{"id":745,"date":"2021-11-09T12:07:12","date_gmt":"2021-11-09T16:07:12","guid":{"rendered":"https:\/\/fase1.org\/registrate\/"},"modified":"2022-12-22T10:42:47","modified_gmt":"2022-12-22T14:42:47","slug":"registrate","status":"publish","type":"page","link":"https:\/\/fase1.org\/en\/registrate\/","title":{"rendered":"Register"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_section full_width=&#8221;stretch_row&#8221; el_class=&#8221;dash-bg-01&#8243; el_id=&#8221;registrate_heading&#8221;][vc_row css=&#8221;.vc_custom_1636054214344{padding-top: 24px !important;padding-bottom: 40px !important;background-color: #00123a !important;background-position: center !important;background-repeat: no-repeat !important;background-size: cover !important;border-radius: 20px !important;}&#8221; el_id=&#8221;como-funciona-blue-box&#8221;][vc_column][vc_column_text css=&#8221;.vc_custom_1658842115858{margin-top: 0px !important;margin-bottom: 0px !important;}&#8221; el_class=&#8221;white&#8221;]<\/p>\n<h1 style=\"text-align: center;\">Register<\/h1>\n<p>[\/vc_column_text][vc_column_text css=&#8221;.vc_custom_1671718894149{margin-top: 0px !important;margin-bottom: 0px !important;padding-right: 10px !important;padding-left: 10px !important;}&#8221; el_class=&#8221;white&#8221; el_id=&#8221;main-page-heading-description&#8221;]<\/p>\n<p style=\"text-align: center;\">You\u2019re about to start Fase1! Complete the form and you will be closer to the starting point.<\/p>\n<p>[\/vc_column_text][\/vc_column][\/vc_row][\/vc_section][vc_section full_width=&#8221;stretch_row&#8221; el_class=&#8221;dash-bump-01&#8243;][vc_row equal_height=&#8221;yes&#8221; content_placement=&#8221;middle&#8221; css=&#8221;.vc_custom_1636120801031{margin-top: 50px !important;margin-bottom: 50px !important;padding-top: 24px !important;padding-bottom: 24px !important;}&#8221; el_class=&#8221;lab-border-outline-row&#8221;][vc_column][vc_empty_space height=&#8221;44px&#8221;]<script>\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 d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_10' style='display:none'>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_custom\">* Required field<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_10'  action='\/en\/wp-json\/wp\/v2\/pages\/745' data-formid='10' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_10' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_10_178\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_178'>Name<\/label><div class='ginput_container'><input name='input_178' id='input_10_178' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_10_178'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_10_1\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  >\u00a1Est\u00e1s a punto de comenzar en Fase 1! Completa el formulario y estar\u00e1s m\u00e1s cerca del punto de partida. <\/div><div id=\"field_10_65\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_65'>Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_10_65' type='text' value='' class='large'    placeholder='Name' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_66\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_66'>First last name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_10_66' type='text' value='' class='large'    placeholder='First last name' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_67\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_67'>Second last name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_10_67' type='text' value='' class='large'    placeholder='Second last name' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_3\" class=\"gfield gfield--type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_3'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_10_3' type='email' value='' class='large'   placeholder='Email' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_10_4\" class=\"gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_4'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_10_4' type='tel' value='' class='large'  placeholder='Phone' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_135\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_135'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_135' id='input_10_135' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='Date of Birth' aria-describedby=\"input_10_135_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_135_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_135' class='gform_hidden' value='https:\/\/fase1.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_22\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_22'>Last four digits of your social security number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_10_22' type='text' value='' class='large'    placeholder='Last four digits of your social security number' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you a resident of Puerto Rico?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_23'>\n\t\t\t<div class='gchoice gchoice_10_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='S\u00ed'  id='choice_10_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_23_0' id='label_10_23_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_10_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_23_1' id='label_10_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_68\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Were you a resident of Puerto Rico at the time of hurricanes Irma and Maria?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_68'>\n\t\t\t<div class='gchoice gchoice_10_68_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='S\u00ed'  id='choice_10_68_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_68_0' id='label_10_68_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_68_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='No'  id='choice_10_68_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_68_1' id='label_10_68_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_70\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_70'>If not, please explain:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_70' id='input_10_70' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_10_120\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>Physical address<\/strong><\/div><div id=\"field_10_113\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_113'>Physical address - Line 1<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_113' id='input_10_113' type='text' value='' class='large'    placeholder='Address line 1' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_115\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_115'>Physical address - Line 2<\/label><div class='ginput_container ginput_container_text'><input name='input_115' id='input_10_115' type='text' value='' class='large'    placeholder='Address line 2'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_117\" class=\"gfield gfield--type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_117'>Physical address - City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_117' id='input_10_117' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>City<\/option><option value='Adjuntas' >Adjuntas<\/option><option value='Aguada' >Aguada<\/option><option value='Aguadilla' >Aguadilla<\/option><option value='Aguas Buenas' >Aguas Buenas<\/option><option value='Aibonito' >Aibonito<\/option><option value='Arecibo' >Arecibo<\/option><option value='Arroyo' >Arroyo<\/option><option value='A\u00f1asco' >A\u00f1asco<\/option><option value='Barceloneta' >Barceloneta<\/option><option value='Barranquitas' >Barranquitas<\/option><option value='Bayam\u00f3n' >Bayam\u00f3n<\/option><option value='Cabo Rojo' >Cabo Rojo<\/option><option value='Caguas' >Caguas<\/option><option value='Camuy' >Camuy<\/option><option value='Can\u00f3vanas' >Can\u00f3vanas<\/option><option value='Carolina' >Carolina<\/option><option value='Cata\u00f1o' >Cata\u00f1o<\/option><option value='Cayey' >Cayey<\/option><option value='Ceiba' >Ceiba<\/option><option value='Ciales' >Ciales<\/option><option value='Cidra' >Cidra<\/option><option value='Coamo' >Coamo<\/option><option value='Comer\u00edo' >Comer\u00edo<\/option><option value='Corozal' >Corozal<\/option><option value='Culebra' >Culebra<\/option><option value='Dorado' >Dorado<\/option><option value='Fajardo' >Fajardo<\/option><option value='Florida' >Florida<\/option><option value='Guayama' >Guayama<\/option><option value='Guayanilla' >Guayanilla<\/option><option value='Guaynabo' >Guaynabo<\/option><option value='Gurabo' >Gurabo<\/option><option value='Gu\u00e1nica' >Gu\u00e1nica<\/option><option value='Hatillo' >Hatillo<\/option><option value='Hormigueros' >Hormigueros<\/option><option value='Humacao' >Humacao<\/option><option value='Isabela' >Isabela<\/option><option value='Jayuya' >Jayuya<\/option><option value='Juana D\u00edaz' >Juana D\u00edaz<\/option><option value='Juncos' >Juncos<\/option><option value='Lajas' >Lajas<\/option><option value='Lares' >Lares<\/option><option value='Las Mar\u00edas' >Las Mar\u00edas<\/option><option value='Las Piedras' >Las Piedras<\/option><option value='Loiza' >Loiza<\/option><option value='Luquillo' >Luquillo<\/option><option value='Manat\u00ed' >Manat\u00ed<\/option><option value='Maricao' >Maricao<\/option><option value='Maunabo' >Maunabo<\/option><option value='Mayag\u00fcez' >Mayag\u00fcez<\/option><option value='Moca' >Moca<\/option><option value='Morovis' >Morovis<\/option><option value='Naguabo' >Naguabo<\/option><option value='Naranjito' >Naranjito<\/option><option value='Orocovis' >Orocovis<\/option><option value='Patillas' >Patillas<\/option><option value='Pe\u00f1uelas' >Pe\u00f1uelas<\/option><option value='Ponce' >Ponce<\/option><option value='Quebradillas' >Quebradillas<\/option><option value='Rinc\u00f3n' >Rinc\u00f3n<\/option><option value='Rio Grande' >Rio Grande<\/option><option value='Sabana Grande' >Sabana Grande<\/option><option value='Salinas' >Salinas<\/option><option value='San Germ\u00e1n' >San Germ\u00e1n<\/option><option value='San Juan' >San Juan<\/option><option value='San Lorenzo' >San Lorenzo<\/option><option value='San Sebasti\u00e1n' >San Sebasti\u00e1n<\/option><option value='Santa Isabel' >Santa Isabel<\/option><option value='Toa Alta' >Toa Alta<\/option><option value='Toa Baja' >Toa Baja<\/option><option value='Trujillo Alto' >Trujillo Alto<\/option><option value='Utuado' >Utuado<\/option><option value='Vega Alta' >Vega Alta<\/option><option value='Vega Baja' >Vega Baja<\/option><option value='Vieques' >Vieques<\/option><option value='Villalba' >Villalba<\/option><option value='Yabucoa' >Yabucoa<\/option><option value='Yauco' >Yauco<\/option><\/select><\/div><\/div><div id=\"field_10_118\" class=\"gfield gfield--type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_118'>Physical address - State<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_118' id='input_10_118' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>State<\/option><option value='PR' >Puerto Rico<\/option><\/select><\/div><\/div><div id=\"field_10_119\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_119'>Physical address - Zip code<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_119' id='input_10_119' type='text' value='' class='large'    placeholder='Zip code' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_121\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>Mailing address<\/strong><\/div><fieldset id=\"field_10_123\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full copy-113-to-124 copy-115-to-125 copy-117-to-126 copy-118-to-127 copy-119-to-128 gwcopy field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address - Check here if it&#039;s the same as the physical address<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_123'><div class='gchoice gchoice_10_123_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.1' type='checkbox'  value='Check here if it&#039;s the same as the physical address'  id='choice_10_123_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_123_1' id='label_10_123_1' class='gform-field-label gform-field-label--type-inline'>Check here if it's the same as the physical address<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_124\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_124'>Mailing address - Line 1<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_124' id='input_10_124' type='text' value='' class='large'    placeholder='Address line 1' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_125\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_125'>Mailing address - Line 2<\/label><div class='ginput_container ginput_container_text'><input name='input_125' id='input_10_125' type='text' value='' class='large'    placeholder='Address line 2'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_126\" class=\"gfield gfield--type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_126'>Mailing address - City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_126' id='input_10_126' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>City<\/option><option value='Adjuntas' >Adjuntas<\/option><option value='Aguada' >Aguada<\/option><option value='Aguadilla' >Aguadilla<\/option><option value='Aguas Buenas' >Aguas Buenas<\/option><option value='Aibonito' >Aibonito<\/option><option value='Arecibo' >Arecibo<\/option><option value='Arroyo' >Arroyo<\/option><option value='A\u00f1asco' >A\u00f1asco<\/option><option value='Barceloneta' >Barceloneta<\/option><option value='Barranquitas' >Barranquitas<\/option><option value='Bayam\u00f3n' >Bayam\u00f3n<\/option><option value='Cabo Rojo' >Cabo Rojo<\/option><option value='Caguas' >Caguas<\/option><option value='Camuy' >Camuy<\/option><option value='Can\u00f3vanas' >Can\u00f3vanas<\/option><option value='Carolina' >Carolina<\/option><option value='Cata\u00f1o' >Cata\u00f1o<\/option><option value='Cayey' >Cayey<\/option><option value='Ceiba' >Ceiba<\/option><option value='Ciales' >Ciales<\/option><option value='Cidra' >Cidra<\/option><option value='Coamo' >Coamo<\/option><option value='Comer\u00edo' >Comer\u00edo<\/option><option value='Corozal' >Corozal<\/option><option value='Culebra' >Culebra<\/option><option value='Dorado' >Dorado<\/option><option value='Fajardo' >Fajardo<\/option><option value='Florida' >Florida<\/option><option value='Guayama' >Guayama<\/option><option value='Guayanilla' >Guayanilla<\/option><option value='Guaynabo' >Guaynabo<\/option><option value='Gurabo' >Gurabo<\/option><option value='Gu\u00e1nica' >Gu\u00e1nica<\/option><option value='Hatillo' >Hatillo<\/option><option value='Hormigueros' >Hormigueros<\/option><option value='Humacao' >Humacao<\/option><option value='Isabela' >Isabela<\/option><option value='Jayuya' >Jayuya<\/option><option value='Juana D\u00edaz' >Juana D\u00edaz<\/option><option value='Juncos' >Juncos<\/option><option value='Lajas' >Lajas<\/option><option value='Lares' >Lares<\/option><option value='Las Mar\u00edas' >Las Mar\u00edas<\/option><option value='Las Piedras' >Las Piedras<\/option><option value='Loiza' >Loiza<\/option><option value='Luquillo' >Luquillo<\/option><option value='Manat\u00ed' >Manat\u00ed<\/option><option value='Maricao' >Maricao<\/option><option value='Maunabo' >Maunabo<\/option><option value='Mayag\u00fcez' >Mayag\u00fcez<\/option><option value='Moca' >Moca<\/option><option value='Morovis' >Morovis<\/option><option value='Naguabo' >Naguabo<\/option><option value='Naranjito' >Naranjito<\/option><option value='Orocovis' >Orocovis<\/option><option value='Patillas' >Patillas<\/option><option value='Pe\u00f1uelas' >Pe\u00f1uelas<\/option><option value='Ponce' >Ponce<\/option><option value='Quebradillas' >Quebradillas<\/option><option value='Rinc\u00f3n' >Rinc\u00f3n<\/option><option value='Rio Grande' >Rio Grande<\/option><option value='Sabana Grande' >Sabana Grande<\/option><option value='Salinas' >Salinas<\/option><option value='San Germ\u00e1n' >San Germ\u00e1n<\/option><option value='San Juan' >San Juan<\/option><option value='San Lorenzo' >San Lorenzo<\/option><option value='San Sebasti\u00e1n' >San Sebasti\u00e1n<\/option><option value='Santa Isabel' >Santa Isabel<\/option><option value='Toa Alta' >Toa Alta<\/option><option value='Toa Baja' >Toa Baja<\/option><option value='Trujillo Alto' >Trujillo Alto<\/option><option value='Utuado' >Utuado<\/option><option value='Vega Alta' >Vega Alta<\/option><option value='Vega Baja' >Vega Baja<\/option><option value='Vieques' >Vieques<\/option><option value='Villalba' >Villalba<\/option><option value='Yabucoa' >Yabucoa<\/option><option value='Yauco' >Yauco<\/option><\/select><\/div><\/div><div id=\"field_10_127\" class=\"gfield gfield--type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_127'>Mailing address -State<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_127' id='input_10_127' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>State<\/option><option value='PR' >Puerto Rico<\/option><\/select><\/div><\/div><div id=\"field_10_128\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_128'>Mailing address - Zip code<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_128' id='input_10_128' type='text' value='' class='large'    placeholder='Zip code' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_28\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Employment Status<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_28'>\n\t\t\t<div class='gchoice gchoice_10_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Employed'  id='choice_10_28_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_28_0' id='label_10_28_0' class='gform-field-label gform-field-label--type-inline'>Employed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Not Employed'  id='choice_10_28_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_28_1' id='label_10_28_1' class='gform-field-label gform-field-label--type-inline'>Not Employed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_29\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Highest Level of Education<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_29'>\n\t\t\t<div class='gchoice gchoice_10_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Completed College'  id='choice_10_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_29_0' id='label_10_29_0' class='gform-field-label gform-field-label--type-inline'>Completed College<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Completed High School'  id='choice_10_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_29_1' id='label_10_29_1' class='gform-field-label gform-field-label--type-inline'>Completed High School<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_29_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Some College'  id='choice_10_29_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_29_2' id='label_10_29_2' class='gform-field-label gform-field-label--type-inline'>Some College<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_29_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Some High School'  id='choice_10_29_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_29_3' id='label_10_29_3' class='gform-field-label gform-field-label--type-inline'>Some High School<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you need assistance to develop your business idea?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_30'>\n\t\t\t<div class='gchoice gchoice_10_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='S\u00ed'  id='choice_10_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_30_0' id='label_10_30_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='No'  id='choice_10_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_30_1' id='label_10_30_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_71\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you want to develop a startup or small buisness and don\u2019t know how?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_71'>\n\t\t\t<div class='gchoice gchoice_10_71_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='S\u00ed'  id='choice_10_71_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_71_0' id='label_10_71_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_71_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='No'  id='choice_10_71_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_71_1' id='label_10_71_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_72\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you interested in taking short courses and\/or training to develop your business idea?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_72'>\n\t\t\t<div class='gchoice gchoice_10_72_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='S\u00ed'  id='choice_10_72_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_72_0' id='label_10_72_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_72_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='No'  id='choice_10_72_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_72_1' id='label_10_72_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_73\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Would you like to participate in an incubator program?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_73'>\n\t\t\t<div class='gchoice gchoice_10_73_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='S\u00ed'  id='choice_10_73_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_73_0' id='label_10_73_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_73_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='No'  id='choice_10_73_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_73_1' id='label_10_73_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_74\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Business Information<\/h3><\/div><fieldset id=\"field_10_31\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have an established business?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_31'>\n\t\t\t<div class='gchoice gchoice_10_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='S\u00ed'  id='choice_10_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_31_0' id='label_10_31_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='No'  id='choice_10_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_31_1' id='label_10_31_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_31_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='En desarrollo'  id='choice_10_31_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_31_2' id='label_10_31_2' class='gform-field-label gform-field-label--type-inline'>In development<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_75\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_75'>Business name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_10_75' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_76\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_76'>Business EIN or Tax ID Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_76' id='input_10_76' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_77\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_77'>Number of owners<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_77' id='input_10_77' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><\/select><\/div><\/div><fieldset id=\"field_10_36\" class=\"gfield gfield--type-list gfield--width-full gp-field-maxrows-9 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Owner Information<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Complete name<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Ownership percentage<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_36_cell1 gform-grid-col' data-label='Complete name'><input aria-invalid='false'   aria-label='Complete name, Row 1' data-aria-label-template='Complete name, Row {0}' type='text' name='input_36[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_36_cell2 gform-grid-col' data-label='Ownership percentage'><input aria-invalid='false'   aria-label='Ownership percentage, Row 1' data-aria-label-template='Ownership percentage, Row {0}' type='text' name='input_36[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 9)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 9)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_10_78\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_78'>Number of employees (Do not include owners)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_78' id='input_10_78' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='0' >0<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='M\u00e1s de 15' >M\u00e1s de 15<\/option><\/select><\/div><\/div><div id=\"field_10_79\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_79'>How many employees participate in Fase1?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_79' id='input_10_79' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='0' >0<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='M\u00e1s de 15' >M\u00e1s de 15<\/option><\/select><\/div><\/div><fieldset id=\"field_10_80\" class=\"gfield gfield--type-list gfield--width-full gp-field-maxrows-15 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please provide name of employees participating in Fase1<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Name<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Phone<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Address<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_80_cell1 gform-grid-col' data-label='Name'><input aria-invalid='false'   aria-label='Name, Row 1' data-aria-label-template='Name, Row {0}' type='text' name='input_80[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_80_cell2 gform-grid-col' data-label='Phone'><input aria-invalid='false'   aria-label='Phone, Row 1' data-aria-label-template='Phone, Row {0}' type='text' name='input_80[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_80_cell3 gform-grid-col' data-label='Address'><input aria-invalid='false'   aria-label='Address, Row 1' data-aria-label-template='Address, Row {0}' type='text' name='input_80[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 15)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 15)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_10_81\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Received Financial Aid<\/h3><\/div><fieldset id=\"field_10_38\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you previously received any financial assistance for your business?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_38'>\n\t\t\t<div class='gchoice gchoice_10_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='S\u00ed'  id='choice_10_38_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_38_0' id='label_10_38_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='No'  id='choice_10_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_38_1' id='label_10_38_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_92\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >List of financial assistance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_92'><div class='gchoice gchoice_10_92_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.1' type='checkbox'  value='Small Business Administration (SBA)'  id='choice_10_92_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_92_1' id='label_10_92_1' class='gform-field-label gform-field-label--type-inline'>Small Business Administration (SBA)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_92_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.2' type='checkbox'  value='Federal Emergency Management Agency (FEMA)'  id='choice_10_92_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_92_2' id='label_10_92_2' class='gform-field-label gform-field-label--type-inline'>Federal Emergency Management Agency (FEMA)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_92_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.3' type='checkbox'  value='National Flood Insurance Program (NFIP)'  id='choice_10_92_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_92_3' id='label_10_92_3' class='gform-field-label gform-field-label--type-inline'>National Flood Insurance Program (NFIP)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_92_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.4' type='checkbox'  value='Private Insurance'  id='choice_10_92_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_92_4' id='label_10_92_4' class='gform-field-label gform-field-label--type-inline'>Private Insurance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_92_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.5' type='checkbox'  value='U.S. Department of Housing and Urban Development (HUD)'  id='choice_10_92_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_92_5' id='label_10_92_5' class='gform-field-label gform-field-label--type-inline'>U.S. Department of Housing and Urban Development (HUD)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_92_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.6' type='checkbox'  value='Central Office For Recovery, Reconstruction, And Resiliency (COR3)'  id='choice_10_92_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_92_6' id='label_10_92_6' class='gform-field-label gform-field-label--type-inline'>Central Office For Recovery, Reconstruction, And Resiliency (COR3)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_92_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.7' type='checkbox'  value='Increased Cost of Compliance coverage (ICC)'  id='choice_10_92_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_92_7' id='label_10_92_7' class='gform-field-label gform-field-label--type-inline'>Increased Cost of Compliance coverage (ICC)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_92_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.8' type='checkbox'  value='Nonprofit or Charitable Funding'  id='choice_10_92_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_92_8' id='label_10_92_8' class='gform-field-label gform-field-label--type-inline'>Nonprofit or Charitable Funding<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_92_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.9' type='checkbox'  value='Community Development Block Grant Program - Coronavirus Response Grants (CDBG-CV)'  id='choice_10_92_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_92_9' id='label_10_92_9' class='gform-field-label gform-field-label--type-inline'>Community Development Block Grant Program - Coronavirus Response Grants (CDBG-CV)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_92_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.11' type='checkbox'  value='Business Interruption Grant (BIG) from the Puerto Rico Department of Economic Development and Commerce'  id='choice_10_92_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_92_11' id='label_10_92_11' class='gform-field-label gform-field-label--type-inline'>Business Interruption Grant (BIG) from the Puerto Rico Department of Economic Development and Commerce<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_92_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.12' type='checkbox'  value='Economic Injury Disaster Loan (EIDL) from the Small Business Administration (SBA)'  id='choice_10_92_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_92_12' id='label_10_92_12' class='gform-field-label gform-field-label--type-inline'>Economic Injury Disaster Loan (EIDL) from the Small Business Administration (SBA)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_92_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.13' type='checkbox'  value='Paycheck Protection Program (PPP) from the Small Business Administration (SBA)'  id='choice_10_92_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_92_13' id='label_10_92_13' class='gform-field-label gform-field-label--type-inline'>Paycheck Protection Program (PPP) from the Small Business Administration (SBA)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_92_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.14' type='checkbox'  value='Private foundations'  id='choice_10_92_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_92_14' id='label_10_92_14' class='gform-field-label gform-field-label--type-inline'>Private foundations<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_92_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.15' type='checkbox'  value='Puerto Rican Central Government and Municipalities'  id='choice_10_92_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_92_15' id='label_10_92_15' class='gform-field-label gform-field-label--type-inline'>Puerto Rican Central Government and Municipalities<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_92_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.16' type='checkbox'  value='Other benefits or economic incentives'  id='choice_10_92_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_92_16' id='label_10_92_16' class='gform-field-label gform-field-label--type-inline'>Other benefits or economic incentives<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_96\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Small Business Administration (SBA)<\/h3><\/div><div id=\"field_10_93\" class=\"gfield gfield--type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_93'>Amount<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_93' id='input_10_93' type='text' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_94\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_94'>Date received<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_94' id='input_10_94' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_94_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_94_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_94' class='gform_hidden' value='https:\/\/fase1.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_95\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_95'>Purpose of funding<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_95' id='input_10_95' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_10_97\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Federal Emergency Management Agency (FEMA)<\/h3><\/div><div id=\"field_10_98\" class=\"gfield gfield--type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_98'>Amount<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_98' id='input_10_98' type='text' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_99\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_99'>Date received<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_99' id='input_10_99' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_99_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_99_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_99' class='gform_hidden' value='https:\/\/fase1.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_100\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_100'>Purpose of funding<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_100' id='input_10_100' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_10_101\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">National Flood Insurance Program (NFIP)<\/h3><\/div><div id=\"field_10_102\" class=\"gfield gfield--type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_102'>Amount<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_102' id='input_10_102' type='text' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_103\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_103'>Date received<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_103' id='input_10_103' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_103_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_103_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_103' class='gform_hidden' value='https:\/\/fase1.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_104\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_104'>Purpose of funding<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_104' id='input_10_104' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_10_105\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Private Insurance<\/h3><\/div><div id=\"field_10_106\" class=\"gfield gfield--type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_106'>Amount<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_106' id='input_10_106' type='text' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_107\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_107'>Date received<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_107' id='input_10_107' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_107_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_107_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_107' class='gform_hidden' value='https:\/\/fase1.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_108\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_108'>Purpose of funding<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_108' id='input_10_108' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_10_136\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">U.S. Department of Housing and Urban Development (HUD)<\/h3><\/div><div id=\"field_10_137\" class=\"gfield gfield--type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_137'>Amount<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_137' id='input_10_137' type='text' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_138\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_138'>Date received<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_138' id='input_10_138' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_138_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_138_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_138' class='gform_hidden' value='https:\/\/fase1.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_139\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_139'>Purpose of funding<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_139' id='input_10_139' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_10_140\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Central Office For Recovery, Reconstruction, And Resiliency (COR3)<\/h3><\/div><div id=\"field_10_141\" class=\"gfield gfield--type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_141'>Amount<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_141' id='input_10_141' type='text' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_142\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_142'>Date received<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_142' id='input_10_142' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_142_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_142_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_142' class='gform_hidden' value='https:\/\/fase1.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_143\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_143'>Purpose of funding<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_143' id='input_10_143' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_10_144\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Increased Cost of Compliance coverage (ICC)<\/h3><\/div><div id=\"field_10_145\" class=\"gfield gfield--type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_145'>Amount<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_145' id='input_10_145' type='text' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_146\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_146'>Date received<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_146' id='input_10_146' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_146_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_146_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_146' class='gform_hidden' value='https:\/\/fase1.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_147\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_147'>Purpose of funding<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_147' id='input_10_147' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_10_148\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Nonprofit or Charitable Funding (Red Cross, United Way, local church, etc.)<\/h3><\/div><div id=\"field_10_149\" class=\"gfield gfield--type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_149'>Amount<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_149' id='input_10_149' type='text' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_150\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_150'>Date received<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_150' id='input_10_150' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_150_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_150_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_150' class='gform_hidden' value='https:\/\/fase1.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_151\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_151'>Purpose of funding<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_151' id='input_10_151' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_10_152\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Community Development Block Grant Program - Coronavirus Response Grants (CDBG-CV)<\/h3><\/div><div id=\"field_10_153\" class=\"gfield gfield--type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_153'>Amount<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_153' id='input_10_153' type='text' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_154\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_154'>Date received<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_154' id='input_10_154' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_154_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_154_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_154' class='gform_hidden' value='https:\/\/fase1.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_155\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_155'>Purpose of funding<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_155' id='input_10_155' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_10_156\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Business Interruption Grant (BIG) from the Puerto Rico Department of Economic Development and Commerce (DDEC, for its Spanish acronym)<\/h3><\/div><div id=\"field_10_157\" class=\"gfield gfield--type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_157'>Amount<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_157' id='input_10_157' type='text' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_158\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_158'>Date received<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_158' id='input_10_158' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_158_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_158_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_158' class='gform_hidden' value='https:\/\/fase1.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_159\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_159'>Purpose of funding<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_159' id='input_10_159' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_10_160\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Economic Injury Disaster Loan (EIDL) from the Small Business Administration (SBA)<\/h3><\/div><div id=\"field_10_161\" class=\"gfield gfield--type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_161'>Amount<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_161' id='input_10_161' type='text' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_162\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_162'>Date received<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_162' id='input_10_162' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_162_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_162_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_162' class='gform_hidden' value='https:\/\/fase1.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_163\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_163'>Purpose of funding<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_163' id='input_10_163' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_10_164\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Paycheck Protection Program (PPP) from the Small Business Administration (SBA)<\/h3><\/div><div id=\"field_10_165\" class=\"gfield gfield--type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_165'>Amount<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_165' id='input_10_165' type='text' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_166\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_166'>Date received<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_166' id='input_10_166' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_166_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_166_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_166' class='gform_hidden' value='https:\/\/fase1.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_167\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_167'>Purpose of funding<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_167' id='input_10_167' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_10_168\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Private foundations<\/h3><\/div><div id=\"field_10_169\" class=\"gfield gfield--type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_169'>Amount<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_169' id='input_10_169' type='text' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_170\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_170'>Date received<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_170' id='input_10_170' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_170_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_170_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_170' class='gform_hidden' value='https:\/\/fase1.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_171\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_171'>Purpose of funding<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_171' id='input_10_171' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_10_172\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Puerto Rican Central Government and Municipalities<\/h3><\/div><div id=\"field_10_173\" class=\"gfield gfield--type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_173'>Amount<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_173' id='input_10_173' type='text' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_174\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_174'>Date received<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_174' id='input_10_174' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_174_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_174_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_174' class='gform_hidden' value='https:\/\/fase1.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_175\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_175'>Purpose of funding<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_175' id='input_10_175' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_10_109\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Other benefits or economic incentives<\/h3><\/div><div id=\"field_10_110\" class=\"gfield gfield--type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_110'>Amount<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_110' id='input_10_110' type='text' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_111\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_111'>Date received<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_111' id='input_10_111' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_111_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_111_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_111' class='gform_hidden' value='https:\/\/fase1.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_112\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_112'>Purpose of funding<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_112' id='input_10_112' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_10_176\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SBA Loans<\/h3><\/div><fieldset id=\"field_10_129\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you applied for an SBA loan?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_129'>\n\t\t\t<div class='gchoice gchoice_10_129_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='S\u00ed'  id='choice_10_129_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_129_0' id='label_10_129_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_129_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='No'  id='choice_10_129_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_129_1' id='label_10_129_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_130\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you declined an SBA loan?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_130'>\n\t\t\t<div class='gchoice gchoice_10_130_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='S\u00ed'  id='choice_10_130_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_130_0' id='label_10_130_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_130_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='No'  id='choice_10_130_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_130_1' id='label_10_130_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_131\" class=\"gfield gfield--type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_131'>What was the amount of the loan?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_131' id='input_10_131' type='text' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_134\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_134'>Why was the loan not accepted?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_134' id='input_10_134' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_10_82\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Family Income Information<\/h3><\/div><fieldset id=\"field_10_42\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Indicate your Head of Household Status selecting one of the following options.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_42'>\n\t\t\t<div class='gchoice gchoice_10_42_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Single Head of Household - Female'  id='choice_10_42_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_42_0' id='label_10_42_0' class='gform-field-label gform-field-label--type-inline'>Single Head of Household - Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_42_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Single Head of Household -- Male'  id='choice_10_42_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_42_1' id='label_10_42_1' class='gform-field-label gform-field-label--type-inline'>Single Head of Household -- Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_42_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Not a Single Head of Household'  id='choice_10_42_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_42_2' id='label_10_42_2' class='gform-field-label gform-field-label--type-inline'>Not a Single Head of Household<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_42_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Prefer not to answer'  id='choice_10_42_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_42_3' id='label_10_42_3' class='gform-field-label gform-field-label--type-inline'>Prefer not to answer<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_83\" class=\"gfield gfield--type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_83'>Number of persons in your household<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_83' id='input_10_83' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_177\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_177'>Sources of income<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_177' id='input_10_177' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_85\" class=\"gfield gfield--type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_85'>Total household income<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_85' id='input_10_85' type='text' step='any'   value='' class='large'    placeholder='$' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_43\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Indicate the annual family income<\/h3>\n\n<p>* Select the box that represents the range of annual household income. Be sure to include all sources of income that apply: wages, earnings, welfare, child support, alimony, pensions, social security, child income, and\/or any other income. The amount must be before any deductions for taxes, insurance, medical expenses, child support, etc.<\/p><\/div><fieldset id=\"field_10_44\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Select the appropriate range of combined annual income for all people in the household<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_10_44'>When selecting the number of people living in your household, look at the box below to select your income level.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_44'>\n\t\t\t<div class='gchoice gchoice_10_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='1'  id='choice_10_44_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_10_44\"   \/>\n\t\t\t\t\t<label for='choice_10_44_0' id='label_10_44_0' class='gform-field-label gform-field-label--type-inline'>1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='2'  id='choice_10_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_44_1' id='label_10_44_1' class='gform-field-label gform-field-label--type-inline'>2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_44_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='3'  id='choice_10_44_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_44_2' id='label_10_44_2' class='gform-field-label gform-field-label--type-inline'>3<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_44_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='4'  id='choice_10_44_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_44_3' id='label_10_44_3' class='gform-field-label gform-field-label--type-inline'>4<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_44_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='5'  id='choice_10_44_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_44_4' id='label_10_44_4' class='gform-field-label gform-field-label--type-inline'>5<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_44_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='6'  id='choice_10_44_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_44_5' id='label_10_44_5' class='gform-field-label gform-field-label--type-inline'>6<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_44_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='7'  id='choice_10_44_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_44_6' id='label_10_44_6' class='gform-field-label gform-field-label--type-inline'>7<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_44_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='8'  id='choice_10_44_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_44_7' id='label_10_44_7' class='gform-field-label gform-field-label--type-inline'>8<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_44_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='More than 8 members in your household'  id='choice_10_44_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_44_8' id='label_10_44_8' class='gform-field-label gform-field-label--type-inline'>More than 8 members in your household<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_45\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full intensive_conditional field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >1 - My annual Household income is:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_45'>\n\t\t\t<div class='gchoice gchoice_10_45_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='At or below $31,100'  id='choice_10_45_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_45_0' id='label_10_45_0' class='gform-field-label gform-field-label--type-inline'>At or below $31,100<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_45_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='At or above $31,101'  id='choice_10_45_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_45_1' id='label_10_45_1' class='gform-field-label gform-field-label--type-inline'>At or above $31,101<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_46\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full intensive_conditional field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2 - My annual Household income is:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_46'>\n\t\t\t<div class='gchoice gchoice_10_46_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='At or below $35,550'  id='choice_10_46_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_46_0' id='label_10_46_0' class='gform-field-label gform-field-label--type-inline'>At or below $35,550<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_46_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='At or above $35,551'  id='choice_10_46_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_46_1' id='label_10_46_1' class='gform-field-label gform-field-label--type-inline'>At or above $35,551<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_47\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full intensive_conditional field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >3 - My annual Household income is:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_47'>\n\t\t\t<div class='gchoice gchoice_10_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='At or below $40,000'  id='choice_10_47_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_47_0' id='label_10_47_0' class='gform-field-label gform-field-label--type-inline'>At or below $40,000<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='At or above $40,001'  id='choice_10_47_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_47_1' id='label_10_47_1' class='gform-field-label gform-field-label--type-inline'>At or above $40,001<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_48\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full intensive_conditional field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >4 - My annual Household income is:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_48'>\n\t\t\t<div class='gchoice gchoice_10_48_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='At or below $44,400'  id='choice_10_48_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_48_0' id='label_10_48_0' class='gform-field-label gform-field-label--type-inline'>At or below $44,400<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_48_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='At or above $44,401'  id='choice_10_48_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_48_1' id='label_10_48_1' class='gform-field-label gform-field-label--type-inline'>At or above $44,401<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_49\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full intensive_conditional field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5 - My annual Household income is:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_49'>\n\t\t\t<div class='gchoice gchoice_10_49_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='At or below $48,000'  id='choice_10_49_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_49_0' id='label_10_49_0' class='gform-field-label gform-field-label--type-inline'>At or below $48,000<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_49_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='At or above $48,001'  id='choice_10_49_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_49_1' id='label_10_49_1' class='gform-field-label gform-field-label--type-inline'>At or above $48,001<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_50\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full intensive_conditional field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >6 - My annual Household income is:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_50'>\n\t\t\t<div class='gchoice gchoice_10_50_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='At or below $51,550'  id='choice_10_50_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_50_0' id='label_10_50_0' class='gform-field-label gform-field-label--type-inline'>At or below $51,550<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_50_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='At or above $51,551'  id='choice_10_50_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_50_1' id='label_10_50_1' class='gform-field-label gform-field-label--type-inline'>At or above $51,551<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_51\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full intensive_conditional field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >7 - My annual Household income is:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_51'>\n\t\t\t<div class='gchoice gchoice_10_51_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='At or below $55,100'  id='choice_10_51_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_51_0' id='label_10_51_0' class='gform-field-label gform-field-label--type-inline'>At or below $55,100<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_51_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='At or above $55,101'  id='choice_10_51_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_51_1' id='label_10_51_1' class='gform-field-label gform-field-label--type-inline'>At or above $55,101<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_52\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full intensive_conditional field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >8 - My annual Household income is:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_52'>\n\t\t\t<div class='gchoice gchoice_10_52_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='At or below $58,650'  id='choice_10_52_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_52_0' id='label_10_52_0' class='gform-field-label gform-field-label--type-inline'>At or below $58,650<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_52_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='At or above $58,651'  id='choice_10_52_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_52_1' id='label_10_52_1' class='gform-field-label gform-field-label--type-inline'>At or above $58,651<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_86\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>**Note: Income information will not be used to determine eligibility for Fase1.<\/p><\/div><fieldset id=\"field_10_53\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Indicate your Race &amp; Ethnicity selecting one of the options below<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_53'>\n\t\t\t<div class='gchoice gchoice_10_53_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='American Indian\/Alaskan Native'  id='choice_10_53_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_53_0' id='label_10_53_0' class='gform-field-label gform-field-label--type-inline'>American Indian\/Alaskan Native<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_53_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Asian'  id='choice_10_53_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_53_1' id='label_10_53_1' class='gform-field-label gform-field-label--type-inline'>Asian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_53_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Black\/African American'  id='choice_10_53_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_53_2' id='label_10_53_2' class='gform-field-label gform-field-label--type-inline'>Black\/African American<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_53_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Native Hawaiian\/Other Pacific Islander'  id='choice_10_53_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_53_3' id='label_10_53_3' class='gform-field-label gform-field-label--type-inline'>Native Hawaiian\/Other Pacific Islander<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_53_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='White'  id='choice_10_53_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_53_4' id='label_10_53_4' class='gform-field-label gform-field-label--type-inline'>White<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_53_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Indian\/Alaskan Native &amp; White'  id='choice_10_53_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_53_5' id='label_10_53_5' class='gform-field-label gform-field-label--type-inline'>Indian\/Alaskan Native & White<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_53_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Asian &amp; White'  id='choice_10_53_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_53_6' id='label_10_53_6' class='gform-field-label gform-field-label--type-inline'>Asian & White<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_53_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Black\/African American &amp; White'  id='choice_10_53_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_53_7' id='label_10_53_7' class='gform-field-label gform-field-label--type-inline'>Black\/African American & White<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_54\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full intensive_conditional field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Hispanic - American Indian\/Alaskan Native<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_54'>\n\t\t\t<div class='gchoice gchoice_10_54_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Non-Hispanic - No Hispano\/Latino'  id='choice_10_54_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_54_0' id='label_10_54_0' class='gform-field-label gform-field-label--type-inline'>Non-Hispanic - No Hispano\/Latino<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_54_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Hispanic - Hispano\/Latino'  id='choice_10_54_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_54_1' id='label_10_54_1' class='gform-field-label gform-field-label--type-inline'>Hispanic - Hispano\/Latino<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_55\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full intensive_conditional field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Hispanic - Asian<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_55'>\n\t\t\t<div class='gchoice gchoice_10_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Non-Hispanic - No Hispano\/Latino'  id='choice_10_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_55_0' id='label_10_55_0' class='gform-field-label gform-field-label--type-inline'>Non-Hispanic - No Hispano\/Latino<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Hispanic - Hispano\/Latino'  id='choice_10_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_55_1' id='label_10_55_1' class='gform-field-label gform-field-label--type-inline'>Hispanic - Hispano\/Latino<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_56\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full intensive_conditional field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Hispanic - Black\/African American<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_56'>\n\t\t\t<div class='gchoice gchoice_10_56_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='Non-Hispanic - No Hispano\/Latino'  id='choice_10_56_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_56_0' id='label_10_56_0' class='gform-field-label gform-field-label--type-inline'>Non-Hispanic - No Hispano\/Latino<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_56_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='Hispanic - Hispano\/Latino'  id='choice_10_56_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_56_1' id='label_10_56_1' class='gform-field-label gform-field-label--type-inline'>Hispanic - Hispano\/Latino<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_57\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full intensive_conditional field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Hispanic - Native Hawaiian\/Other Pacific Islander<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_57'>\n\t\t\t<div class='gchoice gchoice_10_57_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Non-Hispanic - No Hispano\/Latino'  id='choice_10_57_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_57_0' id='label_10_57_0' class='gform-field-label gform-field-label--type-inline'>Non-Hispanic - No Hispano\/Latino<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_57_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Hispanic - Hispano\/Latino'  id='choice_10_57_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_57_1' id='label_10_57_1' class='gform-field-label gform-field-label--type-inline'>Hispanic - Hispano\/Latino<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_58\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full intensive_conditional field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Hispanic - White<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_58'>\n\t\t\t<div class='gchoice gchoice_10_58_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='Non-Hispanic - No Hispano\/Latino'  id='choice_10_58_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_58_0' id='label_10_58_0' class='gform-field-label gform-field-label--type-inline'>Non-Hispanic - No Hispano\/Latino<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_58_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='Hispanic - Hispano\/Latino'  id='choice_10_58_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_58_1' id='label_10_58_1' class='gform-field-label gform-field-label--type-inline'>Hispanic - Hispano\/Latino<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_59\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full intensive_conditional field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Hispanic - Indian\/Alaskan Native &amp; White<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_59'>\n\t\t\t<div class='gchoice gchoice_10_59_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='Non-Hispanic - No Hispano\/Latino'  id='choice_10_59_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_59_0' id='label_10_59_0' class='gform-field-label gform-field-label--type-inline'>Non-Hispanic - No Hispano\/Latino<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_59_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='Hispanic - Hispano\/Latino'  id='choice_10_59_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_59_1' id='label_10_59_1' class='gform-field-label gform-field-label--type-inline'>Hispanic - Hispano\/Latino<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_60\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full intensive_conditional field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Hispanic - Asian &amp; White<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_60'>\n\t\t\t<div class='gchoice gchoice_10_60_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Non-Hispanic - No Hispano\/Latino'  id='choice_10_60_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_60_0' id='label_10_60_0' class='gform-field-label gform-field-label--type-inline'>Non-Hispanic - No Hispano\/Latino<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_60_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Hispanic - Hispano\/Latino'  id='choice_10_60_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_60_1' id='label_10_60_1' class='gform-field-label gform-field-label--type-inline'>Hispanic - Hispano\/Latino<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_61\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full intensive_conditional field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Hispanic - Black\/African American &amp; White<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_61'>\n\t\t\t<div class='gchoice gchoice_10_61_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Non-Hispanic - No Hispano\/Latino'  id='choice_10_61_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_61_0' id='label_10_61_0' class='gform-field-label gform-field-label--type-inline'>Non-Hispanic - No Hispano\/Latino<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_61_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Hispanic - Hispano\/Latino'  id='choice_10_61_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_61_1' id='label_10_61_1' class='gform-field-label gform-field-label--type-inline'>Hispanic - Hispano\/Latino<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_87\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Other Training Programs<\/h3><\/div><fieldset id=\"field_10_88\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Please indicate if you are currently enrolled or were enrolled in an equal or similar course (or courses) under any other CDBG-DR funded program<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_88'>\n\t\t\t<div class='gchoice gchoice_10_88_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='S\u00ed'  id='choice_10_88_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_88_0' id='label_10_88_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_88_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='No'  id='choice_10_88_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_88_1' id='label_10_88_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_89\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_89'>Specify course or courses, program and dates.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_89' id='input_10_89' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_10_91\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>I\/we certify that the information provided in this Workforce Training Intake Form is true and correct to the best of my knowledge. I\/we acknowledge that false, misleading, or incomplete information constitutes just cause for denial of participation in the Community Development Block Grant \u2013 Disaster Recovery (CDBG-DR Program) Program. I further acknowledge that providing false, misleading or incomplete information may result in the restitution of funds incurred in any type of assistance provided to me under the Program.  I\/we agree to provide, upon request, documentation on all income sources to the Puerto Rico Department of Housing (PRDOH), the U.S. Department of Housing and Urban Development (HUD), and\/or the Subrecipient.<\/p>\n\n<p><strong>Warning: Any person who knowingly makes a false claim or statement to HUD may be subject to civil or criminal penalties under 18 U.S.C. \u00a7 287, 1001 and 31 U.S.C. \u00a7 3729.<\/strong><\/p><\/div><div id=\"field_10_62\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>I understand that including my name in the box below is equivalent to accepting and signing this form.<\/strong><\/div><div id=\"field_10_63\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_63'>Name and both last names<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_10_63' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_64\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_64'>Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">* Required field<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_64' id='input_10_64' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_64_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_64_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_64' class='gform_hidden' value='https:\/\/fase1.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_21\" class=\"gfield gfield--type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_21' id='input_10_21' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_10_19\" class=\"gfield gfield--type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_19'>CAPTCHA<\/label><div id='input_10_19' class='ginput_container ginput_recaptcha' data-sitekey='6LebqSYdAAAAAAFhBWkBxed_l6X_IQLtMxpKHXVo'  data-theme='light' data-tabindex='-1' data-size='invisible' data-badge='bottomleft'><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_10' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_10' value='postback' \/>\n            <input type='hidden' 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