www.plannedparenthood.org
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104.17.82.66
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Submitted URL: http://www.plannedparenthood.org/
Effective URL: https://www.plannedparenthood.org/
Submission: On November 28 via api from US — Scanned from DE
Effective URL: https://www.plannedparenthood.org/
Submission: On November 28 via api from US — Scanned from DE
Form analysis 5 forms found in the DOM
GET /search
<form action="/search" method="GET" class="site-search min-margin" id="site-search" novalidate="">
<label class="search-label" for="site-search-field">Search</label>
<div class="search-field-wrap">
<input type="search" name="q" class="site-search-field" id="site-search-field" aria-invalid="false" maxlength="300" required="">
<button type="submit" class="button site-search-find-button">Find</button>
</div>
</form>GET /search
<form action="/search" method="GET" class="site-search min-margin" id="mobile-site-search" novalidate="">
<label class="mobile-search-label" tabindex="-1" aria-hidden="true">
<svg class="icon">
<use xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="/static/icons/sprite.svg#search-heavy"></use>
</svg>
<span class="site-search-button-label">Search</span>
</label>
<div class="search-field-wrap">
<input type="search" name="q" class="site-search-field" id="site-search-field" aria-invalid="false" aria-label="Search" maxlength="300" required="">
<button type="submit" class="button site-search-find-button" aria-label="Find" data-section-name="header" data-header-category="sitesearch" data-object="top navigation hamburger">
<svg class="icon">
<title>Find</title>
<use xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="/static/icons/sprite.svg#search-heavy"></use>
</svg>
</button>
</div>
</form>GET https://www.weareplannedparenthood.org/onlineactions/2U7UN1iNhESWUfDs4gDPNg2
<form id="donate-form-plugin" data-form-name="C3 donation form" class="partial-donate-form" target="_blank" action="https://www.weareplannedparenthood.org/onlineactions/2U7UN1iNhESWUfDs4gDPNg2" method="GET">
<input type="hidden" id="sourceID" name="sourceID" value="1017635">
<input type="hidden" id="refwidget" name="refwidget" value="Homepage_Hero_Widget">
<fieldset>
<label class="don-radio-container monthly" data-gift-type="monthly" for="monthly">
<input type="radio" name="SelectedFrequency" id="monthly" value="4" data-amount-default="35">
<span class="donate-radio"></span>
<span>Monthly</span>
</label>
<label class="don-radio-container once" data-gift-type="one-time" for="one_time">
<input type="radio" name="SelectedFrequency" id="one_time" value="0" data-amount-default="100" checked="">
<span class="donate-radio"></span>
<span>One-Time</span>
</label>
</fieldset>
<p class="gift-type-subtext">
<img src="/static/assets/img/curved-arrow.svg" width="30" height="37" alt="arrow">
<span>A monthly gift does even more to support access to health care</span>
</p>
<div class="form-label">
<strong><span id="giftPayment"></span> GIFT AMOUNT</strong> <span class="min-amount">($5 min.)</span>
</div>
<div class="gift-amount-container hidden" id="month-container">
<label data-gift-amount="50" for="month50">
<input type="radio" name="recurringAm" value="50.00" class="amount_option" id="month50">
<span class="gift-amount">$50</span>
</label>
<label data-gift-amount="35" for="month35">
<input type="radio" name="recurringAm" value="35.00" class="amount_option" id="month35">
<span class="gift-amount">$35</span>
</label>
<label data-gift-amount="25" for="month25">
<input type="radio" name="recurringAm" value="25.00" class="amount_option" id="month25">
<span class="gift-amount">$25</span>
</label>
<label data-gift-amount="15" for="month15">
<input type="radio" name="recurringAm" value="15.00" class="amount_option" id="month15">
<span class="gift-amount">$15</span>
</label>
</div>
<div class="gift-amount-container " id="once-container">
<label data-gift-amount="200" for="once200">
<input type="radio" name="am" value="200.00" class="amount_option" id="once200">
<span class="gift-amount">$200</span>
</label>
<label data-gift-amount="100" for="once100">
<input type="radio" name="am" value="100.00" class="amount_option" id="once100" checked="">
<span class="gift-amount">$100</span>
</label>
<label data-gift-amount="60" for="once60">
<input type="radio" name="am" value="60.00" class="amount_option" id="once60">
<span class="gift-amount">$60</span>
</label>
<label data-gift-amount="35" for="once35">
<input type="radio" name="am" value="35.00" class="amount_option" id="once35">
<span class="gift-amount">$35</span>
</label>
</div>
<div class="donate-link-container">
<label for="other_amount" class="other-amount">
<input type="number" step="0.01" placeholder="5.00" name="am" id="other_amount" data-gift-amount="other" aria-label="Other Amount">
<span>$</span>
</label>
<div class="errors" id="errorMessage"></div>
<button class="button" type="submit" id="donate-link" aria-describedby="note-below" data-cta-button-name="DONATE NOW" data-donation-cta="HomepageHero Widget"> DONATE NOW </button>
<div class="at-markup TrackingPixel" style="display: none;"> <img alt="" src="https://secure.everyaction.com/v1/Track/2U7UN1iNhESWUfDs4gDPNg2" style="display:none"> </div>
</div>
<p class="suggest-amount" id="note-below"> Most people are giving $<span id="amount-suggest">100 right now</span>. Please, give what you can. </p>
</form>POST /_ea_proxy
<form method="post" novalidate="" data-abide="" autocomplete="off" action="/_ea_proxy" data-e="0ozeoi-e">
<input type="hidden" name="ea_form_id" value="2nYqi-15tE6uajkbt9Z3zw2" aria-describedby="ccqsmg-abide-error">
<input type="hidden" name="PersonalUrl" value="" aria-describedby="ccqsmg-abide-error">
<input type="hidden" name="SourceCodeId" value="" aria-describedby="ccqsmg-abide-error">
<div class="grid-x grid-padding-x">
<div class="cell field">
<div class="ea_fieldset">
<fieldset aria-label="Fields marked with * are required">
<div class="ea_field field">
<label for="PostalCode">Zip Code* </label>
<input name="PostalCode" id="PostalCode" title="Zip Code" value="" required="" maxlength="10" data-validation="postalCode" type="text" aria-describedby="ccqsmg-abide-error">
<span class="form-error" data-form-error-for="PostalCode" id="ccqsmg-abide-error" role="alert">This field is required.</span>
</div>
<div class="ea_field field">
<label for="EmailAddress">Email Address* </label>
<input name="EmailAddress" id="EmailAddress" title="Email Address" value="" required="" maxlength="100" data-validation="email" type="email" aria-describedby="xi0rhx-abide-error">
<span class="form-error" data-form-error-for="EmailAddress" role="alert" id="xi0rhx-abide-error">This field is required.</span>
</div>
<div class="field ea_markup">
<input type="hidden" id="id_YesSignMeUpForUpdatesForBinder" name="YesSignMeUpForUpdatesForBinder" value="true" checked="">
<p class="form-disclaimer">I agree to receive email updates from Planned Parenthood organizations. I may unsubscribe at any time.</p>
</div>
<div class="ea_submit form-actions">
<button type="submit" class="button
" name="submitForm">
<span>Subscribe</span>
</button>
</div>
</fieldset>
</div>
</div>
</div>
</form>POST
<form class="clearfix" method="post" novalidate="" action="" accept-charset="utf-8" autocomplete="on">
<div data-name="undefined" data-subview="submit_view" data-subview-index="1"></div>
<fieldset class="at-fieldset ContributionInformation" id="NVContributionForm1271434-ContributionInformation" style="border: none;">
<legend class="at-legend">Gift Information</legend>
<div class="at-fields">
<div class="at-row at-row-full ">
<div class="form-unit form-unit-radio form-item-selectedfrequency" id="NVContributionForm1271434-ContributionInformation-SelectedFrequency">
<div class="radios" role="radiogroup" aria-labelledby="NVContributionForm1271434-ContributionInformation-SelectedFrequency">
<label title="One-Time" class="at-radio-label-0" role="radio">
<input type="radio" name="SelectedFrequency" checked="" value="0"> One-Time </label><label title="Monthly" class="at-radio-label-4" role="radio">
<input type="radio" name="SelectedFrequency" value="4"> Monthly </label>
<div class="radio-description radio-description-value-0">A monthly gift does even more to protect reproductive rights</div>
</div>
</div>
</div>
<div class="at-row at-row-full ">
<input id="ProcessingCurrency_Value" type="hidden" name="ProcessingCurrency.Value" value="USD">
</div>
<div class="at-row at-row-full ">
<div class="form-item form-type-radios form-item-selectamount" id="NVContributionForm1271434-ContributionInformation-SelectAmount">
<div class="at-row SelectAmount OtherAmount NonRecurringButtons">
<div class="at-radio">
<div class="at-radios clearfix">
<label class="label-amount" title="$200">
<input name="SelectAmount" type="radio" value="200.00"> $200 <a></a> </label><label class="label-amount" title="$100">
<input name="SelectAmount" type="radio" value="100.00"> $100 <a></a> </label><label class="label-amount" title="$60">
<input name="SelectAmount" type="radio" value="60.00"> $60 <a></a> </label><label class="label-amount" title="$35">
<input name="SelectAmount" type="radio" value="35.00"> $35 <a></a> </label><label class="label-amount label-otheramount" title="Other">
<input name="SelectAmount" type="radio" class="radio-other" value="other"> Other <input type="number" tabindex="-1" autocomplete="transaction-amount" class="edit-otheramount" name="OtherAmount" title="Other Amount"
placeholder="0.00">
<span class="label-otheramount-prefix">$</span>
</label>
</div>
</div>
</div>
</div>
</div><label class="at-check CoverCostsAmount" id="NVContributionForm1271434-ContributionInformation-CoverCostsAmount"><input type="checkbox" name="CoverCostsAmount"> <span class="at-checkbox-title-container"><span class="at-checkbox-title"
id="NVContributionForm1271434-ContributionInformation-CoverCostsAmount-label">I'd like to help cover the transaction fees for my contribution</span><span>I'd like to cover the processing fees, making my total gift <span
class="contr">$103.25</span>, so <span class="amCon">$100.00</span> goes to protect reproductive health.</span></span>
</label>
</div>
</fieldset>
<fieldset class="at-fieldset TributeGift" id="NVContributionForm1271434-TributeGift">
<div class="at-fields">
<div class="at-row at-row-full EnableTributeGift">
<label class="at-check EnableTributeGift" id="NVContributionForm1271434-TributeGift-EnableTributeGift"><input type="checkbox" name="EnableTributeGift"> <span class="at-checkbox-title-container"><span class="at-checkbox-title"
id="NVContributionForm1271434-TributeGift-EnableTributeGift-label">I'd like to make this gift in honor or in memory of someone special</span></span>
</label>
</div>
<div class="at-row">
<div class="at-tribute-gift" style="display:none">
<div class="form-unit form-unit-radio form-item-inhonororinmemoryof" id="NVContributionForm1271434-TributeGift-InHonorOrInMemoryOf"><label id="NVContributionForm1271434-TributeGift-InHonorOrInMemoryOf"> Is this an Honorary or Memorial
Gift?</label>
<div class="radios" role="radiogroup" aria-labelledby="NVContributionForm1271434-TributeGift-InHonorOrInMemoryOf">
<label title="In honor of" class="at-radio-label-2" role="radio">
<input type="radio" name="InHonorOrInMemoryOf" checked="" value="2"> In honor of </label><label title="In memory of" class="at-radio-label-1" role="radio">
<input type="radio" name="InHonorOrInMemoryOf" value="1"> In memory of </label>
</div>
</div><label class="at-text HonoreeName" id="NVContributionForm1271434-TributeGift-HonoreeName">Honoree Name<input type="text" autocomplete="on" required="" title="Honoree Name (required)" name="HonoreeName" value="" maxlength="100">
</label>
</div>
</div>
</div>
</fieldset>
<fieldset class="at-fieldset RecipientInformation" id="NVContributionForm1271434-RecipientInformation" style="display: none;">
<div class="at-fields">
<div class="at-row">
<label class="at-check IncludeRecipient" id="NVContributionForm1271434-RecipientInformation-IncludeRecipient"><input type="checkbox" name="IncludeRecipient"> <span class="at-checkbox-title-container"><span class="at-checkbox-title"
id="NVContributionForm1271434-RecipientInformation-IncludeRecipient-label">I'd like to notify someone of this contribution</span></span>
</label>
</div>
<div class="at-recipient-info" style="display: none;">
<div class="mail-checks radios at-row">
<div class="email-container">
<label class="email-tile clicked" for="email">
<input type="checkbox" name="email" id="email" value="email">
<i class="fas fa-2x fa-paper-plane" aria-hidden="true"> </i><br>
<span class="mail-text">I'd like an e-card to be sent via email</span>
</label>
<div class="deliv"> (delivered instantly or on a specific date of your choosing) </div>
</div>
<div class="mail-container">
<label class="mail-tile" for="mail">
<input type="checkbox" name="mail" id="mail" value="mail">
<i class="far fa-2x fa-envelope" aria-hidden="true"> </i><br>
<span class="mail-text">I'd like a physical card to be sent via the mail</span>
</label>
<div class="deliv">(delivered within 2 - 3 weeks)</div>
</div>
</div>
<div class="at-title basic-info">Who would you like to notify?</div>
<div class="at-row at-row-solo at-row-full RecipientInfoHeaderHtml basic-info">
<div class="at-markup RecipientInfoHeaderHtml basic-info" id="NVContributionForm1271434-RecipientInformation-RecipientInfoHeaderHtml">
<p>We will send an email notification to the email address you provide below. We are unable to send anonymous notifications — the recipient will see your name and email address.</p>
</div>
</div>
<div class="at-row RecipientFirstName RecipientLastName basic-info"><label class="at-text RecipientFirstName" id="NVContributionForm1271434-RecipientInformation-RecipientFirstName">First Name*<input type="text" autocomplete="on" required=""
title="First Name* (required)" name="RecipientFirstName" value="" maxlength="50">
</label><label class="at-text RecipientLastName" id="NVContributionForm1271434-RecipientInformation-RecipientLastName">Last Name*<input type="text" autocomplete="on" required="" title="Last Name* (required)" name="RecipientLastName"
value="" maxlength="50">
</label></div>
<div class="at-row at-row-solo RecipientStreetAddress mail" style="display: none;"><label class="at-text RecipientStreetAddress mail" id="NVContributionForm1271434-RecipientInformation-RecipientStreetAddress" style="display: none;">Street
Address*<input type="text" autocomplete="on" required="" title="Street Address* (required)" name="RecipientStreetAddress" value="" maxlength="100">
</label></div>
<div class="at-row RecipientCountry RecipientPostalCode RecipientCity RecipientStateProvince mail" style="display: none;"><label class="at-select RecipientCountry mail" id="NVContributionForm1271434-RecipientInformation-RecipientCountry"
style="">Country*<select required="" autocomplete="on" title="Country*" name="RecipientCountry" class="required select2-hidden-accessible" id="NVContributionForm1271434-RecipientInformation-RecipientCountry-select" tabindex="-1"
aria-hidden="true">
<option value="" disabled="">- Select -</option>
<option value="AF">Afghanistan</option>
<option value="AX">Åland Islands</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AD">Andorra</option>
<option value="AO">Angola</option>
<option value="AI">Anguilla</option>
<option value="AQ">Antarctica</option>
<option value="AG">Antigua and Barbuda</option>
<option value="AR">Argentina</option>
<option value="AM">Armenia</option>
<option value="AW">Aruba</option>
<option value="AU">Australia</option>
<option value="AT">Austria</option>
<option value="AZ">Azerbaijan</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BD">Bangladesh</option>
<option value="BB">Barbados</option>
<option value="BY">Belarus</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BJ">Benin</option>
<option value="BM">Bermuda</option>
<option value="BT">Bhutan</option>
<option value="BO">Bolivia (Plurinational State of)</option>
<option value="BQ">Bonaire, Sint Eustatius and Saba</option>
<option value="BA">Bosnia and Herzegovina</option>
<option value="BW">Botswana</option>
<option value="BV">Bouvet Island</option>
<option value="BR">Brazil</option>
<option value="IO">British Indian Ocean Territory</option>
<option value="VG">British Virgin Islands</option>
<option value="BN">Brunei Darussalam</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="CV">Cabo Verde</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="KY">Cayman Islands</option>
<option value="CF">Central African Republic</option>
<option value="TD">Chad</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CX">Christmas Island</option>
<option value="CC">Cocos (Keeling) Islands</option>
<option value="CO">Colombia</option>
<option value="KM">Comoros</option>
<option value="CG">Congo</option>
<option value="CD">Congo (Democratic Republic of the)</option>
<option value="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="CI">Côte d'Ivoire</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CW">Curaçao</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czechia</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="GQ">Equatorial Guinea</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="SZ">Eswatini</option>
<option value="ET">Ethiopia</option>
<option value="FK">Falkland Islands (Malvinas)</option>
<option value="FO">Faroe Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="GF">French Guiana</option>
<option value="PF">French Polynesia</option>
<option value="TF">French Southern Territories</option>
<option value="GA">Gabon</option>
<option value="GM">Gambia</option>
<option value="GE">Georgia</option>
<option value="DE">Germany</option>
<option value="GH">Ghana</option>
<option value="GI">Gibraltar</option>
<option value="GR">Greece</option>
<option value="GL">Greenland</option>
<option value="GD">Grenada</option>
<option value="GP">Guadeloupe</option>
<option value="GT">Guatemala</option>
<option value="GG">Guernsey</option>
<option value="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard Island and McDonald Islands</option>
<option value="VA">Holy See</option>
<option value="HN">Honduras</option>
<option value="HK">Hong Kong</option>
<option value="HU">Hungary</option>
<option value="IS">Iceland</option>
<option value="IN">India</option>
<option value="ID">Indonesia</option>
<option value="IR">Iran (Islamic Republic of)</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IM">Isle of Man</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JE">Jersey</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KP">Korea (Democratic People's Republic of)</option>
<option value="KR">Korea (Republic of)</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Lao People's Democratic Republic</option>
<option value="LV">Latvia</option>
<option value="LB">Lebanon</option>
<option value="LS">Lesotho</option>
<option value="LR">Liberia</option>
<option value="LY">Libya</option>
<option value="LI">Liechtenstein</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="MO">Macao</option>
<option value="MG">Madagascar</option>
<option value="MW">Malawi</option>
<option value="MY">Malaysia</option>
<option value="MV">Maldives</option>
<option value="ML">Mali</option>
<option value="MT">Malta</option>
<option value="MQ">Martinique</option>
<option value="MR">Mauritania</option>
<option value="MU">Mauritius</option>
<option value="YT">Mayotte</option>
<option value="MX">Mexico</option>
<option value="FM">Micronesia (Federated States of)</option>
<option value="MD">Moldova (Republic of)</option>
<option value="MC">Monaco</option>
<option value="MN">Mongolia</option>
<option value="ME">Montenegro</option>
<option value="MS">Montserrat</option>
<option value="MA">Morocco</option>
<option value="MZ">Mozambique</option>
<option value="MM">Myanmar</option>
<option value="NA">Namibia</option>
<option value="NR">Nauru</option>
<option value="NP">Nepal</option>
<option value="NL">Netherlands</option>
<option value="NC">New Caledonia</option>
<option value="NZ">New Zealand</option>
<option value="NI">Nicaragua</option>
<option value="NE">Niger</option>
<option value="NG">Nigeria</option>
<option value="NU">Niue</option>
<option value="NF">Norfolk Island</option>
<option value="MK">North Macedonia</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PK">Pakistan</option>
<option value="PW">Palau</option>
<option value="PS">Palestine (State of)</option>
<option value="PA">Panama</option>
<option value="PG">Papua New Guinea</option>
<option value="PY">Paraguay</option>
<option value="PE">Peru</option>
<option value="PH">Philippines</option>
<option value="PN">Pitcairn</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="QA">Qatar</option>
<option value="RE">Réunion</option>
<option value="RO">Romania</option>
<option value="RU">Russian Federation</option>
<option value="RW">Rwanda</option>
<option value="BL">Saint Barthélemy</option>
<option value="SH">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="MF">Saint Martin (French part)</option>
<option value="PM">Saint Pierre and Miquelon</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</option>
<option value="ST">Sao Tome and Principe</option>
<option value="SA">Saudi Arabia</option>
<option value="SN">Senegal</option>
<option value="RS">Serbia</option>
<option value="SC">Seychelles</option>
<option value="SL">Sierra Leone</option>
<option value="SG">Singapore</option>
<option value="SX">Sint Maarten (Dutch part)</option>
<option value="SK">Slovakia</option>
<option value="SI">Slovenia</option>
<option value="SB">Solomon Islands</option>
<option value="SO">Somalia</option>
<option value="ZA">South Africa</option>
<option value="GS">South Georgia and the South Sandwich Islands</option>
<option value="SS">South Sudan</option>
<option value="ES">Spain</option>
<option value="LK">Sri Lanka</option>
<option value="SD">Sudan</option>
<option value="SR">Suriname</option>
<option value="SJ">Svalbard and Jan Mayen</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syrian Arab Republic</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania (United Republic of)</option>
<option value="TH">Thailand</option>
<option value="TL">Timor-Leste</option>
<option value="TG">Togo</option>
<option value="TK">Tokelau</option>
<option value="TO">Tonga</option>
<option value="TT">Trinidad and Tobago</option>
<option value="TN">Tunisia</option>
<option value="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks and Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom</option>
<option value="US">United States</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VE">Venezuela (Bolivarian Republic of)</option>
<option value="VN">Viet Nam</option>
<option value="WF">Wallis and Futuna</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" style="width: 100px;"><span class="selection"><span class="select2-selection select2-selection--single" role="combobox" aria-haspopup="true"
aria-expanded="false" title="Country*" tabindex="0" aria-labelledby="select2-NVContributionForm1271434-RecipientInformation-RecipientCountry-select-container"><span class="select2-selection__rendered"
id="select2-NVContributionForm1271434-RecipientInformation-RecipientCountry-select-container" title="United States">United States</span><span class="select2-selection__arrow"
role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
</label><label class="at-text RecipientPostalCode" id="NVContributionForm1271434-RecipientInformation-RecipientPostalCode">Postal Code*<input type="tel" autocomplete="on" pattern="^\d{5}([\-]\d{4})?$" required=""
title="Postal Code* (required)" name="RecipientPostalCode" value="" maxlength="10">
</label><label class="at-text RecipientCity" id="NVContributionForm1271434-RecipientInformation-RecipientCity">City*<input type="text" autocomplete="on" required="" title="City* (required)" name="RecipientCity" value="" maxlength="25">
</label><label class="at-select RecipientStateProvince" id="NVContributionForm1271434-RecipientInformation-RecipientStateProvince">State/Province*<select required="" autocomplete="on" title="State/Province*" name="RecipientStateProvince"
class="required" id="NVContributionForm1271434-RecipientInformation-RecipientStateProvince-select">
<option value="" disabled="">- State -</option>
<option value="AK">AK</option>
<option value="AL">AL</option>
<option value="AR">AR</option>
<option value="AZ">AZ</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DC">DC</option>
<option value="DE">DE</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="HI">HI</option>
<option value="IA">IA</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="MA">MA</option>
<option value="MD">MD</option>
<option value="ME">ME</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MO">MO</option>
<option value="MS">MS</option>
<option value="MT">MT</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="NE">NE</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NV">NV</option>
<option value="NY">NY</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="RI">RI</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VA">VA</option>
<option value="VT">VT</option>
<option value="WA">WA</option>
<option value="WI">WI</option>
<option value="WV">WV</option>
<option value="WY">WY</option>
<option value="AS">AS</option>
<option value="FM">FM</option>
<option value="GU">GU</option>
<option value="MH">MH</option>
<option value="MP">MP</option>
<option value="PR">PR</option>
<option value="PW">PW</option>
<option value="VI">VI</option>
<option value="AA">AA</option>
<option value="AE">AE</option>
<option value="AP">AP</option>
</select>
</label></div>
<div class="at-row at-row-solo RecipientEmailAddress e-mail"><label class="at-text RecipientEmailAddress e-mail" id="NVContributionForm1271434-RecipientInformation-RecipientEmailAddress">Email* <small>(Optional)</small><input type="email"
autocomplete="on" pattern="^([\w!#$%&'*+\-\/=?\^`\{\|\}~]+\.)*[\w!#$%&'*+\-\/=?\^`\{\|\}~]+@((((([a-zA-Z0-9]{1}[a-zA-Z0-9\-]{0,62}[a-zA-Z0-9]{1})|[a-zA-Z])\.)+[a-zA-Z]{2,62})|(\d{1,3}\.){3}\d{1,3}(:\d{1,5})?)$" false=""
title="Email*" name="RecipientEmailAddress" value="" maxlength="100">
</label></div>
<div class="at-row at-row-solo Ecard">
<div class="form-unit form-unit-radio form-item-ecard" id="NVContributionForm1271434-RecipientInformation-Ecard"></div>
</div>
<div class="at-row at-row-solo NotificationSendDate"><label class="at-date notificationsenddate" id="NVContributionForm1271434-RecipientInformation-NotificationSendDate"></label></div>
<div class="at-row at-row-solo NotificationMessage"><label class="at-area NotificationMessage" id="NVContributionForm1271434-RecipientInformation-NotificationMessage"></label></div>
</div>
<div class="at-row ecard-section e-mail">
<div class="at-recipient-msg" style="display: none;">
<div class="form-unit form-unit-radio form-item-ecard" id="NVContributionForm1271434-RecipientInformation-Ecard">
<div class="at-title"> Select an Ecard </div>
<div class="at-ecards clearfix">
<div class="at-ecard selected IHO-card iho-msg-1">
<div class="at-ecard-img">
<img src="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/11607/images/Online%20Actions/E-Card/ecard-iho-msg-1.gif" alt="A generous contribution has been made in your honor.">
</div>
<input name="ecard" type="radio" value="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/11607/images/Online%20Actions/E-Card/ecard-iho-msg-1.gif" checked="">
</div>
<div class="at-ecard IHO-card iho-msg-2">
<div class="at-ecard-img">
<img src="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/11607/images/Online%20Actions/E-Card/ecard-iho-msg-2.gif" alt="A generous contribution has been made in your honor.">
</div>
<input name="ecard" type="radio" value="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/11607/images/Online%20Actions/E-Card/ecard-iho-msg-2.gif">
</div>
<div class="at-ecard IHO-card iho-msg-3">
<div class="at-ecard-img">
<img src="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/11607/images/Online%20Actions/E-Card/ecard-iho-msg-3.gif" alt="A generous contribution has been made in your honor.">
</div>
<input name="ecard" type="radio" value="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/11607/images/Online%20Actions/E-Card/ecard-iho-msg-3.gif">
</div>
<div class="at-ecard IHO-card iho-msg-4">
<div class="at-ecard-img">
<img src="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/11607/images/Online%20Actions/E-Card/ecard-iho-msg-4.gif" alt="A generous contribution has been made in your honor.">
</div>
<input name="ecard" type="radio" value="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/11607/images/Online%20Actions/E-Card/ecard-iho-msg-4.gif">
</div>
<div class="at-ecard IHO-card iho-msg-5">
<div class="at-ecard-img">
<img src="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/11607/images/Online%20Actions/E-Card/ecard-iho-msg-5.gif" alt="A generous contribution has been made in your honor.">
</div>
<input name="ecard" type="radio" value="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/11607/images/Online%20Actions/E-Card/ecard-iho-msg-5.gif">
</div>
<div class="at-ecard IHO-card iho-msg-6">
<div class="at-ecard-img">
<img src="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/11607/images/Online%20Actions/E-Card/ecard-iho-msg-6.gif" alt="A generous contribution has been made in your honor.">
</div>
<input name="ecard" type="radio" value="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/11607/images/Online%20Actions/E-Card/ecard-iho-msg-6.gif">
</div>
<div class="at-ecard IMO-card imo-msg-1 card-hidden">
<div class="at-ecard-img">
<img src="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/11607/images/Online%20Actions/E-Card/ecard-imo-msg-1.gif" alt="A generous contribution has been made in your honor.">
</div>
<input name="ecard" type="radio" value="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/11607/images/Online%20Actions/E-Card/ecard-imo-msg-1.gif">
</div>
<div class="at-ecard IMO-card imo-msg-2 card-hidden">
<div class="at-ecard-img">
<img src="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/11607/images/Online%20Actions/E-Card/ecard-imo-msg-2.gif" alt="A generous contribution has been made in your honor.">
</div>
<input name="ecard" type="radio" value="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/11607/images/Online%20Actions/E-Card/ecard-imo-msg-2.gif">
</div>
<div class="at-ecard IMO-card imo-msg-3 card-hidden">
<div class="at-ecard-img">
<img src="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/11607/images/Online%20Actions/E-Card/ecard-imo-msg-3.gif" alt="A generous contribution has been made in your honor.">
</div>
<input name="ecard" type="radio" value="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/11607/images/Online%20Actions/E-Card/ecard-imo-msg-3.gif">
</div>
<button type="button" class="at-preview-ecard btn-at btn-at-link">Preview Ecard</button>
</div>
</div><label class="at-date notificationsenddate" id="NVContributionForm1271434-RecipientInformation-NotificationSendDate">Send Date <small>(Optional)</small><input type="text" title="Send Date" name="NotificationSendDate" value=""
maxlength="10" size="10" class="hasDatepicker" placeholder="MM/DD/YYYY" autocomplete="off" id="dp1732817733511">
</label><label class="at-area NotificationMessage" id="NVContributionForm1271434-RecipientInformation-NotificationMessage" style="display: block;">Message* <small>(Optional)</small><textarea false="" title="Message*"
name="NotificationMessage" maxlength="4000"></textarea>
</label>
</div>
</div>
</div>
</fieldset>
<fieldset class="at-fieldset PaymentMethodSection" id="NVContributionForm1271434-PaymentMethodSection">
<div class="at-fields">
<div class="at-row at-row-full PaymentMethod">
<div class="at-payment-method-buttons" id="NVContributionForm1271434-PaymentMethodSection-PaymentMethod">
<div class="at-radio-set at-radio-set-buttons at-align-flex-right">
<div class="at-btn-radio-wrapper at-credit-card-button-wrapper">
<input id="creditcard_radio_1271434" type="radio" name="PaymentMethod" value="creditcard">
<label for="creditcard_radio_1271434" class="at-btn-radio large" tabindex="0">Credit Card</label>
</div>
<div class="at-btn-radio-wrapper at-eft-button-wrapper">
<input id="eft_radio_1271434" type="radio" name="PaymentMethod" value="eft">
<label for="eft_radio_1271434" class="at-btn-radio large" tabindex="0"> Pay with Bank Account </label>
</div>
<div class="at-btn-radio-wrapper at-paypal-button-wrapper">
<input id="paypal_radio_1271434" type="radio" name="PaymentMethod" value="paypal">
<label for="paypal_radio_1271434" class="at-btn-radio small at-paypal-button" title="Pay with PayPal" aria-label="Pay with PayPal" tabindex="0">
<span aria-hidden="true"> </span>
</label>
</div>
</div>
</div>
</div>
</div>
</fieldset>
<fieldset class="at-fieldset ContactInformation" id="NVContributionForm1271434-ContactInformation" style="display: none;">
<legend class="at-legend">Billing Information</legend>
<div class="at-fields">
<div class="at-row FirstName LastName"><label class="at-text FirstName" id="NVContributionForm1271434-ContactInformation-FirstName">First Name<input type="text" autocomplete="given-name" x-autocompletetype="given-name" required=""
title="First Name (required)" name="FirstName" value="" maxlength="20">
</label><label class="at-text LastName" id="NVContributionForm1271434-ContactInformation-LastName">Last Name<input type="text" autocomplete="family-name" x-autocompletetype="surname" required="" title="Last Name (required)" name="LastName"
value="" maxlength="25">
</label></div>
<div class="at-row AddressLine1 AddressLine2"><label class="at-text AddressLine1" id="NVContributionForm1271434-ContactInformation-AddressLine1">Street Address<input type="text" autocomplete="address-line1" x-autocompletetype="address-line1"
required="" title="Street Address (required)" name="AddressLine1" value="" maxlength="99">
</label><label class="at-text AddressLine2" id="NVContributionForm1271434-ContactInformation-AddressLine2">Address Line 2 <small>(Optional)</small><input type="text" autocomplete="address-line2" x-autocompletetype="address-line2" false=""
title="Address Line 2" name="AddressLine2" value="" maxlength="99">
</label></div>
<div class="at-row Country PostalCode City StateProvince"><label class="at-select Country" id="NVContributionForm1271434-ContactInformation-Country">Country <small>(Optional)</small><select autocomplete="country-name"
x-autocompletetype="country" title="Country" name="Country" class="select2-hidden-accessible" id="NVContributionForm1271434-ContactInformation-Country-select" tabindex="-1" aria-hidden="true">
<option value="">- Select -</option>
<option value="AF">Afghanistan</option>
<option value="AX">Åland Islands</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AD">Andorra</option>
<option value="AO">Angola</option>
<option value="AI">Anguilla</option>
<option value="AQ">Antarctica</option>
<option value="AG">Antigua and Barbuda</option>
<option value="AR">Argentina</option>
<option value="AM">Armenia</option>
<option value="AW">Aruba</option>
<option value="AU">Australia</option>
<option value="AT">Austria</option>
<option value="AZ">Azerbaijan</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BD">Bangladesh</option>
<option value="BB">Barbados</option>
<option value="BY">Belarus</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BJ">Benin</option>
<option value="BM">Bermuda</option>
<option value="BT">Bhutan</option>
<option value="BO">Bolivia (Plurinational State of)</option>
<option value="BQ">Bonaire, Sint Eustatius and Saba</option>
<option value="BA">Bosnia and Herzegovina</option>
<option value="BW">Botswana</option>
<option value="BV">Bouvet Island</option>
<option value="BR">Brazil</option>
<option value="IO">British Indian Ocean Territory</option>
<option value="VG">British Virgin Islands</option>
<option value="BN">Brunei Darussalam</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="CV">Cabo Verde</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="KY">Cayman Islands</option>
<option value="CF">Central African Republic</option>
<option value="TD">Chad</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CX">Christmas Island</option>
<option value="CC">Cocos (Keeling) Islands</option>
<option value="CO">Colombia</option>
<option value="KM">Comoros</option>
<option value="CG">Congo</option>
<option value="CD">Congo (Democratic Republic of the)</option>
<option value="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="CI">Côte d'Ivoire</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CW">Curaçao</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czechia</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="GQ">Equatorial Guinea</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="SZ">Eswatini</option>
<option value="ET">Ethiopia</option>
<option value="FK">Falkland Islands (Malvinas)</option>
<option value="FO">Faroe Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="GF">French Guiana</option>
<option value="PF">French Polynesia</option>
<option value="TF">French Southern Territories</option>
<option value="GA">Gabon</option>
<option value="GM">Gambia</option>
<option value="GE">Georgia</option>
<option value="DE">Germany</option>
<option value="GH">Ghana</option>
<option value="GI">Gibraltar</option>
<option value="GR">Greece</option>
<option value="GL">Greenland</option>
<option value="GD">Grenada</option>
<option value="GP">Guadeloupe</option>
<option value="GT">Guatemala</option>
<option value="GG">Guernsey</option>
<option value="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard Island and McDonald Islands</option>
<option value="VA">Holy See</option>
<option value="HN">Honduras</option>
<option value="HK">Hong Kong</option>
<option value="HU">Hungary</option>
<option value="IS">Iceland</option>
<option value="IN">India</option>
<option value="ID">Indonesia</option>
<option value="IR">Iran (Islamic Republic of)</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IM">Isle of Man</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JE">Jersey</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KP">Korea (Democratic People's Republic of)</option>
<option value="KR">Korea (Republic of)</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Lao People's Democratic Republic</option>
<option value="LV">Latvia</option>
<option value="LB">Lebanon</option>
<option value="LS">Lesotho</option>
<option value="LR">Liberia</option>
<option value="LY">Libya</option>
<option value="LI">Liechtenstein</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="MO">Macao</option>
<option value="MG">Madagascar</option>
<option value="MW">Malawi</option>
<option value="MY">Malaysia</option>
<option value="MV">Maldives</option>
<option value="ML">Mali</option>
<option value="MT">Malta</option>
<option value="MQ">Martinique</option>
<option value="MR">Mauritania</option>
<option value="MU">Mauritius</option>
<option value="YT">Mayotte</option>
<option value="MX">Mexico</option>
<option value="FM">Micronesia (Federated States of)</option>
<option value="MD">Moldova (Republic of)</option>
<option value="MC">Monaco</option>
<option value="MN">Mongolia</option>
<option value="ME">Montenegro</option>
<option value="MS">Montserrat</option>
<option value="MA">Morocco</option>
<option value="MZ">Mozambique</option>
<option value="MM">Myanmar</option>
<option value="NA">Namibia</option>
<option value="NR">Nauru</option>
<option value="NP">Nepal</option>
<option value="NL">Netherlands</option>
<option value="NC">New Caledonia</option>
<option value="NZ">New Zealand</option>
<option value="NI">Nicaragua</option>
<option value="NE">Niger</option>
<option value="NG">Nigeria</option>
<option value="NU">Niue</option>
<option value="NF">Norfolk Island</option>
<option value="MK">North Macedonia</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PK">Pakistan</option>
<option value="PW">Palau</option>
<option value="PS">Palestine (State of)</option>
<option value="PA">Panama</option>
<option value="PG">Papua New Guinea</option>
<option value="PY">Paraguay</option>
<option value="PE">Peru</option>
<option value="PH">Philippines</option>
<option value="PN">Pitcairn</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="QA">Qatar</option>
<option value="RE">Réunion</option>
<option value="RO">Romania</option>
<option value="RU">Russian Federation</option>
<option value="RW">Rwanda</option>
<option value="BL">Saint Barthélemy</option>
<option value="SH">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="MF">Saint Martin (French part)</option>
<option value="PM">Saint Pierre and Miquelon</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</option>
<option value="ST">Sao Tome and Principe</option>
<option value="SA">Saudi Arabia</option>
<option value="SN">Senegal</option>
<option value="RS">Serbia</option>
<option value="SC">Seychelles</option>
<option value="SL">Sierra Leone</option>
<option value="SG">Singapore</option>
<option value="SX">Sint Maarten (Dutch part)</option>
<option value="SK">Slovakia</option>
<option value="SI">Slovenia</option>
<option value="SB">Solomon Islands</option>
<option value="SO">Somalia</option>
<option value="ZA">South Africa</option>
<option value="GS">South Georgia and the South Sandwich Islands</option>
<option value="SS">South Sudan</option>
<option value="ES">Spain</option>
<option value="LK">Sri Lanka</option>
<option value="SD">Sudan</option>
<option value="SR">Suriname</option>
<option value="SJ">Svalbard and Jan Mayen</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syrian Arab Republic</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania (United Republic of)</option>
<option value="TH">Thailand</option>
<option value="TL">Timor-Leste</option>
<option value="TG">Togo</option>
<option value="TK">Tokelau</option>
<option value="TO">Tonga</option>
<option value="TT">Trinidad and Tobago</option>
<option value="TN">Tunisia</option>
<option value="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks and Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom</option>
<option value="US">United States</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VE">Venezuela (Bolivarian Republic of)</option>
<option value="VN">Viet Nam</option>
<option value="WF">Wallis and Futuna</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" style="width: 267px;"><span class="selection"><span class="select2-selection select2-selection--single" role="combobox" aria-haspopup="true"
aria-expanded="false" title="Country" tabindex="0" aria-labelledby="select2-NVContributionForm1271434-ContactInformation-Country-select-container"><span class="select2-selection__rendered"
id="select2-NVContributionForm1271434-ContactInformation-Country-select-container" title="United States">United States</span><span class="select2-selection__arrow"
role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
</label><label class="at-text PostalCode" id="NVContributionForm1271434-ContactInformation-PostalCode">Postal Code<input type="tel" autocomplete="postal-code" x-autocompletetype="postal-code" pattern="^\d{5}([\-]\d{4})?$" required=""
title="Postal Code (required)" name="PostalCode" value="" maxlength="10">
</label><label class="at-text City" id="NVContributionForm1271434-ContactInformation-City">City<input type="text" autocomplete="address-level2" x-autocompletetype="locality" required="" title="City (required)" name="City" value=""
maxlength="25">
</label><label class="at-select StateProvince" id="NVContributionForm1271434-ContactInformation-StateProvince">State/Province<select required="" autocomplete="address-level1" x-autocompletetype="administrative-area" title="State/Province"
name="StateProvince" class=" required" id="NVContributionForm1271434-ContactInformation-StateProvince-select">
<option value="" disabled="">- State -</option>
<option value="AK">AK</option>
<option value="AL">AL</option>
<option value="AR">AR</option>
<option value="AZ">AZ</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DC">DC</option>
<option value="DE">DE</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="HI">HI</option>
<option value="IA">IA</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="MA">MA</option>
<option value="MD">MD</option>
<option value="ME">ME</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MO">MO</option>
<option value="MS">MS</option>
<option value="MT">MT</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="NE">NE</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NV">NV</option>
<option value="NY">NY</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="RI">RI</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VA">VA</option>
<option value="VT">VT</option>
<option value="WA">WA</option>
<option value="WI">WI</option>
<option value="WV">WV</option>
<option value="WY">WY</option>
<option value="AS">AS</option>
<option value="FM">FM</option>
<option value="GU">GU</option>
<option value="MH">MH</option>
<option value="MP">MP</option>
<option value="PR">PR</option>
<option value="PW">PW</option>
<option value="VI">VI</option>
<option value="AA">AA</option>
<option value="AE">AE</option>
<option value="AP">AP</option>
</select>
</label></div>
<div class="at-row EmailAddress MobilePhone"><label class="at-text EmailAddress" id="NVContributionForm1271434-ContactInformation-EmailAddress">Email<input type="email" autocomplete="email" x-autocompletetype="email"
pattern="^([\w!#$%&'*+\-\/=?\^`\{\|\}~]+\.)*[\w!#$%&'*+\-\/=?\^`\{\|\}~]+@((((([a-zA-Z0-9]{1}[a-zA-Z0-9\-]{0,62}[a-zA-Z0-9]{1})|[a-zA-Z])\.)+[a-zA-Z]{2,62})|(\d{1,3}\.){3}\d{1,3}(:\d{1,5})?)$" required="" title="Email (required)"
name="EmailAddress" value="" maxlength="100" placeholder="email@email.com">
</label><label class="at-text MobilePhone" id="NVContributionForm1271434-ContactInformation-MobilePhone">Mobile Phone <small>(Optional)</small>
<div class="intl-tel-input iti iti--allow-dropdown">
<div class="iti__flag-container">
<div class="iti__selected-flag" role="combobox" aria-controls="iti-0__country-listbox" aria-owns="iti-0__country-listbox" aria-expanded="false" tabindex="0" title="United States: +1" aria-activedescendant="iti-0__item-us-preferred">
<div class="iti__flag iti__us"></div>
<div class="iti__arrow"></div>
</div>
</div><input type="tel" class="intl-phone-MobilePhone" name="MobilePhone" title="Mobile Phone" data-intl-tel-input-id="0">
</div>
</label></div>
<div class="at-row at-row-solo SmsSubscribeMobilePhone"><input id="SmsSubscribeMobilePhone_Value" type="hidden" name="SmsSubscribeMobilePhone.Value" value="true"></div>
<div class="at-row at-row-solo at-row-full SmsLegalDisclaimer">
<div class="at-markup SmsLegalDisclaimer at-legal" id="NVContributionForm1271434-ContactInformation-SmsLegalDisclaimer">By providing your cell phone number, you agree to receive calls and texts to that number from Planned Parenthood
organizations that may be automatically dialed or prerecorded on Planned Parenthood issues and other ways to get involved. Msg freq varies. STOP to quit. Msg & Data Rates May Apply.
<a href="https://www.plannedparenthood.org/terms-use" target="_blank">Terms</a>.<br><br>
</div>
</div>
<div class="at-row at-row-solo at-row-full YesSignMeUpForUpdatesForBinder"><label class="at-check YesSignMeUpForUpdatesForBinder" id="NVContributionForm1271434-ContactInformation-YesSignMeUpForUpdatesForBinder"><input type="checkbox"
checked="" required="" name="YesSignMeUpForUpdatesForBinder"> <span class="at-checkbox-title-container"><span class="at-checkbox-title" id="NVContributionForm1271434-ContactInformation-YesSignMeUpForUpdatesForBinder-label">You'll receive
emails from Planned Parenthood organizations. You may unsubscribe at any time.</span></span>
</label></div>
<div class="at-row "><label class="at-text PersonalUrl" id="NVContributionForm1271434-ContactInformation-PersonalUrl"> <small>(Optional)</small><input type="text" autocomplete="on" false="" title="" name="PersonalUrl" value="" maxlength="">
</label></div>
<div class="at-row "><input id="SocialNetworkTrackingId_Value" type="hidden" name="SocialNetworkTrackingId.Value"></div>
<div class="at-row "><input id="SocialNetwork_Value" type="hidden" name="SocialNetwork.Value"></div>
<div class="at-row ">
<div class="at-markup TrackingPixel" id="NVContributionForm1271434-ContactInformation-TrackingPixel" style="display: none;"><img alt=""
src="https://secure.everyaction.com/v1/Track/CQYf3KYieEy68YC1hgDcYg2?formSessionId=f685d6b6-567b-4ef8-9a3f-a9acdb884a80&bName=chrome&dType=desktop&formVersion=11/6/2024 6:45:08 PM|&fUrl=aHR0cHM6Ly93d3cucGxhbm5lZHBhcmVudGhvb2Qub3JnLw%3D%3D&fRef="
style="display:none"></div>
</div>
</div>
</fieldset>
<fieldset class="at-fieldset PaymentInformation" id="NVContributionForm1271434-PaymentInformation" style="display: none;">
<legend class="at-legend">Payment Information</legend>
<div class="at-fields">
<div class="at-row "><label class="at-text at-cc-number" id="NVContributionForm1271434-PaymentInformation-Account">Card Number<div class="cc-type-wrapper vgs-loading-placeholder" style="display: none;">
<div class="cc-type unknown"></div>
<input type="tel" autocomplete="cc-number" title="Credit Card Number" placeholder="•••• •••• •••• ••••" readonly="true">
</div>
<div id="vgs-Account-1271434" class="vgs-cc-iframe-wrapper vgs-input-container vgs-collect-container__empty vgs-collect-container__invalid isEmpty" tabindex="-1"><iframe title="Secure card number input frame"
src="https://js.verygoodvault.com/vgs-collect/2.18.4/lib/index.html#name=Account&placeholder=%E2%80%A2%E2%80%A2%E2%80%A2%E2%80%A2%20%E2%80%A2%E2%80%A2%E2%80%A2%E2%80%A2%20%E2%80%A2%E2%80%A2%E2%80%A2%E2%80%A2%20%E2%80%A2%E2%80%A2%E2%80%A2%E2%80%A2&type=card-number&validations%5B0%5D=validCardNumber&validations%5B1%5D=required&autoComplete=cc-number&formId=randomId28035315770678590264&fieldId=randomId2803532121676597322&createdAt=1732817736092&tnt=dG50dzFwem5sYW0%3D&env=bGl2ZQ%3D%3D&logLevel=default&satellitePort=&vgsCollectSessionId=1cd2a008-378e-45ff-9cfd-dd4b73d98f88&css%5BfontSize%5D=.875rem&css%5BfontFamily%5D=monospace&css%5BlineHeight%5D=1&css%5BbackgroundColor%5D=%23fff&css%5B%26%3A%3Aplaceholder%5D%5Bcolor%5D=%23ced4da&css%5B%26%3A%3Aplaceholder%5D%5BfontWeight%5D=bold"
frameborder="0" scrolling="0" allowtransparency="true" id="randomId2803532121676597322" form-id="randomId28035315770678590264" data-gtm-yt-inspected-666187_821="true" data-gtm-yt-inspected-61934708_454="true"></iframe></div>
</label><label class="at-text at-cc-expiration" id="NVContributionForm1271434-PaymentInformation-ExpirationDate">Expiration Date<div class="vgs-loading-placeholder" style="display: none;">
<input type="tel" autocomplete="cc-exp" title="Expiration Date (MM / YY)" placeholder="MM / YY" readonly="true">
</div>
<div id="vgs-ExpirationDate-1271434" class="vgs-ccexpiration-iframe-wrapper vgs-input-container vgs-collect-container__empty vgs-collect-container__invalid isEmpty"><iframe title="Secure card expiration date input frame"
src="https://js.verygoodvault.com/vgs-collect/2.18.4/lib/index.html#name=ExpirationDate&placeholder=MM%20%2F%20YY&type=card-expiration-date&serializers=W3sibmFtZSI6InNlcGFyYXRlIiwib3B0aW9ucyI6eyJtb250aE5hbWUiOiJFeHBpcmF0aW9uTW9udGgiLCJ5ZWFyTmFtZSI6IkV4cGlyYXRpb25ZZWFyIn19XQ%3D%3D&validations%5B0%5D=validCardExpirationDate&validations%5B1%5D=required&autoComplete=cc-exp&formId=randomId28035315770678590264&fieldId=randomId2803413937544029786&createdAt=1732817736099&tnt=dG50dzFwem5sYW0%3D&env=bGl2ZQ%3D%3D&logLevel=default&satellitePort=&vgsCollectSessionId=1cd2a008-378e-45ff-9cfd-dd4b73d98f88&css%5BfontSize%5D=.875rem&css%5BfontFamily%5D=monospace&css%5BlineHeight%5D=1&css%5BbackgroundColor%5D=%23fff&css%5B%26%3A%3Aplaceholder%5D%5Bcolor%5D=%23ced4da&css%5B%26%3A%3Aplaceholder%5D%5BfontWeight%5D=bold"
frameborder="0" scrolling="0" allowtransparency="true" id="randomId2803413937544029786" form-id="randomId28035315770678590264" data-gtm-yt-inspected-666187_821="true" data-gtm-yt-inspected-61934708_454="true"></iframe></div>
</label></div>
<div class="at-row">
<div class="at-paypal-accepted-here" style="display: none;">
<div class="at-payment-integration-container" style="display: none;">
<img src="//static.everyaction.com/ea-actiontag/assets/images/paypal-logo.png" alt="PayPal">
<p>You’ve authorized this payment through PayPal.</p>
<div>Contribution Amount: <b class="at-paypal-amount"></b></div>
<div>Account: <b class="at-paypal-account-info"></b></div>
</div>
<label class="paypal-label">
<input type="hidden" name="paypalNonce" value="">
</label>
</div>
</div>
<div class="at-row">
<div class="at-eft-accepted-here" style="display: none;">
<label class="account-type-label">Account Type <select title="Account Type" name="bankAccountType" id="bankAccountType" style="width:50%;" class="eft-input">
<option value="Checking">Checking</option>
<option value="Savings">Savings</option>
</select>
</label>
<label class="routing-number-label at-row-half">Routing Number <a class="at-whatsthis" tabindex="0">What's This?</a>
<input type="tel" name="routingNumber" id="routingNumber" placeholder="•••••••••" style="width:100%;" maxlength="9" class="eft-input">
</label>
<label class="account-number-label at-row-half">Account Number <a class="at-whatsthis" tabindex="0">What's This?</a>
<input type="tel" name="bankAccountNumber" id="bankAccountNumber" placeholder="•••••••••••••••••" style="width:100%;" maxlength="17" class="eft-input">
</label>
<label class="confirm-account-number-label at-row-half">Confirm Account Number <input type="tel" name="confirmBankAccountNumber" id="confirmBankAccountNumber" placeholder="•••••••••••••••••" style="width:100%;" maxlength="17"
class="eft-input">
</label>
<label class="at-check authorize-payment-label">
<input type="checkbox" name="authorizePayment" id="authorizePayment" class="eft-input">
<span>I authorize the use of my bank account as a payment method and authorize this organization to debit my bank account via the Automated Clearing House system to fulfill my donation commitment. This authority will remain in effect
until revoked in writing by the account holder.</span>
</label>
</div>
</div>
</div>
</fieldset>
<fieldset class="at-fieldset AdditionalInformation" id="NVContributionForm1271434-AdditionalInformation" style="display: none;">
<legend class="at-legend">Additional Information</legend>
<div class="at-fields">
<div class="at-row at-row-full CustomFieldHeaderHtml">
<div class="at-markup CustomFieldHeaderHtml" id="NVContributionForm1271434-AdditionalInformation-CustomFieldHeaderHtml" style="display: none;"></div>
</div>
<div class="at-row at-row-full CustomFormFieldQuestion_6308388360774211_MappedCustomFormFieldQuestion_39">
<label class="at-text CustomFormFieldQuestion_6308388360774211_MappedCustomFormFieldQuestion_39" id="NVContributionForm1271434-AdditionalInformation-CustomFormFieldQuestion_6308388360774211_MappedCustomFormFieldQuestion_39">Affiliate Code
<small>(Optional)</small><input type="text" autocomplete="on" false="" title="Affiliate Code" name="CustomFormFieldQuestion_6308388360774211_MappedCustomFormFieldQuestion_39" value="" maxlength="75">
</label>
</div>
<div class="at-row at-row-full CustomFormFieldQuestion_3612949719869257_MappedCustomFormFieldQuestion_40">
<label class="at-text CustomFormFieldQuestion_3612949719869257_MappedCustomFormFieldQuestion_40" id="NVContributionForm1271434-AdditionalInformation-CustomFormFieldQuestion_3612949719869257_MappedCustomFormFieldQuestion_40">Affiliate
Percentage <small>(Optional)</small><input type="text" autocomplete="on" pattern="^(\d+(\.\d{0,2})?)|((\.\d{1,2}))$" false="" title="Affiliate Percentage" name="CustomFormFieldQuestion_3612949719869257_MappedCustomFormFieldQuestion_40"
value="" maxlength="">
</label>
</div>
<div class="at-row at-row-full CustomFormFieldQuestion_3051141421354305_MappedCustomFormFieldQuestion_44">
<label class="at-text CustomFormFieldQuestion_3051141421354305_MappedCustomFormFieldQuestion_44" id="NVContributionForm1271434-AdditionalInformation-CustomFormFieldQuestion_3051141421354305_MappedCustomFormFieldQuestion_44">Google Analytics
clientId <small>(Optional)</small><input type="text" autocomplete="on" false="" title="Google Analytics clientId" name="CustomFormFieldQuestion_3051141421354305_MappedCustomFormFieldQuestion_44" value="" maxlength="75">
</label>
</div>
<div class="at-row at-row-full CustomFormFieldQuestion_3550172044842605_MappedCustomFormFieldQuestion_46">
<label class="at-text CustomFormFieldQuestion_3550172044842605_MappedCustomFormFieldQuestion_46" id="NVContributionForm1271434-AdditionalInformation-CustomFormFieldQuestion_3550172044842605_MappedCustomFormFieldQuestion_46">Salesforce Code
<small>(Optional)</small><input type="text" autocomplete="on" false="" title="Salesforce Code" name="CustomFormFieldQuestion_3550172044842605_MappedCustomFormFieldQuestion_46" value="" maxlength="75">
</label>
</div>
<div class="at-row at-row-full CustomFieldFooterHtml">
<div class="at-markup CustomFieldFooterHtml" id="NVContributionForm1271434-AdditionalInformation-CustomFieldFooterHtml" style="display: none;"></div>
</div>
</div>
</fieldset>
<div class="at-form-submit clearfix">
<input type="submit" value="Donate Now" class="at-submit btn-at btn-at-primary" style="display: none;">
<div class="at-markup secure-processing-single-step-div" style="display: none;">
<label class="secure-processing-label at-text"> Your donation will be securely processed.<div class="glyphicons glyphicons-lock" aria-hidden="true"></div>
</label>
</div>
</div>
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GIVING TUESDAY: ALL DONATIONS ARE MATCHED $1-FOR-$1!
This Giving Tuesday help protect access to health care, sex education, and
reproductive rights for everyone.
Monthly One-Time
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