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enctype="multipart/form-data" name="form_31545398735868" id="31545398735868" accept-charset="utf-8" autocomplete="on"><input type="hidden" name="formID" value="31545398735868" /><input type="hidden" id="JWTContainer" value="" /><input type="hidden" id="cardinalOrderNumber" value="" /><input type="hidden" id="jsExecutionTracker" name="jsExecutionTracker" value="build-date-1732700076390" /><input type="hidden" id="submitSource" name="submitSource" value="unknown" /><input type="hidden" id="buildDate" name="buildDate" value="1732700076390" /><input type="hidden" name="eventObserver" value="1" /> <div role="main" class="form-all"> <ul class="form-section page-section" role="presentation"> <li class="form-line" data-type="control_image" id="id_43"> <div id="cid_43" class="form-input-wide"> <div style="text-align:center" aria-hidden="true" role="none"><img alt="Image-43" loading="lazy" class="form-image" style="border:0" src="https://www.jotform.com/uploads/nsnainc/form_files/NSNAlogo-whiteRGB.196.png" height="57px" width="378px" data-component="image" role="none" aria-hidden="true" tabindex="-1" /></div> </div> </li> <li id="cid_1" class="form-input-wide" data-type="control_head"> <div class="form-header-group header-default"> <div class="header-text httac htvam"> <h2 id="header_1" class="form-header" data-component="header">Contact NSNA</h2> </div> </div> </li> <li class="form-line" data-type="control_radio" id="id_37"><label class="form-label form-label-top form-label-auto" id="label_37" aria-hidden="false"> How would you like to contact us? </label> <div id="cid_37" class="form-input-wide"> <div class="form-single-column" role="group" aria-labelledby="label_37" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_37" type="radio" class="form-radio" id="input_37_0" name="q37_howWould" value="By mail, phone or fax" /><label id="label_input_37_0" for="input_37_0">By mail, phone or fax</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_37" type="radio" class="form-radio" id="input_37_1" name="q37_howWould" value="By email" /><label id="label_input_37_1" for="input_37_1">By email</label></span></div> </div> </li> <li class="form-line form-field-hidden" style="display:none;" data-type="control_text" id="id_38"> <div id="cid_38" class="form-input-wide"> <div id="text_38" class="form-html" data-component="text" tabindex="-1"> <p><strong><span style="font-size:small;">NSNA HEADQUARTERS</span></strong></p> <p><span style="font-size:small;"><a href="https://maps.google.com/maps?q=45+Main+Street+Suite+606,+Brooklyn+NY+11201&hnear=45+Main+St+%23606,+Brooklyn,+Kings,+New+York+11201&t=m&z=16" target="_blank" rel="nofollow">National Student Nurses' Association</a></span></p> <p><span style="font-size:small;"><a href="https://maps.google.com/maps?q=45+Main+Street+Suite+606,+Brooklyn+NY+11201&hnear=45+Main+St+%23606,+Brooklyn,+Kings,+New+York+11201&t=m&z=16" target="_blank" rel="nofollow">45 Main Street, Suite 606</a></span></p> <p><span style="font-size:small;"><a href="https://maps.google.com/maps?q=45+Main+Street+Suite+606,+Brooklyn+NY+11201&hnear=45+Main+St+%23606,+Brooklyn,+Kings,+New+York+11201&t=m&z=16" target="_blank" rel="nofollow">Brooklyn, NY 11201 </a></span></p> <p><span style="font-size:small;">Tel: 718-210-0705 </span></p> <p><span style="font-size:small;">Fax: 718-797-1186 </span></p> <p><span style="font-size:small;"><a href="http://www.nsna.org/Directions.aspx" target="_blank" rel="nofollow">Click here for directions to NSNA</a></span></p> </div> </div> </li> <li class="form-line form-field-hidden" style="display:none;" data-type="control_text" id="id_17"> <div id="cid_17" class="form-input-wide"> <div id="text_17" class="form-html" data-component="text" tabindex="-1"> 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class="dragger-item"></span><input aria-describedby="label_16" type="radio" class="form-radio validate[required]" id="input_16_1" name="q16_topic" required="" value="I need my NSNA membership number" /><label id="label_input_16_1" for="input_16_1">I need my NSNA membership number</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_16" type="radio" class="form-radio validate[required]" id="input_16_2" name="q16_topic" required="" value="Advertising, Exhibiting and Sponsorship Opportunities" /><label id="label_input_16_2" for="input_16_2">Advertising, Exhibiting and Sponsorship Opportunities</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_16" type="radio" class="form-radio validate[required]" id="input_16_3" name="q16_topic" required="" value="Billing (NSNA Members)" /><label id="label_input_16_3" for="input_16_3">Billing (NSNA Members)</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_16" type="radio" class="form-radio validate[required]" id="input_16_4" name="q16_topic" required="" value="Billing (Accts Receivable/Payable for vendors, advertisers, etc)" /><label id="label_input_16_4" for="input_16_4">Billing (Accts Receivable/Payable for vendors, advertisers, etc)</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_16" type="radio" class="form-radio validate[required]" id="input_16_5" name="q16_topic" required="" value="Contact Board of Directors or Nominating/Elections Committee" /><label id="label_input_16_5" for="input_16_5">Contact Board of Directors or Nominating/Elections Committee</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_16" type="radio" class="form-radio validate[required]" id="input_16_6" name="q16_topic" required="" value="Imprint (Submit an article or query)" /><label id="label_input_16_6" for="input_16_6">Imprint (Submit an article or query)</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_16" type="radio" class="form-radio validate[required]" id="input_16_7" name="q16_topic" required="" value="Logo (NSNA Logo Request)" /><label id="label_input_16_7" for="input_16_7">Logo (NSNA Logo Request)</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_16" type="radio" class="form-radio validate[required]" id="input_16_8" name="q16_topic" required="" value="Membership: General (Benefits, Constituency, etc)" /><label id="label_input_16_8" for="input_16_8">Membership: General (Benefits, Constituency, etc)</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_16" type="radio" class="form-radio validate[required]" id="input_16_9" name="q16_topic" required="" value="Membership: Total School Membership Plan" /><label id="label_input_16_9" for="input_16_9">Membership: Total School Membership Plan</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_16" type="radio" class="form-radio validate[required]" id="input_16_10" name="q16_topic" required="" value="Membership: Request a School Membership List" /><label id="label_input_16_10" for="input_16_10">Membership: Request a School Membership List</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_16" type="radio" class="form-radio validate[required]" id="input_16_11" name="q16_topic" required="" value="Minutes: Submit State Association Minutes" /><label id="label_input_16_11" for="input_16_11">Minutes: Submit State Association Minutes</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_16" type="radio" class="form-radio validate[required]" id="input_16_12" name="q16_topic" required="" value="Newsletters: Submit State or School Newsletters" /><label id="label_input_16_12" for="input_16_12">Newsletters: Submit State or School Newsletters</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_16" type="radio" class="form-radio validate[required]" id="input_16_13" name="q16_topic" required="" value="Request for Materials (Getting the Pieces to Fit, Brochures, etc)" /><label id="label_input_16_13" for="input_16_13">Request for Materials (Getting the Pieces to Fit, Brochures, etc)</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_16" type="radio" class="form-radio validate[required]" id="input_16_14" name="q16_topic" required="" value="Scholarships and Grant Programs" /><label id="label_input_16_14" for="input_16_14">Scholarships and Grant Programs</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_16" type="radio" class="form-radio validate[required]" id="input_16_15" name="q16_topic" required="" value="Start-a-Chapter Information" /><label id="label_input_16_15" for="input_16_15">Start-a-Chapter Information</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_16" type="radio" class="form-radio validate[required]" id="input_16_16" name="q16_topic" required="" value="Project InTouch" /><label id="label_input_16_16" for="input_16_16">Project InTouch</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_16" type="radio" class="form-radio validate[required]" id="input_16_17" name="q16_topic" required="" value="Public Relations, Press and Communications" /><label id="label_input_16_17" for="input_16_17">Public Relations, Press and Communications</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_16" type="radio" class="form-radio validate[required]" id="input_16_18" name="q16_topic" required="" value="Resolutions" /><label id="label_input_16_18" for="input_16_18">Resolutions</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_16" type="radio" class="form-radio validate[required]" id="input_16_19" name="q16_topic" required="" value="Website – General (I can't find something I'm looking for)" /><label id="label_input_16_19" for="input_16_19">Website – General (I can't find something I'm looking for)</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_16" type="radio" class="form-radio validate[required]" id="input_16_20" name="q16_topic" required="" value="Website – Technical Issues (Contact Webmaster)" /><label id="label_input_16_20" for="input_16_20">Website – Technical Issues (Contact Webmaster)</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_16" type="radio" class="form-radio validate[required]" id="input_16_21" name="q16_topic" required="" value="Convention Question" /><label id="label_input_16_21" for="input_16_21">Convention Question</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_16" type="radio" class="form-radio validate[required]" id="input_16_22" name="q16_topic" required="" value="Awards" /><label id="label_input_16_22" for="input_16_22">Awards</label></span><span class="form-radio-item" style="clear:left"><input type="radio" class="form-radio-other form-radio validate[required]" name="q16_topic" id="other_16" tabindex="0" aria-label="Other" value="other" /><label id="label_other_16" style="text-indent:0" for="other_16"><span class="jfHiddenTextLabel">Other</span> </label><input type="text" class="form-radio-other-input form-textbox" name="q16_topic[other]" data-otherhint="Other" size="15" id="input_16" placeholder="Other" /><br /></span></div> </div> </li> <li class="form-line form-field-hidden" style="display:none;" data-type="control_text" id="id_35"> <div id="cid_35" class="form-input-wide"> <div id="text_35" class="form-html" data-component="text" tabindex="-1"> <p><span style="color:#333333;"><strong><span style="font-size:medium;">Request NSNA Membership Number</span></strong></span></p> <p><span style="font-size:medium;"><a href="http://form.jotform.co/form/31985586625873" target="_blank" rel="nofollow">Please use this form to request your membership number.</a></span></p> </div> </div> </li> <li class="form-line form-field-hidden" style="display:none;" data-type="control_text" id="id_36"> <div id="cid_36" class="form-input-wide"> <div id="text_36" class="form-html" data-component="text" tabindex="-1"> <p><strong><span style="font-size:medium;">Advertising Information Request</span></strong></p> <p><span style="font-size:medium;">Are you or your client interested in NSNA's advertising options? Please use <a href="http://form.jotform.co/form/31834236414854" target="_blank" rel="nofollow">this form</a>.</span></p> </div> </div> </li> <li class="form-line form-field-hidden" style="display:none;" data-type="control_text" id="id_11"> <div id="cid_11" class="form-input-wide"> <div id="text_11" class="form-html" data-component="text" tabindex="-1"> <p><strong><span style="font-family:arial, helvetica, sans-serif;font-size:medium;">Contact Board of Directors:</span></strong></p> <p><span style="font-family:arial, helvetica, sans-serif;font-size:medium;">Please use <a href="http://form.jotform.co/form/31984835277872" target="_blank" rel="nofollow">this form</a> to contact a member of the Board of Directors, Nominating & Elections Committee, or ANA/NLN consultant to the Board.</span></p> </div> </div> </li> <li class="form-line form-field-hidden" style="display:none;" data-type="control_text" id="id_32"> <div id="cid_32" class="form-input-wide"> <div id="text_32" class="form-html" data-component="text" tabindex="-1"> <p><strong><span style="font-size:medium;"><em>Imprint </em>Submissions</span></strong></p> <p><span style="font-size:medium;">Please use <a href="http://form.jotform.co/form/32026207893857" target="_blank" rel="nofollow">this form</a> to submit an article or query; or for general <em>Imprint </em>information.</span></p> </div> </div> </li> <li class="form-line form-field-hidden" style="display:none;" data-type="control_text" id="id_41"> <div id="cid_41" class="form-input-wide"> <div id="text_41" class="form-html" data-component="text" tabindex="-1"> <p><span style="font-size:medium;"><strong>Newsletter Submissions</strong></span></p> <p><span style="font-size:medium;">Please use <a href="http://form.jotform.co/form/32056567235859" target="_blank" rel="nofollow">this form</a> to submit your state association's or school chapter's newsletter. Submitted newsletters published from the month of March to the following February are automatically entered into the NSNA Newsletter Contest.</span></p> </div> </div> </li> <li class="form-line form-field-hidden" style="display:none;" data-type="control_text" id="id_12"> <div id="cid_12" class="form-input-wide"> <div id="text_12" class="form-html" data-component="text" tabindex="-1"> <p><strong><span style="font-family:arial, helvetica, sans-serif;font-size:medium;">Start-a-Chapter Request</span></strong></p> <p><span style="font-family:arial, helvetica, sans-serif;font-size:medium;">Please use <a href="http://form.jotform.co/form/31985104477864" target="_blank" rel="nofollow">this form</a> to request Start-a-Chapter information.</span></p> </div> </div> </li> <li class="form-line form-field-hidden" style="display:none;" data-type="control_text" id="id_33"> <div id="cid_33" class="form-input-wide"> <div id="text_33" class="form-html" data-component="text" tabindex="-1"> <p><strong><span style="font-size:medium;">State Minutes</span></strong></p> <p><span style="font-size:medium;">To submit official meeting minutes for a state association, please use <a href="http://form.jotform.us/form/31496025387156" target="_blank" rel="nofollow">this form</a>.</span></p> </div> </div> </li> <li class="form-line form-field-hidden" style="display:none;" data-type="control_text" id="id_10"> <div id="cid_10" class="form-input-wide"> <div id="text_10" class="form-html" data-component="text" tabindex="-1"> <p class="MsoNormal"><span style="font-size:11pt;font-family:arial, helvetica, sans-serif;color:#cc0033;">Unfortunately, NSNA policy states that "the NSNA logo may not be used by anyone, including members of school or state chapters."</span></p> <p class="MsoNormal"><span style="color:#cc0033;font-family:arial, helvetica, sans-serif;font-size:11pt;">Official state and school constituent chapters, however, may use wording such as "[name of state association/school chapter] is an official constituent of the National Student Nurses’ Association, Inc."</span></p> </div> </div> </li> <li class="form-line jf-required form-field-hidden" style="display:none;" data-type="control_fullname" id="id_3"><label class="form-label form-label-top form-label-auto" id="label_3" for="first_3" aria-hidden="false"> Full Name:<span class="form-required">*</span> </label> <div id="cid_3" class="form-input-wide jf-required"> <div data-wrapper-react="true"><span class="form-sub-label-container" style="vertical-align:top" data-input-type="first"><input type="text" id="first_3" name="q3_fullName[first]" class="form-textbox validate[required]" data-defaultvalue="" autoComplete="section-input_3 given-name" size="10" data-component="first" aria-labelledby="label_3 sublabel_3_first" required="" value="" /><label class="form-sub-label" for="first_3" id="sublabel_3_first" style="min-height:13px">First Name</label></span><span class="form-sub-label-container" style="vertical-align:top" data-input-type="last"><input type="text" id="last_3" name="q3_fullName[last]" class="form-textbox validate[required]" data-defaultvalue="" autoComplete="section-input_3 family-name" size="15" data-component="last" aria-labelledby="label_3 sublabel_3_last" required="" value="" /><label class="form-sub-label" for="last_3" id="sublabel_3_last" style="min-height:13px">Last Name</label></span></div> </div> </li> <li class="form-line jf-required form-field-hidden" style="display:none;" data-type="control_email" id="id_4"><label class="form-label form-label-top form-label-auto" id="label_4" for="input_4" aria-hidden="false"> Email:<span class="form-required">*</span> </label> <div id="cid_4" class="form-input-wide jf-required"> <div data-wrapper-react="true"><input type="email" id="input_4" name="q4_email" class="form-textbox validate[required, Email]" data-defaultvalue="" autoComplete="section-input_4 email" size="30" placeholder="ex: myname@example.com" data-component="email" aria-labelledby="label_4" required="" value="" /><br /><label class="form-sub-label" style="border:0;clip:rect(0 0 0 0);height:1px;margin:-1px;overflow:hidden;padding:0;position:absolute;width:1px;white-space:nowrap" for="input_4_confirm">Confirmation Email</label><input type="email" id="input_4_confirm" name="q4_email" class="form-textbox validate[required, Email, Email_Confirm]" data-defaultvalue="" autoComplete="nope" style="margin-top:8px" size="30" placeholder="Confirm Email" data-component="emailConfirmation" aria-labelledby="" value="" /></div> </div> </li> <li class="form-line" data-type="control_textbox" id="id_44"><label class="form-label form-label-top form-label-auto" id="label_44" for="input_44" aria-hidden="false"> School Name </label> <div id="cid_44" class="form-input-wide"> <span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_44" name="q44_schoolName" data-type="input-textbox" class="form-textbox" data-defaultvalue="" size="20" data-component="textbox" aria-labelledby="label_44 sublabel_input_44" value="" /><label class="form-sub-label" for="input_44" id="sublabel_input_44" style="min-height:13px">Please provide the campus as well if the school has multiple campuses</label></span> </div> </li> <li class="form-line form-field-hidden" style="display:none;" data-type="control_phone" id="id_7"><label class="form-label form-label-top form-label-auto" id="label_7" for="input_7_area" aria-hidden="false"> Phone: </label> <div id="cid_7" class="form-input-wide"> <div data-wrapper-react="true"><span class="form-sub-label-container" style="vertical-align:top" data-input-type="areaCode"><input type="tel" id="input_7_area" name="q7_phone[area]" class="form-textbox" data-defaultvalue="" autoComplete="section-input_7 tel-area-code" data-component="areaCode" aria-labelledby="label_7 sublabel_7_area" value="" /><span class="phone-separate" aria-hidden="true"> -</span><label class="form-sub-label" for="input_7_area" id="sublabel_7_area" style="min-height:13px">Area Code</label></span><span class="form-sub-label-container" style="vertical-align:top" data-input-type="phone"><input type="tel" id="input_7_phone" name="q7_phone[phone]" class="form-textbox" data-defaultvalue="" autoComplete="section-input_7 tel-local" data-component="phone" aria-labelledby="label_7 sublabel_7_phone" value="" /><label class="form-sub-label" for="input_7_phone" id="sublabel_7_phone" style="min-height:13px">Phone Number</label></span></div> </div> </li> <li class="form-line jf-required form-field-hidden" style="display:none;" data-type="control_radio" id="id_9"><label class="form-label form-label-top form-label-auto" id="label_9" aria-hidden="false"> I am...<span class="form-required">*</span> </label> <div id="cid_9" class="form-input-wide jf-required"> <div class="form-single-column" role="group" aria-labelledby="label_9" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_9" type="radio" class="form-radio validate[required]" id="input_9_0" name="q9_iAm" required="" value="NSNA Member" /><label id="label_input_9_0" for="input_9_0">NSNA Member</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_9" type="radio" class="form-radio validate[required]" id="input_9_1" name="q9_iAm" required="" value="Faculty/Advisor/Consultant" /><label id="label_input_9_1" for="input_9_1">Faculty/Advisor/Consultant</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_9" type="radio" class="form-radio validate[required]" id="input_9_2" name="q9_iAm" required="" value="Non-member" /><label id="label_input_9_2" for="input_9_2">Non-member</label></span></div> </div> </li> <li class="form-line form-field-hidden" style="display:none;" data-type="control_textbox" id="id_14"><label class="form-label form-label-top form-label-auto" id="label_14" for="input_14" aria-hidden="false"> Subject Line (optional) </label> <div id="cid_14" class="form-input-wide"> <span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_14" name="q14_subjectLine14" data-type="input-textbox" class="form-textbox" data-defaultvalue="Question, comment or topic" size="40" placeholder=" " data-component="textbox" aria-labelledby="label_14 sublabel_input_14" value="Question, comment or topic" /><label class="form-sub-label" for="input_14" id="sublabel_input_14" style="min-height:13px">Optional Subject Line for Email</label></span> </div> </li> <li class="form-line jf-required form-field-hidden" style="display:none;" data-type="control_textarea" id="id_6"><label class="form-label form-label-top" id="label_6" for="input_6" aria-hidden="false"> Message<span class="form-required">*</span> </label> <div id="cid_6" class="form-input-wide jf-required"> <textarea id="input_6" class="form-textarea validate[required]" name="q6_message6" cols="40" rows="6" data-component="textarea" required="" aria-labelledby="label_6"></textarea> </div> </li> <li class="form-line" data-type="control_address" id="id_45"><label class="form-label form-label-top form-label-auto" id="label_45" for="input_45_addr_line1" aria-hidden="false"> Address (Please provide a mailing address if you are requesting for materials) </label> <div id="cid_45" class="form-input-wide"> <div summary="" class="form-address-table jsTest-addressField"> <div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-street-line jsTest-address-lineField"><span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_45_addr_line1" name="q45_address[addr_line1]" class="form-textbox form-address-line" data-defaultvalue="" autoComplete="section-input_45 address-line1" data-component="address_line_1" aria-labelledby="label_45 sublabel_45_addr_line1" value="" /><label class="form-sub-label" for="input_45_addr_line1" id="sublabel_45_addr_line1" style="min-height:13px">Street Address</label></span></span></div> <div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-street-line jsTest-address-lineField"><span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_45_addr_line2" name="q45_address[addr_line2]" class="form-textbox form-address-line" data-defaultvalue="" autoComplete="section-input_45 address-line2" data-component="address_line_2" aria-labelledby="label_45 sublabel_45_addr_line2" value="" /><label class="form-sub-label" for="input_45_addr_line2" id="sublabel_45_addr_line2" style="min-height:13px">Street Address Line 2</label></span></span></div> <div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-city-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_45_city" name="q45_address[city]" class="form-textbox form-address-city" data-defaultvalue="" autoComplete="section-input_45 address-level2" data-component="city" aria-labelledby="label_45 sublabel_45_city" value="" /><label class="form-sub-label" for="input_45_city" id="sublabel_45_city" style="min-height:13px">City</label></span></span><span class="form-address-line form-address-state-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_45_state" name="q45_address[state]" class="form-textbox form-address-state" data-defaultvalue="" autoComplete="section-input_45 address-level1" data-component="state" aria-labelledby="label_45 sublabel_45_state" value="" /><label class="form-sub-label" for="input_45_state" id="sublabel_45_state" style="min-height:13px">State / Province </label></span></span></div> <div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-zip-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_45_postal" name="q45_address[postal]" class="form-textbox form-address-postal" data-defaultvalue="" autoComplete="section-input_45 postal-code" data-component="zip" aria-labelledby="label_45 sublabel_45_postal" value="" /><label class="form-sub-label" for="input_45_postal" id="sublabel_45_postal" style="min-height:13px">Zip Code</label></span></span></div> </div> </div> </li> <li class="form-line form-field-hidden" style="display:none;" data-type="control_radio" id="id_40"><label class="form-label form-label-top" id="label_40" aria-hidden="false"> Do you need to send us a file? </label> <div id="cid_40" class="form-input-wide"> <div class="form-single-column" role="group" aria-labelledby="label_40" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_40" type="radio" class="form-radio" id="input_40_0" name="q40_doYou" value="Yes" /><label id="label_input_40_0" for="input_40_0">Yes</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_40" type="radio" class="form-radio" id="input_40_1" name="q40_doYou" value="No" /><label id="label_input_40_1" for="input_40_1">No</label></span></div> </div> </li> <li class="form-line form-field-hidden" style="display:none;" data-type="control_fileupload" id="id_39"><label class="form-label form-label-top form-label-auto" id="label_39" for="input_39" aria-hidden="false"> Upload File(s) - Please wait until file finishes loading before submitting </label> <div id="cid_39" class="form-input-wide"> <div data-wrapper-react="true"><span class="form-sub-label-container" style="vertical-align:top"> <div class="qq-uploader-buttonText-value">Upload a File</div><input type="file" id="input_39" name="q39_uploadFiles39[]" multiple="" class="form-upload-multiple" data-file-accept="pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif, ppt, pptx, psd, msg, pub, log" data-file-maxsize="12288" data-file-minsize="0" data-file-limit="0" data-component="fileupload" /><label class="form-sub-label" for="input_39" style="min-height:13px">12 MB limit</label> </span><span style="display:none" class="cancelText">Cancel</span><span style="display:none" class="ofText">of</span></div> </div> </li> <li class="form-line form-field-hidden" style="display:none;" data-type="control_button" id="id_42"> <div id="cid_42" class="form-input-wide"> <div data-align="auto" class="form-buttons-wrapper form-buttons-auto jsTest-button-wrapperField"><button id="input_42" type="submit" class="form-submit-button submit-button jf-form-buttons jsTest-submitField legacy-submit" data-component="button" data-content="">Submit</button></div> </div> </li> <li style="display:none">Should be Empty: <input type="text" name="website" value="" type="hidden" /></li> </ul> </div> <script> JotForm.showJotFormPowered = "0"; </script> <script> JotForm.poweredByText = "Powered by Jotform"; </script><input type="hidden" class="simple_spc" id="simple_spc" name="simple_spc" value="31545398735868" /> <script type="text/javascript"> var all_spc = document.querySelectorAll("form[id='31545398735868'] .si" + "mple" + "_spc"); for (var i = 0; i < all_spc.length; i++) { all_spc[i].value = "31545398735868-31545398735868"; } </script> </form></body> </html><script type="text/javascript">JotForm.isNewSACL=true;</script>