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src="https://giving.brighamandwomens.org/wp-content/uploads/2022/08/cropped-bwh-logo-1.png" class="custom-logo" alt="Brigham and Women's Hospital" decoding="async" fetchpriority="high" srcset="https://giving.brighamandwomens.org/wp-content/uploads/2022/08/cropped-bwh-logo-1.png 2190w, https://giving.brighamandwomens.org/wp-content/uploads/2022/08/cropped-bwh-logo-1-300x34.png 300w, https://giving.brighamandwomens.org/wp-content/uploads/2022/08/cropped-bwh-logo-1-1024x117.png 1024w, https://giving.brighamandwomens.org/wp-content/uploads/2022/08/cropped-bwh-logo-1-768x88.png 768w, https://giving.brighamandwomens.org/wp-content/uploads/2022/08/cropped-bwh-logo-1-1536x175.png 1536w, https://giving.brighamandwomens.org/wp-content/uploads/2022/08/cropped-bwh-logo-1-2048x234.png 2048w" sizes="100vw" /></a> <div class="site-branding-text"> <h1 class="site-title"><a href="https://giving.brighamandwomens.org/" rel="home">Brigham and Women's Hospital</a></h1> </div> <a href="#content" 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</div> <div class="panel-content"> <div class="wrap"> <header class="entry-header"> <h2 class="entry-title">A homepage section</h2> </header> <div class="entry-content"> <script type="text/javascript"> jQuery(document).ready(function($) { $.fn.checkboxLimit = function(n) { var checkboxes = this; this.toggleDisable = function() { // if we have reached or exceeded the limit, disable all other checkboxes if(this.filter(':checked').length >= n) { var unchecked = this.not(':checked'); unchecked.prop('disabled', true); } // if we are below the limit, make sure all checkboxes are available else { this.prop('disabled', false); } } // when form is rendered, toggle disable checkboxes.bind('gform_post_render', checkboxes.toggleDisable()); // when checkbox is clicked, toggle disable checkboxes.click(function(event) { checkboxes.toggleDisable(); // if we are equal to or below the limit, the field should be checked return checkboxes.filter(':checked').length <= n; }); } }); </script> <div id="acf-logo-gen"></div><div id="acf-intro"><h1>Your gift makes a difference</h1> <p>With your support, Brigham and Women鈥檚 Hospital is able to deliver the highest quality patient care, pursue the most innovative and promising medical research, and train the brightest medical minds to become the next generation of healthcare leaders.</p> </div> <div class='gf_browser_unknown gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_5' style='display:none'><div id='gf_5' class='gform_anchor' tabindex='-1'></div><form method='post' enctype='multipart/form-data' target='gform_ajax_frame_5' id='gform_5' action='/#gf_5' data-formid='5' novalidate name="donation"> <div class='gform-body gform_body'><ul id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id="field_5_90" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_90" ></li><li id="field_5_66" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_66" ><h1>Your gift makes a difference</h1> With your support, Brigham and Women鈥檚 Hospital is able to deliver the highest quality patient care, pursue the most innovative and promising medical research, and train the brightest medical minds to become the next generation of healthcare leaders.</li><li id="field_5_2" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_2" ><h2 class="gsection_title">Gift information</h2></li><li id="field_5_87" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_87" >Make a gift using your <a href="https://give.brighamandwomens.org/donor-advised-fund/?utm_medium=web&utm_source=donation-page&utm_campaign=20XXAGWM&utm_content=daf-link" target="_blank">Donor-Advised Fund</a></li><li id="field_5_58" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio giving_level_buttons field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_5_58" ><label class='gfield_label gform-field-label' >Gift Amount</label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_58'> <li class='gchoice gchoice_5_58_0'> <input name='input_58' type='radio' value='50' id='choice_5_58_0' /> <label for='choice_5_58_0' id='label_5_58_0' class='gform-field-label gform-field-label--type-inline'><div class="giving_level_label"><span></span><span>$50</span></div></label> </li> <li class='gchoice gchoice_5_58_1'> <input name='input_58' type='radio' value='100' checked='checked' id='choice_5_58_1' /> <label for='choice_5_58_1' id='label_5_58_1' class='gform-field-label gform-field-label--type-inline'><div class="giving_level_label"><span></span><span>$100</span></div></label> </li> <li class='gchoice gchoice_5_58_2'> <input name='input_58' type='radio' value='250' id='choice_5_58_2' /> <label for='choice_5_58_2' id='label_5_58_2' class='gform-field-label gform-field-label--type-inline'><div class="giving_level_label"><span></span><span>$250</span></div></label> </li> <li class='gchoice gchoice_5_58_3'> <input name='input_58' type='radio' value='500' id='choice_5_58_3' /> <label for='choice_5_58_3' id='label_5_58_3' class='gform-field-label gform-field-label--type-inline'><div class="giving_level_label"><span></span><span>$500</span></div></label> </li> <li class='gchoice gchoice_5_58_4'> <input name='input_58' type='radio' value='0' id='choice_5_58_4' /> <label for='choice_5_58_4' id='label_5_58_4' class='gform-field-label gform-field-label--type-inline'><div class="giving_level_label"><span></span><span>Other</span></div></label> </li></ul></div></li><li id="field_5_105" class="gfield gfield--type-text gfield--input-type-text txtGiftAmount gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_105" ><label class='gfield_label gform-field-label' for='input_5_105'>Your Gift Amount<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_105' id='input_5_105' type='text' value='' class='medium' aria-required="true" aria-invalid="false" /> </div><span class="currency_symbol">$</span></li><li id="field_5_89" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_89" ><script type="text/javascript"> jQuery(function($) { $.fn.inputFilter = function(inputFilter) { return this.on("input keydown keyup mousedown mouseup select contextmenu drop", function() { if (inputFilter(this.value)) { this.oldValue = this.value; this.oldSelectionStart = this.selectionStart; this.oldSelectionEnd = this.selectionEnd; } else if (this.hasOwnProperty("oldValue")) { this.value = this.oldValue; this.setSelectionRange(this.oldSelectionStart, this.oldSelectionEnd); } else { this.value = ""; } }); }; $("#input_5_105").inputFilter(function(value) { return /^\d*[.]?\d{0,2}$/.test(value); }); }); </script></li><li id="field_5_95" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_95" ></li><li id="field_5_30" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_5_30" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Recurring Gift</label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_5_30'><li class='gchoice gchoice_5_30_1'> <input class='gfield-choice-input' name='input_30.1' type='checkbox' value='Yes' id='choice_5_30_1' /> <label for='choice_5_30_1' id='label_5_30_1' class='gform-field-label gform-field-label--type-inline'>Make this a monthly donation</label> </li></ul></div></li><li id="field_5_80" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_80" >Your first monthly gift will be charged within one business day, this will set the date for all subsequent automatic charges. You can cancel at any time.</li><li id="field_5_55" class="gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_5_55" ><label class='gfield_label gform-field-label' for='input_5_55'>Naming Message</label><div class='gfield_description' id='gfield_description_5_55'>Please indicate your personalized message and your name as you would like it to appear. (160 characters max)</div><div class='ginput_container ginput_container_textarea'><textarea name='input_55' id='input_5_55' class='textarea small' aria-describedby="gfield_description_5_55" maxlength='160' placeholder='Your custom message' aria-invalid="false" rows='10' cols='50'></textarea></div></li><li id="field_5_91" class="gfield gfield--type-html gfield--input-type-html html_block_nomargin_bottom gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_91" >How would you like your gift to be designated?</li><li id="field_5_76" class="gfield gfield--type-select gfield--input-type-select gf_left_half field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_5_76" ><label class='gfield_label gform-field-label' for='input_5_76'>Gift Designation</label><div class='ginput_container ginput_container_select'><select name='input_76' id='input_5_76' class='medium gfield_select' aria-invalid="false" ><option value='where it is needed most' >Where it is needed most</option><option value='other' >Other</option></select></div></li><li id="field_5_46" class="gfield gfield--type-text gfield--input-type-text gf_right_half field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_5_46" ><label class='gfield_label gform-field-label' for='input_5_46'>Gift Designation – Other</label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_5_46' type='text' value='' class='medium' maxlength='250' placeholder='Other gift designation' aria-invalid="false" /> </div></li><li id="field_5_68" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_68" ></li><li id="field_5_81" class="gfield gfield--type-html gfield--input-type-html html_block_nomargin_bottom gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_81" >Would you like us to send you a ?</li><li id="field_5_69" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox bwh-premium-offer field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_5_69" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Premium offer item</label><div class='gfield_description' id='gfield_description_5_69'>Would you like to receive a ?</div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_5_69'><li class='gchoice gchoice_5_69_1'> <input class='gfield-choice-input' name='input_69.1' type='checkbox' value='' checked='checked' id='choice_5_69_1' aria-describedby="gfield_description_5_69"/> <label for='choice_5_69_1' id='label_5_69_1' class='gform-field-label gform-field-label--type-inline'>Yes, please send me a </label> </li></ul></div></li><li id="field_5_92" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_92" ><h2 class="gsection_title">Your information</h2></li><li id="field_5_12" class="gfield gfield--type-name gfield--input-type-name bwh_field_nomargin_bottom apple-name-info gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_12" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_complex ginput_container ginput_container--name has_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_5_12'> <span id='input_5_12_2_container' class='name_prefix name_prefix_select gform-grid-col gform-grid-col--size-auto' > <select name='input_12.2' id='input_5_12_2' aria-required='false' > <option value=''>Title</option><option value='Mr.' >Mr.</option><option value='Mrs.' >Mrs.</option><option value='Miss' >Miss</option><option value='Ms.' >Ms.</option><option value='Mx.' >Mx.</option><option value='Dr.' >Dr.</option> </select> <label for='input_5_12_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Title</label> </span> <span id='input_5_12_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' > <input type='text' name='input_12.3' id='input_5_12_3' value='' aria-required='true' placeholder='First Name' /> <label for='input_5_12_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First Name</label> </span> <span id='input_5_12_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' > <input type='text' name='input_12.6' id='input_5_12_6' value='' aria-required='true' placeholder='Last Name' /> <label for='input_5_12_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Last Name</label> </span> </div></li><li id="field_5_11" class="gfield gfield--type-email gfield--input-type-email gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_5_11" ><label class='gfield_label gform-field-label' for='input_5_11'>Donor Email<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_email'> <input name='input_11' id='input_5_11' type='email' value='' class='medium' placeholder='Email' aria-required="true" aria-invalid="false" /> </div></li><li id="field_5_22" class="gfield gfield--type-phone gfield--input-type-phone gf_right_half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_5_22" ><label class='gfield_label gform-field-label' for='input_5_22'>Donor Phone Number</label><div class='ginput_container ginput_container_phone'><input name='input_22' id='input_5_22' type='tel' value='' class='medium' placeholder='Phone (Optional)' aria-invalid="false" /></div></li><li id="field_5_3" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_3" ><h2 class="gsection_title">Tribute information</h2></li><li id="field_5_59" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_5_59" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Tribute gift</label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_5_59'><li class='gchoice gchoice_5_59_1'> <input class='gfield-choice-input' name='input_59.1' type='checkbox' value='yes' id='choice_5_59_1' /> <label for='choice_5_59_1' id='label_5_59_1' class='gform-field-label gform-field-label--type-inline'>This gift is in honor/memory of someone</label> </li></ul></div></li><li id="field_5_60" class="gfield gfield--type-select gfield--input-type-select gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_60" ><label class='gfield_label gform-field-label' for='input_5_60'>Tribute Type<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_select'><select name='input_60' id='input_5_60' class='medium gfield_select' aria-required="true" aria-invalid="false" ><option value='in honor of' >in honor of</option><option value='in memory of' >in memory of</option></select></div></li><li id="field_5_62" class="gfield gfield--type-text gfield--input-type-text gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_62" ><label class='gfield_label gform-field-label' for='input_5_62'>Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_5_62' type='text' value='' class='medium' maxlength='250' placeholder='Person's name that is in honor or memory of' aria-required="true" aria-invalid="false" /> </div></li><li id="field_5_20" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_5_20" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Tribute Gift Notification Preference</label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_5_20'><li class='gchoice gchoice_5_20_1'> <input class='gfield-choice-input' name='input_20.1' type='checkbox' value='mail notification' id='choice_5_20_1' /> <label for='choice_5_20_1' id='label_5_20_1' class='gform-field-label gform-field-label--type-inline'>Please send notification of my gift via mail</label> </li><li class='gchoice gchoice_5_20_2'> <input class='gfield-choice-input' name='input_20.2' type='checkbox' value='email notification' id='choice_5_20_2' /> <label for='choice_5_20_2' id='label_5_20_2' class='gform-field-label gform-field-label--type-inline'>Please send notification of my gift via email</label> </li></ul></div></li><li id="field_5_109" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_109" >Please note, tribute notification will be sent as soon as your gift is processed. </li><li id="field_5_96" class="gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_96" ><label class='gfield_label gform-field-label' for='input_5_96'>Email of person to notify<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_email'> <input name='input_96' id='input_5_96' type='email' value='' class='large' placeholder='notification_receiver_email@example.com' aria-required="true" aria-invalid="false" /> </div></li><li id="field_5_16" class="gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_16" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name of person to notify<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_complex ginput_container ginput_container--name has_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_5_16'> <span id='input_5_16_2_container' class='name_prefix name_prefix_select gform-grid-col gform-grid-col--size-auto' > <select name='input_16.2' id='input_5_16_2' aria-required='false' > <option value=''>Title</option><option value='Mr.' >Mr.</option><option value='Mrs.' >Mrs.</option><option value='Miss' >Miss</option><option value='Ms.' >Ms.</option><option value='Mx.' >Mx.</option><option value='Dr.' >Dr.</option> </select> <label for='input_5_16_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Title</label> </span> <span id='input_5_16_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' > <input type='text' name='input_16.3' id='input_5_16_3' value='' aria-required='true' placeholder='First Name' /> <label for='input_5_16_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First Name</label> </span> <span id='input_5_16_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' > <input type='text' name='input_16.6' id='input_5_16_6' value='' aria-required='true' placeholder='Last Name' /> <label for='input_5_16_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Last Name</label> </span> </div></li><li id="field_5_98" class="gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_98" ><label class='gfield_label gform-field-label' for='input_5_98'>This gift is from</label><div class='ginput_container ginput_container_text'><input name='input_98' id='input_5_98' type='text' value='' class='large' maxlength='250' placeholder='e.g. Mr. and Mrs. John Smith' aria-invalid="false" /> </div></li><li id="field_5_15" class="gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_15" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address of person to notify<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label> <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_5_15' > <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_15_1_container' > <input type='text' name='input_15.1' id='input_5_15_1' value='' placeholder='Address Line 1' aria-required='true' /> <label for='input_5_15_1' id='input_5_15_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Address Line 1</label> </span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_15_2_container' > <input type='text' name='input_15.2' id='input_5_15_2' value='' placeholder='Address Line 2' aria-required='false' /> <label for='input_5_15_2' id='input_5_15_2_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Address Line 2</label> </span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_15_3_container' > <input type='text' name='input_15.3' id='input_5_15_3' value='' placeholder='City' aria-required='true' /> <label for='input_5_15_3' id='input_5_15_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>City</label> </span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_15_4_container' > <input type='text' name='input_15.4' id='input_5_15_4' value='' placeholder='State/Province' aria-required='true' /> <label for='input_5_15_4' id='input_5_15_4_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>State / Province / Region</label> </span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_15_5_container' > <input type='text' name='input_15.5' id='input_5_15_5' value='' placeholder='Zip/Postal Code' aria-required='true' /> <label for='input_5_15_5' id='input_5_15_5_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>ZIP / Postal Code</label> </span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_5_15_6_container' > <select name='input_15.6' id='input_5_15_6' aria-required='true' ><option value='' >Country</option><option value='Afghanistan' >Afghanistan</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Anguilla' >Anguilla</option><option value='Antarctica' >Antarctica</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Aruba' >Aruba</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Bouvet Island' >Bouvet Island</option><option value='Brazil' >Brazil</option><option value='British Indian Ocean Territory' >British Indian Ocean Territory</option><option value='Brunei Darussalam' >Brunei Darussalam</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cabo Verde' >Cabo Verde</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cayman Islands' >Cayman Islands</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Christmas Island' >Christmas Island</option><option value='Cocos Islands' >Cocos Islands</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo' >Congo</option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the</option><option value='Cook Islands' >Cook Islands</option><option value='Costa Rica' >Costa Rica</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Cura莽ao' >Cura莽ao</option><option value='Cyprus' >Cyprus</option><option value='Czechia' >Czechia</option><option value='C么te d'Ivoire' >C么te d'Ivoire</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Eswatini' >Eswatini</option><option value='Ethiopia' >Ethiopia</option><option value='Falkland Islands' >Falkland Islands</option><option value='Faroe Islands' >Faroe Islands</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='French Guiana' >French Guiana</option><option value='French Polynesia' >French Polynesia</option><option value='French Southern Territories' >French Southern Territories</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Gibraltar' >Gibraltar</option><option value='Greece' >Greece</option><option value='Greenland' >Greenland</option><option value='Grenada' >Grenada</option><option value='Guadeloupe' >Guadeloupe</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guernsey' >Guernsey</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands</option><option value='Holy See' >Holy See</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Isle of Man' >Isle of Man</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jersey' >Jersey</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='Korea, Democratic People's Republic of' >Korea, Democratic People's Republic of</option><option value='Korea, Republic of' >Korea, Republic of</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Lao People's Democratic Republic' >Lao People's Democratic Republic</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macao' >Macao</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Martinique' >Martinique</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mayotte' >Mayotte</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Montserrat' >Montserrat</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Caledonia' >New Caledonia</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Niue' >Niue</option><option value='Norfolk Island' >Norfolk Island</option><option value='North Macedonia' >North Macedonia</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Norway' >Norway</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine, State of' >Palestine, State of</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Pitcairn' >Pitcairn</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Romania' >Romania</option><option value='Russian Federation' >Russian Federation</option><option value='Rwanda' >Rwanda</option><option value='R茅union' >R茅union</option><option value='Saint Barth茅lemy' >Saint Barth茅lemy</option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Martin' >Saint Martin</option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia' >Serbia</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Sint Maarten' >Sint Maarten</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands</option><option value='South Sudan' >South Sudan</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria Arab Republic' >Syria Arab Republic</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of</option><option value='Thailand' >Thailand</option><option value='Timor-Leste' >Timor-Leste</option><option value='Togo' >Togo</option><option value='Tokelau' >Tokelau</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkmenistan' >Turkmenistan</option><option value='Turks and Caicos Islands' >Turks and Caicos Islands</option><option value='Tuvalu' >Tuvalu</option><option value='T眉rkiye' >T眉rkiye</option><option value='US Minor Outlying Islands' >US Minor Outlying Islands</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='United States' selected='selected'>United States</option><option value='Uruguay' >Uruguay</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Venezuela' >Venezuela</option><option value='Viet Nam' >Viet Nam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Wallis and Futuna' >Wallis and Futuna</option><option value='Western Sahara' >Western Sahara</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option><option value='脜land Islands' >脜land Islands</option></select> <label for='input_5_15_6' id='input_5_15_6_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Country</label> </span> <div class='gf_clear gf_clear_complex'></div> </div></li><li id="field_5_99" class="gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_5_99" ><label class='gfield_label gform-field-label' for='input_5_99'>Special message/instructions for this tribute gift</label><div class='ginput_container ginput_container_textarea'><textarea name='input_99' id='input_5_99' class='textarea small' maxlength='200' placeholder='Optional: Special instructions or message to include when notifying the above party of your gift' aria-invalid="false" rows='10' cols='50'></textarea></div></li><li id="field_5_4" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_4" ><h2 class="gsection_title">Payment and billing information</h2></li><li id="field_5_84" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio pay_method_buttons field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_5_84" ><label class='gfield_label gform-field-label' >Payment Method</label><div class='gfield_description' id='gfield_description_5_84'>Choose your payment method</div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_84'> <li class='gchoice gchoice_5_84_0'> <input name='input_84' type='radio' value='Credit Card' checked='checked' id='choice_5_84_0' /> <label for='choice_5_84_0' id='label_5_84_0' class='gform-field-label gform-field-label--type-inline'>Credit Card</label> </li> <li class='gchoice gchoice_5_84_1'> <input name='input_84' type='radio' value='Apple Pay' id='choice_5_84_1' /> <label for='choice_5_84_1' id='label_5_84_1' class='gform-field-label gform-field-label--type-inline'>Apple Pay</label> </li> <li class='gchoice gchoice_5_84_2'> <input name='input_84' type='radio' value='PayPal' id='choice_5_84_2' /> <label for='choice_5_84_2' id='label_5_84_2' class='gform-field-label gform-field-label--type-inline'>PayPal</label> </li> <li class='gchoice gchoice_5_84_3'> <input name='input_84' type='radio' value='echeck' id='choice_5_84_3' /> <label for='choice_5_84_3' id='label_5_84_3' class='gform-field-label gform-field-label--type-inline'>eCheck</label> </li></ul></div></li><li id="field_5_7" class="gfield gfield--type-creditcard gfield--input-type-creditcard gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_5_7" ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_5_7_1'>Credit Card<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_complex ginput_container ginput_container_creditcard gform-grid-row' id='input_5_7'><span class='ginput_full gform-grid-col' id='input_5_7_1_container' > <div class='gform_card_icon_container'><div class='gform_card_icon gform_card_icon_amex' >American Express</div><div class='gform_card_icon gform_card_icon_discover' >Discover</div><div class='gform_card_icon gform_card_icon_mastercard' >MasterCard</div><div class='gform_card_icon gform_card_icon_visa' >Visa</div><span class='screen-reader-text' id='field_5_7_supported_creditcards'>Supported Credit Cards: American Express, Discover, MasterCard, Visa</span></div> <input type='text' name='input_7.1' id='input_5_7_1' value='' onchange='gformMatchCard("input_5_7_1");' onkeyup='gformMatchCard("input_5_7_1");' autocomplete='off' pattern='[0-9]*' title='Only digits are allowed' placeholder='Card Number' aria-required='true' /> <label for='input_5_7_1' id='input_5_7_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Card Number</label> </span><span class='ginput_full ginput_cardextras gform-grid-col gform-grid-row' id='input_5_7_2_container'> <span class='ginput_cardinfo_left' id='input_5_7_2_cardinfo_left'> <span class='ginput_card_expiration_container ginput_card_field'> <select name='input_7.2[]' id='input_5_7_2_month' class='ginput_card_expiration ginput_card_expiration_month' aria-required='true' > <option value=''>Expiration Month</option><option value='1' >01</option><option value='2' >02</option><option value='3' >03</option><option value='4' >04</option><option value='5' >05</option><option value='6' >06</option><option value='7' >07</option><option value='8' >08</option><option value='9' >09</option><option value='10' >10</option><option value='11' >11</option><option value='12' >12</option> </select> <select name='input_7.2[]' id='input_5_7_2_year' class='ginput_card_expiration ginput_card_expiration_year' aria-required='true' > <option value=''>Expiration Year</option><option value='2024' >2024</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><option value='2036' >2036</option><option value='2037' >2037</option><option value='2038' >2038</option><option value='2039' >2039</option><option value='2040' >2040</option><option value='2041' >2041</option><option value='2042' >2042</option><option value='2043' >2043</option> </select> </span> <label for='input_5_7_2_month' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Expiration Date</label> </span><span class='ginput_cardinfo_right gform-grid-col' id='input_5_7_2_cardinfo_right'> <input type='text' name='input_7.3' id='input_5_7_3' class='ginput_card_security_code' value='' autocomplete='off' pattern='[0-9]*' title='Only digits are allowed' placeholder='Security Code' aria-required='true' /> <span class='ginput_card_security_code_icon'> </span> <label for='input_5_7_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Security Code</label> </span> </span><span class='ginput_full gform-grid-col' id='input_5_7_5_container'> <input type='text' name='input_7.5' id='input_5_7_5' value='' placeholder='Name on card' aria-required='false' /> <label for='input_5_7_5' id='input_5_7_5_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Cardholder Name</label> </span> </div></li><li id="field_5_97" class="gfield gfield--type-ach gfield--input-type-ach gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_5_97" ><label class='gfield_label gfield_label_before_complex' for='input_5_97_1'>ACH<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_complex ginput_container ginput_container_ach' id='input_5_97'><span class='ginput_left' id='input_5_97_1_container' > <input type='text' name='input_97.1' id='input_5_97_1' value='' autocomplete='off' pattern='[0-9]*' title='Only digits are allowed' placeholder='Account Number' aria-required='true' /> <label for='input_5_97_1' id='input_5_97_1_label' class='hidden_sub_label screen-reader-text'>Account Number</label> </span><span class='ginput_right' id='input_5_97_3_container'> <select name='input_97.3' id='input_5_97_3' class='ginput_card_expiration' aria-required='true' > <option value=''>Select</option><option value='S' >Savings</option><option value='C' >Checking</option> </select> <label for='input_5_97_3' id='input_5_97_3_label' class='hidden_sub_label screen-reader-text'>Account Type</label> </span><span class='ginput_full' id='input_5_97_2_container' > <input type='text' name='input_97.2' id='input_5_97_2' value='' autocomplete='off' pattern='[0-9]*' title='Only digits are allowed' placeholder='Routing Number' aria-required='true' /> <label for='input_5_97_2' id='input_5_97_2_label' class='hidden_sub_label screen-reader-text'>Routing Number</label> </span><span class='ginput_full' id='input_5_97_4_container'> <input type='text' name='input_97.4' id='input_5_97_4' value='' placeholder='Name on Account' aria-required='false' /> <label for='input_5_97_4' id='input_5_97_4_label' class='hidden_sub_label screen-reader-text'>Account Holder Name</label> </span> </div></li><li id="field_5_35" class="gfield gfield--type-text gfield--input-type-text bwh_giving_corp_name field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_5_35" ><label class='gfield_label gform-field-label' for='input_5_35'>Corporation Name</label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_5_35' type='text' value='' class='large' maxlength='250' placeholder='Corporate card name (if applicable)' aria-invalid="false" /> </div></li><li id="field_5_10" class="gfield gfield--type-address gfield--input-type-address apple-billing-address gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_10" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Billing Address<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label> <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_5_10' > <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_10_1_container' > <input type='text' name='input_10.1' id='input_5_10_1' value='' placeholder='Address Line 1' aria-required='true' /> <label for='input_5_10_1' id='input_5_10_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Address Line 1</label> </span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_10_2_container' > <input type='text' name='input_10.2' id='input_5_10_2' value='' placeholder='Address Line 2' aria-required='false' /> <label for='input_5_10_2' id='input_5_10_2_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Address Line 2</label> </span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_10_3_container' > <input type='text' name='input_10.3' id='input_5_10_3' value='' placeholder='City' aria-required='true' /> <label for='input_5_10_3' id='input_5_10_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>City</label> </span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_10_4_container' > <input type='text' name='input_10.4' id='input_5_10_4' value='' placeholder='State / Province / Region' aria-required='true' /> <label for='input_5_10_4' id='input_5_10_4_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>State / Province / Region</label> </span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_10_5_container' > <input type='text' name='input_10.5' id='input_5_10_5' value='' placeholder='ZIP / Postal Code' aria-required='true' /> <label for='input_5_10_5' id='input_5_10_5_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>ZIP / Postal Code</label> </span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_5_10_6_container' > <select name='input_10.6' id='input_5_10_6' aria-required='true' ><option value='' >Country</option><option value='Afghanistan' >Afghanistan</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Anguilla' >Anguilla</option><option value='Antarctica' >Antarctica</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Aruba' >Aruba</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Bouvet Island' >Bouvet Island</option><option value='Brazil' >Brazil</option><option value='British Indian Ocean Territory' >British Indian Ocean Territory</option><option value='Brunei Darussalam' >Brunei Darussalam</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cabo Verde' >Cabo Verde</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cayman Islands' >Cayman Islands</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Christmas Island' >Christmas Island</option><option value='Cocos Islands' >Cocos Islands</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo' >Congo</option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the</option><option value='Cook Islands' >Cook Islands</option><option value='Costa Rica' >Costa Rica</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Cura莽ao' >Cura莽ao</option><option value='Cyprus' >Cyprus</option><option value='Czechia' >Czechia</option><option value='C么te d'Ivoire' >C么te d'Ivoire</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Eswatini' >Eswatini</option><option value='Ethiopia' >Ethiopia</option><option value='Falkland Islands' >Falkland Islands</option><option value='Faroe Islands' >Faroe Islands</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='French Guiana' >French Guiana</option><option value='French Polynesia' >French Polynesia</option><option value='French Southern Territories' >French Southern Territories</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Gibraltar' >Gibraltar</option><option value='Greece' >Greece</option><option value='Greenland' >Greenland</option><option value='Grenada' >Grenada</option><option value='Guadeloupe' >Guadeloupe</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guernsey' >Guernsey</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands</option><option value='Holy See' >Holy See</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Isle of Man' >Isle of Man</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jersey' >Jersey</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='Korea, Democratic People's Republic of' >Korea, Democratic People's Republic of</option><option value='Korea, Republic of' >Korea, Republic of</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Lao People's Democratic Republic' >Lao People's Democratic Republic</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macao' >Macao</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Martinique' >Martinique</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mayotte' >Mayotte</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Montserrat' >Montserrat</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Caledonia' >New Caledonia</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Niue' >Niue</option><option value='Norfolk Island' >Norfolk Island</option><option value='North Macedonia' >North Macedonia</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Norway' >Norway</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine, State of' >Palestine, State of</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Pitcairn' >Pitcairn</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Romania' >Romania</option><option value='Russian Federation' >Russian Federation</option><option value='Rwanda' >Rwanda</option><option value='R茅union' >R茅union</option><option value='Saint Barth茅lemy' >Saint Barth茅lemy</option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Martin' >Saint Martin</option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia' >Serbia</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Sint Maarten' >Sint Maarten</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands</option><option value='South Sudan' >South Sudan</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria Arab Republic' >Syria Arab Republic</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of</option><option value='Thailand' >Thailand</option><option value='Timor-Leste' >Timor-Leste</option><option value='Togo' >Togo</option><option value='Tokelau' >Tokelau</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkmenistan' >Turkmenistan</option><option value='Turks and Caicos Islands' >Turks and Caicos Islands</option><option value='Tuvalu' >Tuvalu</option><option value='T眉rkiye' >T眉rkiye</option><option value='US Minor Outlying Islands' >US Minor Outlying Islands</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='United States' selected='selected'>United States</option><option value='Uruguay' >Uruguay</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Venezuela' >Venezuela</option><option value='Viet Nam' >Viet Nam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Wallis and Futuna' >Wallis and Futuna</option><option value='Western Sahara' >Western Sahara</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option><option value='脜land Islands' >脜land Islands</option></select> <label for='input_5_10_6' id='input_5_10_6_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Country</label> </span> <div class='gf_clear gf_clear_complex'></div> </div></li><li id="field_5_74" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_74" ><h2 class="gsection_title">Additional information</h2></li><li id="field_5_63" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_5_63" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Is Anonymous Gift</label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_5_63'><li class='gchoice gchoice_5_63_1'> <input class='gfield-choice-input' name='input_63.1' type='checkbox' value='Yes' id='choice_5_63_1' /> <label for='choice_5_63_1' id='label_5_63_1' class='gform-field-label gform-field-label--type-inline'>I am making this gift anonymously</label> </li></ul></div></li><li id="field_5_32" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_5_32" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Is Matching Gift</label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_5_32'><li class='gchoice gchoice_5_32_1'> <input class='gfield-choice-input' name='input_32.1' type='checkbox' value='Yes' id='choice_5_32_1' /> <label for='choice_5_32_1' id='label_5_32_1' class='gform-field-label gform-field-label--type-inline'>My employer will match this gift</label> </li></ul></div></li><li id="field_5_33" class="gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_5_33" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><label class='gfield_label gform-field-label' for='input_5_33'>Employer Name</label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_5_33' type='text' value='' class='medium' maxlength='250' aria-describedby="gfield_description_5_33" aria-invalid="false" /> </div><div class='gfield_description' id='gfield_description_5_33'>disable this field since we now have Amply field</div></li><li id="field_5_100" class="gfield gfield--type-amply gfield--input-type-amply gfield_contains_required field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_5_100" ><label class='gfield_label gform-field-label' for='input_5_100'>Matching Gift Employer Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='gfield_description' id='gfield_description_5_100'>If the matching gift employer name is provided here, please expect action required email(s) from Amply Support (support@giveamply.com) to fulfill the matching gift process</div></li><li id="field_5_101" class="gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_5_101" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><label class='gfield_label gform-field-label' for='input_5_101'>Matching Gift Donation ID</label><div class='ginput_container ginput_container_text'><input name='input_101' id='input_5_101' type='text' value='' class='medium' aria-describedby="gfield_description_5_101" aria-invalid="false" /> </div><div class='gfield_description' id='gfield_description_5_101'>This is the donation id that will be passed to Amply for matching gift tracking</div></li><li id="field_5_31" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_5_31" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Is Interested in Planned Giving</label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_5_31'><li class='gchoice gchoice_5_31_1'> <input class='gfield-choice-input' name='input_31.1' type='checkbox' value='I am interested in including or have already included Brigham in my trust/estate plans' id='choice_5_31_1' /> <label for='choice_5_31_1' id='label_5_31_1' class='gform-field-label gform-field-label--type-inline'>I am interested in including or have already included Brigham in my trust/estate plans</label> </li></ul></div></li><li id="field_5_56" class="gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_5_56" ><label class='gfield_label gform-field-label' for='input_5_56'>Comments</label><div class='ginput_container ginput_container_textarea'><textarea name='input_56' id='input_5_56' class='textarea small' maxlength='250' placeholder='Additional comments about my gift' aria-invalid="false" rows='10' cols='50'></textarea></div></li><li id="field_5_106" class="gfield gfield--type-captcha gfield--input-type-captcha field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_5_106" ><label class='gfield_label gform-field-label' for='input_5_106'>CAPTCHA</label><div id='input_5_106' class='ginput_container ginput_recaptcha' data-sitekey='6Lfp0ukUAAAAAMdBkiQNaNQTizEX26cGL5Rkuush' data-theme='light' data-tabindex='-1' data-size='invisible' data-badge='bottomright'></div></li><li id="field_5_57" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_5_57" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><h2 class="gsection_title">Internal Use Only</h2></li><li id="field_5_79" class="gfield gfield--type-product gfield--input-type-calculation bwh_gift_total gfield_price gfield_price_5_79 gfield_product_5_79 gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_79" ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_5_79_1'>Total Gift Amount<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_product_calculation'> <input type='hidden' name='input_79.1' value='Total Gift Amount' class='gform_hidden' /> <span class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:</span> <span class='gform-field-label gform-field-label--type-sub-large ginput_product_price' id='input_5_79'>$0.00</span> <input type='hidden' name='input_79.2' id='ginput_base_price_5_79' class='gform_hidden' value='$0.00'/> <input type='hidden' name='input_79.3' value='1' class='ginput_quantity_5_79 gform_hidden' /> </div></li><li id="field_5_78" class="gfield gfield--type-total gfield--input-type-total gfield_price gfield_price_5_ gfield_total gfield_total_5_ field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" aria-atomic="true" aria-live="polite" data-js-reload="field_5_78" ><label class='gfield_label gform-field-label' for='input_5_78'>Total Amount being Processed</label><div class='ginput_container ginput_container_total'> <span class='ginput_total ginput_total_5'>$0.00</span> <input type='hidden' name='input_78' id='input_5_78' class='gform_hidden'/> </div></li><li id="field_5_70" class="gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_70" ><div class='ginput_container ginput_container_text'><input name='input_70' id='input_5_70' type='hidden' class='gform_hidden' aria-invalid="false" value='0' /></div></li><li id="field_5_65" class="gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_65" ><div class='ginput_container ginput_container_text'><input name='input_65' id='input_5_65' type='hidden' class='gform_hidden' aria-invalid="false" value='1' /></div></li><li id="field_5_86" class="gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_5_86" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><label class='gfield_label gform-field-label' for='input_5_86'>Hide Gift Designation</label><div class='ginput_container ginput_container_text'><input name='input_86' id='input_5_86' type='text' value='0' class='medium' aria-describedby="gfield_description_5_86" aria-invalid="false" /> </div><div class='gfield_description' id='gfield_description_5_86'>to control whether the gift designation option should be presented to visitors or not</div></li><li id="field_5_102" class="gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_102" ><div class='ginput_container ginput_container_text'><input name='input_102' id='input_5_102' type='hidden' class='gform_hidden' aria-invalid="false" value='0' /></div></li><li id="field_5_67" class="gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_67" ><div class='ginput_container ginput_container_text'><input name='input_67' id='input_5_67' type='hidden' class='gform_hidden' aria-invalid="false" value='0' /></div></li><li id="field_5_71" class="gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_71" ><div class='ginput_container ginput_container_text'><input name='input_71' id='input_5_71' type='hidden' class='gform_hidden' aria-invalid="false" value='1' /></div></li><li id="field_5_94" class="gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_94" ><div class='ginput_container ginput_container_text'><input name='input_94' id='input_5_94' type='hidden' class='gform_hidden' aria-invalid="false" value='0' /></div></li><li id="field_5_93" class="gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_93" ><div class='ginput_container ginput_container_text'><input name='input_93' id='input_5_93' type='hidden' class='gform_hidden' aria-invalid="false" value='0' /></div></li><li id="field_5_54" class="gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_5_54" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><label class='gfield_label gform-field-label' for='input_5_54'>Fundraising Unit<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_5_54' type='text' value='general' class='medium' aria-required="true" aria-invalid="false" /> </div></li><li id="field_5_85" class="gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_5_85" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><label class='gfield_label gform-field-label' for='input_5_85'>Appeal Program</label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_5_85' type='text' value='general' class='medium' aria-describedby="gfield_description_5_85" aria-invalid="false" /> </div><div class='gfield_description' id='gfield_description_5_85'>A fundraising program that the appeal associated with, e.g. straight solicitation</div></li><li id="field_5_13" class="gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_5_13" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><label class='gfield_label gform-field-label' for='input_5_13'>Appeal Code<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_5_13' type='text' value='22XXAGWM' class='medium' placeholder='Appeal/Package Code' aria-required="true" aria-invalid="false" /> </div></li><li id="field_5_28" class="gfield gfield--type-website gfield--input-type-website field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_hidden" data-js-reload="field_5_28" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><label class='gfield_label gform-field-label' for='input_5_28'>Referer URL</label><div class='ginput_container ginput_container_website'> <input name='input_28' id='input_5_28' type='url' value='' class='medium' placeholder='Referer url' aria-invalid="false"/> </div></li><li id="field_5_29" class="gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_hidden" data-js-reload="field_5_29" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><label class='gfield_label gform-field-label' for='input_5_29'>User Agent</label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_5_29' type='text' value='Mozilla/5.0 (Windows NT 10.0; Win64; x64) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/91.0.4472.114 Safari/537.36 Edg/91.0.864.54' class='medium' aria-invalid="false" /> </div></li><li id="field_5_36" class="gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_5_36" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><label class='gfield_label gform-field-label' for='input_5_36'>utm_medium</label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_5_36' type='text' value='' class='medium' placeholder='utm_medium' aria-invalid="false" /> </div></li><li id="field_5_37" class="gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_5_37" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><label class='gfield_label gform-field-label' for='input_5_37'>utm_source</label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_5_37' type='text' value='' class='medium' placeholder='utm_source' aria-invalid="false" /> </div></li><li id="field_5_38" class="gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_5_38" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><label class='gfield_label gform-field-label' for='input_5_38'>utm_campaign</label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_5_38' type='text' value='' class='medium' placeholder='utm_campaign' aria-invalid="false" /> </div></li><li id="field_5_39" class="gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_5_39" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><label class='gfield_label gform-field-label' for='input_5_39'>utm_content</label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_5_39' type='text' value='' class='medium' placeholder='utm_content' aria-invalid="false" /> </div></li><li id="field_5_107" class="gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_5_107" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><label class='gfield_label gform-field-label' for='input_5_107'>space holder</label><div class='ginput_container ginput_container_text'><input name='input_107' id='input_5_107' type='text' value='' class='medium' aria-describedby="gfield_description_5_107" aria-invalid="false" /> </div><div class='gfield_description' id='gfield_description_5_107'>space holder for later use</div></li><li id="field_5_108" class="gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden" data-js-reload="field_5_108" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'></i><span>Hidden</span></div><label class='gfield_label gform-field-label' for='input_5_108'>mkto_email_id</label><div class='ginput_container ginput_container_text'><input name='input_108' id='input_5_108' type='text' value='' class='medium' maxlength='8' 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