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Old Dominion University - Acceptiva
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To complete your transaction you'll need to open the form in a new tab. Click the button below to continue.</p><p><input type="button" value="Continue" onclick="window.open(self.location)" style="background-color: #026eb7; border: none; border-radius: 3px; box-shadow: 1px 1px 1px #333; color: #fff; cursor: pointer; font-size: 1em; font-weight: bold; padding: 10px 20px;"></p><p style="margin-top: 50px;"><span id="siteseal"></span><img src="assets/img/acceptiva-logo.png" height="32"></p></div> <div id="container"> <form id="payform" action="?cst=1701ca" method="post" onsubmit="return check_form(this)"> <input type="hidden" id="page_id_str" name="page_id_str" value="1701ca"> <input type="hidden" id="confirm" name="confirm" value="true"> <input type="hidden" id="payment_type" name="payment_type" value=""> <input type="hidden" id="tm" name="tm" value=""> <fieldset> <div id="banner"> <a href="http://www.olddominionaf.com/"><img class="banner_img" src="https://secure.acceptiva.com/assets/img/_headers/1/1701ca.png?ver=1734446324"></a> </div> <div class="fieldsetinside"> <div id="section-1" data-section-link-id="1" class="crumbs section noprint"> <ul> <li><a class="active"><span>STEP ONE</span><br>ENTER INFO</a></li> <li><a><span>STEP TWO</span><br>CONFIRMATION</a></li> <li><a><span>STEP THREE</span><br>RECEIPT</a></li> </ul> </div> <div style="color: red; text-align: center;"><div name="error_page"></div></div> <div id="section-20" data-section-link-id="20" class="section editable pgraph"><p><span style="font-family: verdana, geneva, sans-serif;">The Old Dominion Athletic Foundation, commonly referred to as the ODAF, was established in 1964 with the mission to provide the resources necessary for the success of Old Dominion Athletics and our student-athletes. Over the years the ODAF has helped to provide unique opportunities for countless ODU Student-Athletes. ODAF Membership is open to all alumni and friends of Old Dominion University. Members of the ODAF receive exclusive annual benefits.</span><br /><br /><span style="font-family: verdana, geneva, sans-serif;">A great way for ODAF members to increase their Priority Point ranking is by joining the 110% Club. Members increasing their contribution by 10% or more from the previous year will be rewarded with 10 Bonus Priority Points and a unique 110% Club gift!</span></p> <p><span style="font-family: verdana, geneva, sans-serif;">We encourage our donors to review our membership structure before making their 2025 philanthropic ODAF donation. <a href="https://www.olddominionaf.com/membership/membership-benefits/" target="_blank" rel="noopener noreferrer">Click Here</a> to learn more!</span></p></div> <div style="clear: both;"></div> <div id="section-25" data-section-link-id="25" class="section editable"> <div class="heading">Contribution Amount</div> <div name="error_25"></div> <div class="section-pwp radio"> <div id="section-25-item-36" data-section-link-id="25" data-item-link-id="36" class="item pickwprice"><input type="hidden" name="items[25][36][amount]" value="47,803.00"> <label for="items_25_36_checked"><span name="error_25_36"></span>Scholarship Society</label> <div class="input"> <input type="radio" id="items_25_36_checked" name="items[25][checked][0]" value="36" class="form-control" style="float: left; height: unset; width: unset;"> <span>$47,803.00</span> </div> </div> <div id="section-25-item-30" data-section-link-id="25" data-item-link-id="30" class="item pickwprice"><input type="hidden" name="items[25][30][amount]" value="25,000.00"> <label for="items_25_30_checked"><span name="error_25_30"></span>Championship Monarch</label> <div class="input"> <input type="radio" id="items_25_30_checked" name="items[25][checked][0]" value="30" class="form-control" style="float: left; height: unset; width: unset;"> <span>$25,000.00</span> </div> </div> <div id="section-25-item-29" data-section-link-id="25" data-item-link-id="29" class="item pickwprice"><input type="hidden" name="items[25][29][amount]" value="15,000.00"> <label for="items_25_29_checked"><span name="error_25_29"></span>Royal Monarch</label> <div class="input"> <input type="radio" id="items_25_29_checked" name="items[25][checked][0]" value="29" class="form-control" style="float: left; height: unset; width: unset;"> <span>$15,000.00</span> </div> </div> <div id="section-25-item-34" data-section-link-id="25" data-item-link-id="34" class="item pickwprice"><input type="hidden" name="items[25][34][amount]" value="10,000.00"> <label for="items_25_34_checked"><span name="error_25_34"></span>Platinum Monarch</label> <div class="input"> <input type="radio" id="items_25_34_checked" name="items[25][checked][0]" value="34" class="form-control" style="float: left; height: unset; width: unset;"> <span>$10,000.00</span> </div> </div> <div id="section-25-item-28" data-section-link-id="25" data-item-link-id="28" class="item pickwprice"><input type="hidden" name="items[25][28][amount]" value="7,500.00"> <label for="items_25_28_checked"><span name="error_25_28"></span>Golden Monarch</label> <div class="input"> <input type="radio" id="items_25_28_checked" name="items[25][checked][0]" value="28" class="form-control" style="float: left; height: unset; width: unset;"> <span>$7,500.00</span> </div> </div> <div id="section-25-item-20" data-section-link-id="25" data-item-link-id="20" class="item pickwprice"><input type="hidden" name="items[25][20][amount]" value="5,000.00"> <label for="items_25_20_checked"><span name="error_25_20"></span>Diamond Monarch</label> <div class="input"> <input type="radio" id="items_25_20_checked" name="items[25][checked][0]" value="20" class="form-control" style="float: left; height: unset; width: unset;"> <span>$5,000.00</span> </div> </div> <div id="section-25-item-21" data-section-link-id="25" data-item-link-id="21" class="item pickwprice"><input type="hidden" name="items[25][21][amount]" value="2,500.00"> <label for="items_25_21_checked"><span name="error_25_21"></span>Silver Monarch</label> <div class="input"> <input type="radio" id="items_25_21_checked" name="items[25][checked][0]" value="21" class="form-control" style="float: left; height: unset; width: unset;"> <span>$2,500.00</span> </div> </div> <div id="section-25-item-23" data-section-link-id="25" data-item-link-id="23" class="item pickwprice"><input type="hidden" name="items[25][23][amount]" value="1,000.00"> <label for="items_25_23_checked"><span name="error_25_23"></span>Blue Monarch</label> <div class="input"> <input type="radio" id="items_25_23_checked" name="items[25][checked][0]" value="23" class="form-control" style="float: left; height: unset; width: unset;"> <span>$1,000.00</span> </div> </div> <div id="section-25-item-24" data-section-link-id="25" data-item-link-id="24" class="item pickwprice"><input type="hidden" name="items[25][24][amount]" value="500.00"> <label for="items_25_24_checked"><span name="error_25_24"></span>Blue Knight</label> <div class="input"> <input type="radio" id="items_25_24_checked" name="items[25][checked][0]" value="24" class="form-control" style="float: left; height: unset; width: unset;"> <span>$500.00</span> </div> </div> <div id="section-25-item-27" data-section-link-id="25" data-item-link-id="27" class="item pickwprice"><input type="hidden" name="items[25][27][amount]" value="100.00"> <label for="items_25_27_checked"><span name="error_25_27"></span>White Knight</label> <div class="input"> <input type="radio" id="items_25_27_checked" name="items[25][checked][0]" value="27" class="form-control" style="float: left; height: unset; width: unset;"> <span>$100.00</span> </div> </div> <div id="section-25-item-26" data-section-link-id="25" data-item-link-id="26" class="item pickwprice"> <label for="items_25_26_checked"><span name="error_25_26"></span>Other Amount</label> <div class="input"> <input type="radio" id="items_25_26_checked" name="items[25][checked][0]" value="26" class="form-control" style="float: left; height: unset; width: unset;"> <input type="number" id="items_25_26_amount" name="items[25][26][amount]" value="" class="format_amount form-control" onkeypress="prevent_nonnumeric_input(event)" onblur="fix_number(this); if (this.value*1 != 0) $('#items_25_26_checked').prop('checked', true);" autocomplete="off" placeholder="$0.00" min="0" step="0.01" style="float: left;"> </div> </div> <div class="recurring-freq">Choose A Frequency</div> <div id="section-25-item-31" data-section-link-id="25" data-item-link-id="31" class="item recurring"> <label for="items[25][recur_freq]">Recurring Gift Frequency:</label> <select id="items[25][recur_freq]" name="items[25][recur_freq]" class="form-control" onchange="change_recur_freq(this, 25)"><option value="0" selected>One Time</option><option value="3">Monthly</option></select> </div> <div id="section-25-item-32" data-section-link-id="25" data-item-link-id="32" class="item recurring recurring25" style="display: none; padding-bottom: 0.5em;"> <label for="items_25_32_value">Charge Start Options:<span class="required">*</span></label> <input type="hidden" id="items_25_recur_start_date" name="items[25][recur_start_date]" value="03/01/2025" section-link-id="25" installment-amt-div-id="items_25_38_div">03/01/2025 <span name="error_25_32"></span> </div> <div id="section-25-item-33" data-section-link-id="25" data-item-link-id="33" class="item recurring recurring25" style="display: none;"> <label for="items[25][recur_end_criteria]">Charge End Options:</label> <select id="items[25][recur_end_criteria]" name="items[25][recur_end_criteria]" class="form-control" onchange="change_recur_end_criteria(this, 25)"><option value="3" selected>End By Given Date</option></select> </div> <div id="items_25_recur_end_num_div" class="recurring recurring25" style="display: none;"> <label for="items[25][recur_end_num]">Total Number of Charges:</label> <select id="items[25][recur_end_num]" name="items[25][recur_end_num]" class="form-control"><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option value="12" selected>12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option></select> </div> <div id="items_25_recur_end_amount_div" class="recurring recurring25" style="display: none;"> <label for="items_25_recur_end_amount">Total Dollar Amount: <span class="required">*</span></label> <input type="number" id="items_25_recur_end_amount" name="items[25][recur_end_amount]" value="" class="format_amount form-control" onkeypress="prevent_nonnumeric_input(event)" onblur="fix_number(this)" autocomplete="off" placeholder="$0.00" min="0" step="0.01"> <span name="error_25_33"></span> </div> <div id="items_25_recur_end_date_div" class="recurring recurring25 dates" style="display: none;"> <label for="items_25_recur_end_date">Charge End Date: <span class="required">*</span></label> <input type="hidden" id="items_25_recur_end_date" name="items[25][recur_end_date]" value="12/31/2025">12/31/2025 <span name="error_25_33"></span> </div> <div id="section-25-item-37" data-section-link-id="25" data-item-link-id="37" class="item recurring recurring25" style="display: none;"> <label for="items_25_37_amount">Installment Amount:</label> <div class="pledge"> <span id="items_25_37_amount">$0.00</span> <a id="items_25_37" href="#" onclick="calculate_total(this); return false;">Calculate</a> </div> </div> <div id="section-25-item-38" data-section-link-id="25" data-item-link-id="38" class="item recurring recurring25" style="display: none;"> <span name="error_25_38"></span> <label for="items_25_38_amount"> <input type="checkbox" id="items_25_38_checked" name="items[25][38][checked]" class="form-control" onclick="document.getElementById('items_25_38_amount').style.display = (!this.checked ? 'none' : '');"> Check here to pay a different amount today. </label> <input type="number" id="items_25_38_amount" name="items[25][38][amount]" value="0" class="format_amount form-control" onkeypress="prevent_nonnumeric_input(event)" onblur="fix_number(this)" autocomplete="off" placeholder="$0.00" min="0" step="0.01" style="display: none;"> </div> <div id="section-25-item-39" data-section-link-id="25" data-item-link-id="39" class="item recurring recurring25" style="display: none;"> <label for="items_25_39_amount">Remaining Amount:</label> <div class="pledge"> <span id="items_25_39_amount">---</span> <a id="items_25_39" href="#" onclick="calculate_total(this); return false;">Calculate</a> </div> </div> <div style="clear: both;"></div> </div> </div> <div style="clear: both;"></div> <div id="section-29" data-section-link-id="29" class="total_line section"> <input type="button" id="total" value="Calculate Total" class="calculate_button" onclick="calculate_total(this)"> <div> <span style="line-height: 150%;">Total:</span> <span id="amt_today">$0.00</span> </div> <div style="display: none;"> <span>Future Commitment: </span> <span id="amt_future">$0.00</span> </div> </div> <div id="section-26" data-section-link-id="26" class="section editable pgraph"><div>If you would like to gift stock or make a gift from your IRA or DAF, <a href="https://www.freewill.com/smartgiving/odu?utm_source=partner&utm_medium=website&utm_campaign=odu_waystogivepg&product=CRYPTO">click here</a>.<br /><br />If you are making a payment on a pledge please enter your total pledge amount in the comment box below.<br /><br />**For information on Endowments and/or Capital Projects please contact Jena Virga, Executive Director of the Old Dominion Athletic Foundation office at (757) 683-6963.</div></div> </div> </fieldset> <fieldset> <div class="fieldsetinside"> <div id="field-55" data-field-link-id="55" class="fieldrow editable group0 set0"> <div class="label"><label for="allocation">I would like my gift to support:<span class="required"> *</span></label></div> <div class="input"><select id="allocation" name="allocation" class="form-control required-if-shown required"><option value="">-- Select An Option --</option><option value="ODAF Annual Fund (Highest Point Value)" selected>ODAF Annual Fund (Highest Point Value)</option><option value="Baseball">Baseball</option><option value="Men's Basketball">Men's Basketball</option><option value="Women's Basketball">Women's Basketball</option><option value="Field Hockey">Field Hockey</option><option value="Football">Football</option><option value="Men's Golf">Men's Golf</option><option value="Women's Golf">Women's Golf</option><option value="Lacrosse">Lacrosse</option><option value="Rowing">Rowing</option><option value="Sailing">Sailing</option><option value="Men's Soccer">Men's Soccer</option><option value="Women's Soccer">Women's Soccer</option><option value="Swimming">Swimming</option><option value="Men's Tennis">Men's Tennis</option><option value="Women's Tennis">Women's Tennis</option><option value="Volleyball">Volleyball</option><option value="Spirit Squad">Spirit Squad</option><option value="Other / Endowments - Specify in Comment Box">Other / Endowments - Specify in Comment Box</option></select></div> </div> <div id="field-65" data-field-link-id="65" class="fieldrow editable group0 set0"> <div class="label"><label for="referredby">Who referred you?</label></div> <div class="input"><input type="text" id="referredby" name="referredby" value="" class="form-control"><span class="comment">+25 Bonus Points per referral</span></div> </div> <div id="field-59" data-field-link-id="59" class="fieldrow editable group0 set0"> <div class="label"><label for="comments">Comments:</label></div> <div class="input"><textarea id="comments" name="comments" rows="3" class="form-control"></textarea><span class="comment">Endowment Name/Fund Name/Pledge Payment/Other</span></div> </div> </div> </fieldset> <fieldset class="default-field"> <div class="fieldsetinside"> <div id="field-53" data-field-link-id="53" class="fieldrow editable heading group0 set0">Payer Details</div> <div id="field-62" data-field-link-id="62" class="fieldrow editable group0 set0"> <div class="label"><label for="odafnumber">ODAF Member #</label></div> <div class="input"><input type="text" id="odafnumber" name="odafnumber" value="" class="form-control"></div> </div> <div id="field-21" data-field-link-id="21" class="fieldrow editable group0 set0"> <div class="label"><label for="payer_fname">First Name:<span class="required"> *</span></label></div> <div class="input"><input type="text" id="payer_fname" name="payer_fname" value="" maxlength="30" class="form-control default-field required-if-shown required payer windows1252"></div> </div> <div id="field-61" data-field-link-id="61" class="fieldrow editable group0 set0"> <div class="label"><label for="middle_initial">Middle Initial:</label></div> <div class="input"><input type="text" id="middle_initial" name="middle_initial" value="" class="form-control"></div> </div> <div id="field-22" data-field-link-id="22" class="fieldrow editable group0 set0"> <div class="label"><label for="payer_lname">Last Name:<span class="required"> *</span></label></div> <div class="input"><input type="text" id="payer_lname" name="payer_lname" value="" maxlength="35" class="form-control default-field required-if-shown required payer windows1252"></div> </div> <div id="field-23" data-field-link-id="23" class="fieldrow editable group0 set0"> <div class="label"><label for="billing_address">Billing Address:<span class="required"> *</span></label></div> <div class="input"><input type="text" id="billing_address" name="billing_address" value="" maxlength="32" class="form-control default-field required-if-shown required payer windows1252"><span class="comment">This is the address where your credit card statements are mailed.</span></div> </div> <div id="field-24" data-field-link-id="24" class="fieldrow editable group0 set0"> <div class="label"><label for="billing_address2">Address 2:</label></div> <div class="input"><input type="text" id="billing_address2" name="billing_address2" value="" maxlength="32" class="form-control default-field payer windows1252"></div> </div> <div id="field-25" data-field-link-id="25" class="fieldrow editable group0 set0"> <div class="label"><label for="billing_city">City:<span class="required"> *</span></label></div> <div class="input"><input type="text" id="billing_city" name="billing_city" value="" maxlength="32" class="form-control default-field required-if-shown required payer windows1252"></div> </div> <div id="field-26" data-field-link-id="26" class="fieldrow editable group0 set0"> <div class="label"><label for="billing_state"><span id="state_prompt">State / Province:</span><span class="required"> *</span></label></div> <div class="input"> <input type="text" id="billing_state" name="billing_state" value="" class="form-control default-field required-if-shown required"> </div> </div> <div id="field-27" data-field-link-id="27" class="fieldrow editable group0 set0"> <div class="label"><label for="billing_zip">Zip Code:<span class="required"> *</span></label></div> <div class="input"><input type="text" id="billing_zip" name="billing_zip" value="" maxlength="10" class="form-control default-field required-if-shown required payer windows1252"></div> </div> <div id="field-28" data-field-link-id="28" class="fieldrow editable group0 set0"> <div class="label"><label for="billing_country">Country:<span class="required"> *</span></label></div> <div class="input"><select id="billing_country" name="billing_country" class="form-control default-field required-if-shown required payer" onchange="change_country(this)"><option value="">-- Select An Option --</option><option value="USA">United States of America</option><option value="CAN">Canada</option><option value="AFG">Afghanistan</option><option value="ALA">Aland Islands</option><option value="ALB">Albania</option><option value="DZA">Algeria</option><option value="ASM">American Samoa</option><option value="AND">Andorra</option><option value="AGO">Angola</option><option value="AIA">Anguilla</option><option value="ATA">Antarctica</option><option value="ATG">Antigua & Barbuda</option><option value="ARG">Argentina</option><option value="ARM">Armenia</option><option value="ABW">Aruba</option><option value="AUS">Australia</option><option value="AUT">Austria</option><option value="AZE">Azerbaijan</option><option value="BHS">Bahamas</option><option value="BHR">Bahrain</option><option value="BGD">Bangladesh</option><option value="BRB">Barbados</option><option value="BLR">Belarus</option><option value="BEL">Belgium</option><option value="BLZ">Belize</option><option value="BEN">Benin</option><option value="BMU">Bermuda</option><option value="BTN">Bhutan</option><option value="BOL">Bolivia</option><option value="BES">Bonaire, Saint Eustatius and Saba</option><option value="BIH">Bosnia & Herzegovina</option><option value="BWA">Botswana</option><option value="BVT">Bouvet Island (Bouvetoya)</option><option value="BRA">Brazil</option><option value="IOT">British Indian Ocean Territory</option><option value="VGB">British Virgin Islands</option><option value="BRN">Brunei Darussalam</option><option value="BGR">Bulgaria</option><option value="BFA">Burkina Faso</option><option value="BDI">Burundi</option><option value="KHM">Cambodia</option><option value="CMR">Cameroon</option><option value="CPV">Cape Verde</option><option value="CYM">Cayman Islands</option><option value="CAF">Central African Republic</option><option value="TCD">Chad</option><option value="CHL">Chile</option><option value="CHN">China</option><option value="CXR">Christmas Island</option><option value="CCK">Cocos (Keeling) Islands</option><option value="COL">Colombia</option><option value="COM">Comoros</option><option value="COD">Democratic Republic of Congo</option><option value="COK">Cook Islands</option><option value="CRI">Costa Rica</option><option value="CIV">Cote D'Ivoire & Ivory Coast</option><option value="CUB">Cuba</option><option value="CUW">Curacao</option><option value="CYP">Cyprus</option><option value="CZE">Czech Republic</option><option value="DNK">Denmark</option><option value="DJI">Djibouti</option><option value="DMA">Dominica</option><option value="DOM">Dominican Republic</option><option value="ECU">Ecuador</option><option value="EGY">Egypt</option><option value="SLV">El Salvador</option><option value="GNQ">Equatorial Guinea</option><option value="ERI">Eritrea</option><option value="EST">Estonia</option><option value="ETH">Ethiopia</option><option value="FRO">Faeroe Islands</option><option value="FLK">Falkland Islands (Malvinas)</option><option value="FJI">Fiji</option><option value="FIN">Finland</option><option value="FRA">France</option><option value="GUF">French Guiana</option><option value="PYF">French Polynesia</option><option value="ATF">French Southern Territories</option><option value="GAB">Gabon & Gabonese Republic</option><option value="GMB">Gambia</option><option value="GEO">Georgia</option><option value="DEU">Germany</option><option value="GHA">Ghana</option><option value="GIB">Gibraltar</option><option value="GRC">Greece & Hellenic Republic</option><option value="GRL">Greenland</option><option value="GRD">Grenada</option><option value="GLP">Guadaloupe</option><option value="GGY">Guernsey</option><option value="GUM">Guam</option><option value="GTM">Guatemala</option><option value="GIN">Guinea</option><option value="GNB">Guinea-Bissau</option><option value="GUY">Guyana</option><option value="HTI">Haiti</option><option value="HMD">Heard & McDonald Islands</option><option value="VAT">Holy See (Vatican City State)</option><option value="HND">Honduras</option><option value="HKG">Hong Kong</option><option value="HRV">Croatia</option><option value="HUN">Hungary</option><option value="ISL">Iceland</option><option value="IND">India</option><option value="IDN">Indonesia</option><option value="IRN">Iran</option><option value="IRQ">Iraq</option><option value="IRL">Ireland</option><option value="IMN">Isle of Man</option><option value="ISR">Israel</option><option value="ITA">Italy</option><option value="JAM">Jamaica</option><option value="JPN">Japan</option><option value="JEY">Jersey</option><option value="JOR">Jordan</option><option value="KAZ">Kazakhstan</option><option value="KEN">Kenya</option><option value="KIR">Kiribati</option><option value="PRK">Democratic People's Republic of Korea</option><option value="KOR">Republic of Korea</option><option value="KWT">Kuwait</option><option value="KGZ">Kyrgyz Republic</option><option value="LAO">Lao People's Democratic Republic</option><option value="LVA">Latvia</option><option value="LBN">Lebanon & Lebanese Republic</option><option value="LSO">Lesotho</option><option value="LBR">Liberia</option><option value="LBY">Libyan Arab Jamahiriya</option><option value="LIE">Liechtenstein</option><option value="LTU">Lithuania</option><option value="LUX">Luxembourg</option><option value="MAC">Macao</option><option value="MKD">Macedonia</option><option value="MDG">Madagascar</option><option value="MWI">Malawi</option><option value="MYS">Malaysia</option><option value="MDV">Maldives</option><option value="MLI">Mali</option><option value="MLT">Malta</option><option value="MHL">Marshall Islands</option><option value="MTQ">Martinique</option><option value="MRT">Mauritania</option><option value="MUS">Mauritius</option><option value="MYT">Mayotte</option><option value="MEX">Mexico</option><option value="FSM">Micronesia</option><option value="MDA">Moldova</option><option value="MCO">Monaco</option><option value="MNG">Mongolia</option><option value="MNE">Montenegro</option><option value="MSR">Montserrat</option><option value="MAR">Morocco</option><option value="MOZ">Mozambique</option><option value="MMR">Myanmar</option><option value="NAM">Namibia</option><option value="NRU">Nauru</option><option value="NPL">Nepal</option><option value="ANT">Netherlands Antilles</option><option value="NLD">Netherlands</option><option value="NCL">New Caledonia</option><option value="NZL">New Zealand</option><option value="NIC">Nicaragua</option><option value="NER">Niger</option><option value="NGA">Nigeria</option><option value="NIU">Niue</option><option value="NFK">Norfolk Island</option><option value="MNP">Northern Mariana Islands</option><option value="NOR">Norway</option><option value="OMN">Oman</option><option value="PAK">Pakistan</option><option value="PLW">Palau</option><option value="PSE">Palestinian Territory</option><option value="PAN">Panama</option><option value="PNG">Papua New Guinea</option><option value="PRY">Paraguay</option><option value="PER">Peru</option><option value="PHL">Philippines</option><option value="PCN">Pitcairn Island</option><option value="POL">Poland</option><option value="PRT">Portugal</option><option value="PRI">Puerto Rico</option><option value="QAT">Qatar</option><option value="COG">Republic of Congo</option><option value="REU">Reunion</option><option value="ROU">Romania</option><option value="RUS">Russian Federation</option><option value="RWA">Rwanda</option><option value="BLM">St. Barthelemy</option><option value="SHN">St. Helena</option><option value="KNA">St. Kitts & Nevis</option><option value="LCA">St. Lucia</option><option value="MAF">St. Martin</option><option value="SPM">St. Pierre & Miquelon</option><option value="VCT">St. Vincent & the Grenadines</option><option value="WSM">Samoa</option><option value="SMR">San Marino</option><option value="STP">Sao Tome & Principe</option><option value="SAU">Saudi Arabia</option><option value="SEN">Senegal</option><option value="SRB">Serbia</option><option value="SCG">Serbia & Montenegro</option><option value="SYC">Seychelles</option><option value="SLE">Sierra Leone</option><option value="SGP" selected>Singapore</option><option value="SXM">Sint Maarten</option><option value="SVK">Slovakia</option><option value="SVN">Slovenia</option><option value="SLB">Solomon Islands</option><option value="SOM">Somalia</option><option value="ZAF">South Africa</option><option value="SGS">South Georgia & South Sandwich Islands</option><option value="ESP">Spain</option><option value="LKA">Sri Lanka</option><option value="SDN">Sudan</option><option value="SSD">South Sudan</option><option value="SUR">Suriname</option><option value="SJM">Svalbard & Jan Mayen Islands</option><option value="SWZ">Swaziland</option><option value="SWE">Sweden</option><option value="CHE">Switzerland</option><option value="SYR">Syrian Arab Republic</option><option value="TWN">Taiwan</option><option value="TJK">Tajikistan</option><option value="TZA">Tanzania</option><option value="THA">Thailand</option><option value="TLS">Timor-Leste</option><option value="TGO">Togo & Togolese Republic</option><option value="TKL">Tokelau (Tokelau Islands)</option><option value="TON">Tonga</option><option value="TTO">Trinidad & Tobago</option><option value="TUN">Tunisia</option><option value="TUR">Turkey</option><option value="TKM">Turkmenistan</option><option value="TCA">Turks & Caicos Islands</option><option value="TUV">Tuvalu</option><option value="UGA">Uganda</option><option value="UKR">Ukraine</option><option value="ARE">United Arab Emirates</option><option value="GBR">United Kingdom of Great Britain & N. Ireland</option><option value="UMI">United States Minor Outlying Islands</option><option value="VIR">United States Virgin Islands</option><option value="URY">Uruguay</option><option value="UZB">Uzbekistan</option><option value="VUT">Vanuatu</option><option value="VEN">Venezuela</option><option value="VNM">Viet Nam</option><option value="WLF">Wallis & Futuna Islands</option><option value="ESH">Western Sahara</option><option value="YEM">Yemen</option><option value="ZMB">Zambia</option><option value="ZWE">Zimbabwe</option></select></div> </div> <div id="field-50" data-field-link-id="50" class="fieldrow editable group0 set0"> <div class="label"><label for="payer_phone">Home Phone:</label></div> <div class="input"><input type="tel" id="payer_phone" name="payer_phone" value="" onkeypress="prevent_nonphone_input(event)" maxlength="32" class="form-control default-field payer windows1252"></div> </div> <div id="field-54" data-field-link-id="54" class="fieldrow editable group0 set0"> <div class="label"><label for="businesstelephone">Business Phone:</label></div> <div class="input"><input type="text" id="businesstelephone" name="businesstelephone" value="" class="form-control"></div> </div> <div id="field-29" data-field-link-id="29" class="fieldrow editable group0 set0"> <div class="label"><label for="payer_email">Preferred E-mail:<span class="required"> *</span></label></div> <div class="input"><input type="email" id="payer_email" name="payer_email" value="" class="form-control default-field required-if-shown required payer format_email windows1252"><span class="comment">A transaction receipt will be emailed to this address.</span></div> </div> <div id="field-52" data-field-link-id="52" class="fieldrow editable group0 set0"> <div class="label"><label for="alumnus">Are you an Alumnus?</label></div> <div class="input"><input type="text" id="alumnus" name="alumnus" value="" class="form-control"><span class="comment">If so, please enter class year.</span></div> </div> </div> </fieldset> <fieldset> <div class="fieldsetinside"> <div id="field-40" data-field-link-id="40" class="fieldrow editable heading group0 set0">Your Payment Information</div> <div id="payment-modes"> <h3 id="payment_panel_1" data-payment-mode="1" class="payment-panel"> <div class="payment-option-radio"></div> <div class="payment-option-icon-group"><img id="payment-type-visa" src="assets/img/payment_types/visa.svg" alt="Visa" title="Visa" class="payment-option-icon"><img id="payment-type-mastercard" src="assets/img/payment_types/mastercard.svg" alt="MasterCard" title="MasterCard" class="payment-option-icon"><img id="payment-type-amex" src="assets/img/payment_types/amex.svg" alt="American Express" title="American Express" class="payment-option-icon"></div> </h3> <div><div class="fieldrow payfieldrow"> <div class="label"><label for="cc_acct_name">Name on Card:<span class="required"> *</span></label></div> <div class="input"><input type="text" id="cc_acct_name" name="cc_acct_name" value="" class="windows1252 form-control" maxlength="64" style="width: 50%;"></div> </div> <div class="fieldrow payfieldrow"> <div class="label"><label for="cc_num">Card Number:<span class="required"> *</span></label></div> <div class="input"><input type="text" id="cc_num" name="cc_num" value="" class="windows1252 form-control" maxlength="25" style="width: 50%;" autocomplete="off"></div> </div> <div class="fieldrow payfieldrow"> <div class="label"><label for="cc_cvv">Security Code:<span class="required"> *</span></label></div> <div class="input"><input type="text" id="cc_cvv" name="cc_cvv" value="" class="windows1252 form-control" maxlength="4" style="width: 20%;"></div> </div> <div class="fieldrow payfieldrow"> <div class="label"><label>Expiration Date:<span class="required"> *</span></label></div> <div class="input"><select id="cc_exp_mo" name="cc_exp_mo" class="form-control" style="display: inline; margin-right: 5px; width: 50px;"><option value="" selected>Mo</option><option value="01">1</option><option value="02">2</option><option value="03">3</option><option value="04">4</option><option value="05">5</option><option value="06">6</option><option value="07">7</option><option value="08">8</option><option value="09">9</option><option value="10">10</option><option value="11">11</option><option value="12">12</option></select><select id="cc_exp_yr" name="cc_exp_yr" class="form-control" style="display: inline; width: 80px;"><option value="" selected>Year</option><option value="2025">2025</option><option value="2026">2026</option><option value="2027">2027</option><option value="2028">2028</option><option value="2029">2029</option><option value="2030">2030</option><option value="2031">2031</option><option value="2032">2032</option><option value="2033">2033</option><option value="2034">2034</option><option value="2035">2035</option></select></div> </div> </div> </div> <div id="grecaptcha" name="grecaptcha" class="form-group"></div> <script> var showrecaptcha = function() { grecaptcha.render("grecaptcha", {"sitekey" : "6Lc-EsMSAAAAAAydmjZhBbRY2SXrFqzEaDOG-yI1"}); 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