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          <label for="input_10"> Anonymous </label>
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        </div>
        <div id="cid_10" class="form-input">
          <div class="form-single-column">
            <input type="checkbox" name="anonymous" value="true" />
          </div>
        </div>
      </li>
      <li class="form-line" id="id_5">
        <div class="form-label-left" id="label_5">
          <label for="input_5">
            E-mail<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_5"> Email Address </label>
        </div>
        <div id="cid_5" class="form-input">
          <input type="email" class=" form-textbox validate[required, Email]" id="input_5" name="q5_email" size="30" value="" />
        </div>
      </li>
      <li class="form-line" id="id_23">
        <div id="cid_23" class="form-input-wide">
          <div id="text_23" class="form-html">
            <p style="text-align: center;">
              <em>
              </em>
              <u>
                <em>
                  <strong>
                    You will receive a beautiful certificate(s) showing which portion of the Torah your letter/word etc. has been inscribed
                  </strong>
                </em>
                <strong>
                  .
                </strong>
              </u>
            </p>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_13">
        <div class="form-label-left" id="label_13">
          <label for="input_13"> Letter for Adult </label>
          <label class="label-message" for="input_13"> $36 each </label>
        </div>
        <div id="cid_13" class="form-input">
          <input type="number" class="form-number-input  form-textbox" id="input_13" name="q13_number" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" />
        </div>
      </li>
      <li class="form-line" id="id_15">
        <div class="form-label-left" id="label_15">
          <label for="input_15"> Letter for Child </label>
          <label class="label-message" for="input_15"> $18 each </label>
        </div>
        <div id="cid_15" class="form-input">
          <input type="number" class="form-number-input  form-textbox" id="input_15" name="q15_quantity" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" />
        </div>
      </li>
      <li class="form-line" id="id_14">
        <div class="form-label-left" id="label_14">
          <label for="input_14"> Word/s in the Torah </label>
          <label class="label-message" for="input_14"> $108 each </label>
        </div>
        <div id="cid_14" class="form-input">
          <input type="number" class="form-number-input  form-textbox" id="input_14" name="q14_number14" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" />
        </div>
      </li>
      <li class="form-line" id="id_20">
        <div class="form-label-left" id="label_20">
          <label for="input_20"> Torah verse/s </label>
          <label class="label-message" for="input_20"> $360 each </label>
        </div>
        <div id="cid_20" class="form-input">
          <input type="number" class="form-number-input  form-textbox" id="input_20" name="q20_number20" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" />
        </div>
      </li>
      <li class="form-line" id="id_21">
        <div class="form-label-left" id="label_21">
          <label for="input_21"> Specifics </label>
          <label class="label-message" for="input_21"> optional </label>
        </div>
        <div id="cid_21" class="form-input">
          <textarea id="input_21" class="form-textarea" name="q21_input21" cols="40" rows="6"></textarea>
        </div>
      </li>
      <li class="form-line" id="id_22">
        <div id="cid_22" class="form-input-wide">
          <div id="text_22" class="form-html">
            <p style="text-align: center;">
              <em>
                <u>
                  <strong>
                    All dedications below will be featured on a beautiful Torah wall in the Chabad House lobby.
                  </strong>
                </u>
              </em>
            </p>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_16">
        <div class="form-label-left" id="label_16">
          <label for="input_16"> Available Portions: </label>
          <label class="label-message" for="input_16"> $613 Each </label>
        </div>
        <div id="cid_16" class="form-input">
          <select class="form-dropdown" style="width:150px" id="input_16" name="q16_input16">
            <option value="">  </option>
            <option value="Lech-Lecha, לֶךְ-לְךָ"> Lech-Lecha, לֶךְ-לְךָ </option>
            <option value="Vayeira, וַיֵּרָא"> Vayeira, וַיֵּרָא </option>
            <option value="Chayei Sarah, חַיֵּי שָׂרָה"> Chayei Sarah, חַיֵּי שָׂרָה </option>
            <option value="Vayishlach, וַיִּשְׁלַח"> Vayishlach, וַיִּשְׁלַח </option>
            <option value="Vayeshev, וַיֵּשֶׁב"> Vayeshev, וַיֵּשֶׁב </option>
            <option value="Miketz, מִקֵּץ"> Miketz, מִקֵּץ </option>
            <option value="Vayigash, וַיִּגַּשׁ"> Vayigash, וַיִּגַּשׁ </option>
            <option value="Bo, בֹּא"> Bo, בֹּא </option>
            <option value="Beshalach, בְּשַׁלַּח"> Beshalach, בְּשַׁלַּח </option>
            <option value="Tetzaveh, תְּצַוֶּה"> Tetzaveh, תְּצַוֶּה </option>
            <option value="Ki Tisa, כִּי תִשָּׂא"> Ki Tisa, כִּי תִשָּׂא </option>
            <option value="Vayakhel, וַיַּקְהֵל"> Vayakhel, וַיַּקְהֵל </option>
            <option value="Pekudei, פְקוּדֵי"> Pekudei, פְקוּדֵי </option>
            <option value="Vayikra, וַיִּקְרָא"> Vayikra, וַיִּקְרָא </option>
            <option value="Tzav, צַו"> Tzav, צַו </option>
            <option value="Shemini, שְּׁמִינִי"> Shemini, שְּׁמִינִי </option>
            <option value="Tazria, תַזְרִיעַ"> Tazria, תַזְרִיעַ </option>
            <option value="Metzora, מְּצֹרָע"> Metzora, מְּצֹרָע </option>
            <option value="Acharei Mot, אַחֲרֵי מוֹת"> Acharei Mot, אַחֲרֵי מוֹת </option>
            <option value="Kedoshim, קְדֹשִׁים"> Kedoshim, קְדֹשִׁים </option>
            <option value="Emor, אֱמֹר"> Emor, אֱמֹר </option>
            <option value="Behar, בְּהַר"> Behar, בְּהַר </option>
            <option value="Bechukotai, בְּחֻקֹּתַי"> Bechukotai, בְּחֻקֹּתַי </option>
            <option value="Bamidbar, בְּמִדְבַּר"> Bamidbar, בְּמִדְבַּר </option>
            <option value="Naso, נָשֹׂא"> Naso, נָשֹׂא </option>
            <option value="Shlach, שְׁלַח"> Shlach, שְׁלַח </option>
            <option value="Korach, קֹרַח"> Korach, קֹרַח </option>
            <option value="Chukat, חֻקַּת"> Chukat, חֻקַּת </option>
            <option value="Balak, בָּלָק"> Balak, בָּלָק </option>
            <option value="Pinchas, פִּינְחָס"> Pinchas, פִּינְחָס </option>
            <option value="Matot, מַּטּוֹת"> Matot, מַּטּוֹת </option>
            <option value="Masei, מַסְעֵי"> Masei, מַסְעֵי </option>
            <option value="Devarim, דְּבָרִים"> Devarim, דְּבָרִים </option>
            <option value="Va'etchanan, וָאֶתְחַנַּן"> Va'etchanan, וָאֶתְחַנַּן </option>
            <option value="Eikev, עֵקֶב"> Eikev, עֵקֶב </option>
            <option value="Re'eh, רְאֵה"> Re'eh, רְאֵה </option>
            <option value="Ki Tavo, כִּי-תָבוֹא"> Ki Tavo, כִּי-תָבוֹא </option>
          </select>
        </div>
      </li>
      <li class="form-line" id="id_18">
        <div class="form-label-left" id="label_18">
          <label for="input_18"> Special Portions </label>
          <label class="label-message" for="input_18"> $1800 Each </label>
        </div>
        <div id="cid_18" class="form-input">
          <select class="form-dropdown" style="width:150px" id="input_18" name="q18_input18">
            <option value="">  </option>
            <option value="Asres Hadibros: The Ten Commandments (TAKEN)"> Asres Hadibros: The Ten Commandments (TAKEN) </option>
            <option value="Shema: Central tenet of the Jewish faith"> Shema: Central tenet of the Jewish faith </option>
            <option value="Midot Harachamim:  G-d’s 13 attributes of Mercy"> Midot Harachamim: G-d’s 13 attributes of Mercy </option>
            <option value="Birchat Kohanim: Priestly benediction of love and kindness"> Birchat Kohanim: Priestly benediction of love and kindness </option>
            <option value="Shirat Hayam: The song of Az Yashir"> Shirat Hayam: The song of Az Yashir </option>
            <option value="Manna: Blessings of material plenty and sustenance"> Manna: Blessings of material plenty and sustenance </option>
            <option value="Hamalach: The blessings of Children (TAKEN)"> Hamalach: The blessings of Children (TAKEN) </option>
          </select>
        </div>
      </li>
      <li class="form-line" id="id_17">
        <div class="form-label-left" id="label_17">
          <label for="input_17"> TORAH ITEMS: </label>
          <label class="label-message" for="input_17">  </label>
        </div>
        <div id="cid_17" class="form-input">
          <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_17_0" name="q17_input17[]" value="Gartel (Belt) - $720" />
              <label id="label_input_17_0" for="input_17_0"><span>Gartel (Belt) - $720</span>
              </label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_17_1" name="q17_input17[]" value="Gartel (Belt) Holidays - $720" />
              <label id="label_input_17_1" for="input_17_1"><span>Gartel (Belt) Holidays - $720</span>
              </label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_17_2" name="q17_input17[]" value="Mantel Cover Holidays - $2400" />
              <label id="label_input_17_2" for="input_17_2"><span>Mantel Cover Holidays - $2400</span>
              </label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_17_3" name="q17_input17[]" value="Atzei Chaim (Torah Rollers) - $3600" />
              <label id="label_input_17_3" for="input_17_3"><span>Atzei Chaim (Torah Rollers) - $3600</span>
              </label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_17_4" name="q17_input17[]" value="Kesser Torah (Crown) - $7200" />
              <label id="label_input_17_4" for="input_17_4"><span>Kesser Torah (Crown) - $7200</span>
              </label></span><span class="clearfix"></span>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_19">
        <div class="form-label-left" id="label_19">
          <label for="input_19"> Other Amount </label>
          <label class="label-message" for="input_19">  </label>
        </div>
        <div id="cid_19" class="form-input">
          <div class="form-single-column"><span class="form-radio-item simple-mode"><label id="label_input_19" for="input_19"><span>$</span>
              </label>
              <input type="text" class="form-textbox" id="input_19" name="q19_input19" value="" onkeypress="validateNumber(event)" /></span><span class="clearfix"></span>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_8">
        <div class="form-label-left" id="label_8">
          <label for="input_8"> Dedication </label>
          <label class="label-message" for="input_8">  </label>
        </div>
        <div id="cid_8" class="form-input">
          <textarea id="input_8" class="form-textarea" name="q8_dedication8" cols="35" rows="6"></textarea>
        </div>
      </li>
      <li class="form-line" id="id_11">
        <div class="form-label-left" id="label_11">
          <label for="input_11"> Total </label>
        </div>
        <div id="cid_11" class="form-input">
          <div id="total_amount">
            $0.00
          </div>
        </div>
      </li>
      <li class="form-line" id="id_12">
        <div class="form-label-left" id="label_12">
          <label for="input_12"> Payment </label>
          <label class="label-message" for="input_12">  </label>
        </div>
        <div id="cid_12" class="form-input">
          <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0">
            <tbody><tr>
              <td colspan="2" class="form-payment-methods form-multiple-column"><span class="form-radio-item"><input class="paymentMethod form-radio validate[paymentMethod] form-radio" type="radio" id="input_12_creditCard" name="q12_payment[payment_method]" value="creditCard" onclick="BuildSource.creditCard(this)" />
                  <label for="input_12_creditCard"> Credit Card </label>
                   </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[paymentMethod] form-radio" type="radio" id="input_12_other" name="q12_payment[payment_method]" value="other" onclick="BuildSource.other(this)" />
                  <label for="input_12_other"> Check </label>
                   </span>
              </td>
            </tr>
            <tr class="credit_card hide">
              <th colspan="2">
                Credit Card
              </th>
            </tr>
            <tr class="credit_card hide">
              <td colspan="2" style="padding:0">
                <table cellpadding="0" cellspacing="0">
                  <tbody><tr>
                    <td colspan="2"><span class="form-sub-label-container"><select class="form-textbox validate[visible]" name="q12_payment[cc_type]" id="input_12_cc_type">
                          <option value="Visa"> Visa </option>
                          <option value="Mastercard"> MasterCard </option>
                          <option value="Amex"> American Express </option>
                          <option value="Discover"> Discover </option>
                        </select>
                        <label class="form-sub-label" for="input_12_cc_type" id="sublabel_cc_type"> Credit Card Type </label></span>
                    </td>
                  </tr>
                  <tr>
                    <td><span class="form-sub-label-container"><input class="form-textbox form-creditcard validate[visible, creditcard]" type="text" name="q12_payment[cc_number]" id="input_12_cc_number" size="20" autocomplete="off" />
                        <label class="form-sub-label" for="input_12_cc_number" id="sublabel_cc_number"> Credit Card Number </label></span>
                    </td>
                    <td class="cc_ccv "><span class="form-sub-label-container"><input class="form-textbox validate[visible]" type="text" name="q12_payment[cc_ccv]" id="input_12_cc_ccv" size="6" autocomplete="off" />
                        <label class="form-sub-label" for="input_12_cc_ccv" id="sublabel_cc_ccv"> Security Code </label></span>
                    </td>
                  </tr>
                  <tr>
                    <td colspan="2" class="cc_name_on_card "><span class="form-sub-label-container"><input class="form-textbox validate[visible]" type="text" name="q12_payment[cc_nameOnCard]" id="input_12_cc_nameOnCard" size="33" autocomplete="off" />
                        <label class="form-sub-label" for="input_12_cc_nameOnCard" id="sublabel_cc_nameOnCard"> Name on Card </label></span>
                    </td>
                  </tr>
                  <tr class="credit_card hide">
                    <td colspan=""><span class="form-sub-label-container"><select class="form-textbox validate[visible]" name="q12_payment[cc_exp_month]" id="input_12_cc_exp_month">
                          <option>  </option>
                          <option value="1"> 1 - January </option>
                          <option value="2"> 2 - February </option>
                          <option value="3"> 3 - March </option>
                          <option value="4"> 4 - April </option>
                          <option value="5"> 5 - May </option>
                          <option value="6"> 6 - June </option>
                          <option value="7"> 7 - July </option>
                          <option value="8"> 8 - August </option>
                          <option value="9"> 9 - September </option>
                          <option value="10"> 10 - October </option>
                          <option value="11"> 11 - November </option>
                          <option value="12"> 12 - December </option>
                        </select>
                        <label class="form-sub-label" for="input_12_cc_exp_month" id="sublabel_cc_exp_month"> Expiration Month </label></span>
                    </td>
                    <td><span class="form-sub-label-container"><select class="form-textbox validate[visible]" name="q12_payment[cc_exp_year]" id="input_12_cc_exp_year">
                          <option>  </option>
                          <option value="2018"> 2018 </option>
                          <option value="2019"> 2019 </option>
                          <option value="2020"> 2020 </option>
                          <option value="2021"> 2021 </option>
                          <option value="2022"> 2022 </option>
                          <option value="2023"> 2023 </option>
                          <option value="2024"> 2024 </option>
                          <option value="2025"> 2025 </option>
                          <option value="2026"> 2026 </option>
                          <option value="2027"> 2027 </option>
                        </select>
                        <label class="form-sub-label" for="input_12_cc_exp_year" id="sublabel_cc_exp_year"> Expiration Year </label></span>
                    </td>
                  </tr>
                </tbody></table>
              </td>
            </tr>
            <tr class="other hide">
              <td colspan="2">
                Please mail checks to:
                <br />
                Chabad of Las Cruces
                <br />
                2907 East Idaho Ave
                <br />
                Las Cruces, NM 88011
              </td>
            </tr>
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