Forms Form Assembly

<!-- FORM: HEAD SECTION -->

<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
<meta name="referrer" content="no-referrer-when-downgrade">
<script type="text/javascript">
    document.addEventListener("DOMContentLoaded", function() {
        const FORM_TIME_START = Math.floor((new Date).getTime() / 1000);
        let formElement = document.getElementById("tfa_0");
        if (null === formElement) {
            formElement = document.getElementById("0");
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        let appendJsTimerElement = function() {
            let formTimeDiff = Math.floor((new Date).getTime() / 1000) - FORM_TIME_START;
            let cumulatedTimeElement = document.getElementById("tfa_dbCumulatedTime");
            if (null !== cumulatedTimeElement) {
                let cumulatedTime = parseInt(cumulatedTimeElement.value);
                if (null !== cumulatedTime && cumulatedTime > 0) {
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            let jsTimeInput = document.createElement("input");
            jsTimeInput.setAttribute("type", "hidden");
            jsTimeInput.setAttribute("value", formTimeDiff.toString());
            jsTimeInput.setAttribute("name", "tfa_dbElapsedJsTime");
            jsTimeInput.setAttribute("id", "tfa_dbElapsedJsTime");
            jsTimeInput.setAttribute("autocomplete", "off");
            if (null !== formElement) {
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        if (null !== formElement) {
            if (formElement.addEventListener) {
                formElement.addEventListener('submit', appendJsTimerElement, false);
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                formElement.attachEvent('onsubmit', appendJsTimerElement);
            }
        }
    });
</script>

<link href="https://chicagocouncil.tfaforms.net/dist/form-builder/5.0.0/wforms-layout.css?v=8d6b9a894f881b7209b0c7dc67261cc2c0638402" rel="stylesheet" type="text/css" />

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<script type="text/javascript" src="https://chicagocouncil.tfaforms.net/wForms/3.11/js/wforms.js?v=8d6b9a894f881b7209b0c7dc67261cc2c0638402"></script>
<script type="text/javascript">
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<!-- FORM: BODY SECTION -->
<div class="wFormContainer" style="max-width: 750px; width:auto;">
    <div class="wFormHeader"></div>
    <style type="text/css">
        #tfa_536,
        *[id^="tfa_536["] {
            width: 205px !important;
        }

        #tfa_536-D,
        *[id^="tfa_536["][class~="field-container-D"] {
            width: auto !important;
        }

        #tfa_537,
        *[id^="tfa_537["] {
            width: 205px !important;
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        #tfa_537-D,
        *[id^="tfa_537["][class~="field-container-D"] {
            width: auto !important;
        }

        #tfa_550-L,
        label[id^="tfa_550["] {
            width: -60px !important;
            min-width: 0px;
        }
    </style>
    <div class="">
        <div class="wForm" id="109-WRPR" dir="ltr">
            <div class="codesection" id="code-109">
                <style type="text/css">
                    /******BEGIN FORM LEVEL STYLES******/
                    /*BACKGROUND IMAGE */
                    body.wFormWebPage {
                        background-image: ;
                        background-repeat: no-repeat;
                        background-size: 100%;
                        background-attachment: fixed;
                        margin: 10px 0 0 0;
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                    /*CENTERED TOP LOGO*/
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                    </script>
                </style>

                <script>
                    /// this formats the 'Total Amount Due' field as currency
                    function dispCurrency(number) {
                        try {
                            number = number * 1.0;
                            return number.toLocaleString('en-US', {
                                style: 'currency',
                                currency: 'USD'
                            });
                        } catch (err) {
                            return number;
                        }
                    }

                    function parseCurrency(currency) {
                        try {
                            var number = Number(currency.replace(/[^0-9.-]+/g, ""));
                            return number;
                        } catch (err) {
                            return string;
                        }
                    }
                </script>
            </div>
            <form method="post" action="https://chicagocouncil.tfaforms.net/responses/processor" class="hintsBelow labelsAbove" id="109" role="form">
                <div class="htmlSection" id="tfa_546">
                    <div class="htmlContent" id="tfa_546-HTML"><span style="color: #062d5d;">Wednesday, October 28th at 5:00pm CT<br></span>
                        <span>
                            Your tax-deductible contribution to the Council is critical in bringing together leading global voices, conducting independent research, and engaging the public to explore ideas that will shape our global future.
                        </span>
                    </div>
                </div>
                <div class="htmlSection" id="tfa_547">
                    <div class="htmlContent" id="tfa_547-HTML"><img style="max-width: 100%;width: 150px; padding-right: 20px;" alt="Charity Navigator Four Star Charity" src="https://www.thechicagocouncil.org/sites/default/files/cn4stars-bw.png"><b>Tax ID Number: 36-2181969</b>
                    </div>
                </div>
                <fieldset id="tfa_498" class="section">
                    <legend id="tfa_498-L">Registrant Information</legend>
                    <div id="tfa_3" class="section inline group">
                        <div class="oneField field-container-D    " id="tfa_1-D">
                            <label id="tfa_1-L" class="label preField reqMark" for="tfa_1">First Name:</label><br>
                            <div class="inputWrapper"><input type="text" id="tfa_1" name="tfa_1" value="" aria-required="true" title="First Name:" class="required"></div>
                        </div>
                        <div class="oneField field-container-D    " id="tfa_2-D">
                            <label id="tfa_2-L" class="label preField reqMark" for="tfa_2">Last Name:</label><br>
                            <div class="inputWrapper"><input type="text" id="tfa_2" name="tfa_2" value="" aria-required="true" title="Last Name:" class="required"></div>
                        </div>
                        <div class="oneField field-container-D    " id="tfa_185-D">
                            <label id="tfa_185-L" class="label preField reqMark" for="tfa_185">Title:</label><br>
                            <div class="inputWrapper"><input type="text" id="tfa_185" name="tfa_185" value="" aria-required="true" title="Title:" class="required"></div>
                        </div>
                        <div class="oneField field-container-D    " id="tfa_186-D">
                            <label id="tfa_186-L" class="label preField reqMark" for="tfa_186">Company:</label><br>
                            <div class="inputWrapper"><input type="text" id="tfa_186" name="tfa_186" value="" aria-required="true" title="Company:" class="required"></div>
                        </div>
                        <div class="oneField field-container-D    " id="tfa_4-D">
                            <label id="tfa_4-L" class="label preField reqMark" for="tfa_4">Email:</label><br>
                            <div class="inputWrapper"><input type="text" id="tfa_4" name="tfa_4" value="" aria-required="true" title="Email:" class="required"></div>
                        </div>
                        <div id="tfa_193" class="section inline group">
                            <div id="tfa_557" class="section empty group"></div>
                            <div class="oneField field-container-D    " id="tfa_189-D">
                                <label id="tfa_189-L" class="label preField reqMark" for="tfa_189">Phone Type:</label><br>
                                <div class="inputWrapper"><select id="tfa_189" name="tfa_189" title="Phone Type:" aria-required="true" class="required">
                                        <option value="">Please select...</option>
                                        <option value="tfa_190" id="tfa_190" data-conditionals="#tfa_188" class="">Home</option>
                                        <option value="tfa_191" id="tfa_191" data-conditionals="#tfa_559" class="">Work</option>
                                        <option value="tfa_192" id="tfa_192" data-conditionals="#tfa_561" class="" selected data-default-value="true">Mobile</option>
                                    </select></div>
                            </div>
                            <div class="oneField field-container-D    " id="tfa_188-D">
                                <label id="tfa_188-L" class="label preField reqMark" for="tfa_188">Home Phone:</label><br>
                                <div class="inputWrapper">
                                    <input type="text" id="tfa_188" name="tfa_188" value="" placeholder="###-###-####" aria-required="true" aria-describedby="tfa_188-HH" autoformat="###-###-####" data-condition="`#tfa_190`" title="Home Phone:" class="required"><span class="field-hint-inactive" id="tfa_188-H"><span id="tfa_188-HH" class="hint">Please enter your phone number with area code</span></span>
                                </div>
                            </div>
                            <div class="oneField field-container-D    " id="tfa_559-D">
                                <label id="tfa_559-L" class="label preField reqMark" for="tfa_559">Work Phone:</label><br>
                                <div class="inputWrapper">
                                    <input type="text" id="tfa_559" name="tfa_559" value="" placeholder="###-###-####" aria-required="true" aria-describedby="tfa_559-HH" autoformat="###-###-####" data-condition="`#tfa_191`" title="Work Phone:" class="required"><span class="field-hint-inactive" id="tfa_559-H"><span id="tfa_559-HH" class="hint">Please enter your phone number with area code</span></span>
                                </div>
                            </div>
                            <div class="oneField field-container-D    " id="tfa_561-D">
                                <label id="tfa_561-L" class="label preField reqMark" for="tfa_561">Mobile Phone:</label><br>
                                <div class="inputWrapper">
                                    <input type="text" id="tfa_561" name="tfa_561" value="" placeholder="###-###-####" aria-required="true" aria-describedby="tfa_561-HH" autoformat="###-###-####" data-condition="`#tfa_192`" title="Mobile Phone:" class="required"><span class="field-hint-inactive" id="tfa_561-H"><span id="tfa_561-HH" class="hint">Please enter your phone number with area code</span></span>
                                </div>
                            </div>
                        </div>
                        <div class="oneField field-container-D    " id="tfa_194-D">
                            <label id="tfa_194-L" class="label preField reqMark" for="tfa_194">Select Address:</label><br>
                            <div class="inputWrapper"><select id="tfa_194" name="tfa_194" title="Select Address:" aria-required="true" class="required">
                                    <option value="">Please select...</option>
                                    <option value="tfa_195" id="tfa_195" class="">Home</option>
                                    <option value="tfa_196" id="tfa_196" class="">Work</option>
                                    <option value="tfa_197" id="tfa_197" class="">Other</option>
                                </select></div>
                        </div>
                        <div id="tfa_257" class="section inline group">
                            <div class="oneField field-container-D    " id="tfa_198-D">
                                <label id="tfa_198-L" class="label preField reqMark" for="tfa_198">Street:</label><br>
                                <div class="inputWrapper"><input type="text" id="tfa_198" name="tfa_198" value="" aria-required="true" title="Street:" class="required"></div>
                            </div>
                            <div class="oneField field-container-D    " id="tfa_199-D">
                                <label id="tfa_199-L" class="label preField reqMark" for="tfa_199">City:</label><br>
                                <div class="inputWrapper"><input type="text" id="tfa_199" name="tfa_199" value="" aria-required="true" title="City:" class="required"></div>
                            </div>
                            <div class="oneField field-container-D    " id="tfa_258-D">
                                <label id="tfa_258-L" class="label preField reqMark" for="tfa_258">ZIP Code:</label><br>
                                <div class="inputWrapper"><input type="text" id="tfa_258" name="tfa_258" value="" aria-required="true" title="ZIP Code:" class="required"></div>
                            </div>
                            <div class="oneField field-container-D    " id="tfa_205-D">
                                <label id="tfa_205-L" class="label preField reqMark" for="tfa_205">State:</label><br>
                                <div class="inputWrapper"><select id="tfa_205" name="tfa_205" title="State:" aria-required="true" class="calc-states required">
                                        <option value="">Please select...</option>
                                        <option value="tfa_206" id="tfa_206" class="calcval-AL">AL</option>
                                        <option value="tfa_207" id="tfa_207" class="calcval-AK">AK</option>
                                        <option value="tfa_208" id="tfa_208" class="calcval-AZ">AZ</option>
                                        <option value="tfa_209" id="tfa_209" class="calcval-AR">AR</option>
                                        <option value="tfa_210" id="tfa_210" class="calcval-CA">CA</option>
                                        <option value="tfa_211" id="tfa_211" class="calcval-CO">CO</option>
                                        <option value="tfa_212" id="tfa_212" class="calcval-CT">CT</option>
                                        <option value="tfa_213" id="tfa_213" class="calcval-DE">DE</option>
                                        <option value="tfa_214" id="tfa_214" class="calcval-DC">DC</option>
                                        <option value="tfa_215" id="tfa_215" class="calcval-FL">FL</option>
                                        <option value="tfa_216" id="tfa_216" class="calcval-GA">GA</option>
                                        <option value="tfa_217" id="tfa_217" class="calcval-HI">HI</option>
                                        <option value="tfa_218" id="tfa_218" class="calcval-ID">ID</option>
                                        <option value="tfa_219" id="tfa_219" class="calcval-IL">IL</option>
                                        <option value="tfa_220" id="tfa_220" class="calcval-IN">IN</option>
                                        <option value="tfa_221" id="tfa_221" class="calcval-IA">IA</option>
                                        <option value="tfa_222" id="tfa_222" class="calcval-KS">KS</option>
                                        <option value="tfa_223" id="tfa_223" class="calcval-KY">KY</option>
                                        <option value="tfa_224" id="tfa_224" class="calcval-LA">LA</option>
                                        <option value="tfa_225" id="tfa_225" class="calcval-ME">ME</option>
                                        <option value="tfa_226" id="tfa_226" class="calcval-MD">MD</option>
                                        <option value="tfa_227" id="tfa_227" class="calcval-MA">MA</option>
                                        <option value="tfa_228" id="tfa_228" class="calcval-MI">MI</option>
                                        <option value="tfa_229" id="tfa_229" class="calcval-MN">MN</option>
                                        <option value="tfa_230" id="tfa_230" class="calcval-MS">MS</option>
                                        <option value="tfa_231" id="tfa_231" class="calcval-MO">MO</option>
                                        <option value="tfa_232" id="tfa_232" class="calcval-MT">MT</option>
                                        <option value="tfa_233" id="tfa_233" class="calcval-NE">NE</option>
                                        <option value="tfa_234" id="tfa_234" class="calcval-NV">NV</option>
                                        <option value="tfa_235" id="tfa_235" class="calcval-NH">NH</option>
                                        <option value="tfa_236" id="tfa_236" class="calcval-NJ">NJ</option>
                                        <option value="tfa_237" id="tfa_237" class="calcval-NM">NM</option>
                                        <option value="tfa_238" id="tfa_238" class="calcval-NY">NY</option>
                                        <option value="tfa_239" id="tfa_239" class="calcval-NC">NC</option>
                                        <option value="tfa_240" id="tfa_240" class="calcval-ND">ND</option>
                                        <option value="tfa_241" id="tfa_241" class="calcval-OH">OH</option>
                                        <option value="tfa_242" id="tfa_242" class="calcval-OK">OK</option>
                                        <option value="tfa_243" id="tfa_243" class="calcval-OR">OR</option>
                                        <option value="tfa_244" id="tfa_244" class="calcval-PA">PA</option>
                                        <option value="tfa_245" id="tfa_245" class="calcval-RI">RI</option>
                                        <option value="tfa_246" id="tfa_246" class="calcval-SC">SC</option>
                                        <option value="tfa_247" id="tfa_247" class="calcval-SD">SD</option>
                                        <option value="tfa_248" id="tfa_248" class="calcval-TN">TN</option>
                                        <option value="tfa_249" id="tfa_249" class="calcval-TX">TX</option>
                                        <option value="tfa_250" id="tfa_250" class="calcval-UT">UT</option>
                                        <option value="tfa_251" id="tfa_251" class="calcval-VT">VT</option>
                                        <option value="tfa_252" id="tfa_252" class="calcval-VA">VA</option>
                                        <option value="tfa_253" id="tfa_253" class="calcval-WA">WA</option>
                                        <option value="tfa_254" id="tfa_254" class="calcval-WV">WV</option>
                                        <option value="tfa_255" id="tfa_255" class="calcval-WI">WI</option>
                                        <option value="tfa_256" id="tfa_256" class="calcval-WY">WY</option>
                                    </select></div>
                            </div>
                            <div class="oneField field-container-D    " id="tfa_259-D">
                                <label id="tfa_259-L" class="label preField reqMark" for="tfa_259">Country:</label><br>
                                <div class="inputWrapper"><select id="tfa_259" name="tfa_259" title="Country:" aria-required="true" class="required">
                                        <option value="">Please select...</option>
                                        <option value="tfa_483" id="tfa_483" class="">United States</option>
                                        <option value="tfa_260" id="tfa_260" class="">Afghanistan</option>
                                        <option value="tfa_261" id="tfa_261" class="">Albania</option>
                                        <option value="tfa_262" id="tfa_262" class="">Algeria</option>
                                        <option value="tfa_263" id="tfa_263" class="">American Samoa</option>
                                        <option value="tfa_264" id="tfa_264" class="">Andorra</option>
                                        <option value="tfa_265" id="tfa_265" class="">Angola</option>
                                        <option value="tfa_266" id="tfa_266" class="">Anguilla</option>
                                        <option value="tfa_267" id="tfa_267" class="">Antarctica</option>
                                        <option value="tfa_268" id="tfa_268" class="">Antigua and Barbuda</option>
                                        <option value="tfa_269" id="tfa_269" class="">Argentina</option>
                                        <option value="tfa_270" id="tfa_270" class="">Armenia</option>
                                        <option value="tfa_271" id="tfa_271" class="">Aruba</option>
                                        <option value="tfa_272" id="tfa_272" class="">Australia</option>
                                        <option value="tfa_273" id="tfa_273" class="">Austria</option>
                                        <option value="tfa_274" id="tfa_274" class="">Azerbaijan</option>
                                        <option value="tfa_275" id="tfa_275" class="">Bahamas</option>
                                        <option value="tfa_276" id="tfa_276" class="">Bahrain</option>
                                        <option value="tfa_277" id="tfa_277" class="">Bangladesh</option>
                                        <option value="tfa_278" id="tfa_278" class="">Barbados</option>
                                        <option value="tfa_279" id="tfa_279" class="">Belarus</option>
                                        <option value="tfa_280" id="tfa_280" class="">Belgium</option>
                                        <option value="tfa_281" id="tfa_281" class="">Belize</option>
                                        <option value="tfa_282" id="tfa_282" class="">Benin</option>
                                        <option value="tfa_283" id="tfa_283" class="">Bermuda</option>
                                        <option value="tfa_284" id="tfa_284" class="">Bhutan</option>
                                        <option value="tfa_285" id="tfa_285" class="">Bolivia</option>
                                        <option value="tfa_286" id="tfa_286" class="">Bosnia and Herzegovina</option>
                                        <option value="tfa_287" id="tfa_287" class="">Botswana</option>
                                        <option value="tfa_288" id="tfa_288" class="">Bouvet Island</option>
                                        <option value="tfa_289" id="tfa_289" class="">Brazil</option>
                                        <option value="tfa_290" id="tfa_290" class="">British Indian Ocean Territory</option>
                                        <option value="tfa_291" id="tfa_291" class="">Brunei</option>
                                        <option value="tfa_292" id="tfa_292" class="">Bulgaria</option>
                                        <option value="tfa_293" id="tfa_293" class="">Burkina Faso</option>
                                        <option value="tfa_294" id="tfa_294" class="">Burundi</option>
                                        <option value="tfa_295" id="tfa_295" class="">Cambodia</option>
                                        <option value="tfa_296" id="tfa_296" class="">Cameroon</option>
                                        <option value="tfa_297" id="tfa_297" class="">Canada</option>
                                        <option value="tfa_298" id="tfa_298" class="">Cape Verde</option>
                                        <option value="tfa_299" id="tfa_299" class="">Cayman Islands</option>
                                        <option value="tfa_300" id="tfa_300" class="">Central African Republic</option>
                                        <option value="tfa_301" id="tfa_301" class="">Chad</option>
                                        <option value="tfa_302" id="tfa_302" class="">Chile</option>
                                        <option value="tfa_303" id="tfa_303" class="">China</option>
                                        <option value="tfa_304" id="tfa_304" class="">Christmas Island</option>
                                        <option value="tfa_305" id="tfa_305" class="">Cocos ( Keeling ) Islands</option>
                                        <option value="tfa_306" id="tfa_306" class="">Colombia</option>
                                        <option value="tfa_307" id="tfa_307" class="">Comoros</option>
                                        <option value="tfa_308" id="tfa_308" class="">Congo</option>
                                        <option value="tfa_309" id="tfa_309" class="">Cook Islands</option>
                                        <option value="tfa_310" id="tfa_310" class="">Costa Rica</option>
                                        <option value="tfa_311" id="tfa_311" class="">Côte d ' Ivoire</option>
                                        <option value="tfa_312" id="tfa_312" class="">Croatia ( Hrvatska )</option>
                                        <option value="tfa_313" id="tfa_313" class="">Cuba</option>
                                        <option value="tfa_314" id="tfa_314" class="">Cyprus</option>
                                        <option value="tfa_315" id="tfa_315" class="">Czech Republic</option>
                                        <option value="tfa_316" id="tfa_316" class="">Congo ( DRC )</option>
                                        <option value="tfa_317" id="tfa_317" class="">Denmark</option>
                                        <option value="tfa_318" id="tfa_318" class="">Djibouti</option>
                                        <option value="tfa_319" id="tfa_319" class="">Dominica</option>
                                        <option value="tfa_320" id="tfa_320" class="">Dominican Republic</option>
                                        <option value="tfa_321" id="tfa_321" class="">East Timor</option>
                                        <option value="tfa_322" id="tfa_322" class="">Ecuador</option>
                                        <option value="tfa_323" id="tfa_323" class="">Egypt</option>
                                        <option value="tfa_324" id="tfa_324" class="">El Salvador</option>
                                        <option value="tfa_325" id="tfa_325" class="">Equatorial Guinea</option>
                                        <option value="tfa_326" id="tfa_326" class="">Eritrea</option>
                                        <option value="tfa_327" id="tfa_327" class="">Estonia</option>
                                        <option value="tfa_328" id="tfa_328" class="">Ethiopia</option>
                                        <option value="tfa_329" id="tfa_329" class="">Falkland Islands ( Islas Malvinas )</option>
                                        <option value="tfa_330" id="tfa_330" class="">Faroe Islands</option>
                                        <option value="tfa_331" id="tfa_331" class="">Fiji Islands</option>
                                        <option value="tfa_332" id="tfa_332" class="">Finland</option>
                                        <option value="tfa_333" id="tfa_333" class="">France</option>
                                        <option value="tfa_334" id="tfa_334" class="">French Guiana</option>
                                        <option value="tfa_335" id="tfa_335" class="">French Polynesia</option>
                                        <option value="tfa_336" id="tfa_336" class="">French Southern and Antarctic Lands</option>
                                        <option value="tfa_337" id="tfa_337" class="">Gabon</option>
                                        <option value="tfa_338" id="tfa_338" class="">Gambia</option>
                                        <option value="tfa_339" id="tfa_339" class="">Georgia</option>
                                        <option value="tfa_340" id="tfa_340" class="">Germany</option>
                                        <option value="tfa_341" id="tfa_341" class="">Ghana</option>
                                        <option value="tfa_342" id="tfa_342" class="">Gibraltar</option>
                                        <option value="tfa_343" id="tfa_343" class="">Greece</option>
                                        <option value="tfa_344" id="tfa_344" class="">Greenland</option>
                                        <option value="tfa_345" id="tfa_345" class="">Grenada</option>
                                        <option value="tfa_346" id="tfa_346" class="">Guadeloupe</option>
                                        <option value="tfa_347" id="tfa_347" class="">Guam</option>
                                        <option value="tfa_348" id="tfa_348" class="">Guatemala</option>
                                        <option value="tfa_349" id="tfa_349" class="">Guinea</option>
                                        <option value="tfa_350" id="tfa_350" class="">Guinea-Bissau</option>
                                        <option value="tfa_351" id="tfa_351" class="">Guyana</option>
                                        <option value="tfa_352" id="tfa_352" class="">Haiti</option>
                                        <option value="tfa_353" id="tfa_353" class="">Heard Island and McDonald Islands</option>
                                        <option value="tfa_354" id="tfa_354" class="">Honduras</option>
                                        <option value="tfa_355" id="tfa_355" class="">Hong Kong SAR</option>
                                        <option value="tfa_356" id="tfa_356" class="">Hungary</option>
                                        <option value="tfa_357" id="tfa_357" class="">Iceland</option>
                                        <option value="tfa_358" id="tfa_358" class="">India</option>
                                        <option value="tfa_359" id="tfa_359" class="">Indonesia</option>
                                        <option value="tfa_360" id="tfa_360" class="">Iran</option>
                                        <option value="tfa_361" id="tfa_361" class="">Iraq</option>
                                        <option value="tfa_362" id="tfa_362" class="">Ireland</option>
                                        <option value="tfa_363" id="tfa_363" class="">Israel</option>
                                        <option value="tfa_364" id="tfa_364" class="">Italy</option>
                                        <option value="tfa_365" id="tfa_365" class="">Jamaica</option>
                                        <option value="tfa_366" id="tfa_366" class="">Japan</option>
                                        <option value="tfa_367" id="tfa_367" class="">Jordan</option>
                                        <option value="tfa_368" id="tfa_368" class="">Kazakhstan</option>
                                        <option value="tfa_369" id="tfa_369" class="">Kenya</option>
                                        <option value="tfa_370" id="tfa_370" class="">Kiribati</option>
                                        <option value="tfa_371" id="tfa_371" class="">Korea</option>
                                        <option value="tfa_372" id="tfa_372" class="">Kuwait</option>
                                        <option value="tfa_373" id="tfa_373" class="">Kyrgyzstan</option>
                                        <option value="tfa_374" id="tfa_374" class="">Laos</option>
                                        <option value="tfa_375" id="tfa_375" class="">Latvia</option>
                                        <option value="tfa_376" id="tfa_376" class="">Lebanon</option>
                                        <option value="tfa_377" id="tfa_377" class="">Lesotho</option>
                                        <option value="tfa_378" id="tfa_378" class="">Liberia</option>
                                        <option value="tfa_379" id="tfa_379" class="">Libya</option>
                                        <option value="tfa_380" id="tfa_380" class="">Liechtenstein</option>
                                        <option value="tfa_381" id="tfa_381" class="">Lithuania</option>
                                        <option value="tfa_382" id="tfa_382" class="">Luxembourg</option>
                                        <option value="tfa_383" id="tfa_383" class="">Macao SAR</option>
                                        <option value="tfa_384" id="tfa_384" class="">Macedonia, Former Yugoslav Republic of</option>
                                        <option value="tfa_385" id="tfa_385" class="">Madagascar</option>
                                        <option value="tfa_386" id="tfa_386" class="">Malawi</option>
                                        <option value="tfa_387" id="tfa_387" class="">Malaysia</option>
                                        <option value="tfa_388" id="tfa_388" class="">Maldives</option>
                                        <option value="tfa_389" id="tfa_389" class="">Mali</option>
                                        <option value="tfa_390" id="tfa_390" class="">Malta</option>
                                        <option value="tfa_391" id="tfa_391" class="">Marshall Islands</option>
                                        <option value="tfa_392" id="tfa_392" class="">Martinique</option>
                                        <option value="tfa_393" id="tfa_393" class="">Mauritania</option>
                                        <option value="tfa_394" id="tfa_394" class="">Mauritius</option>
                                        <option value="tfa_395" id="tfa_395" class="">Mayotte</option>
                                        <option value="tfa_396" id="tfa_396" class="">Mexico</option>
                                        <option value="tfa_397" id="tfa_397" class="">Micronesia</option>
                                        <option value="tfa_398" id="tfa_398" class="">Moldova</option>
                                        <option value="tfa_399" id="tfa_399" class="">Monaco</option>
                                        <option value="tfa_400" id="tfa_400" class="">Mongolia</option>
                                        <option value="tfa_401" id="tfa_401" class="">Montserrat</option>
                                        <option value="tfa_402" id="tfa_402" class="">Morocco</option>
                                        <option value="tfa_403" id="tfa_403" class="">Mozambique</option>
                                        <option value="tfa_404" id="tfa_404" class="">Myanmar</option>
                                        <option value="tfa_405" id="tfa_405" class="">Namibia</option>
                                        <option value="tfa_406" id="tfa_406" class="">Nauru</option>
                                        <option value="tfa_407" id="tfa_407" class="">Nepal</option>
                                        <option value="tfa_408" id="tfa_408" class="">Netherlands</option>
                                        <option value="tfa_409" id="tfa_409" class="">Netherlands Antilles</option>
                                        <option value="tfa_410" id="tfa_410" class="">New Caledonia</option>
                                        <option value="tfa_411" id="tfa_411" class="">New Zealand</option>
                                        <option value="tfa_412" id="tfa_412" class="">Nicaragua</option>
                                        <option value="tfa_413" id="tfa_413" class="">Niger</option>
                                        <option value="tfa_414" id="tfa_414" class="">Nigeria</option>
                                        <option value="tfa_415" id="tfa_415" class="">Niue</option>
                                        <option value="tfa_416" id="tfa_416" class="">Norfolk Island</option>
                                        <option value="tfa_417" id="tfa_417" class="">North Korea</option>
                                        <option value="tfa_418" id="tfa_418" class="">Northern Mariana Islands</option>
                                        <option value="tfa_419" id="tfa_419" class="">Norway</option>
                                        <option value="tfa_420" id="tfa_420" class="">Oman</option>
                                        <option value="tfa_421" id="tfa_421" class="">Pakistan</option>
                                        <option value="tfa_422" id="tfa_422" class="">Palau</option>
                                        <option value="tfa_423" id="tfa_423" class="">Panama</option>
                                        <option value="tfa_424" id="tfa_424" class="">Papua New Guinea</option>
                                        <option value="tfa_425" id="tfa_425" class="">Paraguay</option>
                                        <option value="tfa_426" id="tfa_426" class="">Peru</option>
                                        <option value="tfa_427" id="tfa_427" class="">Philippines</option>
                                        <option value="tfa_428" id="tfa_428" class="">Pitcairn Islands</option>
                                        <option value="tfa_429" id="tfa_429" class="">Poland</option>
                                        <option value="tfa_430" id="tfa_430" class="">Portugal</option>
                                        <option value="tfa_431" id="tfa_431" class="">Puerto Rico</option>
                                        <option value="tfa_432" id="tfa_432" class="">Qatar</option>
                                        <option value="tfa_433" id="tfa_433" class="">Reunion</option>
                                        <option value="tfa_434" id="tfa_434" class="">Romania</option>
                                        <option value="tfa_435" id="tfa_435" class="">Russia</option>
                                        <option value="tfa_436" id="tfa_436" class="">Rwanda</option>
                                        <option value="tfa_437" id="tfa_437" class="">Samoa</option>
                                        <option value="tfa_438" id="tfa_438" class="">San Marino</option>
                                        <option value="tfa_439" id="tfa_439" class="">São Tomé and Prìncipe</option>
                                        <option value="tfa_440" id="tfa_440" class="">Saudi Arabia</option>
                                        <option value="tfa_441" id="tfa_441" class="">Senegal</option>
                                        <option value="tfa_442" id="tfa_442" class="">Serbia and Montenegro</option>
                                        <option value="tfa_443" id="tfa_443" class="">Seychelles</option>
                                        <option value="tfa_444" id="tfa_444" class="">Sierra Leone</option>
                                        <option value="tfa_445" id="tfa_445" class="">Singapore</option>
                                        <option value="tfa_446" id="tfa_446" class="">Slovakia</option>
                                        <option value="tfa_447" id="tfa_447" class="">Slovenia</option>
                                        <option value="tfa_448" id="tfa_448" class="">Solomon Islands</option>
                                        <option value="tfa_449" id="tfa_449" class="">Somalia</option>
                                        <option value="tfa_450" id="tfa_450" class="">South Africa</option>
                                        <option value="tfa_451" id="tfa_451" class="">South Georgia and the South Sandwich Islands</option>
                                        <option value="tfa_452" id="tfa_452" class="">Spain</option>
                                        <option value="tfa_453" id="tfa_453" class="">Sri Lanka</option>
                                        <option value="tfa_454" id="tfa_454" class="">St. Helena</option>
                                        <option value="tfa_455" id="tfa_455" class="">St. Kitts and Nevis</option>
                                        <option value="tfa_456" id="tfa_456" class="">St. Lucia</option>
                                        <option value="tfa_457" id="tfa_457" class="">St. Pierre and Miquelon</option>
                                        <option value="tfa_458" id="tfa_458" class="">St. Vincent and the Grenadines</option>
                                        <option value="tfa_459" id="tfa_459" class="">Sudan</option>
                                        <option value="tfa_460" id="tfa_460" class="">Suriname</option>
                                        <option value="tfa_461" id="tfa_461" class="">Svalbard and Jan Mayen</option>
                                        <option value="tfa_462" id="tfa_462" class="">Swaziland</option>
                                        <option value="tfa_463" id="tfa_463" class="">Sweden</option>
                                        <option value="tfa_464" id="tfa_464" class="">Switzerland</option>
                                        <option value="tfa_465" id="tfa_465" class="">Syria</option>
                                        <option value="tfa_466" id="tfa_466" class="">Taiwan</option>
                                        <option value="tfa_467" id="tfa_467" class="">Tajikistan</option>
                                        <option value="tfa_468" id="tfa_468" class="">Tanzania</option>
                                        <option value="tfa_469" id="tfa_469" class="">Thailand</option>
                                        <option value="tfa_470" id="tfa_470" class="">Togo</option>
                                        <option value="tfa_471" id="tfa_471" class="">Tokelau</option>
                                        <option value="tfa_472" id="tfa_472" class="">Tonga</option>
                                        <option value="tfa_473" id="tfa_473" class="">Trinidad and Tobago</option>
                                        <option value="tfa_474" id="tfa_474" class="">Tunisia</option>
                                        <option value="tfa_475" id="tfa_475" class="">Turkey</option>
                                        <option value="tfa_476" id="tfa_476" class="">Turkmenistan</option>
                                        <option value="tfa_477" id="tfa_477" class="">Turks and Caicos Islands</option>
                                        <option value="tfa_478" id="tfa_478" class="">Tuvalu</option>
                                        <option value="tfa_479" id="tfa_479" class="">Uganda</option>
                                        <option value="tfa_480" id="tfa_480" class="">Ukraine</option>
                                        <option value="tfa_481" id="tfa_481" class="">United Arab Emirates</option>
                                        <option value="tfa_482" id="tfa_482" class="">United Kingdom</option>
                                        <option value="tfa_484" id="tfa_484" class="">United States Minor Outlying Islands</option>
                                        <option value="tfa_485" id="tfa_485" class="">Uruguay</option>
                                        <option value="tfa_486" id="tfa_486" class="">Uzbekistan</option>
                                        <option value="tfa_487" id="tfa_487" class="">Vanuatu</option>
                                        <option value="tfa_488" id="tfa_488" class="">Vatican City</option>
                                        <option value="tfa_489" id="tfa_489" class="">Venezuela</option>
                                        <option value="tfa_490" id="tfa_490" class="">Viet Nam</option>
                                        <option value="tfa_491" id="tfa_491" class="">Virgin Islands ( British )</option>
                                        <option value="tfa_492" id="tfa_492" class="">Virgin Islands</option>
                                        <option value="tfa_493" id="tfa_493" class="">Wallis and Futuna</option>
                                        <option value="tfa_494" id="tfa_494" class="">Yemen</option>
                                        <option value="tfa_495" id="tfa_495" class="">Zambia</option>
                                        <option value="tfa_496" id="tfa_496" class="">Zimbabwe</option>
                                    </select></div>
                            </div>
                        </div>
                    </div>
                </fieldset>
                <fieldset id="tfa_499" class="section">
                    <legend id="tfa_499-L">Select Level</legend>
                    <div id="tfa_510" class="section inline group">
                        <div class="oneField field-container-D    " id="tfa_500-D" role="radiogroup" aria-labelledby="tfa_500-L" data-tfa-labelledby="-L tfa_500-L">
                            <label id="tfa_500-L" class="label preField reqMark">Levels:</label><br>
                            <div class="inputWrapper"><span id="tfa_500" class="choices vertical required"><span class="oneChoice"><input type="radio" value="tfa_501" class="calc-LEVELS calcval-COCHAIR" id="tfa_501" name="tfa_500" aria-required="true" data-conditionals="#tfa_506,#tfa_511" aria-labelledby="tfa_501-L" data-tfa-labelledby="tfa_500-L tfa_501-L"><label class="label postField" id="tfa_501-L" for="tfa_501"><span class="input-radio-faux"></span>
                                            <p class="MsoNormal"><b>$50,000 Cochair</b></p>

                                            <p style="margin-left:13.5pt" class="MsoNormal"><span style="font-size: 10pt;">Special
                                                    recognition throughout the </span><i style="font-size: 10pt;">Global
                                                    Leadership Awards</i><span style="font-size: 10pt;"> virtual event; prominent listing on the event website and
                                                    digital promotion; </span><span style="font-size: 13.3333px;">attend virtual cocktail party with Council experts prior to the event &amp; virtual watch party during the event.</span><span style="font-size: 10pt;">&nbsp;</span></p>
                                        </label></span><span class="oneChoice"><input type="radio" value="tfa_502" class="calc-LEVELS calcval-VICECHAIR" id="tfa_502" name="tfa_500" aria-required="true" data-conditionals="#tfa_506,#tfa_511" aria-labelledby="tfa_502-L" data-tfa-labelledby="tfa_500-L tfa_502-L"><label class="label postField" id="tfa_502-L" for="tfa_502"><span class="input-radio-faux"></span>
                                            <p class="MsoNormal"><b>$25,000 Vice Chair</b></p>

                                            <p style="margin-left:13.5pt" class="MsoNormal"><span style="font-size: 10pt;">Recognition
                                                    throughout the </span><i style="font-size: 10pt;">Global Leadership Awards</i><span style="font-size: 10pt;">
                                                    virtual event; listing on the event website and digital promotion; </span><span style="font-size: 13.3333px;">attend virtual cocktail party with Council experts prior to the event &amp; virtual watch party during the event.</span></p>
                                        </label></span><span class="oneChoice"><input type="radio" value="tfa_503" class="calc-LEVELS calcval-PATRON" id="tfa_503" name="tfa_500" aria-required="true" data-conditionals="#tfa_511" aria-labelledby="tfa_503-L" data-tfa-labelledby="tfa_500-L tfa_503-L"><label class="label postField" id="tfa_503-L" for="tfa_503"><span class="input-radio-faux"></span>
                                            <p class="MsoNormal"><b>$10,000 Patron</b></p>

                                            <p style="margin-left:13.5pt" class="MsoNormal"><span style="font-size:10.0pt">Listing
                                                    on the event website and digital promotion; attend virtual cocktail party with Council experts prior to the
                                                    event &amp; virtual watch party during the event.&nbsp;&nbsp;</span></p>
                                        </label></span><span class="oneChoice"><input type="radio" value="tfa_504" class="calc-LEVELS calcval-IND" id="tfa_504" name="tfa_500" aria-required="true" data-conditionals="#tfa_514" aria-labelledby="tfa_504-L" data-tfa-labelledby="tfa_500-L tfa_504-L"><label class="label postField" id="tfa_504-L" for="tfa_504"><span class="input-radio-faux"></span>
                                            <p class="MsoNormal"><b>$500 Individual</b></p>

                                            <p style="margin-left:13.5pt" class="MsoNormal"><span style="font-size:10.0pt">Access
                                                    to the virtual event.</span></p>
                                        </label></span><span class="oneChoice"><input type="radio" value="tfa_505" class="calc-LEVELS calcval-DON" id="tfa_505" name="tfa_500" aria-required="true" data-conditionals="#tfa_515" aria-labelledby="tfa_505-L" data-tfa-labelledby="tfa_500-L tfa_505-L"><label class="label postField" id="tfa_505-L" for="tfa_505"><span class="input-radio-faux"></span><span style="font-weight: 700;">I am unable to participate but wish to make a contribution (<i>enter amount below</i>)</span></label></span></span></div>
                        </div>
                        <div class="oneField field-container-D     wf-acl-hidden" id="tfa_506-D" role="radiogroup" aria-labelledby="tfa_506-L" data-tfa-labelledby="-L tfa_506-L">
                            <label id="tfa_506-L" class="label preField ">Would you like to host a watch party in your home or virtually?</label><br>
                            <div class="inputWrapper"><span id="tfa_506" class="choices vertical " data-condition="`#tfa_501` OR `#tfa_502`"><span class="oneChoice"><input type="radio" value="tfa_507" class="" id="tfa_507" name="tfa_506" aria-labelledby="tfa_507-L" data-tfa-labelledby="tfa_506-L tfa_507-L"><label class="label postField" id="tfa_507-L" for="tfa_507"><span class="input-radio-faux"></span>Yes</label></span><span class="oneChoice"><input type="radio" value="tfa_508" class="" id="tfa_508" name="tfa_506" aria-labelledby="tfa_508-L" data-tfa-labelledby="tfa_506-L tfa_508-L"><label class="label postField" id="tfa_508-L" for="tfa_508"><span class="input-radio-faux"></span>No</label></span></span></div>
                        </div>
                    </div>
                    <div class="oneField field-container-D     wf-acl-hidden" id="tfa_511-D" role="radiogroup" aria-labelledby="tfa_511-L" data-tfa-labelledby="-L tfa_511-L">
                        <label id="tfa_511-L" class="label preField ">Would you like to participate in a virtual cocktail party prior to the event?</label><br>
                        <div class="inputWrapper"><span id="tfa_511" class="choices vertical " data-condition="`#tfa_501` OR `#tfa_502` OR `#tfa_503`"><span class="oneChoice"><input type="radio" value="tfa_512" class="" id="tfa_512" name="tfa_511" aria-labelledby="tfa_512-L" data-tfa-labelledby="tfa_511-L tfa_512-L"><label class="label postField" id="tfa_512-L" for="tfa_512"><span class="input-radio-faux"></span>Yes</label></span><span class="oneChoice"><input type="radio" value="tfa_513" class="" id="tfa_513" name="tfa_511" aria-labelledby="tfa_513-L" data-tfa-labelledby="tfa_511-L tfa_513-L"><label class="label postField" id="tfa_513-L" for="tfa_513"><span class="input-radio-faux"></span>No</label></span></span></div>
                    </div>
                    <div class="oneField field-container-D     wf-acl-hidden" id="tfa_514-D">
                        <label id="tfa_514-L" class="label preField reqMark" for="tfa_514">Number of Individual tickets:</label><br>
                        <div class="inputWrapper"><input type="text" id="tfa_514" name="tfa_514" value="1" default="1" aria-required="true" data-condition="`#tfa_504`" title="Number of Individual tickets:" class="calc-NUMTICKETS required"></div>
                    </div>
                    <div class="oneField field-container-D    " id="tfa_515-D">
                        <label id="tfa_515-L" class="label preField reqMark" for="tfa_515">Donation Amount:</label><br>
                        <div class="inputWrapper"><input type="text" id="tfa_515" name="tfa_515" value="" aria-required="true" data-condition="`#tfa_505`" title="Donation Amount:" class="calc-DONATIONAMOUNT required"></div>
                    </div>
                </fieldset>
                <fieldset id="tfa_516" class="section">
                    <legend id="tfa_516-L">Select Payment</legend>
                    <div class="oneField field-container-D  labelsLeftAligned  " id="tfa_545-D">
                        <label id="tfa_545-L" class="label preField " for="tfa_545"><b>Total Amount Due:</b></label>
                        <div class="inputWrapper"><input type="text" id="tfa_545" name="tfa_545" value="" readonly title="Total Amount Due:" class="formula=dispCurrency(AmountToCharge) readonly"></div>
                    </div>
                    <div class="oneField field-container-D    " id="tfa_528-D">
                        <label id="tfa_528-L" class="label preField reqMark" for="tfa_528">Preferred listing on digital materials:</label><br>
                        <div class="inputWrapper"><input type="text" id="tfa_528" name="tfa_528" value="" aria-required="true" title="Preferred listing on digital materials:" class="required"></div>
                    </div>
                    <div class="oneField field-container-D    " id="tfa_524-D" role="radiogroup" aria-labelledby="tfa_524-L" data-tfa-labelledby="-L tfa_524-L">
                        <label id="tfa_524-L" class="label preField reqMark">This contribution is:</label><br>
                        <div class="inputWrapper"><span id="tfa_524" class="choices vertical required"><span class="oneChoice"><input type="radio" value="tfa_525" class="" id="tfa_525" name="tfa_524" aria-required="true" aria-labelledby="tfa_525-L" data-tfa-labelledby="tfa_524-L tfa_525-L"><label class="label postField" id="tfa_525-L" for="tfa_525"><span class="input-radio-faux"></span>Individual</label></span><span class="oneChoice"><input type="radio" value="tfa_526" class="" id="tfa_526" name="tfa_524" aria-required="true" aria-labelledby="tfa_526-L" data-tfa-labelledby="tfa_524-L tfa_526-L"><label class="label postField" id="tfa_526-L" for="tfa_526"><span class="input-radio-faux"></span>Corporate</label></span><span class="oneChoice"><input type="radio" value="tfa_527" class="" id="tfa_527" name="tfa_524" aria-required="true" aria-labelledby="tfa_527-L" data-tfa-labelledby="tfa_524-L tfa_527-L"><label class="label postField" id="tfa_527-L" for="tfa_527"><span class="input-radio-faux"></span>Family Foundation</label></span></span></div>
                    </div>
                    <div class="htmlSection" id="tfa_517">
                        <div class="htmlContent" id="tfa_517-HTML">
                            <p class="MsoNormal"><br></p>
                            <p class="MsoNormal">If possible, kindly consider check or wire transfer for
                                gifts of $10,000+.</p>
                        </div>
                    </div>
                    <div class="htmlSection" id="tfa_522">
                        <div class="htmlContent" id="tfa_522-HTML">
                            <p class="MsoNormal"><br></p>
                            <p class="MsoNormal">Make checks payable to:</p>

                            <p class="MsoNormal">Chicago Council on Global Affairs</p>

                            <p class="MsoNormal">180 N. Stetson Ave.</p>

                            <p class="MsoNormal">Suite 1400</p>

                            <p class="MsoNormal">Chicago, IL&nbsp; 60601</p>
                        </div>
                    </div>
                    <div class="oneField field-container-D    " id="tfa_518-D" role="radiogroup" aria-labelledby="tfa_518-L" data-tfa-labelledby="-L tfa_518-L">
                        <label id="tfa_518-L" class="label preField reqMark">Payment Method:</label><br>
                        <div class="inputWrapper"><span id="tfa_518" class="choices vertical required"><span class="oneChoice"><input type="radio" value="tfa_519" class="" id="tfa_519" name="tfa_518" aria-required="true" aria-labelledby="tfa_519-L" data-tfa-labelledby="tfa_518-L tfa_519-L"><label class="label postField" id="tfa_519-L" for="tfa_519"><span class="input-radio-faux"></span>
                                        <p class="MsoNormal">I will send a check to the address above.</p>
                                    </label></span><span class="oneChoice"><input type="radio" value="tfa_521" class="" id="tfa_521" name="tfa_518" aria-required="true" aria-labelledby="tfa_521-L" data-tfa-labelledby="tfa_518-L tfa_521-L"><label class="label postField" id="tfa_521-L" for="tfa_521"><span class="input-radio-faux"></span>I would like to pay via ACH or wire transfer. Please send instructions.</label></span><span class="oneChoice"><input type="radio" value="tfa_548" class="" id="tfa_548" name="tfa_518" aria-required="true" aria-labelledby="tfa_548-L" data-tfa-labelledby="tfa_518-L tfa_548-L"><label class="label postField" id="tfa_548-L" for="tfa_548"><span class="input-radio-faux"></span>Please call me to collect payment information.</label></span><span class="oneChoice"><input type="radio" value="tfa_520" class="" id="tfa_520" name="tfa_518" aria-required="true" data-conditionals="#tfa_523" aria-labelledby="tfa_520-L" data-tfa-labelledby="tfa_518-L tfa_520-L"><label class="label postField" id="tfa_520-L" for="tfa_520"><span class="input-radio-faux"></span>I will pay by credit card.</label></span></span></div>
                    </div>
                    <div id="tfa_523" class="section group" data-condition="`#tfa_520`">
                        <label class="label preField" id="tfa_523-L">Credit Card Information:</label><br>
                        <div class="oneField field-container-D    " id="tfa_529-D">
                            <label id="tfa_529-L" class="label preField reqMark" for="tfa_529">Name on Credit Card:</label><br>
                            <div class="inputWrapper"><input type="text" id="tfa_529" name="tfa_529" value="" aria-required="true" title="Name on Credit Card:" class="required"></div>
                        </div>
                        <div class="oneField field-container-D    " id="tfa_530-D">
                            <label id="tfa_530-L" class="label preField reqMark" for="tfa_530">Credit Card Type:</label><br>
                            <div class="inputWrapper"><select id="tfa_530" name="tfa_530" title="Credit Card Type:" aria-required="true" class="required">
                                    <option value="">Please select...</option>
                                    <option value="tfa_531" id="tfa_531" class="">Visa</option>
                                    <option value="tfa_532" id="tfa_532" class="">Mastercard</option>
                                    <option value="tfa_533" id="tfa_533" class="">Discover</option>
                                    <option value="tfa_534" id="tfa_534" class="">American Express</option>
                                </select></div>
                        </div>
                        <div class="oneField field-container-D    " id="tfa_535-D">
                            <label id="tfa_535-L" class="label preField reqMark" for="tfa_535">Credit Card Number:</label><br>
                            <div class="inputWrapper"><input type="text" id="tfa_535" name="tfa_535" value="" aria-required="true" title="Credit Card Number:" class="validate-custom /^\d+$/g required"></div>
                        </div>
                        <div id="tfa_538" class="section inline group">
                            <div class="oneField field-container-D    " id="tfa_536-D">
                                <label id="tfa_536-L" class="label preField reqMark" for="tfa_536">CVV Number:</label><br>
                                <div class="inputWrapper"><input type="text" id="tfa_536" name="tfa_536" value="" aria-required="true" title="CVV Number:" class="required"></div>
                            </div>
                            <div class="oneField field-container-D    " id="tfa_537-D">
                                <label id="tfa_537-L" class="label preField reqMark" for="tfa_537">Exp Date:</label><br>
                                <div class="inputWrapper"><input type="text" id="tfa_537" name="tfa_537" value="" placeholder="##/##" maxlength="5" aria-required="true" autoformat="##/##" title="Exp Date:" class="validate-custom /[0-1][0-9]\/[1-9][0-9]/g calc-ExpDate required"></div>
                                <script type="text/javascript">
                                    if (typeof wFORMS != 'undefined') {
                                        if (wFORMS.behaviors.validation) {
                                            wFORMS.behaviors.validation.rules['customtfa_537'] = {
                                                selector: '*[id="tfa_537"]',
                                                check: 'validateCustom'
                                            };
                                            wFORMS.behaviors.validation.messages['customtfa_537'] = "Expiration date must be in MM/YY format.";
                                        }
                                    }
                                </script>
                            </div>
                        </div>
                        <div class="oneField field-container-D  labelsAbove  " id="tfa_550-D" role="group" aria-labelledby="tfa_550-L" data-tfa-labelledby="-L tfa_550-L">
                            <div class="inputWrapper"><span id="tfa_550" class="choices vertical "><span class="oneChoice"><input type="checkbox" value="tfa_551" class="calc-CCFee calcval-True" checked data-default-value="true" id="tfa_551" name="tfa_551" aria-labelledby="tfa_551-L" data-tfa-labelledby="tfa_550-L tfa_551-L"><label class="label postField" id="tfa_551-L" for="tfa_551"><span class="input-checkbox-faux"></span><span style="color: rgb(52, 59, 62); font-family: Roboto, sans-serif; font-size: 14.4px;">I would like to cover the 3% credit card processing fee</span></label></span></span></div>
                        </div>
                    </div>
                    <div class="oneField field-container-D  labelsLeftAligned  " id="tfa_554-D">
                        <label id="tfa_554-L" class="label preField " for="tfa_554"><b>Total Amount Due:</b></label>
                        <div class="inputWrapper"><input type="text" id="tfa_554" name="tfa_554" value="" readonly title="Total Amount Due:" class="formula=dispCurrency(AmountToCharge) readonly"></div>
                    </div>
                </fieldset>
                <div id="tfa_544" class="section group wf-acl-hidden">
                    <label class="label preField" id="tfa_544-L">Calculated Fields</label><br>
                    <div class="oneField field-container-D    " id="tfa_539-D">
                        <label id="tfa_539-L" class="label preField " for="tfa_539">Total Charge:</label><br>
                        <div class="inputWrapper"><input type="text" id="tfa_539" name="tfa_539" value="" readonly title="Total Charge:" class='formula=if(LEVELS=="COCHAIR"){COCHAIRPRICE}else{if(LEVELS=="VICECHAIR"){VICECHAIRPRICE}else{if(LEVELS=="PATRON"){PATRONPRICE}else{if(LEVELS=="IND"){INDIVIDUALPRICE}else{DONATIONAMOUNT}}}}; calc-TotalCharge readonly'></div>
                    </div>
                    <div class="oneField field-container-D    " id="tfa_562-D">
                        <label id="tfa_562-L" class="label preField " for="tfa_562">LEVEL</label><br>
                        <div class="inputWrapper"><input type="text" id="tfa_562" name="tfa_562" value="" readonly title="LEVEL" class='formula=if(LEVELS=="COCHAIR"){"Cochair"}else{if(LEVELS=="VICECHAIR"){"ViceChair"}else{if(LEVELS=="PATRON"){"Patron"}else{if(LEVELS=="IND"){"Individual"}else{if(LEVELS=="DON"){"Donor"}else{"Registered"}}}}}; readonly'></div>
                    </div>
                    <div class="oneField field-container-D    " id="tfa_540-D">
                        <label id="tfa_540-L" class="label preField " for="tfa_540">COCHAIRPRICE</label><br>
                        <div class="inputWrapper"><input type="text" id="tfa_540" name="tfa_540" value="" readonly title="COCHAIRPRICE" class="formula=50000 calc-COCHAIRPRICE readonly"></div>
                    </div>
                    <div class="oneField field-container-D    " id="tfa_541-D">
                        <label id="tfa_541-L" class="label preField " for="tfa_541">VICECHAIRPRICE</label><br>
                        <div class="inputWrapper"><input type="text" id="tfa_541" name="tfa_541" value="" readonly title="VICECHAIRPRICE" class="formula=25000 calc-VICECHAIRPRICE readonly"></div>
                    </div>
                    <div class="oneField field-container-D    " id="tfa_542-D">
                        <label id="tfa_542-L" class="label preField " for="tfa_542">PATRONPRICE</label><br>
                        <div class="inputWrapper"><input type="text" id="tfa_542" name="tfa_542" value="" readonly title="PATRONPRICE" class="formula=10000 calc-PATRONPRICE readonly"></div>
                    </div>
                    <div class="oneField field-container-D    " id="tfa_543-D">
                        <label id="tfa_543-L" class="label preField " for="tfa_543">INDIVIDUALPRICE</label><br>
                        <div class="inputWrapper"><input type="text" id="tfa_543" name="tfa_543" value="" readonly title="INDIVIDUALPRICE" class="formula=500*NUMTICKETS calc-INDIVIDUALPRICE readonly"></div>
                    </div>
                    <div class="oneField field-container-D    " id="tfa_549-D">
                        <label id="tfa_549-L" class="label preField " for="tfa_549">Credit Card Fee</label><br>
                        <div class="inputWrapper"><input type="text" id="tfa_549" name="tfa_549" value="" readonly title="Credit Card Fee" class='formula=if(CCFee=="True"){TotalCharge*.03}else{0}; calc-CCFeeAmount readonly'></div>
                    </div>
                    <div class="oneField field-container-D    " id="tfa_552-D">
                        <label id="tfa_552-L" class="label preField reqMark" for="tfa_552">Amount To Charge</label><br>
                        <div class="inputWrapper"><input type="text" id="tfa_552" name="tfa_552" value="" readonly aria-required="true" title="Amount To Charge" class="validate-float formula=TotalCharge+CCFeeAmount calc-AmountToCharge readonly required"></div>
                    </div>
                    <div class="oneField field-container-D    " id="tfa_555-D">
                        <label id="tfa_555-L" class="label preField reqMark" for="tfa_555">Credit Card Month</label><br>
                        <div class="inputWrapper"><input type="text" id="tfa_555" name="tfa_555" value="00" default="00" readonly aria-required="true" min="1" max="12" title="Credit Card Month" class='validate-integer formula=if(ExpDate==""){"12"}else{ExpDate.substring(0,2)}; readonly required'></div>
                    </div>
                    <div class="oneField field-container-D    " id="tfa_556-D">
                        <label id="tfa_556-L" class="label preField reqMark" for="tfa_556">Credit Card Year</label><br>
                        <div class="inputWrapper"><input type="text" id="tfa_556" name="tfa_556" value="00" default="00" readonly aria-required="true" max="9999" title="Credit Card Year" class='validate-integer formula=if(ExpDate==""){"22"}else{ExpDate.substring(3,5)}; readonly required'></div>
                    </div>
                </div>
                <input type="hidden" id="CHARGENT_ORDER_OBJECT_ID_316" name="CHARGENT_ORDER_OBJECT_ID_316" value="" class=""><input type="hidden" id="CHARGENT_ORDER_ID_316" name="CHARGENT_ORDER_ID_316" value="" class=""><input type="hidden" id="CHARGENT_TRANSACTION_ID_316" name="CHARGENT_TRANSACTION_ID_316" value="" class=""><input type="hidden" id="CHARGENT_CASE_ID_316" name="CHARGENT_CASE_ID_316" value="" class=""><input type="hidden" id="CHARGENT_OPP_ID_316" name="CHARGENT_OPP_ID_316" value="" class="">
                <div class="actions" id="109-A"><input type="submit" data-label="Submit" class="primaryAction" id="submit_button" value="Submit"></div>
                <div style="clear:both"></div>
                <input type="hidden" value="109" name="tfa_dbFormId" id="tfa_dbFormId"><input type="hidden" value="" name="tfa_dbResponseId" id="tfa_dbResponseId"><input type="hidden" value="03de7c35c88db46f3275795006a65bc5" name="tfa_dbControl" id="tfa_dbControl"><input type="hidden" value="" name="tfa_dbWorkflowSessionUuid" id="tfa_dbWorkflowSessionUuid"><input type="hidden" value="3" name="tfa_dbVersionId" id="tfa_dbVersionId"><input type="hidden" value="" name="tfa_switchedoff" id="tfa_switchedoff">
            </form>
        </div>
    </div>
    <div class="wFormFooter">
        <p class="supportInfo"><a target="new" class="contactInfoLink" href="https://www.thechicagocouncil.org/contact">Contact Information</a><br></p>
    </div>
    <p class="supportInfo">
    </p>
</div>