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23.185.0.2  Public Scan

Form analysis
1 forms found in the DOM

POST

<form class="clearfix" method="post" novalidate="" action="" accept-charset="utf-8" autocomplete="on">
  <div data-name="undefined" data-subview="submit_view" data-subview-index="0"></div>
  <fieldset class="at-fieldset ContributionInformation" id="NVContributionForm43240-ContributionInformation" style="border: none;">
    <legend class="at-legend">Contribution Information</legend>
    <div class="at-fields">
      <div class="label-donation-amount" style="margin-left: .625rem; font-size: .875rem">Select a donation amount:</div>
      <div class="at-row at-row-full ">
        <input id="ProcessingCurrency_Value" type="hidden" name="ProcessingCurrency.Value" value="USD">
      </div>
      <div class="at-row at-row-full ">
        <div class="form-item form-type-radios form-item-selectamount" id="NVContributionForm43240-ContributionInformation-SelectAmount">
          <div class="at-row SelectAmount OtherAmount NonRecurringButtons">
            <div class="at-radio">
              <div class="at-radios clearfix">
                <label class="label-amount" title="$50">
                  <input name="SelectAmount" type="radio" value="50.00"> $50 <a></a> </label><label class="label-amount" title="$75">
                  <input name="SelectAmount" type="radio" value="75.00"> $75 <a></a> </label><label class="label-amount" title="$100">
                  <input name="SelectAmount" type="radio" value="100.00"> $100 <a></a> </label><label class="label-amount" title="$250">
                  <input name="SelectAmount" type="radio" value="250.00"> $250 <a></a> </label><label class="label-amount" title="$500">
                  <input name="SelectAmount" type="radio" value="500.00"> $500 <a></a> </label><label class="label-amount" title="$1,000">
                  <input name="SelectAmount" type="radio" value="1000.00"> $1,000 <a></a> </label><label class="label-other-amount" for="OtherAmount" style="clear: both;">Or enter other amount:</label><label class="label-amount label-otheramount"
                  title="Other">
                  <input name="SelectAmount" type="radio" class="radio-other" value="other"> Other <input type="number" tabindex="-1" autocomplete="transaction-amount" class="edit-otheramount" name="OtherAmount" title="Other Amount"
                    placeholder="0.00" id="OtherAmount">
                  <span class="label-otheramount-prefix">$</span>
                </label>
              </div>
            </div>
          </div>
        </div>
      </div><label class="at-check  CoverCostsAmount" id="NVContributionForm43240-ContributionInformation-CoverCostsAmount"><input type="checkbox" name="CoverCostsAmount"> <span class="at-checkbox-title-container"><span class="at-checkbox-title"
            id="NVContributionForm43240-ContributionInformation-CoverCostsAmount-label">I’d like to increase my donation to help cover transaction fees.</span></span>
      </label>
    </div>
  </fieldset>
  <fieldset class="at-fieldset TributeGift" id="NVContributionForm43240-TributeGift">
    <div class="at-fields">
      <div class="at-row at-row-full EnableTributeGift">
        <label class="at-check  EnableTributeGift" id="NVContributionForm43240-TributeGift-EnableTributeGift"><input type="checkbox" name="EnableTributeGift"> <span class="at-checkbox-title-container"><span class="at-checkbox-title"
              id="NVContributionForm43240-TributeGift-EnableTributeGift-label">I'd like to make this contribution in honor or in memory of someone</span></span>
        </label>
      </div>
      <div class="at-row">
        <div class="at-tribute-gift" style="display:none">
          <div class="form-unit form-unit-radio form-item-inhonororinmemoryof" id="NVContributionForm43240-TributeGift-InHonorOrInMemoryOf"><label id="NVContributionForm43240-TributeGift-InHonorOrInMemoryOf"> Is this an Honorary or Memorial
              Gift?</label>
            <div class="radios" role="radiogroup" aria-labelledby="NVContributionForm43240-TributeGift-InHonorOrInMemoryOf">
              <label title="In honor of" class="at-radio-label-2" role="radio">
                <input type="radio" name="InHonorOrInMemoryOf" checked="" value="2"> In honor of </label><label title="In memory of" class="at-radio-label-1" role="radio">
                <input type="radio" name="InHonorOrInMemoryOf" value="1"> In memory of </label>
            </div>
          </div><label class="at-text   HonoreeName" id="NVContributionForm43240-TributeGift-HonoreeName">Honoree Name <small>(Optional)</small><input type="text" autocomplete="on" false="" title="Honoree Name" name="HonoreeName" value=""
              maxlength="100">
          </label>
        </div>
      </div>
    </div>
  </fieldset>
  <fieldset class="at-fieldset RecipientInformation" id="NVContributionForm43240-RecipientInformation" style="display: none;">
    <div class="at-fields">
      <div class="at-row">
        <label class="at-check  IncludeRecipient" id="NVContributionForm43240-RecipientInformation-IncludeRecipient"><input type="checkbox" name="IncludeRecipient"> <span class="at-checkbox-title-container"><span class="at-checkbox-title"
              id="NVContributionForm43240-RecipientInformation-IncludeRecipient-label">I'd like to notify someone of this contribution</span></span>
        </label>
      </div>
      <div class="at-recipient-info" style="display: none;">
        <div class="at-title">Who would you like to notify?</div>
        <div class="at-row at-row-solo at-row-full RecipientInfoHeaderHtml">
          <div class="at-markup RecipientInfoHeaderHtml" id="NVContributionForm43240-RecipientInformation-RecipientInfoHeaderHtml">A message will be sent to the recipient to inform them of your contribution. Customize the notification by adding a
            personal message.</div>
        </div>
        <div class="at-row RecipientFirstName RecipientLastName"><label class="at-text   RecipientFirstName" id="NVContributionForm43240-RecipientInformation-RecipientFirstName">First Name <small>(Optional)</small><input type="text" autocomplete="on"
              false="" title="First Name" name="RecipientFirstName" value="" maxlength="50">
          </label><label class="at-text   RecipientLastName" id="NVContributionForm43240-RecipientInformation-RecipientLastName">Last Name <small>(Optional)</small><input type="text" autocomplete="on" false="" title="Last Name"
              name="RecipientLastName" value="" maxlength="50">
          </label></div>
        <div class="at-row at-row-solo RecipientStreetAddress"><label class="at-text   RecipientStreetAddress" id="NVContributionForm43240-RecipientInformation-RecipientStreetAddress">Street Address <small>(Optional)</small><input type="text"
              autocomplete="on" false="" title="Street Address" name="RecipientStreetAddress" value="" maxlength="100">
          </label></div>
        <div class="at-row RecipientCountry RecipientPostalCode RecipientCity RecipientStateProvince"><label class="at-select RecipientCountry" id="NVContributionForm43240-RecipientInformation-RecipientCountry">Country
            <small>(Optional)</small><select autocomplete="on" title="Country" name="RecipientCountry" class="select2-hidden-accessible" id="NVContributionForm43240-RecipientInformation-RecipientCountry-select" tabindex="-1" aria-hidden="true">
              <option value="">- Select -</option>
              <option value="AF">Afghanistan</option>
              <option value="AX">Åland Islands</option>
              <option value="AL">Albania</option>
              <option value="DZ">Algeria</option>
              <option value="AD">Andorra</option>
              <option value="AO">Angola</option>
              <option value="AI">Anguilla</option>
              <option value="AQ">Antarctica</option>
              <option value="AG">Antigua and Barbuda</option>
              <option value="AR">Argentina</option>
              <option value="AM">Armenia</option>
              <option value="AW">Aruba</option>
              <option value="AU">Australia</option>
              <option value="AT">Austria</option>
              <option value="AZ">Azerbaijan</option>
              <option value="BS">Bahamas</option>
              <option value="BH">Bahrain</option>
              <option value="BD">Bangladesh</option>
              <option value="BB">Barbados</option>
              <option value="BY">Belarus</option>
              <option value="BE">Belgium</option>
              <option value="BZ">Belize</option>
              <option value="BJ">Benin</option>
              <option value="BM">Bermuda</option>
              <option value="BT">Bhutan</option>
              <option value="BO">Bolivia (Plurinational State of)</option>
              <option value="BQ">Bonaire, Sint Eustatius and Saba</option>
              <option value="BA">Bosnia and Herzegovina</option>
              <option value="BW">Botswana</option>
              <option value="BV">Bouvet Island</option>
              <option value="BR">Brazil</option>
              <option value="IO">British Indian Ocean Territory</option>
              <option value="VG">British Virgin Islands</option>
              <option value="BN">Brunei Darussalam</option>
              <option value="BG">Bulgaria</option>
              <option value="BF">Burkina Faso</option>
              <option value="BI">Burundi</option>
              <option value="CV">Cabo Verde</option>
              <option value="KH">Cambodia</option>
              <option value="CM">Cameroon</option>
              <option value="CA">Canada</option>
              <option value="KY">Cayman Islands</option>
              <option value="CF">Central African Republic</option>
              <option value="TD">Chad</option>
              <option value="CL">Chile</option>
              <option value="CN">China</option>
              <option value="CX">Christmas Island</option>
              <option value="CC">Cocos (Keeling) Islands</option>
              <option value="CO">Colombia</option>
              <option value="KM">Comoros</option>
              <option value="CG">Congo</option>
              <option value="CD">Congo (Democratic Republic of the)</option>
              <option value="CK">Cook Islands</option>
              <option value="CR">Costa Rica</option>
              <option value="CI">Côte d'Ivoire</option>
              <option value="HR">Croatia</option>
              <option value="CU">Cuba</option>
              <option value="CW">Curaçao</option>
              <option value="CY">Cyprus</option>
              <option value="CZ">Czechia</option>
              <option value="DK">Denmark</option>
              <option value="DJ">Djibouti</option>
              <option value="DM">Dominica</option>
              <option value="DO">Dominican Republic</option>
              <option value="EC">Ecuador</option>
              <option value="EG">Egypt</option>
              <option value="SV">El Salvador</option>
              <option value="GQ">Equatorial Guinea</option>
              <option value="ER">Eritrea</option>
              <option value="EE">Estonia</option>
              <option value="SZ">Eswatini</option>
              <option value="ET">Ethiopia</option>
              <option value="FK">Falkland Islands (Malvinas)</option>
              <option value="FO">Faroe Islands</option>
              <option value="FJ">Fiji</option>
              <option value="FI">Finland</option>
              <option value="FR">France</option>
              <option value="GF">French Guiana</option>
              <option value="PF">French Polynesia</option>
              <option value="TF">French Southern Territories</option>
              <option value="GA">Gabon</option>
              <option value="GM">Gambia</option>
              <option value="GE">Georgia</option>
              <option value="DE">Germany</option>
              <option value="GH">Ghana</option>
              <option value="GI">Gibraltar</option>
              <option value="GR">Greece</option>
              <option value="GL">Greenland</option>
              <option value="GD">Grenada</option>
              <option value="GP">Guadeloupe</option>
              <option value="GT">Guatemala</option>
              <option value="GG">Guernsey</option>
              <option value="GN">Guinea</option>
              <option value="GW">Guinea-Bissau</option>
              <option value="GY">Guyana</option>
              <option value="HT">Haiti</option>
              <option value="HM">Heard Island and McDonald Islands</option>
              <option value="VA">Holy See</option>
              <option value="HN">Honduras</option>
              <option value="HK">Hong Kong</option>
              <option value="HU">Hungary</option>
              <option value="IS">Iceland</option>
              <option value="IN">India</option>
              <option value="ID">Indonesia</option>
              <option value="IR">Iran (Islamic Republic of)</option>
              <option value="IQ">Iraq</option>
              <option value="IE">Ireland</option>
              <option value="IM">Isle of Man</option>
              <option value="IL">Israel</option>
              <option value="IT">Italy</option>
              <option value="JM">Jamaica</option>
              <option value="JP">Japan</option>
              <option value="JE">Jersey</option>
              <option value="JO">Jordan</option>
              <option value="KZ">Kazakhstan</option>
              <option value="KE">Kenya</option>
              <option value="KI">Kiribati</option>
              <option value="KP">Korea (Democratic People's Republic of)</option>
              <option value="KR">Korea (Republic of)</option>
              <option value="KW">Kuwait</option>
              <option value="KG">Kyrgyzstan</option>
              <option value="LA">Lao People's Democratic Republic</option>
              <option value="LV">Latvia</option>
              <option value="LB">Lebanon</option>
              <option value="LS">Lesotho</option>
              <option value="LR">Liberia</option>
              <option value="LY">Libya</option>
              <option value="LI">Liechtenstein</option>
              <option value="LT">Lithuania</option>
              <option value="LU">Luxembourg</option>
              <option value="MO">Macao</option>
              <option value="MG">Madagascar</option>
              <option value="MW">Malawi</option>
              <option value="MY">Malaysia</option>
              <option value="MV">Maldives</option>
              <option value="ML">Mali</option>
              <option value="MT">Malta</option>
              <option value="MQ">Martinique</option>
              <option value="MR">Mauritania</option>
              <option value="MU">Mauritius</option>
              <option value="YT">Mayotte</option>
              <option value="MX">Mexico</option>
              <option value="FM">Micronesia (Federated States of)</option>
              <option value="MD">Moldova (Republic of)</option>
              <option value="MC">Monaco</option>
              <option value="MN">Mongolia</option>
              <option value="ME">Montenegro</option>
              <option value="MS">Montserrat</option>
              <option value="MA">Morocco</option>
              <option value="MZ">Mozambique</option>
              <option value="MM">Myanmar</option>
              <option value="NA">Namibia</option>
              <option value="NR">Nauru</option>
              <option value="NP">Nepal</option>
              <option value="NL">Netherlands</option>
              <option value="NC">New Caledonia</option>
              <option value="NZ">New Zealand</option>
              <option value="NI">Nicaragua</option>
              <option value="NE">Niger</option>
              <option value="NG">Nigeria</option>
              <option value="NU">Niue</option>
              <option value="NF">Norfolk Island</option>
              <option value="MK">North Macedonia</option>
              <option value="NO">Norway</option>
              <option value="OM">Oman</option>
              <option value="PK">Pakistan</option>
              <option value="PW">Palau</option>
              <option value="PS">Palestine (State of)</option>
              <option value="PA">Panama</option>
              <option value="PG">Papua New Guinea</option>
              <option value="PY">Paraguay</option>
              <option value="PE">Peru</option>
              <option value="PH">Philippines</option>
              <option value="PN">Pitcairn</option>
              <option value="PL">Poland</option>
              <option value="PT">Portugal</option>
              <option value="QA">Qatar</option>
              <option value="RE">Réunion</option>
              <option value="RO">Romania</option>
              <option value="RU">Russian Federation</option>
              <option value="RW">Rwanda</option>
              <option value="BL">Saint Barthélemy</option>
              <option value="SH">Saint Helena, Ascension and Tristan da Cunha</option>
              <option value="KN">Saint Kitts and Nevis</option>
              <option value="LC">Saint Lucia</option>
              <option value="MF">Saint Martin (French part)</option>
              <option value="PM">Saint Pierre and Miquelon</option>
              <option value="VC">Saint Vincent and the Grenadines</option>
              <option value="WS">Samoa</option>
              <option value="SM">San Marino</option>
              <option value="ST">Sao Tome and Principe</option>
              <option value="SA">Saudi Arabia</option>
              <option value="SN">Senegal</option>
              <option value="RS">Serbia</option>
              <option value="SC">Seychelles</option>
              <option value="SL">Sierra Leone</option>
              <option value="SG">Singapore</option>
              <option value="SX">Sint Maarten (Dutch part)</option>
              <option value="SK">Slovakia</option>
              <option value="SI">Slovenia</option>
              <option value="SB">Solomon Islands</option>
              <option value="SO">Somalia</option>
              <option value="ZA">South Africa</option>
              <option value="GS">South Georgia and the South Sandwich Islands</option>
              <option value="SS">South Sudan</option>
              <option value="ES">Spain</option>
              <option value="LK">Sri Lanka</option>
              <option value="SD">Sudan</option>
              <option value="SR">Suriname</option>
              <option value="SJ">Svalbard and Jan Mayen</option>
              <option value="SE">Sweden</option>
              <option value="CH">Switzerland</option>
              <option value="SY">Syrian Arab Republic</option>
              <option value="TW">Taiwan</option>
              <option value="TJ">Tajikistan</option>
              <option value="TZ">Tanzania (United Republic of)</option>
              <option value="TH">Thailand</option>
              <option value="TL">Timor-Leste</option>
              <option value="TG">Togo</option>
              <option value="TK">Tokelau</option>
              <option value="TO">Tonga</option>
              <option value="TT">Trinidad and Tobago</option>
              <option value="TN">Tunisia</option>
              <option value="TR">Turkey</option>
              <option value="TM">Turkmenistan</option>
              <option value="TC">Turks and Caicos Islands</option>
              <option value="TV">Tuvalu</option>
              <option value="UG">Uganda</option>
              <option value="UA">Ukraine</option>
              <option value="AE">United Arab Emirates</option>
              <option value="GB">United Kingdom</option>
              <option value="US">United States</option>
              <option value="UM">United States Minor Outlying Islands</option>
              <option value="UY">Uruguay</option>
              <option value="UZ">Uzbekistan</option>
              <option value="VU">Vanuatu</option>
              <option value="VE">Venezuela (Bolivarian Republic of)</option>
              <option value="VN">Viet Nam</option>
              <option value="WF">Wallis and Futuna</option>
              <option value="EH">Western Sahara</option>
              <option value="YE">Yemen</option>
              <option value="ZM">Zambia</option>
              <option value="ZW">Zimbabwe</option>
            </select><span class="select2 select2-container select2-container--default" dir="ltr" style="width: 100px;"><span class="selection"><span class="select2-selection select2-selection--single" role="combobox" aria-haspopup="true"
                  aria-expanded="false" title="Country" tabindex="0" aria-labelledby="select2-NVContributionForm43240-RecipientInformation-RecipientCountry-select-container"><span class="select2-selection__rendered"
                    id="select2-NVContributionForm43240-RecipientInformation-RecipientCountry-select-container" 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>
          </label><label class="at-text   RecipientPostalCode" id="NVContributionForm43240-RecipientInformation-RecipientPostalCode">Postal Code <small>(Optional)</small><input type="tel" autocomplete="on" pattern="^\d{5}([\-]\d{4})?$" false=""
              title="Postal Code" name="RecipientPostalCode" value="" maxlength="10">
          </label><label class="at-text   RecipientCity" id="NVContributionForm43240-RecipientInformation-RecipientCity">City <small>(Optional)</small><input type="text" autocomplete="on" false="" title="City" name="RecipientCity" value=""
              maxlength="25">
          </label><label class="at-select RecipientStateProvince" id="NVContributionForm43240-RecipientInformation-RecipientStateProvince">State/Province <small>(Optional)</small><select autocomplete="on" title="State/Province"
              name="RecipientStateProvince" class="" id="NVContributionForm43240-RecipientInformation-RecipientStateProvince-select">
              <option value="">- State -</option>
              <option value="AK">AK</option>
              <option value="AL">AL</option>
              <option value="AR">AR</option>
              <option value="AZ">AZ</option>
              <option value="CA">CA</option>
              <option value="CO">CO</option>
              <option value="CT">CT</option>
              <option value="DC">DC</option>
              <option value="DE">DE</option>
              <option value="FL">FL</option>
              <option value="GA">GA</option>
              <option value="HI">HI</option>
              <option value="IA">IA</option>
              <option value="ID">ID</option>
              <option value="IL">IL</option>
              <option value="IN">IN</option>
              <option value="KS">KS</option>
              <option value="KY">KY</option>
              <option value="LA">LA</option>
              <option value="MA">MA</option>
              <option value="MD">MD</option>
              <option value="ME">ME</option>
              <option value="MI">MI</option>
              <option value="MN">MN</option>
              <option value="MO">MO</option>
              <option value="MS">MS</option>
              <option value="MT">MT</option>
              <option value="NC">NC</option>
              <option value="ND">ND</option>
              <option value="NE">NE</option>
              <option value="NH">NH</option>
              <option value="NJ">NJ</option>
              <option value="NM">NM</option>
              <option value="NV">NV</option>
              <option value="NY">NY</option>
              <option value="OH">OH</option>
              <option value="OK">OK</option>
              <option value="OR">OR</option>
              <option value="PA">PA</option>
              <option value="RI">RI</option>
              <option value="SC">SC</option>
              <option value="SD">SD</option>
              <option value="TN">TN</option>
              <option value="TX">TX</option>
              <option value="UT">UT</option>
              <option value="VA">VA</option>
              <option value="VT">VT</option>
              <option value="WA">WA</option>
              <option value="WI">WI</option>
              <option value="WV">WV</option>
              <option value="WY">WY</option>
              <option value="AS">AS</option>
              <option value="FM">FM</option>
              <option value="GU">GU</option>
              <option value="MH">MH</option>
              <option value="MP">MP</option>
              <option value="PR">PR</option>
              <option value="PW">PW</option>
              <option value="VI">VI</option>
              <option value="AA">AA</option>
              <option value="AE">AE</option>
              <option value="AP">AP</option>
            </select>
          </label></div>
        <div class="at-row at-row-solo RecipientEmailAddress"><label class="at-text   RecipientEmailAddress" id="NVContributionForm43240-RecipientInformation-RecipientEmailAddress">Email <small>(Optional)</small><input type="email" autocomplete="on"
              pattern="^([\w!#$%&amp;'*+\-\/=?\^`\{\|\}~]+\.)*[\w!#$%&amp;'*+\-\/=?\^`\{\|\}~]+@((((([a-zA-Z0-9]{1}[a-zA-Z0-9\-]{0,62}[a-zA-Z0-9]{1})|[a-zA-Z])\.)+[a-zA-Z]{2,62})|(\d{1,3}\.){3}\d{1,3}(:\d{1,5})?)$" false="" title="Email"
              name="RecipientEmailAddress" value="" maxlength="100">
          </label></div>
        <div class="at-row at-row-solo NotificationMessage"><label class="at-area   NotificationMessage" id="NVContributionForm43240-RecipientInformation-NotificationMessage"></label></div>
      </div>
      <div class="at-row">
        <div class="at-recipient-msg" style="display: none;"><label class="at-area   NotificationMessage" id="NVContributionForm43240-RecipientInformation-NotificationMessage">Message <small>(Optional)</small><textarea false="" title="Message"
              name="NotificationMessage" maxlength="4000"></textarea>
          </label></div>
      </div>
    </div>
  </fieldset>
  <fieldset class="at-fieldset PaymentMethodSection" id="NVContributionForm43240-PaymentMethodSection">
    <div class="at-fields">
      <div class="at-row at-row-full PaymentMethod">
        <div class="at-payment-method-buttons" id="NVContributionForm43240-PaymentMethodSection-PaymentMethod">
          <div class="at-radio-set at-radio-set-buttons at-align-flex-right">
            <div class="at-btn-radio-wrapper at-credit-card-button-wrapper">
              <input id="creditcard_radio_43240" type="radio" name="PaymentMethod" value="creditcard">
              <label for="creditcard_radio_43240" class="at-btn-radio large" tabindex="0"> Pay with Card </label>
            </div>
            <div class="at-btn-radio-wrapper at-paypal-button-wrapper">
              <input id="paypal_radio_43240" type="radio" name="PaymentMethod" value="paypal">
              <label for="paypal_radio_43240" class="at-btn-radio small at-paypal-button" title="Pay with PayPal" aria-label="Pay with PayPal" tabindex="0">
                <span aria-hidden="true">&nbsp;</span>
              </label>
            </div>
          </div>
        </div>
      </div>
    </div>
  </fieldset>
  <fieldset class="at-fieldset AdditionalInformation" id="NVContributionForm43240-AdditionalInformation" style="display: none;">
    <legend class="at-legend" style="display: none;">Additional Information</legend>
    <div class="at-fields">
      <div class="at-row at-row-full CustomFieldHeaderHtml">
        <div class="at-markup CustomFieldHeaderHtml" id="NVContributionForm43240-AdditionalInformation-CustomFieldHeaderHtml">
          <p><!-- BUTTON ***REMEMBER Update the link and width in both places in the code***--></p>
        </div>
      </div>
      <div class="at-row at-row-full TextAreaQuestion_1454422001">
        <label class="at-area   TextAreaQuestion_1454422001" id="NVContributionForm43240-AdditionalInformation-TextAreaQuestion_1454422001">Special Request <small>(Optional)</small><textarea false="" title="Special Request"
            name="TextAreaQuestion_1454422001"></textarea>
        </label>
      </div>
      <div class="at-row at-row-full ActivistCodeQuestion_3076199176764241408">
        <div id="NVContributionForm43240-AdditionalInformation-ActivistCodeQuestion_3076199176764241408"><label style="padding:0px 0px 10px 10px" name="ActivistCodeQuestion_3076199176764241408" class="question-label">
            Preferences&nbsp;<small>(Optional)</small><br>
            <small class="question-required-text" name="ActivistCodeQuestion_3076199176764241408-small" style="display: none"><b>Preferences is required.</b></small>
          </label>
        </div>
      </div>
      <div class="at-row at-row-full ActivistCodeQuestion_3076199176764241408_Interest_4365430">
        <label class="at-check  ActivistCodeQuestion_3076199176764241408_Interest_4365430" id="NVContributionForm43240-AdditionalInformation-ActivistCodeQuestion_3076199176764241408_Interest_4365430"><input type="checkbox"
            name="ActivistCodeQuestion_3076199176764241408_Interest_4365430" aria-describedby="NVContributionForm43240-AdditionalInformation-ActivistCodeQuestion_3076199176764241408"> <span class="at-checkbox-title-container"><span
              class="at-checkbox-title" id="NVContributionForm43240-AdditionalInformation-ActivistCodeQuestion_3076199176764241408_Interest_4365430-label">Prefiero español</span></span>
        </label>
      </div>
      <div class="at-row at-row-full CustomFieldFooterHtml">
        <div class="at-markup CustomFieldFooterHtml" id="NVContributionForm43240-AdditionalInformation-CustomFieldFooterHtml" style="display: none;"></div>
      </div>
    </div>
  </fieldset>
  <fieldset class="at-fieldset ContactInformation" id="NVContributionForm43240-ContactInformation" style="display: none;">
    <legend class="at-legend">PERSONAL INFORMATION</legend>
    <div class="at-fields">
      <div class="at-row Prefix FirstName LastName"><label class="at-text   Prefix" id="NVContributionForm43240-ContactInformation-Prefix">Title <small>(Optional)</small><input type="text" autocomplete="honorific-prefix"
            x-autocompletetype="name-prefix" false="" title="Title" name="Prefix" value="" maxlength="10" list="at-prefixes" style="display: none;">
          <select id="titledd" required="" title="Title" name="Titledropdown" class=" required">
            <option value="" disabled="" selected="">- Title -</option>
            <option value="Brother">Brother</option>
            <option value="Deacon">Deacon</option>
            <option value="Dr">Dr.</option>
            <option value="Dr and Dr">Dr. and Dr.</option>
            <option value="Dr and Mr">Dr. and Mr.</option>
            <option value="Dr and Mrs">Dr. and Mrs.</option>
            <option value="Father">Father</option>
            <option value="Friends">Friends</option>
            <option value="Hon">Honorable</option>
            <option value="Miss">Miss</option>
            <option value="Misses">Misses</option>
            <option value="Msgr">Monsignor</option>
            <option value="Most Rev">Most Reverend</option>
            <option value="Mr">Mr.</option>
            <option value="Mr and Mrs">Mr. and Mrs.</option>
            <option value="Mrs">Mrs.</option>
            <option value="Ms">Ms.</option>
            <option value="Rev">Reverend</option>
            <option value="Rev Mr">Reverend Mother</option>
            <option value="Sr">Sister</option>
          </select></label><label class="at-text   FirstName" id="NVContributionForm43240-ContactInformation-FirstName">First Name *<input type="text" autocomplete="given-name" x-autocompletetype="given-name" required=""
            title="First Name * (required)" name="FirstName" value="" maxlength="20">
        </label><label class="at-text   LastName" id="NVContributionForm43240-ContactInformation-LastName">Last Name *<input type="text" autocomplete="family-name" x-autocompletetype="surname" required="" title="Last Name * (required)"
            name="LastName" value="" maxlength="25">
        </label></div>
      <div class="at-row at-row-solo AddressLine1"><label class="at-text   AddressLine1" id="NVContributionForm43240-ContactInformation-AddressLine1">Street Address *<input type="text" autocomplete="address-line1" x-autocompletetype="address-line1"
            required="" title="Street Address * (required)" name="AddressLine1" value="" maxlength="99">
        </label></div>
      <div class="at-row Country PostalCode City"><label class="at-select Country" id="NVContributionForm43240-ContactInformation-Country">Country *<select required="" autocomplete="country-name" x-autocompletetype="country" title="Country *"
            name="Country" class="required select2-hidden-accessible" id="NVContributionForm43240-ContactInformation-Country-select" tabindex="-1" aria-hidden="true">
            <option value="" disabled="">- Select -</option>
            <option value="AF">Afghanistan</option>
            <option value="AX">Åland Islands</option>
            <option value="AL">Albania</option>
            <option value="DZ">Algeria</option>
            <option value="AD">Andorra</option>
            <option value="AO">Angola</option>
            <option value="AI">Anguilla</option>
            <option value="AQ">Antarctica</option>
            <option value="AG">Antigua and Barbuda</option>
            <option value="AR">Argentina</option>
            <option value="AM">Armenia</option>
            <option value="AW">Aruba</option>
            <option value="AU">Australia</option>
            <option value="AT">Austria</option>
            <option value="AZ">Azerbaijan</option>
            <option value="BS">Bahamas</option>
            <option value="BH">Bahrain</option>
            <option value="BD">Bangladesh</option>
            <option value="BB">Barbados</option>
            <option value="BY">Belarus</option>
            <option value="BE">Belgium</option>
            <option value="BZ">Belize</option>
            <option value="BJ">Benin</option>
            <option value="BM">Bermuda</option>
            <option value="BT">Bhutan</option>
            <option value="BO">Bolivia (Plurinational State of)</option>
            <option value="BQ">Bonaire, Sint Eustatius and Saba</option>
            <option value="BA">Bosnia and Herzegovina</option>
            <option value="BW">Botswana</option>
            <option value="BV">Bouvet Island</option>
            <option value="BR">Brazil</option>
            <option value="IO">British Indian Ocean Territory</option>
            <option value="VG">British Virgin Islands</option>
            <option value="BN">Brunei Darussalam</option>
            <option value="BG">Bulgaria</option>
            <option value="BF">Burkina Faso</option>
            <option value="BI">Burundi</option>
            <option value="CV">Cabo Verde</option>
            <option value="KH">Cambodia</option>
            <option value="CM">Cameroon</option>
            <option value="CA">Canada</option>
            <option value="KY">Cayman Islands</option>
            <option value="CF">Central African Republic</option>
            <option value="TD">Chad</option>
            <option value="CL">Chile</option>
            <option value="CN">China</option>
            <option value="CX">Christmas Island</option>
            <option value="CC">Cocos (Keeling) Islands</option>
            <option value="CO">Colombia</option>
            <option value="KM">Comoros</option>
            <option value="CG">Congo</option>
            <option value="CD">Congo (Democratic Republic of the)</option>
            <option value="CK">Cook Islands</option>
            <option value="CR">Costa Rica</option>
            <option value="CI">Côte d'Ivoire</option>
            <option value="HR">Croatia</option>
            <option value="CU">Cuba</option>
            <option value="CW">Curaçao</option>
            <option value="CY">Cyprus</option>
            <option value="CZ">Czechia</option>
            <option value="DK">Denmark</option>
            <option value="DJ">Djibouti</option>
            <option value="DM">Dominica</option>
            <option value="DO">Dominican Republic</option>
            <option value="EC">Ecuador</option>
            <option value="EG">Egypt</option>
            <option value="SV">El Salvador</option>
            <option value="GQ">Equatorial Guinea</option>
            <option value="ER">Eritrea</option>
            <option value="EE">Estonia</option>
            <option value="SZ">Eswatini</option>
            <option value="ET">Ethiopia</option>
            <option value="FK">Falkland Islands (Malvinas)</option>
            <option value="FO">Faroe Islands</option>
            <option value="FJ">Fiji</option>
            <option value="FI">Finland</option>
            <option value="FR">France</option>
            <option value="GF">French Guiana</option>
            <option value="PF">French Polynesia</option>
            <option value="TF">French Southern Territories</option>
            <option value="GA">Gabon</option>
            <option value="GM">Gambia</option>
            <option value="GE">Georgia</option>
            <option value="DE">Germany</option>
            <option value="GH">Ghana</option>
            <option value="GI">Gibraltar</option>
            <option value="GR">Greece</option>
            <option value="GL">Greenland</option>
            <option value="GD">Grenada</option>
            <option value="GP">Guadeloupe</option>
            <option value="GT">Guatemala</option>
            <option value="GG">Guernsey</option>
            <option value="GN">Guinea</option>
            <option value="GW">Guinea-Bissau</option>
            <option value="GY">Guyana</option>
            <option value="HT">Haiti</option>
            <option value="HM">Heard Island and McDonald Islands</option>
            <option value="VA">Holy See</option>
            <option value="HN">Honduras</option>
            <option value="HK">Hong Kong</option>
            <option value="HU">Hungary</option>
            <option value="IS">Iceland</option>
            <option value="IN">India</option>
            <option value="ID">Indonesia</option>
            <option value="IR">Iran (Islamic Republic of)</option>
            <option value="IQ">Iraq</option>
            <option value="IE">Ireland</option>
            <option value="IM">Isle of Man</option>
            <option value="IL">Israel</option>
            <option value="IT">Italy</option>
            <option value="JM">Jamaica</option>
            <option value="JP">Japan</option>
            <option value="JE">Jersey</option>
            <option value="JO">Jordan</option>
            <option value="KZ">Kazakhstan</option>
            <option value="KE">Kenya</option>
            <option value="KI">Kiribati</option>
            <option value="KP">Korea (Democratic People's Republic of)</option>
            <option value="KR">Korea (Republic of)</option>
            <option value="KW">Kuwait</option>
            <option value="KG">Kyrgyzstan</option>
            <option value="LA">Lao People's Democratic Republic</option>
            <option value="LV">Latvia</option>
            <option value="LB">Lebanon</option>
            <option value="LS">Lesotho</option>
            <option value="LR">Liberia</option>
            <option value="LY">Libya</option>
            <option value="LI">Liechtenstein</option>
            <option value="LT">Lithuania</option>
            <option value="LU">Luxembourg</option>
            <option value="MO">Macao</option>
            <option value="MG">Madagascar</option>
            <option value="MW">Malawi</option>
            <option value="MY">Malaysia</option>
            <option value="MV">Maldives</option>
            <option value="ML">Mali</option>
            <option value="MT">Malta</option>
            <option value="MQ">Martinique</option>
            <option value="MR">Mauritania</option>
            <option value="MU">Mauritius</option>
            <option value="YT">Mayotte</option>
            <option value="MX">Mexico</option>
            <option value="FM">Micronesia (Federated States of)</option>
            <option value="MD">Moldova (Republic of)</option>
            <option value="MC">Monaco</option>
            <option value="MN">Mongolia</option>
            <option value="ME">Montenegro</option>
            <option value="MS">Montserrat</option>
            <option value="MA">Morocco</option>
            <option value="MZ">Mozambique</option>
            <option value="MM">Myanmar</option>
            <option value="NA">Namibia</option>
            <option value="NR">Nauru</option>
            <option value="NP">Nepal</option>
            <option value="NL">Netherlands</option>
            <option value="NC">New Caledonia</option>
            <option value="NZ">New Zealand</option>
            <option value="NI">Nicaragua</option>
            <option value="NE">Niger</option>
            <option value="NG">Nigeria</option>
            <option value="NU">Niue</option>
            <option value="NF">Norfolk Island</option>
            <option value="MK">North Macedonia</option>
            <option value="NO">Norway</option>
            <option value="OM">Oman</option>
            <option value="PK">Pakistan</option>
            <option value="PW">Palau</option>
            <option value="PS">Palestine (State of)</option>
            <option value="PA">Panama</option>
            <option value="PG">Papua New Guinea</option>
            <option value="PY">Paraguay</option>
            <option value="PE">Peru</option>
            <option value="PH">Philippines</option>
            <option value="PN">Pitcairn</option>
            <option value="PL">Poland</option>
            <option value="PT">Portugal</option>
            <option value="QA">Qatar</option>
            <option value="RE">Réunion</option>
            <option value="RO">Romania</option>
            <option value="RU">Russian Federation</option>
            <option value="RW">Rwanda</option>
            <option value="BL">Saint Barthélemy</option>
            <option value="SH">Saint Helena, Ascension and Tristan da Cunha</option>
            <option value="KN">Saint Kitts and Nevis</option>
            <option value="LC">Saint Lucia</option>
            <option value="MF">Saint Martin (French part)</option>
            <option value="PM">Saint Pierre and Miquelon</option>
            <option value="VC">Saint Vincent and the Grenadines</option>
            <option value="WS">Samoa</option>
            <option value="SM">San Marino</option>
            <option value="ST">Sao Tome and Principe</option>
            <option value="SA">Saudi Arabia</option>
            <option value="SN">Senegal</option>
            <option value="RS">Serbia</option>
            <option value="SC">Seychelles</option>
            <option value="SL">Sierra Leone</option>
            <option value="SG">Singapore</option>
            <option value="SX">Sint Maarten (Dutch part)</option>
            <option value="SK">Slovakia</option>
            <option value="SI">Slovenia</option>
            <option value="SB">Solomon Islands</option>
            <option value="SO">Somalia</option>
            <option value="ZA">South Africa</option>
            <option value="GS">South Georgia and the South Sandwich Islands</option>
            <option value="SS">South Sudan</option>
            <option value="ES">Spain</option>
            <option value="LK">Sri Lanka</option>
            <option value="SD">Sudan</option>
            <option value="SR">Suriname</option>
            <option value="SJ">Svalbard and Jan Mayen</option>
            <option value="SE">Sweden</option>
            <option value="CH">Switzerland</option>
            <option value="SY">Syrian Arab Republic</option>
            <option value="TW">Taiwan</option>
            <option value="TJ">Tajikistan</option>
            <option value="TZ">Tanzania (United Republic of)</option>
            <option value="TH">Thailand</option>
            <option value="TL">Timor-Leste</option>
            <option value="TG">Togo</option>
            <option value="TK">Tokelau</option>
            <option value="TO">Tonga</option>
            <option value="TT">Trinidad and Tobago</option>
            <option value="TN">Tunisia</option>
            <option value="TR">Turkey</option>
            <option value="TM">Turkmenistan</option>
            <option value="TC">Turks and Caicos Islands</option>
            <option value="TV">Tuvalu</option>
            <option value="UG">Uganda</option>
            <option value="UA">Ukraine</option>
            <option value="AE">United Arab Emirates</option>
            <option value="GB">United Kingdom</option>
            <option value="US">United States</option>
            <option value="UM">United States Minor Outlying Islands</option>
            <option value="UY">Uruguay</option>
            <option value="UZ">Uzbekistan</option>
            <option value="VU">Vanuatu</option>
            <option value="VE">Venezuela (Bolivarian Republic of)</option>
            <option value="VN">Viet Nam</option>
            <option value="WF">Wallis and Futuna</option>
            <option value="EH">Western Sahara</option>
            <option value="YE">Yemen</option>
            <option value="ZM">Zambia</option>
            <option value="ZW">Zimbabwe</option>
          </select><span class="select2 select2-container select2-container--default" dir="ltr" style="width: 418px;"><span class="selection"><span class="select2-selection select2-selection--single" role="combobox" aria-haspopup="true"
                aria-expanded="false" title="Country *" tabindex="0" aria-labelledby="select2-NVContributionForm43240-ContactInformation-Country-select-container"><span class="select2-selection__rendered"
                  id="select2-NVContributionForm43240-ContactInformation-Country-select-container" 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>
        </label><label class="at-text   PostalCode" id="NVContributionForm43240-ContactInformation-PostalCode">Postal Code *<input type="tel" autocomplete="postal-code" x-autocompletetype="postal-code" pattern="^\d{5}([\-]\d{4})?$" required=""
            title="Postal Code * (required)" name="PostalCode" value="" maxlength="10">
        </label><label class="at-text   City" id="NVContributionForm43240-ContactInformation-City">City *<input type="text" autocomplete="address-level2" x-autocompletetype="locality" required="" title="City * (required)" name="City" value=""
            maxlength="25">
        </label></div>
      <div class="at-row EmailAddress HomePhone MobilePhone"><label class="at-text   EmailAddress" id="NVContributionForm43240-ContactInformation-EmailAddress">Email *<input type="email" autocomplete="email" x-autocompletetype="email"
            pattern="^([\w!#$%&amp;'*+\-\/=?\^`\{\|\}~]+\.)*[\w!#$%&amp;'*+\-\/=?\^`\{\|\}~]+@((((([a-zA-Z0-9]{1}[a-zA-Z0-9\-]{0,62}[a-zA-Z0-9]{1})|[a-zA-Z])\.)+[a-zA-Z]{2,62})|(\d{1,3}\.){3}\d{1,3}(:\d{1,5})?)$" required=""
            title="Email * (required)" name="EmailAddress" value="" maxlength="100" placeholder="email@email.com">
        </label><label class="at-text   HomePhone" id="NVContributionForm43240-ContactInformation-HomePhone">Home Phone <small>(Optional)</small>
          <div class="intl-tel-input iti iti--allow-dropdown">
            <div class="iti__flag-container">
              <div class="iti__selected-flag" role="combobox" aria-controls="iti-0__country-listbox" aria-owns="iti-0__country-listbox" aria-expanded="false" tabindex="0" title="United States: +1" aria-activedescendant="iti-0__item-us-preferred">
                <div class="iti__flag iti__us"></div>
                <div class="iti__arrow"></div>
              </div>
            </div><input type="tel" class="intl-phone-HomePhone" name="HomePhone" title="Home Phone" data-intl-tel-input-id="0">
          </div>
        </label><label class="at-text   MobilePhone" id="NVContributionForm43240-ContactInformation-MobilePhone">Mobile Phone <small>(Optional)</small>
          <div class="intl-tel-input iti iti--allow-dropdown">
            <div class="iti__flag-container">
              <div class="iti__selected-flag" role="combobox" aria-controls="iti-1__country-listbox" aria-owns="iti-1__country-listbox" aria-expanded="false" tabindex="0" title="United States: +1" aria-activedescendant="iti-1__item-us-preferred">
                <div class="iti__flag iti__us"></div>
                <div class="iti__arrow"></div>
              </div>
            </div><input type="tel" class="intl-phone-MobilePhone" name="MobilePhone" title="Mobile Phone" data-intl-tel-input-id="1">
          </div>
        </label></div>
      <div class="at-row at-row-solo SmsSubscribeMobilePhone"><input id="SmsSubscribeMobilePhone_Value" type="hidden" name="SmsSubscribeMobilePhone.Value" value="true"></div>
      <div class="at-row at-row-solo at-row-full SmsLegalDisclaimer">
        <div class="at-markup SmsLegalDisclaimer at-legal" id="NVContributionForm43240-ContactInformation-SmsLegalDisclaimer">
          <p>By submitting your cell phone number you are agreeing to receive periodic text messages. Text HELP for more information. Text STOP to stop receiving messages.</p>
        </div>
      </div>
      <div class="at-row at-row-solo YesSignMeUpForUpdatesForBinder"><input id="YesSignMeUpForUpdatesForBinder_Value" type="hidden" name="YesSignMeUpForUpdatesForBinder.Value" value="true"></div>
      <div class="at-row "><label class="at-text   PersonalUrl" id="NVContributionForm43240-ContactInformation-PersonalUrl"> <small>(Optional)</small><input type="text" autocomplete="on" false="" title="" name="PersonalUrl" value="" maxlength="">
        </label></div>
      <div class="at-row ">
        <div class="at-markup TrackingPixel" id="NVContributionForm43240-ContactInformation-TrackingPixel" style="display: none;"><img alt=""
            src="https://secure.everyaction.com/v1/Track/QxgpW7NCmk2wKW-ZCx13_Q2?formSessionId=ae58e35c-4729-4f5b-a149-a409b3f01612&amp;bName=chrome&amp;dType=desktop&amp;formVersion=1/3/2024 8:38:31 PM|&amp;fUrl=aHR0cHM6Ly9zdXBwb3J0LmNycy5vcmcv&amp;fRef="
            style="display:none"></div>
      </div>
    </div>
    <datalist id="at-prefixes">
      <option value="Dr."></option>
      <option value="Miss"></option>
      <option value="Mr."></option>
      <option value="Mrs."></option>
      <option value="Ms."></option>
      <option value="Mx."></option>
    </datalist>
  </fieldset>
  <fieldset class="at-fieldset PaymentInformation" id="NVContributionForm43240-PaymentInformation" style="display: none;">
    <legend class="at-legend">Billing Information</legend>
    <div class="at-fields">
      <div class="at-row "><label class="at-text at-cc-number" id="NVContributionForm43240-PaymentInformation-Account">Card Number<div class="cc-type-wrapper vgs-loading-placeholder" style="display: none;">
            <div class="cc-type unknown"></div>
            <input type="tel" autocomplete="cc-number" title="Credit Card Number" placeholder="•••• •••• •••• ••••" readonly="true">
          </div>
          <div id="vgs-Account-43240" class="vgs-cc-iframe-wrapper vgs-input-container vgs-collect-container__empty vgs-collect-container__invalid isEmpty" tabindex="-1"><iframe title="Secure card number input frame"
              src="https://js.verygoodvault.com/vgs-collect/2.18.4/lib/index.html#name=Account&amp;placeholder=%E2%80%A2%E2%80%A2%E2%80%A2%E2%80%A2%20%E2%80%A2%E2%80%A2%E2%80%A2%E2%80%A2%20%E2%80%A2%E2%80%A2%E2%80%A2%E2%80%A2%20%E2%80%A2%E2%80%A2%E2%80%A2%E2%80%A2&amp;type=card-number&amp;validations%5B0%5D=validCardNumber&amp;validations%5B1%5D=required&amp;autoComplete=cc-number&amp;formId=randomId2309762947579926686&amp;fieldId=randomId2307561633659560634&amp;createdAt=1721721369000&amp;tnt=dG50dzFwem5sYW0%3D&amp;env=bGl2ZQ%3D%3D&amp;logLevel=default&amp;satellitePort=&amp;vgsCollectSessionId=bcb974ab-43ed-4bb2-bec0-f468759ecc75&amp;css%5BfontSize%5D=.875rem&amp;css%5BfontFamily%5D=monospace&amp;css%5BlineHeight%5D=1&amp;css%5BbackgroundColor%5D=%23fff&amp;css%5B%26%3A%3Aplaceholder%5D%5Bcolor%5D=%23ced4da&amp;css%5B%26%3A%3Aplaceholder%5D%5BfontWeight%5D=bold"
              frameborder="0" scrolling="0" allowtransparency="true" id="randomId2307561633659560634" form-id="randomId2309762947579926686"></iframe></div>
        </label><label class="at-text at-cc-expiration" id="NVContributionForm43240-PaymentInformation-ExpirationDate">Expiration Date<div class="vgs-loading-placeholder" style="display: none;">
            <input type="tel" autocomplete="cc-exp" title="Expiration Date (MM / YY)" placeholder="MM / YY" readonly="true">
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A CRS program in Indonesia provides health awareness for mothers with toddlers.
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