{"id":804,"date":"2016-09-22T01:23:40","date_gmt":"2016-09-22T01:23:40","guid":{"rendered":"http:\/\/canadianvesselregistry.ca\/?page_id=804"},"modified":"2020-11-03T13:57:37","modified_gmt":"2020-11-03T21:57:37","slug":"provisional-certificate","status":"publish","type":"page","link":"https:\/\/vesselregistrar.ca\/nvrc\/provisional-certificate\/","title":{"rendered":"Provisional Certificate"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var 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\/* ]]> *\/\n<\/script>\n\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_77' style='display:none'><div id='gf_77' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">APPLICATION FOR PROVISIONAL CERTIFICATE OF REGISTRY<\/h3>\n                            <p class='gform_description'>A Provisional Certificate of Registry form temporarily allows a registered owner to move a vessel while awaiting completion of the Certificate of Registration. It may also allow for the movement of a vessel to a foreign country in the event that a buyer lives outside of Canada and the vessel must be transported to the new owner.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_77'  action='\/nvrc\/wp-json\/wp\/v2\/pages\/804#gf_77' data-formid='77' novalidate><input id=\"gpnf_session_hash_77\" type=\"hidden\" name=\"gpnf_session_hash\" value=\"5019b3c45f53\">\n        <div id='gf_progressbar_wrapper_77' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<h3 class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>3<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_33' style='width:33%;'><span>33%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_77_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_77' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_77_117\" 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\"  ><label class='gfield_label gform-field-label' for='input_77_117'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_117' id='input_77_117' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_118\" class=\"gfield gfield--type-text gf_right_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_77_118'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_118' id='input_77_118' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_119\" class=\"gfield gfield--type-email 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 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_77_119_container'>\n                                <span id='input_77_119_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_119' id='input_77_119' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_77_119' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_77_119_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_119_2' id='input_77_119_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_77_119_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_77_130\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_130'>Phone Number<\/label><div class='ginput_container ginput_container_text'><input name='input_130' id='input_77_130' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_1\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_1'>Current name of vessel or builder&#039;s identification<\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_77_1' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_73\" class=\"gfield gfield--type-select gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_73'>Intended port of registry<\/label><div class='ginput_container ginput_container_select'><select name='input_73' id='input_77_73' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select port<\/option><option value='BATHURST NB' >BATHURST NB<\/option><option value='BELLEVILLE ON' >BELLEVILLE ON<\/option><option value='BROCKVILLE ON' >BROCKVILLE ON<\/option><option value='CAP-AUX-MEULES QC' >CAP-AUX-MEULES QC<\/option><option value='CARAQUET NB' >CARAQUET NB<\/option><option value='CHARLOTTETOWN PE' >CHARLOTTETOWN PE<\/option><option value='CHATHAM ON' >CHATHAM ON<\/option><option value='CHICOUTIMI QC' >CHICOUTIMI QC<\/option><option value='CORNWALL ON' >CORNWALL ON<\/option><option value='DAWSON YT' >DAWSON YT<\/option><option value='DIGBY NS' >DIGBY NS<\/option><option value='EDMONTON AB' >EDMONTON AB<\/option><option value='GASP\u00c9 QC' >GASP\u00c9 QC<\/option><option value='GODERICH ON' >GODERICH ON<\/option><option value='GRAND MANAN NB' >GRAND MANAN NB<\/option><option value='HALIFAX NS' >HALIFAX NS<\/option><option value='HAMILTON ON' >HAMILTON ON<\/option><option value='HAY RIVER NT' >HAY RIVER NT<\/option><option value='IQALUIT NU' >IQALUIT NU<\/option><option value='KENORA ON' >KENORA ON<\/option><option value='KINGSTON ON' >KINGSTON ON<\/option><option value='LIVERPOOL NS' >LIVERPOOL NS<\/option><option value='LUNENBURG NS' >LUNENBURG NS<\/option><option value='MIDLAND ON' >MIDLAND ON<\/option><option value='MONCTON NB' >MONCTON NB<\/option><option value='MONTREAL QC' >MONTREAL QC<\/option><option value='NANAIMO BC' >NANAIMO BC<\/option><option value='NANTICOKE ON' >NANTICOKE ON<\/option><option value='OTTAWA ON' >OTTAWA ON<\/option><option value='OWEN SOUND ON' >OWEN SOUND ON<\/option><option value='PETERBOROUGH ON' >PETERBOROUGH ON<\/option><option value='PORT ALBERNI BC' >PORT ALBERNI BC<\/option><option value='PORT COLBORNE ON' >PORT COLBORNE ON<\/option><option value='PORT DOVER ON' >PORT DOVER ON<\/option><option value='PORT HAWKESBURY NS' >PORT HAWKESBURY NS<\/option><option value='PRESCOTT ON' >PRESCOTT ON<\/option><option value='PRINCE ALBERT SK' >PRINCE ALBERT SK<\/option><option value='PRINCE RUPERT BC' >PRINCE RUPERT BC<\/option><option value='QU\u00c9BEC QC' >QU\u00c9BEC QC<\/option><option value='SAINT JOHN NB' >SAINT JOHN NB<\/option><option value='SARNIA ON' >SARNIA ON<\/option><option value='SAULT STE. MARIE ON' >SAULT STE. MARIE ON<\/option><option value='SHELBURNE NS' >SHELBURNE NS<\/option><option value='SOREL QC' >SOREL QC<\/option><option value='ST. ANDREWS NB' >ST. ANDREWS NB<\/option><option value='ST. CATHARINES ON' >ST. CATHARINES ON<\/option><option value='ST. JOHN&#039;S NL' >ST. JOHN&#039;S NL<\/option><option value='SYDNEY NS' >SYDNEY NS<\/option><option value='THUNDER BAY ON' >THUNDER BAY ON<\/option><option value='TORONTO ON' >TORONTO ON<\/option><option value='TROIS RIVIERES QC' >TROIS RIVIERES QC<\/option><option value='VANCOUVER BC' >VANCOUVER BC<\/option><option value='VICTORIA BC' >VICTORIA BC<\/option><option value='WALLACEBURG ON' >WALLACEBURG ON<\/option><option value='WEYMOUTH NS' >WEYMOUTH NS<\/option><option value='WHITEHORSE YT' >WHITEHORSE YT<\/option><option value='WINDSOR ON' >WINDSOR ON<\/option><option value='WINNIPEG MB' >WINNIPEG MB<\/option><option value='YARMOUTH NS' >YARMOUTH NS<\/option><option value='YELLOWKNIFE NT' >YELLOWKNIFE NT<\/option><\/select><\/div><\/li><li id=\"field_77_104\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_104'>Date Built<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_104' id='input_77_104' type='text' value='' class='datepicker gform-datepicker ymd_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='YYYY-MM-DD' aria-describedby=\"input_77_104_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_77_104_date_format' class='screen-reader-text'>YYYY dash MM dash DD<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_77_104' class='gform_hidden' value='https:\/\/vesselregistrar.ca\/nvrc\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_77_5\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">PARTICULARS OF VESSEL<\/h2><\/li><li id=\"field_77_6\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Type of propulsion (select one)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_77_6'>\n\t\t\t<li class='gchoice gchoice_77_6_0'>\n\t\t\t\t<input name='input_6' type='radio' value='Self-propelled'  id='choice_77_6_0'    \/>\n\t\t\t\t<label for='choice_77_6_0' id='label_77_6_0' class='gform-field-label gform-field-label--type-inline'>Self-propelled<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_77_6_1'>\n\t\t\t\t<input name='input_6' type='radio' value='Sail'  id='choice_77_6_1'    \/>\n\t\t\t\t<label for='choice_77_6_1' id='label_77_6_1' class='gform-field-label gform-field-label--type-inline'>Sail<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_77_6_2'>\n\t\t\t\t<input name='input_6' type='radio' value='Auxiliary'  id='choice_77_6_2'    \/>\n\t\t\t\t<label for='choice_77_6_2' id='label_77_6_2' class='gform-field-label gform-field-label--type-inline'>Auxiliary<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_77_6_3'>\n\t\t\t\t<input name='input_6' type='radio' value='None'  id='choice_77_6_3'    \/>\n\t\t\t\t<label for='choice_77_6_3' id='label_77_6_3' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_77_105\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Method of propulsion (select one)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_77_105'>\n\t\t\t<li class='gchoice gchoice_77_105_0'>\n\t\t\t\t<input name='input_105' type='radio' value='Single screw'  id='choice_77_105_0'    \/>\n\t\t\t\t<label for='choice_77_105_0' id='label_77_105_0' class='gform-field-label gform-field-label--type-inline'>Single screw<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_77_105_1'>\n\t\t\t\t<input name='input_105' type='radio' value='Twin screw'  id='choice_77_105_1'    \/>\n\t\t\t\t<label for='choice_77_105_1' id='label_77_105_1' class='gform-field-label gform-field-label--type-inline'>Twin screw<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_77_105_2'>\n\t\t\t\t<input name='input_105' type='radio' value='Triple screw'  id='choice_77_105_2'    \/>\n\t\t\t\t<label for='choice_77_105_2' id='label_77_105_2' class='gform-field-label gform-field-label--type-inline'>Triple screw<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_77_105_3'>\n\t\t\t\t<input name='input_105' type='radio' value='Jet'  id='choice_77_105_3'    \/>\n\t\t\t\t<label for='choice_77_105_3' id='label_77_105_3' class='gform-field-label gform-field-label--type-inline'>Jet<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_77_105_4'>\n\t\t\t\t<input name='input_105' type='radio' value='gf_other_choice'  id='choice_77_105_4'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_77_105_other' name='input_105_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_77_109\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_77_8\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Tonnage (select one)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_77_8'>\n\t\t\t<li class='gchoice gchoice_77_8_0'>\n\t\t\t\t<input name='input_8' type='radio' value='Simplified method'  id='choice_77_8_0'    \/>\n\t\t\t\t<label for='choice_77_8_0' id='label_77_8_0' class='gform-field-label gform-field-label--type-inline'>Simplified method<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_77_8_1'>\n\t\t\t\t<input name='input_8' type='radio' value='Estimated'  id='choice_77_8_1'    \/>\n\t\t\t\t<label for='choice_77_8_1' id='label_77_8_1' class='gform-field-label gform-field-label--type-inline'>Estimated<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_77_106\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_77_9\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_9'>Length (m.cm)<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_77_9' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_10\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_10'>Breadth (m.cm)<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_77_10' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_11\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_11'>Depth (m.cm)<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_77_11' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_12\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_12'>Gross tonnage<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_77_12' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_13\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_13'>Net tonnage<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_77_13' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_107\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_77_14\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_14'>Name of builder<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_77_14' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_15\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_15'>Place (City) and year of build<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_77_15' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_16\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_16'>Province\/State<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_77_16' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_17\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_17'>Country<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_77_17' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_108\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_77_110\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Type of vessel (select one)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_77_110'>\n\t\t\t<li class='gchoice gchoice_77_110_0'>\n\t\t\t\t<input name='input_110' type='radio' value='Passenger'  id='choice_77_110_0'    \/>\n\t\t\t\t<label for='choice_77_110_0' id='label_77_110_0' class='gform-field-label gform-field-label--type-inline'>Passenger<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_77_110_1'>\n\t\t\t\t<input name='input_110' type='radio' value='Pleasure'  id='choice_77_110_1'    \/>\n\t\t\t\t<label for='choice_77_110_1' id='label_77_110_1' class='gform-field-label gform-field-label--type-inline'>Pleasure<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_77_110_2'>\n\t\t\t\t<input name='input_110' type='radio' value='gf_other_choice'  id='choice_77_110_2'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_77_110_other' name='input_110_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_77_112\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_112'>Type of construction (select one)<\/label><div class='ginput_container ginput_container_select'><select name='input_112' id='input_77_112' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select one<\/option><option value='Carvel\/Flush' >Carvel\/Flush<\/option><option value='Clinker' >Clinker<\/option><option value='Diagonal' >Diagonal<\/option><option value='Moulded' >Moulded<\/option><option value='Riveted' >Riveted<\/option><option value='Welded' >Welded<\/option><\/select><\/div><\/li><li id=\"field_77_113\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_113'>Hull construction materials (select one)<\/label><div class='ginput_container ginput_container_select'><select name='input_113' id='input_77_113' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select one<\/option><option value='Aluminum' >Aluminum<\/option><option value='Aluminum and Rubber' >Aluminum and Rubber<\/option><option value='Composite' >Composite<\/option><option value='Concrete' >Concrete<\/option><option value='Fabric\/GRP' >Fabric\/GRP<\/option><option value='Iron' >Iron<\/option><option value='Reinforced Plastic' >Reinforced Plastic<\/option><option value='Rubber' >Rubber<\/option><option value='Steel' >Steel<\/option><option value='Wood' >Wood<\/option><\/select><\/div><\/li><li id=\"field_77_21\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_21'>Number of engines<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_77_21' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_114\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Engine Description (select one)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_77_114'>\n\t\t\t<li class='gchoice gchoice_77_114_0'>\n\t\t\t\t<input name='input_114' type='radio' value='Gas'  id='choice_77_114_0'    \/>\n\t\t\t\t<label for='choice_77_114_0' id='label_77_114_0' class='gform-field-label gform-field-label--type-inline'>Gas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_77_114_1'>\n\t\t\t\t<input name='input_114' type='radio' value='Diesel'  id='choice_77_114_1'    \/>\n\t\t\t\t<label for='choice_77_114_1' id='label_77_114_1' class='gform-field-label gform-field-label--type-inline'>Diesel<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_77_114_2'>\n\t\t\t\t<input name='input_114' type='radio' value='gf_other_choice'  id='choice_77_114_2'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_77_114_other' name='input_114_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_77_116\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_77_22\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Is your vessel an air cushion vehicle (ACV), give details<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_77_22'>\n\t\t\t<li class='gchoice gchoice_77_22_0'>\n\t\t\t\t<input name='input_22' type='radio' value='No'  id='choice_77_22_0'    \/>\n\t\t\t\t<label for='choice_77_22_0' id='label_77_22_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_77_22_1'>\n\t\t\t\t<input name='input_22' type='radio' value='Yes'  id='choice_77_22_1'    \/>\n\t\t\t\t<label for='choice_77_22_1' id='label_77_22_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_77_23\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_23'>All up weight (KG):<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_77_23' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_24\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_24'>Model designation:<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_77_24' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_115\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_77_25\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_25'>Particulars of previous registration (if applicable)<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_77_25' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_26\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_26'>Engine power (kW)<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_77_26' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_27\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_27'>Speed knots<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_77_27' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_28\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_77_134\" 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_visible\"  >DETAILS OF EACH OWNER (click below to add owners)<\/li><li id=\"field_77_135\" class=\"gfield gfield--type-form gform-theme__no-reset--children field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_135'>Owners<\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th class=\"gpnf-field-1\">\n\t\t\t\t\tFull Legal Name\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th class=\"gpnf-field-3\">\n\t\t\t\t\tAddress Number of shares (64 shares represents 100% ownership)\t\t\t\t<\/th>\n\t\t\t\t\t\t<th class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f1.label, attr: { 'data-value': f1.label }\"\n\t\t\t\t\tdata-heading=\"Full Legal Name\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f3.label, attr: { 'data-value': f3.label }\"\n\t\t\t\t\tdata-heading=\"Address Number of shares (64 shares represents 100% ownership)\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Entry {0} where Full Legal Name is {1}.'.gformFormat( $index() + 1, f1.label ) }\">Edit<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Entry {0} where Full Legal Name is {1}.'.gformFormat( $index() + 1, f1.label ) }\">Delete<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"3\">\n\t\t\t\tThere are no <span>Entries.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"77\"\n\t\t        data-nestedformid=\"72\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAdd Entry\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tMaximum number of entries reached.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_135\"\n                id=\"input_77_135\"\n                data-bind=\"value: entryIds\"\n                value=\"\" \/><\/li><li id=\"field_77_80\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_77_32\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">DETAILS OF PROPSED VOYAGES(S) (to be completed if vessel is situated in Canada)<\/h2><\/li><li id=\"field_77_33\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_33'>Application is made for the unregistered vessel to sail from<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_77_33' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_34\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_34'>to<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_77_34' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_35\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_35'>The voyage will commence on or after<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_35' id='input_77_35' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='DD-MM-YYYY' aria-describedby=\"input_77_35_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_77_35_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_77_35' class='gform_hidden' value='https:\/\/vesselregistrar.ca\/nvrc\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_77_36\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_36'>and end on or before<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_36' id='input_77_36' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='DD-MM-YYYY' aria-describedby=\"input_77_36_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_77_36_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_77_36' class='gform_hidden' value='https:\/\/vesselregistrar.ca\/nvrc\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_77_37\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_37'>Circumstances for application<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_37' id='input_77_37' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_77_38\" 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_visible\"  >I the undersigned, owner\/authorized representative of the vessel described above hereby certify that the tonnage and the other particulars are the best that can be obtained.<\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_77_41' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_77_2' class='gform_page' data-js='page-field-id-41' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_77_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_77_40\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">INDIVIDUAL<\/h2><\/li><li id=\"field_77_42\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_42'>Signed at<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_77_42' type='text' value='' class='medium'    placeholder='Place'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_43\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_43'>Date Application signed<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_43' id='input_77_43' type='text' value='' class='datepicker gform-datepicker ymd_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='YYYY-MM-DD' aria-describedby=\"input_77_43_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_77_43_date_format' class='screen-reader-text'>YYYY dash MM dash DD<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_77_43' class='gform_hidden' value='https:\/\/vesselregistrar.ca\/nvrc\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_77_137\" class=\"gfield gfield--type-list field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Signature of owner<\/label><style type=\"text\/css\">\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons {\n\t\t\t\t\t\t\tvertical-align: middle !important;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons img {\n\t\t\t\t\t\t\tbackground-color: transparent !important;\n\t\t\t\t\t\t\tbackground-position: 0 0;\n\t\t\t\t\t\t\tbackground-size: 16px 16px !important;\n\t\t\t\t\t\t\tbackground-repeat: no-repeat;\n\t\t\t\t\t\t\tborder: none !important;\n\t\t\t\t\t\t\twidth: 16px !important;\n\t\t\t\t\t\t\theight: 16px !important;\n\t\t\t\t\t\t\topacity: 0.5;\n\t\t\t\t\t\t\ttransition: opacity .5s ease-out;\n\t\t\t\t\t\t    -moz-transition: opacity .5s ease-out;\n\t\t\t\t\t\t    -webkit-transition: opacity .5s ease-out;\n\t\t\t\t\t\t    -o-transition: opacity .5s ease-out;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons a:hover img {\n\t\t\t\t\t\t\topacity: 1.0;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\t<\/style><div class='ginput_container ginput_container_list ginput_list'><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_137_col1' class='gfield_list_col_odd' \/><col id='gfield_list_137_col2' class='gfield_list_col_even' \/><\/colgroup><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_137_cell1' ><input aria-invalid='false'   aria-label='Signature of owner, Row 1' data-aria-label-template='Signature of owner, Row {0}' type='text' name='input_137[]' value=''   \/><\/td><td class='gfield_list_icons'>   <a href='javascript:void(0);' class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)'><img src='https:\/\/vesselregistrar.ca\/nvrc\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' alt='' title='Add a new row' \/><\/a>   <a href='javascript:void(0);' class='delete_list_item' aria-label='Remove this row' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\"><img src='https:\/\/vesselregistrar.ca\/nvrc\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' alt='' title='Remove this row' \/><\/a><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id=\"field_77_45\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">CORPORATION<\/h2><\/li><li id=\"field_77_46\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_46'>I<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_77_46' type='text' value='' class='medium'    placeholder='Name and title'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_54\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_54'>state that I have authority to bind<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_77_54' type='text' value='' class='medium'    placeholder='Name of corporation'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_55\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_55'>I also state that<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_77_55' type='text' value='' class='medium'    placeholder='Name of corporation'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_50\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >is the name of a corporation which legally exists at the date of this Application:<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_77_50'>\n\t\t\t<li class='gchoice gchoice_77_50_0'>\n\t\t\t\t<input name='input_50' type='radio' value='as per the laws of Canada; OR'  id='choice_77_50_0'    \/>\n\t\t\t\t<label for='choice_77_50_0' id='label_77_50_0' class='gform-field-label gform-field-label--type-inline'>as per the laws of Canada; OR<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_77_50_1'>\n\t\t\t\t<input name='input_50' type='radio' value='as per the laws of (province\/state)'  id='choice_77_50_1'    \/>\n\t\t\t\t<label for='choice_77_50_1' id='label_77_50_1' class='gform-field-label gform-field-label--type-inline'>as per the laws of (province\/state)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_77_51\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_51'>Name of province\/state<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_77_51' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_66\" 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_visible\"  >This Application must be signed by any Officer or Director of the corporation who has the authority to bind the corporation. Pursuant to Sections 51(2) and 75.01(2) of the <b><i>Canada Shipping Act, 2001<\/i><\/b> applicants may be required to provide additional information as requested by the Chief Registrar.<br>\nI understand that it is an offence for a person to knowingly make a false or misleading statement in writing and that the penalty can be a fine or imprisonment or both if found guilty in a court of law (Section 37 of the <b><i>Canada Shipping Act, 2001<\/i><\/b>).<\/li><li id=\"field_77_69\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_69'>Signature<\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_77_69' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_64\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_64'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_64' id='input_77_64' type='text' value='' class='datepicker gform-datepicker ymd_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='YYYY-MM-DD' aria-describedby=\"input_77_64_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_77_64_date_format' class='screen-reader-text'>YYYY dash MM dash DD<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_77_64' class='gform_hidden' value='https:\/\/vesselregistrar.ca\/nvrc\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_77_52\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">CORPORATION<\/h2><\/li><li id=\"field_77_53\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_53'>I<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_77_53' type='text' value='' class='medium'    placeholder='Name and title'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_47\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_47'>state that I have authority to bind<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_77_47' type='text' value='' class='medium'    placeholder='Name of corporation'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_48\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_48'>I also state that<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_77_48' type='text' value='' class='medium'    placeholder='Name of corporation'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_57\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >is the name of a corporation which legally exists at the date of this Application:<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_77_57'>\n\t\t\t<li class='gchoice gchoice_77_57_0'>\n\t\t\t\t<input name='input_57' type='radio' value='as per the laws of Canada; OR'  id='choice_77_57_0'    \/>\n\t\t\t\t<label for='choice_77_57_0' id='label_77_57_0' class='gform-field-label gform-field-label--type-inline'>as per the laws of Canada; OR<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_77_57_1'>\n\t\t\t\t<input name='input_57' type='radio' value='as per the laws of (province\/state)'  id='choice_77_57_1'    \/>\n\t\t\t\t<label for='choice_77_57_1' id='label_77_57_1' class='gform-field-label gform-field-label--type-inline'>as per the laws of (province\/state)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_77_58\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_58'>Name of province\/state<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_77_58' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_67\" 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_visible\"  >This Application must be signed by any Officer or Director of the corporation who has the authority to bind the corporation. Pursuant to Sections 51(2) and 75.01(2) of the <b><i>Canada Shipping Act, 2001<\/i><\/b> applicants may be required to provide additional information as requested by the Chief Registrar.<br>\nI understand that it is an offence for a person to knowingly make a false or misleading statement in writing and that the penalty can be a fine or imprisonment or both if found guilty in a court of law (Section 37 of the <b><i>Canada Shipping Act, 2001<\/i><\/b>).<\/li><li id=\"field_77_72\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_72'>Signature<\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_77_72' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_71\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_71'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_71' id='input_77_71' type='text' value='' class='datepicker gform-datepicker ymd_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='YYYY-MM-DD' aria-describedby=\"input_77_71_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_77_71_date_format' class='screen-reader-text'>YYYY dash MM dash DD<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_77_71' class='gform_hidden' value='https:\/\/vesselregistrar.ca\/nvrc\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_77_59' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_77_59' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_77_3' class='gform_page' data-js='page-field-id-59' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_77_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_77_60\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">INDIAN BAND<\/h2><div class='gsection_description' id='gfield_description_77_60'>NOTE:  In the case of an Indian Band, this Application must be made by person(s) authorized by Band Council Resolution <strong>OR<\/strong> by affixing the seal of the Indian Band on this Application.<\/div><\/li><li id=\"field_77_61\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_61'>Name of Indian Band<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_77_61' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_62\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_62'>Signature<\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_77_62' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_63\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_63'>Name of person signing above<\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_77_63' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_70\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_77_70'>Date of Application signed<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_70' id='input_77_70' type='text' value='' class='datepicker gform-datepicker ymd_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='YYYY-MM-DD' aria-describedby=\"input_77_70_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_77_70_date_format' class='screen-reader-text'>YYYY dash MM dash DD<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_77_70' class='gform_hidden' value='https:\/\/vesselregistrar.ca\/nvrc\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_77_102\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_77_101\" class=\"gfield gfield--type-product gfield--input-type-singleproduct gfield_price gfield_price_77_101 gfield_product_77_101 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_77_101_1'>APPLICATION FOR PROVISIONAL CERTIFICATE OF REGISTRY<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_101.1' value='APPLICATION FOR PROVISIONAL CERTIFICATE OF REGISTRY' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_77_101' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_101.2' id='ginput_base_price_77_101' class='gform_hidden' value='$ 295.00 CAD' aria-label='APPLICATION FOR PROVISIONAL CERTIFICATE OF REGISTRY Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_101.3' value='1' class='ginput_quantity_77_101 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_77_133\" class=\"gfield gfield--type-product gfield--input-type-singleproduct gfield_price gfield_price_77_133 gfield_product_77_133 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_77_133_1'>APPLICATION FOR PROVISIONAL CERTIFICATE OF REGISTRY<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_133.1' value='APPLICATION FOR PROVISIONAL CERTIFICATE OF REGISTRY' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_77_133' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_133.2' id='ginput_base_price_77_133' class='gform_hidden' value='$ 0.12 CAD' aria-label='APPLICATION FOR PROVISIONAL CERTIFICATE OF REGISTRY Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_133.3' value='1' class='ginput_quantity_77_133 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_77_131\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Please select any additional services you wish to have processed<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_77_131'><li class='gchoice gchoice_77_131_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.1' type='checkbox'  value='Priority Request\/Rush Processing'  id='choice_77_131_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_131_1' id='label_77_131_1' class='gform-field-label gform-field-label--type-inline'>Priority Request\/Rush Processing<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_77_132\" class=\"gfield gfield--type-product gfield--input-type-singleproduct gfield_price gfield_price_77_132 gfield_product_77_132 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_77_132_1'>Priority Request\/Rush Processing<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_132.1' value='Priority Request\/Rush Processing' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_77_132' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_132.2' id='ginput_base_price_77_132' class='gform_hidden' value='$ 70.00 CAD' aria-label='Priority Request\/Rush Processing Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_132.3' value='1' class='ginput_quantity_77_132 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_77_100\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_77_99\" class=\"gfield gfield--type-total gfield_price gfield_price_77_ gfield_total gfield_total_77_ field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  aria-atomic=\"true\" aria-live=\"polite\" ><label class='gfield_label gform-field-label' for='input_77_99'>Total<\/label><div class='ginput_container ginput_container_total'>\n\t\t\t\t\t\t\t<span class='ginput_total ginput_total_77'>$ 0.00 CAD<\/span>\n\t\t\t\t\t\t\t<input type='hidden' name='input_99' id='input_77_99' class='gform_hidden'\/>\n\t\t\t\t\t\t<\/div><\/li><li id=\"field_77_98\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_77_97\" class=\"gfield gfield--type-checkbox gfield--type-choice 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 gfield_label_before_complex' >Authorization<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_77_97'><li class='gchoice gchoice_77_97_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_97.1' type='checkbox'  value='I agree to pay the above total amount according to the card issuer agreement and hereby authorize the charge for the total amount above for the processing of selected Transport Canada documents. I understand that my application will be processed in the order in which it is received by National Vessel Registry Center Corp, a third-party fee for service company. I understand that application and processing fees are non-refundable as per National Vessel Registry Center Corp&#039;s no refund policy. I understand that submitting another application for vessel documentation will supersede the current\/pending application for that vessel.'  id='choice_77_97_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_97_1' id='label_77_97_1' class='gform-field-label gform-field-label--type-inline'>I agree to pay the above total amount according to the card issuer agreement and hereby authorize the charge for the total amount above for the processing of selected Transport Canada documents. I understand that my application will be processed in the order in which it is received by National Vessel Registry Center Corp, a third-party fee for service company. I understand that application and processing fees are non-refundable as per National Vessel Registry Center Corp's no refund policy. I understand that submitting another application for vessel documentation will supersede the current\/pending application for that vessel.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_77_139\" 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_77_139'>CAPACITY OF PERSON SIGNING (E.G., OWNER, CO-OWNER, PRESIDENT, CEO, OFFICER, DIRECTOR, ETC.)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_139' id='input_77_139' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_96\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_77_138\" class=\"gfield gfield--type-stripe_creditcard gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--type-stripe_creditcard-card\"  ><label class='gfield_label gfield_label_before_complex gform-field-label' for='input_77_138_1'>Credit Card<\/label><div class='ginput_complex ginput_container ginput_container_creditcard ginput_stripe_creditcard gform-grid-row' id='input_77_138'><div class='ginput_full gform-grid-col' id='input_77_138_1_container' data-payment-element='false'><div id='input_77_138_1' class='gform-theme-field-control StripeElement--card'><\/div><label for='input_77_138_1' id='input_77_138_1_label' class='gform-field-label gform-field-label--type-sub'>Card Details<\/label><\/div><!-- .ginput_full --><div class='ginput_full gform-grid-col' id='input_77_138_5_container'>\r\n\t\t\t\t\t<input type='text' name='input_138.5' id='input_77_138_5' value=''>\r\n\t\t\t\t\t<label for='input_77_138_5' id='input_77_138_5_label' class='gform-field-label gform-field-label--type-sub'>Cardholder Name<\/label>\r\n\t\t\t\t<\/div><\/div><!-- .ginput_container -->\r\n\t\t\t<style type=\"text\/css\">\r\n\t\t\t\t:root {\r\n  \t\t\t\t\t--link-login-string: \"Link login\"\r\n\t\t\t\t}\r\n\t\t\t<\/style><\/li><li id=\"field_77_94\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Having Trouble? Check this box to move forward without your Credit Card<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_77_94'><li class='gchoice gchoice_77_94_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_94.1' type='checkbox'  value='*My card information is not working; I would like to continue my submission and receive a call from a specialist regarding payment.'  id='choice_77_94_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_94_1' id='label_77_94_1' class='gform-field-label gform-field-label--type-inline'>*My card information is not working; I would like to continue my submission and receive a call from a specialist regarding payment.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_77_93\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Billing Address<\/h2><\/li><li id=\"field_77_122\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><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 has_city has_zip ginput_container_address gform-grid-row' id='input_77_122' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_77_122_1_container' >\n                                        <label for='input_77_122_1' id='input_77_122_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_122.1' id='input_77_122_1' value=''    aria-required='true'    \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_77_122_2_container' >\n                                        <label for='input_77_122_2' id='input_77_122_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                        <input type='text' name='input_122.2' id='input_77_122_2' value=''     aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_77_122_3_container' >\n                                    <label for='input_77_122_3' id='input_77_122_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_122.3' id='input_77_122_3' value=''    aria-required='true'    \/>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_122.4' id='input_77_122_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_77_122_5_container' >\n                                    <label for='input_77_122_5' id='input_77_122_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code (required for Canadian [A1A 1A1] and US [#####] only)<\/label>\n                                    <input type='text' name='input_122.5' id='input_77_122_5' value=''    aria-required='true'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_122.6' id='input_77_122_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_77_124\" class=\"gfield gfield--type-select gf_half_left 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_77_124'>State\/Province\/Region<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_124' id='input_77_124' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Alberta' >Alberta<\/option><option value='British Columbia' >British Columbia<\/option><option value='Manitoba' >Manitoba<\/option><option value='New Brunswick' >New Brunswick<\/option><option value='Newfoundland &amp; Labrador' >Newfoundland &amp; Labrador<\/option><option value='Northwest Territories' >Northwest Territories<\/option><option value='Nova Scotia' >Nova Scotia<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='Prince Edward Island' >Prince Edward Island<\/option><option value='Quebec' >Quebec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/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><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_77_128\" class=\"gfield gfield--type-text gf_right_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_77_128'>Other<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_128' id='input_77_128' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_126\" class=\"gfield gfield--type-select gf_left_class 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_77_126'>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_126' id='input_77_126' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brazil' >Brazil<\/option><option value='Brunei' >Brunei<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' selected='selected'>Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='East Timor' >East Timor<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='North Korea' >North Korea<\/option><option value='South Korea' >South Korea<\/option><option value='Kosovo' >Kosovo<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Laos' >Laos<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Sudan, South' >Sudan, South<\/option><option value='Suriname' >Suriname<\/option><option value='Swaziland' >Swaziland<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Togo' >Togo<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Vatican City' >Vatican City<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><\/select><\/div><\/li><li id=\"field_77_91\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_77_90\" class=\"gfield gfield--type-checkbox gfield--type-choice shipping-address-input field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_77_90'><li class='gchoice gchoice_77_90_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_90.1' type='checkbox'  value='Is your shipping address different from the one above?'  id='choice_77_90_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_90_1' id='label_77_90_1' class='gform-field-label gform-field-label--type-inline'>Is your shipping address different from the one above?<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_77_89\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Shipping Address<\/h2><\/li><li id=\"field_77_88\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><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 has_city has_zip ginput_container_address gform-grid-row' id='input_77_88' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_77_88_1_container' >\n                                        <label for='input_77_88_1' id='input_77_88_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_88.1' id='input_77_88_1' value=''    aria-required='true'    \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_77_88_2_container' >\n                                        <label for='input_77_88_2' id='input_77_88_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                        <input type='text' name='input_88.2' id='input_77_88_2' value=''     aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_77_88_3_container' >\n                                    <label for='input_77_88_3' id='input_77_88_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_88.3' id='input_77_88_3' value=''    aria-required='true'    \/>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_88.4' id='input_77_88_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_77_88_5_container' >\n                                    <label for='input_77_88_5' id='input_77_88_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code (required for Canadian [A1A 1A1] and US [#####] only)<\/label>\n                                    <input type='text' name='input_88.5' id='input_77_88_5' value=''    aria-required='true'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_88.6' id='input_77_88_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_77_127\" 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\"  ><label class='gfield_label gform-field-label' for='input_77_127'>State\/Province\/Region<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_127' id='input_77_127' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Alberta' >Alberta<\/option><option value='British Columbia' >British Columbia<\/option><option value='Manitoba' >Manitoba<\/option><option value='New Brunswick' >New Brunswick<\/option><option value='Newfoundland &amp; Labrador' >Newfoundland &amp; Labrador<\/option><option value='Northwest Territories' >Northwest Territories<\/option><option value='Nova Scotia' >Nova Scotia<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='Prince Edward Island' >Prince Edward Island<\/option><option value='Quebec' >Quebec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/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><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_77_125\" class=\"gfield gfield--type-text gf_right_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_77_125'>Other<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_125' id='input_77_125' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_129\" class=\"gfield gfield--type-select gf_left_class 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_77_129'>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_129' id='input_77_129' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brazil' >Brazil<\/option><option value='Brunei' >Brunei<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' selected='selected'>Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='East Timor' >East Timor<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='North Korea' >North Korea<\/option><option value='South Korea' >South Korea<\/option><option value='Kosovo' >Kosovo<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Laos' >Laos<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Sudan, South' >Sudan, South<\/option><option value='Suriname' >Suriname<\/option><option value='Swaziland' >Swaziland<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Togo' >Togo<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Vatican City' >Vatican City<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><\/select><\/div><\/li><li id=\"field_77_87\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_77_140\" class=\"gfield 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