careers-ecumen.icims.com
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Submitted URL: https://obct.get-me-jobs.com/t/?d=jy8QFkZMXqYJp98qedZp9_AH%2C0%2C5%2Chttps%3A%2F%2Fwww.get-me-jobs.com%2Fredirect%2Fjob%3Fjid...
Effective URL: https://careers-ecumen.icims.com/jobs/22608/resident-assistant,-full-time/job?utm_campaign=ecumen-seasons-at-maplewood-resident-a...
Submission: On August 29 via manual from US — Scanned from US
Effective URL: https://careers-ecumen.icims.com/jobs/22608/resident-assistant,-full-time/job?utm_campaign=ecumen-seasons-at-maplewood-resident-a...
Submission: On August 29 via manual from US — Scanned from US
Form analysis 8 forms found in the DOM
GET https://www.ecumen.org/
<form action="https://www.ecumen.org/" method="get">
<div class="search-container-inner">
<input type="search" class="search-field form-fluid no-livesearch" placeholder="Search…" value="" name="s" title="Search for:">
<i class="fa fa-search3"></i>
</div>
</form>GET https://www.ecumen.org/
<form action="https://www.ecumen.org/" method="get">
<div class="search-container-inner">
<input type="search" class="search-field form-fluid no-livesearch" placeholder="Search…" value="" name="s" title="Search for:">
<i class="fa fa-search3"></i>
</div>
</form>POST https://www.ecumen.org/wp-admin/admin-post.php
<form method="post" class="gdpr-privacy-preferences-frm" action="https://www.ecumen.org/wp-admin/admin-post.php">
<input type="hidden" name="action" value="uncode_privacy_update_privacy_preferences">
<input type="hidden" id="update-privacy-preferences-nonce" name="update-privacy-preferences-nonce" value="a97bb045ed"><input type="hidden" name="_wp_http_referer" value="/find-a-career/?_ga=2.47328551.1023950021.1649070703-1454670958.1647973843">
<header>
<div class="gdpr-box-title">
<h3>Privacy Preference Center</h3>
<span class="gdpr-close"></span>
</div>
</header>
<div class="gdpr-content">
<div class="gdpr-tab-content">
<div class="gdpr-consent-management gdpr-active">
<header>
<h4>Privacy Preferences</h4>
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<div class="gdpr-info">
<p></p>
</div>
</div>
</div>
</div>
<footer>
<input type="submit" class="btn-accent btn-flat" value="Save Preferences">
</footer>
</form>POST /find-a-career/?_ga=2.47328551.1023950021.1649070703-1454670958.1647973843#gf_24
<form method="post" enctype="multipart/form-data" target="gform_ajax_frame_24" id="gform_24" action="/find-a-career/?_ga=2.47328551.1023950021.1649070703-1454670958.1647973843#gf_24" novalidate="">
<div class="gform_body gform-body">
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<legend class="gfield_label gfield_label_before_complex">Full Name<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name" id="input_24_15">
<span id="input_24_15_3_container" class="name_first">
<input type="text" name="input_15.3" id="input_24_15_3" value="" aria-required="true" placeholder="First Name">
<label for="input_24_15_3" class="hidden_sub_label screen-reader-text">First</label>
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<span id="input_24_15_6_container" class="name_last">
<input type="text" name="input_15.6" id="input_24_15_6" value="" aria-required="true" placeholder="Last Name">
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<div id="field_24_4" class="gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible"><label class="gfield_label" for="input_24_4">Email<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_4" id="input_24_4" type="email" value="" class="medium" placeholder="Email" aria-required="true" aria-invalid="false">
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<fieldset id="field_24_6" class="gfield field_sublabel_hidden_label field_description_below hidden_label gfield_visibility_visible">
<legend class="gfield_label gfield_label_before_complex">Address</legend>
<div class="ginput_complex ginput_container has_street2 has_city has_state has_zip ginput_container_address" id="input_24_6">
<span class="ginput_full address_line_2 ginput_address_line_2" id="input_24_6_2_container">
<input type="text" name="input_6.2" id="input_24_6_2" value="" placeholder="Address" aria-required="false">
<label for="input_24_6_2" id="input_24_6_2_label" class="hidden_sub_label screen-reader-text">Address Line 2</label>
</span><span class="ginput_left address_city ginput_address_city" id="input_24_6_3_container">
<input type="text" name="input_6.3" id="input_24_6_3" value="" placeholder="City" aria-required="false">
<label for="input_24_6_3" id="input_24_6_3_label" class="hidden_sub_label screen-reader-text">City</label>
</span><span class="ginput_right address_state ginput_address_state" id="input_24_6_4_container">
<select name="input_6.4" id="input_24_6_4" aria-required="false">
<option value="" selected="selected">State</option>
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="Vermont">Vermont</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
<option value="Armed Forces Americas">Armed Forces Americas</option>
<option value="Armed Forces Europe">Armed Forces Europe</option>
<option value="Armed Forces Pacific">Armed Forces Pacific</option>
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<label for="input_24_6_4" id="input_24_6_4_label" class="hidden_sub_label screen-reader-text">State</label>
</span><span class="ginput_left address_zip ginput_address_zip" id="input_24_6_5_container">
<input type="text" name="input_6.5" id="input_24_6_5" value="" placeholder="Zip" aria-required="false">
<label for="input_24_6_5" id="input_24_6_5_label" class="hidden_sub_label screen-reader-text">ZIP Code</label>
</span><input type="hidden" class="gform_hidden" name="input_6.6" id="input_24_6_6" value="United States">
<div class="gf_clear gf_clear_complex"></div>
</div>
</fieldset>
<div id="field_24_7" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_24_7">For whom are you inquiring?<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_7" id="input_24_7" class="medium gfield_select" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Please Select</option>
<option value="Self">Self</option>
<option value="Parent">Parent</option>
<option value="Spouse">Spouse</option>
<option value="Relative">Relative</option>
<option value="Client">Client</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="field_24_10" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_24_10">Comments</label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_10" id="input_24_10" class="textarea medium" aria-invalid="false" rows="10" cols="50"></textarea></div>
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<div id="field_24_16" class="gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible"><label class="gfield_label" for="input_24_16">CAPTCHA</label>
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<div style="width: 304px; height: 78px;">
<div><iframe title="reCAPTCHA"
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</div>
</div>
</div>
</div>
</div>
<div class="gform_footer top_label">
<p><i>Ecumen does not accept solicitations. Thank You.</i></p><input type="submit" id="gform_submit_button_24" class="gform_button button" value="Submit"
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<input type="hidden" name="gform_ajax" value="form_id=24&title=&description=&tabindex=0">
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<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_24" value="WyJbXSIsIjQ4ZDM1M2RiZDQ5NDZkMjQ4MjZjMzQwOTkwMTQ2ODhjIl0=">
<input type="hidden" class="gform_hidden" name="gform_target_page_number_24" id="gform_target_page_number_24" value="0">
<input type="hidden" class="gform_hidden" name="gform_source_page_number_24" id="gform_source_page_number_24" value="1">
<input type="hidden" name="gform_field_values" value="">
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</form>POST /find-a-career/?_ga=2.47328551.1023950021.1649070703-1454670958.1647973843#gf_2
<form method="post" enctype="multipart/form-data" target="gform_ajax_frame_2" id="gform_2" action="/find-a-career/?_ga=2.47328551.1023950021.1649070703-1454670958.1647973843#gf_2" novalidate="">
<div class="gform_body gform-body">
<div id="gform_fields_2" class="gform_fields top_label form_sublabel_below description_below">
<div id="field_2_13" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_2_13">Name<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_13" id="input_2_13" type="text" value="" class="medium" aria-required="true" aria-invalid="false"> </div>
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<div id="field_2_2" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_2_2">Email<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_2" id="input_2_2" type="email" value="" class="medium" aria-required="true" aria-invalid="false">
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<div id="field_2_3" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_2_3">Phone (not required)</label>
<div class="ginput_container ginput_container_phone"><input name="input_3" id="input_2_3" type="tel" value="" class="medium" aria-invalid="false"></div>
</div>
<div id="field_2_5" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_2_5">Reason for Contacting<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_5" id="input_2_5" class="large gfield_select" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Select</option>
<option value="General Inquiry">General Inquiry</option>
<option value="Senior Housing or Service Inquiry">Senior Housing or Service Inquiry</option>
<option value="Senior Housing Development or Management Inquiry">Senior Housing Development or Management Inquiry</option>
<option value="Abxtracker">Abxtracker</option>
<option value="The Ecumen Store">The Ecumen Store</option>
<option value="Media Inquiry">Media Inquiry</option>
</select></div>
</div>
<div id="field_2_15" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_2_15">Ecumen Community or Service (if applicable)</label>
<div class="ginput_container ginput_container_select"><select name="input_15" id="input_2_15" class="large gfield_select" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">-None-</option>
<option value="Abiitan Mill City - Minneapolis, MN">Abiitan Mill City - Minneapolis, MN</option>
<option value="Bethel Manor & Winona Shores of Alexandria - MN">Bethel Manor & Winona Shores of Alexandria - MN</option>
<option value="Boardman Meadows - New Richmond, WI">Boardman Meadows - New Richmond, WI</option>
<option value="CedarStone - Cedar Falls, IA">CedarStone - Cedar Falls, IA</option>
<option value="Ecumen Brooks - Owatonna, MN">Ecumen Brooks - Owatonna, MN</option>
<option value="Ecumen Centennial House - Apple Valley, MN">Ecumen Centennial House - Apple Valley, MN</option>
<option value="Ecumen CountrySide - Owatonna, MN">Ecumen CountrySide - Owatonna, MN</option>
<option value="Ecumen Detroit Lakes - MN">Ecumen Detroit Lakes - MN</option>
<option value="Ecumen Evergreens of Fargo - ND">Ecumen Evergreens of Fargo - ND</option>
<option value="Ecumen Evergreens of Moorhead - MN">Ecumen Evergreens of Moorhead - MN</option>
<option value="Ecumen Home Care - Duluth">Ecumen Home Care - Duluth</option>
<option value="Ecumen Home Care - Litchfield">Ecumen Home Care - Litchfield</option>
<option value="Ecumen Home Care - Mankato">Ecumen Home Care - Mankato</option>
<option value="Ecumen Hospice (general inquiries)">Ecumen Hospice (general inquiries)</option>
<option value="Ecumen Hospice - Duluth">Ecumen Hospice - Duluth</option>
<option value="Ecumen Hospice - Litchfield">Ecumen Hospice - Litchfield</option>
<option value="Ecumen Hospice – North Branch">Ecumen Hospice – North Branch</option>
<option value="Ecumen Hospice - Owatonna">Ecumen Hospice - Owatonna</option>
<option value="Ecumen Hospice - Twin Cities">Ecumen Hospice - Twin Cities</option>
<option value="Ecumen Lakeshore - Duluth, MN">Ecumen Lakeshore - Duluth, MN</option>
<option value="Ecumen Lakeview Commons - Maplewood, MN">Ecumen Lakeview Commons - Maplewood, MN</option>
<option value="Ecumen Litchfield - MN">Ecumen Litchfield - MN</option>
<option value="Ecumen Meadows - Worthington, MN">Ecumen Meadows - Worthington, MN</option>
<option value="Ecumen North Branch - MN">Ecumen North Branch - MN</option>
<option value="Ecumen Oaks & Pines - Hutchinson, MN">Ecumen Oaks & Pines - Hutchinson, MN</option>
<option value="Ecumen Pathstone - Mankato, MN">Ecumen Pathstone - Mankato, MN</option>
<option value="Ecumen Point Pleasant Heights - Chisago City, MN">Ecumen Point Pleasant Heights - Chisago City, MN</option>
<option value="Ecumen Prairie Hill - St. Peter, MN">Ecumen Prairie Hill - St. Peter, MN</option>
<option value="Ecumen Prairie Lodge - Brooklyn Center, MN">Ecumen Prairie Lodge - Brooklyn Center, MN</option>
<option value="Ecumen Sand Prairie - St. Peter, MN">Ecumen Sand Prairie - St. Peter, MN</option>
<option value="Ecumen Seasons at Apple Valley - MN">Ecumen Seasons at Apple Valley - MN</option>
<option value="Ecumen Seasons at Maplewood - MN">Ecumen Seasons at Maplewood - MN</option>
<option value="Forest Heights — St. Croix Falls, WI">Forest Heights — St. Croix Falls, WI</option>
<option value="Grand Village - Grand Rapids, MN">Grand Village - Grand Rapids, MN</option>
<option value="Heritage Community - Park Rapids, MN">Heritage Community - Park Rapids, MN</option>
<option value="Lakeland Shores Apartments - Lakeland Shores, MN">Lakeland Shores Apartments - Lakeland Shores, MN</option>
<option value="Lilac Parkway - Robbinsdale, MN">Lilac Parkway - Robbinsdale, MN</option>
<option value="Luther Park at Sandpoint - ID">Luther Park at Sandpoint - ID</option>
<option value="Mount Royal Pines III Assisted Living - Duluth, MN">Mount Royal Pines III Assisted Living - Duluth, MN</option>
<option value="Park Villa Apartments - Park Rapids, MN">Park Villa Apartments - Park Rapids, MN</option>
<option value="Parmly Lakeview Apartments - Chisago City, MN">Parmly Lakeview Apartments - Chisago City, MN</option>
<option value="PrairieStone - Cedar Falls, IA">PrairieStone - Cedar Falls, IA</option>
<option value="Quartet - Bettendorf, IA">Quartet - Bettendorf, IA</option>
<option value="River Town Heights — St. Croix Falls, WI">River Town Heights — St. Croix Falls, WI</option>
<option value="St. Mark's Apartments - Austin, MN">St. Mark's Apartments - Austin, MN</option>
<option value="St. Mark's Living - Austin, MN">St. Mark's Living - Austin, MN</option>
<option value="Sunnyside Care Center - Lake Park, MN">Sunnyside Care Center - Lake Park, MN</option>
<option value="The Harbor at Peace Village - Norwood Young America, MN">The Harbor at Peace Village - Norwood Young America, MN</option>
<option value="The Haven at Peace Village - Norwood Young America, MN">The Haven at Peace Village - Norwood Young America, MN</option>
<option value="The Hillock - Minneapolis, MN">The Hillock - Minneapolis, MN</option>
<option value="Uptown Maple Commons - North Branch, MN">Uptown Maple Commons - North Branch, MN</option>
<option value="Willow Wood Apartments - White Bear Lake, MN">Willow Wood Apartments - White Bear Lake, MN</option>
<option value="Zvago Sales & Design Studio">Zvago Sales & Design Studio</option>
<option value="Zvago Central Village - Apple Valley, MN">Zvago Central Village - Apple Valley, MN</option>
<option value="Zvago Lake Superior - Duluth, MN">Zvago Lake Superior - Duluth, MN</option>
<option value="Zvago Long Lake - MN">Zvago Long Lake - MN</option>
<option value="Zvago Stillwater - MN">Zvago Stillwater - MN</option>
</select></div>
</div>
<div id="field_2_9" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_2_9">For whom are you inquiring?</label>
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<option value="" selected="selected" class="gf_placeholder">-None-</option>
<option value="Self">Self</option>
<option value="Parent">Parent</option>
<option value="Spouse">Spouse</option>
<option value="Relative">Relative</option>
<option value="Client">Client</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="field_2_11" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_2_11">Message<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_11" id="input_2_11" class="textarea medium" placeholder="Comments" aria-required="true" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
<div id="field_2_17" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible">
<div class="ginput_container ginput_container_text"><input name="input_17" id="input_2_17" type="hidden" class="gform_hidden" aria-invalid="false" value=""></div>
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<div id="field_2_16" class="gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible"><label class="gfield_label screen-reader-text" for="input_2_16"></label>
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</div>
<div class="gform_footer top_label">
<p><i>Ecumen does not accept solicitations. Thank You.</i></p><input type="submit" id="gform_submit_button_2" class="gform_button button" value="Send Message"
onclick="if(window["gf_submitting_2"]){return false;} if( !jQuery("#gform_2")[0].checkValidity || jQuery("#gform_2")[0].checkValidity()){window["gf_submitting_2"]=true;} "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_2"]){return false;} if( !jQuery("#gform_2")[0].checkValidity || jQuery("#gform_2")[0].checkValidity()){window["gf_submitting_2"]=true;} jQuery("#gform_2").trigger("submit",[true]); }">
<input type="hidden" name="gform_ajax" value="form_id=2&title=&description=&tabindex=0">
<input type="hidden" class="gform_hidden" name="is_submit_2" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="2">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_2" value="WyJbXSIsIjQ4ZDM1M2RiZDQ5NDZkMjQ4MjZjMzQwOTkwMTQ2ODhjIl0=">
<input type="hidden" class="gform_hidden" name="gform_target_page_number_2" id="gform_target_page_number_2" value="0">
<input type="hidden" class="gform_hidden" name="gform_source_page_number_2" id="gform_source_page_number_2" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
</form>POST /find-a-career/?_ga=2.47328551.1023950021.1649070703-1454670958.1647973843#gf_9
<form method="post" enctype="multipart/form-data" target="gform_ajax_frame_9" id="gform_9" action="/find-a-career/?_ga=2.47328551.1023950021.1649070703-1454670958.1647973843#gf_9" novalidate="">
<div class="gform_body gform-body">
<div id="gform_fields_9" class="gform_fields top_label form_sublabel_below description_below">
<div id="field_9_1" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_9_1">Company Name<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_1" id="input_9_1" type="text" value="" class="medium" aria-required="true" aria-invalid="false"> </div>
</div>
<fieldset id="field_9_3" class="gfield gfield_contains_required field_sublabel_above field_description_below gfield_visibility_visible">
<legend class="gfield_label gfield_label_before_complex">Company Address<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_complex ginput_container has_city has_state has_zip ginput_container_address" id="input_9_3">
<span class="ginput_left address_city ginput_address_city" id="input_9_3_3_container">
<label for="input_9_3_3" id="input_9_3_3_label">City</label>
<input type="text" name="input_3.3" id="input_9_3_3" value="" aria-required="true">
</span><span class="ginput_right address_state ginput_address_state" id="input_9_3_4_container">
<label for="input_9_3_4" id="input_9_3_4_label">State</label>
<select name="input_3.4" id="input_9_3_4" aria-required="true">
<option value="" selected="selected"></option>
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="Vermont">Vermont</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
<option value="Armed Forces Americas">Armed Forces Americas</option>
<option value="Armed Forces Europe">Armed Forces Europe</option>
<option value="Armed Forces Pacific">Armed Forces Pacific</option>
</select>
</span><span class="ginput_left address_zip ginput_address_zip" id="input_9_3_5_container">
<label for="input_9_3_5" id="input_9_3_5_label">ZIP Code</label>
<input type="text" name="input_3.5" id="input_9_3_5" value="" aria-required="true">
</span><input type="hidden" class="gform_hidden" name="input_3.6" id="input_9_3_6" value="United States">
<div class="gf_clear gf_clear_complex"></div>
</div>
</fieldset>
<div id="field_9_4" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_9_4">Company Website</label>
<div class="ginput_container ginput_container_text"><input name="input_4" id="input_9_4" type="text" value="" class="medium" aria-invalid="false"> </div>
</div>
<div id="field_9_5" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_9_5">Primary Contact Name:<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_5" id="input_9_5" type="text" value="" class="medium" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_9_6" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_9_6">Primary Contact Phone:<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_number"><input name="input_6" id="input_9_6" type="number" step="any" value="" class="medium" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_9_7" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_9_7">Primary Contact Email:<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_7" id="input_9_7" type="email" value="" class="medium" aria-required="true" aria-invalid="false">
</div>
</div>
<div id="field_9_9" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_9_9">Business Category<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_9" id="input_9_9" class="medium gfield_select" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">-Select-</option>
<option value="Benefits">Benefits</option>
<option value="Business Development/Facility Refresh">Business Development/Facility Refresh</option>
<option value="Clinical Supplies & Services">Clinical Supplies & Services</option>
<option value="Communication Products & Services">Communication Products & Services</option>
<option value="Dietary Products & Services">Dietary Products & Services</option>
<option value="Document Storage (Physical)">Document Storage (Physical)</option>
<option value="Durable Medical Equipment/Medical Supplies">Durable Medical Equipment/Medical Supplies</option>
<option value="Facilities/ Environmental / Maintenance">Facilities/ Environmental / Maintenance</option>
<option value="Financial Investments">Financial Investments</option>
<option value="Financial Services">Financial Services</option>
<option value="Fleet Services">Fleet Services</option>
<option value="Group Purchasing Organizations">Group Purchasing Organizations</option>
<option value="Freight/Courier Services">Freight/Courier Services</option>
<option value="House Keeping Products">House Keeping Products</option>
<option value="Human Resource Services">Human Resource Services</option>
<option value="Information Systems/IT">Information Systems/IT</option>
<option value="Learning Products & Services">Learning Products & Services</option>
<option value="Legal Services">Legal Services</option>
<option value="Life Enrichment/Resident Activities and Entertainment">Life Enrichment/Resident Activities and Entertainment</option>
<option value="Marketing/Advertising/Commercial Printing Services">Marketing/Advertising/Commercial Printing Services</option>
<option value="Office Supplies (non-IT related)">Office Supplies (non-IT related)</option>
<option value="Payor Contractors">Payor Contractors</option>
<option value="Philanthropy">Philanthropy</option>
<option value="Professional Services (patient related)">Professional Services (patient related)</option>
<option value="Rehabilitation Products & Services">Rehabilitation Products & Services</option>
<option value="Risk Management Products & Services">Risk Management Products & Services</option>
<option value="Spiritual/Religious">Spiritual/Religious</option>
</select></div>
</div>
<div id="field_9_10" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_9_10">What product or service do you provide?<span
class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_10" id="input_9_10" type="text" value="" class="medium" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_9_11" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_9_11">Years in Business<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_11" id="input_9_11" class="medium gfield_select" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">-Select-</option>
<option value="1-3">1-3</option>
<option value="4-7">4-7</option>
<option value="7-10">7-10</option>
<option value="11-15">11-15</option>
<option value="16-19">16-19</option>
<option value="20+">20+</option>
</select></div>
</div>
<div id="field_9_12" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_9_12">Average Number of Years of Active Customer Accounts<span
class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_12" id="input_9_12" class="medium gfield_select" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">-Select-</option>
<option value="1-3">1-3</option>
<option value="4-7">4-7</option>
<option value="7-10">7-10</option>
<option value="11-15">11-15</option>
<option value="16-19">16-19</option>
<option value="20+">20+</option>
</select></div>
</div>
<div id="field_9_13" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_9_13">Number of Employees (Hourly and Salaried)<span
class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_13" id="input_9_13" class="medium gfield_select" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">-Select-</option>
<option value="1-99">1-99</option>
<option value="100-499">100-499</option>
<option value="500-999">500-999</option>
<option value="1000-2499">1000-2499</option>
<option value="2500-4999">2500-4999</option>
<option value="5000+">5000+</option>
</select></div>
</div>
<div id="field_9_14" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_9_14">Does your organization or any of its employees present a conflict
of interest in doing business with Ecumen? If so, please describe.<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_14" id="input_9_14" class="textarea medium" aria-required="true" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
<fieldset id="field_9_15" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible">
<legend class="gfield_label">Is your company publicly or privately held?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_9_15">
<div class="gchoice gchoice_9_15_0">
<input class="gfield-choice-input" name="input_15" type="radio" value="Public" id="choice_9_15_0" onchange="gformToggleRadioOther( this )">
<label for="choice_9_15_0" id="label_9_15_0">Public</label>
</div>
<div class="gchoice gchoice_9_15_1">
<input class="gfield-choice-input" name="input_15" type="radio" value="Private" id="choice_9_15_1" onchange="gformToggleRadioOther( this )">
<label for="choice_9_15_1" id="label_9_15_1">Private</label>
</div>
</div>
</div>
</fieldset>
<div id="field_9_16" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_9_16">Dun & Bradstreet Number (If applicable)<span
class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_16" id="input_9_16" type="text" value="" class="medium" aria-required="true" aria-invalid="false"> </div>
</div>
<fieldset id="field_9_17" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible">
<legend class="gfield_label">Do you utilize sub-contractors for all or a portion of your services?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_9_17">
<div class="gchoice gchoice_9_17_0">
<input class="gfield-choice-input" name="input_17" type="radio" value="Yes" id="choice_9_17_0" onchange="gformToggleRadioOther( this )">
<label for="choice_9_17_0" id="label_9_17_0">Yes</label>
</div>
<div class="gchoice gchoice_9_17_1">
<input class="gfield-choice-input" name="input_17" type="radio" value="No" id="choice_9_17_1" onchange="gformToggleRadioOther( this )">
<label for="choice_9_17_1" id="label_9_17_1">No</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_9_18" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible">
<legend class="gfield_label">Are you currently certified/documented as either a Minority, Woman-owned, or Veteran-owned business?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span>
</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_9_18">
<div class="gchoice gchoice_9_18_0">
<input class="gfield-choice-input" name="input_18" type="radio" value="Yes" id="choice_9_18_0" onchange="gformToggleRadioOther( this )">
<label for="choice_9_18_0" id="label_9_18_0">Yes</label>
</div>
<div class="gchoice gchoice_9_18_1">
<input class="gfield-choice-input" name="input_18" type="radio" value="No" id="choice_9_18_1" onchange="gformToggleRadioOther( this )">
<label for="choice_9_18_1" id="label_9_18_1">No</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_9_19" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible">
<legend class="gfield_label">Does your company or organization have a dedicated account manager located in the state of Minnesota that can service all of our Ecumen locations if needed?<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_9_19">
<div class="gchoice gchoice_9_19_0">
<input class="gfield-choice-input" name="input_19" type="radio" value="Yes" id="choice_9_19_0" onchange="gformToggleRadioOther( this )">
<label for="choice_9_19_0" id="label_9_19_0">Yes</label>
</div>
<div class="gchoice gchoice_9_19_1">
<input class="gfield-choice-input" name="input_19" type="radio" value="No" id="choice_9_19_1" onchange="gformToggleRadioOther( this )">
<label for="choice_9_19_1" id="label_9_19_1">No</label>
</div>
</div>
</div>
</fieldset>
<div id="field_9_20" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_9_20">If you were referred by an Ecumen owned or managed community, please choose the community
name below.</label>
<div class="ginput_container ginput_container_select"><select name="input_20" id="input_9_20" class="medium gfield_select" aria-invalid="false">
<option value="Abiitan Mill City">Abiitan Mill City</option>
<option value="Boardman Meadows">Boardman Meadows</option>
<option value="Clarkfield Care Center & Home Care">Clarkfield Care Center & Home Care</option>
<option value="Ecumen Bethany Community">Ecumen Bethany Community</option>
<option value="Ecumen Brooks">Ecumen Brooks</option>
<option value="Ecumen Centennial House">Ecumen Centennial House</option>
<option value="Ecumen CountrySide Location">Ecumen CountrySide Location</option>
<option value="Ecumen Detroit Lakes">Ecumen Detroit Lakes</option>
<option value="Ecumen Evergreens of Fargo">Ecumen Evergreens of Fargo</option>
<option value="Ecumen Evergreens of Moorhead">Ecumen Evergreens of Moorhead</option>
<option value="Ecumen Home Care & Hospice - Litchfield">Ecumen Home Care & Hospice - Litchfield</option>
<option value="Ecumen Home Care - Lakeshore">Ecumen Home Care - Lakeshore</option>
<option value="Ecumen Home Care - Pathstone">Ecumen Home Care - Pathstone</option>
<option value="Ecumen Home Office – Shoreview">Ecumen Home Office – Shoreview</option>
<option value="Ecumen Hospice - Twin Cities">Ecumen Hospice - Twin Cities</option>
<option value="Ecumen Lakeshore">Ecumen Lakeshore</option>
<option value="Ecumen Lakeview Commons">Ecumen Lakeview Commons</option>
<option value="Ecumen Meadows">Ecumen Meadows</option>
<option value="Ecumen North Branch">Ecumen North Branch</option>
<option value="Ecumen Oaks & Pines">Ecumen Oaks & Pines</option>
<option value="Ecumen of Litchfield">Ecumen of Litchfield</option>
<option value="Ecumen Parmly LifePointes">Ecumen Parmly LifePointes</option>
<option value="Ecumen Pathstone Living">Ecumen Pathstone Living</option>
<option value="Ecumen Point Pleasant Heights">Ecumen Point Pleasant Heights</option>
<option value="Ecumen Prairie Hill">Ecumen Prairie Hill</option>
<option value="Ecumen Prairie Lodge">Ecumen Prairie Lodge</option>
<option value="Ecumen Sand Prairie">Ecumen Sand Prairie</option>
<option value="Ecumen Scenic Shores">Ecumen Scenic Shores</option>
<option value="Ecumen Seasons at Apple Valley">Ecumen Seasons at Apple Valley</option>
<option value="Ecumen Seasons at Maplewood">Ecumen Seasons at Maplewood</option>
<option value="Grand Village">Grand Village</option>
<option value="Heritage at Irene Woods">Heritage at Irene Woods</option>
<option value="Heritage Senior Living">Heritage Senior Living</option>
<option value="Lakeland Shores Apartments">Lakeland Shores Apartments</option>
<option value="Lilac Parkway">Lilac Parkway</option>
<option value="Luther Park at Sandpoint">Luther Park at Sandpoint</option>
<option value="Park Villa Apartments">Park Villa Apartments</option>
<option value="Pelican Valley Health Center">Pelican Valley Health Center</option>
<option value="Rose Senior Living - Avon">Rose Senior Living - Avon</option>
<option value="Rose Senior Living - Clinton Township">Rose Senior Living - Clinton Township</option>
<option value="St. Mark's Living">St. Mark's Living</option>
<option value="Sunnyside Care Center">Sunnyside Care Center</option>
<option value="The Harbor at Peace Village">The Harbor at Peace Village</option>
<option value="Uptown Maple Commons">Uptown Maple Commons</option>
<option value="Willow Wood Apartments">Willow Wood Apartments</option>
<option value="Zvago Central Village">Zvago Central Village</option>
<option value="Zvago Glen Lake">Zvago Glen Lake</option>
<option value="Zvago St.Anthony Park">Zvago St.Anthony Park</option>
</select></div>
</div>
<fieldset id="field_9_21" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible">
<legend class="gfield_label">Are you currently doing business with any Ecumen owned or managed locations?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_9_21">
<div class="gchoice gchoice_9_21_0">
<input class="gfield-choice-input" name="input_21" type="radio" value="Yes" id="choice_9_21_0" onchange="gformToggleRadioOther( this )">
<label for="choice_9_21_0" id="label_9_21_0">Yes</label>
</div>
<div class="gchoice gchoice_9_21_1">
<input class="gfield-choice-input" name="input_21" type="radio" value="No" id="choice_9_21_1" onchange="gformToggleRadioOther( this )">
<label for="choice_9_21_1" id="label_9_21_1">No</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_9_27" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible">
<legend class="gfield_label">Have you done business with Ecumen in the past?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_9_27">
<div class="gchoice gchoice_9_27_0">
<input class="gfield-choice-input" name="input_27" type="radio" value="Yes" id="choice_9_27_0" onchange="gformToggleRadioOther( this )">
<label for="choice_9_27_0" id="label_9_27_0">Yes</label>
</div>
<div class="gchoice gchoice_9_27_1">
<input class="gfield-choice-input" name="input_27" type="radio" value="No" id="choice_9_27_1" onchange="gformToggleRadioOther( this )">
<label for="choice_9_27_1" id="label_9_27_1">No</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_9_26" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible">
<legend class="gfield_label">Has your company been involved in any suits, liens, or judgments within the last five years?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_9_26">
<div class="gchoice gchoice_9_26_0">
<input class="gfield-choice-input" name="input_26" type="radio" value="Yes" id="choice_9_26_0" onchange="gformToggleRadioOther( this )">
<label for="choice_9_26_0" id="label_9_26_0">Yes</label>
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</div>
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<fieldset id="field_9_25" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible">
<legend class="gfield_label">Is your company and its contractor's HIPAA compliant?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_9_25">
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<legend class="gfield_label">Do you have general liability insurance coverage?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_9_24">
<div class="gchoice gchoice_9_24_0">
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<fieldset id="field_9_23" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible">
<legend class="gfield_label">Do you currently sell to other Senior Housing and Services organizations?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_9_23">
<div class="gchoice gchoice_9_23_0">
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<fieldset id="field_9_22" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible">
<legend class="gfield_label">Do you currently work with any Group Purchasing Organizations?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_9_22">
<div class="gchoice gchoice_9_22_0">
<input class="gfield-choice-input" name="input_22" type="radio" value="Yes" id="choice_9_22_0" onchange="gformToggleRadioOther( this )">
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<div id="field_9_29" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_9_29">If your entity is a Group Purchasing Organization, what vendors and industries do you
currently represent?</label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_29" id="input_9_29" class="textarea medium" aria-invalid="false" rows="10" cols="50"></textarea></div>
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<fieldset id="field_9_28" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible">
<legend class="gfield_label">Do you have distribution capabilities?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_9_28">
<div class="gchoice gchoice_9_28_0">
<input class="gfield-choice-input" name="input_28" type="radio" value="Yes" id="choice_9_28_0" onchange="gformToggleRadioOther( this )">
<label for="choice_9_28_0" id="label_9_28_0">Yes</label>
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<div class="gchoice gchoice_9_28_1">
<input class="gfield-choice-input" name="input_28" type="radio" value="No" id="choice_9_28_1" onchange="gformToggleRadioOther( this )">
<label for="choice_9_28_1" id="label_9_28_1">No</label>
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<div id="field_9_33" class="gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible">For companies in start-up/emerging companies, please answer these additional
questions:</div>
<div id="field_9_32" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_9_32">What stage best describes your company’s current product development?</label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_32" id="input_9_32" class="textarea medium" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
<div id="field_9_31" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_9_31">Tell us about the founders of your company.</label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_31" id="input_9_31" class="textarea medium" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
<div id="field_9_30" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_9_30">What key milestones have been accomplished to date?</label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_30" id="input_9_30" class="textarea medium" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
<div id="field_9_34" class="gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible"><label class="gfield_label" for="input_9_34">CAPTCHA</label>
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</div>
</div>
</div>
<div class="gform_footer top_label">
<p><i>Ecumen does not accept solicitations. Thank You.</i></p><input type="submit" id="gform_submit_button_9" class="gform_button button" value="Submit"
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<div id="gform_fields_25" class="gform_fields top_label form_sublabel_below description_below">
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<div class="ginput_container ginput_container_text"><input name="input_13" id="input_25_13" type="text" value="" class="medium" aria-required="true" aria-invalid="false"> </div>
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<div id="field_25_2" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_25_2">Email<span class="gfield_required"><span
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<input name="input_2" id="input_25_2" type="email" value="" class="medium" aria-required="true" aria-invalid="false">
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<div id="field_25_3" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_25_3">Phone (not required)</label>
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<div id="field_25_5" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_25_5">Reason for Contacting<span class="gfield_required"><span
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<option value="Senior Housing or Service Inquiry">Senior Housing or Service Inquiry</option>
<option value="Senior Housing Development or Management Inquiry">Senior Housing Development or Management Inquiry</option>
<option value="The Ecumen Store">The Ecumen Store</option>
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<div id="field_25_15" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_25_15">Ecumen Community or Service (if applicable)</label>
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<option value="Abiitan Mill City - Minneapolis, MN">Abiitan Mill City - Minneapolis, MN</option>
<option value="Bethel Manor & Winona Shores of Alexandria - MN">Bethel Manor & Winona Shores of Alexandria - MN</option>
<option value="Boardman Meadows - New Richmond, WI">Boardman Meadows - New Richmond, WI</option>
<option value="CedarStone - Cedar Falls, IA">CedarStone - Cedar Falls, IA</option>
<option value="Ecumen Brooks - Owatonna, MN">Ecumen Brooks - Owatonna, MN</option>
<option value="Ecumen Centennial House - Apple Valley, MN">Ecumen Centennial House - Apple Valley, MN</option>
<option value="Ecumen CountrySide - Owatonna, MN">Ecumen CountrySide - Owatonna, MN</option>
<option value="Ecumen Detroit Lakes - MN">Ecumen Detroit Lakes - MN</option>
<option value="Ecumen Evergreens of Fargo - ND">Ecumen Evergreens of Fargo - ND</option>
<option value="Ecumen Evergreens of Moorhead - MN">Ecumen Evergreens of Moorhead - MN</option>
<option value="Ecumen Home Care - Duluth">Ecumen Home Care - Duluth</option>
<option value="Ecumen Home Care - Litchfield">Ecumen Home Care - Litchfield</option>
<option value="Ecumen Home Care - Mankato">Ecumen Home Care - Mankato</option>
<option value="Ecumen Hospice (general inquiries)">Ecumen Hospice (general inquiries)</option>
<option value="Ecumen Hospice - Duluth">Ecumen Hospice - Duluth</option>
<option value="Ecumen Hospice - Litchfield">Ecumen Hospice - Litchfield</option>
<option value="Ecumen Hospice – North Branch">Ecumen Hospice – North Branch</option>
<option value="Ecumen Hospice - Owatonna">Ecumen Hospice - Owatonna</option>
<option value="Ecumen Hospice - Twin Cities">Ecumen Hospice - Twin Cities</option>
<option value="Ecumen Lakeshore - Duluth, MN">Ecumen Lakeshore - Duluth, MN</option>
<option value="Ecumen Lakeview Commons - Maplewood, MN">Ecumen Lakeview Commons - Maplewood, MN</option>
<option value="Ecumen Litchfield - MN">Ecumen Litchfield - MN</option>
<option value="Ecumen Meadows - Worthington, MN">Ecumen Meadows - Worthington, MN</option>
<option value="Ecumen North Branch - MN">Ecumen North Branch - MN</option>
<option value="Ecumen Oaks & Pines - Hutchinson, MN">Ecumen Oaks & Pines - Hutchinson, MN</option>
<option value="Ecumen Pathstone - Mankato, MN">Ecumen Pathstone - Mankato, MN</option>
<option value="Ecumen Point Pleasant Heights - Chisago City, MN">Ecumen Point Pleasant Heights - Chisago City, MN</option>
<option value="Ecumen Prairie Hill - St. Peter, MN">Ecumen Prairie Hill - St. Peter, MN</option>
<option value="Ecumen Prairie Lodge - Brooklyn Center, MN">Ecumen Prairie Lodge - Brooklyn Center, MN</option>
<option value="Ecumen Sand Prairie - St. Peter, MN">Ecumen Sand Prairie - St. Peter, MN</option>
<option value="Ecumen Seasons at Apple Valley - MN">Ecumen Seasons at Apple Valley - MN</option>
<option value="Ecumen Seasons at Maplewood - MN">Ecumen Seasons at Maplewood - MN</option>
<option value="Forest Heights — St. Croix Falls, WI">Forest Heights — St. Croix Falls, WI</option>
<option value="Grand Village - Grand Rapids, MN">Grand Village - Grand Rapids, MN</option>
<option value="Heritage Community - Park Rapids, MN">Heritage Community - Park Rapids, MN</option>
<option value="Lakeland Shores Apartments - Lakeland Shores, MN">Lakeland Shores Apartments - Lakeland Shores, MN</option>
<option value="Lilac Parkway - Robbinsdale, MN">Lilac Parkway - Robbinsdale, MN</option>
<option value="Luther Park at Sandpoint - ID">Luther Park at Sandpoint - ID</option>
<option value="Mount Royal Pines III Assisted Living - Duluth, MN">Mount Royal Pines III Assisted Living - Duluth, MN</option>
<option value="Park Villa Apartments - Park Rapids, MN">Park Villa Apartments - Park Rapids, MN</option>
<option value="Parmly Lakeview Apartments - Chisago City, MN">Parmly Lakeview Apartments - Chisago City, MN</option>
<option value="PrairieStone - Cedar Falls, IA">PrairieStone - Cedar Falls, IA</option>
<option value="Quartet - Bettendorf, IA">Quartet - Bettendorf, IA</option>
<option value="River Town Heights — St. Croix Falls, WI">River Town Heights — St. Croix Falls, WI</option>
<option value="St. Mark's Apartments - Austin, MN">St. Mark's Apartments - Austin, MN</option>
<option value="St. Mark's Living - Austin, MN">St. Mark's Living - Austin, MN</option>
<option value="Sunnyside Care Center - Lake Park, MN">Sunnyside Care Center - Lake Park, MN</option>
<option value="The Harbor at Peace Village - Norwood Young America, MN">The Harbor at Peace Village - Norwood Young America, MN</option>
<option value="The Haven at Peace Village - Norwood Young America, MN">The Haven at Peace Village - Norwood Young America, MN</option>
<option value="The Hillock - Minneapolis, MN">The Hillock - Minneapolis, MN</option>
<option value="Uptown Maple Commons - North Branch, MN">Uptown Maple Commons - North Branch, MN</option>
<option value="Willow Wood Apartments - White Bear Lake, MN">Willow Wood Apartments - White Bear Lake, MN</option>
<option value="Zvago Sales & Design Studio">Zvago Sales & Design Studio</option>
<option value="Zvago Central Village - Apple Valley, MN">Zvago Central Village - Apple Valley, MN</option>
<option value="Zvago Lake Superior - Duluth, MN">Zvago Lake Superior - Duluth, MN</option>
<option value="Zvago Long Lake - MN">Zvago Long Lake - MN</option>
<option value="Zvago Stillwater - MN">Zvago Stillwater - MN</option>
</select></div>
</div>
<div id="field_25_9" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_25_9">For whom are you inquiring?</label>
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<div id="field_25_17" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible">
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<div id="field_25_16" class="gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible"><label class="gfield_label screen-reader-text" for="input_25_16"></label>
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<div class="gform_footer top_label">
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</form><form id="mongo-form">
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<div class="BBFormRadioItem BBFormRadioGivingLevelItem">
<div class="BBFormRadioButtonContainer"><input value="50" name="bboxdonation$gift$GivingLevel" type="radio" id="bboxdonation_gift_rdGivingLevel1" checked="checked"
class="BBFormRadioButton BBFormRadioGivingLevel BBFormRadioGivingLevelSelected"><label for="bboxdonation_gift_rdGivingLevel1" class="BBFormRadioLabel BBFormRadioLabelGivingLevel BBFormRadioLabelGivingLevelSelected"><span
class="BBFormRadioAmount">$50</span></label></div>
</div>
<div class="BBFormRadioItem BBFormRadioGivingLevelItem">
<div class="BBFormRadioButtonContainer"><input value="75" name="bboxdonation$gift$GivingLevel" type="radio" id="bboxdonation_gift_rdGivingLevel2" class="BBFormRadioButton BBFormRadioGivingLevel"><label
for="bboxdonation_gift_rdGivingLevel2" class="BBFormRadioLabel BBFormRadioLabelGivingLevel BBFormRadioLabelGivingLevelNotSelected"><span class="BBFormRadioAmount">$75</span></label></div>
</div>
<div class="BBFormRadioItem BBFormRadioGivingLevelItem">
<div class="BBFormRadioButtonContainer"><input value="100" name="bboxdonation$gift$GivingLevel" type="radio" id="bboxdonation_gift_rdGivingLevel3" class="BBFormRadioButton BBFormRadioGivingLevel"><label
for="bboxdonation_gift_rdGivingLevel3" class="BBFormRadioLabel BBFormRadioLabelGivingLevel BBFormRadioLabelGivingLevelNotSelected"><span class="BBFormRadioAmount">$100</span></label></div>
</div>
<div class="BBFormRadioItem BBFormRadioGivingLevelItem">
<div class="BBFormRadioButtonContainer"><input value="rdGivingLevel4" name="bboxdonation$gift$GivingLevel" type="radio" id="bboxdonation_gift_rdGivingLevel4" data-min-payment="5" title="Other gift amount"
class="BBFormRadioButton BBFormRadioGivingLevel BBFormRadioGivingLevelOther"><label for="bboxdonation_gift_rdGivingLevel4" title="Other gift amount" aria-labelledby="bboxdonation_gift_rdGivingLevel4"
class="BBFormRadioLabel BBFormRadioLabelGivingLevel BBFormRadioLabelGivingLevelNotSelected BBFormRadioLabelGivingLevelOther"><span class="BBFormRadioDescriptionOther">Other</span><input
name="bboxdonation$gift$txtOtherAmountButtons" type="tel" id="bboxdonation_gift_txtOtherAmountButtons" class="BBFormTextbox BBFormGiftOtherAmount BBFormCurrency" placeholder="$" data-culture="en-US"
aria-labelledby="bboxdonation_gift_rdGivingLevel4" title="Other gift amount"></label></div>
</div>
</div>
<div class="BBClearFix">
</div>
</div>
<div id="bboxdonation_gift_fldPledgeAmountWhenNoLevels" class="BBFormFieldContainer BBFormNoLevels BBFormPledgeFields" style="display: none;">
<label for="bboxdonation_gift_txtAmountPledge" id="bboxdonation_gift_lblAmountPledge" class="BBFormFieldLabel BBFormFieldLabelAmount BBFormFieldLabelEdit">Amount:</label>
<input name="bboxdonation$gift$txtAmountPledge" type="tel" id="bboxdonation_gift_txtAmountPledge" class="BBFormTextbox BBFormCurrency" required="required" placeholder="$" data-culture="en-US" data-min-payment="10.0000">
</div>
</fieldset>
</div>
<input name="bboxdonation$gift$hdnGivingLevelButtonsEnabled" type="hidden" id="bboxdonation_gift_hdnGivingLevelButtonsEnabled" class="hdnGivingLevelButtonsEnabled" value="true">
<input name="bboxdonation$gift$hdnPledgeDuration" type="hidden" id="bboxdonation_gift_hdnPledgeDuration" class="hdnPledgeDuration">
<input name="bboxdonation$gift$hdnPledgePayment" type="hidden" id="bboxdonation_gift_hdnPledgePayment" class="hdnPledgePayment">
<input name="bboxdonation$gift$hdnGiftButtonsStyle" type="hidden" id="bboxdonation_gift_hdnGiftButtonsStyle" class="hdnGiftButtonsStyle">
<div class="BBFormSection BBFormSectionRecurrenceInfo">
<fieldset>
<legend>
<div id="bboxdonation_recurrence_divHeadingRecurrence" class="BBFormSectionHeading">
<label id="bboxdonation_recurrence_lblHeadingRecurrence" class="BBFormFieldLabelEdit">Recurring Gift</label>
</div>
</legend>
<div class="BBFormFieldContainer">
<div id="bboxdonation_recurrence_divRecurrenceCheckbox">
<input name="bboxdonation$recurrence$chkMonthlyGift" type="checkbox" id="bboxdonation_recurrence_chkMonthlyGift">
<label for="bboxdonation_recurrence_chkMonthlyGift" id="bboxdonation_recurrence_lblRecurringGift" class="BBFormFieldLabel BBFormCheckbox BBFormCheckboxLabel">Make this a monthly gift</label>
</div>
<div class="BBFloatClear"></div>
<div class="BBFormFieldRecurrenceInfo" style="display: none;">
<div id="bboxdonation_recurrence_divRecurrenceInfo">
<div class="BBRecurrenceFieldContainer" style="font-style: normal;">
<span>Give <select name="bboxdonation$recurrence$ddFrequency" id="bboxdonation_recurrence_ddFrequency" class="BBFormSelectList">
<option value="2" optionid="2daec0e2-a395-4833-93f7-4dc9a41794ed">monthly</option>
</select> on <select name="bboxdonation$recurrence$ddFrequencyDate" id="bboxdonation_recurrence_ddFrequencyDate" class="BBFormSelectList" aria-label="frequency">
<option value="1" data-nextpayment="9/1/2022">day 1 of each month</option>
<option value="15" data-nextpayment="9/15/2022">day 15 of each month</option>
</select></span>
</div>
<div>
<span id="lblRecurrenceNextGiftDate">Your first gift will occur on 9/1/2022</span>
</div>
</div>
</div>
</div>
</fieldset>
<input name="bboxdonation$recurrence$hdnRecurringOnly" type="hidden" id="bboxdonation_recurrence_hdnRecurringOnly">
<input name="bboxdonation$recurrence$hdnDateOptions" type="hidden" id="bboxdonation_recurrence_hdnDateOptions" value="[{"frequency":2,"values":"1;15","paymentDates":"9/1/2022;9/15/2022"}]">
<input name="bboxdonation$recurrence$hdnRecurringOptionValue" type="hidden" id="bboxdonation_recurrence_hdnRecurringOptionValue" value="1">
</div>
<div class="BBFormSection BBFormSectionAttributes BBFormSectionGiftAttributes">
<fieldset>
<legend>
<div class="BBFormSectionHeading">
<label id="bboxdonation_giftattributes_lblHeadingAttributes" class="BBFormAttribsHeading BBFormFieldLabelEdit">Choose your way to give</label>
</div>
</legend>
<div class="BBFormSubSection BBFormSubSectionGiftAttributes">
<fieldset>
<legend></legend>
<style type="text/css">
</style>
<div id="bboxdonation_giftattributes_ctl00_divAttrib" class="BBFormFieldContainer BBFormFieldContainerRequired BBFormAttribItem" data-attribtypeid="238" data-datatypeid="6" data-oneperrecord="true">
<label for="bboxdonation_giftattributes_ctl00_ddCodeTable" id="bboxdonation_giftattributes_ctl00_lblAttribDisplayName" class="BBFormFieldLabel"></label>
<select name="bboxdonation$giftattributes$ctl00$ddCodeTable" id="bboxdonation_giftattributes_ctl00_ddCodeTable" class="BBFormSelectList BBFormAttrSelect GhostText" required="required">
<option selected="selected" value="<Please Select>" default="default"><Please Select></option>
<option value="Annual Fund">Annual Fund</option>
<option value="Family Helping Family Fund">Family Helping Family Fund</option>
<option value="Honor Fund">Honor Fund</option>
<option value="Kathryn Roberts Education Endowment Fund">Kathryn Roberts Education Endowment Fund</option>
</select>
<div style="clear: both"></div>
</div>
</fieldset>
</div>
</fieldset>
</div>
<input name="bboxdonation$giftattributes$hdnJsonGiftAttributes" type="hidden" id="bboxdonation_giftattributes_hdnJsonGiftAttributes" class="hdnJsonGiftAttributes">
<div id="bboxdonation_designation_divSection" class="BBFormSection BBDFormSectionDesignationInfo">
<fieldset>
<legend>
<div class="BBFormSectionHeading">
<label id="bboxdonation_designation_lblHeadingDesignation" class="BBFormFieldLabelEdit">If desired, designate a community for your Annual Fund gift</label>
</div>
</legend>
<div class="BBFormFieldContainer">
<label for="bboxdonation_designation_ddDesignations" id="bboxdonation_designation_lblDesignation" class="BBFormFieldLabel BBFormFieldLabelEdit">Use drop-down to choose community:</label>
<select name="bboxdonation$designation$ddDesignations" id="bboxdonation_designation_ddDesignations" class="BBFormSelectList">
<option value="1111">Ecumen (Greatest Need)</option>
<option value="1104">Abiitan</option>
<option value="1105">Bethany Community</option>
<option value="1106">Bethel Manor and Winona Shores</option>
<option value="1107">Brooks</option>
<option value="1108">Centennial House</option>
<option value="1109">Countryside</option>
<option value="1110">Detroit Lakes</option>
<option value="1112">Evergreens of Fargo</option>
<option value="1113">Evergreens of Moorehead</option>
<option value="1114">Grand Village</option>
<option value="1115">Harbor and Haven</option>
<option value="1118">Heritage Community</option>
<option value="1120">Hospice Litchfield</option>
<option value="1121">Hospice North Branch</option>
<option value="1122">Hospice Owatonna</option>
<option value="1123">Hospice Twin Cities</option>
<option value="1124">Lake Crystal</option>
<option value="1125">Lakeland Shores</option>
<option value="1126">Lakeshore</option>
<option value="1127">Lakeview Commons</option>
<option value="1116">Litchfield Home</option>
<option value="1128">Litchfield Housing</option>
<option value="1129">Luther Park</option>
<option value="1130">Meadows</option>
<option value="1131">North Branch</option>
<option value="1132">Oaks</option>
<option value="1133">Parmly Lakeview</option>
<option value="1117">Pathstone Home Care</option>
<option value="1134">Pathstone Living</option>
<option value="1135">Pelican Valley</option>
<option value="1136">Pines</option>
<option value="1137">Point Pleasant Heights</option>
<option value="1138">Prairie Hill</option>
<option value="1139">Prairie Lodge</option>
<option value="1140">Sand Prairie</option>
<option value="1141">Scenic Shores</option>
<option value="1142">Seasons at Apple Valley</option>
<option value="1143">Seasons at Maplewood</option>
<option value="1144">St. Mark's</option>
<option value="1145">Sunnyside</option>
</select>
<label for="bboxdonation_designation_txtOtherDesignation" id="bboxdonation_designation_lblOtherDesignation" style="display: none;">other Use drop-down to choose community:</label>
<input name="bboxdonation$designation$txtOtherDesignation" type="text" id="bboxdonation_designation_txtOtherDesignation" class="BBFormTextbox BBFormOtherDesignation" placeholder="other use drop-down to choose community (optional)"
style="display: none;">
</div>
<div class="BBFormFieldContainer BBFormOtherDesignationContatiner" style="display: none;">
</div>
</fieldset>
</div>
<div class="BBFormSection BBDFormSectionTributeInfo BBFormAddressBlock">
<fieldset>
<legend>
<div class="BBFormSectionHeading">
<label id="bboxdonation_tribute_lblHeadingTribute" class="BBFormFieldLabelEdit">Tribute Gift</label>
</div>
</legend>
<div id="bboxdonation_tribute_divTributeGeneral">
<div class="BBFormFieldContainer">
<input name="bboxdonation$tribute$chkTributeGift" type="checkbox" id="bboxdonation_tribute_chkTributeGift">
<label for="bboxdonation_tribute_chkTributeGift" id="bboxdonation_tribute_lblTributeGift" class="BBFormFieldLabel BBFormCheckbox BBFormCheckboxLabel BBFormFieldLabelEdit">This gift is in honor, memory, or support of someone</label>
</div>
<div id="divGeneralTributeInfo" style="display: none;">
<div class="BBFormFieldContainer BBFormFieldTributeInfo">
<span id="bboxdonation_tribute_lblGeneralTributeInfo" class="BBFormFieldLabel BBFormFieldLabelEdit">This gift is</span>
<select name="bboxdonation$tribute$ddTributeTypes" id="bboxdonation_tribute_ddTributeTypes" class="BBFormSelectList">
<option value="299">in honor of</option>
<option value="298">in memory of</option>
</select>
</div>
<div class="BBFormFieldContainer BBFormFieldTributeInfo">
<label for="bboxdonation_tribute_txtTributeRecordName" id="bboxdonation_tribute_lblTributeRecordName" class="BBFormFieldLabel BBAccessibilityOnly">Tribute honoree name:</label>
<input name="bboxdonation$tribute$txtTributeRecordName" type="text" id="bboxdonation_tribute_txtTributeRecordName" class="BBFormTextbox" required="required" placeholder="full name" maxlength="150">
</div>
</div>
</div>
<div id="divTributeAcknowledge" class="BBFormTributeAcknowledgeContainer" style="display: none;">
<div class="BBFormFieldContainer">
<input name="bboxdonation$tribute$hdnAllowTributeNotification" type="hidden" id="bboxdonation_tribute_hdnAllowTributeNotification" value="1">
<input name="bboxdonation$tribute$chkTributeAcknowledgee" type="checkbox" id="bboxdonation_tribute_chkTributeAcknowledgee">
<label for="bboxdonation_tribute_chkTributeAcknowledgee" id="bboxdonation_tribute_lblTributeAcknowledgee" class="BBFormFieldLabel BBFormCheckbox BBFormCheckboxLabel BBFormFieldLabelEdit">Please notify the following person of my
gift</label>
</div>
<div id="divTributeAcknowledgeeInfo" class="BBFormTributeAcknowledgeeContainer" style="display: none;">
<div class="BBFormIndivFields">
<div class="BBFormFieldContainer BBFormFieldContainerRequired BBTwoFields">
<label for="bboxdonation_tribute_txtFirstName" id="bboxdonation_tribute_lblName" class="BBFormFieldLabel BBFormFieldLabelEdit ">Name:</label>
<div aria-describedby="bboxdonation_tribute_txtFirstName">
<span id="bboxdonation_tribute_lblFirstName" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly ">First name:</span>
</div>
<input name="bboxdonation$tribute$txtFirstName" type="text" id="bboxdonation_tribute_txtFirstName" class="BBFormTextbox" required="required" maxlength="50" placeholder="first name">
<label for="bboxdonation_tribute_txtLastName" id="bboxdonation_tribute_lblLastName" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">Last name:</label>
<input name="bboxdonation$tribute$txtLastName" type="text" id="bboxdonation_tribute_txtLastName" class="BBFormTextbox" required="required" maxlength="100" placeholder="last name">
</div>
</div>
<div class="BBFormFieldTributeAcknowledgee BBFormAddressBlock">
<div class="BBFormAddress">
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="bboxdonation_tribute_tributeAddress_ddCountry" id="bboxdonation_tribute_tributeAddress_lblCountry" class="BBFormFieldLabel BBFormFieldLabelEdit">Country:</label>
<select name="bboxdonation$tribute$tributeAddress$ddCountry" id="bboxdonation_tribute_tributeAddress_ddCountry" class="BBFormSelectList BBFormCountryDropDown" required="required">
<option selected="selected" value="United States" data-country-format="1" data-short-text="US">United States</option>
<option value="Canada" data-country-format="3" data-short-text="CA">Canada</option>
<option value="United Kingdom" data-country-format="2" data-short-text="GB">United Kingdom</option>
<option value="Australia" data-country-format="4" data-short-text="AU">Australia</option>
<option value="New Zealand" data-country-format="5" data-short-text="NZ">New Zealand</option>
<option value="Nepal" data-country-format="1" data-short-text="NP">Nepal</option>
<option value="China" data-country-format="1" data-short-text="CN">China</option>
<option value="Belgium" data-country-format="1" data-short-text="BE">Belgium</option>
<option value="Switzerland" data-country-format="1" data-short-text="CH">Switzerland</option>
<option value="Norway" data-country-format="1" data-short-text="NO">Norway</option>
<option value="Brazil" data-country-format="1" data-short-text="BR">Brazil</option>
<option value="AMERICAN SAMOA" data-country-format="1" data-short-text="AS">AMERICAN SAMOA</option>
<option value="COLOMBIA" data-country-format="1" data-short-text="CO">COLOMBIA</option>
<option value="GUAM" data-country-format="1" data-short-text="GU">GUAM</option>
<option value="INDONESIA" data-country-format="1" data-short-text="ID">INDONESIA</option>
<option value="ISRAEL" data-country-format="1" data-short-text="IL">ISRAEL</option>
<option value="Jamaica" data-country-format="1" data-short-text="JM">Jamaica</option>
<option value="JAPAN" data-country-format="1" data-short-text="JP">JAPAN</option>
<option value="MEXICO" data-country-format="1" data-short-text="MX">MEXICO</option>
<option value="Puerto Rico" data-country-format="1" data-short-text="PR">Puerto Rico</option>
<option value="SOUTH AFRICA" data-country-format="1" data-short-text="ZA">SOUTH AFRICA</option>
<option value="SWEDEN" data-country-format="1" data-short-text="SE">SWEDEN</option>
<option value="UK" data-country-format="1" data-short-text="GB">UK</option>
<option value="Kenya" data-country-format="1" data-short-text="KE">Kenya</option>
</select>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="bboxdonation_tribute_tributeAddress_txtAddress" id="bboxdonation_tribute_tributeAddress_lblAddress" class="BBFormFieldLabel BBFormFieldLabelEdit">Address:</label>
<textarea name="bboxdonation$tribute$tributeAddress$txtAddress" id="bboxdonation_tribute_tributeAddress_txtAddress" class="BBFormTextArea" rows="2" cols="30" required="required" data-country-field="address"
maxlength="150"></textarea>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="1">
<label for="bboxdonation_tribute_tributeAddress_txtCity" id="bboxdonation_tribute_tributeAddress_lblCity" class="BBFormFieldLabel BBFormFieldLabelEdit">City:</label>
<input name="bboxdonation$tribute$tributeAddress$txtCity" type="text" id="bboxdonation_tribute_tributeAddress_txtCity" class="BBFormTextbox" data-country-field="city" data-country-sync="1" required="required" maxlength="50">
</div>
<div class="BBTwoFields BBFieldBillingStateZip">
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="1">
<label for="bboxdonation_tribute_tributeAddress_ddState" id="bboxdonation_tribute_tributeAddress_lblStateZip" class="BBFormFieldLabel BBFormFieldLabelEdit">State & zip:</label>
<div aria-describedby="bboxdonation_tribute_tributeAddress_ddState">
<span id="bboxdonation_tribute_tributeAddress_lblState" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">State:</span>
</div>
<select name="bboxdonation$tribute$tributeAddress$ddState" id="bboxdonation_tribute_tributeAddress_ddState" class="BBFormSelectList GhostText" data-country-sync="1" data-country-field="state" required="required">
<option selected="selected" value="" default="default">state</option>
<option value="AA">AA</option>
<option value="AE">AE</option>
<option value="AL">AL</option>
<option value="AK">AK</option>
<option value="AB">AB</option>
<option value="AS">AS</option>
<option value="AP">AP</option>
<option value="AZ">AZ</option>
<option value="AR">AR</option>
<option value="BC">BC</option>
<option value="CA">CA</option>
<option value="CZ">CZ</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DE">DE</option>
<option value="DC">DC</option>
<option value="FM">FM</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="GU">GU</option>
<option value="HI">HI</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="IA">IA</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="ME">ME</option>
<option value="MB">MB</option>
<option value="MH">MH</option>
<option value="MD">MD</option>
<option value="MA">MA</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MS">MS</option>
<option value="MO">MO</option>
<option value="MT">MT</option>
<option value="NE">NE</option>
<option value="NV">NV</option>
<option value="NB">NB</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NY">NY</option>
<option value="NL">NL</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="MP">MP</option>
<option value="NT">NT</option>
<option value="NS">NS</option>
<option value="NU">NU</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="ON">ON</option>
<option value="OR">OR</option>
<option value="PW">PW</option>
<option value="PA">PA</option>
<option value="PE">PE</option>
<option value="PR">PR</option>
<option value="QC">QC</option>
<option value="RI">RI</option>
<option value="SK">SK</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VT">VT</option>
<option value="VI">VI</option>
<option value="VA">VA</option>
<option value="WA">WA</option>
<option value="WV">WV</option>
<option value="WI">WI</option>
<option value="WY">WY</option>
<option value="YT">YT</option>
</select>
<label for="bboxdonation_tribute_tributeAddress_txtZip" id="bboxdonation_tribute_tributeAddress_lblZip" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">Zip:</label>
<input name="bboxdonation$tribute$tributeAddress$txtZip" type="tel" id="bboxdonation_tribute_tributeAddress_txtZip" class="BBFormTextbox" data-country-field="postcode" data-country-sync="1" required="required" maxlength="12"
placeholder="zip">
</div>
</div>
<div class="BBTwoFields BBFieldBillingStateZip">
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="2" style="display: none;">
<label for="bboxdonation_tribute_tributeAddress_txtUKCity" id="bboxdonation_tribute_tributeAddress_lblUKCityCounty" class="BBFormFieldLabel BBFormFieldLabelEdit">City & county:</label>
<div aria-describedby="bboxdonation_tribute_tributeAddress_txtUKCity">
<span id="bboxdonation_tribute_tributeAddress_lblUKCity" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">City:</span>
</div>
<input name="bboxdonation$tribute$tributeAddress$txtUKCity" type="text" id="bboxdonation_tribute_tributeAddress_txtUKCity" class="BBFormTextbox" data-country-field="city" data-country-sync="1" required="required" maxlength="50"
placeholder="city">
<label for="bboxdonation_tribute_tributeAddress_ddUKCounty" id="bboxdonation_tribute_tributeAddress_lblUKCounty" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">County:</label>
<select name="bboxdonation$tribute$tributeAddress$ddUKCounty" id="bboxdonation_tribute_tributeAddress_ddUKCounty" class="BBFormSelectList GhostText" data-country-field="county">
<option selected="selected" value="" default="default">county (optional)</option>
<option value="Berkeley">Berkeley</option>
<option value="Berkshire">Berkshire</option>
<option value="Carlton">Carlton</option>
<option value="Carver">Carver</option>
<option value="Chisago">Chisago</option>
<option value="Dakota">Dakota</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Goodhue">Goodhue</option>
<option value="Hennepin">Hennepin</option>
<option value="Lyon">Lyon</option>
<option value="Missoula">Missoula</option>
<option value="Nobles">Nobles</option>
<option value="Ramsey">Ramsey</option>
<option value="Rice">Rice</option>
<option value="Sterns">Sterns</option>
<option value="Wright">Wright</option>
</select>
</div>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="2" style="display: none;">
<label for="bboxdonation_tribute_tributeAddress_txtUKPostCode" id="bboxdonation_tribute_tributeAddress_lblUKPostCode" class="BBFormFieldLabel BBFormFieldLabelEdit">Postcode:</label>
<input name="bboxdonation$tribute$tributeAddress$txtUKPostCode" type="text" id="bboxdonation_tribute_tributeAddress_txtUKPostCode" class="BBFormTextbox" data-country-field="postcode" data-country-sync="1" required="required"
maxlength="12">
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="3" style="display: none;">
<label for="bboxdonation_tribute_tributeAddress_txtCACity" id="bboxdonation_tribute_tributeAddress_lblCACity" class="BBFormFieldLabel BBFormFieldLabelEdit">City:</label>
<input name="bboxdonation$tribute$tributeAddress$txtCACity" type="text" id="bboxdonation_tribute_tributeAddress_txtCACity" class="BBFormTextbox" data-country-field="city" data-country-sync="1" required="required" maxlength="50">
</div>
<div class="BBTwoFields BBFieldBillingStateZip">
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="3" style="display: none;">
<label for="bboxdonation_tribute_tributeAddress_ddCAProvince" id="bboxdonation_tribute_tributeAddress_lblCAProvincePostCode" class="BBFormFieldLabel BBFormFieldLabelEdit">Province & postal:</label>
<div aria-describedby="bboxdonation_tribute_tributeAddress_ddCAProvince">
<span id="bboxdonation_tribute_tributeAddress_lblCAProvince" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">Province:</span>
</div>
<select name="bboxdonation$tribute$tributeAddress$ddCAProvince" id="bboxdonation_tribute_tributeAddress_ddCAProvince" class="BBFormSelectList GhostText" data-country-sync="1" data-country-field="state" required="required">
<option selected="selected" value="" default="default">province</option>
<option value="AA">AA</option>
<option value="AE">AE</option>
<option value="AL">AL</option>
<option value="AK">AK</option>
<option value="AB">AB</option>
<option value="AS">AS</option>
<option value="AP">AP</option>
<option value="AZ">AZ</option>
<option value="AR">AR</option>
<option value="BC">BC</option>
<option value="CA">CA</option>
<option value="CZ">CZ</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DE">DE</option>
<option value="DC">DC</option>
<option value="FM">FM</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="GU">GU</option>
<option value="HI">HI</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="IA">IA</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="ME">ME</option>
<option value="MB">MB</option>
<option value="MH">MH</option>
<option value="MD">MD</option>
<option value="MA">MA</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MS">MS</option>
<option value="MO">MO</option>
<option value="MT">MT</option>
<option value="NE">NE</option>
<option value="NV">NV</option>
<option value="NB">NB</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NY">NY</option>
<option value="NL">NL</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="MP">MP</option>
<option value="NT">NT</option>
<option value="NS">NS</option>
<option value="NU">NU</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="ON">ON</option>
<option value="OR">OR</option>
<option value="PW">PW</option>
<option value="PA">PA</option>
<option value="PE">PE</option>
<option value="PR">PR</option>
<option value="QC">QC</option>
<option value="RI">RI</option>
<option value="SK">SK</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VT">VT</option>
<option value="VI">VI</option>
<option value="VA">VA</option>
<option value="WA">WA</option>
<option value="WV">WV</option>
<option value="WI">WI</option>
<option value="WY">WY</option>
<option value="YT">YT</option>
</select>
<label for="bboxdonation_tribute_tributeAddress_txtCAPostCode" id="bboxdonation_tribute_tributeAddress_lblCAPostCode" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">Postal:</label>
<input name="bboxdonation$tribute$tributeAddress$txtCAPostCode" type="text" id="bboxdonation_tribute_tributeAddress_txtCAPostCode" class="BBFormTextbox" required="required" data-country-sync="1" data-country-field="postcode"
maxlength="12" placeholder="postal">
</div>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="4" style="display: none;">
<label for="bboxdonation_tribute_tributeAddress_txtAUCity" id="bboxdonation_tribute_tributeAddress_lblAUCity" class="BBFormFieldLabel BBFormFieldLabelEdit">Suburb:</label>
<input name="bboxdonation$tribute$tributeAddress$txtAUCity" type="text" id="bboxdonation_tribute_tributeAddress_txtAUCity" class="BBFormTextbox" data-country-sync="1" data-country-field="city" required="required" maxlength="50">
</div>
<div class="BBTwoFields BBFieldBillingStateZip">
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="4" style="display: none;">
<label for="bboxdonation_tribute_tributeAddress_ddAUState" id="bboxdonation_tribute_tributeAddress_lblAUStatePostCode" class="BBFormFieldLabel BBFormFieldLabelEdit">State & postcode:</label>
<div aria-describedby="bboxdonation_tribute_tributeAddress_ddAUState">
<span id="bboxdonation_tribute_tributeAddress_lblAUState" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">State:</span>
</div>
<select name="bboxdonation$tribute$tributeAddress$ddAUState" id="bboxdonation_tribute_tributeAddress_ddAUState" class="BBFormSelectList GhostText" data-country-sync="1" data-country-field="state" required="required">
<option selected="selected" value="" default="default">state</option>
<option value="AA">AA</option>
<option value="AE">AE</option>
<option value="AL">AL</option>
<option value="AK">AK</option>
<option value="AB">AB</option>
<option value="AS">AS</option>
<option value="AP">AP</option>
<option value="AZ">AZ</option>
<option value="AR">AR</option>
<option value="BC">BC</option>
<option value="CA">CA</option>
<option value="CZ">CZ</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DE">DE</option>
<option value="DC">DC</option>
<option value="FM">FM</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="GU">GU</option>
<option value="HI">HI</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="IA">IA</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="ME">ME</option>
<option value="MB">MB</option>
<option value="MH">MH</option>
<option value="MD">MD</option>
<option value="MA">MA</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MS">MS</option>
<option value="MO">MO</option>
<option value="MT">MT</option>
<option value="NE">NE</option>
<option value="NV">NV</option>
<option value="NB">NB</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NY">NY</option>
<option value="NL">NL</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="MP">MP</option>
<option value="NT">NT</option>
<option value="NS">NS</option>
<option value="NU">NU</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="ON">ON</option>
<option value="OR">OR</option>
<option value="PW">PW</option>
<option value="PA">PA</option>
<option value="PE">PE</option>
<option value="PR">PR</option>
<option value="QC">QC</option>
<option value="RI">RI</option>
<option value="SK">SK</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VT">VT</option>
<option value="VI">VI</option>
<option value="VA">VA</option>
<option value="WA">WA</option>
<option value="WV">WV</option>
<option value="WI">WI</option>
<option value="WY">WY</option>
<option value="YT">YT</option>
</select>
<label for="bboxdonation_tribute_tributeAddress_txtAUPostCode" id="bboxdonation_tribute_tributeAddress_lblAUPostCode" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">Postcode:</label>
<input name="bboxdonation$tribute$tributeAddress$txtAUPostCode" type="tel" id="bboxdonation_tribute_tributeAddress_txtAUPostCode" class="BBFormTextbox" required="required" data-country-sync="1" data-country-field="postcode"
maxlength="12" placeholder="postcode">
</div>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="5" style="display: none;">
<label for="bboxdonation_tribute_tributeAddress_ddNZSuburb" id="bboxdonation_tribute_tributeAddress_lblNZSuburb" class="BBFormFieldLabel BBFormFieldLabelEdit">Suburb:</label>
<select name="bboxdonation$tribute$tributeAddress$ddNZSuburb" id="bboxdonation_tribute_tributeAddress_ddNZSuburb" class="BBFormSelectList GhostText" required="required" data-country-field="nzsuburb">
<option selected="selected" value="" default="default">suburb</option>
</select>
</div>
<div class="BBTwoFields BBFieldBillingStateZip">
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="5" style="display: none;">
<label for="bboxdonation_tribute_tributeAddress_ddNZCity" id="bboxdonation_tribute_tributeAddress_lblNZCityPostCode" class="BBFormFieldLabel BBFormFieldLabelEdit">City & post code:</label>
<div aria-describedby="bboxdonation_tribute_tributeAddress_ddNZCity">
<span id="bboxdonation_tribute_tributeAddress_lblNZCity" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">City:</span>
</div>
<select name="bboxdonation$tribute$tributeAddress$ddNZCity" id="bboxdonation_tribute_tributeAddress_ddNZCity" class="BBFormSelectList GhostText" required="required" data-country-field="nzcity">
<option selected="selected" value="" default="default">city</option>
</select>
<label for="bboxdonation_tribute_tributeAddress_txtNZPostCode" id="bboxdonation_tribute_tributeAddress_lblNZPostCode" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">Post code:</label>
<input name="bboxdonation$tribute$tributeAddress$txtNZPostCode" type="tel" id="bboxdonation_tribute_tributeAddress_txtNZPostCode" class="BBFormTextbox" required="required" data-country-sync="1" data-country-field="postcode"
maxlength="12" placeholder="post code">
</div>
</div>
</div>
</div>
</div>
</div>
</fieldset>
</div>
<div class="BBFormSection BBDFormSectionComments">
<fieldset>
<legend></legend>
<div id="bboxdonation_comment_fldComments" class="BBFormFieldContainer">
<label for="bboxdonation_comment_txtComments" id="bboxdonation_comment_lblComments" class="BBFormFieldLabel BBFormFieldLabelEdit">If desired, leave a comment (optional):</label>
<textarea name="bboxdonation$comment$txtComments" id="bboxdonation_comment_txtComments" class="BBFormTextArea" rows="2" cols="30" maxlength="255" placeholder="optional"></textarea>
</div>
</fieldset>
</div>
<div id="bboxdonation_billing_divBillingSection" class="BBFormSection BBDFormSectionBillingInfo BBFormAddressBlock" data-section="Billing">
<fieldset>
<legend>
<div id="bboxdonation_billing_divBillingHeader" class="BBFormSectionHeading">
<label id="bboxdonation_billing_lblHeadingContact" class="BBFormFieldLabelEdit">Billing Address</label>
</div>
</legend>
<div id="bboxdonation_billing_fldOrgGift" class="BBFormFieldContainer">
<input name="bboxdonation$billing$chkOrgGift" type="checkbox" id="bboxdonation_billing_chkOrgGift">
<label for="bboxdonation_billing_chkOrgGift" id="bboxdonation_billing_lblOrgGift" class="BBFormFieldLabel BBFormCheckbox BBFormCheckboxLabel BBFormFieldLabelEdit">Make this gift on behalf of an organization</label>
</div>
<div id="fldOrgInfo" class="BBFormOrgFields" style="display: none;">
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="bboxdonation_billing_txtOrgName" id="bboxdonation_billing_lblOrgName" class="BBFormFieldLabel BBFormFieldLabelEdit ">Organization name:</label>
<input name="bboxdonation$billing$txtOrgName" type="text" id="bboxdonation_billing_txtOrgName" class="BBFormTextbox" required="required" data-billing-field="orgname" maxlength="60">
</div>
</div>
<div id="fldIndivInfo" class="BBFormIndivFields">
<div id="divName" class="BBFormFieldContainer BBFormFieldContainerRequired BBTwoFields">
<span id="bboxdonation_billing_lblFullName" class="BBFormFieldLabel BBFormFieldLabelEdit">Name:</span>
<label for="bboxdonation_billing_ddTitle" id="bboxdonation_billing_lblTitle" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">Title:</label>
<label for="bboxdonation_billing_txtFirstName" id="bboxdonation_billing_lblFirstName" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">First name:</label>
<input name="bboxdonation$billing$txtFirstName" type="text" id="bboxdonation_billing_txtFirstName" class="BBFormTextbox" data-billing-field="firstname" maxlength="50" required="required" placeholder="first name">
<label for="bboxdonation_billing_txtLastName" id="bboxdonation_billing_lblLastName" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">Last name:</label>
<input name="bboxdonation$billing$txtLastName" type="text" id="bboxdonation_billing_txtLastName" class="BBFormTextbox" data-billing-field="lastname" maxlength="100" required="required" placeholder="last name">
</div>
</div>
<div id="bboxdonation_billing_divEmail" class="BBFormFieldContainer BBFormFieldContainerRequired BBFormBillingEmail">
<label for="bboxdonation_billing_txtEmail" id="bboxdonation_billing_lblEmail" class="BBFormFieldLabel BBFormFieldLabelEdit">Email:</label>
<input name="bboxdonation$billing$txtEmail" type="email" id="bboxdonation_billing_txtEmail" class="BBFormTextbox" data-billing-field="email" required="required">
</div>
<div id="bboxdonation_billing_divPhone" class="BBFormFieldContainer BBFormBillingPhone BBFormFieldContainerRequired">
<label for="bboxdonation_billing_txtPhone" id="bboxdonation_billing_lblPhone" class="BBFormFieldLabel BBFormFieldLabelEdit">Phone:</label>
<input name="bboxdonation$billing$txtPhone" type="tel" id="bboxdonation_billing_txtPhone" class="BBFormTextbox" data-billing-field="phone" required="required">
</div>
<div class="BBFormAddress">
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="bboxdonation_billing_billingAddress_ddCountry" id="bboxdonation_billing_billingAddress_lblCountry" class="BBFormFieldLabel BBFormFieldLabelEdit">Country:</label>
<select name="bboxdonation$billing$billingAddress$ddCountry" id="bboxdonation_billing_billingAddress_ddCountry" class="BBFormSelectList BBFormCountryDropDown" required="required">
<option selected="selected" value="United States" data-country-format="1" data-short-text="US">United States</option>
<option value="Canada" data-country-format="3" data-short-text="CA">Canada</option>
<option value="United Kingdom" data-country-format="2" data-short-text="GB">United Kingdom</option>
<option value="Australia" data-country-format="4" data-short-text="AU">Australia</option>
<option value="New Zealand" data-country-format="5" data-short-text="NZ">New Zealand</option>
<option value="Nepal" data-country-format="1" data-short-text="NP">Nepal</option>
<option value="China" data-country-format="1" data-short-text="CN">China</option>
<option value="Belgium" data-country-format="1" data-short-text="BE">Belgium</option>
<option value="Switzerland" data-country-format="1" data-short-text="CH">Switzerland</option>
<option value="Norway" data-country-format="1" data-short-text="NO">Norway</option>
<option value="Brazil" data-country-format="1" data-short-text="BR">Brazil</option>
<option value="AMERICAN SAMOA" data-country-format="1" data-short-text="AS">AMERICAN SAMOA</option>
<option value="COLOMBIA" data-country-format="1" data-short-text="CO">COLOMBIA</option>
<option value="GUAM" data-country-format="1" data-short-text="GU">GUAM</option>
<option value="INDONESIA" data-country-format="1" data-short-text="ID">INDONESIA</option>
<option value="ISRAEL" data-country-format="1" data-short-text="IL">ISRAEL</option>
<option value="Jamaica" data-country-format="1" data-short-text="JM">Jamaica</option>
<option value="JAPAN" data-country-format="1" data-short-text="JP">JAPAN</option>
<option value="MEXICO" data-country-format="1" data-short-text="MX">MEXICO</option>
<option value="Puerto Rico" data-country-format="1" data-short-text="PR">Puerto Rico</option>
<option value="SOUTH AFRICA" data-country-format="1" data-short-text="ZA">SOUTH AFRICA</option>
<option value="SWEDEN" data-country-format="1" data-short-text="SE">SWEDEN</option>
<option value="UK" data-country-format="1" data-short-text="GB">UK</option>
<option value="Kenya" data-country-format="1" data-short-text="KE">Kenya</option>
</select>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="bboxdonation_billing_billingAddress_txtAddress" id="bboxdonation_billing_billingAddress_lblAddress" class="BBFormFieldLabel BBFormFieldLabelEdit">Address:</label>
<textarea name="bboxdonation$billing$billingAddress$txtAddress" id="bboxdonation_billing_billingAddress_txtAddress" class="BBFormTextArea" rows="2" cols="30" required="required" data-country-field="address" maxlength="150"></textarea>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="1">
<label for="bboxdonation_billing_billingAddress_txtCity" id="bboxdonation_billing_billingAddress_lblCity" class="BBFormFieldLabel BBFormFieldLabelEdit">City:</label>
<input name="bboxdonation$billing$billingAddress$txtCity" type="text" id="bboxdonation_billing_billingAddress_txtCity" class="BBFormTextbox" data-country-field="city" data-country-sync="1" required="required" maxlength="50">
</div>
<div class="BBTwoFields BBFieldBillingStateZip">
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="1">
<label for="bboxdonation_billing_billingAddress_ddState" id="bboxdonation_billing_billingAddress_lblStateZip" class="BBFormFieldLabel BBFormFieldLabelEdit">State & ZIP:</label>
<div aria-describedby="bboxdonation_billing_billingAddress_ddState">
<span id="bboxdonation_billing_billingAddress_lblState" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">State:</span>
</div>
<select name="bboxdonation$billing$billingAddress$ddState" id="bboxdonation_billing_billingAddress_ddState" class="BBFormSelectList GhostText" data-country-sync="1" data-country-field="state" required="required">
<option selected="selected" value="" default="default">state</option>
<option value="AA">AA</option>
<option value="AE">AE</option>
<option value="AL">AL</option>
<option value="AK">AK</option>
<option value="AB">AB</option>
<option value="AS">AS</option>
<option value="AP">AP</option>
<option value="AZ">AZ</option>
<option value="AR">AR</option>
<option value="BC">BC</option>
<option value="CA">CA</option>
<option value="CZ">CZ</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DE">DE</option>
<option value="DC">DC</option>
<option value="FM">FM</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="GU">GU</option>
<option value="HI">HI</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="IA">IA</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="ME">ME</option>
<option value="MB">MB</option>
<option value="MH">MH</option>
<option value="MD">MD</option>
<option value="MA">MA</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MS">MS</option>
<option value="MO">MO</option>
<option value="MT">MT</option>
<option value="NE">NE</option>
<option value="NV">NV</option>
<option value="NB">NB</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NY">NY</option>
<option value="NL">NL</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="MP">MP</option>
<option value="NT">NT</option>
<option value="NS">NS</option>
<option value="NU">NU</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="ON">ON</option>
<option value="OR">OR</option>
<option value="PW">PW</option>
<option value="PA">PA</option>
<option value="PE">PE</option>
<option value="PR">PR</option>
<option value="QC">QC</option>
<option value="RI">RI</option>
<option value="SK">SK</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VT">VT</option>
<option value="VI">VI</option>
<option value="VA">VA</option>
<option value="WA">WA</option>
<option value="WV">WV</option>
<option value="WI">WI</option>
<option value="WY">WY</option>
<option value="YT">YT</option>
</select>
<label for="bboxdonation_billing_billingAddress_txtZip" id="bboxdonation_billing_billingAddress_lblZip" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">Zip:</label>
<input name="bboxdonation$billing$billingAddress$txtZip" type="tel" id="bboxdonation_billing_billingAddress_txtZip" class="BBFormTextbox" data-country-field="postcode" data-country-sync="1" required="required" maxlength="12"
placeholder="zip">
</div>
</div>
<div class="BBTwoFields BBFieldBillingStateZip">
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="2" style="display: none;">
<label for="bboxdonation_billing_billingAddress_txtUKCity" id="bboxdonation_billing_billingAddress_lblUKCityCounty" class="BBFormFieldLabel BBFormFieldLabelEdit">City & county:</label>
<div aria-describedby="bboxdonation_billing_billingAddress_txtUKCity">
<span id="bboxdonation_billing_billingAddress_lblUKCity" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">City:</span>
</div>
<input name="bboxdonation$billing$billingAddress$txtUKCity" type="text" id="bboxdonation_billing_billingAddress_txtUKCity" class="BBFormTextbox" data-country-field="city" data-country-sync="1" required="required" maxlength="50"
placeholder="city">
<label for="bboxdonation_billing_billingAddress_ddUKCounty" id="bboxdonation_billing_billingAddress_lblUKCounty" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">County:</label>
<select name="bboxdonation$billing$billingAddress$ddUKCounty" id="bboxdonation_billing_billingAddress_ddUKCounty" class="BBFormSelectList GhostText" data-country-field="county">
<option selected="selected" value="" default="default">county (optional)</option>
<option value="Berkeley">Berkeley</option>
<option value="Berkshire">Berkshire</option>
<option value="Carlton">Carlton</option>
<option value="Carver">Carver</option>
<option value="Chisago">Chisago</option>
<option value="Dakota">Dakota</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Goodhue">Goodhue</option>
<option value="Hennepin">Hennepin</option>
<option value="Lyon">Lyon</option>
<option value="Missoula">Missoula</option>
<option value="Nobles">Nobles</option>
<option value="Ramsey">Ramsey</option>
<option value="Rice">Rice</option>
<option value="Sterns">Sterns</option>
<option value="Wright">Wright</option>
</select>
</div>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="2" style="display: none;">
<label for="bboxdonation_billing_billingAddress_txtUKPostCode" id="bboxdonation_billing_billingAddress_lblUKPostCode" class="BBFormFieldLabel BBFormFieldLabelEdit">Postcode:</label>
<input name="bboxdonation$billing$billingAddress$txtUKPostCode" type="text" id="bboxdonation_billing_billingAddress_txtUKPostCode" class="BBFormTextbox" data-country-field="postcode" data-country-sync="1" required="required"
maxlength="12">
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="3" style="display: none;">
<label for="bboxdonation_billing_billingAddress_txtCACity" id="bboxdonation_billing_billingAddress_lblCACity" class="BBFormFieldLabel BBFormFieldLabelEdit">City:</label>
<input name="bboxdonation$billing$billingAddress$txtCACity" type="text" id="bboxdonation_billing_billingAddress_txtCACity" class="BBFormTextbox" data-country-field="city" data-country-sync="1" required="required" maxlength="50">
</div>
<div class="BBTwoFields BBFieldBillingStateZip">
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="3" style="display: none;">
<label for="bboxdonation_billing_billingAddress_ddCAProvince" id="bboxdonation_billing_billingAddress_lblCAProvincePostCode" class="BBFormFieldLabel BBFormFieldLabelEdit">Province & postal:</label>
<div aria-describedby="bboxdonation_billing_billingAddress_ddCAProvince">
<span id="bboxdonation_billing_billingAddress_lblCAProvince" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">Province:</span>
</div>
<select name="bboxdonation$billing$billingAddress$ddCAProvince" id="bboxdonation_billing_billingAddress_ddCAProvince" class="BBFormSelectList GhostText" data-country-sync="1" data-country-field="state" required="required">
<option selected="selected" value="" default="default">province</option>
<option value="AA">AA</option>
<option value="AE">AE</option>
<option value="AL">AL</option>
<option value="AK">AK</option>
<option value="AB">AB</option>
<option value="AS">AS</option>
<option value="AP">AP</option>
<option value="AZ">AZ</option>
<option value="AR">AR</option>
<option value="BC">BC</option>
<option value="CA">CA</option>
<option value="CZ">CZ</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DE">DE</option>
<option value="DC">DC</option>
<option value="FM">FM</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="GU">GU</option>
<option value="HI">HI</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="IA">IA</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="ME">ME</option>
<option value="MB">MB</option>
<option value="MH">MH</option>
<option value="MD">MD</option>
<option value="MA">MA</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MS">MS</option>
<option value="MO">MO</option>
<option value="MT">MT</option>
<option value="NE">NE</option>
<option value="NV">NV</option>
<option value="NB">NB</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NY">NY</option>
<option value="NL">NL</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="MP">MP</option>
<option value="NT">NT</option>
<option value="NS">NS</option>
<option value="NU">NU</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="ON">ON</option>
<option value="OR">OR</option>
<option value="PW">PW</option>
<option value="PA">PA</option>
<option value="PE">PE</option>
<option value="PR">PR</option>
<option value="QC">QC</option>
<option value="RI">RI</option>
<option value="SK">SK</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VT">VT</option>
<option value="VI">VI</option>
<option value="VA">VA</option>
<option value="WA">WA</option>
<option value="WV">WV</option>
<option value="WI">WI</option>
<option value="WY">WY</option>
<option value="YT">YT</option>
</select>
<label for="bboxdonation_billing_billingAddress_txtCAPostCode" id="bboxdonation_billing_billingAddress_lblCAPostCode" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">Postal:</label>
<input name="bboxdonation$billing$billingAddress$txtCAPostCode" type="text" id="bboxdonation_billing_billingAddress_txtCAPostCode" class="BBFormTextbox" required="required" data-country-sync="1" data-country-field="postcode"
maxlength="12" placeholder="postal">
</div>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="4" style="display: none;">
<label for="bboxdonation_billing_billingAddress_txtAUCity" id="bboxdonation_billing_billingAddress_lblAUCity" class="BBFormFieldLabel BBFormFieldLabelEdit">Suburb:</label>
<input name="bboxdonation$billing$billingAddress$txtAUCity" type="text" id="bboxdonation_billing_billingAddress_txtAUCity" class="BBFormTextbox" data-country-sync="1" data-country-field="city" required="required" maxlength="50">
</div>
<div class="BBTwoFields BBFieldBillingStateZip">
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="4" style="display: none;">
<label for="bboxdonation_billing_billingAddress_ddAUState" id="bboxdonation_billing_billingAddress_lblAUStatePostCode" class="BBFormFieldLabel BBFormFieldLabelEdit">State & postcode:</label>
<div aria-describedby="bboxdonation_billing_billingAddress_ddAUState">
<span id="bboxdonation_billing_billingAddress_lblAUState" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">State:</span>
</div>
<select name="bboxdonation$billing$billingAddress$ddAUState" id="bboxdonation_billing_billingAddress_ddAUState" class="BBFormSelectList GhostText" data-country-sync="1" data-country-field="state" required="required">
<option selected="selected" value="" default="default">state</option>
<option value="AA">AA</option>
<option value="AE">AE</option>
<option value="AL">AL</option>
<option value="AK">AK</option>
<option value="AB">AB</option>
<option value="AS">AS</option>
<option value="AP">AP</option>
<option value="AZ">AZ</option>
<option value="AR">AR</option>
<option value="BC">BC</option>
<option value="CA">CA</option>
<option value="CZ">CZ</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DE">DE</option>
<option value="DC">DC</option>
<option value="FM">FM</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="GU">GU</option>
<option value="HI">HI</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="IA">IA</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="ME">ME</option>
<option value="MB">MB</option>
<option value="MH">MH</option>
<option value="MD">MD</option>
<option value="MA">MA</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MS">MS</option>
<option value="MO">MO</option>
<option value="MT">MT</option>
<option value="NE">NE</option>
<option value="NV">NV</option>
<option value="NB">NB</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NY">NY</option>
<option value="NL">NL</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="MP">MP</option>
<option value="NT">NT</option>
<option value="NS">NS</option>
<option value="NU">NU</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="ON">ON</option>
<option value="OR">OR</option>
<option value="PW">PW</option>
<option value="PA">PA</option>
<option value="PE">PE</option>
<option value="PR">PR</option>
<option value="QC">QC</option>
<option value="RI">RI</option>
<option value="SK">SK</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VT">VT</option>
<option value="VI">VI</option>
<option value="VA">VA</option>
<option value="WA">WA</option>
<option value="WV">WV</option>
<option value="WI">WI</option>
<option value="WY">WY</option>
<option value="YT">YT</option>
</select>
<label for="bboxdonation_billing_billingAddress_txtAUPostCode" id="bboxdonation_billing_billingAddress_lblAUPostCode" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">Postcode:</label>
<input name="bboxdonation$billing$billingAddress$txtAUPostCode" type="tel" id="bboxdonation_billing_billingAddress_txtAUPostCode" class="BBFormTextbox" required="required" data-country-sync="1" data-country-field="postcode"
maxlength="12" placeholder="postcode">
</div>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="5" style="display: none;">
<label for="bboxdonation_billing_billingAddress_ddNZSuburb" id="bboxdonation_billing_billingAddress_lblNZSuburb" class="BBFormFieldLabel BBFormFieldLabelEdit">Suburb:</label>
<select name="bboxdonation$billing$billingAddress$ddNZSuburb" id="bboxdonation_billing_billingAddress_ddNZSuburb" class="BBFormSelectList GhostText" required="required" data-country-field="nzsuburb">
<option selected="selected" value="" default="default">suburb</option>
</select>
</div>
<div class="BBTwoFields BBFieldBillingStateZip">
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="5" style="display: none;">
<label for="bboxdonation_billing_billingAddress_ddNZCity" id="bboxdonation_billing_billingAddress_lblNZCityPostCode" class="BBFormFieldLabel BBFormFieldLabelEdit">City & post code:</label>
<div aria-describedby="bboxdonation_billing_billingAddress_ddNZCity">
<span id="bboxdonation_billing_billingAddress_lblNZCity" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">City:</span>
</div>
<select name="bboxdonation$billing$billingAddress$ddNZCity" id="bboxdonation_billing_billingAddress_ddNZCity" class="BBFormSelectList GhostText" required="required" data-country-field="nzcity">
<option selected="selected" value="" default="default">city</option>
</select>
<label for="bboxdonation_billing_billingAddress_txtNZPostCode" id="bboxdonation_billing_billingAddress_lblNZPostCode" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">Post code:</label>
<input name="bboxdonation$billing$billingAddress$txtNZPostCode" type="tel" id="bboxdonation_billing_billingAddress_txtNZPostCode" class="BBFormTextbox" required="required" data-country-sync="1" data-country-field="postcode"
maxlength="12" placeholder="post code">
</div>
</div>
</div>
<div id="bboxdonation_billing_fldAnonymous" class="BBFormFieldContainer">
<input name="bboxdonation$billing$chkAnonymous" type="checkbox" id="bboxdonation_billing_chkAnonymous">
<label for="bboxdonation_billing_chkAnonymous" id="bboxdonation_billing_lblAnonymous" class="BBFormFieldLabel BBFormCheckbox BBFormCheckboxLabel BBFormFieldLabelEdit">I would like this gift to remain anonymous</label>
</div>
</fieldset>
</div>
<div class="BBFormSection BBDFormSectionPaymentInfo">
<fieldset>
<legend>
<div id="bboxdonation_payment_divHeadingPayment" class="BBFormSectionHeading">
<label id="bboxdonation_payment_lblHeadingPayment" class="BBFormFieldLabelEdit">Payment Details</label>
</div>
</legend>
<div id="bboxdonation_payment_PaymentChoices" class="BBFormPaymentChoice">
<div class="BBFormFieldContainer">
<span id="bboxdonation_payment_lblPaymentMethod" class="BBFormFieldLabel BBFormFieldLabelEdit">Payment method:</span>
<div class="BBFormFieldContainerPaymentMethods">
<div id="bboxdonation_payment_divPaymentChoiceCreditCard" class="BBFormFieldContainer BBFormPaymentRadioOptions">
<input value="0" name="bboxdonation$payment$BBFormPaymentChoice" type="radio" id="bboxdonation_payment_BBFormPaymentChoiceCredit" data-pmtchoice="1" checked="checked">
<label for="bboxdonation_payment_BBFormPaymentChoiceCredit" id="bboxdonation_payment_lblChoiceCredit" class="BBFormFieldLabelEdit BBFormRadioPaymentSelected">Credit card</label>
</div>
<div id="bboxdonation_payment_divPaymentChoiceDirectDebit" class="BBFormFieldContainer BBFormPaymentRadioOptions">
<input value="2" name="bboxdonation$payment$BBFormPaymentChoice" type="radio" id="bboxdonation_payment_BBFormPaymentChoiceDirectDebit" data-pmtchoice="1">
<label for="bboxdonation_payment_BBFormPaymentChoiceDirectDebit" id="bboxdonation_payment_lblChoiceDirectDebit" class="BBFormFieldLabelEdit BBFormRadioPaymentNotSelected">Direct debit</label>
</div>
</div>
</div>
</div>
<div id="bboxdonation_payment_BBFormCCDetails" class="BBFormCreditCardDetails">
<div id="bboxdonation_payment_divProcessedByBlackbaud" class="BBFormFieldContainer ">
<a id="bboxsecure" class="BBLinkSecureInfo hasTooltip" href="#bbsecure" rel="https://bbox.blackbaudhosting.com/webforms/components/custom.ashx?handler=blackbaud.appfx.mongo.parts.getcontenthandler&c=secure&callback=?" title="Learn more about how your credit card information will be protected by Blackbaud" tabindex="0" style="text-decoration: none; border-bottom: 1px dashed;">Payment Processed by Blackbaud</a>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="bboxdonation_payment_txtCardholder" id="bboxdonation_payment_lblCardHoldersName" class="BBFormFieldLabel BBFormFieldLabelEdit ">Cardholder name:</label>
<input name="bboxdonation$payment$txtCardholder" type="text" id="bboxdonation_payment_txtCardholder" class="BBFormTextbox" maxlength="60" required="required">
</div>
<div id="DCCreditNumber" class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="bboxdonation_payment_txtCardNumber" id="bboxdonation_payment_lblCCNumber" class="BBFormFieldLabel BBFormFieldLabelEdit ">Card number:</label>
<input name="bboxdonation$payment$txtCardNumber" type="tel" id="bboxdonation_payment_txtCardNumber" class="BBFormTextbox BBCardNumber" autocomplete="off" maxlength="20" required="required">
</div>
<div id="DCCreditType" class="BBFormFieldContainer BBFormFieldContainerRequired BBCCreditType">
<label for="bboxdonation_payment_cboCardType" id="bboxdonation_payment_lblCCType" class="BBFormFieldLabel BBFormFieldLabelEdit" style="visibility: hidden;">Card type:</label>
<div class="BBFormFieldContainer BBFormFieldContainerRequired BBCCreditType">
<select name="bboxdonation$payment$cboCardType" id="bboxdonation_payment_cboCardType" class="BBFormSelectList" required="required" style="display: none;">
<option value="<Please Select>"><Please Select></option>
<option value="5963a708-fc7f-48af-952f-16d574c4b833">Visa</option>
<option value="c4a56513-9fdb-44c5-9b19-e617f2596107">American Express</option>
<option value="bf0ed898-ab0c-4374-9cef-1e66b09e816d">Discover</option>
<option value="b34832f7-8a95-47fa-9c43-bc8682562ea5">MasterCard</option>
</select>
<div id="bboxdonation_payment_divCardTypes">
<div class="BBCardImageContainer">
<img id="bboxdonation_payment_lvwCardTypes_imgCardImage_0" class="BBCardImage" data-card-type="visa" alt="visa" data-card-type-id="5963a708-fc7f-48af-952f-16d574c4b833"
src="https://bbox.blackbaudhosting.com/webforms/images/cards/visa_normal.png">
<img id="bboxdonation_payment_lvwCardTypes_imgCardImage_1" class="BBCardImage" data-card-type="amex" alt="amex" data-card-type-id="c4a56513-9fdb-44c5-9b19-e617f2596107"
src="https://bbox.blackbaudhosting.com/webforms/images/cards/amex_normal.png">
<img id="bboxdonation_payment_lvwCardTypes_imgCardImage_2" class="BBCardImage" data-card-type="discover" alt="discover" data-card-type-id="bf0ed898-ab0c-4374-9cef-1e66b09e816d"
src="https://bbox.blackbaudhosting.com/webforms/images/cards/discover_normal.png">
<img id="bboxdonation_payment_lvwCardTypes_imgCardImage_3" class="BBCardImage" data-card-type="mastercard" alt="mastercard" data-card-type-id="b34832f7-8a95-47fa-9c43-bc8682562ea5"
src="https://bbox.blackbaudhosting.com/webforms/images/cards/mastercard_normal.png">
</div>
</div>
</div>
</div>
<div class="BBExpirationCSC">
<div id="DC_ValidOther" class="BBFormFieldContainer BBFormFieldContainerRequired BBFieldExpiration">
<label for="bboxdonation_payment_cboMonth" id="bboxdonation_payment_lblExpiryLbl" class="BBFormFieldLabel BBFormFieldLabelEdit">Expiration:</label>
<div aria-describedby="bboxdonation_payment_cboMonth">
<span id="bboxdonation_payment_lblMonth" class="BBFormFieldLabel BBAccessibilityOnly">Month:</span>
</div>
<select name="bboxdonation$payment$cboMonth" id="bboxdonation_payment_cboMonth" class="BBFormSelectList GhostText" required="required">
<option value="" default="default">month</option>
<option value="1">01</option>
<option value="2">02</option>
<option value="3">03</option>
<option value="4">04</option>
<option value="5">05</option>
<option value="6">06</option>
<option value="7">07</option>
<option value="8">08</option>
<option value="9">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select>
<label for="bboxdonation_payment_cboYear" id="bboxdonation_payment_lblYear" class="BBFormFieldLabel BBAccessibilityOnly">Year:</label>
<select name="bboxdonation$payment$cboYear" id="bboxdonation_payment_cboYear" class="BBFormSelectList GhostText" required="required">
<option value="" default="default">year</option>
<option value="2022">2022</option>
<option value="2023">2023</option>
<option value="2024">2024</option>
<option value="2025">2025</option>
<option value="2026">2026</option>
<option value="2027">2027</option>
<option value="2028">2028</option>
<option value="2029">2029</option>
<option value="2030">2030</option>
<option value="2031">2031</option>
<option value="2032">2032</option>
<option value="2033">2033</option>
<option value="2034">2034</option>
<option value="2035">2035</option>
<option value="2036">2036</option>
</select>
</div>
<div id="DCCreditSecurityCode" class="BBFormFieldContainer BBFormFieldContainerRequired BBFieldSecurityCode">
<label for="bboxdonation_payment_txtCSC" id="bboxdonation_payment_lblSecCode" class="BBFormFieldLabel BBFormFieldLabelEdit">CSC:</label>
<input name="bboxdonation$payment$txtCSC" type="password" id="bboxdonation_payment_txtCSC" inputmode="numeric" autocomplete="off" class="BBFormTextbox DonationCaptureTextboxNarrow" maxlength="4" style="width: 60px;"
required="required">
<a id="cscWhatsThis" href="#csc" rel="https://bbox.blackbaudhosting.com/webforms/components/custom.ashx?handler=blackbaud.appfx.mongo.parts.getcontenthandler&c=csc&callback=?" title="What are Card Security Codes?" tabindex="-1" style="text-decoration: none;" class="hasTooltip">
<img style="display: inline; border: 0;" alt="Help" src="https://bbox.blackbaudhosting.com/webforms/images/bboxhelp.png"></a>
</div>
</div>
</div>
<div id="bboxdonation_payment_BBFormDDDetails" class="BBFormDirectDebitDetails" style="display: none;">
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="bboxdonation_payment_txtBankName" id="bboxdonation_payment_lblBankName" class="BBFormFieldLabel BBFormFieldLabelEdit ">Bank name:</label>
<input name="bboxdonation$payment$txtBankName" type="text" id="bboxdonation_payment_txtBankName" class="BBFormTextbox" maxlength="60" required="required">
</div>
<div id="BBFormDDRoutingData">
<div id="bboxdonation_payment_BBFormDDRoutingNumber">
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="bboxdonation_payment_txtRoutingNumber" id="bboxdonation_payment_lblRoutingNumber" class="BBFormFieldLabel BBFormFieldLabelEdit ">Routing number:</label>
<input name="bboxdonation$payment$txtRoutingNumber" type="tel" id="bboxdonation_payment_txtRoutingNumber" class="BBFormTextbox" maxlength="9" required="required">
<a id="routingUSWhatsThis" href="#routing" rel="https://bbox.blackbaudhosting.com/webforms/components/custom.ashx?handler=blackbaud.appfx.mongo.parts.getcontenthandler&c=routingus&callback=?" title="What are Routing Numbers?" tabindex="-1" style="text-decoration: none;" class="hasTooltip">
<img style="display: inline; border: 0;" alt="Help" src="https://bbox.blackbaudhosting.com/webforms/images/bboxhelp.png"></a>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="bboxdonation_payment_ddAccountType" id="bboxdonation_payment_lblAccountType" class="BBFormFieldLabel BBFormFieldLabelEdit ">Account type:</label>
<select name="bboxdonation$payment$ddAccountType" id="bboxdonation_payment_ddAccountType" class="BBFormSelectList" required="required">
<option selected="selected" value="Checking">Checking</option>
<option value="Savings">Savings</option>
<option value="Other">Other</option>
</select>
</div>
</div>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="bboxdonation_payment_txtAccountNumber" id="bboxdonation_payment_lblAccount" class="BBFormFieldLabel BBFormFieldLabelEdit ">Account number:</label>
<span id="bboxdonation_payment_spanAccountNumber">
<input name="bboxdonation$payment$txtAccountNumber" type="tel" id="bboxdonation_payment_txtAccountNumber" class="BBFormTextbox BBFormAccountNumber" maxlength="20" required="required">
</span>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="bboxdonation_payment_txtAccountHolder" id="bboxdonation_payment_lblAccountHolder" class="BBFormFieldLabel BBFormFieldLabelEdit ">Account holder:</label>
<input name="bboxdonation$payment$txtAccountHolder" type="text" id="bboxdonation_payment_txtAccountHolder" class="BBFormTextbox" maxlength="60" required="required">
</div>
<!-- hidden field for tracking direct debit account lookups -->
<input name="bboxdonation$payment$hdnDirectDebitLookupCount" type="hidden" id="hdnDirectDebitLookupCount" value="0">
<input name="bboxdonation$payment$hdnDirectDebitShouldLookup" type="hidden" id="hdnDirectDebitShouldLookup" value="0">
</div>
<div id="bboxdonation_payment_BBFormConfirmationBoxWrapper" class="BBFormConfirmationBoxWrapper" style="display: none;">
<div id="bboxdonation_payment_BBFormDDConfirmationBox" class="BBFormDDConfirmationBox">
<div class="BBFormBoxHeader">Is the information you entered to set up the Direct Debit Instruction correct?</div>
<div class="BBFormBoxContent">
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="DDAccountHolder" id="lblDDAccountHolder" class="BBFormFieldLabel"> Account holder: </label>
<span id="bboxdonation_payment_DDAccountHolder" class="BBFormFieldValueLabel"></span>
<br>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="DDSortCode" id="lblDDSortCode" class="BBFormFieldLabel"> Sort Code: </label>
<span id="bboxdonation_payment_DDSortCode" class="BBFormFieldValueLabel"></span>
<br>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="DDAccountNumber" id="lblDDAccountNumber" class="BBFormFieldLabel"> Account number: </label>
<span id="bboxdonation_payment_DDAccountNumber" class="BBFormFieldValueLabel"></span>
<br>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="DDDebitAmount" id="lblDDDebitAmount" class="BBFormFieldLabel"> Amount to be debited: </label>
<span id="bboxdonation_payment_DDDebitAmount" class="BBFormFieldValueLabel"></span>
<br>
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<div class="BBFormFieldContainer BBFormFieldContainerRequired">
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Skip Branding Click here to learn about Ecumen's Health & Safety Steps and COVID 19 Response * Find a career * NEWS & EVENTS * THE ECUMEN STORE * GIVE NOW * ABOUT US * CONTACT US * * 651-766-4300 * LIVING SPACES * Explore Living Spaces * Independent Living * Assisted Living * Memory Care * Affordable housing * Long-term Care * Short-Term Transitional Care * Respite Care * Dining Experience * Community Experience * About The Ecumen Store * Find a Community * SUPPORTIVE SERVICES * Explore Supportive Services * Home Care * Adult Day Services * Hospice Care * Therapy * Care Innovation * About The Ecumen Store * HOSPICE * Explore Hospice Care * Mosaic Moments * Our Story * Service Area * FAQ * Volunteers * GETTING STARTED * How to get started * Planning what’s next * Choosing The Right Living Space * MISSION ADVANCEMENT * Our mission * Our nonprofit legacy * Advocacy * Care Innovation * ABOUT US * Volunteering * Philanthropy * Impact * BUSINESS SOLUTIONS * Community Management Services * Property & land development * Consulting Services * TECHNOLOGY SUITE * Case Studies * Find a career * NEWS & EVENTS * THE ECUMEN STORE * GIVE NOW * ABOUT US * CONTACT US * 3530 Lexington Avenue N Shoreview MN 55126 Phone: 651-766-4300 Toll-Free: 800-221-1507 Ecumen is an equal opportunity employer. Ecumen considers candidates regardless of color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status. Living Spaces Supportive Services Hospice Getting Started Mission Advancement Business Solutions Find a Career News & Events Give Now About Us Contact us Search @2022 Ecumen. All rights reserved. Sitemap Privacy Policy Nondiscrimination and Language Assistance Program PRIVACY PREFERENCE CENTER PRIVACY PREFERENCES CONTACT US Full Name(Required) First Last Email(Required) Phone Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code For whom are you inquiring?(Required) Please SelectSelfParentSpouseRelativeClientOther Comments CAPTCHA Ecumen does not accept solicitations. Thank You. CONTACT US Name(Required) Email(Required) Phone (not required) Reason for Contacting(Required) SelectGeneral InquirySenior Housing or Service InquirySenior Housing Development or Management InquiryAbxtrackerThe Ecumen StoreMedia Inquiry Ecumen Community or Service (if applicable) -None-Abiitan Mill City - Minneapolis, MNBethel Manor & Winona Shores of Alexandria - MNBoardman Meadows - New Richmond, WICedarStone - Cedar Falls, IAEcumen Brooks - Owatonna, MNEcumen Centennial House - Apple Valley, MNEcumen CountrySide - Owatonna, MNEcumen Detroit Lakes - MNEcumen Evergreens of Fargo - NDEcumen Evergreens of Moorhead - MNEcumen Home Care - DuluthEcumen Home Care - LitchfieldEcumen Home Care - MankatoEcumen Hospice (general inquiries)Ecumen Hospice - DuluthEcumen Hospice - LitchfieldEcumen Hospice – North BranchEcumen Hospice - OwatonnaEcumen Hospice - Twin CitiesEcumen Lakeshore - Duluth, MNEcumen Lakeview Commons - Maplewood, MNEcumen Litchfield - MNEcumen Meadows - Worthington, MNEcumen North Branch - MNEcumen Oaks & Pines - Hutchinson, MNEcumen Pathstone - Mankato, MNEcumen Point Pleasant Heights - Chisago City, MNEcumen Prairie Hill - St. Peter, MNEcumen Prairie Lodge - Brooklyn Center, MNEcumen Sand Prairie - St. Peter, MNEcumen Seasons at Apple Valley - MNEcumen Seasons at Maplewood - MNForest Heights — St. Croix Falls, WIGrand Village - Grand Rapids, MNHeritage Community - Park Rapids, MNLakeland Shores Apartments - Lakeland Shores, MNLilac Parkway - Robbinsdale, MNLuther Park at Sandpoint - IDMount Royal Pines III Assisted Living - Duluth, MNPark Villa Apartments - Park Rapids, MNParmly Lakeview Apartments - Chisago City, MNPrairieStone - Cedar Falls, IAQuartet - Bettendorf, IARiver Town Heights — St. Croix Falls, WISt. Mark's Apartments - Austin, MNSt. Mark's Living - Austin, MNSunnyside Care Center - Lake Park, MNThe Harbor at Peace Village - Norwood Young America, MNThe Haven at Peace Village - Norwood Young America, MNThe Hillock - Minneapolis, MNUptown Maple Commons - North Branch, MNWillow Wood Apartments - White Bear Lake, MNZvago Sales & Design StudioZvago Central Village - Apple Valley, MNZvago Lake Superior - Duluth, MNZvago Long Lake - MNZvago Stillwater - MN For whom are you inquiring? -None-SelfParentSpouseRelativeClientOther Message(Required) Ecumen does not accept solicitations. Thank You. VENDOR INQUIRY Company Name(Required) Company Address(Required) City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Company Website Primary Contact Name:(Required) Primary Contact Phone:(Required) Primary Contact Email:(Required) Business Category(Required) -Select-BenefitsBusiness Development/Facility RefreshClinical Supplies & ServicesCommunication Products & ServicesDietary Products & ServicesDocument Storage (Physical)Durable Medical Equipment/Medical SuppliesFacilities/ Environmental / MaintenanceFinancial InvestmentsFinancial ServicesFleet ServicesGroup Purchasing OrganizationsFreight/Courier ServicesHouse Keeping ProductsHuman Resource ServicesInformation Systems/ITLearning Products & ServicesLegal ServicesLife Enrichment/Resident Activities and EntertainmentMarketing/Advertising/Commercial Printing ServicesOffice Supplies (non-IT related)Payor ContractorsPhilanthropyProfessional Services (patient related)Rehabilitation Products & ServicesRisk Management Products & ServicesSpiritual/Religious What product or service do you provide?(Required) Years in Business(Required) -Select-1-34-77-1011-1516-1920+ Average Number of Years of Active Customer Accounts(Required) -Select-1-34-77-1011-1516-1920+ Number of Employees (Hourly and Salaried)(Required) -Select-1-99100-499500-9991000-24992500-49995000+ Does your organization or any of its employees present a conflict of interest in doing business with Ecumen? If so, please describe.(Required) Is your company publicly or privately held?(Required) Public Private Dun & Bradstreet Number (If applicable)(Required) Do you utilize sub-contractors for all or a portion of your services?(Required) Yes No Are you currently certified/documented as either a Minority, Woman-owned, or Veteran-owned business?(Required) Yes No Does your company or organization have a dedicated account manager located in the state of Minnesota that can service all of our Ecumen locations if needed?(Required) Yes No If you were referred by an Ecumen owned or managed community, please choose the community name below. Abiitan Mill CityBoardman MeadowsClarkfield Care Center & Home CareEcumen Bethany CommunityEcumen BrooksEcumen Centennial HouseEcumen CountrySide LocationEcumen Detroit LakesEcumen Evergreens of FargoEcumen Evergreens of MoorheadEcumen Home Care & Hospice - LitchfieldEcumen Home Care - LakeshoreEcumen Home Care - PathstoneEcumen Home Office – ShoreviewEcumen Hospice - Twin CitiesEcumen LakeshoreEcumen Lakeview CommonsEcumen MeadowsEcumen North BranchEcumen Oaks & PinesEcumen of LitchfieldEcumen Parmly LifePointesEcumen Pathstone LivingEcumen Point Pleasant HeightsEcumen Prairie HillEcumen Prairie LodgeEcumen Sand PrairieEcumen Scenic ShoresEcumen Seasons at Apple ValleyEcumen Seasons at MaplewoodGrand VillageHeritage at Irene WoodsHeritage Senior LivingLakeland Shores ApartmentsLilac ParkwayLuther Park at SandpointPark Villa ApartmentsPelican Valley Health CenterRose Senior Living - AvonRose Senior Living - Clinton TownshipSt. Mark's LivingSunnyside Care CenterThe Harbor at Peace VillageUptown Maple CommonsWillow Wood ApartmentsZvago Central VillageZvago Glen LakeZvago St.Anthony Park Are you currently doing business with any Ecumen owned or managed locations?(Required) Yes No Have you done business with Ecumen in the past?(Required) Yes No Has your company been involved in any suits, liens, or judgments within the last five years?(Required) Yes No Is your company and its contractor's HIPAA compliant?(Required) Yes No Do you have general liability insurance coverage?(Required) Yes No Do you currently sell to other Senior Housing and Services organizations?(Required) Yes No Do you currently work with any Group Purchasing Organizations?(Required) Yes No If your entity is a Group Purchasing Organization, what vendors and industries do you currently represent? Do you have distribution capabilities?(Required) Yes No For companies in start-up/emerging companies, please answer these additional questions: What stage best describes your company’s current product development? Tell us about the founders of your company. What key milestones have been accomplished to date? CAPTCHA Ecumen does not accept solicitations. Thank You. QUESTIONS ABOUT AN ECUMEN COMMUNITY OR SERVICE? Complete the form: Name(Required) Email(Required) Phone (not required) Reason for Contacting(Required) SelectSenior Housing or Service InquirySenior Housing Development or Management InquiryThe Ecumen Store Ecumen Community or Service (if applicable) -None-General Inquiry - (no specific community)Abiitan Mill City - Minneapolis, MNBethel Manor & Winona Shores of Alexandria - MNBoardman Meadows - New Richmond, WICedarStone - Cedar Falls, IAEcumen Brooks - Owatonna, MNEcumen Centennial House - Apple Valley, MNEcumen CountrySide - Owatonna, MNEcumen Detroit Lakes - MNEcumen Evergreens of Fargo - NDEcumen Evergreens of Moorhead - MNEcumen Home Care - DuluthEcumen Home Care - LitchfieldEcumen Home Care - MankatoEcumen Hospice (general inquiries)Ecumen Hospice - DuluthEcumen Hospice - LitchfieldEcumen Hospice – North BranchEcumen Hospice - OwatonnaEcumen Hospice - Twin CitiesEcumen Lakeshore - Duluth, MNEcumen Lakeview Commons - Maplewood, MNEcumen Litchfield - MNEcumen Meadows - Worthington, MNEcumen North Branch - MNEcumen Oaks & Pines - Hutchinson, MNEcumen Pathstone - Mankato, MNEcumen Point Pleasant Heights - Chisago City, MNEcumen Prairie Hill - St. Peter, MNEcumen Prairie Lodge - Brooklyn Center, MNEcumen Sand Prairie - St. Peter, MNEcumen Seasons at Apple Valley - MNEcumen Seasons at Maplewood - MNForest Heights — St. Croix Falls, WIGrand Village - Grand Rapids, MNHeritage Community - Park Rapids, MNLakeland Shores Apartments - Lakeland Shores, MNLilac Parkway - Robbinsdale, MNLuther Park at Sandpoint - IDMount Royal Pines III Assisted Living - Duluth, MNPark Villa Apartments - Park Rapids, MNParmly Lakeview Apartments - Chisago City, MNPrairieStone - Cedar Falls, IAQuartet - Bettendorf, IARiver Town Heights — St. Croix Falls, WISt. Mark's Apartments - Austin, MNSt. Mark's Living - Austin, MNSunnyside Care Center - Lake Park, MNThe Harbor at Peace Village - Norwood Young America, MNThe Haven at Peace Village - Norwood Young America, MNThe Hillock - Minneapolis, MNUptown Maple Commons - North Branch, MNWillow Wood Apartments - White Bear Lake, MNZvago Sales & Design StudioZvago Central Village - Apple Valley, MNZvago Lake Superior - Duluth, MNZvago Long Lake - MNZvago Stillwater - MN For whom are you inquiring? -None-SelfParentSpouseRelativeClientOther Message(Required) Ecumen does not accept solicitations. Thank You. Media Contact Angie Andresen | Director of Communications 612-483-8064 | angieandresen@ecumen.org TELL US ABOUT YOU I'M LOOKING TO JOIN ECUMEN I CURRENTLY WORK FOR ECUMEN Donation Amount Gift amount: $50 $75 $100 Other Amount: Recurring Gift Make this a monthly gift Give monthly on day 1 of each monthday 15 of each month Your first gift will occur on 9/1/2022 Choose your way to give <Please Select> Annual Fund Family Helping Family Fund Honor Fund Kathryn Roberts Education Endowment Fund If desired, designate a community for your Annual Fund gift Use drop-down to choose community: Ecumen (Greatest Need) Abiitan Bethany Community Bethel Manor and Winona Shores Brooks Centennial House Countryside Detroit Lakes Evergreens of Fargo Evergreens of Moorehead Grand Village Harbor and Haven Heritage Community Hospice Litchfield Hospice North Branch Hospice Owatonna Hospice Twin Cities Lake Crystal Lakeland Shores Lakeshore Lakeview Commons Litchfield Home Litchfield Housing Luther Park Meadows North Branch Oaks Parmly Lakeview Pathstone Home Care Pathstone Living Pelican Valley Pines Point Pleasant Heights Prairie Hill Prairie Lodge Sand Prairie Scenic Shores Seasons at Apple Valley Seasons at Maplewood St. Mark's Sunnyside other Use drop-down to choose community: Tribute Gift This gift is in honor, memory, or support of someone This gift is in honor of in memory of Tribute honoree name: Please notify the following person of my gift Name: First name: Last name: Country: United States Canada United Kingdom Australia New Zealand Nepal China Belgium Switzerland Norway Brazil AMERICAN SAMOA COLOMBIA GUAM INDONESIA ISRAEL Jamaica JAPAN MEXICO Puerto Rico SOUTH AFRICA SWEDEN UK Kenya Address: City: State & zip: State: state AA AE AL AK AB AS AP AZ AR BC CA CZ CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MB MH MD MA MI MN MS MO MT NE NV NB NH NJ NM NY NL NC ND MP NT NS NU OH OK ON OR PW PA PE PR QC RI SK SC SD TN TX UT VT VI VA WA WV WI WY YT Zip: City & county: City: County: county (optional) Berkeley Berkshire Carlton Carver Chisago Dakota District of Columbia Goodhue Hennepin Lyon Missoula Nobles Ramsey Rice Sterns Wright Postcode: City: Province & postal: Province: province AA AE AL AK AB AS AP AZ AR BC CA CZ CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MB MH MD MA MI MN MS MO MT NE NV NB NH NJ NM NY NL NC ND MP NT NS NU OH OK ON OR PW PA PE PR QC RI SK SC SD TN TX UT VT VI VA WA WV WI WY YT Postal: Suburb: State & postcode: State: state AA AE AL AK AB AS AP AZ AR BC CA CZ CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MB MH MD MA MI MN MS MO MT NE NV NB NH NJ NM NY NL NC ND MP NT NS NU OH OK ON OR PW PA PE PR QC RI SK SC SD TN TX UT VT VI VA WA WV WI WY YT Postcode: Suburb: suburb City & post code: City: city Post code: If desired, leave a comment (optional): Billing Address Make this gift on behalf of an organization Organization name: Name: Title: First name: Last name: Email: Phone: Country: United States Canada United Kingdom Australia New Zealand Nepal China Belgium Switzerland Norway Brazil AMERICAN SAMOA COLOMBIA GUAM INDONESIA ISRAEL Jamaica JAPAN MEXICO Puerto Rico SOUTH AFRICA SWEDEN UK Kenya Address: City: State & ZIP: State: state AA AE AL AK AB AS AP AZ AR BC CA CZ CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MB MH MD MA MI MN MS MO MT NE NV NB NH NJ NM NY NL NC ND MP NT NS NU OH OK ON OR PW PA PE PR QC RI SK SC SD TN TX UT VT VI VA WA WV WI WY YT Zip: City & county: City: County: county (optional) Berkeley Berkshire Carlton Carver Chisago Dakota District of Columbia Goodhue Hennepin Lyon Missoula Nobles Ramsey Rice Sterns Wright Postcode: City: Province & postal: Province: province AA AE AL AK AB AS AP AZ AR BC CA CZ CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MB MH MD MA MI MN MS MO MT NE NV NB NH NJ NM NY NL NC ND MP NT NS NU OH OK ON OR PW PA PE PR QC RI SK SC SD TN TX UT VT VI VA WA WV WI WY YT Postal: Suburb: State & postcode: State: state AA AE AL AK AB AS AP AZ AR BC CA CZ CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MB MH MD MA MI MN MS MO MT NE NV NB NH NJ NM NY NL NC ND MP NT NS NU OH OK ON OR PW PA PE PR QC RI SK SC SD TN TX UT VT VI VA WA WV WI WY YT Postcode: Suburb: suburb City & post code: City: city Post code: I would like this gift to remain anonymous Payment Details Payment method: Credit card Direct debit Payment Processed by Blackbaud Cardholder name: Card number: Card type: <Please Select> Visa American Express Discover MasterCard Expiration: Month: month 01 02 03 04 05 06 07 08 09 10 11 12 Year: year 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 CSC: Bank name: Routing number: Account type: Checking Savings Other Account number: Account holder: Is the information you entered to set up the Direct Debit Instruction correct? Account holder: Sort Code: Account number: Amount to be debited: Collection frequency: Date of first gift: FormField Notifications Ready to chat? Click here .