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class="en__field__label" style="">Tribute Type</label> <div class="en__field__element en__field__element--select"> <select id="en__field_transaction_trbopts" class="en__field__input en__field__input--select" name="transaction.trbopts"> <option value="In Honor Of">In Honor Of</option> <option value="In Memory Of">In Memory Of</option> </select> </div> </div> <div class="en__field en__field--text en__field--735208 en__field--honname"> <label for="en__field_transaction_honname" class="en__field__label" style="">Tribute Name</label> <div class="en__field__element en__field__element--text"> <input id="en__field_transaction_honname" type="text" class="en__field__input en__field__input--text" name="transaction.honname" value=""/> </div> </div> <div class="en__field en__field--text en__field--735207 en__field--gftrsn"> <label for="en__field_transaction_gftrsn" class="en__field__label" style="">Gift Reason</label> <div class="en__field__element en__field__element--text"> <input id="en__field_transaction_gftrsn" type="text" class="en__field__input en__field__input--text" name="transaction.gftrsn" value=""/> </div> </div> </div> </div> </div> <div class="en__component en__component--row en__component--advrow"> <div class="en__component en__component en__component--column en__component--advcolumn form-contact" style=""> <div class="en__component en__component--copyblock" style=" "> <div class="section-title">Enter Your Contact Info</div> </div> <div class="en__component en__component--formblock" style=""> <div class="en__field en__field--text en__field--1401260 en__field--firstName"> <label for="en__field_supporter_firstName" class="en__field__label" style="">First Name</label> <div class="en__field__element en__field__element--text"> <input id="en__field_supporter_firstName" type="text" class="en__field__input en__field__input--text" name="supporter.firstName" value=""/> </div> </div> <div class="en__field en__field--text en__field--1401261 en__field--lastName"> <label for="en__field_supporter_lastName" class="en__field__label" style="">Last Name</label> <div class="en__field__element en__field__element--text"> <input id="en__field_supporter_lastName" type="text" class="en__field__input en__field__input--text" name="supporter.lastName" value=""/> </div> </div> <div class="en__field en__field--text en__field--1401262 en__field--address1 en__mandatory"> <label for="en__field_supporter_address1" class="en__field__label" style="">Address 1</label> <div class="en__field__element en__field__element--text"> <input id="en__field_supporter_address1" type="text" class="en__field__input en__field__input--text" name="supporter.address1" value=""/> </div> </div> <div class="en__field en__field--text en__field--1401268 en__field--address2"> <label for="en__field_supporter_address2" class="en__field__label" style="">Address 2</label> <div class="en__field__element en__field__element--text"> <input id="en__field_supporter_address2" type="text" class="en__field__input en__field__input--text" name="supporter.address2" value=""/> </div> </div> <div class="en__field en__field--text en__field--1401265 en__field--city en__mandatory"> <label for="en__field_supporter_city" class="en__field__label" style="">City</label> <div class="en__field__element en__field__element--text"> <input id="en__field_supporter_city" type="text" class="en__field__input en__field__input--text" name="supporter.city" value=""/> </div> </div> <div class="en__field en__field--select en__field--1401284 en__field--region en__mandatory"> <label for="en__field_supporter_region" class="en__field__label" style="">State</label> <div class="en__field__element en__field__element--select"> <select id="en__field_supporter_region" class="en__field__input en__field__input--select" name="supporter.region"> <option value="">-- State --</option> <option value="AL">Alabama</option> <option value="AK">Alaska</option> <option value="AZ">Arizona</option> <option value="AR">Arkansas</option> <option value="CA">California</option> <option value="CO">Colorado</option> <option value="CT">Connecticut</option> <option value="DE">Delaware</option> <option value="DC">District of Columbia</option> <option value="FL">Florida</option> <option value="GA">Georgia</option> <option value="HI">Hawaii</option> <option value="ID">Idaho</option> <option value="IL">Illinois</option> <option value="IN">Indiana</option> <option value="IA">Iowa</option> <option value="KS">Kansas</option> <option value="KY">Kentucky</option> <option value="LA">Louisiana</option> <option value="ME">Maine</option> <option value="MD">Maryland</option> <option value="MA">Massachusetts</option> <option value="MI">Michigan</option> <option value="MN">Minnesota</option> <option value="MS">Mississippi</option> <option value="MO">Missouri</option> <option value="MT">Montana</option> <option value="NE">Nebraska</option> <option value="NV">Nevada</option> <option value="NH">New Hampshire</option> <option value="NJ">New Jersey</option> <option value="NM">New Mexico</option> <option value="NY">New York</option> <option value="NC">North Carolina</option> <option value="ND">North Dakota</option> <option value="OH">Ohio</option> <option value="OK">Oklahoma</option> <option value="OR">Oregon</option> <option value="PA">Pennsylvania</option> <option value="RI">Rhode Island</option> <option value="SC">South Carolina</option> <option value="SD">South Dakota</option> <option value="TN">Tennessee</option> <option value="TX">Texas</option> <option value="UT">Utah</option> <option value="VT">Vermont</option> <option value="VA">Virginia</option> <option value="WA">Washington</option> <option value="WV">West Virginia</option> <option value="WI">Wisconsin</option> <option value="WY">Wyoming</option> </select> </div> </div> <div class="en__field en__field--text en__field--1401266 en__field--postcode en__mandatory"> <label for="en__field_supporter_postcode" class="en__field__label" style="">Zip Code</label> <div class="en__field__element en__field__element--text"> <input id="en__field_supporter_postcode" type="text" class="en__field__input en__field__input--text" name="supporter.postcode" value=""/> </div> </div> <div class="en__field en__field--select en__field--1401283 en__field--country en__mandatory"> <label for="en__field_supporter_country" class="en__field__label" style="">Country</label> <div class="en__field__element en__field__element--select"> <select id="en__field_supporter_country" class="en__field__input en__field__input--select" name="supporter.country"> <option value="">-- Country --</option> <option value="US">United States</option> <option value="CA">Canada</option> <option value="GB">United Kingdom</option> <option value="AF">Afghanistan</option> <option value="AX">脜land Islands</option> <option value="AL">Albania</option> <option value="DZ">Algeria</option> <option value="AS">American Samoa</option> <option value="AD">Andorra</option> <option value="AO">Angola</option> <option value="AI">Anguilla</option> <option value="AQ">Antarctica</option> <option value="AG">Antigua and Barbuda</option> <option value="AR">Argentina</option> <option value="AM">Armenia</option> <option value="AW">Aruba</option> <option value="AU">Australia</option> <option value="AT">Austria</option> <option value="AZ">Azerbaijan</option> <option value="BS">Bahamas</option> <option value="BH">Bahrain</option> <option value="BD">Bangladesh</option> <option value="BB">Barbados</option> <option value="BY">Belarus</option> <option value="BE">Belgium</option> <option value="BZ">Belize</option> <option value="BJ">Benin</option> <option value="BM">Bermuda</option> <option value="BT">Bhutan</option> <option value="BO">Bolivia, Plurinational State of</option> <option value="BQ">Bonaire, Sint Eustatius and Saba</option> <option value="BA">Bosnia and Herzegovina</option> <option value="BW">Botswana</option> <option value="BV">Bouvet Island</option> <option value="BR">Brazil</option> <option value="IO">British Indian Ocean Territory</option> <option value="BN">Brunei Darussalam</option> <option value="BG">Bulgaria</option> <option value="BF">Burkina Faso</option> <option value="BI">Burundi</option> <option value="CV">Cabo Verde</option> <option value="KH">Cambodia</option> <option value="CM">Cameroon</option> <option value="KY">Cayman Islands</option> <option value="CF">Central African Republic</option> <option value="TD">Chad</option> <option value="CL">Chile</option> <option value="CN">China</option> <option value="CX">Christmas Island</option> <option value="CC">Cocos (Keeling) Islands</option> <option value="CO">Colombia</option> <option value="KM">Comoros</option> <option value="CG">Congo</option> <option value="CD">Congo, the Democratic Republic of the</option> <option value="CK">Cook Islands</option> <option value="CR">Costa Rica</option> <option value="CI">C么te d'Ivoire</option> <option value="HR">Croatia</option> <option value="CU">Cuba</option> <option value="CW">Cura莽ao</option> <option value="CY">Cyprus</option> <option value="CZ">Czech Republic</option> <option value="DK">Denmark</option> <option value="DJ">Djibouti</option> <option value="DM">Dominica</option> <option value="DO">Dominican Republic</option> <option value="EC">Ecuador</option> <option value="EG">Egypt</option> <option value="SV">El Salvador</option> <option value="GQ">Equatorial Guinea</option> <option value="ER">Eritrea</option> <option value="EE">Estonia</option> <option value="ET">Ethiopia</option> <option value="FK">Falkland Islands (Malvinas)</option> <option value="FO">Faroe Islands</option> <option value="FJ">Fiji</option> <option value="FI">Finland</option> <option value="FR">France</option> <option value="GF">French Guiana</option> <option value="PF">French Polynesia</option> <option value="TF">French Southern Territories</option> <option value="GA">Gabon</option> <option value="GM">Gambia</option> <option value="GE">Georgia</option> <option value="DE">Germany</option> <option value="GH">Ghana</option> <option value="GI">Gibraltar</option> <option value="GR">Greece</option> <option value="GL">Greenland</option> <option value="GD">Grenada</option> <option value="GP">Guadeloupe</option> <option value="GU">Guam</option> <option value="GT">Guatemala</option> <option value="GG">Guernsey</option> <option value="GN">Guinea</option> <option value="GW">Guinea-Bissau</option> <option value="GY">Guyana</option> <option value="HT">Haiti</option> <option value="HM">Heard Island and McDonald Islands</option> <option value="VA">Holy See (Vatican City State)</option> <option value="HN">Honduras</option> <option value="HK">Hong Kong</option> <option value="HU">Hungary</option> <option value="IS">Iceland</option> <option value="IN">India</option> <option value="ID">Indonesia</option> <option value="IR">Iran, Islamic Republic of</option> <option value="IQ">Iraq</option> <option value="IE">Ireland</option> <option value="IM">Isle of Man</option> <option value="IL">Israel</option> <option value="IT">Italy</option> <option value="JM">Jamaica</option> <option value="JP">Japan</option> <option value="JE">Jersey</option> <option value="JO">Jordan</option> <option value="KZ">Kazakhstan</option> <option value="KE">Kenya</option> <option value="KI">Kiribati</option> <option value="KP">Korea, Democratic People's Republic of</option> <option value="KR">Korea, Republic of</option> <option value="KW">Kuwait</option> <option value="KG">Kyrgyzstan</option> <option value="LA">Lao People's Democratic Republic</option> <option value="LV">Latvia</option> <option value="LB">Lebanon</option> <option value="LS">Lesotho</option> <option value="LR">Liberia</option> <option value="LY">Libya</option> <option value="LI">Liechtenstein</option> <option value="LT">Lithuania</option> <option value="LU">Luxembourg</option> <option value="MO">Macao</option> <option value="MK">Macedonia, the former Yugoslav Republic of</option> <option value="MG">Madagascar</option> <option value="MW">Malawi</option> <option value="MY">Malaysia</option> <option value="MV">Maldives</option> <option value="ML">Mali</option> <option value="MT">Malta</option> <option value="MH">Marshall Islands</option> <option value="MQ">Martinique</option> <option value="MR">Mauritania</option> <option value="MU">Mauritius</option> <option value="YT">Mayotte</option> <option value="MX">Mexico</option> <option value="FM">Micronesia, Federated States of</option> <option value="MD">Moldova, Republic of</option> <option value="MC">Monaco</option> <option value="MN">Mongolia</option> <option value="ME">Montenegro</option> <option value="MS">Montserrat</option> <option value="MA">Morocco</option> <option value="MZ">Mozambique</option> <option value="MM">Myanmar</option> <option value="NA">Namibia</option> <option value="NR">Nauru</option> <option value="NP">Nepal</option> <option value="NL">Netherlands</option> <option value="NC">New Caledonia</option> <option value="NZ">New Zealand</option> <option value="NI">Nicaragua</option> <option value="NE">Niger</option> <option value="NG">Nigeria</option> <option value="NU">Niue</option> <option value="NF">Norfolk Island</option> <option value="MP">Northern Mariana Islands</option> <option value="NO">Norway</option> <option value="OM">Oman</option> <option value="PK">Pakistan</option> <option value="PW">Palau</option> <option value="PS">Palestine, State of</option> <option value="PA">Panama</option> <option value="PG">Papua New Guinea</option> <option value="PY">Paraguay</option> <option value="PE">Peru</option> <option value="PH">Philippines</option> <option value="PN">Pitcairn</option> <option value="PL">Poland</option> <option value="PT">Portugal</option> <option value="PR">Puerto Rico</option> <option value="QA">Qatar</option> <option value="RE">R茅union</option> <option value="RO">Romania</option> <option value="RU">Russian Federation</option> <option value="RW">Rwanda</option> <option value="BL">Saint Barth茅lemy</option> <option value="SH">Saint Helena, Ascension and Tristan da Cunha</option> <option value="KN">Saint Kitts and Nevis</option> <option value="LC">Saint Lucia</option> <option value="MF">Saint Martin (French part)</option> <option value="PM">Saint Pierre and Miquelon</option> <option value="VC">Saint Vincent and the Grenadines</option> <option value="WS">Samoa</option> <option value="SM">San Marino</option> <option value="ST">Sao Tome and Principe</option> <option value="SA">Saudi Arabia</option> <option value="SN">Senegal</option> <option value="RS">Serbia</option> <option value="SC">Seychelles</option> <option value="SL">Sierra Leone</option> <option value="SG">Singapore</option> <option value="SX">Sint Maarten (Dutch part)</option> <option value="SK">Slovakia</option> <option value="SI">Slovenia</option> <option value="SB">Solomon Islands</option> <option value="SO">Somalia</option> <option value="ZA">South Africa</option> <option value="GS">South Georgia and the South Sandwich Islands</option> <option value="SS">South Sudan</option> <option value="ES">Spain</option> <option value="LK">Sri Lanka</option> <option value="SD">Sudan</option> <option value="SR">Suriname</option> <option value="SJ">Svalbard and Jan Mayen</option> <option value="SZ">Swaziland</option> <option value="SE">Sweden</option> <option value="CH">Switzerland</option> <option value="SY">Syrian Arab Republic</option> <option value="TW">Taiwan, Province of China</option> <option value="TJ">Tajikistan</option> <option value="TZ">Tanzania, United Republic of</option> <option value="TH">Thailand</option> <option value="TL">Timor-Leste</option> <option value="TG">Togo</option> <option value="TK">Tokelau</option> <option value="TO">Tonga</option> <option value="TT">Trinidad and Tobago</option> <option value="TN">Tunisia</option> <option value="TR">Turkey</option> <option value="TM">Turkmenistan</option> <option value="TC">Turks and Caicos Islands</option> <option value="TV">Tuvalu</option> <option value="UG">Uganda</option> <option value="UA">Ukraine</option> <option value="AE">United Arab Emirates</option> <option value="UM">United States Minor Outlying Islands</option> <option value="UY">Uruguay</option> <option value="UZ">Uzbekistan</option> <option value="VU">Vanuatu</option> <option value="VE">Venezuela, Bolivarian Republic of</option> <option value="VN">Viet Nam</option> <option value="VG">Virgin Islands, British</option> <option value="VI">Virgin Islands, U.S.</option> <option value="WF">Wallis and Futuna</option> <option value="EH">Western Sahara</option> <option value="YE">Yemen</option> <option value="ZM">Zambia</option> <option value="ZW">Zimbabwe</option> </select> </div> </div> <div class="en__field en__field--text en__field--1401270 en__field--emailAddress en__mandatory"> <label for="en__field_supporter_emailAddress" class="en__field__label" style="">Email Address</label> <div class="en__field__element en__field__element--text"> <input id="en__field_supporter_emailAddress" type="text" class="en__field__input en__field__input--text" name="supporter.emailAddress" value=""/> </div> </div> <div class="en__field en__field--text en__field--1401269 en__field--NOT_TAGGED_97"> <label for="en__field_supporter_NOT_TAGGED_97" class="en__field__label" style="">Mobile Phone</label> <div class="en__field__element en__field__element--text"> <input id="en__field_supporter_NOT_TAGGED_97" type="text" class="en__field__input en__field__input--text" name="supporter.NOT_TAGGED_97" value=""/> </div> </div> <div class="en__field en__field--checkbox en__field--question en__field--1748 en__field--subscription-q-unsubscribe-all"> <div class="en__field__element en__field__element--checkbox "> <div class="en__field__item"> <input id="en__field_supporter_questions_1748" checked type="checkbox" class="en__field__input 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Take action and help us create a world where all people are treated fairly and equitable, no matter their race, religion, or beliefs. </label> </div> </div> </div> <div class="en__field en__field--checkbox en__field--question en__field--96991 en__field--monthly-defender"> <label class="en__field__label" style="">Monthly Defender</label> <div class="en__field__element en__field__element--checkbox "> <div class="en__field__item"> <input id="en__field_supporter_questions_96991" type="checkbox" class="en__field__input en__field__input--checkbox" value="Y" name="supporter.questions.96991"/> <label for="en__field_supporter_questions_96991" class="en__field__label en__field__label--item">Get your monthly review of the world's most urgent human rights issues and find out how you can take action and create change. Sign up for our monthly e-newsletter, The Defender.</label> </div> </div> </div> <input type="hidden" class="en__field__input en__field__input--hidden" name="transaction.paycurrency" value="USD"/> </div> <div class="en__component en__component--codeblock"><style> .en__field--donor-communications { display: none; } </style></div> <div class="en__component en__component--codeblock"></div> <div class="en__component en__component--codeblock"><script> var placeSearch, autocomplete; var componentForm = { street_number: 'short_name', route: 'long_name', locality: 'long_name', sublocality_level_1 : 'long_name', administrative_area_level_1: 'short_name', country: 'short_name', postal_code: 'short_name' }; var enFieldMap = { // this translates the IDs of the google places address fields to corresponding IDs of the Engaging Networks address fields street_number : 'en__field_supporter_address1', route : 'en__field_supporter_address1', locality : 'en__field_supporter_city', // city sublocality_level_1 : 'en__field_supporter_city', // city but for NY boroughs administrative_area_level_1 : 'en__field_supporter_region', // state postal_code : 'en__field_supporter_postcode', // zip country : 'en__field_supporter_country' // country } function initAutocomplete() { // Create the autocomplete object, restricting the search to geographical // location types. console.log('testinit'); autocomplete = new google.maps.places.Autocomplete( /** @type {!HTMLInputElement} */(document.getElementById('en__field_supporter_address1')), {types: ['geocode']}); // When the user selects an address from the dropdown, populate the address // fields in the form. autocomplete.addListener('place_changed', fillInAddress); } function fillInAddress() { // Get the place details from the autocomplete object. var place = autocomplete.getPlace(); for (var component in componentForm) { document.getElementById(enFieldMap[component]).value = ''; document.getElementById(enFieldMap[component]).disabled = false; } // Get each component of the address from the place details // and fill the corresponding field on the form. for (var i = 0; i < place.address_components.length; i++) { var addressType = place.address_components[i].types[0]; if (componentForm[addressType]) { var val = place.address_components[i][componentForm[addressType]]; console.log('addressType', val); var currentVal = document.getElementById(enFieldMap[addressType]).value; if(currentVal){ document.getElementById(enFieldMap[addressType]).value = currentVal + ' ' + val; } else { document.getElementById(enFieldMap[addressType]).value = val; } } } if (typeof showEditAddress === "function") { // safe to use the function, meaning the editAddress scripts are present showEditAddress(); // show the edit block } } // Bias the autocomplete object to the user's geographical location, // as supplied by the browser's 'navigator.geolocation' object. function geolocate() { if (navigator.geolocation) { navigator.geolocation.getCurrentPosition(function(position) { var geolocation = { lat: position.coords.latitude, lng: position.coords.longitude }; var circle = new google.maps.Circle({ center: geolocation, radius: position.coords.accuracy }); autocomplete.setBounds(circle.getBounds()); }); } } function preventFormSubmit(e) { var key = e.charCode || e.keyCode || 0; if (key == 13) { e.preventDefault(); // prevent the form from submitting when a user selects an address result } } </script> <script src="https://web.archive.org/web/20240927010418js_/https://maps.googleapis.com/maps/api/js?key=AIzaSyDmIlMUwQwxLp99gcu9OtD1_wE3AGnWPOs&libraries=places&callback=initAutocomplete" async defer></script></div> <div class="en__component en__component--codeblock"><style> /* Add styles as needed here */ .en__component.en__component--formblock.address-info { /* background: rgba(0,0,0,.05); padding: 1em; border: 1px solid rgba(0,0,0,. 1);*/ margin: 0 auto 1em; /*display: none; */ } .edit-address { display: none; /* show it once an address is filled */ text-align: right; font-weight: normal; float: right; margin: 0; font-size: .8em; position: absolute; right: 1.5em; line-height: 2.5em; } #edit-address-link { font-weight: normal; text-decoration: underline; } </style> <script> /* Add scripts as needed here */ /* // a callback for when the address is entered function showEditAddress() { $('.edit-address').show(); } // Edit Address -- shows the address fields to the user function editAddress() { $('.en__component.en__component--formblock.address-info').show(); $('#autocomplete-container').hide(); } */ $(function(){ $('#en__field_supporter_address1').on('keydown', function(){ return preventFormSubmit(event); }) /* $('#edit-address-link').on('click', function(e){ e.preventDefault(); editAddress(); }); $('.address-info input').on('change', function(){ if(document.getElementById('autocomplete') !== document.activeElement){ editAddress(); 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height:0;"></div> <div id="en__digitalWallet__paypalTouch" class="en__digitalWallet__button" style="width: 100%;" data-theme="gold"> <div id="en__digitalWallet__paypalTouch__container" class="en__digitalWallet__container" style="margin: 0 0 5px 0"></div> </div> <div style="flex-basis:100%; height:0;"></div> <div id="en__digitalWallet__chariot" class="en__digitalWallet__button" style="width: 100%;" data-theme=""> <div id="en__digitalWallet__chariot__container" class="en__digitalWallet__container"></div> </div> </div> </div> <div class="en__component en__component--formblock" style=""> <div class="en__field en__field--radio en__field--question en__field--340951 en__field--payment-select-v2 en__mandatory"> <label for="en__field_supporter_questions_340951" class="en__field__label" style="">Payment Method</label> <div class="en__field__element en__field__element--radio "> <div class="en__field__item"> <input id="en__field_supporter_questions_3409510" checked type="radio" class="en__field__input en__field__input--radio" value="Credit Card" name="supporter.questions.340951"/> <label for="en__field_supporter_questions_3409510" class="en__field__label en__field__label--item">Credit Card</label> </div> <div class="en__field__item"> <input id="en__field_supporter_questions_3409511" type="radio" class="en__field__input en__field__input--radio" value="ACH" name="supporter.questions.340951"/> <label for="en__field_supporter_questions_3409511" class="en__field__label en__field__label--item">Bank Account / ACH</label> </div> <div class="en__field__item"> <input id="en__field_supporter_questions_3409512" type="radio" class="en__field__input en__field__input--radio" value="PayPal" name="supporter.questions.340951"/> <label for="en__field_supporter_questions_3409512" class="en__field__label en__field__label--item">PayPal</label> </div> </div> </div> <div class="en__field en__field--select en__field--735248 en__field--paymenttype"> <label for="en__field_transaction_paymenttype" class="en__field__label" style="">Payment Type</label> <div class="en__field__element en__field__element--select"> <select id="en__field_transaction_paymenttype" class="en__field__input en__field__input--select" name="transaction.paymenttype"> <option value="">-- Select One --</option> <option selected="selected" value="VI">Visa</option> <option value="MC">Master Card</option> <option value="AX">American Express</option> <option value="DI">Discover</option> <option value="ACH">Bank Account / ACH</option> <option value="Paypal">PayPal</option> </select> </div> </div> <div class="en__field en__field--select en__field--1073680 en__field--bankAccountType"> <label for="en__field_supporter_bankAccountType" class="en__field__label" style="">Bank Account Type</label> <div class="en__field__element en__field__element--select"> <select id="en__field_supporter_bankAccountType" class="en__field__input en__field__input--select" name="supporter.bankAccountType"> <option value="Checking">Checking</option> <option value="Savings">Savings</option> </select> </div> </div> <div class="en__field en__field--number en__field--1073682 en__field--bankRoutingNumber"> <label for="en__field_supporter_bankRoutingNumber" class="en__field__label" style="">Bank Routing Number</label> <div class="en__field__element en__field__element--number"> <input id="en__field_supporter_bankRoutingNumber" type="number" class="en__field__input en__field__input--number" name="supporter.bankRoutingNumber" value="The bank routing number"/> </div> </div> <div class="en__field en__field--number en__field--1073681 en__field--bankAccountNumber"> <label for="en__field_supporter_bankAccountNumber" class="en__field__label" style="">Bank Account Number</label> <div class="en__field__element en__field__element--number"> <input id="en__field_supporter_bankAccountNumber" type="number" class="en__field__input en__field__input--number" name="supporter.bankAccountNumber" value="The bank account number"/> </div> </div> <div class="en__field en__field--checkbox en__field--question en__field--172337 en__field--authorize-ach en__mandatory"> <label class="en__field__label" style="">I authorize the use of my bank account as a payment method and authorize this organization to debit my bank account via the Automated Clearing House system to fulfill my donation commitment. This authority will remain in effect until revoked in writing by the account holder.</label> <div class="en__field__element en__field__element--checkbox "> <div class="en__field__item"> <input id="en__field_supporter_questions_172337" type="checkbox" class="en__field__input en__field__input--checkbox" value="Yes" name="supporter.questions.172337"/> <label for="en__field_supporter_questions_172337" class="en__field__label en__field__label--item">Yes</label> </div> </div> </div> <div class="en__field en__field--text en__field--735250 en__field--creditCardHolderName"> <label for="en__field_supporter_creditCardHolderName" class="en__field__label" style="">Cardholder Name</label> <div class="en__field__element en__field__element--text"> <input id="en__field_supporter_creditCardHolderName" type="text" class="en__field__input en__field__input--text" name="supporter.creditCardHolderName" value=""/> </div> </div> <div class="en__field en__field--vgs en__field--735251 en__field--ccnumber"> <label for="en__field_transaction_ccnumber" class="en__field__label" style="">Credit Card Number</label> <div class="en__field__element en__field__element--vgs"> <input type="hidden" name="transaction.ccnumber"/> <div id="en__field_transaction_ccnumber" class="en__field__input en__field__input--vgs"> </div> </div> </div> <div class="en__field en__field--splitselect en__field--735254 en__field--ccexpire"> <label for="en__field_transaction_ccexpire" class="en__field__label" style="">Credit Card Expiration</label> <div class="en__field__element en__field__element--splitselect"> <input type="hidden" name="transaction.ccexpire.delimiter" value=""> <div class="en__field__item"> <select id="en__field_transaction_ccexpire" class="en__field__input en__field__input--splitselect" name="transaction.ccexpire"> <option value="01">January</option> <option value="02">February</option> <option value="03">March</option> <option value="04">April</option> <option value="05">May</option> <option value="06">June</option> <option value="07">July</option> <option value="08">August</option> <option value="09">September</option> <option value="10">October</option> <option value="11">November</option> <option value="12">December</option> </select> </div> <div class="en__field__item"> <select class="en__field__input en__field__input--splitselect" name="transaction.ccexpire"> <option value="24">2024</option> <option value="25">2025</option> <option value="26">2026</option> <option value="27">2027</option> <option value="28">2028</option> <option value="29">2029</option> <option value="30">2030</option> <option value="31">2031</option> <option value="32">2032</option> <option value="33">2033</option> <option value="34">2034</option> </select> </div> </div> </div> <div class="en__field en__field--vgs en__field--735255 en__field--ccvv"> <label for="en__field_transaction_ccvv" class="en__field__label" style="">CVV Code</label> <div class="en__field__element en__field__element--vgs"> <input type="hidden" name="transaction.ccvv"/> <div id="en__field_transaction_ccvv" class="en__field__input en__field__input--vgs"> </div> </div> </div> <div class="en__field en__field--text en__field--1073683 en__field--NOT_TAGGED_150 en__mandatory"> <label for="en__field_supporter_NOT_TAGGED_150" class="en__field__label" style="">PayPal Billing Agreement</label> <div class="en__field__element en__field__element--text"> <input id="en__field_supporter_NOT_TAGGED_150" type="text" class="en__field__input en__field__input--text" name="supporter.NOT_TAGGED_150" value="By submitting this form you agree to allow Human Rights Watch to take funds from your account monthly." readonly/> </div> </div> </div> <div class="en__component en__component--formblock" style=""> <div class="en__field en__field--checkbox en__field--736411 en__field--NOT_TAGGED_33"> <label class="en__field__label" style="">Different Address</label> <div class="en__field__element en__field__element--checkbox "> <div class="en__field__item"> <input id="en__field_supporter_NOT_TAGGED_33" type="checkbox" class="en__field__input en__field__input--checkbox" value="Y" name="supporter.NOT_TAGGED_33"/> <label for="en__field_supporter_NOT_TAGGED_33" class="en__field__label en__field__label--item">I have a different mailing address</label> </div> </div> </div> </div> <div class="en__component en__component--formblock different-address-block" style=""> <div class="en__field en__field--text en__field--736413 en__field--NOT_TAGGED_27"> <label for="en__field_supporter_NOT_TAGGED_27" class="en__field__label" style="">Primary Address</label> <div class="en__field__element en__field__element--text"> <input id="en__field_supporter_NOT_TAGGED_27" type="text" class="en__field__input en__field__input--text" name="supporter.NOT_TAGGED_27" value=""/> </div> </div> <div class="en__field en__field--text en__field--736414 en__field--NOT_TAGGED_28"> <label for="en__field_supporter_NOT_TAGGED_28" class="en__field__label" style="">Primary Address 2</label> <div class="en__field__element en__field__element--text"> <input id="en__field_supporter_NOT_TAGGED_28" type="text" class="en__field__input en__field__input--text" name="supporter.NOT_TAGGED_28" value=""/> </div> </div> <div class="en__field en__field--text en__field--736416 en__field--NOT_TAGGED_29"> <label for="en__field_supporter_NOT_TAGGED_29" class="en__field__label" style="">Primary City</label> <div class="en__field__element en__field__element--text"> <input id="en__field_supporter_NOT_TAGGED_29" type="text" class="en__field__input en__field__input--text" name="supporter.NOT_TAGGED_29" value=""/> </div> </div> <div class="en__field en__field--select en__field--736417 en__field--NOT_TAGGED_30"> <label for="en__field_supporter_NOT_TAGGED_30" class="en__field__label" style="">Primary State</label> <div class="en__field__element en__field__element--select"> <select id="en__field_supporter_NOT_TAGGED_30" class="en__field__input en__field__input--select" name="supporter.NOT_TAGGED_30"> <option value="">-- Select One --</option> <option value="AL">Alabama</option> <option value="AK">Alaska</option> <option value="AZ">Arizona</option> <option value="CA">California</option> <option value="CO">Colorado</option> <option value="CT">Connecticut</option> <option value="DE">Delaware</option> <option value="DC">District of Columbia</option> <option value="FL">Florida</option> <option value="GA">Georgia</option> <option value="HI">Hawaii</option> <option value="ID">Idaho</option> <option value="IL">Illinois</option> <option value="IN">Indiana</option> <option value="IA">Iowa</option> <option value="KS">Kansas</option> <option value="KY">Kentucky</option> <option value="LA">Louisiana</option> <option value="ME">Maine</option> <option value="MD">Maryland</option> <option value="MA">Massachusetts</option> <option value="MI">Michigan</option> <option value="MN">Minnesota</option> <option value="MS">Mississippi</option> <option value="MO">Missouri</option> <option value="MT">Montana</option> <option value="NE">Nebraska</option> <option value="NV">Nevada</option> <option value="NH">New Hampshire</option> <option value="NJ">New Jersey</option> <option value="NM">New Mexico</option> <option value="NY">New York</option> <option value="NC">North Carolina</option> <option value="ND">North Dakota</option> <option value="OH">Ohio</option> <option value="OK">Oklahoma</option> <option value="OR">Oregon</option> <option value="PA">Pennsylvania</option> <option value="RI">Rhode Island</option> <option value="SC">South Carolina</option> <option value="SD">South Dakota</option> <option value="TN">Tennessee</option> <option value="TX">Texas</option> <option value="UT">Utah</option> <option value="VT">Vermont</option> <option value="VA">Virginia</option> <option value="WA">Washington</option> <option value="WV">West Virginia</option> <option value="WI">Wisconsin</option> <option value="WY">Wyoming</option> <option value="US">N/A</option> </select> </div> </div> <div class="en__field en__field--text en__field--736415 en__field--NOT_TAGGED_31"> <label for="en__field_supporter_NOT_TAGGED_31" class="en__field__label" style="">Primary Zip Code</label> <div class="en__field__element en__field__element--text"> <input id="en__field_supporter_NOT_TAGGED_31" type="text" class="en__field__input en__field__input--text" name="supporter.NOT_TAGGED_31" value=""/> </div> </div> <div class="en__field en__field--select en__field--736418 en__field--NOT_TAGGED_32"> <label for="en__field_supporter_NOT_TAGGED_32" class="en__field__label" style="">Primary Country</label> <div class="en__field__element en__field__element--select"> <select id="en__field_supporter_NOT_TAGGED_32" class="en__field__input en__field__input--select" name="supporter.NOT_TAGGED_32"> <option value="US">United States</option> <option value="GB">United Kingdom</option> <option value="CA">Canada</option> <option value="AF">Afghanistan</option> <option value="AX">脜land Islands</option> <option value="AL">Albania</option> <option value="DZ">Algeria</option> <option value="AS">American Samoa</option> <option value="AD">Andorra</option> <option value="AO">Angola</option> <option value="AI">Anguilla</option> <option value="AQ">Antarctica</option> <option value="AG">Antigua and Barbuda</option> <option value="AR">Argentina</option> <option value="AM">Armenia</option> <option value="AW">Aruba</option> <option value="AU">Australia</option> <option value="AT">Austria</option> <option value="AZ">Azerbaijan</option> <option value="BS">Bahamas</option> <option value="BH">Bahrain</option> <option value="BD">Bangladesh</option> <option value="BB">Barbados</option> <option value="BY">Belarus</option> <option value="BE">Belgium</option> <option value="BZ">Belize</option> <option value="BJ">Benin</option> <option value="BM">Bermuda</option> <option value="BT">Bhutan</option> <option value="BO">Bolivia, Plurinational State of</option> <option value="BQ">Bonaire, Sint Eustatius and Saba</option> <option value="BA">Bosnia and Herzegovina</option> <option value="BW">Botswana</option> <option value="BV">Bouvet Island</option> <option value="BR">Brazil</option> <option value="IO">British Indian Ocean Territory</option> <option value="BN">Brunei Darussalam</option> <option value="BG">Bulgaria</option> <option value="BF">Burkina Faso</option> <option value="BI">Burundi</option> <option value="CV">Cabo Verde</option> <option value="KH">Cambodia</option> <option value="CM">Cameroon</option> <option value="KY">Cayman Islands</option> <option value="CF">Central African Republic</option> <option value="TD">Chad</option> <option value="CL">Chile</option> <option value="CN">China</option> <option value="CX">Christmas Island</option> <option value="CC">Cocos (Keeling) Islands</option> <option value="CO">Colombia</option> <option value="KM">Comoros</option> <option value="CG">Congo</option> <option value="CD">Congo, the Democratic Republic of the</option> <option value="CK">Cook Islands</option> <option value="CR">Costa Rica</option> <option value="CI">C么te d'Ivoire</option> <option value="HR">Croatia</option> <option value="CU">Cuba</option> <option value="CW">Cura莽ao</option> <option value="CY">Cyprus</option> <option value="CZ">Czech Republic</option> <option value="DK">Denmark</option> <option value="DJ">Djibouti</option> <option value="DM">Dominica</option> <option value="DO">Dominican Republic</option> <option value="EC">Ecuador</option> <option value="EG">Egypt</option> <option value="SV">El Salvador</option> <option value="GQ">Equatorial Guinea</option> <option value="ER">Eritrea</option> <option value="EE">Estonia</option> <option value="ET">Ethiopia</option> <option value="FK">Falkland Islands (Malvinas)</option> <option value="FO">Faroe Islands</option> <option value="FJ">Fiji</option> <option value="FI">Finland</option> <option value="FR">France</option> <option value="GF">French Guiana</option> <option value="PF">French Polynesia</option> <option value="TF">French Southern Territories</option> <option value="GA">Gabon</option> <option value="GM">Gambia</option> <option value="GE">Georgia</option> <option value="DE">Germany</option> <option value="GH">Ghana</option> <option value="GI">Gibraltar</option> <option value="GR">Greece</option> <option value="GL">Greenland</option> <option value="GD">Grenada</option> <option value="GP">Guadeloupe</option> <option value="GU">Guam</option> <option value="GT">Guatemala</option> <option value="GG">Guernsey</option> <option value="GN">Guinea</option> <option value="GW">Guinea-Bissau</option> <option value="GY">Guyana</option> <option value="HT">Haiti</option> <option value="HM">Heard Island and McDonald Islands</option> <option value="VA">Holy See (Vatican City State)</option> <option value="HN">Honduras</option> <option value="HK">Hong Kong</option> <option value="HU">Hungary</option> <option value="IS">Iceland</option> <option value="IN">India</option> <option value="ID">Indonesia</option> <option value="IR">Iran, Islamic Republic of</option> <option value="IQ">Iraq</option> <option value="IE">Ireland</option> <option value="IM">Isle of Man</option> <option value="IL">Israel</option> <option value="IT">Italy</option> <option value="JM">Jamaica</option> <option value="JP">Japan</option> <option value="JE">Jersey</option> <option value="JO">Jordan</option> <option value="KZ">Kazakhstan</option> <option value="KE">Kenya</option> <option value="KI">Kiribati</option> <option value="KP">Korea, Democratic People's Republic of</option> <option value="KR">Korea, Republic of</option> <option value="KW">Kuwait</option> <option value="KG">Kyrgyzstan</option> <option value="LA">Lao People's Democratic Republic</option> <option value="LV">Latvia</option> <option value="LB">Lebanon</option> <option value="LS">Lesotho</option> <option value="LR">Liberia</option> <option value="LY">Libya</option> <option value="LI">Liechtenstein</option> <option value="LT">Lithuania</option> <option value="LU">Luxembourg</option> <option value="MO">Macao</option> <option value="MK">Macedonia, the former Yugoslav Republic of</option> <option value="MG">Madagascar</option> <option value="MW">Malawi</option> <option value="MY">Malaysia</option> <option value="MV">Maldives</option> <option value="ML">Mali</option> <option value="MT">Malta</option> <option value="MH">Marshall Islands</option> <option value="MQ">Martinique</option> <option value="MR">Mauritania</option> <option value="MU">Mauritius</option> <option value="YT">Mayotte</option> <option value="MX">Mexico</option> <option value="FM">Micronesia, Federated States of</option> <option value="MD">Moldova, Republic of</option> <option value="MC">Monaco</option> <option value="MN">Mongolia</option> <option value="ME">Montenegro</option> <option value="MS">Montserrat</option> <option value="MA">Morocco</option> <option value="MZ">Mozambique</option> <option value="MM">Myanmar</option> <option value="NA">Namibia</option> <option value="NR">Nauru</option> <option value="NP">Nepal</option> <option value="NL">Netherlands</option> <option value="NC">New Caledonia</option> <option value="NZ">New Zealand</option> <option value="NI">Nicaragua</option> <option value="NE">Niger</option> <option value="NG">Nigeria</option> <option value="NU">Niue</option> <option value="NF">Norfolk Island</option> <option value="MP">Northern Mariana Islands</option> <option value="NO">Norway</option> <option value="OM">Oman</option> <option value="PK">Pakistan</option> <option value="PW">Palau</option> <option value="PS">Palestine, State of</option> <option value="PA">Panama</option> <option value="PG">Papua New Guinea</option> <option value="PY">Paraguay</option> <option value="PE">Peru</option> <option value="PH">Philippines</option> <option value="PN">Pitcairn</option> <option value="PL">Poland</option> <option value="PT">Portugal</option> <option value="PR">Puerto Rico</option> <option value="QA">Qatar</option> <option value="RE">R茅union</option> <option value="RO">Romania</option> <option value="RU">Russian Federation</option> <option value="RW">Rwanda</option> <option value="BL">Saint Barth茅lemy</option> <option value="SH">Saint Helena, Ascension and Tristan da Cunha</option> <option value="KN">Saint Kitts and Nevis</option> <option value="LC">Saint Lucia</option> <option value="MF">Saint Martin (French part)</option> <option value="PM">Saint Pierre and Miquelon</option> <option value="VC">Saint Vincent and the Grenadines</option> <option value="WS">Samoa</option> <option value="SM">San Marino</option> <option value="ST">Sao Tome and Principe</option> <option value="SA">Saudi Arabia</option> <option value="SN">Senegal</option> <option value="RS">Serbia</option> <option value="SC">Seychelles</option> <option value="SL">Sierra Leone</option> <option value="SG">Singapore</option> <option value="SX">Sint Maarten (Dutch part)</option> <option value="SK">Slovakia</option> <option value="SI">Slovenia</option> <option value="SB">Solomon Islands</option> <option value="SO">Somalia</option> <option value="ZA">South Africa</option> <option value="GS">South Georgia and the South Sandwich Islands</option> <option value="SS">South Sudan</option> <option value="ES">Spain</option> <option value="LK">Sri Lanka</option> <option value="SD">Sudan</option> <option value="SR">Suriname</option> <option value="SJ">Svalbard and Jan Mayen</option> <option value="SZ">Swaziland</option> <option value="SE">Sweden</option> <option value="CH">Switzerland</option> <option value="SY">Syrian Arab Republic</option> <option value="TW">Taiwan, Province of China</option> <option value="TJ">Tajikistan</option> <option value="TZ">Tanzania, United Republic of</option> <option value="TH">Thailand</option> <option value="TL">Timor-Leste</option> <option value="TG">Togo</option> <option value="TK">Tokelau</option> <option value="TO">Tonga</option> <option value="TT">Trinidad and Tobago</option> <option value="TN">Tunisia</option> <option value="TR">Turkey</option> <option value="TM">Turkmenistan</option> <option value="TC">Turks and Caicos Islands</option> <option value="TV">Tuvalu</option> <option value="UG">Uganda</option> <option value="UA">Ukraine</option> <option value="AE">United Arab Emirates</option> <option value="UM">United States Minor Outlying Islands</option> <option value="UY">Uruguay</option> <option value="UZ">Uzbekistan</option> <option value="VU">Vanuatu</option> <option value="VE">Venezuela, Bolivarian Republic of</option> <option value="VN">Viet Nam</option> <option value="VG">Virgin Islands, British</option> <option value="VI">Virgin Islands, U.S.</option> <option value="WF">Wallis and Futuna</option> <option value="EH">Western Sahara</option> <option value="YE">Yemen</option> <option value="ZM">Zambia</option> <option value="ZW">Zimbabwe</option> </select> </div> </div> </div> <div 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