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  1. <head>
  2. <meta charset="UTF-8">
  3. </head>
  4. <script src="https://cdn.jotfor.ms/js/vendor/imageinfo.js?v=3.3.9982" type="text/javascript"></script>
  5. <script src="https://cdn.jotfor.ms/file-uploader/fileuploader.js?v=3.3.9982"></script>
  6. <script src="https://cdn.jotfor.ms/static/prototype.forms.js" type="text/javascript"></script>
  7. <script src="https://cdn.jotfor.ms/static/jotform.forms.js?3.3.9982" type="text/javascript"></script>
  8. <script type="text/javascript">
  9. JotForm.init(function(){
  10.  
  11. JotForm.calendarMonths = ["January","February","March","April","May","June","July","August","September","October","November","December"];
  12. JotForm.calendarDays = ["Sunday","Monday","Tuesday","Wednesday","Thursday","Friday","Saturday","Sunday"];
  13. JotForm.calendarOther = {"today":"Today"};
  14. var languageOptions = document.querySelectorAll('#langList li');
  15. for(var langIndex = 0; langIndex < languageOptions.length; langIndex++) {
  16. languageOptions[langIndex].on('click', function(e) { setTimeout(function(){ JotForm.setCalendar("8", false, {"days":{"monday":true,"tuesday":true,"wednesday":true,"thursday":true,"friday":true,"saturday":true,"sunday":true},"future":true,"past":true,"custom":false,"ranges":false,"start":"","end":""}); }, 0); });
  17. }
  18. JotForm.setCalendar("8", false, {"days":{"monday":true,"tuesday":true,"wednesday":true,"thursday":true,"friday":true,"saturday":true,"sunday":true},"future":true,"past":true,"custom":false,"ranges":false,"start":"","end":""});
  19. JotForm.initCaptcha('input_14');
  20. $('input_14_reload').observe('click',function(){ JotForm.reloadCaptcha('input_14') })
  21. JotForm.alterTexts({"alphabetic":"Este campo pode conter apenas letras","alphanumeric":"Este campo só pode conter letras e números.","ccDonationMinLimitError":"Valor mínimo é {minAmount} {currency}","ccInvalidCVC":"Single Product w/ Single Choice Orders ","ccInvalidExpireDate":"Data de expiração inválida.","ccInvalidNumber":"Número do cartão de crédito é inválido.","ccMissingDetails":"Por favor, preencha os detalhes do Cartão de Crédito.","ccMissingDonation":"Por favor, indique valores numéricos para montante da doação.","ccMissingProduct":"Por favor, selecione pelo menos um produto.","characterLimitError":"Muitos caracteres. O limite é de","characterMinLimitError":"Muito poucos caracteres. O mínimo é","confirmClearForm":"Você tem certeza que quer limpar este formulário","confirmEmail":"E-mail não confere","currency":"Este campo apenas admite valores monetários.","cyrillic":"Este campo aceita apenas caracteres cirilicos.","dateInvalid":"Esta data não é válida. O formato da data é {format}","dateInvalidSeparate":"Esta data não é válido. Insira um válido {element}.","dateLimited":"Esta data não está disponível.","disallowDecimals":"Por favor insira um número inteiro.","email":"Digite um endereço de e-mail válido.","fillMask":"Valor do campo deve preencher máscara.","freeEmailError":"Não são permitidas contas de email gratuitas","generalError":"Existem erros no formulário. Por favor corrigi-los antes de continuar.","generalPageError":"Há erros nesta página. Por favor, corrija-os antes de continuar.","gradingScoreError":"Pontuação total deve ser menor ou igual a ","incompleteFields":"Há campos obrigatórios incompletos. Por favor, preencha-os.","inputCarretErrorA":"A entrada não deve ser menor do que o valor mínimo:","inputCarretErrorB":"Valor não deve ser maior do que o máximo:","lessThan":"A sua pontuação deve ser inferior ou igual a","maxDigitsError":"O numero máximo de caracteres permitidos são","maxSelectionsError":"O número máximo de seleções permitidas é","minSelectionsError":"O número mínimo exigido de seleções é","multipleFileUploads_emptyError":"{file} está vazio, por favor selecione os arquivos de novo.","multipleFileUploads_fileLimitError":"Somente são permitidos {fileLimit} envios de arquivos","multipleFileUploads_minSizeError":"{file} é muito pequeno, o tamanho mínimo do arquivo é {minSizeLimit}.","multipleFileUploads_onLeave":"Os arquivos agora estão em upload, se você sair agora o upload será cancelado.","multipleFileUploads_sizeError":"{file} é muito grande, o tamanho máximo é {sizeLimit}.","multipleFileUploads_typeError":"O arquivo {file} é inválido, pois somente as extensões {extensions} são permitidas.","numeric":"Este campo pode conter apenas números","pastDatesDisallowed":"A data não pode ser passada.","required":"Este campo é obrigatório.","requireEveryCell":"Toda célula é requisitada.","requireEveryRow":"Todos os campos são requeridos.","requireOne":"Pelo menos um campo é requisitado.","uploadExtensions":"Só pode fazer upload dos seguintes ficheiros:","uploadFilesize":"O tamanho do arquivo não pode ser maior que:","uploadFilesizemin":"O ficheiro não pode ser menor que:","url":"Este campo apenas pode conter um URL válido","wordLimitError":"Demasiadas palavras. O limite é de","wordMinLimitError":"Muito poucas palavras. O mínimo é"});
  22. JotForm.clearFieldOnHide="disable";
  23. setTimeout(function() {
  24. JotForm.initMultipleUploads();
  25. }, 2);
  26. JotForm.submitError="jumpToFirstError";
  27. /*INIT-END*/
  28. });
  29.  
  30. JotForm.prepareCalculationsOnTheFly([null,{"name":"heading","qid":"1","text":"Confirmacao de Doacao BGE","type":"control_head"},{"name":"submit2","qid":"2","text":"Enviar","type":"control_button"},{"description":"","name":"nomeCompleto","qid":"3","text":"Nome Completo","type":"control_fullname"},{"description":"","name":"nickIngame","qid":"4","subLabel":"","text":"Nick In-game","type":"control_textbox"},{"description":"","name":"email","qid":"5","subLabel":"example@example.com","text":"E-mail","type":"control_email"},null,{"description":"","name":"numeroDe7","qid":"7","text":"Numero de Contato","type":"control_phone"},{"description":"","name":"dataDo","qid":"8","text":"Data do Pagamento","type":"control_datetime"},{"description":"","name":"horarioDo","qid":"9","text":"Horario do Pagamento","type":"control_time"},{"description":"","name":"valorPago","qid":"10","subLabel":"","text":"Valor Pago","type":"control_textbox"},null,{"description":"","name":"qualMetodo","qid":"12","subLabel":"","text":"Qual metodo de Pagamento?","type":"control_dropdown"},{"description":"","name":"envieUma","qid":"13","subLabel":"","text":"Envie uma imagem do comprovante de pagamento","type":"control_fileupload"},{"description":"","name":"coloqueA","qid":"14","text":"Coloque a mensagem como e mostrada","type":"control_captcha"},{"name":"cliquePara","qid":"15","text":"Confirme apenas UMA VEZ e aguarde, temos at&eacute; 72 horas para lhe entregar.","type":"control_text"}]);
  31. setTimeout(function() {
  32. JotForm.paymentExtrasOnTheFly([null,{"name":"heading","qid":"1","text":"Confirmacao de Doacao BGE","type":"control_head"},{"name":"submit2","qid":"2","text":"Enviar","type":"control_button"},{"description":"","name":"nomeCompleto","qid":"3","text":"Nome Completo","type":"control_fullname"},{"description":"","name":"nickIngame","qid":"4","subLabel":"","text":"Nick In-game","type":"control_textbox"},{"description":"","name":"email","qid":"5","subLabel":"example@example.com","text":"E-mail","type":"control_email"},null,{"description":"","name":"numeroDe7","qid":"7","text":"Numero de Contato","type":"control_phone"},{"description":"","name":"dataDo","qid":"8","text":"Data do Pagamento","type":"control_datetime"},{"description":"","name":"horarioDo","qid":"9","text":"Horario do Pagamento","type":"control_time"},{"description":"","name":"valorPago","qid":"10","subLabel":"","text":"Valor Pago","type":"control_textbox"},null,{"description":"","name":"qualMetodo","qid":"12","subLabel":"","text":"Qual metodo de Pagamento?","type":"control_dropdown"},{"description":"","name":"envieUma","qid":"13","subLabel":"","text":"Envie uma imagem do comprovante de pagamento","type":"control_fileupload"},{"description":"","name":"coloqueA","qid":"14","text":"Coloque a mensagem como e mostrada","type":"control_captcha"},{"name":"cliquePara","qid":"15","text":"Confirme apenas UMA VEZ e aguarde, temos at&eacute; 72 horas para lhe entregar.","type":"control_text"}]);}, 20);
  33. </script>
  34. <link href="https://cdn.jotfor.ms/static/formCss.css?3.3.9982" rel="stylesheet" type="text/css" />
  35. <link type="text/css" rel="stylesheet" href="https://cdn.jotfor.ms/css/styles/nova.css?3.3.9982" />
  36. <link type="text/css" media="print" rel="stylesheet" href="https://cdn.jotfor.ms/css/printForm.css?3.3.9982" />
  37. <link type="text/css" rel="stylesheet" href="https://cdn.jotfor.ms/themes/CSS/566a91c2977cdfcd478b4567.css?"/>
  38. <style type="text/css">
  39. .form-label-left{
  40. width:150px;
  41. }
  42. .form-line{
  43. padding-top:12px;
  44. padding-bottom:12px;
  45. }
  46. .form-label-right{
  47. width:150px;
  48. }
  49. .form-all{
  50. width:690px;
  51. color:#6a4a3c !important;
  52. font-family:"Lucida Grande", "Lucida Sans Unicode", "Lucida Sans", Verdana, sans-serif;
  53. font-size:14px;
  54. }
  55. </style>
  56.  
  57. <style type="text/css" id="form-designer-style">
  58. /* Injected CSS Code */
  59. .form-label.form-label-auto { display: block; float: none; text-align: left; width: inherit; } /*PREFERENCES STYLE*/
  60. .form-all {
  61. font-family: Lucida Grande, sans-serif;
  62. }
  63. .form-all .qq-upload-button,
  64. .form-all .form-submit-button,
  65. .form-all .form-submit-reset,
  66. .form-all .form-submit-print {
  67. font-family: Lucida Grande, sans-serif;
  68. }
  69. .form-all .form-pagebreak-back-container,
  70. .form-all .form-pagebreak-next-container {
  71. font-family: Lucida Grande, sans-serif;
  72. }
  73. .form-header-group {
  74. font-family: Lucida Grande, sans-serif;
  75. }
  76. .form-label {
  77. font-family: Lucida Grande, sans-serif;
  78. }
  79.  
  80. .form-label.form-label-auto {
  81.  
  82. display: block;
  83. float: none;
  84. text-align: left;
  85. width: 100%;
  86.  
  87. }
  88.  
  89. .form-line {
  90. margin-top: 12px;
  91. margin-bottom: 12px;
  92. }
  93.  
  94. .form-all {
  95. width: 690px;
  96. }
  97.  
  98. .form-label-left,
  99. .form-label-right,
  100. .form-label-left.form-label-auto,
  101. .form-label-right.form-label-auto {
  102. width: 150px;
  103. }
  104.  
  105. .form-all {
  106. font-size: 14px
  107. }
  108. .form-all .qq-upload-button,
  109. .form-all .qq-upload-button,
  110. .form-all .form-submit-button,
  111. .form-all .form-submit-reset,
  112. .form-all .form-submit-print {
  113. font-size: 14px
  114. }
  115. .form-all .form-pagebreak-back-container,
  116. .form-all .form-pagebreak-next-container {
  117. font-size: 14px
  118. }
  119.  
  120. .supernova .form-all, .form-all {
  121. background-color: #b8e986;
  122. border: 1px solid transparent;
  123. }
  124.  
  125. .form-all {
  126. color: #6a4a3c;
  127. }
  128. .form-header-group .form-header {
  129. color: #6a4a3c;
  130. }
  131. .form-header-group .form-subHeader {
  132. color: #6a4a3c;
  133. }
  134. .form-label-top,
  135. .form-label-left,
  136. .form-label-right,
  137. .form-html,
  138. .form-checkbox-item label,
  139. .form-radio-item label {
  140. color: #6a4a3c;
  141. }
  142. .form-sub-label {
  143. color: #846456;
  144. }
  145.  
  146. .supernova {
  147. background-color: #eb6841;
  148. }
  149. .supernova body {
  150. background: transparent;
  151. }
  152.  
  153. .form-textbox,
  154. .form-textarea,
  155. .form-radio-other-input,
  156. .form-checkbox-other-input,
  157. .form-captcha input,
  158. .form-spinner input {
  159. background-color: #fff;
  160. }
  161.  
  162. .supernova {
  163. height: 100%;
  164. background-repeat: repeat;
  165. background-attachment: scroll;
  166. background-position: center top;
  167. }
  168. .supernova {
  169. background-image: url("https://www.jotform.com/uploads/XxJohnSilvaxX/form_files/fundo1.5c66c5f80dd7a5.16774038.png");
  170. }
  171. #stage {
  172. background-image: url("https://www.jotform.com/uploads/XxJohnSilvaxX/form_files/fundo1.5c66c5f80dd7a5.16774038.png");
  173. }
  174.  
  175. .form-all {
  176. background-image: none;
  177. }
  178.  
  179. .ie-8 .form-all:before { display: none; }
  180. .ie-8 {
  181. margin-top: auto;
  182. margin-top: initial;
  183. }
  184.  
  185. /*PREFERENCES STYLE*//*__INSPECT_SEPERATOR__*/
  186. /* Injected CSS Code */
  187. </style>
  188.  
  189. <form class="jotform-form" action="https://submit.jotformz.com/submit/90453373789671/" method="post" enctype="multipart/form-data" name="form_90453373789671" id="90453373789671" accept-charset="utf-8">
  190. <input type="hidden" name="formID" value="90453373789671" />
  191. <div class="form-all">
  192. <ul class="form-section page-section">
  193. <li id="cid_1" class="form-input-wide" data-type="control_head">
  194. <div class="form-header-group ">
  195. <div class="header-text httal htvam">
  196. <h2 id="header_1" class="form-header" data-component="header">
  197. Confirmação de Doação BGE
  198. </h2>
  199. </div>
  200. </div>
  201. </li>
  202. <li class="form-line" data-type="control_text" id="id_15">
  203. <div id="cid_15" class="form-input-wide">
  204. <div id="text_15" class="form-html" data-component="text">
  205. <p>Confirme apenas UMA VEZ e aguarde, temos até 72 horas para lhe entregar.</p>
  206. </div>
  207. </div>
  208. </li>
  209. <li class="form-line" data-type="control_fullname" id="id_3">
  210. <label class="form-label form-label-top form-label-auto" id="label_3" for="first_3"> Nome Completo </label>
  211. <div id="cid_3" class="form-input-wide">
  212. <div data-wrapper-react="true">
  213. <span class="form-sub-label-container" style="vertical-align:top">
  214. <input type="text" id="first_3" name="q3_nomeCompleto[first]" class="form-textbox" size="10" value="" data-component="first" />
  215. <label class="form-sub-label" for="first_3" id="sublabel_first" style="min-height:13px"> Nome próprio </label>
  216. </span>
  217. <span class="form-sub-label-container" style="vertical-align:top">
  218. <input type="text" id="last_3" name="q3_nomeCompleto[last]" class="form-textbox" size="15" value="" data-component="last" />
  219. <label class="form-sub-label" for="last_3" id="sublabel_last" style="min-height:13px"> Sobrenome </label>
  220. </span>
  221. </div>
  222. </div>
  223. </li>
  224. <li class="form-line" data-type="control_textbox" id="id_4">
  225. <label class="form-label form-label-top form-label-auto" id="label_4" for="input_4"> Nick In-game </label>
  226. <div id="cid_4" class="form-input-wide">
  227. <input type="text" id="input_4" name="q4_nickIngame" data-type="input-textbox" class="form-textbox" size="20" value="" data-component="textbox" />
  228. </div>
  229. </li>
  230. <li class="form-line" data-type="control_email" id="id_5">
  231. <label class="form-label form-label-top form-label-auto" id="label_5" for="input_5"> E-mail </label>
  232. <div id="cid_5" class="form-input-wide">
  233. <span class="form-sub-label-container" style="vertical-align:top">
  234. <input type="email" id="input_5" name="q5_email" class="form-textbox validate[Email]" size="30" value="" data-component="email" />
  235. <label class="form-sub-label" for="input_5" style="min-height:13px"> example@example.com </label>
  236. </span>
  237. </div>
  238. </li>
  239. <li class="form-line" data-type="control_phone" id="id_7">
  240. <label class="form-label form-label-top form-label-auto" id="label_7" for="input_7_area"> Número de Contato </label>
  241. <div id="cid_7" class="form-input-wide">
  242. <div data-wrapper-react="true">
  243. <span class="form-sub-label-container" style="vertical-align:top">
  244. <input type="tel" id="input_7_area" name="q7_numeroDe7[area]" class="form-textbox" size="6" value="" data-component="areaCode" />
  245. <span class="phone-separate">
  246. -
  247. </span>
  248. <label class="form-sub-label" for="input_7_area" id="sublabel_area" style="min-height:13px"> Código de área </label>
  249. </span>
  250. <span class="form-sub-label-container" style="vertical-align:top">
  251. <input type="tel" id="input_7_phone" name="q7_numeroDe7[phone]" class="form-textbox" size="12" value="" data-component="phone" />
  252. <label class="form-sub-label" for="input_7_phone" id="sublabel_phone" style="min-height:13px"> Número de Telefone </label>
  253. </span>
  254. </div>
  255. </div>
  256. </li>
  257. <li class="form-line" data-type="control_time" id="id_9">
  258. <label class="form-label form-label-top form-label-auto" id="label_9" for="input_9_hourSelect"> Horário do Pagamento </label>
  259. <div id="cid_9" class="form-input-wide">
  260. <div data-wrapper-react="true">
  261. <span class="form-sub-label-container" style="vertical-align:top">
  262. <select class="time-dropdown form-dropdown" id="input_9_hourSelect" name="q9_horarioDo[hourSelect]" data-component="time-hour">
  263. <option> </option>
  264. <option value="1"> 1 </option>
  265. <option value="2"> 2 </option>
  266. <option value="3"> 3 </option>
  267. <option value="4"> 4 </option>
  268. <option value="5"> 5 </option>
  269. <option value="6"> 6 </option>
  270. <option value="7"> 7 </option>
  271. <option value="8"> 8 </option>
  272. <option value="9"> 9 </option>
  273. <option value="10"> 10 </option>
  274. <option value="11"> 11 </option>
  275. <option value="12"> 12 </option>
  276. </select>
  277. <span class="date-separate">
  278. :
  279. </span>
  280. <label class="form-sub-label" for="input_9_hourSelect" id="sublabel_hour" style="min-height:13px"> Hora </label>
  281. </span>
  282. <span class="form-sub-label-container" style="vertical-align:top">
  283. <select class="time-dropdown form-dropdown" id="input_9_minuteSelect" name="q9_horarioDo[minuteSelect]" data-component="time-minute">
  284. <option> </option>
  285. <option value="00"> 00 </option>
  286. <option value="10"> 10 </option>
  287. <option value="20"> 20 </option>
  288. <option value="30"> 30 </option>
  289. <option value="40"> 40 </option>
  290. <option value="50"> 50 </option>
  291. </select>
  292. <label class="form-sub-label" for="input_9_minuteSelect" id="sublabel_minutes" style="min-height:13px"> Minutos </label>
  293. </span>
  294. <span class="form-sub-label-container" style="vertical-align:top">
  295. <select class="time-dropdown form-dropdown" id="input_9_ampm" name="q9_horarioDo[ampm]" data-component="time-ampm">
  296. <option value="AM"> AM </option>
  297. <option selected="" value="PM"> PM </option>
  298. </select>
  299. <label class="form-sub-label" for="input_9_ampm" style="min-height:13px"> </label>
  300. </span>
  301. </div>
  302. </div>
  303. </li>
  304. <li class="form-line" data-type="control_datetime" id="id_8">
  305. <label class="form-label form-label-top form-label-auto" id="label_8" for="lite_mode_8"> Data do Pagamento </label>
  306. <div id="cid_8" class="form-input-wide">
  307. <div data-wrapper-react="true">
  308. <div style="display:none">
  309. <span class="form-sub-label-container" style="vertical-align:top">
  310. <input type="tel" class="form-textbox validate[limitDate]" id="month_8" name="q8_dataDo[month]" size="2" data-maxlength="2" value="" />
  311. <span class="date-separate">
  312. -
  313. </span>
  314. <label class="form-sub-label" for="month_8" id="sublabel_month" style="min-height:13px"> Mês </label>
  315. </span>
  316. <span class="form-sub-label-container" style="vertical-align:top">
  317. <input type="tel" class="form-textbox validate[limitDate]" id="day_8" name="q8_dataDo[day]" size="2" data-maxlength="2" value="" />
  318. <span class="date-separate">
  319. -
  320. </span>
  321. <label class="form-sub-label" for="day_8" id="sublabel_day" style="min-height:13px"> dia </label>
  322. </span>
  323. <span class="form-sub-label-container" style="vertical-align:top">
  324. <input type="tel" class="form-textbox validate[limitDate]" id="year_8" name="q8_dataDo[year]" size="4" data-maxlength="4" value="" />
  325. <label class="form-sub-label" for="year_8" id="sublabel_year" style="min-height:13px"> Ano </label>
  326. </span>
  327. </div>
  328. <span class="form-sub-label-container" style="vertical-align:top">
  329. <input type="text" class="form-textbox validate[limitDate, validateLiteDate]" id="lite_mode_8" size="12" data-maxlength="12" data-age="" value="" data-format="mmddyyyy" data-seperator="-" placeholder="mm-dd-yyyy" />
  330. <img alt="Pick a Date" id="input_8_pick" src="https://cdn.jotfor.ms/images/calendar.png" style="vertical-align:middle;margin-left:5px" data-component="datetime" />
  331. <label class="form-sub-label" for="lite_mode_8" id="sublabel_litemode" style="min-height:13px"> Data </label>
  332. </span>
  333. <span class="form-sub-label-container" style="vertical-align:top">
  334. <label class="form-sub-label" for="input_8_pick" style="min-height:13px"> </label>
  335. </span>
  336. </div>
  337. </div>
  338. </li>
  339. <li class="form-line" data-type="control_textbox" id="id_10">
  340. <label class="form-label form-label-top form-label-auto" id="label_10" for="input_10"> Valor Pago </label>
  341. <div id="cid_10" class="form-input-wide">
  342. <input type="text" id="input_10" name="q10_valorPago" data-type="input-textbox" class="form-textbox" size="20" value="" data-component="textbox" />
  343. </div>
  344. </li>
  345. <li class="form-line" data-type="control_dropdown" id="id_12">
  346. <label class="form-label form-label-top form-label-auto" id="label_12" for="input_12"> Qual método de Pagamento? </label>
  347. <div id="cid_12" class="form-input-wide">
  348. <select class="form-dropdown" id="input_12" name="q12_qualMetodo" style="width:150px" data-component="dropdown">
  349. <option value=""> </option>
  350. <option value="Depósito em Conta"> Depósito em Conta </option>
  351. <option value="PagSeguro"> PagSeguro </option>
  352. <option value="Paypal"> Paypal </option>
  353. </select>
  354. </div>
  355. </li>
  356. <li class="form-line" data-type="control_fileupload" id="id_13">
  357. <label class="form-label form-label-top form-label-auto" id="label_13" for="input_13"> Envie uma imagem do comprovante de pagamento </label>
  358. <div id="cid_13" class="form-input-wide">
  359. <div data-wrapper-react="true">
  360. <div data-wrapper-react="true">
  361. <div class="qq-uploader-buttonText-value">
  362. Browse Files
  363. </div>
  364. <input type="file" id="input_13" name="q13_envieUma[]" multiple="" class="form-upload-multiple" data-imagevalidate="yes" data-file-accept="pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif" data-file-maxsize="10854" data-file-minsize="0" data-file-limit="" data-component="fileupload" />
  365. </div>
  366. <span style="display:none" class="cancelText">
  367. Cancel
  368. </span>
  369. <span style="display:none" class="ofText">
  370. of
  371. </span>
  372. </div>
  373. </div>
  374. </li>
  375. <li class="form-line jf-required" data-type="control_captcha" id="id_14">
  376. <label class="form-label form-label-top form-label-auto" id="label_14" for="input_14">
  377. Coloque a mensagem como é mostrada
  378. <span class="form-required">
  379. *
  380. </span>
  381. </label>
  382. <div id="cid_14" class="form-input-wide jf-required">
  383. <div class="form-captcha" data-component="captcha">
  384. <label for="input_14"> <img alt="Captcha - Reload if not displayed" id="input_14_captcha" class="form-captcha-image" style="background:url(https://cdn.jotfor.ms/images/loader-big.gif) no-repeat center" src="https://cdn.jotfor.ms/images/blank.gif" width="150" height="41" /> </label>
  385. <div style="white-space:nowrap">
  386. <input type="text" id="input_14" class="form-textbox validate[required]" name="captcha" style="width:130px" required="" />
  387. <img src="https://cdn.jotfor.ms/images/reload.png" alt="Reload" style="cursor:pointer;vertical-align:middle" id="input_14_reload" />
  388. <input type="hidden" name="captcha_id" id="input_14_captcha_id" value="0" />
  389. </div>
  390. </div>
  391. </div>
  392. </li>
  393. <li class="form-line" data-type="control_button" id="id_2">
  394. <div id="cid_2" class="form-input-wide">
  395. <div style="margin-left:156px" class="form-buttons-wrapper">
  396. <button id="input_2" type="submit" class="form-submit-button" data-component="button">
  397. Enviar
  398. </button>
  399. </div>
  400. </div>
  401. </li>
  402. <li style="display:none">
  403. Should be Empty:
  404. <input type="text" name="website" value="" />
  405. </li>
  406. </ul>
  407. </div>
  408. <script>
  409. JotForm.showJotFormPowered = "new_footer";
  410. </script>
  411. <input type="hidden" id="simple_spc" name="simple_spc" value="90453373789671" />
  412. <script type="text/javascript">
  413. document.getElementById("si" + "mple" + "_spc").value = "90453373789671-90453373789671";
  414. </script>
  415. <div class="formFooter-heightMask">
  416. </div>
  417. <div class="formFooter f6">
  418. <a href="https://www.jotform.com/pricing?utm_source=formfooter&utm_medium=banner&utm_term=90453373789671&utm_content=jotform_logo&utm_campaign=powered_by_jotform_le" target="_blank" class="formFooter-logoLink"><img class="formFooter-logo" src="https://cdn.jotfor.ms/assets/img/logo/logo-new@1x.png" alt="" style="height: 44px;"></a>
  419. <div class="formFooter-rightSide">
  420. <span class="formFooter-text">
  421. Now create your own JotForm - It's free!
  422. </span>
  423. <a class="formFooter-button" href="https://www.jotform.com/?utm_source=formfooter&utm_medium=banner&utm_term=90453373789671&utm_content=jotform_button&utm_campaign=powered_by_jotform_le" target="_blank">Create your own JotForm</a>
  424. </div>
  425. </div>
  426. </form>
  427. <script type="text/javascript">JotForm.ownerView=true;</script>
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