abauds.cliogrow.com
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URL:
https://abauds.cliogrow.com/form/10868ac0a84e89697172e7b05f63005b?jwt=eyJhbGciOiJIUzI1NiJ9.eyJkYXRhIjp7fSwiZXhwIjoxNjUzMDY0O...
Submission: On May 11 via manual from US — Scanned from DE
Submission: On May 11 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST /form/10868ac0a84e89697172e7b05f63005b?jwt=eyJhbGciOiJIUzI1NiJ9.eyJkYXRhIjp7fSwiZXhwIjoxNjUyMzkxNjcwLCJzdWIiOiJpbnRha2VfZm9ybXMvc3VibWl0X2p3dC0xMDg2OGFjMGE4NGU4OTY5NzE3MmU3YjA1ZjYzMDA1YiJ9.S7hK4D5jMahezyRQvd0iPgO7SuqplUK6-N1l10TWJYI
<form id="edit-intake-form" class="edit_intake_form"
action="/form/10868ac0a84e89697172e7b05f63005b?jwt=eyJhbGciOiJIUzI1NiJ9.eyJkYXRhIjp7fSwiZXhwIjoxNjUyMzkxNjcwLCJzdWIiOiJpbnRha2VfZm9ybXMvc3VibWl0X2p3dC0xMDg2OGFjMGE4NGU4OTY5NzE3MmU3YjA1ZjYzMDA1YiJ9.S7hK4D5jMahezyRQvd0iPgO7SuqplUK6-N1l10TWJYI"
accept-charset="UTF-8" method="post"><input name="utf8" type="hidden" value="✓"><input type="hidden" name="_method" value="patch"><input type="hidden" name="authenticity_token"
value="i9tF83H5LvCzztogw8xbHy6YNHAvDl760HM9WQ2jpSNG9Kw0lRYi4mPJQ3B0sE0+oS5MfEBL63gVNtRWEMyfjw==">
<div class="clearfix">
<div class="col col-lg-12 clearfix">
<div class=" col col-lg-8 col-centered form-header clearfix">
<style>
h3.letterhead-firm-name {
margin: 0;
font-size: 24px;
}
.letterhead-wrapper {
margin: 20px auto;
width: 800px;
}
.letterhead-container {
display: -webkit-box;
/* wkhtmltopdf uses this one */
display: flex;
-webkit-box-align: center;
background: white;
overflow: hidden;
/* width: 800px; */
}
.letterhead-section {
-webkit-box-flex: 1;
flex: 1;
/*width: 800px;*/
}
.letterhead-container img {
max-width: 100%;
}
.letterhead-default-info {
text-align: right;
}
</style>
<div class="letterhead-container">
<div class="fr-view letterhead-section">
<div style="text-align: center;"><img src="https://s3.us-east-1.amazonaws.com/clio-grow-production/accounts%2F7537%2Fletterhead_images%2F1610565803788-HEADER+LOGO+crop.png" style="width: 600px;" class="fr-fic fr-dii"></div>
</div>
</div>
</div>
</div>
<div class="clearfix"></div>
<div class="col col-lg-8 col-centered">
<input value="899457" type="hidden" name="intake_form[entries_attributes][0][form_field_id]" id="intake_form_entries_attributes_0_form_field_id">
<input value="ContactForm" type="hidden" name="intake_form[entries_attributes][0][kind]" id="intake_form_entries_attributes_0_kind">
<input value="1" type="hidden" name="intake_form[entries_attributes][0][priority]" id="intake_form_entries_attributes_0_priority">
<input maxlength="3154" onkeydown="lengthEnforcer(this)" size="3154" type="hidden" name="intake_form[entries_attributes][0][followup_question_text]" id="intake_form_entries_attributes_0_followup_question_text">
<div class="row">
<div class="col-xs-12">
<div class="form-group-border-client clearfix">
<h3 class="lex-form-heading"> Contact Information </h3>
<div class="form-group hidden intake_form_contacts_contact_block_id"><input class="form-control hidden" type="hidden" value="899457" name="intake_form[contacts][0][contact_block_id]" id="intake_form_contacts_0_contact_block_id"></div>
<div class="col-xs-12 col-sm-2">
<div class="form-group select optional intake_form_contacts_salutation"><label class="control-label select optional" for="intake_form_contacts_0_salutation">Salutation</label><select
class="form-control select optional form-control no-search-chosen" name="intake_form[contacts][0][salutation]" id="intake_form_contacts_0_salutation" style="display: none;">
<option value="">None</option>
<option value="Mr">Mr</option>
<option value="Mrs">Mrs</option>
<option value="Ms">Ms</option>
<option value="Mx">Mx</option>
<option value="Dr">Dr</option>
<option value="Hon">Hon</option>
</select>
<div class="chosen-container chosen-container-single chosen-container-single-nosearch" title="" id="intake_form_contacts_0_salutation_chosen" style="width: 100%;"><a class="chosen-single">
<span>None</span>
<div><b></b></div>
</a>
<div class="chosen-drop">
<div class="chosen-search">
<input class="chosen-search-input" type="text" autocomplete="off" readonly="">
</div>
<ul class="chosen-results"></ul>
</div>
</div>
</div>
</div>
<div class="col-xs-12 col-sm-10 col-lg-3">
<div class="form-group string required intake_form_contacts_first_name"><label class="control-label string required" for="intake_form_contacts_0_first_name">First Name <abbr title="required">*</abbr></label><input
class="form-control string required" maxlength="255" required="required" aria-required="true" size="255" type="text" value="Angelica" name="intake_form[contacts][0][first_name]" id="intake_form_contacts_0_first_name"></div>
</div>
<div class="hidden-xs col-sm-2 hidden-lg"></div>
<div class="col-xs-12 col-sm-10 col-lg-3">
<div class="form-group string optional intake_form_contacts_middle_name"><label class="control-label string optional" for="intake_form_contacts_0_middle_name">Middle Name</label><input class="form-control string optional"
maxlength="255" size="255" type="text" value="" name="intake_form[contacts][0][middle_name]" id="intake_form_contacts_0_middle_name"></div>
</div>
<div class="hidden-xs col-sm-2 hidden-lg"></div>
<div class="col-xs-12 col-sm-10 col-lg-4">
<div class="form-group string required intake_form_contacts_last_name"><label class="control-label string required" for="intake_form_contacts_0_last_name">Last Name <abbr title="required">*</abbr></label><input
class="form-control string required" maxlength="255" required="required" aria-required="true" size="255" type="text" value="Ramos" name="intake_form[contacts][0][last_name]" id="intake_form_contacts_0_last_name"></div>
</div>
<div class="col-xs-12">
<div class="form-group string optional intake_form_contacts_company"><label class="control-label string optional" for="intake_form_contacts_0_company">Company</label><input class="form-control string optional" maxlength="255" size="255"
type="text" name="intake_form[contacts][0][company]" id="intake_form_contacts_0_company"></div>
</div>
</div>
</div>
<div class="col-xs-12">
<div class="form-group-border-client">
<div id="emails_fields">
<div class="lex-form-heading lex-margin-0">Emails</div>
<div class="row">
<div class="col-xs-12 col-sm-6">
<label> Email Address </label>
</div>
<div class="col-xs-6 col-sm-2">
<label> Type </label>
</div>
<div class="col-xs-6 col-sm-2"></div>
</div>
<div class="row">
<div class="nested-fields notBuilder lex-margin-bottom-10px">
<div class="form-group hidden intake_form_contacts_email_addresses_entity_id"><input class="form-control hidden" type="hidden" value="32021560" name="intake_form[contacts][0][email_addresses_attributes][0][entity_id]"
id="intake_form_contacts_0_email_addresses_attributes_0_entity_id"></div>
<div class="form-group hidden intake_form_contacts_email_addresses_entity_type"><input class="form-control hidden" type="hidden" value="Grow::Contact" name="intake_form[contacts][0][email_addresses_attributes][0][entity_type]"
id="intake_form_contacts_0_email_addresses_attributes_0_entity_type"></div>
<div class="row">
<div class="col-xs-12 col-sm-6">
<div class="field">
<div class="form-group email optional intake_form_contacts_email_addresses_address"><input class="form-control string email optional" maxlength="255" aria-label="Email address" type="email" size="255"
name="intake_form[contacts][0][email_addresses_attributes][0][address]" id="intake_form_contacts_0_email_addresses_attributes_0_address"></div>
</div>
</div>
<div class="col-xs-6 col-sm-2">
<div class="field">
<div class="form-group enum optional intake_form_contacts_email_addresses_name"><select class="form-control enum optional form-control search-chosen" aria-label="Email address type"
name="intake_form[contacts][0][email_addresses_attributes][0][name]" id="intake_form_contacts_0_email_addresses_attributes_0_name" style="display: none;">
<option value="work">Work</option>
<option selected="selected" value="home">Home</option>
<option value="other">Other</option>
</select>
<div class="chosen-container chosen-container-single" title="" id="intake_form_contacts_0_email_addresses_attributes_0_name_chosen" style="width: 100%;"><a class="chosen-single">
<span>Home</span>
<div><b></b></div>
</a>
<div class="chosen-drop">
<div class="chosen-search">
<input class="chosen-search-input" type="text" autocomplete="off">
</div>
<ul class="chosen-results"></ul>
</div>
</div>
</div>
</div>
</div>
<div class="col-xs-5 col-sm-2">
<div class="field field_align_fix">
<div class="form-group radio_buttons optional intake_form_contacts_email_addresses_default_email">
<div class="col-sm-9"><input type="hidden" name="intake_form[contacts][0][email_addresses_attributes][0][default_email]" value=""><span class="radio"><input class="radio_buttons optional fn-email-primary-radio" type="radio"
value="true" checked="checked" name="intake_form[contacts][0][email_addresses_attributes][0][default_email]" id="intake_form_contacts_0_email_addresses_attributes_0_default_email_true"><label
class="collection_radio_buttons" for="intake_form_contacts_0_email_addresses_attributes_0_default_email_true">Primary</label></span><span class="radio hidden"><input
class="radio_buttons optional fn-email-primary-radio" readonly="readonly" type="radio" value="false" name="intake_form[contacts][0][email_addresses_attributes][0][default_email]"
id="intake_form_contacts_0_email_addresses_attributes_0_default_email_false"><label class="collection_radio_buttons" for="intake_form_contacts_0_email_addresses_attributes_0_default_email_false">Default email
false</label></span></div>
</div>
</div>
</div>
<div class="col-xs-2 field_align_fix">
</div>
</div>
</div>
</div>
<div class="links">
<a class="add_fields" data-association="email_address" data-associations="email_addresses" data-association-insertion-template="<div class="row">
<div class="nested-fields notBuilder lex-margin-bottom-10px">
<div class="form-group hidden intake_form_contacts_email_addresses_entity_id"><input class="form-control hidden" type="hidden" value="32021560" name="intake_form[contacts][0][email_addresses_attributes][new_email_addresses][entity_id]" id="intake_form_contacts_0_email_addresses_attributes_new_email_addresses_entity_id" /></div>
<div class="form-group hidden intake_form_contacts_email_addresses_entity_type"><input class="form-control hidden" type="hidden" value="Grow::Contact" name="intake_form[contacts][0][email_addresses_attributes][new_email_addresses][entity_type]" id="intake_form_contacts_0_email_addresses_attributes_new_email_addresses_entity_type" /></div>
<div class="row">
<div class="col-xs-12 col-sm-6">
<div class="field">
<div class="form-group email optional intake_form_contacts_email_addresses_address"><input class="form-control string email optional" maxlength="255" aria-label="Email address" type="email" size="255" name="intake_form[contacts][0][email_addresses_attributes][new_email_addresses][address]" id="intake_form_contacts_0_email_addresses_attributes_new_email_addresses_address" /></div>
</div>
</div>
<div class="col-xs-6 col-sm-2">
<div class="field">
<div class="form-group enum optional intake_form_contacts_email_addresses_name"><select class="form-control enum optional form-control search-chosen" aria-label="Email address type" name="intake_form[contacts][0][email_addresses_attributes][new_email_addresses][name]" id="intake_form_contacts_0_email_addresses_attributes_new_email_addresses_name"><option value="work">Work</option>
<option value="home">Home</option>
<option value="other">Other</option></select></div>
</div>
</div>
<div class="col-xs-5 col-sm-2">
<div class="field field_align_fix">
<div class="form-group radio_buttons optional intake_form_contacts_email_addresses_default_email"><div class="col-sm-9"><input type="hidden" name="intake_form[contacts][0][email_addresses_attributes][new_email_addresses][default_email]" value="" /><span class="radio hidden"><input class="radio_buttons optional fn-email-primary-radio" type="radio" value="true" name="intake_form[contacts][0][email_addresses_attributes][new_email_addresses][default_email]" id="intake_form_contacts_0_email_addresses_attributes_new_email_addresses_default_email_true" /><label class="collection_radio_buttons" for="intake_form_contacts_0_email_addresses_attributes_new_email_addresses_default_email_true">Primary</label></span><span class="radio hidden"><input class="radio_buttons optional fn-email-primary-radio" readonly="readonly" type="radio" value="false" checked="checked" name="intake_form[contacts][0][email_addresses_attributes][new_email_addresses][default_email]" id="intake_form_contacts_0_email_addresses_attributes_new_email_addresses_default_email_false" /><label class="collection_radio_buttons" for="intake_form_contacts_0_email_addresses_attributes_new_email_addresses_default_email_false">Default email false</label></span></div></div>
</div>
</div>
<div class="col-xs-2 field_align_fix">
<div class="lex-padding-left-10px">
<input type="hidden" name="intake_form[contacts][0][email_addresses_attributes][new_email_addresses][_destroy]" id="intake_form_contacts_0_email_addresses_attributes_new_email_addresses__destroy" value="false" /><a class="lex-text-stop-red remove_fields dynamic" aria-label="remove email address" href="#">
<i class="fa fa-minus-circle"></i>
<span class="hidden-xs hidden-sm hidden-md">
Remove
</span>
</a> </div>
</div>
</div>
</div>
</div>
" href="#">
<div class="fa fa-plus-circle"></div>
Add Email
</a>
</div>
</div>
</div>
</div>
<div class="col-xs-12">
<div class="form-group-border-client">
<div id="addresses_fields">
<div class="lex-form-heading lex-margin-0">Addresses</div>
<div class="row">
<div class="nested-fields notBuilder lex-margin-bottom-10px" style="padding-bottom: 20px;">
<div class="form-group hidden intake_form_contacts_addresses_entity_id"><input class="form-control hidden" type="hidden" value="32021560" name="intake_form[contacts][0][addresses_attributes][0][entity_id]"
id="intake_form_contacts_0_addresses_attributes_0_entity_id"></div>
<div class="form-group hidden intake_form_contacts_addresses_entity_type"><input class="form-control hidden" type="hidden" value="Grow::Contact" name="intake_form[contacts][0][addresses_attributes][0][entity_type]"
id="intake_form_contacts_0_addresses_attributes_0_entity_type"></div>
<div class="row">
<div class="col-xs-12 col">
<div class="form-group string optional intake_form_contacts_addresses_street"><label class="control-label string optional" for="intake_form_contacts_0_addresses_attributes_0_street">Street Address</label><input
class="form-control string optional" maxlength="255" size="255" type="text" name="intake_form[contacts][0][addresses_attributes][0][street]" id="intake_form_contacts_0_addresses_attributes_0_street"></div>
</div>
</div>
<div class="row">
<div class="col-xs-12 col-sm-3">
<div class="form-group country optional intake_form_contacts_addresses_country"><label class="control-label country optional" for="intake_form_contacts_0_addresses_attributes_0_country">Country</label><select
class="form-control country optional search-chosen person_country" data-placeholder="Select" name="intake_form[contacts][0][addresses_attributes][0][country]" id="intake_form_contacts_0_addresses_attributes_0_country"
style="display: none;">
<option value=""></option>
<option selected="selected" value="US">United States</option>
<option value="CA">Canada</option>
<option value="GB">United Kingdom</option>
<option value="AU">Australia</option>
<option disabled="disabled" value="---------------">---------------</option>
<option value="AF">Afghanistan</option>
<option value="AX">Åland Islands</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AS">American Samoa</option>
<option value="AD">Andorra</option>
<option value="AO">Angola</option>
<option value="AI">Anguilla</option>
<option value="AQ">Antarctica</option>
<option value="AG">Antigua and Barbuda</option>
<option value="AR">Argentina</option>
<option value="AM">Armenia</option>
<option value="AW">Aruba</option>
<option value="AU">Australia</option>
<option value="AT">Austria</option>
<option value="AZ">Azerbaijan</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BD">Bangladesh</option>
<option value="BB">Barbados</option>
<option value="BY">Belarus</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BJ">Benin</option>
<option value="BM">Bermuda</option>
<option value="BT">Bhutan</option>
<option value="BO">Bolivia, 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="BN">Brunei Darussalam</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="CV">Cape Verde</option>
<option value="KY">Cayman Islands</option>
<option value="CF">Central African Republic</option>
<option value="TD">Chad</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CX">Christmas Island</option>
<option value="CC">Cocos (Keeling) Islands</option>
<option value="CO">Colombia</option>
<option value="KM">Comoros</option>
<option value="CG">Congo</option>
<option value="CD">Congo, The 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">Czech Republic</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="GQ">Equatorial Guinea</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="ET">Ethiopia</option>
<option value="FK">Falkland Islands (Malvinas)</option>
<option value="FO">Faroe Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="GF">French Guiana</option>
<option value="PF">French Polynesia</option>
<option value="TF">French Southern Territories</option>
<option value="GA">Gabon</option>
<option value="GM">Gambia</option>
<option value="GE">Georgia</option>
<option value="DE">Germany</option>
<option value="GH">Ghana</option>
<option value="GI">Gibraltar</option>
<option value="GR">Greece</option>
<option value="GL">Greenland</option>
<option value="GD">Grenada</option>
<option value="GP">Guadeloupe</option>
<option value="GU">Guam</option>
<option value="GT">Guatemala</option>
<option value="GG">Guernsey</option>
<option value="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard Island and McDonald Islands</option>
<option value="VA">Holy See (Vatican City State)</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="MK">Macedonia, Republic of</option>
<option value="MG">Madagascar</option>
<option value="MW">Malawi</option>
<option value="MY">Malaysia</option>
<option value="MV">Maldives</option>
<option value="ML">Mali</option>
<option value="MT">Malta</option>
<option value="MH">Marshall Islands</option>
<option value="MQ">Martinique</option>
<option value="MR">Mauritania</option>
<option value="MU">Mauritius</option>
<option value="YT">Mayotte</option>
<option value="MX">Mexico</option>
<option value="FM">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="MP">Northern Mariana Islands</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PK">Pakistan</option>
<option value="PW">Palau</option>
<option value="PS">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="PR">Puerto Rico</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="SZ">Swaziland</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="UM">United States Minor Outlying Islands</option>
<option value="US">United States</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="VG">Virgin Islands, British</option>
<option value="VI">Virgin Islands, U.S.</option>
<option value="WF">Wallis and Futuna</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select>
<div class="chosen-container chosen-container-single" title="" id="intake_form_contacts_0_addresses_attributes_0_country_chosen" style="width: 100%;"><a class="chosen-single">
<span>United States</span>
<div><b></b></div>
</a>
<div class="chosen-drop">
<div class="chosen-search">
<input class="chosen-search-input" type="text" autocomplete="off">
</div>
<ul class="chosen-results"></ul>
</div>
</div>
</div>
</div>
<div class="col-lg-3 col-xs-12">
<div class="form-group string optional intake_form_contacts_addresses_city"><label class="control-label string optional" for="intake_form_contacts_0_addresses_attributes_0_city">City</label><input
class="form-control string optional" maxlength="255" size="255" type="text" name="intake_form[contacts][0][addresses_attributes][0][city]" id="intake_form_contacts_0_addresses_attributes_0_city"></div>
</div>
<div class="col-md-4 col-xs-12 col">
<div class="form-group select optional intake_form_contacts_addresses_province state"><label class="control-label select optional" for="intake_form_contacts_0_addresses_attributes_0_province">State/Region</label><select
class="form-control select optional search-chosen state" data-placeholder="Select" maxlength="255" name="intake_form[contacts][0][addresses_attributes][0][province]"
id="intake_form_contacts_0_addresses_attributes_0_province" style="display: none;">
<option value=""></option>
<option value="AA">Armed Forces Americas</option>
<option value="AE">Armed Forces Europe</option>
<option value="AK">Alaska</option>
<option value="AL">Alabama</option>
<option value="AP">Armed Forces Pacific</option>
<option value="AR">Arkansas</option>
<option value="AS">American Samoa</option>
<option value="AZ">Arizona</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DC">District of Columbia</option>
<option value="DE">Delaware</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="GU">Guam</option>
<option value="HI">Hawaii</option>
<option value="IA">Iowa</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="MA">Massachusetts</option>
<option value="MD">Maryland</option>
<option value="ME">Maine</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MO">Missouri</option>
<option value="MP">Northern Mariana Islands</option>
<option value="MS">Mississippi</option>
<option value="MT">Montana</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="NE">Nebraska</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NV">Nevada</option>
<option value="NY">New York</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="PR">Puerto Rico</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UT">Utah</option>
<option value="VA">Virginia</option>
<option value="VI">Virgin Islands, U.S.</option>
<option value="VT">Vermont</option>
<option value="WA">Washington</option>
<option value="WI">Wisconsin</option>
<option value="WV">West Virginia</option>
<option value="WY">Wyoming</option>
</select>
<div class="chosen-container chosen-container-single" title="" id="intake_form_contacts_0_addresses_attributes_0_province_chosen" style="width: 100%;"><a class="chosen-single chosen-default">
<span>Select</span>
<div><b></b></div>
</a>
<div class="chosen-drop">
<div class="chosen-search">
<input class="chosen-search-input" type="text" autocomplete="off">
</div>
<ul class="chosen-results"></ul>
</div>
</div>
</div>
<div class="form-group string optional intake_form_contacts_addresses_province province hidden"><label class="control-label string optional"
for="intake_form_contacts_0_addresses_attributes_0_province">Province/Region</label><input class="form-control string optional" disabled="" maxlength="255" size="255" type="text"
name="intake_form[contacts][0][addresses_attributes][0][province]" id="intake_form_contacts_0_addresses_attributes_0_province"></div>
</div>
</div>
<div class="row">
<div class="col-lg-3 col-md-3 col">
<div class="form-group string optional intake_form_contacts_addresses_postal_code"><label class="control-label string optional" for="intake_form_contacts_0_addresses_attributes_0_postal_code">Zip/Postal Code</label><input
class="form-control string optional" maxlength="16" size="16" type="text" name="intake_form[contacts][0][addresses_attributes][0][postal_code]" id="intake_form_contacts_0_addresses_attributes_0_postal_code"></div>
</div>
</div>
<div class="row">
<div class="col-xs-6 col-sm-6">
<div class="form-group enum optional intake_form_contacts_addresses_name"><label class="control-label enum optional" for="intake_form_contacts_0_addresses_attributes_0_name">Address Type</label><select
class="form-control enum optional form-control search-chosen" name="intake_form[contacts][0][addresses_attributes][0][name]" id="intake_form_contacts_0_addresses_attributes_0_name" style="display: none;">
<option value="work">Work</option>
<option value="billing">Billing</option>
<option selected="selected" value="home">Home</option>
<option value="other">Other</option>
</select>
<div class="chosen-container chosen-container-single" title="" id="intake_form_contacts_0_addresses_attributes_0_name_chosen" style="width: 100%;"><a class="chosen-single">
<span>Home</span>
<div><b></b></div>
</a>
<div class="chosen-drop">
<div class="chosen-search">
<input class="chosen-search-input" type="text" autocomplete="off">
</div>
<ul class="chosen-results"></ul>
</div>
</div>
</div>
</div>
<div class="col-xs-6 col-sm-3">
<div class="field field_align_fix">
<div class="form-group radio_buttons optional intake_form_contacts_addresses_default_address">
<div class="col-sm-9"><input type="hidden" name="intake_form[contacts][0][addresses_attributes][0][default_address]" value=""><span class="radio"><input class="radio_buttons optional fn-address-primary-radio" type="radio"
value="true" checked="checked" name="intake_form[contacts][0][addresses_attributes][0][default_address]" id="intake_form_contacts_0_addresses_attributes_0_default_address_true"><label class="collection_radio_buttons"
for="intake_form_contacts_0_addresses_attributes_0_default_address_true">Primary</label></span><span class="radio hidden"><input class="radio_buttons optional fn-address-primary-radio" readonly="readonly" type="radio"
value="false" name="intake_form[contacts][0][addresses_attributes][0][default_address]" id="intake_form_contacts_0_addresses_attributes_0_default_address_false"><label class="collection_radio_buttons"
for="intake_form_contacts_0_addresses_attributes_0_default_address_false">Default address false</label></span></div>
</div>
</div>
</div>
<div class="col-xs-3 text-center">
</div>
</div>
</div>
</div>
<div class="links">
<a class="add_fields" data-association="address" data-associations="addresses" data-association-insertion-template="<div class="row">
<div class="nested-fields notBuilder lex-margin-bottom-10px" style="padding-bottom: 20px;">
<div class="form-group hidden intake_form_contacts_addresses_entity_id"><input class="form-control hidden" type="hidden" value="32021560" name="intake_form[contacts][0][addresses_attributes][new_addresses][entity_id]" id="intake_form_contacts_0_addresses_attributes_new_addresses_entity_id" /></div>
<div class="form-group hidden intake_form_contacts_addresses_entity_type"><input class="form-control hidden" type="hidden" value="Grow::Contact" name="intake_form[contacts][0][addresses_attributes][new_addresses][entity_type]" id="intake_form_contacts_0_addresses_attributes_new_addresses_entity_type" /></div>
<div class="row">
<div class="col-xs-12 col">
<div class="form-group string optional intake_form_contacts_addresses_street"><label class="control-label string optional" for="intake_form_contacts_0_addresses_attributes_new_addresses_street">Street Address</label><input class="form-control string optional" maxlength="255" size="255" type="text" name="intake_form[contacts][0][addresses_attributes][new_addresses][street]" id="intake_form_contacts_0_addresses_attributes_new_addresses_street" /></div>
</div>
</div>
<div class="row">
<div class="col-xs-12 col-sm-3">
<div class="form-group country optional intake_form_contacts_addresses_country"><label class="control-label country optional" for="intake_form_contacts_0_addresses_attributes_new_addresses_country">Country</label><select class="form-control country optional search-chosen person_country" data-placeholder="Select" name="intake_form[contacts][0][addresses_attributes][new_addresses][country]" id="intake_form_contacts_0_addresses_attributes_new_addresses_country"><option value=""></option>
<option value="US">United States</option>
<option value="CA">Canada</option>
<option value="GB">United Kingdom</option>
<option value="AU">Australia</option>
<option disabled="disabled" value="---------------">---------------</option>
<option value="AF">Afghanistan</option>
<option value="AX">Åland Islands</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AS">American Samoa</option>
<option value="AD">Andorra</option>
<option value="AO">Angola</option>
<option value="AI">Anguilla</option>
<option value="AQ">Antarctica</option>
<option value="AG">Antigua and Barbuda</option>
<option value="AR">Argentina</option>
<option value="AM">Armenia</option>
<option value="AW">Aruba</option>
<option value="AU">Australia</option>
<option value="AT">Austria</option>
<option value="AZ">Azerbaijan</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BD">Bangladesh</option>
<option value="BB">Barbados</option>
<option value="BY">Belarus</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BJ">Benin</option>
<option value="BM">Bermuda</option>
<option value="BT">Bhutan</option>
<option value="BO">Bolivia, 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="BN">Brunei Darussalam</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="CV">Cape Verde</option>
<option value="KY">Cayman Islands</option>
<option value="CF">Central African Republic</option>
<option value="TD">Chad</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CX">Christmas Island</option>
<option value="CC">Cocos (Keeling) Islands</option>
<option value="CO">Colombia</option>
<option value="KM">Comoros</option>
<option value="CG">Congo</option>
<option value="CD">Congo, The Democratic Republic of the</option>
<option value="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="CI">Côte d&#39;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">Czech Republic</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="GQ">Equatorial Guinea</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="ET">Ethiopia</option>
<option value="FK">Falkland Islands (Malvinas)</option>
<option value="FO">Faroe Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="GF">French Guiana</option>
<option value="PF">French Polynesia</option>
<option value="TF">French Southern Territories</option>
<option value="GA">Gabon</option>
<option value="GM">Gambia</option>
<option value="GE">Georgia</option>
<option value="DE">Germany</option>
<option value="GH">Ghana</option>
<option value="GI">Gibraltar</option>
<option value="GR">Greece</option>
<option value="GL">Greenland</option>
<option value="GD">Grenada</option>
<option value="GP">Guadeloupe</option>
<option value="GU">Guam</option>
<option value="GT">Guatemala</option>
<option value="GG">Guernsey</option>
<option value="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard Island and McDonald Islands</option>
<option value="VA">Holy See (Vatican City State)</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&#39;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&#39;s Democratic Republic</option>
<option value="LV">Latvia</option>
<option value="LB">Lebanon</option>
<option value="LS">Lesotho</option>
<option value="LR">Liberia</option>
<option value="LY">Libya</option>
<option value="LI">Liechtenstein</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="MO">Macao</option>
<option value="MK">Macedonia, Republic of</option>
<option value="MG">Madagascar</option>
<option value="MW">Malawi</option>
<option value="MY">Malaysia</option>
<option value="MV">Maldives</option>
<option value="ML">Mali</option>
<option value="MT">Malta</option>
<option value="MH">Marshall Islands</option>
<option value="MQ">Martinique</option>
<option value="MR">Mauritania</option>
<option value="MU">Mauritius</option>
<option value="YT">Mayotte</option>
<option value="MX">Mexico</option>
<option value="FM">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="MP">Northern Mariana Islands</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PK">Pakistan</option>
<option value="PW">Palau</option>
<option value="PS">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="PR">Puerto Rico</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="SZ">Swaziland</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="UM">United States Minor Outlying Islands</option>
<option value="US">United States</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="VG">Virgin Islands, British</option>
<option value="VI">Virgin Islands, U.S.</option>
<option value="WF">Wallis and Futuna</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option></select></div>
</div>
<div class="col-lg-3 col-xs-12">
<div class="form-group string optional intake_form_contacts_addresses_city"><label class="control-label string optional" for="intake_form_contacts_0_addresses_attributes_new_addresses_city">City</label><input class="form-control string optional" maxlength="255" size="255" type="text" name="intake_form[contacts][0][addresses_attributes][new_addresses][city]" id="intake_form_contacts_0_addresses_attributes_new_addresses_city" /></div>
</div>
<div class="col-md-4 col-xs-12 col">
<div class="form-group select optional intake_form_contacts_addresses_province state"><label class="control-label select optional" for="intake_form_contacts_0_addresses_attributes_new_addresses_province">State/Region</label><select class="form-control select optional search-chosen state" data-placeholder="Select" maxlength="255" name="intake_form[contacts][0][addresses_attributes][new_addresses][province]" id="intake_form_contacts_0_addresses_attributes_new_addresses_province"><option value=""></option>
<option value="AA">Armed Forces Americas</option>
<option value="AE">Armed Forces Europe</option>
<option value="AK">Alaska</option>
<option value="AL">Alabama</option>
<option value="AP">Armed Forces Pacific</option>
<option value="AR">Arkansas</option>
<option value="AS">American Samoa</option>
<option value="AZ">Arizona</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DC">District of Columbia</option>
<option value="DE">Delaware</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="GU">Guam</option>
<option value="HI">Hawaii</option>
<option value="IA">Iowa</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="MA">Massachusetts</option>
<option value="MD">Maryland</option>
<option value="ME">Maine</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MO">Missouri</option>
<option value="MP">Northern Mariana Islands</option>
<option value="MS">Mississippi</option>
<option value="MT">Montana</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="NE">Nebraska</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NV">Nevada</option>
<option value="NY">New York</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="PR">Puerto Rico</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UT">Utah</option>
<option value="VA">Virginia</option>
<option value="VI">Virgin Islands, U.S.</option>
<option value="VT">Vermont</option>
<option value="WA">Washington</option>
<option value="WI">Wisconsin</option>
<option value="WV">West Virginia</option>
<option value="WY">Wyoming</option></select></div>
<div class="form-group string optional intake_form_contacts_addresses_province province hidden"><label class="control-label string optional" for="intake_form_contacts_0_addresses_attributes_new_addresses_province">Province/Region</label><input class="form-control string optional" disabled="disabled" maxlength="255" size="255" type="text" name="intake_form[contacts][0][addresses_attributes][new_addresses][province]" id="intake_form_contacts_0_addresses_attributes_new_addresses_province" /></div>
</div>
</div>
<div class="row">
<div class="col-lg-3 col-md-3 col">
<div class="form-group string optional intake_form_contacts_addresses_postal_code"><label class="control-label string optional" for="intake_form_contacts_0_addresses_attributes_new_addresses_postal_code">Zip/Postal Code</label><input class="form-control string optional" maxlength="16" size="16" type="text" name="intake_form[contacts][0][addresses_attributes][new_addresses][postal_code]" id="intake_form_contacts_0_addresses_attributes_new_addresses_postal_code" /></div>
</div>
</div>
<div class="row">
<div class="col-xs-6 col-sm-6">
<div class="form-group enum optional intake_form_contacts_addresses_name"><label class="control-label enum optional" for="intake_form_contacts_0_addresses_attributes_new_addresses_name">Address Type</label><select class="form-control enum optional form-control search-chosen" name="intake_form[contacts][0][addresses_attributes][new_addresses][name]" id="intake_form_contacts_0_addresses_attributes_new_addresses_name"><option value="work">Work</option>
<option value="billing">Billing</option>
<option value="home">Home</option>
<option value="other">Other</option></select></div>
</div>
<div class="col-xs-6 col-sm-3">
<div class="field field_align_fix">
<div class="form-group radio_buttons optional intake_form_contacts_addresses_default_address"><div class="col-sm-9"><input type="hidden" name="intake_form[contacts][0][addresses_attributes][new_addresses][default_address]" value="" /><span class="radio hidden"><input class="radio_buttons optional fn-address-primary-radio" type="radio" value="true" name="intake_form[contacts][0][addresses_attributes][new_addresses][default_address]" id="intake_form_contacts_0_addresses_attributes_new_addresses_default_address_true" /><label class="collection_radio_buttons" for="intake_form_contacts_0_addresses_attributes_new_addresses_default_address_true">Primary</label></span><span class="radio hidden"><input class="radio_buttons optional fn-address-primary-radio" readonly="readonly" type="radio" value="false" checked="checked" name="intake_form[contacts][0][addresses_attributes][new_addresses][default_address]" id="intake_form_contacts_0_addresses_attributes_new_addresses_default_address_false" /><label class="collection_radio_buttons" for="intake_form_contacts_0_addresses_attributes_new_addresses_default_address_false">Default address false</label></span></div></div>
</div>
</div>
<div class="col-xs-3 text-center">
<input type="hidden" name="intake_form[contacts][0][addresses_attributes][new_addresses][_destroy]" id="intake_form_contacts_0_addresses_attributes_new_addresses__destroy" value="false" /><a class="lex-text-stop-red remove_fields dynamic" href="#">
<div class="field field_align_fix">
<div class="fa fa-minus-circle" style="margin-top: 15px;"></div>
Remove Address
</div>
</a> </div>
</div>
</div>
</div>
" href="#">
<div class="fa fa-plus-circle"></div>
Add Address
</a>
</div>
</div>
</div>
</div>
<div class="col-xs-12">
<div class="form-group-border-client">
<div id="phone_numbers_fields">
<div class="lex-form-heading lex-margin-0">Phone Numbers</div>
<div class="row">
<div class="col-xs-12 col-sm-6">
<label> Phone Number </label>
</div>
<div class="col-xs-6 col-sm-2">
<label> Type </label>
</div>
<div class="col-xs-6 col-sm-2"></div>
</div>
<div class="row">
<div class="nested-fields notBuilder lex-margin-bottom-10px">
<div class="form-group hidden intake_form_contacts_phone_numbers_entity_id"><input class="form-control hidden" type="hidden" value="32021560" name="intake_form[contacts][0][phone_numbers_attributes][0][entity_id]"
id="intake_form_contacts_0_phone_numbers_attributes_0_entity_id"></div>
<div class="form-group hidden intake_form_contacts_phone_numbers_entity_type"><input class="form-control hidden" type="hidden" value="Contact" name="intake_form[contacts][0][phone_numbers_attributes][0][entity_type]"
id="intake_form_contacts_0_phone_numbers_attributes_0_entity_type"></div>
<div class="row lex-margin-bottom-20px">
<div class="col-xs-12 col-sm-6">
<div class="field">
<div class="form-group tel optional intake_form_contacts_phone_numbers_number"><input class="form-control string tel optional" data-phonecode="1" maxlength="255" aria-label="Phone number" type="tel" size="255"
value="+1 (630) 251-1505" name="intake_form[contacts][0][phone_numbers_attributes][0][number]" id="intake_form_contacts_0_phone_numbers_attributes_0_number"></div>
<div class="lex-padding-left-10px tip-text">
<span class="fn-phone-location"></span>
</div>
</div>
</div>
<div class="col-xs-6 col-sm-2">
<div class="field">
<div class="form-group enum optional intake_form_contacts_phone_numbers_name"><select class="form-control enum optional form-control search-chosen" aria-label="Phone number type"
name="intake_form[contacts][0][phone_numbers_attributes][0][name]" id="intake_form_contacts_0_phone_numbers_attributes_0_name" style="display: none;">
<option value="work">Work</option>
<option selected="selected" value="home">Home</option>
<option value="mobile">Mobile</option>
<option value="fax">Fax</option>
<option value="pager">Pager</option>
<option value="skype">Skype</option>
<option value="other">Other</option>
</select>
<div class="chosen-container chosen-container-single" title="" id="intake_form_contacts_0_phone_numbers_attributes_0_name_chosen" style="width: 100%;"><a class="chosen-single">
<span>Home</span>
<div><b></b></div>
</a>
<div class="chosen-drop">
<div class="chosen-search">
<input class="chosen-search-input" type="text" autocomplete="off">
</div>
<ul class="chosen-results"></ul>
</div>
</div>
</div>
</div>
</div>
<div class="col-xs-5 col-sm-2">
<div class="field field_align_fix">
<div class="form-group radio_buttons optional intake_form_contacts_phone_numbers_default_number">
<div class="col-sm-9"><input type="hidden" name="intake_form[contacts][0][phone_numbers_attributes][0][default_number]" value=""><span class="radio"><input class="radio_buttons optional fn-phone-primary-radio" type="radio"
value="true" checked="checked" name="intake_form[contacts][0][phone_numbers_attributes][0][default_number]" id="intake_form_contacts_0_phone_numbers_attributes_0_default_number_true"><label
class="collection_radio_buttons" for="intake_form_contacts_0_phone_numbers_attributes_0_default_number_true">Primary</label></span></div>
</div>
</div>
</div>
<div class="col-xs-1 col-sm-2 field_align_fix">
<div class="lex-padding-left-10px">
<input type="hidden" name="intake_form[contacts][0][phone_numbers_attributes][0][_destroy]" id="intake_form_contacts_0_phone_numbers_attributes_0__destroy" value="false"><a class="lex-text-stop-red remove_fields existing" aria-label="remove phone number" href="#">
<i class="fa fa-minus-circle"></i>
<span class="hidden-xs hidden-sm hidden-md">
Remove
</span>
</a>
</div>
</div>
</div>
</div>
</div>
<input type="hidden" value="26734714" name="intake_form[contacts][0][phone_numbers_attributes][0][id]" id="intake_form_contacts_0_phone_numbers_attributes_0_id">
<div class="links">
<a class="add_fields" data-association="phone_number" data-associations="phone_numbers" data-association-insertion-template="<div class="row">
<div class="nested-fields notBuilder lex-margin-bottom-10px">
<div class="form-group hidden intake_form_contacts_phone_numbers_entity_id"><input class="form-control hidden" type="hidden" value="32021560" name="intake_form[contacts][0][phone_numbers_attributes][new_phone_numbers][entity_id]" id="intake_form_contacts_0_phone_numbers_attributes_new_phone_numbers_entity_id" /></div>
<div class="form-group hidden intake_form_contacts_phone_numbers_entity_type"><input class="form-control hidden" type="hidden" value="Grow::Contact" name="intake_form[contacts][0][phone_numbers_attributes][new_phone_numbers][entity_type]" id="intake_form_contacts_0_phone_numbers_attributes_new_phone_numbers_entity_type" /></div>
<div class="row lex-margin-bottom-20px">
<div class="col-xs-12 col-sm-6">
<div class="field">
<div class="form-group tel optional intake_form_contacts_phone_numbers_number"><input class="form-control string tel optional" data-phonecode="1" maxlength="255" aria-label="Phone number" type="tel" size="255" name="intake_form[contacts][0][phone_numbers_attributes][new_phone_numbers][number]" id="intake_form_contacts_0_phone_numbers_attributes_new_phone_numbers_number" /></div>
<div class="lex-padding-left-10px tip-text">
<span class="fn-phone-location"></span>
</div>
</div>
</div>
<div class="col-xs-6 col-sm-2">
<div class="field">
<div class="form-group enum optional intake_form_contacts_phone_numbers_name"><select class="form-control enum optional form-control search-chosen" aria-label="Phone number type" name="intake_form[contacts][0][phone_numbers_attributes][new_phone_numbers][name]" id="intake_form_contacts_0_phone_numbers_attributes_new_phone_numbers_name"><option value="work">Work</option>
<option value="home">Home</option>
<option value="mobile">Mobile</option>
<option value="fax">Fax</option>
<option value="pager">Pager</option>
<option value="skype">Skype</option>
<option value="other">Other</option></select></div>
</div>
</div>
<div class="col-xs-5 col-sm-2">
<div class="field field_align_fix">
<div class="form-group radio_buttons optional intake_form_contacts_phone_numbers_default_number"><div class="col-sm-9"><input type="hidden" name="intake_form[contacts][0][phone_numbers_attributes][new_phone_numbers][default_number]" value="" /><span class="radio hidden"><input class="radio_buttons optional fn-phone-primary-radio" type="radio" value="true" name="intake_form[contacts][0][phone_numbers_attributes][new_phone_numbers][default_number]" id="intake_form_contacts_0_phone_numbers_attributes_new_phone_numbers_default_number_true" /><label class="collection_radio_buttons" for="intake_form_contacts_0_phone_numbers_attributes_new_phone_numbers_default_number_true">Primary</label></span></div></div>
</div>
</div>
<div class="col-xs-1 col-sm-2 field_align_fix">
<div class="lex-padding-left-10px">
<input type="hidden" name="intake_form[contacts][0][phone_numbers_attributes][new_phone_numbers][_destroy]" id="intake_form_contacts_0_phone_numbers_attributes_new_phone_numbers__destroy" value="false" /><a class="lex-text-stop-red remove_fields dynamic" aria-label="remove phone number" href="#">
<i class="fa fa-minus-circle"></i>
<span class="hidden-xs hidden-sm hidden-md">
Remove
</span>
</a> </div>
</div>
</div>
</div>
</div>
" href="#">
<div class="fa fa-plus-circle"></div>
Add Phone Number
</a>
</div>
</div>
</div>
</div>
</div>
<input value="899475" type="hidden" name="intake_form[entries_attributes][1][form_field_id]" id="intake_form_entries_attributes_1_form_field_id">
<input value="Section" type="hidden" name="intake_form[entries_attributes][1][kind]" id="intake_form_entries_attributes_1_kind">
<input value="2" type="hidden" name="intake_form[entries_attributes][1][priority]" id="intake_form_entries_attributes_1_priority">
<input value="SU HISTORIA " maxlength="3154" onkeydown="lengthEnforcer(this)" size="3154" type="hidden" name="intake_form[entries_attributes][1][followup_question_text]" id="intake_form_entries_attributes_1_followup_question_text">
<h3 class="form-question-section">
<label for="intake_form_entries_attributes_1_value">SU HISTORIA </label>
</h3>
<div class="form-question-section-instructions fr-view">
<div> Por favor conteste cada pregunta a sus mejores abilidades. CON MAS DETALLE LA ABOGADA PUEDE DARLE CONSULTA MAS PRECISA. ***</div>
<div><br></div>
<div><br></div>
<input value="<div>&nbsp;Por favor conteste cada pregunta a sus mejores abilidades. &nbsp;CON MAS DETALLE LA ABOGADA PUEDE DARLE CONSULTA MAS PRECISA. &nbsp;***</div><div><br></div><div><br></div>" type="hidden"
name="intake_form[entries_attributes][1][followup_answer]" id="intake_form_entries_attributes_1_followup_answer">
</div>
<input value="899491" type="hidden" name="intake_form[entries_attributes][2][form_field_id]" id="intake_form_entries_attributes_2_form_field_id">
<input value="TextArea" type="hidden" name="intake_form[entries_attributes][2][kind]" id="intake_form_entries_attributes_2_kind">
<input value="3" type="hidden" name="intake_form[entries_attributes][2][priority]" id="intake_form_entries_attributes_2_priority">
<input value="Si tiene hijos, favor de nombrar cada uno e incluir fecha y pais de nacimiento [Ej: 1) Juan Perez; 5/27/05; Mexico. 2) Alma Perez; 6/21/13; EEUU]:" maxlength="3154" onkeydown="lengthEnforcer(this)" size="3154" type="hidden"
name="intake_form[entries_attributes][2][followup_question_text]" id="intake_form_entries_attributes_2_followup_question_text">
<fieldset class="form-field-set">
<legend>
<h4 class="form-question"><label class="question-type control-label" for="intake_form_entries_attributes_2_value">Si tiene hijos, favor de nombrar cada uno e incluir fecha y pais de nacimiento [Ej: 1) Juan Perez; 5/27/05; Mexico. 2) Alma
Perez; 6/21/13; EEUU]:</label></h4>
</legend>
<textarea rows="5" placeholder="Please enter your response" class="form-control" maxlength="65535" name="intake_form[entries_attributes][2][value]" id="intake_form_entries_attributes_2_value"></textarea>
</fieldset>
<input value="899509" type="hidden" name="intake_form[entries_attributes][3][form_field_id]" id="intake_form_entries_attributes_3_form_field_id">
<input value="YesNo" type="hidden" name="intake_form[entries_attributes][3][kind]" id="intake_form_entries_attributes_3_kind">
<input value="4" type="hidden" name="intake_form[entries_attributes][3][priority]" id="intake_form_entries_attributes_3_priority">
<input value="Tiene familia inmediata ciudadana o residente de los EEUU? " maxlength="3154" onkeydown="lengthEnforcer(this)" size="3154" type="hidden" name="intake_form[entries_attributes][3][followup_question_text]"
id="intake_form_entries_attributes_3_followup_question_text">
<fieldset class="form-field-set">
<legend>
<h4 class="form-question"><label class="question-type control-label" for="intake_form_entries_attributes_3_value">Tiene familia inmediata ciudadana o residente de los EEUU? </label></h4>
</legend>
<div class="radio-label radio">
<input value="Yes" type="hidden" name="intake_form[entries_attributes][3][form_field_options_attributes][0][option_label]" id="intake_form_entries_attributes_3_form_field_options_attributes_0_option_label">
<input class="radio-yes_no" data-target="Yes" type="radio" value="Yes" name="intake_form[entries_attributes][3][value]" id="intake_form_entries_attributes_3_value_yes">
<label for="intake_form_entries_attributes_3_value_yes">Yes</label>
<div class="followup_ques_wrapper">
<div class="hidden yes_no">
<input value="Por favor indique quienes son sus familiares ciudadanos y/o residentes de los EEUU (Ej: hermano ciudadano, papa residente, hijos ciudadanos). " type="hidden"
name="intake_form[entries_attributes][3][form_field_options_attributes][0][followup_questions_attributes][0][question_label]"
id="intake_form_entries_attributes_3_form_field_options_attributes_0_followup_questions_attributes_0_question_label">
<label>Por favor indique quienes son sus familiares ciudadanos y/o residentes de los EEUU (Ej: hermano ciudadano, papa residente, hijos ciudadanos). </label>
<div class="tip-text">
<i class="fa fa-lightbulb-o tip-lightbulb"></i> Familia inmediata incluye SOLAMENTE padres, esposo(a), hermanos, y hijos. Primos, abuelos, y tios NO son familiars inmediatas.
</div>
<input value="" type="hidden" name="intake_form[entries_attributes][3][form_field_options_attributes][0][followup_questions_attributes][0][matter_custom]"
id="intake_form_entries_attributes_3_form_field_options_attributes_0_followup_questions_attributes_0_matter_custom">
<input value="" type="hidden" name="intake_form[entries_attributes][3][form_field_options_attributes][0][followup_questions_attributes][0][contact_custom]"
id="intake_form_entries_attributes_3_form_field_options_attributes_0_followup_questions_attributes_0_contact_custom">
<input type="hidden" name="intake_form[entries_attributes][3][form_field_options_attributes][0][followup_questions_attributes][0][form_template_contact_id]"
id="intake_form_entries_attributes_3_form_field_options_attributes_0_followup_questions_attributes_0_form_template_contact_id">
<input value="Paragraph Text" type="hidden" name="intake_form[entries_attributes][3][form_field_options_attributes][0][followup_questions_attributes][0][question_type]"
id="intake_form_entries_attributes_3_form_field_options_attributes_0_followup_questions_attributes_0_question_type">
<textarea class="grow/paragraph_text optional form-control" maxlength="65535" name="intake_form[entries_attributes][3][form_field_options_attributes][0][followup_questions_attributes][0][answer]"
id="intake_form_entries_attributes_3_form_field_options_attributes_0_followup_questions_attributes_0_answer"></textarea>
</div>
</div>
<input value="No" type="hidden" name="intake_form[entries_attributes][3][form_field_options_attributes][1][option_label]" id="intake_form_entries_attributes_3_form_field_options_attributes_1_option_label">
<input class="radio-yes_no" data-target="No" type="radio" value="No" name="intake_form[entries_attributes][3][value]" id="intake_form_entries_attributes_3_value_no">
<label for="intake_form_entries_attributes_3_value_no">No</label>
<div class="followup_ques_wrapper">
<div class="hidden yes_no">
</div>
</div>
</div>
</fieldset>
<input value="899531" type="hidden" name="intake_form[entries_attributes][4][form_field_id]" id="intake_form_entries_attributes_4_form_field_id">
<input value="YesNo" type="hidden" name="intake_form[entries_attributes][4][kind]" id="intake_form_entries_attributes_4_kind">
<input value="5" type="hidden" name="intake_form[entries_attributes][4][priority]" id="intake_form_entries_attributes_4_priority">
<input value="Ha aplicado para la residencia o un permiso de trabajo en el pasado? " maxlength="3154" onkeydown="lengthEnforcer(this)" size="3154" type="hidden" name="intake_form[entries_attributes][4][followup_question_text]"
id="intake_form_entries_attributes_4_followup_question_text">
<fieldset class="form-field-set">
<legend>
<h4 class="form-question"><label class="question-type control-label" for="intake_form_entries_attributes_4_value">Ha aplicado para la residencia o un permiso de trabajo en el pasado? </label></h4>
</legend>
<div class="radio-label radio">
<input value="Yes" type="hidden" name="intake_form[entries_attributes][4][form_field_options_attributes][0][option_label]" id="intake_form_entries_attributes_4_form_field_options_attributes_0_option_label">
<input class="radio-yes_no" data-target="Yes" type="radio" value="Yes" name="intake_form[entries_attributes][4][value]" id="intake_form_entries_attributes_4_value_yes">
<label for="intake_form_entries_attributes_4_value_yes">Yes</label>
<div class="followup_ques_wrapper">
<div class="hidden yes_no">
<input value="Por favor indique 1) CUANDO y 2) MOTIVO DE LA SOLICITUD/APLICACION. " type="hidden" name="intake_form[entries_attributes][4][form_field_options_attributes][0][followup_questions_attributes][0][question_label]"
id="intake_form_entries_attributes_4_form_field_options_attributes_0_followup_questions_attributes_0_question_label">
<label>Por favor indique 1) CUANDO y 2) MOTIVO DE LA SOLICITUD/APLICACION. </label>
<div class="tip-text">
<i class="fa fa-lightbulb-o tip-lightbulb"></i> EJ: 1) 1995; 2) peticion por medio de papa ciudadano.
</div>
<input value="" type="hidden" name="intake_form[entries_attributes][4][form_field_options_attributes][0][followup_questions_attributes][0][matter_custom]"
id="intake_form_entries_attributes_4_form_field_options_attributes_0_followup_questions_attributes_0_matter_custom">
<input value="" type="hidden" name="intake_form[entries_attributes][4][form_field_options_attributes][0][followup_questions_attributes][0][contact_custom]"
id="intake_form_entries_attributes_4_form_field_options_attributes_0_followup_questions_attributes_0_contact_custom">
<input type="hidden" name="intake_form[entries_attributes][4][form_field_options_attributes][0][followup_questions_attributes][0][form_template_contact_id]"
id="intake_form_entries_attributes_4_form_field_options_attributes_0_followup_questions_attributes_0_form_template_contact_id">
<input value="Single Line Text" type="hidden" name="intake_form[entries_attributes][4][form_field_options_attributes][0][followup_questions_attributes][0][question_type]"
id="intake_form_entries_attributes_4_form_field_options_attributes_0_followup_questions_attributes_0_question_type">
<input class="grow/single_line_text optional form-control" maxlength="255" size="255" type="text" name="intake_form[entries_attributes][4][form_field_options_attributes][0][followup_questions_attributes][0][answer]"
id="intake_form_entries_attributes_4_form_field_options_attributes_0_followup_questions_attributes_0_answer">
</div>
</div>
<input value="No" type="hidden" name="intake_form[entries_attributes][4][form_field_options_attributes][1][option_label]" id="intake_form_entries_attributes_4_form_field_options_attributes_1_option_label">
<input class="radio-yes_no" data-target="No" type="radio" value="No" name="intake_form[entries_attributes][4][value]" id="intake_form_entries_attributes_4_value_no">
<label for="intake_form_entries_attributes_4_value_no">No</label>
<div class="followup_ques_wrapper">
<div class="hidden yes_no">
</div>
</div>
</div>
</fieldset>
<input value="899557" type="hidden" name="intake_form[entries_attributes][5][form_field_id]" id="intake_form_entries_attributes_5_form_field_id">
<input value="YesNo" type="hidden" name="intake_form[entries_attributes][5][kind]" id="intake_form_entries_attributes_5_kind">
<input value="6" type="hidden" name="intake_form[entries_attributes][5][priority]" id="intake_form_entries_attributes_5_priority">
<input value="Alguna vez ha presentado una tarjeta de residencia, visa o cualuquier otro documento falso?" maxlength="3154" onkeydown="lengthEnforcer(this)" size="3154" type="hidden"
name="intake_form[entries_attributes][5][followup_question_text]" id="intake_form_entries_attributes_5_followup_question_text">
<fieldset class="form-field-set">
<legend>
<h4 class="form-question"><label class="question-type control-label" for="intake_form_entries_attributes_5_value">Alguna vez ha presentado una tarjeta de residencia, visa o cualuquier otro documento falso?</label></h4>
</legend>
<div class="radio-label radio">
<input value="Yes" type="hidden" name="intake_form[entries_attributes][5][form_field_options_attributes][0][option_label]" id="intake_form_entries_attributes_5_form_field_options_attributes_0_option_label">
<input class="radio-yes_no" data-target="Yes" type="radio" value="Yes" name="intake_form[entries_attributes][5][value]" id="intake_form_entries_attributes_5_value_yes">
<label for="intake_form_entries_attributes_5_value_yes">Yes</label>
<div class="followup_ques_wrapper">
<div class="hidden yes_no">
<input value="1) que tipo de documento falso? 2) donde lo uso? " type="hidden" name="intake_form[entries_attributes][5][form_field_options_attributes][0][followup_questions_attributes][0][question_label]"
id="intake_form_entries_attributes_5_form_field_options_attributes_0_followup_questions_attributes_0_question_label">
<label>1) que tipo de documento falso? 2) donde lo uso? </label>
<input value="" type="hidden" name="intake_form[entries_attributes][5][form_field_options_attributes][0][followup_questions_attributes][0][matter_custom]"
id="intake_form_entries_attributes_5_form_field_options_attributes_0_followup_questions_attributes_0_matter_custom">
<input value="" type="hidden" name="intake_form[entries_attributes][5][form_field_options_attributes][0][followup_questions_attributes][0][contact_custom]"
id="intake_form_entries_attributes_5_form_field_options_attributes_0_followup_questions_attributes_0_contact_custom">
<input type="hidden" name="intake_form[entries_attributes][5][form_field_options_attributes][0][followup_questions_attributes][0][form_template_contact_id]"
id="intake_form_entries_attributes_5_form_field_options_attributes_0_followup_questions_attributes_0_form_template_contact_id">
<input value="Single Line Text" type="hidden" name="intake_form[entries_attributes][5][form_field_options_attributes][0][followup_questions_attributes][0][question_type]"
id="intake_form_entries_attributes_5_form_field_options_attributes_0_followup_questions_attributes_0_question_type">
<input class="grow/single_line_text optional form-control" maxlength="255" size="255" type="text" name="intake_form[entries_attributes][5][form_field_options_attributes][0][followup_questions_attributes][0][answer]"
id="intake_form_entries_attributes_5_form_field_options_attributes_0_followup_questions_attributes_0_answer">
</div>
</div>
<input value="No" type="hidden" name="intake_form[entries_attributes][5][form_field_options_attributes][1][option_label]" id="intake_form_entries_attributes_5_form_field_options_attributes_1_option_label">
<input class="radio-yes_no" data-target="No" type="radio" value="No" name="intake_form[entries_attributes][5][value]" id="intake_form_entries_attributes_5_value_no">
<label for="intake_form_entries_attributes_5_value_no">No</label>
<div class="followup_ques_wrapper">
<div class="hidden yes_no">
</div>
</div>
</div>
</fieldset>
<input value="899575" type="hidden" name="intake_form[entries_attributes][6][form_field_id]" id="intake_form_entries_attributes_6_form_field_id">
<input value="YesNo" type="hidden" name="intake_form[entries_attributes][6][kind]" id="intake_form_entries_attributes_6_kind">
<input value="7" type="hidden" name="intake_form[entries_attributes][6][priority]" id="intake_form_entries_attributes_6_priority">
<input value="Ud. alguna vez ha dicho que es ciudadan(o/a) de los EEUU? " maxlength="3154" onkeydown="lengthEnforcer(this)" size="3154" type="hidden" name="intake_form[entries_attributes][6][followup_question_text]"
id="intake_form_entries_attributes_6_followup_question_text">
<fieldset class="form-field-set">
<legend>
<h4 class="form-question"><label class="question-type control-label" for="intake_form_entries_attributes_6_value">Ud. alguna vez ha dicho que es ciudadan(o/a) de los EEUU? </label></h4>
</legend>
<div class="radio-label radio">
<input value="Yes" type="hidden" name="intake_form[entries_attributes][6][form_field_options_attributes][0][option_label]" id="intake_form_entries_attributes_6_form_field_options_attributes_0_option_label">
<input class="radio-yes_no" data-target="Yes" type="radio" value="Yes" name="intake_form[entries_attributes][6][value]" id="intake_form_entries_attributes_6_value_yes">
<label for="intake_form_entries_attributes_6_value_yes">Yes</label>
<div class="followup_ques_wrapper">
<div class="hidden yes_no">
<input value="Cuando y adonde? " type="hidden" name="intake_form[entries_attributes][6][form_field_options_attributes][0][followup_questions_attributes][0][question_label]"
id="intake_form_entries_attributes_6_form_field_options_attributes_0_followup_questions_attributes_0_question_label">
<label>Cuando y adonde? </label>
<input value="" type="hidden" name="intake_form[entries_attributes][6][form_field_options_attributes][0][followup_questions_attributes][0][matter_custom]"
id="intake_form_entries_attributes_6_form_field_options_attributes_0_followup_questions_attributes_0_matter_custom">
<input value="" type="hidden" name="intake_form[entries_attributes][6][form_field_options_attributes][0][followup_questions_attributes][0][contact_custom]"
id="intake_form_entries_attributes_6_form_field_options_attributes_0_followup_questions_attributes_0_contact_custom">
<input type="hidden" name="intake_form[entries_attributes][6][form_field_options_attributes][0][followup_questions_attributes][0][form_template_contact_id]"
id="intake_form_entries_attributes_6_form_field_options_attributes_0_followup_questions_attributes_0_form_template_contact_id">
<input value="Single Line Text" type="hidden" name="intake_form[entries_attributes][6][form_field_options_attributes][0][followup_questions_attributes][0][question_type]"
id="intake_form_entries_attributes_6_form_field_options_attributes_0_followup_questions_attributes_0_question_type">
<input class="grow/single_line_text optional form-control" maxlength="255" size="255" type="text" name="intake_form[entries_attributes][6][form_field_options_attributes][0][followup_questions_attributes][0][answer]"
id="intake_form_entries_attributes_6_form_field_options_attributes_0_followup_questions_attributes_0_answer">
</div>
</div>
<input value="No" type="hidden" name="intake_form[entries_attributes][6][form_field_options_attributes][1][option_label]" id="intake_form_entries_attributes_6_form_field_options_attributes_1_option_label">
<input class="radio-yes_no" data-target="No" type="radio" value="No" name="intake_form[entries_attributes][6][value]" id="intake_form_entries_attributes_6_value_no">
<label for="intake_form_entries_attributes_6_value_no">No</label>
<div class="followup_ques_wrapper">
<div class="hidden yes_no">
</div>
</div>
</div>
</fieldset>
<input value="899591" type="hidden" name="intake_form[entries_attributes][7][form_field_id]" id="intake_form_entries_attributes_7_form_field_id">
<input value="YesNo" type="hidden" name="intake_form[entries_attributes][7][kind]" id="intake_form_entries_attributes_7_kind">
<input value="8" type="hidden" name="intake_form[entries_attributes][7][priority]" id="intake_form_entries_attributes_7_priority">
<input value="Ud. alguna vez ha ayudado a alguien (incluyendo familiares) entrar a los EEUU ilegalmente? " maxlength="3154" onkeydown="lengthEnforcer(this)" size="3154" type="hidden"
name="intake_form[entries_attributes][7][followup_question_text]" id="intake_form_entries_attributes_7_followup_question_text">
<fieldset class="form-field-set">
<legend>
<h4 class="form-question"><label class="question-type control-label" for="intake_form_entries_attributes_7_value">Ud. alguna vez ha ayudado a alguien (incluyendo familiares) entrar a los EEUU ilegalmente? </label></h4>
</legend>
<div class="radio-label radio">
<input value="Yes" type="hidden" name="intake_form[entries_attributes][7][form_field_options_attributes][0][option_label]" id="intake_form_entries_attributes_7_form_field_options_attributes_0_option_label">
<input class="radio-yes_no" data-target="Yes" type="radio" value="Yes" name="intake_form[entries_attributes][7][value]" id="intake_form_entries_attributes_7_value_yes">
<label for="intake_form_entries_attributes_7_value_yes">Yes</label>
<div class="followup_ques_wrapper">
<div class="hidden yes_no">
<input value="Cuando y a quien ayudo entrar? " type="hidden" name="intake_form[entries_attributes][7][form_field_options_attributes][0][followup_questions_attributes][0][question_label]"
id="intake_form_entries_attributes_7_form_field_options_attributes_0_followup_questions_attributes_0_question_label">
<label>Cuando y a quien ayudo entrar? </label>
<input value="" type="hidden" name="intake_form[entries_attributes][7][form_field_options_attributes][0][followup_questions_attributes][0][matter_custom]"
id="intake_form_entries_attributes_7_form_field_options_attributes_0_followup_questions_attributes_0_matter_custom">
<input value="" type="hidden" name="intake_form[entries_attributes][7][form_field_options_attributes][0][followup_questions_attributes][0][contact_custom]"
id="intake_form_entries_attributes_7_form_field_options_attributes_0_followup_questions_attributes_0_contact_custom">
<input type="hidden" name="intake_form[entries_attributes][7][form_field_options_attributes][0][followup_questions_attributes][0][form_template_contact_id]"
id="intake_form_entries_attributes_7_form_field_options_attributes_0_followup_questions_attributes_0_form_template_contact_id">
<input value="Single Line Text" type="hidden" name="intake_form[entries_attributes][7][form_field_options_attributes][0][followup_questions_attributes][0][question_type]"
id="intake_form_entries_attributes_7_form_field_options_attributes_0_followup_questions_attributes_0_question_type">
<input class="grow/single_line_text optional form-control" maxlength="255" size="255" type="text" name="intake_form[entries_attributes][7][form_field_options_attributes][0][followup_questions_attributes][0][answer]"
id="intake_form_entries_attributes_7_form_field_options_attributes_0_followup_questions_attributes_0_answer">
</div>
</div>
<input value="No" type="hidden" name="intake_form[entries_attributes][7][form_field_options_attributes][1][option_label]" id="intake_form_entries_attributes_7_form_field_options_attributes_1_option_label">
<input class="radio-yes_no" data-target="No" type="radio" value="No" name="intake_form[entries_attributes][7][value]" id="intake_form_entries_attributes_7_value_no">
<label for="intake_form_entries_attributes_7_value_no">No</label>
<div class="followup_ques_wrapper">
<div class="hidden yes_no">
</div>
</div>
</div>
</fieldset>
<input value="899607" type="hidden" name="intake_form[entries_attributes][8][form_field_id]" id="intake_form_entries_attributes_8_form_field_id">
<input value="YesNo" type="hidden" name="intake_form[entries_attributes][8][kind]" id="intake_form_entries_attributes_8_kind">
<input value="9" type="hidden" name="intake_form[entries_attributes][8][priority]" id="intake_form_entries_attributes_8_priority">
<input value="Ud. entro con visa cuando entro la ultima vez a los EEUU? " maxlength="3154" onkeydown="lengthEnforcer(this)" size="3154" type="hidden" name="intake_form[entries_attributes][8][followup_question_text]"
id="intake_form_entries_attributes_8_followup_question_text">
<fieldset class="form-field-set">
<legend>
<h4 class="form-question"><label class="question-type control-label" for="intake_form_entries_attributes_8_value">Ud. entro con visa cuando entro la ultima vez a los EEUU? </label></h4>
</legend>
<div class="radio-label radio">
<input value="Yes" type="hidden" name="intake_form[entries_attributes][8][form_field_options_attributes][0][option_label]" id="intake_form_entries_attributes_8_form_field_options_attributes_0_option_label">
<input class="radio-yes_no" data-target="Yes" type="radio" value="Yes" name="intake_form[entries_attributes][8][value]" id="intake_form_entries_attributes_8_value_yes">
<label for="intake_form_entries_attributes_8_value_yes">Yes</label>
<div class="followup_ques_wrapper">
<div class="hidden yes_no">
</div>
</div>
<input value="No" type="hidden" name="intake_form[entries_attributes][8][form_field_options_attributes][1][option_label]" id="intake_form_entries_attributes_8_form_field_options_attributes_1_option_label">
<input class="radio-yes_no" data-target="No" type="radio" value="No" name="intake_form[entries_attributes][8][value]" id="intake_form_entries_attributes_8_value_no">
<label for="intake_form_entries_attributes_8_value_no">No</label>
<div class="followup_ques_wrapper">
<div class="hidden yes_no">
</div>
</div>
</div>
</fieldset>
<input value="899619" type="hidden" name="intake_form[entries_attributes][9][form_field_id]" id="intake_form_entries_attributes_9_form_field_id">
<input value="TextArea" type="hidden" name="intake_form[entries_attributes][9][kind]" id="intake_form_entries_attributes_9_kind">
<input value="10" type="hidden" name="intake_form[entries_attributes][9][priority]" id="intake_form_entries_attributes_9_priority">
<input value="Por favor escriba todas sus entradas a y salidas de los EEUU en ORDEN por FECHA. " maxlength="3154" onkeydown="lengthEnforcer(this)" size="3154" type="hidden" name="intake_form[entries_attributes][9][followup_question_text]"
id="intake_form_entries_attributes_9_followup_question_text">
<fieldset class="form-field-set">
<legend>
<h4 class="form-question"><label class="question-type control-label" for="intake_form_entries_attributes_9_value">Por favor escriba todas sus entradas a y salidas de los EEUU en ORDEN por FECHA. </label></h4>
</legend>
<div class="lex-margin-bottom-20px">
<div class="tip-text">
<i class="fa fa-lightbulb-o tip-lightbulb"></i> Ej: 1) Entrada 07/1989-Salida 05/1995; 2) Entrada 04/1997. Nunca mas sali.
</div>
</div>
<textarea rows="5" placeholder="Please enter your response" class="form-control" maxlength="65535" name="intake_form[entries_attributes][9][value]" id="intake_form_entries_attributes_9_value"></textarea>
</fieldset>
<input value="899629" type="hidden" name="intake_form[entries_attributes][10][form_field_id]" id="intake_form_entries_attributes_10_form_field_id">
<input value="YesNo" type="hidden" name="intake_form[entries_attributes][10][kind]" id="intake_form_entries_attributes_10_kind">
<input value="11" type="hidden" name="intake_form[entries_attributes][10][priority]" id="intake_form_entries_attributes_10_priority">
<input value="Ha sido arrestado/detenido por inmigracion? " maxlength="3154" onkeydown="lengthEnforcer(this)" size="3154" type="hidden" name="intake_form[entries_attributes][10][followup_question_text]"
id="intake_form_entries_attributes_10_followup_question_text">
<fieldset class="form-field-set">
<legend>
<h4 class="form-question"><label class="question-type control-label" for="intake_form_entries_attributes_10_value">Ha sido arrestado/detenido por inmigracion? </label></h4>
</legend>
<div class="radio-label radio">
<input value="Yes" type="hidden" name="intake_form[entries_attributes][10][form_field_options_attributes][0][option_label]" id="intake_form_entries_attributes_10_form_field_options_attributes_0_option_label">
<input class="radio-yes_no" data-target="Yes" type="radio" value="Yes" name="intake_form[entries_attributes][10][value]" id="intake_form_entries_attributes_10_value_yes">
<label for="intake_form_entries_attributes_10_value_yes">Yes</label>
<div class="followup_ques_wrapper">
<div class="hidden yes_no">
<input value="Cuando? " type="hidden" name="intake_form[entries_attributes][10][form_field_options_attributes][0][followup_questions_attributes][0][question_label]"
id="intake_form_entries_attributes_10_form_field_options_attributes_0_followup_questions_attributes_0_question_label">
<label>Cuando? </label>
<input value="" type="hidden" name="intake_form[entries_attributes][10][form_field_options_attributes][0][followup_questions_attributes][0][matter_custom]"
id="intake_form_entries_attributes_10_form_field_options_attributes_0_followup_questions_attributes_0_matter_custom">
<input value="" type="hidden" name="intake_form[entries_attributes][10][form_field_options_attributes][0][followup_questions_attributes][0][contact_custom]"
id="intake_form_entries_attributes_10_form_field_options_attributes_0_followup_questions_attributes_0_contact_custom">
<input type="hidden" name="intake_form[entries_attributes][10][form_field_options_attributes][0][followup_questions_attributes][0][form_template_contact_id]"
id="intake_form_entries_attributes_10_form_field_options_attributes_0_followup_questions_attributes_0_form_template_contact_id">
<input value="Single Line Text" type="hidden" name="intake_form[entries_attributes][10][form_field_options_attributes][0][followup_questions_attributes][0][question_type]"
id="intake_form_entries_attributes_10_form_field_options_attributes_0_followup_questions_attributes_0_question_type">
<input class="grow/single_line_text optional form-control" maxlength="255" size="255" type="text" name="intake_form[entries_attributes][10][form_field_options_attributes][0][followup_questions_attributes][0][answer]"
id="intake_form_entries_attributes_10_form_field_options_attributes_0_followup_questions_attributes_0_answer">
<input value="Adonde? " type="hidden" name="intake_form[entries_attributes][10][form_field_options_attributes][0][followup_questions_attributes][1][question_label]"
id="intake_form_entries_attributes_10_form_field_options_attributes_0_followup_questions_attributes_1_question_label">
<label>Adonde? </label>
<input value="" type="hidden" name="intake_form[entries_attributes][10][form_field_options_attributes][0][followup_questions_attributes][1][matter_custom]"
id="intake_form_entries_attributes_10_form_field_options_attributes_0_followup_questions_attributes_1_matter_custom">
<input value="" type="hidden" name="intake_form[entries_attributes][10][form_field_options_attributes][0][followup_questions_attributes][1][contact_custom]"
id="intake_form_entries_attributes_10_form_field_options_attributes_0_followup_questions_attributes_1_contact_custom">
<input type="hidden" name="intake_form[entries_attributes][10][form_field_options_attributes][0][followup_questions_attributes][1][form_template_contact_id]"
id="intake_form_entries_attributes_10_form_field_options_attributes_0_followup_questions_attributes_1_form_template_contact_id">
<input value="Single Line Text" type="hidden" name="intake_form[entries_attributes][10][form_field_options_attributes][0][followup_questions_attributes][1][question_type]"
id="intake_form_entries_attributes_10_form_field_options_attributes_0_followup_questions_attributes_1_question_type">
<input class="grow/single_line_text optional form-control" maxlength="255" size="255" type="text" name="intake_form[entries_attributes][10][form_field_options_attributes][0][followup_questions_attributes][1][answer]"
id="intake_form_entries_attributes_10_form_field_options_attributes_0_followup_questions_attributes_1_answer">
<input value="Le tomaron huellas? " type="hidden" name="intake_form[entries_attributes][10][form_field_options_attributes][0][followup_questions_attributes][2][question_label]"
id="intake_form_entries_attributes_10_form_field_options_attributes_0_followup_questions_attributes_2_question_label">
<label>Le tomaron huellas? </label>
<input value="" type="hidden" name="intake_form[entries_attributes][10][form_field_options_attributes][0][followup_questions_attributes][2][matter_custom]"
id="intake_form_entries_attributes_10_form_field_options_attributes_0_followup_questions_attributes_2_matter_custom">
<input value="" type="hidden" name="intake_form[entries_attributes][10][form_field_options_attributes][0][followup_questions_attributes][2][contact_custom]"
id="intake_form_entries_attributes_10_form_field_options_attributes_0_followup_questions_attributes_2_contact_custom">
<input type="hidden" name="intake_form[entries_attributes][10][form_field_options_attributes][0][followup_questions_attributes][2][form_template_contact_id]"
id="intake_form_entries_attributes_10_form_field_options_attributes_0_followup_questions_attributes_2_form_template_contact_id">
<input value="Single Line Text" type="hidden" name="intake_form[entries_attributes][10][form_field_options_attributes][0][followup_questions_attributes][2][question_type]"
id="intake_form_entries_attributes_10_form_field_options_attributes_0_followup_questions_attributes_2_question_type">
<input class="grow/single_line_text optional form-control" maxlength="255" size="255" type="text" name="intake_form[entries_attributes][10][form_field_options_attributes][0][followup_questions_attributes][2][answer]"
id="intake_form_entries_attributes_10_form_field_options_attributes_0_followup_questions_attributes_2_answer">
</div>
</div>
<input value="No" type="hidden" name="intake_form[entries_attributes][10][form_field_options_attributes][1][option_label]" id="intake_form_entries_attributes_10_form_field_options_attributes_1_option_label">
<input class="radio-yes_no" data-target="No" type="radio" value="No" name="intake_form[entries_attributes][10][value]" id="intake_form_entries_attributes_10_value_no">
<label for="intake_form_entries_attributes_10_value_no">No</label>
<div class="followup_ques_wrapper">
<div class="hidden yes_no">
</div>
</div>
</div>
</fieldset>
<input value="899641" type="hidden" name="intake_form[entries_attributes][11][form_field_id]" id="intake_form_entries_attributes_11_form_field_id">
<input value="YesNo" type="hidden" name="intake_form[entries_attributes][11][kind]" id="intake_form_entries_attributes_11_kind">
<input value="12" type="hidden" name="intake_form[entries_attributes][11][priority]" id="intake_form_entries_attributes_11_priority">
<input value="Ha usted tenido problemas con la policia (incluyendo de transito)? " maxlength="3154" onkeydown="lengthEnforcer(this)" size="3154" type="hidden" name="intake_form[entries_attributes][11][followup_question_text]"
id="intake_form_entries_attributes_11_followup_question_text">
<fieldset class="form-field-set">
<legend>
<h4 class="form-question"><label class="question-type control-label" for="intake_form_entries_attributes_11_value">Ha usted tenido problemas con la policia (incluyendo de transito)? </label></h4>
</legend>
<div class="radio-label radio">
<input value="Yes" type="hidden" name="intake_form[entries_attributes][11][form_field_options_attributes][0][option_label]" id="intake_form_entries_attributes_11_form_field_options_attributes_0_option_label">
<input class="radio-yes_no" data-target="Yes" type="radio" value="Yes" name="intake_form[entries_attributes][11][value]" id="intake_form_entries_attributes_11_value_yes">
<label for="intake_form_entries_attributes_11_value_yes">Yes</label>
<div class="followup_ques_wrapper">
<div class="hidden yes_no">
<input value="Que paso? " type="hidden" name="intake_form[entries_attributes][11][form_field_options_attributes][0][followup_questions_attributes][0][question_label]"
id="intake_form_entries_attributes_11_form_field_options_attributes_0_followup_questions_attributes_0_question_label">
<label>Que paso? </label>
<input value="" type="hidden" name="intake_form[entries_attributes][11][form_field_options_attributes][0][followup_questions_attributes][0][matter_custom]"
id="intake_form_entries_attributes_11_form_field_options_attributes_0_followup_questions_attributes_0_matter_custom">
<input value="" type="hidden" name="intake_form[entries_attributes][11][form_field_options_attributes][0][followup_questions_attributes][0][contact_custom]"
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<input type="hidden" name="intake_form[entries_attributes][11][form_field_options_attributes][0][followup_questions_attributes][0][form_template_contact_id]"
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<input value="Single Line Text" type="hidden" name="intake_form[entries_attributes][11][form_field_options_attributes][0][followup_questions_attributes][0][question_type]"
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<input class="grow/single_line_text optional form-control" maxlength="255" size="255" type="text" name="intake_form[entries_attributes][11][form_field_options_attributes][0][followup_questions_attributes][0][answer]"
id="intake_form_entries_attributes_11_form_field_options_attributes_0_followup_questions_attributes_0_answer">
<input value="Cuando paso? " type="hidden" name="intake_form[entries_attributes][11][form_field_options_attributes][0][followup_questions_attributes][1][question_label]"
id="intake_form_entries_attributes_11_form_field_options_attributes_0_followup_questions_attributes_1_question_label">
<label>Cuando paso? </label>
<input value="" type="hidden" name="intake_form[entries_attributes][11][form_field_options_attributes][0][followup_questions_attributes][1][matter_custom]"
id="intake_form_entries_attributes_11_form_field_options_attributes_0_followup_questions_attributes_1_matter_custom">
<input value="" type="hidden" name="intake_form[entries_attributes][11][form_field_options_attributes][0][followup_questions_attributes][1][contact_custom]"
id="intake_form_entries_attributes_11_form_field_options_attributes_0_followup_questions_attributes_1_contact_custom">
<input type="hidden" name="intake_form[entries_attributes][11][form_field_options_attributes][0][followup_questions_attributes][1][form_template_contact_id]"
id="intake_form_entries_attributes_11_form_field_options_attributes_0_followup_questions_attributes_1_form_template_contact_id">
<input value="Single Line Text" type="hidden" name="intake_form[entries_attributes][11][form_field_options_attributes][0][followup_questions_attributes][1][question_type]"
id="intake_form_entries_attributes_11_form_field_options_attributes_0_followup_questions_attributes_1_question_type">
<input class="grow/single_line_text optional form-control" maxlength="255" size="255" type="text" name="intake_form[entries_attributes][11][form_field_options_attributes][0][followup_questions_attributes][1][answer]"
id="intake_form_entries_attributes_11_form_field_options_attributes_0_followup_questions_attributes_1_answer">
<input value="Si fue a corte obtuvo usted conviction de culpable? " type="hidden" name="intake_form[entries_attributes][11][form_field_options_attributes][0][followup_questions_attributes][2][question_label]"
id="intake_form_entries_attributes_11_form_field_options_attributes_0_followup_questions_attributes_2_question_label">
<label>Si fue a corte obtuvo usted conviction de culpable? </label>
<input value="" type="hidden" name="intake_form[entries_attributes][11][form_field_options_attributes][0][followup_questions_attributes][2][matter_custom]"
id="intake_form_entries_attributes_11_form_field_options_attributes_0_followup_questions_attributes_2_matter_custom">
<input value="" type="hidden" name="intake_form[entries_attributes][11][form_field_options_attributes][0][followup_questions_attributes][2][contact_custom]"
id="intake_form_entries_attributes_11_form_field_options_attributes_0_followup_questions_attributes_2_contact_custom">
<input type="hidden" name="intake_form[entries_attributes][11][form_field_options_attributes][0][followup_questions_attributes][2][form_template_contact_id]"
id="intake_form_entries_attributes_11_form_field_options_attributes_0_followup_questions_attributes_2_form_template_contact_id">
<input value="Single Line Text" type="hidden" name="intake_form[entries_attributes][11][form_field_options_attributes][0][followup_questions_attributes][2][question_type]"
id="intake_form_entries_attributes_11_form_field_options_attributes_0_followup_questions_attributes_2_question_type">
<input class="grow/single_line_text optional form-control" maxlength="255" size="255" type="text" name="intake_form[entries_attributes][11][form_field_options_attributes][0][followup_questions_attributes][2][answer]"
id="intake_form_entries_attributes_11_form_field_options_attributes_0_followup_questions_attributes_2_answer">
</div>
</div>
<input value="No" type="hidden" name="intake_form[entries_attributes][11][form_field_options_attributes][1][option_label]" id="intake_form_entries_attributes_11_form_field_options_attributes_1_option_label">
<input class="radio-yes_no" data-target="No" type="radio" value="No" name="intake_form[entries_attributes][11][value]" id="intake_form_entries_attributes_11_value_no">
<label for="intake_form_entries_attributes_11_value_no">No</label>
<div class="followup_ques_wrapper">
<div class="hidden yes_no">
</div>
</div>
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<input value="YesNo" type="hidden" name="intake_form[entries_attributes][12][kind]" id="intake_form_entries_attributes_12_kind">
<input value="13" type="hidden" name="intake_form[entries_attributes][12][priority]" id="intake_form_entries_attributes_12_priority">
<input value="Esta casado/a? " maxlength="3154" onkeydown="lengthEnforcer(this)" size="3154" type="hidden" name="intake_form[entries_attributes][12][followup_question_text]" id="intake_form_entries_attributes_12_followup_question_text">
<fieldset class="form-field-set">
<legend>
<h4 class="form-question"><label class="question-type control-label" for="intake_form_entries_attributes_12_value">Esta casado/a? </label></h4>
</legend>
<div class="radio-label radio">
<input value="Yes" type="hidden" name="intake_form[entries_attributes][12][form_field_options_attributes][0][option_label]" id="intake_form_entries_attributes_12_form_field_options_attributes_0_option_label">
<input class="radio-yes_no" data-target="Yes" type="radio" value="Yes" name="intake_form[entries_attributes][12][value]" id="intake_form_entries_attributes_12_value_yes">
<label for="intake_form_entries_attributes_12_value_yes">Yes</label>
<div class="followup_ques_wrapper">
<div class="hidden yes_no">
<input value="Como se llama su esposo/a? " type="hidden" name="intake_form[entries_attributes][12][form_field_options_attributes][0][followup_questions_attributes][0][question_label]"
id="intake_form_entries_attributes_12_form_field_options_attributes_0_followup_questions_attributes_0_question_label">
<label>Como se llama su esposo/a? </label>
<input value="" type="hidden" name="intake_form[entries_attributes][12][form_field_options_attributes][0][followup_questions_attributes][0][matter_custom]"
id="intake_form_entries_attributes_12_form_field_options_attributes_0_followup_questions_attributes_0_matter_custom">
<input value="" type="hidden" name="intake_form[entries_attributes][12][form_field_options_attributes][0][followup_questions_attributes][0][contact_custom]"
id="intake_form_entries_attributes_12_form_field_options_attributes_0_followup_questions_attributes_0_contact_custom">
<input type="hidden" name="intake_form[entries_attributes][12][form_field_options_attributes][0][followup_questions_attributes][0][form_template_contact_id]"
id="intake_form_entries_attributes_12_form_field_options_attributes_0_followup_questions_attributes_0_form_template_contact_id">
<input value="Single Line Text" type="hidden" name="intake_form[entries_attributes][12][form_field_options_attributes][0][followup_questions_attributes][0][question_type]"
id="intake_form_entries_attributes_12_form_field_options_attributes_0_followup_questions_attributes_0_question_type">
<input class="grow/single_line_text optional form-control" maxlength="255" size="255" type="text" name="intake_form[entries_attributes][12][form_field_options_attributes][0][followup_questions_attributes][0][answer]"
id="intake_form_entries_attributes_12_form_field_options_attributes_0_followup_questions_attributes_0_answer">
<input value="Donde nacio su esposo/a? " type="hidden" name="intake_form[entries_attributes][12][form_field_options_attributes][0][followup_questions_attributes][1][question_label]"
id="intake_form_entries_attributes_12_form_field_options_attributes_0_followup_questions_attributes_1_question_label">
<label>Donde nacio su esposo/a? </label>
<input value="" type="hidden" name="intake_form[entries_attributes][12][form_field_options_attributes][0][followup_questions_attributes][1][matter_custom]"
id="intake_form_entries_attributes_12_form_field_options_attributes_0_followup_questions_attributes_1_matter_custom">
<input value="" type="hidden" name="intake_form[entries_attributes][12][form_field_options_attributes][0][followup_questions_attributes][1][contact_custom]"
id="intake_form_entries_attributes_12_form_field_options_attributes_0_followup_questions_attributes_1_contact_custom">
<input type="hidden" name="intake_form[entries_attributes][12][form_field_options_attributes][0][followup_questions_attributes][1][form_template_contact_id]"
id="intake_form_entries_attributes_12_form_field_options_attributes_0_followup_questions_attributes_1_form_template_contact_id">
<input value="Single Line Text" type="hidden" name="intake_form[entries_attributes][12][form_field_options_attributes][0][followup_questions_attributes][1][question_type]"
id="intake_form_entries_attributes_12_form_field_options_attributes_0_followup_questions_attributes_1_question_type">
<input class="grow/single_line_text optional form-control" maxlength="255" size="255" type="text" name="intake_form[entries_attributes][12][form_field_options_attributes][0][followup_questions_attributes][1][answer]"
id="intake_form_entries_attributes_12_form_field_options_attributes_0_followup_questions_attributes_1_answer">
<input value="Cual es el estatus inmigratorio de su esposo/a? " type="hidden" name="intake_form[entries_attributes][12][form_field_options_attributes][0][followup_questions_attributes][2][question_label]"
id="intake_form_entries_attributes_12_form_field_options_attributes_0_followup_questions_attributes_2_question_label">
<label>Cual es el estatus inmigratorio de su esposo/a? </label>
<div class="tip-text">
<i class="fa fa-lightbulb-o tip-lightbulb"></i> Ej: indocumentado/a o ciudadano/a o residente.
</div>
<input value="" type="hidden" name="intake_form[entries_attributes][12][form_field_options_attributes][0][followup_questions_attributes][2][matter_custom]"
id="intake_form_entries_attributes_12_form_field_options_attributes_0_followup_questions_attributes_2_matter_custom">
<input value="" type="hidden" name="intake_form[entries_attributes][12][form_field_options_attributes][0][followup_questions_attributes][2][contact_custom]"
id="intake_form_entries_attributes_12_form_field_options_attributes_0_followup_questions_attributes_2_contact_custom">
<input type="hidden" name="intake_form[entries_attributes][12][form_field_options_attributes][0][followup_questions_attributes][2][form_template_contact_id]"
id="intake_form_entries_attributes_12_form_field_options_attributes_0_followup_questions_attributes_2_form_template_contact_id">
<input value="Single Line Text" type="hidden" name="intake_form[entries_attributes][12][form_field_options_attributes][0][followup_questions_attributes][2][question_type]"
id="intake_form_entries_attributes_12_form_field_options_attributes_0_followup_questions_attributes_2_question_type">
<input class="grow/single_line_text optional form-control" maxlength="255" size="255" type="text" name="intake_form[entries_attributes][12][form_field_options_attributes][0][followup_questions_attributes][2][answer]"
id="intake_form_entries_attributes_12_form_field_options_attributes_0_followup_questions_attributes_2_answer">
</div>
</div>
<input value="No" type="hidden" name="intake_form[entries_attributes][12][form_field_options_attributes][1][option_label]" id="intake_form_entries_attributes_12_form_field_options_attributes_1_option_label">
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<label for="intake_form_entries_attributes_12_value_no">No</label>
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<div class="hidden yes_no">
</div>
</div>
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<input value="14" type="hidden" name="intake_form[entries_attributes][13][priority]" id="intake_form_entries_attributes_13_priority">
<input value="COMO SUPO DE ESTA OFICINA? " maxlength="3154" onkeydown="lengthEnforcer(this)" size="3154" type="hidden" name="intake_form[entries_attributes][13][followup_question_text]"
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<fieldset class="form-field-set">
<legend>
<h4 class="form-question"><label class="question-type control-label" for="intake_form_entries_attributes_13_value">COMO SUPO DE ESTA OFICINA? </label></h4>
</legend>
<input placeholder="Please enter your response" class="form-control" maxlength="255" size="255" type="text" name="intake_form[entries_attributes][13][value]" id="intake_form_entries_attributes_13_value">
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<div class="col-lg-8 col-centered">
<div class="forms-spacing">
<input type="hidden" value="32021560" name="intake_form[submitter_id]" id="intake_form_submitter_id">
<input type="hidden" value="17413066" name="intake_form[matter_id]" id="intake_form_matter_id">
<input value="6946540" type="hidden" name="intake_form[id]" id="intake_form_id">
<div class="row">
<div class="col col-lg-6">
<input type="submit" name="save_progress" value="Save Progress & Exit" formnovalidate="formnovalidate" class="lex-button lex-button-gray lex-width-100 lex-margin-top-20px" data-disable-with="Saving...">
</div>
<div class="col col-lg-6">
<input type="submit" name="completed" value="Submit" class="lex-button lex-button-blue lex-width-100 lex-margin-top-20px" data-disable-with="Sending...">
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</div>
</div>
</div>
</div>
</form>Text Content
CONTACT INFORMATION SalutationNone Mr Mrs Ms Mx Dr Hon None First Name * Middle Name Last Name * Company Emails Email Address Type Work Home Other Home PrimaryDefault email false Add Email Addresses Street Address Country United States Canada United Kingdom Australia --------------- Afghanistan Åland 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 Bolivia, Plurinational State of Bonaire, Sint Eustatius 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 Congo, The Democratic Republic of the Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland 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 Iran, Islamic Republic of Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia, Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of 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 Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Réunion Romania Russian Federation Rwanda Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic of 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 States Minor Outlying Islands United States Uruguay Uzbekistan Vanuatu Venezuela, Bolivarian Republic of Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe United States City State/Region Armed Forces Americas Armed Forces Europe Alaska Alabama Armed Forces Pacific Arkansas American Samoa Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Northern Mariana Islands Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas United States Minor Outlying Islands Utah Virginia Virgin Islands, U.S. Vermont Washington Wisconsin West Virginia Wyoming Select Province/Region Zip/Postal Code Address TypeWork Billing Home Other Home PrimaryDefault address false Add Address Phone Numbers Phone Number Type Work Home Mobile Fax Pager Skype Other Home Primary Remove Add Phone Number SU HISTORIA Por favor conteste cada pregunta a sus mejores abilidades. CON MAS DETALLE LA ABOGADA PUEDE DARLE CONSULTA MAS PRECISA. *** SI TIENE HIJOS, FAVOR DE NOMBRAR CADA UNO E INCLUIR FECHA Y PAIS DE NACIMIENTO [EJ: 1) JUAN PEREZ; 5/27/05; MEXICO. 2) ALMA PEREZ; 6/21/13; EEUU]: TIENE FAMILIA INMEDIATA CIUDADANA O RESIDENTE DE LOS EEUU? Yes Por favor indique quienes son sus familiares ciudadanos y/o residentes de los EEUU (Ej: hermano ciudadano, papa residente, hijos ciudadanos). Familia inmediata incluye SOLAMENTE padres, esposo(a), hermanos, y hijos. Primos, abuelos, y tios NO son familiars inmediatas. No HA APLICADO PARA LA RESIDENCIA O UN PERMISO DE TRABAJO EN EL PASADO? Yes Por favor indique 1) CUANDO y 2) MOTIVO DE LA SOLICITUD/APLICACION. EJ: 1) 1995; 2) peticion por medio de papa ciudadano. No ALGUNA VEZ HA PRESENTADO UNA TARJETA DE RESIDENCIA, VISA O CUALUQUIER OTRO DOCUMENTO FALSO? Yes 1) que tipo de documento falso? 2) donde lo uso? No UD. ALGUNA VEZ HA DICHO QUE ES CIUDADAN(O/A) DE LOS EEUU? Yes Cuando y adonde? No UD. ALGUNA VEZ HA AYUDADO A ALGUIEN (INCLUYENDO FAMILIARES) ENTRAR A LOS EEUU ILEGALMENTE? Yes Cuando y a quien ayudo entrar? No UD. ENTRO CON VISA CUANDO ENTRO LA ULTIMA VEZ A LOS EEUU? Yes No POR FAVOR ESCRIBA TODAS SUS ENTRADAS A Y SALIDAS DE LOS EEUU EN ORDEN POR FECHA. Ej: 1) Entrada 07/1989-Salida 05/1995; 2) Entrada 04/1997. Nunca mas sali. HA SIDO ARRESTADO/DETENIDO POR INMIGRACION? Yes Cuando? Adonde? Le tomaron huellas? No HA USTED TENIDO PROBLEMAS CON LA POLICIA (INCLUYENDO DE TRANSITO)? Yes Que paso? Cuando paso? Si fue a corte obtuvo usted conviction de culpable? No ESTA CASADO/A? Yes Como se llama su esposo/a? Donde nacio su esposo/a? Cual es el estatus inmigratorio de su esposo/a? Ej: indocumentado/a o ciudadano/a o residente. No COMO SUPO DE ESTA OFICINA?