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<form class="userform-form" action="" method="post" name="form_5508274" id="5508274" accept-charset="utf-8"><input type="hidden" name="formID" value="5508274" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li class="form-line" id="id_33"><div id="cid_33" class="form-input-wide"> <img alt="" class="form-image" border="0" src="https://w2.chabad.org/media/images/1361/cfpx13617446.png" height="465.49999999999994" width="665" /> </div></li><li class="form-line" id="id_9"><div class="form-label-left" id="label_9"><label for="input_9"> Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_9"> </label></div><div id="cid_9" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q9_fullName9[first]" id="first_9" autocomplete="given-name" />  <label class="form-sub-label" for="first_9" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q9_fullName9[last]" id="last_9" autocomplete="family-name" />  <label class="form-sub-label" for="last_9" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_10"><div class="form-label-left" id="label_10"><label for="input_10"> E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_10"> </label></div><div id="cid_10" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_10" name="q10_email10" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_12"><div class="form-label-left" id="label_12"><label for="input_12"> Phone Number </label><label class="label-message" for="input_12"> </label></div><div id="cid_12" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q12_phoneNumber12[area]" id="input_12_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_12_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q12_phoneNumber12[phone]" id="input_12_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_12_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_14"><div class="form-label-left" id="label_14"><label for="input_14"> Teens </label><label class="label-message" for="input_14"> Grades 8-12</label></div><div id="cid_14" class="form-input"> <input type="number" class="form-number-input  form-textbox" id="input_14" name="q14_adults" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" /> </div></li><li class="form-line" id="id_29"><div class="form-label-left" id="label_29"><label for="input_29"> Friends and Family </label><label class="label-message" for="input_29"> Please invite your friends and family!</label></div><div id="cid_29" class="form-input"> <select class="form-dropdown" style="width:60px" id="input_29" name="q29_input29"><option value=""></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option></select> </div></li><li class="form-line always-hidden" id="id_27"><div class="form-label-left" id="label_27"><label for="input_27"> Place a greeting or ad in our Journal </label><label class="label-message" for="input_27"> This can be an honor of a teen, Rabbi &amp; Rebbetzin, business etc</label></div><div id="cid_27" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_27_0" name="q27_input27[]" value="Quarter Page - $54" /><label id="label_input_27_0" for="input_27_0"><span>Quarter Page - $54</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_27_1" name="q27_input27[]" value="Half Page - $72" /><label id="label_input_27_1" for="input_27_1"><span>Half Page - $72</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_27_2" name="q27_input27[]" value="Full Page - $180" /><label id="label_input_27_2" for="input_27_2"><span>Full Page - $180</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_27_3" name="q27_input27[]" value="Silver - $360 (includes reservations)" /><label id="label_input_27_3" for="input_27_3"><span>Silver - $360 (includes reservations)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_27_4" name="q27_input27[]" value="Gold - $500 (includes reservations)" /><label id="label_input_27_4" for="input_27_4"><span>Gold - $500 (includes reservations)</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line always-hidden" id="id_32"><div id="cid_32" class="form-input-wide"> <div id="text_32" class="form-html"><p><a href="https://drive.google.com/file/d/11bGiaYEA_KXm2vTr-pcVWp5TVcCYj_0G/view?usp=sharing">See sample greeting and ads here</a></p>
</div> </div></li><li class="form-line" id="id_28"><div class="form-label-left" id="label_28"><label for="input_28"> Family and Friends </label><label class="label-message" for="input_28"> Please invite your family and friends!</label></div><div id="cid_28" class="form-input"> <select class="form-dropdown" style="width:60px" id="input_28" name="q28_input28"><option value=""></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option></select> </div></li><li class="form-line always-hidden" id="id_30"><div class="form-label-left" id="label_30"><label for="input_30">  </label><label class="label-message" for="input_30"> </label></div><div id="cid_30" class="form-input"> <span class="form-sub-label-container"><textarea id="input_30" class="form-textarea" name="q30_input30" cols="40" rows="6"></textarea>  <label class="form-sub-label" for="input_30">Image files may be sent to Mendel@chabadnorthridge.com</label></span> </div></li><li class="form-line" id="id_25"><div class="form-label-left" id="label_25"><label for="input_25"> I want to sponsor the event </label><label class="label-message" for="input_25"> </label></div><div id="cid_25" class="form-input"> <div class="form-multiple-column" data-columns="3"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_25_0" name="q25_iWant" value="180" /><label for="input_25_0"><span>$180 USD</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_25_1" name="q25_iWant" value="250" /><label for="input_25_1"><span>$250 USD</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_25_2" name="q25_iWant" value="360" /><label for="input_25_2"><span>$360 USD</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_25_3" name="q25_iWant" value="500" /><label for="input_25_3"><span>$500 USD</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio-other form-radio" name="q25_iWant" id="other_25" value="" /><span><input type="number" min="1" class="form-radio-other-input form-textbox" onkeypress="validateNumber(event)" name="q25_iWant[other]" data-otherhint="Other" size="15" id="input_25" disabled="disabled" /></span><br /></span></div> </div></li><li class="form-line always-hidden" id="id_26"><div class="form-label-left" id="label_26"><label for="input_26"> Ad Message (optional) </label><label class="label-message" for="input_26"> </label></div><div id="cid_26" class="form-input"> <span class="form-sub-label-container"><textarea id="input_26" class="form-textarea" name="q26_input26" cols="40" rows="6"></textarea>  <label class="form-sub-label" for="input_26">Image files may be sent to Mendel@chabadnorthridge.com</label></span> </div></li><li class="form-line" id="id_5"><div class="form-label-left" id="label_5"><label for="input_5"> Total Charge </label></div><div id="cid_5" class="form-input"> <div id="total_amount">$0.00 USD</div> </div></li><li class="form-line" id="id_1"><div class="form-label-left" id="label_1"><label for="input_1"> Payment Method </label><label class="label-message" for="input_1"> </label></div><div id="cid_1" class="form-input"> <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2" class="form-payment-methods form-multiple-column"><span class="form-radio-item"><input class="paymentMethod form-radio validate[paymentMethod] form-radio" type="radio" id="input_1_creditCard" name="q1_paymentMethod[payment_method]" value="creditCard" onclick="BuildSource.creditCard(this)" /><label 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class="cc-field-wrapper"><span class="form-sub-label-container"><input class="form-textbox form-creditcard js-cc-number validate[visible, creditcard]" type="text" name="q1_paymentMethod[cc_number]" id="input_1_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_1_cc_number" id="sublabel_cc_number">Credit Card Number</label></span></div></td><td class="cc_ccv "><span class="form-sub-label-container"><input class="form-textbox validate[visible]" type="text" name="q1_paymentMethod[cc_ccv]" id="input_1_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_1_cc_ccv" id="sublabel_cc_ccv">Security Code</label></span></td></tr><tr><td colspan="2" class="cc_name_on_card "><span class="form-sub-label-container"><input class="form-textbox validate[visible]" type="text" name="q1_paymentMethod[cc_nameOnCard]" id="input_1_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_1_cc_nameOnCard" 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<a href="/article.asp?aid=5508274">CTeen Gala RSVP</a>
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