{"id":950,"date":"2025-09-19T10:59:20","date_gmt":"2025-09-19T10:59:20","guid":{"rendered":"https:\/\/droscarmabele.co.za\/?page_id=950"},"modified":"2025-09-22T03:44:28","modified_gmt":"2025-09-22T03:44:28","slug":"cash-registration-form","status":"publish","type":"page","link":"https:\/\/droscarmabele.co.za\/index.php\/cash-registration-form\/","title":{"rendered":"Cash Registration Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"950\" class=\"elementor elementor-950\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-1be6806 e-flex e-con-boxed e-con e-parent\" data-id=\"1be6806\" data-element_type=\"container\" data-settings=\"{&quot;content_width&quot;:&quot;boxed&quot;}\" data-core-v316-plus=\"true\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-273066c elementor-invisible elementor-widget elementor-widget-wp-widget-fluentform_widget\" data-id=\"273066c\" data-element_type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;fadeIn&quot;}\" data-widget_type=\"wp-widget-fluentform_widget.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<div class='fluentform ff-inherit-theme-style fluentform_wrapper_5'><form data-form_id=\"5\" id=\"fluentform_5\" class=\"frm-fluent-form fluent_form_5 ff-el-form-top ff_form_instance_5_1 ff-form-loading ffs_inherit_theme\" data-form_instance=\"ff_form_instance_5_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Cash Form<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='950' \/><input type=\"hidden\" id=\"_fluentform_5_fluentformnonce\" name=\"_fluentform_5_fluentformnonce\" value=\"2aa1a8769a\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php\/wp-json\/wp\/v2\/pages\/950\" \/><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_1\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h1 style=\"text-align: center\"><em><strong>DR<\/strong><\/em><\/h1><\/div><hr \/><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_2\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><p style=\"text-align: center\"><strong>DETAILS OF MAIN MENBER OF MEDICAL AID\/PERSON RESPONSIBLE FOR THE ACCOUNT<\/strong><\/p>\n<p style=\"text-align: center\"><strong> (Please obtain a copy of ID)<\/strong><\/p><\/div><hr \/><\/div><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_1  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div data-type=\"name-element\" data-name=\"names\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_names_first_name_' >First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_5_names_first_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your First Name\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_names_last_name_' >Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[last_name]\" id=\"ff_5_names_last_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your Last Name\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-left'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_numeric_field' aria-label=\"ID Number\">ID Number <\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric_field\" id=\"ff_5_numeric_field\" class=\"ff-el-form-control\" data-name=\"numeric_field\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group ff-el-form-left'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_numeric_field_1' aria-label=\"Cell Phone Number\">Cell Phone Number <\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric_field_1\" id=\"ff_5_numeric_field_1\" class=\"ff-el-form-control\" data-name=\"numeric_field_1\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group ff-el-form-left'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_email' aria-label=\"E-mail Address\">E-mail Address<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" id=\"ff_5_email\" class=\"ff-el-form-control\" placeholder=\"Email Address\" data-name=\"email\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class=\"ff-name-address-wrapper fluent-address\" data-type=\"address-element\" data-name=\"address_1\" ><div class='ff-el-input--label'><label aria-label=\"Physical Address\">Physical Address<\/label><\/div><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_1_address_line_1_' aria-label=\"Address Line 1\">Address Line 1<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[address_line_1]\" id=\"ff_5_address_1_address_line_1_\" class=\"ff-el-form-control\" placeholder=\"Address Line 1\" data-key_name=\"address_line_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_1_address_line_2_' aria-label=\"Address Line 2\">Address Line 2<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[address_line_2]\" id=\"ff_5_address_1_address_line_2_\" class=\"ff-el-form-control\" placeholder=\"Address Line 2\" data-key_name=\"address_line_2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_1_city_' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[city]\" id=\"ff_5_address_1_city_\" class=\"ff-el-form-control\" placeholder=\"City\" data-key_name=\"city\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_1_state_' aria-label=\"State\">State<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[state]\" id=\"ff_5_address_1_state_\" class=\"ff-el-form-control\" placeholder=\"State\" data-key_name=\"state\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_1_zip_' aria-label=\"Zip Code\">Zip Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[zip]\" id=\"ff_5_address_1_zip_\" class=\"ff-el-form-control\" placeholder=\"Zip\" data-key_name=\"zip\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_1_country_' aria-label=\"Country\">Country<\/label><\/div><div class='ff-el-input--content'><select name=\"address_1[country]\" id=\"ff_5_address_1_country_\" class=\"ff-el-form-control\" placeholder=\"Select Country\" data-key_name=\"country\" aria-invalid='false' aria-required=false><option value=''>Select Country<\/option><option value='AF' >Afghanistan<\/option><option value='AX' >Aland Islands<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctica<\/option><option value='AG' >Antigua and Barbuda<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BY' >Belarus<\/option><option value='PW' >Belau<\/option><option value='BE' >Belgium<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Saint Eustatius and Saba<\/option><option value='BA' >Bosnia and Herzegovina<\/option><option value='BW' >Botswana<\/option><option value='BV' >Bouvet Island<\/option><option value='BR' >Brazil<\/option><option value='IO' >British Indian Ocean Territory<\/option><option value='VG' >British Virgin Islands<\/option><option value='BN' >Brunei<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='KH' >Cambodia<\/option><option value='CM' >Cameroon<\/option><option value='CA' >Canada<\/option><option value='CV' >Cape Verde<\/option><option value='KY' >Cayman Islands<\/option><option value='CF' >Central African Republic<\/option><option value='TD' >Chad<\/option><option value='CL' >Chile<\/option><option value='CN' >China<\/option><option value='CX' >Christmas Island<\/option><option value='CC' >Cocos (Keeling) Islands<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comoros<\/option><option value='CK' >Cook Islands<\/option><option value='CR' >Costa Rica<\/option><option value='HR' >Croatia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura&ccedil;ao<\/option><option value='CY' >Cyprus<\/option><option value='CZ' >Czech Republic<\/option><option value='CD' >Democratic Republic of the Congo (Kinshasa)<\/option><option value='DK' >Denmark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominica<\/option><option value='DO' >Dominican Republic<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egypt<\/option><option value='SV' >El Salvador<\/option><option value='GQ' >Equatorial Guinea<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='ET' >Ethiopia<\/option><option value='FK' >Falkland Islands<\/option><option value='FO' >Faroe Islands<\/option><option value='FJ' >Fiji<\/option><option value='FI' >Finland<\/option><option value='FR' >France<\/option><option value='GF' >French Guiana<\/option><option value='PF' >French Polynesia<\/option><option value='TF' >French Southern Territories<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germany<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GR' >Greece<\/option><option value='GL' >Greenland<\/option><option value='GD' >Grenada<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GN' >Guinea<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HM' >Heard Island and McDonald Islands<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hungary<\/option><option value='IS' >Iceland<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Ireland<\/option><option value='IM' >Isle of Man<\/option><option value='IL' >Israel<\/option><option value='IT' >Italy<\/option><option value='CI' >Ivory Coast<\/option><option value='JM' >Jamaica<\/option><option value='JP' >Japan<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordan<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='XK' >Kosovo<\/option><option value='KW' >Kuwait<\/option><option value='KG' >Kyrgyzstan<\/option><option value='LA' >Laos<\/option><option value='LV' >Latvia<\/option><option value='LB' >Lebanon<\/option><option value='LS' >Lesotho<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libya<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lithuania<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao S.A.R., China<\/option><option value='MK' >Macedonia<\/option><option value='MG' >Madagascar<\/option><option value='MW' >Malawi<\/option><option value='MY' >Malaysia<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MH' >Marshall Islands<\/option><option value='MQ' >Martinique<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldova<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MA' >Morocco<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NL' >Netherlands<\/option><option value='NC' >New Caledonia<\/option><option value='NZ' >New Zealand<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NF' >Norfolk Island<\/option><option value='KP' >North Korea<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norway<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PS' >Palestinian Territory<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua New Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Poland<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='QA' >Qatar<\/option><option value='CG' >Republic of the Congo (Brazzaville)<\/option><option value='RE' >Reunion<\/option><option value='RO' >Romania<\/option><option value='RU' >Russia<\/option><option value='RW' >Rwanda<\/option><option value='BL' >Saint Barth&eacute;lemy<\/option><option value='SH' >Saint Helena<\/option><option value='KN' >Saint Kitts and Nevis<\/option><option value='LC' >Saint Lucia<\/option><option value='SX' >Saint Martin (Dutch part)<\/option><option value='MF' >Saint Martin (French part)<\/option><option value='PM' >Saint Pierre and Miquelon<\/option><option value='VC' >Saint Vincent and the Grenadines<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tome and Principe<\/option><option value='SA' >Saudi Arabia<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SK' >Slovakia<\/option><option value='SI' >Slovenia<\/option><option value='SB' >Solomon Islands<\/option><option value='SO' >Somalia<\/option><option value='ZA' >South Africa<\/option><option value='GS' >South Georgia\/Sandwich Islands<\/option><option value='KR' >South Korea<\/option><option value='SS' >South Sudan<\/option><option value='ES' >Spain<\/option><option value='LK' >Sri Lanka<\/option><option value='SD' >Sudan<\/option><option value='SR' >Suriname<\/option><option value='SJ' >Svalbard and Jan Mayen<\/option><option value='SZ' >Swaziland<\/option><option value='SE' >Sweden<\/option><option value='CH' >Switzerland<\/option><option value='SY' >Syria<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzania<\/option><option value='TH' >Thailand<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad and Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >Turkey<\/option><option value='TM' >Turkmenistan<\/option><option value='TC' >Turks and Caicos Islands<\/option><option value='TV' >Tuvalu<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='AE' >United Arab Emirates<\/option><option value='GB' >United Kingdom (UK)<\/option><option value='US' >United States (US)<\/option><option value='UM' >United States (US) Minor Outlying Islands<\/option><option value='VI' >United States (US) Virgin Islands<\/option><option value='UY' >Uruguay<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VA' >Vatican<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='WF' >Wallis and Futuna<\/option><option value='EH' >Western Sahara<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"ff-name-address-wrapper fluent-address\" data-type=\"address-element\" data-name=\"address_2\" ><div class='ff-el-input--label'><label aria-label=\"Postal Address\">Postal Address<\/label><\/div><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_2_address_line_1_' aria-label=\"Address Line 1\">Address Line 1<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_2[address_line_1]\" id=\"ff_5_address_2_address_line_1_\" class=\"ff-el-form-control\" placeholder=\"Address Line 1\" data-key_name=\"address_line_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_2_address_line_2_' aria-label=\"Address Line 2\">Address Line 2<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_2[address_line_2]\" id=\"ff_5_address_2_address_line_2_\" class=\"ff-el-form-control\" placeholder=\"Address Line 2\" data-key_name=\"address_line_2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_2_city_' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_2[city]\" id=\"ff_5_address_2_city_\" class=\"ff-el-form-control\" placeholder=\"City\" data-key_name=\"city\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_2_state_' aria-label=\"State\">State<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_2[state]\" id=\"ff_5_address_2_state_\" class=\"ff-el-form-control\" placeholder=\"State\" data-key_name=\"state\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_2_zip_' aria-label=\"Zip Code\">Zip Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_2[zip]\" id=\"ff_5_address_2_zip_\" class=\"ff-el-form-control\" placeholder=\"Zip\" data-key_name=\"zip\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_2_country_' aria-label=\"Country\">Country<\/label><\/div><div class='ff-el-input--content'><select name=\"address_2[country]\" id=\"ff_5_address_2_country_\" class=\"ff-el-form-control\" placeholder=\"Select Country\" data-key_name=\"country\" aria-invalid='false' aria-required=false><option value=''>Select Country<\/option><option value='AF' >Afghanistan<\/option><option value='AX' >Aland Islands<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctica<\/option><option value='AG' >Antigua and Barbuda<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BY' >Belarus<\/option><option value='PW' >Belau<\/option><option value='BE' >Belgium<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Saint Eustatius and Saba<\/option><option value='BA' >Bosnia and Herzegovina<\/option><option value='BW' >Botswana<\/option><option value='BV' >Bouvet Island<\/option><option value='BR' >Brazil<\/option><option value='IO' >British Indian Ocean Territory<\/option><option value='VG' >British Virgin Islands<\/option><option value='BN' >Brunei<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='KH' >Cambodia<\/option><option value='CM' >Cameroon<\/option><option value='CA' >Canada<\/option><option value='CV' >Cape Verde<\/option><option value='KY' >Cayman Islands<\/option><option value='CF' >Central African Republic<\/option><option value='TD' >Chad<\/option><option value='CL' >Chile<\/option><option value='CN' >China<\/option><option value='CX' >Christmas Island<\/option><option value='CC' >Cocos (Keeling) Islands<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comoros<\/option><option value='CK' >Cook Islands<\/option><option value='CR' >Costa Rica<\/option><option value='HR' >Croatia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura&ccedil;ao<\/option><option value='CY' >Cyprus<\/option><option value='CZ' >Czech Republic<\/option><option value='CD' >Democratic Republic of the Congo (Kinshasa)<\/option><option value='DK' >Denmark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominica<\/option><option value='DO' >Dominican Republic<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egypt<\/option><option value='SV' >El Salvador<\/option><option value='GQ' >Equatorial Guinea<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='ET' >Ethiopia<\/option><option value='FK' >Falkland Islands<\/option><option value='FO' >Faroe Islands<\/option><option value='FJ' >Fiji<\/option><option value='FI' >Finland<\/option><option value='FR' >France<\/option><option value='GF' >French Guiana<\/option><option value='PF' >French Polynesia<\/option><option value='TF' >French Southern Territories<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germany<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GR' >Greece<\/option><option value='GL' >Greenland<\/option><option value='GD' >Grenada<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GN' >Guinea<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HM' >Heard Island and McDonald Islands<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hungary<\/option><option value='IS' >Iceland<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Ireland<\/option><option value='IM' >Isle of Man<\/option><option value='IL' >Israel<\/option><option value='IT' >Italy<\/option><option value='CI' >Ivory Coast<\/option><option value='JM' >Jamaica<\/option><option value='JP' >Japan<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordan<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='XK' >Kosovo<\/option><option value='KW' >Kuwait<\/option><option value='KG' >Kyrgyzstan<\/option><option value='LA' >Laos<\/option><option value='LV' >Latvia<\/option><option value='LB' >Lebanon<\/option><option value='LS' >Lesotho<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libya<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lithuania<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao S.A.R., China<\/option><option value='MK' >Macedonia<\/option><option value='MG' >Madagascar<\/option><option value='MW' >Malawi<\/option><option value='MY' >Malaysia<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MH' >Marshall Islands<\/option><option value='MQ' >Martinique<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldova<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MA' >Morocco<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NL' >Netherlands<\/option><option value='NC' >New Caledonia<\/option><option value='NZ' >New Zealand<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NF' >Norfolk Island<\/option><option value='KP' >North Korea<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norway<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PS' >Palestinian Territory<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua New Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Poland<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='QA' >Qatar<\/option><option value='CG' >Republic of the Congo (Brazzaville)<\/option><option value='RE' >Reunion<\/option><option value='RO' >Romania<\/option><option value='RU' >Russia<\/option><option value='RW' >Rwanda<\/option><option value='BL' >Saint Barth&eacute;lemy<\/option><option value='SH' >Saint Helena<\/option><option value='KN' >Saint Kitts and Nevis<\/option><option value='LC' >Saint Lucia<\/option><option value='SX' >Saint Martin (Dutch part)<\/option><option value='MF' >Saint Martin (French part)<\/option><option value='PM' >Saint Pierre and Miquelon<\/option><option value='VC' >Saint Vincent and the Grenadines<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tome and Principe<\/option><option value='SA' >Saudi Arabia<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SK' >Slovakia<\/option><option value='SI' >Slovenia<\/option><option value='SB' >Solomon Islands<\/option><option value='SO' >Somalia<\/option><option value='ZA' >South Africa<\/option><option value='GS' >South Georgia\/Sandwich Islands<\/option><option value='KR' >South Korea<\/option><option value='SS' >South Sudan<\/option><option value='ES' >Spain<\/option><option value='LK' >Sri Lanka<\/option><option value='SD' >Sudan<\/option><option value='SR' >Suriname<\/option><option value='SJ' >Svalbard and Jan Mayen<\/option><option value='SZ' >Swaziland<\/option><option value='SE' >Sweden<\/option><option value='CH' >Switzerland<\/option><option value='SY' >Syria<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzania<\/option><option value='TH' >Thailand<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad and Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >Turkey<\/option><option value='TM' >Turkmenistan<\/option><option value='TC' >Turks and Caicos Islands<\/option><option value='TV' >Tuvalu<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='AE' >United Arab Emirates<\/option><option value='GB' >United Kingdom (UK)<\/option><option value='US' >United States (US)<\/option><option value='UM' >United States (US) Minor Outlying Islands<\/option><option value='VI' >United States (US) Virgin Islands<\/option><option value='UY' >Uruguay<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VA' >Vatican<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='WF' >Wallis and Futuna<\/option><option value='EH' >Western Sahara<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-left'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text' aria-label=\"Employer\">Employer<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" data-name=\"input_text\" id=\"ff_5_input_text\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-left'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_1' aria-label=\"Occupation\">Occupation <\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" data-name=\"input_text_1\" id=\"ff_5_input_text_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class=\"ff-name-address-wrapper fluent-address\" data-type=\"address-element\" data-name=\"address_3\" ><div class='ff-el-input--label'><label aria-label=\"Employer&#039;s Physical Address\">Employer's Physical Address<\/label><\/div><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_3_address_line_1_' aria-label=\"Address Line 1\">Address Line 1<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_3[address_line_1]\" id=\"ff_5_address_3_address_line_1_\" class=\"ff-el-form-control\" placeholder=\"Address Line 1\" data-key_name=\"address_line_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_3_address_line_2_' aria-label=\"Address Line 2\">Address Line 2<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_3[address_line_2]\" id=\"ff_5_address_3_address_line_2_\" class=\"ff-el-form-control\" placeholder=\"Address Line 2\" data-key_name=\"address_line_2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_3_city_' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_3[city]\" id=\"ff_5_address_3_city_\" class=\"ff-el-form-control\" placeholder=\"City\" data-key_name=\"city\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_3_state_' aria-label=\"State\">State<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_3[state]\" id=\"ff_5_address_3_state_\" class=\"ff-el-form-control\" placeholder=\"State\" data-key_name=\"state\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_3_zip_' aria-label=\"Zip Code\">Zip Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_3[zip]\" id=\"ff_5_address_3_zip_\" class=\"ff-el-form-control\" placeholder=\"Zip\" data-key_name=\"zip\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_3_country_' aria-label=\"Country\">Country<\/label><\/div><div class='ff-el-input--content'><select name=\"address_3[country]\" id=\"ff_5_address_3_country_\" class=\"ff-el-form-control\" placeholder=\"Select Country\" data-key_name=\"country\" aria-invalid='false' aria-required=false><option value=''>Select Country<\/option><option value='AF' >Afghanistan<\/option><option value='AX' >Aland Islands<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctica<\/option><option value='AG' >Antigua and Barbuda<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BY' >Belarus<\/option><option value='PW' >Belau<\/option><option value='BE' >Belgium<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Saint Eustatius and Saba<\/option><option value='BA' >Bosnia and Herzegovina<\/option><option value='BW' >Botswana<\/option><option value='BV' >Bouvet Island<\/option><option value='BR' >Brazil<\/option><option value='IO' >British Indian Ocean Territory<\/option><option value='VG' >British Virgin Islands<\/option><option value='BN' >Brunei<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='KH' >Cambodia<\/option><option value='CM' >Cameroon<\/option><option value='CA' >Canada<\/option><option value='CV' >Cape Verde<\/option><option value='KY' >Cayman Islands<\/option><option value='CF' >Central African Republic<\/option><option value='TD' >Chad<\/option><option value='CL' >Chile<\/option><option value='CN' >China<\/option><option value='CX' >Christmas Island<\/option><option value='CC' >Cocos (Keeling) Islands<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comoros<\/option><option value='CK' >Cook Islands<\/option><option value='CR' >Costa Rica<\/option><option value='HR' >Croatia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura&ccedil;ao<\/option><option value='CY' >Cyprus<\/option><option value='CZ' >Czech Republic<\/option><option value='CD' >Democratic Republic of the Congo (Kinshasa)<\/option><option value='DK' >Denmark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominica<\/option><option value='DO' >Dominican Republic<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egypt<\/option><option value='SV' >El Salvador<\/option><option value='GQ' >Equatorial Guinea<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='ET' >Ethiopia<\/option><option value='FK' >Falkland Islands<\/option><option value='FO' >Faroe Islands<\/option><option value='FJ' >Fiji<\/option><option value='FI' >Finland<\/option><option value='FR' >France<\/option><option value='GF' >French Guiana<\/option><option value='PF' >French Polynesia<\/option><option value='TF' >French Southern Territories<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germany<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GR' >Greece<\/option><option value='GL' >Greenland<\/option><option value='GD' >Grenada<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GN' >Guinea<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HM' >Heard Island and McDonald Islands<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hungary<\/option><option value='IS' >Iceland<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Ireland<\/option><option value='IM' >Isle of Man<\/option><option value='IL' >Israel<\/option><option value='IT' >Italy<\/option><option value='CI' >Ivory Coast<\/option><option value='JM' >Jamaica<\/option><option value='JP' >Japan<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordan<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='XK' >Kosovo<\/option><option value='KW' >Kuwait<\/option><option value='KG' >Kyrgyzstan<\/option><option value='LA' >Laos<\/option><option value='LV' >Latvia<\/option><option value='LB' >Lebanon<\/option><option value='LS' >Lesotho<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libya<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lithuania<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao S.A.R., China<\/option><option value='MK' >Macedonia<\/option><option value='MG' >Madagascar<\/option><option value='MW' >Malawi<\/option><option value='MY' >Malaysia<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MH' >Marshall Islands<\/option><option value='MQ' >Martinique<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldova<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MA' >Morocco<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NL' >Netherlands<\/option><option value='NC' >New Caledonia<\/option><option value='NZ' >New Zealand<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NF' >Norfolk Island<\/option><option value='KP' >North Korea<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norway<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PS' >Palestinian Territory<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua New Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Poland<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='QA' >Qatar<\/option><option value='CG' >Republic of the Congo (Brazzaville)<\/option><option value='RE' >Reunion<\/option><option value='RO' >Romania<\/option><option value='RU' >Russia<\/option><option value='RW' >Rwanda<\/option><option value='BL' >Saint Barth&eacute;lemy<\/option><option value='SH' >Saint Helena<\/option><option value='KN' >Saint Kitts and Nevis<\/option><option value='LC' >Saint Lucia<\/option><option value='SX' >Saint Martin (Dutch part)<\/option><option value='MF' >Saint Martin (French part)<\/option><option value='PM' >Saint Pierre and Miquelon<\/option><option value='VC' >Saint Vincent and the Grenadines<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tome and Principe<\/option><option value='SA' >Saudi Arabia<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SK' >Slovakia<\/option><option value='SI' >Slovenia<\/option><option value='SB' >Solomon Islands<\/option><option value='SO' >Somalia<\/option><option value='ZA' >South Africa<\/option><option value='GS' >South Georgia\/Sandwich Islands<\/option><option value='KR' >South Korea<\/option><option value='SS' >South Sudan<\/option><option value='ES' >Spain<\/option><option value='LK' >Sri Lanka<\/option><option value='SD' >Sudan<\/option><option value='SR' >Suriname<\/option><option value='SJ' >Svalbard and Jan Mayen<\/option><option value='SZ' >Swaziland<\/option><option value='SE' >Sweden<\/option><option value='CH' >Switzerland<\/option><option value='SY' >Syria<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzania<\/option><option value='TH' >Thailand<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad and Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >Turkey<\/option><option value='TM' >Turkmenistan<\/option><option value='TC' >Turks and Caicos Islands<\/option><option value='TV' >Tuvalu<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='AE' >United Arab Emirates<\/option><option value='GB' >United Kingdom (UK)<\/option><option value='US' >United States (US)<\/option><option value='UM' >United States (US) Minor Outlying Islands<\/option><option value='VI' >United States (US) Virgin Islands<\/option><option value='UY' >Uruguay<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VA' >Vatican<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='WF' >Wallis and Futuna<\/option><option value='EH' >Western Sahara<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-left'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_numeric_field_2' aria-label=\"Employer&#039;s Contact Number\">Employer's Contact Number <\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric_field_2\" id=\"ff_5_numeric_field_2\" class=\"ff-el-form-control\" data-name=\"numeric_field_2\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 57.21%;'><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_3\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><p style=\"text-align: center\"><strong>MEDICAL AID DETAILS<\/strong><\/p>\n<p style=\"text-align: center\"><strong>(if applicable)(Please obtain a copy of the card's front and back)<\/strong><\/p><\/div><hr \/><\/div><div class='ff-el-group ff-el-form-left'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_2' aria-label=\"Medical Aid\">Medical Aid<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_2\" class=\"ff-el-form-control\" data-name=\"input_text_2\" id=\"ff_5_input_text_2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-left'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_numeric_field_3' aria-label=\"Medical Aid Number\">Medical Aid Number<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric_field_3\" id=\"ff_5_numeric_field_3\" class=\"ff-el-form-control\" data-name=\"numeric_field_3\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-left'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_3' aria-label=\"Medical Aid Plan\/Option\">Medical Aid Plan\/Option<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_3\" class=\"ff-el-form-control\" data-name=\"input_text_3\" id=\"ff_5_input_text_3\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 42.79%;'><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_4\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><p style=\"text-align: center\"><strong>PATIENT DETAILS\u00a0<\/strong><\/p><\/div><hr \/><\/div><div data-type=\"name-element\" data-name=\"names_1\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_names_1_first_name_' >First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_1[first_name]\" id=\"ff_5_names_1_first_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your First Name\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_names_1_last_name_' >Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_1[last_name]\" id=\"ff_5_names_1_last_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your Last Name\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-left'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_4' aria-label=\"Dependent code on Medical Aid Card\">Dependent code on Medical Aid Card <\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_4\" class=\"ff-el-form-control\" data-name=\"input_text_4\" id=\"ff_5_input_text_4\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-el-form-left'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_numeric_field_4' aria-label=\"ID\">ID<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric_field_4\" id=\"ff_5_numeric_field_4\" class=\"ff-el-form-control\" data-name=\"numeric_field_4\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group ff-el-form-left'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_dropdown' aria-label=\"Gender\">Gender<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown\" id=\"ff_5_dropdown\" class=\"ff-el-form-control\" data-name=\"dropdown\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\">- Select -<\/option><option value=\"Male\"  >Male<\/option><option value=\"Female \"  >Female<\/option><\/select><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_1  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_5\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><p style=\"text-align: center\"><strong>FRIEND\/RELATIVE AT A DIFFERENT ADDRESS\u00a0<\/strong><\/p><\/div><hr \/><\/div><div data-type=\"name-element\" data-name=\"names_2\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_names_2_first_name_' >First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_2[first_name]\" id=\"ff_5_names_2_first_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your First Name\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_names_2_last_name_' >Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_2[last_name]\" id=\"ff_5_names_2_last_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your Last Name\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_dropdown_1' aria-label=\"Relationship\">Relationship <\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_1\" id=\"ff_5_dropdown_1\" class=\"ff-el-form-control\" data-name=\"dropdown_1\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\">- Select -<\/option><option value=\"Parent\"  >Parent<\/option><option value=\"Sibling \"  >Sibling<\/option><option value=\"Friend\"  >Friend<\/option><option value=\"Other\"  >Other<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_numeric_field_6' aria-label=\"Cell Phone\">Cell Phone <\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric_field_6\" id=\"ff_5_numeric_field_6\" class=\"ff-el-form-control\" data-name=\"numeric_field_6\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_dropdown_2' aria-label=\"GAP Cover\">GAP Cover<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_2\" id=\"ff_5_dropdown_2\" class=\"ff-el-form-control\" data-name=\"dropdown_2\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=false><option value=\"\">- Select -<\/option><option value=\"Yes\"  >Yes<\/option><option value=\"No\"  >No<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_numeric_field_7' aria-label=\"Account Number Assigned on the System\">Account Number Assigned on the System <\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric_field_7\" id=\"ff_5_numeric_field_7\" class=\"ff-el-form-control\" data-name=\"numeric_field_7\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_1  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_6\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><p style=\"text-align: center\"><strong>DETAILS OF REFERRING DOCTOR\u00a0<\/strong><\/p><\/div><hr \/><\/div><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_input_text_5' aria-label=\"GP\/Doctor&#039;s Name and Surname\">GP\/Doctor's Name and Surname<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_5\" class=\"ff-el-form-control\" data-name=\"input_text_5\" id=\"ff_5_input_text_5\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_numeric_field_5' aria-label=\"Contact Number\">Contact Number<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric_field_5\" id=\"ff_5_numeric_field_5\" class=\"ff-el-form-control\" data-name=\"numeric_field_5\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_5\"  class='ff-t-container ff-column-container ff_columns_total_1  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group ff-el-form-left'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_6' aria-label=\"Notes:\">Notes: <\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_6\" class=\"ff-el-form-control\" data-name=\"input_text_6\" id=\"ff_5_input_text_6\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_6\"  class='ff-t-container ff-column-container ff_columns_total_1  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_7\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><p style=\"text-align: center\"><strong>GENERAL CONDITIONS<\/strong><\/p>\n<p style=\"text-align: center\" data-start=\"141\" data-end=\"1034\">I, the undersigned, understand I am personally responsible for payment if my medical aid opts for whatsoever reason not to pay the account. In the event of divorce, the parent accompanying the minor is responsible for settlement of the account. In the event of any legal action being instituted against me for recovery of any amount whatsoever, I shall be liable for all legal costs, including a 20% admin fee on each instalment paid. If the case is defended, I will be liable for legal costs incurred on an attorney\/client scale. Once my account has been handed over, no further correspondence may be entered into with the practice, but only with the debt collection company chosen by the practice. The National Credit Act, no 34 of 2005, is not applicable to this claim. I hereby choose the address stated above as my domicilium citandi et executandi for all purposes under this agreement.<\/p>\n<p style=\"text-align: center\" data-start=\"1036\" data-end=\"1202\"><strong>By signing this document, I proclaim I have read, understood and agreed to the conditions stated above. I confirm that the information provided is true and correct.<\/strong><\/p><\/div><hr \/><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='Terms and Conditions: I have read and agree to the Terms and Conditions and Privacy Policy Contains 2 links. Use tab navigation to review.' class='ff-el-form-check-label ff_tc_label' for=terms-n-condition_09466ee5cdf0c458864bbd5e667ea14e><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"terms-n-condition\" class=\"ff-el-form-check-input\" data-name=\"terms-n-condition\" id=\"terms-n-condition_09466ee5cdf0c458864bbd5e667ea14e\"  value='on' aria-invalid='false' aria-required=false><\/span> <div class='ff_t_c'>I have read and agree to the <a target=\"_blank\" rel=\"noopener\" href=\"#\">Terms and Conditions<\/a> and <a target=\"_blank\" rel=\"noopener\" href=\"#\">Privacy Policy<\/a><\/div><\/label><\/div><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='I consent to have this website store my submitted information so they can respond to my inquiry' class='ff-el-form-check-label ff_tc_label' for=gdpr-agreement_232df71f2e3de71459dd5ddf992a3918><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"gdpr-agreement\" class=\"ff-el-form-check-input ff_gdpr_field\" data-name=\"gdpr-agreement\" id=\"gdpr-agreement_232df71f2e3de71459dd5ddf992a3918\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'>I consent to have this website store my submitted information so they can respond to my inquiry<\/div><\/label><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_8\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><p style=\"text-align: center\" data-start=\"97\" data-end=\"385\">Rhythm Financial Services is the account, management and debt collecting agent to the practice, and herewith agrees to maintain the confidentiality of any confidential information supplied by the patient and undertake to utilise this information strictly for the above-mentioned purpose<\/p>\n<p style=\"text-align: center\" data-start=\"387\" data-end=\"406\"><strong>Tel: 051 407 0803<\/strong><\/p><\/div><hr \/><\/div><div class='ff-el-group ff-text-left ff_submit_btn_wrapper'><button type=\"submit\" class=\"ff-btn ff-btn-submit ff-btn-md ff_btn_no_style\" >Submit Form<\/button><\/div><\/fieldset><\/form><div id='fluentform_5_errors' class='ff-errors-in-stack ff_form_instance_5_1 ff-form-loading_errors ff_form_instance_5_1_errors'><\/div><\/div>        <script type=\"text\/javascript\">\n            window.fluent_form_ff_form_instance_5_1 = {\"id\":\"5\",\"settings\":{\"layout\":{\"labelPlacement\":\"top\",\"asteriskPlacement\":\"asterisk-right\",\"helpMessagePlacement\":\"with_label\",\"errorMessagePlacement\":\"inline\",\"cssClassName\":\"\"},\"restrictions\":{\"denyEmptySubmission\":{\"enabled\":false}}},\"form_instance\":\"ff_form_instance_5_1\",\"form_id_selector\":\"fluentform_5\",\"rules\":{\"names[first_name]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is 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value\",\"global\":true},\"min\":{\"value\":\"\",\"message\":\"Validation fails for minimum value\",\"global_message\":\"Validation fails for minimum value\",\"global\":true},\"max\":{\"value\":\"\",\"message\":\"Validation fails for maximum value\",\"global_message\":\"Validation fails for maximum value\",\"global\":true},\"digits\":{\"value\":\"10\",\"message\":\"Validation fails for limited digits\",\"global_message\":\"Validation fails for limited digits\",\"global\":true}},\"input_text_2\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"numeric_field_3\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\",\"global_message\":\"This field must contain numeric value\",\"global\":true},\"min\":{\"value\":\"\",\"message\":\"Validation 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