{"id":3168,"date":"2019-02-06T04:06:03","date_gmt":"2019-02-06T04:06:03","guid":{"rendered":"https:\/\/www.lifeoptionspittsburgh.com\/?page_id=3168"},"modified":"2019-02-06T05:35:33","modified_gmt":"2019-02-06T05:35:33","slug":"vendor-registration","status":"publish","type":"page","link":"https:\/\/www.lifeoptionspittsburgh.com\/vendor-registration\/","title":{"rendered":"Vendor Registration"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; disabled_on=&#8221;on|on|off&#8221; _builder_version=&#8221;3.19&#8243; background_image=&#8221;https:\/\/www.lifeoptionspittsburgh.com\/wp-content\/uploads\/2018\/12\/Membership.jpg&#8221; background_position=&#8221;top_left&#8221; custom_padding=&#8221;0|0px|202px|0px|false|false&#8221; top_divider_color=&#8221;#faa61a&#8221; top_divider_height=&#8221;132px&#8221; top_divider_flip=&#8221;horizontal&#8221; bottom_divider_style=&#8221;ramp2&#8243; bottom_divider_color=&#8221;#3f99d4&#8243; bottom_divider_height=&#8221;368px&#8221; bottom_divider_flip=&#8221;horizontal&#8221;][et_pb_row custom_padding=&#8221;126px|0px|122px|0px|false|false&#8221; _builder_version=&#8221;3.17.6&#8243;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;3.0.47&#8243; parallax=&#8221;off&#8221; parallax_method=&#8221;on&#8221;][et_pb_text _builder_version=&#8221;3.19.11&#8243; header_font=&#8221;||||||||&#8221; header_text_color=&#8221;#3f99d4&#8243; header_font_size=&#8221;68px&#8221; max_width=&#8221;66%&#8221; module_alignment=&#8221;right&#8221; custom_margin=&#8221;-23px||-49px&#8221; animation_style=&#8221;slide&#8221; animation_direction=&#8221;bottom&#8221; animation_intensity_slide=&#8221;20%&#8221;]<\/p>\n<h1 style=\"text-align: right;\">Vendor Registration<\/h1>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; disabled_on=&#8221;off|off|on&#8221; _builder_version=&#8221;3.19&#8243; background_color=&#8221;#72bf44&#8243; background_image=&#8221;https:\/\/www.lifeoptionspittsburgh.com\/wp-content\/uploads\/2018\/12\/Partner-M.jpg&#8221; background_position=&#8221;center_left&#8221; custom_padding=&#8221;54px|0px|105px|0px|false|false&#8221; top_divider_color=&#8221;#3f99d4&#8243; top_divider_height=&#8221;132px&#8221; top_divider_flip=&#8221;horizontal&#8221; bottom_divider_style=&#8221;ramp2&#8243; bottom_divider_color=&#8221;#3f99d4&#8243; bottom_divider_height=&#8221;238px&#8221; bottom_divider_flip=&#8221;horizontal&#8221;][et_pb_row custom_padding=&#8221;50px|0px|0|0px|false|false&#8221; _builder_version=&#8221;3.17.6&#8243;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;3.17.6&#8243; parallax=&#8221;off&#8221; parallax_method=&#8221;on&#8221;][et_pb_text _builder_version=&#8221;3.19&#8243; header_font=&#8221;||||||||&#8221; header_text_color=&#8221;#3f99d4&#8243; header_font_size=&#8221;48px&#8221;]<\/p>\n<h1 style=\"text-align: right;\">BECOME A PARTNER<\/h1>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; module_id=&#8221;learn-more&#8221; _builder_version=&#8221;3.18.2&#8243; background_color=&#8221;#faa61a&#8221; use_background_color_gradient=&#8221;on&#8221; background_color_gradient_start=&#8221;#3f99d4&#8243; background_color_gradient_end=&#8221;#ffffff&#8221;][et_pb_row custom_padding=&#8221;0|0px|27px|0px|false|false&#8221; custom_margin=&#8221;-39px||&#8221; _builder_version=&#8221;3.18.4&#8243;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;3.0.47&#8243; parallax=&#8221;off&#8221; parallax_method=&#8221;on&#8221;][et_pb_text _builder_version=&#8221;3.19.11&#8243; text_font=&#8221;||||||||&#8221; text_text_color=&#8221;#434244&#8243; text_font_size=&#8221;18px&#8221; text_line_height=&#8221;1.8em&#8221;]<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_chrome gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_5' style='display:none'>\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">VENDOR REGISTRATION FORM<\/h3>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/wp-json\/wp\/v2\/pages\/3168' data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_5_1\" class=\"gfield gfield--type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_1\" ><label class='gfield_label gform-field-label' for='input_5_1'>Business Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_5_1' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_3\" class=\"gfield gfield--type-phone gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_3\" ><label class='gfield_label gform-field-label' for='input_5_3'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_5_3' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_4\" class=\"gfield gfield--type-email gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_4\" ><label class='gfield_label gform-field-label' for='input_5_4'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_4' id='input_5_4' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_5_2\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_2\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_zip ginput_container_address gform-grid-row' id='input_5_2' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_2_1_container' >\n                                        <input type='text' name='input_2.1' id='input_5_2_1' value=''    aria-required='true'    \/>\n                                        <label for='input_5_2_1' id='input_5_2_1_label' class='gform-field-label gform-field-label--type-sub '>Address<\/label>\n                                    <\/span><input type='hidden' class='gform_hidden' name='input_2.4' id='input_5_2_4' value='Pennsylvania'\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_5_2_5_container' >\n                                    <input type='text' name='input_2.5' id='input_5_2_5' value=''    aria-required='true'    \/>\n                                    <label for='input_5_2_5' id='input_5_2_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_2.6' id='input_5_2_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_5_6\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_6\" ><label class='gfield_label gform-field-label' >Do you need electricity?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_6'>\n\t\t\t<li class='gchoice gchoice_5_6_0'>\n\t\t\t\t<input name='input_6' type='radio' value='Yes'  id='choice_5_6_0'    \/>\n\t\t\t\t<label for='choice_5_6_0' id='label_5_6_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_6_1'>\n\t\t\t\t<input name='input_6' type='radio' value='No'  id='choice_5_6_1'    \/>\n\t\t\t\t<label for='choice_5_6_1' id='label_5_6_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_9\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio gf_middle_third gfield_price gfield_price_5_9 gfield_product_5_9 gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_9\" ><label class='gfield_label gform-field-label' >Are you a Life Options Member?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_9'>\n\t\t\t<li class='gchoice gchoice_5_9_0'>\n\t\t\t\t<input name='input_9' type='radio' value='Member|30'  id='choice_5_9_0'    \/>\n\t\t\t\t<label for='choice_5_9_0' id='label_5_9_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_9_1'>\n\t\t\t\t<input name='input_9' type='radio' value='Non-Member|50'  id='choice_5_9_1'    \/>\n\t\t\t\t<label for='choice_5_9_1' id='label_5_9_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_10\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_10\" ><label class='gfield_label gform-field-label' >Payment Options<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_10'>\n\t\t\t<li class='gchoice gchoice_5_10_0'>\n\t\t\t\t<input name='input_10' type='radio' value='Cash\/Check'  id='choice_5_10_0'    \/>\n\t\t\t\t<label for='choice_5_10_0' id='label_5_10_0' class='gform-field-label gform-field-label--type-inline'>Cash\/Check<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_10_1'>\n\t\t\t\t<input name='input_10' type='radio' value='Credit Card'  id='choice_5_10_1'    \/>\n\t\t\t\t<label for='choice_5_10_1' id='label_5_10_1' class='gform-field-label gform-field-label--type-inline'>Credit Card<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_14\" class=\"gfield gfield--type-creditcard gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_14\" ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_5_14_1'>Credit Card<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container_creditcard gform-grid-row' id='input_5_14'><span class='ginput_full gform-grid-col' id='input_5_14_1_container' >\n                                    <div class='gform_card_icon_container'><div class='gform_card_icon gform_card_icon_amex' >American Express<\/div><div class='gform_card_icon gform_card_icon_discover' >Discover<\/div><div class='gform_card_icon gform_card_icon_mastercard' >MasterCard<\/div><div class='gform_card_icon gform_card_icon_visa' >Visa<\/div><span class='screen-reader-text' id='field_5_14_supported_creditcards'>Supported Credit Cards: American Express, Discover, MasterCard, Visa<\/span><\/div>\n                                    <input type='text'  id='input_5_14_1' value=''   onchange='gformMatchCard(\"input_5_14_1\");' onkeyup='gformMatchCard(\"input_5_14_1\");' autocomplete='off' pattern='[0-9]*' title='Only digits are allowed'  aria-required='true'  \/>\n                                    <label for='input_5_14_1' id='input_5_14_1_label' class='gform-field-label gform-field-label--type-sub '>Card Number<\/label>\n                                 <\/span><span class='ginput_full ginput_cardextras gform-grid-col gform-grid-row' id='input_5_14_2_container'>\n                                            <span class='ginput_cardinfo_left' id='input_5_14_2_cardinfo_left'>\n                                                <span class='ginput_card_expiration_container ginput_card_field'>\n                                                    \n                                                       <select  id='input_5_14_2_month'   class='ginput_card_expiration ginput_card_expiration_month' aria-required='true'  >\n                                                           <option value=''>Month<\/option><option value='1' >01<\/option><option value='2' >02<\/option><option value='3' >03<\/option><option value='4' >04<\/option><option value='5' >05<\/option><option value='6' >06<\/option><option value='7' >07<\/option><option value='8' >08<\/option><option value='9' >09<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option>\n                                                       <\/select>\n                                                       \n                                                   \n                                                   \n                                                       <select  id='input_5_14_2_year'   class='ginput_card_expiration ginput_card_expiration_year' aria-required='true'  >\n                                                           <option value=''>Year<\/option><option value='2024' >2024<\/option><option value='2025' >2025<\/option><option value='2026' >2026<\/option><option value='2027' >2027<\/option><option value='2028' >2028<\/option><option value='2029' >2029<\/option><option value='2030' >2030<\/option><option value='2031' >2031<\/option><option value='2032' >2032<\/option><option value='2033' >2033<\/option><option value='2034' >2034<\/option><option value='2035' >2035<\/option><option value='2036' >2036<\/option><option value='2037' 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if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}setTimeout(function(){jQuery('#gform_wrapper_5').replaceWith(confirmation_content);jQuery(document).trigger('gform_confirmation_loaded', [5]);window['gf_submitting_5'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_5').text());}, 50);}else{jQuery('#gform_5').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"5\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);                if (event.defaultPrevented) {                return;         }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_5\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_5\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_5\" );        let postRenderFired = false;                function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            jQuery( document ).trigger( 'gform_post_render', [5, current_page] );            gform.utils.trigger( { event: 'gform\/postRender', native: false, data: { formId: 5, currentPage: current_page } } );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( context, 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'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} );\n<\/script>\n[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;3.17.6&#8243; background_color=&#8221;#000000&#8243; custom_padding=&#8221;0|0px|0|0px|false|false&#8221; global_module=&#8221;151&#8243;][et_pb_row _builder_version=&#8221;3.15&#8243;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;3.0.47&#8243; parallax=&#8221;off&#8221; parallax_method=&#8221;on&#8221;][et_pb_text _builder_version=&#8221;3.17.6&#8243; text_font=&#8221;||||||||&#8221; text_text_color=&#8221;#000000&#8243; link_font=&#8221;||||||||&#8221; link_text_color=&#8221;#ffffff&#8221;]<\/p>\n<p style=\"text-align: left;\"><span style=\"color: #000000;\"><a style=\"color: #000000;\" href=\"https:\/\/tga-simple-prototype.flywheelsites.com\/terms-conditions\/\">TERMS &amp; CONDITIONS<\/a>\u00a0 \u00a0 \u00a0<a style=\"color: #000000;\" href=\"https:\/\/tga-simple-prototype.flywheelsites.com\/privacy-policy\/\">PRIVACY POLICY<\/a>\u00a0 \u00a0 \u00a0<a style=\"color: #000000;\" href=\"https:\/\/tga-simple-prototype.flywheelsites.com\/cookie-policy\/\">COOKIE POLICY<\/a>\u00a0 \u00a0 \u00a0<a style=\"color: #000000;\" href=\"https:\/\/tga-simple-prototype.flywheelsites.com\/contact\/\">CONTACT<\/a><\/span><\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Vendor RegistrationBECOME A PARTNER\n                <div class='gf_browser_chrome gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='1' id='gform_wrapper_5' style='display:none'>\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">VENDOR REGISTRATION FORM<\/h3>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/wp-json\/wp\/v2\/pages\/3168' data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_5_1\" class=\"gfield gfield--type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_1\" ><label class='gfield_label gform-field-label' for='input_5_1'>Business Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_5_1' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_5_3\" class=\"gfield gfield--type-phone gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_3\" ><label class='gfield_label gform-field-label' for='input_5_3'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_5_3' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_4\" class=\"gfield gfield--type-email gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_4\" ><label class='gfield_label gform-field-label' for='input_5_4'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_4' id='input_5_4' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_5_2\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_2\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_zip ginput_container_address gform-grid-row' id='input_5_2' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_2_1_container' >\n                                        <input type='text' name='input_2.1' id='input_5_2_1' value=''    aria-required='true'    \/>\n                                        <label for='input_5_2_1' id='input_5_2_1_label' class='gform-field-label gform-field-label--type-sub '>Address<\/label>\n                                    <\/span><input type='hidden' class='gform_hidden' name='input_2.4' id='input_5_2_4' value='Pennsylvania'\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_5_2_5_container' >\n                                    <input type='text' name='input_2.5' id='input_5_2_5' value=''    aria-required='true'    \/>\n                                    <label for='input_5_2_5' id='input_5_2_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_2.6' id='input_5_2_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_5_6\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_6\" ><label class='gfield_label gform-field-label' >Do you need electricity?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_6'>\n\t\t\t<li class='gchoice gchoice_5_6_0'>\n\t\t\t\t<input name='input_6' type='radio' value='Yes'  id='choice_5_6_0'    \/>\n\t\t\t\t<label for='choice_5_6_0' id='label_5_6_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_6_1'>\n\t\t\t\t<input name='input_6' type='radio' value='No'  id='choice_5_6_1'    \/>\n\t\t\t\t<label for='choice_5_6_1' id='label_5_6_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_9\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio gf_middle_third gfield_price gfield_price_5_9 gfield_product_5_9 gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_9\" ><label class='gfield_label gform-field-label' >Are you a Life Options Member?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_9'>\n\t\t\t<li class='gchoice gchoice_5_9_0'>\n\t\t\t\t<input name='input_9' type='radio' value='Member|30'  id='choice_5_9_0'    \/>\n\t\t\t\t<label for='choice_5_9_0' id='label_5_9_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_9_1'>\n\t\t\t\t<input name='input_9' type='radio' value='Non-Member|50'  id='choice_5_9_1'    \/>\n\t\t\t\t<label for='choice_5_9_1' id='label_5_9_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_10\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_10\" ><label class='gfield_label gform-field-label' >Payment Options<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_10'>\n\t\t\t<li class='gchoice gchoice_5_10_0'>\n\t\t\t\t<input name='input_10' type='radio' value='Cash\/Check'  id='choice_5_10_0'    \/>\n\t\t\t\t<label for='choice_5_10_0' id='label_5_10_0' class='gform-field-label gform-field-label--type-inline'>Cash\/Check<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_10_1'>\n\t\t\t\t<input name='input_10' type='radio' value='Credit Card'  id='choice_5_10_1'    \/>\n\t\t\t\t<label for='choice_5_10_1' id='label_5_10_1' class='gform-field-label gform-field-label--type-inline'>Credit Card<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_14\" class=\"gfield gfield--type-creditcard gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_14\" ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_5_14_1'>Credit Card<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container_creditcard gform-grid-row' id='input_5_14'><span class='ginput_full gform-grid-col' id='input_5_14_1_container' >\n                                    <div class='gform_card_icon_container'><div class='gform_card_icon gform_card_icon_amex' >American Express<\/div><div class='gform_card_icon gform_card_icon_discover' >Discover<\/div><div class='gform_card_icon gform_card_icon_mastercard' >MasterCard<\/div><div class='gform_card_icon gform_card_icon_visa' >Visa<\/div><span class='screen-reader-text' id='field_5_14_supported_creditcards'>Supported Credit Cards: American Express, Discover, MasterCard, Visa<\/span><\/div>\n                                    <input type='text'  id='input_5_14_1' value=''   onchange='gformMatchCard(\"input_5_14_1\");' onkeyup='gformMatchCard(\"input_5_14_1\");' autocomplete='off' pattern='[0-9]*' title='Only digits are allowed'  aria-required='true'  \/>\n                                    <label for='input_5_14_1' id='input_5_14_1_label' class='gform-field-label gform-field-label--type-sub '>Card Number<\/label>\n                                 <\/span><span class='ginput_full ginput_cardextras gform-grid-col gform-grid-row' id='input_5_14_2_container'>\n                                            <span class='ginput_cardinfo_left' id='input_5_14_2_cardinfo_left'>\n                                                <span class='ginput_card_expiration_container ginput_card_field'>\n                                                    \n                                                       <select  id='input_5_14_2_month'   class='ginput_card_expiration ginput_card_expiration_month' aria-required='true'  >\n                                                           <option value=''>Month<\/option><option value='1' >01<\/option><option value='2' >02<\/option><option value='3' >03<\/option><option value='4' >04<\/option><option value='5' >05<\/option><option value='6' >06<\/option><option value='7' >07<\/option><option value='8' >08<\/option><option value='9' >09<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option>\n                                                       <\/select>\n                                                       \n                                                   \n                                                   \n                                                       <select  id='input_5_14_2_year'   class='ginput_card_expiration ginput_card_expiration_year' aria-required='true'  >\n                                                           <option value=''>Year<\/option><option value='2024' >2024<\/option><option value='2025' >2025<\/option><option value='2026' >2026<\/option><option value='2027' >2027<\/option><option value='2028' >2028<\/option><option value='2029' >2029<\/option><option value='2030' >2030<\/option><option value='2031' >2031<\/option><option value='2032' >2032<\/option><option value='2033' >2033<\/option><option value='2034' >2034<\/option><option value='2035' >2035<\/option><option value='2036' >2036<\/option><option value='2037' >2037<\/option><option value='2038' >2038<\/option><option value='2039' >2039<\/option><option value='2040' >2040<\/option><option value='2041' >2041<\/option><option value='2042' >2042<\/option><option value='2043' >2043<\/option>\n                                                       <\/select>\n                                                       \n                                                       \n                                                <\/span>\n                                                 <label for='input_5_14_2_month' class='gform-field-label gform-field-label--type-sub '>Expiration Date<\/label>\n                                            <\/span><span class='ginput_cardinfo_right gform-grid-col' id='input_5_14_2_cardinfo_right'>\n                                                <input type='text'  id='input_5_14_3'   class='ginput_card_security_code' value='' autocomplete='off' pattern='[0-9]*' title='Only digits are allowed'  aria-required='true'  \/>\n                                                <span class='ginput_card_security_code_icon'>&nbsp;<\/span>\n                                                <label for='input_5_14_3' class='gform-field-label gform-field-label--type-sub '>Security Code<\/label>\n                                             <\/span>\n                                        <\/span><span class='ginput_full gform-grid-col' id='input_5_14_5_container'>\n                                            <input type='text'  id='input_5_14_5' value=''    aria-required='false'  \/>\n                                            <label for='input_5_14_5' id='input_5_14_5_label' class='gform-field-label gform-field-label--type-sub '>Cardholder Name<\/label>\n                                        <\/span> <\/div><\/li><li id=\"field_5_13\" class=\"gfield gfield--type-captcha field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_13\" ><label class='gfield_label gform-field-label' for='input_5_13'>CAPTCHA<\/label><div id='input_5_13' class='ginput_container ginput_recaptcha' data-sitekey='6Lc1oogUAAAAAJU5SvaRCXkXs1gF_hSgYDZc4pPQ'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/li><li id=\"field_5_15\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_15\" ><label class='gfield_label gform-field-label' for='input_5_15'>Email<\/label><div class='ginput_container'><input name='input_15' id='input_5_15' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_5_15'>This field is for validation purposes and should be left unchanged.<\/div><\/li><\/ul><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_5' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_5\"]){return false;}  if( !jQuery(\"#gform_5\")[0].checkValidity || jQuery(\"#gform_5\")[0].checkValidity()){window[\"gf_submitting_5\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_5\"]){return false;} if( !jQuery(\"#gform_5\")[0].checkValidity || jQuery(\"#gform_5\")[0].checkValidity()){window[\"gf_submitting_5\"]=true;}  jQuery(\"#gform_5\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_5' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='5' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_5' value='WyJ7XCI5XCI6W1wiNDg0ZGMwNzkzODk1MWNlMDI4ZTA2YjlhZGI1OGFhYTZcIixcImMzNGIyMzE1MjlhMzNiYzE5NTMzNDkzNzNiODNkMzI1XCJdfSIsIjJmNTk4ZWRmNDg0YTY5MzRjZGM3NTZlMGI2OWY0Yzc3Il0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_5' id='gform_target_page_number_5' value='0' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_5' id='gform_source_page_number_5' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div><script type=\"text\/javascript\">\ngform.initializeOnLoaded( function() {gformInitSpinner( 5, 'https:\/\/www.lifeoptionspittsburgh.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_5').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_5');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_5').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! 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