{"id":26804,"date":"2022-12-09T10:38:28","date_gmt":"2022-12-09T10:38:28","guid":{"rendered":"https:\/\/selfhelpafrica.org\/ie\/?page_id=26804"},"modified":"2025-04-03T16:53:46","modified_gmt":"2025-04-03T15:53:46","slug":"donate-direct-debit","status":"publish","type":"page","link":"https:\/\/selfhelpafrica.org\/ie\/donate-direct-debit\/","title":{"rendered":"Donate-Direct-Debit"},"content":{"rendered":"<div id=\"cs-content\" class=\"cs-content\"><div class=\"x-section e26804-e1 mkok-0\"><div class=\"x-row x-container max width e26804-e2 mkok-1 mkok-2\"><div class=\"x-row-inner\"><div class=\"x-col e26804-e3 mkok-3\"><a class=\"x-image e26804-e4 mkok-4\" href=\"https:\/\/selfhelpafrica.org\/ie\/\"><img decoding=\"async\" src=\"https:\/\/selfhelpafrica.org\/ie\/wp-content\/uploads\/sites\/4\/2025\/03\/Self-Help-Africa_Logo_small-web.png\" width=\"180\" height=\"57\" alt=\"Image\"><\/a><\/div><\/div><\/div><\/div><div id=\"x-section-1\" class=\"x-section bg-image\" style=\"margin: 0px;padding: 00px 0px; background-image: url(https:\/\/selfhelpafrica.org\/ie\/wp-content\/uploads\/sites\/4\/2019\/03\/angella-donation-page.jpg); background-color: transparent;\" data-x-element=\"section\" data-x-params=\"{&quot;type&quot;:&quot;image&quot;,&quot;parallax&quot;:false}\"><div id=\"\" class=\"x-container\" style=\"margin: 0px auto;padding: 0px;background: rgba(0, 0, 0, 0) linear-gradient(rgba(0, 0, 0, 0) 0%, rgba(0, 0, 0, .15) 70%, #000 140%) repeat scroll 0 center !important;\" ><div  class=\"x-column x-sm x-1-1\" style=\"padding: 10% 20px 4%;\" ><hr  class=\"x-gap\" style=\"margin: 150px 0 0 0;\"><h1  class=\"h-custom-headline cs-ta-center man h1\" style=\"text-shadow: 0px 0px 8px #000;\"><span><font color=\"#fff\">New Monthly Donation<\/font><\/span><\/h1><hr  class=\"x-hr\" style=\"border-color: #dab525; border-width: 10px;   margin:  17px auto 12px auto; width:20%;border-top-width: 1px;width: 100%;\"><hr class=\"x-line e26804-e11 mkok-5\"\/><\/div><\/div><\/div><div id=\"x-section-2\" class=\"x-section cs-ta-center\" style=\"margin: 0px;padding: 45px 0px 5px;max-width:900px; margin:auto; background-color: transparent;\" ><div id=\"\" class=\"x-container max width\" style=\"margin: 0px auto 30px;padding: 0px 5%;\" ><div  class=\"x-column x-sm x-1-1\" style=\"padding: 0px;max-width:1200px; margin:auto;\" ><div id=\"\" class=\"x-text\" style=\"\" ><p class=\"p-sans-large\">Thank you for setting up a new recurring donation. Your donations enable Self Help Africa to help families across rural Africa to escape from hunger and poverty.<\/p>\n<\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var 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action='\/ie\/wp-json\/wp\/v2\/pages\/26804\/#gf_98' data-formid='98' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_98' class='gform_fields top_label form_sublabel_above description_above validation_below'><li id=\"field_98_56\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_98_56'>Name<\/label><div class='gfield_description' id='gfield_description_98_56'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_56' id='input_98_56' type='text' value='' autocomplete='new-password'\/><\/div><\/li><li id=\"field_98_49\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><hr><\/li><li id=\"field_98_35\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio opt gfield_price gfield_price_98_35 gfield_product_98_35 gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Your Monthly Donation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_98_35'>\n\t\t\t<li class='gchoice gchoice_98_35_0'>\n\t\t\t\t<input name='input_35' type='radio' value='\u20ac10|10'  id='choice_98_35_0' tabindex='1'   \/>\n\t\t\t\t<label for='choice_98_35_0' id='label_98_35_0' class='gform-field-label gform-field-label--type-inline'>\u20ac10<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_98_35_1'>\n\t\t\t\t<input name='input_35' type='radio' value='\u20ac21|21' checked='checked' id='choice_98_35_1' tabindex='2'   \/>\n\t\t\t\t<label for='choice_98_35_1' id='label_98_35_1' class='gform-field-label gform-field-label--type-inline'>\u20ac21<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_98_35_2'>\n\t\t\t\t<input name='input_35' type='radio' value='\u20ac35|35'  id='choice_98_35_2' tabindex='3'   \/>\n\t\t\t\t<label for='choice_98_35_2' id='label_98_35_2' class='gform-field-label gform-field-label--type-inline'>\u20ac35<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_98_35_3'>\n\t\t\t\t<input name='input_35' type='radio' value='\u20ac100|100'  id='choice_98_35_3' tabindex='4'   \/>\n\t\t\t\t<label for='choice_98_35_3' id='label_98_35_3' class='gform-field-label gform-field-label--type-inline'>\u20ac100<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_98_35_4'>\n\t\t\t\t<input name='input_35' type='radio' value='add your own amount|0'  id='choice_98_35_4' tabindex='5'   \/>\n\t\t\t\t<label for='choice_98_35_4' id='label_98_35_4' class='gform-field-label gform-field-label--type-inline'>add your own amount<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_98_2\" class=\"gfield gfield--type-product gfield--input-type-price opt gfield_price gfield_price_98_2 gfield_product_98_2 gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_98_2'>Enter amount you wish to donate monthly<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_product_price'>\n\t\t\t\t\t<input name='input_2' id='input_98_2' type='text' value='' class='medium ginput_amount' tabindex='6' placeholder='\u20ac' aria-required=\"true\" aria-invalid=\"false\"  \/>\n\t\t\t\t<\/div><\/li><li id=\"field_98_25\" class=\"gfield gfield--type-name gfield--input-type-name newt topline field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Direct Debit Mandate (SEPA)<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_98_25'>\n                            \n                            <span id='input_98_25_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_98_25_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_25.3' id='input_98_25_3' value='' tabindex='8'  aria-required='false'   placeholder='First name'  \/>\n                                                <\/span>\n                            \n                            <span id='input_98_25_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_98_25_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_25.6' id='input_98_25_6' value='' tabindex='10'  aria-required='false'   placeholder='Last name'  \/>\n                                                        <\/span>\n                            \n                        <\/div><\/li><li id=\"field_98_33\" class=\"gfield gfield--type-text gfield--input-type-text notitle field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_98_33'>Date of Birth<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_98_33' type='text' value='' class='large'   tabindex='12' placeholder='Date of Birth'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_98_28\" class=\"gfield gfield--type-text gfield--input-type-text notitle gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_98_28'>Account Number - IBAN<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_98_28' type='text' value='' class='large'   tabindex='13' placeholder='Account Number - IBAN' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_98_29\" class=\"gfield gfield--type-text gfield--input-type-text notitle gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_98_29'>Bank Identifier Code - BIC<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_98_29' type='text' value='' class='large'   tabindex='14' placeholder='Bank Identifier Code - BIC' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_98_5\" class=\"gfield gfield--type-email gfield--input-type-email notitle gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_98_5'>Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_98_5' type='email' value='' class='large' tabindex='15'  placeholder='Email address' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_98_27\" class=\"gfield gfield--type-address gfield--input-type-address opt gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Your address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state ginput_container_address gform-grid-row' id='input_98_27' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_98_27_1_container' >\n                                        <label for='input_98_27_1' id='input_98_27_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_27.1' id='input_98_27_1' value='' tabindex='16'  placeholder='Street Address' aria-required='true'    \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_98_27_2_container' >\n                                        <label for='input_98_27_2' id='input_98_27_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                        <input type='text' name='input_27.2' id='input_98_27_2' value='' tabindex='17'  placeholder='Address Line 2'  aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_98_27_3_container' >\n                                    <label for='input_98_27_3' id='input_98_27_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_27.3' id='input_98_27_3' value='' tabindex='18'  placeholder='City\/Town' aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_98_27_4_container' >\n                                        <label for='input_98_27_4' id='input_98_27_4_label' class='gform-field-label gform-field-label--type-sub '>County \/ State \/ Region<\/label>\n                                        <input type='text' name='input_27.4' id='input_98_27_4' value='' tabindex='20'    placeholder='County\/State' aria-required='true'    \/>\n                                      <\/span><input type='hidden' class='gform_hidden' name='input_27.6' id='input_98_27_6' value='Ireland' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_98_31\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio opt yn gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Is there more than one signatory required to sign on this account?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_98_31'>\n\t\t\t<li class='gchoice gchoice_98_31_0'>\n\t\t\t\t<input name='input_31' type='radio' value='Yes'  id='choice_98_31_0' tabindex='22'   \/>\n\t\t\t\t<label for='choice_98_31_0' id='label_98_31_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_98_31_1'>\n\t\t\t\t<input name='input_31' type='radio' value='No' checked='checked' id='choice_98_31_1' tabindex='23'   \/>\n\t\t\t\t<label for='choice_98_31_1' id='label_98_31_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_98_32\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio opt yn gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Can this bank account accept direct debits?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_98_32'>\n\t\t\t<li class='gchoice gchoice_98_32_0'>\n\t\t\t\t<input name='input_32' type='radio' value='Yes' checked='checked' id='choice_98_32_0' tabindex='24'   \/>\n\t\t\t\t<label for='choice_98_32_0' id='label_98_32_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_98_32_1'>\n\t\t\t\t<input name='input_32' type='radio' value='No'  id='choice_98_32_1' tabindex='25'   \/>\n\t\t\t\t<label for='choice_98_32_1' id='label_98_32_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_98_21\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_98_21'>Comments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_21' id='input_98_21' class='textarea medium' tabindex='26'   placeholder='Comments'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_98_34\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div id=\"my-accordion\" class=\"x-accordion\" > <div  class=\"x-accordion-group\" ><div class=\"x-accordion-heading\"><a id=\"tab-69ff7c7a15c0e\" class=\"x-accordion-toggle collapsed\" role=\"tab\" data-x-toggle=\"collapse-b\" data-x-toggleable=\"69ff7c7a15c0e\" data-x-toggle-group=\"my-accordion\" aria-selected=\"false\" aria-expanded=\"false\" aria-controls=\"panel-69ff7c7a15c0e\"><i class='x-framework-icon x-shortcode-accordion-icon' data-x-icon-s='&#x2b;' aria-hidden=true><\/i><span>Direct Debit Legal Information<\/span><\/a><\/div><div id=\"panel-69ff7c7a15c0e\" class=\"x-accordion-body x-collapsed\" role=\"tabpanel\" data-x-toggle-collapse=\"1\" data-x-toggleable=\"69ff7c7a15c0e\" aria-hidden=\"true\" aria-labelledby=\"tab-69ff7c7a15c0e\"><div class=\"x-accordion-inner\">\n<p>Self Help Africa<br>\n4th Floor, Joyce\u2019s Court,<br>\n38 Talbot Street, Dublin 1.<br>\nD01 C861<br>\nIdentifier of the Creditor: IE23ZZZ303228<\/p>\n\n<p>By submitting this mandate form, you authorise (A) Self Help Africa (Gorta) to send instructions to your bank to debit your account and (B) to your bank debit your account in accordance with the instructions from Self Help Africa (Gorta).<\/p>\n\n<p>As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with your bank. A refund must be claimed within 8 weeks starting from the date on which your account was debited. Your rights are explained in a statement that you can obtain from your bank.<\/p>\n\n<\/div><\/div><\/div><\/div><\/li><li id=\"field_98_53\" class=\"gfield gfield--type-total gfield--input-type-total gfield--width-full gfield_price gfield_price_98_ gfield_total gfield_total_98_ field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  aria-atomic=\"true\" aria-live=\"polite\" ><label class='gfield_label gform-field-label' for='input_98_53'>Total<\/label><div class='ginput_container ginput_container_total'>\n\t\t\t\t\t\t\t<span class='ginput_total ginput_total_98'>&#8364; 0.00<\/span>\n\t\t\t\t\t\t\t<input type='hidden' name='input_53' id='input_98_53' class='gform_hidden'\/>\n\t\t\t\t\t\t<\/div><\/li><li id=\"field_98_45\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >We would like to keep you updated on the impact of your donations, our fundraising campaigns and events in your area. Simply let us know if we may contact you:<\/li><li id=\"field_98_54\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_above gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Contact Preferences<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_98_54'><li class='gchoice gchoice_98_54_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.1' type='checkbox'  value='By Email'  id='choice_98_54_1' tabindex='27'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_98_54_1' id='label_98_54_1' class='gform-field-label gform-field-label--type-inline'>By Email<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_98_54_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.2' type='checkbox'  value='By Post'  id='choice_98_54_2' tabindex='28'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_98_54_2' id='label_98_54_2' class='gform-field-label gform-field-label--type-inline'>By Post<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_98_54_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.3' type='checkbox'  value='By Phone'  id='choice_98_54_3' tabindex='29'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_98_54_3' id='label_98_54_3' class='gform-field-label gform-field-label--type-inline'>By Phone<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_98_54_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.4' type='checkbox'  value='Already on Mailing List'  id='choice_98_54_4' tabindex='30'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_98_54_4' id='label_98_54_4' class='gform-field-label gform-field-label--type-inline'>Already on Mailing List<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_98_4\" class=\"gfield gfield--type-text gfield--input-type-text notitle field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_98_4'>Contact phone number<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_98_4' type='text' value='' class='large'   tabindex='31' placeholder='Contact phone number'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_98_47\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_98_47' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_98_47_1_container' >\n                                        <label for='input_98_47_1' id='input_98_47_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_47.1' id='input_98_47_1' value='' tabindex='32'   aria-required='false'    \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_98_47_2_container' >\n                                        <label for='input_98_47_2' id='input_98_47_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                        <input type='text' name='input_47.2' id='input_98_47_2' value='' tabindex='33'    aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_98_47_3_container' >\n                                    <label for='input_98_47_3' id='input_98_47_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_47.3' id='input_98_47_3' value='' tabindex='34'   aria-required='false'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_98_47_4_container' >\n                                        <label for='input_98_47_4' id='input_98_47_4_label' class='gform-field-label gform-field-label--type-sub '>County \/ State \/ Region<\/label>\n                                        <input type='text' name='input_47.4' id='input_98_47_4' value='' tabindex='36'     aria-required='false'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_98_47_5_container' >\n                                    <label for='input_98_47_5' id='input_98_47_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                    <input type='text' name='input_47.5' id='input_98_47_5' value='' tabindex='37'   aria-required='false'    \/>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_98_47_6_container' >\n                                        <label for='input_98_47_6' id='input_98_47_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                        <select name='input_47.6' id='input_98_47_6' tabindex='38'  aria-required='false'    ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='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='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' selected='selected'>Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option 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