function FrameBuilder(formId,appendTo,initialHeight,iframeCode,title){this.formId=formId;this.initialHeight=initialHeight;this.iframeCode=iframeCode;this.frame=null;this.timeInterval=200;this.appendTo=appendTo||false;this.formSubmitted=0;this.init=function(){this.createFrame();this.addFrameContent(this.iframeCode);};this.createFrame=function(){var tmp_is_ie=!!window.ActiveXObject;var htmlCode="<"+"iframe title=\""+title.replace(/[\\"']/g,'\\$&').replace(/&amp;/g,'&')+"\" onload=\"window.parent.scrollTo(0,0)\" src=\"\" allowtransparency=\"true\" name=\""+this.formId+"\" id=\""+this.formId+"\" style=\"width: 1px; min-width: 100%; display: block; overflow: hidden; height:"+this.initialHeight+"px; border: none;\" scrolling=\"no\"></if"+"rame>";if(this.appendTo===false){document.write(htmlCode);}else{var tmp=document.createElement('div');tmp.innerHTML=htmlCode;var a=this.appendTo;document.getElementById(a).appendChild(tmp.firstChild);}
this.frame=document.getElementById(this.formId);if(tmp_is_ie===true){try{var iframe=this.frame;var doc=iframe.contentDocument?iframe.contentDocument:(iframe.contentWindow.document||iframe.document);doc.open();doc.write("");}
catch(err){this.frame.src="javascript:void((function(){document.open();document.domain=\'"+this.getBaseDomain()+"\';document.close();})())";}}
this.addEvent(this.frame,'load',this.bindMethod(this.setTimer,this));var self=this;if(window.chrome!==undefined){this.frame.onload=function(){try{var doc=this.contentWindow.document;var _jotform=this.contentWindow.JotForm;if(doc!==undefined){var form=doc.getElementById(""+self.formId);self.addEvent(form,"submit",function(){if(_jotform.validateAll()){self.formSubmitted=1;}});}}catch(e){}}}};this.addEvent=function(obj,type,fn){if(obj.attachEvent){obj["e"+type+fn]=fn;obj[type+fn]=function(){obj["e"+type+fn](window.event);};obj.attachEvent("on"+type,obj[type+fn]);}
else{obj.addEventListener(type,fn,false);}};this.addFrameContent=function(string){string=string.replace(new RegExp('src\\=\\"[^"]*captcha.php\"><\/scr'+'ipt>','gim'),'src="http://api.recaptcha.net/js/recaptcha_ajax.js"></scr'+'ipt><'+'div id="recaptcha_div"><'+'/div>'+'<'+'style>#recaptcha_logo{ display:none;} #recaptcha_tagline{display:none;} #recaptcha_table{border:none !important;} .recaptchatable .recaptcha_image_cell, #recaptcha_table{ background-color:transparent !important; } <'+'/style>'+'<'+'script defer="defer"> window.onload = function(){ Recaptcha.create("6Ld9UAgAAAAAAMon8zjt30tEZiGQZ4IIuWXLt1ky", "recaptcha_div", {theme: "clean",tabindex: 0,callback: function (){'+'if (document.getElementById("uword")) { document.getElementById("uword").parentNode.removeChild(document.getElementById("uword")); } if (window["validate"] !== undefined) { if (document.getElementById("recaptcha_response_field")){ document.getElementById("recaptcha_response_field").onblur = function(){ validate(document.getElementById("recaptcha_response_field"), "Required"); } } } if (document.getElementById("recaptcha_response_field")){ document.getElementsByName("recaptcha_challenge_field")[0].setAttribute("name", "anum"); } if (document.getElementById("recaptcha_response_field")){ document.getElementsByName("recaptcha_response_field")[0].setAttribute("name", "qCap"); }}})'+' }<'+'/script>');string=string.replace(/(type="text\/javascript">)\s+(validate\(\"[^"]*"\);)/,'$1 jTime = setInterval(function(){if("validate" in window){$2clearTimeout(jTime);}}, 1000);');if(string.match('#sublabel_litemode')){string=string.replace('class="form-all"','class="form-all" style="margin-top:0;"');}
var iframe=this.frame;var doc=iframe.contentDocument?iframe.contentDocument:(iframe.contentWindow.document||iframe.document);doc.open();doc.write(string);setTimeout(function(){doc.close();try{if('JotFormFrameLoaded'in window){JotFormFrameLoaded();}}catch(e){console.log("error on frame loading",e);}},200);};this.setTimer=function(){var self=this;this.interval=setTimeout(function(){self.changeHeight();},this.timeInterval);};this.getBaseDomain=function(){var thn=window.location.hostname;var cc=0;var buff="";for(var i=0;i<thn.length;i++){var chr=thn.charAt(i);if(chr=="."){cc++;}
if(cc==0){buff+=chr;}}
if(cc==2){thn=thn.replace(buff+".","");}
return thn;}
this.changeHeight=function(){var actualHeight=this.getBodyHeight();var currentHeight=this.getViewPortHeight();if(actualHeight===undefined){this.frame.style.height=this.frameHeight;if(!this.frame.style.minHeight){this.frame.style.minHeight="300px";}}else if(Math.abs(actualHeight-currentHeight)>18){this.frame.style.height=(actualHeight)+"px";}
this.setTimer();};this.bindMethod=function(method,scope){return function(){method.apply(scope,arguments);};};this.frameHeight=0;this.getBodyHeight=function(){if(this.formSubmitted===1){return;}
var height;var scrollHeight;var offsetHeight;try{if(this.frame.contentWindow.document.height){height=this.frame.contentWindow.document.height;if(this.frame.contentWindow.document.body.scrollHeight){height=scrollHeight=this.frame.contentWindow.document.body.scrollHeight;}
if(this.frame.contentWindow.document.body.offsetHeight){height=offsetHeight=this.frame.contentWindow.document.body.offsetHeight;}}else if(this.frame.contentWindow.document.body){var isChrome=/Chrome/.test(navigator.userAgent)&&/Google Inc/.test(navigator.vendor);if(this.frame.contentWindow.document.body.scrollHeight){height=scrollHeight=this.frame.contentWindow.document.body.scrollHeight;}
if(isChrome){height=scrollHeight=this.frame.contentWindow.document.height;}
if(this.frame.contentWindow.document.body.offsetHeight){height=offsetHeight=this.frame.contentWindow.document.body.offsetHeight;}
if(scrollHeight&&offsetHeight){height=Math.max(scrollHeight,offsetHeight);}}}catch(e){}
this.frameHeight=height;return height;};this.getViewPortHeight=function(){if(this.formSubmitted===1){return;}
var height=0;try{if(this.frame.contentWindow.window.innerHeight)
{height=this.frame.contentWindow.window.innerHeight-18;}
else if((this.frame.contentWindow.document.documentElement)&&(this.frame.contentWindow.document.documentElement.clientHeight))
{height=this.frame.contentWindow.document.documentElement.clientHeight;}
else if((this.frame.contentWindow.document.body)&&(this.frame.contentWindow.document.body.clientHeight))
{height=this.frame.contentWindow.document.body.clientHeight;}}catch(e){}
return height;};this.init();}
FrameBuilder.get=[];var i60472453012950=new FrameBuilder("60472453012950",false,"","<!DOCTYPE HTML PUBLIC \"-\/\/W3C\/\/DTD HTML 4.01\/\/EN\" \"http:\/\/www.w3.org\/TR\/html4\/strict.dtd\">\n<html class=\"supernova\"><head>\n<meta http-equiv=\"Content-Type\" content=\"text\/html; charset=utf-8\" \/>\n<link rel=\"alternate\" type=\"application\/json+oembed\" href=\"https:\/\/www.jotform.com\/oembed\/?format=json&amp;url=http%3A%2F%2Fwww.jotform.com%2Fform%2F60472453012950\" title=\"oEmbed Form\"><link rel=\"alternate\" type=\"text\/xml+oembed\" href=\"https:\/\/www.jotform.com\/oembed\/?format=xml&amp;url=http%3A%2F%2Fwww.jotform.com%2Fform%2F60472453012950\" title=\"oEmbed Form\">\n<meta property=\"og:title\" content=\"In-Memoriam-Cards.ie Order Form - Paypal Option\" >\n<meta property=\"og:url\" content=\"http:\/\/www.jotformpro.com\/form\/60472453012950\" >\n<meta property=\"og:description\" content=\"Please click the link to complete this form.\">\n<link rel=\"shortcut icon\" href=\"https:\/\/cdn.jotfor.ms\/favicon.ico\">\n<meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0, maximum-scale=1.0, user-scalable=0\" \/>\n<meta name=\"HandheldFriendly\" content=\"true\" \/>\n<title>In-Memoriam-Cards.ie Order Form - Paypal Option<\/title>\n<link href=\"https:\/\/cdn.jotfor.ms\/static\/formCss.css?3.3.2456\" rel=\"stylesheet\" type=\"text\/css\" \/>\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/cdn.jotfor.ms\/css\/styles\/nova.css?3.3.2456\" \/>\n<link type=\"text\/css\" media=\"print\" rel=\"stylesheet\" href=\"https:\/\/cdn.jotfor.ms\/css\/printForm.css?3.3.2456\" \/>\n<style type=\"text\/css\">\n    .form-label-left{\n        width:146px;\n    }\n    .form-line{\n        padding-top:1px;\n        padding-bottom:1px;\n    }\n    .form-label-right{\n        width:146px;\n    }\n    body, html{\n        margin:0;\n        padding:0;\n        background:rgb(204, 204, 204);\n    }\n\n    .form-all{\n        margin:0px auto;\n        padding-top:0px;\n        width:620px;\n        color:#3E4E1A !important;\n        font-family:\"Lucida Grande\", \"Lucida Sans Unicode\", \"Lucida Sans\", Verdana, sans-serif;\n        font-size:12px;\n    }\n    .form-radio-item label, .form-checkbox-item label, .form-grading-label, .form-header{\n        color: #555;\n    }\n\n<\/style>\n\n<style type=\"text\/css\" id=\"form-designer-style\">\n    \/* Injected CSS Code *\/\n.form-all {\n  font-family: \"Lucida Grande\", sans-serif;\n}\n.form-all {\n  width: 620px;\n  width: 100%;\n  max-width: 620px;\n}\n.form-label-left,\n.form-label-right {\n  width: 146px;\n}\n.form-label {\n  white-space: normal;\n}\n.form-label.form-label-auto {\n  display: inline-block;\n  float: left;\n  text-align: left;\n  width: 146px;\n}\n.form-label-left {\n  display: inline-block;\n  white-space: normal;\n  float: left;\n  text-align: left;\n}\n.form-label-right {\n  display: inline-block;\n  white-space: normal;\n  float: left;\n  text-align: right;\n}\n.form-label-top {\n  white-space: normal;\n  display: block;\n  float: none;\n  text-align: left;\n}\n.form-all {\n  font-size: 12px;\n}\n.form-label {\n  font-weight: bold;\n}\n.form-checkbox-item label,\n.form-radio-item label {\n  font-weight: normal;\n}\n.supernova {\n  background-color: #cccccc;\n}\n.supernova body {\n  background-color: transparent;\n}\n\/*\n@width30: (unit(@formWidth, px) + 60px);\n@width60: (unit(@formWidth, px)+ 120px);\n@width90: (unit(@formWidth, px)+ 180px);\n*\/\n\/* | *\/\n@media screen and (min-width: 480px) {\n  .supernova .form-all {\n    border: 1px solid #b3b3b3;\n    -webkit-box-shadow: 0 3px 9px rgba(0, 0, 0, 0.1);\n    -moz-box-shadow: 0 3px 9px rgba(0, 0, 0, 0.1);\n    box-shadow: 0 3px 9px rgba(0, 0, 0, 0.1);\n  }\n}\n\/* | *\/\n\/* | *\/\n@media screen and (max-width: 480px) {\n  .jotform-form {\n    padding: 10px 0;\n  }\n}\n\/* | *\/\n\/* | *\/\n@media screen and (min-width: 480px) and (max-width: 768px) {\n  .jotform-form {\n    padding: 30px 0;\n  }\n}\n\/* | *\/\n\/* | *\/\n@media screen and (min-width: 480px) and (max-width: 619px) {\n  .jotform-form {\n    padding: 30px 0;\n  }\n}\n\/* | *\/\n\/* | *\/\n@media screen and (min-width: 768px) {\n  .jotform-form {\n    padding: 60px 0;\n  }\n}\n\/* | *\/\n\/* | *\/\n@media screen and (max-width: 619px) {\n  .jotform-form {\n    padding: 0;\n  }\n}\n\/* | *\/\n.supernova .form-all,\n.form-all {\n  background-color: #cccccc;\n  border: 1px solid transparent;\n}\n.form-header-group {\n  border-color: #b3b3b3;\n}\n.form-matrix-table tr {\n  border-color: #b3b3b3;\n}\n.form-matrix-table tr:nth-child(2n) {\n  background-color: #bfbfbf;\n}\n.form-all {\n  color: #3e4e1a;\n}\n.form-header-group .form-header {\n  color: #3e4e1a;\n}\n.form-header-group .form-subHeader {\n  color: #5c7427;\n}\n.form-sub-label {\n  color: #5c7427;\n}\n.form-label-top,\n.form-label-left,\n.form-label-right,\n.form-html {\n  color: #3e4e1a;\n}\n.form-checkbox-item label,\n.form-radio-item label {\n  color: #5c7427;\n}\n.form-line.form-line-active {\n  -webkit-transition-property: all;\n  -moz-transition-property: all;\n  -ms-transition-property: all;\n  -o-transition-property: all;\n  transition-property: all;\n  -webkit-transition-duration: 0.3s;\n  -moz-transition-duration: 0.3s;\n  -ms-transition-duration: 0.3s;\n  -o-transition-duration: 0.3s;\n  transition-duration: 0.3s;\n  -webkit-transition-timing-function: ease;\n  -moz-transition-timing-function: ease;\n  -ms-transition-timing-function: ease;\n  -o-transition-timing-function: ease;\n  transition-timing-function: ease;\n  background-color: rgba(255, 255, 255, 0.75);\n}\n\/* \u00f6mer *\/\n.form-radio-item,\n.form-checkbox-item {\n  padding-bottom: 0px !important;\n}\n.form-radio-item:last-child,\n.form-checkbox-item:last-child {\n  padding-bottom: 0;\n}\n\/* \u00f6mer *\/\n[data-type=\"control_radio\"] .form-input,\n[data-type=\"control_checkbox\"] .form-input,\n[data-type=\"control_radio\"] .form-input-wide,\n[data-type=\"control_checkbox\"] .form-input-wide {\n  width: 100%;\n  max-width: 316px;\n}\n.form-radio-item,\n.form-checkbox-item {\n  width: 100%;\n  max-width: 316px;\n  -moz-box-sizing: border-box;\n  -webkit-box-sizing: border-box;\n  box-sizing: border-box;\n}\n.form-textbox.form-radio-other-input,\n.form-textbox.form-checkbox-other-input {\n  width: 80%;\n  margin-left: 3%;\n  -moz-box-sizing: border-box;\n  -webkit-box-sizing: border-box;\n  box-sizing: border-box;\n}\n.form-multiple-column {\n  width: 100%;\n}\n.form-multiple-column .form-radio-item,\n.form-multiple-column .form-checkbox-item {\n  width: 10%;\n}\n.form-multiple-column[data-columncount=\"1\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"1\"] .form-checkbox-item {\n  width: 100%;\n}\n.form-multiple-column[data-columncount=\"2\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"2\"] .form-checkbox-item {\n  width: 50%;\n}\n.form-multiple-column[data-columncount=\"3\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"3\"] .form-checkbox-item {\n  width: 33.33333333%;\n}\n.form-multiple-column[data-columncount=\"4\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"4\"] .form-checkbox-item {\n  width: 25%;\n}\n.form-multiple-column[data-columncount=\"5\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"5\"] .form-checkbox-item {\n  width: 20%;\n}\n.form-multiple-column[data-columncount=\"6\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"6\"] .form-checkbox-item {\n  width: 16.66666667%;\n}\n.form-multiple-column[data-columncount=\"7\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"7\"] .form-checkbox-item {\n  width: 14.28571429%;\n}\n.form-multiple-column[data-columncount=\"8\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"8\"] .form-checkbox-item {\n  width: 12.5%;\n}\n.form-multiple-column[data-columncount=\"9\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"9\"] .form-checkbox-item {\n  width: 11.11111111%;\n}\n.form-single-column .form-checkbox-item,\n.form-single-column .form-radio-item {\n  width: 100%;\n}\n.supernova {\n  height: 100%;\n  background-repeat: no-repeat;\n  background-attachment: scroll;\n  background-position: center top;\n  background-repeat: repeat;\n}\n.supernova {\n  background-image: none;\n}\n#stage {\n  background-image: none;\n}\n\/* | *\/\n.form-all {\n  background-repeat: no-repeat;\n  background-attachment: scroll;\n  background-position: center top;\n  background-repeat: repeat;\n}\n.form-header-group {\n  background-repeat: no-repeat;\n  background-attachment: scroll;\n  background-position: center top;\n}\n.form-line {\n  margin-top: 1px;\n  margin-bottom: 1px;\n}\n.form-line {\n  padding: 4px 12px;\n}\n.form-all .qq-upload-button,\n.form-all .form-submit-button,\n.form-all .form-submit-reset,\n.form-all .form-submit-print {\n  font-size: 1em;\n  padding: 9px 15px;\n  font-family: \"Lucida Grande\", sans-serif;\n  font-size: 12px;\n  font-weight: normal;\n}\n.form-all .form-pagebreak-back,\n.form-all .form-pagebreak-next {\n  font-size: 1em;\n  padding: 9px 15px;\n  font-family: \"Lucida Grande\", sans-serif;\n  font-size: 12px;\n  font-weight: normal;\n}\n\/*\n& when ( @buttonFontType = google ) {\n\t@import (css) \"@{buttonFontLink}\";\n}\n*\/\nh2.form-header {\n  line-height: 1.618em;\n  font-size: 1.714em;\n}\nh2 ~ .form-subHeader {\n  line-height: 1.5em;\n  font-size: 1.071em;\n}\n.form-header-group {\n  text-align: left;\n}\n.form-line {\n  zoom: 1;\n}\n.form-line:before,\n.form-line:after {\n  display: table;\n  content: '';\n  line-height: 0;\n}\n.form-line:after {\n  clear: both;\n}\n.form-sub-label-container {\n  margin-right: 0;\n  float: left;\n  white-space: nowrap;\n  -moz-box-sizing: border-box;\n  -webkit-box-sizing: border-box;\n  box-sizing: border-box;\n}\n.form-sub-label-container .date-separate {\n  visibility: hidden;\n}\n.form-captcha input,\n.form-spinner input {\n  width: 316px;\n}\n.form-textbox,\n.form-textarea {\n  width: 100%;\n  max-width: 316px;\n  -moz-box-sizing: border-box;\n  -webkit-box-sizing: border-box;\n  box-sizing: border-box;\n}\n.form-input,\n.form-address-table,\n.form-matrix-table {\n  width: 100%;\n  max-width: 316px;\n}\n.form-radio-item,\n.form-checkbox-item {\n  width: 100%;\n  max-width: 316px;\n  -moz-box-sizing: border-box;\n  -webkit-box-sizing: border-box;\n  box-sizing: border-box;\n}\n.form-textbox.form-radio-other-input,\n.form-textbox.form-checkbox-other-input {\n  width: 80%;\n  margin-left: 3%;\n  -moz-box-sizing: border-box;\n  -webkit-box-sizing: border-box;\n  box-sizing: border-box;\n}\n.form-multiple-column {\n  width: 100%;\n}\n.form-multiple-column .form-radio-item,\n.form-multiple-column .form-checkbox-item {\n  width: 10%;\n}\n.form-multiple-column[data-columncount=\"1\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"1\"] .form-checkbox-item {\n  width: 100%;\n}\n.form-multiple-column[data-columncount=\"2\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"2\"] .form-checkbox-item {\n  width: 50%;\n}\n.form-multiple-column[data-columncount=\"3\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"3\"] .form-checkbox-item {\n  width: 33.33333333%;\n}\n.form-multiple-column[data-columncount=\"4\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"4\"] .form-checkbox-item {\n  width: 25%;\n}\n.form-multiple-column[data-columncount=\"5\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"5\"] .form-checkbox-item {\n  width: 20%;\n}\n.form-multiple-column[data-columncount=\"6\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"6\"] .form-checkbox-item {\n  width: 16.66666667%;\n}\n.form-multiple-column[data-columncount=\"7\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"7\"] .form-checkbox-item {\n  width: 14.28571429%;\n}\n.form-multiple-column[data-columncount=\"8\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"8\"] .form-checkbox-item {\n  width: 12.5%;\n}\n.form-multiple-column[data-columncount=\"9\"] .form-radio-item,\n.form-multiple-column[data-columncount=\"9\"] .form-checkbox-item {\n  width: 11.11111111%;\n}\n[data-type=\"control_dropdown\"] .form-dropdown {\n  width: 100% !important;\n  max-width: 316px;\n}\n[data-type=\"control_fullname\"] .form-sub-label-container {\n  -moz-box-sizing: border-box;\n  -webkit-box-sizing: border-box;\n  box-sizing: border-box;\n  width: 48%;\n}\n[data-type=\"control_fullname\"] .form-sub-label-container:first-child {\n  margin-right: 4%;\n}\n[data-type=\"control_phone\"] .form-sub-label-container {\n  width: 65%;\n}\n[data-type=\"control_phone\"] .form-sub-label-container:first-child {\n  width: 32.5%;\n  margin-right: 2.5%;\n}\n[data-type=\"control_birthdate\"] .form-sub-label-container {\n  width: 22%;\n  margin-right: 3%;\n}\n[data-type=\"control_birthdate\"] .form-sub-label-container:first-child {\n  width: 50%;\n}\n[data-type=\"control_birthdate\"] .form-sub-label-container:last-child {\n  margin-right: 0;\n}\n[data-type=\"control_birthdate\"] .form-sub-label-container .form-dropdown {\n  width: 100%;\n}\n[data-type=\"control_time\"] .form-sub-label-container {\n  width: 37%;\n  margin-right: 3%;\n}\n[data-type=\"control_time\"] .form-sub-label-container:last-child {\n  width: 20%;\n  margin-right: 0;\n}\n[data-type=\"control_time\"] .form-sub-label-container .form-dropdown {\n  width: 100%;\n}\n[data-type=\"control_datetime\"] .form-sub-label-container {\n  width: 28%;\n  margin-right: 4%;\n}\n[data-type=\"control_datetime\"] .form-sub-label-container:last-child {\n  width: 4%;\n  margin-right: 0;\n}\n[data-type=\"control_datetime\"].allowTime .form-sub-label-container {\n  width: 12%;\n  margin-right: 3%;\n}\n[data-type=\"control_datetime\"].allowTime .form-sub-label-container:last-child {\n  width: 4%;\n  margin-right: 0;\n}\n[data-type=\"control_datetime\"].allowTime .allowTime-container {\n  float: right;\n  width: 51%;\n}\n[data-type=\"control_datetime\"].allowTime .allowTime-container .form-sub-label-container {\n  width: 27%;\n  margin-right: 4%;\n}\n[data-type=\"control_datetime\"].allowTime .allowTime-container .form-sub-label-container:first-child {\n  width: 4%;\n  margin-left: 3%;\n}\n[data-type=\"control_datetime\"].allowTime .allowTime-container .form-sub-label-container:last-child {\n  width: 27%;\n  margin-right: 0;\n}\n[data-type=\"control_datetime\"].allowTime .form-dropdown {\n  width: 100%;\n}\n[data-type=\"control_payment\"] .form-sub-label-container {\n  width: auto;\n}\n[data-type=\"control_payment\"] .form-sub-label-container .form-dropdown {\n  width: 100%;\n}\n.form-address-table td .form-dropdown {\n  width: 100%;\n}\n.form-address-table td .form-sub-label-container {\n  width: 96%;\n}\n.form-address-table td:last-child .form-sub-label-container {\n  margin-left: 4%;\n}\n.form-address-table td[colspan=\"2\"] .form-sub-label-container {\n  width: 100%;\n  margin: 0;\n}\n\/*.form-dropdown,\n.form-radio-item,\n.form-checkbox-item,\n.form-radio-other-input,\n.form-checkbox-other-input,*\/\n.form-captcha input,\n.form-spinner input,\n.form-error-message {\n  padding: 4px 3px 2px 3px;\n}\n.form-header-group {\n  font-family: \"Lucida Grande\", sans-serif;\n}\n.form-section {\n  padding: 0px 0px 0px 0px;\n}\n.form-header-group {\n  margin: 12px 36px 12px 36px;\n}\n.form-header-group {\n  padding: 24px 0px 24px 0px;\n}\n.form-textbox,\n.form-textarea {\n  padding: 4px 3px 2px 3px;\n}\n.form-textbox,\n.form-textarea,\n.form-radio-other-input,\n.form-checkbox-other-input,\n.form-captcha input,\n.form-spinner input {\n  background-color: #ffffff;\n}\n.form-textbox,\n.form-textarea {\n  width: 100%;\n  max-width: 316px;\n  -moz-box-sizing: border-box;\n  -webkit-box-sizing: border-box;\n  box-sizing: border-box;\n}\n[data-type=\"control_textbox\"] .form-input,\n[data-type=\"control_textarea\"] .form-input,\n[data-type=\"control_fullname\"] .form-input,\n[data-type=\"control_phone\"] .form-input,\n[data-type=\"control_datetime\"] .form-input,\n[data-type=\"control_address\"] .form-input,\n[data-type=\"control_email\"] .form-input,\n[data-type=\"control_passwordbox\"] .form-input,\n[data-type=\"control_autocomp\"] .form-input,\n[data-type=\"control_textbox\"] .form-input-wide,\n[data-type=\"control_textarea\"] .form-input-wide,\n[data-type=\"control_fullname\"] .form-input-wide,\n[data-type=\"control_phone\"] .form-input-wide,\n[data-type=\"control_datetime\"] .form-input-wide,\n[data-type=\"control_address\"] .form-input-wide,\n[data-type=\"control_email\"] .form-input-wide,\n[data-type=\"control_passwordbox\"] .form-input-wide,\n[data-type=\"control_autocomp\"] .form-input-wide {\n  width: 100%;\n  max-width: 316px;\n}\n[data-type=\"control_fullname\"] .form-sub-label-container {\n  -moz-box-sizing: border-box;\n  -webkit-box-sizing: border-box;\n  box-sizing: border-box;\n  width: 48%;\n}\n[data-type=\"control_fullname\"] .form-sub-label-container:first-child {\n  margin-right: 4%;\n}\n[data-type=\"control_phone\"] .form-sub-label-container {\n  width: 65%;\n}\n[data-type=\"control_phone\"] .form-sub-label-container:first-child {\n  width: 32.5%;\n  margin-right: 2.5%;\n}\n[data-type=\"control_phone\"] .form-sub-label-container .date-separate {\n  visibility: hidden;\n}\n[data-type=\"control_datetime\"] .form-sub-label-container {\n  width: 28%;\n  margin-right: 4%;\n}\n[data-type=\"control_datetime\"] .form-sub-label-container:last-child {\n  width: 4%;\n  margin-right: 0;\n}\n[data-type=\"control_datetime\"] .form-sub-label-container .date-separate {\n  visibility: hidden;\n}\n[data-type=\"control_datetime\"].allowTime .form-sub-label-container {\n  width: 12%;\n  margin-right: 3%;\n}\n[data-type=\"control_datetime\"].allowTime .form-sub-label-container:last-child {\n  width: 4%;\n  margin-right: 0;\n}\n[data-type=\"control_datetime\"].allowTime .allowTime-container {\n  float: right;\n  width: 51%;\n}\n[data-type=\"control_datetime\"].allowTime .allowTime-container .form-sub-label-container {\n  width: 27%;\n  margin-right: 4%;\n}\n[data-type=\"control_datetime\"].allowTime .allowTime-container .form-sub-label-container:first-child {\n  width: 4%;\n  margin-left: 3%;\n}\n[data-type=\"control_datetime\"].allowTime .allowTime-container .form-sub-label-container:last-child {\n  width: 27%;\n  margin-right: 0;\n}\n[data-type=\"control_datetime\"].allowTime .form-dropdown {\n  width: 100%;\n}\n.form-matrix-table {\n  width: 100%;\n  max-width: 316px;\n}\n.form-address-table {\n  width: 100%;\n  max-width: 316px;\n}\n.form-address-table td .form-dropdown {\n  width: 100%;\n}\n.form-address-table td .form-sub-label-container {\n  width: 96%;\n}\n.form-address-table td:last-child .form-sub-label-container {\n  margin-left: 4%;\n}\n.form-address-table td[colspan=\"2\"] .form-sub-label-container {\n  width: 100%;\n  margin: 0;\n}\n[data-type=\"control_dropdown\"] .form-input,\n[data-type=\"control_birthdate\"] .form-input,\n[data-type=\"control_time\"] .form-input,\n[data-type=\"control_dropdown\"] .form-input-wide,\n[data-type=\"control_birthdate\"] .form-input-wide,\n[data-type=\"control_time\"] .form-input-wide {\n  width: 100%;\n  max-width: 316px;\n}\n[data-type=\"control_dropdown\"] .form-dropdown {\n  width: 100% !important;\n  max-width: 316px;\n}\n[data-type=\"control_birthdate\"] .form-sub-label-container {\n  width: 22%;\n  margin-right: 3%;\n}\n[data-type=\"control_birthdate\"] .form-sub-label-container:first-child {\n  width: 50%;\n}\n[data-type=\"control_birthdate\"] .form-sub-label-container:last-child {\n  margin-right: 0;\n}\n[data-type=\"control_birthdate\"] .form-sub-label-container .form-dropdown {\n  width: 100%;\n}\n[data-type=\"control_time\"] .form-sub-label-container {\n  width: 37%;\n  margin-right: 3%;\n}\n[data-type=\"control_time\"] .form-sub-label-container:last-child {\n  width: 20%;\n  margin-right: 0;\n}\n[data-type=\"control_time\"] .form-sub-label-container .form-dropdown {\n  width: 100%;\n}\n.form-label {\n  margin-right: 7px;\n  margin-bottom: 0;\n}\n.form-label {\n  font-family: \"Lucida Grande\", sans-serif;\n}\nli[data-type=\"control_image\"] div {\n  text-align: left;\n}\nli[data-type=\"control_image\"] img {\n  border: none;\n  border-width: 0px !important;\n  border-style: solid !important;\n  border-color: false !important;\n}\n.form-line-column {\n  width: auto;\n  width: 50%;\n  -moz-box-sizing: border-box;\n  -webkit-box-sizing: border-box;\n  box-sizing: border-box;\n}\n.form-line-column.form-col-1 {\n  padding-left: 12px;\n  padding-right: 6px;\n}\n.form-line-column.form-col-0 {\n  padding-left: 6px;\n  padding-right: 12px;\n}\n.form-line-column.form-col-3 {\n  padding-left: 12px;\n  padding-right: 6px;\n}\n.form-line-column.form-col-2 {\n  padding-left: 6px;\n  padding-right: 12px;\n}\n.form-line-column.form-col-5 {\n  padding-left: 12px;\n  padding-right: 6px;\n}\n.form-line-column.form-col-4 {\n  padding-left: 6px;\n  padding-right: 12px;\n}\n.form-line-column.form-col-7 {\n  padding-left: 12px;\n  padding-right: 6px;\n}\n.form-line-column.form-col-6 {\n  padding-left: 6px;\n  padding-right: 12px;\n}\n.form-line-column.form-col-9 {\n  padding-left: 12px;\n  padding-right: 6px;\n}\n.form-line-column.form-col-8 {\n  padding-left: 6px;\n  padding-right: 12px;\n}\n.form-line-column.form-col-11 {\n  padding-left: 12px;\n  padding-right: 6px;\n}\n.form-line-column.form-col-10 {\n  padding-left: 6px;\n  padding-right: 12px;\n}\n.form-line-column.form-col-13 {\n  padding-left: 12px;\n  padding-right: 6px;\n}\n.form-line-column.form-col-12 {\n  padding-left: 6px;\n  padding-right: 12px;\n}\n.form-line-column.form-col-15 {\n  padding-left: 12px;\n  padding-right: 6px;\n}\n.form-line-column.form-col-14 {\n  padding-left: 6px;\n  padding-right: 12px;\n}\n.form-line-column.form-col-17 {\n  padding-left: 12px;\n  padding-right: 6px;\n}\n.form-line-column.form-col-16 {\n  padding-left: 6px;\n  padding-right: 12px;\n}\n.form-line-column.form-col-19 {\n  padding-left: 12px;\n  padding-right: 6px;\n}\n.form-line-column.form-col-18 {\n  padding-left: 6px;\n  padding-right: 12px;\n}\n.form-line-column.form-col-21 {\n  padding-left: 12px;\n  padding-right: 6px;\n}\n.form-line-column.form-col-20 {\n  padding-left: 6px;\n  padding-right: 12px;\n}\n.form-line-error {\n  overflow: hidden;\n  -webkit-transition-property: none;\n  -moz-transition-property: none;\n  -ms-transition-property: none;\n  -o-transition-property: none;\n  transition-property: none;\n  -webkit-transition-duration: 0.3s;\n  -moz-transition-duration: 0.3s;\n  -ms-transition-duration: 0.3s;\n  -o-transition-duration: 0.3s;\n  transition-duration: 0.3s;\n  -webkit-transition-timing-function: ease;\n  -moz-transition-timing-function: ease;\n  -ms-transition-timing-function: ease;\n  -o-transition-timing-function: ease;\n  transition-timing-function: ease;\n  background-color: #fff4f4;\n}\n.form-line-error .form-error-message {\n  background-color: #ff3200;\n  clear: both;\n  float: none;\n}\n.form-line-error .form-error-message .form-error-arrow {\n  border-bottom-color: #ff3200;\n}\n.form-line-error input:not(#coupon-input),\n.form-line-error textarea,\n.form-line-error .form-validation-error {\n  border: 1px solid #ff3200;\n  -webkit-box-shadow: 0 0 3px #ff3200;\n  -moz-box-shadow: 0 0 3px #ff3200;\n  box-shadow: 0 0 3px #ff3200;\n}\n.ie-8 .form-all {\n  margin-top: auto;\n  margin-top: initial;\n}\n.ie-8 .form-all:before {\n  display: none;\n}\n\/* | *\/\n@media screen and (max-width: 480px), screen and (max-device-width: 768px) and (orientation: portrait), screen and (max-device-width: 415px) and (orientation: landscape) {\n  .jotform-form {\n    padding: 0;\n  }\n  .form-all {\n    border: 0;\n    width: 100%;\n    max-width: initial;\n  }\n  .form-sub-label-container {\n    width: 100%;\n    margin: 0;\n  }\n  .form-input {\n    width: 100%;\n  }\n  .form-label {\n    width: 100%!important;\n  }\n  .form-line {\n    padding: 2% 5%;\n    -moz-box-sizing: border-box;\n    -webkit-box-sizing: border-box;\n    box-sizing: border-box;\n  }\n  input[type=text],\n  input[type=email],\n  input[type=tel],\n  textarea {\n    width: 100%;\n    -moz-box-sizing: border-box;\n    -webkit-box-sizing: border-box;\n    box-sizing: border-box;\n    max-width: initial !important;\n  }\n  .form-input,\n  .form-input-wide,\n  .form-textarea,\n  .form-textbox,\n  .form-dropdown {\n    max-width: initial !important;\n  }\n  div.form-header-group {\n    padding: 24px 0px !important;\n    margin: 0 12px 2% !important;\n    margin-left: 5% !important;\n    margin-right: 5% !important;\n    -moz-box-sizing: border-box;\n    -webkit-box-sizing: border-box;\n    box-sizing: border-box;\n  }\n  [data-type=\"control_button\"] {\n    margin-bottom: 0 !important;\n  }\n  .form-buttons-wrapper {\n    margin: 0!important;\n  }\n  .form-buttons-wrapper button {\n    width: 100%;\n  }\n  table {\n    width: 100%!important;\n    max-width: initial !important;\n  }\n  table td + td {\n    padding-left: 3%;\n  }\n  .form-checkbox-item input,\n  .form-radio-item input {\n    width: auto;\n  }\n  .form-collapse-table {\n    margin: 0 5%;\n  }\n}\n\/* | *\/\n\n\/*__INSPECT_SEPERATOR__*\/\n\n    \/* Injected CSS Code *\/\n<\/style>\n\n<script src=\"https:\/\/cdn.jotfor.ms\/file-uploader\/fileuploader.js?v=3.3.2456\"><\/script>\n<script src=\"https:\/\/cdn.jotfor.ms\/js\/vendor\/jquery-1.8.0.min.js?3.3.2456\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn.jotfor.ms\/js\/vendor\/autoFill.min.js?v=3.3.2456\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn.jotfor.ms\/static\/prototype.forms.js\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn.jotfor.ms\/static\/jotform.forms.js?3.3.2456\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn.jotfor.ms\/js\/paypal.js?v=3.3.2456\" type=\"text\/javascript\"><\/script>\n<script type=\"text\/javascript\">\n   JotForm.init(function(){\n     $('input_79_confirm').hint('Confirm Email');\n     $$('#input_79_confirm')[0].setAttribute('onPaste', 'return false;');\n      setTimeout(function() {\n          $('input_79').hint('ex: myname@example.com');\n       }, 20);\nJotForm.initCaptcha('input_55');\n$('input_55_reload').observe('click',function(){ JotForm.reloadCaptcha('input_55') })\n\tJotForm.clearFieldOnHide=\"disable\";\n      setTimeout(function() {\n          JotForm.initMultipleUploads();\n      }, 2);\n      setTimeout(function() {\n          JotForm.autoFillInitialize({\"bindChange\":\"on\",\"menu\":\"enable\",\"timeout\":\"4\",\"ttl\":\"86400\"});\n      }, 10)\n    \/*INIT-END*\/\n});\n\n   JotForm.prepareCalculationsOnTheFly([null,{\"name\":\"clickTo\",\"qid\":\"1\",\"text\":\"Place Order Form (Paypal Option)\",\"type\":\"control_head\"},null,null,null,{\"name\":\"ageif\",\"qid\":\"5\",\"text\":\"Age (if required)\",\"type\":\"control_textbox\"},null,null,null,null,null,null,{\"name\":\"numberOf12\",\"qid\":\"12\",\"text\":\"Number of Double Memoriam Cards required\",\"type\":\"control_textbox\"},{\"name\":\"noOf\",\"qid\":\"13\",\"text\":\"No of Holders required\",\"type\":\"control_textbox\"},null,{\"name\":\"clickTo15\",\"qid\":\"15\",\"text\":\"Details of Deceased\",\"type\":\"control_head\"},{\"name\":\"clickTo16\",\"qid\":\"16\",\"text\":\"Customer Details\",\"type\":\"control_head\"},{\"name\":\"clickTo17\",\"qid\":\"17\",\"text\":\"Double Memorial Cards (Outside)\",\"type\":\"control_head\"},{\"name\":\"imageNo18\",\"qid\":\"18\",\"text\":\"Image No (back)\",\"type\":\"control_dropdown\"},null,null,null,{\"name\":\"ownVerse22\",\"qid\":\"22\",\"text\":\"Own Verse (if desired)\",\"type\":\"control_textarea\"},null,{\"name\":\"ownif24\",\"qid\":\"24\",\"text\":\"Own (if required)\",\"type\":\"control_textbox\"},{\"name\":\"clickTo25\",\"qid\":\"25\",\"text\":\"Double Memorial Cards (Inside)\",\"type\":\"control_head\"},{\"name\":\"backgroundNo\",\"qid\":\"26\",\"text\":\"Background No\",\"type\":\"control_dropdown\"},{\"name\":\"dmileftFrame\",\"qid\":\"27\",\"text\":\"(DMIleft) Frame No\",\"type\":\"control_dropdown\"},{\"name\":\"shortVerse\",\"qid\":\"28\",\"text\":\"Short Verse No\",\"type\":\"control_dropdown\"},{\"name\":\"ownShort29\",\"qid\":\"29\",\"text\":\"Own Short Verse (if required\",\"type\":\"control_textarea\"},{\"name\":\"smbwFront\",\"qid\":\"30\",\"text\":\"(SM\/B\/W front) Verse No\",\"type\":\"control_dropdown\"},{\"name\":\"ownVerse\",\"qid\":\"31\",\"text\":\"Own Verse (if required)\",\"type\":\"control_textarea\"},null,null,{\"name\":\"clickTo34\",\"qid\":\"34\",\"text\":\"Acknowledgement Cards\",\"type\":\"control_head\"},null,{\"name\":\"imageNo36\",\"qid\":\"36\",\"text\":\"Image No\",\"type\":\"control_dropdown\"},{\"name\":\"wording\",\"qid\":\"37\",\"text\":\"Wording\",\"type\":\"control_dropdown\"},{\"name\":\"ownWording38\",\"qid\":\"38\",\"text\":\"Own Wording (if required)\",\"type\":\"control_textarea\"},null,null,null,null,null,null,null,null,null,null,null,null,{\"name\":\"clickTo51\",\"qid\":\"51\",\"text\":\"Holder for Bookmarks or Single Card\",\"type\":\"control_head\"},{\"name\":\"holderNo52\",\"qid\":\"52\",\"text\":\"Holder No\",\"type\":\"control_dropdown\"},null,null,{\"name\":\"enterThe55\",\"qid\":\"55\",\"text\":\"Enter the message as it's shown\",\"type\":\"control_captcha\"},null,{\"name\":\"numberOf\",\"qid\":\"57\",\"text\":\"Number of Bookmarks required\",\"type\":\"control_textbox\"},{\"name\":\"numberOf58\",\"qid\":\"58\",\"text\":\"Number of Wallet cards required\",\"type\":\"control_textbox\"},{\"name\":\"numberOf59\",\"qid\":\"59\",\"text\":\"Number of Acknowledgement Cards\",\"type\":\"control_textbox\"},{\"name\":\"dmoImage60\",\"qid\":\"60\",\"text\":\"(DMO) Image No (front)\",\"type\":\"control_dropdown\"},null,null,null,{\"name\":\"acknowledgmentPicturesphotos\",\"qid\":\"64\",\"text\":\"Acknowledgment Pictures\/Photos\",\"type\":\"control_fileupload\"},{\"name\":\"memorialCard\",\"qid\":\"65\",\"text\":\"Memorial Card Pictures\/Photos\",\"type\":\"control_fileupload\"},null,{\"name\":\"uploadOne\",\"qid\":\"67\",\"text\":\"Upload one or more Pictures\/Photos\",\"type\":\"control_fileupload\"},{\"name\":\"clickTo68\",\"qid\":\"68\",\"text\":\"Other Pictures\/Photos\",\"type\":\"control_head\"},null,{\"name\":\"comments\",\"qid\":\"70\",\"text\":\"Comments\",\"type\":\"control_textarea\"},{\"name\":\"comments71\",\"qid\":\"71\",\"text\":\"Comments\",\"type\":\"control_textarea\"},null,{\"name\":\"comments73\",\"qid\":\"73\",\"text\":\"Comments\",\"type\":\"control_textarea\"},null,null,{\"name\":\"comments76\",\"qid\":\"76\",\"text\":\"Comments\",\"type\":\"control_textarea\"},{\"name\":\"comments77\",\"qid\":\"77\",\"text\":\"Comments\",\"type\":\"control_textarea\"},{\"name\":\"phoneNumber78\",\"qid\":\"78\",\"text\":\"Phone Number\",\"type\":\"control_phone\"},{\"name\":\"email79\",\"qid\":\"79\",\"text\":\"E-mail\",\"type\":\"control_email\"},{\"name\":\"address80\",\"qid\":\"80\",\"text\":\"Address\",\"type\":\"control_address\"},{\"name\":\"address81\",\"qid\":\"81\",\"text\":\"Address\",\"type\":\"control_address\"},{\"name\":\"dateOf82\",\"qid\":\"82\",\"text\":\"Date of Death\",\"type\":\"control_birthdate\"},{\"name\":\"fullName83\",\"qid\":\"83\",\"text\":\"Full Name\",\"type\":\"control_fullname\"},{\"name\":\"fullName84\",\"qid\":\"84\",\"text\":\"Full Name\",\"type\":\"control_fullname\"},{\"name\":\"specialDouble85\",\"qid\":\"85\",\"text\":\"Special Double Design Card\",\"type\":\"control_radio\"},{\"name\":\"specialAcknowledgement86\",\"qid\":\"86\",\"text\":\"Special  Acknowledgement Design\",\"type\":\"control_radio\"},{\"name\":\"ackCard\",\"qid\":\"87\",\"text\":\"(Ack Card Type\",\"type\":\"control_radio\"},{\"name\":\"specialBookmark\",\"qid\":\"88\",\"text\":\"Special Bookmark Design\",\"type\":\"control_radio\"},{\"name\":\"specialDesign\",\"qid\":\"89\",\"text\":\"Special Design Holder\",\"type\":\"control_radio\"},{\"name\":\"front90\",\"qid\":\"90\",\"text\":\"Front\",\"type\":\"control_radio\"},{\"name\":\"clickTo91\",\"qid\":\"91\",\"text\":\"Order Details\",\"type\":\"control_head\"},{\"name\":\"specialWallet\",\"qid\":\"92\",\"text\":\"Special Wallet Design Card\",\"type\":\"control_radio\"},null,null,null,{\"name\":\"smbwBack\",\"qid\":\"96\",\"text\":\"(SM\/B\/W back) Verse No\",\"type\":\"control_dropdown\"},null,null,{\"name\":\"backgroundNo99\",\"qid\":\"99\",\"text\":\"Background No\",\"type\":\"control_dropdown\"},null,null,null,{\"name\":\"comments103\",\"qid\":\"103\",\"text\":\"Comments\",\"type\":\"control_textarea\"},null,null,{\"name\":\"clickTo106\",\"qid\":\"106\",\"text\":\"Single Memoriam \/ Bookmark \/ Wallet Card (Front)\",\"type\":\"control_head\"},{\"name\":\"clickTo107\",\"qid\":\"107\",\"text\":\"Single Memoriam \/ Bookmark \/ Wallet Card (Back)\",\"type\":\"control_head\"},null,{\"name\":\"ownVerse109\",\"qid\":\"109\",\"text\":\"Own Verse (if required)\",\"type\":\"control_textarea\"},{\"name\":\"backgroundNo110\",\"qid\":\"110\",\"text\":\"Background No\",\"type\":\"control_dropdown\"},{\"name\":\"comments111\",\"qid\":\"111\",\"text\":\"Comments\",\"type\":\"control_textarea\"},{\"name\":\"memorialCard112\",\"qid\":\"112\",\"text\":\"Memorial Card Pictures\/Photos\",\"type\":\"control_fileupload\"},{\"name\":\"clickTo113\",\"qid\":\"113\",\"text\":\"Double Memorial Cards (Inside)\",\"type\":\"control_head\"},{\"name\":\"verseNo\",\"qid\":\"114\",\"text\":\"Verse No (front\",\"type\":\"control_dropdown\"},{\"name\":\"ownVerse115\",\"qid\":\"115\",\"text\":\"Own Verse (if required)\",\"type\":\"control_textarea\"},{\"name\":\"backgroundNo116\",\"qid\":\"116\",\"text\":\"Background No\",\"type\":\"control_dropdown\"},{\"name\":\"comments117\",\"qid\":\"117\",\"text\":\"Comments\",\"type\":\"control_textarea\"},{\"name\":\"dmirightVerse\",\"qid\":\"118\",\"text\":\"(DMIright) Verse No\",\"type\":\"control_dropdown\"},{\"name\":\"verseNo119\",\"qid\":\"119\",\"text\":\"Verse No (Back)\",\"type\":\"control_dropdown\"},{\"name\":\"imageNo\",\"qid\":\"120\",\"text\":\"Image No\",\"type\":\"control_dropdown\"},{\"name\":\"imageNo121\",\"qid\":\"121\",\"text\":\"Image No\",\"type\":\"control_dropdown\"},{\"name\":\"imageNo122\",\"qid\":\"122\",\"text\":\"Image No\",\"type\":\"control_dropdown\"},{\"name\":\"numberOf123\",\"qid\":\"123\",\"text\":\"Number of Single Memoriam Cards required\",\"type\":\"control_textbox\"},{\"name\":\"specialSingle\",\"qid\":\"124\",\"text\":\"Special Single Design Card\",\"type\":\"control_radio\"},{\"name\":\"depositPayment125\",\"qid\":\"125\",\"text\":\"Deposit Payment (Paypal)\",\"type\":\"control_paypal\"},{\"name\":\"clickTo126\",\"qid\":\"126\",\"text\":\"Deposit Payment (Paypal)\",\"type\":\"control_head\"},{\"name\":\"submit127\",\"qid\":\"127\",\"text\":\"Proceed to Paypal\",\"type\":\"control_button\"}]);\n   setTimeout(function() {\nJotForm.paymentExtrasOnTheFly([null,{\"name\":\"clickTo\",\"qid\":\"1\",\"text\":\"Place Order Form (Paypal Option)\",\"type\":\"control_head\"},null,null,null,{\"name\":\"ageif\",\"qid\":\"5\",\"text\":\"Age (if required)\",\"type\":\"control_textbox\"},null,null,null,null,null,null,{\"name\":\"numberOf12\",\"qid\":\"12\",\"text\":\"Number of Double Memoriam Cards required\",\"type\":\"control_textbox\"},{\"name\":\"noOf\",\"qid\":\"13\",\"text\":\"No of Holders required\",\"type\":\"control_textbox\"},null,{\"name\":\"clickTo15\",\"qid\":\"15\",\"text\":\"Details of Deceased\",\"type\":\"control_head\"},{\"name\":\"clickTo16\",\"qid\":\"16\",\"text\":\"Customer Details\",\"type\":\"control_head\"},{\"name\":\"clickTo17\",\"qid\":\"17\",\"text\":\"Double Memorial Cards (Outside)\",\"type\":\"control_head\"},{\"name\":\"imageNo18\",\"qid\":\"18\",\"text\":\"Image No (back)\",\"type\":\"control_dropdown\"},null,null,null,{\"name\":\"ownVerse22\",\"qid\":\"22\",\"text\":\"Own Verse (if desired)\",\"type\":\"control_textarea\"},null,{\"name\":\"ownif24\",\"qid\":\"24\",\"text\":\"Own (if required)\",\"type\":\"control_textbox\"},{\"name\":\"clickTo25\",\"qid\":\"25\",\"text\":\"Double Memorial Cards (Inside)\",\"type\":\"control_head\"},{\"name\":\"backgroundNo\",\"qid\":\"26\",\"text\":\"Background No\",\"type\":\"control_dropdown\"},{\"name\":\"dmileftFrame\",\"qid\":\"27\",\"text\":\"(DMIleft) Frame No\",\"type\":\"control_dropdown\"},{\"name\":\"shortVerse\",\"qid\":\"28\",\"text\":\"Short Verse No\",\"type\":\"control_dropdown\"},{\"name\":\"ownShort29\",\"qid\":\"29\",\"text\":\"Own Short Verse (if required\",\"type\":\"control_textarea\"},{\"name\":\"smbwFront\",\"qid\":\"30\",\"text\":\"(SM\/B\/W front) Verse No\",\"type\":\"control_dropdown\"},{\"name\":\"ownVerse\",\"qid\":\"31\",\"text\":\"Own Verse (if required)\",\"type\":\"control_textarea\"},null,null,{\"name\":\"clickTo34\",\"qid\":\"34\",\"text\":\"Acknowledgement Cards\",\"type\":\"control_head\"},null,{\"name\":\"imageNo36\",\"qid\":\"36\",\"text\":\"Image No\",\"type\":\"control_dropdown\"},{\"name\":\"wording\",\"qid\":\"37\",\"text\":\"Wording\",\"type\":\"control_dropdown\"},{\"name\":\"ownWording38\",\"qid\":\"38\",\"text\":\"Own Wording (if required)\",\"type\":\"control_textarea\"},null,null,null,null,null,null,null,null,null,null,null,null,{\"name\":\"clickTo51\",\"qid\":\"51\",\"text\":\"Holder for Bookmarks or Single Card\",\"type\":\"control_head\"},{\"name\":\"holderNo52\",\"qid\":\"52\",\"text\":\"Holder No\",\"type\":\"control_dropdown\"},null,null,{\"name\":\"enterThe55\",\"qid\":\"55\",\"text\":\"Enter the message as it's shown\",\"type\":\"control_captcha\"},null,{\"name\":\"numberOf\",\"qid\":\"57\",\"text\":\"Number of Bookmarks required\",\"type\":\"control_textbox\"},{\"name\":\"numberOf58\",\"qid\":\"58\",\"text\":\"Number of Wallet cards required\",\"type\":\"control_textbox\"},{\"name\":\"numberOf59\",\"qid\":\"59\",\"text\":\"Number of Acknowledgement Cards\",\"type\":\"control_textbox\"},{\"name\":\"dmoImage60\",\"qid\":\"60\",\"text\":\"(DMO) Image No (front)\",\"type\":\"control_dropdown\"},null,null,null,{\"name\":\"acknowledgmentPicturesphotos\",\"qid\":\"64\",\"text\":\"Acknowledgment Pictures\/Photos\",\"type\":\"control_fileupload\"},{\"name\":\"memorialCard\",\"qid\":\"65\",\"text\":\"Memorial Card Pictures\/Photos\",\"type\":\"control_fileupload\"},null,{\"name\":\"uploadOne\",\"qid\":\"67\",\"text\":\"Upload one or more Pictures\/Photos\",\"type\":\"control_fileupload\"},{\"name\":\"clickTo68\",\"qid\":\"68\",\"text\":\"Other Pictures\/Photos\",\"type\":\"control_head\"},null,{\"name\":\"comments\",\"qid\":\"70\",\"text\":\"Comments\",\"type\":\"control_textarea\"},{\"name\":\"comments71\",\"qid\":\"71\",\"text\":\"Comments\",\"type\":\"control_textarea\"},null,{\"name\":\"comments73\",\"qid\":\"73\",\"text\":\"Comments\",\"type\":\"control_textarea\"},null,null,{\"name\":\"comments76\",\"qid\":\"76\",\"text\":\"Comments\",\"type\":\"control_textarea\"},{\"name\":\"comments77\",\"qid\":\"77\",\"text\":\"Comments\",\"type\":\"control_textarea\"},{\"name\":\"phoneNumber78\",\"qid\":\"78\",\"text\":\"Phone Number\",\"type\":\"control_phone\"},{\"name\":\"email79\",\"qid\":\"79\",\"text\":\"E-mail\",\"type\":\"control_email\"},{\"name\":\"address80\",\"qid\":\"80\",\"text\":\"Address\",\"type\":\"control_address\"},{\"name\":\"address81\",\"qid\":\"81\",\"text\":\"Address\",\"type\":\"control_address\"},{\"name\":\"dateOf82\",\"qid\":\"82\",\"text\":\"Date of Death\",\"type\":\"control_birthdate\"},{\"name\":\"fullName83\",\"qid\":\"83\",\"text\":\"Full Name\",\"type\":\"control_fullname\"},{\"name\":\"fullName84\",\"qid\":\"84\",\"text\":\"Full Name\",\"type\":\"control_fullname\"},{\"name\":\"specialDouble85\",\"qid\":\"85\",\"text\":\"Special Double Design Card\",\"type\":\"control_radio\"},{\"name\":\"specialAcknowledgement86\",\"qid\":\"86\",\"text\":\"Special  Acknowledgement Design\",\"type\":\"control_radio\"},{\"name\":\"ackCard\",\"qid\":\"87\",\"text\":\"(Ack Card Type\",\"type\":\"control_radio\"},{\"name\":\"specialBookmark\",\"qid\":\"88\",\"text\":\"Special Bookmark Design\",\"type\":\"control_radio\"},{\"name\":\"specialDesign\",\"qid\":\"89\",\"text\":\"Special Design Holder\",\"type\":\"control_radio\"},{\"name\":\"front90\",\"qid\":\"90\",\"text\":\"Front\",\"type\":\"control_radio\"},{\"name\":\"clickTo91\",\"qid\":\"91\",\"text\":\"Order Details\",\"type\":\"control_head\"},{\"name\":\"specialWallet\",\"qid\":\"92\",\"text\":\"Special Wallet Design Card\",\"type\":\"control_radio\"},null,null,null,{\"name\":\"smbwBack\",\"qid\":\"96\",\"text\":\"(SM\/B\/W back) Verse No\",\"type\":\"control_dropdown\"},null,null,{\"name\":\"backgroundNo99\",\"qid\":\"99\",\"text\":\"Background No\",\"type\":\"control_dropdown\"},null,null,null,{\"name\":\"comments103\",\"qid\":\"103\",\"text\":\"Comments\",\"type\":\"control_textarea\"},null,null,{\"name\":\"clickTo106\",\"qid\":\"106\",\"text\":\"Single Memoriam \/ Bookmark \/ Wallet Card (Front)\",\"type\":\"control_head\"},{\"name\":\"clickTo107\",\"qid\":\"107\",\"text\":\"Single Memoriam \/ Bookmark \/ Wallet Card (Back)\",\"type\":\"control_head\"},null,{\"name\":\"ownVerse109\",\"qid\":\"109\",\"text\":\"Own Verse (if required)\",\"type\":\"control_textarea\"},{\"name\":\"backgroundNo110\",\"qid\":\"110\",\"text\":\"Background No\",\"type\":\"control_dropdown\"},{\"name\":\"comments111\",\"qid\":\"111\",\"text\":\"Comments\",\"type\":\"control_textarea\"},{\"name\":\"memorialCard112\",\"qid\":\"112\",\"text\":\"Memorial Card Pictures\/Photos\",\"type\":\"control_fileupload\"},{\"name\":\"clickTo113\",\"qid\":\"113\",\"text\":\"Double Memorial Cards (Inside)\",\"type\":\"control_head\"},{\"name\":\"verseNo\",\"qid\":\"114\",\"text\":\"Verse No (front\",\"type\":\"control_dropdown\"},{\"name\":\"ownVerse115\",\"qid\":\"115\",\"text\":\"Own Verse (if required)\",\"type\":\"control_textarea\"},{\"name\":\"backgroundNo116\",\"qid\":\"116\",\"text\":\"Background No\",\"type\":\"control_dropdown\"},{\"name\":\"comments117\",\"qid\":\"117\",\"text\":\"Comments\",\"type\":\"control_textarea\"},{\"name\":\"dmirightVerse\",\"qid\":\"118\",\"text\":\"(DMIright) Verse No\",\"type\":\"control_dropdown\"},{\"name\":\"verseNo119\",\"qid\":\"119\",\"text\":\"Verse No (Back)\",\"type\":\"control_dropdown\"},{\"name\":\"imageNo\",\"qid\":\"120\",\"text\":\"Image No\",\"type\":\"control_dropdown\"},{\"name\":\"imageNo121\",\"qid\":\"121\",\"text\":\"Image No\",\"type\":\"control_dropdown\"},{\"name\":\"imageNo122\",\"qid\":\"122\",\"text\":\"Image No\",\"type\":\"control_dropdown\"},{\"name\":\"numberOf123\",\"qid\":\"123\",\"text\":\"Number of Single Memoriam Cards required\",\"type\":\"control_textbox\"},{\"name\":\"specialSingle\",\"qid\":\"124\",\"text\":\"Special Single Design Card\",\"type\":\"control_radio\"},{\"name\":\"depositPayment125\",\"qid\":\"125\",\"text\":\"Deposit Payment (Paypal)\",\"type\":\"control_paypal\"},{\"name\":\"clickTo126\",\"qid\":\"126\",\"text\":\"Deposit Payment (Paypal)\",\"type\":\"control_head\"},{\"name\":\"submit127\",\"qid\":\"127\",\"text\":\"Proceed to Paypal\",\"type\":\"control_button\"}]);}, 20); \n<\/script>\n<\/head>\n<body>\n<form class=\"jotform-form\" action=\"https:\/\/submit.jotformpro.com\/submit\/60472453012950\/\" method=\"post\" enctype=\"multipart\/form-data\" name=\"form_60472453012950\" id=\"60472453012950\" accept-charset=\"utf-8\">\n  <input type=\"hidden\" name=\"formID\" value=\"60472453012950\" \/>\n  <div class=\"form-all\">\n    <ul class=\"form-section page-section\">\n      <li id=\"cid_1\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h1 id=\"header_1\" class=\"form-header\" data-component=\"header\">\n              Place Order Form (Paypal Option)\n            <\/h1>\n            <div id=\"subHeader_1\" class=\"form-subHeader\">\n              Please fill out as appropriate\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_15\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h3 id=\"header_15\" class=\"form-header\" data-component=\"header\">\n              Details of Deceased\n            <\/h3>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_fullname\" id=\"id_83\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_83\" for=\"first_83\">\n          Full Name\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_83\" class=\"form-input jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input type=\"text\" id=\"first_83\" name=\"q83_fullName83[first]\" class=\"form-textbox validate[required]\" size=\"10\" value=\"\" data-component=\"first\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"first_83\" id=\"sublabel_first\" style=\"min-height:13px;\"> First Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input type=\"text\" id=\"last_83\" name=\"q83_fullName83[last]\" class=\"form-textbox validate[required]\" size=\"15\" value=\"\" data-component=\"last\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"last_83\" id=\"sublabel_last\" style=\"min-height:13px;\"> Last Name <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_birthdate\" id=\"id_82\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_82\" for=\"input_82\"> Date of Death <\/label>\n        <div id=\"cid_82\" class=\"form-input\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <select name=\"q82_dateOf82[day]\" id=\"input_82_day\" class=\"form-dropdown\" data-component=\"birthdate-day\">\n                <option>  <\/option>\n                <option value=\"1\"> 1 <\/option>\n                <option value=\"2\"> 2 <\/option>\n                <option value=\"3\"> 3 <\/option>\n                <option value=\"4\"> 4 <\/option>\n                <option value=\"5\"> 5 <\/option>\n                <option value=\"6\"> 6 <\/option>\n                <option value=\"7\"> 7 <\/option>\n                <option value=\"8\"> 8 <\/option>\n                <option value=\"9\"> 9 <\/option>\n                <option value=\"10\"> 10 <\/option>\n                <option value=\"11\"> 11 <\/option>\n                <option value=\"12\"> 12 <\/option>\n                <option value=\"13\"> 13 <\/option>\n                <option value=\"14\"> 14 <\/option>\n                <option value=\"15\"> 15 <\/option>\n                <option value=\"16\"> 16 <\/option>\n                <option value=\"17\"> 17 <\/option>\n                <option value=\"18\"> 18 <\/option>\n                <option value=\"19\"> 19 <\/option>\n                <option value=\"20\"> 20 <\/option>\n                <option value=\"21\"> 21 <\/option>\n                <option value=\"22\"> 22 <\/option>\n                <option value=\"23\"> 23 <\/option>\n                <option value=\"24\"> 24 <\/option>\n                <option value=\"25\"> 25 <\/option>\n                <option value=\"26\"> 26 <\/option>\n                <option value=\"27\"> 27 <\/option>\n                <option value=\"28\"> 28 <\/option>\n                <option value=\"29\"> 29 <\/option>\n                <option value=\"30\"> 30 <\/option>\n                <option value=\"31\"> 31 <\/option>\n              <\/select>\n              <label class=\"form-sub-label\" for=\"input_82_day\" id=\"sublabel_day\" style=\"min-height:13px;\"> Day <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <select name=\"q82_dateOf82[month]\" id=\"input_82_month\" class=\"form-dropdown\" data-component=\"birthdate-month\">\n                <option>  <\/option>\n                <option value=\"January\"> January <\/option>\n                <option value=\"February\"> February <\/option>\n                <option value=\"March\"> March <\/option>\n                <option value=\"April\"> April <\/option>\n                <option value=\"May\"> May <\/option>\n                <option value=\"June\"> June <\/option>\n                <option value=\"July\"> July <\/option>\n                <option value=\"August\"> August <\/option>\n                <option value=\"September\"> September <\/option>\n                <option value=\"October\"> October <\/option>\n                <option value=\"November\"> November <\/option>\n                <option value=\"December\"> December <\/option>\n              <\/select>\n              <label class=\"form-sub-label\" for=\"input_82_month\" id=\"sublabel_month\" style=\"min-height:13px;\"> Month <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <select name=\"q82_dateOf82[year]\" id=\"input_82_year\" class=\"form-dropdown\" data-component=\"birthdate-year\">\n                <option>  <\/option>\n                <option value=\"2017\"> 2017 <\/option>\n                <option value=\"2016\"> 2016 <\/option>\n                <option value=\"2015\"> 2015 <\/option>\n                <option value=\"2014\"> 2014 <\/option>\n                <option value=\"2013\"> 2013 <\/option>\n                <option value=\"2012\"> 2012 <\/option>\n                <option value=\"2011\"> 2011 <\/option>\n                <option value=\"2010\"> 2010 <\/option>\n                <option value=\"2009\"> 2009 <\/option>\n                <option value=\"2008\"> 2008 <\/option>\n                <option value=\"2007\"> 2007 <\/option>\n                <option value=\"2006\"> 2006 <\/option>\n                <option value=\"2005\"> 2005 <\/option>\n                <option value=\"2004\"> 2004 <\/option>\n                <option value=\"2003\"> 2003 <\/option>\n                <option value=\"2002\"> 2002 <\/option>\n                <option value=\"2001\"> 2001 <\/option>\n                <option value=\"2000\"> 2000 <\/option>\n                <option value=\"1999\"> 1999 <\/option>\n                <option value=\"1998\"> 1998 <\/option>\n                <option value=\"1997\"> 1997 <\/option>\n                <option value=\"1996\"> 1996 <\/option>\n                <option value=\"1995\"> 1995 <\/option>\n                <option value=\"1994\"> 1994 <\/option>\n                <option value=\"1993\"> 1993 <\/option>\n                <option value=\"1992\"> 1992 <\/option>\n                <option value=\"1991\"> 1991 <\/option>\n                <option value=\"1990\"> 1990 <\/option>\n                <option value=\"1989\"> 1989 <\/option>\n                <option value=\"1988\"> 1988 <\/option>\n                <option value=\"1987\"> 1987 <\/option>\n                <option value=\"1986\"> 1986 <\/option>\n                <option value=\"1985\"> 1985 <\/option>\n                <option value=\"1984\"> 1984 <\/option>\n                <option value=\"1983\"> 1983 <\/option>\n                <option value=\"1982\"> 1982 <\/option>\n                <option value=\"1981\"> 1981 <\/option>\n                <option value=\"1980\"> 1980 <\/option>\n                <option value=\"1979\"> 1979 <\/option>\n                <option value=\"1978\"> 1978 <\/option>\n                <option value=\"1977\"> 1977 <\/option>\n                <option value=\"1976\"> 1976 <\/option>\n                <option value=\"1975\"> 1975 <\/option>\n                <option value=\"1974\"> 1974 <\/option>\n                <option value=\"1973\"> 1973 <\/option>\n                <option value=\"1972\"> 1972 <\/option>\n                <option value=\"1971\"> 1971 <\/option>\n                <option value=\"1970\"> 1970 <\/option>\n                <option value=\"1969\"> 1969 <\/option>\n                <option value=\"1968\"> 1968 <\/option>\n                <option value=\"1967\"> 1967 <\/option>\n                <option value=\"1966\"> 1966 <\/option>\n                <option value=\"1965\"> 1965 <\/option>\n                <option value=\"1964\"> 1964 <\/option>\n                <option value=\"1963\"> 1963 <\/option>\n                <option value=\"1962\"> 1962 <\/option>\n                <option value=\"1961\"> 1961 <\/option>\n                <option value=\"1960\"> 1960 <\/option>\n                <option value=\"1959\"> 1959 <\/option>\n                <option value=\"1958\"> 1958 <\/option>\n                <option value=\"1957\"> 1957 <\/option>\n                <option value=\"1956\"> 1956 <\/option>\n                <option value=\"1955\"> 1955 <\/option>\n                <option value=\"1954\"> 1954 <\/option>\n                <option value=\"1953\"> 1953 <\/option>\n                <option value=\"1952\"> 1952 <\/option>\n                <option value=\"1951\"> 1951 <\/option>\n                <option value=\"1950\"> 1950 <\/option>\n                <option value=\"1949\"> 1949 <\/option>\n                <option value=\"1948\"> 1948 <\/option>\n                <option value=\"1947\"> 1947 <\/option>\n                <option value=\"1946\"> 1946 <\/option>\n                <option value=\"1945\"> 1945 <\/option>\n                <option value=\"1944\"> 1944 <\/option>\n                <option value=\"1943\"> 1943 <\/option>\n                <option value=\"1942\"> 1942 <\/option>\n                <option value=\"1941\"> 1941 <\/option>\n                <option value=\"1940\"> 1940 <\/option>\n                <option value=\"1939\"> 1939 <\/option>\n                <option value=\"1938\"> 1938 <\/option>\n                <option value=\"1937\"> 1937 <\/option>\n                <option value=\"1936\"> 1936 <\/option>\n                <option value=\"1935\"> 1935 <\/option>\n                <option value=\"1934\"> 1934 <\/option>\n                <option value=\"1933\"> 1933 <\/option>\n                <option value=\"1932\"> 1932 <\/option>\n                <option value=\"1931\"> 1931 <\/option>\n                <option value=\"1930\"> 1930 <\/option>\n                <option value=\"1929\"> 1929 <\/option>\n                <option value=\"1928\"> 1928 <\/option>\n                <option value=\"1927\"> 1927 <\/option>\n                <option value=\"1926\"> 1926 <\/option>\n                <option value=\"1925\"> 1925 <\/option>\n                <option value=\"1924\"> 1924 <\/option>\n                <option value=\"1923\"> 1923 <\/option>\n                <option value=\"1922\"> 1922 <\/option>\n                <option value=\"1921\"> 1921 <\/option>\n                <option value=\"1920\"> 1920 <\/option>\n              <\/select>\n              <label class=\"form-sub-label\" for=\"input_82_year\" id=\"sublabel_year\" style=\"min-height:13px;\"> Year <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_address\" id=\"id_81\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_81\" for=\"input_81_addr_line1\"> Address <\/label>\n        <div id=\"cid_81\" class=\"form-input\">\n          <table summary=\"\" class=\"form-address-table\" cellpadding=\"0\" cellspacing=\"0\">\n            <tbody>\n              <tr>\n                <td colspan=\"2\">\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                    <input type=\"text\" id=\"input_81_addr_line1\" name=\"q81_address81[addr_line1]\" class=\"form-textbox form-address-line\" value=\"\" data-component=\"address_line_1\" \/>\n                    <label class=\"form-sub-label\" for=\"input_81_addr_line1\" id=\"sublabel_81_addr_line1\" style=\"min-height:13px;\"> Street Address <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td colspan=\"2\">\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                    <input type=\"text\" id=\"input_81_addr_line2\" name=\"q81_address81[addr_line2]\" class=\"form-textbox form-address-line\" size=\"46\" value=\"\" data-component=\"address_line_2\" \/>\n                    <label class=\"form-sub-label\" for=\"input_81_addr_line2\" id=\"sublabel_81_addr_line2\" style=\"min-height:13px;\"> Street Address Line 2 <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td width=\"50%\">\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                    <input type=\"text\" id=\"input_81_city\" name=\"q81_address81[city]\" class=\"form-textbox form-address-city\" size=\"21\" value=\"\" data-component=\"city\" \/>\n                    <label class=\"form-sub-label\" for=\"input_81_city\" id=\"sublabel_81_city\" style=\"min-height:13px;\"> City <\/label>\n                  <\/span>\n                <\/td>\n                <td>\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                    <input type=\"text\" id=\"input_81_state\" name=\"q81_address81[state]\" class=\"form-textbox form-address-state\" size=\"22\" value=\"\" data-component=\"state\" \/>\n                    <label class=\"form-sub-label\" for=\"input_81_state\" id=\"sublabel_81_state\" style=\"min-height:13px;\"> County \/ State \/ Province <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td width=\"50%\">\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                    <input type=\"text\" id=\"input_81_postal\" name=\"q81_address81[postal]\" class=\"form-textbox form-address-postal\" size=\"10\" value=\"\" data-component=\"zip\" \/>\n                    <label class=\"form-sub-label\" for=\"input_81_postal\" id=\"sublabel_81_postal\" style=\"min-height:13px;\"> Postal \/ Zip Code <\/label>\n                  <\/span>\n                <\/td>\n                <td>\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                    <select class=\"form-dropdown form-address-country\" name=\"q81_address81[country]\" id=\"input_81_country\" data-component=\"country\">\n                      <option value=\"\"> Please Select <\/option>\n                      <option value=\"United States\"> United States <\/option>\n                      <option value=\"Afghanistan\"> Afghanistan <\/option>\n                      <option value=\"Albania\"> Albania <\/option>\n                      <option value=\"Algeria\"> Algeria <\/option>\n                      <option value=\"American Samoa\"> American Samoa <\/option>\n                      <option value=\"Andorra\"> Andorra <\/option>\n                      <option value=\"Angola\"> Angola <\/option>\n                      <option value=\"Anguilla\"> Anguilla <\/option>\n                      <option value=\"Antigua and Barbuda\"> Antigua and Barbuda <\/option>\n                      <option value=\"Argentina\"> Argentina <\/option>\n                      <option value=\"Armenia\"> Armenia <\/option>\n                      <option value=\"Aruba\"> Aruba <\/option>\n                      <option value=\"Australia\"> Australia <\/option>\n                      <option value=\"Austria\"> Austria <\/option>\n                      <option value=\"Azerbaijan\"> Azerbaijan <\/option>\n                      <option value=\"The Bahamas\"> The Bahamas <\/option>\n                      <option value=\"Bahrain\"> Bahrain <\/option>\n                      <option value=\"Bangladesh\"> Bangladesh <\/option>\n                      <option value=\"Barbados\"> Barbados <\/option>\n                      <option value=\"Belarus\"> Belarus <\/option>\n                      <option value=\"Belgium\"> Belgium <\/option>\n                      <option value=\"Belize\"> Belize <\/option>\n                      <option value=\"Benin\"> Benin <\/option>\n                      <option value=\"Bermuda\"> Bermuda <\/option>\n                      <option value=\"Bhutan\"> Bhutan <\/option>\n                      <option value=\"Bolivia\"> Bolivia <\/option>\n                      <option value=\"Bosnia and Herzegovina\"> Bosnia and Herzegovina <\/option>\n                      <option value=\"Botswana\"> Botswana <\/option>\n                      <option value=\"Brazil\"> Brazil <\/option>\n                      <option value=\"Brunei\"> Brunei <\/option>\n                      <option value=\"Bulgaria\"> Bulgaria <\/option>\n                      <option value=\"Burkina Faso\"> Burkina Faso <\/option>\n                      <option value=\"Burundi\"> Burundi <\/option>\n                      <option value=\"Cambodia\"> Cambodia <\/option>\n                      <option value=\"Cameroon\"> Cameroon <\/option>\n                      <option value=\"Canada\"> Canada <\/option>\n                      <option value=\"Cape Verde\"> Cape Verde <\/option>\n                      <option value=\"Cayman Islands\"> Cayman Islands <\/option>\n                      <option value=\"Central African Republic\"> Central African Republic <\/option>\n                      <option value=\"Chad\"> Chad <\/option>\n                      <option value=\"Chile\"> Chile <\/option>\n                      <option value=\"China\"> China <\/option>\n                      <option value=\"Christmas Island\"> Christmas Island <\/option>\n                      <option value=\"Cocos (Keeling) Islands\"> Cocos (Keeling) Islands <\/option>\n                      <option value=\"Colombia\"> Colombia <\/option>\n                      <option value=\"Comoros\"> Comoros <\/option>\n                      <option value=\"Congo\"> Congo <\/option>\n                      <option value=\"Cook Islands\"> Cook Islands <\/option>\n                      <option value=\"Costa Rica\"> Costa Rica <\/option>\n                      <option value=\"Cote d&#x27;Ivoire\"> Cote d&#x27;Ivoire <\/option>\n                      <option value=\"Croatia\"> Croatia <\/option>\n                      <option value=\"Cuba\"> Cuba <\/option>\n                      <option value=\"Cyprus\"> Cyprus <\/option>\n                      <option value=\"Czech Republic\"> Czech Republic <\/option>\n                      <option value=\"Democratic Republic of the Congo\"> Democratic Republic of the Congo <\/option>\n                      <option value=\"Denmark\"> Denmark <\/option>\n                      <option value=\"Djibouti\"> Djibouti <\/option>\n                      <option value=\"Dominica\"> Dominica <\/option>\n                      <option value=\"Dominican Republic\"> Dominican Republic <\/option>\n                      <option value=\"Ecuador\"> Ecuador <\/option>\n                      <option value=\"Egypt\"> Egypt <\/option>\n                      <option value=\"El Salvador\"> El Salvador <\/option>\n                      <option value=\"Equatorial Guinea\"> Equatorial Guinea <\/option>\n                      <option value=\"Eritrea\"> Eritrea <\/option>\n                      <option value=\"Estonia\"> Estonia <\/option>\n                      <option value=\"Ethiopia\"> Ethiopia <\/option>\n                      <option value=\"Falkland Islands\"> Falkland Islands <\/option>\n                      <option value=\"Faroe Islands\"> Faroe Islands <\/option>\n                      <option value=\"Fiji\"> Fiji <\/option>\n                      <option value=\"Finland\"> Finland <\/option>\n                      <option value=\"France\"> France <\/option>\n                      <option value=\"French Polynesia\"> French Polynesia <\/option>\n                      <option value=\"Gabon\"> Gabon <\/option>\n                      <option value=\"The Gambia\"> The Gambia <\/option>\n                      <option value=\"Georgia\"> Georgia <\/option>\n                      <option value=\"Germany\"> Germany <\/option>\n                      <option value=\"Ghana\"> Ghana <\/option>\n                      <option value=\"Gibraltar\"> Gibraltar <\/option>\n                      <option value=\"Greece\"> Greece <\/option>\n                      <option value=\"Greenland\"> Greenland <\/option>\n                      <option value=\"Grenada\"> Grenada <\/option>\n                      <option value=\"Guadeloupe\"> Guadeloupe <\/option>\n                      <option value=\"Guam\"> Guam <\/option>\n                      <option value=\"Guatemala\"> Guatemala <\/option>\n                      <option value=\"Guernsey\"> Guernsey <\/option>\n                      <option value=\"Guinea\"> Guinea <\/option>\n                      <option value=\"Guinea-Bissau\"> Guinea-Bissau <\/option>\n                      <option value=\"Guyana\"> Guyana <\/option>\n                      <option value=\"Haiti\"> Haiti <\/option>\n                      <option value=\"Honduras\"> Honduras <\/option>\n                      <option value=\"Hong Kong\"> Hong Kong <\/option>\n                      <option value=\"Hungary\"> Hungary <\/option>\n                      <option value=\"Iceland\"> Iceland <\/option>\n                      <option value=\"India\"> India <\/option>\n                      <option value=\"Indonesia\"> Indonesia <\/option>\n                      <option value=\"Iran\"> Iran <\/option>\n                      <option value=\"Iraq\"> Iraq <\/option>\n                      <option value=\"Ireland\"> Ireland <\/option>\n                      <option value=\"Israel\"> Israel <\/option>\n                      <option value=\"Italy\"> Italy <\/option>\n                      <option value=\"Jamaica\"> Jamaica <\/option>\n                      <option value=\"Japan\"> Japan <\/option>\n                      <option value=\"Jersey\"> Jersey <\/option>\n                      <option value=\"Jordan\"> Jordan <\/option>\n                      <option value=\"Kazakhstan\"> Kazakhstan <\/option>\n                      <option value=\"Kenya\"> Kenya <\/option>\n                      <option value=\"Kiribati\"> Kiribati <\/option>\n                      <option value=\"North Korea\"> North Korea <\/option>\n                      <option value=\"South Korea\"> South Korea <\/option>\n                      <option value=\"Kosovo\"> Kosovo <\/option>\n                      <option value=\"Kuwait\"> Kuwait <\/option>\n                      <option value=\"Kyrgyzstan\"> Kyrgyzstan <\/option>\n                      <option value=\"Laos\"> Laos <\/option>\n                      <option value=\"Latvia\"> Latvia <\/option>\n                      <option value=\"Lebanon\"> Lebanon <\/option>\n                      <option value=\"Lesotho\"> Lesotho <\/option>\n                      <option value=\"Liberia\"> Liberia <\/option>\n                      <option value=\"Libya\"> Libya <\/option>\n                      <option value=\"Liechtenstein\"> Liechtenstein <\/option>\n                      <option value=\"Lithuania\"> Lithuania <\/option>\n                      <option value=\"Luxembourg\"> Luxembourg <\/option>\n                      <option value=\"Macau\"> Macau <\/option>\n                      <option value=\"Macedonia\"> Macedonia <\/option>\n                      <option value=\"Madagascar\"> Madagascar <\/option>\n                      <option value=\"Malawi\"> Malawi <\/option>\n                      <option value=\"Malaysia\"> Malaysia <\/option>\n                      <option value=\"Maldives\"> Maldives <\/option>\n                      <option value=\"Mali\"> Mali <\/option>\n                      <option value=\"Malta\"> Malta <\/option>\n                      <option value=\"Marshall Islands\"> Marshall Islands <\/option>\n                      <option value=\"Martinique\"> Martinique <\/option>\n                      <option value=\"Mauritania\"> Mauritania <\/option>\n                      <option value=\"Mauritius\"> Mauritius <\/option>\n                      <option value=\"Mayotte\"> Mayotte <\/option>\n                      <option value=\"Mexico\"> Mexico <\/option>\n                      <option value=\"Micronesia\"> Micronesia <\/option>\n                      <option value=\"Moldova\"> Moldova <\/option>\n                      <option value=\"Monaco\"> Monaco <\/option>\n                      <option value=\"Mongolia\"> Mongolia <\/option>\n                      <option value=\"Montenegro\"> Montenegro <\/option>\n                      <option value=\"Montserrat\"> Montserrat <\/option>\n                      <option value=\"Morocco\"> Morocco <\/option>\n                      <option value=\"Mozambique\"> Mozambique <\/option>\n                      <option value=\"Myanmar\"> Myanmar <\/option>\n                      <option value=\"Nagorno-Karabakh\"> Nagorno-Karabakh <\/option>\n                      <option value=\"Namibia\"> Namibia <\/option>\n                      <option value=\"Nauru\"> Nauru <\/option>\n                      <option value=\"Nepal\"> Nepal <\/option>\n                      <option value=\"Netherlands\"> Netherlands <\/option>\n                      <option value=\"Netherlands Antilles\"> Netherlands Antilles <\/option>\n                      <option value=\"New Caledonia\"> New Caledonia <\/option>\n                      <option value=\"New Zealand\"> New Zealand <\/option>\n                      <option value=\"Nicaragua\"> Nicaragua <\/option>\n                      <option value=\"Niger\"> Niger <\/option>\n                      <option value=\"Nigeria\"> Nigeria <\/option>\n                      <option value=\"Niue\"> Niue <\/option>\n                      <option value=\"Norfolk Island\"> Norfolk Island <\/option>\n                      <option value=\"Turkish Republic of Northern Cyprus\"> Turkish Republic of Northern Cyprus <\/option>\n                      <option value=\"Northern Mariana\"> Northern Mariana <\/option>\n                      <option value=\"Norway\"> Norway <\/option>\n                      <option value=\"Oman\"> Oman <\/option>\n                      <option value=\"Pakistan\"> Pakistan <\/option>\n                      <option value=\"Palau\"> Palau <\/option>\n                      <option value=\"Palestine\"> Palestine <\/option>\n                      <option value=\"Panama\"> Panama <\/option>\n                      <option value=\"Papua New Guinea\"> Papua New Guinea <\/option>\n                      <option value=\"Paraguay\"> Paraguay <\/option>\n                      <option value=\"Peru\"> Peru <\/option>\n                      <option value=\"Philippines\"> Philippines <\/option>\n                      <option value=\"Pitcairn Islands\"> Pitcairn Islands <\/option>\n                      <option value=\"Poland\"> Poland <\/option>\n                      <option value=\"Portugal\"> Portugal <\/option>\n                      <option value=\"Puerto Rico\"> Puerto Rico <\/option>\n                      <option value=\"Qatar\"> Qatar <\/option>\n                      <option value=\"Republic of the Congo\"> Republic of the Congo <\/option>\n                      <option value=\"Romania\"> Romania <\/option>\n                      <option value=\"Russia\"> Russia <\/option>\n                      <option value=\"Rwanda\"> Rwanda <\/option>\n                      <option value=\"Saint Barthelemy\"> Saint Barthelemy <\/option>\n                      <option value=\"Saint Helena\"> Saint Helena <\/option>\n                      <option value=\"Saint Kitts and Nevis\"> Saint Kitts and Nevis <\/option>\n                      <option value=\"Saint Lucia\"> Saint Lucia <\/option>\n                      <option value=\"Saint Martin\"> Saint Martin <\/option>\n                      <option value=\"Saint Pierre and Miquelon\"> Saint Pierre and Miquelon <\/option>\n                      <option value=\"Saint Vincent and the Grenadines\"> Saint Vincent and the Grenadines <\/option>\n                      <option value=\"Samoa\"> Samoa <\/option>\n                      <option value=\"San Marino\"> San Marino <\/option>\n                      <option value=\"Sao Tome and Principe\"> Sao Tome and Principe <\/option>\n                      <option value=\"Saudi Arabia\"> Saudi Arabia <\/option>\n                      <option value=\"Senegal\"> Senegal <\/option>\n                      <option value=\"Serbia\"> Serbia <\/option>\n                      <option value=\"Seychelles\"> Seychelles <\/option>\n                      <option value=\"Sierra Leone\"> Sierra Leone <\/option>\n                      <option value=\"Singapore\"> Singapore <\/option>\n                      <option value=\"Slovakia\"> Slovakia <\/option>\n                      <option value=\"Slovenia\"> Slovenia <\/option>\n                      <option value=\"Solomon Islands\"> Solomon Islands <\/option>\n                      <option value=\"Somalia\"> Somalia <\/option>\n                      <option value=\"Somaliland\"> Somaliland <\/option>\n                      <option value=\"South Africa\"> South Africa <\/option>\n                      <option value=\"South Ossetia\"> South Ossetia <\/option>\n                      <option value=\"South Sudan\"> South Sudan <\/option>\n                      <option value=\"Spain\"> Spain <\/option>\n                      <option value=\"Sri Lanka\"> Sri Lanka <\/option>\n                      <option value=\"Sudan\"> Sudan <\/option>\n                      <option value=\"Suriname\"> Suriname <\/option>\n                      <option value=\"Svalbard\"> Svalbard <\/option>\n                      <option value=\"Swaziland\"> Swaziland <\/option>\n                      <option value=\"Sweden\"> Sweden <\/option>\n                      <option value=\"Switzerland\"> Switzerland <\/option>\n                      <option value=\"Syria\"> Syria <\/option>\n                      <option value=\"Taiwan\"> Taiwan <\/option>\n                      <option value=\"Tajikistan\"> Tajikistan <\/option>\n                      <option value=\"Tanzania\"> Tanzania <\/option>\n                      <option value=\"Thailand\"> Thailand <\/option>\n                      <option value=\"Timor-Leste\"> Timor-Leste <\/option>\n                      <option value=\"Togo\"> Togo <\/option>\n                      <option value=\"Tokelau\"> Tokelau <\/option>\n                      <option value=\"Tonga\"> Tonga <\/option>\n                      <option value=\"Transnistria Pridnestrovie\"> Transnistria Pridnestrovie <\/option>\n                      <option value=\"Trinidad and Tobago\"> Trinidad and Tobago <\/option>\n                      <option value=\"Tristan da Cunha\"> Tristan da Cunha <\/option>\n                      <option value=\"Tunisia\"> Tunisia <\/option>\n                      <option value=\"Turkey\"> Turkey <\/option>\n                      <option value=\"Turkmenistan\"> Turkmenistan <\/option>\n                      <option value=\"Turks and Caicos Islands\"> Turks and Caicos Islands <\/option>\n                      <option value=\"Tuvalu\"> Tuvalu <\/option>\n                      <option value=\"Uganda\"> Uganda <\/option>\n                      <option value=\"Ukraine\"> Ukraine <\/option>\n                      <option value=\"United Arab Emirates\"> United Arab Emirates <\/option>\n                      <option value=\"United Kingdom\"> United Kingdom <\/option>\n                      <option value=\"Uruguay\"> Uruguay <\/option>\n                      <option value=\"Uzbekistan\"> Uzbekistan <\/option>\n                      <option value=\"Vanuatu\"> Vanuatu <\/option>\n                      <option value=\"Vatican City\"> Vatican City <\/option>\n                      <option value=\"Venezuela\"> Venezuela <\/option>\n                      <option value=\"Vietnam\"> Vietnam <\/option>\n                      <option value=\"British Virgin Islands\"> British Virgin Islands <\/option>\n                      <option value=\"Isle of Man\"> Isle of Man <\/option>\n                      <option value=\"US Virgin Islands\"> US Virgin Islands <\/option>\n                      <option value=\"Wallis and Futuna\"> Wallis and Futuna <\/option>\n                      <option value=\"Western Sahara\"> Western Sahara <\/option>\n                      <option value=\"Yemen\"> Yemen <\/option>\n                      <option value=\"Zambia\"> Zambia <\/option>\n                      <option value=\"Zimbabwe\"> Zimbabwe <\/option>\n                      <option value=\"other\"> Other <\/option>\n                    <\/select>\n                    <label class=\"form-sub-label\" for=\"input_81_country\" id=\"sublabel_81_country\" style=\"min-height:13px;\"> Country <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n            <\/tbody>\n          <\/table>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_5\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_5\" for=\"input_5\"> Age (if required) <\/label>\n        <div id=\"cid_5\" class=\"form-input\">\n          <input type=\"text\" id=\"input_5\" name=\"q5_ageif\" data-type=\"input-textbox\" class=\"form-textbox validate[Numeric]\" size=\"3\" value=\"\" placeholder=\" \" data-component=\"textbox\" \/>\n        <\/div>\n      <\/li>\n      <li id=\"cid_16\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_16\" class=\"form-header\" data-component=\"header\">\n              Customer Details\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_fullname\" id=\"id_84\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_84\" for=\"first_84\">\n          Full Name\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_84\" class=\"form-input jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input type=\"text\" id=\"first_84\" name=\"q84_fullName84[first]\" class=\"form-textbox validate[required]\" size=\"10\" value=\"\" data-component=\"first\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"first_84\" id=\"sublabel_first\" style=\"min-height:13px;\"> First Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input type=\"text\" id=\"last_84\" name=\"q84_fullName84[last]\" class=\"form-textbox validate[required]\" size=\"15\" value=\"\" data-component=\"last\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"last_84\" id=\"sublabel_last\" style=\"min-height:13px;\"> Last Name <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_address\" id=\"id_80\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_80\" for=\"input_80_addr_line1\"> Address <\/label>\n        <div id=\"cid_80\" class=\"form-input\">\n          <table summary=\"\" class=\"form-address-table\" cellpadding=\"0\" cellspacing=\"0\">\n            <tbody>\n              <tr>\n                <td colspan=\"2\">\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                    <input type=\"text\" id=\"input_80_addr_line1\" name=\"q80_address80[addr_line1]\" class=\"form-textbox form-address-line\" value=\"\" data-component=\"address_line_1\" \/>\n                    <label class=\"form-sub-label\" for=\"input_80_addr_line1\" id=\"sublabel_80_addr_line1\" style=\"min-height:13px;\"> Street Address <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td colspan=\"2\">\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                    <input type=\"text\" id=\"input_80_addr_line2\" name=\"q80_address80[addr_line2]\" class=\"form-textbox form-address-line\" size=\"46\" value=\"\" data-component=\"address_line_2\" \/>\n                    <label class=\"form-sub-label\" for=\"input_80_addr_line2\" id=\"sublabel_80_addr_line2\" style=\"min-height:13px;\"> Street Address Line 2 <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td width=\"50%\">\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                    <input type=\"text\" id=\"input_80_city\" name=\"q80_address80[city]\" class=\"form-textbox form-address-city\" size=\"21\" value=\"\" data-component=\"city\" \/>\n                    <label class=\"form-sub-label\" for=\"input_80_city\" id=\"sublabel_80_city\" style=\"min-height:13px;\"> City <\/label>\n                  <\/span>\n                <\/td>\n                <td>\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                    <input type=\"text\" id=\"input_80_state\" name=\"q80_address80[state]\" class=\"form-textbox form-address-state\" size=\"22\" value=\"\" data-component=\"state\" \/>\n                    <label class=\"form-sub-label\" for=\"input_80_state\" id=\"sublabel_80_state\" style=\"min-height:13px;\"> County \/ State \/ Province <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td width=\"50%\">\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                    <input type=\"text\" id=\"input_80_postal\" name=\"q80_address80[postal]\" class=\"form-textbox form-address-postal\" size=\"10\" value=\"\" data-component=\"zip\" \/>\n                    <label class=\"form-sub-label\" for=\"input_80_postal\" id=\"sublabel_80_postal\" style=\"min-height:13px;\"> Postal \/ Zip Code <\/label>\n                  <\/span>\n                <\/td>\n                <td>\n                  <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n                    <select class=\"form-dropdown form-address-country\" name=\"q80_address80[country]\" id=\"input_80_country\" data-component=\"country\">\n                      <option value=\"\"> Please Select <\/option>\n                      <option value=\"United States\"> United States <\/option>\n                      <option value=\"Afghanistan\"> Afghanistan <\/option>\n                      <option value=\"Albania\"> Albania <\/option>\n                      <option value=\"Algeria\"> Algeria <\/option>\n                      <option value=\"American Samoa\"> American Samoa <\/option>\n                      <option value=\"Andorra\"> Andorra <\/option>\n                      <option value=\"Angola\"> Angola <\/option>\n                      <option value=\"Anguilla\"> Anguilla <\/option>\n                      <option value=\"Antigua and Barbuda\"> Antigua and Barbuda <\/option>\n                      <option value=\"Argentina\"> Argentina <\/option>\n                      <option value=\"Armenia\"> Armenia <\/option>\n                      <option value=\"Aruba\"> Aruba <\/option>\n                      <option value=\"Australia\"> Australia <\/option>\n                      <option value=\"Austria\"> Austria <\/option>\n                      <option value=\"Azerbaijan\"> Azerbaijan <\/option>\n                      <option value=\"The Bahamas\"> The Bahamas <\/option>\n                      <option value=\"Bahrain\"> Bahrain <\/option>\n                      <option value=\"Bangladesh\"> Bangladesh <\/option>\n                      <option value=\"Barbados\"> Barbados <\/option>\n                      <option value=\"Belarus\"> Belarus <\/option>\n                      <option value=\"Belgium\"> Belgium <\/option>\n                      <option value=\"Belize\"> Belize <\/option>\n                      <option value=\"Benin\"> Benin <\/option>\n                      <option value=\"Bermuda\"> Bermuda <\/option>\n                      <option value=\"Bhutan\"> Bhutan <\/option>\n                      <option value=\"Bolivia\"> Bolivia <\/option>\n                      <option value=\"Bosnia and Herzegovina\"> Bosnia and Herzegovina <\/option>\n                      <option value=\"Botswana\"> Botswana <\/option>\n                      <option value=\"Brazil\"> Brazil <\/option>\n                      <option value=\"Brunei\"> Brunei <\/option>\n                      <option value=\"Bulgaria\"> Bulgaria <\/option>\n                      <option value=\"Burkina Faso\"> Burkina Faso <\/option>\n                      <option value=\"Burundi\"> Burundi <\/option>\n                      <option value=\"Cambodia\"> Cambodia <\/option>\n                      <option value=\"Cameroon\"> Cameroon <\/option>\n                      <option value=\"Canada\"> Canada <\/option>\n                      <option value=\"Cape Verde\"> Cape Verde <\/option>\n                      <option value=\"Cayman Islands\"> Cayman Islands <\/option>\n                      <option value=\"Central African Republic\"> Central African Republic <\/option>\n                      <option value=\"Chad\"> Chad <\/option>\n                      <option value=\"Chile\"> Chile <\/option>\n                      <option value=\"China\"> China <\/option>\n                      <option value=\"Christmas Island\"> Christmas Island <\/option>\n                      <option value=\"Cocos (Keeling) Islands\"> Cocos (Keeling) Islands <\/option>\n                      <option value=\"Colombia\"> Colombia <\/option>\n                      <option value=\"Comoros\"> Comoros <\/option>\n                      <option value=\"Congo\"> Congo <\/option>\n                      <option value=\"Cook Islands\"> Cook Islands <\/option>\n                      <option value=\"Costa Rica\"> Costa Rica <\/option>\n                      <option value=\"Cote d&#x27;Ivoire\"> Cote d&#x27;Ivoire <\/option>\n                      <option value=\"Croatia\"> Croatia <\/option>\n                      <option value=\"Cuba\"> Cuba <\/option>\n                      <option value=\"Cyprus\"> Cyprus <\/option>\n                      <option value=\"Czech Republic\"> Czech Republic <\/option>\n                      <option value=\"Democratic Republic of the Congo\"> Democratic Republic of the Congo <\/option>\n                      <option value=\"Denmark\"> Denmark <\/option>\n                      <option value=\"Djibouti\"> Djibouti <\/option>\n                      <option value=\"Dominica\"> Dominica <\/option>\n                      <option value=\"Dominican Republic\"> Dominican Republic <\/option>\n                      <option value=\"Ecuador\"> Ecuador <\/option>\n                      <option value=\"Egypt\"> Egypt <\/option>\n                      <option value=\"El Salvador\"> El Salvador <\/option>\n                      <option value=\"Equatorial Guinea\"> Equatorial Guinea <\/option>\n                      <option value=\"Eritrea\"> Eritrea <\/option>\n                      <option value=\"Estonia\"> Estonia <\/option>\n                      <option value=\"Ethiopia\"> Ethiopia <\/option>\n                      <option value=\"Falkland Islands\"> Falkland Islands <\/option>\n                      <option value=\"Faroe Islands\"> Faroe Islands <\/option>\n                      <option value=\"Fiji\"> Fiji <\/option>\n                      <option value=\"Finland\"> Finland <\/option>\n                      <option value=\"France\"> France <\/option>\n                      <option value=\"French Polynesia\"> French Polynesia <\/option>\n                      <option value=\"Gabon\"> Gabon <\/option>\n                      <option value=\"The Gambia\"> The Gambia <\/option>\n                      <option value=\"Georgia\"> Georgia <\/option>\n                      <option value=\"Germany\"> Germany <\/option>\n                      <option value=\"Ghana\"> Ghana <\/option>\n                      <option value=\"Gibraltar\"> Gibraltar <\/option>\n                      <option value=\"Greece\"> Greece <\/option>\n                      <option value=\"Greenland\"> Greenland <\/option>\n                      <option value=\"Grenada\"> Grenada <\/option>\n                      <option value=\"Guadeloupe\"> Guadeloupe <\/option>\n                      <option value=\"Guam\"> Guam <\/option>\n                      <option value=\"Guatemala\"> Guatemala <\/option>\n                      <option value=\"Guernsey\"> Guernsey <\/option>\n                      <option value=\"Guinea\"> Guinea <\/option>\n                      <option value=\"Guinea-Bissau\"> Guinea-Bissau <\/option>\n                      <option value=\"Guyana\"> Guyana <\/option>\n                      <option value=\"Haiti\"> Haiti <\/option>\n                      <option value=\"Honduras\"> Honduras <\/option>\n                      <option value=\"Hong Kong\"> Hong Kong <\/option>\n                      <option value=\"Hungary\"> Hungary <\/option>\n                      <option value=\"Iceland\"> Iceland <\/option>\n                      <option value=\"India\"> India <\/option>\n                      <option value=\"Indonesia\"> Indonesia <\/option>\n                      <option value=\"Iran\"> Iran <\/option>\n                      <option value=\"Iraq\"> Iraq <\/option>\n                      <option value=\"Ireland\"> Ireland <\/option>\n                      <option value=\"Israel\"> Israel <\/option>\n                      <option value=\"Italy\"> Italy <\/option>\n                      <option value=\"Jamaica\"> Jamaica <\/option>\n                      <option value=\"Japan\"> Japan <\/option>\n                      <option value=\"Jersey\"> Jersey <\/option>\n                      <option value=\"Jordan\"> Jordan <\/option>\n                      <option value=\"Kazakhstan\"> Kazakhstan <\/option>\n                      <option value=\"Kenya\"> Kenya <\/option>\n                      <option value=\"Kiribati\"> Kiribati <\/option>\n                      <option value=\"North Korea\"> North Korea <\/option>\n                      <option value=\"South Korea\"> South Korea <\/option>\n                      <option value=\"Kosovo\"> Kosovo <\/option>\n                      <option value=\"Kuwait\"> Kuwait <\/option>\n                      <option value=\"Kyrgyzstan\"> Kyrgyzstan <\/option>\n                      <option value=\"Laos\"> Laos <\/option>\n                      <option value=\"Latvia\"> Latvia <\/option>\n                      <option value=\"Lebanon\"> Lebanon <\/option>\n                      <option value=\"Lesotho\"> Lesotho <\/option>\n                      <option value=\"Liberia\"> Liberia <\/option>\n                      <option value=\"Libya\"> Libya <\/option>\n                      <option value=\"Liechtenstein\"> Liechtenstein <\/option>\n                      <option value=\"Lithuania\"> Lithuania <\/option>\n                      <option value=\"Luxembourg\"> Luxembourg <\/option>\n                      <option value=\"Macau\"> Macau <\/option>\n                      <option value=\"Macedonia\"> Macedonia <\/option>\n                      <option value=\"Madagascar\"> Madagascar <\/option>\n                      <option value=\"Malawi\"> Malawi <\/option>\n                      <option value=\"Malaysia\"> Malaysia <\/option>\n                      <option value=\"Maldives\"> Maldives <\/option>\n                      <option value=\"Mali\"> Mali <\/option>\n                      <option value=\"Malta\"> Malta <\/option>\n                      <option value=\"Marshall Islands\"> Marshall Islands <\/option>\n                      <option value=\"Martinique\"> Martinique <\/option>\n                      <option value=\"Mauritania\"> Mauritania <\/option>\n                      <option value=\"Mauritius\"> Mauritius <\/option>\n                      <option value=\"Mayotte\"> Mayotte <\/option>\n                      <option value=\"Mexico\"> Mexico <\/option>\n                      <option value=\"Micronesia\"> Micronesia <\/option>\n                      <option value=\"Moldova\"> Moldova <\/option>\n                      <option value=\"Monaco\"> Monaco <\/option>\n                      <option value=\"Mongolia\"> Mongolia <\/option>\n                      <option value=\"Montenegro\"> Montenegro <\/option>\n                      <option value=\"Montserrat\"> Montserrat <\/option>\n                      <option value=\"Morocco\"> Morocco <\/option>\n                      <option value=\"Mozambique\"> Mozambique <\/option>\n                      <option value=\"Myanmar\"> Myanmar <\/option>\n                      <option value=\"Nagorno-Karabakh\"> Nagorno-Karabakh <\/option>\n                      <option value=\"Namibia\"> Namibia <\/option>\n                      <option value=\"Nauru\"> Nauru <\/option>\n                      <option value=\"Nepal\"> Nepal <\/option>\n                      <option value=\"Netherlands\"> Netherlands <\/option>\n                      <option value=\"Netherlands Antilles\"> Netherlands Antilles <\/option>\n                      <option value=\"New Caledonia\"> New Caledonia <\/option>\n                      <option value=\"New Zealand\"> New Zealand <\/option>\n                      <option value=\"Nicaragua\"> Nicaragua <\/option>\n                      <option value=\"Niger\"> Niger <\/option>\n                      <option value=\"Nigeria\"> Nigeria <\/option>\n                      <option value=\"Niue\"> Niue <\/option>\n                      <option value=\"Norfolk Island\"> Norfolk Island <\/option>\n                      <option value=\"Turkish Republic of Northern Cyprus\"> Turkish Republic of Northern Cyprus <\/option>\n                      <option value=\"Northern Mariana\"> Northern Mariana <\/option>\n                      <option value=\"Norway\"> Norway <\/option>\n                      <option value=\"Oman\"> Oman <\/option>\n                      <option value=\"Pakistan\"> Pakistan <\/option>\n                      <option value=\"Palau\"> Palau <\/option>\n                      <option value=\"Palestine\"> Palestine <\/option>\n                      <option value=\"Panama\"> Panama <\/option>\n                      <option value=\"Papua New Guinea\"> Papua New Guinea <\/option>\n                      <option value=\"Paraguay\"> Paraguay <\/option>\n                      <option value=\"Peru\"> Peru <\/option>\n                      <option value=\"Philippines\"> Philippines <\/option>\n                      <option value=\"Pitcairn Islands\"> Pitcairn Islands <\/option>\n                      <option value=\"Poland\"> Poland <\/option>\n                      <option value=\"Portugal\"> Portugal <\/option>\n                      <option value=\"Puerto Rico\"> Puerto Rico <\/option>\n                      <option value=\"Qatar\"> Qatar <\/option>\n                      <option value=\"Republic of the Congo\"> Republic of the Congo <\/option>\n                      <option value=\"Romania\"> Romania <\/option>\n                      <option value=\"Russia\"> Russia <\/option>\n                      <option value=\"Rwanda\"> Rwanda <\/option>\n                      <option value=\"Saint Barthelemy\"> Saint Barthelemy <\/option>\n                      <option value=\"Saint Helena\"> Saint Helena <\/option>\n                      <option value=\"Saint Kitts and Nevis\"> Saint Kitts and Nevis <\/option>\n                      <option value=\"Saint Lucia\"> Saint Lucia <\/option>\n                      <option value=\"Saint Martin\"> Saint Martin <\/option>\n                      <option value=\"Saint Pierre and Miquelon\"> Saint Pierre and Miquelon <\/option>\n                      <option value=\"Saint Vincent and the Grenadines\"> Saint Vincent and the Grenadines <\/option>\n                      <option value=\"Samoa\"> Samoa <\/option>\n                      <option value=\"San Marino\"> San Marino <\/option>\n                      <option value=\"Sao Tome and Principe\"> Sao Tome and Principe <\/option>\n                      <option value=\"Saudi Arabia\"> Saudi Arabia <\/option>\n                      <option value=\"Senegal\"> Senegal <\/option>\n                      <option value=\"Serbia\"> Serbia <\/option>\n                      <option value=\"Seychelles\"> Seychelles <\/option>\n                      <option value=\"Sierra Leone\"> Sierra Leone <\/option>\n                      <option value=\"Singapore\"> Singapore <\/option>\n                      <option value=\"Slovakia\"> Slovakia <\/option>\n                      <option value=\"Slovenia\"> Slovenia <\/option>\n                      <option value=\"Solomon Islands\"> Solomon Islands <\/option>\n                      <option value=\"Somalia\"> Somalia <\/option>\n                      <option value=\"Somaliland\"> Somaliland <\/option>\n                      <option value=\"South Africa\"> South Africa <\/option>\n                      <option value=\"South Ossetia\"> South Ossetia <\/option>\n                      <option value=\"South Sudan\"> South Sudan <\/option>\n                      <option value=\"Spain\"> Spain <\/option>\n                      <option value=\"Sri Lanka\"> Sri Lanka <\/option>\n                      <option value=\"Sudan\"> Sudan <\/option>\n                      <option value=\"Suriname\"> Suriname <\/option>\n                      <option value=\"Svalbard\"> Svalbard <\/option>\n                      <option value=\"Swaziland\"> Swaziland <\/option>\n                      <option value=\"Sweden\"> Sweden <\/option>\n                      <option value=\"Switzerland\"> Switzerland <\/option>\n                      <option value=\"Syria\"> Syria <\/option>\n                      <option value=\"Taiwan\"> Taiwan <\/option>\n                      <option value=\"Tajikistan\"> Tajikistan <\/option>\n                      <option value=\"Tanzania\"> Tanzania <\/option>\n                      <option value=\"Thailand\"> Thailand <\/option>\n                      <option value=\"Timor-Leste\"> Timor-Leste <\/option>\n                      <option value=\"Togo\"> Togo <\/option>\n                      <option value=\"Tokelau\"> Tokelau <\/option>\n                      <option value=\"Tonga\"> Tonga <\/option>\n                      <option value=\"Transnistria Pridnestrovie\"> Transnistria Pridnestrovie <\/option>\n                      <option value=\"Trinidad and Tobago\"> Trinidad and Tobago <\/option>\n                      <option value=\"Tristan da Cunha\"> Tristan da Cunha <\/option>\n                      <option value=\"Tunisia\"> Tunisia <\/option>\n                      <option value=\"Turkey\"> Turkey <\/option>\n                      <option value=\"Turkmenistan\"> Turkmenistan <\/option>\n                      <option value=\"Turks and Caicos Islands\"> Turks and Caicos Islands <\/option>\n                      <option value=\"Tuvalu\"> Tuvalu <\/option>\n                      <option value=\"Uganda\"> Uganda <\/option>\n                      <option value=\"Ukraine\"> Ukraine <\/option>\n                      <option value=\"United Arab Emirates\"> United Arab Emirates <\/option>\n                      <option value=\"United Kingdom\"> United Kingdom <\/option>\n                      <option value=\"Uruguay\"> Uruguay <\/option>\n                      <option value=\"Uzbekistan\"> Uzbekistan <\/option>\n                      <option value=\"Vanuatu\"> Vanuatu <\/option>\n                      <option value=\"Vatican City\"> Vatican City <\/option>\n                      <option value=\"Venezuela\"> Venezuela <\/option>\n                      <option value=\"Vietnam\"> Vietnam <\/option>\n                      <option value=\"British Virgin Islands\"> British Virgin Islands <\/option>\n                      <option value=\"Isle of Man\"> Isle of Man <\/option>\n                      <option value=\"US Virgin Islands\"> US Virgin Islands <\/option>\n                      <option value=\"Wallis and Futuna\"> Wallis and Futuna <\/option>\n                      <option value=\"Western Sahara\"> Western Sahara <\/option>\n                      <option value=\"Yemen\"> Yemen <\/option>\n                      <option value=\"Zambia\"> Zambia <\/option>\n                      <option value=\"Zimbabwe\"> Zimbabwe <\/option>\n                      <option value=\"other\"> Other <\/option>\n                    <\/select>\n                    <label class=\"form-sub-label\" for=\"input_80_country\" id=\"sublabel_80_country\" style=\"min-height:13px;\"> Country <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n            <\/tbody>\n          <\/table>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_phone\" id=\"id_78\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_78\" for=\"input_78_area\"> Phone Number <\/label>\n        <div id=\"cid_78\" class=\"form-input\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input type=\"tel\" id=\"input_78_area\" name=\"q78_phoneNumber78[area]\" class=\"form-textbox\" size=\"3\" value=\"\" data-component=\"areaCode\" \/>\n              <span class=\"phone-separate\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"input_78_area\" id=\"sublabel_area\" style=\"min-height:13px;\"> Area Code <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input type=\"tel\" id=\"input_78_phone\" name=\"q78_phoneNumber78[phone]\" class=\"form-textbox\" size=\"8\" value=\"\" data-component=\"phone\" \/>\n              <label class=\"form-sub-label\" for=\"input_78_phone\" id=\"sublabel_phone\" style=\"min-height:13px;\"> Phone Number <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_email\" id=\"id_79\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_79\" for=\"input_79\">\n          E-mail\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_79\" class=\"form-input jf-required\">\n          <div data-wrapper-react=\"true\">\n            <input type=\"email\" id=\"input_79\" name=\"q79_email79\" class=\"form-textbox validate[required, Email]\" size=\"30\" value=\"\" placeholder=\"ex: myname@example.com\" data-component=\"email\" required=\"\" \/>\n            <br\/>\n            <label class=\"form-sub-label\" style=\"display:none;\" for=\"input_79_confirm\"> Confirmation Email <\/label>\n            <input type=\"email\" id=\"input_79_confirm\" name=\"q79_email79\" class=\"form-textbox validate[required, Email, Email_Confirm]\" style=\"margin-top:8px;\" size=\"30\" value=\"\" placeholder=\"Confirm Email\" data-component=\"emailConfirmation\" \/>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_91\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_91\" class=\"form-header\" data-component=\"header\">\n              Order Details\n            <\/h2>\n            <div id=\"subHeader_91\" class=\"form-subHeader\">\n              (Minimum order of 25)\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1\" data-type=\"control_textbox\" id=\"id_12\">\n        <label class=\"form-label form-label-top\" id=\"label_12\" for=\"input_12\"> Number of Double Memoriam Cards required <\/label>\n        <div id=\"cid_12\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_12\" name=\"q12_numberOf12\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"3\" value=\"\" placeholder=\" \" data-component=\"textbox\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-2\" data-type=\"control_radio\" id=\"id_85\">\n        <label class=\"form-label form-label-top\" id=\"label_85\" for=\"input_85\"> Special Double Design Card <\/label>\n        <div id=\"cid_85\" class=\"form-input-wide\">\n          <div class=\"form-single-column\" data-component=\"radio\">\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_85_0\" name=\"q85_specialDouble85\" value=\"Yes\" \/>\n              <label id=\"label_input_85_0\" for=\"input_85_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_85_1\" name=\"q85_specialDouble85\" value=\"No\" \/>\n              <label id=\"label_input_85_1\" for=\"input_85_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-3\" data-type=\"control_textbox\" id=\"id_123\">\n        <label class=\"form-label form-label-top\" id=\"label_123\" for=\"input_123\"> Number of Single Memoriam Cards required <\/label>\n        <div id=\"cid_123\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_123\" name=\"q123_numberOf123\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"3\" value=\"\" placeholder=\" \" data-component=\"textbox\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-4\" data-type=\"control_radio\" id=\"id_124\">\n        <label class=\"form-label form-label-top\" id=\"label_124\" for=\"input_124\"> Special Single Design Card <\/label>\n        <div id=\"cid_124\" class=\"form-input-wide\">\n          <div class=\"form-single-column\" data-component=\"radio\">\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_124_0\" name=\"q124_specialSingle\" value=\"Yes\" \/>\n              <label id=\"label_input_124_0\" for=\"input_124_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_124_1\" name=\"q124_specialSingle\" value=\"No\" \/>\n              <label id=\"label_input_124_1\" for=\"input_124_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-5\" data-type=\"control_textbox\" id=\"id_58\">\n        <label class=\"form-label form-label-top\" id=\"label_58\" for=\"input_58\"> Number of Wallet cards required <\/label>\n        <div id=\"cid_58\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_58\" name=\"q58_numberOf58\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"4\" value=\"\" placeholder=\" \" data-component=\"textbox\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-6\" data-type=\"control_radio\" id=\"id_92\">\n        <label class=\"form-label form-label-top\" id=\"label_92\" for=\"input_92\"> Special Wallet Design Card <\/label>\n        <div id=\"cid_92\" class=\"form-input-wide\">\n          <div class=\"form-single-column\" data-component=\"radio\">\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_92_0\" name=\"q92_specialWallet\" value=\"Yes\" \/>\n              <label id=\"label_input_92_0\" for=\"input_92_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_92_1\" name=\"q92_specialWallet\" value=\"No\" \/>\n              <label id=\"label_input_92_1\" for=\"input_92_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-7\" data-type=\"control_textbox\" id=\"id_57\">\n        <label class=\"form-label form-label-top\" id=\"label_57\" for=\"input_57\"> Number of Bookmarks required <\/label>\n        <div id=\"cid_57\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_57\" name=\"q57_numberOf\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"4\" value=\"\" placeholder=\" \" data-component=\"textbox\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-8\" data-type=\"control_radio\" id=\"id_88\">\n        <label class=\"form-label form-label-top\" id=\"label_88\" for=\"input_88\"> Special Bookmark Design <\/label>\n        <div id=\"cid_88\" class=\"form-input-wide\">\n          <div class=\"form-single-column\" data-component=\"radio\">\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_88_0\" name=\"q88_specialBookmark\" value=\"Yes\" \/>\n              <label id=\"label_input_88_0\" for=\"input_88_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_88_1\" name=\"q88_specialBookmark\" value=\"No\" \/>\n              <label id=\"label_input_88_1\" for=\"input_88_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-9\" data-type=\"control_textbox\" id=\"id_59\">\n        <label class=\"form-label form-label-top\" id=\"label_59\" for=\"input_59\"> Number of Acknowledgement Cards <\/label>\n        <div id=\"cid_59\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_59\" name=\"q59_numberOf59\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"4\" value=\"\" placeholder=\" \" data-component=\"textbox\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-10\" data-type=\"control_radio\" id=\"id_86\">\n        <label class=\"form-label form-label-top\" id=\"label_86\" for=\"input_86\"> Special Acknowledgement Design <\/label>\n        <div id=\"cid_86\" class=\"form-input-wide\">\n          <div class=\"form-single-column\" data-component=\"radio\">\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_86_0\" name=\"q86_specialAcknowledgement86\" value=\"Yes\" \/>\n              <label id=\"label_input_86_0\" for=\"input_86_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_86_1\" name=\"q86_specialAcknowledgement86\" value=\"No\" \/>\n              <label id=\"label_input_86_1\" for=\"input_86_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-11\" data-type=\"control_textbox\" id=\"id_13\">\n        <label class=\"form-label form-label-top\" id=\"label_13\" for=\"input_13\"> No of Holders required <\/label>\n        <div id=\"cid_13\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_13\" name=\"q13_noOf\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"4\" value=\"\" placeholder=\" \" data-component=\"textbox\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-12\" data-type=\"control_radio\" id=\"id_89\">\n        <label class=\"form-label form-label-top\" id=\"label_89\" for=\"input_89\"> Special Design Holder <\/label>\n        <div id=\"cid_89\" class=\"form-input-wide\">\n          <div class=\"form-single-column\" data-component=\"radio\">\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_89_0\" name=\"q89_specialDesign\" value=\"Yes\" \/>\n              <label id=\"label_input_89_0\" for=\"input_89_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_89_1\" name=\"q89_specialDesign\" value=\"No\" \/>\n              <label id=\"label_input_89_1\" for=\"input_89_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_17\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_17\" class=\"form-header\" data-component=\"header\">\n              Double Memorial Cards (Outside)\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_dropdown\" id=\"id_60\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_60\" for=\"input_60\"> (DMO) Image No (front) <\/label>\n        <div id=\"cid_60\" class=\"form-input\">\n          <select class=\"form-dropdown\" id=\"input_60\" name=\"q60_dmoImage60\" style=\"width:150px;\" data-component=\"dropdown\">\n            <option value=\"\">  <\/option>\n            <option value=\"M1\"> M1 <\/option>\n            <option value=\"M2\"> M2 <\/option>\n            <option value=\"M3\"> M3 <\/option>\n            <option value=\"M4\"> M4 <\/option>\n            <option value=\"M5\"> M5 <\/option>\n            <option value=\"M6\"> M6 <\/option>\n            <option value=\"M7\"> M7 <\/option>\n            <option value=\"M8\"> M8 <\/option>\n            <option value=\"M9\"> M9 <\/option>\n            <option value=\"M10\"> M10 <\/option>\n            <option value=\"M11\"> M11 <\/option>\n            <option value=\"M12\"> M12 <\/option>\n            <option value=\"M13\"> M13 <\/option>\n            <option value=\"M14\"> M14 <\/option>\n            <option value=\"M15\"> M15 <\/option>\n            <option value=\"M16\"> M16 <\/option>\n            <option value=\"M17\"> M17 <\/option>\n            <option value=\"M18\"> M18 <\/option>\n            <option value=\"M19\"> M19 <\/option>\n            <option value=\"M20\"> M20 <\/option>\n            <option value=\"M21\"> M21 <\/option>\n            <option value=\"M22\"> M22 <\/option>\n            <option value=\"M23\"> M23 <\/option>\n            <option value=\"M24\"> M24 <\/option>\n            <option value=\"M25\"> M25 <\/option>\n            <option value=\"M26\"> M26 <\/option>\n            <option value=\"M27\"> M27 <\/option>\n            <option value=\"M28\"> M28 <\/option>\n            <option value=\"M29\"> M29 <\/option>\n            <option value=\"M30\"> M30 <\/option>\n            <option value=\"M31\"> M31 <\/option>\n            <option value=\"M32\"> M32 <\/option>\n            <option value=\"M33\"> M33 <\/option>\n            <option value=\"M34\"> M34 <\/option>\n            <option value=\"M35\"> M35 <\/option>\n            <option value=\"M36\"> M36 <\/option>\n            <option value=\"M37\"> M37 <\/option>\n            <option value=\"M38\"> M38 <\/option>\n            <option value=\"M39\"> M39 <\/option>\n            <option value=\"M40\"> M40 <\/option>\n            <option value=\"M41\"> M41 <\/option>\n            <option value=\"M42\"> M42 <\/option>\n            <option value=\"M43\"> M43 <\/option>\n            <option value=\"M44\"> M44 <\/option>\n            <option value=\"M45\"> M45 <\/option>\n            <option value=\"M46\"> M46 <\/option>\n            <option value=\"M47\"> M47 <\/option>\n            <option value=\"M48\"> M48 <\/option>\n            <option value=\"M39\"> M39 <\/option>\n            <option value=\"M50\"> M50 <\/option>\n            <option value=\"M51\"> M51 <\/option>\n            <option value=\"M52\"> M52 <\/option>\n            <option value=\"M53\"> M53 <\/option>\n            <option value=\"M54\"> M54 <\/option>\n            <option value=\"M55\"> M55 <\/option>\n            <option value=\"M56\"> M56 <\/option>\n            <option value=\"M57\"> M57 <\/option>\n            <option value=\"M58\"> M58 <\/option>\n            <option value=\"M59\"> M59 <\/option>\n            <option value=\"M60\"> M60 <\/option>\n            <option value=\"M61\"> M61 <\/option>\n            <option value=\"M62\"> M62 <\/option>\n            <option value=\"M63\"> M63 <\/option>\n            <option value=\"M64\"> M64 <\/option>\n            <option value=\"M65\"> M65 <\/option>\n            <option value=\"M66\"> M66 <\/option>\n            <option value=\"M67\"> M67 <\/option>\n            <option value=\"M68\"> M68 <\/option>\n            <option value=\"M69\"> M69 <\/option>\n            <option value=\"M70\"> M70 <\/option>\n            <option value=\"M71\"> M71 <\/option>\n            <option value=\"M72\"> M72 <\/option>\n            <option value=\"M73\"> M73 <\/option>\n            <option value=\"M74\"> M74 <\/option>\n            <option value=\"M75\"> M75 <\/option>\n            <option value=\"M76\"> M76 <\/option>\n            <option value=\"M77\"> M77 <\/option>\n            <option value=\"M78\"> M78 <\/option>\n            <option value=\"M79\"> M79 <\/option>\n            <option value=\"M80\"> M80 <\/option>\n            <option value=\"M81\"> M81 <\/option>\n            <option value=\"M82\"> M82 <\/option>\n            <option value=\"M83\"> M83 <\/option>\n            <option value=\"M84\"> M84 <\/option>\n            <option value=\"M85\"> M85 <\/option>\n            <option value=\"M86\"> M86 <\/option>\n            <option value=\"M87\"> M87 <\/option>\n            <option value=\"M88\"> M88 <\/option>\n            <option value=\"M89\"> M89 <\/option>\n            <option value=\"M90\"> M90 <\/option>\n            <option value=\"M91\"> M91 <\/option>\n            <option value=\"M92\"> M92 <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_dropdown\" id=\"id_18\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_18\" for=\"input_18\"> Image No (back) <\/label>\n        <div id=\"cid_18\" class=\"form-input\">\n          <select class=\"form-dropdown\" id=\"input_18\" name=\"q18_imageNo18\" style=\"width:150px;\" data-component=\"dropdown\">\n            <option value=\"\">  <\/option>\n            <option value=\"M1\"> M1 <\/option>\n            <option value=\"M2\"> M2 <\/option>\n            <option value=\"M3\"> M3 <\/option>\n            <option value=\"M4\"> M4 <\/option>\n            <option value=\"M5\"> M5 <\/option>\n            <option value=\"M6\"> M6 <\/option>\n            <option value=\"M7\"> M7 <\/option>\n            <option value=\"M8\"> M8 <\/option>\n            <option value=\"M9\"> M9 <\/option>\n            <option value=\"M10\"> M10 <\/option>\n            <option value=\"M11\"> M11 <\/option>\n            <option value=\"M12\"> M12 <\/option>\n            <option value=\"M13\"> M13 <\/option>\n            <option value=\"M14\"> M14 <\/option>\n            <option value=\"M15\"> M15 <\/option>\n            <option value=\"M16\"> M16 <\/option>\n            <option value=\"M17\"> M17 <\/option>\n            <option value=\"M18\"> M18 <\/option>\n            <option value=\"M19\"> M19 <\/option>\n            <option value=\"M20\"> M20 <\/option>\n            <option value=\"M21\"> M21 <\/option>\n            <option value=\"M22\"> M22 <\/option>\n            <option value=\"M23\"> M23 <\/option>\n            <option value=\"M24\"> M24 <\/option>\n            <option value=\"M25\"> M25 <\/option>\n            <option value=\"M26\"> M26 <\/option>\n            <option value=\"M27\"> M27 <\/option>\n            <option value=\"M28\"> M28 <\/option>\n            <option value=\"M29\"> M29 <\/option>\n            <option value=\"M30\"> M30 <\/option>\n            <option value=\"M31\"> M31 <\/option>\n            <option value=\"M32\"> M32 <\/option>\n            <option value=\"M33\"> M33 <\/option>\n            <option value=\"M34\"> M34 <\/option>\n            <option value=\"M35\"> M35 <\/option>\n            <option value=\"M36\"> M36 <\/option>\n            <option value=\"M37\"> M37 <\/option>\n            <option value=\"M38\"> M38 <\/option>\n            <option value=\"M39\"> M39 <\/option>\n            <option value=\"M40\"> M40 <\/option>\n            <option value=\"M41\"> M41 <\/option>\n            <option value=\"M42\"> M42 <\/option>\n            <option value=\"M43\"> M43 <\/option>\n            <option value=\"M44\"> M44 <\/option>\n            <option value=\"M45\"> M45 <\/option>\n            <option value=\"M46\"> M46 <\/option>\n            <option value=\"M47\"> M47 <\/option>\n            <option value=\"M48\"> M48 <\/option>\n            <option value=\"M49\"> M49 <\/option>\n            <option value=\"M50\"> M50 <\/option>\n            <option value=\"M51\"> M51 <\/option>\n            <option value=\"M52\"> M52 <\/option>\n            <option value=\"M53\"> M53 <\/option>\n            <option value=\"M54\"> M54 <\/option>\n            <option value=\"M55\"> M55 <\/option>\n            <option value=\"M56\"> M56 <\/option>\n            <option value=\"M57\"> M57 <\/option>\n            <option value=\"M58\"> M58 <\/option>\n            <option value=\"M59\"> M59 <\/option>\n            <option value=\"M60\"> M60 <\/option>\n            <option value=\"M61\"> M61 <\/option>\n            <option value=\"M62\"> M62 <\/option>\n            <option value=\"M63\"> M63 <\/option>\n            <option value=\"M64\"> M64 <\/option>\n            <option value=\"M65\"> M65 <\/option>\n            <option value=\"M66\"> M66 <\/option>\n            <option value=\"M67\"> M67 <\/option>\n            <option value=\"M68\"> M68 <\/option>\n            <option value=\"M69\"> M69 <\/option>\n            <option value=\"M70\"> M70 <\/option>\n            <option value=\"M71\"> M71 <\/option>\n            <option value=\"M72\"> M72 <\/option>\n            <option value=\"M73\"> M73 <\/option>\n            <option value=\"M74\"> M74 <\/option>\n            <option value=\"M75\"> M75 <\/option>\n            <option value=\"M76\"> M76 <\/option>\n            <option value=\"M77\"> M77 <\/option>\n            <option value=\"M78\"> M78 <\/option>\n            <option value=\"M79\"> M79 <\/option>\n            <option value=\"M80\"> M80 <\/option>\n            <option value=\"M81\"> M81 <\/option>\n            <option value=\"M82\"> M82 <\/option>\n            <option value=\"M83\"> M83 <\/option>\n            <option value=\"M84\"> M84 <\/option>\n            <option value=\"M85\"> M85 <\/option>\n            <option value=\"M86\"> M86 <\/option>\n            <option value=\"M87\"> M87 <\/option>\n            <option value=\"M88\"> M88 <\/option>\n            <option value=\"M89\"> M89 <\/option>\n            <option value=\"M90\"> M90 <\/option>\n            <option value=\"M91\"> M91 <\/option>\n            <option value=\"M92\"> M92 <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_dropdown\" id=\"id_114\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_114\" for=\"input_114\"> Verse No (front <\/label>\n        <div id=\"cid_114\" class=\"form-input\">\n          <select class=\"form-dropdown\" id=\"input_114\" name=\"q114_verseNo\" style=\"width:150px;\" data-component=\"dropdown\">\n            <option value=\"\">  <\/option>\n            <option value=\"V1 (Safely home)\"> V1 (Safely home) <\/option>\n            <option value=\"V2 (Prayer of St. Francis)\"> V2 (Prayer of St. Francis) <\/option>\n            <option value=\"V3 (The Memorare)\"> V3 (The Memorare) <\/option>\n            <option value=\"V4 (My Jesus Mercy)\"> V4 (My Jesus Mercy) <\/option>\n            <option value=\"V5 (We hold you close)\"> V5 (We hold you close) <\/option>\n            <option value=\"V6 (There is no might)\"> V6 (There is no might) <\/option>\n            <option value=\"V7 (She has gone no)\"> V7 (She has gone no) <\/option>\n            <option value=\"V8 (Lonely is the home)\"> V8 (Lonely is the home) <\/option>\n            <option value=\"V9 (O Devine Master)\"> V9 (O Devine Master) <\/option>\n            <option value=\"V10 (My Lord and My God)\"> V10 (My Lord and My God) <\/option>\n            <option value=\"V11 (Pray for me as I will)\"> V11 (Pray for me as I will) <\/option>\n            <option value=\"V12 (What she suffered she...)\"> V12 (What she suffered she...) <\/option>\n            <option value=\"V13 (Gone from our home)\"> V13 (Gone from our home) <\/option>\n            <option value=\"V14 (Oh You whom I have...)\"> V14 (Oh You whom I have...) <\/option>\n            <option value=\"V15 (Those who die in grace)\"> V15 (Those who die in grace) <\/option>\n            <option value=\"V16 (When I must leave you)\"> V16 (When I must leave you) <\/option>\n            <option value=\"V17 (She never failed to do...)\"> V17 (She never failed to do...) <\/option>\n            <option value=\"V18 (I am the resurrection)\"> V18 (I am the resurrection) <\/option>\n            <option value=\"V19 (Footprints)\"> V19 (Footprints) <\/option>\n            <option value=\"V20 (They say there is a reason)\"> V20 (They say there is a reason) <\/option>\n            <option value=\"V21 (All I ask of you)\"> V21 (All I ask of you) <\/option>\n            <option value=\"V22 (Solace)\"> V22 (Solace) <\/option>\n            <option value=\"V23 (Togetherness)\"> V23 (Togetherness) <\/option>\n            <option value=\"V24 (Your life was one of kind...)\"> V24 (Your life was one of kind...) <\/option>\n            <option value=\"V25 (We sat beside your bedside)\"> V25 (We sat beside your bedside) <\/option>\n            <option value=\"V26 (A bouquet of beautiful...)\"> V26 (A bouquet of beautiful...) <\/option>\n            <option value=\"V27 (I&#x27;m free)\"> V27 (I&#x27;m free) <\/option>\n            <option value=\"V28 (His smile)\"> V28 (His smile) <\/option>\n            <option value=\"V29 (Miss me but let me go)\"> V29 (Miss me but let me go) <\/option>\n            <option value=\"V30 (Prayer to our lady of Knock)\"> V30 (Prayer to our lady of Knock) <\/option>\n            <option value=\"V31 (We give our loved ones...) \"> V31 (We give our loved ones...) <\/option>\n            <option value=\"V32 (Now I am contented)\"> V32 (Now I am contented) <\/option>\n            <option value=\"V33 (A way of life)\"> V33 (A way of life) <\/option>\n            <option value=\"V34 (My Rosary)\"> V34 (My Rosary) <\/option>\n            <option value=\"V35 (The lord is my shepherd)\"> V35 (The lord is my shepherd) <\/option>\n            <option value=\"V36 (May he support us all...)\"> V36 (May he support us all...) <\/option>\n            <option value=\"V37 (God&#x27;s Garden)\"> V37 (God&#x27;s Garden) <\/option>\n            <option value=\"V38 (Do not stand at my grave)\"> V38 (Do not stand at my grave) <\/option>\n            <option value=\"V39 (Road to eternity)\"> V39 (Road to eternity) <\/option>\n            <option value=\"V40 (After glow)\"> V40 (After glow) <\/option>\n            <option value=\"V41 (God grant us the serenity)\"> V41 (God grant us the serenity) <\/option>\n            <option value=\"V42 (The rose beyond the wall)\"> V42 (The rose beyond the wall) <\/option>\n            <option value=\"V43 (A letter from heaven)\"> V43 (A letter from heaven) <\/option>\n            <option value=\"V44 (Just a prayer from the family)\"> V44 (Just a prayer from the family) <\/option>\n            <option value=\"V45 (Remember me)\"> V45 (Remember me) <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_dropdown\" id=\"id_119\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_119\" for=\"input_119\"> Verse No (Back) <\/label>\n        <div id=\"cid_119\" class=\"form-input\">\n          <select class=\"form-dropdown\" id=\"input_119\" name=\"q119_verseNo119\" style=\"width:150px;\" data-component=\"dropdown\">\n            <option value=\"\">  <\/option>\n            <option value=\"V1 (Safely home)\"> V1 (Safely home) <\/option>\n            <option value=\"V2 (Prayer of St. Francis)\"> V2 (Prayer of St. Francis) <\/option>\n            <option value=\"V3 (The Memorare)\"> V3 (The Memorare) <\/option>\n            <option value=\"V4 (My Jesus Mercy)\"> V4 (My Jesus Mercy) <\/option>\n            <option value=\"V5 (We hold you close)\"> V5 (We hold you close) <\/option>\n            <option value=\"V6 (There is no might)\"> V6 (There is no might) <\/option>\n            <option value=\"V7 (She has gone no)\"> V7 (She has gone no) <\/option>\n            <option value=\"V8 (Lonely is the home)\"> V8 (Lonely is the home) <\/option>\n            <option value=\"V9 (O Devine Master)\"> V9 (O Devine Master) <\/option>\n            <option value=\"V10 (My Lord and My God)\"> V10 (My Lord and My God) <\/option>\n            <option value=\"V11 (Pray for me as I will)\"> V11 (Pray for me as I will) <\/option>\n            <option value=\"V12 (What she suffered she...)\"> V12 (What she suffered she...) <\/option>\n            <option value=\"V13 (Gone from our home)\"> V13 (Gone from our home) <\/option>\n            <option value=\"V14 (Oh You whom I have...)\"> V14 (Oh You whom I have...) <\/option>\n            <option value=\"V15 (Those who die in grace)\"> V15 (Those who die in grace) <\/option>\n            <option value=\"V16 (When I must leave you)\"> V16 (When I must leave you) <\/option>\n            <option value=\"V17 (She never failed to do...)\"> V17 (She never failed to do...) <\/option>\n            <option value=\"V18 (I am the resurrection)\"> V18 (I am the resurrection) <\/option>\n            <option value=\"V19 (Footprints)\"> V19 (Footprints) <\/option>\n            <option value=\"V20 (They say there is a reason)\"> V20 (They say there is a reason) <\/option>\n            <option value=\"V21 (All I ask of you)\"> V21 (All I ask of you) <\/option>\n            <option value=\"V22 (Solace)\"> V22 (Solace) <\/option>\n            <option value=\"V23 (Togetherness)\"> V23 (Togetherness) <\/option>\n            <option value=\"V24 (Your life was one of kind...)\"> V24 (Your life was one of kind...) <\/option>\n            <option value=\"V25 (We sat beside your bedside)\"> V25 (We sat beside your bedside) <\/option>\n            <option value=\"V26 (A bouquet of beautiful...)\"> V26 (A bouquet of beautiful...) <\/option>\n            <option value=\"V27 (I&#x27;m free)\"> V27 (I&#x27;m free) <\/option>\n            <option value=\"V28 (His smile)\"> V28 (His smile) <\/option>\n            <option value=\"V29 (Miss me but let me go)\"> V29 (Miss me but let me go) <\/option>\n            <option value=\"V30 (Prayer to our lady of Knock)\"> V30 (Prayer to our lady of Knock) <\/option>\n            <option value=\"V31 (We give our loved ones...) \"> V31 (We give our loved ones...) <\/option>\n            <option value=\"V32 (Now I am contented)\"> V32 (Now I am contented) <\/option>\n            <option value=\"V33 (A way of life)\"> V33 (A way of life) <\/option>\n            <option value=\"V34 (My Rosary)\"> V34 (My Rosary) <\/option>\n            <option value=\"V35 (The lord is my shepherd)\"> V35 (The lord is my shepherd) <\/option>\n            <option value=\"V36 (May he support us all...)\"> V36 (May he support us all...) <\/option>\n            <option value=\"V37 (God&#x27;s Garden)\"> V37 (God&#x27;s Garden) <\/option>\n            <option value=\"V38 (Do not stand at my grave)\"> V38 (Do not stand at my grave) <\/option>\n            <option value=\"V39 (Road to eternity)\"> V39 (Road to eternity) <\/option>\n            <option value=\"V40 (After glow)\"> V40 (After glow) <\/option>\n            <option value=\"V41 (God grant us the serenity)\"> V41 (God grant us the serenity) <\/option>\n            <option value=\"V42 (The rose beyond the wall)\"> V42 (The rose beyond the wall) <\/option>\n            <option value=\"V43 (A letter from heaven)\"> V43 (A letter from heaven) <\/option>\n            <option value=\"V44 (Just a prayer from the family)\"> V44 (Just a prayer from the family) <\/option>\n            <option value=\"V45 (Remember me)\"> V45 (Remember me) <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1\" data-type=\"control_textarea\" id=\"id_22\">\n        <label class=\"form-label form-label-top\" id=\"label_22\" for=\"input_22\"> Own Verse (if desired) <\/label>\n        <div id=\"cid_22\" class=\"form-input-wide\">\n          <textarea id=\"input_22\" class=\"form-textarea\" name=\"q22_ownVerse22\" cols=\"40\" rows=\"6\" data-component=\"textarea\"><\/textarea>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_90\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_90\" for=\"input_90\"> Front <\/label>\n        <div id=\"cid_90\" class=\"form-input\">\n          <div class=\"form-single-column\" data-component=\"radio\">\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_90_0\" name=\"q90_front90\" value=\"In Loving Memory\" \/>\n              <label id=\"label_input_90_0\" for=\"input_90_0\"> In Loving Memory <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_90_1\" name=\"q90_front90\" value=\"In Fond Remembrance\" \/>\n              <label id=\"label_input_90_1\" for=\"input_90_1\"> In Fond Remembrance <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_90_2\" name=\"q90_front90\" value=\"Remembering...\" \/>\n              <label id=\"label_input_90_2\" for=\"input_90_2\"> Remembering... <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_24\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_24\" for=\"input_24\"> Own (if required) <\/label>\n        <div id=\"cid_24\" class=\"form-input\">\n          <input type=\"text\" id=\"input_24\" name=\"q24_ownif24\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"50\" value=\"\" placeholder=\" \" data-component=\"textbox\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_dropdown\" id=\"id_26\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_26\" for=\"input_26\"> Background No <\/label>\n        <div id=\"cid_26\" class=\"form-input\">\n          <select class=\"form-dropdown\" id=\"input_26\" name=\"q26_backgroundNo\" style=\"width:150px;\" data-component=\"dropdown\">\n            <option value=\"\">  <\/option>\n            <option value=\"B1 Light\"> B1 Light <\/option>\n            <option value=\"B1 Strong\"> B1 Strong <\/option>\n            <option value=\"B2 Light\"> B2 Light <\/option>\n            <option value=\"B2 Strong\"> B2 Strong <\/option>\n            <option value=\"B3 Light\"> B3 Light <\/option>\n            <option value=\"B3 Strong\"> B3 Strong <\/option>\n            <option value=\"B4 Light\"> B4 Light <\/option>\n            <option value=\"B4 Strong\"> B4 Strong <\/option>\n            <option value=\"B5 Light\"> B5 Light <\/option>\n            <option value=\"B5 Strong\"> B5 Strong <\/option>\n            <option value=\"B6 Light\"> B6 Light <\/option>\n            <option value=\"B6 Strong\"> B6 Strong <\/option>\n            <option value=\"B7 Light\"> B7 Light <\/option>\n            <option value=\"B7 Strong\"> B7 Strong <\/option>\n            <option value=\"B8 Light\"> B8 Light <\/option>\n            <option value=\"B8 Strong\"> B8 Strong <\/option>\n            <option value=\"B9 Light\"> B9 Light <\/option>\n            <option value=\"B9 Strong\"> B9 Strong <\/option>\n            <option value=\"B10 Light\"> B10 Light <\/option>\n            <option value=\"B10 Strong\"> B10 Strong <\/option>\n            <option value=\"B12 (White)\"> B12 (White) <\/option>\n            <option value=\"B13\"> B13 <\/option>\n            <option value=\"B14\"> B14 <\/option>\n            <option value=\"B15\"> B15 <\/option>\n            <option value=\"B16\"> B16 <\/option>\n            <option value=\"B17\"> B17 <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_70\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_70\" for=\"input_70\"> Comments <\/label>\n        <div id=\"cid_70\" class=\"form-input\">\n          <textarea id=\"input_70\" class=\"form-textarea\" name=\"q70_comments\" cols=\"40\" rows=\"6\" data-component=\"textarea\"><\/textarea>\n        <\/div>\n      <\/li>\n      <li id=\"cid_25\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_25\" class=\"form-header\" data-component=\"header\">\n              Double Memorial Cards (Inside)\n            <\/h2>\n            <div id=\"subHeader_25\" class=\"form-subHeader\">\n              (Left)\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1\" data-type=\"control_dropdown\" id=\"id_27\">\n        <label class=\"form-label form-label-top\" id=\"label_27\" for=\"input_27\"> (DMIleft) Frame No <\/label>\n        <div id=\"cid_27\" class=\"form-input-wide\">\n          <select class=\"form-dropdown\" id=\"input_27\" name=\"q27_dmileftFrame\" style=\"width:150px;\" data-component=\"dropdown\">\n            <option value=\"\">  <\/option>\n            <option value=\"F1\"> F1 <\/option>\n            <option value=\"F2\"> F2 <\/option>\n            <option value=\"F3\"> F3 <\/option>\n            <option value=\"FS4\"> FS4 <\/option>\n            <option value=\"FS5\"> FS5 <\/option>\n            <option value=\"FS6\"> FS6 <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-2\" data-type=\"control_dropdown\" id=\"id_28\">\n        <label class=\"form-label form-label-top\" id=\"label_28\" for=\"input_28\"> Short Verse No <\/label>\n        <div id=\"cid_28\" class=\"form-input-wide\">\n          <select class=\"form-dropdown\" id=\"input_28\" name=\"q28_shortVerse\" style=\"width:150px;\" data-component=\"dropdown\">\n            <option value=\"\">  <\/option>\n            <option value=\"V7 (She has gone to)\"> V7 (She has gone to) <\/option>\n            <option value=\"V11 (Pray for me as I will)\"> V11 (Pray for me as I will) <\/option>\n            <option value=\"V14 (Oh! You whom I have...\"> V14 (Oh! You whom I have... <\/option>\n            <option value=\"V15 (Those who die in grace)\"> V15 (Those who die in grace) <\/option>\n            <option value=\"V18 (I am the resurrection)\"> V18 (I am the resurrection) <\/option>\n            <option value=\"V21 (All I ask of you)\"> V21 (All I ask of you) <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_29\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_29\" for=\"input_29\"> Own Short Verse (if required <\/label>\n        <div id=\"cid_29\" class=\"form-input\">\n          <textarea id=\"input_29\" class=\"form-textarea\" name=\"q29_ownShort29\" cols=\"40\" rows=\"6\" data-component=\"textarea\"><\/textarea>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_fileupload\" id=\"id_65\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_65\" for=\"input_65\"> Memorial Card Pictures\/Photos <\/label>\n        <div id=\"cid_65\" class=\"form-input\">\n          <div data-wrapper-react=\"true\">\n            <div data-wrapper-react=\"true\">\n              <div class=\"qq-uploader-buttonText-value\">\n                Upload a File\n              <\/div>\n              <input type=\"file\" id=\"input_65\" name=\"q65_memorialCard[]\" multiple=\"\" class=\"form-upload-multiple\" data-file-accept=\"pdf, doc, docx, xls, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif\" data-file-maxsize=\"10240\" data-file-minsize=\"0\" data-file-limit=\"0\" data-component=\"fileupload\" \/>\n            <\/div>\n            <span style=\"display:none;\" class=\"cancelText\">\n              Cancel\n            <\/span>\n            <span style=\"display:none;\" class=\"ofText\">\n              of\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_71\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_71\" for=\"input_71\"> Comments <\/label>\n        <div id=\"cid_71\" class=\"form-input\">\n          <textarea id=\"input_71\" class=\"form-textarea\" name=\"q71_comments71\" cols=\"40\" rows=\"6\" data-component=\"textarea\"><\/textarea>\n        <\/div>\n      <\/li>\n      <li id=\"cid_113\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_113\" class=\"form-header\" data-component=\"header\">\n              Double Memorial Cards (Inside)\n            <\/h2>\n            <div id=\"subHeader_113\" class=\"form-subHeader\">\n              (Right)\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_dropdown\" id=\"id_118\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_118\" for=\"input_118\"> (DMIright) Verse No <\/label>\n        <div id=\"cid_118\" class=\"form-input\">\n          <select class=\"form-dropdown\" id=\"input_118\" name=\"q118_dmirightVerse\" style=\"width:150px;\" data-component=\"dropdown\">\n            <option value=\"\">  <\/option>\n            <option value=\"V1 (Safely home)\"> V1 (Safely home) <\/option>\n            <option value=\"V2 (Prayer of St. Francis)\"> V2 (Prayer of St. Francis) <\/option>\n            <option value=\"V3 (The Memorare)\"> V3 (The Memorare) <\/option>\n            <option value=\"V4 (My Jesus Mercy)\"> V4 (My Jesus Mercy) <\/option>\n            <option value=\"V5 (We hold you close)\"> V5 (We hold you close) <\/option>\n            <option value=\"V6 (There is no might)\"> V6 (There is no might) <\/option>\n            <option value=\"V7 (She has gone no)\"> V7 (She has gone no) <\/option>\n            <option value=\"V8 (Lonely is the home)\"> V8 (Lonely is the home) <\/option>\n            <option value=\"V9 (O Devine Master)\"> V9 (O Devine Master) <\/option>\n            <option value=\"V10 (My Lord and My God)\"> V10 (My Lord and My God) <\/option>\n            <option value=\"V11 (Pray for me as I will)\"> V11 (Pray for me as I will) <\/option>\n            <option value=\"V12 (What she suffered she...)\"> V12 (What she suffered she...) <\/option>\n            <option value=\"V13 (Gone from our home)\"> V13 (Gone from our home) <\/option>\n            <option value=\"V14 (Oh You whom I have...)\"> V14 (Oh You whom I have...) <\/option>\n            <option value=\"V15 (Those who die in grace)\"> V15 (Those who die in grace) <\/option>\n            <option value=\"V16 (When I must leave you)\"> V16 (When I must leave you) <\/option>\n            <option value=\"V17 (She never failed to do...)\"> V17 (She never failed to do...) <\/option>\n            <option value=\"V18 (I am the resurrection)\"> V18 (I am the resurrection) <\/option>\n            <option value=\"V19 (Footprints)\"> V19 (Footprints) <\/option>\n            <option value=\"V20 (They say there is a reason)\"> V20 (They say there is a reason) <\/option>\n            <option value=\"V21 (All I ask of you)\"> V21 (All I ask of you) <\/option>\n            <option value=\"V22 (Solace)\"> V22 (Solace) <\/option>\n            <option value=\"V23 (Togetherness)\"> V23 (Togetherness) <\/option>\n            <option value=\"V24 (Your life was one of kind...)\"> V24 (Your life was one of kind...) <\/option>\n            <option value=\"V25 (We sat beside your bedside)\"> V25 (We sat beside your bedside) <\/option>\n            <option value=\"V26 (A bouquet of beautiful...)\"> V26 (A bouquet of beautiful...) <\/option>\n            <option value=\"V27 (I&#x27;m free)\"> V27 (I&#x27;m free) <\/option>\n            <option value=\"V28 (His smile)\"> V28 (His smile) <\/option>\n            <option value=\"V29 (Miss me but let me go)\"> V29 (Miss me but let me go) <\/option>\n            <option value=\"V30 (Prayer to our lady of Knock)\"> V30 (Prayer to our lady of Knock) <\/option>\n            <option value=\"V31 (We give our loved ones...) \"> V31 (We give our loved ones...) <\/option>\n            <option value=\"V32 (Now I am contented)\"> V32 (Now I am contented) <\/option>\n            <option value=\"V33 (A way of life)\"> V33 (A way of life) <\/option>\n            <option value=\"V34 (My Rosary)\"> V34 (My Rosary) <\/option>\n            <option value=\"V35 (The lord is my shepherd)\"> V35 (The lord is my shepherd) <\/option>\n            <option value=\"V36 (May he support us all...)\"> V36 (May he support us all...) <\/option>\n            <option value=\"V37 (God&#x27;s Garden)\"> V37 (God&#x27;s Garden) <\/option>\n            <option value=\"V38 (Do not stand at my grave)\"> V38 (Do not stand at my grave) <\/option>\n            <option value=\"V39 (Road to eternity)\"> V39 (Road to eternity) <\/option>\n            <option value=\"V40 (After glow)\"> V40 (After glow) <\/option>\n            <option value=\"V41 (God grant us the serenity)\"> V41 (God grant us the serenity) <\/option>\n            <option value=\"V42 (The rose beyond the wall)\"> V42 (The rose beyond the wall) <\/option>\n            <option value=\"V43 (A letter from heaven)\"> V43 (A letter from heaven) <\/option>\n            <option value=\"V44 (Just a prayer from the family)\"> V44 (Just a prayer from the family) <\/option>\n            <option value=\"V45 (Remember me)\"> V45 (Remember me) <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_31\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_31\" for=\"input_31\"> Own Verse (if required) <\/label>\n        <div id=\"cid_31\" class=\"form-input\">\n          <textarea id=\"input_31\" class=\"form-textarea\" name=\"q31_ownVerse\" cols=\"40\" rows=\"6\" data-component=\"textarea\"><\/textarea>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_dropdown\" id=\"id_116\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_116\" for=\"input_116\"> Background No <\/label>\n        <div id=\"cid_116\" class=\"form-input\">\n          <select class=\"form-dropdown\" id=\"input_116\" name=\"q116_backgroundNo116\" style=\"width:150px;\" data-component=\"dropdown\">\n            <option value=\"\">  <\/option>\n            <option value=\"B1 Light\"> B1 Light <\/option>\n            <option value=\"B1 Strong\"> B1 Strong <\/option>\n            <option value=\"B2 Light\"> B2 Light <\/option>\n            <option value=\"B2 Strong\"> B2 Strong <\/option>\n            <option value=\"B3 Light\"> B3 Light <\/option>\n            <option value=\"B3 Strong\"> B3 Strong <\/option>\n            <option value=\"B4 Light\"> B4 Light <\/option>\n            <option value=\"B4 Strong\"> B4 Strong <\/option>\n            <option value=\"B5 Light\"> B5 Light <\/option>\n            <option value=\"B5 Strong\"> B5 Strong <\/option>\n            <option value=\"B6 Light\"> B6 Light <\/option>\n            <option value=\"B6 Strong\"> B6 Strong <\/option>\n            <option value=\"B7 Light\"> B7 Light <\/option>\n            <option value=\"B7 Strong\"> B7 Strong <\/option>\n            <option value=\"B8 Light\"> B8 Light <\/option>\n            <option value=\"B8 Strong\"> B8 Strong <\/option>\n            <option value=\"B9 Light\"> B9 Light <\/option>\n            <option value=\"B9 Strong\"> B9 Strong <\/option>\n            <option value=\"B10 Light\"> B10 Light <\/option>\n            <option value=\"B10 Strong\"> B10 Strong <\/option>\n            <option value=\"B12 (White)\"> B12 (White) <\/option>\n            <option value=\"B13\"> B13 <\/option>\n            <option value=\"B14\"> B14 <\/option>\n            <option value=\"B15\"> B15 <\/option>\n            <option value=\"B16\"> B16 <\/option>\n            <option value=\"B17\"> B17 <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_117\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_117\" for=\"input_117\"> Comments <\/label>\n        <div id=\"cid_117\" class=\"form-input\">\n          <textarea id=\"input_117\" class=\"form-textarea\" name=\"q117_comments117\" cols=\"40\" rows=\"6\" data-component=\"textarea\"><\/textarea>\n        <\/div>\n      <\/li>\n      <li id=\"cid_106\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_106\" class=\"form-header\" data-component=\"header\">\n              Single Memoriam \/ Bookmark \/ Wallet Card (Front)\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_dropdown\" id=\"id_30\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_30\" for=\"input_30\"> (SM\/B\/W front) Verse No <\/label>\n        <div id=\"cid_30\" class=\"form-input\">\n          <select class=\"form-dropdown\" id=\"input_30\" name=\"q30_smbwFront\" style=\"width:150px;\" data-component=\"dropdown\">\n            <option value=\"\">  <\/option>\n            <option value=\"V1 (Safely home)\"> V1 (Safely home) <\/option>\n            <option value=\"V2 (Prayer of St. Francis)\"> V2 (Prayer of St. Francis) <\/option>\n            <option value=\"V3 (The Memorare)\"> V3 (The Memorare) <\/option>\n            <option value=\"V4 (My Jesus Mercy)\"> V4 (My Jesus Mercy) <\/option>\n            <option value=\"V5 (We hold you close)\"> V5 (We hold you close) <\/option>\n            <option value=\"V6 (There is no might)\"> V6 (There is no might) <\/option>\n            <option value=\"V7 (She has gone no)\"> V7 (She has gone no) <\/option>\n            <option value=\"V8 (Lonely is the home)\"> V8 (Lonely is the home) <\/option>\n            <option value=\"V9 (O Devine Master)\"> V9 (O Devine Master) <\/option>\n            <option value=\"V10 (My Lord and My God)\"> V10 (My Lord and My God) <\/option>\n            <option value=\"V11 (Pray for me as I will)\"> V11 (Pray for me as I will) <\/option>\n            <option value=\"V12 (What she suffered she...)\"> V12 (What she suffered she...) <\/option>\n            <option value=\"V13 (Gone from our home)\"> V13 (Gone from our home) <\/option>\n            <option value=\"V14 (Oh You whom I have...)\"> V14 (Oh You whom I have...) <\/option>\n            <option value=\"V15 (Those who die in grace)\"> V15 (Those who die in grace) <\/option>\n            <option value=\"V16 (When I must leave you)\"> V16 (When I must leave you) <\/option>\n            <option value=\"V17 (She never failed to do...)\"> V17 (She never failed to do...) <\/option>\n            <option value=\"V18 (I am the resurrection)\"> V18 (I am the resurrection) <\/option>\n            <option value=\"V19 (Footprints)\"> V19 (Footprints) <\/option>\n            <option value=\"V20 (They say there is a reason)\"> V20 (They say there is a reason) <\/option>\n            <option value=\"V21 (All I ask of you)\"> V21 (All I ask of you) <\/option>\n            <option value=\"V22 (Solace)\"> V22 (Solace) <\/option>\n            <option value=\"V23 (Togetherness)\"> V23 (Togetherness) <\/option>\n            <option value=\"V24 (Your life was one of kind...)\"> V24 (Your life was one of kind...) <\/option>\n            <option value=\"V25 (We sat beside your bedside)\"> V25 (We sat beside your bedside) <\/option>\n            <option value=\"V26 (A bouquet of beautiful...)\"> V26 (A bouquet of beautiful...) <\/option>\n            <option value=\"V27 (I&#x27;m free)\"> V27 (I&#x27;m free) <\/option>\n            <option value=\"V28 (His smile)\"> V28 (His smile) <\/option>\n            <option value=\"V29 (Miss me but let me go)\"> V29 (Miss me but let me go) <\/option>\n            <option value=\"V30 (Prayer to our lady of Knock)\"> V30 (Prayer to our lady of Knock) <\/option>\n            <option value=\"V31 (We give our loved ones...) \"> V31 (We give our loved ones...) <\/option>\n            <option value=\"V32 (Now I am contented)\"> V32 (Now I am contented) <\/option>\n            <option value=\"V33 (A way of life)\"> V33 (A way of life) <\/option>\n            <option value=\"V34 (My Rosary)\"> V34 (My Rosary) <\/option>\n            <option value=\"V35 (The lord is my shepherd)\"> V35 (The lord is my shepherd) <\/option>\n            <option value=\"V36 (May he support us all...)\"> V36 (May he support us all...) <\/option>\n            <option value=\"V37 (God&#x27;s Garden)\"> V37 (God&#x27;s Garden) <\/option>\n            <option value=\"V38 (Do not stand at my grave)\"> V38 (Do not stand at my grave) <\/option>\n            <option value=\"V39 (Road to eternity)\"> V39 (Road to eternity) <\/option>\n            <option value=\"V40 (After glow)\"> V40 (After glow) <\/option>\n            <option value=\"V41 (God grant us the serenity)\"> V41 (God grant us the serenity) <\/option>\n            <option value=\"V42 (The rose beyond the wall)\"> V42 (The rose beyond the wall) <\/option>\n            <option value=\"V43 (A letter from heaven)\"> V43 (A letter from heaven) <\/option>\n            <option value=\"V44 (Just a prayer from the family)\"> V44 (Just a prayer from the family) <\/option>\n            <option value=\"V45 (Remember me)\"> V45 (Remember me) <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_dropdown\" id=\"id_121\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_121\" for=\"input_121\"> Image No <\/label>\n        <div id=\"cid_121\" class=\"form-input\">\n          <select class=\"form-dropdown\" id=\"input_121\" name=\"q121_imageNo121\" style=\"width:150px;\" data-component=\"dropdown\">\n            <option value=\"\">  <\/option>\n            <option value=\"M1\"> M1 <\/option>\n            <option value=\"M2\"> M2 <\/option>\n            <option value=\"M3\"> M3 <\/option>\n            <option value=\"M4\"> M4 <\/option>\n            <option value=\"M5\"> M5 <\/option>\n            <option value=\"M6\"> M6 <\/option>\n            <option value=\"M7\"> M7 <\/option>\n            <option value=\"M8\"> M8 <\/option>\n            <option value=\"M9\"> M9 <\/option>\n            <option value=\"M10\"> M10 <\/option>\n            <option value=\"M11\"> M11 <\/option>\n            <option value=\"M12\"> M12 <\/option>\n            <option value=\"M13\"> M13 <\/option>\n            <option value=\"M14\"> M14 <\/option>\n            <option value=\"M15\"> M15 <\/option>\n            <option value=\"M16\"> M16 <\/option>\n            <option value=\"M17\"> M17 <\/option>\n            <option value=\"M18\"> M18 <\/option>\n            <option value=\"M19\"> M19 <\/option>\n            <option value=\"M20\"> M20 <\/option>\n            <option value=\"M21\"> M21 <\/option>\n            <option value=\"M22\"> M22 <\/option>\n            <option value=\"M23\"> M23 <\/option>\n            <option value=\"M24\"> M24 <\/option>\n            <option value=\"M25\"> M25 <\/option>\n            <option value=\"M26\"> M26 <\/option>\n            <option value=\"M27\"> M27 <\/option>\n            <option value=\"M28\"> M28 <\/option>\n            <option value=\"M29\"> M29 <\/option>\n            <option value=\"M30\"> M30 <\/option>\n            <option value=\"M31\"> M31 <\/option>\n            <option value=\"M32\"> M32 <\/option>\n            <option value=\"M33\"> M33 <\/option>\n            <option value=\"M34\"> M34 <\/option>\n            <option value=\"M35\"> M35 <\/option>\n            <option value=\"M36\"> M36 <\/option>\n            <option value=\"M37\"> M37 <\/option>\n            <option value=\"M38\"> M38 <\/option>\n            <option value=\"M39\"> M39 <\/option>\n            <option value=\"M40\"> M40 <\/option>\n            <option value=\"M41\"> M41 <\/option>\n            <option value=\"M42\"> M42 <\/option>\n            <option value=\"M43\"> M43 <\/option>\n            <option value=\"M44\"> M44 <\/option>\n            <option value=\"M45\"> M45 <\/option>\n            <option value=\"M46\"> M46 <\/option>\n            <option value=\"M47\"> M47 <\/option>\n            <option value=\"M48\"> M48 <\/option>\n            <option value=\"M49\"> M49 <\/option>\n            <option value=\"M50\"> M50 <\/option>\n            <option value=\"M51\"> M51 <\/option>\n            <option value=\"M52\"> M52 <\/option>\n            <option value=\"M53\"> M53 <\/option>\n            <option value=\"M54\"> M54 <\/option>\n            <option value=\"M55\"> M55 <\/option>\n            <option value=\"M56\"> M56 <\/option>\n            <option value=\"M57\"> M57 <\/option>\n            <option value=\"M58\"> M58 <\/option>\n            <option value=\"M59\"> M59 <\/option>\n            <option value=\"M60\"> M60 <\/option>\n            <option value=\"M61\"> M61 <\/option>\n            <option value=\"M62\"> M62 <\/option>\n            <option value=\"M63\"> M63 <\/option>\n            <option value=\"M64\"> M64 <\/option>\n            <option value=\"M65\"> M65 <\/option>\n            <option value=\"M66\"> M66 <\/option>\n            <option value=\"M67\"> M67 <\/option>\n            <option value=\"M68\"> M68 <\/option>\n            <option value=\"M69\"> M69 <\/option>\n            <option value=\"M70\"> M70 <\/option>\n            <option value=\"M71\"> M71 <\/option>\n            <option value=\"M72\"> M72 <\/option>\n            <option value=\"M73\"> M73 <\/option>\n            <option value=\"M74\"> M74 <\/option>\n            <option value=\"M75\"> M75 <\/option>\n            <option value=\"M76\"> M76 <\/option>\n            <option value=\"M77\"> M77 <\/option>\n            <option value=\"M78\"> M78 <\/option>\n            <option value=\"M79\"> M79 <\/option>\n            <option value=\"M80\"> M80 <\/option>\n            <option value=\"M81\"> M81 <\/option>\n            <option value=\"M82\"> M82 <\/option>\n            <option value=\"M83\"> M83 <\/option>\n            <option value=\"M84\"> M84 <\/option>\n            <option value=\"M85\"> M85 <\/option>\n            <option value=\"M86\"> M86 <\/option>\n            <option value=\"M87\"> M87 <\/option>\n            <option value=\"M88\"> M88 <\/option>\n            <option value=\"M89\"> M89 <\/option>\n            <option value=\"M90\"> M90 <\/option>\n            <option value=\"M91\"> M91 <\/option>\n            <option value=\"M92\"> M92 <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_115\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_115\" for=\"input_115\"> Own Verse (if required) <\/label>\n        <div id=\"cid_115\" class=\"form-input\">\n          <textarea id=\"input_115\" class=\"form-textarea\" name=\"q115_ownVerse115\" cols=\"40\" rows=\"6\" data-component=\"textarea\"><\/textarea>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_dropdown\" id=\"id_99\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_99\" for=\"input_99\"> Background No <\/label>\n        <div id=\"cid_99\" class=\"form-input\">\n          <select class=\"form-dropdown\" id=\"input_99\" name=\"q99_backgroundNo99\" style=\"width:150px;\" data-component=\"dropdown\">\n            <option value=\"\">  <\/option>\n            <option value=\"B1 Light\"> B1 Light <\/option>\n            <option value=\"B1 Strong\"> B1 Strong <\/option>\n            <option value=\"B2 Light\"> B2 Light <\/option>\n            <option value=\"B2 Strong\"> B2 Strong <\/option>\n            <option value=\"B3 Light\"> B3 Light <\/option>\n            <option value=\"B3 Strong\"> B3 Strong <\/option>\n            <option value=\"B4 Light\"> B4 Light <\/option>\n            <option value=\"B4 Strong\"> B4 Strong <\/option>\n            <option value=\"B5 Light\"> B5 Light <\/option>\n            <option value=\"B5 Strong\"> B5 Strong <\/option>\n            <option value=\"B6 Light\"> B6 Light <\/option>\n            <option value=\"B6 Strong\"> B6 Strong <\/option>\n            <option value=\"B7 Light\"> B7 Light <\/option>\n            <option value=\"B7 Strong\"> B7 Strong <\/option>\n            <option value=\"B8 Light\"> B8 Light <\/option>\n            <option value=\"B8 Strong\"> B8 Strong <\/option>\n            <option value=\"B9 Light\"> B9 Light <\/option>\n            <option value=\"B9 Strong\"> B9 Strong <\/option>\n            <option value=\"B10 Light\"> B10 Light <\/option>\n            <option value=\"B10 Strong\"> B10 Strong <\/option>\n            <option value=\"B12 (White)\"> B12 (White) <\/option>\n            <option value=\"B13\"> B13 <\/option>\n            <option value=\"B14\"> B14 <\/option>\n            <option value=\"B15\"> B15 <\/option>\n            <option value=\"B16\"> B16 <\/option>\n            <option value=\"B17\"> B17 <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_fileupload\" id=\"id_112\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_112\" for=\"input_112\"> Memorial Card Pictures\/Photos <\/label>\n        <div id=\"cid_112\" class=\"form-input\">\n          <div data-wrapper-react=\"true\">\n            <div data-wrapper-react=\"true\">\n              <div class=\"qq-uploader-buttonText-value\">\n                Upload a File\n              <\/div>\n              <input type=\"file\" id=\"input_112\" name=\"q112_memorialCard112[]\" multiple=\"\" class=\"form-upload-multiple\" data-file-accept=\"pdf, doc, docx, xls, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif\" data-file-maxsize=\"10240\" data-file-minsize=\"0\" data-file-limit=\"0\" data-component=\"fileupload\" \/>\n            <\/div>\n            <span style=\"display:none;\" class=\"cancelText\">\n              Cancel\n            <\/span>\n            <span style=\"display:none;\" class=\"ofText\">\n              of\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_103\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_103\" for=\"input_103\"> Comments <\/label>\n        <div id=\"cid_103\" class=\"form-input\">\n          <textarea id=\"input_103\" class=\"form-textarea\" name=\"q103_comments103\" cols=\"40\" rows=\"6\" data-component=\"textarea\"><\/textarea>\n        <\/div>\n      <\/li>\n      <li id=\"cid_107\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_107\" class=\"form-header\" data-component=\"header\">\n              Single Memoriam \/ Bookmark \/ Wallet Card (Back)\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_dropdown\" id=\"id_96\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_96\" for=\"input_96\"> (SM\/B\/W back) Verse No <\/label>\n        <div id=\"cid_96\" class=\"form-input\">\n          <select class=\"form-dropdown\" id=\"input_96\" name=\"q96_smbwBack\" style=\"width:150px;\" data-component=\"dropdown\">\n            <option value=\"\">  <\/option>\n            <option value=\"V1 (Safely home)\"> V1 (Safely home) <\/option>\n            <option value=\"V2 (Prayer of St. Francis)\"> V2 (Prayer of St. Francis) <\/option>\n            <option value=\"V3 (The Memorare)\"> V3 (The Memorare) <\/option>\n            <option value=\"V4 (My Jesus Mercy)\"> V4 (My Jesus Mercy) <\/option>\n            <option value=\"V5 (We hold you close)\"> V5 (We hold you close) <\/option>\n            <option value=\"V6 (There is no might)\"> V6 (There is no might) <\/option>\n            <option value=\"V7 (She has gone no)\"> V7 (She has gone no) <\/option>\n            <option value=\"V8 (Lonely is the home)\"> V8 (Lonely is the home) <\/option>\n            <option value=\"V9 (O Devine Master)\"> V9 (O Devine Master) <\/option>\n            <option value=\"V10 (My Lord and My God)\"> V10 (My Lord and My God) <\/option>\n            <option value=\"V11 (Pray for me as I will)\"> V11 (Pray for me as I will) <\/option>\n            <option value=\"V12 (What she suffered she...)\"> V12 (What she suffered she...) <\/option>\n            <option value=\"V13 (Gone from our home)\"> V13 (Gone from our home) <\/option>\n            <option value=\"V14 (Oh You whom I have...)\"> V14 (Oh You whom I have...) <\/option>\n            <option value=\"V15 (Those who die in grace)\"> V15 (Those who die in grace) <\/option>\n            <option value=\"V16 (When I must leave you)\"> V16 (When I must leave you) <\/option>\n            <option value=\"V17 (She never failed to do...)\"> V17 (She never failed to do...) <\/option>\n            <option value=\"V18 (I am the resurrection)\"> V18 (I am the resurrection) <\/option>\n            <option value=\"V19 (Footprints)\"> V19 (Footprints) <\/option>\n            <option value=\"V20 (They say there is a reason)\"> V20 (They say there is a reason) <\/option>\n            <option value=\"V21 (All I ask of you)\"> V21 (All I ask of you) <\/option>\n            <option value=\"V22 (Solace)\"> V22 (Solace) <\/option>\n            <option value=\"V23 (Togetherness)\"> V23 (Togetherness) <\/option>\n            <option value=\"V24 (Your life was one of kind...)\"> V24 (Your life was one of kind...) <\/option>\n            <option value=\"V25 (We sat beside your bedside)\"> V25 (We sat beside your bedside) <\/option>\n            <option value=\"V26 (A bouquet of beautiful...)\"> V26 (A bouquet of beautiful...) <\/option>\n            <option value=\"V27 (I&#x27;m free)\"> V27 (I&#x27;m free) <\/option>\n            <option value=\"V28 (His smile)\"> V28 (His smile) <\/option>\n            <option value=\"V29 (Miss me but let me go)\"> V29 (Miss me but let me go) <\/option>\n            <option value=\"V30 (Prayer to our lady of Knock)\"> V30 (Prayer to our lady of Knock) <\/option>\n            <option value=\"V31 (We give our loved ones...) \"> V31 (We give our loved ones...) <\/option>\n            <option value=\"V32 (Now I am contented)\"> V32 (Now I am contented) <\/option>\n            <option value=\"V33 (A way of life)\"> V33 (A way of life) <\/option>\n            <option value=\"V34 (My Rosary)\"> V34 (My Rosary) <\/option>\n            <option value=\"V35 (The lord is my shepherd)\"> V35 (The lord is my shepherd) <\/option>\n            <option value=\"V36 (May he support us all...)\"> V36 (May he support us all...) <\/option>\n            <option value=\"V37 (God&#x27;s Garden)\"> V37 (God&#x27;s Garden) <\/option>\n            <option value=\"V38 (Do not stand at my grave)\"> V38 (Do not stand at my grave) <\/option>\n            <option value=\"V39 (Road to eternity)\"> V39 (Road to eternity) <\/option>\n            <option value=\"V40 (After glow)\"> V40 (After glow) <\/option>\n            <option value=\"V41 (God grant us the serenity)\"> V41 (God grant us the serenity) <\/option>\n            <option value=\"V42 (The rose beyond the wall)\"> V42 (The rose beyond the wall) <\/option>\n            <option value=\"V43 (A letter from heaven)\"> V43 (A letter from heaven) <\/option>\n            <option value=\"V44 (Just a prayer from the family)\"> V44 (Just a prayer from the family) <\/option>\n            <option value=\"V45 (Remember me)\"> V45 (Remember me) <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_dropdown\" id=\"id_120\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_120\" for=\"input_120\"> Image No <\/label>\n        <div id=\"cid_120\" class=\"form-input\">\n          <select class=\"form-dropdown\" id=\"input_120\" name=\"q120_imageNo\" style=\"width:150px;\" data-component=\"dropdown\">\n            <option value=\"\">  <\/option>\n            <option value=\"M1\"> M1 <\/option>\n            <option value=\"M2\"> M2 <\/option>\n            <option value=\"M3\"> M3 <\/option>\n            <option value=\"M4\"> M4 <\/option>\n            <option value=\"M5\"> M5 <\/option>\n            <option value=\"M6\"> M6 <\/option>\n            <option value=\"M7\"> M7 <\/option>\n            <option value=\"M8\"> M8 <\/option>\n            <option value=\"M9\"> M9 <\/option>\n            <option value=\"M10\"> M10 <\/option>\n            <option value=\"M11\"> M11 <\/option>\n            <option value=\"M12\"> M12 <\/option>\n            <option value=\"M13\"> M13 <\/option>\n            <option value=\"M14\"> M14 <\/option>\n            <option value=\"M15\"> M15 <\/option>\n            <option value=\"M16\"> M16 <\/option>\n            <option value=\"M17\"> M17 <\/option>\n            <option value=\"M18\"> M18 <\/option>\n            <option value=\"M19\"> M19 <\/option>\n            <option value=\"M20\"> M20 <\/option>\n            <option value=\"M21\"> M21 <\/option>\n            <option value=\"M22\"> M22 <\/option>\n            <option value=\"M23\"> M23 <\/option>\n            <option value=\"M24\"> M24 <\/option>\n            <option value=\"M25\"> M25 <\/option>\n            <option value=\"M26\"> M26 <\/option>\n            <option value=\"M27\"> M27 <\/option>\n            <option value=\"M28\"> M28 <\/option>\n            <option value=\"M29\"> M29 <\/option>\n            <option value=\"M30\"> M30 <\/option>\n            <option value=\"M31\"> M31 <\/option>\n            <option value=\"M32\"> M32 <\/option>\n            <option value=\"M33\"> M33 <\/option>\n            <option value=\"M34\"> M34 <\/option>\n            <option value=\"M35\"> M35 <\/option>\n            <option value=\"M36\"> M36 <\/option>\n            <option value=\"M37\"> M37 <\/option>\n            <option value=\"M38\"> M38 <\/option>\n            <option value=\"M39\"> M39 <\/option>\n            <option value=\"M40\"> M40 <\/option>\n            <option value=\"M41\"> M41 <\/option>\n            <option value=\"M42\"> M42 <\/option>\n            <option value=\"M43\"> M43 <\/option>\n            <option value=\"M44\"> M44 <\/option>\n            <option value=\"M45\"> M45 <\/option>\n            <option value=\"M46\"> M46 <\/option>\n            <option value=\"M47\"> M47 <\/option>\n            <option value=\"M48\"> M48 <\/option>\n            <option value=\"M49\"> M49 <\/option>\n            <option value=\"M50\"> M50 <\/option>\n            <option value=\"M51\"> M51 <\/option>\n            <option value=\"M52\"> M52 <\/option>\n            <option value=\"M53\"> M53 <\/option>\n            <option value=\"M54\"> M54 <\/option>\n            <option value=\"M55\"> M55 <\/option>\n            <option value=\"M56\"> M56 <\/option>\n            <option value=\"M57\"> M57 <\/option>\n            <option value=\"M58\"> M58 <\/option>\n            <option value=\"M59\"> M59 <\/option>\n            <option value=\"M60\"> M60 <\/option>\n            <option value=\"M61\"> M61 <\/option>\n            <option value=\"M62\"> M62 <\/option>\n            <option value=\"M63\"> M63 <\/option>\n            <option value=\"M64\"> M64 <\/option>\n            <option value=\"M65\"> M65 <\/option>\n            <option value=\"M66\"> M66 <\/option>\n            <option value=\"M67\"> M67 <\/option>\n            <option value=\"M68\"> M68 <\/option>\n            <option value=\"M69\"> M69 <\/option>\n            <option value=\"M70\"> M70 <\/option>\n            <option value=\"M71\"> M71 <\/option>\n            <option value=\"M72\"> M72 <\/option>\n            <option value=\"M73\"> M73 <\/option>\n            <option value=\"M74\"> M74 <\/option>\n            <option value=\"M75\"> M75 <\/option>\n            <option value=\"M76\"> M76 <\/option>\n            <option value=\"M77\"> M77 <\/option>\n            <option value=\"M78\"> M78 <\/option>\n            <option value=\"M79\"> M79 <\/option>\n            <option value=\"M80\"> M80 <\/option>\n            <option value=\"M81\"> M81 <\/option>\n            <option value=\"M82\"> M82 <\/option>\n            <option value=\"M83\"> M83 <\/option>\n            <option value=\"M84\"> M84 <\/option>\n            <option value=\"M85\"> M85 <\/option>\n            <option value=\"M86\"> M86 <\/option>\n            <option value=\"M87\"> M87 <\/option>\n            <option value=\"M88\"> M88 <\/option>\n            <option value=\"M89\"> M89 <\/option>\n            <option value=\"M90\"> M90 <\/option>\n            <option value=\"M91\"> M91 <\/option>\n            <option value=\"M92\"> M92 <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_109\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_109\" for=\"input_109\"> Own Verse (if required) <\/label>\n        <div id=\"cid_109\" class=\"form-input\">\n          <textarea id=\"input_109\" class=\"form-textarea\" name=\"q109_ownVerse109\" cols=\"40\" rows=\"6\" data-component=\"textarea\"><\/textarea>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_dropdown\" id=\"id_110\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_110\" for=\"input_110\"> Background No <\/label>\n        <div id=\"cid_110\" class=\"form-input\">\n          <select class=\"form-dropdown\" id=\"input_110\" name=\"q110_backgroundNo110\" style=\"width:150px;\" data-component=\"dropdown\">\n            <option value=\"\">  <\/option>\n            <option value=\"B1 Light\"> B1 Light <\/option>\n            <option value=\"B1 Strong\"> B1 Strong <\/option>\n            <option value=\"B2 Light\"> B2 Light <\/option>\n            <option value=\"B2 Strong\"> B2 Strong <\/option>\n            <option value=\"B3 Light\"> B3 Light <\/option>\n            <option value=\"B3 Strong\"> B3 Strong <\/option>\n            <option value=\"B4 Light\"> B4 Light <\/option>\n            <option value=\"B4 Strong\"> B4 Strong <\/option>\n            <option value=\"B5 Light\"> B5 Light <\/option>\n            <option value=\"B5 Strong\"> B5 Strong <\/option>\n            <option value=\"B6 Light\"> B6 Light <\/option>\n            <option value=\"B6 Strong\"> B6 Strong <\/option>\n            <option value=\"B7 Light\"> B7 Light <\/option>\n            <option value=\"B7 Strong\"> B7 Strong <\/option>\n            <option value=\"B8 Light\"> B8 Light <\/option>\n            <option value=\"B8 Strong\"> B8 Strong <\/option>\n            <option value=\"B9 Light\"> B9 Light <\/option>\n            <option value=\"B9 Strong\"> B9 Strong <\/option>\n            <option value=\"B10 Light\"> B10 Light <\/option>\n            <option value=\"B10 Strong\"> B10 Strong <\/option>\n            <option value=\"B12 (White)\"> B12 (White) <\/option>\n            <option value=\"B13\"> B13 <\/option>\n            <option value=\"B14\"> B14 <\/option>\n            <option value=\"B15\"> B15 <\/option>\n            <option value=\"B16\"> B16 <\/option>\n            <option value=\"B17\"> B17 <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_111\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_111\" for=\"input_111\"> Comments <\/label>\n        <div id=\"cid_111\" class=\"form-input\">\n          <textarea id=\"input_111\" class=\"form-textarea\" name=\"q111_comments111\" cols=\"40\" rows=\"6\" data-component=\"textarea\"><\/textarea>\n        <\/div>\n      <\/li>\n      <li id=\"cid_51\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_51\" class=\"form-header\" data-component=\"header\">\n              Holder for Bookmarks or Single Card\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1\" data-type=\"control_dropdown\" id=\"id_52\">\n        <label class=\"form-label form-label-top\" id=\"label_52\" for=\"input_52\"> Holder No <\/label>\n        <div id=\"cid_52\" class=\"form-input-wide\">\n          <select class=\"form-dropdown\" id=\"input_52\" name=\"q52_holderNo52\" style=\"width:150px;\" data-component=\"dropdown\">\n            <option value=\"\">  <\/option>\n            <option value=\"H1\"> H1 <\/option>\n            <option value=\"H2\"> H2 <\/option>\n            <option value=\"H3\"> H3 <\/option>\n            <option value=\"H4\"> H4 <\/option>\n            <option value=\"H5\"> H5 <\/option>\n            <option value=\"H6\"> H6 <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-2\" data-type=\"control_dropdown\" id=\"id_122\">\n        <label class=\"form-label form-label-top\" id=\"label_122\" for=\"input_122\"> Image No <\/label>\n        <div id=\"cid_122\" class=\"form-input-wide\">\n          <select class=\"form-dropdown\" id=\"input_122\" name=\"q122_imageNo122\" style=\"width:150px;\" data-component=\"dropdown\">\n            <option value=\"\">  <\/option>\n            <option value=\"M1\"> M1 <\/option>\n            <option value=\"M2\"> M2 <\/option>\n            <option value=\"M3\"> M3 <\/option>\n            <option value=\"M4\"> M4 <\/option>\n            <option value=\"M5\"> M5 <\/option>\n            <option value=\"M6\"> M6 <\/option>\n            <option value=\"M7\"> M7 <\/option>\n            <option value=\"M8\"> M8 <\/option>\n            <option value=\"M9\"> M9 <\/option>\n            <option value=\"M10\"> M10 <\/option>\n            <option value=\"M11\"> M11 <\/option>\n            <option value=\"M12\"> M12 <\/option>\n            <option value=\"M13\"> M13 <\/option>\n            <option value=\"M14\"> M14 <\/option>\n            <option value=\"M15\"> M15 <\/option>\n            <option value=\"M16\"> M16 <\/option>\n            <option value=\"M17\"> M17 <\/option>\n            <option value=\"M18\"> M18 <\/option>\n            <option value=\"M19\"> M19 <\/option>\n            <option value=\"M20\"> M20 <\/option>\n            <option value=\"M21\"> M21 <\/option>\n            <option value=\"M22\"> M22 <\/option>\n            <option value=\"M23\"> M23 <\/option>\n            <option value=\"M24\"> M24 <\/option>\n            <option value=\"M25\"> M25 <\/option>\n            <option value=\"M26\"> M26 <\/option>\n            <option value=\"M27\"> M27 <\/option>\n            <option value=\"M28\"> M28 <\/option>\n            <option value=\"M29\"> M29 <\/option>\n            <option value=\"M30\"> M30 <\/option>\n            <option value=\"M31\"> M31 <\/option>\n            <option value=\"M32\"> M32 <\/option>\n            <option value=\"M33\"> M33 <\/option>\n            <option value=\"M34\"> M34 <\/option>\n            <option value=\"M35\"> M35 <\/option>\n            <option value=\"M36\"> M36 <\/option>\n            <option value=\"M37\"> M37 <\/option>\n            <option value=\"M38\"> M38 <\/option>\n            <option value=\"M39\"> M39 <\/option>\n            <option value=\"M40\"> M40 <\/option>\n            <option value=\"M41\"> M41 <\/option>\n            <option value=\"M42\"> M42 <\/option>\n            <option value=\"M43\"> M43 <\/option>\n            <option value=\"M44\"> M44 <\/option>\n            <option value=\"M45\"> M45 <\/option>\n            <option value=\"M46\"> M46 <\/option>\n            <option value=\"M47\"> M47 <\/option>\n            <option value=\"M48\"> M48 <\/option>\n            <option value=\"M49\"> M49 <\/option>\n            <option value=\"M50\"> M50 <\/option>\n            <option value=\"M51\"> M51 <\/option>\n            <option value=\"M52\"> M52 <\/option>\n            <option value=\"M53\"> M53 <\/option>\n            <option value=\"M54\"> M54 <\/option>\n            <option value=\"M55\"> M55 <\/option>\n            <option value=\"M56\"> M56 <\/option>\n            <option value=\"M57\"> M57 <\/option>\n            <option value=\"M58\"> M58 <\/option>\n            <option value=\"M59\"> M59 <\/option>\n            <option value=\"M60\"> M60 <\/option>\n            <option value=\"M61\"> M61 <\/option>\n            <option value=\"M62\"> M62 <\/option>\n            <option value=\"M63\"> M63 <\/option>\n            <option value=\"M64\"> M64 <\/option>\n            <option value=\"M65\"> M65 <\/option>\n            <option value=\"M66\"> M66 <\/option>\n            <option value=\"M67\"> M67 <\/option>\n            <option value=\"M68\"> M68 <\/option>\n            <option value=\"M69\"> M69 <\/option>\n            <option value=\"M70\"> M70 <\/option>\n            <option value=\"M71\"> M71 <\/option>\n            <option value=\"M72\"> M72 <\/option>\n            <option value=\"M73\"> M73 <\/option>\n            <option value=\"M74\"> M74 <\/option>\n            <option value=\"M75\"> M75 <\/option>\n            <option value=\"M76\"> M76 <\/option>\n            <option value=\"M77\"> M77 <\/option>\n            <option value=\"M78\"> M78 <\/option>\n            <option value=\"M79\"> M79 <\/option>\n            <option value=\"M80\"> M80 <\/option>\n            <option value=\"M81\"> M81 <\/option>\n            <option value=\"M82\"> M82 <\/option>\n            <option value=\"M83\"> M83 <\/option>\n            <option value=\"M84\"> M84 <\/option>\n            <option value=\"M85\"> M85 <\/option>\n            <option value=\"M86\"> M86 <\/option>\n            <option value=\"M87\"> M87 <\/option>\n            <option value=\"M88\"> M88 <\/option>\n            <option value=\"M89\"> M89 <\/option>\n            <option value=\"M90\"> M90 <\/option>\n            <option value=\"M91\"> M91 <\/option>\n            <option value=\"M92\"> M92 <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_76\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_76\" for=\"input_76\"> Comments <\/label>\n        <div id=\"cid_76\" class=\"form-input\">\n          <textarea id=\"input_76\" class=\"form-textarea\" name=\"q76_comments76\" cols=\"40\" rows=\"6\" data-component=\"textarea\"><\/textarea>\n        <\/div>\n      <\/li>\n      <li id=\"cid_34\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_34\" class=\"form-header\" data-component=\"header\">\n              Acknowledgement Cards\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_87\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_87\" for=\"input_87\"> (Ack Card Type <\/label>\n        <div id=\"cid_87\" class=\"form-input\">\n          <div class=\"form-single-column\" data-component=\"radio\">\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_87_0\" name=\"q87_ackCard\" value=\"Single Card\" \/>\n              <label id=\"label_input_87_0\" for=\"input_87_0\"> Single Card <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left;\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_87_1\" name=\"q87_ackCard\" value=\"Double Card\" \/>\n              <label id=\"label_input_87_1\" for=\"input_87_1\"> Double Card <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1\" data-type=\"control_dropdown\" id=\"id_36\">\n        <label class=\"form-label form-label-top\" id=\"label_36\" for=\"input_36\"> Image No <\/label>\n        <div id=\"cid_36\" class=\"form-input-wide\">\n          <select class=\"form-dropdown\" id=\"input_36\" name=\"q36_imageNo36\" style=\"width:150px;\" data-component=\"dropdown\">\n            <option value=\"\">  <\/option>\n            <option value=\"M1\"> M1 <\/option>\n            <option value=\"M2\"> M2 <\/option>\n            <option value=\"M3\"> M3 <\/option>\n            <option value=\"M4\"> M4 <\/option>\n            <option value=\"M5\"> M5 <\/option>\n            <option value=\"M6\"> M6 <\/option>\n            <option value=\"M7\"> M7 <\/option>\n            <option value=\"M8\"> M8 <\/option>\n            <option value=\"M9\"> M9 <\/option>\n            <option value=\"M10\"> M10 <\/option>\n            <option value=\"M11\"> M11 <\/option>\n            <option value=\"M12\"> M12 <\/option>\n            <option value=\"M13\"> M13 <\/option>\n            <option value=\"M14\"> M14 <\/option>\n            <option value=\"M15\"> M15 <\/option>\n            <option value=\"M16\"> M16 <\/option>\n            <option value=\"M17\"> M17 <\/option>\n            <option value=\"M18\"> M18 <\/option>\n            <option value=\"M19\"> M19 <\/option>\n            <option value=\"M20\"> M20 <\/option>\n            <option value=\"M21\"> M21 <\/option>\n            <option value=\"M22\"> M22 <\/option>\n            <option value=\"M23\"> M23 <\/option>\n            <option value=\"M24\"> M24 <\/option>\n            <option value=\"M25\"> M25 <\/option>\n            <option value=\"M26\"> M26 <\/option>\n            <option value=\"M27\"> M27 <\/option>\n            <option value=\"M28\"> M28 <\/option>\n            <option value=\"M29\"> M29 <\/option>\n            <option value=\"M30\"> M30 <\/option>\n            <option value=\"M31\"> M31 <\/option>\n            <option value=\"M32\"> M32 <\/option>\n            <option value=\"M33\"> M33 <\/option>\n            <option value=\"M34\"> M34 <\/option>\n            <option value=\"M35\"> M35 <\/option>\n            <option value=\"M36\"> M36 <\/option>\n            <option value=\"M37\"> M37 <\/option>\n            <option value=\"M38\"> M38 <\/option>\n            <option value=\"M39\"> M39 <\/option>\n            <option value=\"M40\"> M40 <\/option>\n            <option value=\"M41\"> M41 <\/option>\n            <option value=\"M42\"> M42 <\/option>\n            <option value=\"M43\"> M43 <\/option>\n            <option value=\"M44\"> M44 <\/option>\n            <option value=\"M45\"> M45 <\/option>\n            <option value=\"M46\"> M46 <\/option>\n            <option value=\"M47\"> M47 <\/option>\n            <option value=\"M48\"> M48 <\/option>\n            <option value=\"M49\"> M49 <\/option>\n            <option value=\"M50\"> M50 <\/option>\n            <option value=\"M51\"> M51 <\/option>\n            <option value=\"M52\"> M52 <\/option>\n            <option value=\"M53\"> M53 <\/option>\n            <option value=\"M54\"> M54 <\/option>\n            <option value=\"M55\"> M55 <\/option>\n            <option value=\"M56\"> M56 <\/option>\n            <option value=\"M57\"> M57 <\/option>\n            <option value=\"M58\"> M58 <\/option>\n            <option value=\"M59\"> M59 <\/option>\n            <option value=\"M60\"> M60 <\/option>\n            <option value=\"M61\"> M61 <\/option>\n            <option value=\"M62\"> M62 <\/option>\n            <option value=\"M63\"> M63 <\/option>\n            <option value=\"M64\"> M64 <\/option>\n            <option value=\"M65\"> M65 <\/option>\n            <option value=\"M66\"> M66 <\/option>\n            <option value=\"M67\"> M67 <\/option>\n            <option value=\"M68\"> M68 <\/option>\n            <option value=\"M69\"> M69 <\/option>\n            <option value=\"M70\"> M70 <\/option>\n            <option value=\"M71\"> M71 <\/option>\n            <option value=\"M72\"> M72 <\/option>\n            <option value=\"M73\"> M73 <\/option>\n            <option value=\"M74\"> M74 <\/option>\n            <option value=\"M75\"> M75 <\/option>\n            <option value=\"M76\"> M76 <\/option>\n            <option value=\"M77\"> M77 <\/option>\n            <option value=\"M78\"> M78 <\/option>\n            <option value=\"M79\"> M79 <\/option>\n            <option value=\"M80\"> M80 <\/option>\n            <option value=\"M81\"> M81 <\/option>\n            <option value=\"M82\"> M82 <\/option>\n            <option value=\"M83\"> M83 <\/option>\n            <option value=\"M84\"> M84 <\/option>\n            <option value=\"M85\"> M85 <\/option>\n            <option value=\"M86\"> M86 <\/option>\n            <option value=\"M87\"> M87 <\/option>\n            <option value=\"M88\"> M88 <\/option>\n            <option value=\"M89\"> M89 <\/option>\n            <option value=\"M90\"> M90 <\/option>\n            <option value=\"M91\"> M91 <\/option>\n            <option value=\"M92\"> M92 <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-2\" data-type=\"control_dropdown\" id=\"id_37\">\n        <label class=\"form-label form-label-top\" id=\"label_37\" for=\"input_37\"> Wording <\/label>\n        <div id=\"cid_37\" class=\"form-input-wide\">\n          <select class=\"form-dropdown\" id=\"input_37\" name=\"q37_wording\" style=\"width:150px;\" data-component=\"dropdown\">\n            <option value=\"\">  <\/option>\n            <option value=\"A\"> A <\/option>\n            <option value=\"B\"> B <\/option>\n            <option value=\"C\"> C <\/option>\n            <option value=\"D\"> D <\/option>\n            <option value=\"E\"> E <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_38\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_38\" for=\"input_38\"> Own Wording (if required) <\/label>\n        <div id=\"cid_38\" class=\"form-input\">\n          <textarea id=\"input_38\" class=\"form-textarea\" name=\"q38_ownWording38\" cols=\"40\" rows=\"6\" data-component=\"textarea\"><\/textarea>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_fileupload\" id=\"id_64\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_64\" for=\"input_64\"> Acknowledgment Pictures\/Photos <\/label>\n        <div id=\"cid_64\" class=\"form-input\">\n          <div data-wrapper-react=\"true\">\n            <div data-wrapper-react=\"true\">\n              <div class=\"qq-uploader-buttonText-value\">\n                Upload a File\n              <\/div>\n              <input type=\"file\" id=\"input_64\" name=\"q64_acknowledgmentPicturesphotos[]\" multiple=\"\" class=\"form-upload-multiple\" data-file-accept=\"pdf, doc, docx, xls, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif\" data-file-maxsize=\"10240\" data-file-minsize=\"0\" data-file-limit=\"0\" data-component=\"fileupload\" \/>\n            <\/div>\n            <span style=\"display:none;\" class=\"cancelText\">\n              Cancel\n            <\/span>\n            <span style=\"display:none;\" class=\"ofText\">\n              of\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_73\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_73\" for=\"input_73\"> Comments <\/label>\n        <div id=\"cid_73\" class=\"form-input\">\n          <textarea id=\"input_73\" class=\"form-textarea\" name=\"q73_comments73\" cols=\"40\" rows=\"6\" data-component=\"textarea\"><\/textarea>\n        <\/div>\n      <\/li>\n      <li id=\"cid_68\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_68\" class=\"form-header\" data-component=\"header\">\n              Other Pictures\/Photos\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_fileupload\" id=\"id_67\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_67\" for=\"input_67\"> Upload one or more Pictures\/Photos <\/label>\n        <div id=\"cid_67\" class=\"form-input\">\n          <div data-wrapper-react=\"true\">\n            <div data-wrapper-react=\"true\">\n              <div class=\"qq-uploader-buttonText-value\">\n                Upload a File\n              <\/div>\n              <input type=\"file\" id=\"input_67\" name=\"q67_uploadOne[]\" multiple=\"\" class=\"form-upload-multiple\" data-file-accept=\"pdf, doc, docx, xls, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif\" data-file-maxsize=\"10240\" data-file-minsize=\"0\" data-file-limit=\"0\" data-component=\"fileupload\" \/>\n            <\/div>\n            <span style=\"display:none;\" class=\"cancelText\">\n              Cancel\n            <\/span>\n            <span style=\"display:none;\" class=\"ofText\">\n              of\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_77\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_77\" for=\"input_77\"> Comments <\/label>\n        <div id=\"cid_77\" class=\"form-input\">\n          <textarea id=\"input_77\" class=\"form-textarea\" name=\"q77_comments77\" cols=\"40\" rows=\"6\" data-component=\"textarea\"><\/textarea>\n        <\/div>\n      <\/li>\n      <li id=\"cid_126\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_126\" class=\"form-header\" data-component=\"header\">\n              Deposit Payment (Paypal)\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_paypal\" id=\"id_125\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_125\" for=\"input_125\"> Deposit Payment (Paypal) <\/label>\n        <div id=\"cid_125\" class=\"form-input\">\n          <div data-wrapper-react=\"true\">\n            <input type=\"hidden\" name=\"simple_fpc\" data-payment_type=\"paypal\" data-component=\"payment1\" value=\"125\" \/>\n            <input type=\"hidden\" name=\"payment_total_checksum\" id=\"payment_total_checksum\" data-component=\"payment2\" \/>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top;\">\n              <input type=\"text\" class=\"form-textbox validate[Numeric]\" id=\"input_125_donation\" name=\"q125_depositPayment125[price]\" value=\"50\" data-min-amount=\"50\" data-component=\"paymentDonation\" \/>\n              EUR\n              <label class=\"form-sub-label\" for=\"input_125_donation\" style=\"min-height:13px;\"> Deposit <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_captcha\" id=\"id_55\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_55\" for=\"input_55\">\n          Enter the message as it's shown\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_55\" class=\"form-input jf-required\">\n          <div class=\"form-captcha\" data-component=\"captcha\">\n            <label for=\"input_55\"> <img alt=\"Captcha - Reload if not displayed\" id=\"input_55_captcha\" class=\"form-captcha-image\" style=\"background:url(https:\/\/cdn.jotfor.ms\/images\/loader-big.gif) no-repeat center;\" src=\"https:\/\/cdn.jotfor.ms\/images\/blank.gif\" width=\"150\" height=\"41\" \/> <\/label>\n            <div style=\"white-space:nowrap;\">\n              <input type=\"text\" id=\"input_55\" class=\"form-textbox validate[required]\" name=\"captcha\" style=\"width:130px;\" required=\"\" \/>\n              <img src=\"https:\/\/cdn.jotfor.ms\/images\/reload.png\" alt=\"Reload\" style=\"cursor:pointer;vertical-align:middle;\" id=\"input_55_reload\" \/>\n              <input type=\"hidden\" name=\"captcha_id\" id=\"input_55_captcha_id\" value=\"0\" 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