csah.webauthor.com
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2606:4700::6811:4337
Public Scan
Submitted URL: https://lnks.gd/l/eyJhbGciOiJIUzI1NiJ9.eyJidWxsZXRpbl9saW5rX2lkIjoxMDYsInVyaSI6ImJwMjpjbGljayIsImJ1bGxldGluX2lkI...
Effective URL: https://csah.webauthor.com/go/apply.cfm
Submission: On November 19 via api from US — Scanned from DE
Effective URL: https://csah.webauthor.com/go/apply.cfm
Submission: On November 19 via api from US — Scanned from DE
Form analysis 2 forms found in the DOM
GET http://saluteheroes.org/
<form action="http://saluteheroes.org/" method="get" id="search">
<input type="text" placeholder="SEARCH" id="s" name="s" required="">
<button type="submit" value="GO"></button>
</form>Name: QuickForm — POST /go/apply.cfm
<form allow_multiple_submissions="false" print_mode="false" onsubmit="return frmValidCheck(this);" style="margin:0;width:95%;" save_toggle="true" persist="false" name="QuickForm" action="/go/apply.cfm" show_hints="true" method="POST" id="QuickForm"
novalidate="">
<div class="XMFormGroup box" style="margin-bottom:10px;background-color:#ffffff;padding:5px;border:1px solid #dadada;border-radius:4px;" id="FormTitle">
<div class="XMFormGroupHeader">
<table width="100%" cellpadding="0" style="table-layout:fixed" cellspacing="0">
<colgroup>
<col style="width:auto;">
</colgroup>
<tbody>
<tr>
<td>
<div id="FormTitleSectionLabel" class="SectionLabel">
<div style="margin:10px 0 10px 0">General Information</div>
</div>
</td>
</tr>
</tbody>
</table>
</div>
<div id="SectionBodyFormTitle" class="XMFormBody">
<table border="0" class="rwdmulti" cellpadding="0" vspace="0" cellspacing="0" width="100%">
<tbody>
<tr>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_first_name">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgfirst_name" width="16" height="16" align="absmiddle"><img src="/lib/img/icon/asterisk.gif" id="ReqImgfirst_name"
align="absmiddle"></td>
<td valign="top"><label id="form_label_first_name" class="XMLabel" for="first_name" style="">First Name</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="20" id="first_name" vtype="text" hint="" placeholder="" vlabel="First Name" vrequired="true"
class="clInput form-control clInput form-control" style="width:98%;" type="text" name="first_name" value="">
</td>
</tr>
</tbody>
</table>
</td>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_middle_name">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgmiddle_name" width="16" height="16" align="absmiddle"><img src="/lib/img/icon/asterisk.gif" id="ReqImgmiddle_name"
align="absmiddle"></td>
<td valign="top"><label id="form_label_middle_name" class="XMLabel" for="middle_name" style="">Middle Name</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="20" id="middle_name" vtype="text" hint="" placeholder="" vlabel="Middle Name" vrequired="true"
class="clInput form-control clInput form-control" style="width:98%;" type="text" name="middle_name" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_last_name">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImglast_name" width="16" height="16" align="absmiddle"><img src="/lib/img/icon/asterisk.gif" id="ReqImglast_name"
align="absmiddle"></td>
<td valign="top"><label id="form_label_last_name" class="XMLabel" for="last_name" style="">Last Name</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="20" id="last_name" vtype="text" hint="" placeholder="" vlabel="Last Name" vrequired="true"
class="clInput form-control clInput form-control" style="width:98%;" type="text" name="last_name" value="">
</td>
</tr>
</tbody>
</table>
</td>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_email">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgemail" width="16" height="16" align="absmiddle"><img src="/lib/img/icon/asterisk.gif" id="ReqImgemail"
align="absmiddle"></td>
<td valign="top"><label id="form_label_email" class="XMLabel" for="email" style="">Email Address</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input id="email" mask="" maxlength="70" vtype="email" hint="" placeholder="name@domain.com" vlabel="Email Address" vrequired="true"
class="clInput form-control xm-input-email" style="width:98%;" type="email" name="email" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_permanent">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgpermanent" align="absmiddle" width="16" height="16"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgpermanent" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_permanent" class="XMLabel" for="permanent" style="">
<div style="font-weight:bold;margin: 10px 0 10px 0;">Permanent Address</div>
</label>
<div style="word-wrap:break-word;;">
<div class="xmFieldValue" id="permanent"></div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_address_1">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgaddress_1" width="16" height="16" align="absmiddle"><img src="/lib/img/icon/asterisk.gif" id="ReqImgaddress_1"
align="absmiddle"></td>
<td valign="top"><label id="form_label_address_1" class="XMLabel" for="address_1" style="">Street Address</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="100" id="address_1" vtype="text" hint="" placeholder="" vlabel="Street Address" vrequired="true"
class="clInput form-control clInput form-control" style="width:98%;" type="text" name="address_1" value="">
</td>
</tr>
</tbody>
</table>
</td>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_city">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgcity" width="16" height="16" align="absmiddle"><img src="/lib/img/icon/asterisk.gif" id="ReqImgcity"
align="absmiddle"></td>
<td valign="top"><label id="form_label_city" class="XMLabel" for="city" style="">City</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="50" id="city" vtype="text" hint="" placeholder="" vlabel="City" vrequired="true"
class="clInput form-control clInput form-control" style="width:98%;" type="text" name="city" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_state">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgstate" width="16" height="16" align="absmiddle"><img src="/lib/img/icon/asterisk.gif" id="ReqImgstate"
align="absmiddle"></td>
<td valign="top"><label id="form_label_state" class="XMLabel" for="state" style="">State</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="75" id="state" vtype="text" hint="" placeholder="" vlabel="State" vrequired="true"
class="clInput form-control clInput form-control" style="width:98%;" type="text" name="state" value="">
</td>
</tr>
</tbody>
</table>
</td>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_zip">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgzip" width="16" height="16" align="absmiddle"><img src="/lib/img/icon/asterisk.gif" id="ReqImgzip" align="absmiddle">
</td>
<td valign="top"><label id="form_label_zip" class="XMLabel" for="zip" style="">Zip Code</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="20" id="zip" vtype="text" hint="" placeholder="" vlabel="Zip Code" vrequired="true"
class="clInput form-control clInput form-control" style="width:98%;" type="text" name="zip" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_phone">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgphone" width="16" height="16" align="absmiddle"><img src="/lib/img/icon/asterisk.gif" id="ReqImgphone"
align="absmiddle"></td>
<td valign="top"><label id="form_label_phone" class="XMLabel" for="phone" style="">Phone</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="20" id="phone" vtype="text" hint="" placeholder="" vlabel="Phone" vrequired="true"
class="clInput form-control clInput form-control" style="width:98%;" type="text" name="phone" value=""> (ie.: xxx-xxx-xxxx) </td>
</tr>
</tbody>
</table>
</td>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_mobile">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgmobile" width="16" height="16" align="absmiddle"><img src="/lib/img/icon/asterisk.gif" id="ReqImgmobile"
align="absmiddle"></td>
<td valign="top"><label id="form_label_mobile" class="XMLabel" for="mobile" style="">Cell Number</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="20" id="mobile" vtype="text" hint="" placeholder="" vlabel="Cell Number" vrequired="true"
class="clInput form-control clInput form-control" style="width:98%;" type="text" name="mobile" value=""> (ie.: xxx-xxx-xxxx) </td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_mailing">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgmailing" align="absmiddle" width="16" height="16"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgmailing" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_mailing" class="XMLabel" for="mailing" style="">
<div style="font-weight:bold;margin: 10px 0 10px 0;">Mailing Address <span style="font-style:italic;font-weight:normal;">(If different from permanent address)</span></div>
</label>
<div style="word-wrap:break-word;;">
<div class="xmFieldValue" id="mailing"></div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_mailing_address_1">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgmailing_address_1" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgmailing_address_1" align="absmiddle"></td>
<td valign="top"><label id="form_label_mailing_address_1" class="XMLabel" for="mailing_address_1" style="">Street Address</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="100" id="mailing_address_1" vtype="text" hint="" placeholder="" vlabel="Street Address" vrequired="false"
class="clInput form-control clInput form-control" style="width:98%;" type="text" name="mailing_address_1" value="">
</td>
</tr>
</tbody>
</table>
</td>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_mailing_city">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgmailing_city" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgmailing_city" align="absmiddle"></td>
<td valign="top"><label id="form_label_mailing_city" class="XMLabel" for="mailing_city" style="">City</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="50" id="mailing_city" vtype="text" hint="" placeholder="" vlabel="City" vrequired="false"
class="clInput form-control clInput form-control" style="width:98%;" type="text" name="mailing_city" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_mailing_state">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgmailing_state" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgmailing_state" align="absmiddle"></td>
<td valign="top"><label id="form_label_mailing_state" class="XMLabel" for="mailing_state" style="">State</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="75" id="mailing_state" vtype="text" hint="" placeholder="" vlabel="State" vrequired="false"
class="clInput form-control clInput form-control" style="width:98%;" type="text" name="mailing_state" value="">
<div style="margin-bottom: 20px;"></div>
</td>
</tr>
</tbody>
</table>
</td>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_mailing_zip">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgmailing_zip" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgmailing_zip" align="absmiddle"></td>
<td valign="top"><label id="form_label_mailing_zip" class="XMLabel" for="mailing_zip" style="">Zip Code</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="20" id="mailing_zip" vtype="text" hint="" placeholder="" vlabel="Zip Code" vrequired="false"
class="clInput form-control clInput form-control" style="width:98%;" type="text" name="mailing_zip" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_gender">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImggender" width="16" height="16" align="absmiddle"><img src="/lib/img/icon/asterisk.gif" id="ReqImggender"
align="absmiddle"></td>
<td valign="top"><label id="form_label_gender" class="XMLabel" for="gender" style="">Gender</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><select vrequired="true" groups="" hint="" style="" class="clSelect form-control form-control" multiple_select_size="5" delimiter="^" placeholder=""
name="gender" vlabel="Gender" vtype="select" allow_multiple="false" id="gender" default="">
<option selected="" style="" label="Select One" value="">Select One</option>
<option style="" label="Male" value="Male">Male</option>
<option style="" label="Female" value="Female">Female</option>
</select>
</td>
</tr>
</tbody>
</table>
</td>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_date_of_birth">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgdate_of_birth" width="16" height="16" align="absmiddle"><img src="/lib/img/icon/asterisk.gif"
id="ReqImgdate_of_birth" align="absmiddle"></td>
<td valign="top"><label id="form_label_date_of_birth" class="XMLabel" for="date_of_birth" style="">Birth Date</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;">
<input type="text" autocomplete="off" dateformat="m/d/yyyy" placeholder="" class="clInput form-control datepicker date-picker hasDatepicker" vtype="date" style="min-width:90px;;" datetype="date" name="date_of_birth"
vlabel="Birth Date" vrequired="true" id="date_of_birth" value=""><img class="ui-datepicker-trigger" src="/lib/img/icon/famfam/calendar.png" alt="..." title="...">
<script language="javascript">
dateXM["date_of_birth"] = {
dateFormat: "mm/dd/yy",
showOn: "both",
buttonImage: "/lib/img/icon/famfam/calendar.png",
buttonImageOnly: true,
beforeShowDay: function(date) {
var day = date.getDay();
return [true];
},
numberOfMonths: 1,
changeMonth: false,
changeYear: true,
yearRange: "-110:+20",
onClose: function() {
var $this = $(this);
$this.trigger("calendarClose");
},
onSelect: function(selectedDateTime, i) {
var $this = $(this);
if (selectedDateTime !== i.lastVal) {
$this.change();
}
},
showOtherMonths: true,
selectOtherMonths: true
};
setupDatePickerKeyUp("date_of_birth");
$(document).ready(function(e) {
$('#date_of_birth').datepicker(dateXM["date_of_birth"]);
$('#date_of_birth').focus(function(e) {
$(this).select();
});
$('#date_of_birth').blur(function(e) {
var $this = $(this);
if ($this.tooltip) $this.tooltip("destroy");
//console.log(!isDate($this.val()));
if ($this.val() != "") {
if (!isDate($this.val())) {
$this.tooltip({
trigger: "manual",
title: "You must enter a valid date",
placement: "top"
}).tooltip("show");
$this.val("");
$this.focus();
}
}
});
});
</script>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_marital_classification">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgmarital_classification" width="16" height="16" align="absmiddle"><img src="/lib/img/icon/asterisk.gif"
id="ReqImgmarital_classification" align="absmiddle"></td>
<td valign="top"><label id="form_label_marital_classification" class="XMLabel" for="marital_classification" style="">Marital Status</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><select vrequired="true" onchange="setRequiredField($xm('spouse_name'),this.value!='Single');" groups="" hint="" style=""
class="clSelect form-control form-control" multiple_select_size="5" delimiter="^" placeholder="" name="marital_classification" vlabel="Marital Status" vtype="select" allow_multiple="false" id="marital_classification"
default="">
<option selected="" style="" label="Select One" value="">Select One</option>
<option style="" label="Single" value="Single">Single</option>
<option style="" label="Married" value="Married">Married</option>
<option style="" label="Separated" value="Separated">Separated</option>
<option style="" label="Divorced" value="Divorced">Divorced</option>
</select>
</td>
</tr>
</tbody>
</table>
</td>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_spouse_name">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgspouse_name" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgspouse_name" align="absmiddle"></td>
<td valign="top"><label id="form_label_spouse_name" class="XMLabel" for="spouse_name" style="">Spouse's Name</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="30" id="spouse_name" vtype="text" hint="" placeholder="" vlabel="Spouse's Name" vrequired="false"
class="clInput form-control clInput form-control" style="width:98%;" type="text" name="spouse_name" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_has_children">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImghas_children" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif" id="ReqImghas_children"
align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_has_children" class="XMLabel" for="has_children" style="">Do you have children?</label>
<div style="word-wrap:break-word;;">
<div id="has_children_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="has_children_options" class="cbOptions">
<div id="has_children_options_list">
<style>
#has_children_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_has_children_1" for="has_children_1">
<input onclick="toggle('form_row_children_description',this.value==1);setRequiredField($xm('children_description'),this.value==1);" vtype="radio" hint="" placeholder="" vlabel="Do you have children?" vrequired="true"
type="radio" name="has_children" id="has_children_1" value="1" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_has_children_2" for="has_children_2">
<input onclick="toggle('form_row_children_description',this.value==1);setRequiredField($xm('children_description'),this.value==1);" vtype="radio" hint="" placeholder="" vlabel="Do you have children?" vrequired="true"
type="radio" name="has_children" id="has_children_2" value="0" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_children_description">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgchildren_description" align="absmiddle" width="16" height="16"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgchildren_description" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_children_description" class="XMLabel" for="children_description" style="">For each child, please indicate the following:<div style="margin: 10px;">1. Biological, Step Children, or Other (specify
other)<br>2. Male or Female<br>3. Age</div></label>
<div style="word-wrap:break-word;;"><textarea class="clTextArea form-control form-control" style="height:50px;width:98%;;" maxlength="500" onkeyup=";" id="children_description" vtype="textarea" hint="" placeholder=""
vlabel="For each child, please indicate the following:1. Biological, Step Children, or Other (specify other)2. Male or Female3. Age" vrequired="false" rows="10" name="children_description"></textarea>
<div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
</tr>
</tbody>
</table>
<span class="xm-box-shadow xm-box-shadow2"></span>
</div>
</div>
<div class="XMFormGroup box" style="margin-bottom:10px;background-color:#ffffff;padding:5px;border:1px solid #dadada;border-radius:4px;" id="Sectiondivstylemargin10px010px0usmilitarybackgrounddiv">
<div class="XMFormGroupHeader">
<table width="100%" cellpadding="0" style="table-layout:fixed" cellspacing="0">
<colgroup>
<col style="width:auto;">
</colgroup>
<tbody>
<tr>
<td>
<div id="Sectiondivstylemargin10px010px0usmilitarybackgrounddivSectionLabel" class="SectionLabel">
<div style="margin:10px 0 10px 0">U.S. Military Background</div>
</div>
</td>
</tr>
</tbody>
</table>
</div>
<div id="SectionBodySectiondivstylemargin10px010px0usmilitarybackgrounddiv" class="XMFormBody">
<table border="0" class="rwdmulti" cellpadding="0" vspace="0" cellspacing="0" width="100%">
<tbody>
<tr>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_branch_service">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgbranch_service" width="16" height="16" align="absmiddle"><img src="/lib/img/icon/asterisk.gif"
id="ReqImgbranch_service" align="absmiddle"></td>
<td valign="top"><label id="form_label_branch_service" class="XMLabel" for="branch_service" style="">Branch of Service</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><select vrequired="true"
onchange="toggle('form_row_branch_service_other',this.value=='Other');setRequiredField($xm('branch_service_other'),this.value=='Other');" groups="" hint="" style="" class="clSelect form-control form-control"
multiple_select_size="5" delimiter="," placeholder="" name="branch_service" vlabel="Branch of Service" vtype="select" allow_multiple="false" id="branch_service" default="">
<option selected="" style="" label="Select One" value="">Select One</option>
<option style="" label="Army" value="Army">Army</option>
<option style="" label="Navy" value="Navy">Navy</option>
<option style="" label="Marines" value="Marines">Marines</option>
<option style="" label="Air Force" value="Air Force">Air Force</option>
<option style="" label="Other" value="Other">Other</option>
</select>
</td>
</tr>
</tbody>
</table>
</td>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_branch_service_other">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgbranch_service_other" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgbranch_service_other" align="absmiddle"></td>
<td valign="top"><label id="form_label_branch_service_other" class="XMLabel" for="branch_service_other" style="">If Other, please specify</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="30" id="branch_service_other" vtype="text" hint="" placeholder="" vlabel="If Other, please specify" vrequired="false"
class="clInput form-control clInput form-control" style="" type="text" name="branch_service_other" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_rank">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgrank" width="16" height="16" align="absmiddle"><img src="/lib/img/icon/asterisk.gif" id="ReqImgrank"
align="absmiddle"></td>
<td valign="top"><label id="form_label_rank" class="XMLabel" for="rank" style="">Rank</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="30" id="rank" vtype="text" hint="" placeholder="" vlabel="Rank" vrequired="true"
class="clInput form-control clInput form-control" style="width:98%;" type="text" name="rank" value="">
</td>
</tr>
</tbody>
</table>
</td>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_date_of_enlistment">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgdate_of_enlistment" width="16" height="16" align="absmiddle"><img src="/lib/img/icon/asterisk.gif"
id="ReqImgdate_of_enlistment" align="absmiddle"></td>
<td valign="top"><label id="form_label_date_of_enlistment" class="XMLabel" for="date_of_enlistment" style="">Most recent enlistment date</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;">
<input type="text" autocomplete="off" dateformat="m/d/yyyy" placeholder="" class="clInput form-control datepicker date-picker hasDatepicker" vtype="date" style="min-width:90px;;" datetype="date" name="date_of_enlistment"
vlabel="Most recent enlistment date" vrequired="true" id="date_of_enlistment" value=""><img class="ui-datepicker-trigger" src="/lib/img/icon/famfam/calendar.png" alt="..." title="...">
<script language="javascript">
dateXM["date_of_enlistment"] = {
dateFormat: "mm/dd/yy",
showOn: "both",
buttonImage: "/lib/img/icon/famfam/calendar.png",
buttonImageOnly: true,
beforeShowDay: function(date) {
var day = date.getDay();
return [true];
},
numberOfMonths: 1,
changeMonth: false,
changeYear: true,
yearRange: "-110:+20",
onClose: function() {
var $this = $(this);
$this.trigger("calendarClose");
},
onSelect: function(selectedDateTime, i) {
var $this = $(this);
if (selectedDateTime !== i.lastVal) {
$this.change();
}
},
showOtherMonths: true,
selectOtherMonths: true
};
setupDatePickerKeyUp("date_of_enlistment");
$(document).ready(function(e) {
$('#date_of_enlistment').datepicker(dateXM["date_of_enlistment"]);
$('#date_of_enlistment').focus(function(e) {
$(this).select();
});
$('#date_of_enlistment').blur(function(e) {
var $this = $(this);
if ($this.tooltip) $this.tooltip("destroy");
//console.log(!isDate($this.val()));
if ($this.val() != "") {
if (!isDate($this.val())) {
$this.tooltip({
trigger: "manual",
title: "You must enter a valid date",
placement: "top"
}).tooltip("show");
$this.val("");
$this.focus();
}
}
});
});
</script>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_military_status">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgmilitary_status" width="16" height="16" align="absmiddle"><img src="/lib/img/icon/asterisk.gif"
id="ReqImgmilitary_status" align="absmiddle"></td>
<td valign="top"><label id="form_label_military_status" class="XMLabel" for="military_status" style="">Military Status</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="20" id="military_status" vtype="text" hint="" placeholder="" vlabel="Military Status" vrequired="true"
class="clInput form-control clInput form-control" style="width:98%;" type="text" name="military_status" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_active_duty">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgactive_duty" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif" id="ReqImgactive_duty"
align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_active_duty" class="XMLabel" for="active_duty" style="">Are you still on active duty?</label>
<div style="word-wrap:break-word;;">
<div id="active_duty_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="active_duty_options" class="cbOptions">
<div id="active_duty_options_list">
<style>
#active_duty_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_active_duty_1" for="active_duty_1">
<input onclick="checkEligibility(this.form);" vtype="radio" hint="" placeholder="" vlabel="Are you still on active duty?" vrequired="true" type="radio" name="active_duty" id="active_duty_1" value="1"
class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_active_duty_2" for="active_duty_2">
<input onclick="checkEligibility(this.form);" vtype="radio" hint="" placeholder="" vlabel="Are you still on active duty?" vrequired="true" type="radio" name="active_duty" id="active_duty_2" value="0"
class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_date_of_discharge">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgdate_of_discharge" width="16" height="16" align="absmiddle"><img src="/lib/img/icon/asterisk.gif"
id="ReqImgdate_of_discharge" align="absmiddle"></td>
<td valign="top"><label id="form_label_date_of_discharge" class="XMLabel" for="date_of_discharge" style="">Most recent date of discharge</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;">
<input type="text" autocomplete="off" dateformat="m/d/yyyy" onblur="checkEligibility(this.form);" placeholder="" class="clInput form-control datepicker date-picker hasDatepicker" vtype="date" style="min-width:90px;;"
datetype="date" name="date_of_discharge" vlabel="Most recent date of discharge" vrequired="true" id="date_of_discharge" value=""><img class="ui-datepicker-trigger" src="/lib/img/icon/famfam/calendar.png" alt="..." title="...">
<script language="javascript">
dateXM["date_of_discharge"] = {
dateFormat: "mm/dd/yy",
showOn: "both",
buttonImage: "/lib/img/icon/famfam/calendar.png",
buttonImageOnly: true,
beforeShowDay: function(date) {
var day = date.getDay();
return [true];
},
numberOfMonths: 1,
changeMonth: false,
changeYear: true,
yearRange: "-110:+20",
onClose: function() {
var $this = $(this);
$this.trigger("calendarClose");
},
onSelect: function(selectedDateTime, i) {
var $this = $(this);
if (selectedDateTime !== i.lastVal) {
$this.change();
}
},
showOtherMonths: true,
selectOtherMonths: true
};
setupDatePickerKeyUp("date_of_discharge");
$(document).ready(function(e) {
$('#date_of_discharge').datepicker(dateXM["date_of_discharge"]);
$('#date_of_discharge').focus(function(e) {
$(this).select();
});
$('#date_of_discharge').blur(function(e) {
var $this = $(this);
if ($this.tooltip) $this.tooltip("destroy");
//console.log(!isDate($this.val()));
if ($this.val() != "") {
if (!isDate($this.val())) {
$this.tooltip({
trigger: "manual",
title: "You must enter a valid date",
placement: "top"
}).tooltip("show");
$this.val("");
$this.focus();
}
}
});
});
</script>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_honorable_discharge">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImghonorable_discharge" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif"
id="ReqImghonorable_discharge" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_honorable_discharge" class="XMLabel" for="honorable_discharge" style="">Did you receive an honorable discharge?</label>
<div style="word-wrap:break-word;;">
<div id="honorable_discharge_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="honorable_discharge_options" class="cbOptions">
<div id="honorable_discharge_options_list">
<style>
#honorable_discharge_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_honorable_discharge_1" for="honorable_discharge_1">
<input onclick="checkEligibility(this.form);" vtype="radio" hint="" placeholder="" vlabel="Did you receive an honorable discharge?" vrequired="true" type="radio" name="honorable_discharge" id="honorable_discharge_1"
value="1" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_honorable_discharge_2" for="honorable_discharge_2">
<input onclick="checkEligibility(this.form);" vtype="radio" hint="" placeholder="" vlabel="Did you receive an honorable discharge?" vrequired="true" type="radio" name="honorable_discharge" id="honorable_discharge_2"
value="0" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_reservist">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgreservist" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif" id="ReqImgreservist"
align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_reservist" class="XMLabel" for="reservist" style="">Are you in the Reserves?</label>
<div style="word-wrap:break-word;;">
<div id="reservist_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="reservist_options" class="cbOptions">
<div id="reservist_options_list">
<style>
#reservist_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_reservist_1" for="reservist_1">
<input vtype="radio" hint="" placeholder="" vlabel="Are you in the Reserves?" vrequired="true" type="radio" name="reservist" id="reservist_1" value="1" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_reservist_2" for="reservist_2">
<input vtype="radio" hint="" placeholder="" vlabel="Are you in the Reserves?" vrequired="true" type="radio" name="reservist" id="reservist_2" value="0" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_guardsman">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgguardsman" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif" id="ReqImgguardsman"
align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_guardsman" class="XMLabel" for="guardsman" style="">Are you a Guardsman?</label>
<div style="word-wrap:break-word;;">
<div id="guardsman_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="guardsman_options" class="cbOptions">
<div id="guardsman_options_list">
<style>
#guardsman_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_guardsman_1" for="guardsman_1">
<input vtype="radio" hint="" placeholder="" vlabel="Are you a Guardsman?" vrequired="true" type="radio" name="guardsman" id="guardsman_1" value="1" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_guardsman_2" for="guardsman_2">
<input vtype="radio" hint="" placeholder="" vlabel="Are you a Guardsman?" vrequired="true" type="radio" name="guardsman" id="guardsman_2" value="0" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_date_deployed">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgdate_deployed" width="16" height="16" align="absmiddle"><img src="/lib/img/icon/asterisk.gif"
id="ReqImgdate_deployed" align="absmiddle"></td>
<td valign="top"><label id="form_label_date_deployed" class="XMLabel" for="date_deployed" style="">When was your last deployment?</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;">
<input type="text" autocomplete="off" dateformat="m/d/yyyy" onblur="checkEligibility(this.form);" placeholder="" class="clInput form-control datepicker date-picker hasDatepicker" vtype="date" style="min-width:90px;;"
datetype="date" name="date_deployed" vlabel="When was your last deployment?" vrequired="true" id="date_deployed" value=""><img class="ui-datepicker-trigger" src="/lib/img/icon/famfam/calendar.png" alt="..." title="...">
<script language="javascript">
dateXM["date_deployed"] = {
dateFormat: "mm/dd/yy",
showOn: "both",
buttonImage: "/lib/img/icon/famfam/calendar.png",
buttonImageOnly: true,
beforeShowDay: function(date) {
var day = date.getDay();
return [true];
},
numberOfMonths: 1,
changeMonth: false,
changeYear: true,
yearRange: "-110:+20",
onClose: function() {
var $this = $(this);
$this.trigger("calendarClose");
},
onSelect: function(selectedDateTime, i) {
var $this = $(this);
if (selectedDateTime !== i.lastVal) {
$this.change();
}
},
showOtherMonths: true,
selectOtherMonths: true
};
setupDatePickerKeyUp("date_deployed");
$(document).ready(function(e) {
$('#date_deployed').datepicker(dateXM["date_deployed"]);
$('#date_deployed').focus(function(e) {
$(this).select();
});
$('#date_deployed').blur(function(e) {
var $this = $(this);
if ($this.tooltip) $this.tooltip("destroy");
//console.log(!isDate($this.val()));
if ($this.val() != "") {
if (!isDate($this.val())) {
$this.tooltip({
trigger: "manual",
title: "You must enter a valid date",
placement: "top"
}).tooltip("show");
$this.val("");
$this.focus();
}
}
});
});
</script>
</td>
</tr>
</tbody>
</table>
</td>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_num_of_tours">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgnum_of_tours" width="16" height="16" align="absmiddle"><img src="/lib/img/icon/asterisk.gif" id="ReqImgnum_of_tours"
align="absmiddle"></td>
<td valign="top"><label id="form_label_num_of_tours" class="XMLabel" for="num_of_tours" style="">How many tours?</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;width:250px;max-width:100%;;"><input id="num_of_tours" mask="" maxlength="3" vtype="numeric" hint="" placeholder="" vlabel="How many tours?" vrequired="true"
class="clInput form-control xm-input-numeric" style=";max-width:100%;;text-align:right;" type="text" name="num_of_tours" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_conflict">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgconflict" width="16" height="16" align="absmiddle"><img src="/lib/img/icon/asterisk.gif" id="ReqImgconflict"
align="absmiddle"></td>
<td valign="top"><label id="form_label_conflict" class="XMLabel" for="conflict" style="">Which conflict did you participate in?</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><select vrequired="true"
onchange="checkEligibility(this.form);toggle('form_row_conflict_other',this.value=='Other');setRequiredField($xm('conflict_other'),this.value=='Other');" groups="" hint="" style="" class="clSelect form-control form-control"
multiple_select_size="5" delimiter="," placeholder="" name="conflict" vlabel="Which conflict did you participate in?" vtype="select" allow_multiple="false" id="conflict" default="">
<option selected="" style="" label="Select One" value="">Select One</option>
<option style="" label="OEF" value="OEF">OEF</option>
<option style="" label="OIF" value="OIF">OIF</option>
<option style="" label="Both (OEF and OIF)" value="Both (OEF and OIF)">Both (OEF and OIF)</option>
<option style="" label="Other" value="Other">Other</option>
</select>
</td>
</tr>
</tbody>
</table>
</td>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_conflict_other">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgconflict_other" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgconflict_other" align="absmiddle"></td>
<td valign="top"><label id="form_label_conflict_other" class="XMLabel" for="conflict_other" style="">If Other, please specify</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="30" id="conflict_other" vtype="text" hint="" placeholder="" vlabel="If Other, please specify" vrequired="false"
class="clInput form-control clInput form-control" style="" type="text" name="conflict_other" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_date_returned_us">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgdate_returned_us" width="16" height="16" align="absmiddle"><img src="/lib/img/icon/asterisk.gif"
id="ReqImgdate_returned_us" align="absmiddle"></td>
<td valign="top"><label id="form_label_date_returned_us" class="XMLabel" for="date_returned_us" style="">When did you most recently return back to USA?</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;">
<input type="text" autocomplete="off" dateformat="m/d/yyyy" placeholder="" class="clInput form-control datepicker date-picker hasDatepicker" vtype="date" style="min-width:90px;;" datetype="date" name="date_returned_us"
vlabel="When did you most recently return back to USA?" vrequired="true" id="date_returned_us" value=""><img class="ui-datepicker-trigger" src="/lib/img/icon/famfam/calendar.png" alt="..." title="...">
<script language="javascript">
dateXM["date_returned_us"] = {
dateFormat: "mm/dd/yy",
showOn: "both",
buttonImage: "/lib/img/icon/famfam/calendar.png",
buttonImageOnly: true,
beforeShowDay: function(date) {
var day = date.getDay();
return [true];
},
numberOfMonths: 1,
changeMonth: false,
changeYear: true,
yearRange: "-110:+20",
onClose: function() {
var $this = $(this);
$this.trigger("calendarClose");
},
onSelect: function(selectedDateTime, i) {
var $this = $(this);
if (selectedDateTime !== i.lastVal) {
$this.change();
}
},
showOtherMonths: true,
selectOtherMonths: true
};
setupDatePickerKeyUp("date_returned_us");
$(document).ready(function(e) {
$('#date_returned_us').datepicker(dateXM["date_returned_us"]);
$('#date_returned_us').focus(function(e) {
$(this).select();
});
$('#date_returned_us').blur(function(e) {
var $this = $(this);
if ($this.tooltip) $this.tooltip("destroy");
//console.log(!isDate($this.val()));
if ($this.val() != "") {
if (!isDate($this.val())) {
$this.tooltip({
trigger: "manual",
title: "You must enter a valid date",
placement: "top"
}).tooltip("show");
$this.val("");
$this.focus();
}
}
});
});
</script>
</td>
</tr>
</tbody>
</table>
</td>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_dd_214">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgdd_214" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif" id="ReqImgdd_214"
align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_dd_214" class="XMLabel" for="dd_214" style="">Do you have a DD 214?</label>
<div style="word-wrap:break-word;;">
<div id="dd_214_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="dd_214_options" class="cbOptions">
<div id="dd_214_options_list">
<style>
#dd_214_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_dd_214_1" for="dd_214_1">
<input vtype="radio" hint="" placeholder="" vlabel="Do you have a DD 214?" vrequired="true" type="radio" name="dd_214" id="dd_214_1" value="1" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_dd_214_2" for="dd_214_2">
<input vtype="radio" hint="" placeholder="" vlabel="Do you have a DD 214?" vrequired="true" type="radio" name="dd_214" id="dd_214_2" value="0" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_medal_award">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgmedal_award" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif" id="ReqImgmedal_award"
align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_medal_award" class="XMLabel" for="medal_award" style="">Have you been awarded any medals?</label>
<div style="word-wrap:break-word;;">
<div id="medal_award_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="medal_award_options" class="cbOptions">
<div id="medal_award_options_list">
<style>
#medal_award_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_medal_award_1" for="medal_award_1">
<input onclick="toggle('form_row_medal_award_description',this.value==1);" vtype="radio" hint="" placeholder="" vlabel="Have you been awarded any medals?" vrequired="true" type="radio" name="medal_award"
id="medal_award_1" value="1" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_medal_award_2" for="medal_award_2">
<input onclick="toggle('form_row_medal_award_description',this.value==1);" vtype="radio" hint="" placeholder="" vlabel="Have you been awarded any medals?" vrequired="true" type="radio" name="medal_award"
id="medal_award_2" value="0" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_medal_award_description">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgmedal_award_description" align="absmiddle" width="16" height="16"><img src="/lib/img/clear.gif" width="16"
height="16" id="ReqImgmedal_award_description" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_medal_award_description" class="XMLabel" for="medal_award_description" style="">If so, please list them below</label>
<div style="word-wrap:break-word;;"><textarea class="clTextArea form-control form-control" style="height:50px;width:98%;;" maxlength="1000" onkeyup=";" id="medal_award_description" vtype="textarea" hint="" placeholder=""
vlabel="If so, please list them below" vrequired="false" rows="10" name="medal_award_description"></textarea>
<div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
</tr>
</tbody>
</table>
<span class="xm-box-shadow xm-box-shadow2"></span>
</div>
</div>
<div class="XMFormGroup box" style="margin-bottom:10px;background-color:#ffffff;padding:5px;border:1px solid #dadada;border-radius:4px;" id="Sectiondivstylemargin10px010px0disabilitystatusdiv">
<div class="XMFormGroupHeader">
<table width="100%" cellpadding="0" style="table-layout:fixed" cellspacing="0">
<colgroup>
<col style="width:auto;">
</colgroup>
<tbody>
<tr>
<td>
<div id="Sectiondivstylemargin10px010px0disabilitystatusdivSectionLabel" class="SectionLabel">
<div style="margin:10px 0 10px 0">Disability Status</div>
</div>
</td>
</tr>
</tbody>
</table>
</div>
<div id="SectionBodySectiondivstylemargin10px010px0disabilitystatusdiv" class="XMFormBody">
<table border="0" class="rwdmulti" cellpadding="0" vspace="0" cellspacing="0" width="100%">
<tbody>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_date_of_injury">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgdate_of_injury" width="16" height="16" align="absmiddle"><img src="/lib/img/icon/asterisk.gif"
id="ReqImgdate_of_injury" align="absmiddle"></td>
<td valign="top"><label id="form_label_date_of_injury" class="XMLabel" for="date_of_injury" style="">Date of injury</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;">
<input type="text" autocomplete="off" dateformat="m/d/yyyy" placeholder="" class="clInput form-control datepicker date-picker hasDatepicker" vtype="date" style="min-width:90px;;" datetype="date" name="date_of_injury"
vlabel="Date of injury" vrequired="true" id="date_of_injury" value=""><img class="ui-datepicker-trigger" src="/lib/img/icon/famfam/calendar.png" alt="..." title="...">
<script language="javascript">
dateXM["date_of_injury"] = {
dateFormat: "mm/dd/yy",
showOn: "both",
buttonImage: "/lib/img/icon/famfam/calendar.png",
buttonImageOnly: true,
beforeShowDay: function(date) {
var day = date.getDay();
return [true];
},
numberOfMonths: 1,
changeMonth: false,
changeYear: true,
yearRange: "-110:+20",
onClose: function() {
var $this = $(this);
$this.trigger("calendarClose");
},
onSelect: function(selectedDateTime, i) {
var $this = $(this);
if (selectedDateTime !== i.lastVal) {
$this.change();
}
},
showOtherMonths: true,
selectOtherMonths: true
};
setupDatePickerKeyUp("date_of_injury");
$(document).ready(function(e) {
$('#date_of_injury').datepicker(dateXM["date_of_injury"]);
$('#date_of_injury').focus(function(e) {
$(this).select();
});
$('#date_of_injury').blur(function(e) {
var $this = $(this);
if ($this.tooltip) $this.tooltip("destroy");
//console.log(!isDate($this.val()));
if ($this.val() != "") {
if (!isDate($this.val())) {
$this.tooltip({
trigger: "manual",
title: "You must enter a valid date",
placement: "top"
}).tooltip("show");
$this.val("");
$this.focus();
}
}
});
});
</script>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_injury_location">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImginjury_location" width="16" height="16" align="absmiddle"><img src="/lib/img/icon/asterisk.gif"
id="ReqImginjury_location" align="absmiddle"></td>
<td valign="top"><label id="form_label_injury_location" class="XMLabel" for="injury_location" style="">Where were you injured?</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><select vrequired="true"
onchange="toggle('form_row_injury_location_other',this.value=='Other');setRequiredField($xm('injury_location_other'),this.value=='Other');" groups="" hint="" style="" class="clSelect form-control form-control"
multiple_select_size="5" delimiter="," placeholder="" name="injury_location" vlabel="Where were you injured?" vtype="select" allow_multiple="false" id="injury_location" default="">
<option selected="" style="" label="Select One" value="">Select One</option>
<option style="" label="Iraq" value="Iraq">Iraq</option>
<option style="" label="Afghanistan" value="Afghanistan">Afghanistan</option>
<option style="" label="Other" value="Other">Other</option>
</select>
</td>
</tr>
</tbody>
</table>
</td>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_injury_location_other">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImginjury_location_other" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImginjury_location_other" align="absmiddle"></td>
<td valign="top"><label id="form_label_injury_location_other" class="XMLabel" for="injury_location_other" style="">If Other, please specify</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="30" id="injury_location_other" vtype="text" hint="" placeholder="" vlabel="If Other, please specify" vrequired="false"
class="clInput form-control clInput form-control" style="" type="text" name="injury_location_other" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_injury_description">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImginjury_description" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif"
id="ReqImginjury_description" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_injury_description" class="XMLabel" for="injury_description" style="">What are your injuries?</label>
<div style="word-wrap:break-word;;"><textarea class="clTextArea form-control form-control" style="height:50px;width:98%;;" maxlength="3000" onkeyup=";" id="injury_description" vtype="textarea" hint="" placeholder=""
vlabel="What are your injuries?" vrequired="true" rows="10" name="injury_description"></textarea>
<div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_injury_circumstances">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImginjury_circumstances" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif"
id="ReqImginjury_circumstances" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_injury_circumstances" class="XMLabel" for="injury_circumstances" style="">What are the circumstances of your injuries and how did they occur?</label>
<div style="word-wrap:break-word;;"><textarea class="clTextArea form-control form-control" style="height:50px;width:98%;;" maxlength="3000" onkeyup=";" id="injury_circumstances" vtype="textarea" hint="" placeholder=""
vlabel="What are the circumstances of your injuries and how did they occur?" vrequired="true" rows="10" name="injury_circumstances"></textarea>
<div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_injury_medevaced">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImginjury_medevaced" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif"
id="ReqImginjury_medevaced" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_injury_medevaced" class="XMLabel" for="injury_medevaced" style="">Were you Medevaced out of country where injury occurred?</label>
<div style="word-wrap:break-word;;">
<div id="injury_medevaced_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="injury_medevaced_options" class="cbOptions">
<div id="injury_medevaced_options_list">
<style>
#injury_medevaced_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_injury_medevaced_1" for="injury_medevaced_1">
<input vtype="radio" hint="" placeholder="" vlabel="Were you Medevaced out of country where injury occurred?" vrequired="true" type="radio" name="injury_medevaced" id="injury_medevaced_1" value="1"
class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_injury_medevaced_2" for="injury_medevaced_2">
<input vtype="radio" hint="" placeholder="" vlabel="Were you Medevaced out of country where injury occurred?" vrequired="true" type="radio" name="injury_medevaced" id="injury_medevaced_2" value="0"
class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_injury_medevaced_description">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImginjury_medevaced_description" align="absmiddle" width="16" height="16"><img src="/lib/img/clear.gif" width="16"
height="16" id="ReqImginjury_medevaced_description" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_injury_medevaced_description" class="XMLabel" for="injury_medevaced_description" style="">Explain</label>
<div style="word-wrap:break-word;;"><textarea class="clTextArea form-control form-control" style="height:50px;width:98%;;" maxlength="1000" onkeyup=";" id="injury_medevaced_description" vtype="textarea" hint="" placeholder=""
vlabel="Explain" vrequired="false" rows="10" name="injury_medevaced_description"></textarea>
<div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_brain_injury">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgbrain_injury" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif" id="ReqImgbrain_injury"
align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_brain_injury" class="XMLabel" for="brain_injury" style="">Have you been diagnosed with Traumatic Brain Injury?</label>
<div style="word-wrap:break-word;;">
<div id="brain_injury_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="brain_injury_options" class="cbOptions">
<div id="brain_injury_options_list">
<style>
#brain_injury_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_brain_injury_1" for="brain_injury_1">
<input vtype="radio" hint="" placeholder="" vlabel="Have you been diagnosed with Traumatic Brain Injury?" vrequired="true" type="radio" name="brain_injury" id="brain_injury_1" value="1" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_brain_injury_2" for="brain_injury_2">
<input vtype="radio" hint="" placeholder="" vlabel="Have you been diagnosed with Traumatic Brain Injury?" vrequired="true" type="radio" name="brain_injury" id="brain_injury_2" value="0" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_PTSD">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgPTSD" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif" id="ReqImgPTSD"
align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_PTSD" class="XMLabel" for="PTSD" style="">Have you been diagnosed with Post Traumatic Stress Disorder?</label>
<div style="word-wrap:break-word;;">
<div id="PTSD_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="PTSD_options" class="cbOptions">
<div id="PTSD_options_list">
<style>
#PTSD_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_PTSD_1" for="PTSD_1">
<input vtype="radio" hint="" placeholder="" vlabel="Have you been diagnosed with Post Traumatic Stress Disorder?" vrequired="true" type="radio" name="PTSD" id="PTSD_1" value="1" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_PTSD_2" for="PTSD_2">
<input vtype="radio" hint="" placeholder="" vlabel="Have you been diagnosed with Post Traumatic Stress Disorder?" vrequired="true" type="radio" name="PTSD" id="PTSD_2" value="0" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_disability_rating_number">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgdisability_rating_number" align="absmiddle" width="16" height="16"><img src="/lib/img/clear.gif" width="16"
height="16" id="ReqImgdisability_rating_number" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_disability_rating_number" class="XMLabel" for="disability_rating_number" style="">Total combined disability rating from DOD (PEB/MEB)</label>
<div style="word-wrap:break-word;;width:250px;max-width:100%;;"><input id="disability_rating_number" mask="" maxlength="3" vtype="numeric" hint="" placeholder="" vlabel="Total combined disability rating from DOD (PEB/MEB)"
vrequired="false" class="clInput form-control xm-input-numeric" style=";max-width:100%;;text-align:right;" onblur="checkEligibility(this.form);" type="text" name="disability_rating_number" value=""> % </div>
</td>
</tr>
</tbody>
</table>
</td>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_extra_question_asked_by_kathy1">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgextra_question_asked_by_kathy1" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif"
id="ReqImgextra_question_asked_by_kathy1" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_extra_question_asked_by_kathy1" class="XMLabel" for="extra_question_asked_by_kathy1" style="">Did you receive a 30% or greater disability rating for a single sustained injury?</label>
<div style="word-wrap:break-word;;">
<div id="extra_question_asked_by_kathy1_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="extra_question_asked_by_kathy1_options" class="cbOptions">
<div id="extra_question_asked_by_kathy1_options_list">
<style>
#extra_question_asked_by_kathy1_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_extra_question_asked_by_kathy1_1" for="extra_question_asked_by_kathy1_1">
<input onclick="checkEligibility(this.form);" vtype="radio" hint="" placeholder="" vlabel="Did you receive a 30% or greater disability rating for a single sustained injury?" vrequired="true" type="radio"
name="extra_question_asked_by_kathy1" id="extra_question_asked_by_kathy1_1" value="1" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_extra_question_asked_by_kathy1_2" for="extra_question_asked_by_kathy1_2">
<input onclick="checkEligibility(this.form);" vtype="radio" hint="" placeholder="" vlabel="Did you receive a 30% or greater disability rating for a single sustained injury?" vrequired="true" type="radio"
name="extra_question_asked_by_kathy1" id="extra_question_asked_by_kathy1_2" value="0" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_disability_rating_breakdown_DOD">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgdisability_rating_breakdown_DOD" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif"
id="ReqImgdisability_rating_breakdown_DOD" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_disability_rating_breakdown_DOD" class="XMLabel" for="disability_rating_breakdown_DOD" style="">Breakdown of your rating per injury</label>
<div style="word-wrap:break-word;;"><textarea class="clTextArea form-control form-control" style="height:50px;width:98%;;" maxlength="200" onkeyup=";" id="disability_rating_breakdown_DOD" vtype="textarea" hint="" placeholder=""
vlabel="Breakdown of your rating per injury" vrequired="true" rows="10" name="disability_rating_breakdown_DOD"></textarea>
<div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_medically_retired">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgmedically_retired" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif"
id="ReqImgmedically_retired" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_medically_retired" class="XMLabel" for="medically_retired" style="">Are you medically retired?</label>
<div style="word-wrap:break-word;;">
<div id="medically_retired_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="medically_retired_options" class="cbOptions">
<div id="medically_retired_options_list">
<style>
#medically_retired_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_medically_retired_1" for="medically_retired_1">
<input vtype="radio" hint="" placeholder="" vlabel="Are you medically retired?" vrequired="true" type="radio" name="medically_retired" id="medically_retired_1" value="1" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_medically_retired_2" for="medically_retired_2">
<input vtype="radio" hint="" placeholder="" vlabel="Are you medically retired?" vrequired="true" type="radio" name="medically_retired" id="medically_retired_2" value="0" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_disability_rating_number_VA">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgdisability_rating_number_VA" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif"
id="ReqImgdisability_rating_number_VA" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_disability_rating_number_VA" class="XMLabel" for="disability_rating_number_VA" style="">Total combined disability rating from VA</label>
<div style="word-wrap:break-word;;width:250px;max-width:100%;;"><input id="disability_rating_number_VA" mask="" maxlength="3" vtype="numeric" hint="" placeholder="" vlabel="Total combined disability rating from VA"
vrequired="true" class="clInput form-control xm-input-numeric" style=";max-width:100%;;text-align:right;" onblur="checkEligibility(this.form);" type="text" name="disability_rating_number_VA" value=""> % </div>
</td>
</tr>
</tbody>
</table>
</td>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_extra_question_asked_by_kathy2">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgextra_question_asked_by_kathy2" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif"
id="ReqImgextra_question_asked_by_kathy2" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_extra_question_asked_by_kathy2" class="XMLabel" for="extra_question_asked_by_kathy2" style="">Did you receive a 30% or greater disability rating for a single sustained injury?</label>
<div style="word-wrap:break-word;;">
<div id="extra_question_asked_by_kathy2_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="extra_question_asked_by_kathy2_options" class="cbOptions">
<div id="extra_question_asked_by_kathy2_options_list">
<style>
#extra_question_asked_by_kathy2_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_extra_question_asked_by_kathy2_1" for="extra_question_asked_by_kathy2_1">
<input onclick="checkEligibility(this.form);" vtype="radio" hint="" placeholder="" vlabel="Did you receive a 30% or greater disability rating for a single sustained injury?" vrequired="true" type="radio"
name="extra_question_asked_by_kathy2" id="extra_question_asked_by_kathy2_1" value="1" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_extra_question_asked_by_kathy2_2" for="extra_question_asked_by_kathy2_2">
<input onclick="checkEligibility(this.form);" vtype="radio" hint="" placeholder="" vlabel="Did you receive a 30% or greater disability rating for a single sustained injury?" vrequired="true" type="radio"
name="extra_question_asked_by_kathy2" id="extra_question_asked_by_kathy2_2" value="0" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_disability_rating_breakdown_VA">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgdisability_rating_breakdown_VA" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif"
id="ReqImgdisability_rating_breakdown_VA" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_disability_rating_breakdown_VA" class="XMLabel" for="disability_rating_breakdown_VA" style="">Breakdown of your rating per injury</label>
<div style="word-wrap:break-word;;"><textarea class="clTextArea form-control form-control" style="height:50px;width:98%;;" maxlength="200" onkeyup=";" id="disability_rating_breakdown_VA" vtype="textarea" hint="" placeholder=""
vlabel="Breakdown of your rating per injury" vrequired="true" rows="10" name="disability_rating_breakdown_VA"></textarea>
<div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_injury_service_connected">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImginjury_service_connected" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif"
id="ReqImginjury_service_connected" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_injury_service_connected" class="XMLabel" for="injury_service_connected" style="">Are your injuries service connected?</label>
<div style="word-wrap:break-word;;">
<div id="injury_service_connected_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="injury_service_connected_options" class="cbOptions">
<div id="injury_service_connected_options_list">
<style>
#injury_service_connected_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_injury_service_connected_1" for="injury_service_connected_1">
<input onclick="checkEligibility(this.form);" vtype="radio" hint="" placeholder="" vlabel="Are your injuries service connected?" vrequired="true" type="radio" name="injury_service_connected"
id="injury_service_connected_1" value="1" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_injury_service_connected_2" for="injury_service_connected_2">
<input onclick="checkEligibility(this.form);" vtype="radio" hint="" placeholder="" vlabel="Are your injuries service connected?" vrequired="true" type="radio" name="injury_service_connected"
id="injury_service_connected_2" value="0" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_injury_combat_related">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImginjury_combat_related" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif"
id="ReqImginjury_combat_related" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_injury_combat_related" class="XMLabel" for="injury_combat_related" style="">Are your injuries combat related?</label>
<div style="word-wrap:break-word;;">
<div id="injury_combat_related_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="injury_combat_related_options" class="cbOptions">
<div id="injury_combat_related_options_list">
<style>
#injury_combat_related_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_injury_combat_related_1" for="injury_combat_related_1">
<input onclick="checkEligibility(this.form);" vtype="radio" hint="" placeholder="" vlabel="Are your injuries combat related?" vrequired="true" type="radio" name="injury_combat_related" id="injury_combat_related_1"
value="1" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_injury_combat_related_2" for="injury_combat_related_2">
<input onclick="checkEligibility(this.form);" vtype="radio" hint="" placeholder="" vlabel="Are your injuries combat related?" vrequired="true" type="radio" name="injury_combat_related" id="injury_combat_related_2"
value="0" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_collecting_VA_disability">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgcollecting_VA_disability" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif"
id="ReqImgcollecting_VA_disability" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_collecting_VA_disability" class="XMLabel" for="collecting_VA_disability" style="">Are you collecting disability benefits from the VA?</label>
<div style="word-wrap:break-word;;">
<div id="collecting_VA_disability_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="collecting_VA_disability_options" class="cbOptions">
<div id="collecting_VA_disability_options_list">
<style>
#collecting_VA_disability_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_collecting_VA_disability_1" for="collecting_VA_disability_1">
<input onclick="toggle('form_row_collecting_VA_disability_amount',this.value==1);setRequiredField($xm('collecting_VA_disability_amount'),this.value==1);toggle('form_row_collecting_VA_disability_status',this.value==0);"
vtype="radio" hint="" placeholder="" vlabel="Are you collecting disability benefits from the VA?" vrequired="true" type="radio" name="collecting_VA_disability" id="collecting_VA_disability_1" value="1"
class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_collecting_VA_disability_2" for="collecting_VA_disability_2">
<input onclick="toggle('form_row_collecting_VA_disability_amount',this.value==1);setRequiredField($xm('collecting_VA_disability_amount'),this.value==1);toggle('form_row_collecting_VA_disability_status',this.value==0);"
vtype="radio" hint="" placeholder="" vlabel="Are you collecting disability benefits from the VA?" vrequired="true" type="radio" name="collecting_VA_disability" id="collecting_VA_disability_2" value="0"
class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_collecting_VA_disability_amount">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgcollecting_VA_disability_amount" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16"
height="16" id="ReqImgcollecting_VA_disability_amount" align="absmiddle"></td>
<td valign="top"><label id="form_label_collecting_VA_disability_amount" class="XMLabel" for="collecting_VA_disability_amount" style="">Monthly Amount</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;width:250px;max-width:100%;;"><input id="collecting_VA_disability_amount" mask="" maxlength="10" vtype="numeric" hint="" placeholder="" vlabel="Monthly Amount"
vrequired="false" class="clInput form-control xm-input-numeric" style=";max-width:100%;;text-align:right;" type="text" name="collecting_VA_disability_amount" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_collecting_VA_disability_status">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgcollecting_VA_disability_status" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16"
height="16" id="ReqImgcollecting_VA_disability_status" align="absmiddle"></td>
<td valign="top"><label id="form_label_collecting_VA_disability_status" class="XMLabel" for="collecting_VA_disability_status" style="">Status</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="20" id="collecting_VA_disability_status" vtype="text" hint="" placeholder="" vlabel="Status" vrequired="false"
class="clInput form-control clInput form-control" style="" type="text" name="collecting_VA_disability_status" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_collecting_DOD_retirement">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgcollecting_DOD_retirement" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif"
id="ReqImgcollecting_DOD_retirement" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_collecting_DOD_retirement" class="XMLabel" for="collecting_DOD_retirement" style="">Are you collecting retirement pay from the DOD?</label>
<div style="word-wrap:break-word;;">
<div id="collecting_DOD_retirement_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="collecting_DOD_retirement_options" class="cbOptions">
<div id="collecting_DOD_retirement_options_list">
<style>
#collecting_DOD_retirement_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_collecting_DOD_retirement_1" for="collecting_DOD_retirement_1">
<input
onclick="toggle('form_row_collecting_DOD_retirement_amount',this.value==1);toggle('form_row_collecting_DOD_retirement_status',this.value==0);setRequiredField($xm('collecting_DOD_retirement_amount'),this.value==1);"
vtype="radio" hint="" placeholder="" vlabel="Are you collecting retirement pay from the DOD?" vrequired="true" type="radio" name="collecting_DOD_retirement" id="collecting_DOD_retirement_1" value="1"
class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_collecting_DOD_retirement_2" for="collecting_DOD_retirement_2">
<input
onclick="toggle('form_row_collecting_DOD_retirement_amount',this.value==1);toggle('form_row_collecting_DOD_retirement_status',this.value==0);setRequiredField($xm('collecting_DOD_retirement_amount'),this.value==1);"
vtype="radio" hint="" placeholder="" vlabel="Are you collecting retirement pay from the DOD?" vrequired="true" type="radio" name="collecting_DOD_retirement" id="collecting_DOD_retirement_2" value="0"
class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_collecting_DOD_retirement_amount">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgcollecting_DOD_retirement_amount" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16"
height="16" id="ReqImgcollecting_DOD_retirement_amount" align="absmiddle"></td>
<td valign="top"><label id="form_label_collecting_DOD_retirement_amount" class="XMLabel" for="collecting_DOD_retirement_amount" style="">Monthly Amount</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;width:250px;max-width:100%;;"><input id="collecting_DOD_retirement_amount" mask="" maxlength="10" vtype="numeric" hint="" placeholder="" vlabel="Monthly Amount"
vrequired="false" class="clInput form-control xm-input-numeric" style=";max-width:100%;;text-align:right;" type="text" name="collecting_DOD_retirement_amount" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_collecting_DOD_retirement_status">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgcollecting_DOD_retirement_status" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16"
height="16" id="ReqImgcollecting_DOD_retirement_status" align="absmiddle"></td>
<td valign="top"><label id="form_label_collecting_DOD_retirement_status" class="XMLabel" for="collecting_DOD_retirement_status" style="">Status</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="20" id="collecting_DOD_retirement_status" vtype="text" hint="" placeholder="" vlabel="Status" vrequired="false"
class="clInput form-control clInput form-control" style="" type="text" name="collecting_DOD_retirement_status" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_collected_TSGLI">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgcollected_TSGLI" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif"
id="ReqImgcollected_TSGLI" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_collected_TSGLI" class="XMLabel" for="collected_TSGLI" style="">Did you collect Traumatic Servicemembers' Group Life Insurance (TSGLI)?</label>
<div style="word-wrap:break-word;;">
<div id="collected_TSGLI_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="collected_TSGLI_options" class="cbOptions">
<div id="collected_TSGLI_options_list">
<style>
#collected_TSGLI_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_collected_TSGLI_1" for="collected_TSGLI_1">
<input onclick="toggle('form_row_collected_TSGLI_amount',this.value==1);toggle('form_row_collected_TSGLI_status',this.value==0);setRequiredField($xm('collected_TSGLI_amount'),this.value==1);" vtype="radio" hint=""
placeholder="" vlabel="Did you collect Traumatic Servicemembers' Group Life Insurance (TSGLI)?" vrequired="true" type="radio" name="collected_TSGLI" id="collected_TSGLI_1" value="1" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_collected_TSGLI_2" for="collected_TSGLI_2">
<input onclick="toggle('form_row_collected_TSGLI_amount',this.value==1);toggle('form_row_collected_TSGLI_status',this.value==0);setRequiredField($xm('collected_TSGLI_amount'),this.value==1);" vtype="radio" hint=""
placeholder="" vlabel="Did you collect Traumatic Servicemembers' Group Life Insurance (TSGLI)?" vrequired="true" type="radio" name="collected_TSGLI" id="collected_TSGLI_2" value="0" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_collected_TSGLI_amount">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgcollected_TSGLI_amount" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgcollected_TSGLI_amount" align="absmiddle"></td>
<td valign="top"><label id="form_label_collected_TSGLI_amount" class="XMLabel" for="collected_TSGLI_amount" style="">Amount Collected</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;width:250px;max-width:100%;;"><input id="collected_TSGLI_amount" mask="" maxlength="10" vtype="numeric" hint="" placeholder="" vlabel="Amount Collected"
vrequired="false" class="clInput form-control xm-input-numeric" style=";max-width:100%;;text-align:right;" type="text" name="collected_TSGLI_amount" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_collected_TSGLI_status">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgcollected_TSGLI_status" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgcollected_TSGLI_status" align="absmiddle"></td>
<td valign="top"><label id="form_label_collected_TSGLI_status" class="XMLabel" for="collected_TSGLI_status" style="">Status</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="20" id="collected_TSGLI_status" vtype="text" hint="" placeholder="" vlabel="Status" vrequired="false"
class="clInput form-control clInput form-control" style="" type="text" name="collected_TSGLI_status" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_collecting_unemployment">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgcollecting_unemployment" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif"
id="ReqImgcollecting_unemployment" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_collecting_unemployment" class="XMLabel" for="collecting_unemployment" style="">Are you collecting unemployment compensation?</label>
<div style="word-wrap:break-word;;">
<div id="collecting_unemployment_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="collecting_unemployment_options" class="cbOptions">
<div id="collecting_unemployment_options_list">
<style>
#collecting_unemployment_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_collecting_unemployment_1" for="collecting_unemployment_1">
<input onclick="toggle('form_row_collecting_unemployment_amount',this.value==1);toggle('form_row_collecting_unemployment_status',this.value==0);setRequiredField($xm('collecting_unemployment_amount'),this.value==1);"
vtype="radio" hint="" placeholder="" vlabel="Are you collecting unemployment compensation?" vrequired="true" type="radio" name="collecting_unemployment" id="collecting_unemployment_1" value="1" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_collecting_unemployment_2" for="collecting_unemployment_2">
<input onclick="toggle('form_row_collecting_unemployment_amount',this.value==1);toggle('form_row_collecting_unemployment_status',this.value==0);setRequiredField($xm('collecting_unemployment_amount'),this.value==1);"
vtype="radio" hint="" placeholder="" vlabel="Are you collecting unemployment compensation?" vrequired="true" type="radio" name="collecting_unemployment" id="collecting_unemployment_2" value="0" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_collecting_unemployment_amount">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgcollecting_unemployment_amount" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16"
height="16" id="ReqImgcollecting_unemployment_amount" align="absmiddle"></td>
<td valign="top"><label id="form_label_collecting_unemployment_amount" class="XMLabel" for="collecting_unemployment_amount" style="">Monthly Amount</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;width:250px;max-width:100%;;"><input id="collecting_unemployment_amount" mask="" maxlength="10" vtype="numeric" hint="" placeholder="" vlabel="Monthly Amount"
vrequired="false" class="clInput form-control xm-input-numeric" style=";max-width:100%;;text-align:right;" type="text" name="collecting_unemployment_amount" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_collecting_unemployment_status">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgcollecting_unemployment_status" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16"
height="16" id="ReqImgcollecting_unemployment_status" align="absmiddle"></td>
<td valign="top"><label id="form_label_collecting_unemployment_status" class="XMLabel" for="collecting_unemployment_status" style="">Status</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="20" id="collecting_unemployment_status" vtype="text" hint="" placeholder="" vlabel="Status" vrequired="false"
class="clInput form-control clInput form-control" style="" type="text" name="collecting_unemployment_status" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_collecting_CRSC">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgcollecting_CRSC" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif"
id="ReqImgcollecting_CRSC" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_collecting_CRSC" class="XMLabel" for="collecting_CRSC" style="">Are you collecting Combat Related Special Compensation (CRSC)?</label>
<div style="word-wrap:break-word;;">
<div id="collecting_CRSC_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="collecting_CRSC_options" class="cbOptions">
<div id="collecting_CRSC_options_list">
<style>
#collecting_CRSC_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_collecting_CRSC_1" for="collecting_CRSC_1">
<input onclick="toggle('form_row_collecting_CRSC_amount',this.value==1);toggle('form_row_collecting_CRSC_status',this.value==0);setRequiredField($xm('collecting_CRSC_amount'),this.value==1);" vtype="radio" hint=""
placeholder="" vlabel="Are you collecting Combat Related Special Compensation (CRSC)?" vrequired="true" type="radio" name="collecting_CRSC" id="collecting_CRSC_1" value="1" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_collecting_CRSC_2" for="collecting_CRSC_2">
<input onclick="toggle('form_row_collecting_CRSC_amount',this.value==1);toggle('form_row_collecting_CRSC_status',this.value==0);setRequiredField($xm('collecting_CRSC_amount'),this.value==1);" vtype="radio" hint=""
placeholder="" vlabel="Are you collecting Combat Related Special Compensation (CRSC)?" vrequired="true" type="radio" name="collecting_CRSC" id="collecting_CRSC_2" value="0" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_collecting_CRSC_amount">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgcollecting_CRSC_amount" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgcollecting_CRSC_amount" align="absmiddle"></td>
<td valign="top"><label id="form_label_collecting_CRSC_amount" class="XMLabel" for="collecting_CRSC_amount" style="">Monthly Amount</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;width:250px;max-width:100%;;"><input id="collecting_CRSC_amount" mask="" maxlength="10" vtype="numeric" hint="" placeholder="" vlabel="Monthly Amount"
vrequired="false" class="clInput form-control xm-input-numeric" style=";max-width:100%;;text-align:right;" type="text" name="collecting_CRSC_amount" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_collecting_CRSC_status">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgcollecting_CRSC_status" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgcollecting_CRSC_status" align="absmiddle"></td>
<td valign="top"><label id="form_label_collecting_CRSC_status" class="XMLabel" for="collecting_CRSC_status" style="">Status</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="20" id="collecting_CRSC_status" vtype="text" hint="" placeholder="" vlabel="Status" vrequired="false"
class="clInput form-control clInput form-control" style="" type="text" name="collecting_CRSC_status" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_collecting_SSN">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgcollecting_SSN" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif"
id="ReqImgcollecting_SSN" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_collecting_SSN" class="XMLabel" for="collecting_SSN" style="">Are you collecting Social Security?</label>
<div style="word-wrap:break-word;;">
<div id="collecting_SSN_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="collecting_SSN_options" class="cbOptions">
<div id="collecting_SSN_options_list">
<style>
#collecting_SSN_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_collecting_SSN_1" for="collecting_SSN_1">
<input
onclick="toggle('form_row_collecting_SSN_amount',this.value==1);toggle('form_row_collecting_SSN_status',this.value==0);setRequiredField($xm('collecting_SSN_amount'),this.value==1);toggle('form_row_collecting_SSN_denied',this.value==0);"
vtype="radio" hint="" placeholder="" vlabel="Are you collecting Social Security?" vrequired="true" type="radio" name="collecting_SSN" id="collecting_SSN_1" value="1" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_collecting_SSN_2" for="collecting_SSN_2">
<input
onclick="toggle('form_row_collecting_SSN_amount',this.value==1);toggle('form_row_collecting_SSN_status',this.value==0);setRequiredField($xm('collecting_SSN_amount'),this.value==1);toggle('form_row_collecting_SSN_denied',this.value==0);"
vtype="radio" hint="" placeholder="" vlabel="Are you collecting Social Security?" vrequired="true" type="radio" name="collecting_SSN" id="collecting_SSN_2" value="0" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_collecting_SSN_amount">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgcollecting_SSN_amount" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgcollecting_SSN_amount" align="absmiddle"></td>
<td valign="top"><label id="form_label_collecting_SSN_amount" class="XMLabel" for="collecting_SSN_amount" style="">Monthly Amount</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;width:250px;max-width:100%;;"><input id="collecting_SSN_amount" mask="" maxlength="10" vtype="numeric" hint="" placeholder="" vlabel="Monthly Amount"
vrequired="false" class="clInput form-control xm-input-numeric" style=";max-width:100%;;text-align:right;" type="text" name="collecting_SSN_amount" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_collecting_SSN_status">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgcollecting_SSN_status" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgcollecting_SSN_status" align="absmiddle"></td>
<td valign="top"><label id="form_label_collecting_SSN_status" class="XMLabel" for="collecting_SSN_status" style="">Status</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="20" id="collecting_SSN_status" vtype="text" hint="" placeholder="" vlabel="Status" vrequired="false"
class="clInput form-control clInput form-control" style="" type="text" name="collecting_SSN_status" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_collecting_SSN_denied">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgcollecting_SSN_denied" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgcollecting_SSN_denied" align="absmiddle"></td>
<td valign="top"><label id="form_label_collecting_SSN_denied" class="XMLabel" for="collecting_SSN_denied" style="">If Denied, Why?</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="100" id="collecting_SSN_denied" vtype="text" hint="" placeholder="" vlabel="If Denied, Why?" vrequired="false"
class="clInput form-control clInput form-control" style="width: 720px;" type="text" name="collecting_SSN_denied" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
</tr>
</tbody>
</table>
<span class="xm-box-shadow xm-box-shadow2"></span>
</div>
</div>
<div class="XMFormGroup box" style="margin-bottom:10px;background-color:#ffffff;padding:5px;border:1px solid #dadada;border-radius:4px;" id="Sectiondivstylemargin10px010px0financialstatusdiv">
<div class="XMFormGroupHeader">
<table width="100%" cellpadding="0" style="table-layout:fixed" cellspacing="0">
<colgroup>
<col style="width:auto;">
</colgroup>
<tbody>
<tr>
<td>
<div id="Sectiondivstylemargin10px010px0financialstatusdivSectionLabel" class="SectionLabel">
<div style="margin:10px 0 10px 0">Financial Status</div>
</div>
</td>
</tr>
</tbody>
</table>
</div>
<div id="SectionBodySectiondivstylemargin10px010px0financialstatusdiv" class="XMFormBody">
<table border="0" class="rwdmulti" cellpadding="0" vspace="0" cellspacing="0" width="100%">
<tbody>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_currently_employed">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgcurrently_employed" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif"
id="ReqImgcurrently_employed" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_currently_employed" class="XMLabel" for="currently_employed" style="">Are you employed?</label>
<div style="word-wrap:break-word;;">
<div id="currently_employed_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="currently_employed_options" class="cbOptions">
<div id="currently_employed_options_list">
<style>
#currently_employed_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_currently_employed_1" for="currently_employed_1">
<input
onclick="toggle('form_row_employer_name',this.value==1);toggle('form_row_job_title',this.value==1);toggle('form_row_job_function',this.value==1);setRequiredField($xm('job_function'),this.value==1);toggle('form_row_salary',this.value==1);setRequiredField($xm('salary'),this.value==1);"
vtype="radio" hint="" placeholder="" vlabel="Are you employed?" vrequired="true" type="radio" name="currently_employed" id="currently_employed_1" value="1" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_currently_employed_2" for="currently_employed_2">
<input
onclick="toggle('form_row_employer_name',this.value==1);toggle('form_row_job_title',this.value==1);toggle('form_row_job_function',this.value==1);setRequiredField($xm('job_function'),this.value==1);toggle('form_row_salary',this.value==1);setRequiredField($xm('salary'),this.value==1);"
vtype="radio" hint="" placeholder="" vlabel="Are you employed?" vrequired="true" type="radio" name="currently_employed" id="currently_employed_2" value="0" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_employer_name">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgemployer_name" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgemployer_name" align="absmiddle"></td>
<td valign="top"><label id="form_label_employer_name" class="XMLabel" for="employer_name" style="">Where? (Employer Name)</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="100" id="employer_name" vtype="text" hint="" placeholder="" vlabel="Where? (Employer Name)" vrequired="false"
class="clInput form-control clInput form-control" style="" type="text" name="employer_name" value="">
</td>
</tr>
</tbody>
</table>
</td>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_job_title">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgjob_title" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgjob_title" align="absmiddle"></td>
<td valign="top"><label id="form_label_job_title" class="XMLabel" for="job_title" style="">What is your title?</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="100" id="job_title" vtype="text" hint="" placeholder="" vlabel="What is your title?" vrequired="false"
class="clInput form-control clInput form-control" style="width:98%;" type="text" name="job_title" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_job_function">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgjob_function" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgjob_function" align="absmiddle"></td>
<td valign="top"><label id="form_label_job_function" class="XMLabel" for="job_function" style="">Explain job function</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="150" id="job_function" vtype="text" hint="" placeholder="" vlabel="Explain job function" vrequired="false"
class="clInput form-control clInput form-control" style="width:98%;" type="text" name="job_function" value="">
</td>
</tr>
</tbody>
</table>
</td>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_salary">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgsalary" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgsalary" align="absmiddle"></td>
<td valign="top"><label id="form_label_salary" class="XMLabel" for="salary" style="">Monthly Salary<br>(take-home pay)</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;width:250px;max-width:100%;;"><input id="salary" mask="" maxlength="10" vtype="numeric" hint="" placeholder="" vlabel="Monthly Salary(take-home pay)"
vrequired="false" class="clInput form-control xm-input-numeric" style=";max-width:100%;;text-align:right;" type="text" name="salary" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_spouse_currently_employed">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgspouse_currently_employed" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif"
id="ReqImgspouse_currently_employed" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_spouse_currently_employed" class="XMLabel" for="spouse_currently_employed" style="">If married, is your spouse employed?</label>
<div style="word-wrap:break-word;;">
<div id="spouse_currently_employed_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="spouse_currently_employed_options" class="cbOptions">
<div id="spouse_currently_employed_options_list">
<style>
#spouse_currently_employed_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_spouse_currently_employed_1" for="spouse_currently_employed_1">
<input
onclick="toggle('form_row_spouse_employer_name',this.value=='Yes');toggle('form_row_spouse_job_function',this.value=='Yes');setRequiredField($xm('spouse_job_function'),this.value=='Yes');toggle('form_row_spouse_salary',this.value=='Yes');setRequiredField($xm('spouse_salary'),this.value=='Yes');"
vtype="radio" hint="" placeholder="" vlabel="If married, is your spouse employed?" vrequired="true" type="radio" name="spouse_currently_employed" id="spouse_currently_employed_1" value="Yes" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_spouse_currently_employed_2" for="spouse_currently_employed_2">
<input
onclick="toggle('form_row_spouse_employer_name',this.value=='Yes');toggle('form_row_spouse_job_function',this.value=='Yes');setRequiredField($xm('spouse_job_function'),this.value=='Yes');toggle('form_row_spouse_salary',this.value=='Yes');setRequiredField($xm('spouse_salary'),this.value=='Yes');"
vtype="radio" hint="" placeholder="" vlabel="If married, is your spouse employed?" vrequired="true" type="radio" name="spouse_currently_employed" id="spouse_currently_employed_2" value="No" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
<label class="chkRadOptInline" id="label_spouse_currently_employed_3" for="spouse_currently_employed_3">
<input
onclick="toggle('form_row_spouse_employer_name',this.value=='Yes');toggle('form_row_spouse_job_function',this.value=='Yes');setRequiredField($xm('spouse_job_function'),this.value=='Yes');toggle('form_row_spouse_salary',this.value=='Yes');setRequiredField($xm('spouse_salary'),this.value=='Yes');"
vtype="radio" hint="" placeholder="" vlabel="If married, is your spouse employed?" vrequired="true" type="radio" name="spouse_currently_employed" id="spouse_currently_employed_3" value="NA" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Not Applicable</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_spouse_employer_name">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgspouse_employer_name" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgspouse_employer_name" align="absmiddle"></td>
<td valign="top"><label id="form_label_spouse_employer_name" class="XMLabel" for="spouse_employer_name" style="">Where? (Employer Name)</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="100" id="spouse_employer_name" vtype="text" hint="" placeholder="" vlabel="Where? (Employer Name)" vrequired="false"
class="clInput form-control clInput form-control" style="" type="text" name="spouse_employer_name" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_spouse_job_function">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgspouse_job_function" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgspouse_job_function" align="absmiddle"></td>
<td valign="top"><label id="form_label_spouse_job_function" class="XMLabel" for="spouse_job_function" style="">Explain job function</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="150" id="spouse_job_function" vtype="text" hint="" placeholder="" vlabel="Explain job function" vrequired="false"
class="clInput form-control clInput form-control" style="" type="text" name="spouse_job_function" value="">
</td>
</tr>
</tbody>
</table>
</td>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_spouse_salary">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgspouse_salary" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgspouse_salary" align="absmiddle"></td>
<td valign="top"><label id="form_label_spouse_salary" class="XMLabel" for="spouse_salary" style="">Monthly Salary<br>(take-home pay)</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;width:250px;max-width:100%;;"><input id="spouse_salary" mask="" maxlength="10" vtype="numeric" hint="" placeholder="" vlabel="Monthly Salary(take-home pay)"
vrequired="false" class="clInput form-control xm-input-numeric" style=";max-width:100%;;text-align:right;" type="text" name="spouse_salary" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_other_income">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgother_income" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif" id="ReqImgother_income"
align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_other_income" class="XMLabel" for="other_income" style="">Any other income?</label>
<div style="word-wrap:break-word;;">
<div id="other_income_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="other_income_options" class="cbOptions">
<div id="other_income_options_list">
<style>
#other_income_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_other_income_1" for="other_income_1">
<input onclick="toggle('form_row_other_income_description',this.value==1);setRequiredField($xm('other_income_description'),this.value==1);" vtype="radio" hint="" placeholder="" vlabel="Any other income?"
vrequired="true" type="radio" name="other_income" id="other_income_1" value="1" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_other_income_2" for="other_income_2">
<input onclick="toggle('form_row_other_income_description',this.value==1);setRequiredField($xm('other_income_description'),this.value==1);" vtype="radio" hint="" placeholder="" vlabel="Any other income?"
vrequired="true" type="radio" name="other_income" id="other_income_2" value="0" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_other_income_description">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgother_income_description" align="absmiddle" width="16" height="16"><img src="/lib/img/clear.gif" width="16"
height="16" id="ReqImgother_income_description" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_other_income_description" class="XMLabel" for="other_income_description" style="">If yes, please explain</label>
<div style="word-wrap:break-word;;"><textarea class="clTextArea form-control form-control" style="height: 50px;width: 98%;;" maxlength="300" onkeyup=";" id="other_income_description" vtype="textarea" hint="" placeholder=""
vlabel="If yes, please explain" vrequired="false" rows="10" name="other_income_description"></textarea>
<div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_disabled_caregiver">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgdisabled_caregiver" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif"
id="ReqImgdisabled_caregiver" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_disabled_caregiver" class="XMLabel" for="disabled_caregiver" style="">Are you a caregiver of a disabled dependent?</label>
<div style="word-wrap:break-word;;">
<div id="disabled_caregiver_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="disabled_caregiver_options" class="cbOptions">
<div id="disabled_caregiver_options_list">
<style>
#disabled_caregiver_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_disabled_caregiver_1" for="disabled_caregiver_1">
<input onclick="toggle('form_row_disabled_caregiver_collecting_compensation',this.value==1);" vtype="radio" hint="" placeholder="" vlabel="Are you a caregiver of a disabled dependent?" vrequired="true" type="radio"
name="disabled_caregiver" id="disabled_caregiver_1" value="1" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_disabled_caregiver_2" for="disabled_caregiver_2">
<input onclick="toggle('form_row_disabled_caregiver_collecting_compensation',this.value==1);" vtype="radio" hint="" placeholder="" vlabel="Are you a caregiver of a disabled dependent?" vrequired="true" type="radio"
name="disabled_caregiver" id="disabled_caregiver_2" value="0" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_disabled_caregiver_collecting_compensation">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgdisabled_caregiver_collecting_compensation" align="absmiddle" width="16" height="16"><img src="/lib/img/clear.gif"
width="16" height="16" id="ReqImgdisabled_caregiver_collecting_compensation" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_disabled_caregiver_collecting_compensation" class="XMLabel" for="disabled_caregiver_collecting_compensation" style="">If so, is that dependent collecting social security or disability compensation?</label>
<div style="word-wrap:break-word;;">
<div id="disabled_caregiver_collecting_compensation_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="disabled_caregiver_collecting_compensation_options" class="cbOptions">
<div id="disabled_caregiver_collecting_compensation_options_list">
<style>
#disabled_caregiver_collecting_compensation_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_disabled_caregiver_collecting_compensation_1" for="disabled_caregiver_collecting_compensation_1">
<input onclick="toggle('form_row_disabled_caregiver_collecting_compensation_amount',this.value==1);setRequiredField($xm('disabled_caregiver_collecting_compensation_amount'),this.value==1);" vtype="radio" hint=""
placeholder="" vlabel="If so, is that dependent collecting social security or disability compensation?" vrequired="false" type="radio" name="disabled_caregiver_collecting_compensation"
id="disabled_caregiver_collecting_compensation_1" value="1" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_disabled_caregiver_collecting_compensation_2" for="disabled_caregiver_collecting_compensation_2">
<input onclick="toggle('form_row_disabled_caregiver_collecting_compensation_amount',this.value==1);setRequiredField($xm('disabled_caregiver_collecting_compensation_amount'),this.value==1);" vtype="radio" hint=""
placeholder="" vlabel="If so, is that dependent collecting social security or disability compensation?" vrequired="false" type="radio" name="disabled_caregiver_collecting_compensation"
id="disabled_caregiver_collecting_compensation_2" value="0" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_disabled_caregiver_collecting_compensation_amount">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgdisabled_caregiver_collecting_compensation_amount" width="16" height="16" align="absmiddle"><img
src="/lib/img/clear.gif" width="16" height="16" id="ReqImgdisabled_caregiver_collecting_compensation_amount" align="absmiddle"></td>
<td valign="top"><label id="form_label_disabled_caregiver_collecting_compensation_amount" class="XMLabel" for="disabled_caregiver_collecting_compensation_amount" style="">Monthly Amount</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;width:250px;max-width:100%;;"><input id="disabled_caregiver_collecting_compensation_amount" mask="" maxlength="10" vtype="numeric" hint="" placeholder=""
vlabel="Monthly Amount" vrequired="false" class="clInput form-control xm-input-numeric" style=";max-width:100%;;text-align:right;" type="text" name="disabled_caregiver_collecting_compensation_amount" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_spouse_caregiver">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgspouse_caregiver" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif"
id="ReqImgspouse_caregiver" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_spouse_caregiver" class="XMLabel" for="spouse_caregiver" style="">If married, is your spouse a full-time caregiver?</label>
<div style="word-wrap:break-word;;">
<div id="spouse_caregiver_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="spouse_caregiver_options" class="cbOptions">
<div id="spouse_caregiver_options_list">
<style>
#spouse_caregiver_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_spouse_caregiver_1" for="spouse_caregiver_1">
<input onclick="toggle('form_row_spouse_caregiver_collecting_compensation',this.value=='Yes');" vtype="radio" hint="" placeholder="" vlabel="If married, is your spouse a full-time caregiver?" vrequired="true"
type="radio" name="spouse_caregiver" id="spouse_caregiver_1" value="Yes" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_spouse_caregiver_2" for="spouse_caregiver_2">
<input onclick="toggle('form_row_spouse_caregiver_collecting_compensation',this.value=='Yes');" vtype="radio" hint="" placeholder="" vlabel="If married, is your spouse a full-time caregiver?" vrequired="true"
type="radio" name="spouse_caregiver" id="spouse_caregiver_2" value="No" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
<label class="chkRadOptInline" id="label_spouse_caregiver_3" for="spouse_caregiver_3">
<input onclick="toggle('form_row_spouse_caregiver_collecting_compensation',this.value=='Yes');" vtype="radio" hint="" placeholder="" vlabel="If married, is your spouse a full-time caregiver?" vrequired="true"
type="radio" name="spouse_caregiver" id="spouse_caregiver_3" value="NA" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Not Applicable</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_spouse_caregiver_collecting_compensation">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgspouse_caregiver_collecting_compensation" align="absmiddle" width="16" height="16"><img src="/lib/img/clear.gif"
width="16" height="16" id="ReqImgspouse_caregiver_collecting_compensation" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_spouse_caregiver_collecting_compensation" class="XMLabel" for="spouse_caregiver_collecting_compensation" style="">If yes, do they qualify for, or are receiving a stipend under the Caregivers and Veterans
Omnibus Health Services Act 2010? <a href="http://www.caregiver.va.gov" target="_blank">http://www.caregiver.va.gov</a></label>
<div style="word-wrap:break-word;;">
<div id="spouse_caregiver_collecting_compensation_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="spouse_caregiver_collecting_compensation_options" class="cbOptions">
<div id="spouse_caregiver_collecting_compensation_options_list">
<style>
#spouse_caregiver_collecting_compensation_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_spouse_caregiver_collecting_compensation_1" for="spouse_caregiver_collecting_compensation_1">
<input onclick="toggle('form_row_spouse_caregiver_collecting_compensation_amount',this.value==1);setRequiredField($xm('spouse_caregiver_collecting_compensation_amount'),this.value==1);" vtype="radio" hint=""
placeholder="" vlabel="If yes, do they qualify for, or are receiving a stipend under the Caregivers and Veterans Omnibus Health Services Act 2010? http://www.caregiver.va.gov" vrequired="false" type="radio"
name="spouse_caregiver_collecting_compensation" id="spouse_caregiver_collecting_compensation_1" value="1" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_spouse_caregiver_collecting_compensation_2" for="spouse_caregiver_collecting_compensation_2">
<input onclick="toggle('form_row_spouse_caregiver_collecting_compensation_amount',this.value==1);setRequiredField($xm('spouse_caregiver_collecting_compensation_amount'),this.value==1);" vtype="radio" hint=""
placeholder="" vlabel="If yes, do they qualify for, or are receiving a stipend under the Caregivers and Veterans Omnibus Health Services Act 2010? http://www.caregiver.va.gov" vrequired="false" type="radio"
name="spouse_caregiver_collecting_compensation" id="spouse_caregiver_collecting_compensation_2" value="0" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_spouse_caregiver_collecting_compensation_amount">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgspouse_caregiver_collecting_compensation_amount" width="16" height="16" align="absmiddle"><img
src="/lib/img/clear.gif" width="16" height="16" id="ReqImgspouse_caregiver_collecting_compensation_amount" align="absmiddle"></td>
<td valign="top"><label id="form_label_spouse_caregiver_collecting_compensation_amount" class="XMLabel" for="spouse_caregiver_collecting_compensation_amount" style="">Monthly Amount</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;width:250px;max-width:100%;;"><input id="spouse_caregiver_collecting_compensation_amount" mask="" maxlength="10" vtype="numeric" hint="" placeholder=""
vlabel="Monthly Amount" vrequired="false" class="clInput form-control xm-input-numeric" style=";max-width:100%;;text-align:right;" type="text" name="spouse_caregiver_collecting_compensation_amount" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_financial_difficulties">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgfinancial_difficulties" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif"
id="ReqImgfinancial_difficulties" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_financial_difficulties" class="XMLabel" for="financial_difficulties" style="">Are you experiencing severe financial difficulty?</label>
<div style="word-wrap:break-word;;">
<div id="financial_difficulties_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="financial_difficulties_options" class="cbOptions">
<div id="financial_difficulties_options_list">
<style>
#financial_difficulties_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_financial_difficulties_1" for="financial_difficulties_1">
<input onclick="toggle('form_row_financial_difficulties_description',this.value==1);setRequiredField($xm('financial_difficulties_description'),this.value==1);" vtype="radio" hint="" placeholder=""
vlabel="Are you experiencing severe financial difficulty?" vrequired="true" type="radio" name="financial_difficulties" id="financial_difficulties_1" value="1" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_financial_difficulties_2" for="financial_difficulties_2">
<input onclick="toggle('form_row_financial_difficulties_description',this.value==1);setRequiredField($xm('financial_difficulties_description'),this.value==1);" vtype="radio" hint="" placeholder=""
vlabel="Are you experiencing severe financial difficulty?" vrequired="true" type="radio" name="financial_difficulties" id="financial_difficulties_2" value="0" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_financial_difficulties_description">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgfinancial_difficulties_description" align="absmiddle" width="16" height="16"><img src="/lib/img/clear.gif" width="16"
height="16" id="ReqImgfinancial_difficulties_description" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_financial_difficulties_description" class="XMLabel" for="financial_difficulties_description" style="">If so, please explain below</label>
<div style="word-wrap:break-word;;"><textarea class="clTextArea form-control form-control" style="height:50px;width: 98%;;" maxlength="3000" onkeyup=";" id="financial_difficulties_description" vtype="textarea" hint=""
placeholder="" vlabel="If so, please explain below" vrequired="false" rows="10" name="financial_difficulties_description"></textarea>
<div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_delinquent_bills">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgdelinquent_bills" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif"
id="ReqImgdelinquent_bills" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_delinquent_bills" class="XMLabel" for="delinquent_bills" style="">Do you have a delinquent status on any of your monthly bills?</label>
<div style="word-wrap:break-word;;">
<div id="delinquent_bills_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="delinquent_bills_options" class="cbOptions">
<div id="delinquent_bills_options_list">
<style>
#delinquent_bills_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_delinquent_bills_1" for="delinquent_bills_1">
<input
onclick="toggle('form_row_delinquent_bills_description',this.value==1);setRequiredField($xm('delinquent_bills_description'),this.value==1);toggle('form_row_delinquent_bills_assistance',this.value==1);setRequiredField($xm('delinquent_bills_assistance'),this.value==1);"
vtype="radio" hint="" placeholder="" vlabel="Do you have a delinquent status on any of your monthly bills?" vrequired="true" type="radio" name="delinquent_bills" id="delinquent_bills_1" value="1"
class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_delinquent_bills_2" for="delinquent_bills_2">
<input
onclick="toggle('form_row_delinquent_bills_description',this.value==1);setRequiredField($xm('delinquent_bills_description'),this.value==1);toggle('form_row_delinquent_bills_assistance',this.value==1);setRequiredField($xm('delinquent_bills_assistance'),this.value==1);"
vtype="radio" hint="" placeholder="" vlabel="Do you have a delinquent status on any of your monthly bills?" vrequired="true" type="radio" name="delinquent_bills" id="delinquent_bills_2" value="0"
class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_delinquent_bills_description">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgdelinquent_bills_description" align="absmiddle" width="16" height="16"><img src="/lib/img/clear.gif" width="16"
height="16" id="ReqImgdelinquent_bills_description" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_delinquent_bills_description" class="XMLabel" for="delinquent_bills_description" style="">If yes, how many months are you behind on your payments? Please explain.</label>
<div style="word-wrap:break-word;;"><textarea class="clTextArea form-control form-control" style="height:50px;width: 98%;;" maxlength="500" onkeyup=";" id="delinquent_bills_description" vtype="textarea" hint="" placeholder=""
vlabel="If yes, how many months are you behind on your payments? Please explain." vrequired="false" rows="10" name="delinquent_bills_description"></textarea>
<div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_delinquent_bills_assistance">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgdelinquent_bills_assistance" align="absmiddle" width="16" height="16"><img src="/lib/img/clear.gif" width="16"
height="16" id="ReqImgdelinquent_bills_assistance" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_delinquent_bills_assistance" class="XMLabel" for="delinquent_bills_assistance" style="">Please list the bills (with amount due), you are requesting assistance with</label>
<div style="word-wrap:break-word;;"><textarea class="clTextArea form-control form-control" style="height:50px;width: 98%;;" maxlength="500" onkeyup=";" id="delinquent_bills_assistance" vtype="textarea" hint="" placeholder=""
vlabel="Please list the bills (with amount due), you are requesting assistance with" vrequired="false" rows="10" name="delinquent_bills_assistance"></textarea>
<div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_other_organization_assistance">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgother_organization_assistance" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif"
id="ReqImgother_organization_assistance" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_other_organization_assistance" class="XMLabel" for="other_organization_assistance" style="">Have you received financial assistance from another organization within the last 12 months?</label>
<div style="word-wrap:break-word;;">
<div id="other_organization_assistance_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="other_organization_assistance_options" class="cbOptions">
<div id="other_organization_assistance_options_list">
<style>
#other_organization_assistance_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_other_organization_assistance_1" for="other_organization_assistance_1">
<input onclick="toggle('form_row_other_organization_assistance_description',this.value==1);setRequiredField($xm('other_organization_assistance_description'),this.value==1);" vtype="radio" hint="" placeholder=""
vlabel="Have you received financial assistance from another organization within the last 12 months?" vrequired="true" type="radio" name="other_organization_assistance" id="other_organization_assistance_1" value="1"
class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_other_organization_assistance_2" for="other_organization_assistance_2">
<input onclick="toggle('form_row_other_organization_assistance_description',this.value==1);setRequiredField($xm('other_organization_assistance_description'),this.value==1);" vtype="radio" hint="" placeholder=""
vlabel="Have you received financial assistance from another organization within the last 12 months?" vrequired="true" type="radio" name="other_organization_assistance" id="other_organization_assistance_2" value="0"
class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_other_organization_assistance_description">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgother_organization_assistance_description" align="absmiddle" width="16" height="16"><img src="/lib/img/clear.gif"
width="16" height="16" id="ReqImgother_organization_assistance_description" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_other_organization_assistance_description" class="XMLabel" for="other_organization_assistance_description" style="">If yes, please explain</label>
<div style="word-wrap:break-word;;"><textarea class="clTextArea form-control form-control" style="height: 50px;width: 98%;;" maxlength="300" onkeyup=";" id="other_organization_assistance_description" vtype="textarea" hint=""
placeholder="" vlabel="If yes, please explain" vrequired="false" rows="10" name="other_organization_assistance_description"></textarea>
<div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
</tr>
</tbody>
</table>
<span class="xm-box-shadow xm-box-shadow2"></span>
</div>
</div>
<div class="XMFormGroup box" style="margin-bottom:10px;background-color:#ffffff;padding:5px;border:1px solid #dadada;border-radius:4px;" id="Sectiondivstylemargin10px010px0educationstatusdiv">
<div class="XMFormGroupHeader">
<table width="100%" cellpadding="0" style="table-layout:fixed" cellspacing="0">
<colgroup>
<col style="width:auto;">
</colgroup>
<tbody>
<tr>
<td>
<div id="Sectiondivstylemargin10px010px0educationstatusdivSectionLabel" class="SectionLabel">
<div style="margin:10px 0 10px 0">Education Status</div>
</div>
</td>
</tr>
</tbody>
</table>
</div>
<div id="SectionBodySectiondivstylemargin10px010px0educationstatusdiv" class="XMFormBody">
<table border="0" class="rwdmulti" cellpadding="0" vspace="0" cellspacing="0" width="100%">
<tbody>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_student">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgstudent" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif" id="ReqImgstudent"
align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_student" class="XMLabel" for="student" style="">Are you a student?</label>
<div style="word-wrap:break-word;;">
<div id="student_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="student_options" class="cbOptions">
<div id="student_options_list">
<style>
#student_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_student_1" for="student_1">
<input
onclick="toggle('form_row_student_school',this.value==1);toggle('form_row_student_type',this.value==1);toggle('form_row_student_school_aid',this.value==1);toggle('form_row_student_GI_Bill',this.value==1);toggle('form_row_student_Voc_Rehab',this.value==1);setRequiredField($xm('student_school'),this.value==1);setRequiredField($xm('student_type'),this.value==1);setRequiredField($xm('student_GI_Bill'),this.value==1);setRequiredField($xm('student_Voc_Rehab'),this.value==1);"
vtype="radio" hint="" placeholder="" vlabel="Are you a student?" vrequired="true" type="radio" name="student" id="student_1" value="1" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_student_2" for="student_2">
<input
onclick="toggle('form_row_student_school',this.value==1);toggle('form_row_student_type',this.value==1);toggle('form_row_student_school_aid',this.value==1);toggle('form_row_student_GI_Bill',this.value==1);toggle('form_row_student_Voc_Rehab',this.value==1);setRequiredField($xm('student_school'),this.value==1);setRequiredField($xm('student_type'),this.value==1);setRequiredField($xm('student_GI_Bill'),this.value==1);setRequiredField($xm('student_Voc_Rehab'),this.value==1);"
vtype="radio" hint="" placeholder="" vlabel="Are you a student?" vrequired="true" type="radio" name="student" id="student_2" value="0" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_student_school">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgstudent_school" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgstudent_school" align="absmiddle"></td>
<td valign="top"><label id="form_label_student_school" class="XMLabel" for="student_school" style="">If so, where?</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="100" id="student_school" vtype="text" hint="" placeholder="" vlabel="If so, where?" vrequired="false"
class="clInput form-control clInput form-control" style="" type="text" name="student_school" value="">
</td>
</tr>
</tbody>
</table>
</td>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_student_type">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImgstudent_type" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgstudent_type" align="absmiddle"></td>
<td valign="top"><label id="form_label_student_type" class="XMLabel" for="student_type" style="">Student Type</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;"><select vrequired="false" groups="" hint="" style="" class="clSelect form-control form-control" multiple_select_size="5" delimiter="," placeholder=""
name="student_type" vlabel="Student Type" vtype="select" allow_multiple="false" id="student_type" default="">
<option style="" label="Full-time" value="Full-time">Full-time</option>
<option style="" label="Part-time" value="Part-time">Part-time</option>
</select>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_student_school_aid">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgstudent_school_aid" align="absmiddle" width="16" height="16"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgstudent_school_aid" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_student_school_aid" class="XMLabel" for="student_school_aid" style="">Are you receiving school aid through:</label>
<div style="word-wrap:break-word;;">
<div class="xmFieldValue" id="student_school_aid"></div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_student_GI_Bill">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgstudent_GI_Bill" align="absmiddle" width="16" height="16"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgstudent_GI_Bill" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_student_GI_Bill" class="XMLabel" for="student_GI_Bill" style="">GI Bill</label>
<div style="word-wrap:break-word;;">
<div id="student_GI_Bill_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="student_GI_Bill_options" class="cbOptions">
<div id="student_GI_Bill_options_list">
<style>
#student_GI_Bill_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_student_GI_Bill_1" for="student_GI_Bill_1">
<input vtype="radio" hint="" placeholder="" vlabel="GI Bill" vrequired="false" type="radio" name="student_GI_Bill" id="student_GI_Bill_1" value="1" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_student_GI_Bill_2" for="student_GI_Bill_2">
<input vtype="radio" hint="" placeholder="" vlabel="GI Bill" vrequired="false" type="radio" name="student_GI_Bill" id="student_GI_Bill_2" value="0" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
<td class="XMFormRow" valign="top" colspan="1" style="width:50.00%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_student_Voc_Rehab">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImgstudent_Voc_Rehab" align="absmiddle" width="16" height="16"><img src="/lib/img/clear.gif" width="16" height="16"
id="ReqImgstudent_Voc_Rehab" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_student_Voc_Rehab" class="XMLabel" for="student_Voc_Rehab" style="">Voc-Rehab</label>
<div style="word-wrap:break-word;;">
<div id="student_Voc_Rehab_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="student_Voc_Rehab_options" class="cbOptions">
<div id="student_Voc_Rehab_options_list">
<style>
#student_Voc_Rehab_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_student_Voc_Rehab_1" for="student_Voc_Rehab_1">
<input vtype="radio" hint="" placeholder="" vlabel="Voc-Rehab" vrequired="false" type="radio" name="student_Voc_Rehab" id="student_Voc_Rehab_1" value="1" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_student_Voc_Rehab_2" for="student_Voc_Rehab_2">
<input vtype="radio" hint="" placeholder="" vlabel="Voc-Rehab" vrequired="false" type="radio" name="student_Voc_Rehab" id="student_Voc_Rehab_2" value="0" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style=";" id="form_row_government_stipend">
<td valign="top" style="white-space:nowrap" width="32" class="nonMobile"><img src="/lib/img/clear.gif" id="ValImggovernment_stipend" align="absmiddle" width="16" height="16"><img src="/lib/img/icon/asterisk.gif"
id="ReqImggovernment_stipend" align="absmiddle"></td>
<td valign="top" class="XMFieldWrapper" style="padding-right:8px;">
<label id="form_label_government_stipend" class="XMLabel" for="government_stipend" style="">Are you receiving a stipend from government educational programs?</label>
<div style="word-wrap:break-word;;">
<div id="government_stipend_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="government_stipend_options" class="cbOptions">
<div id="government_stipend_options_list">
<style>
#government_stipend_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_government_stipend_1" for="government_stipend_1">
<input onclick="toggle('form_row_government_stipend_amount',this.value==1);setRequiredField($xm('government_stipend_amount'),this.value==1);" vtype="radio" hint="" placeholder=""
vlabel="Are you receiving a stipend from government educational programs?" vrequired="true" type="radio" name="government_stipend" id="government_stipend_1" value="1" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_government_stipend_2" for="government_stipend_2">
<input onclick="toggle('form_row_government_stipend_amount',this.value==1);setRequiredField($xm('government_stipend_amount'),this.value==1);" vtype="radio" hint="" placeholder=""
vlabel="Are you receiving a stipend from government educational programs?" vrequired="true" type="radio" name="government_stipend" id="government_stipend_2" value="0" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="XMFormRow" valign="top" colspan="2" style="width:100%;">
<table width="100%" border="0" class="rwd" cellpadding="0" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="" style="display:none;;" id="form_row_government_stipend_amount">
<td valign="top" width="32" class="nonMobile" style="white-space:nowrap"><img src="/lib/img/clear.gif" id="ValImggovernment_stipend_amount" width="16" height="16" align="absmiddle"><img src="/lib/img/clear.gif" width="16"
height="16" id="ReqImggovernment_stipend_amount" align="absmiddle"></td>
<td valign="top"><label id="form_label_government_stipend_amount" class="XMLabel" for="government_stipend_amount" style="">Amount per Month?</label></td>
<td valign="top" class="XMFieldWrapper" style="word-wrap:break-word;;width:250px;max-width:100%;;"><input id="government_stipend_amount" mask="" maxlength="10" vtype="numeric" hint="" placeholder="" vlabel="Amount per Month?"
vrequired="false" class="clInput form-control xm-input-numeric" style=";max-width:100%;;text-align:right;" type="text" name="government_stipend_amount" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
</tr>
</tbody>
</table>
<span class="xm-box-shadow xm-box-shadow2"></span>
</div>
</div>
<div class="XMFormGroup box" style="margin-bottom:10px;background-color:#ffffff;padding:5px;border:1px solid #dadada;border-radius:4px;" id="Section">
<div id="SectionBodySection" class="XMFormBody">
<table width="100%" class="rwd" border="0" cellpadding="2" cellspacing="0" style="table-layout:fixed">
<colgroup>
<col style="width:32px;">
<col style="width:160px;">
<col style="width:auto;text-overflow:ellipsis;">
</colgroup>
<tbody>
<tr class="XMFormRow" style=";" id="form_row_referral">
<td valign="top" style="white-space:nowrap" class="nonMobile" width="32"><img src="/lib/img/icon/asterisk.gif" id="ReqImgreferral" align="absmiddle"><img src="/lib/img/clear.gif" id="ValImgreferral" align="absmiddle" width="16"
height="16"></td>
<td class="XMFieldWrapper" colspan="2" valign="top">
<label id="form_label_referral" class="XMLabel" for="referral" style="">How did you hear about the Coalition to Salute America's Heroes?</label>
<div style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="100" id="referral" vtype="text" hint="" placeholder="" vlabel="How did you hear about the Coalition to Salute America's Heroes?" vrequired="true"
class="clInput form-control clInput form-control" style="" type="text" name="referral" value=""></div>
</td>
</tr>
<tr class="XMFormRow" style=";" id="form_row_representative_code">
<td valign="top" style="white-space:nowrap" class="nonMobile" width="32"><img src="/lib/img/clear.gif" width="16" height="16" id="ReqImgrepresentative_code" align="absmiddle"><img src="/lib/img/clear.gif" id="ValImgrepresentative_code"
align="absmiddle" width="16" height="16"></td>
<td class="XMFieldWrapper" colspan="2" valign="top">
<label id="form_label_representative_code" class="XMLabel" for="representative_code" style="">Please enter code here if applicable</label>
<div style="word-wrap:break-word;;"><input onkeyup="" lang="en" maxlength="20" id="representative_code" vtype="text" hint="" placeholder="" vlabel="Please enter code here if applicable" vrequired="false"
class="clInput form-control clInput form-control" style="" type="text" name="representative_code" value=""></div>
</td>
</tr>
<tr class="XMFormRow" style=";" id="form_row_contact">
<td valign="top" style="white-space:nowrap" class="nonMobile" width="32"><img src="/lib/img/icon/asterisk.gif" id="ReqImgcontact" align="absmiddle"><img src="/lib/img/clear.gif" id="ValImgcontact" align="absmiddle" width="16" height="16">
</td>
<td class="XMFieldWrapper" colspan="2" valign="top">
<label id="form_label_contact" class="XMLabel" for="contact" style="">May we contact you for more information?</label>
<div style="word-wrap:break-word;;">
<div id="contact_wrapper" data-expanded="false" class="input-group cbWrapper" style="background-color:#ffffff;max-height:300px;">
<div id="contact_options" class="cbOptions">
<div id="contact_options_list">
<style>
#contact_options_list {
display: flex;
flex-flow: row wrap;
flex-wrap: wrap !important;
}
</style>
<label class="chkRadOptInline" id="label_contact_1" for="contact_1">
<input vtype="radio" hint="" placeholder="" vlabel="May we contact you for more information?" vrequired="true" type="radio" name="contact" id="contact_1" value="1" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">Yes</span>
</label>
<label class="chkRadOptInline" id="label_contact_2" for="contact_2">
<input vtype="radio" hint="" placeholder="" vlabel="May we contact you for more information?" vrequired="true" type="radio" name="contact" id="contact_2" value="0" class="clRadioCheck ">
<span class="xmSiChk-label " data-tooltip="">No</span>
</label>
</div>
</div>
</div>
</div>
</td>
</tr>
<tr class="XMFormRow" style=";" id="form_row_info">
<td valign="top" style="white-space:nowrap" class="nonMobile" width="32"><img src="/lib/img/clear.gif" width="16" height="16" id="ReqImginfo" align="absmiddle"><img src="/lib/img/clear.gif" id="ValImginfo" align="absmiddle" width="16"
height="16"></td>
<td class="XMFieldWrapper" colspan="2" valign="top">
<div style="word-wrap:break-word;;">
<span style="font-weight: bold; text-decoration: underline;">NOTICE </span>
<p>The completion of this application does not guarantee the awarding of emergency financial assistance from the Coalition to Salute America's Heroes.</p>
<p>Please note that while the Coalition wishes we could help all qualified individuals who seek assistance, regrettably we only have limited funds to meet the needs of qualified veterans. Therefore, we can only respond to requests
based on our available resources.</p>
<p>The applicant agrees that the name appearing in the signature block below is the true and legal name of the applicant and serves as an electronic "signature" to this application. Further, the applicant attests to the fact that the
information contained herein is true and accurate to the best of the applicant's knowledge.</p>
<table cellspacing="0" cellpadding="0" border="0">
<tbody>
<tr>
<td style="width: 150px;">Full name</td>
<td>
<div class="XMFieldWrapper" style=""><input onkeyup="" lang="en" maxlength="30" id="signature" vtype="text" hint="" placeholder="" vlabel="Full name" vrequired="true" class="clInput form-control clInput form-control" style=""
type="text" name="signature" value=""></div>
</td>
</tr>
</tbody>
</table>
</div>
</td>
</tr>
</tbody>
</table>
<span class="xm-box-shadow xm-box-shadow2"></span>
</div>
</div>
<div id="ValidationMessagesQuickForm" class="alert alert-danger" style="display:none;"></div>
<div class="xm-save-box">
<div class="xm-save-holder">
<ul class="xm-btn-list">
<li><input onkeyup="" lang="en" id="actionxm" vtype="submit" hint="" placeholder="" vlabel="" vrequired="false" class="btn btn-primary" style="" onclick="return checkEligibility(this.form);" type="submit" name="actionxm"
value="Submit Application"></li>
</ul>
</div>
</div>
</form>Text Content
COALITION TO SALUTE AMERICA'S HEROES PROVIDING EMERGENCY FINANCIAL AID AND OTHER SERVICES TO VETERANS SEVERELY WOUNDED IN IRAQ AND AFGHANISTAN Make a secure online donation Set up monthly giving PROGRAM APPLICATION FOR EMERGENCY FINANCIAL AID YOU SACRIFICED. WE ARE HERE TO HELP. The mission of the Coalition to Salute America's Heroes is to assist veterans who have been severely injured while serving in Operation Iraqi Freedom and Operation Enduring Freedom, and their families, and to encourage other organizations and the general public to participate in this effort. To be considered for Emergency Financial Aid, applicants must meet the following minimum eligibility requirements: * An injury sustained during combat in Operation Iraqi Freedom or Operation Enduring Freedom, or in support of those operations in a hostile environment; * A disability rating assigned by the Department of Defense or the Department of Veterans Affairs of 30 percent or greater from a single, sustained injury; * Currently experiencing severe financial hardship; * Completion of a Coalition to Salute America's Heroes aid application and timely submission of supporting documentation as requested; and * Completion of a phone interview with a Coalition to Salute America's Heroes case manager. Please note that while the Coalition wishes we could help all qualified individuals who seek assistance, regrettably we only have limited funds to meet the needs of qualified veterans. Therefore, we can only respond to requests based on our available resources. Please also note that the Coalition sincerely respects your privacy. The information you provide below will be kept confidential and not shared with any third party. indicates required field. General Information First Name Middle Name Last Name Email Address Permanent Address Street Address City State Zip Code Phone (ie.: xxx-xxx-xxxx) Cell Number (ie.: xxx-xxx-xxxx) Mailing Address (If different from permanent address) Street Address City State Zip Code Gender Select OneMaleFemale Birth Date Marital Status Select OneSingleMarriedSeparatedDivorced Spouse's Name Do you have children? Yes No For each child, please indicate the following: 1. Biological, Step Children, or Other (specify other) 2. Male or Female 3. Age U.S. Military Background Branch of Service Select OneArmyNavyMarinesAir ForceOther If Other, please specify Rank Most recent enlistment date Military Status Are you still on active duty? Yes No Most recent date of discharge Did you receive an honorable discharge? Yes No Are you in the Reserves? Yes No Are you a Guardsman? Yes No When was your last deployment? How many tours? Which conflict did you participate in? Select OneOEFOIFBoth (OEF and OIF)Other If Other, please specify When did you most recently return back to USA? Do you have a DD 214? Yes No Have you been awarded any medals? Yes No If so, please list them below Disability Status Date of injury Where were you injured? Select OneIraqAfghanistanOther If Other, please specify What are your injuries? What are the circumstances of your injuries and how did they occur? Were you Medevaced out of country where injury occurred? Yes No Explain Have you been diagnosed with Traumatic Brain Injury? Yes No Have you been diagnosed with Post Traumatic Stress Disorder? Yes No Total combined disability rating from DOD (PEB/MEB) % Did you receive a 30% or greater disability rating for a single sustained injury? Yes No Breakdown of your rating per injury Are you medically retired? Yes No Total combined disability rating from VA % Did you receive a 30% or greater disability rating for a single sustained injury? Yes No Breakdown of your rating per injury Are your injuries service connected? Yes No Are your injuries combat related? Yes No Are you collecting disability benefits from the VA? Yes No Monthly Amount Status Are you collecting retirement pay from the DOD? Yes No Monthly Amount Status Did you collect Traumatic Servicemembers' Group Life Insurance (TSGLI)? Yes No Amount Collected Status Are you collecting unemployment compensation? Yes No Monthly Amount Status Are you collecting Combat Related Special Compensation (CRSC)? Yes No Monthly Amount Status Are you collecting Social Security? Yes No Monthly Amount Status If Denied, Why? Financial Status Are you employed? Yes No Where? (Employer Name) What is your title? Explain job function Monthly Salary (take-home pay) If married, is your spouse employed? Yes No Not Applicable Where? (Employer Name) Explain job function Monthly Salary (take-home pay) Any other income? Yes No If yes, please explain Are you a caregiver of a disabled dependent? Yes No If so, is that dependent collecting social security or disability compensation? Yes No Monthly Amount If married, is your spouse a full-time caregiver? Yes No Not Applicable If yes, do they qualify for, or are receiving a stipend under the Caregivers and Veterans Omnibus Health Services Act 2010? http://www.caregiver.va.gov Yes No Monthly Amount Are you experiencing severe financial difficulty? Yes No If so, please explain below Do you have a delinquent status on any of your monthly bills? Yes No If yes, how many months are you behind on your payments? Please explain. Please list the bills (with amount due), you are requesting assistance with Have you received financial assistance from another organization within the last 12 months? Yes No If yes, please explain Education Status Are you a student? Yes No If so, where? Student Type Full-timePart-time Are you receiving school aid through: GI Bill Yes No Voc-Rehab Yes No Are you receiving a stipend from government educational programs? Yes No Amount per Month? How did you hear about the Coalition to Salute America's Heroes? Please enter code here if applicable May we contact you for more information? Yes No NOTICE The completion of this application does not guarantee the awarding of emergency financial assistance from the Coalition to Salute America's Heroes. Please note that while the Coalition wishes we could help all qualified individuals who seek assistance, regrettably we only have limited funds to meet the needs of qualified veterans. Therefore, we can only respond to requests based on our available resources. The applicant agrees that the name appearing in the signature block below is the true and legal name of the applicant and serves as an electronic "signature" to this application. Further, the applicant attests to the fact that the information contained herein is true and accurate to the best of the applicant's knowledge. Full name * Coalition to Salute America's Heroes 552 Fort Evans Road, Suite 300 Leesburg, VA 20176 703-291-4605 www.saluteheroes.org Copyright 2013 Coalition to Salute America's HeroesContact UsResourcesPrivacyLike us on Facebook