<!DOCTYPE HTML PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/html4/loose.dtd">


<html xmlns="http://www.w3.org/1999/xhtml" lang="en" xml:lang="en">
<head id="Head1">
<meta http-equiv="X-UA-Compatible" content="IE=edge" />
<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
<meta http-equiv="Content-Language" content="en" />

<meta name="handheldFriendly" content="true" />
<meta name="viewport" content="width=device-width, initial-scale=1.0, maximum-scale=1.0, user-scalable=0" />
<meta name="keywords" content="Order,Shmmurah,Matzah" />
<meta name="title" content="Order Shmmurah Matzah - Chabad of Los Alamitos" />
<meta property="og:type" content="website" />
<meta name="scope-aids" content="1821537-1821545-1821549-5478701-5478885" />
<meta name="article-keywords" content="2185-2170-2898" />
<meta name="scope-aid" content="1821537" />
<meta name="scope-aid" content="1821545" />
<meta name="scope-aid" content="1821549" />
<meta name="scope-aid" content="5478701" />
<meta name="scope-aid" content="5478885" />
<meta name="article-keyword" content="2185" />
<meta name="article-keyword" content="2170" />
<meta name="article-keyword" content="2898" />
<meta property="og:url" content="https://www.chabadlosal.com/templates/articlecco_cdo/aid/5478885/jewish/Order-Shmmurah-Matzah.htm" />
<meta property="twitter:card" content="summary_large_image" />
<meta property="twitter:site" content="@chabad" />
<meta property="og:title" content="Order Shmmurah Matzah - Chabad of Los Alamitos" /><link rel="canonical" href="https://www.chabadlosal.com/templates/articlecco_cdo/aid/5478885/jewish/Order-Shmmurah-Matzah.htm" />
<link rel="Stylesheet" href="/css/fonts/font-awesome/font-awesome-5.css?g=10&v=98662BF4" id="kfont-awesome" type="text/css"/>
<link rel="Stylesheet" href="/css/DefaultGrid.css?g=10&v=44B79007" id="kgrid" type="text/css"/>
<link rel="Stylesheet" href="/css/Elements.css?g=10&v=E669C926" id="k6" type="text/css"/>
<link rel="Stylesheet" href="/css/vendor/ds/tokens/sites.css?g=10&v=151BA9A2" id="ksites-ds-css" type="text/css"/>
<link rel="Stylesheet" href="/css/new/main.css?g=10&v=2B7F734E" id="k7" type="text/css"/>
<link rel="Stylesheet" href="/css/global.css?g=10&v=D37C5613" id="k3" type="text/css"/>
<link rel="Stylesheet" href="/css/global-print.css?g=10&v=1FE80AC1" id="k5" type="text/css" media="print"/>
<link rel="Stylesheet" href="/css/cco/home/widget-styles.css?g=10&v=B14CEBA0" id="k6" type="text/css"/>
<link rel="Stylesheet" href="/css/sites6/default-theme.css?g=10&v=F68E803F" id="k" type="text/css"/>
<link rel="Stylesheet" href="/css/old/global.css?g=10&v=F7C22456" id="k2898" type="text/css"/>
<link rel="Stylesheet" href="/css/cco/templates/forms/formCss2.css?g=10&v=9F45CAAB" id="kFormCss" type="text/css"/>
<link rel="Stylesheet" href="/css/cco/templates/forms/themes/nova.css?g=10&v=25554DFF" id="kNova" type="text/css"/>
<link rel="Stylesheet" href="/css/bootstrap/grid.css?g=10&v=B92FCAD8" id="kbootstrap4-grid" type="text/css"/>
<link rel="Stylesheet" href="/css/Library/reader-comments.css?g=10&v=5F31D0D8" id="kCommentsStylesheet" type="text/css"/>
<link rel="Stylesheet" href="/css/inline/BookInfo.css?g=10&v=14B88022" id="kBookInfoCss" type="text/css"/>
<!--[if lte IE 8]> <link rel="Stylesheet" href="/css/global-ie.css?g=10&v=E699B0F3" id="k4" type="text/css"/> <![endif]-->
<script>$q=[];$j=function(f){$q.push(f);}</script><title>
	Order Shmmurah Matzah - Chabad of Los Alamitos
</title>


<script>
	window.dataLayer = window.dataLayer || [];
	dataLayer.push({"event":"datalayer-initialized","page":{"numberOfComments":0,"publicationDate":"2022-03-31","primaryArticleId":5478885,"title":"","author":"","authorId":0,"contentLevel1":"My Site","contentLevel2":"Synagogue & Services","contentLevel3":"Pesach","contentLevel4":"Order Shmmurah Matzah","siteName":"Chabad of Los Alamitos"},"time":{"upcomingHoliday":"Shavuot","daysToUpcomingHoliday":9,"hebrewDate":"5786-02-26"}});
		dataLayer.push({ 'articleHierarchy': '-1821537-1821545-1821549-5478701-5478885-', 'keywords': '-k2898-k2170-k2185-', 'k': '-1821537-1821545-1821549-5478701-5478885--k2898-k2170-k2185-' });
	
</script>
<script>

(function(c,h,a,b,a,d){c[a]=c[a]||[];c[a].push({'gtm.start':
new Date().getTime(),event:'gtm.js'});var f=h.getElementsByTagName(b)[0],
j=h.createElement(b);j.async=true;
j.src='https://w6.chabad.org/mitzvah-tank.js';f.parentNode.insertBefore(j,f);
})(window,document,0,'script','dataLayer');</script>

	<!-- Start of StatCounter Code -->
	<script type="text/javascript">
	var sc_project = 7812626;var sc_partition = 89;var sc_invisible = 1;var sc_remove_link=1;var sc_security = "b1582d84";var sc_https = 1;
	</script>
	<script type="text/javascript" src="https://secure.statcounter.com/counter/counter_xhtml.js" defer async></script>
	<noscript><img src="//c90.statcounter.com/counter.php?sc_project=7812626&amp;java=0&amp;security=b1582d84&amp;invisible=1" border="0" /> </noscript>
	<!-- End of StatCounter Code -->


<style>
div#orDonate {
    background: #317cb8;
    padding: 5px;
    border-radius: 20px;
    color: #fff;
}
div#orDonate {
    margin: 20px 0px 20px 0px;
    font-family: Muli,sans-serif;
    font-size: 17px;
    font-weight: 600;
}
a#buttonOther {
    margin: 5px;
}
div#buttonSection {
    display: flex;
    flex-wrap: wrap;
    justify-content: center;
}
a#buttonOther {
    font-family: Muli,sans-serif;
    background-color: #ffb400;
    color: #000;
    -webkit-transition: box-shadow .3s ease-in-out,color .3s ease-in-out;
    transition: .3s ease-in-out,color .3s ease-in-out;
    padding: 11px;
    border-radius: 100px;
    font-weight: 600;
}
a#buttonOther:hover {
    background-color: #ff9900;
    text-decoration: none;
}
#header.on-scroll .clearfix.branding-search {
    display: flex;
}
@media only screen and (max-width: 800px) {
div#orDonate {
    margin: 21px 0px -4px 0px;
}
div#buttonSection {
    flex-direction: column;
}
div#header {
    height: 90px!important;
    display: flex;
    align-items: center;
}
.on-scroll .cs-mobile-menu-open {
    margin-top: -64px;
}
}
section#donate {
    background-color: #ffffffb3!important;
    backdrop-filter: blur(3px);
}
#id_7 #cid_7 span.form-checkbox-item.clear-left:first-of-type {
    background: #54afcb;
    color: #fff;
    padding: 10px;
    font-size: 16px;
    cursor: pointer !important;
}
#id_7 #cid_7 span.form-checkbox-item.clear-left:first-of-type input#input_7_0 {
    display: none;
}
#id_7 #cid_7 span.form-checkbox-item.clear-left:first-of-type span {
    cursor: pointer;
}
</style>
</head>
<body class="lang_en dir_ltr cco_body form secure">

	<div id="cco_body">
		<div class="content g960 no_margin no_overflow" id="co_content_container">
			
			
	

	<article class="content js-content" >
	

<div id="formContainer"><script type="text/javascript">var defaultCurrency = { value: 'USD', symbol: '$'};
$j(function(){
window.multiplier = 0;
window.formJson = Object.extend([{"form_height":513,"6_text":"\u003cp\u003e\u003cspan style=\"font-size: 20px;\"\u003eOrder Shmmurah Matzah\u003c/span\u003e\u003c/p\u003e","6_name":"doubleclickTo","6_qid":6,"6_type":"control_text","6_order":1,"1_text":"Full Name","1_message":"","1_labelAlign":"Auto","1_required":"Yes","1_prefix":"No","1_suffix":"No","1_middle":"No","1_description":"","1_sublabels":{"prefix":"Prefix","first":"First Name","middle":"Middle Name","last":"Last Name","suffix":"Suffix"},"1_readonly":"No","1_name":"fullName","1_qid":1,"1_type":"control_fullname","1_order":2,"3_receivesReceipts":"No","3_text":"E-mail","3_message":"","3_labelAlign":"Auto","3_required":"Yes","3_size":30,"3_validation":"Email","3_maxsize":"","3_defaultValue":"","3_subLabel":"","3_hint":"ex: myname@example.com","3_description":"","3_confirmation":"No","3_confirmationHint":"Confirm Email","3_readonly":"No","3_name":"email","3_qid":3,"3_type":"control_email","3_order":3,"9_text":"1 matzah per box","9_message":"","9_labelAlign":"Auto","9_required":"Yes","9_size":5,"9_maxsize":"","9_minValue":"","9_maxValue":"","9_defaultValue":"","9_subLabel":"$36 a box","9_hint":"ex: 23","9_description":"","9_readonly":"No","9_pricePerItem":36,"9_name":"number","9_qid":9,"9_type":"control_number","9_order":4,"10_text":"","10_message":"","10_labelAlign":"Auto","10_required":"No","10_options":"I\u0027d like to make an optional donation to support Chabad for Passover","10_special":"None","10_allowOther":"No","10_otherText":"Other","10_spreadCols":"1","10_selected":"","10_minSelection":"","10_maxSelection":"","10_description":"","10_name":"input10","10_qid":10,"10_type":"control_checkbox","10_order":5,"11_text":"Donation Amount","11_message":"","11_labelAlign":"Auto","11_required":"No","11_options":"50|75|100","11_special":"None","11_allowOther":"No","11_otherText":"Other","11_selected":"","11_spreadCols":"3","11_description":"","11_mode":"textbox","11_name":"input11","11_qid":11,"11_type":"control_amount","11_order":6,"5_text":"Address","5_message":"","5_labelAlign":"Auto","5_required":"Yes","5_selectedCountry":"","5_description":"","5_subfields":"st1|st2|city|state|zip|country","5_sublabels":{"cc_firstName":"First Name","cc_lastName":"Last Name","cc_number":"Credit Card Number","cc_ccv":"Security Code","cc_exp_month":"Expiration Month","cc_exp_year":"Expiration Year","addr_line1":"Street Address","addr_line2":"Street Address Line 2","city":"City","state":"State / Province","postal":"Postal / Zip Code","country":"Country"},"5_name":"address","5_qid":5,"5_type":"control_address","5_order":7,"7_labelAlign":"Auto","7_text":"Total","7_partialPayEnabled":"No","7_partialPayType":"dollar","7_partialPayMinimum":0,"7_required":"No","7_offsetGiftEnabled":"No","7_offsetGift":3,"7_name":"total","7_qid":7,"7_type":"control_totalamount","7_order":8,"8_text":"Payment","8_message":"","8_labelAlign":"Auto","8_required":"No","8_duplicatable":false,"8_selectedCountry":"","8_description":"","8_sublabels":{"cc_firstName":"First Name","cc_lastName":"Last Name","cc_type":"Credit Card Type","cc_number":"Credit Card Number","cc_ccv":"Security Code","cc_nameOnCard":"Name on Card","cc_IdNumber":"Israel Identity Number","cc_exp_month":"Expiration Month","cc_exp_year":"Expiration Year","eCheck_bankName":"Bank Name","eCheck_routingNumber":"Routing Number","eCheck_accountNumber":"Account Number","eCheck_accountType":"Account Type","addr_line1":"Street Address","addr_line2":"Street Address Line 2","city":"City","state":"State / Province","postal":"Postal / Zip Code","country":"Country"},"8_name":"payment","8_qid":8,"8_type":"control_payform","8_order":9,"8_options":{"currency":"default","creditCard":{"value":"Credit Card","enabled":true,"fields":[{"name":"ccv","value":"CCV","enabled":true},{"name":"nameOnCard","value":"Name on Card","enabled":true},{"name":"billingAddress","value":"Billing Address","enabled":true},{"name":"israelIdentityNumber","value":"Israel Identity Number","enabled":true}],"processorIndex":2,"type":[{"name":"Visa","value":"Visa","enabled":true},{"name":"Mastercard","value":"MasterCard","enabled":true},{"name":"Amex","value":"American Express","enabled":true},{"name":"Discover","value":"Discover","enabled":true},{"name":"Isracard","value":"Isracard","enabled":false}],"payMe":false},"paypal":{"value":"Paypal","enabled":false,"processorIndex":1},"eCheck":{"value":"eCheck","enabled":false},"other":{"value":"Other","enabled":false,"altText":"","message":""}},"4_text":"Optin","4_labelAlign":"Auto","4_description":"","4_required":"No","4_list":"-1","4_duplicatable":false,"4_name":"optin","4_qid":4,"4_type":"control_optin","4_order":10,"2_text":"Submit","2_buttonAlign":"Auto","2_clear":"No","2_print":"No","2_name":"submit","2_qid":2,"2_type":"control_button","2_order":11,"form_title":"Untitled Form","form_pagetitle":"Form","form_styles":"nova","form_font":"","form_fontsize":"14","form_fontcolor":"","form_optioncolor":"","form_lineSpacing":"12","form_background":"","form_formWidth":"685","form_labelWidth":"150","form_alignment":"Left","form_thankurl":"","form_thanktext":"","form_highlightLine":"Enabled","form_activeRedirect":"default","form_sendpostdata":"No","form_unique":"None","form_uniqueField":"\u003cField Id\u003e","form_status":"Enabled","form_injectCSS":"","form_hideMailEmptyFields":"disable","form_showProgressBar":"disable","form_formStrings":[{"alphabetic":"This field can only contain letters","alphanumeric":"This field can only contain letters and numbers.","confirmClearForm":"Are you sure you want to clear the form?","confirmEmail":"E-mail does not match","email":"Enter a valid e-mail address","generalError":"There are errors on the form. Please fix them before continuing.","generalPageError":"There are errors on this page. Please fix them before continuing.","gradingScoreError":"Score total should only be less than or equal to","incompleteFields":"There are incomplete required fields. Please complete them.","inputCarretErrorA":"Input should not be less than the minimum value:","inputCarretErrorB":"Input should not be greater than the maximum value:","lessThan":"Your score should be less than or equal to","maxDigitsError":"The maximum digits allowed is","maxSelectionsError":"The maximum number of selections allowed is","minSelectionsError":"The minimum required number of selections is","multipleFileUploads_emptyError":"{file} is empty, please select files again without it.","multipleFileUploads_minSizeError":"{file} is too small, minimum file size is {minSizeLimit}.","multipleFileUploads_onLeave":"The files are being uploaded, if you leave now the upload will be cancelled.","multipleFileUploads_sizeError":"{file} is too large, maximum file size is {sizeLimit}.","multipleFileUploads_typeError":"{file} has invalid extension. Only {extensions} are allowed.","numeric":"This field can only contain numeric values","pastDatesDisallowed":"Date must not be in the past.","pleaseWait":"Please wait...","required":"This field is required.","requireEveryRow":"Every row is required.","requireOne":"At least one field required.","submissionLimit":"Sorry! Only one entry is allowed.  Multiple submissions are disabled for this form.","uploadExtensions":"You can only upload following files:","uploadFilesize":"File size cannot be bigger than:"}],"form_limitSubmission":"No Limit","form_expireDate":"No Limit","form_messageOfLimitedForm":"This form is currently unavailable!","form_emails":[],"form_language":"","form_sendEmail":"Yes","form_style":"Default","form_theme":"nova","form_id":5478885,"form_formStringsChanged":"yes","form_slug":5478885,"form_stopHighlight":"Yes","form_conditions":[{"type":"field","link":"Any","terms":[{"field":"10","operator":"isFilled","value":false}],"action":{"field":"11","visibility":"Show"}}]}][0] || {}, window.formJson || {});
window.isSecureForm = true
});

			if (typeof(Userform) ==='undefined')
			{
				Userform={init:function(args){
					$j(function(){
						Userform.init.apply(Userform, [args]);
					})
				},
				setConditions:function(args){
					$j(function(){
						Userform.setConditions.apply(Userform, [args]);
					})
				}};
			}
</script><script type="text/javascript">
   Userform.setConditions([{"type":"field","link":"Any","terms":[{"field":"10","operator":"isFilled","value":false}],"action":{"field":"11","visibility":"Show"}}]);
   Userform.init(function(){
      $('input_3').hint('ex: myname@example.com');
      $('input_9').hint('ex: 23');
      Userform.alterTexts({"alphabetic":"This field can only contain letters","alphanumeric":"This field can only contain letters and numbers.","confirmClearForm":"Are you sure you want to clear the form?","confirmEmail":"E-mail does not match","email":"Enter a valid e-mail address","generalError":"There are errors on the form. Please fix them before continuing.","generalPageError":"There are errors on this page. Please fix them before continuing.","gradingScoreError":"Score total should only be less than or equal to","incompleteFields":"There are incomplete required fields. Please complete them.","inputCarretErrorA":"Input should not be less than the minimum value:","inputCarretErrorB":"Input should not be greater than the maximum value:","lessThan":"Your score should be less than or equal to","maxDigitsError":"The maximum digits allowed is","maxSelectionsError":"The maximum number of selections allowed is","minSelectionsError":"The minimum required number of selections is","multipleFileUploads_emptyError":"{file} is empty, please select files again without it.","multipleFileUploads_minSizeError":"{file} is too small, minimum file size is {minSizeLimit}.","multipleFileUploads_onLeave":"The files are being uploaded, if you leave now the upload will be cancelled.","multipleFileUploads_sizeError":"{file} is too large, maximum file size is {sizeLimit}.","multipleFileUploads_typeError":"{file} has invalid extension. Only {extensions} are allowed.","numeric":"This field can only contain numeric values","pastDatesDisallowed":"Date must not be in the past.","pleaseWait":"Please wait...","required":"This field is required.","requireEveryRow":"Every row is required.","requireOne":"At least one field required.","submissionLimit":"Sorry! Only one entry is allowed.  Multiple submissions are disabled for this form.","uploadExtensions":"You can only upload following files:","uploadFilesize":"File size cannot be bigger than:"});
   });
</script>
<style type="text/css" id="GenFormStyles">
    .form-label{
        width:150px !important;
    }
    .form-label-left{
        width:150px !important;
    }
    .form-line{
        padding-top:12px;
        padding-bottom:12px;
    }
    .form-label-right{
        width:150px !important;
    }
    .form-all {
        font-size:14px;
    }
.co_body .content .form-all p {
 font-size:14px;

}
@media screen and (max-width: 600px) {.form-label-left{	float:none;	display:block;}.form-buttons-wrapper.button-align-auto{text-indent: 0!important;}}</style>

<form class="userform-form" action="" method="post" name="form_5478885" id="5478885" accept-charset="utf-8">
  <input type="hidden" name="formID" value="5478885" />
  <div class="form-all dir_ltr" dir="ltr">
    <ul class="form-section">
      <li class="form-line" id="id_6">
        <div id="cid_6" class="form-input-wide">
          <div id="text_6" class="form-html">
            <p><span style="font-size: 20px;">Order Shmmurah Matzah</span>
            </p>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_1">
        <div class="form-label-left" id="label_1">
          <label for="input_1">
            Full Name<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_1">  </label>
        </div>
        <div id="cid_1" class="form-input"><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q1_fullName[first]" id="first_1" autocomplete="given-name" />
            <label class="form-sub-label" for="first_1" id="sublabel_first"> First Name </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q1_fullName[last]" id="last_1" autocomplete="family-name" />
            <label class="form-sub-label" for="last_1" id="sublabel_last"> Last Name </label></span>
        </div>
      </li>
      <li class="form-line" id="id_3">
        <div class="form-label-left" id="label_3">
          <label for="input_3">
            E-mail<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_3">  </label>
        </div>
        <div id="cid_3" class="form-input">
          <input type="email" class=" form-textbox validate[required, Email]" id="input_3" name="q3_email" size="30" value="" autocomplete="email" />
        </div>
      </li>
      <li class="form-line" id="id_9">
        <div class="form-label-left" id="label_9">
          <label for="input_9">
            1 matzah per box<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 type="number" class="form-number-input  form-textbox validate[required]" id="input_9" name="q9_number" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" />
            <label class="form-sub-label" for="input_9"> $36 a box </label></span>
        </div>
      </li>
      <li class="form-line" id="id_10">
        <div class="form-label-left" id="label_10">
          <label for="input_10">  </label>
          <label class="label-message" for="input_10">  </label>
        </div>
        <div id="cid_10" class="form-input">
          <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_10_0" name="q10_input10[]" value="I'd like to make an optional donation to support Chabad for Passover" />
              <label id="label_input_10_0" for="input_10_0"><span>I'd like to make an optional donation to support Chabad for Passover</span>
              </label></span><span class="clearfix"></span>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_11">
        <div class="form-label-left" id="label_11">
          <label for="input_11"> Donation Amount </label>
          <label class="label-message" for="input_11">  </label>
        </div>
        <div id="cid_11" class="form-input">
          <div class="form-single-column"><span class="form-radio-item simple-mode"><label id="label_input_11" for="input_11"><span>$</span>
              </label>
              <input type="text" class="form-textbox" id="input_11" name="q11_input11" value="" onkeypress="validateNumber(event)" /></span><span class="clearfix"></span>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_5">
        <div class="form-label-left" id="label_5">
          <label for="input_5">
            Address<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_5">  </label>
        </div>
        <div id="cid_5" class="form-input">
          <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0">
            <tbody><tr>
              <td colspan="2"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-line" type="text" name="q5_address[addr_line1]" id="input_5_addr_line1" size="46" autocomplete="address-line1" />
                  <label class="form-sub-label" for="input_5_addr_line1" id="sublabel_5_addr_line1"> Street Address </label></span>
              </td>
            </tr>
            <tr>
              <td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line no-validation" type="text" name="q5_address[addr_line2]" id="input_5_addr_line2" size="46" autocomplete="address-line2" />
                  <label class="form-sub-label" for="input_5_addr_line2" id="sublabel_5_addr_line2"> Street Address Line 2 </label></span>
              </td>
            </tr>
            <tr>
              <td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-city" type="text" name="q5_address[city]" id="input_5_city" size="21" autocomplete="address-level2" />
                  <label class="form-sub-label" for="input_5_city" id="sublabel_5_city"> City </label></span>
              </td>
              <td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q5_address[state]" id="input_5_state" size="22" autocomplete="address-level1" />
                  <label class="form-sub-label" for="input_5_state" id="sublabel_5_state"> State / Province </label></span>
              </td>
            </tr>
            <tr>
              <td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-postal" type="text" name="q5_address[postal]" id="input_5_postal" size="10" autocomplete="postal-code" />
                  <label class="form-sub-label" for="input_5_postal" id="sublabel_5_postal"> Postal / Zip Code </label></span>
              </td>
              <td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q5_address[country]" id="input_5_country" autocomplete="country-name">
                    <option value="" selected="selected"> Please Select </option>
                    <option value="United States"> United States </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="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="The Bahamas"> The 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="Bosnia and Herzegovina"> Bosnia and Herzegovina </option>
                    <option value="Botswana"> Botswana </option>
                    <option value="Brazil"> Brazil </option>
                    <option value="Brunei"> Brunei </option>
                    <option value="Bulgaria"> Bulgaria </option>
                    <option value="Burkina Faso"> Burkina Faso </option>
                    <option value="Burundi"> Burundi </option>
                    <option value="Cambodia"> Cambodia </option>
                    <option value="Cameroon"> Cameroon </option>
                    <option value="Canada"> Canada </option>
                    <option value="Cape Verde"> Cape Verde </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="People's Republic of China"> People's Republic of China </option>
                    <option value="Republic of China"> Republic of China </option>
                    <option value="Christmas Island"> Christmas Island </option>
                    <option value="Cocos (Keeling) Islands"> Cocos (Keeling) Islands </option>
                    <option value="Colombia"> Colombia </option>
                    <option value="Comoros"> Comoros </option>
                    <option value="Congo"> Congo </option>
                    <option value="Cook Islands"> Cook Islands </option>
                    <option value="Costa Rica"> Costa Rica </option>
                    <option value="Cote d'Ivoire"> Cote d'Ivoire </option>
                    <option value="Croatia"> Croatia </option>
                    <option value="Cuba"> Cuba </option>
                    <option value="Cyprus"> Cyprus </option>
                    <option value="Czech Republic"> Czech Republic </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 Polynesia"> French Polynesia </option>
                    <option value="Gabon"> Gabon </option>
                    <option value="The Gambia"> The 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="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="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="North Korea"> North Korea </option>
                    <option value="South Korea"> South Korea </option>
                    <option value="Kosovo"> Kosovo </option>
                    <option value="Kuwait"> Kuwait </option>
                    <option value="Kyrgyzstan"> Kyrgyzstan </option>
                    <option value="Laos"> Laos </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="Macau"> Macau </option>
                    <option value="Macedonia"> Macedonia </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="Northern Mariana"> Northern Mariana </option>
                    <option value="Norway"> Norway </option>
                    <option value="Oman"> Oman </option>
                    <option value="Pakistan"> Pakistan </option>
                    <option value="Palau"> Palau </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 Islands"> Pitcairn Islands </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="Russia"> Russia </option>
                    <option value="Rwanda"> Rwanda </option>
                    <option value="Saint Barthelemy"> Saint Barthelemy </option>
                    <option value="Saint Helena"> Saint Helena </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="Slovakia"> Slovakia </option>
                    <option value="Slovenia"> Slovenia </option>
                    <option value="Solomon Islands"> Solomon Islands </option>
                    <option value="Somalia"> Somalia </option>
                    <option value="Somaliland"> Somaliland </option>
                    <option value="South Africa"> South Africa </option>
                    <option value="South Ossetia"> South Ossetia </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"> Svalbard </option>
                    <option value="Sweden"> Sweden </option>
                    <option value="Switzerland"> Switzerland </option>
                    <option value="Syria"> Syria </option>
                    <option value="Taiwan"> Taiwan </option>
                    <option value="Tajikistan"> Tajikistan </option>
                    <option value="Tanzania"> Tanzania </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="Tristan da Cunha"> Tristan da Cunha </option>
                    <option value="Tunisia"> Tunisia </option>
                    <option value="Turkey"> Turkey </option>
                    <option value="Turkmenistan"> Turkmenistan </option>
                    <option value="Turks and Caicos Islands"> Turks and Caicos Islands </option>
                    <option value="Tuvalu"> Tuvalu </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="Uruguay"> Uruguay </option>
                    <option value="Uzbekistan"> Uzbekistan </option>
                    <option value="Vanuatu"> Vanuatu </option>
                    <option value="Vatican City"> Vatican City </option>
                    <option value="Venezuela"> Venezuela </option>
                    <option value="Vietnam"> Vietnam </option>
                    <option value="British Virgin Islands"> British Virgin Islands </option>
                    <option value="US Virgin Islands"> US Virgin Islands </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="other"> Other </option>
                  </select>
                  <label class="form-sub-label" for="input_5_country" id="sublabel_5_country"> Country </label></span>
              </td>
            </tr>
          </tbody></table>
        </div>
      </li>
      <li class="form-line" id="id_7">
        <div class="form-label-left" id="label_7">
          <label for="input_7"> Total </label>
        </div>
        <div id="cid_7" class="form-input">
          <div id="total_amount">
            $0.00
          </div>
        </div>
      </li>
      <li class="form-line" id="id_8">
        <div class="form-label-left" id="label_8">
          <label for="input_8"> Payment </label>
          <label class="label-message" for="input_8">  </label>
        </div>
        <div id="cid_8" 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">
              </td>
            </tr>
            <tr class="credit_card ">
              <th colspan="2">
                Credit Card
              </th>
            </tr>
            <tr class="credit_card ">
              <td colspan="2" style="padding:0">
                <table cellpadding="0" cellspacing="0">
                  <tbody><tr>
                    <td colspan="2"><span class="form-sub-label-container"><select class="form-textbox validate[visible]" name="q8_payment[cc_type]" id="input_8_cc_type" autocomplete="cc-type">
                          <option value="Visa"> Visa </option>
                          <option value="Mastercard"> MasterCard </option>
                          <option value="Amex"> American Express </option>
                          <option value="Discover"> Discover </option>
                        </select>
                        <label class="form-sub-label" for="input_8_cc_type" id="sublabel_cc_type"> Credit Card Type </label></span>
                    </td>
                  </tr>
                  <tr>
                    <td><span class="form-sub-label-container"><input class="form-textbox form-creditcard js-cc-number validate[visible, creditcard]" type="text" name="q8_payment[cc_number]" id="input_8_cc_number" autocomplete="cc-number" size="20" />
                        <label class="form-sub-label" for="input_8_cc_number" id="sublabel_cc_number"> Credit Card Number </label></span>
                    </td>
                    <td class="cc_ccv "><span class="form-sub-label-container"><input class="form-textbox validate[visible]" type="text" name="q8_payment[cc_ccv]" id="input_8_cc_ccv" autocomplete="cc-csc" size="6" />
                        <label class="form-sub-label" for="input_8_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="q8_payment[cc_nameOnCard]" id="input_8_cc_nameOnCard" autocomplete="cc-name" size="33" />
                        <label class="form-sub-label" for="input_8_cc_nameOnCard" id="sublabel_cc_nameOnCard"> Name on Card </label></span>
                    </td>
                  </tr>
                  <tr class="credit_card ">
                    <td colspan=""><span class="form-sub-label-container"><select class="form-textbox validate[visible]" name="q8_payment[cc_exp_month]" id="input_8_cc_exp_month" autocomplete="cc-exp-month">
                          <option>  </option>
                          <option value="1"> 1 - January </option>
                          <option value="2"> 2 - February </option>
                          <option value="3"> 3 - March </option>
                          <option value="4"> 4 - April </option>
                          <option value="5"> 5 - May </option>
                          <option value="6"> 6 - June </option>
                          <option value="7"> 7 - July </option>
                          <option value="8"> 8 - August </option>
                          <option value="9"> 9 - September </option>
                          <option value="10"> 10 - October </option>
                          <option value="11"> 11 - November </option>
                          <option value="12"> 12 - December </option>
                        </select>
                        <label class="form-sub-label" for="input_8_cc_exp_month" id="sublabel_cc_exp_month"> Expiration Month </label></span>
                    </td>
                    <td><span class="form-sub-label-container"><select class="form-textbox validate[visible]" name="q8_payment[cc_exp_year]" id="input_8_cc_exp_year" autocomplete="cc-exp-year">
                          <option>  </option>
                          <option value="2022"> 2022 </option>
                          <option value="2023"> 2023 </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>
                        </select>
                        <label class="form-sub-label" for="input_8_cc_exp_year" id="sublabel_cc_exp_year"> Expiration Year </label></span>
                    </td>
                  </tr>
                </tbody></table>
              </td>
            </tr>
            <tr class="billing_address ">
              <th colspan="2">
                Billing Address
              </th>
            </tr>
            <tr class="billing_address ">
              <td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line" type="text" name="q8_payment[addr_line1]" id="input_8_addr_line1" autocomplete="billing address-line1" />
                  <label class="form-sub-label" for="input_8_addr_line1" id="sublabel_8_addr_line1"> Street Address </label></span>
              </td>
            </tr>
            <tr class="billing_address ">
              <td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line no-validation" type="text" name="q8_payment[addr_line2]" id="input_8_addr_line2" size="46" autocomplete="billing address-line2" />
                  <label class="form-sub-label" for="input_8_addr_line2" id="sublabel_8_addr_line2"> Street Address Line 2 </label></span>
              </td>
            </tr>
            <tr class="billing_address ">
              <td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-city" type="text" name="q8_payment[city]" id="input_8_city" autocomplete="billing address-level2" />
                  <label class="form-sub-label" for="input_8_city" id="sublabel_8_city"> City </label></span>
              </td>
              <td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q8_payment[state]" id="input_8_state" autocomplete="billing address-level1" />
                  <label class="form-sub-label" for="input_8_state" id="sublabel_8_state"> State / Province </label></span>
              </td>
            </tr>
            <tr class="billing_address ">
              <td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-postal" type="text" name="q8_payment[postal]" id="input_8_postal" size="10" autocomplete="billing postal-code" />
                  <label class="form-sub-label" for="input_8_postal" id="sublabel_8_postal"> Postal / Zip Code </label></span>
              </td>
              <td><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q8_payment[country]" id="input_8_country" autocomplete="billing country-name">
                    <option value="" selected="selected"> Please Select </option>
                    <option value="United States"> United States </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="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="The Bahamas"> The 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="Bosnia and Herzegovina"> Bosnia and Herzegovina </option>
                    <option value="Botswana"> Botswana </option>
                    <option value="Brazil"> Brazil </option>
                    <option value="Brunei"> Brunei </option>
                    <option value="Bulgaria"> Bulgaria </option>
                    <option value="Burkina Faso"> Burkina Faso </option>
                    <option value="Burundi"> Burundi </option>
                    <option value="Cambodia"> Cambodia </option>
                    <option value="Cameroon"> Cameroon </option>
                    <option value="Canada"> Canada </option>
                    <option value="Cape Verde"> Cape Verde </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="People's Republic of China"> People's Republic of China </option>
                    <option value="Republic of China"> Republic of China </option>
                    <option value="Christmas Island"> Christmas Island </option>
                    <option value="Cocos (Keeling) Islands"> Cocos (Keeling) Islands </option>
                    <option value="Colombia"> Colombia </option>
                    <option value="Comoros"> Comoros </option>
                    <option value="Congo"> Congo </option>
                    <option value="Cook Islands"> Cook Islands </option>
                    <option value="Costa Rica"> Costa Rica </option>
                    <option value="Cote d'Ivoire"> Cote d'Ivoire </option>
                    <option value="Croatia"> Croatia </option>
                    <option value="Cuba"> Cuba </option>
                    <option value="Cyprus"> Cyprus </option>
                    <option value="Czech Republic"> Czech Republic </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 Polynesia"> French Polynesia </option>
                    <option value="Gabon"> Gabon </option>
                    <option value="The Gambia"> The 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="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="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="North Korea"> North Korea </option>
                    <option value="South Korea"> South Korea </option>
                    <option value="Kosovo"> Kosovo </option>
                    <option value="Kuwait"> Kuwait </option>
                    <option value="Kyrgyzstan"> Kyrgyzstan </option>
                    <option value="Laos"> Laos </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="Macau"> Macau </option>
                    <option value="Macedonia"> Macedonia </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="Northern Mariana"> Northern Mariana </option>
                    <option value="Norway"> Norway </option>
                    <option value="Oman"> Oman </option>
                    <option value="Pakistan"> Pakistan </option>
                    <option value="Palau"> Palau </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 Islands"> Pitcairn Islands </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="Russia"> Russia </option>
                    <option value="Rwanda"> Rwanda </option>
                    <option value="Saint Barthelemy"> Saint Barthelemy </option>
                    <option value="Saint Helena"> Saint Helena </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="Slovakia"> Slovakia </option>
                    <option value="Slovenia"> Slovenia </option>
                    <option value="Solomon Islands"> Solomon Islands </option>
                    <option value="Somalia"> Somalia </option>
                    <option value="Somaliland"> Somaliland </option>
                    <option value="South Africa"> South Africa </option>
                    <option value="South Ossetia"> South Ossetia </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"> Svalbard </option>
                    <option value="Sweden"> Sweden </option>
                    <option value="Switzerland"> Switzerland </option>
                    <option value="Syria"> Syria </option>
                    <option value="Taiwan"> Taiwan </option>
                    <option value="Tajikistan"> Tajikistan </option>
                    <option value="Tanzania"> Tanzania </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="Tristan da Cunha"> Tristan da Cunha </option>
                    <option value="Tunisia"> Tunisia </option>
                    <option value="Turkey"> Turkey </option>
                    <option value="Turkmenistan"> Turkmenistan </option>
                    <option value="Turks and Caicos Islands"> Turks and Caicos Islands </option>
                    <option value="Tuvalu"> Tuvalu </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="Uruguay"> Uruguay </option>
                    <option value="Uzbekistan"> Uzbekistan </option>
                    <option value="Vanuatu"> Vanuatu </option>
                    <option value="Vatican City"> Vatican City </option>
                    <option value="Venezuela"> Venezuela </option>
                    <option value="Vietnam"> Vietnam </option>
                    <option value="British Virgin Islands"> British Virgin Islands </option>
                    <option value="US Virgin Islands"> US Virgin Islands </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="other"> Other </option>
                  </select>
                  <label class="form-sub-label" for="input_8_country" id="sublabel_8_country"> Country </label></span>
              </td>
          </tr></tbody></table>
        </div>
      </li>
      <li class="form-line" id="id_4">
        <div class="form-label-left form-label-hidden" id="label_4">
        </div>
        <div id="cid_4" class="form-input">
          <div class="form-single-column form-checkbox-item">
            <input name="optin" value="true" type="checkbox" checked="checked" class="form-checkbox" id="input_4" />
            <label id="label_input_4" for="input_4"> I would like to receive news and updates by email </label>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_2">
        <div id="cid_2" class="form-input-wide">
          <div style="text-align: center; text-indent:156px;" class="form-buttons-wrapper button-align-auto">
            <button id="input_2" type="submit" class="form-submit-button  form-submit-button-none;">
              Submit
            </button>
          </div>
        </div>
      </li>
      <li style="display:none">
        Should be Empty:
        <input type="text" name="website" value="" />
      </li>
    </ul>
  </div>
  <input type="hidden" id="simple_spc" name="simple_spc" value="5478885" />
  <script type="text/javascript">
  document.getElementById("si" + "mple" + "_spc").value = "5478885-5478885";
  </script>
<div>


<script>
	var recaptchaIsEnterprise = false;
		 var recaptchaV2Key = "6LcG_TcUAAAAAKAVgwgW39ujc9OCjXSoQYFIA-Su";

</script>

	<input type="hidden" class="js-recaptcha-input" name="cdo-captcha-response" value="" data-div-id="c91a714b-64ab-4d74-9198-b4a696661928" data-processed="false" />
	<div class="js-recaptcha-wrapper" id="c91a714b-64ab-4d74-9198-b4a696661928"></div>	
</div></form></div>
<div class="center small">
	<img valign="absbottom" src="https://w2.chabad.org/images/global/icons/lock.gif" width="16" height="16" alt="Secure"> This page uses TLS encryption to keep your data secure.
</div>
	<div class="break_floats"></div>
	

<div class="content-footer">
	<!-- END CACHE -->
	
	
	
	
	
</div>
	</article>

		</div>
	</div>


<script type="text/javascript" src="https://w2.chabad.org/scripts/js/os/jquery-latest.min.js?g=10&v=0293E3EC"></script>
<script type="text/javascript" src="https://w2.chabad.org/scripts/js/os/jquery/jquery.inputmask.min.js?g=10&v=BF33D3B4"></script>
<script type="text/javascript" src="https://w2.chabad.org/scripts/js/co/dist/CoLib.js?g=10&v=F809B22F"></script>
<script type="text/javascript" src="https://w2.chabad.org/scripts/js/WebComponents/bundles/magen-cdo-global.js?g=10&v=1A38CE64"></script>
<script type="text/javascript" src="https://w2.chabad.org/scripts/js/embededform.js?g=10&v=EC0310B1"></script>
<script type="text/javascript" src="https://w2.chabad.org/scripts/js/templates/sites6.js?g=10&v=E04072E1"></script>
<script type="text/javascript" src="https://w2.chabad.org/scripts/js/custom/multimedia/infolayer.js?g=10&v=ED1B8531"></script>
<script type="text/javascript" src="https://w2.chabad.org/scripts/js/templates/forms/userform.js?g=10&v=7F5B58AF"></script>
<script type="text/javascript" src="https://w2.chabad.org/scripts/js/custom/commentsloader.js?g=10&v=AD6AAB79"></script>
<script type="text/javascript" src="https://w2.chabad.org/scripts/js/templates/FormDecoder.js?g=10&v=83AF6F1A"></script>
<script type="text/javascript" src="https://w2.chabad.org/scripts/js/custom/deprecated.js?v=D506A83E&g=10"></script>
<script type="text/javascript" src="https://w2.chabad.org/scripts/js/OverrideJSDocumentWrite.js?g=10&v=9A0227AA"></script><script>$j = $j.fn ? $j : jQuery;$j(()=>{$q.forEach(f=>{try{f.call(window);}catch(ex){console.error(ex);}});})</script>
<script  language="javascript" type="text/javascript"> Co.Settings      = {CacheClassName:'js-cache-default',MosadName:'Chabad of Los Alamitos'}; Co.ArticleId     = '5478885';Co.SectionId     = 1821549;Co.PartnerSiteId = 0;Co.SiteId        = 23;Co.IsMobilePage  = false;Co.IsResponsive  = false;Co.DbDomain      = 'ChabadLosAl.com';Co.LanguageCode  = '';Co.LoginStatus   = 'None';</script>


</body>
</html>