{"id":1165,"date":"2022-05-31T17:31:02","date_gmt":"2022-05-31T21:31:02","guid":{"rendered":"https:\/\/forms.csi.ca\/?page_id=1165"},"modified":"2023-07-28T10:07:42","modified_gmt":"2023-07-28T14:07:42","slug":"exception-request-form","status":"publish","type":"page","link":"https:\/\/forms.csi.ca\/?page_id=1165","title":{"rendered":"Exception Request Form"},"content":{"rendered":"<div class=\"wpforms-container wpforms-container-full wpforms-container-save-resume wpforms-block wpforms-block-88d709b5-cef5-4031-9ac8-ba11345f948c fields-to-confirmation\" id=\"wpforms-1150\"><form id=\"wpforms-form-1150\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"1150\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F1165&#038;wpforms_form_id=1150\" data-token=\"6ffa1346b7c589b5555b13c6ba4db746\" data-token-time=\"1785326981\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-1150-field_41-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"41\"><h3 id=\"wpforms-1150-field_41\">PERSONAL INFORMATION<\/h3><\/div><div id=\"wpforms-1150-field_1-container\" class=\"wpforms-field wpforms-field-number wpforms-one-half wpforms-first\" data-field-type=\"number\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-1150-field_1\">Student ID <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" id=\"wpforms-1150-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" step=\"any\" required><\/div><div id=\"wpforms-1150-field_32-container\" class=\"wpforms-field wpforms-field-date-time wpforms-one-half\" data-field-type=\"date-time\" data-field-id=\"32\"><label class=\"wpforms-field-label\">Identity Verification Birthdate <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-date-dropdown-wrap wpforms-field-small\"><select name=\"wpforms[fields][32][date][d]\" id=\"wpforms-1150-field_32-day\" class=\"wpforms-field-date-time-date-day wpforms-field-required\"  required><option value=\"\" class=\"placeholder\" selected disabled>DD<\/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><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><select name=\"wpforms[fields][32][date][m]\" id=\"wpforms-1150-field_32-month\" class=\"wpforms-field-date-time-date-month wpforms-field-required\"  required><option value=\"\" class=\"placeholder\" selected disabled>MM<\/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><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><select name=\"wpforms[fields][32][date][y]\" id=\"wpforms-1150-field_32-year\" class=\"wpforms-field-date-time-date-year wpforms-field-required\"  required><option value=\"\" class=\"placeholder\" selected disabled>YYYY<\/option><option value=\"2027\" >2027<\/option><option value=\"2026\" >2026<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><option value=\"1925\" >1925<\/option><option value=\"1924\" >1924<\/option><option value=\"1923\" >1923<\/option><option value=\"1922\" >1922<\/option><option value=\"1921\" >1921<\/option><option value=\"1920\" >1920<\/option><\/select><\/div><\/div><div id=\"wpforms-1150-field_3-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"3\"><label class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-1150-field_3\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][3][first]\" required><label for=\"wpforms-1150-field_3\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-fifth\"><input type=\"text\" id=\"wpforms-1150-field_3-middle\" class=\"wpforms-field-name-middle\" name=\"wpforms[fields][3][middle]\" ><label for=\"wpforms-1150-field_3-middle\" class=\"wpforms-field-sublabel after\">Middle<\/label><\/div><div class=\"wpforms-field-row-block wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-1150-field_3-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][3][last]\" required><label for=\"wpforms-1150-field_3-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-1150-field_4-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-half wpforms-first wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"4\"><label class=\"wpforms-field-label\">Gender <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-1150-field_4\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1150-field_4_1\" name=\"wpforms[fields][4]\" value=\"Female\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1150-field_4_1\">Female<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1150-field_4_2\" name=\"wpforms[fields][4]\" value=\"Male\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1150-field_4_2\">Male<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-1150-field_4_3\" name=\"wpforms[fields][4]\" value=\"Non-Binary\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1150-field_4_3\">Non-Binary<\/label><\/li><\/ul><\/div><div id=\"wpforms-1150-field_28-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-half wpforms-list-inline\" data-field-type=\"radio\" data-field-id=\"28\"><label class=\"wpforms-field-label\">Language preference for communication <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-1150-field_28\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1150-field_28_1\" name=\"wpforms[fields][28]\" value=\"English\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1150-field_28_1\">English<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1150-field_28_2\" name=\"wpforms[fields][28]\" value=\"French\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1150-field_28_2\">French<\/label><\/li><\/ul><\/div><div id=\"wpforms-1150-field_7-container\" class=\"wpforms-field wpforms-field-email wpforms-one-half wpforms-first\" data-field-type=\"email\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-1150-field_7\">Preferred Email Address <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-1150-field_7\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][7]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-1150-field_8-container\" class=\"wpforms-field wpforms-field-email wpforms-one-half\" data-field-type=\"email\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-1150-field_8\">Alternate Email Address<\/label><input type=\"email\" id=\"wpforms-1150-field_8\" class=\"wpforms-field-medium\" name=\"wpforms[fields][8]\" spellcheck=\"false\" ><\/div><div id=\"wpforms-1150-field_46-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-trigger\" data-field-type=\"radio\" data-field-id=\"46\"><label class=\"wpforms-field-label\">Phone number to reach you <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-1150-field_46\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1150-field_46_1\" name=\"wpforms[fields][46]\" value=\"Personal\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1150-field_46_1\">Personal<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1150-field_46_2\" name=\"wpforms[fields][46]\" value=\"Business\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1150-field_46_2\">Business<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-1150-field_46_3\" name=\"wpforms[fields][46]\" value=\"Both\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1150-field_46_3\">Both<\/label><\/li><\/ul><\/div><div id=\"wpforms-1150-field_21-container\" class=\"wpforms-field wpforms-field-phone wpforms-one-half wpforms-first wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"phone\" data-field-id=\"21\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1150-field_21\">Personal Phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-1150-field_21\" class=\"wpforms-field-medium wpforms-field-required wpforms-masked-input\" data-inputmask=\"&#039;mask&#039;: &#039;(999) 999-9999&#039;\" data-rule-us-phone-field=\"true\" data-inputmask-inputmode=\"tel\" name=\"wpforms[fields][21]\" aria-label=\"Personal Phone\" required><\/div><div id=\"wpforms-1150-field_10-container\" class=\"wpforms-field wpforms-field-phone wpforms-one-half wpforms-first wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"phone\" data-field-id=\"10\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1150-field_10\">Business Phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-1150-field_10\" class=\"wpforms-field-medium wpforms-field-required wpforms-masked-input\" data-inputmask=\"&#039;mask&#039;: &#039;(999) 999-9999&#039;\" data-rule-us-phone-field=\"true\" data-inputmask-inputmode=\"tel\" name=\"wpforms[fields][10]\" aria-label=\"Business Phone\" required><\/div><div id=\"wpforms-1150-field_47-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-trigger\" data-field-type=\"radio\" data-field-id=\"47\"><label class=\"wpforms-field-label\">Address preference <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-1150-field_47\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1150-field_47_1\" name=\"wpforms[fields][47]\" value=\"Home Address\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1150-field_47_1\">Home Address<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1150-field_47_2\" name=\"wpforms[fields][47]\" value=\"Business Address\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1150-field_47_2\">Business Address<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-1150-field_47_3\" name=\"wpforms[fields][47]\" value=\"Both\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1150-field_47_3\">Both<\/label><\/li><\/ul><\/div><div id=\"wpforms-1150-field_14-container\" class=\"wpforms-field wpforms-field-address wpforms-one-half wpforms-first wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"address\" data-field-id=\"14\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1150-field_14\">Home Address <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-1150-field_14\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][14][address1]\" placeholder=\"Street Address, P.O. box\" required><label for=\"wpforms-1150-field_14\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-1150-field_14-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][14][address2]\" placeholder=\"Apartment, suite, unit, floor, etc.\" ><label for=\"wpforms-1150-field_14-address2\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-1150-field_14-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][14][city]\" placeholder=\"City\" required><label for=\"wpforms-1150-field_14-city\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-1150-field_14-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][14][state]\" placeholder=\"State \/ Province\" required><label for=\"wpforms-1150-field_14-state\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-1150-field_14-postal\" class=\"wpforms-field-address-postal wpforms-field-required\" name=\"wpforms[fields][14][postal]\" placeholder=\"ZIP \/ Postal\" required><label for=\"wpforms-1150-field_14-postal\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Postal Code<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-1150-field_14-country\" class=\"wpforms-field-address-country wpforms-field-required\" name=\"wpforms[fields][14][country]\" required><option class=\"placeholder\" value=\"\" selected disabled>&#8212; Select country &#8212;<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia (Plurinational State of)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Democratic Republic of the)<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"SZ\" >Eswatini (Kingdom of)<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran (Islamic Republic of)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republic of)<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea (Democratic People&#039;s Republic of)<\/option><option value=\"KR\" >Korea (Republic of)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia (Federated States of)<\/option><option value=\"MD\" >Moldova (Republic of)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MK\" >North Macedonia (Republic of)<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (State of)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Republic of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (United Republic of)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"TR\" >T\u00fcrkiye<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"US\" >United States of America<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican City State<\/option><option value=\"VE\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (U.S.)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AX\" >\u00c5land Islands<\/option><\/select><label for=\"wpforms-1150-field_14-country\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Country<\/label><\/div><\/div><\/div><div id=\"wpforms-1150-field_34-container\" class=\"wpforms-field wpforms-field-text employer wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"text\" data-field-id=\"34\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1150-field_34\">Employer<\/label><input type=\"text\" id=\"wpforms-1150-field_34\" class=\"wpforms-field-medium\" name=\"wpforms[fields][34]\" ><\/div><div id=\"wpforms-1150-field_11-container\" class=\"wpforms-field wpforms-field-address wpforms-one-half wpforms-first wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"address\" data-field-id=\"11\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1150-field_11\">Business Address<\/label><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-1150-field_11\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][11][address1]\" placeholder=\"Street Address, P.O. box\" ><label for=\"wpforms-1150-field_11\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-1150-field_11-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][11][address2]\" placeholder=\"Apartment, suite, unit, floor, etc.\" ><label for=\"wpforms-1150-field_11-address2\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-1150-field_11-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][11][city]\" placeholder=\"City\" ><label for=\"wpforms-1150-field_11-city\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-1150-field_11-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][11][state]\" placeholder=\"State \/ Province\" ><label for=\"wpforms-1150-field_11-state\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-1150-field_11-postal\" class=\"wpforms-field-address-postal\" name=\"wpforms[fields][11][postal]\" placeholder=\"ZIP \/ Postal\" ><label for=\"wpforms-1150-field_11-postal\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Postal Code<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-1150-field_11-country\" class=\"wpforms-field-address-country\" name=\"wpforms[fields][11][country]\" ><option class=\"placeholder\" value=\"\" selected disabled>&#8212; Select country &#8212;<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia (Plurinational State of)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Democratic Republic of the)<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"SZ\" >Eswatini (Kingdom of)<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran (Islamic Republic of)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republic of)<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea (Democratic People&#039;s Republic of)<\/option><option value=\"KR\" >Korea (Republic of)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia (Federated States of)<\/option><option value=\"MD\" >Moldova (Republic of)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MK\" >North Macedonia (Republic of)<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (State of)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Republic of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (United Republic of)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"TR\" >T\u00fcrkiye<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"US\" >United States of America<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican City State<\/option><option value=\"VE\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (U.S.)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AX\" >\u00c5land Islands<\/option><\/select><label for=\"wpforms-1150-field_11-country\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Country<\/label><\/div><\/div><\/div><div id=\"wpforms-1150-field_48-container\" class=\"wpforms-field wpforms-field-html\" data-field-type=\"html\" data-field-id=\"48\"><div id=\"wpforms-1150-field_48\"><b><span class=\"billing\"><\/span><\/b><\/div><\/div><div id=\"wpforms-1150-field_49-container\" class=\"wpforms-field wpforms-field-hidden\" data-field-type=\"hidden\" data-field-id=\"49\"><input type=\"hidden\" id=\"wpforms-1150-field_49\" name=\"wpforms[fields][49]\"><\/div><div id=\"wpforms-1150-field_15-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"15\"><h3 id=\"wpforms-1150-field_15\"> REQUIREMENT DETAILS<\/h3><\/div><div id=\"wpforms-1150-field_17-container\" class=\"wpforms-field wpforms-field-html\" data-field-type=\"html\" data-field-id=\"17\"><div id=\"wpforms-1150-field_17\"><p>I AM REQUESTING AN EXCEPTION FROM CSI POLICY FOR THE FOLLOWING COURSE: (Details available at <a href=\"https:\/\/www.csi.ca\/en\/\" target=\"_blank\">www.csi.ca<\/a>)<\/p><\/div><\/div><div id=\"wpforms-1150-field_24-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-1150-field_24\">Course Name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1150-field_24\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][24]\" required><\/div><div id=\"wpforms-1150-field_25-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-type=\"checkbox\" data-field-id=\"25\"><label class=\"wpforms-field-label\">Exception being requested <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-1150-field_25\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1150-field_25_1\" name=\"wpforms[fields][25][]\" value=\"Course Extension\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1150-field_25_1\">Course Extension<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1150-field_25_2\" name=\"wpforms[fields][25][]\" value=\"Reduction of waiting period prior to re-enrolment\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1150-field_25_2\">Reduction of waiting period prior to re-enrolment<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1150-field_25_3\" name=\"wpforms[fields][25][]\" value=\"Other\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1150-field_25_3\">Other<\/label><\/li><\/ul><\/div><div id=\"wpforms-1150-field_27-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"text\" data-field-id=\"27\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1150-field_27\">Exception being requested &quot;Other&quot;<\/label><input type=\"text\" id=\"wpforms-1150-field_27\" class=\"wpforms-field-medium\" name=\"wpforms[fields][27]\" ><\/div><div id=\"wpforms-1150-field_35-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-type=\"checkbox\" data-field-id=\"35\"><label class=\"wpforms-field-label\">Circumstance <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-1150-field_35\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1150-field_35_1\" name=\"wpforms[fields][35][]\" value=\"Medical \/ Family\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1150-field_35_1\">Medical \/ Family<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1150-field_35_2\" name=\"wpforms[fields][35][]\" value=\"Bereavement\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1150-field_35_2\">Bereavement<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1150-field_35_3\" name=\"wpforms[fields][35][]\" value=\"Other\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1150-field_35_3\">Other<\/label><\/li><\/ul><\/div><div id=\"wpforms-1150-field_31-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"31\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1150-field_31\">Paragraph Text <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-1150-field_31\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][31]\" placeholder=\"Please provide details explaining the need for the exception.\" required><\/textarea><\/div><div id=\"wpforms-1150-field_37-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-type=\"checkbox\" data-field-id=\"37\"><label class=\"wpforms-field-label\">Documents to support the need for an exception <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-1150-field_37\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1150-field_37_1\" name=\"wpforms[fields][37][]\" value=\"Medical Documentation\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1150-field_37_1\">Medical Documentation<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1150-field_37_2\" name=\"wpforms[fields][37][]\" value=\"Death Certificate\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1150-field_37_2\">Death Certificate<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1150-field_37_3\" name=\"wpforms[fields][37][]\" value=\"Other\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1150-field_37_3\">Other<\/label><\/li><\/ul><\/div><div id=\"wpforms-1150-field_38-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"text\" data-field-id=\"38\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1150-field_38\">If &quot;other&quot;<\/label><input type=\"text\" id=\"wpforms-1150-field_38\" class=\"wpforms-field-medium\" name=\"wpforms[fields][38]\" ><\/div><div id=\"wpforms-1150-field_39-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-type=\"file-upload\" data-field-id=\"39\"><label class=\"wpforms-field-label\" for=\"wpforms-1150-field_39\">Upload Documents <span class=\"wpforms-required-label\">*<\/span><\/label><div\n\t\tclass=\"wpforms-uploader wpforms-field-required\"\n\t\tdata-field-id=\"39\"\n\t\tdata-form-id=\"1150\"\n\t\tdata-input-name=\"wpforms_1150_39\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,x-wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages\"\n\t\tdata-max-size=\"52428800\"\n\t\tdata-max-file-number=\"20\"\n\t\tdata-post-max-size=\"52428800\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg  viewBox=\"0 0 640 640\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M352 173.3L352 384C352 401.7 337.7 416 320 416C302.3 416 288 401.7 288 384L288 173.3L246.6 214.7C234.1 227.2 213.8 227.2 201.3 214.7C188.8 202.2 188.8 181.9 201.3 169.4L297.3 73.4C309.8 60.9 330.1 60.9 342.6 73.4L438.6 169.4C451.1 181.9 451.1 202.2 438.6 214.7C426.1 227.2 405.8 227.2 393.3 214.7L352 173.3zM320 464C364.2 464 400 428.2 400 384L480 384C515.3 384 544 412.7 544 448L544 480C544 515.3 515.3 544 480 544L160 544C124.7 544 96 515.3 96 480L96 448C96 412.7 124.7 384 160 384L240 384C240 428.2 275.8 464 320 464zM464 488C477.3 488 488 477.3 488 464C488 450.7 477.3 440 464 440C450.7 440 440 450.7 440 464C440 477.3 450.7 488 464 488z\"\/>\n\t\t<\/svg>\n\n\t\t<span class=\"modern-title\">\n\t\t\t\t\t\t\tDrag &amp; Drop Files, \t\t\t\t<span>Choose Files to Upload<\/span>\n\t\t\t\t\t<\/span>\n\n\t\t\t\t\t<span class=\"modern-hint\">You can upload up to 20 files.<\/span>\n\t\t\t<\/div>\n<\/div>\n\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-1150-field_39\"\n\t\tname=\"wpforms_1150_39\" required\t\tvalue=\"\">\n<div class=\"wpforms-field-description\">I have attached the following documents to support the need for an exception at this time (Please refer to Requirements &#038; Criteria for exceptions From CSI\r\nPolicy at www.csi.ca )<\/div><\/div><div id=\"wpforms-1150-field_19-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"19\"><h3 id=\"wpforms-1150-field_19\">DECLARATION AND SIGNATURE OF APPLICANT<\/h3><\/div><div id=\"wpforms-1150-field_42-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"42\"><label class=\"wpforms-field-label wpforms-label-hide\">Declaration <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-1150-field_42\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1150-field_42_1\" name=\"wpforms[fields][42][]\" value=\"I, the undersigned state that the information contained in this request is accurate and permit CSI to verify any information provided in this request.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1150-field_42_1\">I, the undersigned state that the information contained in this request is accurate and permit CSI to verify any information provided in this request.<\/label><\/li><\/ul><\/div><div id=\"wpforms-1150-field_18-container\" class=\"wpforms-field wpforms-field-signature\" data-field-type=\"signature\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-1150-field_18\">Signature <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1150-field_18\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][18]\" autocomplete=\"off\" inputmode=\"none\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\" data-input-method=\"draw\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-1150-field_18-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Clear Signature\" tabindex=\"0\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"1em\" height=\"1em\" preserveAspectRatio=\"xMidYMid meet\" viewBox=\"0 0 1536 1536\">\n\t\t\t\t\t<path fill=\"var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )\" d=\"M1149 994q0-26-19-45L949 768l181-181q19-19 19-45q0-27-19-46l-90-90q-19-19-46-19q-26 0-45 19L768 587L587 406q-19-19-45-19q-27 0-46 19l-90 90q-19 19-19 46q0 26 19 45l181 181l-181 181q-19 19-19 45q0 27 19 46l90 90q19 19 46 19q26 0 45-19l181-181l181 181q19 19 45 19q27 0 46-19l90-90q19-19 19-46zm387-226q0 209-103 385.5T1153.5 1433T768 1536t-385.5-103T103 1153.5T0 768t103-385.5T382.5 103T768 0t385.5 103T1433 382.5T1536 768z\"\/>\n\t\t\t\t<\/svg>\n\t\t\t\t<div class=\"wpforms-signature-clear-caption\">Clear Signature<\/div>\n\t\t\t<\/div><\/div><\/div><div id=\"wpforms-1150-field_44-container\" class=\"wpforms-field wpforms-field-hidden\" data-field-type=\"hidden\" data-field-id=\"44\"><input type=\"hidden\" id=\"wpforms-1150-field_44\" name=\"wpforms[fields][44]\" value=\"1017978\"><\/div><div id=\"wpforms-1150-field_45-container\" class=\"wpforms-field wpforms-field-hidden\" data-field-type=\"hidden\" data-field-id=\"45\"><input type=\"hidden\" id=\"wpforms-1150-field_45\" name=\"wpforms[fields][45]\" value=\"Exception Request\"><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"1150\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/forms.csi.ca\/index.php?rest_route=\/wp\/v2\/pages\/1165\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-1150\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Next\" aria-live=\"assertive\" value=\"wpforms-submit\">Next<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/forms.csi.ca\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\n\n\n<script src=\"https:\/\/ajax.googleapis.com\/ajax\/libs\/jquery\/3.6.0\/jquery.min.js\"><\/script>\n<script>\n\/\/billing account\n$.urlParam = function(name){\n\tvar results = new RegExp('[\\?&]' + name + '=([^&#]*)').exec(window.location.href);\n\treturn results[1] || 0;\n};\nvar b_number = $.urlParam('billing');\n$( \".billing\" ).append( \"Billing Account Number: \" + b_number );\n<\/script>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":50,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"inline_featured_image":false,"footnotes":""},"class_list":["post-1165","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/forms.csi.ca\/index.php?rest_route=\/wp\/v2\/pages\/1165","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/forms.csi.ca\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/forms.csi.ca\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/forms.csi.ca\/index.php?rest_route=\/wp\/v2\/users\/50"}],"replies":[{"embeddable":true,"href":"https:\/\/forms.csi.ca\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1165"}],"version-history":[{"count":0,"href":"https:\/\/forms.csi.ca\/index.php?rest_route=\/wp\/v2\/pages\/1165\/revisions"}],"wp:attachment":[{"href":"https:\/\/forms.csi.ca\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1165"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}