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	High Holiday DIY Kits - Chabad of the Central Valley
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			<h1 class="article-header__title js-article-title js-page-title">High Holiday Meal-To-Go Kit Reservations</h1>
		
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<form class="userform-form" action="" method="post" name="form_4871355" id="4871355" accept-charset="utf-8"><input type="hidden" name="formID" value="4871355" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li id="cid_13" class="form-input-wide"> <div class="form-header-group"><h2 id="header_13" class="form-header">High Holidays at home? We got you covered with High Holiday Meals-To-Go kits.</h2></div> </li><li class="form-line" id="id_12"><div id="cid_12" class="form-input-wide"> <img alt="" class="form-image" border="0" src="https://w2.chabad.org/media/images/1136/oinn11360235.jpg" height="245" width="650" /> </div></li><li class="form-line" id="id_3"><div id="cid_3" class="form-input-wide"> <div id="text_3" class="form-html"><p>This New Year, we are once again offering Meals To Go due to the challenges for many community members.   We will be offering Services at Chabad for those that wish to join in-person, as well as kits, including holiday meals to be picked up before Rosh Hashana.</p>

<p>Please fill out this form to order your High Holidays Meals-To-Go kits by Sunday 12:00 Noon September 1024, 2024, to be picked up on Tuesday or Wednesday October 1 or October 2-3.  </p>

<p>Call Chanie 559-288-3048 to arrange a time to pick up your kit at Chabad Fresno.</p>
</div> </div></li><li id="cid_4" class="form-input-wide"> <div class="form-header-group"><h2 id="header_4" class="form-header">Orders must be submitted by Wednesday 12:00 Noon September 3, 2025.</h2></div> </li><li class="form-line" id="id_5"><div class="form-label-left" id="label_5"><label for="input_5"> Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_5"> </label></div><div id="cid_5" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q5_fullName[first]" id="first_5" autocomplete="given-name" />  <label class="form-sub-label" for="first_5" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q5_fullName[last]" id="last_5" autocomplete="family-name" />  <label class="form-sub-label" for="last_5" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_6"><div class="form-label-left" id="label_6"><label for="input_6"> E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_6"> </label></div><div id="cid_6" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_6" name="q6_email" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_8"><div class="form-label-left" id="label_8"><label for="input_8"> Home Phone<span class="form-required">*</span> </label><label class="label-message" for="input_8"> </label></div><div id="cid_8" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q8_phoneNumber[area]" id="input_8_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_8_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q8_phoneNumber[phone]" id="input_8_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_8_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_9"><div class="form-label-left" id="label_9"><label for="input_9"> Cell Phone<span class="form-required">*</span> </label><label class="label-message" for="input_9"> </label></div><div id="cid_9" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q9_phoneNumber9[area]" id="input_9_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_9_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q9_phoneNumber9[phone]" id="input_9_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_9_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_10"><div class="form-label-left" id="label_10"><label for="input_10"> Address<span class="form-required">*</span> </label><label class="label-message" for="input_10"> </label></div><div id="cid_10" class="form-input"> <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-line" type="text" name="q10_address[addr_line1]" id="input_10_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_10_addr_line1" id="sublabel_10_addr_line1">Street Address</label></span></td></tr><tr><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line no-validation" type="text" name="q10_address[addr_line2]" id="input_10_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_10_addr_line2" id="sublabel_10_addr_line2">Street Address Line 2</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-city" type="text" name="q10_address[city]" id="input_10_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_10_city" id="sublabel_10_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q10_address[state]" id="input_10_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_10_state" id="sublabel_10_state">State / Province</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-postal" type="text" name="q10_address[postal]" id="input_10_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_10_postal" id="sublabel_10_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q10_address[country]" id="input_10_country" autocomplete="country-name"><option value="" selected="selected">Please Select</option><option value="United States">United States</option><option value="Afghanistan">Afghanistan</option><option value="Albania">Albania</option><option value="Algeria">Algeria</option><option value="American Samoa">American Samoa</option><option value="Andorra">Andorra</option><option value="Angola">Angola</option><option value="Anguilla">Anguilla</option><option value="Antigua and Barbuda">Antigua and Barbuda</option><option value="Argentina">Argentina</option><option value="Armenia">Armenia</option><option value="Aruba">Aruba</option><option value="Australia">Australia</option><option value="Austria">Austria</option><option value="Azerbaijan">Azerbaijan</option><option value="The Bahamas">The Bahamas</option><option value="Bahrain">Bahrain</option><option value="Bangladesh">Bangladesh</option><option value="Barbados">Barbados</option><option value="Belarus">Belarus</option><option value="Belgium">Belgium</option><option value="Belize">Belize</option><option value="Benin">Benin</option><option value="Bermuda">Bermuda</option><option value="Bhutan">Bhutan</option><option value="Bolivia">Bolivia</option><option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option><option value="Botswana">Botswana</option><option value="Brazil">Brazil</option><option value="Brunei">Brunei</option><option value="Bulgaria">Bulgaria</option><option value="Burkina Faso">Burkina Faso</option><option value="Burundi">Burundi</option><option value="Cambodia">Cambodia</option><option value="Cameroon">Cameroon</option><option value="Canada">Canada</option><option value="Cape Verde">Cape Verde</option><option value="Cayman Islands">Cayman Islands</option><option value="Central African Republic">Central African Republic</option><option value="Chad">Chad</option><option value="Chile">Chile</option><option value="People's Republic of China">People's Republic of China</option><option value="Republic of China">Republic of China</option><option value="Christmas Island">Christmas Island</option><option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option><option value="Colombia">Colombia</option><option value="Comoros">Comoros</option><option value="Congo">Congo</option><option value="Cook Islands">Cook Islands</option><option value="Costa Rica">Costa Rica</option><option value="Cote d'Ivoire">Cote d'Ivoire</option><option value="Croatia">Croatia</option><option value="Cuba">Cuba</option><option value="Cyprus">Cyprus</option><option value="Czech Republic">Czech Republic</option><option value="Denmark">Denmark</option><option value="Djibouti">Djibouti</option><option value="Dominica">Dominica</option><option value="Dominican Republic">Dominican Republic</option><option value="Ecuador">Ecuador</option><option value="Egypt">Egypt</option><option value="El Salvador">El Salvador</option><option value="Equatorial Guinea">Equatorial Guinea</option><option value="Eritrea">Eritrea</option><option value="Estonia">Estonia</option><option value="Eswatini">Eswatini</option><option value="Ethiopia">Ethiopia</option><option value="Falkland Islands">Falkland Islands</option><option value="Faroe Islands">Faroe Islands</option><option value="Fiji">Fiji</option><option value="Finland">Finland</option><option value="France">France</option><option value="French Polynesia">French Polynesia</option><option value="Gabon">Gabon</option><option value="The Gambia">The Gambia</option><option value="Georgia">Georgia</option><option value="Germany">Germany</option><option value="Ghana">Ghana</option><option value="Gibraltar">Gibraltar</option><option value="Greece">Greece</option><option value="Greenland">Greenland</option><option value="Grenada">Grenada</option><option value="Guadeloupe">Guadeloupe</option><option value="Guam">Guam</option><option value="Guatemala">Guatemala</option><option value="Guernsey">Guernsey</option><option value="Guinea">Guinea</option><option value="Guinea-Bissau">Guinea-Bissau</option><option value="Guyana">Guyana</option><option value="Haiti">Haiti</option><option value="Honduras">Honduras</option><option value="Hong Kong">Hong Kong</option><option value="Hungary">Hungary</option><option value="Iceland">Iceland</option><option value="India">India</option><option value="Indonesia">Indonesia</option><option value="Iran">Iran</option><option value="Iraq">Iraq</option><option value="Ireland">Ireland</option><option value="Israel">Israel</option><option value="Italy">Italy</option><option value="Jamaica">Jamaica</option><option 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Caledonia</option><option value="New Zealand">New Zealand</option><option value="Nicaragua">Nicaragua</option><option value="Niger">Niger</option><option value="Nigeria">Nigeria</option><option value="Niue">Niue</option><option value="Norfolk Island">Norfolk Island</option><option value="Northern Mariana">Northern Mariana</option><option value="Norway">Norway</option><option value="Oman">Oman</option><option value="Pakistan">Pakistan</option><option value="Palau">Palau</option><option value="Panama">Panama</option><option value="Papua New Guinea">Papua New Guinea</option><option value="Paraguay">Paraguay</option><option value="Peru">Peru</option><option value="Philippines">Philippines</option><option value="Pitcairn Islands">Pitcairn Islands</option><option value="Poland">Poland</option><option value="Portugal">Portugal</option><option value="Puerto Rico">Puerto Rico</option><option value="Qatar">Qatar</option><option value="Romania">Romania</option><option value="Russia">Russia</option><option value="Rwanda">Rwanda</option><option value="Saint Barthelemy">Saint Barthelemy</option><option value="Saint Helena">Saint Helena</option><option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option><option value="Saint Lucia">Saint Lucia</option><option value="Saint Martin">Saint Martin</option><option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option><option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option><option value="Samoa">Samoa</option><option value="San Marino">San Marino</option><option value="Sao Tome and Principe">Sao Tome and Principe</option><option value="Saudi Arabia">Saudi Arabia</option><option value="Senegal">Senegal</option><option value="Serbia">Serbia</option><option value="Seychelles">Seychelles</option><option value="Sierra Leone">Sierra Leone</option><option value="Singapore">Singapore</option><option value="Slovakia">Slovakia</option><option value="Slovenia">Slovenia</option><option value="Solomon Islands">Solomon Islands</option><option value="Somalia">Somalia</option><option value="Somaliland">Somaliland</option><option value="South Africa">South Africa</option><option value="South Ossetia">South Ossetia</option><option value="Spain">Spain</option><option value="Sri Lanka">Sri Lanka</option><option value="Sudan">Sudan</option><option value="Suriname">Suriname</option><option value="Svalbard">Svalbard</option><option value="Sweden">Sweden</option><option value="Switzerland">Switzerland</option><option value="Syria">Syria</option><option value="Taiwan">Taiwan</option><option value="Tajikistan">Tajikistan</option><option value="Tanzania">Tanzania</option><option value="Thailand">Thailand</option><option value="Timor-Leste">Timor-Leste</option><option value="Togo">Togo</option><option value="Tokelau">Tokelau</option><option value="Tonga">Tonga</option><option value="Trinidad and Tobago">Trinidad and Tobago</option><option value="Tristan da Cunha">Tristan da Cunha</option><option value="Tunisia">Tunisia</option><option value="Turkey">Turkey</option><option value="Turkmenistan">Turkmenistan</option><option value="Turks and Caicos Islands">Turks and Caicos Islands</option><option value="Tuvalu">Tuvalu</option><option value="Uganda">Uganda</option><option value="Ukraine">Ukraine</option><option value="United Arab Emirates">United Arab Emirates</option><option value="United Kingdom">United Kingdom</option><option value="Uruguay">Uruguay</option><option value="Uzbekistan">Uzbekistan</option><option value="Vanuatu">Vanuatu</option><option value="Vatican City">Vatican City</option><option value="Venezuela">Venezuela</option><option value="Vietnam">Vietnam</option><option value="British Virgin Islands">British Virgin Islands</option><option value="US Virgin Islands">US Virgin Islands</option><option value="Wallis and Futuna">Wallis and Futuna</option><option value="Western Sahara">Western Sahara</option><option value="Yemen">Yemen</option><option value="Zambia">Zambia</option><option value="Zimbabwe">Zimbabwe</option><option value="other">Other</option></select>  <label class="form-sub-label" for="input_10_country" id="sublabel_10_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_11"><div id="cid_11" class="form-input-wide"> <div id="text_11" class="form-html"><p>If you don’t have your own Machzor, <a href="/Article.asp?AID=4859759">click here</a> to download a complete printable Machzor (PDF) . Please contact us if you have trouble downloading and printing it yourself.</p></div> </div></li><li class="form-line" id="id_14"><div id="cid_14" class="form-input-wide"> <div id="text_14" class="form-html"><p> All kits are made with the utmost safety precautions taken into concern. </p><p>Singular kits will be packaged in their own containers.  </p><p><span style="font-size: 18px;"><strong>Orders of 8-10 will be packaged in 9x13 aluminum pans.  </strong></span></p></div> </div></li><li class="form-line" id="id_20"><div class="form-label-left" id="label_20"><label for="input_20"> Chanie's Signature Plain Round Challah </label><label class="label-message" for="input_20"> </label></div><div id="cid_20" class="form-input"> <span class="form-sub-label-container"><select class="form-dropdown" style="width:150px" id="input_20" name="q20_input20"><option value=""></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option></select>  <label class="form-sub-label" for="input_20">$10/Challah</label></span> </div></li><li class="form-line" id="id_32"><div class="form-label-left" id="label_32"><label for="input_32"> Chanie's Raisin Honey Round Challah </label><label class="label-message" for="input_32"> </label></div><div id="cid_32" class="form-input"> <span class="form-sub-label-container"><select class="form-dropdown" style="width:150px" id="input_32" name="q32_input32"><option value=""></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option></select>  <label class="form-sub-label" for="input_32">$12/Challah</label></span> </div></li><li class="form-line" id="id_33"><div class="form-label-left" id="label_33"><label for="input_33"> Chanie's Apple Honey Round Challah </label><label class="label-message" for="input_33"> </label></div><div id="cid_33" class="form-input"> <span class="form-sub-label-container"><select class="form-dropdown" style="width:150px" id="input_33" name="q33_input33"><option value=""></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option></select>  <label class="form-sub-label" for="input_33">$12/Challah</label></span> </div></li><li class="form-line" id="id_21"><div class="form-label-left" id="label_21"><label for="input_21"> Grape Juice Bottle </label><label class="label-message" for="input_21"> </label></div><div id="cid_21" class="form-input"> <span class="form-sub-label-container"><select class="form-dropdown" style="width:150px" id="input_21" name="q21_input21"><option value=""></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option></select>  <label class="form-sub-label" for="input_21">$10/Bottle</label></span> </div></li><li class="form-line" id="id_34"><div class="form-label-left" id="label_34"><label for="input_34"> Chanie's Honey Cake </label><label class="label-message" for="input_34"> </label></div><div id="cid_34" class="form-input"> <span class="form-sub-label-container"><select class="form-dropdown" style="width:150px" id="input_34" name="q34_input34"><option value=""></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option></select>  <label class="form-sub-label" for="input_34">$15/9 inch Round Cake</label></span> </div></li><li class="form-line" id="id_28"><div class="form-label-left" id="label_28"><label for="input_28"> Apple and Honey Stick ($5) </label><label class="label-message" for="input_28"> </label></div><div id="cid_28" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_28" name="q28_input28"><option value=""></option><option value="1">1</option><option value="2">2</option></select> </div></li><li class="form-line" id="id_23"><div class="form-label-left" id="label_23"><label for="input_23"> Fish Course </label><label class="label-message" for="input_23"> </label></div><div id="cid_23" class="form-input"> <span class="form-sub-label-container"><select class="form-dropdown" style="width:150px" id="input_23" name="q23_input23"><option value=""></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option></select>  <label class="form-sub-label" for="input_23">$45/Fish Order</label></span> </div></li><li class="form-line" id="id_26"><div class="form-label-left" id="label_26"><label for="input_26"> Main Dish 1st Evening </label><label class="label-message" for="input_26"> </label></div><div id="cid_26" class="form-input"> <span class="form-sub-label-container"><select class="form-dropdown" style="width:150px" id="input_26" name="q26_input26"><option value=""></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option></select>  <label class="form-sub-label" for="input_26">$45/Main Dish</label></span> </div></li><li class="form-line" id="id_25"><div class="form-label-left" id="label_25"><label for="input_25"> Main Dish 2nd Evening </label><label class="label-message" for="input_25"> </label></div><div id="cid_25" class="form-input"> <span class="form-sub-label-container"><select class="form-dropdown" style="width:150px" id="input_25" name="q25_input25"><option value=""></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option></select>  <label class="form-sub-label" for="input_25">$45/Main Dish</label></span> </div></li><li class="form-line" id="id_17"><div class="form-label-left" id="label_17"><label for="input_17"> I would like to make a donation to support these activities and to sponsor a High Holiday Meal-To-Go kit for someone in need. </label><label class="label-message" for="input_17"> </label></div><div id="cid_17" class="form-input"> <div class="form-multiple-column" data-columns="2"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_17_0" name="q17_input17" value="50.00" /><label for="input_17_0"><span>$50.00</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_17_1" name="q17_input17" value="75.00" /><label for="input_17_1"><span>$75.00</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_17_2" name="q17_input17" value="100.00" /><label for="input_17_2"><span>$100.00</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_17_3" name="q17_input17" value="180.00" /><label for="input_17_3"><span>$180.00</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_17_4" name="q17_input17" value="500.00" /><label for="input_17_4"><span>$500.00</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_17_5" name="q17_input17" value="1000.00" /><label for="input_17_5"><span>$1000.00</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_17_6" name="q17_input17" value="1800.00" /><label for="input_17_6"><span>$1800.00</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_16"><div class="form-label-left" id="label_16"><label for="input_16"> Payment </label><label class="label-message" for="input_16"> </label></div><div id="cid_16" class="form-input"> <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2" class="form-payment-methods form-multiple-column"><span class="form-radio-item"><input class="paymentMethod form-radio validate[paymentMethod] form-radio" type="radio" id="input_16_creditCard" name="q16_payment[payment_method]" value="creditCard" onclick="BuildSource.creditCard(this)" /><label for="input_16_creditCard">Credit Card</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[paymentMethod] form-radio" type="radio" id="input_16_other" name="q16_payment[payment_method]" value="other" onclick="BuildSource.other(this)" /><label for="input_16_other">Zelle, Check, Cash</label> </span></td></tr><tr class="credit_card hide"><th colspan="2">Credit Card</th></tr><tr class="credit_card hide"><td colspan="2" style="padding:0"><table cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"><span class="form-sub-label-container">  <label class="form-sub-label">We accept Visa, MasterCard, American Express, Discover</label></span><div class="cc-icons"><div class="cc-icon visa-icon"></div><div class="cc-icon mastercard-icon"></div><div class="cc-icon amex-icon"></div><div class="cc-icon discover-icon"></div></div><input type="hidden" name="q16_payment[cc_type]" id="input_16_cc_type" value="" /></td></tr><tr><td><div class="cc-field-wrapper"><span class="form-sub-label-container"><input class="form-textbox form-creditcard js-cc-number validate[visible, creditcard]" type="text" name="q16_payment[cc_number]" id="input_16_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_16_cc_number" id="sublabel_cc_number">Credit Card Number</label></span></div></td><td class="cc_ccv "><span class="form-sub-label-container"><input class="form-textbox validate[visible]" type="text" name="q16_payment[cc_ccv]" id="input_16_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_16_cc_ccv" id="sublabel_cc_ccv">Security Code</label></span></td></tr><tr><td colspan="2" class="cc_name_on_card "><span class="form-sub-label-container"><input class="form-textbox validate[visible]" type="text" name="q16_payment[cc_nameOnCard]" id="input_16_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_16_cc_nameOnCard" id="sublabel_cc_nameOnCard">Name on Card</label></span></td></tr><tr class="credit_card hide"><td colspan=""><span class="form-sub-label-container"><select class="form-textbox validate[visible]" name="q16_payment[cc_exp_month]" id="input_16_cc_exp_month" autocomplete="cc-exp-month"><option></option><option value="1">1 - January</option><option value="2">2 - February</option><option value="3">3 - March</option><option value="4">4 - April</option><option value="5">5 - May</option><option value="6">6 - June</option><option value="7">7 - July</option><option value="8">8 - August</option><option value="9">9 - September</option><option value="10">10 - October</option><option value="11">11 - November</option><option value="12">12 - December</option></select>  <label class="form-sub-label" for="input_16_cc_exp_month" id="sublabel_cc_exp_month">Expiration Month</label></span></td><td><span class="form-sub-label-container"><select class="form-textbox validate[visible]" name="q16_payment[cc_exp_year]" id="input_16_cc_exp_year" autocomplete="cc-exp-year"><option></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></select>  <label class="form-sub-label" for="input_16_cc_exp_year" id="sublabel_cc_exp_year">Expiration Year</label></span></td></tr></tbody></table></td></tr><tr class="other hide"><td colspan="2"></td></tr><tr class="billing_address hide"><th colspan="2">Billing Address</th></tr><tr class="billing_address hide"><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line" type="text" name="q16_payment[addr_line1]" id="input_16_addr_line1" autocomplete="billing address-line1" />  <label class="form-sub-label" for="input_16_addr_line1" id="sublabel_16_addr_line1">Street Address</label></span></td></tr><tr class="billing_address hide"><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-city" type="text" name="q16_payment[city]" id="input_16_city" autocomplete="billing address-level2" />  <label class="form-sub-label" for="input_16_city" id="sublabel_16_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q16_payment[state]" id="input_16_state" autocomplete="billing address-level1" />  <label class="form-sub-label" for="input_16_state" id="sublabel_16_state">State / Province</label></span></td></tr><tr class="billing_address hide"><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-postal" type="text" name="q16_payment[postal]" id="input_16_postal" size="10" autocomplete="billing postal-code" />  <label class="form-sub-label" for="input_16_postal" id="sublabel_16_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q16_payment[country]" id="input_16_country" autocomplete="billing country-name"><option value="" selected="selected">Please Select</option><option value="United States">United States</option><option value="Afghanistan">Afghanistan</option><option value="Albania">Albania</option><option value="Algeria">Algeria</option><option value="American Samoa">American Samoa</option><option value="Andorra">Andorra</option><option value="Angola">Angola</option><option value="Anguilla">Anguilla</option><option value="Antigua and Barbuda">Antigua and Barbuda</option><option value="Argentina">Argentina</option><option value="Armenia">Armenia</option><option value="Aruba">Aruba</option><option value="Australia">Australia</option><option value="Austria">Austria</option><option value="Azerbaijan">Azerbaijan</option><option value="The Bahamas">The Bahamas</option><option value="Bahrain">Bahrain</option><option value="Bangladesh">Bangladesh</option><option value="Barbados">Barbados</option><option value="Belarus">Belarus</option><option value="Belgium">Belgium</option><option value="Belize">Belize</option><option value="Benin">Benin</option><option value="Bermuda">Bermuda</option><option value="Bhutan">Bhutan</option><option value="Bolivia">Bolivia</option><option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option><option value="Botswana">Botswana</option><option value="Brazil">Brazil</option><option value="Brunei">Brunei</option><option value="Bulgaria">Bulgaria</option><option value="Burkina Faso">Burkina Faso</option><option value="Burundi">Burundi</option><option value="Cambodia">Cambodia</option><option value="Cameroon">Cameroon</option><option value="Canada">Canada</option><option value="Cape Verde">Cape Verde</option><option value="Cayman Islands">Cayman Islands</option><option value="Central African Republic">Central African Republic</option><option value="Chad">Chad</option><option value="Chile">Chile</option><option value="People's Republic of China">People's Republic of China</option><option value="Republic of China">Republic of China</option><option value="Christmas Island">Christmas Island</option><option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option><option value="Colombia">Colombia</option><option value="Comoros">Comoros</option><option value="Congo">Congo</option><option value="Cook Islands">Cook Islands</option><option value="Costa Rica">Costa Rica</option><option value="Cote d'Ivoire">Cote d'Ivoire</option><option value="Croatia">Croatia</option><option value="Cuba">Cuba</option><option value="Cyprus">Cyprus</option><option value="Czech Republic">Czech Republic</option><option value="Denmark">Denmark</option><option value="Djibouti">Djibouti</option><option value="Dominica">Dominica</option><option value="Dominican Republic">Dominican Republic</option><option value="Ecuador">Ecuador</option><option value="Egypt">Egypt</option><option value="El Salvador">El Salvador</option><option value="Equatorial Guinea">Equatorial Guinea</option><option value="Eritrea">Eritrea</option><option value="Estonia">Estonia</option><option value="Eswatini">Eswatini</option><option value="Ethiopia">Ethiopia</option><option value="Falkland Islands">Falkland Islands</option><option value="Faroe Islands">Faroe Islands</option><option value="Fiji">Fiji</option><option value="Finland">Finland</option><option value="France">France</option><option value="French Polynesia">French Polynesia</option><option value="Gabon">Gabon</option><option value="The Gambia">The Gambia</option><option value="Georgia">Georgia</option><option value="Germany">Germany</option><option value="Ghana">Ghana</option><option value="Gibraltar">Gibraltar</option><option value="Greece">Greece</option><option value="Greenland">Greenland</option><option value="Grenada">Grenada</option><option value="Guadeloupe">Guadeloupe</option><option value="Guam">Guam</option><option value="Guatemala">Guatemala</option><option value="Guernsey">Guernsey</option><option value="Guinea">Guinea</option><option value="Guinea-Bissau">Guinea-Bissau</option><option value="Guyana">Guyana</option><option value="Haiti">Haiti</option><option value="Honduras">Honduras</option><option value="Hong Kong">Hong Kong</option><option value="Hungary">Hungary</option><option value="Iceland">Iceland</option><option value="India">India</option><option value="Indonesia">Indonesia</option><option value="Iran">Iran</option><option value="Iraq">Iraq</option><option value="Ireland">Ireland</option><option value="Israel">Israel</option><option value="Italy">Italy</option><option value="Jamaica">Jamaica</option><option value="Japan">Japan</option><option value="Jersey">Jersey</option><option value="Jordan">Jordan</option><option value="Kazakhstan">Kazakhstan</option><option value="Kenya">Kenya</option><option value="Kiribati">Kiribati</option><option value="North Korea">North Korea</option><option value="South Korea">South Korea</option><option value="Kosovo">Kosovo</option><option value="Kuwait">Kuwait</option><option value="Kyrgyzstan">Kyrgyzstan</option><option value="Laos">Laos</option><option value="Latvia">Latvia</option><option value="Lebanon">Lebanon</option><option value="Lesotho">Lesotho</option><option value="Liberia">Liberia</option><option value="Libya">Libya</option><option value="Liechtenstein">Liechtenstein</option><option value="Lithuania">Lithuania</option><option value="Luxembourg">Luxembourg</option><option value="Macau">Macau</option><option value="Macedonia">Macedonia</option><option value="Madagascar">Madagascar</option><option value="Malawi">Malawi</option><option value="Malaysia">Malaysia</option><option value="Maldives">Maldives</option><option value="Mali">Mali</option><option value="Malta">Malta</option><option value="Marshall Islands">Marshall Islands</option><option value="Martinique">Martinique</option><option value="Mauritania">Mauritania</option><option value="Mauritius">Mauritius</option><option value="Mayotte">Mayotte</option><option value="Mexico">Mexico</option><option value="Micronesia">Micronesia</option><option value="Moldova">Moldova</option><option value="Monaco">Monaco</option><option value="Mongolia">Mongolia</option><option value="Montenegro">Montenegro</option><option value="Montserrat">Montserrat</option><option value="Morocco">Morocco</option><option value="Mozambique">Mozambique</option><option value="Myanmar">Myanmar</option><option value="Namibia">Namibia</option><option value="Nauru">Nauru</option><option value="Nepal">Nepal</option><option value="Netherlands">Netherlands</option><option value="New Caledonia">New Caledonia</option><option value="New Zealand">New Zealand</option><option value="Nicaragua">Nicaragua</option><option value="Niger">Niger</option><option value="Nigeria">Nigeria</option><option value="Niue">Niue</option><option value="Norfolk Island">Norfolk Island</option><option value="Northern Mariana">Northern Mariana</option><option value="Norway">Norway</option><option value="Oman">Oman</option><option value="Pakistan">Pakistan</option><option value="Palau">Palau</option><option value="Panama">Panama</option><option value="Papua New Guinea">Papua New Guinea</option><option value="Paraguay">Paraguay</option><option value="Peru">Peru</option><option value="Philippines">Philippines</option><option value="Pitcairn Islands">Pitcairn Islands</option><option value="Poland">Poland</option><option value="Portugal">Portugal</option><option value="Puerto Rico">Puerto Rico</option><option value="Qatar">Qatar</option><option value="Romania">Romania</option><option value="Russia">Russia</option><option value="Rwanda">Rwanda</option><option value="Saint Barthelemy">Saint Barthelemy</option><option value="Saint Helena">Saint Helena</option><option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option><option value="Saint Lucia">Saint Lucia</option><option value="Saint Martin">Saint Martin</option><option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option><option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option><option value="Samoa">Samoa</option><option value="San Marino">San Marino</option><option value="Sao Tome and Principe">Sao Tome and Principe</option><option value="Saudi Arabia">Saudi Arabia</option><option value="Senegal">Senegal</option><option value="Serbia">Serbia</option><option value="Seychelles">Seychelles</option><option value="Sierra Leone">Sierra Leone</option><option value="Singapore">Singapore</option><option value="Slovakia">Slovakia</option><option value="Slovenia">Slovenia</option><option value="Solomon Islands">Solomon Islands</option><option value="Somalia">Somalia</option><option value="Somaliland">Somaliland</option><option value="South Africa">South Africa</option><option value="South Ossetia">South Ossetia</option><option value="Spain">Spain</option><option value="Sri Lanka">Sri Lanka</option><option value="Sudan">Sudan</option><option value="Suriname">Suriname</option><option value="Svalbard">Svalbard</option><option value="Sweden">Sweden</option><option value="Switzerland">Switzerland</option><option value="Syria">Syria</option><option value="Taiwan">Taiwan</option><option value="Tajikistan">Tajikistan</option><option value="Tanzania">Tanzania</option><option value="Thailand">Thailand</option><option value="Timor-Leste">Timor-Leste</option><option value="Togo">Togo</option><option value="Tokelau">Tokelau</option><option value="Tonga">Tonga</option><option value="Trinidad and Tobago">Trinidad and Tobago</option><option value="Tristan da Cunha">Tristan da Cunha</option><option value="Tunisia">Tunisia</option><option value="Turkey">Turkey</option><option value="Turkmenistan">Turkmenistan</option><option value="Turks and Caicos Islands">Turks and Caicos Islands</option><option value="Tuvalu">Tuvalu</option><option value="Uganda">Uganda</option><option value="Ukraine">Ukraine</option><option value="United Arab Emirates">United Arab Emirates</option><option value="United Kingdom">United Kingdom</option><option value="Uruguay">Uruguay</option><option value="Uzbekistan">Uzbekistan</option><option value="Vanuatu">Vanuatu</option><option value="Vatican City">Vatican City</option><option value="Venezuela">Venezuela</option><option value="Vietnam">Vietnam</option><option value="British Virgin Islands">British Virgin Islands</option><option value="US Virgin Islands">US Virgin Islands</option><option value="Wallis and Futuna">Wallis and Futuna</option><option value="Western Sahara">Western Sahara</option><option value="Yemen">Yemen</option><option value="Zambia">Zambia</option><option value="Zimbabwe">Zimbabwe</option><option value="other">Other</option></select>  <label class="form-sub-label" for="input_16_country" id="sublabel_16_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_15"><div 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