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https://support.nmcrs.org/a/educationassistance?contactdata=4enMRx9B4VbU8w7QhoedSa974gWa2T5FaeuQKjIF618ceAx75E1m8kExRElDdv...
Submission: On April 06 via manual from US — Scanned from DE
Submission: On April 06 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST v1
<form class="clearfix" method="post" novalidate="" action="v1" accept-charset="utf-8" autocomplete="on">
<div class="at-markup FastAction" id="NVContributionForm1541347-FastAction">
<div class="fastaction-block">
<div class="fastAction clearfix">
<p>
<span class="fa-cta">
<a href="#fastaction-login" class="profile-link" aria-label="FastAction">
<img class="profile-link-fa-image" src="//static.everyaction.com/ea-actiontag/assets/images/fast-action.svg">
</a>
<span><a href="https://fastaction.ngpvan.com##whats-this" class="circle" id="fastaction-whatsthis" data-popup="true" data-popup-width="515" data-popup-height="540" target="_blank">?</a></span>
</span>
<span class="fa-lead"> Take future action with a single click.<br>
<a href="#fastaction-login" class="call-modal" id="fastaction-widget-login">Log in</a> or <a href="#fastaction-signup" class="call-modal" id="fastaction-widget-signup">Sign up</a> for <i>Fast</i><b>Action</b>
</span>
</p>
</div>
</div>
</div>
<ol class="at-steps clearfix">
<li data-step="0" class="at-step active">
<a title="" href="#ContributionInformation">
<span class="step-title">Amount</span>
</a>
</li>
<li data-step="1" class="at-step ">
<a title="" href="#ContactInformation">
<span class="step-title">Details</span>
</a>
</li>
<li data-step="2" class="at-step ">
<a title="" href="#PaymentInformation">
<span class="step-title">Payment</span>
</a>
</li>
</ol>
<div class="at-error-console"></div>
<div data-name="undefined" data-subview="submit_view" data-subview-index="2"></div>
<fieldset class="at-fieldset ContributionInformation" id="NVContributionForm1541347-ContributionInformation" style="border: none;">
<legend class="at-legend">Amount</legend>
<div class="at-fields">
<div class="at-row at-row-full ">
<div class="form-unit form-unit-radio form-item-selectedfrequency" id="NVContributionForm1541347-ContributionInformation-SelectedFrequency">
<div class="radios" role="radiogroup" aria-labelledby="NVContributionForm1541347-ContributionInformation-SelectedFrequency">
<label title="Monthly" class="at-radio-label-4" role="radio">
<input type="radio" name="SelectedFrequency" value="4"> Monthly </label><label title="One-Time" class="at-radio-label-0" role="radio">
<input type="radio" name="SelectedFrequency" checked="" value="0"> One-Time </label>
<div class="radio-description radio-description-value-0">Consider giving monthly</div>
</div>
</div>
</div>
<div class="at-row at-row-full ">
<input id="ProcessingCurrency_Value" type="hidden" name="ProcessingCurrency.Value" value="USD">
</div>
<div class="at-row at-row-full ">
<div class="form-item form-type-radios form-item-selectamount" id="NVContributionForm1541347-ContributionInformation-SelectAmount">
<div class="at-row SelectAmount OtherAmount NonRecurringButtons">
<div class="at-radio">
<div class="at-radios clearfix">
<label class="label-amount" title="$500">
<input name="SelectAmount" type="radio" value="500.00"> $500 <a></a> </label><label class="label-amount" title="$250">
<input name="SelectAmount" type="radio" value="250.00"> $250 <a></a> </label><label class="label-amount" title="$100">
<input name="SelectAmount" type="radio" value="100.00"> $100 <a></a> </label><label class="label-amount" title="$50">
<input name="SelectAmount" type="radio" value="50.00"> $50 <a></a> </label><label class="label-amount" title="$25">
<input name="SelectAmount" type="radio" value="25.00"> $25 <a></a> </label><label class="label-amount label-otheramount" title="Other">
<input name="SelectAmount" type="radio" class="radio-other" value="other"> Other <input type="number" tabindex="-1" autocomplete="transaction-amount" class="edit-otheramount" name="OtherAmount" title="Other Amount"
placeholder="0.00">
<span class="label-otheramount-prefix">$</span>
</label>
</div>
</div>
</div>
</div>
</div>
</div>
</fieldset>
<fieldset class="at-fieldset TributeGift" id="NVContributionForm1541347-TributeGift">
<div class="at-fields">
<div class="at-row at-row-full EnableTributeGift">
<label class="at-check EnableTributeGift" id="NVContributionForm1541347-TributeGift-EnableTributeGift"><input type="checkbox" name="EnableTributeGift"> <span class="at-checkbox-title-container"><span class="at-checkbox-title"
id="NVContributionForm1541347-TributeGift-EnableTributeGift-label">I'd like to make this contribution in honor or in memory of someone</span></span>
</label>
</div>
<div class="at-row">
<div class="at-tribute-gift" style="display:none">
<div class="form-unit form-unit-radio form-item-inhonororinmemoryof" id="NVContributionForm1541347-TributeGift-InHonorOrInMemoryOf"><label id="NVContributionForm1541347-TributeGift-InHonorOrInMemoryOf"> Is this an Honorary or Memorial
Gift?</label>
<div class="radios" role="radiogroup" aria-labelledby="NVContributionForm1541347-TributeGift-InHonorOrInMemoryOf">
<label title="In honor of" class="at-radio-label-2" role="radio">
<input type="radio" name="InHonorOrInMemoryOf" checked="" value="2"> In honor of </label><label title="In memory of" class="at-radio-label-1" role="radio">
<input type="radio" name="InHonorOrInMemoryOf" value="1"> In memory of </label>
</div>
</div><label class="at-text HonoreeName" id="NVContributionForm1541347-TributeGift-HonoreeName">Honoree Name <small>(Optional)</small><input type="text" autocomplete="on" false="" title="Honoree Name" name="HonoreeName" value=""
maxlength="100">
</label>
</div>
</div>
</div>
</fieldset>
<fieldset class="at-fieldset RecipientInformation" id="NVContributionForm1541347-RecipientInformation" style="display: none;">
<div class="at-fields">
<div class="at-row">
<label class="at-check IncludeRecipient" id="NVContributionForm1541347-RecipientInformation-IncludeRecipient"><input type="checkbox" name="IncludeRecipient"> <span class="at-checkbox-title-container"><span class="at-checkbox-title"
id="NVContributionForm1541347-RecipientInformation-IncludeRecipient-label">I'd like to notify someone of this contribution</span></span>
</label>
</div>
<div class="at-recipient-info" style="display: none;">
<div class="at-title">Who would you like to notify?</div>
<div class="at-row at-row-solo at-row-full RecipientInfoHeaderHtml">
<div class="at-markup RecipientInfoHeaderHtml" id="NVContributionForm1541347-RecipientInformation-RecipientInfoHeaderHtml">A message will be sent to the recipient to inform them of your contribution. Customize the notification by adding a
personal message.</div>
</div>
<div class="at-row RecipientFirstName RecipientLastName"><label class="at-text RecipientFirstName" id="NVContributionForm1541347-RecipientInformation-RecipientFirstName">First Name <small>(Optional)</small><input type="text"
autocomplete="on" false="" title="First Name" name="RecipientFirstName" value="" maxlength="50">
</label><label class="at-text RecipientLastName" id="NVContributionForm1541347-RecipientInformation-RecipientLastName">Last Name <small>(Optional)</small><input type="text" autocomplete="on" false="" title="Last Name"
name="RecipientLastName" value="" maxlength="50">
</label></div>
<div class="at-row at-row-solo RecipientStreetAddress"><label class="at-text RecipientStreetAddress" id="NVContributionForm1541347-RecipientInformation-RecipientStreetAddress">Street Address <small>(Optional)</small><input type="text"
autocomplete="on" false="" title="Street Address" name="RecipientStreetAddress" value="" maxlength="100">
</label></div>
<div class="at-row RecipientCountry RecipientPostalCode RecipientCity RecipientStateProvince"><label class="at-select RecipientCountry" id="NVContributionForm1541347-RecipientInformation-RecipientCountry">Country
<small>(Optional)</small><select autocomplete="on" title="Country" name="RecipientCountry" class="select2-hidden-accessible" id="NVContributionForm1541347-RecipientInformation-RecipientCountry-select" tabindex="-1" aria-hidden="true">
<option value="">- Select -</option>
<option value="AF">Afghanistan</option>
<option value="AX">Åland Islands</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</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="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 (Plurinational State of)</option>
<option value="BQ">Bonaire, Sint 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 Darussalam</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="CV">Cabo Verde</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</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="CG">Congo</option>
<option value="CD">Congo (Democratic Republic of the)</option>
<option value="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="CI">Côte d'Ivoire</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CW">Curaçao</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czechia</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="SZ">Eswatini</option>
<option value="ET">Ethiopia</option>
<option value="FK">Falkland Islands (Malvinas)</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="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="VA">Holy See</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 (Islamic Republic of)</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="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="KP">Korea (Democratic People's Republic of)</option>
<option value="KR">Korea (Republic of)</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Lao People's Democratic Republic</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</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="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 (Federated States of)</option>
<option value="MD">Moldova (Republic of)</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="MK">North Macedonia</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PK">Pakistan</option>
<option value="PW">Palau</option>
<option value="PS">Palestine (State of)</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="QA">Qatar</option>
<option value="RE">Réunion</option>
<option value="RO">Romania</option>
<option value="RU">Russian Federation</option>
<option value="RW">Rwanda</option>
<option value="BL">Saint Barthélemy</option>
<option value="SH">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="LC">Saint Lucia</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="SX">Sint Maarten (Dutch part)</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 and the South Sandwich Islands</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="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syrian Arab Republic</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania (United Republic of)</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</option>
<option value="US">United States</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VE">Venezuela (Bolivarian Republic of)</option>
<option value="VN">Viet Nam</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><span class="select2 select2-container select2-container--default" dir="ltr" style="width: 100px;"><span class="selection"><span class="select2-selection select2-selection--single" role="combobox" aria-haspopup="true"
aria-expanded="false" title="Country" tabindex="0" aria-labelledby="select2-NVContributionForm1541347-RecipientInformation-RecipientCountry-select-container"><span class="select2-selection__rendered"
id="select2-NVContributionForm1541347-RecipientInformation-RecipientCountry-select-container" title="United States">United States</span><span class="select2-selection__arrow"
role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
</label><label class="at-text RecipientPostalCode" id="NVContributionForm1541347-RecipientInformation-RecipientPostalCode">Postal Code <small>(Optional)</small><input type="tel" autocomplete="on" pattern="^\d{5}([\-]\d{4})?$" false=""
title="Postal Code" name="RecipientPostalCode" value="" maxlength="10">
</label><label class="at-text RecipientCity" id="NVContributionForm1541347-RecipientInformation-RecipientCity">City <small>(Optional)</small><input type="text" autocomplete="on" false="" title="City" name="RecipientCity" value=""
maxlength="25">
</label><label class="at-select RecipientStateProvince" id="NVContributionForm1541347-RecipientInformation-RecipientStateProvince">State/Province <small>(Optional)</small><select autocomplete="on" title="State/Province"
name="RecipientStateProvince" class="" id="NVContributionForm1541347-RecipientInformation-RecipientStateProvince-select">
<option value="">- State -</option>
<option value="AK">AK</option>
<option value="AL">AL</option>
<option value="AR">AR</option>
<option value="AZ">AZ</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DC">DC</option>
<option value="DE">DE</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="HI">HI</option>
<option value="IA">IA</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="MA">MA</option>
<option value="MD">MD</option>
<option value="ME">ME</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MO">MO</option>
<option value="MS">MS</option>
<option value="MT">MT</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="NE">NE</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NV">NV</option>
<option value="NY">NY</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="RI">RI</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VA">VA</option>
<option value="VT">VT</option>
<option value="WA">WA</option>
<option value="WI">WI</option>
<option value="WV">WV</option>
<option value="WY">WY</option>
<option value="AS">AS</option>
<option value="FM">FM</option>
<option value="GU">GU</option>
<option value="MH">MH</option>
<option value="MP">MP</option>
<option value="PR">PR</option>
<option value="PW">PW</option>
<option value="VI">VI</option>
<option value="AA">AA</option>
<option value="AE">AE</option>
<option value="AP">AP</option>
</select>
</label></div>
<div class="at-row at-row-solo RecipientEmailAddress"><label class="at-text RecipientEmailAddress" id="NVContributionForm1541347-RecipientInformation-RecipientEmailAddress">Email <small>(Optional)</small><input type="email"
autocomplete="on" pattern="^([\w!#$%&'*+\-\/=?\^`{|}~]+\.)*[\w!#$%&'*+\-\/=?\^`{|}~]+@((((([a-zA-Z0-9]{1}[a-zA-Z0-9\-]{0,62}[a-zA-Z0-9]{1})|[a-zA-Z])\.)+[a-zA-Z]{2,62})|(\d{1,3}\.){3}\d{1,3}(:\d{1,5})?)$" false="" title="Email"
name="RecipientEmailAddress" value="" maxlength="100">
</label></div>
<div class="at-row at-row-solo NotificationSendDate"><label class="at-date notificationsenddate" id="NVContributionForm1541347-RecipientInformation-NotificationSendDate"></label></div>
<div class="at-row at-row-solo NotificationMessage"><label class="at-area NotificationMessage" id="NVContributionForm1541347-RecipientInformation-NotificationMessage"></label></div>
</div>
<div class="at-row">
<div class="at-recipient-msg" style="display: none;"><label class="at-date notificationsenddate" id="NVContributionForm1541347-RecipientInformation-NotificationSendDate">Send Date <small>(Optional)</small><input type="text"
title="Send Date" name="NotificationSendDate" value="" maxlength="10" size="10" class="hasDatepicker" placeholder="MM/DD/YYYY" autocomplete="off" id="dp1680761209937">
</label><label class="at-area NotificationMessage" id="NVContributionForm1541347-RecipientInformation-NotificationMessage">Message <small>(Optional)</small><textarea false="" title="Message" name="NotificationMessage"
maxlength="4000"></textarea>
</label></div>
</div>
</div>
</fieldset>
<fieldset class="at-fieldset ContactInformation hideStep" id="NVContributionForm1541347-ContactInformation" style="display: block;">
<legend class="at-legend">Details</legend>
<div class="at-fields">
<div class="at-row service-branch-container"><label class="at-select CustomFormFieldQuestion_7450549325552829_MappedCustomFormFieldQuestion_256 service-branch"
id="NVContributionForm1541347-Interests-CustomFormFieldQuestion_7450549325552829_MappedCustomFormFieldQuestion_256">Service Branch <small>(Optional)</small><select autocomplete="on" title="Service Branch"
name="CustomFormFieldQuestion_7450549325552829_MappedCustomFormFieldQuestion_256" class=" " id="NVContributionForm1541347-Interests-CustomFormFieldQuestion_7450549325552829_MappedCustomFormFieldQuestion_256-select">
<option value="">- Select -</option>
<option value="1">Air Force</option>
<option value="2">Army</option>
<option value="3">Coast Guard</option>
<option value="4">Marine Corps</option>
<option value="5">Navy</option>
</select>
</label><label class="at-select CustomFormFieldQuestion_4094548792056130_MappedCustomFormFieldQuestion_257 service-status"
id="NVContributionForm1541347-Interests-CustomFormFieldQuestion_4094548792056130_MappedCustomFormFieldQuestion_257">Status <small>(Optional)</small><select autocomplete="on" title="Status"
name="CustomFormFieldQuestion_4094548792056130_MappedCustomFormFieldQuestion_257" class=" " id="NVContributionForm1541347-Interests-CustomFormFieldQuestion_4094548792056130_MappedCustomFormFieldQuestion_257-select">
<option value="">- Select -</option>
<option value="1">Active</option>
<option value="2">Former</option>
<option value="3">Reserve</option>
<option value="4">Retired</option>
</select>
</label><label class="at-text CustomFormFieldQuestion_3944578255679310_MappedCustomFormFieldQuestion_258 service-rank" id="NVContributionForm1541347-Interests-CustomFormFieldQuestion_3944578255679310_MappedCustomFormFieldQuestion_258">Rank
<small>(Optional)</small><input type="text" autocomplete="on" false="" title="Rank" name="CustomFormFieldQuestion_3944578255679310_MappedCustomFormFieldQuestion_258" value="" maxlength="75">
</label></div>
<div class="at-row Prefix FirstName LastName Suffix"><label class="at-text Prefix" id="NVContributionForm1541347-ContactInformation-Prefix">Prefix <small>(Optional)</small><input type="text" autocomplete="honorific-prefix"
x-autocompletetype="name-prefix" false="" title="Prefix" name="Prefix" value="" maxlength="10" list="at-prefixes">
</label><label class="at-text FirstName" id="NVContributionForm1541347-ContactInformation-FirstName">First Name<input type="text" autocomplete="given-name" x-autocompletetype="given-name" required="" title="First Name (required)"
name="FirstName" value="" maxlength="20">
</label><label class="at-text LastName" id="NVContributionForm1541347-ContactInformation-LastName">Last Name<input type="text" autocomplete="family-name" x-autocompletetype="surname" required="" title="Last Name (required)" name="LastName"
value="" maxlength="25">
</label><label class="at-text Suffix" id="NVContributionForm1541347-ContactInformation-Suffix">Suffix <small>(Optional)</small><input type="text" autocomplete="honorific-suffix" x-autocompletetype="name-suffix" false="" title="Suffix"
name="Suffix" value="" maxlength="5">
</label></div>
<div class="at-row at-row-solo AddressLine1"><label class="at-text AddressLine1" id="NVContributionForm1541347-ContactInformation-AddressLine1">Street Address<input type="text" autocomplete="address-line1" x-autocompletetype="address-line1"
required="" title="Street Address (required)" name="AddressLine1" value="" maxlength="99">
</label></div>
<div class="at-row PostalCode City StateProvince"><label class="at-text PostalCode" id="NVContributionForm1541347-ContactInformation-PostalCode">Zip Code<input type="tel" autocomplete="postal-code" x-autocompletetype="postal-code"
pattern="^\d{5}([\-]\d{4})?$" required="" title="Zip Code (required)" name="PostalCode" value="" maxlength="10">
</label><label class="at-text City" id="NVContributionForm1541347-ContactInformation-City">City<input type="text" autocomplete="address-level2" x-autocompletetype="locality" required="" title="City (required)" name="City" value=""
maxlength="25">
</label><label class="at-select StateProvince" id="NVContributionForm1541347-ContactInformation-StateProvince">State/Province<select required="" autocomplete="address-level1" x-autocompletetype="administrative-area" title="State/Province"
name="StateProvince" class=" required" id="NVContributionForm1541347-ContactInformation-StateProvince-select">
<option value="" disabled="">- State -</option>
<option value="AK">AK</option>
<option value="AL">AL</option>
<option value="AR">AR</option>
<option value="AZ">AZ</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DC">DC</option>
<option value="DE">DE</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="HI">HI</option>
<option value="IA">IA</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="MA">MA</option>
<option value="MD">MD</option>
<option value="ME">ME</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MO">MO</option>
<option value="MS">MS</option>
<option value="MT">MT</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="NE">NE</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NV">NV</option>
<option value="NY">NY</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="RI">RI</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VA">VA</option>
<option value="VT">VT</option>
<option value="WA">WA</option>
<option value="WI">WI</option>
<option value="WV">WV</option>
<option value="WY">WY</option>
<option value="AS">AS</option>
<option value="FM">FM</option>
<option value="GU">GU</option>
<option value="MH">MH</option>
<option value="MP">MP</option>
<option value="PR">PR</option>
<option value="PW">PW</option>
<option value="VI">VI</option>
<option value="AA">AA</option>
<option value="AE">AE</option>
<option value="AP">AP</option>
</select>
</label></div>
<div class="at-row EmailAddress HomePhone MobilePhone"><label class="at-text EmailAddress" id="NVContributionForm1541347-ContactInformation-EmailAddress">Email Address<input type="email" autocomplete="email" x-autocompletetype="email"
pattern="^([\w!#$%&'*+\-\/=?\^`{|}~]+\.)*[\w!#$%&'*+\-\/=?\^`{|}~]+@((((([a-zA-Z0-9]{1}[a-zA-Z0-9\-]{0,62}[a-zA-Z0-9]{1})|[a-zA-Z])\.)+[a-zA-Z]{2,62})|(\d{1,3}\.){3}\d{1,3}(:\d{1,5})?)$" required=""
title="Email Address (required)" name="EmailAddress" value="" maxlength="100" placeholder="email@email.com">
</label><label class="at-text HomePhone" id="NVContributionForm1541347-ContactInformation-HomePhone">Home Phone <small>(Optional)</small>
<div class="intl-tel-input iti iti--allow-dropdown">
<div class="iti__flag-container">
<div class="iti__selected-flag" role="combobox" aria-controls="iti-0__country-listbox" aria-owns="iti-0__country-listbox" aria-expanded="false" tabindex="0" title="United States: +1" aria-activedescendant="iti-0__item-us-preferred">
<div class="iti__flag iti__us"></div>
<div class="iti__arrow"></div>
</div>
</div><input type="tel" class="intl-phone-HomePhone" name="HomePhone" title="Home Phone" data-intl-tel-input-id="0">
</div>
</label><label class="at-text MobilePhone" id="NVContributionForm1541347-ContactInformation-MobilePhone">Mobile Phone <small>(Optional)</small>
<div class="intl-tel-input iti iti--allow-dropdown">
<div class="iti__flag-container">
<div class="iti__selected-flag" role="combobox" aria-controls="iti-1__country-listbox" aria-owns="iti-1__country-listbox" aria-expanded="false" tabindex="0" title="United States: +1" aria-activedescendant="iti-1__item-us-preferred">
<div class="iti__flag iti__us"></div>
<div class="iti__arrow"></div>
</div>
</div><input type="tel" class="intl-phone-MobilePhone" name="MobilePhone" title="Mobile Phone" data-intl-tel-input-id="1">
</div>
</label></div>
<div class="at-row at-row-solo at-row-full YesSignMeUpForUpdatesForBinder"><label class="at-check YesSignMeUpForUpdatesForBinder" id="NVContributionForm1541347-ContactInformation-YesSignMeUpForUpdatesForBinder"><input type="checkbox"
checked="" name="YesSignMeUpForUpdatesForBinder"> <span class="at-checkbox-title-container"><span class="at-checkbox-title" id="NVContributionForm1541347-ContactInformation-YesSignMeUpForUpdatesForBinder-label">Yes, sign me up for email
updates.</span></span>
</label></div>
<div class="at-row "><label class="at-text PersonalUrl" id="NVContributionForm1541347-ContactInformation-PersonalUrl"> <small>(Optional)</small><input type="text" autocomplete="on" false="" title="" name="PersonalUrl" value="" maxlength="">
</label></div>
<div class="at-row "><input id="SocialNetworkTrackingId_Value" type="hidden" name="SocialNetworkTrackingId.Value"></div>
<div class="at-row "><input id="SocialNetwork_Value" type="hidden" name="SocialNetwork.Value"></div>
<div class="at-row ">
<div class="at-markup TrackingPixel" id="NVContributionForm1541347-ContactInformation-TrackingPixel" style="display: none;"><img alt=""
src="https://secure.everyaction.com/v1/Track/Rhuj-bp_SkW8Xbufa9Zuhg2?contactdata=4enMRx9B4VbU8w7QhoedSa974gWa2T5FaeuQKjIF618ceAx75E1m8kExRElDdvyEx8P8CmBkbrpxazkUv6hNojUg11AbSVoK4rJ06FLJrQkrVCALgd5L9qRI6+KRjEK4JHGNzAxpZCtC5c6GM0DyexSj4ZsYwt9HndTKtoAl3KReYZnodDMD2tcN0iQ3w07iOJlx7q0ueSLjzgSxBLwm9Rd7BgT293xe6COALvN0yliPzQVMVTPmx58MpQYYE6i+&formSessionId=f364c37f-1e46-452e-9cda-8990e1bbd176&bName=chrome&dType=desktop&fUrl=aHR0cHM6Ly9zdXBwb3J0Lm5tY3JzLm9yZy9hL2VkdWNhdGlvbmFzc2lzdGFuY2U%2FY29udGFjdGRhdGE9NGVuTVJ4OUI0VmJVOHc3UWhvZWRTYTk3NGdXYTJUNUZhZXVRS2pJRjYxOGNlQXg3NUUxbThrRXhSRWxEZHZ5RXg4UDhDbUJrYnJweGF6a1V2NmhOb2pVZzExQWJTVm9LNHJKMDZGTEpyUWtyVkNBTGdkNUw5cVJJNitLUmpFSzRKSEdOekF4cFpDdEM1YzZHTTBEeWV4U2o0WnNZd3Q5SG5kVEt0b0FsM0tSZVlabm9kRE1EMnRjTjBpUTN3MDdpT0pseDdxMHVlU0xqemdTeEJMd205UmQ3QmdUMjkzeGU2Q09BTHZOMHlsaVB6UVZNVlRQbXg1OE1wUVlZRTZpKw%3D%3D&fRef="
style="display:none"></div>
</div>
</div>
<datalist id="at-prefixes">
<option value="Dr."></option>
<option value="Miss"></option>
<option value="Mr."></option>
<option value="Mrs."></option>
<option value="Ms."></option>
<option value="Mx."></option>
</datalist>
</fieldset>
<fieldset class="at-fieldset PaymentInformation hideStep" id="NVContributionForm1541347-PaymentInformation" style="display: block;">
<legend class="at-legend">Payment</legend>
<div class="at-fields">
<div class="at-row "><label class="at-text at-cc-number" id="NVContributionForm1541347-PaymentInformation-Account">Card Number<div class="cc-type-wrapper vgs-loading-placeholder" style="display: none;">
<div class="cc-type unknown"></div>
<input type="tel" autocomplete="cc-number" title="Credit Card Number" placeholder="•••• •••• •••• ••••" readonly="true">
</div>
<div id="vgs-Account-1541347" class="vgs-cc-iframe-wrapper vgs-input-container vgs-collect-container__empty vgs-collect-container__invalid isEmpty" tabindex="-1"><iframe title="Secure card number input frame"
src="https://js.verygoodvault.com/vgs-collect/2.14.0/lib/index.html#name=Account&placeholder=%E2%80%A2%E2%80%A2%E2%80%A2%E2%80%A2%20%E2%80%A2%E2%80%A2%E2%80%A2%E2%80%A2%20%E2%80%A2%E2%80%A2%E2%80%A2%E2%80%A2%20%E2%80%A2%E2%80%A2%E2%80%A2%E2%80%A2&type=card-number&validations%5B0%5D=validCardNumber&validations%5B1%5D=required&autoComplete=cc-number&formId=randomId608039867625035892&fieldId=randomId6008100384766081703&createdAt=1680761210621&tnt=dG50dzFwem5sYW0%3D&env=bGl2ZQ%3D%3D&logLevel=default&satellitePort=&vgsCollectSessionId=5d56483b-0c01-4444-b203-f628b13985a0&css%5BfontSize%5D=.875rem&css%5BfontFamily%5D=monospace&css%5BlineHeight%5D=1&css%5BbackgroundColor%5D=%23fff&css%5B%26%3A%3Aplaceholder%5D%5Bcolor%5D=%23ced4da&css%5B%26%3A%3Aplaceholder%5D%5BfontWeight%5D=bold"
frameborder="0" scrolling="0" allowtransparency="true" id="randomId6008100384766081703" form-id="randomId608039867625035892"></iframe></div>
</label><label class="at-text at-cc-expiration" id="NVContributionForm1541347-PaymentInformation-ExpirationDate">Expiration Date<div class="vgs-loading-placeholder" style="display: none;">
<input type="tel" autocomplete="cc-exp" title="Expiration Date (MM / YY)" placeholder="MM / YY" readonly="true">
</div>
<div id="vgs-ExpirationDate-1541347" class="vgs-ccexpiration-iframe-wrapper vgs-input-container vgs-collect-container__empty vgs-collect-container__invalid isEmpty"><iframe title="Secure card expiration date input frame"
src="https://js.verygoodvault.com/vgs-collect/2.14.0/lib/index.html#name=ExpirationDate&placeholder=MM%20%2F%20YY&type=card-expiration-date&serializers=W3sibmFtZSI6InNlcGFyYXRlIiwib3B0aW9ucyI6eyJtb250aE5hbWUiOiJFeHBpcmF0aW9uTW9udGgiLCJ5ZWFyTmFtZSI6IkV4cGlyYXRpb25ZZWFyIn19XQ%3D%3D&validations%5B0%5D=validCardExpirationDate&validations%5B1%5D=required&autoComplete=cc-exp&formId=randomId608039867625035892&fieldId=randomId6005852052608969616&createdAt=1680761210628&tnt=dG50dzFwem5sYW0%3D&env=bGl2ZQ%3D%3D&logLevel=default&satellitePort=&vgsCollectSessionId=5d56483b-0c01-4444-b203-f628b13985a0&css%5BfontSize%5D=.875rem&css%5BfontFamily%5D=monospace&css%5BlineHeight%5D=1&css%5BbackgroundColor%5D=%23fff&css%5B%26%3A%3Aplaceholder%5D%5Bcolor%5D=%23ced4da&css%5B%26%3A%3Aplaceholder%5D%5BfontWeight%5D=bold"
frameborder="0" scrolling="0" allowtransparency="true" id="randomId6005852052608969616" form-id="randomId608039867625035892"></iframe></div>
</label></div>
<div class="at-row ">
<div class="at-markup UpdateMyProfile at-mode-person-only" id="NVContributionForm1541347-PaymentInformation-UpdateMyProfile">
<div class="updateMyProfileSection" style=""><label style="display:inline;"><input type="checkbox" name="updateMyProfile" checked="checked"><span><span class="text">Remember me so that I can use <i>Fast</i><b>Action</b> next
time.</span></span></label></div>
</div>
</div>
<div class="at-row">
<div class="at-paypal-accepted-here" style="display: none;">
<div class="at-payment-integration-container" style="display: none;">
<img src="//d1aqhv4sn5kxtx.cloudfront.net/images/paypal-logo.png" alt="PayPal">
<p>You’ve authorized this payment through PayPal.</p>
<div>Contribution Amount: <b class="at-paypal-amount"></b></div>
<div>Account: <b class="at-paypal-account-info"></b></div>
</div>
<label class="paypal-label">
<input type="hidden" name="paypalNonce" value="">
</label>
</div>
</div>
</div>
</fieldset>
<fieldset class="at-fieldset Interests hideStep" id="NVContributionForm1541347-Interests" style="display: block;">
<legend class="at-legend">Finish</legend>
<div class="at-fields">
<div class="at-row at-row-full CustomFormFieldQuestion_7450549325552829_MappedCustomFormFieldQuestion_256">
</div>
<div class="at-row at-row-full CustomFormFieldQuestion_4094548792056130_MappedCustomFormFieldQuestion_257">
</div>
<div class="at-row at-row-full CustomFormFieldQuestion_3944578255679310_MappedCustomFormFieldQuestion_258">
</div>
</div>
</fieldset>
<fieldset class="at-fieldset PaymentMethodSection" id="NVContributionForm1541347-PaymentMethodSection">
<div class="at-fields">
<div class="at-row at-row-full PaymentMethod">
<div class="at-payment-method-buttons" id="NVContributionForm1541347-PaymentMethodSection-PaymentMethod">
<div class="at-radio-set at-radio-set-buttons at-align-flex-right">
<div class="at-btn-radio-wrapper at-credit-card-button-wrapper">
<input id="creditcard_radio_1541347" type="radio" name="PaymentMethod" value="creditcard">
<label for="creditcard_radio_1541347" class="at-btn-radio large" tabindex="0"> Pay with Card </label>
</div>
<div class="at-btn-radio-wrapper at-paypal-button-wrapper">
<input id="paypal_radio_1541347" type="radio" name="PaymentMethod" value="paypal">
<label for="paypal_radio_1541347" class="at-btn-radio small at-paypal-button" title="Pay with PayPal" aria-label="Pay with PayPal" tabindex="0">
<span aria-hidden="true"> </span>
</label>
</div>
</div>
</div>
</div>
</div>
</fieldset>
<style>
.at .at-steps li {
width: 33.233333333333334%
}
</style>
<div class="at-form-submit clearfix">
<div class="step-prevNext clearfix" style="display: none;">
<div class="prevNext next">
<button class="submitStep btn-at btn-at-primary" style="display: none;">Contribute $50</button>
<a tabindex="0" role="button" class="nextStep btn-at btn-at-primary">Next</a>
</div>
<div class="prevNext prev">
<a tabindex="0" role="button" class="prevStep btn-at btn-at-link" style="display: none;">Back</a>
</div>
</div> <input type="submit" value="Contribute $50" class="at-submit btn-at btn-at-primary" style="visibility: hidden; position: absolute;">
<footer class="at-markup FooterHtml clearfix" style="display: none;">
</footer>
</div>
</form>Text Content
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