dysautonomiainternational.salsalabs.org
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Submitted URL: http://www.curedys.org/
Effective URL: https://dysautonomiainternational.salsalabs.org/2021dysautonomiadonate/index.html
Submission: On March 14 via api from US — Scanned from DE
Effective URL: https://dysautonomiainternational.salsalabs.org/2021dysautonomiadonate/index.html
Submission: On March 14 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
<form class="sli-form fv-form fv-form-salsa" data-fv-framework="salsa" novalidate="novalidate" data-ignite-form-id="d8c21a08-a98d-499f-a908-e4af50809142" id="form_igBozGOJvqdU">
<div class="sli-element sli-text" id="id_2def3287-cfe8-474c-a7bc-64ac514187bf">
<div id="id_2def3287-cfe8-474c-a7bc-64ac514187bf_inner">
<p> <span style="font-size:20px"><strong>Donate by Credit Card</strong></span> </p>
</div>
</div>
<div class="sli-row" id="id_ecc0014b-970f-4bd8-ba30-f268cce518a6">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns " data-ignite-container-type="elementStep" id="id_0b7502b7-c1a6-4756-a40c-070db4829c84" data-ignite-step-id="1">
<div class="sli-donation-amountblock sli-element" id="id_584ff172-698f-4e03-a74e-1de56643666e" data-ignite-enable-onetime="true" data-ignite-enable-recurring-amounts="true" data-ignite-field-id="DonationAmount">
<div class="sli-donationAmounts">
<div class="sli-oneTimeDonation" id="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_oneTime" data-ignite-onetime-amount="data-ignite-onetime-amount">
<ul class="sli-oneTimeDonationAmounts sli-style-button" style="justify-content: flex-start;">
<li><input class="sli-oneTimeAmountRadio" name="donationAmtToggle" id="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_onetime_amt_25" type="radio" data-ignite-amount="25.00" data-fv-onetimeamount="true"
data-sli-widget="_igBozGOJvqdU" data-fv-row=".sli-oneTimeDonation" data-fv-err-container=".sli-oneTimeDonationError" data-fv-onetimeamount-message="Please select a donation amount, or enter your own amount"
data-fv-field="donationAmtToggle"><label class="sli-oneTimeAmountLabel sli-amount-label sli-tiny sli-flat" id="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_onetime_amt_25_label"
for="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_onetime_amt_25">$25</label></li>
<li><input class="sli-oneTimeAmountRadio" name="donationAmtToggle" id="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_onetime_amt_50" type="radio" data-ignite-amount="50.00" data-fv-field="donationAmtToggle"
data-sli-widget="_igBozGOJvqdU"><label class="sli-oneTimeAmountLabel sli-amount-label sli-tiny sli-flat" id="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_onetime_amt_50_label"
for="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_onetime_amt_50">$50</label></li>
<li><input class="sli-oneTimeAmountRadio" name="donationAmtToggle" id="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_onetime_amt_100" type="radio" data-ignite-amount="100.00" data-fv-field="donationAmtToggle"
data-sli-widget="_igBozGOJvqdU"><label class="sli-oneTimeAmountLabel sli-amount-label sli-tiny sli-flat" id="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_onetime_amt_100_label"
for="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_onetime_amt_100">$100</label></li>
<li><input class="sli-oneTimeAmountRadio" name="donationAmtToggle" id="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_onetime_amt_250" type="radio" data-ignite-amount="250.00" data-fv-field="donationAmtToggle"
data-sli-widget="_igBozGOJvqdU"><label class="sli-oneTimeAmountLabel sli-amount-label sli-tiny sli-flat" id="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_onetime_amt_250_label"
for="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_onetime_amt_250">$250</label></li>
<li><input class="sli-oneTimeAmountRadio" name="donationAmtToggle" id="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_onetime_amt_500" type="radio" data-ignite-amount="500.00" data-fv-field="donationAmtToggle"
data-sli-widget="_igBozGOJvqdU"><label class="sli-oneTimeAmountLabel sli-amount-label sli-tiny sli-flat" id="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_onetime_amt_500_label"
for="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_onetime_amt_500">$500</label></li>
<li style=" display: block;"><input class="sli-oneTimeAmountRadio sli-oneTimeCustomAmount" name="donationAmtToggleOther" id="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_onetime_custom_radio" type="radio"
data-ignite-custom-onetime="data-ignite-custom-onetime" aria-label="custom one-time donation amount" data-sli-widget="_igBozGOJvqdU">
<div class="sli-input-group"> <label class="sli-oneTimeAmountLabel sli-amount-label sli-customAmount sli-input-group-label sli-tiny sli-flat" id="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_onetime_custom_label"
for="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_onetime_custom" autocomplete="off">$</label> <input class="sli-oneTimeAmountInput sli-customAmount sli-input sli-input-group-field sli-tiny" size="5"
id="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_onetime_custom" type="text" placeholder="Other" name="customOneTime" autocomplete="off" data-ignite-custom-onetime-input="donationAmtToggle" data-fv-row=".sli-oneTimeDonation"
data-fv-err-container=".sli-oneTimeDonationError" data-fv-numeric="true" data-fv-numeric-message="Please enter a dollar amount" data-fv-notempty="true" data-fv-notempty-message="An amount is required" data-fv-greaterthan="true"
data-fv-greaterthan-inclusive="false" data-fv-greaterthan-value="0.0" data-fv-greaterthan-message="Please enter a positive amount" data-fv-field="customOneTime"> </div>
</li>
</ul>
<div class="sli-oneTimeDonationError sli-field-error"><small class="sli-field-error" data-fv-validator="onetimeAmount" data-fv-for="donationAmtToggle" data-fv-result="NOT_VALIDATED" style="display: none;">Please select a donation amount,
or enter your own amount</small><small class="sli-field-error" data-fv-validator="greaterThan" data-fv-for="customOneTime" data-fv-result="NOT_VALIDATED" style="display: none;">Please enter a positive amount</small><small
class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="customOneTime" data-fv-result="NOT_VALIDATED" style="display: none;">An amount is required</small><small class="sli-field-error" data-fv-validator="numeric"
data-fv-for="customOneTime" data-fv-result="NOT_VALIDATED" style="display: none;">Please enter a dollar amount</small></div>
</div>
<div class="sli-recurringDonation" id="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_recurring" data-ignite-recurring-amount="data-ignite-recurring-amount" style="display:none;">
<p data-ignite-recurrence-frequency="Monthly" class=" sli-recurringFrequency" style="margin: 0;">Donation will repeat monthly.</p>
<ul class="sli-recurringDonationAmounts sli-style-button" style="justify-content: flex-start;">
<li><input class="sli-recurringAmountRadio" name="donationAmtToggle2" id="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_recurringAmt_10" type="radio" data-ignite-amount="10.00" data-fv-recurringamount="true"
data-sli-widget="_igBozGOJvqdU" data-fv-row=".sli-recurringDonation" data-fv-err-container=".sli-recurringDonationError" data-fv-recurringamount-message="Please select a donation amount, or enter your own amount"
data-fv-field="donationAmtToggle2"><label class="sli-recurringAmountLabel sli-amount-label sli-tiny sli-flat" id="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_recurringAmt_10_label"
for="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_recurringAmt_10">$10</label></li>
<li><input class="sli-recurringAmountRadio" name="donationAmtToggle2" id="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_recurringAmt_25" type="radio" data-ignite-amount="25.00" data-fv-field="donationAmtToggle2"
data-sli-widget="_igBozGOJvqdU"><label class="sli-recurringAmountLabel sli-amount-label sli-tiny sli-flat" id="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_recurringAmt_25_label"
for="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_recurringAmt_25">$25</label></li>
<li><input class="sli-recurringAmountRadio" name="donationAmtToggle2" id="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_recurringAmt_50" type="radio" data-ignite-amount="50.00" data-fv-field="donationAmtToggle2"
data-sli-widget="_igBozGOJvqdU"><label class="sli-recurringAmountLabel sli-amount-label sli-tiny sli-flat" id="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_recurringAmt_50_label"
for="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_recurringAmt_50">$50</label></li>
<li><input class="sli-recurringAmountRadio" name="donationAmtToggle2" id="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_recurringAmt_75" type="radio" data-ignite-amount="75.00" data-fv-field="donationAmtToggle2"
data-sli-widget="_igBozGOJvqdU"><label class="sli-recurringAmountLabel sli-amount-label sli-tiny sli-flat" id="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_recurringAmt_75_label"
for="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_recurringAmt_75">$75</label></li>
<li><input class="sli-recurringAmountRadio" name="donationAmtToggle2" id="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_recurringAmt_100" type="radio" data-ignite-amount="100.00" data-fv-field="donationAmtToggle2"
data-sli-widget="_igBozGOJvqdU"><label class="sli-recurringAmountLabel sli-amount-label sli-tiny sli-flat" id="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_recurringAmt_100_label"
for="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_recurringAmt_100">$100</label></li>
<li style=" display: block;"><input class="sli-recurringAmountRadio sli-recurringCustomAmount" name="donationAmtToggle2Other" id="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_recurringAmt_custom_radio" type="radio"
aria-label="recurring donation custom amount" data-sli-widget="_igBozGOJvqdU">
<div class="sli-input-group"> <label class="sli-recurringAmountLabel sli-amount-label sli-customAmount sli-input-group-label sli-tiny sli-flat" id="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_recurringAmt_custom_label"
for="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_recurringAmt_custom" autocomplete="off">$</label> <input class="sli-recurringAmountInput sli-customAmount sli-input sli-input-group-field sli-tiny" size="5"
id="id_584ff172-698f-4e03-a74e-1de56643666e_ISOyXDNMQW_recurringAmt_custom" type="text" placeholder="Other" name="customRecurringAmount" data-fv-row=".sli-recurringDonation" data-fv-err-container=".sli-recurringDonationError"
data-fv-numeric="true" data-fv-numeric-message="Please enter a dollar amount" data-fv-notempty="true" data-fv-notempty-message="An amount is required" data-fv-greaterthan="true" data-fv-greaterthan-inclusive="false"
data-fv-greaterthan-value="0.0" data-fv-greaterthan-message="Please enter a positive amount" autocomplete="off" data-fv-field="customRecurringAmount"> </div>
</li>
</ul>
<div class="sli-recurringDonationError sli-field-error"><small class="sli-field-error" data-fv-validator="recurringAmount" data-fv-for="donationAmtToggle2" data-fv-result="NOT_VALIDATED" style="display: none;">Please select a donation
amount, or enter your own amount</small><small class="sli-field-error" data-fv-validator="greaterThan" data-fv-for="customRecurringAmount" data-fv-result="NOT_VALIDATED" style="display: none;">Please enter a positive
amount</small><small class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="customRecurringAmount" data-fv-result="NOT_VALIDATED" style="display: none;">An amount is required</small><small class="sli-field-error"
data-fv-validator="numeric" data-fv-for="customRecurringAmount" data-fv-result="NOT_VALIDATED" style="display: none;">Please enter a dollar amount</small></div>
</div>
</div>
</div>
<div class="sli-element sli-text" id="id_4d84cd94-745b-4c31-9088-096cfd6ef0a0">
<div id="id_4d84cd94-745b-4c31-9088-096cfd6ef0a0_inner">
<p> All donations are processed in US Dollars. </p>
</div>
</div>
<div class="sli-donorPaysFees sli-element " id="id_6e5c797f-2baa-448b-8ec4-9506086076d4_qfLhqeLCzx" data-ignite-field-id="DonorPaysFees"> <label class="sli-label"
for="id_6e5c797f-2baa-448b-8ec4-9506086076d4_qfLhqeLCzx_donorPaysFees_input"><input class="sli-input" id="id_6e5c797f-2baa-448b-8ec4-9506086076d4_qfLhqeLCzx_donorPaysFees_input" type="checkbox" name="donorPaysFees" value="true"
style="margin-right: 5px;" salsa-reference-name="donorpaysfeescb">Increase my donation to cover processing fees.</label> </div>
<div class="sli-row" id="id_b0832f4a-c00a-45f6-8fb3-4a0d8baa7d5a">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_300eff89-b6f5-4012-a338-85278669f218">
<div class="sli-selectRecurring sli-element " id="id_bdf6fd4b-7879-4acd-aafc-acabc4b387ad_zgOHVvPvDH" data-ignite-field-id="MakeRecurring"> <label class="sli-label"
for="id_bdf6fd4b-7879-4acd-aafc-acabc4b387ad_zgOHVvPvDH_makeRecurring_input"><input class="sli-input" id="id_bdf6fd4b-7879-4acd-aafc-acabc4b387ad_zgOHVvPvDH_makeRecurring_input" type="checkbox" name="makeRecurring" value="true"
style="margin-right: 5px;" salsa-reference-name="makerecurringcb">I would like to make this a recurring monthly donation.</label> </div>
</div>
</div>
<div class="sli-row" id="id_459e8047-ba97-4383-abc4-768829824d59">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_9520a19d-d0f0-4454-90e4-3135510e75df">
<div class="sli-donation-designation sli-columns sli-large-12 sli-element " id="id_59e89adc-ace4-4bf7-9436-888e9d00f38e" data-ignite-field-id="482032f6-9369-4e7a-a59f-834139323a9d">
<div> <label class="sli-label" for="id_59e89adc-ace4-4bf7-9436-888e9d00f38e_designation_input">Designate my donation to:</label> <select class="sli-input" id="id_59e89adc-ace4-4bf7-9436-888e9d00f38e_designation_input" name="designation"
salsa-reference-name="donation-designation">
<option value="General support (education, awareness, support, advocacy, etc.)">General support (education, awareness, support, advocacy, etc.)</option>
<option value="The POTS Research Fund">The POTS Research Fund</option>
<option value="The Dysautonomia Research Fund">The Dysautonomia Research Fund</option>
<option value="Long COVID Research Fund">Long COVID Research Fund</option>
<option value="The Amelia Moore Conference Scholarship Fund">The Amelia Moore Conference Scholarship Fund</option>
<option value="Where it's needed most">Where it's needed most</option>
</select> </div>
</div>
<div class="sli-donationsummary-dedication sli-columns sli-large-12 sli-select-radio sli-element " id="id_73f1aa0d-ec8f-4957-90ff-38305243992d_dedication" salsa-reference-name="dedication_type">
<div> <label class="sli-label" for="id_73f1aa0d-ec8f-4957-90ff-38305243992d_dedication">Donation Dedication</label>
<ul>
<li><input name="dedicationType" id="id_73f1aa0d-ec8f-4957-90ff-38305243992d_NONE" value="NONE" type="radio" checked="checked">None</li>
<li><input name="dedicationType" id="id_73f1aa0d-ec8f-4957-90ff-38305243992d_InHonorOf" value="InHonorOf" type="radio">In Honor Of</li>
<li><input name="dedicationType" id="id_73f1aa0d-ec8f-4957-90ff-38305243992d_InMemoryOf" value="InMemoryOf" type="radio">In Memory Of</li>
</ul> <input class="sli-input" type="text" disabled="" name="dedication" data-fv-row=".sli-donationsummary-dedication" data-fv-nohtml="true" data-fv-nohtml-message="Your input is invalid" maxlength="250" data-fv-stringlength="true"
data-fv-stringlength-message="Please limit your input to less than 250 characters" data-fv-notempty="true" data-fv-notempty-message="Please provide a dedication" data-ignite-field-id="6a921941-0a96-474a-9c1d-f51aa791811b"
salsa-reference-name="donationsummary-dedication" data-fv-field="dedication">
<div class="sli-dedicationError"></div>
<style ignite-allow-style="ignite-allow-style">
#id_73f1aa0d-ec8f-4957-90ff-38305243992d_dedication li {
display: inline;
padding: 8px;
}
#id_73f1aa0d-ec8f-4957-90ff-38305243992d_dedication input[type=radio] {
margin-right: 4px;
}
#id_73f1aa0d-ec8f-4957-90ff-38305243992d_dedication ul {
margin: 4px;
padding: 0px;
}
@media screen and (max-width:640px) {
#id_73f1aa0d-ec8f-4957-90ff-38305243992d_dedication li {
display: block;
padding: 2px 0 0 0;
}
}
</style>
</div> <small class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="dedication" data-fv-result="NOT_VALIDATED" style="display: none;">Please provide a dedication</small><small class="sli-field-error"
data-fv-validator="stringLength" data-fv-for="dedication" data-fv-result="NOT_VALIDATED" style="display: none;">Please limit your input to less than 250 characters</small><small class="sli-field-error" data-fv-validator="nohtml"
data-fv-for="dedication" data-fv-result="NOT_VALIDATED" style="display: none;">Your input is invalid</small>
</div>
<div class="sli-donationsummary-notify sli-element sli-form-field sli-columns sli-large-12 " id="id_56c8d8f8-8f11-4796-bcd5-0bd8cf1d6700">
<div> <label class="sli-label" for="id_56c8d8f8-8f11-4796-bcd5-0bd8cf1d6700_notify_input">Please enter the name and email or postal address of the person(s) you would like us to notify:</label> <input class="sli-input"
id="id_56c8d8f8-8f11-4796-bcd5-0bd8cf1d6700_notify_input" type="text" name="field-donationsummary-notify" data-ignite-field-id="4abbf015-7829-4bda-a574-94ac97994229" data-fv-nohtml="true" data-fv-nohtml-message="Your input is invalid"
maxlength="250" data-fv-stringlength="true" data-fv-stringlength-message="Please limit your input to less than 250 characters" salsa-reference-name="donationsummary-notify" data-fv-field="field-donationsummary-notify"> </div> <small
class="sli-field-error" data-fv-validator="stringLength" data-fv-for="field-donationsummary-notify" data-fv-result="NOT_VALIDATED" style="display: none;">Please limit your input to less than 250 characters</small><small
class="sli-field-error" data-fv-validator="nohtml" data-fv-for="field-donationsummary-notify" data-fv-result="NOT_VALIDATED" style="display: none;">Your input is invalid</small>
</div>
<div class="sli-element sli-button-element" id="id_c228e6c0-8b3f-488e-9614-4ffaf20d4093">
<a class="sli-button sli-flat sli-expand" track="true" data-ignite-button-step="2" data-ignite-skip-validation="false" style="background-color:rgb(147, 196, 125);" tabindex="0" role="button">Next: Your Info >></a> </div>
<div class="sli-row" id="id_779cd423-4726-46aa-adc0-fa1749d51a9a">
<div class="sli-large-6 sli-medium-6 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_ab5f84df-39fc-4219-8881-10e77ea97df7"></div>
<div class="sli-large-6 sli-medium-6 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_59b7ba60-a68b-41a6-9ec9-5044c19cf9bf"></div>
</div>
</div>
</div>
</div>
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns " data-ignite-container-type="elementStep" id="id_4d473057-e4f5-4618-bfe6-98b856e9cf98" style="display: none;" data-ignite-step-id="2">
<div class="sli-element sli-text" id="id_8fa88147-a74e-4a91-80c9-97eb3f9171ee">
<div id="id_8fa88147-a74e-4a91-80c9-97eb3f9171ee_inner">
<p> <strong><span style="font-size:20px">Your Information</span></strong> </p>
</div>
</div>
<div class="sli-row" id="id_4913276a-45ec-42b8-9fd1-f5a9c5cf5529">
<div class="sli-large-6 sli-medium-6 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_381093af-25cc-4a97-b298-cd229cbe3fbb">
<div class="sli-field-person-firstname sli-form-field sli-element" data-ignite-field-id="5d5a2165-f19e-4371-851b-183a6b92402b" id="id_83b7b5bb-f1a3-4d9f-b0da-9946bbca0763"> <label class="sli-required-true sli-label"
for="id_83b7b5bb-f1a3-4d9f-b0da-9946bbca0763_input" id="id_83b7b5bb-f1a3-4d9f-b0da-9946bbca0763_label">First Name*</label> <input class="sli-input sli-input-person-firstname" type="text"
data-ignite-field-id="5d5a2165-f19e-4371-851b-183a6b92402b" name="field-person-firstname" maxlength="36" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" data-fv-stringlength="true"
data-fv-stringlengthmessage="Please limit your input to at most 36 characters." id="id_83b7b5bb-f1a3-4d9f-b0da-9946bbca0763_input" salsa-reference-name="person-firstname" data-fv-field="field-person-firstname"> <small
class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="field-person-firstname" data-fv-result="NOT_VALIDATED" style="display: none;">This field requires a value</small><small class="sli-field-error"
data-fv-validator="stringLength" data-fv-for="field-person-firstname" data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid</small></div>
</div>
<div class="sli-large-6 sli-medium-6 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_1b967c77-cc08-4fbb-9545-4298ca27c4b0">
<div class="sli-field-person-lastname sli-form-field sli-element" data-ignite-field-id="8d21a878-287a-491f-a362-b8ee2aa71819" id="id_fab587ff-0b4b-4ecf-9721-8de235926a9e"> <label class="sli-required-true sli-label"
for="id_fab587ff-0b4b-4ecf-9721-8de235926a9e_input" id="id_fab587ff-0b4b-4ecf-9721-8de235926a9e_label">Last Name*</label> <input class="sli-input sli-input-person-lastname" type="text"
data-ignite-field-id="8d21a878-287a-491f-a362-b8ee2aa71819" name="field-person-lastname" maxlength="100" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" data-fv-stringlength="true"
data-fv-stringlengthmessage="Please limit your input to at most 100 characters." id="id_fab587ff-0b4b-4ecf-9721-8de235926a9e_input" salsa-reference-name="person-lastname" data-fv-field="field-person-lastname"> <small
class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="field-person-lastname" data-fv-result="NOT_VALIDATED" style="display: none;">This field requires a value</small><small class="sli-field-error"
data-fv-validator="stringLength" data-fv-for="field-person-lastname" data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid</small></div>
</div>
</div>
<div class="sli-row" id="id_43eca370-9749-410c-91d3-36a4fcc11076">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_5aced26e-33a6-4403-af35-89d44eef12d2">
<div class="sli-field-address-line1 sli-form-field sli-element" data-ignite-field-id="f775c79a-df41-43fb-96de-ee2360254689" id="id_32af2d33-36eb-4815-a548-198082c0031e"> <label class="sli-required-true sli-label"
for="id_32af2d33-36eb-4815-a548-198082c0031e_input" id="id_32af2d33-36eb-4815-a548-198082c0031e_label">Address, line 1*</label> <input class="sli-input sli-input-address-line1" type="text"
data-ignite-field-id="f775c79a-df41-43fb-96de-ee2360254689" name="field-address-line1" maxlength="128" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" data-fv-stringlength="true"
data-fv-stringlengthmessage="Please limit your input to at most 128 characters." id="id_32af2d33-36eb-4815-a548-198082c0031e_input" salsa-reference-name="address-line1" data-fv-field="field-address-line1"> <small class="sli-field-error"
data-fv-validator="notEmpty" data-fv-for="field-address-line1" data-fv-result="NOT_VALIDATED" style="display: none;">This field requires a value</small><small class="sli-field-error" data-fv-validator="stringLength"
data-fv-for="field-address-line1" data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid</small></div>
</div>
</div>
<div class="sli-row" id="id_48074727-5a07-4595-bd79-e283c5556275">
<div class="sli-large-4 sli-medium-4 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_ee5b65c0-83b7-4006-b116-0249109cfa17">
<div class="sli-field-address-city sli-form-field sli-element" data-ignite-field-id="a102d60f-f8ab-47eb-8ee0-864cfa1fc5b2" id="id_5e8c27a8-be42-4dab-b74c-9fc638a4f107"> <label class="sli-required-true sli-label"
for="id_5e8c27a8-be42-4dab-b74c-9fc638a4f107_input" id="id_5e8c27a8-be42-4dab-b74c-9fc638a4f107_label">City*</label> <input class="sli-input sli-input-address-city" type="text" data-ignite-field-id="a102d60f-f8ab-47eb-8ee0-864cfa1fc5b2"
name="field-address-city" maxlength="64" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" data-fv-stringlength="true"
data-fv-stringlengthmessage="Please limit your input to at most 64 characters." id="id_5e8c27a8-be42-4dab-b74c-9fc638a4f107_input" salsa-reference-name="address-city" data-fv-field="field-address-city"> <small class="sli-field-error"
data-fv-validator="notEmpty" data-fv-for="field-address-city" data-fv-result="NOT_VALIDATED" style="display: none;">This field requires a value</small><small class="sli-field-error" data-fv-validator="stringLength"
data-fv-for="field-address-city" data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid</small></div>
<div class="sli-field-address-zip sli-form-field sli-element" data-ignite-field-id="44e5ad15-1fdd-4ba8-bf38-f5cbaad023c2" id="id_021f8dca-5424-4d5e-93bc-8271df60bd85"> <label class="sli-required-true sli-label"
for="id_021f8dca-5424-4d5e-93bc-8271df60bd85_input" id="id_021f8dca-5424-4d5e-93bc-8271df60bd85_label">Postal Code*</label> <input class="sli-input sli-input-address-zip" type="text"
data-ignite-field-id="44e5ad15-1fdd-4ba8-bf38-f5cbaad023c2" name="field-address-zip" maxlength="20" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" data-fv-stringlength="true"
data-fv-stringlengthmessage="Please limit your input to at most 20 characters." data-fv-zipcode="true" data-fv-zipcode-priority="1" data-fv-zipcode-country="US" data-fv-zipcode-message="This value is not valid as a %s postal code"
data-fv-regexp="true" data-fv-regexp-priority="2" data-fv-regexp-regexp="^(\d{5}|\d{5}-\d{4})?$" data-fv-regexp-message="Zip Code must be formatted as: "55555" or "55555-5555""
id="id_021f8dca-5424-4d5e-93bc-8271df60bd85_input" salsa-reference-name="address-zip" data-fv-field="field-address-zip"> <small class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="field-address-zip"
data-fv-result="NOT_VALIDATED" style="display: none;">This field requires a value</small><small class="sli-field-error" data-fv-validator="regexp" data-fv-for="field-address-zip" data-fv-result="NOT_VALIDATED" style="display: none;">Zip
Code must be formatted as: "55555" or "55555-5555"</small><small class="sli-field-error" data-fv-validator="stringLength" data-fv-for="field-address-zip" data-fv-result="NOT_VALIDATED" style="display: none;">This value is not
valid</small><small class="sli-field-error" data-fv-validator="zipCode" data-fv-for="field-address-zip" data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid as a %s postal code</small></div>
</div>
<div class="sli-large-4 sli-medium-4 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_acf02432-b377-4f5c-a821-971257376665">
<div class="sli-field-address-state sli-form-field sli-element" data-ignite-field-id="3f8b9098-ff2d-4384-bb95-425f113028c0" id="id_028891f6-914f-462f-b323-877d7c068b5c"> <label class="sli-required-true sli-label"
for="id_028891f6-914f-462f-b323-877d7c068b5c_input" id="id_028891f6-914f-462f-b323-877d7c068b5c_label">State/Province*</label> <select class="sli-select-address-state sli-input" name="field-address-state"
data-ignite-field-id="3f8b9098-ff2d-4384-bb95-425f113028c0" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" id="id_028891f6-914f-462f-b323-877d7c068b5c_input"
salsa-reference-name="address-state" data-fv-field="field-address-state">
<option value="">Choose one...</option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AS">American Samoa</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="AA">Armed Forces America</option>
<option value="AE">Armed Forces Europe</option>
<option value="AP">Armed Forces Pacific</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="GU">Guam</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="MP">Northern Mariana Islands</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="VT">Vermont</option>
<option value="VI">Virgin Islands</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select> <small class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="field-address-state" data-fv-result="NOT_VALIDATED" style="display: none;">This field requires a value</small></div>
</div>
<div class="sli-large-4 sli-medium-4 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_6a9a06c8-6668-488c-932e-0b5524d71b29">
<div class="sli-field-address-country sli-form-field sli-element" data-ignite-field-id="f71a3605-b3a8-4650-af21-47387674a8eb" id="id_94be3fbc-58e3-4a17-8ea4-282397021b74"> <label class="sli-required-true sli-label"
for="id_94be3fbc-58e3-4a17-8ea4-282397021b74_input" id="id_94be3fbc-58e3-4a17-8ea4-282397021b74_label">Country*</label> <select class="sli-select-address-country sli-input" name="field-address-country"
data-ignite-field-id="f71a3605-b3a8-4650-af21-47387674a8eb" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" id="id_94be3fbc-58e3-4a17-8ea4-282397021b74_input"
salsa-reference-name="address-country" data-fv-field="field-address-country">
<option value="AF">Afghanistan</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="CV">Cabo Verde</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="KY">Cayman Islands</option>
<option value="CF">Central African Republic</option>
<option value="TD">Chad</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CX">Christmas Island</option>
<option value="CC">Cocos (Keeling) Islands</option>
<option value="CO">Colombia</option>
<option value="KM">Comoros</option>
<option value="CG">Congo</option>
<option value="CD">Congo, The Democratic Republic of the</option>
<option value="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CW">Curaçao</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czechia</option>
<option value="CI">Côte d'Ivoire</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="GQ">Equatorial Guinea</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="SZ">Eswatini</option>
<option value="ET">Ethiopia</option>
<option value="FK">Falkland Islands (Malvinas)</option>
<option value="FO">Faroe Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="GF">French Guiana</option>
<option value="PF">French Polynesia</option>
<option value="TF">French Southern Territories</option>
<option value="GA">Gabon</option>
<option value="GM">Gambia</option>
<option value="GE">Georgia</option>
<option value="DE">Germany</option>
<option value="GH">Ghana</option>
<option value="GI">Gibraltar</option>
<option value="GR">Greece</option>
<option value="GL">Greenland</option>
<option value="GD">Grenada</option>
<option value="GP">Guadeloupe</option>
<option value="GU">Guam</option>
<option value="GT">Guatemala</option>
<option value="GG">Guernsey</option>
<option value="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard Island 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="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="MK">North Macedonia</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="RO">Romania</option>
<option value="RU">Russian Federation</option>
<option value="RW">Rwanda</option>
<option value="RE">Réunion</option>
<option value="BL">Saint Barthélemy</option>
<option value="SH">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="MF">Saint Martin (French part)</option>
<option value="PM">Saint Pierre and Miquelon</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</option>
<option value="ST">Sao Tome and Principe</option>
<option value="SA">Saudi Arabia</option>
<option value="SN">Senegal</option>
<option value="RS">Serbia</option>
<option value="SC">Seychelles</option>
<option value="SL">Sierra Leone</option>
<option value="SG">Singapore</option>
<option value="SX">Sint Maarten (Dutch part)</option>
<option value="SK">Slovakia</option>
<option value="SI">Slovenia</option>
<option value="SB">Solomon Islands</option>
<option value="SO">Somalia</option>
<option value="ZA">South Africa</option>
<option value="GS">South Georgia and the South Sandwich Islands</option>
<option value="SS">South Sudan</option>
<option value="ES">Spain</option>
<option value="LK">Sri Lanka</option>
<option value="SD">Sudan</option>
<option value="SR">Suriname</option>
<option value="SJ">Svalbard and Jan Mayen</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syrian Arab Republic</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania, United Republic of</option>
<option value="TH">Thailand</option>
<option value="TL">Timor-Leste</option>
<option value="TG">Togo</option>
<option value="TK">Tokelau</option>
<option value="TO">Tonga</option>
<option value="TT">Trinidad and Tobago</option>
<option value="TN">Tunisia</option>
<option value="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks and Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom</option>
<option value="US" selected="selected">United States</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="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>
<option value="AX">Åland Islands</option>
</select> <small class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="field-address-country" data-fv-result="NOT_VALIDATED" style="display: none;">This field requires a value</small></div>
</div>
</div>
<div class="sli-row" id="id_30273ec5-d5ee-4e35-b1c5-57988d33b2bb">
<div class="sli-large-6 sli-medium-6 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_fa4bbd41-6730-491e-87df-07413a2b70a1">
<div class="sli-field-contact-email sli-form-field sli-element" data-ignite-field-id="2851b463-606f-40c8-bb3d-d31f399e6896" id="id_79e49d63-93ba-49bf-a756-594bb813a6e2"> <label class="sli-required-true sli-label"
for="id_79e49d63-93ba-49bf-a756-594bb813a6e2_input" id="id_79e49d63-93ba-49bf-a756-594bb813a6e2_label">Email Address*</label> <input class="sli-input sli-input-contact-email" type="email"
data-ignite-field-id="2851b463-606f-40c8-bb3d-d31f399e6896" name="field-contact-email" maxlength="128" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" data-fv-stringlength="true"
data-fv-stringlengthmessage="Please limit your input to at most 128 characters." data-fv-regexp="true" data-fv-regexp-regexp="^[^@\s]+@([^@\s]+\.)+[^@\s]+$" data-fv-regexp-message="Please enter a valid email address"
id="id_79e49d63-93ba-49bf-a756-594bb813a6e2_input" salsa-reference-name="contact-email" data-fv-field="field-contact-email"> <small class="sli-field-error" data-fv-validator="emailAddress" data-fv-for="field-contact-email"
data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid</small><small class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="field-contact-email" data-fv-result="NOT_VALIDATED"
style="display: none;">This field requires a value</small><small class="sli-field-error" data-fv-validator="regexp" data-fv-for="field-contact-email" data-fv-result="NOT_VALIDATED" style="display: none;">Please enter a valid email
address</small><small class="sli-field-error" data-fv-validator="stringLength" data-fv-for="field-contact-email" data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid</small></div>
</div>
<div class="sli-large-6 sli-medium-6 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_8aca3793-0768-4273-b71a-4c53525eae92"></div>
</div>
<div class="sli-row" id="id_cb0d5c45-caac-4afa-831e-9f97b959a6f6">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_8f02f7c3-5ce6-42c1-80d1-d39dc7f846a6"></div>
</div>
<div class="sli-row" id="id_15695835-7198-492f-b92f-8d4ab09dff94">
<div class="sli-large-6 sli-medium-6 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_acfc9516-60af-4c47-b71c-1894be4cff0d">
<div class="sli-element sli-button-element" id="id_bdabe377-5fb4-4bf1-b316-9fda92bf34e5">
<a class="sli-button sli-flat sli-expand" track="true" data-ignite-button-step="1" data-ignite-skip-validation="true" style="background-color:rgb(0, 175, 215);" tabindex="0" role="button"><< Back</a> </div>
</div>
<div class="sli-large-6 sli-medium-6 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_cc1620a7-0e5e-4a1d-85d0-a9885083d432">
<div class="sli-element sli-button-element" id="id_a691d474-373f-4d5f-a522-d55f79c1cd04">
<a class="sli-button sli-flat sli-expand" track="true" data-ignite-button-step="3" data-ignite-skip-validation="false" style="background-color:rgb(0, 175, 215);" tabindex="0" role="button">Next: Last Step! >></a> </div>
</div>
</div>
</div>
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="elementStep" id="id_ff7541b9-6c16-41de-8812-792c7ba6f798" style="display: none;" data-ignite-step-id="3">
<div class="sli-row" id="id_75bb5ab8-40fe-4f33-9c55-45173adcb065">
<div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_7729f29b-62d3-4d3a-ab49-4e55288ef34f">
<div class="sli-element sli-text" id="id_c9cd614f-963f-4dc7-a09b-e228b1d78bdd">
<div id="id_c9cd614f-963f-4dc7-a09b-e228b1d78bdd_inner">
<p> <strong><span style="font-size:20px">Payment Information</span></strong> </p>
</div>
</div>
<div class="sli-donation-paymentblock sli-element" id="id_cc633a2d-9775-43dd-8535-2fa6a5419ead">
<div class="sli-paymentType" id="id_cc633a2d-9775-43dd-8535-2fa6a5419ead_paymentType">
<div class="sli-ccType sli-label" for="payment_type"> Payment Type: </div>
<div style="display:inline-block;"> <input name="payment_type" type="radio" value="CREDIT_CARD" checked="checked" id="kLNgDpvccE"> <label class="sli-label" for="kLNgDpvccE">Credit Card</label> </div>
<div style="display:inline-block;"> <input name="payment_type" sli-payment-type="ACH" style="display:none;" type="radio" value="ACH" id="eaVUxfPJcf"> <label class="sli-label" style="display:none;" sli-payment-type="ACH"
for="eaVUxfPJcf">eCheck</label> </div>
<div style="display:inline-block;"> <input name="payment_type" sli-payment-type="PAYPAL" style="display:none;" type="radio" value="PAYPAL" id="YjvPIshkvY"> <label class="sli-label" style="display:none;" sli-payment-type="PAYPAL"
for="YjvPIshkvY">PayPal</label> </div>
</div>
<div id="id_cc633a2d-9775-43dd-8535-2fa6a5419ead_echeck_wepay" data-ignite-echeck-wepay="ignite-echeck-wepay"> <label class="sli-ccLabel sli-label" for="ZzLVGWMJMK">Bank Account*</label>
<div class="sli-row">
<div class="sli-columns sli-medium-4 sli-large-4 sli-end sli-form-field"></div> <input class="sli-ccInput sli-input" type="text" id="ZzLVGWMJMK" data-fv-field="wepay_bank" data-fv-notempty-message="Bank Account is required"
readonly="readonly" required="required" name="wepay_bank">
<div class="sli-columns sli-large-8 sli-medium-8"> <input class="sli-button" id="id_cc633a2d-9775-43dd-8535-2fa6a5419ead_bankSelect" type="button" value="Select a Bank Account" name="bank-popup"> <small
class="sli-field-error sli-wepay-error" style="display: none;"></small> </div> <small class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="wepay_bank" data-fv-result="NOT_VALIDATED" style="display: none;">Bank Account
is required</small>
</div>
</div>
<div id="id_cc633a2d-9775-43dd-8535-2fa6a5419ead_echeck" data-ignite-echeck="ignite-echeck">
<div class="sli-row">
<div class="sli-columns sli-medium-8 sli-large-8 sli-small-12 sli-end sli-form-field"> <label class="sli-ccLabel sli-label" for="QPygdUfxey">Name on Account*</label> <input class="sli-ccInput sli-input" type="text" name="holder_name"
id="QPygdUfxey" required="required" data-fv-notempty="true" data-fv-notemtpy-message="Please enter the holder name" pattern="^.+\s+.*$" data-fv-regexp-message="Holder name must have at least 2 parts" data-fv-field="holder_name">
<small class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="holder_name" data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid</small><small class="sli-field-error" data-fv-validator="regexp"
data-fv-for="holder_name" data-fv-result="NOT_VALIDATED" style="display: none;">Holder name must have at least 2 parts</small></div>
</div>
<div class="sli-row">
<div class="sli-columns sli-large-8 sli-medium-8 sli-form-field"> <label class="sli-ccLabel sli-label" for="xsnajrzJLs">Bank Routing Number*</label> <input class="sli-ccInput sli-input" type="text" name="bank_routing" id="xsnajrzJLs"
required="required" maxlength="9" dava-fv-field="bank_routing" data-fv-notempty="true" data-fv-notemtpy-message="Bank Routing Number is required" data-fv-stringlength="true" data-fv-stringlength-min="9"
data-fv-stringlength-max="9" data-fv-stringlength-message="Bank Routing Number must be 9 characters long" data-fv-digits="true" data-fv-digits-message="Please enter only digits" data-fv-field="bank_routing"> <small
class="sli-field-error" data-fv-validator="digits" data-fv-for="bank_routing" data-fv-result="NOT_VALIDATED" style="display: none;">Please enter only digits</small><small class="sli-field-error" data-fv-validator="notEmpty"
data-fv-for="bank_routing" data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid</small><small class="sli-field-error" data-fv-validator="stringLength" data-fv-for="bank_routing"
data-fv-result="NOT_VALIDATED" style="display: none;">Bank Routing Number must be 9 characters long</small></div>
</div>
<div class="sli-row">
<div class="sli-columns sli-large-8 sli-medium-8 sli-form-field"> <label class="sli-ccLabel sli-label" for="oJMGHknugw">Bank Account Number*</label> <input class="sli-bankAccount sli-ccInput sli-input" type="text" name="bank_account"
id="oJMGHknugw" required="required" maxlength="17" dava-fv-field="bank_account" data-fv-notempty="true" data-fv-notemtpy-message="Bank Account Number is required" data-fv-stringlength="true" data-fv-stringlength-min="4"
data-fv-stringlength-max="17" data-fv-stringlength-message="Bank Account Number must be from 4 to 17 characters long" data-fv-digits="true" data-fv-digits-message="Please enter only digits" data-fv-field="bank_account"> <small
class="sli-field-error" data-fv-validator="digits" data-fv-for="bank_account" data-fv-result="NOT_VALIDATED" style="display: none;">Please enter only digits</small><small class="sli-field-error" data-fv-validator="notEmpty"
data-fv-for="bank_account" data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid</small><small class="sli-field-error" data-fv-validator="stringLength" data-fv-for="bank_account"
data-fv-result="NOT_VALIDATED" style="display: none;">Bank Account Number must be from 4 to 17 characters long</small></div>
</div>
</div>
<div id="id_cc633a2d-9775-43dd-8535-2fa6a5419ead_cc" data-ignite-cc="ignite-cc">
<ul class="sli-cards">
<li class="sli-visa off" style=""></li>
<li class="sli-mastercard off" style=""></li>
<li class="sli-discover off" style=""></li>
<li class="sli-amex off" style=""></li>
</ul>
<div class="sli-row">
<div class="sli-columns sli-large-8 sli-medium-8 sli-form-field"> <label class="sli-ccLabel sli-label" for="RcAmJxGklu">Card Number*</label> <input class="sli-ccInput sli-input" name="card_number" id="RcAmJxGklu" type="text"
required="required" data-fv-notempty-message="A credit card number is required" maxlength="16" autocomplete="off" data-fv-creditcard="true" data-fv-creditcard-message="Please enter a valid credit card number"
data-fv-field="card_number"> <small class="sli-field-error" data-fv-validator="creditCard" data-fv-for="card_number" data-fv-result="NOT_VALIDATED" style="display: none;">Please enter a valid credit card number</small><small
class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="card_number" data-fv-result="NOT_VALIDATED" style="display: none;">A credit card number is required</small><small class="sli-field-error"
data-fv-validator="stringLength" data-fv-for="card_number" data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid</small></div>
<div class="sli-columns sli-large-4 sli-medium-4 sli-end sli-form-field"> <label class="sli-ccExpCcvLabel sli-label" for="UwFgPvuvRX">Security Code*</label> <input class="sli-ccExpCcvInput sli-input" name="cvv" id="UwFgPvuvRX"
type="text" required="required" data-fv-notempty-message="CVV/CCV is required" maxlength="4" size="4" autocomplete="off" data-fv-cvv="true" data-fv-cvv_ccfield="card_number" data-dv-cvv-message="Your CVV is invalid"
data-fv-field="cvv"> <small class="sli-field-error" data-fv-validator="cvv" data-fv-for="cvv" data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid</small><small class="sli-field-error"
data-fv-validator="notEmpty" data-fv-for="cvv" data-fv-result="NOT_VALIDATED" style="display: none;">CVV/CCV is required</small><small class="sli-field-error" data-fv-validator="stringLength" data-fv-for="cvv"
data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid</small></div>
</div>
<div class="sli-row">
<div class="sli-columns sli-large-6 sli-medium-6 sli-form-field"> <label class="sli-ccExpMonthLabel sli-label" for="ExlynnZvCb">Expiration Month*</label> <select class="sli-ccInput sli-input" name="expiry_month" id="ExlynnZvCb"
required="required" data-fv-notempty-message="Month is required" style="display: block;" data-fv-field="expiry_month">
<option value="" selected="selected">MM</option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select> <small class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="expiry_month" data-fv-result="NOT_VALIDATED" style="display: none;">Month is required</small></div>
<div class="sli-columns sli-large-6 sli-medium-6 sli-end sli-form-field"> <label class="sli-ccExpMonthLabel sli-label" for="mfGSecplla">Expiration Year*</label> <select class="sli-ccInput sli-input" name="expiry_year" id="mfGSecplla"
required="required" data-fv-notempty-message="Year is required" style="display: block;" data-fv-field="expiry_year">
<option value="" selected="">YYYY</option>
<option value="24">2024</option>
<option value="25">2025</option>
<option value="26">2026</option>
<option value="27">2027</option>
<option value="28">2028</option>
<option value="29">2029</option>
<option value="30">2030</option>
<option value="31">2031</option>
<option value="32">2032</option>
<option value="33">2033</option>
<option value="34">2034</option>
<option value="35">2035</option>
<option value="36">2036</option>
<option value="37">2037</option>
<option value="38">2038</option>
<option value="39">2039</option>
<option value="40">2040</option>
<option value="41">2041</option>
<option value="42">2042</option>
<option value="43">2043</option>
</select> <small class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="expiry_year" data-fv-result="NOT_VALIDATED" style="display: none;">Year is required</small></div>
</div>
<div class="sli-row">
<div class="sli-columns sli-large-12 sli-small-12 sli-end sli-form-field"> <label class="sli-ccNameLabel sli-label" for="cbEbJQINBs">Name on Card*</label> <input class="sli-ccNameInput sli-input" name="name_on_card" id="cbEbJQINBs"
type="text" autocomplete="off" required="required" data-fv-callback="true" data-fv-callback-callback="validateCCName" data-fv-field="name_on_card"> <small class="sli-field-error" data-fv-validator="callback"
data-fv-for="name_on_card" data-fv-result="NOT_VALIDATED" style="display: none;">This value is not valid</small><small class="sli-field-error" data-fv-validator="notEmpty" data-fv-for="name_on_card" data-fv-result="NOT_VALIDATED"
style="display: none;">This value is not valid</small></div>
</div>
</div>
</div>
</div>
</div>
<div class="sli-row" id="id_73a9b8cc-67f3-4e3d-bf6b-e254493444b9">
<div class="sli-large-6 sli-medium-6 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_227dcf15-75d9-4b92-adc5-6f45b6921fd5">
<div class="sli-element sli-button-element" id="id_43f69a7a-11e4-4985-849d-adf8caacf331">
<a class="sli-button sli-flat sli-expand" track="true" data-ignite-button-step="2" data-ignite-skip-validation="true" style="background-color:rgb(0, 175, 215);" tabindex="0" role="button"><< Back</a> </div>
</div>
<div class="sli-large-6 sli-medium-6 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_5145afaa-cf3c-4674-88f5-bfcfd4b1c6b2">
<div class="sli-element sli-button-element" id="id_765e60ab-acce-49dd-a67d-b33f7bb36cb0">
<a class="sli-button sli-flat sli-expand" track="true" data-ignite-submit-button="data-ignite-submit-button" style="background-color:rgb(7, 14, 145);" tabindex="0" role="button">Donate Now!</a>
<div class="sli-processing" style="display:none;"></div>
</div>
</div>
</div>
</div>
</div>
</form>Text Content
Loading.... Your contribution to Dysautonomia International supports dysautonomia research, physician education, public awareness, patient empowerment and advocacy. You can direct your donation to the program areas you are most interested in supporting. Help make a difference in the lives of millions of people living with autonomic nervous system disorders today! Donate by Credit Card * $25 * $50 * $100 * $250 * $500 * $ Please select a donation amount, or enter your own amountPlease enter a positive amountAn amount is requiredPlease enter a dollar amount Donation will repeat monthly. * $10 * $25 * $50 * $75 * $100 * $ Please select a donation amount, or enter your own amountPlease enter a positive amountAn amount is requiredPlease enter a dollar amount All donations are processed in US Dollars. Increase my donation to cover processing fees. I would like to make this a recurring monthly donation. 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