('responsive_payment_typecc_type', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_type_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
<input type="hidden" name="recurring_options_name_install_plan" id="recurring_options_name_install_plan" value="responsive_payment_typecc_type">
</div>
</div>
<div id="responsive_payment_typecc_number_row" class="form-row form-text">
<div class="form-content">
<span class="field-required"></span>
<label for="responsive_payment_typecc_numbername">Credit Card Number:</label>
<input type="text" name="responsive_payment_typecc_numbername" id="responsive_payment_typecc_numbername" value="" maxlength="22" autocomplete="off">
<input type="hidden" name="responsive_payment_typecc_numbersubmit" id="responsive_payment_typecc_numbersubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('responsive_payment_typecc_number', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_number_row', _display);
this.disable_submit_flag(_hidden);
}
observe_component('null', new ComponentDisplayer('responsive_payment_typecc_number'));
</script><noscript> </noscript>
</div>
</div>
<div id="responsive_payment_typecc_exp_date_row" class="form-row form-date">
<div class="form-content">
<span class="field-required"></span>
<label for="responsive_payment_typecc_exp_date_MONTH">
<span class="label-text">Expiration Date:</span><span class="aural-only">Select month of credit card</span>
</label>
<label for="responsive_payment_typecc_exp_date_YEAR"><span class="aural-only">Select Expiration Year</span></label>
<div class="date-input-container">
<!-- testing 60528 -->
<fieldset class="cardExpGroup">
<select name="responsive_payment_typecc_exp_date_MONTH" id="responsive_payment_typecc_exp_date_MONTH" onchange="fire_obs_comp_event('responsive_payment_typecc_exp_date_MONTH', this)"
data-select2-id="responsive_payment_typecc_exp_date_MONTH" tabindex="-1" class="select2-hidden-accessible" aria-hidden="true">
<option value="0" selected="selected" data-select2-id="12"></option>
<option value="1" data-select2-id="17">01</option>
<option value="2" data-select2-id="18">02</option>
<option value="3" data-select2-id="19">03</option>
<option value="4" data-select2-id="20">04</option>
<option value="5" data-select2-id="21">05</option>
<option value="6" data-select2-id="22">06</option>
<option value="7" data-select2-id="23">07</option>
<option value="8" data-select2-id="24">08</option>
<option value="9" data-select2-id="25">09</option>
<option value="10" data-select2-id="26">10</option>
<option value="11" data-select2-id="27">11</option>
<option value="12" data-select2-id="28">12</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" data-select2-id="29" style="width: 48%;"><span class="selection"><span class="select2-selection select2-selection--single" role="combobox"
aria-haspopup="true" aria-expanded="false" tabindex="0" aria-labelledby="select2-responsive_payment_typecc_exp_date_MONTH-container"><span class="select2-selection__rendered"
id="select2-responsive_payment_typecc_exp_date_MONTH-container" role="textbox" aria-readonly="true"><span class="select2-selection__placeholder">MM</span></span><span class="select2-selection__arrow"
role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
<select name="responsive_payment_typecc_exp_date_YEAR" id="responsive_payment_typecc_exp_date_YEAR" onchange="fire_obs_comp_event('responsive_payment_typecc_exp_date_YEAR', this)"
data-select2-id="responsive_payment_typecc_exp_date_YEAR" tabindex="-1" class="select2-hidden-accessible" aria-hidden="true">
<option value="0" selected="selected" data-select2-id="14"></option>
<option value="2024" data-select2-id="30">2024</option>
<option value="2025" data-select2-id="31">2025</option>
<option value="2026" data-select2-id="32">2026</option>
<option value="2027" data-select2-id="33">2027</option>
<option value="2028" data-select2-id="34">2028</option>
<option value="2029" data-select2-id="35">2029</option>
<option value="2030" data-select2-id="36">2030</option>
<option value="2031" data-select2-id="37">2031</option>
<option value="2032" data-select2-id="38">2032</option>
<option value="2033" data-select2-id="39">2033</option>
<option value="2034" data-select2-id="40">2034</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" data-select2-id="41" style="width: 48%;"><span class="selection"><span class="select2-selection select2-selection--single" role="combobox"
aria-haspopup="true" aria-expanded="false" tabindex="0" aria-labelledby="select2-responsive_payment_typecc_exp_date_YEAR-container"><span class="select2-selection__rendered"
id="select2-responsive_payment_typecc_exp_date_YEAR-container" role="textbox" aria-readonly="true"><span class="select2-selection__placeholder">YYYY</span></span><span class="select2-selection__arrow"
role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
</fieldset>
<input type="hidden" name="responsive_payment_typecc_exp_date_DAY" id="responsive_payment_typecc_exp_date_DAY" value="1">
<!-- a0 responsive_payment_typecc_exp_date a1: 2024 a3: 12 -->
<script type="text/javascript">
<!--
var comp1 = new ObservableComponent('responsive_payment_typecc_exp_date_MONTH', '');
comp1.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_exp_date_Row', _display);
this.disable_submit_flag(_hidden);
}
var comp2 = new ObservableComponent('responsive_payment_typecc_exp_date_YEAR', '');
comp2.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_exp_date_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script><noscript> </noscript>
</div>
<input type="hidden" name="responsive_payment_typecc_exp_datesubmit" id="responsive_payment_typecc_exp_datesubmit" value="true">
<script type="text/javascript">
var comp = new ObservableComponent('responsive_payment_typecc_exp_date', 'input');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_exp_date_row', _display);
disable_submit_flag('responsive_payment_typecc_exp_datesubmit', _hidden);
}
comp.disable = function(_disabled) {
disable_element('responsive_payment_typecc_exp_date_MONTH', _disabled);
disable_element('responsive_payment_typecc_exp_date_DAY', _disabled);
disable_element('responsive_payment_typecc_exp_date_YEAR', _disabled);
disable_element('responsive_payment_typecc_exp_date_HOUR12', _disabled);
disable_element('responsive_payment_typecc_exp_date_HOUR24', _disabled); //For UK, 24 hour clock used
disable_element('responsive_payment_typecc_exp_date_MINUTE', _disabled);
disable_element('responsive_payment_typecc_exp_date_AMPM', _disabled);
}
</script><noscript> </noscript>
</div>
</div>
<div id="responsive_payment_typecc_cvv_row" class="form-row form-text cvv-input">
<div class="form-content">
<span class="field-required"></span>
<label for="responsive_payment_typecc_cvvname">
<span class="FormLabelText">CVV Number:</span>
</label>
<a data-fancybox="cvv-help" data-src="#cvv-help" href="javascript:void(0);" class="FancyHelpLink" id="FancyCVV" title="What is this? Opens new window.">What is this?</a><a href="http://help.convio.net/site/PageServer?s_site=adarda&pagename=user_donation_cvv" class="HelpLink" title="What is this? Opens new window.">What is this?</a>
<input type="text" name="responsive_payment_typecc_cvvname" id="responsive_payment_typecc_cvvname" value="" maxlength="4" autocomplete="cc-csc">
<input type="hidden" name="responsive_payment_typecc_cvvsubmit" id="responsive_payment_typecc_cvvsubmit" value="true">
<script type="text/javascript">
//chrome is mapping cvv as card name
if (/CriOS/.test(navigator.userAgent) || (/Chrome/.test(navigator.userAgent) && /Google Inc/.test(navigator.vendor))) {
document.getElementById('responsive_payment_typecc_cvvname').autocomplete = 'cc-csc';
}
var comp = new ObservableComponent('responsive_payment_typecc_cvv', 'name');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('responsive_payment_typecc_cvv_row', _display);
this.disable_submit_flag(_hidden);
}
</script><noscript> </noscript>
</div>
</div>
</div>
<div id="payment_check_container" class="payment-field-container" style="display: none;">
<h3 style="display: none;">Check Information</h3>
</div>
<script>
document.addEventListener("DOMContentLoaded", function() {
addHiddenInputIfNotExist("currency_locale", "currency_locale", "en_US");
addHiddenInputIfNotExist("cc_available", "cc_available", "null");
addHiddenInputIfNotExist("debit_available", "debit_available", "null");
addHiddenInputIfNotExist("paypal_available", "paypal_available", "null");
addHiddenInputIfNotExist("wallets_available", "wallets_available", "null");
addHiddenInputIfNotExist("secure_url", "secure_url", "https://act.alz.org/site/");
addHiddenInputIfNotExist("is_admin_app", "is_admin_app", "F");
addHiddenInputIfNotExist("environment_id", "environment_id", "");
addHiddenInputIfNotExist("merchant_account_configuration_id", "merchant_account_configuration_id", "");
addHiddenInputIfNotExist("pco_javascript_location", "pco_javascript_location", "");
addHiddenInputIfNotExist("primary_color", "primary_color", "null");
addHiddenInputIfNotExist("application_name", "application_name", "TeamRaiser");
addHiddenInputIfNotExist("pco_language_locale", "pco_language_locale", "en_US");
addHiddenInputIfNotExist("pco_environment_zone", "pco_environment_zone", "p-usa01");
});
</script>
<input type="hidden" name="responsive_payment_typesubmit" id="responsive_payment_typesubmit" value="true">
<script type="text/javascript">
function PaymentObserver() {
this.observe = function(_event) {
var sVal = _event.component.get();
switch (sVal) {
case 'check':
hide_element('payment_cc_container');
hide_element('payment_bank_container');
show_element('payment_check_container');
break;
case 'credit':
hide_element('payment_bank_container');
hide_element('payment_check_container');
show_element('payment_cc_container');
break;
case 'ach':
hide_element('payment_cc_container');
hide_element('payment_check_container');
show_element('payment_bank_container');
break;
case 'paypal':
case 'amazon':
case 'mobilepay':
default:
// hide all
hide_element('payment_bank_container');
hide_element('payment_cc_container');
hide_element('payment_check_container');
break;
}
}
}
// Set the observer to show/hide the relevant fields
observe_component('responsive_payment_typepay_typeradio', new PaymentObserver());
</script><noscript> </noscript>
</div>
<div class="custom-field-container form-row " style="display: none;">
<div class="form-content">
<div class="form-input-label-block">
<label for="source_code_direct_entry_input">Source Code Direct Entry</label>
</div>
<input type="text" name="source_code_direct_entry_input" id="source_code_direct_entry_input" value="" maxlength="255">
<input type="hidden" name="source_code_direct_entrysubmit" id="source_code_direct_entrysubmit" value="true">
</div>
</div>
<div class="custom-field-container form-row " style="display: none;">
<div class="form-content">
<div class="form-input-label-block">
<label for="gift_affiliation_dropdown">Gift Affiliation</label>
</div>
<select name="gift_affiliation_dropdown" id="gift_affiliation_dropdown" size="1">
<option selected="selected" value="null">null</option>
<option value="423">423</option>
<option value="424">424</option>
<option value="53">53</option>
<option value="412">412</option>
<option value="21">21</option>
<option value="12">12</option>
<option value="169">169</option>
<option value="37">37</option>
<option value="75">75</option>
<option value="181">181</option>
<option value="117">117</option>
<option value="140">140</option>
<option value="139">139</option>
<option value="24">24</option>
<option value="28">28</option>
<option value="156">156</option>
<option value="6">6</option>
<option value="129">129</option>
<option value="38">38</option>
<option value="46">46</option>
<option value="138">138</option>
<option value="172">172</option>
<option value="135">135</option>
<option value="54">54</option>
<option value="67">67</option>
<option value="232">232</option>
<option value="78">78</option>
<option value="83">83</option>
<option value="90">90</option>
<option value="104">104</option>
<option value="113">113</option>
<option value="157">157</option>
<option value="185">185</option>
<option value="194">194</option>
<option value="100">100</option>
<option value="174">174</option>
<option value="118">118</option>
<option value="59">59</option>
<option value="120">120</option>
<option value="81">81</option>
<option value="82">82</option>
<option value="87">87</option>
<option value="143">143</option>
<option value="97">97</option>
<option value="208">208</option>
<option value="99">99</option>
<option value="205">205</option>
<option value="105">105</option>
<option value="184">184</option>
<option value="999">999</option>
<option value="109">109</option>
<option value="115">115</option>
<option value="121">121</option>
<option value="177">177</option>
<option value="116">116</option>
<option value="20">20</option>
<option value="144">144</option>
<option value="147">147</option>
<option value="17">17</option>
<option value="148">148</option>
<option value="159">159</option>
<option value="123">123</option>
<option value="201">201</option>
<option value="19">19</option>
<option value="161">161</option>
<option value="214">214</option>
<option value="162">162</option>
<option value="33">33</option>
<option value="182">182</option>
<option value="195">195</option>
<option value="178">178</option>
<option value="179">179</option>
<option value="173">173</option>
<option value="191">191</option>
<option value="190">190</option>
<option value="130">130</option>
<option value="128">128</option>
<option value="417">417</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('gift_affiliation_dropdown', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('gift_affiliation_dropdown_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="gift_affiliationsubmit" id="gift_affiliationsubmit" value="true">
</div>
</div>
<div class="custom-field-container form-row " style="display: none;">
<div class="form-content">
<div class="form-input-label-block">
<label for="batch_id_input">Batch ID</label>
</div>
<input type="text" name="batch_id_input" id="batch_id_input" value="" maxlength="255">
<input type="hidden" name="batch_idsubmit" id="batch_idsubmit" value="true">
</div>
</div>
<div class="button-container clearfix">
<div class="button-sub-container">
<button class="step-button action-button finish-step" type="submit" id="pstep_finish" name="pstep_finish" value="Donate Now">Donate Now</button>
</div>
</div>
<input type="hidden" name="idb" id="idb" value="131988973">
<input type="hidden" name="df_id" id="df_id" value="60528">
<input type="hidden" name="mfc_pref" id="mfc_pref" value="T">
<div class="form-row">
<div class="html-caption-container">
<!--<p><a href="https://act.alz.org/site/SPageNavigator/challengedisclaimer/" target="_blank" style="font-size: 15px; color: #336699;">View Match disclaimer</a></p>-->
<div style="text-align: center; margin-top:20px;">
<a href="https://www.charitywatch.org/charities/alzheimers-association-national-office" target="_blank">
<img src="https://act.alz.org/images/content/pagebuilder/CW_TopRated_RGB_WEB_120px.jpg">
</a>
<a href="https://www.charitynavigator.org/ein/133039601" target="_blank">
<img src="https://act.alz.org/images/content/pagebuilder/Charity_Navigator_4_Star_Logo.jpg" width="180" style="padding-left:20px; margin:0 auto; width:180px;">
</a>
</div>
</div>
</div>
<div class="custom-field-container form-row " style="display: none;">
<div class="form-content">
<div class="form-input-label-block">
<label for="sms_opt_out_hidden_dropdown">SMS opt out hidden</label>
</div>
<select name="sms_opt_out_hidden_dropdown" id="sms_opt_out_hidden_dropdown" size="1" data-select2-id="sms_opt_out_hidden_dropdown" tabindex="0" class="" aria-hidden="false">
<option value="true" data-select2-id="16">True</option>
<option value="false" data-select2-id="42">False</option>
</select>
<script type="text/javascript">
<!--
var comp = new ObservableComponent('sms_opt_out_hidden_dropdown', '');
comp.hide = function(_hidden) {
var _display = _hidden ? 'none' : '';
set_display('sms_opt_out_hidden_dropdown_Row', _display);
this.disable_submit_flag(_hidden);
}
//
-->
</script>
<noscript><br>Required</noscript>
<input type="hidden" name="sms_opt_out_hiddensubmit" id="sms_opt_out_hiddensubmit" value="true">
</div>
</div>
<div id="captcha_row" class="form-row form-captcha">
<div class="form-content">
<input type="hidden" name="captcha_text" id="captcha_text" value="">
<input type="hidden" name="captcha_text_proxy_submit" id="captcha_text_proxy_submit" value="">
<script src="https://www.google.com/recaptcha/api.js?render=6LcVyLgZAAAAAIaCdeocZ0n27ZV5AVFs-ptKOles"></script>
<script type="text/javascript">
Y.use('jquery-noconflict', function() {
jQuery(document).ready(function() {
jQuery('#captcha_text').parents('form').find('input[type="submit"], button[type="submit"]').click(function(e) {
e.preventDefault();
e.stopPropagation();
jQuery('#captcha_text_proxy_submit').val(this.value);
jQuery('#captcha_text_proxy_submit').prop('name', this.name);
grecaptcha.ready(function() {
grecaptcha.execute('6LcVyLgZAAAAAIaCdeocZ0n27ZV5AVFs-ptKOles', {
action: 'submit'
}).then(function(token) {
jQuery('#captcha_text').val(token);
if (typeof checkDoubleClick === "function") {
if (checkDoubleClick()) {
jQuery('#captcha_text').parents('form')[0].submit();
}
} else {
jQuery('#captcha_text').parents('form')[0].submit();
}
});
});
});
});
});
</script>
<style type="text/css">
.grecaptcha-badge {
visibility: visible !important;
}
</style>
</div>
<input type="hidden" name="captchasubmit" id="captchasubmit" value="true">
</div>
</div>
<input type="hidden" name="60528.donation" id="60528.donation" value="form1">
</div>
<script type="text/javascript">
var submitted = false;
function checkDoubleClick() {
var elCheck = '';
if (elCheck == 'el') {
alert('Form submission is not enabled when previewing an individual data element.');
return false;
} else if (submitted) {
alert('You have already submitted this payment. Please wait....');
return false;
} else {
submitted = true;
return true;
}
}
</script><noscript> </noscript>
</form>Text Content
* Other Ways to Donate * Donate to a Walker * Donate to The Longest Day® RING IN THE NEW YEAR WITH A GIFT THAT CAN GO 4X AS FAR TO HELP FIGHT ALZHEIMER'S. Set a New Year's resolution to make the most of this ONE-DAY chance to have your year-end gift go 4X as far to help provide essential care and support and advance Alzheimer's research. This extraordinary opportunity is brought to us by The Independent Stave Company and the Boswell Family, who have generously pledged to QUADRUPLE-MATCH any gift we receive by MIDNIGHT TONIGHT — up to a total of $100,000 — in support of Alzheimer's research efforts and local chapter programs and services. Please give now. View Match disclaimer. src field source affiliate code field GIFT AMOUNT Field Is Required A monthly gift shows your commitment to care, support, and research. $50 $100 $250 Your Best Gift Enter amount Make this a monthly gift Thank you for your generous gift. IS THIS A TRIBUTE GIFT? Yes, this is an honor or memorial gift In Memory Of: honors an individual who has passed away In Honor Of: marks a special occasion for a friend or family member Honor Gift Type: In Memory of In Honor of Required Please specify name of individual you would like to honor or memorialize. Honoree Name: Yes, please send a notification to someone about this gift. NOTIFICATION INFORMATION If you would like us to notify someone of this gift, please provide full name and address for the individual that you want to be notified. Full Name: Street 1: Street 2: City: State/Province: AK - Alaska AL - Alabama AR - Arkansas AZ - Arizona CA - California CO - Colorado CT - Connecticut DC - District of Columbia DE - Delaware FL - Florida GA - Georgia HI - Hawaii IA - Iowa ID - Idaho IL - Illinois IN - Indiana KS - Kansas KY - Kentucky LA - Louisiana MA - Massachusetts MD - Maryland ME - Maine MI - Michigan MN - Minnesota MO - Missouri MS - Mississippi MT - Montana NC - North Carolina ND - North Dakota NE - Nebraska NH - New Hampshire NJ - New Jersey NM - New Mexico NV - Nevada NY - New York OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming AS - American Samoa FM - Federated States of Micronesia GU - Guam MH - Marshall Islands MP - Northern Mariana Islands PR - Puerto Rico PW - Palau VI - Virgin Islands AA - Armed Forces Americas AE - Armed Forces AP - Armed Forces Pacific AB - Alberta BC - British Columbia MB - Manitoba NB - New Brunswick NL - Newfoundland and Labrador NS - Nova Scotia NT - Northwest Territories NU - Nunavut ON - Ontario PE - Prince Edward Island QC - Quebec SK - Saskatchewan YT - Yukon None Required ZIP/Postal Code: Notification Recipient Country: United States Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bonaire, Sint Eustatios and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia Cuba Curacao Cyprus Czech Republic Democratic People's Republic of Korea The Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Federated States of Micronesia Fiji Finland The Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iraq Ireland Islamic Republic of Iran Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Plurinational State of Bolivia Poland Portugal Puerto Rico Qatar Republic of Korea Republic of Moldova Reunion Romania Russian Federation Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles S. Georgia & S. Sandwich Isls. Sierra Leone Singapore Sint Maarten (Dutch) Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United Republic of Tanzania Uruguay USA Minor Outlying Islands Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands (British) Virgin Islands (USA) Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe United States Required Enter message that you would like the individual to receive (e.g. "Congratulations on your 50th anniversary!"). Message Body: Character count: 250 Message Closing/Signature: Character count: 50 YOUR INFORMATION First Name: Last Name: Email Address: Street 1: Street 2: ZIP/Postal Code: City: State AK - Alaska AL - Alabama AR - Arkansas AZ - Arizona CA - California CO - Colorado CT - Connecticut DC - District of Columbia DE - Delaware FL - Florida GA - Georgia HI - Hawaii IA - Iowa ID - Idaho IL - Illinois IN - Indiana KS - Kansas KY - Kentucky LA - Louisiana MA - Massachusetts MD - Maryland ME - Maine MI - Michigan MN - Minnesota MO - Missouri MS - Mississippi MT - Montana NC - North Carolina ND - North Dakota NE - Nebraska NH - New Hampshire NJ - New Jersey NM - New Mexico NV - Nevada NY - New York OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming AS - American Samoa FM - Federated States of Micronesia GU - Guam MH - Marshall Islands MP - Northern Mariana Islands PR - Puerto Rico PW - Palau VI - Virgin Islands AA - Armed Forces Americas AE - Armed Forces AP - Armed Forces Pacific AB - Alberta BC - British Columbia MB - Manitoba NB - New Brunswick NL - Newfoundland and Labrador NS - Nova Scotia NT - Northwest Territories NU - Nunavut ON - Ontario PE - Prince Edward Island QC - Quebec SK - Saskatchewan YT - Yukon None Required Country: United States Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bonaire, Sint Eustatios and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia Cuba Curacao Cyprus Czech Republic Democratic People's Republic of Korea The Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Federated States of Micronesia Fiji Finland The Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iraq Ireland Islamic Republic of Iran Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Plurinational State of Bolivia Poland Portugal Puerto Rico Qatar Republic of Korea Republic of Moldova Reunion Romania Russian Federation Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles S. Georgia & S. Sandwich Isls. Sierra Leone Singapore Sint Maarten (Dutch) Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United Republic of Tanzania Uruguay USA Minor Outlying Islands Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands (British) Virgin Islands (USA) Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe United States Required Phone Number: (Optional) By entering your mobile number, you will be opted in to receive text message updates from the Alzheimer's Association and stay involved in the fight to end Alzheimer's. You will be able to opt-out of these messages at any time. 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CHECK INFORMATION Source Code Direct Entry Gift Affiliation null 423 424 53 412 21 12 169 37 75 181 117 140 139 24 28 156 6 129 38 46 138 172 135 54 67 232 78 83 90 104 113 157 185 194 100 174 118 59 120 81 82 87 143 97 208 99 205 105 184 999 109 115 121 177 116 20 144 147 17 148 159 123 201 19 161 214 162 33 182 195 178 179 173 191 190 130 128 417 Required Batch ID Donate Now SMS opt out hidden True False Required Home Office 225 N. Michigan Ave., Fl. 17, Chicago, IL 60601 © 2024 Alzheimer's Association®. All rights reserved. Alzheimer's Association is a not-for-profit 501(c)(3) organization. Federal tax ID 13-3039601 | Security & Privacy Policy | alz.org Donations are tax-deductible. The Verification Code is imprinted on credit cards to help merchants verify transactions when the actual card is not present, such as Internet purchases or donations. The merchant uses this number as part of the authorization process with the card issuer. Please use the images below to locate the verification code for your card type. Visa, Master Card, and Discover: The verification code for Visa, Master Card, and Discover is a 3-digit number printed on the back of your card. It appears after the account number or last 4-digits of your account number, in the signature panel. American Express: The American Express verification code is a 4-digit number printed on the front of your card. It appears above and to the right of the embossed account number. To make a payment directly from your bank account, you will need to provide the routing number for your bank, as well as your account number. Both of these numbers can be found at the bottom of a check issued for your bank account. At the bottom of your check you will find three numbers - the routing number which is always 9 digits long for U.S. banks, the account number which can be up to 17 digits long, and the check number which will match the number found in the upper right corner of the check. These sets of numbers can appear in a variety of orders on your check. However, you will always find the routing number surrounded by this symbol , and the account number will always be to the left of this symbol . Please use the image below for an example of how your routing and account numbers may appear on your check. Sample Check: The routing number comes first and is surrounded by the symbol, the account number comes next and is followed by the symbol.