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			<h1 class="article-header__title js-article-title js-page-title">Sell Your Chometz! </h1>
		
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$j(function(){
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window.formJson = Object.extend([{"form_height":450,"1_text":"Sell Your Chometz","1_subHeader":"","1_headerType":"Default","1_name":"clickTo","1_qid":1,"1_type":"control_head","1_order":1,"3_text":"\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" id=\"table5\" style=\"border: 1px dotted rgb(211, 211, 211);\" width=\"768\"\u003e\n\t\u003ctbody\u003e\n\t\t\u003ctr\u003e\n\t\t\t\u003ctd style=\"border: 1px dotted rgb(211, 211, 211);\" valign=\"top\" width=\"100%\"\u003e\n\t\t\t\u003cp\u003eSince it is prohibited to possess chometz on Pesach, any chometz left undisposed\u003cbr\u003e\n\t\t\tmust be sold to a non-Jew. [Any chometz remaining in the possession of a Jew during\u003cbr\u003e\n\t\t\tPesach may not be used, eaten, bought or sold even after Pesach.]\u003c/p\u003e\n\n\t\t\t\u003cp\u003eTherefore, all chometz that will not be eaten or burned before Pesach and all chometz\u003cbr\u003e\n\t\t\tutensils that will not be thoroughly cleaned by then should be stored away.\u003c/p\u003e\n\n\t\t\t\u003cp\u003eThe storage area should be locked or taped shut to be leased to the non-Jew at the\u003cbr\u003e\n\t\t\ttime of the chometz sale.\u003c/p\u003e\n\n\t\t\t\u003cp\u003eSince there are many legal intricacies in this sale, only a competent rabbi should be\u003cbr\u003e\n\t\t\tentrusted with its execution. The rabbi acts as our agent both to sell the chometz to\u003cbr\u003e\n\t\t\tthe non-Jew on the morning before Pesach starts and also to buy it back the evening\u003cbr\u003e\n\t\t\tafter Pesach ends.\u003c/p\u003e\n\n\t\t\t\u003ch2\u003eThe following form can be copied, modified, filled out, printed and submitted to the office\u003cbr\u003e\n\t\t\tNO LATER THAN\u0026#160;\u003cspan style=\"background-color:#e74c3c;\"\u003eTuesday, March 31st 12:00 PM.\u003c/span\u003e\u0026#160;If you are unable to submit your form\u003cbr\u003e\n\t\t\tto the office in person, you may submit your form online.\u003c/h2\u003e\n\t\t\t\u003c/td\u003e\n\t\t\u003c/tr\u003e\n\t\u003c/tbody\u003e\n\u003c/table\u003e\n","3_name":"doubleclickTo","3_qid":3,"3_type":"control_text","3_order":2,"4_text":"\u003ctable class=\"h3\" id=\"table8\" width=\"88%\" cellspacing=\"0\" cellpadding=\"6\" border=\"0\" bgcolor=\"#dddddd\" style=\"border: 1px dotted rgb(211, 211, 211); border-collapse: collapse;\"\u003e     \u003ctbody\u003e         \u003ctr\u003e             \u003ctd colspan=\"2\" height=\"19\" style=\"border: 1px dotted rgb(211, 211, 211);\"\u003e\u003cp\u003e\u003cu\u003e\u003cspan style=\"font-size: 16px;\"\u003e\u003cstrong\u003eDelegation of Power to Sell Chometz\u003c/strong\u003e\u003c/span\u003e\u003c/u\u003e\u003cspan style=\"font-size: 16px;\"\u003e\u003c/span\u003e\u003cspan style=\"\"\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan style=\"font-family: Arial;\"\u003e\u003cspan style=\"font-size: 14px;\"\u003eI the undersigned, fully empower and permit Rabbi Sholom Deitsch to act in my place and stead, and on my behalf to sell all chometz possessed by me, knowingly or unknowingly as defined by the Torah and Rabbinic Law (e.g. chometz, possible chometz, and all kind of chometz mixtures).\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan style=\"font-family: Arial;\"\u003e\u003cspan style=\"font-size: 14px;\"\u003eAlso chometz that tends to harden and adhere to inside surfaces of pans, pots, or cooking utensils, the utensils themselves, and all kinds of live animals and pets that have been eating chometz and mixtures thereof.\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan style=\"font-family: Arial;\"\u003e\u003cspan style=\"font-size: 14px;\"\u003eRabbi Sholom Deitsch is also empowered to lease all places wherein the chometz owned by me may be found, particularly at the address/es listed below, and elsewhere.\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan style=\"font-family: Arial;\"\u003e\u003cspan style=\"font-size: 14px;\"\u003eRabbi Sholom Deitsch has full right to appoint any agent or substitute in his stead and said substitute shall have full right to sell and lease as provided herein.\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan style=\"font-family: Arial;\"\u003e\u003cspan style=\"font-size: 14px;\"\u003eRabbi Sholom Deitsch also has the full power and right to act as he deems fit and proper in accordance with all the details of the Bill of Sale used in the transaction to sell all my chometz, chometz mixtures, etc., as provided herein. This power is in conformity with all Torah, Rabbinic and Civil laws.\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e         \u003c/tr\u003e     \u003c/tbody\u003e \u003c/table\u003e","4_name":"doubleclickTo4","4_qid":4,"4_type":"control_text","4_order":3,"5_text":"Full Name","5_message":"","5_labelAlign":"Auto","5_required":"Yes","5_prefix":"No","5_suffix":"No","5_middle":"No","5_description":"","5_sublabels":{"prefix":"Prefix","first":"First Name","middle":"Middle Name","last":"Last Name","suffix":"Suffix"},"5_readonly":"No","5_name":"fullName","5_qid":5,"5_type":"control_fullname","5_order":4,"6_text":"Address","6_message":"","6_labelAlign":"Auto","6_required":"Yes","6_selectedCountry":"","6_description":"","6_subfields":"st1|st2|city|state|zip|country","6_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"},"6_name":"address","6_qid":6,"6_type":"control_address","6_order":5,"10_text":"Phone Number","10_message":"","10_labelAlign":"Auto","10_required":"Yes","10_validation":"Numeric","10_countryCode":"No","10_inputMask":"disable","10_inputMaskValue":"(###) ###-####","10_description":"","10_sublabels":{"country":"Country Code","area":"Area Code","phone":"Phone Number","full":"Phone Number"},"10_readonly":"No","10_name":"phoneNumber","10_qid":10,"10_type":"control_phone","10_order":6,"7_receivesReceipts":"Yes","7_text":"E-mail","7_message":"","7_labelAlign":"Auto","7_required":"Yes","7_size":30,"7_validation":"Email","7_maxsize":"","7_defaultValue":"","7_subLabel":"","7_hint":"ex: myname@example.com","7_description":"","7_confirmation":"No","7_confirmationHint":"Confirm Email","7_readonly":"No","7_name":"email","7_qid":7,"7_type":"control_email","7_order":7,"8_text":"Optin","8_labelAlign":"Auto","8_description":"","8_required":"No","8_list":"-1","8_duplicatable":false,"8_name":"optin","8_qid":8,"8_type":"control_optin","8_order":8,"9_text":"Comments","9_message":"","9_labelAlign":"Auto","9_required":"No","9_cols":40,"9_rows":6,"9_validation":"None","9_entryLimit":"None-0","9_maxsize":"","9_defaultValue":"","9_subLabel":"","9_hint":"","9_description":"","9_readonly":"No","9_wysiwyg":"Disable","9_name":"input9","9_qid":9,"9_type":"control_textarea","9_order":9,"14_text":"\u003cp\u003e\u003cstrong\u003eIt is appropriate to make a donation when selling chometz.\u0026#160; 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<form class="userform-form" action="" method="post" name="form_7283011" id="7283011" accept-charset="utf-8"><input type="hidden" name="formID" value="7283011" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li id="cid_1" class="form-input-wide"> <div class="form-header-group"><h2 id="header_1" class="form-header">Sell Your Chometz</h2></div> </li><li class="form-line" id="id_3"><div id="cid_3" class="form-input-wide"> <div id="text_3" class="form-html"><table border="0" cellpadding="0" cellspacing="0" id="table5" style="border: 1px dotted rgb(211, 211, 211);" width="768">
        <tbody>
                <tr>
                        <td style="border: 1px dotted rgb(211, 211, 211);" valign="top" width="100%">
                        <p>Since it is prohibited to possess chometz on Pesach, any chometz left undisposed<br />
                        must be sold to a non-Jew. [Any chometz remaining in the possession of a Jew during<br />
                        Pesach may not be used, eaten, bought or sold even after Pesach.]</p>

                        <p>Therefore, all chometz that will not be eaten or burned before Pesach and all chometz<br />
                        utensils that will not be thoroughly cleaned by then should be stored away.</p>

                        <p>The storage area should be locked or taped shut to be leased to the non-Jew at the<br />
                        time of the chometz sale.</p>

                        <p>Since there are many legal intricacies in this sale, only a competent rabbi should be<br />
                        entrusted with its execution. The rabbi acts as our agent both to sell the chometz to<br />
                        the non-Jew on the morning before Pesach starts and also to buy it back the evening<br />
                        after Pesach ends.</p>

                        <h2>The following form can be copied, modified, filled out, printed and submitted to the office<br />
                        NO LATER THAN <span style="background-color:#e74c3c;">Tuesday, March 31st 12:00 PM.</span> If you are unable to submit your form<br />
                        to the office in person, you may submit your form online.</h2>
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</div> </div></li><li class="form-line" id="id_4"><div id="cid_4" class="form-input-wide"> <div id="text_4" class="form-html"><table class="h3" id="table8" width="88%" cellspacing="0" cellpadding="6" border="0" bgcolor="#dddddd" style="border: 1px dotted rgb(211, 211, 211); border-collapse: collapse;">     <tbody>         <tr>             <td colspan="2" height="19" style="border: 1px dotted rgb(211, 211, 211);"><p><u><span style="font-size: 16px;"><strong>Delegation of Power to Sell Chometz</strong></span></u><span style="font-size: 16px;"></span><span style=""></span></p><p><span style="font-family: Arial;"><span style="font-size: 14px;">I the undersigned, fully empower and permit Rabbi Sholom Deitsch to act in my place and stead, and on my behalf to sell all chometz possessed by me, knowingly or unknowingly as defined by the Torah and Rabbinic Law (e.g. chometz, possible chometz, and all kind of chometz mixtures).</span></span></p><p><span style="font-family: Arial;"><span style="font-size: 14px;">Also chometz that tends to harden and adhere to inside surfaces of pans, pots, or cooking utensils, the utensils themselves, and all kinds of live animals and pets that have been eating chometz and mixtures thereof.</span></span></p><p><span style="font-family: Arial;"><span style="font-size: 14px;">Rabbi Sholom Deitsch is also empowered to lease all places wherein the chometz owned by me may be found, particularly at the address/es listed below, and elsewhere.</span></span></p><p><span style="font-family: Arial;"><span style="font-size: 14px;">Rabbi Sholom Deitsch has full right to appoint any agent or substitute in his stead and said substitute shall have full right to sell and lease as provided herein.</span></span></p><p><span style="font-family: Arial;"><span style="font-size: 14px;">Rabbi Sholom Deitsch also has the full power and right to act as he deems fit and proper in accordance with all the details of the Bill of Sale used in the transaction to sell all my chometz, chometz mixtures, etc., as provided herein. This power is in conformity with all Torah, Rabbinic and Civil laws.</span></span></p></td>         </tr>     </tbody> </table></div> </div></li><li class="form-line" id="id_5"><div class="form-label-left" id="label_5"><label for="input_5"> Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_5"> </label></div><div id="cid_5" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q5_fullName[first]" id="first_5" autocomplete="given-name" />  <label class="form-sub-label" for="first_5" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q5_fullName[last]" id="last_5" autocomplete="family-name" />  <label class="form-sub-label" for="last_5" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_6"><div class="form-label-left" id="label_6"><label for="input_6"> Address<span class="form-required">*</span> </label><label class="label-message" for="input_6"> </label></div><div id="cid_6" 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="q6_address[addr_line1]" id="input_6_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_6_addr_line1" id="sublabel_6_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="q6_address[addr_line2]" id="input_6_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_6_addr_line2" id="sublabel_6_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="q6_address[city]" id="input_6_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_6_city" id="sublabel_6_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q6_address[state]" id="input_6_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_6_state" id="sublabel_6_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="q6_address[postal]" id="input_6_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_6_postal" id="sublabel_6_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q6_address[country]" id="input_6_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 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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 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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_6_country" id="sublabel_6_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_10"><div class="form-label-left" id="label_10"><label for="input_10"> Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_10"> </label></div><div id="cid_10" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q10_phoneNumber[area]" id="input_10_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_10_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q10_phoneNumber[phone]" id="input_10_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_10_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_7"><div class="form-label-left" id="label_7"><label for="input_7"> E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_7"> </label></div><div id="cid_7" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_7" name="q7_email" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_8"><div class="form-label-left form-label-hidden" id="label_8"></div><div id="cid_8" 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_8" /><label id="label_input_8" for="input_8">I would like to receive news and updates by email</label></div> </div></li><li class="form-line" id="id_9"><div class="form-label-left" id="label_9"><label for="input_9"> Comments </label><label class="label-message" for="input_9"> </label></div><div id="cid_9" class="form-input"> <textarea id="input_9" class="form-textarea" name="q9_input9" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_14"><div id="cid_14" class="form-input-wide"> <div id="text_14" class="form-html"><p><strong>It is appropriate to make a donation when selling chometz.  Please consider making a donation at this time.</strong></p></div> </div></li><li class="form-line" id="id_12"><div class="form-label-left" id="label_12"><label for="input_12"> Donation </label><label class="label-message" for="input_12"> </label></div><div id="cid_12" class="form-input"> <div class="form-multiple-column" data-columns="2"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_12_0" name="q12_input12" value="18" /><label for="input_12_0"><span>$18</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_12_1" name="q12_input12" value="36" /><label for="input_12_1"><span>$36</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_12_2" name="q12_input12" value="54" /><label for="input_12_2"><span>$54</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_12_3" name="q12_input12" value="72" /><label for="input_12_3"><span>$72</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_12_4" name="q12_input12" value="90" /><label for="input_12_4"><span>$90</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_12_5" name="q12_input12" value="118" /><label for="input_12_5"><span>$118</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_12_6" name="q12_input12" value="180" /><label for="input_12_6"><span>$180</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_12_7" name="q12_input12" value="360" /><label for="input_12_7"><span>$360</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_12_8" name="q12_input12" value="540" /><label for="input_12_8"><span>$540</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_12_9" name="q12_input12" value="1000" /><label for="input_12_9"><span>$1000</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_12_10" name="q12_input12" value="1800" /><label for="input_12_10"><span>$1800</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio-other form-radio" name="q12_input12" id="other_12" value="" /><span><input type="number" min="1" class="form-radio-other-input form-textbox" onkeypress="validateNumber(event)" name="q12_input12[other]" data-otherhint="Other" size="15" id="input_12" disabled="disabled" /></span><br /></span></div> </div></li><li class="form-line" id="id_13"><div class="form-label-left" id="label_13"><label for="input_13"> Total </label></div><div id="cid_13" class="form-input"> <div id="total_amount">$0.00 </div> </div></li><li class="form-line" id="id_11"><div class="form-label-left" id="label_11"><label for="input_11"> Payment </label><label class="label-message" for="input_11"> </label></div><div id="cid_11" 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">  <label class="form-sub-label">We accept Visa, MasterCard, American Express, Discover</label></span><div class="cc-icons"><div class="cc-icon visa-icon"></div><div class="cc-icon mastercard-icon"></div><div class="cc-icon amex-icon"></div><div class="cc-icon discover-icon"></div></div><input type="hidden" name="q11_payment[cc_type]" id="input_11_cc_type" value="" /></td></tr><tr><td><div 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="q11_payment[cc_number]" id="input_11_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_11_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="q11_payment[cc_ccv]" id="input_11_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_11_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="q11_payment[cc_nameOnCard]" id="input_11_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_11_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="q11_payment[cc_exp_month]" id="input_11_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_11_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="q11_payment[cc_exp_year]" id="input_11_cc_exp_year" autocomplete="cc-exp-year"><option></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></select>  <label class="form-sub-label" for="input_11_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="q11_payment[addr_line1]" id="input_11_addr_line1" autocomplete="billing address-line1" />  <label class="form-sub-label" for="input_11_addr_line1" id="sublabel_11_addr_line1">Street Address</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="q11_payment[city]" id="input_11_city" autocomplete="billing address-level2" />  <label class="form-sub-label" for="input_11_city" id="sublabel_11_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q11_payment[state]" id="input_11_state" autocomplete="billing address-level1" />  <label class="form-sub-label" for="input_11_state" id="sublabel_11_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="q11_payment[postal]" id="input_11_postal" size="10" autocomplete="billing postal-code" />  <label class="form-sub-label" for="input_11_postal" id="sublabel_11_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q11_payment[country]" id="input_11_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_11_country" id="sublabel_11_country">Country</label></span></td></tr></tbody></table> </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> 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