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.radio-button-style-item:nth-child(2) { background-image: url("data:image/svg+xml,%3Csvg xmlns='//www.w3.org/2000/svg' fill='none' viewBox='0 0 60 63'%3E%3Cdefs/%3E%3Crect width='24' height='24' x='.5' y='.5' fill='%23fff' stroke='%23C3CAD8' rx='12'/%3E%3Crect width='24' height='24' x='.5' y='37.5' fill='%23fff' stroke='%232E69FF' rx='12'/%3E%3Crect width='24' height='24' x='35.5' y='37.5' fill='%23fff' stroke='%23C3CAD8' rx='1.5'/%3E%3Crect width='24' height='24' x='35.5' y='37.5' fill='%232E69FF' stroke='%232E69FF' rx='1.5'/%3E%3Crect width='24' height='24' x='35.5' y='.5' fill='%23fff' stroke='%23C3CAD8' rx='1.5'/%3E%3Crect width='24.9' height='24.9' x='.2' y='37.1' fill='%232E69FF' rx='12.5'/%3E%3Ccircle cx='12.7' cy='49.6' r='3.7' fill='%23fff'/%3E%3Crect width='24' height='24' x='35.5' y='37.5' fill='%23fff' stroke='%23C3CAD8' rx='1.5'/%3E%3Crect width='24' height='24' x='35.5' y='37.5' fill='%232E69FF' stroke='%232E69FF' rx='1.5'/%3E%3Crect width='7' height='7' x='44' y='46' fill='%23fff' rx='1'/%3E%3C/svg%3E");
}
.radio-button-style-item:nth-child(3) { background-image: url("data:image/svg+xml,%3Csvg xmlns='//www.w3.org/2000/svg' fill='none' viewBox='0 0 62 63'%3E%3Cdefs/%3E%3Crect width='24' height='24' x='.5' y='.5' fill='%23fff' stroke='%23C3CAD8' rx='12'/%3E%3Crect width='22' height='22' x='1.5' y='1.5' stroke='%23C3CAD8' stroke-width='3' rx='11'/%3E%3Cpath fill='%232E69FF' d='M9.3 47c-.7-.8-1.8-.8-2.5 0-.8.7-.8 1.8 0 2.5l3.6 3.7c.4.4.8.6 1.3.6.6 0 1-.2 1.3-.6l12.9-13c.7-.7.7-1.8 0-2.5-.7-.8-1.8-.8-2.6 0L11.7 49.3 9.3 47z'/%3E%3Cpath fill='%232E69FF' d='M12.7 62.1c7 0 12.6-5.5 12.6-12.5 0-1-.8-1.8-1.8-1.8-1.1 0-1.8.7-1.8 1.8 0 5-4 9-9 9s-8.9-4-8.9-9a8.8 8.8 0 0112-8.4c.9.4 2-.2 2.3-1 .4-1-.2-2-1-2.4a12 12 0 00-4.4-.7C5.7 37.1.2 42.7.2 49.6c0 7 5.6 12.5 12.5 12.5z'/%3E%3Cmask id='a' fill='%23fff'%3E%3Crect width='25' height='25' x='35' rx='2'/%3E%3C/mask%3E%3Crect width='25' height='25' x='35' fill='%23fff' stroke='%23C3CAD8' stroke-width='6' mask='url(%23a)' rx='2'/%3E%3Cpath fill='%232E69FF' d='M51.5 39.8a1.5 1.5 0 000-3v3zm8.1 9.3a1.5 1.5 0 10-3 0h3zm-3.5 10h-17v3h17v-3zm-17.6-.6V40.3h-3v18.2h3zm.5-18.7h12.5v-3H39v3zm20.6 18.7v-9.4h-3v9.4h3zM39 59a.5.5 0 01-.5-.5h-3c0 2 1.6 3.5 3.5 3.5v-3zm17.1 3c2 0 3.5-1.5 3.5-3.5h-3c0 .3-.2.5-.5.5v3zM38.5 40.3c0-.3.3-.5.5-.5v-3c-1.9 0-3.5 1.6-3.5 3.5h3zM44.8 46.8c-.7-.8-1.8-.8-2.5 0-.8.7-.8 1.8 0 2.5l3.6 3.7c.3.3.7.5 1.3.5.5 0 .9-.2 1.2-.5l12.7-12.8c.7-.7.7-1.8 0-2.5-.7-.8-1.8-.8-2.6 0L47.2 49l-2.4-2.3z'/%3E%3C/svg%3E");
}
.radio-button-style-item:nth-child(4) { background-image: url("data:image/svg+xml,%3Csvg xmlns='//www.w3.org/2000/svg' fill='none' viewBox='0 0 53 57'%3E%3Cdefs/%3E%3Ccircle cx='9' cy='9' r='9' fill='%23C3CAD8'/%3E%3Cpath stroke='%23C3CAD8' stroke-linecap='round' stroke-linejoin='round' stroke-width='4' d='M37 9l4.3 5L50 4'/%3E%3Ccircle cx='9' cy='47.8' r='9' fill='%232E69FF'/%3E%3Cpath stroke='%232E69FF' stroke-linecap='round' stroke-linejoin='round' stroke-width='4' d='M37.4 48.5l4.1 4.6 8.2-9.3'/%3E%3C/svg%3E");
}
.radio-button-style-item:nth-child(5) { display: none;
}
.radio-button-style-item:nth-child(6) { background-image: url("data:image/svg+xml,%3Csvg xmlns='//www.w3.org/2000/svg' fill='none' viewBox='0 0 45 63'%3E%3Cdefs/%3E%3Crect width='45' height='26' y='37' fill='%232E69FF' rx='13'/%3E%3Ccircle cx='31' cy='50' r='10' fill='%23fff'/%3E%3Crect width='45' height='26' fill='%23C3CAD8' rx='13'/%3E%3Ccircle cx='14' cy='13' r='10' fill='%23fff'/%3E%3C/svg%3E");
}
.radio-button-style-item:nth-child(7) { background-image: url("data:image/svg+xml,%3Csvg xmlns='//www.w3.org/2000/svg' fill='none' viewBox='0 0 45 63'%3E%3Cdefs/%3E%3Crect width='45' height='26' y='37' fill='%232E69FF' rx='13'/%3E%3Ccircle cx='31' cy='50' r='10' fill='%23fff'/%3E%3Ccircle cx='27.4' cy='48.5' r='1.4' fill='%232E69FF'/%3E%3Ccircle cx='34.5' cy='48.5' r='1.4' fill='%232E69FF'/%3E%3Cpath fill='%232E69FF' d='M31 56c2 0 3.5-1.3 3.5-3h-7c0 1.7 1.6 3 3.5 3z'/%3E%3Crect width='45' height='26' fill='%23C3CAD8' rx='13'/%3E%3Ccircle cx='14' cy='13' r='10' fill='%23fff'/%3E%3Ccircle cx='10.4' cy='11.5' r='1.4' fill='%23C3CAD8'/%3E%3Ccircle cx='17.5' cy='11.5' r='1.4' fill='%23C3CAD8'/%3E%3Cpath fill='%23C3CAD8' d='M14 16c-2 0-3.5 1.3-3.5 3h7c0-1.7-1.6-3-3.5-3z'/%3E%3C/svg%3E");
}
#propsFormLayout #enableFormCols { display: none;
}
#propsLabels .sb-input-color + .sb-seperator + .sb-col-half + .sb-col-half.even { display: none;
}
#propsRadio .sb-option.sb-col-half.even.sb-input-color + .sb-seperator + .sb-option,
#propsRadio .sb-option + .sb-seperator + .sb-option.sb-col-half { display: none;
}
#propsRadio .sb-option.sb-col-half.even.sb-input-color { padding-left: 18px; padding-right: 12px;
}
#propsPageBreaks .sb-option:nth-child(20),
#propsPageBreaks .sb-seperator:nth-child(21) { display: none;
}
#propsButtons .sb-option:nth-child(20),
#propsButtons .sb-seperator:nth-child(21) { display: none;
}
#buttonSizeChangeContainer { display: none;
}
#buttonSizeChangeContainer + .sb-option.sb-col-half.even { padding-left: 18px; padding-right: 12px;
} /*PREFERENCES STYLE*/ .form-all { font-family: Inter, sans-serif; } .form-all .qq-upload-button, .form-all .form-submit-button, .form-all .form-submit-reset, .form-all .form-submit-print { font-family: Inter, sans-serif; } .form-all .form-pagebreak-back-container, .form-all .form-pagebreak-next-container { font-family: Inter, sans-serif; } .form-header-group { font-family: Inter, sans-serif; } .form-label { font-family: Inter, sans-serif; } .form-label.form-label-auto { display: block; float: none; text-align: left; width: 100%; } .form-line { margin-top: 12px; margin-bottom: 12px; } .form-all { max-width: 752px; width: 100%; } .form-label.form-label-left, .form-label.form-label-right, .form-label.form-label-left.form-label-auto, .form-label.form-label-right.form-label-auto { width: 230px; } .form-all { font-size: 16px } .form-all .qq-upload-button, .form-all .qq-upload-button, .form-all .form-submit-button, .form-all .form-submit-reset, .form-all .form-submit-print { font-size: 16px } .form-all .form-pagebreak-back-container, .form-all .form-pagebreak-next-container { font-size: 16px } .supernova .form-all, .form-all { background-color: #e7e1ef; } .form-all { color: #2C3345; } .form-header-group .form-header { color: #2C3345; } .form-header-group .form-subHeader { color: #2C3345; } .form-label-top, .form-label-left, .form-label-right, .form-html, .form-checkbox-item label, .form-radio-item label { color: #2C3345; } .form-sub-label { color: #464d5f; } .supernova { background-color: #ecedf3; } .supernova body { background: transparent; } .form-textbox, .form-textarea, .form-dropdown, .form-radio-other-input, .form-checkbox-other-input, .form-captcha input, .form-spinner input { background-color: #fff; } .supernova { background-image: none; } #stage { background-image: none; } .form-all { background-image: none; } .form-all { position: relative; } .form-all:before { content: ""; background-image: url("https://www.jotform.com/uploads/allureima/form_files/allure-flat-logo.6194338d659bc7.04315118.png"); display: inline-block; height: 100px; position: absolute; background-size: 300px 100px; background-repeat: no-repeat; width: 100%; } .form-all { margin-top: 120px !important; } .form-all:before { top: -110px; background-position: top center; } .ie-8 .form-all:before { display: none; } .ie-8 { margin-top: auto; margin-top: initial; } /*PREFERENCES STYLE*//*__INSPECT_SEPERATOR__*/
.form-label.form-label-auto { display: block; float: none; text-align: left; width: 100%; } /* Injected CSS Code */
</style> <form class="jotform-form" action="https://submit.jotform.com/submit/213196393952161/" method="post" name="form_213196393952161" id="213196393952161" accept-charset="utf-8" autocomplete="on"> <input type="hidden" name="formID" value="213196393952161" /> <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.jotform.com/uploads/allureima/form_files/allure-flat-logo.6194338d659bc7.04315118.png" height="100" width="300"> </div> <style> .formLogoWrapper { display:inline-block; position: absolute; width: 100%;} .form-all:before { background: none !important;} .formLogoWrapper.Center { top: -110px; 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"> Teacher Education Program Contract </h1> </div> </div> </li> <li class="form-line jf-required" data-type="control_fullname" id="id_44"> <label class="form-label form-label-top form-label-auto" id="label_44" for="first_44"> Please enter your Full Name <span class="form-required"> * </span> </label> <div id="cid_44" class="form-input-wide jf-required" data-layout="full"> <div data-wrapper-react="true"> <span class="form-sub-label-container" style="vertical-align:top" data-input-type="first"> <input type="text" id="first_44" name="q44_pleaseEnter[first]" class="form-textbox validate[required]" data-defaultvalue="" size="10" value="" data-component="first" aria-labelledby="label_44 sublabel_44_first" required="" /> <label class="form-sub-label" for="first_44" id="sublabel_44_first" style="min-height:13px" aria-hidden="false"> First Name </label> </span> <span class="form-sub-label-container" style="vertical-align:top" data-input-type="last"> <input type="text" id="last_44" name="q44_pleaseEnter[last]" class="form-textbox validate[required]" data-defaultvalue="" size="15" value="" data-component="last" aria-labelledby="label_44 sublabel_44_last" required="" /> <label class="form-sub-label" for="last_44" id="sublabel_44_last" style="min-height:13px" aria-hidden="false"> Last Name </label> </span> </div> </div> </li> <li class="form-line" data-type="control_inline" id="id_28"> <div id="cid_28" class="form-input-wide" data-layout="full"> <div id="FITB_28" class="FITB formRender"> <p><strong>This Good-faith Contract is between the prospective teacher: <span class="fitb-replace-tag">{pleaseEnter}</span>, The Instructor, and Allure Institute of Makeup Artistry (a DBA of Pacific Styling College LLC), or The School, as will be referred to from here onwards.</strong></p> </div> </div> </li> <li class="form-line fixed-width jf-required" data-type="control_textbox" id="id_30"> <label class="form-label form-label-top form-label-auto" id="label_30" for="input_30"> The School offers Teacher Education Program to help train our future instructors in various aspects of beauty education. As an appreciation for your hard work and dedication to our brand, The School bears the cost of the course for their prospective teachers, in exchange for a Good-Faith Contractual agreement that you (The Instructor) will serve as an independently contracted instructor for a minimum period of time as detailed below in this contract. <span class="form-required"> * </span> </label> <div id="cid_30" class="form-input-wide jf-required" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"> <input type="text" id="input_30" name="q30_theSchool30" data-type="input-textbox" class="form-textbox validate[required, minCharLimit]" data-defaultvalue="" style="width:100px" size="100" value="" maxLength="4" data-minlength="2" data-component="textbox" aria-labelledby="label_30 sublabel_input_30" required="" /> <label class="form-sub-label" for="input_30" id="sublabel_input_30" style="min-height:13px" aria-hidden="false"> Type your Initials if you agree </label> </span> </div> </li> <li class="form-line fixed-width jf-required" data-type="control_textbox" id="id_32"> <label class="form-label form-label-top form-label-auto" id="label_32" for="input_32"> The minimum period of service we request from each participating candidate is 12 calendar months, from the date of this contract, per course offered under this program. (ex. if you are applying for 2 programs, then the minimum service period we would request is 24 months) <span class="form-required"> * </span> </label> <div id="cid_32" class="form-input-wide jf-required" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"> <input type="text" id="input_32" name="q32_theMinimum" data-type="input-textbox" class="form-textbox validate[required, minCharLimit]" data-defaultvalue="" style="width:100px" size="100" value="" maxLength="4" data-minlength="2" data-component="textbox" aria-labelledby="label_32 sublabel_input_32" required="" /> <label class="form-sub-label" for="input_32" id="sublabel_input_32" style="min-height:13px" aria-hidden="false"> Type your Initials if you agree </label> </span> </div> </li> <li class="form-line jf-required" data-type="control_checkbox" id="id_33"> <label class="form-label form-label-top form-label-auto" id="label_33" for="input_33"> Which Course(s) will you be applying for under this Program? <span class="form-required"> * </span> </label> <div id="cid_33" class="form-input-wide jf-required" data-layout="full"> <div class="form-multiple-column" data-columncount="2" role="group" aria-labelledby="label_33" data-component="checkbox"> <span class="form-checkbox-item"> <span class="dragger-item"> </span> <input type="checkbox" aria-describedby="label_33" class="form-checkbox validate[required, maxselection,minselection]" id="input_33_0" name="q33_name33[]" value="Professional Makeup Artistry" data-calcvalue="1" required="" data-maxselection="7" data-minselection="1" /> <label id="label_input_33_0" for="input_33_0"> Professional Makeup Artistry </label> </span> <span class="form-checkbox-item"> <span class="dragger-item"> </span> <input type="checkbox" aria-describedby="label_33" class="form-checkbox validate[required, maxselection,minselection]" id="input_33_1" name="q33_name33[]" value="Eyelash Extensions (Volume &amp; Classic)" data-calcvalue="1" required="" data-maxselection="7" data-minselection="1" /> <label id="label_input_33_1" for="input_33_1"> Eyelash Extensions (Volume & Classic) </label> </span> <span class="form-checkbox-item" style="clear:left"> <span class="dragger-item"> </span> <input type="checkbox" aria-describedby="label_33" class="form-checkbox validate[required, maxselection,minselection]" id="input_33_2" name="q33_name33[]" value="Micorblading" data-calcvalue="1" required="" data-maxselection="7" data-minselection="1" /> <label id="label_input_33_2" for="input_33_2"> Micorblading </label> </span> <span class="form-checkbox-item"> <span class="dragger-item"> </span> <input type="checkbox" aria-describedby="label_33" class="form-checkbox validate[required, maxselection,minselection]" id="input_33_3" name="q33_name33[]" value="Microshading" data-calcvalue="1" required="" data-maxselection="7" data-minselection="1" /> <label id="label_input_33_3" for="input_33_3"> Microshading </label> </span> <span class="form-checkbox-item" style="clear:left"> <span class="dragger-item"> </span> <input type="checkbox" aria-describedby="label_33" class="form-checkbox validate[required, maxselection,minselection]" id="input_33_4" name="q33_name33[]" value="Hair Styling" data-calcvalue="1" required="" data-maxselection="7" data-minselection="1" /> <label id="label_input_33_4" for="input_33_4"> Hair Styling </label> </span> <span class="form-checkbox-item"> <span class="dragger-item"> </span> <input type="checkbox" aria-describedby="label_33" class="form-checkbox validate[required, maxselection,minselection]" id="input_33_5" name="q33_name33[]" value="Special FX" data-calcvalue="1" required="" data-maxselection="7" data-minselection="1" /> <label id="label_input_33_5" for="input_33_5"> Special FX </label> </span> <span class="form-checkbox-item formCheckboxOther"> <input type="checkbox" data-calcvalue="1" class="form-checkbox-other form-checkbox validate[required, maxselection,minselection]" data-maxselection="7" name="q33_name33[other]" id="other_33" value="other" aria-label="Other" /> <label id="label_other_33" style="text-indent:0" for="other_33"> Other </label> <span id="other_33_input" class="other-input-container" style="display:none"> <input type="text" class="form-checkbox-other-input form-textbox" name="q33_name33[other]" data-otherhint="Other" size="15" id="input_33" data-placeholder="Please type another option here" placeholder="Please type another option here" /> </span> </span> </div> </div> </li> <li class="form-line" data-type="control_number" id="id_35"> <label class="form-label form-label-top form-label-auto" id="label_35" for="input_35"> Total number of Programs: </label> <div id="cid_35" class="form-input-wide" data-layout="half"> <input type="number" id="input_35" name="q35_totalNumber35" data-type="input-number" class="form-readonly form-number-input form-textbox" data-defaultvalue="" style="width:310px" size="310" value="" tabindex="-1" data-component="number" aria-labelledby="label_35" readonly="" step="any" /> </div> </li> <li class="form-line" data-type="control_number" id="id_36"> <label class="form-label form-label-top form-label-auto" id="label_36" for="input_36"> Minimum period The School is requesting you, The Instructor, to commit to serving as a independently contracted instructor: </label> <div id="cid_36" class="form-input-wide" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"> <input type="number" id="input_36" name="q36_minimumPeriod" data-type="input-number" class="form-readonly form-number-input form-textbox" data-defaultvalue="" style="width:310px" size="310" value="" tabindex="-1" placeholder="12 months per course" data-component="number" aria-labelledby="label_36 sublabel_input_36" readonly="" step="any" /> <label class="form-sub-label" for="input_36" id="sublabel_input_36" style="min-height:13px" aria-hidden="false"> months from the date of this contract </label> </span> </div> </li> <li id="cid_43" class="form-input-wide" data-type="control_head"> <div class="form-header-group header-default"> <div class="header-text httal htvam"> <h2 id="header_43" class="form-header" data-component="header"> If you agree with the above stated terms of this Good-Faith Contract, please complete all the fields below and sign &amp; date the form. </h2> </div> </div> </li> <li class="form-line jf-required" data-type="control_textbox" id="id_50"> <label class="form-label form-label-top form-label-auto" id="label_50" for="input_50"> Print Your Name <span class="form-required"> * </span> </label> <div id="cid_50" class="form-input-wide jf-required" data-layout="half"> <input type="text" id="input_50" name="q50_printYour" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" style="width:310px" size="310" value="" data-component="textbox" aria-labelledby="label_50" required="" /> </div> </li> <li class="form-line jf-required" data-type="control_phone" id="id_38"> <label class="form-label form-label-top form-label-auto" id="label_38" for="input_38_full"> Phone Number <span class="form-required"> * </span> </label> <div id="cid_38" class="form-input-wide jf-required" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"> <input type="tel" id="input_38_full" name="q38_phoneNumber[full]" data-type="mask-number" class="mask-phone-number form-textbox validate[required, Fill Mask]" data-defaultvalue="" style="width:310px" data-masked="true" value="" placeholder="(000) 000-0000" data-component="phone" aria-labelledby="label_38 sublabel_38_masked" required="" /> <label class="form-sub-label" for="input_38_full" id="sublabel_38_masked" style="min-height:13px" aria-hidden="false"> Please enter a valid phone number. </label> </span> </div> </li> <li class="form-line jf-required" data-type="control_address" id="id_39"> <label class="form-label form-label-top form-label-auto" id="label_39" for="input_39_addr_line1"> Address <span class="form-required"> * </span> </label> <div id="cid_39" 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_39_addr_line1" name="q39_address[addr_line1]" class="form-textbox validate[required] form-address-line" data-defaultvalue="" value="" data-component="address_line_1" aria-labelledby="label_39 sublabel_39_addr_line1" required="" /> <label class="form-sub-label" for="input_39_addr_line1" id="sublabel_39_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_39_addr_line2" name="q39_address[addr_line2]" class="form-textbox form-address-line" data-defaultvalue="" value="" data-component="address_line_2" aria-labelledby="label_39 sublabel_39_addr_line2" /> <label class="form-sub-label" for="input_39_addr_line2" id="sublabel_39_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_39_city" name="q39_address[city]" class="form-textbox validate[required] form-address-city" data-defaultvalue="" value="" data-component="city" aria-labelledby="label_39 sublabel_39_city" required="" /> <label class="form-sub-label" for="input_39_city" id="sublabel_39_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_39_state" name="q39_address[state]" class="form-textbox validate[required] form-address-state" data-defaultvalue="" value="" data-component="state" aria-labelledby="label_39 sublabel_39_state" required="" /> <label class="form-sub-label" for="input_39_state" id="sublabel_39_state" style="min-height:13px" aria-hidden="false"> State / Province </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_39_postal" name="q39_address[postal]" class="form-textbox validate[required] form-address-postal" data-defaultvalue="" value="" data-component="zip" aria-labelledby="label_39 sublabel_39_postal" required="" /> <label class="form-sub-label" for="input_39_postal" id="sublabel_39_postal" style="min-height:13px" aria-hidden="false"> Postal / Zip Code </label> </span> </span> </div> </div> </div> </li> <li class="form-line" data-type="control_email" id="id_40"> <label class="form-label form-label-top form-label-auto" id="label_40" for="input_40"> Email </label> <div id="cid_40" class="form-input-wide" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"> <input type="email" id="input_40" name="q40_email" class="form-textbox validate[Email]" data-defaultvalue="" style="width:310px" size="310" value="" placeholder="(optional)" data-component="email" aria-labelledby="label_40 sublabel_input_40" /> <label class="form-sub-label" for="input_40" id="sublabel_input_40" style="min-height:13px" aria-hidden="false"> example@example.com </label> </span> </div> </li> <li class="form-line fixed-width jf-required" data-type="control_signature" id="id_29"> <label class="form-label form-label-top form-label-auto" id="label_29" for="input_29"> Signature <span class="form-required"> * </span> </label> <div id="cid_29" class="form-input-wide jf-required" data-layout="half"> <div data-wrapper-react="true"> <div id="signature_pad_29" class="signature-pad-wrapper" style="width:452px;height:116px"> <div data-wrapper-react="true"> <!--[if IE 7]> <script type="text/javascript" src="/js/vendor/json2.js"></script> <![endif]--> </div> <div class="signature-line signature-wrapper signature-placeholder" data-component="signature" style="width:452px;height:116px"> <div id="sig_pad_29" data-width="450" data-height="114" data-id="29" data-required="true" class="pad validate[required]" aria-labelledby="label_29"> </div> <input type="hidden" name="q29_signature" class="output4" id="input_29" /> </div> <span class="clear-pad-btn clear-pad" role="button" tabindex="0"> Clear </span> </div> <div data-wrapper-react="true"> <script type="text/javascript"> window.signatureForm = true </script> </div> </div> </div> </li> <li class="form-line jf-required" data-type="control_datetime" id="id_7"> <label class="form-label form-label-top form-label-auto" id="label_7" for="lite_mode_7"> Today's Date <span class="form-required"> * </span> </label> <div id="cid_7" class="form-input-wide 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_7" name="q7_todaysDate[month]" size="2" data-maxlength="2" data-age="" maxLength="2" value="" required="" autoComplete="off" aria-labelledby="label_7 sublabel_7_month" /> <span class="date-separate" aria-hidden="true"> - </span> <label class="form-sub-label" for="month_7" id="sublabel_7_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_7" name="q7_todaysDate[day]" size="2" data-maxlength="2" data-age="" maxLength="2" value="" required="" autoComplete="off" aria-labelledby="label_7 sublabel_7_day" /> <span class="date-separate" aria-hidden="true"> - </span> <label class="form-sub-label" for="day_7" id="sublabel_7_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_7" name="q7_todaysDate[year]" size="4" data-maxlength="4" data-age="" maxLength="4" value="" required="" autoComplete="off" aria-labelledby="label_7 sublabel_7_year" /> <label class="form-sub-label" for="year_7" id="sublabel_7_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_7" size="12" data-maxlength="12" maxLength="12" data-age="" value="" required="" data-format="mmddyyyy" data-seperator="-" placeholder="MM-DD-YYYY" autoComplete="off" aria-labelledby="label_7 sublabel_7_litemode" /> <img class=" newDefaultTheme-dateIcon icon-liteMode" alt="Pick a Date" id="input_7_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" for="lite_mode_7" id="sublabel_7_litemode" style="min-height:13px" aria-hidden="false"> Date </label> </span> </div> </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"> <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 = "old_footer"; </script> <script> JotForm.poweredByText = "Powered by Jotform"; </script> <input type="hidden" id="passProtectToken" name="passProtectToken" value="cbfa550e6d369b0a8797573c562b0f9ac29bb6f3169762d2971843977a7ceaef" /> <input type="hidden" class="simple_spc" id="simple_spc" name="simple_spc" value="213196393952161" /> <script type="text/javascript"> var all_spc = document.querySelectorAll("form[id='213196393952161'] .si" + "mple" + "_spc");
for (var i = 0; i < all_spc.length; i++)
{ all_spc[i].value = "213196393952161-213196393952161";
} </script>
</form>
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