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              </label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_12_4" name="q12_sponsorshipOptions12" value="Sponsor - $10,000" />
              <label id="label_input_12_4" for="input_12_4"><span>Sponsor - $10,000</span>
              </label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_12_5" name="q12_sponsorshipOptions12" value="Patron - $5,000" />
              <label id="label_input_12_5" for="input_12_5"><span>Patron - $5,000</span>
              </label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_12_6" name="q12_sponsorshipOptions12" value="Friend full–page ad - $3,600" />
              <label id="label_input_12_6" for="input_12_6"><span>Friend full–page ad - $3,600</span>
              </label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_12_7" name="q12_sponsorshipOptions12" value="Supporter full–page ad - $2,500" />
              <label id="label_input_12_7" for="input_12_7"><span>Supporter full–page ad - $2,500</span>
              </label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_12_8" name="q12_sponsorshipOptions12" value="Full–page ad - $1,800" />
              <label id="label_input_12_8" for="input_12_8"><span>Full–page ad - $1,800</span>
              </label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_12_9" name="q12_sponsorshipOptions12" value="Half–Page ad - $900" />
              <label id="label_input_12_9" for="input_12_9"><span>Half–Page ad - $900</span>
              </label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_12_10" name="q12_sponsorshipOptions12" value="Individual Reservation(s) - $600" />
              <label id="label_input_12_10" for="input_12_10"><span>Individual Reservation(s) - $600</span>
              </label></span><span class="clearfix"></span>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_10">
        <div class="form-label-top" id="label_10">
          <label for="input_10"> Ad Text </label>
          <label class="label-message" for="input_10"> Print ready ads can be emailed to dinner@chabadic.com. Full page ad: 7” x 9”. Half page ad: 4” x 9”. </label>
        </div>
        <div id="cid_10" class="form-input-wide">
          <textarea id="input_10" class="form-textarea" name="q10_adText" cols="40" rows="6"></textarea>
        </div>
      </li>
      <li class="form-line" id="id_8">
        <div class="form-label-top" id="label_8">
          <label for="input_8"> Number of dinner guests attending </label>
          <label class="label-message" for="input_8"> as included in selected sponsorship </label>
        </div>
        <div id="cid_8" class="form-input-wide">
          <input type="number" class="form-number-input  form-textbox" id="input_8" name="q8_numberOf" style="width:60px" size="5" value="" data-type="input-number" min="0" data-numbermin="0" />
        </div>
      </li>
      <li class="form-line" id="id_9">
        <div class="form-label-top" id="label_9">
          <label for="input_9"> Number of Dinner Reservations </label>
          <label class="label-message" for="input_9"> $600 per reservation </label>
        </div>
        <div id="cid_9" class="form-input-wide">
          <input type="number" class="form-number-input  form-textbox" id="input_9" name="q9_numberOf9" style="width:60px" size="5" value="" data-type="input-number" min="0" data-numbermin="0" />
        </div>
      </li>
      <li class="form-line" id="id_14">
        <div class="form-label-top" id="label_14">
          <label for="input_14"> Names of Guests </label>
          <label class="label-message" for="input_14">  </label>
        </div>
        <div id="cid_14" class="form-input-wide">
          <textarea id="input_14" class="form-textarea" name="q14_input14" cols="40" rows="6"></textarea>
        </div>
      </li>
      <li class="form-line" id="id_11">
        <div class="form-label-top" id="label_11">
          <label for="input_11"> I Cannot Attend </label>
          <label class="label-message" for="input_11"> Unable to attend but would like to contribute to the success of this event. </label>
        </div>
        <div id="cid_11" class="form-input-wide">
          <input type="number" class="form-number-input  form-textbox" id="input_11" name="q11_iCannot" style="width:60px" size="5" value="" data-type="input-number" min="0" data-numbermin="0" />
        </div>
      </li>
      <li class="form-line" id="id_3">
        <div class="form-label-top" id="label_3">
          <label for="input_3"> Total </label>
        </div>
        <div id="cid_3" class="form-input-wide">
          <div id="total_amount">
            $0.00
          </div>
        </div>
      </li>
      <li class="form-line" id="id_4">
        <div class="form-label-top" id="label_4">
          <label for="input_4">
            Payment<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_4">  </label>
        </div>
        <div id="cid_4" class="form-input-wide">
          <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0">
            <tbody><tr>
              <td colspan="2" class="form-payment-methods form-multiple-column"><span class="form-radio-item"><input class="paymentMethod form-radio validate[required, paymentMethod] form-radio" type="radio" id="input_4_creditCard" name="q4_payment[payment_method]" value="creditCard" onclick="BuildSource.creditCard(this)" />
                  <label for="input_4_creditCard"> Credit Card </label>
                   </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[required, paymentMethod] form-radio" type="radio" id="input_4_other" name="q4_payment[payment_method]" value="other" onclick="BuildSource.other(this)" />
                  <label for="input_4_other"> Check </label>
                   </span>
              </td>
            </tr>
            <tr class="credit_card hide">
              <th colspan="2">
                Credit Card
              </th>
            </tr>
            <tr class="credit_card hide">
              <td colspan="2" style="padding:0">
                <table cellpadding="0" cellspacing="0">
                  <tbody><tr>
                    <td colspan="2"><span class="form-sub-label-container"><select class="form-textbox validate[required, visible]" name="q4_payment[cc_type]" id="input_4_cc_type">
                          <option value="Visa"> Visa </option>
                          <option value="Mastercard"> MasterCard </option>
                          <option value="Amex"> American Express </option>
                          <option value="Discover"> Discover </option>
                        </select>
                        <label class="form-sub-label" for="input_4_cc_type" id="sublabel_cc_type"> Credit Card Type </label></span>
                    </td>
                  </tr>
                  <tr>
                    <td><span class="form-sub-label-container"><input class="form-textbox form-creditcard validate[required, visible, creditcard]" type="text" name="q4_payment[cc_number]" id="input_4_cc_number" size="20" autocomplete="off" />
                        <label class="form-sub-label" for="input_4_cc_number" id="sublabel_cc_number"> Credit Card Number </label></span>
                    </td>
                    <td class="cc_ccv "><span class="form-sub-label-container"><input class="form-textbox validate[required, visible]" type="text" name="q4_payment[cc_ccv]" id="input_4_cc_ccv" size="6" autocomplete="off" />
                        <label class="form-sub-label" for="input_4_cc_ccv" id="sublabel_cc_ccv"> Security Code </label></span>
                    </td>
                  </tr>
                  <tr>
                    <td colspan="2" class="cc_name_on_card "><span class="form-sub-label-container"><input class="form-textbox validate[required, visible]" type="text" name="q4_payment[cc_nameOnCard]" id="input_4_cc_nameOnCard" size="33" autocomplete="off" />
                        <label class="form-sub-label" for="input_4_cc_nameOnCard" id="sublabel_cc_nameOnCard"> Name on Card </label></span>
                    </td>
                  </tr>
                  <tr class="credit_card hide">
                    <td colspan=""><span class="form-sub-label-container"><select class="form-textbox validate[required, visible]" name="q4_payment[cc_exp_month]" id="input_4_cc_exp_month">
                          <option>  </option>
                          <option value="1"> 1 - January </option>
                          <option value="2"> 2 - February </option>
                          <option value="3"> 3 - March </option>
                          <option value="4"> 4 - April </option>
                          <option value="5"> 5 - May </option>
                          <option value="6"> 6 - June </option>
                          <option value="7"> 7 - July </option>
                          <option value="8"> 8 - August </option>
                          <option value="9"> 9 - September </option>
                          <option value="10"> 10 - October </option>
                          <option value="11"> 11 - November </option>
                          <option value="12"> 12 - December </option>
                        </select>
                        <label class="form-sub-label" for="input_4_cc_exp_month" id="sublabel_cc_exp_month"> Expiration Month </label></span>
                    </td>
                    <td><span class="form-sub-label-container"><select class="form-textbox validate[required, visible]" name="q4_payment[cc_exp_year]" id="input_4_cc_exp_year">
                          <option>  </option>
                          <option value="2017"> 2017 </option>
                          <option value="2018"> 2018 </option>
                          <option value="2019"> 2019 </option>
                          <option value="2020"> 2020 </option>
                          <option value="2021"> 2021 </option>
                          <option value="2022"> 2022 </option>
                          <option value="2023"> 2023 </option>
                          <option value="2024"> 2024 </option>
                          <option value="2025"> 2025 </option>
                          <option value="2026"> 2026 </option>
                        </select>
                        <label class="form-sub-label" for="input_4_cc_exp_year" id="sublabel_cc_exp_year"> Expiration Year </label></span>
                    </td>
                  </tr>
                </tbody></table>
              </td>
            </tr>
            <tr class="other hide">
              <td colspan="2">
                Checks can be made out to Belev Echad and mailed to:
                <br />
                Belev Echad
                <br />
                206 East 95th Street Suite 1A
                <br />
                New York, NY 10128-3813
                <br />
              </td>
            </tr>
            <tr class="billing_address hide">
              <th colspan="2">
                Billing Address
              </th>
            </tr>
            <tr class="billing_address hide">
              <td colspan="2"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-line" type="text" name="q4_payment[addr_line1]" id="input_4_addr_line1" />
                  <label class="form-sub-label" for="input_4_addr_line1" id="sublabel_4_addr_line1"> Street Address </label></span>
              </td>
            </tr>
            <tr class="billing_address hide">
              <td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line no-validation" type="text" name="q4_payment[addr_line2]" id="input_4_addr_line2" size="46" />
                  <label class="form-sub-label" for="input_4_addr_line2" id="sublabel_4_addr_line2"> Street Address Line 2 </label></span>
              </td>
            </tr>
            <tr class="billing_address hide">
              <td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-city" type="text" name="q4_payment[city]" id="input_4_city" />
                  <label class="form-sub-label" for="input_4_city" id="sublabel_4_city"> City </label></span>
              </td>
              <td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q4_payment[state]" id="input_4_state" />
                  <label class="form-sub-label" for="input_4_state" id="sublabel_4_state"> State / Province </label></span>
              </td>
            </tr>
            <tr class="billing_address hide">
              <td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-postal" type="text" name="q4_payment[postal]" id="input_4_postal" size="10" />
                  <label class="form-sub-label" for="input_4_postal" id="sublabel_4_postal"> Postal / Zip Code </label></span>
              </td>
              <td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q4_payment[country]" id="input_4_country">
                    <option value="" selected="selected"> Please Select </option>
                    <option selected="selected" value="United States"> United States </option>
                    <option value="Afghanistan"> Afghanistan </option>
                    <option value="Albania"> Albania </option>
                    <option value="Algeria"> Algeria </option>
                    <option value="American Samoa"> American Samoa </option>
                    <option value="Andorra"> Andorra </option>
                    <option value="Angola"> Angola </option>
                    <option value="Anguilla"> Anguilla </option>
                    <option value="Antigua and Barbuda"> Antigua and Barbuda </option>
                    <option value="Argentina"> Argentina </option>
                    <option value="Armenia"> Armenia </option>
                    <option value="Aruba"> Aruba </option>
                    <option value="Australia"> Australia </option>
                    <option value="Austria"> Austria </option>
                    <option value="Azerbaijan"> Azerbaijan </option>
                    <option value="The Bahamas"> The Bahamas </option>
                    <option value="Bahrain"> Bahrain </option>
                    <option value="Bangladesh"> Bangladesh </option>
                    <option value="Barbados"> Barbados </option>
                    <option value="Belarus"> Belarus </option>
                    <option value="Belgium"> Belgium </option>
                    <option value="Belize"> Belize </option>
                    <option value="Benin"> Benin </option>
                    <option value="Bermuda"> Bermuda </option>
                    <option value="Bhutan"> Bhutan </option>
                    <option value="Bolivia"> Bolivia </option>
                    <option value="Bosnia and Herzegovina"> Bosnia and Herzegovina </option>
                    <option value="Botswana"> Botswana </option>
                    <option value="Brazil"> Brazil </option>
                    <option value="Brunei"> Brunei </option>
                    <option value="Bulgaria"> Bulgaria </option>
                    <option value="Burkina Faso"> Burkina Faso </option>
                    <option value="Burundi"> Burundi </option>
                    <option value="Cambodia"> Cambodia </option>
                    <option value="Cameroon"> Cameroon </option>
                    <option value="Canada"> Canada </option>
                    <option value="Cape Verde"> Cape Verde </option>
                    <option value="Cayman Islands"> Cayman Islands </option>
                    <option value="Central African Republic"> Central African Republic </option>
                    <option value="Chad"> Chad </option>
                    <option value="Chile"> Chile </option>
                    <option value="People's Republic of China"> People's Republic of China </option>
                    <option value="Republic of China"> Republic of China </option>
                    <option value="Christmas Island"> Christmas Island </option>
                    <option value="Cocos (Keeling) Islands"> Cocos (Keeling) Islands </option>
                    <option value="Colombia"> Colombia </option>
                    <option value="Comoros"> Comoros </option>
                    <option value="Congo"> Congo </option>
                    <option value="Cook Islands"> Cook Islands </option>
                    <option value="Costa Rica"> Costa Rica </option>
                    <option value="Cote d'Ivoire"> Cote d'Ivoire </option>
                    <option value="Croatia"> Croatia </option>
                    <option value="Cuba"> Cuba </option>
                    <option value="Cyprus"> Cyprus </option>
                    <option value="Czech Republic"> Czech Republic </option>
                    <option value="Denmark"> Denmark </option>
                    <option value="Djibouti"> Djibouti </option>
                    <option value="Dominica"> Dominica </option>
                    <option value="Dominican Republic"> Dominican Republic </option>
                    <option value="Ecuador"> Ecuador </option>
                    <option value="Egypt"> Egypt </option>
                    <option value="El Salvador"> El Salvador </option>
                    <option value="Equatorial Guinea"> Equatorial Guinea </option>
                    <option value="Eritrea"> Eritrea </option>
                    <option value="Estonia"> Estonia </option>
                    <option value="Ethiopia"> Ethiopia </option>
                    <option value="Falkland Islands"> Falkland Islands </option>
                    <option value="Faroe Islands"> Faroe Islands </option>
                    <option value="Fiji"> Fiji </option>
                    <option value="Finland"> Finland </option>
                    <option value="France"> France </option>
                    <option value="French Polynesia"> French Polynesia </option>
                    <option value="Gabon"> Gabon </option>
                    <option value="The Gambia"> The Gambia </option>
                    <option value="Georgia"> Georgia </option>
                    <option value="Germany"> Germany </option>
                    <option value="Ghana"> Ghana </option>
                    <option value="Gibraltar"> Gibraltar </option>
                    <option value="Greece"> Greece </option>
                    <option value="Greenland"> Greenland </option>
                    <option value="Grenada"> Grenada </option>
                    <option value="Guadeloupe"> Guadeloupe </option>
                    <option value="Guam"> Guam </option>
                    <option value="Guatemala"> Guatemala </option>
                    <option value="Guernsey"> Guernsey </option>
                    <option value="Guinea"> Guinea </option>
                    <option value="Guinea-Bissau"> Guinea-Bissau </option>
                    <option value="Guyana"> Guyana </option>
                    <option value="Haiti"> Haiti </option>
                    <option value="Honduras"> Honduras </option>
                    <option value="Hong Kong"> Hong Kong </option>
                    <option value="Hungary"> Hungary </option>
                    <option value="Iceland"> Iceland </option>
                    <option value="India"> India </option>
                    <option value="Indonesia"> Indonesia </option>
                    <option value="Iran"> Iran </option>
                    <option value="Iraq"> Iraq </option>
                    <option value="Ireland"> Ireland </option>
                    <option value="Israel"> Israel </option>
                    <option value="Italy"> Italy </option>
                    <option value="Jamaica"> Jamaica </option>
                    <option value="Japan"> Japan </option>
                    <option value="Jersey"> Jersey </option>
                    <option value="Jordan"> Jordan </option>
                    <option value="Kazakhstan"> Kazakhstan </option>
                    <option value="Kenya"> Kenya </option>
                    <option value="Kiribati"> Kiribati </option>
                    <option value="North Korea"> North Korea </option>
                    <option value="South Korea"> South Korea </option>
                    <option value="Kosovo"> Kosovo </option>
                    <option value="Kuwait"> Kuwait </option>
                    <option value="Kyrgyzstan"> Kyrgyzstan </option>
                    <option value="Laos"> Laos </option>
                    <option value="Latvia"> Latvia </option>
                    <option value="Lebanon"> Lebanon </option>
                    <option value="Lesotho"> Lesotho </option>
                    <option value="Liberia"> Liberia </option>
                    <option value="Libya"> Libya </option>
                    <option value="Liechtenstein"> Liechtenstein </option>
                    <option value="Lithuania"> Lithuania </option>
                    <option value="Luxembourg"> Luxembourg </option>
                    <option value="Macau"> Macau </option>
                    <option value="Macedonia"> Macedonia </option>
                    <option value="Madagascar"> Madagascar </option>
                    <option value="Malawi"> Malawi </option>
                    <option value="Malaysia"> Malaysia </option>
                    <option value="Maldives"> Maldives </option>
                    <option value="Mali"> Mali </option>
                    <option value="Malta"> Malta </option>
                    <option value="Marshall Islands"> Marshall Islands </option>
                    <option value="Martinique"> Martinique </option>
                    <option value="Mauritania"> Mauritania </option>
                    <option value="Mauritius"> Mauritius </option>
                    <option value="Mayotte"> Mayotte </option>
                    <option value="Mexico"> Mexico </option>
                    <option value="Micronesia"> Micronesia </option>
                    <option value="Moldova"> Moldova </option>
                    <option value="Monaco"> Monaco </option>
                    <option value="Mongolia"> Mongolia </option>
                    <option value="Montenegro"> Montenegro </option>
                    <option value="Montserrat"> Montserrat </option>
                    <option value="Morocco"> Morocco </option>
                    <option value="Mozambique"> Mozambique </option>
                    <option value="Myanmar"> Myanmar </option>
                    <option value="Nagorno-Karabakh"> Nagorno-Karabakh </option>
                    <option value="Namibia"> Namibia </option>
                    <option value="Nauru"> Nauru </option>
                    <option value="Nepal"> Nepal </option>
                    <option value="Netherlands"> Netherlands </option>
                    <option value="Netherlands Antilles"> Netherlands Antilles </option>
                    <option value="New Caledonia"> New Caledonia </option>
                    <option value="New Zealand"> New Zealand </option>
                    <option value="Nicaragua"> Nicaragua </option>
                    <option value="Niger"> Niger </option>
                    <option value="Nigeria"> Nigeria </option>
                    <option value="Niue"> Niue </option>
                    <option value="Norfolk Island"> Norfolk Island </option>
                    <option value="Turkish Republic of Northern Cyprus"> Turkish Republic of Northern Cyprus </option>
                    <option value="Northern Mariana"> Northern Mariana </option>
                    <option value="Norway"> Norway </option>
                    <option value="Oman"> Oman </option>
                    <option value="Pakistan"> Pakistan </option>
                    <option value="Palau"> Palau </option>
                    <option value="Panama"> Panama </option>
                    <option value="Papua New Guinea"> Papua New Guinea </option>
                    <option value="Paraguay"> Paraguay </option>
                    <option value="Peru"> Peru </option>
                    <option value="Philippines"> Philippines </option>
                    <option value="Pitcairn Islands"> Pitcairn Islands </option>
                    <option value="Poland"> Poland </option>
                    <option value="Portugal"> Portugal </option>
                    <option value="Puerto Rico"> Puerto Rico </option>
                    <option value="Qatar"> Qatar </option>
                    <option value="Romania"> Romania </option>
                    <option value="Russia"> Russia </option>
                    <option value="Rwanda"> Rwanda </option>
                    <option value="Saint Barthelemy"> Saint Barthelemy </option>
                    <option value="Saint Helena"> Saint Helena </option>
                    <option value="Saint Kitts and Nevis"> Saint Kitts and Nevis </option>
                    <option value="Saint Lucia"> Saint Lucia </option>
                    <option value="Saint Martin"> Saint Martin </option>
                    <option value="Saint Pierre and Miquelon"> Saint Pierre and Miquelon </option>
                    <option value="Saint Vincent and the Grenadines"> Saint Vincent and the Grenadines </option>
                    <option value="Samoa"> Samoa </option>
                    <option value="San Marino"> San Marino </option>
                    <option value="Sao Tome and Principe"> Sao Tome and Principe </option>
                    <option value="Saudi Arabia"> Saudi Arabia </option>
                    <option value="Senegal"> Senegal </option>
                    <option value="Serbia"> Serbia </option>
                    <option value="Seychelles"> Seychelles </option>
                    <option value="Sierra Leone"> Sierra Leone </option>
                    <option value="Singapore"> Singapore </option>
                    <option value="Slovakia"> Slovakia </option>
                    <option value="Slovenia"> Slovenia </option>
                    <option value="Solomon Islands"> Solomon Islands </option>
                    <option value="Somalia"> Somalia </option>
                    <option value="Somaliland"> Somaliland </option>
                    <option value="South Africa"> South Africa </option>
                    <option value="South Ossetia"> South Ossetia </option>
                    <option value="Spain"> Spain </option>
                    <option value="Sri Lanka"> Sri Lanka </option>
                    <option value="Sudan"> Sudan </option>
                    <option value="Suriname"> Suriname </option>
                    <option value="Svalbard"> Svalbard </option>
                    <option value="Swaziland"> Swaziland </option>
                    <option value="Sweden"> Sweden </option>
                    <option value="Switzerland"> Switzerland </option>
                    <option value="Syria"> Syria </option>
                    <option value="Taiwan"> Taiwan </option>
                    <option value="Tajikistan"> Tajikistan </option>
                    <option value="Tanzania"> Tanzania </option>
                    <option value="Thailand"> Thailand </option>
                    <option value="Timor-Leste"> Timor-Leste </option>
                    <option value="Togo"> Togo </option>
                    <option value="Tokelau"> Tokelau </option>
                    <option value="Tonga"> Tonga </option>
                    <option value="Transnistria Pridnestrovie"> Transnistria Pridnestrovie </option>
                    <option value="Trinidad and Tobago"> Trinidad and Tobago </option>
                    <option value="Tristan da Cunha"> Tristan da Cunha </option>
                    <option value="Tunisia"> Tunisia </option>
                    <option value="Turkey"> Turkey </option>
                    <option value="Turkmenistan"> Turkmenistan </option>
                    <option value="Turks and Caicos Islands"> Turks and Caicos Islands </option>
                    <option value="Tuvalu"> Tuvalu </option>
                    <option value="Uganda"> Uganda </option>
                    <option value="Ukraine"> Ukraine </option>
                    <option value="United Arab Emirates"> United Arab Emirates </option>
                    <option value="United Kingdom"> United Kingdom </option>
                    <option value="Uruguay"> Uruguay </option>
                    <option value="Uzbekistan"> Uzbekistan </option>
                    <option value="Vanuatu"> Vanuatu </option>
                    <option value="Vatican City"> Vatican City </option>
                    <option value="Venezuela"> Venezuela </option>
                    <option value="Vietnam"> Vietnam </option>
                    <option value="British Virgin Islands"> British Virgin Islands </option>
                    <option value="US Virgin Islands"> US Virgin Islands </option>
                    <option value="Wallis and Futuna"> Wallis and Futuna </option>
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