www.weareplannedparenthood.org
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Submitted URL: https://michiganchoice.org/
Effective URL: https://www.weareplannedparenthood.org/onlineactions/bSOWsEK_106TLK4YYWQg1A2
Submission: On October 09 via api from US — Scanned from DE
Effective URL: https://www.weareplannedparenthood.org/onlineactions/bSOWsEK_106TLK4YYWQg1A2
Submission: On October 09 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST v1
<form class="clearfix" method="post" novalidate="" action="v1" accept-charset="utf-8" autocomplete="on">
<div data-name="undefined" data-subview="submit_view" data-subview-index="2"></div>
<fieldset class="at-fieldset ContributionInformation" id="NVContributionForm82690-ContributionInformation" style="border: none;">
<legend class="at-legend">Design your gift</legend>
<div class="at-fields">
<div class="at-row at-row-full ">
<div class="form-unit form-unit-radio form-item-selectedfrequency" id="NVContributionForm82690-ContributionInformation-SelectedFrequency">
<div class="radios" role="radiogroup" aria-labelledby="NVContributionForm82690-ContributionInformation-SelectedFrequency">
<label title="One-Time" class="at-radio-label-0" role="radio">
<input type="radio" name="SelectedFrequency" checked="" value="0"> One-Time </label><label title="Monthly" class="at-radio-label-4" role="radio">
<input type="radio" name="SelectedFrequency" value="4"> Monthly </label>
<div class="radio-description radio-description-value-0">A monthly gift does even more to support reproductive health care</div>
</div>
</div>
</div>
<div class="at-row at-row-full ">
<input id="ProcessingCurrency_Value" type="hidden" name="ProcessingCurrency.Value" value="USD">
</div>
<div class="at-row at-row-full ">
<div class="form-item form-type-radios form-item-selectamount" id="NVContributionForm82690-ContributionInformation-SelectAmount">
<div class="at-row SelectAmount OtherAmount NonRecurringButtons">
<div class="at-radio">
<div class="at-radios clearfix">
<label class="label-amount incrediblyLong" title="KDMS* ($1,000)">
<input name="SelectAmount" type="radio" value="1000.00"> KDMS* ($1,000) <a></a> </label><label class="label-amount" title="$500">
<input name="SelectAmount" type="radio" value="500.00"> $500 <a></a> </label><label class="label-amount" title="$100">
<input name="SelectAmount" type="radio" value="100.00"> $100 <a></a> </label><label class="label-amount" title="$75">
<input name="SelectAmount" type="radio" value="75.00"> $75 <a></a> </label><label class="label-amount" title="$50">
<input name="SelectAmount" type="radio" value="50.00"> $50 <a></a> </label><label class="label-amount" title="$25">
<input name="SelectAmount" type="radio" value="25.00"> $25 <a></a> </label><label class="label-amount label-otheramount" title="Other">
<input name="SelectAmount" type="radio" class="radio-other" value="other"> Other <input type="number" tabindex="-1" autocomplete="transaction-amount" class="edit-otheramount" name="OtherAmount" title="Other Amount"
placeholder="0.00">
<span class="label-otheramount-prefix">$</span>
</label>
</div>
</div>
</div>
</div>
</div><label class="at-check CoverCostsAmount" id="NVContributionForm82690-ContributionInformation-CoverCostsAmount"><input type="checkbox" name="CoverCostsAmount"> <span class="at-checkbox-title-container"><span class="at-checkbox-title"
id="NVContributionForm82690-ContributionInformation-CoverCostsAmount-label">I'd like to cover the transaction fees for my contribution</span></span>
</label>
</div>
</fieldset>
<fieldset class="at-fieldset TributeGift" id="NVContributionForm82690-TributeGift">
<div class="at-fields">
<div class="at-row at-row-full EnableTributeGift">
<label class="at-check EnableTributeGift" id="NVContributionForm82690-TributeGift-EnableTributeGift"><input type="checkbox" name="EnableTributeGift"> <span class="at-checkbox-title-container"><span class="at-checkbox-title"
id="NVContributionForm82690-TributeGift-EnableTributeGift-label">I'd like to make this contribution in honor or in memory of someone</span></span>
</label>
</div>
<div class="at-row">
<div class="at-tribute-gift" style="display:none">
<div class="form-unit form-unit-radio form-item-inhonororinmemoryof" id="NVContributionForm82690-TributeGift-InHonorOrInMemoryOf"><label id="NVContributionForm82690-TributeGift-InHonorOrInMemoryOf"> Is this an Honorary or Memorial
Gift?</label>
<div class="radios" role="radiogroup" aria-labelledby="NVContributionForm82690-TributeGift-InHonorOrInMemoryOf">
<label title="In honor of" class="at-radio-label-2" role="radio">
<input type="radio" name="InHonorOrInMemoryOf" checked="" value="2"> In honor of </label><label title="In memory of" class="at-radio-label-1" role="radio">
<input type="radio" name="InHonorOrInMemoryOf" value="1"> In memory of </label>
</div>
</div><label class="at-text HonoreeName" id="NVContributionForm82690-TributeGift-HonoreeName">Honoree Name<input type="text" autocomplete="on" required="" title="Honoree Name (required)" name="HonoreeName" value="" maxlength="100">
</label>
</div>
</div>
</div>
</fieldset>
<fieldset class="at-fieldset RecipientInformation" id="NVContributionForm82690-RecipientInformation" style="display: none;">
<div class="at-fields">
<div class="at-row">
<label class="at-check IncludeRecipient" id="NVContributionForm82690-RecipientInformation-IncludeRecipient"><input type="checkbox" name="IncludeRecipient"> <span class="at-checkbox-title-container"><span class="at-checkbox-title"
id="NVContributionForm82690-RecipientInformation-IncludeRecipient-label">I'd like to notify someone of this contribution</span></span>
</label>
</div>
<div class="at-recipient-info" style="display: none;">
<div class="mail-checks radios at-row">
<div class="email-container">
<label class="email-tile clicked" for="email">
<input type="checkbox" name="email" id="email" value="email">
<i class="fas fa-2x fa-paper-plane" aria-hidden="true"> </i><br>
<span class="mail-text">I'd like an e-card to be sent via email</span>
</label>
<div class="deliv"> (delivered instantly or on a specific date of your choosing) </div>
</div>
<div class="mail-container">
<label class="mail-tile" for="mail">
<input type="checkbox" name="mail" id="mail" value="mail">
<i class="far fa-2x fa-envelope" aria-hidden="true"> </i><br>
<span class="mail-text">I'd like a physical card to be sent via the mail</span>
</label>
<div class="deliv">(delivered within 2 - 3 weeks)</div>
</div>
</div>
<div class="at-title basic-info">Who would you like to notify?</div>
<div class="at-row at-row-solo at-row-full RecipientInfoHeaderHtml basic-info">
<div class="at-markup RecipientInfoHeaderHtml basic-info" id="NVContributionForm82690-RecipientInformation-RecipientInfoHeaderHtml" style="display: none;">We will send an email notification to the email address you provide below. We are
unable to send anonymous notifications — the recipient will see your name and email address.</div>
</div>
<div class="at-row RecipientFirstName RecipientLastName basic-info"><label class="at-text RecipientFirstName" id="NVContributionForm82690-RecipientInformation-RecipientFirstName">First Name*<input type="text" autocomplete="on" required=""
title="First Name* (required)" name="RecipientFirstName" value="" maxlength="50">
</label><label class="at-text RecipientLastName" id="NVContributionForm82690-RecipientInformation-RecipientLastName">Last Name*<input type="text" autocomplete="on" required="" title="Last Name* (required)" name="RecipientLastName"
value="" maxlength="50">
</label></div>
<div class="at-row at-row-solo RecipientStreetAddress mail" style="display: none;"><label class="at-text RecipientStreetAddress mail" id="NVContributionForm82690-RecipientInformation-RecipientStreetAddress" style="display: none;">Street
Address* <small>(Optional)</small><input type="text" autocomplete="on" false="" title="Street Address*" name="RecipientStreetAddress" value="" maxlength="100">
</label></div>
<div class="at-row RecipientCountry RecipientPostalCode RecipientCity RecipientStateProvince mail" style="display: none;"><label class="at-select RecipientCountry mail" id="NVContributionForm82690-RecipientInformation-RecipientCountry"
style="">Country* <small>(Optional)</small><select autocomplete="on" title="Country*" name="RecipientCountry" class="select2-hidden-accessible" id="NVContributionForm82690-RecipientInformation-RecipientCountry-select" tabindex="-1"
aria-hidden="true">
<option value="">- Select -</option>
<option value="AF">Afghanistan</option>
<option value="AX">Åland Islands</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AD">Andorra</option>
<option value="AO">Angola</option>
<option value="AI">Anguilla</option>
<option value="AQ">Antarctica</option>
<option value="AG">Antigua and Barbuda</option>
<option value="AR">Argentina</option>
<option value="AM">Armenia</option>
<option value="AW">Aruba</option>
<option value="AU">Australia</option>
<option value="AT">Austria</option>
<option value="AZ">Azerbaijan</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BD">Bangladesh</option>
<option value="BB">Barbados</option>
<option value="BY">Belarus</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BJ">Benin</option>
<option value="BM">Bermuda</option>
<option value="BT">Bhutan</option>
<option value="BO">Bolivia (Plurinational State of)</option>
<option value="BQ">Bonaire, Sint Eustatius and Saba</option>
<option value="BA">Bosnia and Herzegovina</option>
<option value="BW">Botswana</option>
<option value="BV">Bouvet Island</option>
<option value="BR">Brazil</option>
<option value="IO">British Indian Ocean Territory</option>
<option value="VG">British Virgin Islands</option>
<option value="BN">Brunei Darussalam</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="CV">Cabo Verde</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="KY">Cayman Islands</option>
<option value="CF">Central African Republic</option>
<option value="TD">Chad</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CX">Christmas Island</option>
<option value="CC">Cocos (Keeling) Islands</option>
<option value="CO">Colombia</option>
<option value="KM">Comoros</option>
<option value="CG">Congo</option>
<option value="CD">Congo (Democratic Republic of the)</option>
<option value="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="CI">Côte d'Ivoire</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CW">Curaçao</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czechia</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="GQ">Equatorial Guinea</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="SZ">Eswatini</option>
<option value="ET">Ethiopia</option>
<option value="FK">Falkland Islands (Malvinas)</option>
<option value="FO">Faroe Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="GF">French Guiana</option>
<option value="PF">French Polynesia</option>
<option value="TF">French Southern Territories</option>
<option value="GA">Gabon</option>
<option value="GM">Gambia</option>
<option value="GE">Georgia</option>
<option value="DE">Germany</option>
<option value="GH">Ghana</option>
<option value="GI">Gibraltar</option>
<option value="GR">Greece</option>
<option value="GL">Greenland</option>
<option value="GD">Grenada</option>
<option value="GP">Guadeloupe</option>
<option value="GT">Guatemala</option>
<option value="GG">Guernsey</option>
<option value="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard Island and McDonald Islands</option>
<option value="VA">Holy See</option>
<option value="HN">Honduras</option>
<option value="HK">Hong Kong</option>
<option value="HU">Hungary</option>
<option value="IS">Iceland</option>
<option value="IN">India</option>
<option value="ID">Indonesia</option>
<option value="IR">Iran (Islamic Republic of)</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IM">Isle of Man</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JE">Jersey</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KP">Korea (Democratic People's Republic of)</option>
<option value="KR">Korea (Republic of)</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Lao People's Democratic Republic</option>
<option value="LV">Latvia</option>
<option value="LB">Lebanon</option>
<option value="LS">Lesotho</option>
<option value="LR">Liberia</option>
<option value="LY">Libya</option>
<option value="LI">Liechtenstein</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="MO">Macao</option>
<option value="MG">Madagascar</option>
<option value="MW">Malawi</option>
<option value="MY">Malaysia</option>
<option value="MV">Maldives</option>
<option value="ML">Mali</option>
<option value="MT">Malta</option>
<option value="MQ">Martinique</option>
<option value="MR">Mauritania</option>
<option value="MU">Mauritius</option>
<option value="YT">Mayotte</option>
<option value="MX">Mexico</option>
<option value="FM">Micronesia (Federated States of)</option>
<option value="MD">Moldova (Republic of)</option>
<option value="MC">Monaco</option>
<option value="MN">Mongolia</option>
<option value="ME">Montenegro</option>
<option value="MS">Montserrat</option>
<option value="MA">Morocco</option>
<option value="MZ">Mozambique</option>
<option value="MM">Myanmar</option>
<option value="NA">Namibia</option>
<option value="NR">Nauru</option>
<option value="NP">Nepal</option>
<option value="NL">Netherlands</option>
<option value="NC">New Caledonia</option>
<option value="NZ">New Zealand</option>
<option value="NI">Nicaragua</option>
<option value="NE">Niger</option>
<option value="NG">Nigeria</option>
<option value="NU">Niue</option>
<option value="NF">Norfolk Island</option>
<option value="MK">North Macedonia</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PK">Pakistan</option>
<option value="PW">Palau</option>
<option value="PS">Palestine (State of)</option>
<option value="PA">Panama</option>
<option value="PG">Papua New Guinea</option>
<option value="PY">Paraguay</option>
<option value="PE">Peru</option>
<option value="PH">Philippines</option>
<option value="PN">Pitcairn</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="QA">Qatar</option>
<option value="RE">Réunion</option>
<option value="RO">Romania</option>
<option value="RU">Russian Federation</option>
<option value="RW">Rwanda</option>
<option value="BL">Saint Barthélemy</option>
<option value="SH">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="MF">Saint Martin (French part)</option>
<option value="PM">Saint Pierre and Miquelon</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</option>
<option value="ST">Sao Tome and Principe</option>
<option value="SA">Saudi Arabia</option>
<option value="SN">Senegal</option>
<option value="RS">Serbia</option>
<option value="SC">Seychelles</option>
<option value="SL">Sierra Leone</option>
<option value="SG">Singapore</option>
<option value="SX">Sint Maarten (Dutch part)</option>
<option value="SK">Slovakia</option>
<option value="SI">Slovenia</option>
<option value="SB">Solomon Islands</option>
<option value="SO">Somalia</option>
<option value="ZA">South Africa</option>
<option value="GS">South Georgia and the South Sandwich Islands</option>
<option value="SS">South Sudan</option>
<option value="ES">Spain</option>
<option value="LK">Sri Lanka</option>
<option value="SD">Sudan</option>
<option value="SR">Suriname</option>
<option value="SJ">Svalbard and Jan Mayen</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syrian Arab Republic</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania (United Republic of)</option>
<option value="TH">Thailand</option>
<option value="TL">Timor-Leste</option>
<option value="TG">Togo</option>
<option value="TK">Tokelau</option>
<option value="TO">Tonga</option>
<option value="TT">Trinidad and Tobago</option>
<option value="TN">Tunisia</option>
<option value="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks and Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom</option>
<option value="US">United States</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VE">Venezuela (Bolivarian Republic of)</option>
<option value="VN">Viet Nam</option>
<option value="WF">Wallis and Futuna</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" style="width: 100px;"><span class="selection"><span class="select2-selection select2-selection--single" role="combobox" aria-haspopup="true"
aria-expanded="false" title="Country*" tabindex="0" aria-labelledby="select2-NVContributionForm82690-RecipientInformation-RecipientCountry-select-container"><span class="select2-selection__rendered"
id="select2-NVContributionForm82690-RecipientInformation-RecipientCountry-select-container" title="United States">United States</span><span class="select2-selection__arrow"
role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
</label><label class="at-text RecipientPostalCode" id="NVContributionForm82690-RecipientInformation-RecipientPostalCode">Postal Code* <small>(Optional)</small><input type="tel" autocomplete="on" pattern="^\d{5}([\-]\d{4})?$" false=""
title="Postal Code*" name="RecipientPostalCode" value="" maxlength="10">
</label><label class="at-text RecipientCity" id="NVContributionForm82690-RecipientInformation-RecipientCity">City* <small>(Optional)</small><input type="text" autocomplete="on" false="" title="City*" name="RecipientCity" value=""
maxlength="25">
</label><label class="at-select RecipientStateProvince" id="NVContributionForm82690-RecipientInformation-RecipientStateProvince">State/Province* <small>(Optional)</small><select autocomplete="on" title="State/Province*"
name="RecipientStateProvince" class="" id="NVContributionForm82690-RecipientInformation-RecipientStateProvince-select">
<option value="">- State -</option>
<option value="AK">AK</option>
<option value="AL">AL</option>
<option value="AR">AR</option>
<option value="AZ">AZ</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DC">DC</option>
<option value="DE">DE</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="HI">HI</option>
<option value="IA">IA</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="MA">MA</option>
<option value="MD">MD</option>
<option value="ME">ME</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MO">MO</option>
<option value="MS">MS</option>
<option value="MT">MT</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="NE">NE</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NV">NV</option>
<option value="NY">NY</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="RI">RI</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VA">VA</option>
<option value="VT">VT</option>
<option value="WA">WA</option>
<option value="WI">WI</option>
<option value="WV">WV</option>
<option value="WY">WY</option>
<option value="AS">AS</option>
<option value="FM">FM</option>
<option value="GU">GU</option>
<option value="MH">MH</option>
<option value="MP">MP</option>
<option value="PR">PR</option>
<option value="PW">PW</option>
<option value="VI">VI</option>
<option value="AA">AA</option>
<option value="AE">AE</option>
<option value="AP">AP</option>
</select>
</label></div>
<div class="at-row at-row-solo RecipientEmailAddress e-mail"><label class="at-text RecipientEmailAddress e-mail" id="NVContributionForm82690-RecipientInformation-RecipientEmailAddress">Email* <small>(Optional)</small><input type="email"
autocomplete="on" pattern="^([\w!#$%&'*+\-\/=?\^`\{\|\}~]+\.)*[\w!#$%&'*+\-\/=?\^`\{\|\}~]+@((((([a-zA-Z0-9]{1}[a-zA-Z0-9\-]{0,62}[a-zA-Z0-9]{1})|[a-zA-Z])\.)+[a-zA-Z]{2,62})|(\d{1,3}\.){3}\d{1,3}(:\d{1,5})?)$" false=""
title="Email*" name="RecipientEmailAddress" value="" maxlength="100">
</label></div>
<div class="at-row at-row-solo Ecard">
<div class="form-unit form-unit-radio form-item-ecard" id="NVContributionForm82690-RecipientInformation-Ecard"></div>
</div>
<div class="at-row at-row-solo NotificationSendDate"><label class="at-date notificationsenddate" id="NVContributionForm82690-RecipientInformation-NotificationSendDate"></label></div>
<div class="at-row at-row-solo at-row-full NotificationSendCopy"><label class="at-check NotificationSendCopy" id="NVContributionForm82690-RecipientInformation-NotificationSendCopy"></label></div>
<div class="at-row at-row-solo NotificationMessage"><label class="at-area NotificationMessage" id="NVContributionForm82690-RecipientInformation-NotificationMessage"></label>
<div class="at-title">Message</div>
<div class="msg-1"><input type="radio" name="radioMsg" id="msg-1" value="As a token of gratitude, a gift has been made in your honor."><label for="msg-1" value="As a token of gratitude, a gift has been made in your honor.">As a token of
gratitude, a gift has been made in your honor.</label></div>
<div class="msg-2"><input type="radio" name="radioMsg" id="msg-2" value="Happy Birthday!"><label value="Happy Birthday!" for="msg-2">Happy Birthday!</label></div>
<div class="msg-3"><input type="radio" name="radioMsg" id="msg-3" value="So thankful for you!"><label value="So thankful for you!" for="msg-3">So thankful for you!</label></div>
<div class="msg-4"><input type="radio" name="radioMsg" id="msg-4" value="Be Mine"><label value="Be Mine" for="msg-4">Be Mine</label></div>
<div class="msg-5"><input type="radio" name="radioMsg" id="msg-5" value="In loving memory"><label value="In loving memory" for="msg-5">In loving memory</label></div>
</div>
</div>
<div class="at-row ecard-section e-mail">
<div class="at-recipient-msg" style="display: none;">
<div class="form-unit form-unit-radio form-item-ecard" id="NVContributionForm82690-RecipientInformation-Ecard">
<div class="at-title"> Select an Ecard </div>
<div class="at-ecards clearfix">
<div class="at-ecard selected">
<div class="at-ecard-img">
<img src="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/19850/images/ecards/bluestate_PP_ecards-2-Holiday_2020_sk1.gif" alt="bluestate_PP_ecards-2-Holiday_2020_sk1">
</div>
<input name="ecard" type="radio" value="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/19850/images/ecards/bluestate_PP_ecards-2-Holiday_2020_sk1.gif" checked="">
</div>
<div class="at-ecard">
<div class="at-ecard-img">
<img src="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/19850/images/ecards/bluestate_PP_ecards-4-Birthday_2020_sk1.gif" alt="bluestate_PP_ecards-4-Birthday_2020_sk1">
</div>
<input name="ecard" type="radio" value="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/19850/images/ecards/bluestate_PP_ecards-4-Birthday_2020_sk1.gif">
</div>
<div class="at-ecard">
<div class="at-ecard-img">
<img src="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/19850/images/ecards/bluestate_PP_ecards-5-Wedding_2020_sk1.gif" alt="bluestate_PP_ecards-5-Wedding_2020_sk1">
</div>
<input name="ecard" type="radio" value="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/19850/images/ecards/bluestate_PP_ecards-5-Wedding_2020_sk1.gif">
</div>
<div class="at-ecard">
<div class="at-ecard-img">
<img src="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/19850/images/ecards/bluestate_PP_ecards-9-IMO_2020_sk1.gif" alt="bluestate_PP_ecards-9-IMO_2020_sk1">
</div>
<input name="ecard" type="radio" value="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/19850/images/ecards/bluestate_PP_ecards-9-IMO_2020_sk1.gif">
</div>
<div class="at-ecard">
<div class="at-ecard-img">
<img src="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/19850/images/ecards/bluestate_PP_ecards-8-IMO_2020_sk1.gif" alt="bluestate_PP_ecards-8-IMO_2020_sk1">
</div>
<input name="ecard" type="radio" value="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/19850/images/ecards/bluestate_PP_ecards-8-IMO_2020_sk1.gif">
</div>
<div class="at-ecard">
<div class="at-ecard-img">
<img src="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/19850/images/ecards/bluestate_PP_ecards-3-General_2020_sk1.gif" alt="bluestate_PP_ecards-3-General_2020_sk1">
</div>
<input name="ecard" type="radio" value="//nvlupin.blob.core.windows.net/images/van/AV/PPFA/1/19850/images/ecards/bluestate_PP_ecards-3-General_2020_sk1.gif">
</div>
<button type="button" class="at-preview-ecard btn-at btn-at-link">Preview Ecard</button>
</div>
</div><label class="at-date notificationsenddate" id="NVContributionForm82690-RecipientInformation-NotificationSendDate">Send Date <small>(Optional)</small><input type="text" title="Send Date" name="NotificationSendDate" value=""
maxlength="10" size="10" class="hasDatepicker" placeholder="MM/DD/YYYY" autocomplete="off" id="dp1728473495975">
</label><label class="at-check NotificationSendCopy" id="NVContributionForm82690-RecipientInformation-NotificationSendCopy"><input type="checkbox" name="NotificationSendCopy"> <span class="at-checkbox-title-container"><span
class="at-checkbox-title" id="NVContributionForm82690-RecipientInformation-NotificationSendCopy-label">Please send me a copy of the email when the email is sent</span></span>
</label><label class="at-area NotificationMessage" id="NVContributionForm82690-RecipientInformation-NotificationMessage" style="display: inline;">Message <small>(Optional)</small><textarea false="" title="Message"
name="NotificationMessage" maxlength="4000"></textarea>
</label>
</div>
</div>
</div>
</fieldset>
<fieldset class="at-fieldset ContactInformation" id="NVContributionForm82690-ContactInformation">
<div class="at-fields">
<div class="at-row FirstName LastName"><label class="at-text FirstName" id="NVContributionForm82690-ContactInformation-FirstName">First Name<input type="text" autocomplete="given-name" x-autocompletetype="given-name" required=""
title="First Name (required)" name="FirstName" value="" maxlength="20">
</label><label class="at-text LastName" id="NVContributionForm82690-ContactInformation-LastName">Last Name<input type="text" autocomplete="family-name" x-autocompletetype="surname" required="" title="Last Name (required)" name="LastName"
value="" maxlength="25">
</label></div>
<div class="at-row at-row-solo Pronoun"><label class="at-select Pronoun" id="NVContributionForm82690-ContactInformation-Pronoun">Pronouns <small>(Optional)</small><select autocomplete="on" title="Pronouns" name="Pronoun" class=" "
id="NVContributionForm82690-ContactInformation-Pronoun-select">
<option value="">- Select -</option>
<option value="5">(F)ae/(F)aer/(F)aers</option>
<option value="19">Any/All Pronouns</option>
<option value="6">E/Em/Eirs</option>
<option value="7">Ey/Em/Eirs</option>
<option value="2">He/Him/His</option>
<option value="18">He/She/They</option>
<option value="16">He/Them/Theirs</option>
<option value="17">Name Only</option>
<option value="8">Per/Per/Pers</option>
<option value="1">She/Her/Hers</option>
<option value="15">She/Them/Theirs</option>
<option value="9">Sie/Sie/Hirs</option>
<option value="10">Tey/Ter/Ters</option>
<option value="3">They/Them/Theirs</option>
<option value="11">Ve/Ver/Vers</option>
<option value="12">Ve/Ver/Vis</option>
<option value="4">Xe/Xem/Xyrs</option>
<option value="13">Ze/Hir/Hirs</option>
<option value="14">Zie/Zim/Zis</option>
</select>
</label></div>
<div class="at-row Genders SexualOrientation Race Ethnicity"><label class="at-select Genders multi-select" id="NVContributionForm82690-ContactInformation-Genders">Gender <small>(Optional)</small><select multiple="" autocomplete="on"
title="Gender" name="Genders" class="select2-hidden-accessible" id="NVContributionForm82690-ContactInformation-Genders-select" tabindex="-1" aria-hidden="true">
<option value="">- Select -</option>
<option value="18">Agender</option>
<option value="51">Cisgender</option>
<option value="5">Gender Fluid</option>
<option value="6">Gender Non-conforming</option>
<option value="7">Genderqueer</option>
<option value="27">Intersex</option>
<option value="10">Man</option>
<option value="12">Non-Binary</option>
<option value="56">Not Listed</option>
<option value="16">Transgender</option>
<option value="17">Woman</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" style="width: 264px;"><span class="selection"><span class="select2-selection select2-selection--multiple" role="combobox" aria-haspopup="true"
aria-expanded="false" title="Gender" tabindex="-1">
<ul class="select2-selection__rendered">
<li class="select2-search select2-search--inline"><input class="select2-search__field" type="search" tabindex="0" autocomplete="off" autocorrect="off" autocapitalize="off" spellcheck="false" role="textbox" aria-autocomplete="list"
placeholder="- Select -" style="width: 262px;"></li>
</ul>
</span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
</label><label class="at-select SexualOrientation multi-select" id="NVContributionForm82690-ContactInformation-SexualOrientation">Sexual Orientation <small>(Optional)</small><select multiple="" autocomplete="on" title="Sexual Orientation"
name="SexualOrientation" class="select2-hidden-accessible" id="NVContributionForm82690-ContactInformation-SexualOrientation-select" tabindex="-1" aria-hidden="true">
<option value="">- Select -</option>
<option value="5">Bisexual</option>
<option value="21">Gay</option>
<option value="22">Lesbian</option>
<option value="25">Not Listed</option>
<option value="16">Queer</option>
<option value="24">Straight/Heterosexual</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" style="width: 264px;"><span class="selection"><span class="select2-selection select2-selection--multiple" role="combobox" aria-haspopup="true"
aria-expanded="false" title="Sexual Orientation" tabindex="-1">
<ul class="select2-selection__rendered">
<li class="select2-search select2-search--inline"><input class="select2-search__field" type="search" tabindex="0" autocomplete="off" autocorrect="off" autocapitalize="off" spellcheck="false" role="textbox" aria-autocomplete="list"
placeholder="- Select -" style="width: 262px;"></li>
</ul>
</span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
</label><label class="at-select Race multi-select" id="NVContributionForm82690-ContactInformation-Race">Race <small>(Optional)</small><select multiple="" autocomplete="on" title="Race" name="Race" class="select2-hidden-accessible"
id="NVContributionForm82690-ContactInformation-Race-select" tabindex="-1" aria-hidden="true">
<option value="">- Select -</option>
<option value="24">Arab American and/or Middle Eastern</option>
<option value="20">Asian American, East Asian, South Asian, and/or Southeast Asian</option>
<option value="21">Black, African, and/or African American</option>
<option value="3">Caucasian or White</option>
<option value="23">Hispanic and/or Latina/o/x</option>
<option value="22">Native American and/or Indigenous</option>
<option value="5">Native Hawaiian</option>
<option value="25">Not Listed</option>
<option value="7">Pacific Islander</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" style="width: 264px;"><span class="selection"><span class="select2-selection select2-selection--multiple" role="combobox" aria-haspopup="true"
aria-expanded="false" title="Race" tabindex="-1">
<ul class="select2-selection__rendered">
<li class="select2-search select2-search--inline"><input class="select2-search__field" type="search" tabindex="0" autocomplete="off" autocorrect="off" autocapitalize="off" spellcheck="false" role="textbox" aria-autocomplete="list"
placeholder="- Select -" style="width: 262px;"></li>
</ul>
</span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
</label><label class="at-select Ethnicity multi-select" id="NVContributionForm82690-ContactInformation-Ethnicity">Ethnicity <small>(Optional)</small><select multiple="" autocomplete="on" title="Ethnicity" name="Ethnicity"
class="select2-hidden-accessible" id="NVContributionForm82690-ContactInformation-Ethnicity-select" tabindex="-1" aria-hidden="true">
<option value="">- Select -</option>
<option value="1">Afghani</option>
<option value="78">African American</option>
<option value="2">Arab</option>
<option value="21">Arabian</option>
<option value="22">Armenian</option>
<option value="4">Bangladeshi</option>
<option value="97">Bengali</option>
<option value="5">Bhutanese</option>
<option value="6">Brazilian</option>
<option value="54">Bulgarian</option>
<option value="55">Burmese</option>
<option value="56">Cambodian</option>
<option value="93">Chamorro</option>
<option value="98">Chin</option>
<option value="7">Chinese</option>
<option value="44">Czechoslovakian</option>
<option value="75">Danish</option>
<option value="46">Dutch</option>
<option value="8">East African</option>
<option value="88">Egyptian</option>
<option value="26">English (British)</option>
<option value="57">Estonian</option>
<option value="58">Ethiopian</option>
<option value="9">Filipino</option>
<option value="59">Finnish</option>
<option value="27">French</option>
<option value="28">German</option>
<option value="47">Greek</option>
<option value="10">Haitian</option>
<option value="77">Hawaiian</option>
<option value="82">Hispanic</option>
<option value="11">Hmong</option>
<option value="48">Hungarian</option>
<option value="60">Icelandic</option>
<option value="25">Indian</option>
<option value="12">Indo Carribean</option>
<option value="61">Indonesian</option>
<option value="30">Irish</option>
<option value="31">Italian</option>
<option value="32">Japanese</option>
<option value="99">Karen</option>
<option value="40">Korean</option>
<option value="13">Lao</option>
<option value="20">Latino</option>
<option value="64">Latvian</option>
<option value="90">Lebanese</option>
<option value="65">Lithuanian</option>
<option value="66">Malaysian</option>
<option value="67">Manx</option>
<option value="96">Mien</option>
<option value="83">Mixed Ethnicity</option>
<option value="101">Mongolian</option>
<option value="89">Morrocan</option>
<option value="138">Native Alaskan</option>
<option value="35">Native American</option>
<option value="14">Nepali</option>
<option value="84">Non-Hispanic White</option>
<option value="45">Norwegian</option>
<option value="136">Not Listed</option>
<option value="103">Okinawan</option>
<option value="143">Pacific Islander</option>
<option value="15">Pakistani</option>
<option value="86">Persian</option>
<option value="34">Polish</option>
<option value="68">Portuguese</option>
<option value="50">Russian</option>
<option value="39">Samoan</option>
<option value="36">Scottish</option>
<option value="104">Singaporean</option>
<option value="16">Somali</option>
<option value="17">Sri Lankan</option>
<option value="37">Swedish</option>
<option value="71">Swiss</option>
<option value="137">Tagalog</option>
<option value="105">Taiwanese</option>
<option value="72">Thai</option>
<option value="18">Tibetan</option>
<option value="106">Tongan</option>
<option value="73">Turkish</option>
<option value="51">Ukrainian</option>
<option value="120">Unknown</option>
<option value="19">Vietnamese</option>
<option value="52">Welsh</option>
<option value="87">Yemeni</option>
<option value="74">Yugoslavian</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" style="width: 264px;"><span class="selection"><span class="select2-selection select2-selection--multiple" role="combobox" aria-haspopup="true"
aria-expanded="false" title="Ethnicity" tabindex="-1">
<ul class="select2-selection__rendered">
<li class="select2-search select2-search--inline"><input class="select2-search__field" type="search" tabindex="0" autocomplete="off" autocorrect="off" autocapitalize="off" spellcheck="false" role="textbox" aria-autocomplete="list"
placeholder="- Select -" style="width: 262px;"></li>
</ul>
</span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
</label></div>
<div class="at-row at-row-solo AddressLine1"><label class="at-text AddressLine1" id="NVContributionForm82690-ContactInformation-AddressLine1">Street Address<input type="text" autocomplete="address-line1" x-autocompletetype="address-line1"
required="" title="Street Address (required)" name="AddressLine1" value="" maxlength="99">
</label></div>
<div class="at-row Country PostalCode City StateProvince"><label class="at-select Country" id="NVContributionForm82690-ContactInformation-Country">Country <small>(Optional)</small><select autocomplete="country-name" x-autocompletetype="country"
title="Country" name="Country" class="select2-hidden-accessible" id="NVContributionForm82690-ContactInformation-Country-select" tabindex="-1" aria-hidden="true">
<option value="">- Select -</option>
<option value="AF">Afghanistan</option>
<option value="AX">Åland Islands</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AD">Andorra</option>
<option value="AO">Angola</option>
<option value="AI">Anguilla</option>
<option value="AQ">Antarctica</option>
<option value="AG">Antigua and Barbuda</option>
<option value="AR">Argentina</option>
<option value="AM">Armenia</option>
<option value="AW">Aruba</option>
<option value="AU">Australia</option>
<option value="AT">Austria</option>
<option value="AZ">Azerbaijan</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BD">Bangladesh</option>
<option value="BB">Barbados</option>
<option value="BY">Belarus</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BJ">Benin</option>
<option value="BM">Bermuda</option>
<option value="BT">Bhutan</option>
<option value="BO">Bolivia (Plurinational State of)</option>
<option value="BQ">Bonaire, Sint Eustatius and Saba</option>
<option value="BA">Bosnia and Herzegovina</option>
<option value="BW">Botswana</option>
<option value="BV">Bouvet Island</option>
<option value="BR">Brazil</option>
<option value="IO">British Indian Ocean Territory</option>
<option value="VG">British Virgin Islands</option>
<option value="BN">Brunei Darussalam</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="CV">Cabo Verde</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="KY">Cayman Islands</option>
<option value="CF">Central African Republic</option>
<option value="TD">Chad</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CX">Christmas Island</option>
<option value="CC">Cocos (Keeling) Islands</option>
<option value="CO">Colombia</option>
<option value="KM">Comoros</option>
<option value="CG">Congo</option>
<option value="CD">Congo (Democratic Republic of the)</option>
<option value="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="CI">Côte d'Ivoire</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CW">Curaçao</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czechia</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="GQ">Equatorial Guinea</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="SZ">Eswatini</option>
<option value="ET">Ethiopia</option>
<option value="FK">Falkland Islands (Malvinas)</option>
<option value="FO">Faroe Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="GF">French Guiana</option>
<option value="PF">French Polynesia</option>
<option value="TF">French Southern Territories</option>
<option value="GA">Gabon</option>
<option value="GM">Gambia</option>
<option value="GE">Georgia</option>
<option value="DE">Germany</option>
<option value="GH">Ghana</option>
<option value="GI">Gibraltar</option>
<option value="GR">Greece</option>
<option value="GL">Greenland</option>
<option value="GD">Grenada</option>
<option value="GP">Guadeloupe</option>
<option value="GT">Guatemala</option>
<option value="GG">Guernsey</option>
<option value="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard Island and McDonald Islands</option>
<option value="VA">Holy See</option>
<option value="HN">Honduras</option>
<option value="HK">Hong Kong</option>
<option value="HU">Hungary</option>
<option value="IS">Iceland</option>
<option value="IN">India</option>
<option value="ID">Indonesia</option>
<option value="IR">Iran (Islamic Republic of)</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IM">Isle of Man</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JE">Jersey</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KP">Korea (Democratic People's Republic of)</option>
<option value="KR">Korea (Republic of)</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Lao People's Democratic Republic</option>
<option value="LV">Latvia</option>
<option value="LB">Lebanon</option>
<option value="LS">Lesotho</option>
<option value="LR">Liberia</option>
<option value="LY">Libya</option>
<option value="LI">Liechtenstein</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="MO">Macao</option>
<option value="MG">Madagascar</option>
<option value="MW">Malawi</option>
<option value="MY">Malaysia</option>
<option value="MV">Maldives</option>
<option value="ML">Mali</option>
<option value="MT">Malta</option>
<option value="MQ">Martinique</option>
<option value="MR">Mauritania</option>
<option value="MU">Mauritius</option>
<option value="YT">Mayotte</option>
<option value="MX">Mexico</option>
<option value="FM">Micronesia (Federated States of)</option>
<option value="MD">Moldova (Republic of)</option>
<option value="MC">Monaco</option>
<option value="MN">Mongolia</option>
<option value="ME">Montenegro</option>
<option value="MS">Montserrat</option>
<option value="MA">Morocco</option>
<option value="MZ">Mozambique</option>
<option value="MM">Myanmar</option>
<option value="NA">Namibia</option>
<option value="NR">Nauru</option>
<option value="NP">Nepal</option>
<option value="NL">Netherlands</option>
<option value="NC">New Caledonia</option>
<option value="NZ">New Zealand</option>
<option value="NI">Nicaragua</option>
<option value="NE">Niger</option>
<option value="NG">Nigeria</option>
<option value="NU">Niue</option>
<option value="NF">Norfolk Island</option>
<option value="MK">North Macedonia</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PK">Pakistan</option>
<option value="PW">Palau</option>
<option value="PS">Palestine (State of)</option>
<option value="PA">Panama</option>
<option value="PG">Papua New Guinea</option>
<option value="PY">Paraguay</option>
<option value="PE">Peru</option>
<option value="PH">Philippines</option>
<option value="PN">Pitcairn</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="QA">Qatar</option>
<option value="RE">Réunion</option>
<option value="RO">Romania</option>
<option value="RU">Russian Federation</option>
<option value="RW">Rwanda</option>
<option value="BL">Saint Barthélemy</option>
<option value="SH">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="MF">Saint Martin (French part)</option>
<option value="PM">Saint Pierre and Miquelon</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</option>
<option value="ST">Sao Tome and Principe</option>
<option value="SA">Saudi Arabia</option>
<option value="SN">Senegal</option>
<option value="RS">Serbia</option>
<option value="SC">Seychelles</option>
<option value="SL">Sierra Leone</option>
<option value="SG">Singapore</option>
<option value="SX">Sint Maarten (Dutch part)</option>
<option value="SK">Slovakia</option>
<option value="SI">Slovenia</option>
<option value="SB">Solomon Islands</option>
<option value="SO">Somalia</option>
<option value="ZA">South Africa</option>
<option value="GS">South Georgia and the South Sandwich Islands</option>
<option value="SS">South Sudan</option>
<option value="ES">Spain</option>
<option value="LK">Sri Lanka</option>
<option value="SD">Sudan</option>
<option value="SR">Suriname</option>
<option value="SJ">Svalbard and Jan Mayen</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syrian Arab Republic</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania (United Republic of)</option>
<option value="TH">Thailand</option>
<option value="TL">Timor-Leste</option>
<option value="TG">Togo</option>
<option value="TK">Tokelau</option>
<option value="TO">Tonga</option>
<option value="TT">Trinidad and Tobago</option>
<option value="TN">Tunisia</option>
<option value="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks and Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom</option>
<option value="US">United States</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VE">Venezuela (Bolivarian Republic of)</option>
<option value="VN">Viet Nam</option>
<option value="WF">Wallis and Futuna</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
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role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
</label><label class="at-text PostalCode" id="NVContributionForm82690-ContactInformation-PostalCode">Postal Code<input type="tel" autocomplete="postal-code" x-autocompletetype="postal-code" pattern="^\d{5}([\-]\d{4})?$" required=""
title="Postal Code (required)" name="PostalCode" value="" maxlength="10">
</label><label class="at-text City" id="NVContributionForm82690-ContactInformation-City">City<input type="text" autocomplete="address-level2" x-autocompletetype="locality" required="" title="City (required)" name="City" value=""
maxlength="25">
</label><label class="at-select StateProvince" id="NVContributionForm82690-ContactInformation-StateProvince">State/Province<select required="" autocomplete="address-level1" x-autocompletetype="administrative-area" title="State/Province"
name="StateProvince" class=" required" id="NVContributionForm82690-ContactInformation-StateProvince-select">
<option value="" disabled="">- State -</option>
<option value="AK">AK</option>
<option value="AL">AL</option>
<option value="AR">AR</option>
<option value="AZ">AZ</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DC">DC</option>
<option value="DE">DE</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="HI">HI</option>
<option value="IA">IA</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="MA">MA</option>
<option value="MD">MD</option>
<option value="ME">ME</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MO">MO</option>
<option value="MS">MS</option>
<option value="MT">MT</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="NE">NE</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NV">NV</option>
<option value="NY">NY</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="RI">RI</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VA">VA</option>
<option value="VT">VT</option>
<option value="WA">WA</option>
<option value="WI">WI</option>
<option value="WV">WV</option>
<option value="WY">WY</option>
<option value="AS">AS</option>
<option value="FM">FM</option>
<option value="GU">GU</option>
<option value="MH">MH</option>
<option value="MP">MP</option>
<option value="PR">PR</option>
<option value="PW">PW</option>
<option value="VI">VI</option>
<option value="AA">AA</option>
<option value="AE">AE</option>
<option value="AP">AP</option>
</select>
</label></div>
<div class="at-row EmailAddress HomePhone MobilePhone"><label class="at-text EmailAddress" id="NVContributionForm82690-ContactInformation-EmailAddress">Email<input type="email" autocomplete="email" x-autocompletetype="email"
pattern="^([\w!#$%&'*+\-\/=?\^`\{\|\}~]+\.)*[\w!#$%&'*+\-\/=?\^`\{\|\}~]+@((((([a-zA-Z0-9]{1}[a-zA-Z0-9\-]{0,62}[a-zA-Z0-9]{1})|[a-zA-Z])\.)+[a-zA-Z]{2,62})|(\d{1,3}\.){3}\d{1,3}(:\d{1,5})?)$" required="" title="Email (required)"
name="EmailAddress" value="" maxlength="100" placeholder="email@email.com">
</label><label class="at-text HomePhone" id="NVContributionForm82690-ContactInformation-HomePhone">Home Phone <small>(Optional)</small>
<div class="intl-tel-input iti iti--allow-dropdown">
<div class="iti__flag-container">
<div class="iti__selected-flag" role="combobox" aria-controls="iti-0__country-listbox" aria-owns="iti-0__country-listbox" aria-expanded="false" tabindex="0" title="United States: +1" aria-activedescendant="iti-0__item-us-preferred">
<div class="iti__flag iti__us"></div>
<div class="iti__arrow"></div>
</div>
</div><input type="tel" class="intl-phone-HomePhone" name="HomePhone" title="Home Phone" data-intl-tel-input-id="0">
</div>
</label><label class="at-text MobilePhone" id="NVContributionForm82690-ContactInformation-MobilePhone">Mobile Phone <small>(Optional)</small>
<div class="intl-tel-input iti iti--allow-dropdown">
<div class="iti__flag-container">
<div class="iti__selected-flag" role="combobox" aria-controls="iti-1__country-listbox" aria-owns="iti-1__country-listbox" aria-expanded="false" tabindex="0" title="United States: +1" aria-activedescendant="iti-1__item-us-preferred">
<div class="iti__flag iti__us"></div>
<div class="iti__arrow"></div>
</div>
</div><input type="tel" class="intl-phone-MobilePhone" name="MobilePhone" title="Mobile Phone" data-intl-tel-input-id="1">
</div>
</label></div>
<div class="at-row at-row-solo at-row-full SmsSubscribeMobilePhone"><label class="at-check SmsSubscribeMobilePhone" id="NVContributionForm82690-ContactInformation-SmsSubscribeMobilePhone"><input type="checkbox" checked=""
name="SmsSubscribeMobilePhone"> <span class="at-checkbox-title-container"><span class="at-checkbox-title" id="NVContributionForm82690-ContactInformation-SmsSubscribeMobilePhone-label">Sign me up for SMS messages.</span></span>
</label></div>
<div class="at-row at-row-solo at-row-full SmsLegalDisclaimer at-indented">
<div class="at-markup SmsLegalDisclaimer at-legal" id="NVContributionForm82690-ContactInformation-SmsLegalDisclaimer">
<p>By submitting your mobile phone number you are agreeing to receive periodic text messages from this organization. Message and data rates may apply. Text HELP for more information. Text STOP to stop receiving messages.</p>
</div>
</div>
<div class="at-row at-row-solo at-row-full YesSignMeUpForUpdatesForBinder require"><label class="at-check YesSignMeUpForUpdatesForBinder" id="NVContributionForm82690-ContactInformation-YesSignMeUpForUpdatesForBinder"><input type="checkbox"
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receive emails from Planned Parenthood organizations. I may unsubscribe at any time.</span></span>
</label></div>
<div class="at-row "><label class="at-text PersonalUrl" id="NVContributionForm82690-ContactInformation-PersonalUrl"> <small>(Optional)</small><input type="text" autocomplete="on" false="" title="" name="PersonalUrl" value="" maxlength="">
</label></div>
<div class="at-row ">
<div class="at-markup TrackingPixel" id="NVContributionForm82690-ContactInformation-TrackingPixel" style="display: none;"><img alt=""
src="https://secure.everyaction.com/v1/Track/bSOWsEK_106TLK4YYWQg1A2?formSessionId=eb7b8771-801d-4871-b76b-40f6fd7ff966&bName=chrome&dType=desktop&formVersion=4/11/2024 7:10:51 PM|9/3/2024 5:36:08 PM&fUrl=aHR0cHM6Ly93d3cud2VhcmVwbGFubmVkcGFyZW50aG9vZC5vcmcvb25saW5lYWN0aW9ucy9iU09Xc0VLXzEwNlRMSzRZWVdRZzFBMg%3D%3D&fRef="
style="display:none"></div>
</div>
</div>
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<fieldset class="at-fieldset EmployerMatching" id="NVContributionForm82690-EmployerMatching">
<legend class="at-legend">Employer Matching</legend>
<div class="at-fields">
<div class="at-row at-row-full EmployerMatchingHeaderHtml">
<div class="at-markup EmployerMatchingHeaderHtml" id="NVContributionForm82690-EmployerMatching-EmployerMatchingHeaderHtml">Enter your work email address to determine if your gift is eligible to be matched by your employer</div>
</div>
<div class="at-row at-row-full MatchingWorkEmail">
<label class="at-text MatchingWorkEmail" id="NVContributionForm82690-EmployerMatching-MatchingWorkEmail">Work Email <small>(Optional)</small><input type="email" autocomplete="on"
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</label>
</div>
</div>
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<fieldset class="at-fieldset PaymentInformation" id="NVContributionForm82690-PaymentInformation">
<legend class="at-legend">Payment Information</legend>
<div class="at-row">
<div class="at-payment-method-buttons" id="NVContributionForm82690-PaymentInformation-PaymentMethod"></div>
</div>
<div class="at-fields">
<div class="at-row "><label class="at-text at-cc-number" id="NVContributionForm82690-PaymentInformation-Account">Card Number<div class="cc-type-wrapper vgs-loading-placeholder" style="display: none;">
<div class="cc-type unknown"></div>
<input type="tel" autocomplete="cc-number" title="Credit Card Number" placeholder="•••• •••• •••• ••••" readonly="true">
</div>
<div id="vgs-Account-82690" class="vgs-cc-iframe-wrapper vgs-input-container vgs-collect-container__empty vgs-collect-container__invalid isEmpty" tabindex="-1"><iframe title="Secure card number input frame"
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<input type="tel" autocomplete="cc-exp" title="Expiration Date (MM / YY)" placeholder="MM / YY" readonly="true">
</div>
<div id="vgs-ExpirationDate-82690" class="vgs-ccexpiration-iframe-wrapper vgs-input-container vgs-collect-container__empty vgs-collect-container__invalid isEmpty"><iframe title="Secure card expiration date input frame"
src="https://js.verygoodvault.com/vgs-collect/2.18.4/lib/index.html#name=ExpirationDate&placeholder=MM%20%2F%20YY&type=card-expiration-date&serializers=W3sibmFtZSI6InNlcGFyYXRlIiwib3B0aW9ucyI6eyJtb250aE5hbWUiOiJFeHBpcmF0aW9uTW9udGgiLCJ5ZWFyTmFtZSI6IkV4cGlyYXRpb25ZZWFyIn19XQ%3D%3D&validations%5B0%5D=validCardExpirationDate&validations%5B1%5D=required&autoComplete=cc-exp&formId=randomId9010774955039787337&fieldId=randomId9014110227699609457&createdAt=1728473496833&tnt=dG50dzFwem5sYW0%3D&env=bGl2ZQ%3D%3D&logLevel=default&satellitePort=&vgsCollectSessionId=5a2fdd15-d0ee-4f61-9522-d08c2cdee436&css%5BfontSize%5D=.875rem&css%5BfontFamily%5D=monospace&css%5BlineHeight%5D=1&css%5BbackgroundColor%5D=%23fff&css%5B%26%3A%3Aplaceholder%5D%5Bcolor%5D=%23ced4da&css%5B%26%3A%3Aplaceholder%5D%5BfontWeight%5D=bold"
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</label></div>
</div>
</fieldset>
<div class="at-form-submit clearfix">
<input type="submit" value="Donate $100" class="at-submit btn-at btn-at-primary">
<div class="at-markup secure-processing-single-step-div" style="display: block;">
<label class="secure-processing-label at-text"> Your donation will be securely processed.<div class="glyphicons glyphicons-lock" aria-hidden="true"></div>
</label>
</div>
</div>
</form>Text Content
Planned Parenthood of Michigan Support Planned Parenthood in Michigan DONATE TO PLANNED PARENTHOOD OF MICHIGAN For more than 100 years, Planned Parenthood has promoted a common-sense approach to women's health and well-being based on respect for each individual's right to make informed, independent decisions about sex, health, and family planning. As a trusted health care provider and a passionate advocate, Planned Parenthood delivers vital health care, sex education, and sexual health information to thousands of women, men, and teens each year. In fact, one in five women in America will turn to Planned Parenthood for professional, confidential, nonjudgmental health care. We can't thank you enough! Your support brings life-saving health care to people in Michigan communities just like yours. We couldn't do this work without you. Gifts to PPMI, a 501(c)(3) nonprofit organization, are tax deductible to the extent allowed by law. CONSIDER A SUSTAINING GIFT Your automatic monthly gift allows more of your support to go directly to on-the-ground efforts to promote healthy Michigan communities and the right of all individuals to manage their sexual health by providing health care and education and serving as a strong advocate for reproductive justice. Become a sustaining donor and help ensure Planned Parenthood of Michigan will always be ready to take action to defend and offer reproductive health care for women, men, and young people who need it most! You can change or stop your sustaining donation at any time. KATHARINE DEXTER MCCORMICK SOCIETY* With your gift of at least $1,000 or a sustaining gift of at least $84 per month, you will join in the Katharine Dexter McCormick Society. The birth control pill is often heralded as the most important medical advancement in human history. But without the sole financial support of Katharine Dexter McCormick, a Michigan-born benefactor, the pill might never have been invented! PPMI honors her legacy through the Katharine Dexter McCormick Society, a philanthropic group of leaders who support our mission and services, thereby ensuring that the women of future generations are empowered to shape their own lives and futures. Design your gift One-Time Monthly A monthly gift does even more to support reproductive health care KDMS* ($1,000) $500 $100 $75 $50 $25 Other $ I'd like to cover the transaction fees for my contribution I'd like to make this contribution in honor or in memory of someone Is this an Honorary or Memorial Gift? In honor of In memory of Honoree Name I'd like to notify someone of this contribution I'd like an e-card to be sent via email (delivered instantly or on a specific date of your choosing) I'd like a physical card to be sent via the mail (delivered within 2 - 3 weeks) Who would you like to notify? We will send an email notification to the email address you provide below. We are unable to send anonymous notifications — the recipient will see your name and email address. 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