form.jotform.com
Open in
urlscan Pro
35.201.118.58
Public Scan
Submitted URL: https://form.refund.gs/
Effective URL: https://form.jotform.com/223538934399067
Submission: On January 12 via automatic, source certstream-suspicious — Scanned from FI
Effective URL: https://form.jotform.com/223538934399067
Submission: On January 12 via automatic, source certstream-suspicious — Scanned from FI
Form analysis 1 forms found in the DOM
Name: form_223538934399067 — POST https://submit.jotform.com/submit/223538934399067/
<form class="jotform-form" action="https://submit.jotform.com/submit/223538934399067/" method="post" name="form_223538934399067" id="223538934399067" accept-charset="utf-8" autocomplete="on" novalidate="true"><input type="hidden" name="formID"
value="223538934399067"><input type="hidden" id="JWTContainer" value=""><input type="hidden" id="cardinalOrderNumber" value="">
<div role="main" class="form-all">
<div class="formLogoWrapper Center">
<img loading="lazy" class="formLogoImg" src="https://www.geeksandcom.com/wp-content/uploads/2014/12/Better-call-saul1.jpg" height="151" width="310">
</div>
<style>
.formLogoWrapper {
display: inline-block;
position: absolute;
width: 100%;
}
.form-all:before {
background: none !important;
}
.formLogoWrapper.Center {
top: -161px;
text-align: center;
}
</style>
<ul class="form-section page-section">
<li id="cid_1" class="form-input-wide" data-type="control_head">
<div class="form-header-group header-large">
<div class="header-text httal htvam">
<h1 id="header_1" class="form-header" data-component="header">Order Form</h1>
</div>
</div>
</li>
<li class="form-line jf-required" data-type="control_textbox" id="id_6"><label class="form-label form-label-left" id="label_6" for="input_6"> Telegram Username (@)<span class="form-required">*</span> </label>
<div id="cid_6" class="form-input jf-required" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_6" name="q6_telegramUsername" data-type="input-textbox"
class="form-textbox validate[required]" data-defaultvalue="" style="width:310px" size="310" value="" placeholder="@MyFavoriteCustomer" data-component="textbox" aria-labelledby="label_6 sublabel_input_6" required=""> <label
class="form-sub-label" for="input_6" id="sublabel_input_6" style="min-height:13px" aria-hidden="false">Set your username in settings for easier communication via Telegram.</label></span> </div>
</li>
<li class="form-line jf-required" data-type="control_textbox" id="id_7"><label class="form-label form-label-left" id="label_7" for="input_7"> Store<span class="form-required">*</span> </label>
<div id="cid_7" class="form-input jf-required" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_7" name="q7_store" data-type="input-textbox"
class="form-textbox validate[required]" data-defaultvalue="" style="width:310px" size="310" value="" placeholder="Amazon.com" data-component="textbox" aria-labelledby="label_7 sublabel_input_7" required=""> <label class="form-sub-label"
for="input_7" id="sublabel_input_7" style="min-height:13px" aria-hidden="false">Fill out the domain.</label></span> </div>
</li>
<li class="form-line jf-required" data-type="control_radio" id="id_12"><label class="form-label form-label-top form-label-auto" id="label_12" for="input_12"> How do you prefer to pay for your order?<span class="form-required">*</span> </label>
<div id="cid_12" class="form-input-wide jf-required" data-layout="full">
<div class="form-single-column" role="group" aria-labelledby="label_12" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input type="radio" aria-describedby="label_12"
class="form-radio validate[required]" id="input_12_0" name="q12_howDo" value="Cryptocurrency" required=""><label id="label_input_12_0" for="input_12_0">Cryptocurrency</label></span><span class="form-radio-item"
style="clear:left"><span class="dragger-item"></span><input type="radio" aria-describedby="label_12" class="form-radio validate[required]" id="input_12_1" name="q12_howDo" value="Paypal (+5%)" required=""><label id="label_input_12_1"
for="input_12_1">Paypal (+5%)</label></span></div>
</div>
</li>
<li class="form-line jf-required" data-type="control_radio" id="id_13"><label class="form-label form-label-top form-label-auto" id="label_13" for="input_13"> What option do you want?<span class="form-required">*</span> </label>
<div id="cid_13" class="form-input-wide jf-required" data-layout="full">
<div class="form-single-column" role="group" aria-labelledby="label_13" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input type="radio" aria-describedby="label_13"
class="form-radio validate[required]" id="input_13_0" name="q13_whatOption" value="Refund" required=""><label id="label_input_13_0" for="input_13_0">Refund</label></span><span class="form-radio-item" style="clear:left"><span
class="dragger-item"></span><input type="radio" aria-describedby="label_13" class="form-radio validate[required]" id="input_13_1" name="q13_whatOption" value="Replacement" required=""><label id="label_input_13_1"
for="input_13_1">Replacement</label></span></div>
</div>
</li>
<li class="form-line jf-required" data-type="control_textbox" id="id_15"><label class="form-label form-label-left" id="label_15" for="input_15"> Total Order Amount<span class="form-required">*</span> </label>
<div id="cid_15" class="form-input jf-required" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_15" name="q15_totalOrder" data-type="input-textbox"
class="form-textbox validate[required]" data-defaultvalue="" style="width:310px" size="310" value="" placeholder="$1930.34" data-component="textbox" aria-labelledby="label_15 sublabel_input_15" required=""> <label class="form-sub-label"
for="input_15" id="sublabel_input_15" style="min-height:13px" aria-hidden="false">Item cost + shipping + and everything else.</label></span> </div>
</li>
<li id="cid_16" class="form-input-wide" data-type="control_pagebreak">
<div class="form-pagebreak" data-component="pagebreak">
<div class="form-pagebreak-back-container" style="width: 216px;"></div>
<div class="form-pagebreak-next-container"><button id="form-pagebreak-next_16" type="button" class="form-pagebreak-next jf-form-buttons" data-component="pagebreak-next">Next</button></div>
<div style="clear:both" class="pageInfo form-sub-label" id="pageInfo_16"></div>
</div>
</li>
</ul>
<ul class="form-section page-section" style="display:none;">
<li class="form-line jf-required" data-type="control_textbox" id="id_20"><label class="form-label form-label-left" id="label_20" for="input_20"> Order Name<span class="form-required">*</span> </label>
<div id="cid_20" class="form-input jf-required" data-layout="half"> <input type="text" id="input_20" name="q20_orderName" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" style="width:310px" size="310"
value="" placeholder="John Doe" data-component="textbox" aria-labelledby="label_20" required=""> </div>
</li>
<li class="form-line jf-required" data-type="control_textbox" id="id_24"><label class="form-label form-label-left" id="label_24" for="input_24"> Order Number<span class="form-required">*</span> </label>
<div id="cid_24" class="form-input jf-required" data-layout="half"> <input type="text" id="input_24" name="q24_orderNumber" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" style="width:310px" size="310"
value="" placeholder="#19002323AB" data-component="textbox" aria-labelledby="label_24" required=""> </div>
</li>
<li class="form-line jf-required" data-type="control_email" id="id_17"><label class="form-label form-label-left" id="label_17" for="input_17"> Order Email<span class="form-required">*</span> </label>
<div id="cid_17" class="form-input jf-required" data-layout="half"> <input type="email" id="input_17" name="q17_orderEmail" class="form-textbox validate[required, Email]" data-defaultvalue="" style="width:310px" size="310" value=""
placeholder="example@example.com" data-component="email" aria-labelledby="label_17" required=""> </div>
</li>
<li class="form-line jf-required" data-type="control_textbox" id="id_22"><label class="form-label form-label-left" id="label_22" for="input_22"> Phone Number<span class="form-required">*</span> </label>
<div id="cid_22" class="form-input jf-required" data-layout="half"> <input type="text" id="input_22" name="q22_phoneNumber" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" style="width:310px" size="310"
value="" placeholder="+1 814 386 6759" data-component="textbox" aria-labelledby="label_22" required=""> </div>
</li>
<li class="form-line form-line-column form-col-1 jf-required" data-type="control_address" id="id_34" data-compound-hint="Street 1,Apt 120,New York City,New York,10025,,United States"><label class="form-label form-label-top form-label-auto"
id="label_34" for="input_34_addr_line1"> Order & Shipping Address<span class="form-required">*</span> </label>
<div id="cid_34" class="form-input-wide jf-required" data-layout="full">
<div summary="" class="form-address-table jsTest-addressField">
<div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-street-line jsTest-address-lineField"><span class="form-sub-label-container" style="vertical-align:top"><input type="text"
id="input_34_addr_line1" name="q34_orderamp[addr_line1]" class="form-textbox validate[required] form-address-line" data-defaultvalue="" autocomplete="section-input_34 address-line1" value="" placeholder="Street 1"
data-component="address_line_1" aria-labelledby="label_34 sublabel_34_addr_line1" required=""> <label class="form-sub-label" for="input_34_addr_line1" id="sublabel_34_addr_line1" style="min-height:13px" aria-hidden="false">Street
Address</label></span></span></div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-street-line jsTest-address-lineField"><span class="form-sub-label-container" style="vertical-align:top"><input type="text"
id="input_34_addr_line2" name="q34_orderamp[addr_line2]" class="form-textbox form-address-line" data-defaultvalue="" autocomplete="section-input_34 address-line2" value="" placeholder="Apt 120" data-component="address_line_2"
aria-labelledby="label_34 sublabel_34_addr_line2"> <label class="form-sub-label" for="input_34_addr_line2" id="sublabel_34_addr_line2" style="min-height:13px" aria-hidden="false">Street Address Line 2</label></span></span></div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-city-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><input type="text"
id="input_34_city" name="q34_orderamp[city]" class="form-textbox validate[required] form-address-city" data-defaultvalue="" autocomplete="section-input_34 address-level2" value="" placeholder="New York City" data-component="city"
aria-labelledby="label_34 sublabel_34_city" required=""> <label class="form-sub-label" for="input_34_city" id="sublabel_34_city" style="min-height:13px" aria-hidden="false">City</label></span></span><span
class="form-address-line form-address-state-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_34_state" name="q34_orderamp[state]"
class="form-textbox form-address-state" data-defaultvalue="" autocomplete="section-input_34 address-level1" value="" placeholder="New York" data-component="state" aria-labelledby="label_34 sublabel_34_state"> <label
class="form-sub-label" for="input_34_state" id="sublabel_34_state" style="min-height:13px" aria-hidden="false">State</label></span></span></div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-zip-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><input type="text"
id="input_34_postal" name="q34_orderamp[postal]" class="form-textbox validate[required] form-address-postal" data-defaultvalue="" autocomplete="section-input_34 postal-code" value="" placeholder="10025" data-component="zip"
aria-labelledby="label_34 sublabel_34_postal" required=""> <label class="form-sub-label" for="input_34_postal" id="sublabel_34_postal" style="min-height:13px" aria-hidden="false">Zip Code</label></span></span><span
class="form-address-line form-address-country-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><select
class="form-dropdown validate[required] form-address-country noTranslate is-active" name="q34_orderamp[country]" id="input_34_country" data-component="country" required="" aria-labelledby="label_34 sublabel_34_country"
autocomplete="section-input_34 country">
<option value="">Please Select</option>
<option selected="" value="United States">United States</option>
<option value="Afghanistan">Afghanistan</option>
<option value="Albania">Albania</option>
<option value="Algeria">Algeria</option>
<option value="American Samoa">American Samoa</option>
<option value="Andorra">Andorra</option>
<option value="Angola">Angola</option>
<option value="Anguilla">Anguilla</option>
<option value="Antigua and Barbuda">Antigua and Barbuda</option>
<option value="Argentina">Argentina</option>
<option value="Armenia">Armenia</option>
<option value="Aruba">Aruba</option>
<option value="Australia">Australia</option>
<option value="Austria">Austria</option>
<option value="Azerbaijan">Azerbaijan</option>
<option value="The Bahamas">The Bahamas</option>
<option value="Bahrain">Bahrain</option>
<option value="Bangladesh">Bangladesh</option>
<option value="Barbados">Barbados</option>
<option value="Belarus">Belarus</option>
<option value="Belgium">Belgium</option>
<option value="Belize">Belize</option>
<option value="Benin">Benin</option>
<option value="Bermuda">Bermuda</option>
<option value="Bhutan">Bhutan</option>
<option value="Bolivia">Bolivia</option>
<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
<option value="Botswana">Botswana</option>
<option value="Brazil">Brazil</option>
<option value="Brunei">Brunei</option>
<option value="Bulgaria">Bulgaria</option>
<option value="Burkina Faso">Burkina Faso</option>
<option value="Burundi">Burundi</option>
<option value="Cambodia">Cambodia</option>
<option value="Cameroon">Cameroon</option>
<option value="Canada">Canada</option>
<option value="Cape Verde">Cape Verde</option>
<option value="Cayman Islands">Cayman Islands</option>
<option value="Central African Republic">Central African Republic</option>
<option value="Chad">Chad</option>
<option value="Chile">Chile</option>
<option value="China">China</option>
<option value="Christmas Island">Christmas Island</option>
<option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option>
<option value="Colombia">Colombia</option>
<option value="Comoros">Comoros</option>
<option value="Congo">Congo</option>
<option value="Cook Islands">Cook Islands</option>
<option value="Costa Rica">Costa Rica</option>
<option value="Cote d'Ivoire">Cote d'Ivoire</option>
<option value="Croatia">Croatia</option>
<option value="Cuba">Cuba</option>
<option value="Curaçao">Curaçao</option>
<option value="Cyprus">Cyprus</option>
<option value="Czech Republic">Czech Republic</option>
<option value="Democratic Republic of the Congo">Democratic Republic of the Congo</option>
<option value="Denmark">Denmark</option>
<option value="Djibouti">Djibouti</option>
<option value="Dominica">Dominica</option>
<option value="Dominican Republic">Dominican Republic</option>
<option value="Ecuador">Ecuador</option>
<option value="Egypt">Egypt</option>
<option value="El Salvador">El Salvador</option>
<option value="Equatorial Guinea">Equatorial Guinea</option>
<option value="Eritrea">Eritrea</option>
<option value="Estonia">Estonia</option>
<option value="Ethiopia">Ethiopia</option>
<option value="Falkland Islands">Falkland Islands</option>
<option value="Faroe Islands">Faroe Islands</option>
<option value="Fiji">Fiji</option>
<option value="Finland">Finland</option>
<option value="France">France</option>
<option value="French Polynesia">French Polynesia</option>
<option value="Gabon">Gabon</option>
<option value="The Gambia">The Gambia</option>
<option value="Georgia">Georgia</option>
<option value="Germany">Germany</option>
<option value="Ghana">Ghana</option>
<option value="Gibraltar">Gibraltar</option>
<option value="Greece">Greece</option>
<option value="Greenland">Greenland</option>
<option value="Grenada">Grenada</option>
<option value="Guadeloupe">Guadeloupe</option>
<option value="Guam">Guam</option>
<option value="Guatemala">Guatemala</option>
<option value="Guernsey">Guernsey</option>
<option value="Guinea">Guinea</option>
<option value="Guinea-Bissau">Guinea-Bissau</option>
<option value="Guyana">Guyana</option>
<option value="Haiti">Haiti</option>
<option value="Honduras">Honduras</option>
<option value="Hong Kong">Hong Kong</option>
<option value="Hungary">Hungary</option>
<option value="Iceland">Iceland</option>
<option value="India">India</option>
<option value="Indonesia">Indonesia</option>
<option value="Iran">Iran</option>
<option value="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Israel">Israel</option>
<option value="Italy">Italy</option>
<option value="Jamaica">Jamaica</option>
<option value="Japan">Japan</option>
<option value="Jersey">Jersey</option>
<option value="Jordan">Jordan</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kiribati">Kiribati</option>
<option value="North Korea">North Korea</option>
<option value="South Korea">South Korea</option>
<option value="Kosovo">Kosovo</option>
<option value="Kuwait">Kuwait</option>
<option value="Kyrgyzstan">Kyrgyzstan</option>
<option value="Laos">Laos</option>
<option value="Latvia">Latvia</option>
<option value="Lebanon">Lebanon</option>
<option value="Lesotho">Lesotho</option>
<option value="Liberia">Liberia</option>
<option value="Libya">Libya</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lithuania">Lithuania</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macau">Macau</option>
<option value="Macedonia">Macedonia</option>
<option value="Madagascar">Madagascar</option>
<option value="Malawi">Malawi</option>
<option value="Malaysia">Malaysia</option>
<option value="Maldives">Maldives</option>
<option value="Mali">Mali</option>
<option value="Malta">Malta</option>
<option value="Marshall Islands">Marshall Islands</option>
<option value="Martinique">Martinique</option>
<option value="Mauritania">Mauritania</option>
<option value="Mauritius">Mauritius</option>
<option value="Mayotte">Mayotte</option>
<option value="Mexico">Mexico</option>
<option value="Micronesia">Micronesia</option>
<option value="Moldova">Moldova</option>
<option value="Monaco">Monaco</option>
<option value="Mongolia">Mongolia</option>
<option value="Montenegro">Montenegro</option>
<option value="Montserrat">Montserrat</option>
<option value="Morocco">Morocco</option>
<option value="Mozambique">Mozambique</option>
<option value="Myanmar">Myanmar</option>
<option value="Nagorno-Karabakh">Nagorno-Karabakh</option>
<option value="Namibia">Namibia</option>
<option value="Nauru">Nauru</option>
<option value="Nepal">Nepal</option>
<option value="Netherlands">Netherlands</option>
<option value="Netherlands Antilles">Netherlands Antilles</option>
<option value="New Caledonia">New Caledonia</option>
<option value="New Zealand">New Zealand</option>
<option value="Nicaragua">Nicaragua</option>
<option value="Niger">Niger</option>
<option value="Nigeria">Nigeria</option>
<option value="Niue">Niue</option>
<option value="Norfolk Island">Norfolk Island</option>
<option value="Turkish Republic of Northern Cyprus">Turkish Republic of Northern Cyprus</option>
<option value="Northern Mariana">Northern Mariana</option>
<option value="Norway">Norway</option>
<option value="Oman">Oman</option>
<option value="Pakistan">Pakistan</option>
<option value="Palau">Palau</option>
<option value="Palestine">Palestine</option>
<option value="Panama">Panama</option>
<option value="Papua New Guinea">Papua New Guinea</option>
<option value="Paraguay">Paraguay</option>
<option value="Peru">Peru</option>
<option value="Philippines">Philippines</option>
<option value="Pitcairn Islands">Pitcairn Islands</option>
<option value="Poland">Poland</option>
<option value="Portugal">Portugal</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Qatar">Qatar</option>
<option value="Republic of the Congo">Republic of the Congo</option>
<option value="Romania">Romania</option>
<option value="Russia">Russia</option>
<option value="Rwanda">Rwanda</option>
<option value="Saint Barthelemy">Saint Barthelemy</option>
<option value="Saint Helena">Saint Helena</option>
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
<option value="Saint Lucia">Saint Lucia</option>
<option value="Saint Martin">Saint Martin</option>
<option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option>
<option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option>
<option value="Samoa">Samoa</option>
<option value="San Marino">San Marino</option>
<option value="Sao Tome and Principe">Sao Tome and Principe</option>
<option value="Saudi Arabia">Saudi Arabia</option>
<option value="Senegal">Senegal</option>
<option value="Serbia">Serbia</option>
<option value="Seychelles">Seychelles</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapore">Singapore</option>
<option value="Slovakia">Slovakia</option>
<option value="Slovenia">Slovenia</option>
<option value="Solomon Islands">Solomon Islands</option>
<option value="Somalia">Somalia</option>
<option value="Somaliland">Somaliland</option>
<option value="South Africa">South Africa</option>
<option value="South Ossetia">South Ossetia</option>
<option value="South Sudan">South Sudan</option>
<option value="Spain">Spain</option>
<option value="Sri Lanka">Sri Lanka</option>
<option value="Sudan">Sudan</option>
<option value="Suriname">Suriname</option>
<option value="Svalbard">Svalbard</option>
<option value="eSwatini">eSwatini</option>
<option value="Sweden">Sweden</option>
<option value="Switzerland">Switzerland</option>
<option value="Syria">Syria</option>
<option value="Taiwan">Taiwan</option>
<option value="Tajikistan">Tajikistan</option>
<option value="Tanzania">Tanzania</option>
<option value="Thailand">Thailand</option>
<option value="Timor-Leste">Timor-Leste</option>
<option value="Togo">Togo</option>
<option value="Tokelau">Tokelau</option>
<option value="Tonga">Tonga</option>
<option value="Transnistria Pridnestrovie">Transnistria Pridnestrovie</option>
<option value="Trinidad and Tobago">Trinidad and Tobago</option>
<option value="Tristan da Cunha">Tristan da Cunha</option>
<option value="Tunisia">Tunisia</option>
<option value="Turkey">Turkey</option>
<option value="Turkmenistan">Turkmenistan</option>
<option value="Turks and Caicos Islands">Turks and Caicos Islands</option>
<option value="Tuvalu">Tuvalu</option>
<option value="Uganda">Uganda</option>
<option value="Ukraine">Ukraine</option>
<option value="United Arab Emirates">United Arab Emirates</option>
<option value="United Kingdom">United Kingdom</option>
<option value="Uruguay">Uruguay</option>
<option value="Uzbekistan">Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Vatican City">Vatican City</option>
<option value="Venezuela">Venezuela</option>
<option value="Vietnam">Vietnam</option>
<option value="British Virgin Islands">British Virgin Islands</option>
<option value="Isle of Man">Isle of Man</option>
<option value="US Virgin Islands">US Virgin Islands</option>
<option value="Wallis and Futuna">Wallis and Futuna</option>
<option value="Western Sahara">Western Sahara</option>
<option value="Yemen">Yemen</option>
<option value="Zambia">Zambia</option>
<option value="Zimbabwe">Zimbabwe</option>
<option value="other">Other</option>
</select> <label class="form-sub-label" for="input_34_country" id="sublabel_34_country" style="min-height:13px" aria-hidden="false">Country</label></span></span></div>
</div>
</div>
</li>
<li class="form-line form-line-column form-col-2" data-type="control_address" id="id_35" data-compound-hint=",,,,,,"><label class="form-label form-label-top" id="label_35" for="input_35_addr_line1"> Billing Address (if different) </label>
<div id="cid_35" class="form-input-wide" data-layout="full">
<div summary="" class="form-address-table jsTest-addressField">
<div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-street-line jsTest-address-lineField"><span class="form-sub-label-container" style="vertical-align:top"><input type="text"
id="input_35_addr_line1" name="q35_address35[addr_line1]" class="form-textbox form-address-line" data-defaultvalue="" autocomplete="section-input_35 address-line1" value="" data-component="address_line_1"
aria-labelledby="label_35 sublabel_35_addr_line1" required=""> <label class="form-sub-label" for="input_35_addr_line1" id="sublabel_35_addr_line1" style="min-height:13px" aria-hidden="false">Street Address</label></span></span>
</div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-street-line jsTest-address-lineField"><span class="form-sub-label-container" style="vertical-align:top"><input type="text"
id="input_35_addr_line2" name="q35_address35[addr_line2]" class="form-textbox form-address-line" data-defaultvalue="" autocomplete="section-input_35 address-line2" value="" data-component="address_line_2"
aria-labelledby="label_35 sublabel_35_addr_line2"> <label class="form-sub-label" for="input_35_addr_line2" id="sublabel_35_addr_line2" style="min-height:13px" aria-hidden="false">Street Address Line 2</label></span></span></div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-city-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><input type="text"
id="input_35_city" name="q35_address35[city]" class="form-textbox form-address-city" data-defaultvalue="" autocomplete="section-input_35 address-level2" value="" data-component="city" aria-labelledby="label_35 sublabel_35_city"
required=""> <label class="form-sub-label" for="input_35_city" id="sublabel_35_city" style="min-height:13px" aria-hidden="false">City</label></span></span><span
class="form-address-line form-address-state-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_35_state" name="q35_address35[state]"
class="form-textbox form-address-state" data-defaultvalue="" autocomplete="section-input_35 address-level1" value="" data-component="state" aria-labelledby="label_35 sublabel_35_state"> <label class="form-sub-label"
for="input_35_state" id="sublabel_35_state" style="min-height:13px" aria-hidden="false">State</label></span></span></div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-zip-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><input type="text"
id="input_35_postal" name="q35_address35[postal]" class="form-textbox form-address-postal" data-defaultvalue="" autocomplete="section-input_35 postal-code" value="" data-component="zip"
aria-labelledby="label_35 sublabel_35_postal" required=""> <label class="form-sub-label" for="input_35_postal" id="sublabel_35_postal" style="min-height:13px" aria-hidden="false">Zip Code</label></span></span><span
class="form-address-line form-address-country-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><select class="form-dropdown form-address-country noTranslate is-active"
name="q35_address35[country]" id="input_35_country" data-component="country" required="" aria-labelledby="label_35 sublabel_35_country" autocomplete="section-input_35 country">
<option value="">Please Select</option>
<option selected="" value="United States">United States</option>
<option value="Afghanistan">Afghanistan</option>
<option value="Albania">Albania</option>
<option value="Algeria">Algeria</option>
<option value="American Samoa">American Samoa</option>
<option value="Andorra">Andorra</option>
<option value="Angola">Angola</option>
<option value="Anguilla">Anguilla</option>
<option value="Antigua and Barbuda">Antigua and Barbuda</option>
<option value="Argentina">Argentina</option>
<option value="Armenia">Armenia</option>
<option value="Aruba">Aruba</option>
<option value="Australia">Australia</option>
<option value="Austria">Austria</option>
<option value="Azerbaijan">Azerbaijan</option>
<option value="The Bahamas">The Bahamas</option>
<option value="Bahrain">Bahrain</option>
<option value="Bangladesh">Bangladesh</option>
<option value="Barbados">Barbados</option>
<option value="Belarus">Belarus</option>
<option value="Belgium">Belgium</option>
<option value="Belize">Belize</option>
<option value="Benin">Benin</option>
<option value="Bermuda">Bermuda</option>
<option value="Bhutan">Bhutan</option>
<option value="Bolivia">Bolivia</option>
<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
<option value="Botswana">Botswana</option>
<option value="Brazil">Brazil</option>
<option value="Brunei">Brunei</option>
<option value="Bulgaria">Bulgaria</option>
<option value="Burkina Faso">Burkina Faso</option>
<option value="Burundi">Burundi</option>
<option value="Cambodia">Cambodia</option>
<option value="Cameroon">Cameroon</option>
<option value="Canada">Canada</option>
<option value="Cape Verde">Cape Verde</option>
<option value="Cayman Islands">Cayman Islands</option>
<option value="Central African Republic">Central African Republic</option>
<option value="Chad">Chad</option>
<option value="Chile">Chile</option>
<option value="China">China</option>
<option value="Christmas Island">Christmas Island</option>
<option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option>
<option value="Colombia">Colombia</option>
<option value="Comoros">Comoros</option>
<option value="Congo">Congo</option>
<option value="Cook Islands">Cook Islands</option>
<option value="Costa Rica">Costa Rica</option>
<option value="Cote d'Ivoire">Cote d'Ivoire</option>
<option value="Croatia">Croatia</option>
<option value="Cuba">Cuba</option>
<option value="Curaçao">Curaçao</option>
<option value="Cyprus">Cyprus</option>
<option value="Czech Republic">Czech Republic</option>
<option value="Democratic Republic of the Congo">Democratic Republic of the Congo</option>
<option value="Denmark">Denmark</option>
<option value="Djibouti">Djibouti</option>
<option value="Dominica">Dominica</option>
<option value="Dominican Republic">Dominican Republic</option>
<option value="Ecuador">Ecuador</option>
<option value="Egypt">Egypt</option>
<option value="El Salvador">El Salvador</option>
<option value="Equatorial Guinea">Equatorial Guinea</option>
<option value="Eritrea">Eritrea</option>
<option value="Estonia">Estonia</option>
<option value="Ethiopia">Ethiopia</option>
<option value="Falkland Islands">Falkland Islands</option>
<option value="Faroe Islands">Faroe Islands</option>
<option value="Fiji">Fiji</option>
<option value="Finland">Finland</option>
<option value="France">France</option>
<option value="French Polynesia">French Polynesia</option>
<option value="Gabon">Gabon</option>
<option value="The Gambia">The Gambia</option>
<option value="Georgia">Georgia</option>
<option value="Germany">Germany</option>
<option value="Ghana">Ghana</option>
<option value="Gibraltar">Gibraltar</option>
<option value="Greece">Greece</option>
<option value="Greenland">Greenland</option>
<option value="Grenada">Grenada</option>
<option value="Guadeloupe">Guadeloupe</option>
<option value="Guam">Guam</option>
<option value="Guatemala">Guatemala</option>
<option value="Guernsey">Guernsey</option>
<option value="Guinea">Guinea</option>
<option value="Guinea-Bissau">Guinea-Bissau</option>
<option value="Guyana">Guyana</option>
<option value="Haiti">Haiti</option>
<option value="Honduras">Honduras</option>
<option value="Hong Kong">Hong Kong</option>
<option value="Hungary">Hungary</option>
<option value="Iceland">Iceland</option>
<option value="India">India</option>
<option value="Indonesia">Indonesia</option>
<option value="Iran">Iran</option>
<option value="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Israel">Israel</option>
<option value="Italy">Italy</option>
<option value="Jamaica">Jamaica</option>
<option value="Japan">Japan</option>
<option value="Jersey">Jersey</option>
<option value="Jordan">Jordan</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kiribati">Kiribati</option>
<option value="North Korea">North Korea</option>
<option value="South Korea">South Korea</option>
<option value="Kosovo">Kosovo</option>
<option value="Kuwait">Kuwait</option>
<option value="Kyrgyzstan">Kyrgyzstan</option>
<option value="Laos">Laos</option>
<option value="Latvia">Latvia</option>
<option value="Lebanon">Lebanon</option>
<option value="Lesotho">Lesotho</option>
<option value="Liberia">Liberia</option>
<option value="Libya">Libya</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lithuania">Lithuania</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macau">Macau</option>
<option value="Macedonia">Macedonia</option>
<option value="Madagascar">Madagascar</option>
<option value="Malawi">Malawi</option>
<option value="Malaysia">Malaysia</option>
<option value="Maldives">Maldives</option>
<option value="Mali">Mali</option>
<option value="Malta">Malta</option>
<option value="Marshall Islands">Marshall Islands</option>
<option value="Martinique">Martinique</option>
<option value="Mauritania">Mauritania</option>
<option value="Mauritius">Mauritius</option>
<option value="Mayotte">Mayotte</option>
<option value="Mexico">Mexico</option>
<option value="Micronesia">Micronesia</option>
<option value="Moldova">Moldova</option>
<option value="Monaco">Monaco</option>
<option value="Mongolia">Mongolia</option>
<option value="Montenegro">Montenegro</option>
<option value="Montserrat">Montserrat</option>
<option value="Morocco">Morocco</option>
<option value="Mozambique">Mozambique</option>
<option value="Myanmar">Myanmar</option>
<option value="Nagorno-Karabakh">Nagorno-Karabakh</option>
<option value="Namibia">Namibia</option>
<option value="Nauru">Nauru</option>
<option value="Nepal">Nepal</option>
<option value="Netherlands">Netherlands</option>
<option value="Netherlands Antilles">Netherlands Antilles</option>
<option value="New Caledonia">New Caledonia</option>
<option value="New Zealand">New Zealand</option>
<option value="Nicaragua">Nicaragua</option>
<option value="Niger">Niger</option>
<option value="Nigeria">Nigeria</option>
<option value="Niue">Niue</option>
<option value="Norfolk Island">Norfolk Island</option>
<option value="Turkish Republic of Northern Cyprus">Turkish Republic of Northern Cyprus</option>
<option value="Northern Mariana">Northern Mariana</option>
<option value="Norway">Norway</option>
<option value="Oman">Oman</option>
<option value="Pakistan">Pakistan</option>
<option value="Palau">Palau</option>
<option value="Palestine">Palestine</option>
<option value="Panama">Panama</option>
<option value="Papua New Guinea">Papua New Guinea</option>
<option value="Paraguay">Paraguay</option>
<option value="Peru">Peru</option>
<option value="Philippines">Philippines</option>
<option value="Pitcairn Islands">Pitcairn Islands</option>
<option value="Poland">Poland</option>
<option value="Portugal">Portugal</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Qatar">Qatar</option>
<option value="Republic of the Congo">Republic of the Congo</option>
<option value="Romania">Romania</option>
<option value="Russia">Russia</option>
<option value="Rwanda">Rwanda</option>
<option value="Saint Barthelemy">Saint Barthelemy</option>
<option value="Saint Helena">Saint Helena</option>
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
<option value="Saint Lucia">Saint Lucia</option>
<option value="Saint Martin">Saint Martin</option>
<option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option>
<option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option>
<option value="Samoa">Samoa</option>
<option value="San Marino">San Marino</option>
<option value="Sao Tome and Principe">Sao Tome and Principe</option>
<option value="Saudi Arabia">Saudi Arabia</option>
<option value="Senegal">Senegal</option>
<option value="Serbia">Serbia</option>
<option value="Seychelles">Seychelles</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapore">Singapore</option>
<option value="Slovakia">Slovakia</option>
<option value="Slovenia">Slovenia</option>
<option value="Solomon Islands">Solomon Islands</option>
<option value="Somalia">Somalia</option>
<option value="Somaliland">Somaliland</option>
<option value="South Africa">South Africa</option>
<option value="South Ossetia">South Ossetia</option>
<option value="South Sudan">South Sudan</option>
<option value="Spain">Spain</option>
<option value="Sri Lanka">Sri Lanka</option>
<option value="Sudan">Sudan</option>
<option value="Suriname">Suriname</option>
<option value="Svalbard">Svalbard</option>
<option value="eSwatini">eSwatini</option>
<option value="Sweden">Sweden</option>
<option value="Switzerland">Switzerland</option>
<option value="Syria">Syria</option>
<option value="Taiwan">Taiwan</option>
<option value="Tajikistan">Tajikistan</option>
<option value="Tanzania">Tanzania</option>
<option value="Thailand">Thailand</option>
<option value="Timor-Leste">Timor-Leste</option>
<option value="Togo">Togo</option>
<option value="Tokelau">Tokelau</option>
<option value="Tonga">Tonga</option>
<option value="Transnistria Pridnestrovie">Transnistria Pridnestrovie</option>
<option value="Trinidad and Tobago">Trinidad and Tobago</option>
<option value="Tristan da Cunha">Tristan da Cunha</option>
<option value="Tunisia">Tunisia</option>
<option value="Turkey">Turkey</option>
<option value="Turkmenistan">Turkmenistan</option>
<option value="Turks and Caicos Islands">Turks and Caicos Islands</option>
<option value="Tuvalu">Tuvalu</option>
<option value="Uganda">Uganda</option>
<option value="Ukraine">Ukraine</option>
<option value="United Arab Emirates">United Arab Emirates</option>
<option value="United Kingdom">United Kingdom</option>
<option value="Uruguay">Uruguay</option>
<option value="Uzbekistan">Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Vatican City">Vatican City</option>
<option value="Venezuela">Venezuela</option>
<option value="Vietnam">Vietnam</option>
<option value="British Virgin Islands">British Virgin Islands</option>
<option value="Isle of Man">Isle of Man</option>
<option value="US Virgin Islands">US Virgin Islands</option>
<option value="Wallis and Futuna">Wallis and Futuna</option>
<option value="Western Sahara">Western Sahara</option>
<option value="Yemen">Yemen</option>
<option value="Zambia">Zambia</option>
<option value="Zimbabwe">Zimbabwe</option>
<option value="other">Other</option>
</select> <label class="form-sub-label" for="input_35_country" id="sublabel_35_country" style="min-height:13px" aria-hidden="false">Country</label></span></span></div>
</div>
</div>
</li>
<li class="form-line jf-required" data-type="control_textbox" id="id_25"><label class="form-label form-label-left" id="label_25" for="input_25"> Order Payment Method<span class="form-required">*</span> </label>
<div id="cid_25" class="form-input jf-required" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_25" name="q25_orderPayment" data-type="input-textbox"
class="form-textbox validate[required]" data-defaultvalue="" style="width:310px" size="310" value="" placeholder="Visa, 4930" data-component="textbox" aria-labelledby="label_25 sublabel_input_25" required=""> <label
class="form-sub-label" for="input_25" id="sublabel_input_25" style="min-height:13px" aria-hidden="false">If card, add the last 4 digits.</label></span> </div>
</li>
<li class="form-line jf-required" data-type="control_textarea" id="id_26"><label class="form-label form-label-left" id="label_26" for="input_26"> Order Products<span class="form-required">*</span> </label>
<div id="cid_26" class="form-input jf-required" data-layout="full"> <span class="form-sub-label-container" style="vertical-align:top"><textarea id="input_26" class="form-textarea validate[required] custom-hint-group form-custom-hint"
name="q26_orderProducts" style="width:648px;height:163px" data-component="textarea" required="" aria-labelledby="label_26 sublabel_input_26" data-customhint="1x Gucci Messenger Bag (Black)" customhinted="true"
placeholder="1x Gucci Messenger Bag (Black)" spellcheck="false"></textarea> <label class="form-sub-label" for="input_26" id="sublabel_input_26" style="min-height:13px" aria-hidden="false">Add images to imgur to better present your
order. For partial refunds, circle the items clearly that you want to be prioritized refund.</label></span> </div>
</li>
<li class="form-line jf-required" data-type="control_datetime" id="id_27"><label class="form-label form-label-left" id="label_27" for="lite_mode_27"> Order Date<span class="form-required">*</span> </label>
<div id="cid_27" class="form-input jf-required" data-layout="half">
<div data-wrapper-react="true">
<div style="display:none"><span class="form-sub-label-container" style="vertical-align:top"><input type="tel" class="form-textbox validate[required, limitDate]" id="month_27" name="q27_orderDate[month]" size="2" data-maxlength="2"
data-age="" maxlength="2" value="" required="" autocomplete="section-input_27 off" aria-labelledby="label_27 sublabel_27_month" inputmode="numeric"><span class="date-separate" aria-hidden="true"> -</span><label
class="form-sub-label" for="month_27" id="sublabel_27_month" style="min-height:13px" aria-hidden="false">Month</label></span><span class="form-sub-label-container" style="vertical-align:top"><input type="tel"
class="form-textbox validate[required, limitDate]" id="day_27" name="q27_orderDate[day]" size="2" data-maxlength="2" data-age="" maxlength="2" value="" required="" autocomplete="section-input_27 off"
aria-labelledby="label_27 sublabel_27_day" inputmode="numeric"><span class="date-separate" aria-hidden="true"> -</span><label class="form-sub-label" for="day_27" id="sublabel_27_day" style="min-height:13px"
aria-hidden="false">Day</label></span><span class="form-sub-label-container" style="vertical-align:top"><input type="tel" class="form-textbox validate[required, limitDate]" id="year_27" name="q27_orderDate[year]" size="4"
data-maxlength="4" data-age="" maxlength="4" value="" required="" autocomplete="section-input_27 off" aria-labelledby="label_27 sublabel_27_year"> <label class="form-sub-label" for="year_27" id="sublabel_27_year"
style="min-height:13px" aria-hidden="false">Year</label></span></div><span class="form-sub-label-container" style="vertical-align:top"><input type="text" class="form-textbox validate[required, limitDate, validateLiteDate]"
id="lite_mode_27" size="12" data-maxlength="12" data-age="" value="" required="" data-format="mmddyyyy" data-seperator="-" placeholder="MM-DD-YYYY" autocomplete="section-input_27 off" aria-labelledby="label_27"
inputmode="numeric"><img class=" newDefaultTheme-dateIcon icon-liteMode" alt="Pick a Date" id="input_27_pick" src="https://cdn.jotfor.ms/images/calendar.png" data-component="datetime" aria-hidden="true" data-allow-time="No"
data-version="v2"> <label class="form-sub-label is-empty" for="lite_mode_27" id="sublabel_27_litemode" style="min-height:13px" aria-hidden="false"></label></span>
</div>
</div>
</li>
<li class="form-line jf-required" data-type="control_datetime" id="id_28"><label class="form-label form-label-left" id="label_28" for="lite_mode_28"> Arrival Date<span class="form-required">*</span> </label>
<div id="cid_28" class="form-input jf-required" data-layout="half">
<div data-wrapper-react="true">
<div style="display:none"><span class="form-sub-label-container" style="vertical-align:top"><input type="tel" class="form-textbox validate[required, limitDate]" id="month_28" name="q28_arrivalDate[month]" size="2" data-maxlength="2"
data-age="" maxlength="2" value="" required="" autocomplete="section-input_28 off" aria-labelledby="label_28 sublabel_28_month" inputmode="numeric"><span class="date-separate" aria-hidden="true"> -</span><label
class="form-sub-label" for="month_28" id="sublabel_28_month" style="min-height:13px" aria-hidden="false">Month</label></span><span class="form-sub-label-container" style="vertical-align:top"><input type="tel"
class="form-textbox validate[required, limitDate]" id="day_28" name="q28_arrivalDate[day]" size="2" data-maxlength="2" data-age="" maxlength="2" value="" required="" autocomplete="section-input_28 off"
aria-labelledby="label_28 sublabel_28_day" inputmode="numeric"><span class="date-separate" aria-hidden="true"> -</span><label class="form-sub-label" for="day_28" id="sublabel_28_day" style="min-height:13px"
aria-hidden="false">Day</label></span><span class="form-sub-label-container" style="vertical-align:top"><input type="tel" class="form-textbox validate[required, limitDate]" id="year_28" name="q28_arrivalDate[year]" size="4"
data-maxlength="4" data-age="" maxlength="4" value="" required="" autocomplete="section-input_28 off" aria-labelledby="label_28 sublabel_28_year"> <label class="form-sub-label" for="year_28" id="sublabel_28_year"
style="min-height:13px" aria-hidden="false">Year</label></span></div><span class="form-sub-label-container" style="vertical-align:top"><input type="text" class="form-textbox validate[required, limitDate, validateLiteDate]"
id="lite_mode_28" size="12" data-maxlength="12" data-age="" value="" required="" data-format="mmddyyyy" data-seperator="-" placeholder="MM-DD-YYYY" autocomplete="section-input_28 off" aria-labelledby="label_28"
inputmode="numeric"><img class=" newDefaultTheme-dateIcon icon-liteMode" alt="Pick a Date" id="input_28_pick" src="https://cdn.jotfor.ms/images/calendar.png" data-component="datetime" aria-hidden="true" data-allow-time="No"
data-version="v2"> <label class="form-sub-label is-empty" for="lite_mode_28" id="sublabel_28_litemode" style="min-height:13px" aria-hidden="false"></label></span>
</div>
</div>
</li>
<li class="form-line jf-required" data-type="control_radio" id="id_29"><label class="form-label form-label-top" id="label_29" for="input_29"> How did you receive & accept your package(s)?<span class="form-required">*</span> </label>
<div id="cid_29" class="form-input-wide jf-required" data-layout="full">
<div class="form-single-column" role="group" aria-labelledby="label_29" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input type="radio" aria-describedby="label_29"
class="form-radio validate[required]" id="input_29_0" name="q29_howDid" value="Real Signature (the name that matches order name or family member)" required=""><label id="label_input_29_0" for="input_29_0">Real Signature (the name that
matches order name or family member)</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input type="radio" aria-describedby="label_29" class="form-radio validate[required]"
id="input_29_1" name="q29_howDid" value="Fake signature (name that's not on my address)" required=""><label id="label_input_29_1" for="input_29_1">Fake signature (name that's not on my address)</label></span><span
class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input type="radio" aria-describedby="label_29" class="form-radio validate[required]" id="input_29_2" name="q29_howDid" value="No signature (hand to hand)"
required=""><label id="label_input_29_2" for="input_29_2">No signature (hand to hand)</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input type="radio" aria-describedby="label_29"
class="form-radio validate[required]" id="input_29_3" name="q29_howDid" value="No signature (left outside the house)" required=""><label id="label_input_29_3" for="input_29_3">No signature (left outside the house)</label></span><span
class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input type="radio" aria-describedby="label_29" class="form-radio validate[required]" id="input_29_4" name="q29_howDid"
value="Post office / Pick up Point / Packstation" required=""><label id="label_input_29_4" for="input_29_4">Post office / Pick up Point / Packstation</label></span><span class="form-radio-item formRadioOther" style="clear:left"><input
type="radio" class="form-radio-other form-radio validate[required]" name="q29_howDid" id="other_29" value="other" tabindex="0" aria-label="Other"><label id="label_other_29" style="text-indent:0" for="other_29">Other</label><span
id="other_29_input" class="other-input-container is-none" style=""><input type="text" class="form-radio-other-input form-textbox" name="q29_howDid[other]" data-otherhint="Other" size="15" id="input_29"
data-placeholder="Please type another option here" placeholder="Please type another option here"></span></span></div>
</div>
</li>
<li class="form-line form-line-column form-col-1 jf-required" data-type="control_textbox" id="id_30"><label class="form-label form-label-top" id="label_30" for="input_30"> Tracking Number(s)<span class="form-required">*</span> </label>
<div id="cid_30" class="form-input-wide jf-required" data-layout="half"> <input type="text" id="input_30" name="q30_trackingNumbers" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" style="width:310px"
size="310" value="" placeholder="777123123123, 776123124634" data-component="textbox" aria-labelledby="label_30" required=""> </div>
</li>
<li class="form-line form-line-column form-col-2 jf-required" data-type="control_textbox" id="id_31"><label class="form-label form-label-top" id="label_31" for="input_31"> Courier Delivering<span class="form-required">*</span> </label>
<div id="cid_31" class="form-input-wide jf-required" data-layout="half"> <input type="text" id="input_31" name="q31_courierDelivering" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" style="width:310px"
size="310" value="" placeholder="FEDEX" data-component="textbox" aria-labelledby="label_31" required=""> </div>
</li>
<li class="form-line" data-type="control_textarea" id="id_32"><label class="form-label form-label-left" id="label_32" for="input_32"> Additional Notes (Optional) </label>
<div id="cid_32" class="form-input" data-layout="full"> <textarea id="input_32" class="form-textarea" name="q32_additionalNotes" style="width:648px;height:163px" data-component="textarea" aria-labelledby="label_32"></textarea> </div>
</li>
<li class="form-line" data-type="control_button" id="id_2">
<div id="cid_2" class="form-input-wide" data-layout="full">
<div data-align="auto" class="form-buttons-wrapper form-buttons-auto jsTest-button-wrapperField form-pagebreak">
<div class="form-pagebreak-back-container"><button id="form-pagebreak-back_16" type="button" class="form-pagebreak-back jf-form-buttons" data-component="pagebreak-back">Back</button></div><button id="input_2" type="submit"
class="form-submit-button submit-button jf-form-buttons jsTest-submitField" data-component="button" data-content="">Submit</button>
</div>
</div>
</li>
<li style="display:none">Should be Empty: <input type="text" name="website" value=""></li>
</ul>
</div>
<script>
JotForm.showJotFormPowered = "0";
</script>
<script>
JotForm.poweredByText = "Powered by Jotform";
</script><input type="hidden" class="simple_spc" id="simple_spc" name="simple_spc" value="223538934399067-223538934399067">
<script type="text/javascript">
var all_spc = document.querySelectorAll("form[id='223538934399067'] .si" + "mple" + "_spc");
for (var i = 0; i < all_spc.length; i++) {
all_spc[i].value = "223538934399067-223538934399067";
}
</script>
<input type="hidden" name="event_id" value="1673498763360_223538934399067_Vo7oV9v">
</form>Text Content
* ORDER FORM * Telegram Username (@)* Set your username in settings for easier communication via Telegram. * Store* Fill out the domain. * How do you prefer to pay for your order?* CryptocurrencyPaypal (+5%) * What option do you want?* RefundReplacement * Total Order Amount* Item cost + shipping + and everything else. * Next * Order Name* * Order Number* * Order Email* * Phone Number* * Order & Shipping Address* Street Address Street Address Line 2 City State Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Turkish Republic of Northern Cyprus Northern Mariana Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Republic of the Congo Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia South Sudan Spain Sri Lanka Sudan Suriname Svalbard eSwatini Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Transnistria Pridnestrovie Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands Isle of Man US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country * Billing Address (if different) Street Address Street Address Line 2 City State Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Turkish Republic of Northern Cyprus Northern Mariana Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Republic of the Congo Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia South Sudan Spain Sri Lanka Sudan Suriname Svalbard eSwatini Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Transnistria Pridnestrovie Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands Isle of Man US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country * Order Payment Method* If card, add the last 4 digits. * Order Products* Add images to imgur to better present your order. For partial refunds, circle the items clearly that you want to be prioritized refund. * Order Date* -Month -Day Year * Arrival Date* -Month -Day Year * How did you receive & accept your package(s)?* Real Signature (the name that matches order name or family member)Fake signature (name that's not on my address)No signature (hand to hand)No signature (left outside the house)Post office / Pick up Point / PackstationOther * Tracking Number(s)* * Courier Delivering* * Additional Notes (Optional) * Back Submit * Should be Empty: January‹› 2023«» January 2023TodaySMTWTFS12345678910111213141516171819202122232425262728293031123456789101112131415161718 January‹› 2023«» January 2023TodaySMTWTFS12345678910111213141516171819202122232425262728293031123456789101112131415161718