{"id":96,"date":"2020-03-25T18:17:20","date_gmt":"2020-03-25T18:17:20","guid":{"rendered":"http:\/\/forms.saic.edu\/continuingstudies\/?page_id=96"},"modified":"2024-04-02T19:50:01","modified_gmt":"2024-04-02T19:50:01","slug":"cs-payment-form","status":"publish","type":"page","link":"https:\/\/web.saic.edu\/continuingstudies\/cs-payment-form\/","title":{"rendered":"Online Payments &#8211; SAIC Continuing Studies"},"content":{"rendered":"\n<h3>Please complete a form for each student.&nbsp; Please do not pay for more than one student on this form.&nbsp;<\/h3>\n\n\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_8' style='display:none'><style>#gform_wrapper_8[data-form-index=\"0\"].gform-theme,[data-parent-form=\"8_0\"]{--gf-color-primary: #204ce5;--gf-color-primary-rgb: 32, 76, 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gfield_visibility_visible\"  data-js-reload=\"field_8_1\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Your Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_8_1'>\n                            \n                            <span id='input_8_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_8_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_8_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_8_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_8_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_8_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_8_7\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_8_7\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label gfield_label_before_complex' >I am paying rent for someone else:<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_8_7'><li class='gchoice gchoice_8_7_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.1' type='checkbox'  value='Yes'  id='choice_8_7_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_7_1' id='label_8_7_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_8\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_8\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Student name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_8_8'>\n                            \n                            <span id='input_8_8_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_8.3' id='input_8_8_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_8_8_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_8_8_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_8.6' id='input_8_8_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_8_8_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_8_12\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_12\" ><label class='gfield_label gform-field-label' for='input_8_12'>Student Birthdate<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_12' id='input_8_12' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_8_12_date_format gfield_description_8_12\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_8_12_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_8_12' class='gform_hidden' value='https:\/\/web.saic.edu\/continuingstudies\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_8_12'>Format: mm\/dd\/yyyy<\/div><\/li><li id=\"field_8_11\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_11\" ><label class='gfield_label gform-field-label' for='input_8_11'>Student ID<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_8_11' type='text' value='' class='medium'  aria-describedby=\"gfield_description_8_11\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_8_11'>You can find the student ID on any invoices or statements of account you have received.<\/div><\/li><li id=\"field_8_5\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_5\" ><label class='gfield_label gform-field-label' for='input_8_5'>Country<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_5' id='input_8_5' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='US' >United States<\/option><option value='CA' >Canada<\/option><option value='AF' >Afghanistan<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AS' >American Samoa (US)<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla (UK)<\/option><option value='AG' >Antigua and Barbuda<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BY' >Belarus<\/option><option value='BE' >Belgium<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda (UK)<\/option><option value='BT' >Bhutan<\/option><option value='BO' >Bolivia<\/option><option value='BA' >Bosnia and Herzegovina<\/option><option value='BW' >Botswana<\/option><option value='BR' >Brazil<\/option><option value='VG' >British Virgin Islands (UK)<\/option><option value='BN' >Brunei Darussalam<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='KH' >Cambodia<\/option><option value='CM' >Cameroon<\/option><option value='CV' >Cape Verde<\/option><option value='KY' >Cayman Islands (UK)<\/option><option value='CF' >Central African Republic<\/option><option value='TD' >Chad<\/option><option value='CL' >Chile<\/option><option value='CN' >China<\/option><option value='CX' >Christmas Island (AU)<\/option><option value='CC' >Cocos (Keeling) Islands (AU)<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comoros<\/option><option value='CD' >&quot;Congo<\/option><option value='CG' >&quot;Congo<\/option><option value='CK' >Cook Islands (NZ)<\/option><option value='CR' >Costa Rica<\/option><option value='CI' >Cote D&#039;Ivoire<\/option><option value='HR' >Croatia<\/option><option value='CU' >Cuba<\/option><option value='CY' >Cyprus<\/option><option value='CZ' >Czech Republic<\/option><option value='DK' >Denmark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominica<\/option><option value='DO' >Dominican Republic<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egypt<\/option><option value='SV' >El Salvador<\/option><option value='GQ' >Equatorial Guinea<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='ET' >Ethiopia<\/option><option value='FK' >Falkland Islands (UK)<\/option><option value='FO' >Faroe Islands (DK)<\/option><option value='FJ' >Fiji<\/option><option value='FI' >Finland<\/option><option value='FR' >France<\/option><option value='GF' >French Guiana (FR)<\/option><option value='PF' >French Polynesia (FR)<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germany<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar (UK)<\/option><option value='GR' >Greece<\/option><option value='GL' >Greenland (DK)<\/option><option value='GD' >Grenada<\/option><option value='GP' >Guadeloupe (FR)<\/option><option value='GU' >Guam (US)<\/option><option value='GT' >Guatemala<\/option><option value='GN' >Guinea<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='VA' >Holy See (Vatican City)<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong (CN)<\/option><option value='HU' >Hungary<\/option><option value='IS' >Iceland<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Ireland<\/option><option value='IL' >Israel<\/option><option value='IT' >Italy<\/option><option value='JM' >Jamaica<\/option><option value='JP' >Japan<\/option><option value='JO' >Jordan<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='KP' >&quot;Korea<\/option><option value='KR' >&quot;Korea<\/option><option value='KW' >Kuwait<\/option><option value='KG' >Kyrgyzstan<\/option><option value='LA' >Laos<\/option><option value='LV' >Latvia<\/option><option value='LB' >Lebanon<\/option><option value='LS' >Lesotho<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libya<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lithuania<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macau (CN)<\/option><option value='MK' >Macedonia<\/option><option value='MG' >Madagascar<\/option><option value='MW' >Malawi<\/option><option value='MY' >Malaysia<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MH' >Marshall Islands<\/option><option value='MQ' >Martinique (FR)<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte (FR)<\/option><option value='MX' >Mexico<\/option><option value='FM' >&quot;Micronesia<\/option><option value='MD' >Moldova Republic of<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='MS' >Montserrat (UK)<\/option><option value='MA' >Morocco<\/option><option value='RW' >Rwanda<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='AN' >Netherlands Antilles (NL)<\/option><option value='NL' >Netherlands<\/option><option value='NC' >New Caledonia (FR)<\/option><option value='NZ' >New Zealand<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NF' >Norfolk Island (AU)<\/option><option value='MP' >Northern Mariana Islands (US)<\/option><option value='NO' >Norway<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PW' >Palau<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua New Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn Islands (UK)<\/option><option value='PL' >Poland<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico (US)<\/option><option value='QA' >Qatar<\/option><option value='RE' >Reunion (FR)<\/option><option value='RO' >Romania<\/option><option value='RU' >Russia<\/option><option value='SH' >Saint Helena (UK)<\/option><option value='KN' >Saint Kitts and Nevis<\/option><option value='LC' >Saint Lucia<\/option><option value='PM' >Saint Pierre &amp; Miquelon (FR)<\/option><option value='VC' >Saint Vincent and the Grenadines<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tome and Principe<\/option><option value='SA' >Saudi Arabia<\/option><option value='SN' >Senegal<\/option><option value='CS' >Serbia and Montenegro<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SK' >Slovakia<\/option><option value='SI' >Slovenia<\/option><option value='SB' >Solomon Islands<\/option><option value='SO' >Somalia<\/option><option value='ZA' >South Africa<\/option><option value='GS' >South Georgia (UK)<\/option><option value='ES' >Spain<\/option><option value='LK' >Sri Lanka<\/option><option value='SD' >Sudan<\/option><option value='SR' >Suriname<\/option><option value='SZ' >Swaziland<\/option><option value='SE' >Sweden<\/option><option value='CH' >Switzerland<\/option><option value='SY' >Syria<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzania<\/option><option value='TH' >Thailand<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad and Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >Turkey<\/option><option value='TM' >Turkmenistan<\/option><option value='TC' >Turks and Caicos Islands (UK)<\/option><option value='TV' >Tuvalu<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='AE' >United Arab Emirates<\/option><option value='GB' >United Kingdom<\/option><option value='UY' >Uruguay<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='VI' >Virgin Islands (US)<\/option><option value='WF' >Wallis and Futuna (FR)<\/option><option value='EH' >Western Sahara<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><\/select><\/div><\/li><li id=\"field_8_2\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_2\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 ginput_container_address gform-grid-row' id='input_8_2' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_8_2_1_container' >\n                                        <input type='text' name='input_2.1' id='input_8_2_1' value=''    aria-required='true'    \/>\n                                        <label for='input_8_2_1' id='input_8_2_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_8_2_2_container' >\n                                        <input type='text' name='input_2.2' id='input_8_2_2' value=''     aria-required='false'   \/>\n                                        <label for='input_8_2_2' id='input_8_2_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><input type='hidden' class='gform_hidden' name='input_2.4' id='input_8_2_4' value=''\/><input type='hidden' class='gform_hidden' name='input_2.6' id='input_8_2_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_8_14\" class=\"gfield gfield--type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_14\" ><label class='gfield_label gform-field-label' for='input_8_14'>City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_8_14' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_8_15\" class=\"gfield gfield--type-select gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_15\" ><label class='gfield_label gform-field-label' for='input_8_15'>State<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_15' id='input_8_15' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' >Select state<\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select><\/div><\/li><li id=\"field_8_17\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_17\" ><label class='gfield_label gform-field-label' for='input_8_17'>State \/ Province<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_8_17' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_8_16\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_16\" ><label class='gfield_label gform-field-label' for='input_8_16'>Zip \/ Postal Code<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_8_16' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_8_3\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_3\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_8_3_container'>\n                                <span id='input_8_3_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_3' id='input_8_3' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_8_3' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_8_3_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_3_2' id='input_8_3_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_8_3_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/li><li id=\"field_8_4\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_4\" ><label class='gfield_label gform-field-label' for='input_8_4'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_8_4' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_8_19\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_19\" ><label class='gfield_label gform-field-label' for='input_8_19'>Phone (int)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_19' id='input_8_19' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_8_9\" class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_9\" ><label class='gfield_label gform-field-label' for='input_8_9'>Amount<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_9' id='input_8_9' type='number' step='any' min='1'  value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_8_9 gfield_description_8_9\" \/><div class='gfield_description instruction ' id='gfield_instruction_8_9'>Please enter a number greater than or equal to <strong>1<\/strong>.<\/div><\/div><div class='gfield_description' id='gfield_description_8_9'>Please enter the amount from your bill. <\/div><\/li><li id=\"field_8_18\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  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