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  1. <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01//EN" "http://www.w3.org/TR/html4/strict.dtd">
  2. <html><head>
  3. <meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
  4. <meta name="viewport" content="width=device-width, initial-scale=1.0, maximum-scale=1.0, user-scalable=0" />
  5. <meta name="HandheldFriendly" content="true" />
  6. <title>Jesus Foundation Application Form - Scholarship Grant</title>
  7. <link type="text/css" rel="stylesheet" href="css/styles/form.css?v3.1.1525"/>
  8. <link href="css/calendarview.css?v3.1.1525" rel="stylesheet" type="text/css" />
  9. <link type="text/css" rel="stylesheet" href="http://support.jotform.com/css/styles/nova.css?3.1.1525" />
  10. <link type="text/css" media="print" rel="stylesheet" href="http://support.jotform.com/css/printForm.css?3.1.1525" />
  11. <style type="text/css">
  12.     .form-label{
  13.         width:300px !important;
  14.     }
  15.     .form-label-left{
  16.         width:300px !important;
  17.     }
  18.     .form-line{
  19.         padding-top:5px;
  20.         padding-bottom:5px;
  21.     }
  22.     .form-label-right{
  23.         width:300px !important;
  24.     }
  25.     .form-all{
  26.         width:900px;
  27.         background:#FFFFFF;
  28.         color:#000000 !important;
  29.         font-family:'Lucida Grande','Lucida Sans Unicode','Lucida Sans','Verdana','Tahoma','sans-serif';
  30.         font-size:13px;
  31.     }
  32.     /* Injected CSS Code */
  33. .form-header-group{
  34. background:#FF0000;
  35. color:#FFFFFF;
  36. padding-top:4px;
  37. padding-bottom:4px;
  38. padding-left:4px;
  39. }.form-label-left{
  40. width:400px;}
  41.     /* Injected CSS Code */
  42. </style>
  43.  
  44. <link type="text/css" rel="stylesheet" href="css/styles/buttons/form-submit-button-simple_green.css?3.1.1525"/>
  45. <!--[if lt IE 9]><script src="http://support.jotform.com/js/vendor/flashcanvas.js?3.1.1525" type="text/javascript"></script><![endif]-->
  46. <script src="http://support.jotform.com/js/vendor/jquery-1.8.0.min.js?3.1.1525" type="text/javascript"></script>
  47. <script src="http://support.jotform.com/js/vendor/jSignature.min.noconflict.js?3.1.1525" type="text/javascript"></script>
  48. <script src="http://support.jotform.com/js/vendor/jotform.signaturepad.js?3.1.1525" type="text/javascript"></script>
  49. <script src="js/prototype.js?v=3.1.1525" type="text/javascript"></script>
  50. <script src="js/json2.js?v=3.1.1525" type="text/javascript"></script>
  51. <script src="js/protoplus.js?v=3.1.1525" type="text/javascript"></script>
  52. <script src="js/protoplus-ui.js?v=3.1.1525" type="text/javascript"></script>
  53. <script src="js/jotform.js?v=3.1.1525" type="text/javascript"></script>
  54. <script src="js/calendarview.js?v=3.1.1525" type="text/javascript"></script>
  55. <script type="text/javascript">
  56.    JotForm.setConditions([{"action":[{"field":"152","visibility":"Show"}],"index":"0","link":"Any","priority":"0","terms":[{"field":"150","operator":"equals","value":"No"}],"type":"field"},{"action":[{"field":"153","visibility":"Show"}],"index":"1","link":"Any","priority":"2","terms":[{"field":"150","operator":"equals","value":"Droped out"}],"type":"field"},{"action":[{"field":"138","visibility":"Show"}],"index":"2","link":"Any","priority":"3","terms":[{"field":"137","operator":"equals","value":"Yes"}],"type":"field"},{"action":[{"field":"140","visibility":"Show"}],"index":"3","link":"Any","priority":"4","terms":[{"field":"139","operator":"greaterThan","value":"0"}],"type":"field"},{"action":[{"field":"168","visibility":"Show"},{"field":"173","visibility":"Show"}],"index":"4","link":"Any","priority":"5","terms":[{"field":"171","operator":"equals","value":"Yes"}],"type":"field"},{"action":[{"field":"151","visibility":"Show"},{"field":"154","visibility":"Show"}],"index":"5","link":"Any","priority":"6","terms":[{"field":"150","operator":"equals","value":"Yes"}],"type":"field"},{"action":[{"field":"174","visibility":"Show"}],"index":"6","link":"Any","priority":"8","terms":[{"field":"171","operator":"equals","value":"No"}],"type":"field"},{"action":[{"field":"197","visibility":"Hide"},{"field":"199","visibility":"Hide"}],"index":"10","link":"Any","priority":"10","terms":[{"field":"196","operator":"isFilled","value":false}],"type":"field"},{"action":[{"field":"156","visibility":"Show"},{"field":"160","visibility":"Hide"},{"field":"161","visibility":"Hide"},{"field":"162","visibility":"Hide"},{"field":"163","visibility":"Hide"},{"field":"164","visibility":"Hide"},{"field":"157","visibility":"Hide"}],"index":"8","link":"Any","terms":[{"field":"155","operator":"equals","value":"No"}],"type":"field"},{"action":[{"field":"159","visibility":"Show"}],"index":"9","link":"Any","terms":[{"field":"157","operator":"equals","value":"No"}],"type":"field"},{"action":[{"field":"176","visibility":"Show"}],"index":"11","link":"Any","priority":"11","terms":[{"field":"175","operator":"equals","value":"No"}],"type":"field"},{"action":[{"field":"160","visibility":"Show"},{"field":"165","visibility":"Show"},{"field":"161","visibility":"Show"},{"field":"162","visibility":"Show"},{"field":"163","visibility":"Show"},{"field":"164","visibility":"Show"}],"index":"7","link":"Any","terms":[{"field":"157","operator":"equals","value":"Yes"}],"type":"field"},{"action":[{"field":"178","visibility":"Show"}],"index":"12","link":"Any","priority":"12","terms":[{"field":"177","operator":"equals","value":"No"}],"type":"field"},{"action":[{"field":"188","visibility":"Show"}],"index":"13","link":"Any","priority":"13","terms":[{"field":"187","operator":"equals","value":"Yes"}],"type":"field"},{"action":[{"field":"190","visibility":"Show"}],"index":"14","link":"Any","priority":"14","terms":[{"field":"189","operator":"equals","value":"No"}],"type":"field"},{"action":[{"field":"141","visibility":"Show"}],"index":"16","link":"Any","priority":"16","terms":[{"field":"280","operator":"equals","value":"No"}],"type":"field"},{"action":[{"field":"147","visibility":"Hide"},{"field":"148","visibility":"Hide"}],"index":"17","link":"Any","priority":"17","terms":[{"field":"150","operator":"equals","value":"Droped out"}],"type":"field"},{"action":[{"field":"282","visibility":"Hide"}],"index":"18","link":"Any","priority":"18","terms":[{"field":"171","operator":"equals","value":"No"}],"type":"field"},{"action":[{"field":"283","visibility":"Show"}],"index":"19","link":"Any","priority":"19","terms":[{"field":"175","operator":"equals","value":"Yes"}],"type":"field"},{"action":[{"field":"284","visibility":"Show"}],"index":"20","link":"Any","priority":"20","terms":[{"field":"177","operator":"equals","value":"Yes"}],"type":"field"},{"action":[{"field":"175","visibility":"Hide"},{"field":"177","visibility":"Hide"}],"index":"21","link":"Any","priority":"21","terms":[{"field":"171","operator":"equals","value":"Yes"}],"type":"field"},{"action":[{"field":"286","visibility":"Show"},{"field":"285","visibility":"Show"},{"field":"134","visibility":"Show"},{"field":"287","visibility":"Show"}],"index":"22","link":"Any","priority":"22","terms":[{"field":"290","operator":"equals","value":"No"}],"type":"field"}]);
  57.    JotForm.init(function(){
  58.       $('input_143').hint('ex: myname@example.com');
  59.       $('input_134').hint('ex: myname@example.com');
  60.       $('input_139').hint('ex: 5');
  61.       JotForm.setCalendar("151", false);
  62.       JotForm.displayLocalTime("hour_151", "min_151", "ampm_151");
  63.       JotForm.setCalendar("152", false);
  64.       JotForm.displayLocalTime("hour_152", "min_152", "ampm_152");
  65.       JotForm.setCalendar("163", false);
  66.       JotForm.displayLocalTime("hour_163", "min_163", "ampm_163");
  67.       JotForm.setCalendar("164", false);
  68.       JotForm.displayLocalTime("hour_164", "min_164", "ampm_164");
  69.       JotForm.setCalendar("211", false);
  70.       JotForm.displayLocalTime("hour_211", "min_211", "ampm_211");
  71.       $('input_221').hint('ex: myname@example.com');
  72.       $('input_220').hint('e.g. Mentor, Instructor, Friend');
  73.       $('input_226').hint('ex: myname@example.com');
  74.       $('input_228').hint('e.g. Mentor, Instructor, Friend');
  75.   });
  76.  
  77.   function copyFullName() {
  78.       //Read Names
  79.       var firstName;
  80.       firstName = document.forms["form_32535151535853"]["first_132"].value;
  81.      
  82.       var midName;
  83.       midName = document.forms["form_32535151535853"]["middle_132"].value;
  84.  
  85.       var lastName;
  86.       lastName = document.forms["form_32535151535853"]["last_132"].value;
  87.  
  88.       //Populate Names fields (3 occurance)
  89.       document.forms["form_32535151535853"]["input_230"].value = firstName + " " + midName + " " + lastName;
  90.       document.forms["form_32535151535853"]["input_240"].value = firstName + " " + midName + " " + lastName;
  91.       document.forms["form_32535151535853"]["input_250"].value = firstName + " " + midName + " " + lastName;
  92.   }
  93.  
  94.   function copyParentsName() {
  95.        //Read Parent's Name
  96.       var parentsName;
  97.       parentsName = document.forms["form_32535151535853"]["input_285"].value;
  98.  
  99.       //Populate parents fields (3 occurance)
  100.       document.forms["form_32535151535853"]["input_231"].value = parentsName;
  101.       document.forms["form_32535151535853"]["input_241"].value = parentsName;
  102.       document.forms["form_32535151535853"]["input_251"].value = parentsName;
  103.   }
  104. </script>
  105. </head>
  106. <body>
  107. <form class="jotform-form" action="http://support.jotform.com/submit.php" method="post" name="form_32535151535853" id="32535151535853" accept-charset="utf-8">
  108.   <input type="hidden" name="formID" value="32535151535853" />
  109.   <div class="form-all">
  110.     <ul class="form-section">
  111.       <li class="form-line" id="id_126">
  112.         <div id="cid_126" class="form-input-wide">
  113.           <div id="text_126" class="form-html">
  114.             <div style="width: 100%; height: 450px; background: #333333; border: #333333 2px solid;">
  115.               <img style="width: 98%; height: 230px; margin: 220px 0 0 1%;" src="http://www.rajabajar.com/jesusfoundation/backlogo.png" alt="" />
  116.             </div>
  117.             <div style="width: 100%; min-height: 250px; background: #CCCCCC; border: #666666 2px solid; border-top: none;">
  118.               <div style="margin-left: 8%; width: 80%; color: #ff0000; border: #CCCCCC 2px solid; font-size: 28px; text-align: right;">
  119.                 Scholarship Selection Application Form
  120.               </div>
  121.               <div style="margin: 70px 0 0 8%; width: 200px; float: left; border: #CCCCCC 1px solid; text-align: right;">
  122.                 <div>
  123.                   www.jesusfoundation.net
  124.                 </div>
  125.                 <div>
  126.                   info@jesusfoundation.net
  127.                 </div>
  128.                 <div style="font-size: 12px;">
  129.                   1-407-900-7458
  130.                 </div>
  131.                 <div style="font-size: 12px;">
  132.                   234-(0)-701-228-5517
  133.                 </div>
  134.                 <a href="http://www.jesusfoundation.net/JFonFB"><img style="margin-left: 8%; width: 70px; height: 25px;" src="http://www.rajabajar.com/jesusfoundation/facebook.png" alt="" /></a>
  135.               </div>
  136.             </div>
  137.           </div>
  138.         </div>
  139.       </li>
  140.       <li id="cid_128" class="form-input-wide">
  141.         <div class="form-pagebreak">
  142.           <div class="form-pagebreak-back-container form-label-left">
  143.             <button type="button" class="form-pagebreak-back  form-submit-button-simple_green" id="form-pagebreak-back_128">
  144.               Back
  145.             </button>
  146.           </div>
  147.           <div class="form-pagebreak-next-container">
  148.             <button type="button" class="form-pagebreak-next  form-submit-button-simple_green" id="form-pagebreak-next_128">
  149.               Next
  150.             </button>
  151.           </div>
  152.         </div>
  153.       </li>
  154.     </ul>
  155.     <ul class="form-section" style="display:none;">
  156.       <li class="form-line" id="id_129">
  157.         <div id="cid_129" class="form-input-wide">
  158.           <div id="text_129" class="form-html">
  159.             <div style="width: 38%; float: right; height: 100px; margin: 30px 6% 0 0;">
  160.               <img style="float: right;" src="http://www.rajabajar.com/jesusfoundation/logo.png" alt="" />
  161.             </div>
  162.             <div style="margin: -20px 0 20px 0; float: left; width: 90%; font-size: 22px;">
  163.               Scholarship Selection Application Form
  164.             </div>
  165.             <div style="margin: 0 0 2px 0; float: left; width: 90%; font-size: 26px; font-weight: bold;">
  166.               For the Practical Entrepreneurship Program
  167.             </div>
  168.             <div style="margin: 0 0 2px 0; float: left; width: 90%; font-size: 21px; font-weight: normal; color: #ff0000;">
  169.               Please complete application form truthfully and in its entirety.
  170.             </div>
  171.             <div style="margin: 0 0 2px 0; float: left; width: 90%; font-size: 18px; font-weight: normal; color: #ff0000;">
  172.               <div style="background: #FFFF00; width: 70%;"><span style="background-color: #00ff00;"><strong>
  173.                     Only fully completed applications can be submitted.
  174.                   </strong></span>
  175.               </div>
  176.             </div>
  177.           </div>
  178.         </div>
  179.       </li>
  180.       <li class="form-line" id="id_276">
  181.         <div id="cid_276" class="form-input-wide">
  182.           <div id="text_276" class="form-html">
  183.             <div style="background: #FF0000; color: #ffffff; padding-top: 4px; padding-bottom: 4px; padding-left: 4px; font-size: 16pt; font-family: Arial; letter-spacing: 1pt;"><span style="color: #ffffff; font-family: Arial;"><span style="font-size: 21px; letter-spacing: 1px;"><strong>
  184.                     PERSONAL INFORMATION
  185.                   </strong></span></span>
  186.             </div>
  187.           </div>
  188.         </div>
  189.       </li>
  190.       <li class="form-line" id="id_132">
  191.         <label class="form-label-left" id="label_132" for="input_132">
  192.           Full Name<span class="form-required">*</span>
  193.         </label>
  194.         <div id="cid_132" class="form-input"><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q132_fullName132[first]" id="first_132" onblur="copyFullName();" />
  195.             <label class="form-sub-label" for="first_132" id="sublabel_first"> First Name </label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q132_fullName132[middle]" id="middle_132" onblur="copyFullName();" />
  196.             <label class="form-sub-label" for="middle_132" id="sublabel_middle"> Middle Name </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q132_fullName132[last]" id="last_132" onblur="copyFullName();" />
  197.             <label class="form-sub-label" for="last_132" id="sublabel_last"> Last Name </label></span>
  198.         </div>
  199.       </li>
  200.       <li class="form-line" id="id_133">
  201.         <label class="form-label-left" id="label_133" for="input_133">
  202.           Date of birth<span class="form-required">*</span>
  203.         </label>
  204.         <div id="cid_133" class="form-input"><span class="form-sub-label-container"><select class="form-dropdown validate[required]" name="q133_dateOf[month]" id="input_133_month">
  205.               <option>  </option>
  206.               <option value="January"> January </option>
  207.               <option value="February"> February </option>
  208.               <option value="March"> March </option>
  209.               <option value="April"> April </option>
  210.               <option value="May"> May </option>
  211.               <option value="June"> June </option>
  212.               <option value="July"> July </option>
  213.               <option value="August"> August </option>
  214.               <option value="September"> September </option>
  215.               <option value="October"> October </option>
  216.               <option value="November"> November </option>
  217.               <option value="December"> December </option>
  218.             </select>
  219.             <label class="form-sub-label" for="input_133_month" id="sublabel_month"> Month </label></span><span class="form-sub-label-container"><select class="form-dropdown validate[required]" name="q133_dateOf[day]" id="input_133_day">
  220.               <option>  </option>
  221.               <option value="1"> 1 </option>
  222.               <option value="2"> 2 </option>
  223.               <option value="3"> 3 </option>
  224.               <option value="4"> 4 </option>
  225.               <option value="5"> 5 </option>
  226.               <option value="6"> 6 </option>
  227.               <option value="7"> 7 </option>
  228.               <option value="8"> 8 </option>
  229.               <option value="9"> 9 </option>
  230.               <option value="10"> 10 </option>
  231.               <option value="11"> 11 </option>
  232.               <option value="12"> 12 </option>
  233.               <option value="13"> 13 </option>
  234.               <option value="14"> 14 </option>
  235.               <option value="15"> 15 </option>
  236.               <option value="16"> 16 </option>
  237.               <option value="17"> 17 </option>
  238.               <option value="18"> 18 </option>
  239.               <option value="19"> 19 </option>
  240.               <option value="20"> 20 </option>
  241.               <option value="21"> 21 </option>
  242.               <option value="22"> 22 </option>
  243.               <option value="23"> 23 </option>
  244.               <option value="24"> 24 </option>
  245.               <option value="25"> 25 </option>
  246.               <option value="26"> 26 </option>
  247.               <option value="27"> 27 </option>
  248.               <option value="28"> 28 </option>
  249.               <option value="29"> 29 </option>
  250.               <option value="30"> 30 </option>
  251.               <option value="31"> 31 </option>
  252.             </select>
  253.             <label class="form-sub-label" for="input_133_day" id="sublabel_day"> Day </label></span><span class="form-sub-label-container"><select class="form-dropdown validate[required]" name="q133_dateOf[year]" id="input_133_year">
  254.               <option>  </option>
  255.               <option value="2037"> 2037 </option>
  256.               <option value="2036"> 2036 </option>
  257.               <option value="2035"> 2035 </option>
  258.               <option value="2034"> 2034 </option>
  259.               <option value="2033"> 2033 </option>
  260.               <option value="2032"> 2032 </option>
  261.               <option value="2031"> 2031 </option>
  262.               <option value="2030"> 2030 </option>
  263.               <option value="2029"> 2029 </option>
  264.               <option value="2028"> 2028 </option>
  265.               <option value="2027"> 2027 </option>
  266.               <option value="2026"> 2026 </option>
  267.               <option value="2025"> 2025 </option>
  268.               <option value="2024"> 2024 </option>
  269.               <option value="2023"> 2023 </option>
  270.               <option value="2022"> 2022 </option>
  271.               <option value="2021"> 2021 </option>
  272.               <option value="2020"> 2020 </option>
  273.               <option value="2019"> 2019 </option>
  274.               <option value="2018"> 2018 </option>
  275.               <option value="2017"> 2017 </option>
  276.               <option value="2016"> 2016 </option>
  277.               <option value="2015"> 2015 </option>
  278.               <option value="2014"> 2014 </option>
  279.               <option value="2013"> 2013 </option>
  280.               <option value="2012"> 2012 </option>
  281.               <option value="2011"> 2011 </option>
  282.               <option value="2010"> 2010 </option>
  283.               <option value="2009"> 2009 </option>
  284.               <option value="2008"> 2008 </option>
  285.               <option value="2007"> 2007 </option>
  286.               <option value="2006"> 2006 </option>
  287.               <option value="2005"> 2005 </option>
  288.               <option value="2004"> 2004 </option>
  289.               <option value="2003"> 2003 </option>
  290.               <option value="2002"> 2002 </option>
  291.               <option value="2001"> 2001 </option>
  292.               <option value="2000"> 2000 </option>
  293.               <option value="1999"> 1999 </option>
  294.               <option value="1998"> 1998 </option>
  295.               <option value="1997"> 1997 </option>
  296.               <option value="1996"> 1996 </option>
  297.               <option value="1995"> 1995 </option>
  298.               <option value="1994"> 1994 </option>
  299.               <option value="1993"> 1993 </option>
  300.               <option value="1992"> 1992 </option>
  301.               <option value="1991"> 1991 </option>
  302.               <option value="1990"> 1990 </option>
  303.               <option value="1989"> 1989 </option>
  304.               <option value="1988"> 1988 </option>
  305.               <option value="1987"> 1987 </option>
  306.               <option value="1986"> 1986 </option>
  307.               <option value="1985"> 1985 </option>
  308.               <option value="1984"> 1984 </option>
  309.               <option value="1983"> 1983 </option>
  310.               <option value="1982"> 1982 </option>
  311.               <option value="1981"> 1981 </option>
  312.               <option value="1980"> 1980 </option>
  313.               <option value="1979"> 1979 </option>
  314.               <option value="1978"> 1978 </option>
  315.               <option value="1977"> 1977 </option>
  316.               <option value="1976"> 1976 </option>
  317.               <option value="1975"> 1975 </option>
  318.               <option value="1974"> 1974 </option>
  319.               <option value="1973"> 1973 </option>
  320.               <option value="1972"> 1972 </option>
  321.               <option value="1971"> 1971 </option>
  322.               <option value="1970"> 1970 </option>
  323.               <option value="1969"> 1969 </option>
  324.               <option value="1968"> 1968 </option>
  325.               <option value="1967"> 1967 </option>
  326.               <option value="1966"> 1966 </option>
  327.               <option value="1965"> 1965 </option>
  328.               <option value="1964"> 1964 </option>
  329.               <option value="1963"> 1963 </option>
  330.               <option value="1962"> 1962 </option>
  331.               <option value="1961"> 1961 </option>
  332.               <option value="1960"> 1960 </option>
  333.               <option value="1959"> 1959 </option>
  334.               <option value="1958"> 1958 </option>
  335.               <option value="1957"> 1957 </option>
  336.               <option value="1956"> 1956 </option>
  337.               <option value="1955"> 1955 </option>
  338.               <option value="1954"> 1954 </option>
  339.               <option value="1953"> 1953 </option>
  340.               <option value="1952"> 1952 </option>
  341.               <option value="1951"> 1951 </option>
  342.               <option value="1950"> 1950 </option>
  343.               <option value="1949"> 1949 </option>
  344.               <option value="1948"> 1948 </option>
  345.               <option value="1947"> 1947 </option>
  346.               <option value="1946"> 1946 </option>
  347.               <option value="1945"> 1945 </option>
  348.               <option value="1944"> 1944 </option>
  349.               <option value="1943"> 1943 </option>
  350.               <option value="1942"> 1942 </option>
  351.               <option value="1941"> 1941 </option>
  352.               <option value="1940"> 1940 </option>
  353.               <option value="1939"> 1939 </option>
  354.               <option value="1938"> 1938 </option>
  355.               <option value="1937"> 1937 </option>
  356.               <option value="1936"> 1936 </option>
  357.               <option value="1935"> 1935 </option>
  358.               <option value="1934"> 1934 </option>
  359.               <option value="1933"> 1933 </option>
  360.               <option value="1932"> 1932 </option>
  361.               <option value="1931"> 1931 </option>
  362.               <option value="1930"> 1930 </option>
  363.               <option value="1929"> 1929 </option>
  364.               <option value="1928"> 1928 </option>
  365.               <option value="1927"> 1927 </option>
  366.               <option value="1926"> 1926 </option>
  367.               <option value="1925"> 1925 </option>
  368.               <option value="1924"> 1924 </option>
  369.               <option value="1923"> 1923 </option>
  370.               <option value="1922"> 1922 </option>
  371.               <option value="1921"> 1921 </option>
  372.               <option value="1920"> 1920 </option>
  373.             </select>
  374.             <label class="form-sub-label" for="input_133_year" id="sublabel_year"> Year </label></span>
  375.         </div>
  376.       </li>
  377.       <li class="form-line" id="id_290">
  378.         <label class="form-label-left" id="label_290" for="input_290">
  379.           Have you turned 18 years yet?<span class="form-required">*</span>
  380.         </label>
  381.         <div id="cid_290" class="form-input">
  382.           <div class="form-single-column"><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox validate[required]" id="input_290_0" name="q290_haveYou[]" value="Yes" />
  383.               <label for="input_290_0"> Yes </label></span><span class="clearfix"></span><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox validate[required]" id="input_290_1" name="q290_haveYou[]" value="No" />
  384.               <label for="input_290_1"> No </label></span><span class="clearfix"></span>
  385.           </div>
  386.         </div>
  387.       </li>
  388.       <li class="form-line" id="id_143">
  389.         <label class="form-label-left" id="label_143" for="input_143">
  390.           E-mail<span class="form-required">*</span>
  391.         </label>
  392.         <div id="cid_143" class="form-input">
  393.           <input type="email" class=" form-textbox validate[required, Email]" id="input_143" name="q143_email143" size="30" value="" />
  394.         </div>
  395.       </li>
  396.       <li class="form-line" id="id_291">
  397.         <label class="form-label-left" id="label_291" for="input_291">
  398.           Contact Phone<span class="form-required">*</span>
  399.         </label>
  400.         <div id="cid_291" class="form-input">
  401.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_291" name="q291_contactPhone" size="20" value="" />
  402.         </div>
  403.       </li>
  404.       <li class="form-line" id="id_123">
  405.         <label class="form-label-left" id="label_123" for="input_123">
  406.           Home address<span class="form-required">*</span>
  407.         </label>
  408.         <div id="cid_123" class="form-input">
  409.           <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0">
  410.             <tr>
  411.               <td colspan="2"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-line" type="text" name="q123_homeAddress[addr_line1]" id="input_123_addr_line1" />
  412.                   <label class="form-sub-label" for="input_123_addr_line1" id="sublabel_123_addr_line1"> Street Address </label></span>
  413.               </td>
  414.             </tr>
  415.             <tr style="display: none;">
  416.               <td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line" type="text" name="q123_homeAddress[addr_line2]" id="input_123_addr_line2" size="46" />
  417.                   <label class="form-sub-label" for="input_123_addr_line2"> &nbsp;&nbsp;&nbsp; </label></span>
  418.               </td>
  419.             </tr>
  420.             <tr>
  421.               <td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-city" type="text" name="q123_homeAddress[city]" id="input_123_city" size="21" />
  422.                   <label class="form-sub-label" for="input_123_city" id="sublabel_123_city"> City </label></span>
  423.               </td>
  424.               <td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q123_homeAddress[state]" id="input_123_state" size="22" />
  425.                   <label class="form-sub-label" for="input_123_state" id="sublabel_123_state"> State </label></span>
  426.               </td>
  427.             </tr>
  428.             <tr>
  429.               <td width="50%" style="display: none;"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-postal" type="text" name="q123_homeAddress[postal]" id="input_123_postal" size="10" />
  430.                   <label class="form-sub-label" for="input_123_postal"> &nbsp;&nbsp;&nbsp; </label></span>
  431.               </td>
  432.               <td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q123_homeAddress[country]" id="input_123_country">
  433.                     <option value="" selected> Please Select </option>
  434.                     <option value="United States"> United States </option>
  435.                     <option value="Afghanistan"> Afghanistan </option>
  436.                     <option value="Albania"> Albania </option>
  437.                     <option value="Algeria"> Algeria </option>
  438.                     <option value="American Samoa"> American Samoa </option>
  439.                     <option value="Andorra"> Andorra </option>
  440.                     <option value="Angola"> Angola </option>
  441.                     <option value="Anguilla"> Anguilla </option>
  442.                     <option value="Antigua and Barbuda"> Antigua and Barbuda </option>
  443.                     <option value="Argentina"> Argentina </option>
  444.                     <option value="Armenia"> Armenia </option>
  445.                     <option value="Aruba"> Aruba </option>
  446.                     <option value="Australia"> Australia </option>
  447.                     <option value="Austria"> Austria </option>
  448.                     <option value="Azerbaijan"> Azerbaijan </option>
  449.                     <option value="The Bahamas"> The Bahamas </option>
  450.                     <option value="Bahrain"> Bahrain </option>
  451.                     <option value="Bangladesh"> Bangladesh </option>
  452.                     <option value="Barbados"> Barbados </option>
  453.                     <option value="Belarus"> Belarus </option>
  454.                     <option value="Belgium"> Belgium </option>
  455.                     <option value="Belize"> Belize </option>
  456.                     <option value="Benin"> Benin </option>
  457.                     <option value="Bermuda"> Bermuda </option>
  458.                     <option value="Bhutan"> Bhutan </option>
  459.                     <option value="Bolivia"> Bolivia </option>
  460.                     <option value="Bosnia and Herzegovina"> Bosnia and Herzegovina </option>
  461.                     <option value="Botswana"> Botswana </option>
  462.                     <option value="Brazil"> Brazil </option>
  463.                     <option value="Brunei"> Brunei </option>
  464.                     <option value="Bulgaria"> Bulgaria </option>
  465.                     <option value="Burkina Faso"> Burkina Faso </option>
  466.                     <option value="Burundi"> Burundi </option>
  467.                     <option value="Cambodia"> Cambodia </option>
  468.                     <option value="Cameroon"> Cameroon </option>
  469.                     <option value="Canada"> Canada </option>
  470.                     <option value="Cape Verde"> Cape Verde </option>
  471.                     <option value="Cayman Islands"> Cayman Islands </option>
  472.                     <option value="Central African Republic"> Central African Republic </option>
  473.                     <option value="Chad"> Chad </option>
  474.                     <option value="Chile"> Chile </option>
  475.                     <option value="People's Republic of China"> People's Republic of China </option>
  476.                     <option value="Republic of China"> Republic of China </option>
  477.                     <option value="Christmas Island"> Christmas Island </option>
  478.                     <option value="Cocos (Keeling) Islands"> Cocos (Keeling) Islands </option>
  479.                     <option value="Colombia"> Colombia </option>
  480.                     <option value="Comoros"> Comoros </option>
  481.                     <option value="Congo"> Congo </option>
  482.                     <option value="Cook Islands"> Cook Islands </option>
  483.                     <option value="Costa Rica"> Costa Rica </option>
  484.                     <option value="Cote d'Ivoire"> Cote d'Ivoire </option>
  485.                     <option value="Croatia"> Croatia </option>
  486.                     <option value="Cuba"> Cuba </option>
  487.                     <option value="Cyprus"> Cyprus </option>
  488.                     <option value="Czech Republic"> Czech Republic </option>
  489.                     <option value="Denmark"> Denmark </option>
  490.                     <option value="Djibouti"> Djibouti </option>
  491.                     <option value="Dominica"> Dominica </option>
  492.                     <option value="Dominican Republic"> Dominican Republic </option>
  493.                     <option value="Ecuador"> Ecuador </option>
  494.                     <option value="Egypt"> Egypt </option>
  495.                     <option value="El Salvador"> El Salvador </option>
  496.                     <option value="Equatorial Guinea"> Equatorial Guinea </option>
  497.                     <option value="Eritrea"> Eritrea </option>
  498.                     <option value="Estonia"> Estonia </option>
  499.                     <option value="Ethiopia"> Ethiopia </option>
  500.                     <option value="Falkland Islands"> Falkland Islands </option>
  501.                     <option value="Faroe Islands"> Faroe Islands </option>
  502.                     <option value="Fiji"> Fiji </option>
  503.                     <option value="Finland"> Finland </option>
  504.                     <option value="France"> France </option>
  505.                     <option value="French Polynesia"> French Polynesia </option>
  506.                     <option value="Gabon"> Gabon </option>
  507.                     <option value="The Gambia"> The Gambia </option>
  508.                     <option value="Georgia"> Georgia </option>
  509.                     <option value="Germany"> Germany </option>
  510.                     <option value="Ghana"> Ghana </option>
  511.                     <option value="Gibraltar"> Gibraltar </option>
  512.                     <option value="Greece"> Greece </option>
  513.                     <option value="Greenland"> Greenland </option>
  514.                     <option value="Grenada"> Grenada </option>
  515.                     <option value="Guadeloupe"> Guadeloupe </option>
  516.                     <option value="Guam"> Guam </option>
  517.                     <option value="Guatemala"> Guatemala </option>
  518.                     <option value="Guernsey"> Guernsey </option>
  519.                     <option value="Guinea"> Guinea </option>
  520.                     <option value="Guinea-Bissau"> Guinea-Bissau </option>
  521.                     <option value="Guyana"> Guyana </option>
  522.                     <option value="Haiti"> Haiti </option>
  523.                     <option value="Honduras"> Honduras </option>
  524.                     <option value="Hong Kong"> Hong Kong </option>
  525.                     <option value="Hungary"> Hungary </option>
  526.                     <option value="Iceland"> Iceland </option>
  527.                     <option value="India"> India </option>
  528.                     <option value="Indonesia"> Indonesia </option>
  529.                     <option value="Iran"> Iran </option>
  530.                     <option value="Iraq"> Iraq </option>
  531.                     <option value="Ireland"> Ireland </option>
  532.                     <option value="Israel"> Israel </option>
  533.                     <option value="Italy"> Italy </option>
  534.                     <option value="Jamaica"> Jamaica </option>
  535.                     <option value="Japan"> Japan </option>
  536.                     <option value="Jersey"> Jersey </option>
  537.                     <option value="Jordan"> Jordan </option>
  538.                     <option value="Kazakhstan"> Kazakhstan </option>
  539.                     <option value="Kenya"> Kenya </option>
  540.                     <option value="Kiribati"> Kiribati </option>
  541.                     <option value="North Korea"> North Korea </option>
  542.                     <option value="South Korea"> South Korea </option>
  543.                     <option value="Kosovo"> Kosovo </option>
  544.                     <option value="Kuwait"> Kuwait </option>
  545.                     <option value="Kyrgyzstan"> Kyrgyzstan </option>
  546.                     <option value="Laos"> Laos </option>
  547.                     <option value="Latvia"> Latvia </option>
  548.                     <option value="Lebanon"> Lebanon </option>
  549.                     <option value="Lesotho"> Lesotho </option>
  550.                     <option value="Liberia"> Liberia </option>
  551.                     <option value="Libya"> Libya </option>
  552.                     <option value="Liechtenstein"> Liechtenstein </option>
  553.                     <option value="Lithuania"> Lithuania </option>
  554.                     <option value="Luxembourg"> Luxembourg </option>
  555.                     <option value="Macau"> Macau </option>
  556.                     <option value="Macedonia"> Macedonia </option>
  557.                     <option value="Madagascar"> Madagascar </option>
  558.                     <option value="Malawi"> Malawi </option>
  559.                     <option value="Malaysia"> Malaysia </option>
  560.                     <option value="Maldives"> Maldives </option>
  561.                     <option value="Mali"> Mali </option>
  562.                     <option value="Malta"> Malta </option>
  563.                     <option value="Marshall Islands"> Marshall Islands </option>
  564.                     <option value="Martinique"> Martinique </option>
  565.                     <option value="Mauritania"> Mauritania </option>
  566.                     <option value="Mauritius"> Mauritius </option>
  567.                     <option value="Mayotte"> Mayotte </option>
  568.                     <option value="Mexico"> Mexico </option>
  569.                     <option value="Micronesia"> Micronesia </option>
  570.                     <option value="Moldova"> Moldova </option>
  571.                     <option value="Monaco"> Monaco </option>
  572.                     <option value="Mongolia"> Mongolia </option>
  573.                     <option value="Montenegro"> Montenegro </option>
  574.                     <option value="Montserrat"> Montserrat </option>
  575.                     <option value="Morocco"> Morocco </option>
  576.                     <option value="Mozambique"> Mozambique </option>
  577.                     <option value="Myanmar"> Myanmar </option>
  578.                     <option value="Nagorno-Karabakh"> Nagorno-Karabakh </option>
  579.                     <option value="Namibia"> Namibia </option>
  580.                     <option value="Nauru"> Nauru </option>
  581.                     <option value="Nepal"> Nepal </option>
  582.                     <option value="Netherlands"> Netherlands </option>
  583.                     <option value="Netherlands Antilles"> Netherlands Antilles </option>
  584.                     <option value="New Caledonia"> New Caledonia </option>
  585.                     <option value="New Zealand"> New Zealand </option>
  586.                     <option value="Nicaragua"> Nicaragua </option>
  587.                     <option value="Niger"> Niger </option>
  588.                     <option value="Nigeria"> Nigeria </option>
  589.                     <option value="Niue"> Niue </option>
  590.                     <option value="Norfolk Island"> Norfolk Island </option>
  591.                     <option value="Turkish Republic of Northern Cyprus"> Turkish Republic of Northern Cyprus </option>
  592.                     <option value="Northern Mariana"> Northern Mariana </option>
  593.                     <option value="Norway"> Norway </option>
  594.                     <option value="Oman"> Oman </option>
  595.                     <option value="Pakistan"> Pakistan </option>
  596.                     <option value="Palau"> Palau </option>
  597.                     <option value="Palestine"> Palestine </option>
  598.                     <option value="Panama"> Panama </option>
  599.                     <option value="Papua New Guinea"> Papua New Guinea </option>
  600.                     <option value="Paraguay"> Paraguay </option>
  601.                     <option value="Peru"> Peru </option>
  602.                     <option value="Philippines"> Philippines </option>
  603.                     <option value="Pitcairn Islands"> Pitcairn Islands </option>
  604.                     <option value="Poland"> Poland </option>
  605.                     <option value="Portugal"> Portugal </option>
  606.                     <option value="Puerto Rico"> Puerto Rico </option>
  607.                     <option value="Qatar"> Qatar </option>
  608.                     <option value="Romania"> Romania </option>
  609.                     <option value="Russia"> Russia </option>
  610.                     <option value="Rwanda"> Rwanda </option>
  611.                     <option value="Saint Barthelemy"> Saint Barthelemy </option>
  612.                     <option value="Saint Helena"> Saint Helena </option>
  613.                     <option value="Saint Kitts and Nevis"> Saint Kitts and Nevis </option>
  614.                     <option value="Saint Lucia"> Saint Lucia </option>
  615.                     <option value="Saint Martin"> Saint Martin </option>
  616.                     <option value="Saint Pierre and Miquelon"> Saint Pierre and Miquelon </option>
  617.                     <option value="Saint Vincent and the Grenadines"> Saint Vincent and the Grenadines </option>
  618.                     <option value="Samoa"> Samoa </option>
  619.                     <option value="San Marino"> San Marino </option>
  620.                     <option value="Sao Tome and Principe"> Sao Tome and Principe </option>
  621.                     <option value="Saudi Arabia"> Saudi Arabia </option>
  622.                     <option value="Senegal"> Senegal </option>
  623.                     <option value="Serbia"> Serbia </option>
  624.                     <option value="Seychelles"> Seychelles </option>
  625.                     <option value="Sierra Leone"> Sierra Leone </option>
  626.                     <option value="Singapore"> Singapore </option>
  627.                     <option value="Slovakia"> Slovakia </option>
  628.                     <option value="Slovenia"> Slovenia </option>
  629.                     <option value="Solomon Islands"> Solomon Islands </option>
  630.                     <option value="Somalia"> Somalia </option>
  631.                     <option value="Somaliland"> Somaliland </option>
  632.                     <option value="South Africa"> South Africa </option>
  633.                     <option value="South Ossetia"> South Ossetia </option>
  634.                     <option value="Spain"> Spain </option>
  635.                     <option value="Sri Lanka"> Sri Lanka </option>
  636.                     <option value="Sudan"> Sudan </option>
  637.                     <option value="Suriname"> Suriname </option>
  638.                     <option value="Svalbard"> Svalbard </option>
  639.                     <option value="Swaziland"> Swaziland </option>
  640.                     <option value="Sweden"> Sweden </option>
  641.                     <option value="Switzerland"> Switzerland </option>
  642.                     <option value="Syria"> Syria </option>
  643.                     <option value="Taiwan"> Taiwan </option>
  644.                     <option value="Tajikistan"> Tajikistan </option>
  645.                     <option value="Tanzania"> Tanzania </option>
  646.                     <option value="Thailand"> Thailand </option>
  647.                     <option value="Timor-Leste"> Timor-Leste </option>
  648.                     <option value="Togo"> Togo </option>
  649.                     <option value="Tokelau"> Tokelau </option>
  650.                     <option value="Tonga"> Tonga </option>
  651.                     <option value="Transnistria Pridnestrovie"> Transnistria Pridnestrovie </option>
  652.                     <option value="Trinidad and Tobago"> Trinidad and Tobago </option>
  653.                     <option value="Tristan da Cunha"> Tristan da Cunha </option>
  654.                     <option value="Tunisia"> Tunisia </option>
  655.                     <option value="Turkey"> Turkey </option>
  656.                     <option value="Turkmenistan"> Turkmenistan </option>
  657.                     <option value="Turks and Caicos Islands"> Turks and Caicos Islands </option>
  658.                     <option value="Tuvalu"> Tuvalu </option>
  659.                     <option value="Uganda"> Uganda </option>
  660.                     <option value="Ukraine"> Ukraine </option>
  661.                     <option value="United Arab Emirates"> United Arab Emirates </option>
  662.                     <option value="United Kingdom"> United Kingdom </option>
  663.                     <option value="Uruguay"> Uruguay </option>
  664.                     <option value="Uzbekistan"> Uzbekistan </option>
  665.                     <option value="Vanuatu"> Vanuatu </option>
  666.                     <option value="Vatican City"> Vatican City </option>
  667.                     <option value="Venezuela"> Venezuela </option>
  668.                     <option value="Vietnam"> Vietnam </option>
  669.                     <option value="British Virgin Islands"> British Virgin Islands </option>
  670.                     <option value="US Virgin Islands"> US Virgin Islands </option>
  671.                     <option value="Wallis and Futuna"> Wallis and Futuna </option>
  672.                     <option value="Western Sahara"> Western Sahara </option>
  673.                     <option value="Yemen"> Yemen </option>
  674.                     <option value="Zambia"> Zambia </option>
  675.                     <option value="Zimbabwe"> Zimbabwe </option>
  676.                     <option value="other"> Other </option>
  677.                   </select>
  678.                   <label class="form-sub-label" for="input_123_country" id="sublabel_123_country"> Country </label></span>
  679.               </td>
  680.             </tr>
  681.           </table>
  682.         </div>
  683.       </li>
  684.       <li class="form-line" id="id_280">
  685.         <label class="form-label-left" id="label_280" for="input_280"> Is your mailing address same as the above? </label>
  686.         <div id="cid_280" class="form-input">
  687.           <div class="form-single-column"><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox" id="input_280_0" name="q280_isYour280[]" value="Yes" />
  688.               <label for="input_280_0"> Yes </label></span><span class="clearfix"></span><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox" id="input_280_1" name="q280_isYour280[]" value="No" />
  689.               <label for="input_280_1"> No </label></span><span class="clearfix"></span>
  690.           </div>
  691.         </div>
  692.       </li>
  693.       <li class="form-line" id="id_141">
  694.         <label class="form-label-left" id="label_141" for="input_141"> Mailing Address (if different from above address) </label>
  695.         <div id="cid_141" class="form-input">
  696.           <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0">
  697.             <tr>
  698.               <td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line" type="text" name="q141_mailingAddress141[addr_line1]" id="input_141_addr_line1" />
  699.                   <label class="form-sub-label" for="input_141_addr_line1" id="sublabel_141_addr_line1"> Street Address </label></span>
  700.               </td>
  701.             </tr>
  702.             <tr style="display: none;">
  703.               <td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line" type="text" name="q141_mailingAddress141[addr_line2]" id="input_141_addr_line2" size="46" />
  704.                   <label class="form-sub-label" for="input_141_addr_line2" id="sublabel_141_addr_line2"> Street Address Line 2 </label></span>
  705.               </td>
  706.             </tr>
  707.             <tr>
  708.               <td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-city" type="text" name="q141_mailingAddress141[city]" id="input_141_city" size="21" />
  709.                   <label class="form-sub-label" for="input_141_city" id="sublabel_141_city"> City </label></span>
  710.               </td>
  711.               <td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q141_mailingAddress141[state]" id="input_141_state" size="22" />
  712.                   <label class="form-sub-label" for="input_141_state" id="sublabel_141_state"> State / Province </label></span>
  713.               </td>
  714.             </tr>
  715.             <tr>
  716.               <td width="50%" style="display: none;"><span class="form-sub-label-container"><input class="form-textbox form-address-postal" type="text" name="q141_mailingAddress141[postal]" id="input_141_postal" size="10" />
  717.                   <label class="form-sub-label" for="input_141_postal" id="sublabel_141_postal"> Postal / Zip Code </label></span>
  718.               </td>
  719.               <td><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q141_mailingAddress141[country]" id="input_141_country">
  720.                     <option value="" selected> Please Select </option>
  721.                     <option value="United States"> United States </option>
  722.                     <option value="Afghanistan"> Afghanistan </option>
  723.                     <option value="Albania"> Albania </option>
  724.                     <option value="Algeria"> Algeria </option>
  725.                     <option value="American Samoa"> American Samoa </option>
  726.                     <option value="Andorra"> Andorra </option>
  727.                     <option value="Angola"> Angola </option>
  728.                     <option value="Anguilla"> Anguilla </option>
  729.                     <option value="Antigua and Barbuda"> Antigua and Barbuda </option>
  730.                     <option value="Argentina"> Argentina </option>
  731.                     <option value="Armenia"> Armenia </option>
  732.                     <option value="Aruba"> Aruba </option>
  733.                     <option value="Australia"> Australia </option>
  734.                     <option value="Austria"> Austria </option>
  735.                     <option value="Azerbaijan"> Azerbaijan </option>
  736.                     <option value="The Bahamas"> The Bahamas </option>
  737.                     <option value="Bahrain"> Bahrain </option>
  738.                     <option value="Bangladesh"> Bangladesh </option>
  739.                     <option value="Barbados"> Barbados </option>
  740.                     <option value="Belarus"> Belarus </option>
  741.                     <option value="Belgium"> Belgium </option>
  742.                     <option value="Belize"> Belize </option>
  743.                     <option value="Benin"> Benin </option>
  744.                     <option value="Bermuda"> Bermuda </option>
  745.                     <option value="Bhutan"> Bhutan </option>
  746.                     <option value="Bolivia"> Bolivia </option>
  747.                     <option value="Bosnia and Herzegovina"> Bosnia and Herzegovina </option>
  748.                     <option value="Botswana"> Botswana </option>
  749.                     <option value="Brazil"> Brazil </option>
  750.                     <option value="Brunei"> Brunei </option>
  751.                     <option value="Bulgaria"> Bulgaria </option>
  752.                     <option value="Burkina Faso"> Burkina Faso </option>
  753.                     <option value="Burundi"> Burundi </option>
  754.                     <option value="Cambodia"> Cambodia </option>
  755.                     <option value="Cameroon"> Cameroon </option>
  756.                     <option value="Canada"> Canada </option>
  757.                     <option value="Cape Verde"> Cape Verde </option>
  758.                     <option value="Cayman Islands"> Cayman Islands </option>
  759.                     <option value="Central African Republic"> Central African Republic </option>
  760.                     <option value="Chad"> Chad </option>
  761.                     <option value="Chile"> Chile </option>
  762.                     <option value="People's Republic of China"> People's Republic of China </option>
  763.                     <option value="Republic of China"> Republic of China </option>
  764.                     <option value="Christmas Island"> Christmas Island </option>
  765.                     <option value="Cocos (Keeling) Islands"> Cocos (Keeling) Islands </option>
  766.                     <option value="Colombia"> Colombia </option>
  767.                     <option value="Comoros"> Comoros </option>
  768.                     <option value="Congo"> Congo </option>
  769.                     <option value="Cook Islands"> Cook Islands </option>
  770.                     <option value="Costa Rica"> Costa Rica </option>
  771.                     <option value="Cote d'Ivoire"> Cote d'Ivoire </option>
  772.                     <option value="Croatia"> Croatia </option>
  773.                     <option value="Cuba"> Cuba </option>
  774.                     <option value="Cyprus"> Cyprus </option>
  775.                     <option value="Czech Republic"> Czech Republic </option>
  776.                     <option value="Denmark"> Denmark </option>
  777.                     <option value="Djibouti"> Djibouti </option>
  778.                     <option value="Dominica"> Dominica </option>
  779.                     <option value="Dominican Republic"> Dominican Republic </option>
  780.                     <option value="Ecuador"> Ecuador </option>
  781.                     <option value="Egypt"> Egypt </option>
  782.                     <option value="El Salvador"> El Salvador </option>
  783.                     <option value="Equatorial Guinea"> Equatorial Guinea </option>
  784.                     <option value="Eritrea"> Eritrea </option>
  785.                     <option value="Estonia"> Estonia </option>
  786.                     <option value="Ethiopia"> Ethiopia </option>
  787.                     <option value="Falkland Islands"> Falkland Islands </option>
  788.                     <option value="Faroe Islands"> Faroe Islands </option>
  789.                     <option value="Fiji"> Fiji </option>
  790.                     <option value="Finland"> Finland </option>
  791.                     <option value="France"> France </option>
  792.                     <option value="French Polynesia"> French Polynesia </option>
  793.                     <option value="Gabon"> Gabon </option>
  794.                     <option value="The Gambia"> The Gambia </option>
  795.                     <option value="Georgia"> Georgia </option>
  796.                     <option value="Germany"> Germany </option>
  797.                     <option value="Ghana"> Ghana </option>
  798.                     <option value="Gibraltar"> Gibraltar </option>
  799.                     <option value="Greece"> Greece </option>
  800.                     <option value="Greenland"> Greenland </option>
  801.                     <option value="Grenada"> Grenada </option>
  802.                     <option value="Guadeloupe"> Guadeloupe </option>
  803.                     <option value="Guam"> Guam </option>
  804.                     <option value="Guatemala"> Guatemala </option>
  805.                     <option value="Guernsey"> Guernsey </option>
  806.                     <option value="Guinea"> Guinea </option>
  807.                     <option value="Guinea-Bissau"> Guinea-Bissau </option>
  808.                     <option value="Guyana"> Guyana </option>
  809.                     <option value="Haiti"> Haiti </option>
  810.                     <option value="Honduras"> Honduras </option>
  811.                     <option value="Hong Kong"> Hong Kong </option>
  812.                     <option value="Hungary"> Hungary </option>
  813.                     <option value="Iceland"> Iceland </option>
  814.                     <option value="India"> India </option>
  815.                     <option value="Indonesia"> Indonesia </option>
  816.                     <option value="Iran"> Iran </option>
  817.                     <option value="Iraq"> Iraq </option>
  818.                     <option value="Ireland"> Ireland </option>
  819.                     <option value="Israel"> Israel </option>
  820.                     <option value="Italy"> Italy </option>
  821.                     <option value="Jamaica"> Jamaica </option>
  822.                     <option value="Japan"> Japan </option>
  823.                     <option value="Jersey"> Jersey </option>
  824.                     <option value="Jordan"> Jordan </option>
  825.                     <option value="Kazakhstan"> Kazakhstan </option>
  826.                     <option value="Kenya"> Kenya </option>
  827.                     <option value="Kiribati"> Kiribati </option>
  828.                     <option value="North Korea"> North Korea </option>
  829.                     <option value="South Korea"> South Korea </option>
  830.                     <option value="Kosovo"> Kosovo </option>
  831.                     <option value="Kuwait"> Kuwait </option>
  832.                     <option value="Kyrgyzstan"> Kyrgyzstan </option>
  833.                     <option value="Laos"> Laos </option>
  834.                     <option value="Latvia"> Latvia </option>
  835.                     <option value="Lebanon"> Lebanon </option>
  836.                     <option value="Lesotho"> Lesotho </option>
  837.                     <option value="Liberia"> Liberia </option>
  838.                     <option value="Libya"> Libya </option>
  839.                     <option value="Liechtenstein"> Liechtenstein </option>
  840.                     <option value="Lithuania"> Lithuania </option>
  841.                     <option value="Luxembourg"> Luxembourg </option>
  842.                     <option value="Macau"> Macau </option>
  843.                     <option value="Macedonia"> Macedonia </option>
  844.                     <option value="Madagascar"> Madagascar </option>
  845.                     <option value="Malawi"> Malawi </option>
  846.                     <option value="Malaysia"> Malaysia </option>
  847.                     <option value="Maldives"> Maldives </option>
  848.                     <option value="Mali"> Mali </option>
  849.                     <option value="Malta"> Malta </option>
  850.                     <option value="Marshall Islands"> Marshall Islands </option>
  851.                     <option value="Martinique"> Martinique </option>
  852.                     <option value="Mauritania"> Mauritania </option>
  853.                     <option value="Mauritius"> Mauritius </option>
  854.                     <option value="Mayotte"> Mayotte </option>
  855.                     <option value="Mexico"> Mexico </option>
  856.                     <option value="Micronesia"> Micronesia </option>
  857.                     <option value="Moldova"> Moldova </option>
  858.                     <option value="Monaco"> Monaco </option>
  859.                     <option value="Mongolia"> Mongolia </option>
  860.                     <option value="Montenegro"> Montenegro </option>
  861.                     <option value="Montserrat"> Montserrat </option>
  862.                     <option value="Morocco"> Morocco </option>
  863.                     <option value="Mozambique"> Mozambique </option>
  864.                     <option value="Myanmar"> Myanmar </option>
  865.                     <option value="Nagorno-Karabakh"> Nagorno-Karabakh </option>
  866.                     <option value="Namibia"> Namibia </option>
  867.                     <option value="Nauru"> Nauru </option>
  868.                     <option value="Nepal"> Nepal </option>
  869.                     <option value="Netherlands"> Netherlands </option>
  870.                     <option value="Netherlands Antilles"> Netherlands Antilles </option>
  871.                     <option value="New Caledonia"> New Caledonia </option>
  872.                     <option value="New Zealand"> New Zealand </option>
  873.                     <option value="Nicaragua"> Nicaragua </option>
  874.                     <option value="Niger"> Niger </option>
  875.                     <option value="Nigeria"> Nigeria </option>
  876.                     <option value="Niue"> Niue </option>
  877.                     <option value="Norfolk Island"> Norfolk Island </option>
  878.                     <option value="Turkish Republic of Northern Cyprus"> Turkish Republic of Northern Cyprus </option>
  879.                     <option value="Northern Mariana"> Northern Mariana </option>
  880.                     <option value="Norway"> Norway </option>
  881.                     <option value="Oman"> Oman </option>
  882.                     <option value="Pakistan"> Pakistan </option>
  883.                     <option value="Palau"> Palau </option>
  884.                     <option value="Palestine"> Palestine </option>
  885.                     <option value="Panama"> Panama </option>
  886.                     <option value="Papua New Guinea"> Papua New Guinea </option>
  887.                     <option value="Paraguay"> Paraguay </option>
  888.                     <option value="Peru"> Peru </option>
  889.                     <option value="Philippines"> Philippines </option>
  890.                     <option value="Pitcairn Islands"> Pitcairn Islands </option>
  891.                     <option value="Poland"> Poland </option>
  892.                     <option value="Portugal"> Portugal </option>
  893.                     <option value="Puerto Rico"> Puerto Rico </option>
  894.                     <option value="Qatar"> Qatar </option>
  895.                     <option value="Romania"> Romania </option>
  896.                     <option value="Russia"> Russia </option>
  897.                     <option value="Rwanda"> Rwanda </option>
  898.                     <option value="Saint Barthelemy"> Saint Barthelemy </option>
  899.                     <option value="Saint Helena"> Saint Helena </option>
  900.                     <option value="Saint Kitts and Nevis"> Saint Kitts and Nevis </option>
  901.                     <option value="Saint Lucia"> Saint Lucia </option>
  902.                     <option value="Saint Martin"> Saint Martin </option>
  903.                     <option value="Saint Pierre and Miquelon"> Saint Pierre and Miquelon </option>
  904.                     <option value="Saint Vincent and the Grenadines"> Saint Vincent and the Grenadines </option>
  905.                     <option value="Samoa"> Samoa </option>
  906.                     <option value="San Marino"> San Marino </option>
  907.                     <option value="Sao Tome and Principe"> Sao Tome and Principe </option>
  908.                     <option value="Saudi Arabia"> Saudi Arabia </option>
  909.                     <option value="Senegal"> Senegal </option>
  910.                     <option value="Serbia"> Serbia </option>
  911.                     <option value="Seychelles"> Seychelles </option>
  912.                     <option value="Sierra Leone"> Sierra Leone </option>
  913.                     <option value="Singapore"> Singapore </option>
  914.                     <option value="Slovakia"> Slovakia </option>
  915.                     <option value="Slovenia"> Slovenia </option>
  916.                     <option value="Solomon Islands"> Solomon Islands </option>
  917.                     <option value="Somalia"> Somalia </option>
  918.                     <option value="Somaliland"> Somaliland </option>
  919.                     <option value="South Africa"> South Africa </option>
  920.                     <option value="South Ossetia"> South Ossetia </option>
  921.                     <option value="Spain"> Spain </option>
  922.                     <option value="Sri Lanka"> Sri Lanka </option>
  923.                     <option value="Sudan"> Sudan </option>
  924.                     <option value="Suriname"> Suriname </option>
  925.                     <option value="Svalbard"> Svalbard </option>
  926.                     <option value="Swaziland"> Swaziland </option>
  927.                     <option value="Sweden"> Sweden </option>
  928.                     <option value="Switzerland"> Switzerland </option>
  929.                     <option value="Syria"> Syria </option>
  930.                     <option value="Taiwan"> Taiwan </option>
  931.                     <option value="Tajikistan"> Tajikistan </option>
  932.                     <option value="Tanzania"> Tanzania </option>
  933.                     <option value="Thailand"> Thailand </option>
  934.                     <option value="Timor-Leste"> Timor-Leste </option>
  935.                     <option value="Togo"> Togo </option>
  936.                     <option value="Tokelau"> Tokelau </option>
  937.                     <option value="Tonga"> Tonga </option>
  938.                     <option value="Transnistria Pridnestrovie"> Transnistria Pridnestrovie </option>
  939.                     <option value="Trinidad and Tobago"> Trinidad and Tobago </option>
  940.                     <option value="Tristan da Cunha"> Tristan da Cunha </option>
  941.                     <option value="Tunisia"> Tunisia </option>
  942.                     <option value="Turkey"> Turkey </option>
  943.                     <option value="Turkmenistan"> Turkmenistan </option>
  944.                     <option value="Turks and Caicos Islands"> Turks and Caicos Islands </option>
  945.                     <option value="Tuvalu"> Tuvalu </option>
  946.                     <option value="Uganda"> Uganda </option>
  947.                     <option value="Ukraine"> Ukraine </option>
  948.                     <option value="United Arab Emirates"> United Arab Emirates </option>
  949.                     <option value="United Kingdom"> United Kingdom </option>
  950.                     <option value="Uruguay"> Uruguay </option>
  951.                     <option value="Uzbekistan"> Uzbekistan </option>
  952.                     <option value="Vanuatu"> Vanuatu </option>
  953.                     <option value="Vatican City"> Vatican City </option>
  954.                     <option value="Venezuela"> Venezuela </option>
  955.                     <option value="Vietnam"> Vietnam </option>
  956.                     <option value="British Virgin Islands"> British Virgin Islands </option>
  957.                     <option value="US Virgin Islands"> US Virgin Islands </option>
  958.                     <option value="Wallis and Futuna"> Wallis and Futuna </option>
  959.                     <option value="Western Sahara"> Western Sahara </option>
  960.                     <option value="Yemen"> Yemen </option>
  961.                     <option value="Zambia"> Zambia </option>
  962.                     <option value="Zimbabwe"> Zimbabwe </option>
  963.                     <option value="other"> Other </option>
  964.                   </select>
  965.                   <label class="form-sub-label" for="input_141_country" id="sublabel_141_country"> Country </label></span>
  966.               </td>
  967.             </tr>
  968.           </table>
  969.         </div>
  970.       </li>
  971.       <li class="form-line" id="id_286">
  972.         <div id="cid_286" class="form-input-wide">
  973.           <div id="text_286" class="form-html">
  974.             <p>
  975.               <strong>
  976.                 If you are younger than 18 years old, consent is required from your guardian in order to submit your application form.
  977.               </strong>
  978.             </p>
  979.           </div>
  980.         </div>
  981.       </li>
  982.       <li class="form-line" id="id_285">
  983.         <label class="form-label-left" id="label_285" for="input_285">
  984.           Guardian’s Full Name<span class="form-required">*</span>
  985.         </label>
  986.         <div id="cid_285" class="form-input">
  987.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_285" onblur="copyParentsName();" name="q285_guardiansFull" size="20" value="" />
  988.         </div>
  989.       </li>
  990.       <li class="form-line" id="id_134">
  991.         <label class="form-label-left" id="label_134" for="input_134">
  992.           Guardian's Email Address<span class="form-required">*</span>
  993.         </label>
  994.         <div id="cid_134" class="form-input">
  995.           <input type="email" class=" form-textbox validate[required, Email]" id="input_134" name="q134_guardiansEmail134" size="30" value="" />
  996.         </div>
  997.       </li>
  998.       <li class="form-line" id="id_287">
  999.         <label class="form-label-left" id="label_287" for="input_287">
  1000.           Guardian's Phone Number<span class="form-required">*</span>
  1001.         </label>
  1002.         <div id="cid_287" class="form-input">
  1003.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_287" name="q287_guardiansPhone287" size="20" value="" />
  1004.         </div>
  1005.       </li>
  1006.       <li class="form-line" id="id_136">
  1007.         <label class="form-label-left" id="label_136" for="input_136">
  1008.           Are you married?<span class="form-required">*</span>
  1009.         </label>
  1010.         <div id="cid_136" class="form-input">
  1011.           <div class="form-multiple-column"><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox validate[required]" id="input_136_0" name="q136_areYou136[]" value="Yes" />
  1012.               <label for="input_136_0"> Yes </label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox validate[required]" id="input_136_1" name="q136_areYou136[]" value="No" />
  1013.               <label for="input_136_1"> No </label></span><span class="clearfix"></span>
  1014.           </div>
  1015.         </div>
  1016.       </li>
  1017.       <li class="form-line" id="id_137">
  1018.         <label class="form-label-left" id="label_137" for="input_137">
  1019.           Do you have children?<span class="form-required">*</span>
  1020.         </label>
  1021.         <div id="cid_137" class="form-input">
  1022.           <div class="form-multiple-column"><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox validate[required]" id="input_137_0" name="q137_doYou137[]" value="Yes" />
  1023.               <label for="input_137_0"> Yes </label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox validate[required]" id="input_137_1" name="q137_doYou137[]" value="No" />
  1024.               <label for="input_137_1"> No </label></span><span class="clearfix"></span>
  1025.           </div>
  1026.         </div>
  1027.       </li>
  1028.       <li class="form-line" id="id_138">
  1029.         <label class="form-label-left" id="label_138" for="input_138">
  1030.           If yes to above, how many children?<span class="form-required">*</span>
  1031.         </label>
  1032.         <div id="cid_138" class="form-input">
  1033.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_138" name="q138_ifYes138" size="20" value="" />
  1034.         </div>
  1035.       </li>
  1036.       <li class="form-line" id="id_139">
  1037.         <label class="form-label-left" id="label_139" for="input_139">
  1038.           How many people depend on you financially?<span class="form-required">*</span>
  1039.         </label>
  1040.         <div id="cid_139" class="form-input">
  1041.           <input type="number" class="form-number-input  form-textbox validate[required]" id="input_139" name="q139_howMany" style="width:60px" size="5" value="" data-type="input-number" />
  1042.         </div>
  1043.       </li>
  1044.       <li class="form-line" id="id_140">
  1045.         <label class="form-label-left" id="label_140" for="input_140">
  1046.           If the answer to the above is greater than zero, how do you provide for them?<span class="form-required">*</span>
  1047.         </label>
  1048.         <div id="cid_140" class="form-input">
  1049.           <textarea id="input_140" class="form-textarea validate[required]" name="q140_ifThe" cols="40" rows="6"></textarea>
  1050.         </div>
  1051.       </li>
  1052.       <li class="form-line" id="id_145">
  1053.         <label class="form-label-left" id="label_145" for="input_145">
  1054.           Religion (check only one option)<span class="form-required">*</span>
  1055.         </label>
  1056.         <div id="cid_145" class="form-input">
  1057.           <div class="form-multiple-column"><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox validate[required, maxSelection]" data-maxSelection=1 id="input_145_0" name="q145_religioncheck[]" value="Christian" />
  1058.               <label for="input_145_0"> Christian </label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox validate[required, maxSelection]" data-maxSelection=1 id="input_145_1" name="q145_religioncheck[]" value="Christian (Born Again)" />
  1059.               <label for="input_145_1"> Christian (Born Again) </label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox validate[required, maxSelection]" data-maxSelection=1 id="input_145_2" name="q145_religioncheck[]" value="Catholic" />
  1060.               <label for="input_145_2"> Catholic </label></span><span class="clearfix"></span><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox validate[required, maxSelection]" data-maxSelection=1 id="input_145_3" name="q145_religioncheck[]" value="Jehovah’s Witness" />
  1061.               <label for="input_145_3"> Jehovah’s Witness </label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox validate[required, maxSelection]" data-maxSelection=1 id="input_145_4" name="q145_religioncheck[]" value="Seventh Day Adventist" />
  1062.               <label for="input_145_4"> Seventh Day Adventist </label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox validate[required, maxSelection]" data-maxSelection=1 id="input_145_5" name="q145_religioncheck[]" value="Muslim" />
  1063.               <label for="input_145_5"> Muslim </label></span><span class="clearfix"></span><span class="form-checkbox-item" style="clear:left"><input type="checkbox" class="form-checkbox-other form-checkbox validate[required, maxSelection]" data-maxSelection=1 name="q145_religioncheck[other]" id="other_145" value="" />
  1064.               <input type="text" class="form-checkbox-other-input" name="" data-otherHint="Other" size="15" id="input_145" disabled="disabled" />
  1065.               <br /></span>
  1066.           </div>
  1067.         </div>
  1068.       </li>
  1069.       <li class="form-line" id="id_146">
  1070.         <label class="form-label-left" id="label_146" for="input_146">
  1071.           Name and Address of place of worship<span class="form-required">*</span>
  1072.         </label>
  1073.         <div id="cid_146" class="form-input">
  1074.           <textarea id="input_146" class="form-textarea validate[required]" name="q146_nameAnd" cols="40" rows="6"></textarea>
  1075.         </div>
  1076.       </li>
  1077.       <li id="cid_265" class="form-input-wide">
  1078.         <div class="form-pagebreak">
  1079.           <div class="form-pagebreak-back-container form-label-left">
  1080.             <button type="button" class="form-pagebreak-back  form-submit-button-simple_green" id="form-pagebreak-back_265">
  1081.               Back
  1082.             </button>
  1083.           </div>
  1084.           <div class="form-pagebreak-next-container">
  1085.             <button type="button" class="form-pagebreak-next  form-submit-button-simple_green" id="form-pagebreak-next_265">
  1086.               Next
  1087.             </button>
  1088.           </div>
  1089.         </div>
  1090.       </li>
  1091.     </ul>
  1092.     <ul class="form-section" style="display:none;">
  1093.       <li class="form-line" id="id_275">
  1094.         <div id="cid_275" class="form-input-wide">
  1095.           <div id="text_275" class="form-html">
  1096.             <div style="background: #FF0000; color: #ffffff; padding-top: 4px; padding-bottom: 4px; padding-left: 4px; font-size: 16pt; font-family: Arial; letter-spacing: 1pt;"><span style="color: #ffffff; font-family: Arial;"><span style="font-size: 21px; letter-spacing: 1px;"><strong>
  1097.                     ACADEMIC INFORMATION
  1098.                   </strong></span></span>
  1099.             </div>
  1100.           </div>
  1101.         </div>
  1102.       </li>
  1103.       <li class="form-line" id="id_150">
  1104.         <label class="form-label-left" id="label_150" for="input_150">
  1105.           Have you completed Secondary School?<span class="form-required">*</span>
  1106.         </label>
  1107.         <div id="cid_150" class="form-input">
  1108.           <div class="form-single-column"><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox validate[required]" id="input_150_0" name="q150_haveYou150[]" value="Yes" />
  1109.               <label for="input_150_0"> Yes </label></span><span class="clearfix"></span><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox validate[required]" id="input_150_1" name="q150_haveYou150[]" value="No" />
  1110.               <label for="input_150_1"> No </label></span><span class="clearfix"></span><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox validate[required]" id="input_150_2" name="q150_haveYou150[]" value="Dropped out" />
  1111.               <label for="input_150_2"> Dropped out </label></span><span class="clearfix"></span>
  1112.           </div>
  1113.         </div>
  1114.       </li>
  1115.       <li class="form-line" id="id_147">
  1116.         <label class="form-label-left" id="label_147" for="input_147">
  1117.           Name of Secondary School<span class="form-required">*</span>
  1118.         </label>
  1119.         <div id="cid_147" class="form-input">
  1120.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_147" name="q147_nameOf" size="45" value="" />
  1121.         </div>
  1122.       </li>
  1123.       <li class="form-line" id="id_148">
  1124.         <label class="form-label-left" id="label_148" for="input_148">
  1125.           Address of Secondary School<span class="form-required">*</span>
  1126.         </label>
  1127.         <div id="cid_148" class="form-input">
  1128.           <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0">
  1129.             <tr>
  1130.               <td colspan="2"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-line" type="text" name="q148_addressOf148[addr_line1]" id="input_148_addr_line1" />
  1131.                   <label class="form-sub-label" for="input_148_addr_line1" id="sublabel_148_addr_line1"> Street Address </label></span>
  1132.               </td>
  1133.             </tr>
  1134.             <tr style="display: none;">
  1135.               <td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line" type="text" name="q148_addressOf148[addr_line2]" id="input_148_addr_line2" size="46" />
  1136.                   <label class="form-sub-label" for="input_148_addr_line2" id="sublabel_148_addr_line2"> Street Address Line 2 </label></span>
  1137.               </td>
  1138.             </tr>
  1139.             <tr>
  1140.               <td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-city" type="text" name="q148_addressOf148[city]" id="input_148_city" size="21" />
  1141.                   <label class="form-sub-label" for="input_148_city" id="sublabel_148_city"> City </label></span>
  1142.               </td>
  1143.               <td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q148_addressOf148[state]" id="input_148_state" size="22" />
  1144.                   <label class="form-sub-label" for="input_148_state" id="sublabel_148_state"> State / Province </label></span>
  1145.               </td>
  1146.             </tr>
  1147.             <tr>
  1148.               <td width="50%" style="display: none;"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-postal" type="text" name="q148_addressOf148[postal]" id="input_148_postal" size="10" />
  1149.                   <label class="form-sub-label" for="input_148_postal" id="sublabel_148_postal"> Postal / Zip Code </label></span>
  1150.               </td>
  1151.               <td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q148_addressOf148[country]" id="input_148_country">
  1152.                     <option value="" selected> Please Select </option>
  1153.                     <option value="United States"> United States </option>
  1154.                     <option value="Afghanistan"> Afghanistan </option>
  1155.                     <option value="Albania"> Albania </option>
  1156.                     <option value="Algeria"> Algeria </option>
  1157.                     <option value="American Samoa"> American Samoa </option>
  1158.                     <option value="Andorra"> Andorra </option>
  1159.                     <option value="Angola"> Angola </option>
  1160.                     <option value="Anguilla"> Anguilla </option>
  1161.                     <option value="Antigua and Barbuda"> Antigua and Barbuda </option>
  1162.                     <option value="Argentina"> Argentina </option>
  1163.                     <option value="Armenia"> Armenia </option>
  1164.                     <option value="Aruba"> Aruba </option>
  1165.                     <option value="Australia"> Australia </option>
  1166.                     <option value="Austria"> Austria </option>
  1167.                     <option value="Azerbaijan"> Azerbaijan </option>
  1168.                     <option value="The Bahamas"> The Bahamas </option>
  1169.                     <option value="Bahrain"> Bahrain </option>
  1170.                     <option value="Bangladesh"> Bangladesh </option>
  1171.                     <option value="Barbados"> Barbados </option>
  1172.                     <option value="Belarus"> Belarus </option>
  1173.                     <option value="Belgium"> Belgium </option>
  1174.                     <option value="Belize"> Belize </option>
  1175.                     <option value="Benin"> Benin </option>
  1176.                     <option value="Bermuda"> Bermuda </option>
  1177.                     <option value="Bhutan"> Bhutan </option>
  1178.                     <option value="Bolivia"> Bolivia </option>
  1179.                     <option value="Bosnia and Herzegovina"> Bosnia and Herzegovina </option>
  1180.                     <option value="Botswana"> Botswana </option>
  1181.                     <option value="Brazil"> Brazil </option>
  1182.                     <option value="Brunei"> Brunei </option>
  1183.                     <option value="Bulgaria"> Bulgaria </option>
  1184.                     <option value="Burkina Faso"> Burkina Faso </option>
  1185.                     <option value="Burundi"> Burundi </option>
  1186.                     <option value="Cambodia"> Cambodia </option>
  1187.                     <option value="Cameroon"> Cameroon </option>
  1188.                     <option value="Canada"> Canada </option>
  1189.                     <option value="Cape Verde"> Cape Verde </option>
  1190.                     <option value="Cayman Islands"> Cayman Islands </option>
  1191.                     <option value="Central African Republic"> Central African Republic </option>
  1192.                     <option value="Chad"> Chad </option>
  1193.                     <option value="Chile"> Chile </option>
  1194.                     <option value="People's Republic of China"> People's Republic of China </option>
  1195.                     <option value="Republic of China"> Republic of China </option>
  1196.                     <option value="Christmas Island"> Christmas Island </option>
  1197.                     <option value="Cocos (Keeling) Islands"> Cocos (Keeling) Islands </option>
  1198.                     <option value="Colombia"> Colombia </option>
  1199.                     <option value="Comoros"> Comoros </option>
  1200.                     <option value="Congo"> Congo </option>
  1201.                     <option value="Cook Islands"> Cook Islands </option>
  1202.                     <option value="Costa Rica"> Costa Rica </option>
  1203.                     <option value="Cote d'Ivoire"> Cote d'Ivoire </option>
  1204.                     <option value="Croatia"> Croatia </option>
  1205.                     <option value="Cuba"> Cuba </option>
  1206.                     <option value="Cyprus"> Cyprus </option>
  1207.                     <option value="Czech Republic"> Czech Republic </option>
  1208.                     <option value="Denmark"> Denmark </option>
  1209.                     <option value="Djibouti"> Djibouti </option>
  1210.                     <option value="Dominica"> Dominica </option>
  1211.                     <option value="Dominican Republic"> Dominican Republic </option>
  1212.                     <option value="Ecuador"> Ecuador </option>
  1213.                     <option value="Egypt"> Egypt </option>
  1214.                     <option value="El Salvador"> El Salvador </option>
  1215.                     <option value="Equatorial Guinea"> Equatorial Guinea </option>
  1216.                     <option value="Eritrea"> Eritrea </option>
  1217.                     <option value="Estonia"> Estonia </option>
  1218.                     <option value="Ethiopia"> Ethiopia </option>
  1219.                     <option value="Falkland Islands"> Falkland Islands </option>
  1220.                     <option value="Faroe Islands"> Faroe Islands </option>
  1221.                     <option value="Fiji"> Fiji </option>
  1222.                     <option value="Finland"> Finland </option>
  1223.                     <option value="France"> France </option>
  1224.                     <option value="French Polynesia"> French Polynesia </option>
  1225.                     <option value="Gabon"> Gabon </option>
  1226.                     <option value="The Gambia"> The Gambia </option>
  1227.                     <option value="Georgia"> Georgia </option>
  1228.                     <option value="Germany"> Germany </option>
  1229.                     <option value="Ghana"> Ghana </option>
  1230.                     <option value="Gibraltar"> Gibraltar </option>
  1231.                     <option value="Greece"> Greece </option>
  1232.                     <option value="Greenland"> Greenland </option>
  1233.                     <option value="Grenada"> Grenada </option>
  1234.                     <option value="Guadeloupe"> Guadeloupe </option>
  1235.                     <option value="Guam"> Guam </option>
  1236.                     <option value="Guatemala"> Guatemala </option>
  1237.                     <option value="Guernsey"> Guernsey </option>
  1238.                     <option value="Guinea"> Guinea </option>
  1239.                     <option value="Guinea-Bissau"> Guinea-Bissau </option>
  1240.                     <option value="Guyana"> Guyana </option>
  1241.                     <option value="Haiti"> Haiti </option>
  1242.                     <option value="Honduras"> Honduras </option>
  1243.                     <option value="Hong Kong"> Hong Kong </option>
  1244.                     <option value="Hungary"> Hungary </option>
  1245.                     <option value="Iceland"> Iceland </option>
  1246.                     <option value="India"> India </option>
  1247.                     <option value="Indonesia"> Indonesia </option>
  1248.                     <option value="Iran"> Iran </option>
  1249.                     <option value="Iraq"> Iraq </option>
  1250.                     <option value="Ireland"> Ireland </option>
  1251.                     <option value="Israel"> Israel </option>
  1252.                     <option value="Italy"> Italy </option>
  1253.                     <option value="Jamaica"> Jamaica </option>
  1254.                     <option value="Japan"> Japan </option>
  1255.                     <option value="Jersey"> Jersey </option>
  1256.                     <option value="Jordan"> Jordan </option>
  1257.                     <option value="Kazakhstan"> Kazakhstan </option>
  1258.                     <option value="Kenya"> Kenya </option>
  1259.                     <option value="Kiribati"> Kiribati </option>
  1260.                     <option value="North Korea"> North Korea </option>
  1261.                     <option value="South Korea"> South Korea </option>
  1262.                     <option value="Kosovo"> Kosovo </option>
  1263.                     <option value="Kuwait"> Kuwait </option>
  1264.                     <option value="Kyrgyzstan"> Kyrgyzstan </option>
  1265.                     <option value="Laos"> Laos </option>
  1266.                     <option value="Latvia"> Latvia </option>
  1267.                     <option value="Lebanon"> Lebanon </option>
  1268.                     <option value="Lesotho"> Lesotho </option>
  1269.                     <option value="Liberia"> Liberia </option>
  1270.                     <option value="Libya"> Libya </option>
  1271.                     <option value="Liechtenstein"> Liechtenstein </option>
  1272.                     <option value="Lithuania"> Lithuania </option>
  1273.                     <option value="Luxembourg"> Luxembourg </option>
  1274.                     <option value="Macau"> Macau </option>
  1275.                     <option value="Macedonia"> Macedonia </option>
  1276.                     <option value="Madagascar"> Madagascar </option>
  1277.                     <option value="Malawi"> Malawi </option>
  1278.                     <option value="Malaysia"> Malaysia </option>
  1279.                     <option value="Maldives"> Maldives </option>
  1280.                     <option value="Mali"> Mali </option>
  1281.                     <option value="Malta"> Malta </option>
  1282.                     <option value="Marshall Islands"> Marshall Islands </option>
  1283.                     <option value="Martinique"> Martinique </option>
  1284.                     <option value="Mauritania"> Mauritania </option>
  1285.                     <option value="Mauritius"> Mauritius </option>
  1286.                     <option value="Mayotte"> Mayotte </option>
  1287.                     <option value="Mexico"> Mexico </option>
  1288.                     <option value="Micronesia"> Micronesia </option>
  1289.                     <option value="Moldova"> Moldova </option>
  1290.                     <option value="Monaco"> Monaco </option>
  1291.                     <option value="Mongolia"> Mongolia </option>
  1292.                     <option value="Montenegro"> Montenegro </option>
  1293.                     <option value="Montserrat"> Montserrat </option>
  1294.                     <option value="Morocco"> Morocco </option>
  1295.                     <option value="Mozambique"> Mozambique </option>
  1296.                     <option value="Myanmar"> Myanmar </option>
  1297.                     <option value="Nagorno-Karabakh"> Nagorno-Karabakh </option>
  1298.                     <option value="Namibia"> Namibia </option>
  1299.                     <option value="Nauru"> Nauru </option>
  1300.                     <option value="Nepal"> Nepal </option>
  1301.                     <option value="Netherlands"> Netherlands </option>
  1302.                     <option value="Netherlands Antilles"> Netherlands Antilles </option>
  1303.                     <option value="New Caledonia"> New Caledonia </option>
  1304.                     <option value="New Zealand"> New Zealand </option>
  1305.                     <option value="Nicaragua"> Nicaragua </option>
  1306.                     <option value="Niger"> Niger </option>
  1307.                     <option value="Nigeria"> Nigeria </option>
  1308.                     <option value="Niue"> Niue </option>
  1309.                     <option value="Norfolk Island"> Norfolk Island </option>
  1310.                     <option value="Turkish Republic of Northern Cyprus"> Turkish Republic of Northern Cyprus </option>
  1311.                     <option value="Northern Mariana"> Northern Mariana </option>
  1312.                     <option value="Norway"> Norway </option>
  1313.                     <option value="Oman"> Oman </option>
  1314.                     <option value="Pakistan"> Pakistan </option>
  1315.                     <option value="Palau"> Palau </option>
  1316.                     <option value="Palestine"> Palestine </option>
  1317.                     <option value="Panama"> Panama </option>
  1318.                     <option value="Papua New Guinea"> Papua New Guinea </option>
  1319.                     <option value="Paraguay"> Paraguay </option>
  1320.                     <option value="Peru"> Peru </option>
  1321.                     <option value="Philippines"> Philippines </option>
  1322.                     <option value="Pitcairn Islands"> Pitcairn Islands </option>
  1323.                     <option value="Poland"> Poland </option>
  1324.                     <option value="Portugal"> Portugal </option>
  1325.                     <option value="Puerto Rico"> Puerto Rico </option>
  1326.                     <option value="Qatar"> Qatar </option>
  1327.                     <option value="Romania"> Romania </option>
  1328.                     <option value="Russia"> Russia </option>
  1329.                     <option value="Rwanda"> Rwanda </option>
  1330.                     <option value="Saint Barthelemy"> Saint Barthelemy </option>
  1331.                     <option value="Saint Helena"> Saint Helena </option>
  1332.                     <option value="Saint Kitts and Nevis"> Saint Kitts and Nevis </option>
  1333.                     <option value="Saint Lucia"> Saint Lucia </option>
  1334.                     <option value="Saint Martin"> Saint Martin </option>
  1335.                     <option value="Saint Pierre and Miquelon"> Saint Pierre and Miquelon </option>
  1336.                     <option value="Saint Vincent and the Grenadines"> Saint Vincent and the Grenadines </option>
  1337.                     <option value="Samoa"> Samoa </option>
  1338.                     <option value="San Marino"> San Marino </option>
  1339.                     <option value="Sao Tome and Principe"> Sao Tome and Principe </option>
  1340.                     <option value="Saudi Arabia"> Saudi Arabia </option>
  1341.                     <option value="Senegal"> Senegal </option>
  1342.                     <option value="Serbia"> Serbia </option>
  1343.                     <option value="Seychelles"> Seychelles </option>
  1344.                     <option value="Sierra Leone"> Sierra Leone </option>
  1345.                     <option value="Singapore"> Singapore </option>
  1346.                     <option value="Slovakia"> Slovakia </option>
  1347.                     <option value="Slovenia"> Slovenia </option>
  1348.                     <option value="Solomon Islands"> Solomon Islands </option>
  1349.                     <option value="Somalia"> Somalia </option>
  1350.                     <option value="Somaliland"> Somaliland </option>
  1351.                     <option value="South Africa"> South Africa </option>
  1352.                     <option value="South Ossetia"> South Ossetia </option>
  1353.                     <option value="Spain"> Spain </option>
  1354.                     <option value="Sri Lanka"> Sri Lanka </option>
  1355.                     <option value="Sudan"> Sudan </option>
  1356.                     <option value="Suriname"> Suriname </option>
  1357.                     <option value="Svalbard"> Svalbard </option>
  1358.                     <option value="Swaziland"> Swaziland </option>
  1359.                     <option value="Sweden"> Sweden </option>
  1360.                     <option value="Switzerland"> Switzerland </option>
  1361.                     <option value="Syria"> Syria </option>
  1362.                     <option value="Taiwan"> Taiwan </option>
  1363.                     <option value="Tajikistan"> Tajikistan </option>
  1364.                     <option value="Tanzania"> Tanzania </option>
  1365.                     <option value="Thailand"> Thailand </option>
  1366.                     <option value="Timor-Leste"> Timor-Leste </option>
  1367.                     <option value="Togo"> Togo </option>
  1368.                     <option value="Tokelau"> Tokelau </option>
  1369.                     <option value="Tonga"> Tonga </option>
  1370.                     <option value="Transnistria Pridnestrovie"> Transnistria Pridnestrovie </option>
  1371.                     <option value="Trinidad and Tobago"> Trinidad and Tobago </option>
  1372.                     <option value="Tristan da Cunha"> Tristan da Cunha </option>
  1373.                     <option value="Tunisia"> Tunisia </option>
  1374.                     <option value="Turkey"> Turkey </option>
  1375.                     <option value="Turkmenistan"> Turkmenistan </option>
  1376.                     <option value="Turks and Caicos Islands"> Turks and Caicos Islands </option>
  1377.                     <option value="Tuvalu"> Tuvalu </option>
  1378.                     <option value="Uganda"> Uganda </option>
  1379.                     <option value="Ukraine"> Ukraine </option>
  1380.                     <option value="United Arab Emirates"> United Arab Emirates </option>
  1381.                     <option value="United Kingdom"> United Kingdom </option>
  1382.                     <option value="Uruguay"> Uruguay </option>
  1383.                     <option value="Uzbekistan"> Uzbekistan </option>
  1384.                     <option value="Vanuatu"> Vanuatu </option>
  1385.                     <option value="Vatican City"> Vatican City </option>
  1386.                     <option value="Venezuela"> Venezuela </option>
  1387.                     <option value="Vietnam"> Vietnam </option>
  1388.                     <option value="British Virgin Islands"> British Virgin Islands </option>
  1389.                     <option value="US Virgin Islands"> US Virgin Islands </option>
  1390.                     <option value="Wallis and Futuna"> Wallis and Futuna </option>
  1391.                     <option value="Western Sahara"> Western Sahara </option>
  1392.                     <option value="Yemen"> Yemen </option>
  1393.                     <option value="Zambia"> Zambia </option>
  1394.                     <option value="Zimbabwe"> Zimbabwe </option>
  1395.                     <option value="other"> Other </option>
  1396.                   </select>
  1397.                   <label class="form-sub-label" for="input_148_country" id="sublabel_148_country"> Country </label></span>
  1398.               </td>
  1399.             </tr>
  1400.           </table>
  1401.         </div>
  1402.       </li>
  1403.       <li class="form-line" id="id_151">
  1404.         <label class="form-label-right" id="label_151" for="input_151">
  1405.           Graduation date<span class="form-required">*</span>
  1406.         </label>
  1407.         <div id="cid_151" class="form-input"><span class="form-sub-label-container"><input class="form-textbox validate[required]" id="month_151" name="q151_graduationDate[month]" type="tel" size="2" maxlength="2" value="" /><span class="date-separate">&nbsp;/</span>
  1408.             <label class="form-sub-label" for="month_151" id="sublabel_month"> Month </label></span><span class="form-sub-label-container"><input class="noDefault form-textbox validate[required]" id="day_151" name="q151_graduationDate[day]" type="tel" size="2" maxlength="2" value="" /><span class="date-separate">&nbsp;/</span>
  1409.             <label class="form-sub-label" for="day_151" id="sublabel_day"> Day </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" id="year_151" name="q151_graduationDate[year]" type="tel" size="4" maxlength="4" value="" />
  1410.             <label class="form-sub-label" for="year_151" id="sublabel_year"> Year </label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_151_pick" src="http://support.jotform.com/images/calendar.png" align="absmiddle" />
  1411.             <label class="form-sub-label" for="input_151_pick"> &nbsp;&nbsp;&nbsp; </label></span>
  1412.         </div>
  1413.       </li>
  1414.       <li class="form-line" id="id_152">
  1415.         <label class="form-label-right" id="label_152" for="input_152">
  1416.           Expected graduation date<span class="form-required">*</span>
  1417.         </label>
  1418.         <div id="cid_152" class="form-input"><span class="form-sub-label-container"><input class="form-textbox validate[required]" id="month_152" name="q152_expectedGraduation152[month]" type="tel" size="2" maxlength="2" value="" /><span class="date-separate">&nbsp;/</span>
  1419.             <label class="form-sub-label" for="month_152" id="sublabel_month"> Month </label></span><span class="form-sub-label-container"><input class="noDefault form-textbox validate[required]" id="day_152" name="q152_expectedGraduation152[day]" type="tel" size="2" maxlength="2" value="" /><span class="date-separate">&nbsp;/</span>
  1420.             <label class="form-sub-label" for="day_152" id="sublabel_day"> Day </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" id="year_152" name="q152_expectedGraduation152[year]" type="tel" size="4" maxlength="4" value="" />
  1421.             <label class="form-sub-label" for="year_152" id="sublabel_year"> Year </label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_152_pick" src="http://support.jotform.com/images/calendar.png" align="absmiddle" />
  1422.             <label class="form-sub-label" for="input_152_pick"> &nbsp;&nbsp;&nbsp; </label></span>
  1423.         </div>
  1424.       </li>
  1425.       <li class="form-line" id="id_153">
  1426.         <label class="form-label-right" id="label_153" for="input_153">
  1427.           Provide Reason:<span class="form-required">*</span>
  1428.         </label>
  1429.         <div id="cid_153" class="form-input">
  1430.           <textarea id="input_153" class="form-textarea validate[required]" name="q153_provideReason" cols="40" rows="6"></textarea>
  1431.         </div>
  1432.       </li>
  1433.       <li class="form-line" id="id_154">
  1434.         <label class="form-label-right" id="label_154" for="input_154">
  1435.           Secondary School results<span class="form-required">*</span>
  1436.         </label>
  1437.         <div id="cid_154" class="form-input">
  1438.           <table summary="" cellpadding="4" cellspacing="0" class="form-matrix-table">
  1439.             <tr>
  1440.               <th style="border:none">
  1441.                 &nbsp;
  1442.               </th>
  1443.               <th class="form-matrix-column-headers form-matrix-column_0">
  1444.                 A(s)
  1445.               </th>
  1446.               <th class="form-matrix-column-headers form-matrix-column_1">
  1447.                 B(s)
  1448.               </th>
  1449.               <th class="form-matrix-column-headers form-matrix-column_2">
  1450.                 C(s)
  1451.               </th>
  1452.               <th class="form-matrix-column-headers form-matrix-column_3">
  1453.                 Other(s)
  1454.               </th>
  1455.             </tr>
  1456.             <tr>
  1457.               <th align="left" class="form-matrix-row-headers">
  1458.                 How Many SSCE/GCE:
  1459.               </th>
  1460.               <td align="center" class="form-matrix-values">
  1461.                 <input class="form-textbox validate[required]" type="text" size="5" name="q154_secondarySchool[0][]" />
  1462.               </td>
  1463.               <td align="center" class="form-matrix-values">
  1464.                 <input class="form-textbox validate[required]" type="text" size="5" name="q154_secondarySchool[0][]" />
  1465.               </td>
  1466.               <td align="center" class="form-matrix-values">
  1467.                 <input class="form-textbox validate[required]" type="text" size="5" name="q154_secondarySchool[0][]" />
  1468.               </td>
  1469.               <td align="center" class="form-matrix-values">
  1470.                 <input class="form-textbox validate[required]" type="text" size="5" name="q154_secondarySchool[0][]" />
  1471.               </td>
  1472.             </tr>
  1473.           </table>
  1474.         </div>
  1475.       </li>
  1476.       <li class="form-line" id="id_155">
  1477.         <label class="form-label-left" id="label_155" for="input_155">
  1478.           Are you planning on pursuing a Post-secondary education?<span class="form-required">*</span>
  1479.         </label>
  1480.         <div id="cid_155" class="form-input">
  1481.           <div class="form-single-column"><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox validate[required]" id="input_155_0" name="q155_areYou155[]" value="Yes" />
  1482.               <label for="input_155_0"> Yes </label></span><span class="clearfix"></span><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox validate[required]" id="input_155_1" name="q155_areYou155[]" value="No" />
  1483.               <label for="input_155_1"> No </label></span><span class="clearfix"></span>
  1484.           </div>
  1485.         </div>
  1486.       </li>
  1487.       <li class="form-line" id="id_156">
  1488.         <label class="form-label-left" id="label_156" for="input_156">
  1489.           Explain<span class="form-required">*</span>
  1490.         </label>
  1491.         <div id="cid_156" class="form-input">
  1492.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_156" name="q156_explain" size="50" value="" />
  1493.         </div>
  1494.       </li>
  1495.       <li class="form-line" id="id_157">
  1496.         <label class="form-label-left" id="label_157" for="input_157">
  1497.           Are you currently in College/University?<span class="form-required">*</span>
  1498.         </label>
  1499.         <div id="cid_157" class="form-input">
  1500.           <div class="form-single-column"><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox validate[required]" id="input_157_0" name="q157_areYou157[]" value="Yes" />
  1501.               <label for="input_157_0"> Yes </label></span><span class="clearfix"></span><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox validate[required]" id="input_157_1" name="q157_areYou157[]" value="No" />
  1502.               <label for="input_157_1"> No </label></span><span class="clearfix"></span>
  1503.           </div>
  1504.         </div>
  1505.       </li>
  1506.       <li class="form-line" id="id_159">
  1507.         <label class="form-label-left" id="label_159" for="input_159">
  1508.           What are you doing now<span class="form-required">*</span>
  1509.         </label>
  1510.         <div id="cid_159" class="form-input">
  1511.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_159" name="q159_whatAre" size="50" value="" />
  1512.         </div>
  1513.       </li>
  1514.       <li class="form-line" id="id_160">
  1515.         <label class="form-label-left" id="label_160" for="input_160">
  1516.           Name of College/University<span class="form-required">*</span>
  1517.         </label>
  1518.         <div id="cid_160" class="form-input">
  1519.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_160" name="q160_nameOf160" size="50" value="" />
  1520.         </div>
  1521.       </li>
  1522.       <li class="form-line" id="id_161">
  1523.         <label class="form-label-left" id="label_161" for="input_161">
  1524.           Address of College/University<span class="form-required">*</span>
  1525.         </label>
  1526.         <div id="cid_161" class="form-input">
  1527.           <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0">
  1528.             <tr>
  1529.               <td colspan="2"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-line" type="text" name="q161_addressOf[addr_line1]" id="input_161_addr_line1" />
  1530.                   <label class="form-sub-label" for="input_161_addr_line1" id="sublabel_161_addr_line1"> Street Address </label></span>
  1531.               </td>
  1532.             </tr>
  1533.             <tr style="display: none;">
  1534.               <td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line" type="text" name="q161_addressOf[addr_line2]" id="input_161_addr_line2" size="46" />
  1535.                   <label class="form-sub-label" for="input_161_addr_line2" id="sublabel_161_addr_line2"> Street Address Line 2 </label></span>
  1536.               </td>
  1537.             </tr>
  1538.             <tr>
  1539.               <td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-city" type="text" name="q161_addressOf[city]" id="input_161_city" size="21" />
  1540.                   <label class="form-sub-label" for="input_161_city" id="sublabel_161_city"> City </label></span>
  1541.               </td>
  1542.               <td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q161_addressOf[state]" id="input_161_state" size="22" />
  1543.                   <label class="form-sub-label" for="input_161_state" id="sublabel_161_state"> State / Province </label></span>
  1544.               </td>
  1545.             </tr>
  1546.             <tr>
  1547.               <td width="50%" style="display: none;"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-postal" type="text" name="q161_addressOf[postal]" id="input_161_postal" size="10" />
  1548.                   <label class="form-sub-label" for="input_161_postal" id="sublabel_161_postal"> Postal / Zip Code </label></span>
  1549.               </td>
  1550.               <td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q161_addressOf[country]" id="input_161_country">
  1551.                     <option value="" selected> Please Select </option>
  1552.                     <option value="United States"> United States </option>
  1553.                     <option value="Afghanistan"> Afghanistan </option>
  1554.                     <option value="Albania"> Albania </option>
  1555.                     <option value="Algeria"> Algeria </option>
  1556.                     <option value="American Samoa"> American Samoa </option>
  1557.                     <option value="Andorra"> Andorra </option>
  1558.                     <option value="Angola"> Angola </option>
  1559.                     <option value="Anguilla"> Anguilla </option>
  1560.                     <option value="Antigua and Barbuda"> Antigua and Barbuda </option>
  1561.                     <option value="Argentina"> Argentina </option>
  1562.                     <option value="Armenia"> Armenia </option>
  1563.                     <option value="Aruba"> Aruba </option>
  1564.                     <option value="Australia"> Australia </option>
  1565.                     <option value="Austria"> Austria </option>
  1566.                     <option value="Azerbaijan"> Azerbaijan </option>
  1567.                     <option value="The Bahamas"> The Bahamas </option>
  1568.                     <option value="Bahrain"> Bahrain </option>
  1569.                     <option value="Bangladesh"> Bangladesh </option>
  1570.                     <option value="Barbados"> Barbados </option>
  1571.                     <option value="Belarus"> Belarus </option>
  1572.                     <option value="Belgium"> Belgium </option>
  1573.                     <option value="Belize"> Belize </option>
  1574.                     <option value="Benin"> Benin </option>
  1575.                     <option value="Bermuda"> Bermuda </option>
  1576.                     <option value="Bhutan"> Bhutan </option>
  1577.                     <option value="Bolivia"> Bolivia </option>
  1578.                     <option value="Bosnia and Herzegovina"> Bosnia and Herzegovina </option>
  1579.                     <option value="Botswana"> Botswana </option>
  1580.                     <option value="Brazil"> Brazil </option>
  1581.                     <option value="Brunei"> Brunei </option>
  1582.                     <option value="Bulgaria"> Bulgaria </option>
  1583.                     <option value="Burkina Faso"> Burkina Faso </option>
  1584.                     <option value="Burundi"> Burundi </option>
  1585.                     <option value="Cambodia"> Cambodia </option>
  1586.                     <option value="Cameroon"> Cameroon </option>
  1587.                     <option value="Canada"> Canada </option>
  1588.                     <option value="Cape Verde"> Cape Verde </option>
  1589.                     <option value="Cayman Islands"> Cayman Islands </option>
  1590.                     <option value="Central African Republic"> Central African Republic </option>
  1591.                     <option value="Chad"> Chad </option>
  1592.                     <option value="Chile"> Chile </option>
  1593.                     <option value="People's Republic of China"> People's Republic of China </option>
  1594.                     <option value="Republic of China"> Republic of China </option>
  1595.                     <option value="Christmas Island"> Christmas Island </option>
  1596.                     <option value="Cocos (Keeling) Islands"> Cocos (Keeling) Islands </option>
  1597.                     <option value="Colombia"> Colombia </option>
  1598.                     <option value="Comoros"> Comoros </option>
  1599.                     <option value="Congo"> Congo </option>
  1600.                     <option value="Cook Islands"> Cook Islands </option>
  1601.                     <option value="Costa Rica"> Costa Rica </option>
  1602.                     <option value="Cote d'Ivoire"> Cote d'Ivoire </option>
  1603.                     <option value="Croatia"> Croatia </option>
  1604.                     <option value="Cuba"> Cuba </option>
  1605.                     <option value="Cyprus"> Cyprus </option>
  1606.                     <option value="Czech Republic"> Czech Republic </option>
  1607.                     <option value="Denmark"> Denmark </option>
  1608.                     <option value="Djibouti"> Djibouti </option>
  1609.                     <option value="Dominica"> Dominica </option>
  1610.                     <option value="Dominican Republic"> Dominican Republic </option>
  1611.                     <option value="Ecuador"> Ecuador </option>
  1612.                     <option value="Egypt"> Egypt </option>
  1613.                     <option value="El Salvador"> El Salvador </option>
  1614.                     <option value="Equatorial Guinea"> Equatorial Guinea </option>
  1615.                     <option value="Eritrea"> Eritrea </option>
  1616.                     <option value="Estonia"> Estonia </option>
  1617.                     <option value="Ethiopia"> Ethiopia </option>
  1618.                     <option value="Falkland Islands"> Falkland Islands </option>
  1619.                     <option value="Faroe Islands"> Faroe Islands </option>
  1620.                     <option value="Fiji"> Fiji </option>
  1621.                     <option value="Finland"> Finland </option>
  1622.                     <option value="France"> France </option>
  1623.                     <option value="French Polynesia"> French Polynesia </option>
  1624.                     <option value="Gabon"> Gabon </option>
  1625.                     <option value="The Gambia"> The Gambia </option>
  1626.                     <option value="Georgia"> Georgia </option>
  1627.                     <option value="Germany"> Germany </option>
  1628.                     <option value="Ghana"> Ghana </option>
  1629.                     <option value="Gibraltar"> Gibraltar </option>
  1630.                     <option value="Greece"> Greece </option>
  1631.                     <option value="Greenland"> Greenland </option>
  1632.                     <option value="Grenada"> Grenada </option>
  1633.                     <option value="Guadeloupe"> Guadeloupe </option>
  1634.                     <option value="Guam"> Guam </option>
  1635.                     <option value="Guatemala"> Guatemala </option>
  1636.                     <option value="Guernsey"> Guernsey </option>
  1637.                     <option value="Guinea"> Guinea </option>
  1638.                     <option value="Guinea-Bissau"> Guinea-Bissau </option>
  1639.                     <option value="Guyana"> Guyana </option>
  1640.                     <option value="Haiti"> Haiti </option>
  1641.                     <option value="Honduras"> Honduras </option>
  1642.                     <option value="Hong Kong"> Hong Kong </option>
  1643.                     <option value="Hungary"> Hungary </option>
  1644.                     <option value="Iceland"> Iceland </option>
  1645.                     <option value="India"> India </option>
  1646.                     <option value="Indonesia"> Indonesia </option>
  1647.                     <option value="Iran"> Iran </option>
  1648.                     <option value="Iraq"> Iraq </option>
  1649.                     <option value="Ireland"> Ireland </option>
  1650.                     <option value="Israel"> Israel </option>
  1651.                     <option value="Italy"> Italy </option>
  1652.                     <option value="Jamaica"> Jamaica </option>
  1653.                     <option value="Japan"> Japan </option>
  1654.                     <option value="Jersey"> Jersey </option>
  1655.                     <option value="Jordan"> Jordan </option>
  1656.                     <option value="Kazakhstan"> Kazakhstan </option>
  1657.                     <option value="Kenya"> Kenya </option>
  1658.                     <option value="Kiribati"> Kiribati </option>
  1659.                     <option value="North Korea"> North Korea </option>
  1660.                     <option value="South Korea"> South Korea </option>
  1661.                     <option value="Kosovo"> Kosovo </option>
  1662.                     <option value="Kuwait"> Kuwait </option>
  1663.                     <option value="Kyrgyzstan"> Kyrgyzstan </option>
  1664.                     <option value="Laos"> Laos </option>
  1665.                     <option value="Latvia"> Latvia </option>
  1666.                     <option value="Lebanon"> Lebanon </option>
  1667.                     <option value="Lesotho"> Lesotho </option>
  1668.                     <option value="Liberia"> Liberia </option>
  1669.                     <option value="Libya"> Libya </option>
  1670.                     <option value="Liechtenstein"> Liechtenstein </option>
  1671.                     <option value="Lithuania"> Lithuania </option>
  1672.                     <option value="Luxembourg"> Luxembourg </option>
  1673.                     <option value="Macau"> Macau </option>
  1674.                     <option value="Macedonia"> Macedonia </option>
  1675.                     <option value="Madagascar"> Madagascar </option>
  1676.                     <option value="Malawi"> Malawi </option>
  1677.                     <option value="Malaysia"> Malaysia </option>
  1678.                     <option value="Maldives"> Maldives </option>
  1679.                     <option value="Mali"> Mali </option>
  1680.                     <option value="Malta"> Malta </option>
  1681.                     <option value="Marshall Islands"> Marshall Islands </option>
  1682.                     <option value="Martinique"> Martinique </option>
  1683.                     <option value="Mauritania"> Mauritania </option>
  1684.                     <option value="Mauritius"> Mauritius </option>
  1685.                     <option value="Mayotte"> Mayotte </option>
  1686.                     <option value="Mexico"> Mexico </option>
  1687.                     <option value="Micronesia"> Micronesia </option>
  1688.                     <option value="Moldova"> Moldova </option>
  1689.                     <option value="Monaco"> Monaco </option>
  1690.                     <option value="Mongolia"> Mongolia </option>
  1691.                     <option value="Montenegro"> Montenegro </option>
  1692.                     <option value="Montserrat"> Montserrat </option>
  1693.                     <option value="Morocco"> Morocco </option>
  1694.                     <option value="Mozambique"> Mozambique </option>
  1695.                     <option value="Myanmar"> Myanmar </option>
  1696.                     <option value="Nagorno-Karabakh"> Nagorno-Karabakh </option>
  1697.                     <option value="Namibia"> Namibia </option>
  1698.                     <option value="Nauru"> Nauru </option>
  1699.                     <option value="Nepal"> Nepal </option>
  1700.                     <option value="Netherlands"> Netherlands </option>
  1701.                     <option value="Netherlands Antilles"> Netherlands Antilles </option>
  1702.                     <option value="New Caledonia"> New Caledonia </option>
  1703.                     <option value="New Zealand"> New Zealand </option>
  1704.                     <option value="Nicaragua"> Nicaragua </option>
  1705.                     <option value="Niger"> Niger </option>
  1706.                     <option value="Nigeria"> Nigeria </option>
  1707.                     <option value="Niue"> Niue </option>
  1708.                     <option value="Norfolk Island"> Norfolk Island </option>
  1709.                     <option value="Turkish Republic of Northern Cyprus"> Turkish Republic of Northern Cyprus </option>
  1710.                     <option value="Northern Mariana"> Northern Mariana </option>
  1711.                     <option value="Norway"> Norway </option>
  1712.                     <option value="Oman"> Oman </option>
  1713.                     <option value="Pakistan"> Pakistan </option>
  1714.                     <option value="Palau"> Palau </option>
  1715.                     <option value="Palestine"> Palestine </option>
  1716.                     <option value="Panama"> Panama </option>
  1717.                     <option value="Papua New Guinea"> Papua New Guinea </option>
  1718.                     <option value="Paraguay"> Paraguay </option>
  1719.                     <option value="Peru"> Peru </option>
  1720.                     <option value="Philippines"> Philippines </option>
  1721.                     <option value="Pitcairn Islands"> Pitcairn Islands </option>
  1722.                     <option value="Poland"> Poland </option>
  1723.                     <option value="Portugal"> Portugal </option>
  1724.                     <option value="Puerto Rico"> Puerto Rico </option>
  1725.                     <option value="Qatar"> Qatar </option>
  1726.                     <option value="Romania"> Romania </option>
  1727.                     <option value="Russia"> Russia </option>
  1728.                     <option value="Rwanda"> Rwanda </option>
  1729.                     <option value="Saint Barthelemy"> Saint Barthelemy </option>
  1730.                     <option value="Saint Helena"> Saint Helena </option>
  1731.                     <option value="Saint Kitts and Nevis"> Saint Kitts and Nevis </option>
  1732.                     <option value="Saint Lucia"> Saint Lucia </option>
  1733.                     <option value="Saint Martin"> Saint Martin </option>
  1734.                     <option value="Saint Pierre and Miquelon"> Saint Pierre and Miquelon </option>
  1735.                     <option value="Saint Vincent and the Grenadines"> Saint Vincent and the Grenadines </option>
  1736.                     <option value="Samoa"> Samoa </option>
  1737.                     <option value="San Marino"> San Marino </option>
  1738.                     <option value="Sao Tome and Principe"> Sao Tome and Principe </option>
  1739.                     <option value="Saudi Arabia"> Saudi Arabia </option>
  1740.                     <option value="Senegal"> Senegal </option>
  1741.                     <option value="Serbia"> Serbia </option>
  1742.                     <option value="Seychelles"> Seychelles </option>
  1743.                     <option value="Sierra Leone"> Sierra Leone </option>
  1744.                     <option value="Singapore"> Singapore </option>
  1745.                     <option value="Slovakia"> Slovakia </option>
  1746.                     <option value="Slovenia"> Slovenia </option>
  1747.                     <option value="Solomon Islands"> Solomon Islands </option>
  1748.                     <option value="Somalia"> Somalia </option>
  1749.                     <option value="Somaliland"> Somaliland </option>
  1750.                     <option value="South Africa"> South Africa </option>
  1751.                     <option value="South Ossetia"> South Ossetia </option>
  1752.                     <option value="Spain"> Spain </option>
  1753.                     <option value="Sri Lanka"> Sri Lanka </option>
  1754.                     <option value="Sudan"> Sudan </option>
  1755.                     <option value="Suriname"> Suriname </option>
  1756.                     <option value="Svalbard"> Svalbard </option>
  1757.                     <option value="Swaziland"> Swaziland </option>
  1758.                     <option value="Sweden"> Sweden </option>
  1759.                     <option value="Switzerland"> Switzerland </option>
  1760.                     <option value="Syria"> Syria </option>
  1761.                     <option value="Taiwan"> Taiwan </option>
  1762.                     <option value="Tajikistan"> Tajikistan </option>
  1763.                     <option value="Tanzania"> Tanzania </option>
  1764.                     <option value="Thailand"> Thailand </option>
  1765.                     <option value="Timor-Leste"> Timor-Leste </option>
  1766.                     <option value="Togo"> Togo </option>
  1767.                     <option value="Tokelau"> Tokelau </option>
  1768.                     <option value="Tonga"> Tonga </option>
  1769.                     <option value="Transnistria Pridnestrovie"> Transnistria Pridnestrovie </option>
  1770.                     <option value="Trinidad and Tobago"> Trinidad and Tobago </option>
  1771.                     <option value="Tristan da Cunha"> Tristan da Cunha </option>
  1772.                     <option value="Tunisia"> Tunisia </option>
  1773.                     <option value="Turkey"> Turkey </option>
  1774.                     <option value="Turkmenistan"> Turkmenistan </option>
  1775.                     <option value="Turks and Caicos Islands"> Turks and Caicos Islands </option>
  1776.                     <option value="Tuvalu"> Tuvalu </option>
  1777.                     <option value="Uganda"> Uganda </option>
  1778.                     <option value="Ukraine"> Ukraine </option>
  1779.                     <option value="United Arab Emirates"> United Arab Emirates </option>
  1780.                     <option value="United Kingdom"> United Kingdom </option>
  1781.                     <option value="Uruguay"> Uruguay </option>
  1782.                     <option value="Uzbekistan"> Uzbekistan </option>
  1783.                     <option value="Vanuatu"> Vanuatu </option>
  1784.                     <option value="Vatican City"> Vatican City </option>
  1785.                     <option value="Venezuela"> Venezuela </option>
  1786.                     <option value="Vietnam"> Vietnam </option>
  1787.                     <option value="British Virgin Islands"> British Virgin Islands </option>
  1788.                     <option value="US Virgin Islands"> US Virgin Islands </option>
  1789.                     <option value="Wallis and Futuna"> Wallis and Futuna </option>
  1790.                     <option value="Western Sahara"> Western Sahara </option>
  1791.                     <option value="Yemen"> Yemen </option>
  1792.                     <option value="Zambia"> Zambia </option>
  1793.                     <option value="Zimbabwe"> Zimbabwe </option>
  1794.                     <option value="other"> Other </option>
  1795.                   </select>
  1796.                   <label class="form-sub-label" for="input_161_country" id="sublabel_161_country"> Country </label></span>
  1797.               </td>
  1798.             </tr>
  1799.           </table>
  1800.         </div>
  1801.       </li>
  1802.       <li class="form-line" id="id_162">
  1803.         <label class="form-label-left" id="label_162" for="input_162">
  1804.           Discipline/Major<span class="form-required">*</span>
  1805.         </label>
  1806.         <div id="cid_162" class="form-input">
  1807.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_162" name="q162_disciplinemajor" size="50" value="" />
  1808.         </div>
  1809.       </li>
  1810.       <li class="form-line" id="id_163">
  1811.         <label class="form-label-left" id="label_163" for="input_163">
  1812.           Matriculation date (mmm/dd/yyyy)<span class="form-required">*</span>
  1813.         </label>
  1814.         <div id="cid_163" class="form-input"><span class="form-sub-label-container"><input class="form-textbox validate[required]" id="month_163" name="q163_matriculationDate[month]" type="tel" size="2" maxlength="2" value="" /><span class="date-separate">&nbsp;/</span>
  1815.             <label class="form-sub-label" for="month_163" id="sublabel_month"> Month </label></span><span class="form-sub-label-container"><input class="noDefault form-textbox validate[required]" id="day_163" name="q163_matriculationDate[day]" type="tel" size="2" maxlength="2" value="" /><span class="date-separate">&nbsp;/</span>
  1816.             <label class="form-sub-label" for="day_163" id="sublabel_day"> Day </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" id="year_163" name="q163_matriculationDate[year]" type="tel" size="4" maxlength="4" value="" />
  1817.             <label class="form-sub-label" for="year_163" id="sublabel_year"> Year </label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_163_pick" src="http://support.jotform.com/images/calendar.png" align="absmiddle" />
  1818.             <label class="form-sub-label" for="input_163_pick"> &nbsp;&nbsp;&nbsp; </label></span>
  1819.         </div>
  1820.       </li>
  1821.       <li class="form-line" id="id_164">
  1822.         <label class="form-label-left" id="label_164" for="input_164">
  1823.           Date of graduation (mmm/dd/yyyy)<span class="form-required">*</span>
  1824.         </label>
  1825.         <div id="cid_164" class="form-input"><span class="form-sub-label-container"><input class="form-textbox validate[required]" id="month_164" name="q164_dateOf164[month]" type="tel" size="2" maxlength="2" value="" /><span class="date-separate">&nbsp;/</span>
  1826.             <label class="form-sub-label" for="month_164" id="sublabel_month"> Month </label></span><span class="form-sub-label-container"><input class="noDefault form-textbox validate[required]" id="day_164" name="q164_dateOf164[day]" type="tel" size="2" maxlength="2" value="" /><span class="date-separate">&nbsp;/</span>
  1827.             <label class="form-sub-label" for="day_164" id="sublabel_day"> Day </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" id="year_164" name="q164_dateOf164[year]" type="tel" size="4" maxlength="4" value="" />
  1828.             <label class="form-sub-label" for="year_164" id="sublabel_year"> Year </label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_164_pick" src="http://support.jotform.com/images/calendar.png" align="absmiddle" />
  1829.             <label class="form-sub-label" for="input_164_pick"> &nbsp;&nbsp;&nbsp; </label></span>
  1830.         </div>
  1831.       </li>
  1832.       <li class="form-line" id="id_165">
  1833.         <label class="form-label-left" id="label_165" for="input_165">
  1834.           Current GPA<span class="form-required">*</span>
  1835.         </label>
  1836.         <div id="cid_165" class="form-input">
  1837.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_165" name="q165_currentGpa" size="50" value="" />
  1838.         </div>
  1839.       </li>
  1840.       <li class="form-line" id="id_169">
  1841.         <label class="form-label-left" id="label_169" for="input_169"> When over the next 6 months would you NOT be available for training- program could range from 1 week to 3 months </label>
  1842.         <div id="cid_169" class="form-input">
  1843.           <input type="text" class=" form-textbox" data-type="input-textbox" id="input_169" name="q169_whenOver169" size="50" value="" />
  1844.         </div>
  1845.       </li>
  1846.       <li id="cid_170" class="form-input-wide">
  1847.         <div class="form-pagebreak">
  1848.           <div class="form-pagebreak-back-container form-label-left">
  1849.             <button type="button" class="form-pagebreak-back  form-submit-button-simple_green" id="form-pagebreak-back_170">
  1850.               Back
  1851.             </button>
  1852.           </div>
  1853.           <div class="form-pagebreak-next-container">
  1854.             <button type="button" class="form-pagebreak-next  form-submit-button-simple_green" id="form-pagebreak-next_170">
  1855.               Next
  1856.             </button>
  1857.           </div>
  1858.         </div>
  1859.       </li>
  1860.     </ul>
  1861.     <ul class="form-section" style="display:none;">
  1862.       <li class="form-line" id="id_274">
  1863.         <div id="cid_274" class="form-input-wide">
  1864.           <div id="text_274" class="form-html">
  1865.             <div style="background: #FF0000; color: #ffffff; padding-top: 4px; padding-bottom: 4px; padding-left: 4px; font-size: 16pt; font-family: Arial; letter-spacing: 1pt;"><span style="color: #ffffff; font-family: Arial;"><span style="font-size: 21px; letter-spacing: 1px;"><strong>
  1866.                     EMPLOYMENT INFORMATION
  1867.                   </strong></span></span>
  1868.             </div>
  1869.           </div>
  1870.         </div>
  1871.       </li>
  1872.       <li class="form-line" id="id_171">
  1873.         <label class="form-label-left" id="label_171" for="input_171">
  1874.           Are you currently employed or have you secured employment post-graduation?<span class="form-required">*</span>
  1875.         </label>
  1876.         <div id="cid_171" class="form-input">
  1877.           <div class="form-single-column"><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox validate[required]" id="input_171_0" name="q171_areYou[]" value="Yes" />
  1878.               <label for="input_171_0"> Yes </label></span><span class="clearfix"></span><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox validate[required]" id="input_171_1" name="q171_areYou[]" value="No" />
  1879.               <label for="input_171_1"> No </label></span><span class="clearfix"></span>
  1880.           </div>
  1881.         </div>
  1882.       </li>
  1883.       <li class="form-line" id="id_282">
  1884.         <label class="form-label-left" id="label_282" for="input_282">
  1885.           What is you current monthly take home pay<span class="form-required">*</span>
  1886.         </label>
  1887.         <div id="cid_282" class="form-input">
  1888.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_282" name="q282_whatIs" size="20" value="" />
  1889.         </div>
  1890.       </li>
  1891.       <li class="form-line" id="id_168">
  1892.         <label class="form-label-right" id="label_168" for="input_168">
  1893.           Name of Employer<span class="form-required">*</span>
  1894.         </label>
  1895.         <div id="cid_168" class="form-input">
  1896.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_168" name="q168_nameOf168" size="20" value="" />
  1897.         </div>
  1898.       </li>
  1899.       <li class="form-line" id="id_173">
  1900.         <label class="form-label-right" id="label_173" for="input_173">
  1901.           Position<span class="form-required">*</span>
  1902.         </label>
  1903.         <div id="cid_173" class="form-input">
  1904.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_173" name="q173_position" size="20" value="" />
  1905.         </div>
  1906.       </li>
  1907.       <li class="form-line" id="id_174">
  1908.         <label class="form-label-right" id="label_174" for="input_174">
  1909.           Explain your source of livelihood:<span class="form-required">*</span>
  1910.         </label>
  1911.         <div id="cid_174" class="form-input">
  1912.           <textarea id="input_174" class="form-textarea validate[required]" name="q174_explainYour174" cols="40" rows="6"></textarea>
  1913.         </div>
  1914.       </li>
  1915.       <li class="form-line" id="id_175">
  1916.         <label class="form-label-left" id="label_175" for="input_175">
  1917.           Are you self-employed or have a business or a joint venture with other individuals?<span class="form-required">*</span>
  1918.         </label>
  1919.         <div id="cid_175" class="form-input">
  1920.           <div class="form-single-column"><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox validate[required]" id="input_175_0" name="q175_areYou175[]" value="Yes" />
  1921.               <label for="input_175_0"> Yes </label></span><span class="clearfix"></span><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox validate[required]" id="input_175_1" name="q175_areYou175[]" value="No" />
  1922.               <label for="input_175_1"> No </label></span><span class="clearfix"></span>
  1923.           </div>
  1924.         </div>
  1925.       </li>
  1926.       <li class="form-line" id="id_283">
  1927.         <label class="form-label-left" id="label_283" for="input_283">
  1928.           What is your current take-home pay<span class="form-required">*</span>
  1929.         </label>
  1930.         <div id="cid_283" class="form-input">
  1931.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_283" name="q283_whatIs283" size="20" value="" />
  1932.         </div>
  1933.       </li>
  1934.       <li class="form-line" id="id_176">
  1935.         <label class="form-label-right" id="label_176" for="input_176">
  1936.           Your source of livelihood:<span class="form-required">*</span>
  1937.         </label>
  1938.         <div id="cid_176" class="form-input">
  1939.           <textarea id="input_176" class="form-textarea validate[required]" name="q176_yourSource" cols="40" rows="6"></textarea>
  1940.         </div>
  1941.       </li>
  1942.       <li class="form-line" id="id_177">
  1943.         <label class="form-label-left" id="label_177" for="input_177">
  1944.           Are you a missionary or do you rely on churches and other organizations for funding?<span class="form-required">*</span>
  1945.         </label>
  1946.         <div id="cid_177" class="form-input">
  1947.           <div class="form-single-column"><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox validate[required]" id="input_177_0" name="q177_areYou177[]" value="Yes" />
  1948.               <label for="input_177_0"> Yes </label></span><span class="clearfix"></span><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox validate[required]" id="input_177_1" name="q177_areYou177[]" value="No" />
  1949.               <label for="input_177_1"> No </label></span><span class="clearfix"></span>
  1950.           </div>
  1951.         </div>
  1952.       </li>
  1953.       <li class="form-line" id="id_284">
  1954.         <label class="form-label-left" id="label_284" for="input_284">
  1955.           What is your current take-home pay<span class="form-required">*</span>
  1956.         </label>
  1957.         <div id="cid_284" class="form-input">
  1958.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_284" name="q284_whatIs284" size="20" value="" />
  1959.         </div>
  1960.       </li>
  1961.       <li class="form-line" id="id_178">
  1962.         <label class="form-label-right" id="label_178" for="input_178">
  1963.           Current Source of livelihood<span class="form-required">*</span>
  1964.         </label>
  1965.         <div id="cid_178" class="form-input">
  1966.           <textarea id="input_178" class="form-textarea validate[required]" name="q178_currentSource" cols="40" rows="6"></textarea>
  1967.         </div>
  1968.       </li>
  1969.       <li class="form-line" id="id_179">
  1970.         <label class="form-label-left" id="label_179" for="input_179">
  1971.           If you marked No for all of the above, explain your plans to gain employment (this includes plans to start a business of your own or other opportunities you may be pursuing).<span class="form-required">*</span>
  1972.         </label>
  1973.         <div id="cid_179" class="form-input">
  1974.           <textarea id="input_179" class="form-textarea validate[required]" name="q179_ifYou179" cols="40" rows="6"></textarea>
  1975.         </div>
  1976.       </li>
  1977.       <li id="cid_180" class="form-input-wide">
  1978.         <div class="form-pagebreak">
  1979.           <div class="form-pagebreak-back-container form-label-left">
  1980.             <button type="button" class="form-pagebreak-back  form-submit-button-simple_green" id="form-pagebreak-back_180">
  1981.               Back
  1982.             </button>
  1983.           </div>
  1984.           <div class="form-pagebreak-next-container">
  1985.             <button type="button" class="form-pagebreak-next  form-submit-button-simple_green" id="form-pagebreak-next_180">
  1986.               Next
  1987.             </button>
  1988.           </div>
  1989.         </div>
  1990.       </li>
  1991.     </ul>
  1992.     <ul class="form-section" style="display:none;">
  1993.       <li class="form-line" id="id_273">
  1994.         <div id="cid_273" class="form-input-wide">
  1995.           <div id="text_273" class="form-html">
  1996.             <div style="background: #FF0000; color: #ffffff; padding-top: 4px; padding-bottom: 4px; padding-left: 4px; font-size: 16pt; font-family: Arial; letter-spacing: 1pt;">
  1997.               <strong>
  1998.                 OTHER INFORMATION
  1999.               </strong>
  2000.             </div>
  2001.           </div>
  2002.         </div>
  2003.       </li>
  2004.       <li class="form-line" id="id_182">
  2005.         <label class="form-label-top" id="label_182" for="input_182">
  2006.           Internet Access<span class="form-required">*</span>
  2007.         </label>
  2008.         <div id="cid_182" class="form-input-wide">
  2009.           <table summary="" cellpadding="4" cellspacing="0" class="form-matrix-table">
  2010.             <tr>
  2011.               <th style="border:none">
  2012.                 &nbsp;
  2013.               </th>
  2014.               <th class="form-matrix-column-headers form-matrix-column_0">
  2015.                 At Home
  2016.               </th>
  2017.               <th class="form-matrix-column-headers form-matrix-column_1">
  2018.                 Business Center
  2019.               </th>
  2020.               <th class="form-matrix-column-headers form-matrix-column_2">
  2021.                 At School/other
  2022.               </th>
  2023.             </tr>
  2024.             <tr>
  2025.               <th align="left" class="form-matrix-row-headers">
  2026.                 Where do you obtain access?
  2027.               </th>
  2028.               <td align="center" class="form-matrix-values">
  2029.                 <input class="form-checkbox validate[required]" type="checkbox" name="q182_internetAccess182[0][]" value="At Home" />
  2030.               </td>
  2031.               <td align="center" class="form-matrix-values">
  2032.                 <input class="form-checkbox validate[required]" type="checkbox" name="q182_internetAccess182[0][]" value="Business Center" />
  2033.               </td>
  2034.               <td align="center" class="form-matrix-values">
  2035.                 <input class="form-checkbox validate[required]" type="checkbox" name="q182_internetAccess182[0][]" value="At School/other" />
  2036.               </td>
  2037.             </tr>
  2038.           </table>
  2039.         </div>
  2040.       </li>
  2041.       <li class="form-line" id="id_183">
  2042.         <label class="form-label-top" id="label_183" for="input_183">
  2043.           Computer Access<span class="form-required">*</span>
  2044.         </label>
  2045.         <div id="cid_183" class="form-input-wide">
  2046.           <table summary="" cellpadding="4" cellspacing="0" class="form-matrix-table">
  2047.             <tr>
  2048.               <th style="border:none">
  2049.                 &nbsp;
  2050.               </th>
  2051.               <th class="form-matrix-column-headers form-matrix-column_0">
  2052.                 At Home
  2053.               </th>
  2054.               <th class="form-matrix-column-headers form-matrix-column_1">
  2055.                 Business Center
  2056.               </th>
  2057.               <th class="form-matrix-column-headers form-matrix-column_2">
  2058.                 At School/other
  2059.               </th>
  2060.             </tr>
  2061.             <tr>
  2062.               <th align="left" class="form-matrix-row-headers">
  2063.                 Where do you get access?
  2064.               </th>
  2065.               <td align="center" class="form-matrix-values">
  2066.                 <input class="form-checkbox validate[required]" type="checkbox" name="q183_computerAccess[0][]" value="At Home" />
  2067.               </td>
  2068.               <td align="center" class="form-matrix-values">
  2069.                 <input class="form-checkbox validate[required]" type="checkbox" name="q183_computerAccess[0][]" value="Business Center" />
  2070.               </td>
  2071.               <td align="center" class="form-matrix-values">
  2072.                 <input class="form-checkbox validate[required]" type="checkbox" name="q183_computerAccess[0][]" value="At School/other" />
  2073.               </td>
  2074.             </tr>
  2075.           </table>
  2076.         </div>
  2077.       </li>
  2078.       <li class="form-line" id="id_184">
  2079.         <label class="form-label-top" id="label_184" for="input_184">
  2080.           Accommodation<span class="form-required">*</span>
  2081.         </label>
  2082.         <div id="cid_184" class="form-input-wide">
  2083.           <table summary="" cellpadding="4" cellspacing="0" class="form-matrix-table">
  2084.             <tr>
  2085.               <th style="border:none">
  2086.                 &nbsp;
  2087.               </th>
  2088.               <th class="form-matrix-column-headers form-matrix-column_0">
  2089.                 Parents’/Relative’s home
  2090.               </th>
  2091.               <th class="form-matrix-column-headers form-matrix-column_1">
  2092.                 Own home
  2093.               </th>
  2094.               <th class="form-matrix-column-headers form-matrix-column_2">
  2095.                 Rent
  2096.               </th>
  2097.               <th class="form-matrix-column-headers form-matrix-column_3">
  2098.                 Campus
  2099.               </th>
  2100.             </tr>
  2101.             <tr>
  2102.               <th align="left" class="form-matrix-row-headers">
  2103.                 Accommodation situation?
  2104.               </th>
  2105.               <td align="center" class="form-matrix-values">
  2106.                 <input class="form-checkbox validate[required]" type="checkbox" name="q184_input184[0][]" value="Parents’/Relative’s home" />
  2107.               </td>
  2108.               <td align="center" class="form-matrix-values">
  2109.                 <input class="form-checkbox validate[required]" type="checkbox" name="q184_input184[0][]" value="Own home" />
  2110.               </td>
  2111.               <td align="center" class="form-matrix-values">
  2112.                 <input class="form-checkbox validate[required]" type="checkbox" name="q184_input184[0][]" value="Rent" />
  2113.               </td>
  2114.               <td align="center" class="form-matrix-values">
  2115.                 <input class="form-checkbox validate[required]" type="checkbox" name="q184_input184[0][]" value="Campus  " />
  2116.               </td>
  2117.             </tr>
  2118.           </table>
  2119.         </div>
  2120.       </li>
  2121.       <li class="form-line" id="id_185">
  2122.         <label class="form-label-top" id="label_185" for="input_185">
  2123.           Transportation<span class="form-required">*</span>
  2124.         </label>
  2125.         <div id="cid_185" class="form-input-wide">
  2126.           <table summary="" cellpadding="4" cellspacing="0" class="form-matrix-table">
  2127.             <tr>
  2128.               <th style="border:none">
  2129.                 &nbsp;
  2130.               </th>
  2131.               <th class="form-matrix-column-headers form-matrix-column_0">
  2132.                 Parent’s car
  2133.               </th>
  2134.               <th class="form-matrix-column-headers form-matrix-column_1">
  2135.                 Own car
  2136.               </th>
  2137.               <th class="form-matrix-column-headers form-matrix-column_2">
  2138.                 Public transportation
  2139.               </th>
  2140.               <th class="form-matrix-column-headers form-matrix-column_3">
  2141.                 Other
  2142.               </th>
  2143.             </tr>
  2144.             <tr>
  2145.               <th align="left" class="form-matrix-row-headers">
  2146.                 How do you get to school ?
  2147.               </th>
  2148.               <td align="center" class="form-matrix-values">
  2149.                 <input class="form-checkbox validate[required]" type="checkbox" name="q185_input185[0][]" value="Parent’s car " />
  2150.               </td>
  2151.               <td align="center" class="form-matrix-values">
  2152.                 <input class="form-checkbox validate[required]" type="checkbox" name="q185_input185[0][]" value="Own car" />
  2153.               </td>
  2154.               <td align="center" class="form-matrix-values">
  2155.                 <input class="form-checkbox validate[required]" type="checkbox" name="q185_input185[0][]" value="Public transportation" />
  2156.               </td>
  2157.               <td align="center" class="form-matrix-values">
  2158.                 <input class="form-checkbox validate[required]" type="checkbox" name="q185_input185[0][]" value="Other" />
  2159.               </td>
  2160.             </tr>
  2161.           </table>
  2162.         </div>
  2163.       </li>
  2164.       <li class="form-line" id="id_186">
  2165.         <label class="form-label-top" id="label_186" for="input_186">
  2166.           Funding<span class="form-required">*</span>
  2167.         </label>
  2168.         <div id="cid_186" class="form-input-wide">
  2169.           <table summary="" cellpadding="4" cellspacing="0" class="form-matrix-table">
  2170.             <tr>
  2171.               <th style="border:none">
  2172.                 &nbsp;
  2173.               </th>
  2174.               <th class="form-matrix-column-headers form-matrix-column_0">
  2175.                 Parents
  2176.               </th>
  2177.               <th class="form-matrix-column-headers form-matrix-column_1">
  2178.                 Self-sponsored
  2179.               </th>
  2180.               <th class="form-matrix-column-headers form-matrix-column_2">
  2181.                 Scholarship
  2182.               </th>
  2183.               <th class="form-matrix-column-headers form-matrix-column_3">
  2184.                 Relatives
  2185.               </th>
  2186.             </tr>
  2187.             <tr>
  2188.               <th align="left" class="form-matrix-row-headers">
  2189.                 Who pays for your tuition, room and board, and books? (select all that apply)
  2190.               </th>
  2191.               <td align="center" class="form-matrix-values">
  2192.                 <input class="form-checkbox validate[required]" type="checkbox" name="q186_input186[0][]" value="Parents" />
  2193.               </td>
  2194.               <td align="center" class="form-matrix-values">
  2195.                 <input class="form-checkbox validate[required]" type="checkbox" name="q186_input186[0][]" value="Self-sponsored" />
  2196.               </td>
  2197.               <td align="center" class="form-matrix-values">
  2198.                 <input class="form-checkbox validate[required]" type="checkbox" name="q186_input186[0][]" value="Scholarship" />
  2199.               </td>
  2200.               <td align="center" class="form-matrix-values">
  2201.                 <input class="form-checkbox validate[required]" type="checkbox" name="q186_input186[0][]" value="Relatives" />
  2202.               </td>
  2203.             </tr>
  2204.           </table>
  2205.         </div>
  2206.       </li>
  2207.       <li class="form-line" id="id_187">
  2208.         <label class="form-label-left" id="label_187" for="input_187">
  2209.           Are you concerned about your job prospects?<span class="form-required">*</span>
  2210.         </label>
  2211.         <div id="cid_187" class="form-input">
  2212.           <div class="form-single-column"><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox validate[required]" id="input_187_0" name="q187_areYou187[]" value="Yes" />
  2213.               <label for="input_187_0"> Yes </label></span><span class="clearfix"></span><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox validate[required]" id="input_187_1" name="q187_areYou187[]" value="No" />
  2214.               <label for="input_187_1"> No </label></span><span class="clearfix"></span>
  2215.           </div>
  2216.         </div>
  2217.       </li>
  2218.       <li class="form-line" id="id_188">
  2219.         <label class="form-label-right" id="label_188" for="input_188">
  2220.           If you answered Yes to the above, describe the challenges you are facing, explain what you think will help with improving your chances.<span class="form-required">*</span>
  2221.         </label>
  2222.         <div id="cid_188" class="form-input">
  2223.           <textarea id="input_188" class="form-textarea validate[required]" name="q188_ifYou188" cols="40" rows="6"></textarea>
  2224.         </div>
  2225.       </li>
  2226.       <li class="form-line" id="id_189">
  2227.         <label class="form-label-left" id="label_189" for="input_189">
  2228.           Are your parents, siblings or other family members willing and able to help you until you are able to secure employment?<span class="form-required">*</span>
  2229.         </label>
  2230.         <div id="cid_189" class="form-input">
  2231.           <div class="form-single-column"><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox validate[required]" id="input_189_0" name="q189_areYour[]" value="Yes" />
  2232.               <label for="input_189_0"> Yes </label></span><span class="clearfix"></span><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox validate[required]" id="input_189_1" name="q189_areYour[]" value="No" />
  2233.               <label for="input_189_1"> No </label></span><span class="clearfix"></span>
  2234.           </div>
  2235.         </div>
  2236.       </li>
  2237.       <li class="form-line" id="id_190">
  2238.         <label class="form-label-right" id="label_190" for="input_190">
  2239.           If you answered No to the above question, explain why<span class="form-required">*</span>
  2240.         </label>
  2241.         <div id="cid_190" class="form-input">
  2242.           <textarea id="input_190" class="form-textarea validate[required]" name="q190_ifYou190" cols="40" rows="6"></textarea>
  2243.         </div>
  2244.       </li>
  2245.       <li class="form-line" id="id_191">
  2246.         <label class="form-label-left" id="label_191" for="input_191">
  2247.           Would you be willing to volunteer your time to help Jesus Foundation organize career development training programs?<span class="form-required">*</span>
  2248.         </label>
  2249.         <div id="cid_191" class="form-input">
  2250.           <div class="form-single-column"><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox validate[required]" id="input_191_0" name="q191_wouldYou[]" value="Yes, only if I am selected for a Jesus Foundation scholarship" />
  2251.               <label for="input_191_0"> Yes, only if I am selected for a Jesus Foundation scholarship </label></span><span class="clearfix"></span><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox validate[required]" id="input_191_1" name="q191_wouldYou[]" value="Yes, whether or not I am selected for Jesus Foundation scholarship" />
  2252.               <label for="input_191_1"> Yes, whether or not I am selected for Jesus Foundation scholarship </label></span><span class="clearfix"></span><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox validate[required]" id="input_191_2" name="q191_wouldYou[]" value="No" />
  2253.               <label for="input_191_2"> No </label></span><span class="clearfix"></span>
  2254.           </div>
  2255.         </div>
  2256.       </li>
  2257.       <li id="cid_193" class="form-input-wide">
  2258.         <div class="form-pagebreak">
  2259.           <div class="form-pagebreak-back-container form-label-left">
  2260.             <button type="button" class="form-pagebreak-back  form-submit-button-simple_green" id="form-pagebreak-back_193">
  2261.               Back
  2262.             </button>
  2263.           </div>
  2264.           <div class="form-pagebreak-next-container">
  2265.             <button type="button" class="form-pagebreak-next  form-submit-button-simple_green" id="form-pagebreak-next_193">
  2266.               Next
  2267.             </button>
  2268.           </div>
  2269.         </div>
  2270.       </li>
  2271.     </ul>
  2272.     <ul class="form-section" style="display:none;">
  2273.       <li class="form-line" id="id_272">
  2274.         <div id="cid_272" class="form-input-wide">
  2275.           <div id="text_272" class="form-html">
  2276.             <div style="background: #FF0000; color: #ffffff; padding-top: 4px; padding-bottom: 4px; padding-left: 4px; font-size: 16pt; font-family: Arial; letter-spacing: 1pt;"><span style="color: #ffffff; font-family: Arial;"><span style="font-size: 21px; letter-spacing: 1px;"><strong>
  2277.                     INTERESTS
  2278.                   </strong></span></span>
  2279.             </div>
  2280.           </div>
  2281.         </div>
  2282.       </li>
  2283.       <li class="form-line" id="id_266">
  2284.         <label class="form-label-top" id="label_266" for="input_266">
  2285.           Assuming money is not an objective, which of the following industries would you enjoy working in on a full-time basis (pick one only)<span class="form-required">*</span>
  2286.         </label>
  2287.         <div id="cid_266" class="form-input-wide">
  2288.           <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_266_0" name="q266_assumingMoney266" value="Agriculture" />
  2289.               <label for="input_266_0"> Agriculture </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_266_1" name="q266_assumingMoney266" value="Hospitality" />
  2290.               <label for="input_266_1"> Hospitality </label></span><span class="clearfix"></span><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_266_2" name="q266_assumingMoney266" value="Arts &amp; Crafts" />
  2291.               <label for="input_266_2"> Arts &amp; Crafts </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_266_3" name="q266_assumingMoney266" value="Information Technology" />
  2292.               <label for="input_266_3"> Information Technology </label></span><span class="clearfix"></span><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_266_4" name="q266_assumingMoney266" value="Banking &amp; Financial Services" />
  2293.               <label for="input_266_4"> Banking &amp; Financial Services </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_266_5" name="q266_assumingMoney266" value="Media" />
  2294.               <label for="input_266_5"> Media </label></span><span class="clearfix"></span><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_266_6" name="q266_assumingMoney266" value="Building/Construction" />
  2295.               <label for="input_266_6"> Building/Construction </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_266_7" name="q266_assumingMoney266" value="Oil &amp; Gas" />
  2296.               <label for="input_266_7"> Oil &amp; Gas </label></span><span class="clearfix"></span><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_266_8" name="q266_assumingMoney266" value="Catering/ Culinary services" />
  2297.               <label for="input_266_8"> Catering/ Culinary services </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_266_9" name="q266_assumingMoney266" value="Power Generation/Transmission" />
  2298.               <label for="input_266_9"> Power Generation/Transmission </label></span><span class="clearfix"></span><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_266_10" name="q266_assumingMoney266" value="Christian Ministry" />
  2299.               <label for="input_266_10"> Christian Ministry </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_266_11" name="q266_assumingMoney266" value="Publishing" />
  2300.               <label for="input_266_11"> Publishing </label></span><span class="clearfix"></span><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_266_12" name="q266_assumingMoney266" value="Education" />
  2301.               <label for="input_266_12"> Education </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_266_13" name="q266_assumingMoney266" value="Software" />
  2302.               <label for="input_266_13"> Software </label></span><span class="clearfix"></span><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_266_14" name="q266_assumingMoney266" value="Entertainment" />
  2303.               <label for="input_266_14"> Entertainment </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_266_15" name="q266_assumingMoney266" value="Sports" />
  2304.               <label for="input_266_15"> Sports </label></span><span class="clearfix"></span><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_266_16" name="q266_assumingMoney266" value="Fashion" />
  2305.               <label for="input_266_16"> Fashion </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio validate[required]" id="input_266_17" name="q266_assumingMoney266" value="Transportation" />
  2306.               <label for="input_266_17"> Transportation </label></span><span class="clearfix"></span><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_266_18" name="q266_assumingMoney266" value="Health Care" />
  2307.               <label for="input_266_18"> Health Care </label></span><span class="clearfix"></span><span class="form-radio-item" style="clear:left"><input type="radio" class="form-radio-other form-radio validate[required]" name="q266_assumingMoney266" id="other_266" value="" />
  2308.               <input type="text" class="form-radio-other-input" name="q266_assumingMoney266[other]" data-otherHint="Other" size="15" id="input_266" disabled="disabled" />
  2309.               <br /></span>
  2310.           </div>
  2311.         </div>
  2312.       </li>
  2313.       <li class="form-line" id="id_271">
  2314.         <div id="cid_271" class="form-input-wide">
  2315.           <div id="text_271" class="form-html">
  2316.             <div style="background: #FF0000; color: #ffffff; padding-top: 4px; padding-bottom: 4px; padding-left: 4px; font-size: 16pt; font-family: Arial; letter-spacing: 1pt;"><span style="color: #ffffff; font-family: Arial;"><span style="font-size: 21px; letter-spacing: 1px;"><strong>
  2317.                     COMPUTER SKILLS
  2318.                   </strong></span></span>
  2319.             </div>
  2320.           </div>
  2321.         </div>
  2322.       </li>
  2323.       <li class="form-line" id="id_195">
  2324.         <div id="cid_195" class="form-input-wide">
  2325.           <div id="text_195" class="form-html">
  2326.             <div style="font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 10px;">
  2327.               On a scale of 1 to 5", rate your proficiency in one of the skill sets below and indicate if you believe computing skills are necessary for you to obtain employment or start your own business. "5" being very proficient/very important.
  2328.             </div>
  2329.           </div>
  2330.         </div>
  2331.       </li>
  2332.       <li class="form-line" id="id_196">
  2333.         <label class="form-label-left" id="label_196" for="input_196"> I have never learnt any computer skills </label>
  2334.         <div id="cid_196" class="form-input">
  2335.           <div class="form-single-column"><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox" id="input_196_0" name="q196_iHave196[]" value="Option 1" />
  2336.               <label for="input_196_0"> Option 1 </label></span><span class="clearfix"></span><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox" id="input_196_1" name="q196_iHave196[]" value="Option 2" />
  2337.               <label for="input_196_1"> Option 2 </label></span><span class="clearfix"></span><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox" id="input_196_2" name="q196_iHave196[]" value="Option 3" />
  2338.               <label for="input_196_2"> Option 3 </label></span><span class="clearfix"></span>
  2339.           </div>
  2340.         </div>
  2341.       </li>
  2342.       <li class="form-line" id="id_197">
  2343.         <label class="form-label-top" id="label_197" for="input_197">
  2344.           Computer Skill sets<span class="form-required">*</span>
  2345.         </label>
  2346.         <div id="cid_197" class="form-input-wide">
  2347.           <table summary="" cellpadding="4" cellspacing="0" class="form-matrix-table">
  2348.             <tr>
  2349.               <th style="border:none">
  2350.                 &nbsp;
  2351.               </th>
  2352.               <th class="form-matrix-column-headers form-matrix-column_0">
  2353.                 1
  2354.               </th>
  2355.               <th class="form-matrix-column-headers form-matrix-column_1">
  2356.                 2
  2357.               </th>
  2358.               <th class="form-matrix-column-headers form-matrix-column_2">
  2359.                 3
  2360.               </th>
  2361.               <th class="form-matrix-column-headers form-matrix-column_3">
  2362.                 4
  2363.               </th>
  2364.               <th class="form-matrix-column-headers form-matrix-column_4">
  2365.                 5
  2366.               </th>
  2367.             </tr>
  2368.             <tr>
  2369.               <th align="left" class="form-matrix-row-headers">
  2370.                 General use of computers
  2371.               </th>
  2372.               <td align="center" class="form-matrix-values">
  2373.                 <input class="form-radio validate[required]" type="radio" name="q197_computerSkill[0]" value="1" />
  2374.               </td>
  2375.               <td align="center" class="form-matrix-values">
  2376.                 <input class="form-radio validate[required]" type="radio" name="q197_computerSkill[0]" value="2" />
  2377.               </td>
  2378.               <td align="center" class="form-matrix-values">
  2379.                 <input class="form-radio validate[required]" type="radio" name="q197_computerSkill[0]" value="3" />
  2380.               </td>
  2381.               <td align="center" class="form-matrix-values">
  2382.                 <input class="form-radio validate[required]" type="radio" name="q197_computerSkill[0]" value="4" />
  2383.               </td>
  2384.               <td align="center" class="form-matrix-values">
  2385.                 <input class="form-radio validate[required]" type="radio" name="q197_computerSkill[0]" value="5" />
  2386.               </td>
  2387.             </tr>
  2388.             <tr>
  2389.               <th align="left" class="form-matrix-row-headers">
  2390.                 Microsoft Office Suite- Excel, Word, Power Point, Access
  2391.               </th>
  2392.               <td align="center" class="form-matrix-values">
  2393.                 <input class="form-radio validate[required]" type="radio" name="q197_computerSkill[1]" value="1" />
  2394.               </td>
  2395.               <td align="center" class="form-matrix-values">
  2396.                 <input class="form-radio validate[required]" type="radio" name="q197_computerSkill[1]" value="2" />
  2397.               </td>
  2398.               <td align="center" class="form-matrix-values">
  2399.                 <input class="form-radio validate[required]" type="radio" name="q197_computerSkill[1]" value="3" />
  2400.               </td>
  2401.               <td align="center" class="form-matrix-values">
  2402.                 <input class="form-radio validate[required]" type="radio" name="q197_computerSkill[1]" value="4" />
  2403.               </td>
  2404.               <td align="center" class="form-matrix-values">
  2405.                 <input class="form-radio validate[required]" type="radio" name="q197_computerSkill[1]" value="5" />
  2406.               </td>
  2407.             </tr>
  2408.             <tr>
  2409.               <th align="left" class="form-matrix-row-headers">
  2410.                 HTML, Web Design
  2411.               </th>
  2412.               <td align="center" class="form-matrix-values">
  2413.                 <input class="form-radio validate[required]" type="radio" name="q197_computerSkill[2]" value="1" />
  2414.               </td>
  2415.               <td align="center" class="form-matrix-values">
  2416.                 <input class="form-radio validate[required]" type="radio" name="q197_computerSkill[2]" value="2" />
  2417.               </td>
  2418.               <td align="center" class="form-matrix-values">
  2419.                 <input class="form-radio validate[required]" type="radio" name="q197_computerSkill[2]" value="3" />
  2420.               </td>
  2421.               <td align="center" class="form-matrix-values">
  2422.                 <input class="form-radio validate[required]" type="radio" name="q197_computerSkill[2]" value="4" />
  2423.               </td>
  2424.               <td align="center" class="form-matrix-values">
  2425.                 <input class="form-radio validate[required]" type="radio" name="q197_computerSkill[2]" value="5" />
  2426.               </td>
  2427.             </tr>
  2428.             <tr>
  2429.               <th align="left" class="form-matrix-row-headers">
  2430.                 Adobe Photoshop
  2431.               </th>
  2432.               <td align="center" class="form-matrix-values">
  2433.                 <input class="form-radio validate[required]" type="radio" name="q197_computerSkill[3]" value="1" />
  2434.               </td>
  2435.               <td align="center" class="form-matrix-values">
  2436.                 <input class="form-radio validate[required]" type="radio" name="q197_computerSkill[3]" value="2" />
  2437.               </td>
  2438.               <td align="center" class="form-matrix-values">
  2439.                 <input class="form-radio validate[required]" type="radio" name="q197_computerSkill[3]" value="3" />
  2440.               </td>
  2441.               <td align="center" class="form-matrix-values">
  2442.                 <input class="form-radio validate[required]" type="radio" name="q197_computerSkill[3]" value="4" />
  2443.               </td>
  2444.               <td align="center" class="form-matrix-values">
  2445.                 <input class="form-radio validate[required]" type="radio" name="q197_computerSkill[3]" value="5" />
  2446.               </td>
  2447.             </tr>
  2448.           </table>
  2449.         </div>
  2450.       </li>
  2451.       <li class="form-line" id="id_199">
  2452.         <label class="form-label-left" id="label_199" for="input_199"> Other (provide description) </label>
  2453.         <div id="cid_199" class="form-input">
  2454.           <textarea id="input_199" class="form-textarea" name="q199_otherprovide" cols="40" rows="6"></textarea>
  2455.         </div>
  2456.       </li>
  2457.       <li class="form-line" id="id_270">
  2458.         <div id="cid_270" class="form-input-wide">
  2459.           <div id="text_270" class="form-html">
  2460.             <div style="background: #FF0000; color: #ffffff; padding-top: 4px; padding-bottom: 4px; padding-left: 4px; font-size: 16pt; font-family: Arial; letter-spacing: 1pt;">
  2461.               <strong>
  2462.                 INFORMATION ON TRAINING PROGRAMS
  2463.               </strong>
  2464.             </div>
  2465.           </div>
  2466.         </div>
  2467.       </li>
  2468.       <li class="form-line" id="id_201">
  2469.         <label class="form-label-top" id="label_201" for="input_201">
  2470.           If you have already started or completed a training program (excluding secondary or university education), How much did you pay for the training?<span class="form-required">*</span>
  2471.         </label>
  2472.         <div id="cid_201" class="form-input-wide">
  2473.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_201" name="q201_ifYou201" size="30" value="" />
  2474.         </div>
  2475.       </li>
  2476.       <li class="form-line" id="id_202">
  2477.         <label class="form-label-top" id="label_202" for="input_202">
  2478.           How did you pay for the training? (from: savings, parents, relatives, friends, church, scholarship?)<span class="form-required">*</span>
  2479.         </label>
  2480.         <div id="cid_202" class="form-input-wide">
  2481.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_202" name="q202_howDid202" size="30" value="" />
  2482.         </div>
  2483.       </li>
  2484.       <li class="form-line" id="id_203">
  2485.         <label class="form-label-top" id="label_203" for="input_203">
  2486.           What was the training program?<span class="form-required">*</span>
  2487.         </label>
  2488.         <div id="cid_203" class="form-input-wide">
  2489.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_203" name="q203_whatWas" size="30" value="" />
  2490.         </div>
  2491.       </li>
  2492.       <li class="form-line" id="id_204">
  2493.         <label class="form-label-top" id="label_204" for="input_204">
  2494.           Name of organization that provided the training?<span class="form-required">*</span>
  2495.         </label>
  2496.         <div id="cid_204" class="form-input-wide">
  2497.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_204" name="q204_nameOf204" size="30" value="" />
  2498.         </div>
  2499.       </li>
  2500.       <li class="form-line" id="id_205">
  2501.         <div id="cid_205" class="form-input-wide">
  2502.           <div id="text_205" class="form-html">
  2503.             <p>
  2504.               <hr/>
  2505.             </p>
  2506.           </div>
  2507.         </div>
  2508.       </li>
  2509.       <li class="form-line" id="id_206">
  2510.         <label class="form-label-top" id="label_206" for="input_206">
  2511.           If you have not yet obtained any specialized training to enable you pursue your interest or skills, please provide the type of training you are interested in<span class="form-required">*</span>
  2512.         </label>
  2513.         <div id="cid_206" class="form-input-wide">
  2514.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_206" name="q206_ifYou" size="30" value="" />
  2515.         </div>
  2516.       </li>
  2517.       <li class="form-line" id="id_207">
  2518.         <label class="form-label-top" id="label_207" for="input_207">
  2519.           Name of Organization providing the training<span class="form-required">*</span>
  2520.         </label>
  2521.         <div id="cid_207" class="form-input-wide">
  2522.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_207" name="q207_nameOf207" size="30" value="" />
  2523.         </div>
  2524.       </li>
  2525.       <li class="form-line" id="id_208">
  2526.         <label class="form-label-top" id="label_208" for="input_208">
  2527.           How much can you afford to pay for a similar program?<span class="form-required">*</span>
  2528.         </label>
  2529.         <div id="cid_208" class="form-input-wide">
  2530.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_208" name="q208_howMuch" size="30" value="" />
  2531.         </div>
  2532.       </li>
  2533.       <li class="form-line" id="id_209">
  2534.         <div id="cid_209" class="form-input-wide">
  2535.           <div id="text_209" class="form-html">
  2536.             <p>
  2537.               <hr/>
  2538.             </p>
  2539.           </div>
  2540.         </div>
  2541.       </li>
  2542.       <li class="form-line" id="id_210">
  2543.         <label class="form-label-top" id="label_210" for="input_210"> If you have not yet obtained any specialized training to enable you pursue your interest or skills, are you interested in a program advertised by Jesus Foundation? Provide name of the program </label>
  2544.         <div id="cid_210" class="form-input-wide">
  2545.           <input type="text" class=" form-textbox" data-type="input-textbox" id="input_210" name="q210_ifYou210" size="30" value="" />
  2546.         </div>
  2547.       </li>
  2548.       <li class="form-line" id="id_211">
  2549.         <label class="form-label-top" id="label_211" for="input_211"> Commencement date of the program: </label>
  2550.         <div id="cid_211" class="form-input-wide"><span class="form-sub-label-container"><input class="form-textbox" id="month_211" name="q211_commencementDate[month]" type="tel" size="2" maxlength="2" value="" /><span class="date-separate">&nbsp;/</span>
  2551.             <label class="form-sub-label" for="month_211" id="sublabel_month"> Month </label></span><span class="form-sub-label-container"><input class="noDefault form-textbox" id="day_211" name="q211_commencementDate[day]" type="tel" size="2" maxlength="2" value="" /><span class="date-separate">&nbsp;/</span>
  2552.             <label class="form-sub-label" for="day_211" id="sublabel_day"> Day </label></span><span class="form-sub-label-container"><input class="form-textbox" id="year_211" name="q211_commencementDate[year]" type="tel" size="4" maxlength="4" value="" />
  2553.             <label class="form-sub-label" for="year_211" id="sublabel_year"> Year </label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_211_pick" src="http://support.jotform.com/images/calendar.png" align="absmiddle" />
  2554.             <label class="form-sub-label" for="input_211_pick"> &nbsp;&nbsp;&nbsp; </label></span>
  2555.         </div>
  2556.       </li>
  2557.       <li class="form-line" id="id_212">
  2558.         <label class="form-label-top" id="label_212" for="input_212">
  2559.           How much can you afford to pay for a similar program?<span class="form-required">*</span>
  2560.         </label>
  2561.         <div id="cid_212" class="form-input-wide">
  2562.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_212" name="q212_howMuch212" size="30" value="" />
  2563.         </div>
  2564.       </li>
  2565.       <li id="cid_214" class="form-input-wide">
  2566.         <div class="form-pagebreak">
  2567.           <div class="form-pagebreak-back-container form-label-left">
  2568.             <button type="button" class="form-pagebreak-back  form-submit-button-simple_green" id="form-pagebreak-back_214">
  2569.               Back
  2570.             </button>
  2571.           </div>
  2572.           <div class="form-pagebreak-next-container">
  2573.             <button type="button" class="form-pagebreak-next  form-submit-button-simple_green" id="form-pagebreak-next_214">
  2574.               Next
  2575.             </button>
  2576.           </div>
  2577.         </div>
  2578.       </li>
  2579.     </ul>
  2580.     <ul class="form-section" style="display:none;">
  2581.       <li class="form-line" id="id_213">
  2582.         <div id="cid_213" class="form-input-wide">
  2583.           <div id="text_213" class="form-html">
  2584.             <div style="background: #FF0000; color: #ffffff; padding-top: 4px; padding-bottom: 4px; padding-left: 4px; font-size: 16pt; font-family: Arial; letter-spacing: 1pt;">
  2585.               <strong>
  2586.                 WRITE-UP
  2587.               </strong>
  2588.             </div>
  2589.             <div>
  2590.               In the space provided below, describe how you intend to leverage on your existing or prospective skill set (e.g. computer skills) or interests (e.g. hospitality/fashion etc.) to gain employment or create a business.
  2591.             </div>
  2592.           </div>
  2593.         </div>
  2594.       </li>
  2595.       <li class="form-line" id="id_215">
  2596.         <label class="form-label-top" id="label_215" for="input_215">
  2597.           If you have not started pursuing your interest, please explain why.<span class="form-required">*</span>
  2598.         </label>
  2599.         <div id="cid_215" class="form-input-wide">
  2600.           <textarea id="input_215" class="form-textarea validate[required]" name="q215_ifYou215" cols="90" rows="30"></textarea>
  2601.         </div>
  2602.       </li>
  2603.       <li id="cid_216" class="form-input-wide">
  2604.         <div class="form-pagebreak">
  2605.           <div class="form-pagebreak-back-container form-label-left">
  2606.             <button type="button" class="form-pagebreak-back  form-submit-button-simple_green" id="form-pagebreak-back_216">
  2607.               Back
  2608.             </button>
  2609.           </div>
  2610.           <div class="form-pagebreak-next-container">
  2611.             <button type="button" class="form-pagebreak-next  form-submit-button-simple_green" id="form-pagebreak-next_216">
  2612.               Next
  2613.             </button>
  2614.           </div>
  2615.         </div>
  2616.       </li>
  2617.     </ul>
  2618.     <ul class="form-section" style="display:none;">
  2619.       <li class="form-line" id="id_217">
  2620.         <div id="cid_217" class="form-input-wide">
  2621.           <div id="text_217" class="form-html">
  2622.             <div style="background: #FF0000; color: #ffffff; padding-top: 4px; padding-bottom: 4px; padding-left: 4px; font-size: 16pt; font-family: Arial; letter-spacing: 1pt;">
  2623.               <strong>
  2624.                 REFERENCES
  2625.               </strong>
  2626.             </div>
  2627.             <div><span style="font-size: 9.0pt; font-family: Arial;">Provide two character references (i.e. teachers, lecturers, pastors, employers (current or previous), please
  2628.                 <strong><span style="text-decoration: underline;">do not</span>
  2629.                 </strong>
  2630.                 include family members or relatives).</span>
  2631.             </div>
  2632.           </div>
  2633.         </div>
  2634.       </li>
  2635.       <li class="form-line" id="id_218">
  2636.         <label class="form-label-left" id="label_218" for="input_218">
  2637.           Name<span class="form-required">*</span>
  2638.         </label>
  2639.         <div id="cid_218" class="form-input">
  2640.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_218" name="q218_name" size="50" value="" />
  2641.         </div>
  2642.       </li>
  2643.       <li class="form-line" id="id_219">
  2644.         <label class="form-label-left" id="label_219" for="input_219">
  2645.           Title & Place of employment<span class="form-required">*</span>
  2646.        </label>
  2647.        <div id="cid_219" class="form-input">
  2648.          <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_219" name="q219_title" size="50" value="" />
  2649.        </div>
  2650.      </li>
  2651.      <li class="form-line" id="id_221">
  2652.        <label class="form-label-left" id="label_221" for="input_221">
  2653.          Contact Email<span class="form-required">*</span>
  2654.        </label>
  2655.        <div id="cid_221" class="form-input">
  2656.          <input type="email" class=" form-textbox validate[required, Email]" id="input_221" name="q221_contactEmail221" size="30" value="" />
  2657.        </div>
  2658.      </li>
  2659.      <li class="form-line" id="id_294">
  2660.        <label class="form-label-left" id="label_294" for="input_294">
  2661.          Contact Phone<span class="form-required">*</span>
  2662.        </label>
  2663.        <div id="cid_294" class="form-input">
  2664.          <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_294" name="q294_contactPhone294" size="20" value="" />
  2665.        </div>
  2666.      </li>
  2667.      <li class="form-line" id="id_220">
  2668.        <label class="form-label-left" id="label_220" for="input_220">
  2669.          Relationship to Referee<span class="form-required">*</span>
  2670.        </label>
  2671.        <div id="cid_220" class="form-input">
  2672.          <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_220" name="q220_relationshipTo" size="50" value="" />
  2673.        </div>
  2674.      </li>
  2675.      <li class="form-line" id="id_224">
  2676.        <div id="cid_224" class="form-input-wide">
  2677.          <div id="text_224" class="form-html">
  2678.            <p>
  2679.              <hr/>
  2680.            </p>
  2681.          </div>
  2682.        </div>
  2683.      </li>
  2684.      <li class="form-line" id="id_223">
  2685.        <label class="form-label-left" id="label_223" for="input_223">
  2686.          Name<span class="form-required">*</span>
  2687.        </label>
  2688.        <div id="cid_223" class="form-input">
  2689.          <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_223" name="q223_name223" size="50" value="" />
  2690.        </div>
  2691.      </li>
  2692.      <li class="form-line" id="id_225">
  2693.        <label class="form-label-left" id="label_225" for="input_225">
  2694.          Title & Place of employment<span class="form-required">*</span>
  2695.        </label>
  2696.        <div id="cid_225" class="form-input">
  2697.          <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_225" name="q225_title225" size="50" value="" />
  2698.        </div>
  2699.      </li>
  2700.      <li class="form-line" id="id_226">
  2701.        <label class="form-label-left" id="label_226" for="input_226">
  2702.          Contact Email<span class="form-required">*</span>
  2703.        </label>
  2704.        <div id="cid_226" class="form-input">
  2705.          <input type="email" class=" form-textbox validate[required, Email]" id="input_226" name="q226_contactEmail" size="30" value="" />
  2706.        </div>
  2707.      </li>
  2708.      <li class="form-line" id="id_293">
  2709.        <label class="form-label-left" id="label_293" for="input_293">
  2710.          Contact Phone<span class="form-required">*</span>
  2711.        </label>
  2712.        <div id="cid_293" class="form-input">
  2713.          <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_293" name="q293_contactPhone293" size="20" value="" />
  2714.        </div>
  2715.      </li>
  2716.      <li class="form-line" id="id_228">
  2717.        <label class="form-label-left" id="label_228" for="input_228">
  2718.          Relationship to Referee<span class="form-required">*</span>
  2719.        </label>
  2720.        <div id="cid_228" class="form-input">
  2721.          <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_228" name="q228_relationshipTo228" size="50" value="" />
  2722.        </div>
  2723.      </li>
  2724.      <li class="form-line" id="id_229">
  2725.        <div id="cid_229" class="form-input-wide">
  2726.          <div id="text_229" class="form-html">
  2727.            <p>
  2728.              <hr/>
  2729.            </p>
  2730.          </div>
  2731.        </div>
  2732.      </li>
  2733.      <li class="form-line form-line-column" id="id_230">
  2734.        <label class="form-label-top" id="label_230" for="input_230">
  2735.          Name of Applicant (Print)<span class="form-required">*</span>
  2736.        </label>
  2737.        <div id="cid_230" class="form-input-wide">
  2738.          <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_230" name="q230_nameOf230" size="30" value="" />
  2739.        </div>
  2740.      </li>
  2741.      <li class="form-line form-line-column" id="id_231">
  2742.        <label class="form-label-top" id="label_231" for="input_231"> Name of Parent/Guardian (for applicant under the age of 18 years) </label>
  2743.        <div id="cid_231" class="form-input-wide">
  2744.          <input type="text" class=" form-textbox" data-type="input-textbox" id="input_231" name="q231_nameOf231" size="60" value="" />
  2745.        </div>
  2746.      </li>
  2747.      <li class="form-line form-line-column" id="id_232">
  2748.        <label class="form-label-top" id="label_232" for="input_232"> Signature of Applicant </label>
  2749.        <div id="cid_232" class="form-input-wide">
  2750.          <div id="signature_pad_232" class="signature-pad-wrapper" style="width:222px">
  2751.            <!--[if IE 7]>
  2752.              <script type="text/javascript" src="/js/vendor/json2.js"></script>
  2753.            <![endif]-->
  2754.            <div class="signature-line signature-wrapper">
  2755.              <div id="sig_pad_232" data-width="220" data-height="70" data-id="232" data-required="false" class="pad" style="border:1px solid #AAA;margin-top:2px;margin-left:1px; width:220px">
  2756.               </div>
  2757.               <input type="hidden" name="q232_signatureOf" class="output4" id="sig_pad_232">
  2758.             </div><span class="clear-pad" style="cursor:pointer;text-decoration:underline;float:right;font-weight:bold;font-size:12px;">Clear</span>
  2759.           </div>
  2760.           <script type="text/javascript">
  2761.           window.signatureForm = true
  2762.           </script>
  2763.         </div>
  2764.       </li>
  2765.       <li class="form-line form-line-column" id="id_233">
  2766.         <label class="form-label-top" id="label_233" for="input_233"> Signature of Parent/Guardian (for applicant under the age of 18 years) </label>
  2767.         <div id="cid_233" class="form-input-wide">
  2768.           <div id="signature_pad_233" class="signature-pad-wrapper" style="width:400px">
  2769.             <!--[if IE 7]>
  2770.              <script type="text/javascript" src="/js/vendor/json2.js"></script>
  2771.            <![endif]-->
  2772.             <div class="signature-line signature-wrapper">
  2773.               <div id="sig_pad_233" data-width="398" data-height="70" data-id="233" data-required="false" class="pad" style="border:1px solid #AAA;margin-top:2px;margin-left:1px; width:398px">
  2774.               </div>
  2775.               <input type="hidden" name="q233_signatureOf233" class="output4" id="sig_pad_233">
  2776.             </div><span class="clear-pad" style="cursor:pointer;text-decoration:underline;float:right;font-weight:bold;font-size:12px;">Clear</span>
  2777.           </div>
  2778.           <script type="text/javascript">
  2779.           window.signatureForm = true
  2780.           </script>
  2781.         </div>
  2782.       </li>
  2783.       <li class="form-line" id="id_277">
  2784.         <label class="form-label-left" id="label_277" for="input_277"> I certify the above information is true and correct to the best of my knowledge* </label>
  2785.         <div id="cid_277" class="form-input">
  2786.           <div class="form-single-column"><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox" id="input_277_0" name="q277_iCertify277[]" value="&nbsp;" />
  2787.               <label for="input_277_0"> &nbsp; </label></span><span class="clearfix"></span>
  2788.           </div>
  2789.         </div>
  2790.       </li>
  2791.       <li class="form-line" id="id_235">
  2792.         <div id="cid_235" class="form-input-wide">
  2793.           <div id="text_235" class="form-html">
  2794.             <p class="MsoNormal"><span style="font-size: 9.0pt; mso-bidi-font-family: Arial; color: red;">* Please note- if you are completing this application online and submitting it through the web you do not need to print this form in order to sign it.&nbsp; Instead, by checking the "I certify the above information is true and correct to the best of my knowledge" box, we would accept this as your electronic signature.&nbsp; Please sign this form if you are submitting a scanned version through email, otherwise your application will not be accepted.</span>
  2795.             </p>
  2796.           </div>
  2797.         </div>
  2798.       </li>
  2799.       <li class="form-line" id="id_236">
  2800.         <div id="cid_236" class="form-input-wide">
  2801.           <div id="text_236" class="form-html">
  2802.             <p class="MsoNormal"><span style="font-size: 9.0pt; mso-bidi-font-family: Arial; color: #17365d;">** If you are under the age of 18 years, please click the "Request Consent" button at the end of this application. You are required to provide the email address of your parent/guardian.&nbsp; An email will be sent to them to obtain their consent for your application as well as the above disclaimer.&nbsp; You will still need to complete your parent/guardian&rsquo;s name and details on this section of the application form.</span>
  2803.             </p>
  2804.           </div>
  2805.         </div>
  2806.       </li>
  2807.       <li id="cid_237" class="form-input-wide">
  2808.         <div class="form-pagebreak">
  2809.           <div class="form-pagebreak-back-container form-label-left">
  2810.             <button type="button" class="form-pagebreak-back  form-submit-button-simple_green" id="form-pagebreak-back_237">
  2811.               Back
  2812.             </button>
  2813.           </div>
  2814.           <div class="form-pagebreak-next-container">
  2815.             <button type="button" class="form-pagebreak-next  form-submit-button-simple_green" id="form-pagebreak-next_237">
  2816.               Next
  2817.             </button>
  2818.           </div>
  2819.         </div>
  2820.       </li>
  2821.     </ul>
  2822.     <ul class="form-section" style="display:none;">
  2823.       <li class="form-line" id="id_269">
  2824.         <div id="cid_269" class="form-input-wide">
  2825.           <div id="text_269" class="form-html">
  2826.             <div style="background: #FF0000; color: #ffffff; padding-top: 4px; padding-bottom: 4px; padding-left: 4px; font-size: 16pt; font-family: Arial; letter-spacing: 1pt;">
  2827.               <strong>
  2828.                 DISCLAIMER- LIABILITY
  2829.               </strong>
  2830.             </div>
  2831.           </div>
  2832.         </div>
  2833.       </li>
  2834.       <li class="form-line" id="id_239">
  2835.         <div id="cid_239" class="form-input-wide">
  2836.           <div id="text_239" class="form-html">
  2837.             </p>
  2838.             <p class="MsoNormal" style="margin-bottom: 3.0pt;"><span style="font-size: 9.0pt; mso-bidi-font-family: Arial;">Jesus Foundation does not provide liability insurance for the protection of individuals, groups, organizations, businesses, spectators, volunteers or others who may participate in the training program(s) sponsored or organized by us or for which we provide scholarships.</span>
  2839.             </p>
  2840.             </p>
  2841.             <p class="MsoNormal" style="margin-bottom: 3.0pt;"><span style="font-size: 9.0pt; mso-bidi-font-family: Arial;">In consideration for your participation in the training program(s), the individual, group, organization, business, spectator, volunteer, or other, does hereby release and forever discharge Jesus Foundation, and its officers, directors, board, employees and volunteers, jointly and severally from any and all actions, causes of actions, claims and demands for, upon or by reason of any damage, loss or injury, which hereafter may be sustained by participating in the training program(s).</span>
  2842.             </p>
  2843.             </p>
  2844.             <p class="MsoNormal" style="margin-bottom: 3.0pt;"><span style="font-size: 9.0pt; mso-bidi-font-family: Arial;">This release extends and applies to, and also covers and includes all unknown, unforeseen, unanticipated and unsuspected injuries, damages, loss and liability and the consequences thereof, as well as those now disclosed and known to exist.&nbsp; The provisions of any state, federal, local or territorial law or state providing substance that releases shall not extend to claims, demands, injuries, or damages which are known or unsuspected to exist at this time, to the person executing such release
  2845.                 are hereby expressly waived.</span>
  2846.             </p>
  2847.             </p>
  2848.             <p class="MsoNormal" style="margin-bottom: 3.0pt;"><span style="font-size: 9.0pt; mso-bidi-font-family: Arial;">I hereby agree on behalf of my heirs, executors, administrators and assigns, to indemnify Jesus Foundation and its officers, directors, board, employees and volunteers, jointly and severally from any and all actions, causes of actions, claims and demands for, upon or by reason of any damage, loss or injury which hereafter may be sustained by participating in a training program sponsored or organized by us or for which you are a scholarship recipient.</span>
  2849.             </p>
  2850.             </p>
  2851.             <p class="MsoNormal" style="margin-bottom: 3.0pt;"><span style="font-size: 9.0pt; mso-bidi-font-family: Arial;">It is further understood and agreed that said participation in a training program is not to be construed as an admission of any liability and acceptance of assumption of responsibility by Jesus Foundation, its officers, directors, board, employees and volunteers jointly and severally, for all damages and expenses for which Jesus Foundation, its officers, directors, board, employees and volunteers become liable as a result of any alleged act of the applicant.</span>
  2852.             </p>
  2853.             </p>
  2854.             </p>
  2855.           </div>
  2856.         </div>
  2857.       </li>
  2858.       <li class="form-line form-line-column" id="id_240">
  2859.         <label class="form-label-top" id="label_240" for="input_240">
  2860.           Name of Applicant (Print)<span class="form-required">*</span>
  2861.         </label>
  2862.         <div id="cid_240" class="form-input-wide">
  2863.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_240" name="q240_nameOf240" size="30" value="" />
  2864.         </div>
  2865.       </li>
  2866.       <li class="form-line form-line-column" id="id_241">
  2867.         <label class="form-label-top" id="label_241" for="input_241"> Name of Parent/Guardian (for applicant under the age of 18 years) </label>
  2868.         <div id="cid_241" class="form-input-wide">
  2869.           <input type="text" class=" form-textbox" data-type="input-textbox" id="input_241" name="q241_nameOf241" size="60" value="" />
  2870.         </div>
  2871.       </li>
  2872.       <li class="form-line form-line-column" id="id_242">
  2873.         <label class="form-label-top" id="label_242" for="input_242"> Signature of Applicant </label>
  2874.         <div id="cid_242" class="form-input-wide">
  2875.           <div id="signature_pad_242" class="signature-pad-wrapper" style="width:222px">
  2876.             <!--[if IE 7]>
  2877.              <script type="text/javascript" src="/js/vendor/json2.js"></script>
  2878.            <![endif]-->
  2879.             <div class="signature-line signature-wrapper">
  2880.               <div id="sig_pad_242" data-width="220" data-height="70" data-id="242" data-required="false" class="pad" style="border:1px solid #AAA;margin-top:2px;margin-left:1px; width:220px">
  2881.               </div>
  2882.               <input type="hidden" name="q242_signatureOf242" class="output4" id="sig_pad_242">
  2883.             </div><span class="clear-pad" style="cursor:pointer;text-decoration:underline;float:right;font-weight:bold;font-size:12px;">Clear</span>
  2884.           </div>
  2885.           <script type="text/javascript">
  2886.           window.signatureForm = true
  2887.           </script>
  2888.         </div>
  2889.       </li>
  2890.       <li class="form-line form-line-column" id="id_243">
  2891.         <label class="form-label-top" id="label_243" for="input_243"> Signature of Parent/Guardian (for applicant under the age of 18 years) </label>
  2892.         <div id="cid_243" class="form-input-wide">
  2893.           <div id="signature_pad_243" class="signature-pad-wrapper" style="width:400px">
  2894.             <!--[if IE 7]>
  2895.              <script type="text/javascript" src="/js/vendor/json2.js"></script>
  2896.            <![endif]-->
  2897.             <div class="signature-line signature-wrapper">
  2898.               <div id="sig_pad_243" data-width="398" data-height="70" data-id="243" data-required="false" class="pad" style="border:1px solid #AAA;margin-top:2px;margin-left:1px; width:398px">
  2899.               </div>
  2900.               <input type="hidden" name="q243_signatureOf243" class="output4" id="sig_pad_243">
  2901.             </div><span class="clear-pad" style="cursor:pointer;text-decoration:underline;float:right;font-weight:bold;font-size:12px;">Clear</span>
  2902.           </div>
  2903.           <script type="text/javascript">
  2904.           window.signatureForm = true
  2905.           </script>
  2906.         </div>
  2907.       </li>
  2908.       <li class="form-line" id="id_278">
  2909.         <label class="form-label-left" id="label_278" for="input_278"> I certify the above information is true and correct to the best of my knowledge* </label>
  2910.         <div id="cid_278" class="form-input">
  2911.           <div class="form-single-column"><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox" id="input_278_0" name="q278_iCertify278[]" value="&nbsp;" />
  2912.               <label for="input_278_0"> &nbsp; </label></span><span class="clearfix"></span>
  2913.           </div>
  2914.         </div>
  2915.       </li>
  2916.       <li class="form-line" id="id_245">
  2917.         <div id="cid_245" class="form-input-wide">
  2918.           <div id="text_245" class="form-html">
  2919.             <p class="MsoNormal"><span style="font-size: 9.0pt; mso-bidi-font-family: Arial; color: red;">* Please note- if you are completing this application online and submitting it through the web you do not need to print this form in order to sign it.&nbsp; Instead, by checking the "I certify the above information is true and correct to the best of my knowledge" box, we would accept this as your electronic signature.&nbsp; Please sign this form if you are submitting a scanned version through email, otherwise your application will not be accepted.</span>
  2920.             </p>
  2921.           </div>
  2922.         </div>
  2923.       </li>
  2924.       <li class="form-line" id="id_246">
  2925.         <div id="cid_246" class="form-input-wide">
  2926.           <div id="text_246" class="form-html">
  2927.             </p>
  2928.             <p><span style="font-size: 9.0pt; font-family: Arial; mso-fareast-font-family: " Times New Roman "; color: #17365d; mso-ansi-language: EN-US; mso-fareast-language: EN-US; mso-bidi-language: AR-SA;">** If you are under the age of 18 years and are completing this application online, please click the "Request Consent" button at the end of this application. You are required to provide the email address of your parent/guardian.&nbsp; An email will be sent to them to obtain their consent for your application as well as the above disclaimer.&nbsp; You will still need to complete your parent/guardian&rsquo;s name and details on this section of the application form.&nbsp; Please provide your parent/guardian
  2929.                 this application to sign where indicated only if you are submitting a scanned version through email, otherwise your application will not be accepted.</span>
  2930.             </p>
  2931.           </div>
  2932.         </div>
  2933.       </li>
  2934.       <li id="cid_247" class="form-input-wide">
  2935.         <div class="form-pagebreak">
  2936.           <div class="form-pagebreak-back-container form-label-left">
  2937.             <button type="button" class="form-pagebreak-back  form-submit-button-simple_green" id="form-pagebreak-back_247">
  2938.               Back
  2939.             </button>
  2940.           </div>
  2941.           <div class="form-pagebreak-next-container">
  2942.             <button type="button" class="form-pagebreak-next  form-submit-button-simple_green" id="form-pagebreak-next_247">
  2943.               Next
  2944.             </button>
  2945.           </div>
  2946.         </div>
  2947.       </li>
  2948.     </ul>
  2949.     <ul class="form-section" style="display:none;">
  2950.       <li class="form-line" id="id_268">
  2951.         <div id="cid_268" class="form-input-wide">
  2952.           <div id="text_268" class="form-html">
  2953.             <p>
  2954.               <div style="background: #FF0000; color: #ffffff; padding-top: 4px; padding-bottom: 4px; padding-left: 4px; font-size: 16pt; font-family: Arial; letter-spacing: 1pt;">
  2955.                 <strong>
  2956.                   CERTIFICATION AND AUTHORIZATION FOR RELEASE OF INFORMATION
  2957.                 </strong>
  2958.               </div>
  2959.             </p>
  2960.           </div>
  2961.         </div>
  2962.       </li>
  2963.       <li class="form-line" id="id_249">
  2964.         <div id="cid_249" class="form-input-wide">
  2965.           <div id="text_249" class="form-html">
  2966.             <p class="MsoNormal"><span style="font-size: 9.0pt;">I certify that all of the information I provided above is to the best of my knowledge and belief, true, correct and complete.&nbsp; I understand that any false statements made in this questionnaire would disqualify my application.</span>
  2967.             </p>
  2968.             </p>
  2969.             <p class="MsoNormal"><span style="font-size: 9.0pt;">I hereby authorize Jesus Foundation, its officers, directors, board, employees and volunteers to contact my references and/or academic institutions to verify the information provided in this questionnaire/application.</span>
  2970.             </p>
  2971.             </p>
  2972.             <p class="MsoNormal"><span style="font-size: 9.0pt;">I hereby further authorize Jesus Foundation and any of their authorized representatives to use, disclose, release and furnish personal information I provide to persons or organizations for the purpose of selecting and determining my eligibility for a training program.</span>
  2973.             </p>
  2974.             </p>
  2975.             <p class="MsoNormal"><span style="font-size: 9.0pt;">I understand that this information will be used to determine my eligibility for a training program and the completion of this questionnaire does not guarantee my acceptance.</span>
  2976.             </p>
  2977.             </p>
  2978.             <p class="MsoNormal"><span style="font-size: 9.0pt;">Should I be accepted into a training program under the auspices of Jesus Foundation that I have identified will be beneficial to me, I agree to participate in all activities including sessions on the gospel of Jesus Christ.</span>
  2979.             </p>
  2980.             </p>
  2981.             <p class="MsoNormal"><span style="font-size: 9.0pt;">Jesus Foundation promotes its activities via the use of different media sources including but not limited to social media, online/website, printed material, audio or video recording etc.</span>
  2982.             </p>
  2983.             </p>
  2984.             <p class="MsoNormal"><span style="font-size: 9.0pt;">I hereby grant permission to the rights of my image, likeness and sound of my voice (hereafter referred to as "likeness") as recorded on audio or video tape or photograph during a Jesus Foundation sponsored training program, without payment or any other consideration.&nbsp; I understand that my likeness may be edited, copied, exhibited, published or distributed for the purpose of promoting Jesus Foundation.&nbsp; I waive the right to inspect or approve any such promotional product wherein my likeness
  2985.                 appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my likeness for the purpose of promoting Jesus Foundation.&nbsp; I also understand that this material may be used in diverse educational/training settings.</span>
  2986.             </p>
  2987.             </p>
  2988.             <p class="MsoNormal"><span style="font-size: 9.0pt;">By signing this release I understand this permission signifies that my likeness may be electronically displayed via the internet or in a public educational setting.</span>
  2989.             </p>
  2990.             </p>
  2991.             <p class="MsoNormal"><span style="font-size: 9.0pt;">There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed.</span>
  2992.             </p>
  2993.             </p>
  2994.             <p class="MsoNormal"><span style="font-size: 9.0pt;">By signing this form I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing my information or likeness for the purposes of promoting Jesus Foundation and its activities.</span>
  2995.             </p>
  2996.           </div>
  2997.         </div>
  2998.       </li>
  2999.       <li class="form-line form-line-column" id="id_250">
  3000.         <label class="form-label-top" id="label_250" for="input_250">
  3001.           Name of Applicant (Print)<span class="form-required">*</span>
  3002.         </label>
  3003.         <div id="cid_250" class="form-input-wide">
  3004.           <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_250" name="q250_nameOf250" size="30" value="" />
  3005.         </div>
  3006.       </li>
  3007.       <li class="form-line form-line-column" id="id_251">
  3008.         <label class="form-label-top" id="label_251" for="input_251"> Name of Parent/Guardian (for applicant under the age of 18 years) </label>
  3009.         <div id="cid_251" class="form-input-wide">
  3010.           <input type="text" class=" form-textbox" data-type="input-textbox" id="input_251" name="q251_nameOf251" size="60" value="" />
  3011.         </div>
  3012.       </li>
  3013.       <li class="form-line form-line-column" id="id_252">
  3014.         <label class="form-label-top" id="label_252" for="input_252"> Signature of Applicant </label>
  3015.         <div id="cid_252" class="form-input-wide">
  3016.           <div id="signature_pad_252" class="signature-pad-wrapper" style="width:222px">
  3017.             <!--[if IE 7]>
  3018.              <script type="text/javascript" src="/js/vendor/json2.js"></script>
  3019.            <![endif]-->
  3020.             <div class="signature-line signature-wrapper">
  3021.               <div id="sig_pad_252" data-width="220" data-height="70" data-id="252" data-required="false" class="pad" style="border:1px solid #AAA;margin-top:2px;margin-left:1px; width:220px">
  3022.               </div>
  3023.               <input type="hidden" name="q252_signatureOf252" class="output4" id="sig_pad_252">
  3024.             </div><span class="clear-pad" style="cursor:pointer;text-decoration:underline;float:right;font-weight:bold;font-size:12px;">Clear</span>
  3025.           </div>
  3026.           <script type="text/javascript">
  3027.           window.signatureForm = true
  3028.           </script>
  3029.         </div>
  3030.       </li>
  3031.       <li class="form-line form-line-column" id="id_253">
  3032.         <label class="form-label-top" id="label_253" for="input_253"> Signature of Parent/Guardian (for applicant under the age of 18 years) </label>
  3033.         <div id="cid_253" class="form-input-wide">
  3034.           <div id="signature_pad_253" class="signature-pad-wrapper" style="width:400px">
  3035.             <!--[if IE 7]>
  3036.              <script type="text/javascript" src="/js/vendor/json2.js"></script>
  3037.            <![endif]-->
  3038.             <div class="signature-line signature-wrapper">
  3039.               <div id="sig_pad_253" data-width="398" data-height="70" data-id="253" data-required="false" class="pad" style="border:1px solid #AAA;margin-top:2px;margin-left:1px; width:398px">
  3040.               </div>
  3041.               <input type="hidden" name="q253_signatureOf253" class="output4" id="sig_pad_253">
  3042.             </div><span class="clear-pad" style="cursor:pointer;text-decoration:underline;float:right;font-weight:bold;font-size:12px;">Clear</span>
  3043.           </div>
  3044.           <script type="text/javascript">
  3045.           window.signatureForm = true
  3046.           </script>
  3047.         </div>
  3048.       </li>
  3049.       <li class="form-line" id="id_279">
  3050.         <label class="form-label-left" id="label_279" for="input_279">
  3051.           I certify the above information is true and correct to the best of my knowledge*<span class="form-required">*</span>
  3052.         </label>
  3053.         <div id="cid_279" class="form-input">
  3054.           <div class="form-single-column"><span class="form-checkbox-item" style="clear:left;"><input type="checkbox" class="form-checkbox validate[required]" id="input_279_0" name="q279_iCertify[]" value="&nbsp;" />
  3055.               <label for="input_279_0"> &nbsp; </label></span><span class="clearfix"></span>
  3056.           </div>
  3057.         </div>
  3058.       </li>
  3059.       <li class="form-line" id="id_255">
  3060.         <div id="cid_255" class="form-input-wide">
  3061.           <div id="text_255" class="form-html">
  3062.             <p class="MsoNormal"><span style="font-size: 9.0pt; mso-bidi-font-family: Arial; color: red;">* Please note- if you are completing this application online and submitting it through the web you do not need to print this form in order to sign it.&nbsp; Instead, by checking the "I certify the above information is true and correct to the best of my knowledge" box, we would accept this as your electronic signature.&nbsp; Please sign this form if you are submitting a scanned version through email, otherwise your application will not be accepted.</span>
  3063.             </p>
  3064.           </div>
  3065.         </div>
  3066.       </li>
  3067.       <li class="form-line" id="id_256">
  3068.         <div id="cid_256" class="form-input-wide">
  3069.           <div id="text_256" class="form-html">
  3070.             </p>
  3071.             <p><span style="font-size: 9.0pt; font-family: Arial; mso-fareast-font-family: " Times New Roman "; color: #17365d; mso-ansi-language: EN-US; mso-fareast-language: EN-US; mso-bidi-language: AR-SA;">** If you are under the age of 18 years and are completing this application online, please click the "Request Consent" button at the end of this application. You are required to provide the email address of your parent/guardian.&nbsp; An email will be sent to them to obtain their consent for your application as well as the above disclaimer.&nbsp; You will still need to complete your parent/guardian&rsquo;s name and details on this section of the application form.&nbsp; Please provide your parent/guardian
  3072.                 this application to sign where indicated only if you are submitting a scanned version through email, otherwise your application will not be accepted.</span>
  3073.             </p>
  3074.           </div>
  3075.         </div>
  3076.       </li>
  3077.       <li class="form-line" id="id_267">
  3078.         <div id="cid_267" class="form-input-wide">
  3079.           <div id="text_267" class="form-html">
  3080.             <p>
  3081.               <hr/>
  3082.             </p>
  3083.           </div>
  3084.         </div>
  3085.       </li>
  3086.       <li class="form-line" id="id_105">
  3087.         <div id="cid_105" class="form-input-wide">
  3088.           <div style="margin-left:306px" class="form-buttons-wrapper">
  3089.             <button id="input_105" type="submit" class="form-submit-button">
  3090.               Submit Form
  3091.             </button>
  3092.           </div>
  3093.         </div>
  3094.       </li>
  3095.       <li style="display:none">
  3096.         Should be Empty:
  3097.         <input type="text" name="website" value="" />
  3098.       </li>
  3099.     </ul>
  3100.   </div>
  3101.   <input type="hidden" id="simple_spc" name="simple_spc" value="32535151535853" />
  3102.   <script type="text/javascript">
  3103.   document.getElementById("si" + "mple" + "_spc").value = "32535151535853-32535151535853";
  3104.   </script>
  3105. </form></body>
  3106. </html>
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