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Wedding services will be officiated by Rabbi Adi Goodman.\u0026#160;\u003c/span\u003e\u003c/p\u003e\n\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"color: rgb(128, 0, 128);\"\u003ePlease fill out all of the below fields and submit back to us when completed.\u003cbr\u003e\nAll paperwork should be emailed to rabbi@jewishmonterra.com\u003cbr\u003e\nWe look forward to celebrating with you on your special day.\u003c/span\u003e\u003cbr\u003e\n\u003cstrong\u003e\u003cspan style=\"color: rgb(128, 0, 128);\"\u003eMAZAL\u0026#160;TOV!\u0026#160;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n","17_name":"doubleclickTo","17_qid":17,"17_type":"control_text","17_order":1,"27_text":"\u003cp\u003e\u003cspan style=\"color: rgb(153, 51, 0); font-size: 20px;\"\u003e\u003cstrong\u003eSection 1 - Groom Questionnaire\u0026#160;\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003eGeneral information about the Groom\u003c/p\u003e\u003cp\u003e\u003cspan style=\"color: rgb(153, 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Number"},"29_readonly":"No","29_name":"phoneNumber29","29_qid":29,"29_type":"control_phone","29_order":4,"3_receivesReceipts":"No","3_text":"Groom\u0027s E-mail Address:","3_message":"","3_labelAlign":"Auto","3_required":"Yes","3_size":30,"3_validation":"Email","3_maxsize":"","3_defaultValue":"","3_subLabel":"","3_hint":"ex: myname@example.com","3_description":"","3_confirmation":"No","3_confirmationHint":"Confirm Email","3_readonly":"No","3_name":"email","3_qid":3,"3_type":"control_email","3_order":5,"6_text":"Groom\u0027s Address:","6_message":"","6_labelAlign":"Auto","6_required":"Yes","6_selectedCountry":"","6_description":"","6_subfields":"st1|st2|city|state|zip|country","6_sublabels":{"cc_firstName":"First Name","cc_lastName":"Last Name","cc_number":"Credit Card Number","cc_ccv":"Security Code","cc_exp_month":"Expiration Month","cc_exp_year":"Expiration Year","addr_line1":"Street Address","addr_line2":"Street Address Line 2","city":"City","state":"State / Province","postal":"Postal / Zip Code","country":"Country"},"6_name":"address","6_qid":6,"6_type":"control_address","6_order":6,"7_text":"Groom\u0027s Birth Date:","7_message":"","7_labelAlign":"Auto","7_required":"Yes","7_format":"mmddyyyy","7_yearFrom":"","7_yearTo":"","7_months":[[],[],[],[],[],[],[],[],[],[],[],[]],"7_description":"","7_sublabels":{"month":"Month","day":"Day","year":"Year"},"7_name":"birthDate","7_qid":7,"7_type":"control_birthdate","7_order":7,"8_text":"Groom\u0027s Time of Birth:","8_message":"","8_labelAlign":"Auto","8_required":"Yes","8_range":"No","8_timeFormat":"AM/PM","8_showDayPeriods":"both","8_defaultTime":"No","8_step":"10","8_description":"","8_timeDiff":"No","8_sublabels":{"hour":"Hour","minutes":"Minutes","hourRange":"Hour","minutesRange":"Minutes"},"8_name":"input8","8_qid":8,"8_type":"control_time","8_order":8,"9_text":"Groom\u0027s Place of Birth:","9_message":"","9_labelAlign":"Auto","9_required":"Yes","9_size":20,"9_validation":"None","9_maxsize":"","9_inputTextMask":"","9_defaultValue":"","9_subLabel":"","9_hint":" ","9_description":"","9_readonly":"No","9_name":"input9","9_qid":9,"9_type":"control_textbox","9_order":9,"20_text":"Groom\u0027s Hebrew Name:","20_message":"","20_labelAlign":"Auto","20_required":"Yes","20_size":20,"20_validation":"None","20_maxsize":"","20_inputTextMask":"","20_defaultValue":"","20_subLabel":"","20_hint":" ","20_description":"","20_readonly":"No","20_name":"input20","20_qid":20,"20_type":"control_textbox","20_order":10,"14_text":"What is the groom\u0027s Jewish Status:","14_message":"","14_labelAlign":"Auto","14_required":"Yes","14_options":"Cohen|Levi|Yisroel|Not Sure","14_special":"None","14_allowOther":"No","14_otherText":"Other","14_calculateOther":"No","14_spreadCols":"1","14_selected":"","14_minSelection":"","14_maxSelection":"","14_description":"","14_name":"input14","14_qid":14,"14_type":"control_checkbox","14_order":11,"13_text":"Groom\u0027s Father\u0027s Name:","13_message":"","13_labelAlign":"Auto","13_required":"Yes","13_prefix":"No","13_suffix":"No","13_middle":"No","13_description":"","13_sublabels":{"prefix":"Prefix","first":"First Name","middle":"Middle Name","last":"Last Name","suffix":"Suffix"},"13_readonly":"No","13_name":"fullName13","13_qid":13,"13_type":"control_fullname","13_order":12,"21_text":"Groom\u0027s Father\u0027s Hebrew Name:","21_message":"","21_labelAlign":"Auto","21_required":"Yes","21_size":20,"21_validation":"None","21_maxsize":"","21_inputTextMask":"","21_defaultValue":"","21_subLabel":"","21_hint":" ","21_description":"","21_readonly":"No","21_name":"input21","21_qid":21,"21_type":"control_textbox","21_order":13,"30_text":"Groom\u0027s Mother\u0027s Name:","30_message":"","30_labelAlign":"Auto","30_required":"Yes","30_prefix":"No","30_suffix":"No","30_middle":"No","30_description":"","30_sublabels":{"prefix":"Prefix","first":"First Name","middle":"Middle Name","last":"Last Name","suffix":"Suffix"},"30_readonly":"No","30_name":"fullName30","30_qid":30,"30_type":"control_fullname","30_order":14,"12_text":"Groom\u0027s Maternal Grandmother\u0027s  Hebrew Name:","12_message":"","12_labelAlign":"Auto","12_required":"Yes","12_size":20,"12_validation":"None","12_maxsize":"","12_inputTextMask":"","12_defaultValue":"","12_subLabel":"","12_hint":" ","12_description":"","12_readonly":"No","12_name":"input12","12_qid":12,"12_type":"control_textbox","12_order":15,"48_text":"Groom\u0027s Mother\u0027s Full Name:","48_message":"","48_labelAlign":"Auto","48_required":"Yes","48_prefix":"No","48_suffix":"No","48_middle":"No","48_description":"","48_sublabels":{"prefix":"Prefix","first":"First Name","middle":"Middle Name","last":"Last Name","suffix":"Suffix"},"48_readonly":"No","48_name":"fullName48","48_qid":48,"48_type":"control_fullname","48_order":16,"31_text":"Groom\u0027s Mother\u0027s Hebrew Name:","31_message":"","31_labelAlign":"Auto","31_required":"Yes","31_size":20,"31_validation":"None","31_maxsize":"","31_inputTextMask":"","31_defaultValue":"","31_subLabel":"","31_hint":" ","31_description":"","31_readonly":"No","31_name":"input31","31_qid":31,"31_type":"control_textbox","31_order":17,"28_text":"\u003cp\u003e\u003cspan style=\"color: rgb(153, 51, 0); font-size: 20px;\"\u003e\u003cstrong\u003eSection 2 - Marriageable Status\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u0026#160;This section only applies to those that have conversions in the family, are widowed, or are divorced. If section 2 does not apply, you can continue from section 3.\u003c/p\u003e\u003cp\u003e\u003cspan style=\"color: rgb(153, 51, 0); font-size: 20px;\"\u003e\u003c/span\u003e\u003cspan style=\"color: rgb(153, 51, 102);\"\u003e\u003c/span\u003e\u003c/p\u003e","28_name":"doubleclickTo28","28_qid":28,"28_type":"control_text","28_order":18,"15_text":"Are there any conversions on the groom\u0027s side:","15_message":"","15_labelAlign":"Auto","15_required":"Yes","15_options":"Yes on the groom\u0027s fathers side|Yes on the groom\u0027s Mothers side|No conversions on either side","15_special":"None","15_allowOther":"No","15_otherText":"Other","15_calculateOther":"No","15_spreadCols":"1","15_selected":"","15_minSelection":"","15_maxSelection":"","15_description":"","15_name":"input15","15_qid":15,"15_type":"control_checkbox","15_order":19,"16_text":"Conversion details","16_message":"If there are conversions on either side please provide the name of the Beth Din that completed the conversion process and the date of conversion","16_labelAlign":"Auto","16_required":"No","16_cols":40,"16_rows":"2","16_validation":"None","16_entryLimit":"None-0","16_maxsize":"","16_defaultValue":"","16_subLabel":"","16_hint":"","16_description":"","16_readonly":"No","16_wysiwyg":"Disable","16_name":"input16","16_qid":16,"16_type":"control_textarea","16_order":20,"22_text":"Has the groom been previously married?","22_message":"","22_labelAlign":"Auto","22_required":"Yes","22_options":"This will be the groom\u0027s first marriage|Divorced|Widowed","22_special":"None","22_allowOther":"No","22_otherText":"Other","22_calculateOther":"No","22_spreadCols":"1","22_selected":"","22_minSelection":"","22_maxSelection":"","22_description":"","22_name":"input22","22_qid":22,"22_type":"control_checkbox","22_order":21,"22_pricing":"0||","23_text":"Date of previous marriage","23_message":"If applies","23_labelAlign":"Auto","23_required":"No","23_format":"mmddyyyy","23_allowTime":"No","23_timeFormat":"AM/PM","23_showDayPeriods":"both","23_defaultTime":"Yes","23_onlyFuture":"No","23_step":"10","23_autoCalendar":"Yes","23_description":"","23_startWeekOn":"Sunday","23_sublabels":{"day":"Day","month":"Month","year":"Year","last":"Last Name","hour":"Hour","minutes":"Minutes"},"23_name":"input23","23_qid":23,"23_type":"control_datetime","23_order":22,"24_text":"Location of previous marriage","24_message":"If applies","24_labelAlign":"Auto","24_required":"No","24_size":20,"24_validation":"None","24_maxsize":"","24_inputTextMask":"","24_defaultValue":"","24_subLabel":"","24_hint":" ","24_description":"","24_readonly":"No","24_name":"input24","24_qid":24,"24_type":"control_textbox","24_order":23,"25_text":"Date of divorce","25_message":"If applies","25_labelAlign":"Auto","25_required":"No","25_format":"mmddyyyy","25_allowTime":"No","25_timeFormat":"AM/PM","25_showDayPeriods":"both","25_defaultTime":"Yes","25_onlyFuture":"No","25_step":"10","25_autoCalendar":"Yes","25_description":"","25_startWeekOn":"Sunday","25_sublabels":{"day":"Day","month":"Month","year":"Year","last":"Last Name","hour":"Hour","minutes":"Minutes"},"25_name":"input25","25_qid":25,"25_type":"control_datetime","25_order":24,"26_text":"In the case of Divorce, Was a Get given?","26_message":"","26_labelAlign":"Auto","26_required":"No","26_options":"Yes|No|Previous spouse was not Jewish","26_special":"None","26_allowOther":"No","26_otherText":"Other","26_calculateOther":"No","26_spreadCols":"1","26_selected":"","26_minSelection":"","26_maxSelection":"","26_description":"","26_name":"input26","26_qid":26,"26_type":"control_checkbox","26_order":25,"33_text":"Date \"The Get\" was given","33_message":"If applies","33_labelAlign":"Auto","33_required":"No","33_format":"mmddyyyy","33_allowTime":"No","33_timeFormat":"AM/PM","33_showDayPeriods":"both","33_defaultTime":"Yes","33_onlyFuture":"No","33_step":"10","33_autoCalendar":"Yes","33_description":"","33_startWeekOn":"Sunday","33_sublabels":{"day":"Day","month":"Month","year":"Year","last":"Last Name","hour":"Hour","minutes":"Minutes"},"33_name":"input33","33_qid":33,"33_type":"control_datetime","33_order":26,"70_text":"Name of the Beth Din that performed the Get Ceremony","70_message":"If applies","70_labelAlign":"Auto","70_required":"No","70_size":20,"70_validation":"None","70_maxsize":"","70_inputTextMask":"","70_defaultValue":"","70_subLabel":"","70_hint":" ","70_description":"","70_readonly":"No","70_name":"input70","70_qid":70,"70_type":"control_textbox","70_order":27,"34_text":"Address of Beth Din","34_message":"","34_labelAlign":"Auto","34_required":"No","34_selectedCountry":"","34_description":"","34_subfields":"st1|st2|city|state|zip|country","34_sublabels":{"cc_firstName":"First Name","cc_lastName":"Last Name","cc_number":"Credit Card Number","cc_ccv":"Security Code","cc_exp_month":"Expiration Month","cc_exp_year":"Expiration Year","addr_line1":"Street Address","addr_line2":"Street Address Line 2","city":"City","state":"State / Province","postal":"Postal / Zip Code","country":"Country"},"34_name":"address34","34_qid":34,"34_type":"control_address","34_order":28,"35_text":"Phone Number of Beth Din","35_message":"","35_labelAlign":"Auto","35_required":"No","35_validation":"Numeric","35_countryCode":"No","35_inputMask":"disable","35_inputMaskValue":"(###) ###-####","35_description":"","35_sublabels":{"country":"Country Code","area":"Area Code","phone":"Phone Number","full":"Phone Number"},"35_readonly":"No","35_name":"phoneNumber35","35_qid":35,"35_type":"control_phone","35_order":29,"36_text":"\u003cp\u003e\u003cspan style=\"color: rgb(153, 51, 0); font-size: 20px;\"\u003e\u003cstrong\u003eSection 3 - Wedding Details\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan style=\"color: rgb(153, 51, 0); font-size: 20px;\"\u003e\u003c/span\u003e\u003cspan style=\"color: rgb(153, 51, 102);\"\u003e\u003c/span\u003e\u003c/p\u003e","36_name":"doubleclickTo36","36_qid":36,"36_type":"control_text","36_order":30,"37_text":"Date and Time of the Wedding","37_message":"","37_labelAlign":"Auto","37_required":"Yes","37_format":"mmddyyyy","37_allowTime":"Yes","37_timeFormat":"AM/PM","37_showDayPeriods":"both","37_defaultTime":"Yes","37_onlyFuture":"No","37_step":"10","37_autoCalendar":"Yes","37_description":"","37_startWeekOn":"Sunday","37_sublabels":{"day":"Day","month":"Month","year":"Year","last":"Last Name","hour":"Hour","minutes":"Minutes"},"37_name":"input37","37_qid":37,"37_type":"control_datetime","37_order":31,"74_text":"Venue address","74_message":"Exact location how it is listed","74_labelAlign":"Auto","74_required":"Yes","74_selectedCountry":"","74_description":"","74_subfields":"st1|st2|city|state|zip|country","74_sublabels":{"cc_firstName":"First Name","cc_lastName":"Last Name","cc_number":"Credit Card Number","cc_ccv":"Security Code","cc_exp_month":"Expiration Month","cc_exp_year":"Expiration Year","addr_line1":"Street Address","addr_line2":"Street Address Line 2","city":"City","state":"State / Province","postal":"Postal / Zip Code","country":"Country"},"74_name":"address74","74_qid":74,"74_type":"control_address","74_order":32,"41_text":"Will there be a custom Ketuba being prepared?","41_message":"","41_labelAlign":"Auto","41_required":"Yes","41_options":"Yes|No","41_special":"None","41_allowOther":"No","41_otherText":"Other","41_calculateOther":"No","41_spreadCols":"1","41_selected":"","41_minSelection":"","41_maxSelection":"","41_description":"","41_name":"input41","41_qid":41,"41_type":"control_checkbox","41_order":33,"83_text":"\u003cp\u003e\u003cspan style=\"color: rgb(153, 51, 0); font-size: 20px;\"\u003e\u003cstrong\u003eSection 4 - Agreement\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan style=\"color: rgb(153, 51, 0); font-size: 20px;\"\u003e\u003c/span\u003e\u003cspan style=\"color: rgb(153, 51, 102);\"\u003e\u003c/span\u003e\u003c/p\u003e","83_name":"doubleclickTo83","83_qid":83,"83_type":"control_text","83_order":34,"42_text":"Declaration for the groom","42_message":"Please check box. A checked box is considered as a signature","42_labelAlign":"Auto","42_required":"Yes","42_options":"I herby declare that all the details above were given with goodwill and are correct. I, therefore, request a marriage to be conducted according to the laws of Moses and Israel.|Decline","42_special":"None","42_allowOther":"No","42_otherText":"Other","42_calculateOther":"No","42_spreadCols":"1","42_selected":"","42_minSelection":"","42_maxSelection":"","42_description":"","42_name":"input42","42_qid":42,"42_type":"control_checkbox","42_order":35,"43_text":"Classes","43_message":"Please check box. A checked box is considered as a signature","43_labelAlign":"Auto","43_required":"Yes","43_options":"I agree to have at least 4 marriage classes with Rabbi Adi before the wedding|Decline","43_special":"None","43_allowOther":"No","43_otherText":"Other","43_calculateOther":"No","43_spreadCols":"1","43_selected":"","43_minSelection":"","43_maxSelection":"","43_description":"","43_name":"input43","43_qid":43,"43_type":"control_checkbox","43_order":36,"84_text":"\u003cp\u003e\u003cspan style=\"color: rgb(153, 51, 0); font-size: 20px;\"\u003e\u003cstrong\u003eSection 1 - Bride Questionnaire\u0026#160;\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003eGeneral information about the Groom\u003c/p\u003e\u003cp\u003e\u003cspan style=\"color: rgb(153, 51, 0); font-size: 20px;\"\u003e\u003c/span\u003e\u003cspan style=\"color: rgb(153, 51, 102);\"\u003e\u003c/span\u003e\u003c/p\u003e","84_name":"doubleclickTo84","84_qid":84,"84_type":"control_text","84_order":37,"85_text":"Bride\u0027s Full Name:","85_message":"","85_labelAlign":"Auto","85_required":"Yes","85_prefix":"No","85_suffix":"No","85_middle":"No","85_description":"","85_sublabels":{"prefix":"Prefix","first":"First Name","middle":"Middle Name","last":"Last Name","suffix":"Suffix"},"85_readonly":"No","85_name":"fullName85","85_qid":85,"85_type":"control_fullname","85_order":38,"49_text":"Bride\u0027s Cell Phone:","49_message":"","49_labelAlign":"Auto","49_required":"Yes","49_validation":"Numeric","49_countryCode":"No","49_inputMask":"disable","49_inputMaskValue":"(###) ###-####","49_description":"","49_sublabels":{"country":"Country Code","area":"Area Code","phone":"Phone Number","full":"Phone Number"},"49_readonly":"No","49_name":"phoneNumber49","49_qid":49,"49_type":"control_phone","49_order":39,"50_receivesReceipts":"No","50_text":"Bride\u0027s E-mail:","50_message":"","50_labelAlign":"Auto","50_required":"Yes","50_size":30,"50_validation":"Email","50_maxsize":"","50_defaultValue":"","50_subLabel":"","50_hint":"ex: myname@example.com","50_description":"","50_confirmation":"No","50_confirmationHint":"Confirm Email","50_readonly":"No","50_name":"email50","50_qid":50,"50_type":"control_email","50_order":40,"51_text":"Bride\u0027s Address:","51_message":"","51_labelAlign":"Auto","51_required":"Yes","51_selectedCountry":"","51_description":"","51_subfields":"st1|st2|city|state|zip|country","51_sublabels":{"cc_firstName":"First Name","cc_lastName":"Last Name","cc_number":"Credit Card Number","cc_ccv":"Security Code","cc_exp_month":"Expiration Month","cc_exp_year":"Expiration Year","addr_line1":"Street Address","addr_line2":"Street Address Line 2","city":"City","state":"State / Province","postal":"Postal / Zip 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Birth:","54_message":"","54_labelAlign":"Auto","54_required":"Yes","54_size":20,"54_validation":"None","54_maxsize":"","54_inputTextMask":"","54_defaultValue":"","54_subLabel":"","54_hint":" ","54_description":"","54_readonly":"No","54_name":"input54","54_qid":54,"54_type":"control_textbox","54_order":44,"55_text":"Bride\u0027s Hebrew Name:","55_message":"","55_labelAlign":"Auto","55_required":"Yes","55_size":20,"55_validation":"None","55_maxsize":"","55_inputTextMask":"","55_defaultValue":"","55_subLabel":"","55_hint":" ","55_description":"","55_readonly":"No","55_name":"input55","55_qid":55,"55_type":"control_textbox","55_order":45,"56_text":"What is the bride\u0027s Jewish Status:","56_message":"","56_labelAlign":"Auto","56_required":"Yes","56_options":"Cohen|Levi|Yisroel|Not Sure","56_special":"None","56_allowOther":"No","56_otherText":"Other","56_calculateOther":"No","56_spreadCols":"1","56_selected":"","56_minSelection":"","56_maxSelection":"","56_description":"","56_name":"input56","56_qid":56,"56_type":"control_checkbox","56_order":46,"57_text":"Bride\u0027s Father\u0027s Name:","57_message":"","57_labelAlign":"Auto","57_required":"Yes","57_prefix":"No","57_suffix":"No","57_middle":"No","57_description":"","57_sublabels":{"prefix":"Prefix","first":"First Name","middle":"Middle Name","last":"Last Name","suffix":"Suffix"},"57_readonly":"No","57_name":"fullName57","57_qid":57,"57_type":"control_fullname","57_order":47,"58_text":"Bride\u0027s Father\u0027s Hebrew Name:","58_message":"","58_labelAlign":"Auto","58_required":"Yes","58_size":20,"58_validation":"None","58_maxsize":"","58_inputTextMask":"","58_defaultValue":"","58_subLabel":"","58_hint":" ","58_description":"","58_readonly":"No","58_name":"input58","58_qid":58,"58_type":"control_textbox","58_order":48,"59_text":"Bride\u0027s Mother\u0027s Name:","59_message":"","59_labelAlign":"Auto","59_required":"Yes","59_prefix":"No","59_suffix":"No","59_middle":"No","59_description":"","59_sublabels":{"prefix":"Prefix","first":"First Name","middle":"Middle Name","last":"Last Name","suffix":"Suffix"},"59_readonly":"No","59_name":"fullName59","59_qid":59,"59_type":"control_fullname","59_order":49,"60_text":"Bride\u0027s Mother\u0027s Hebrew Name:","60_message":"","60_labelAlign":"Auto","60_required":"Yes","60_size":20,"60_validation":"None","60_maxsize":"","60_inputTextMask":"","60_defaultValue":"","60_subLabel":"","60_hint":" ","60_description":"","60_readonly":"No","60_name":"input60","60_qid":60,"60_type":"control_textbox","60_order":50,"61_text":"Bride\u0027s Maternal Grandmother\u0027s  Hebrew 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<form class="userform-form" action="" method="post" name="form_5755347" id="5755347" accept-charset="utf-8"><input type="hidden" name="formID" value="5755347" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li class="form-line" id="id_17"><div id="cid_17" class="form-input-wide"> <div id="text_17" class="form-html"><p style="text-align: center;"><strong><img align="absMiddle" alt="Wedding Registation Form.png" border="0" height="200" src="https://w2.chabad.org/media/images/1262/vGdu12626628.png" width="600" /></strong></p>

<p style="text-align: center;"><span style="color: rgb(128, 0, 128); font-size: 26px;"><strong>Wedding Registration<br />
Form for the Bride &amp; Groom </strong></span></p>

<p style="text-align: center;"><span style="color: rgb(128, 0, 128);">Mazal Tov and thank you for choosing Chabad At Monterra for your special day. Wedding services will be officiated by Rabbi Adi Goodman. </span></p>

<p style="text-align: center;"><span style="color: rgb(128, 0, 128);">Please fill out all of the below fields and submit back to us when completed.<br />
All paperwork should be emailed to rabbi@jewishmonterra.com<br />
We look forward to celebrating with you on your special day.</span><br />
<strong><span style="color: rgb(128, 0, 128);">MAZAL TOV! </span></strong></p>
</div> </div></li><li class="form-line" id="id_27"><div id="cid_27" class="form-input-wide"> <div id="text_27" class="form-html"><p><span style="color: rgb(153, 51, 0); font-size: 20px;"><strong>Section 1 - Groom Questionnaire </strong></span></p><p>General information about the Groom</p><p><span style="color: rgb(153, 51, 0); font-size: 20px;"></span><span style="color: rgb(153, 51, 102);"></span></p></div> </div></li><li class="form-line" id="id_1"><div class="form-label-left" id="label_1"><label for="input_1"> Groom's Full Name:<span class="form-required">*</span> </label><label class="label-message" for="input_1"> </label></div><div id="cid_1" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q1_fullName[first]" id="first_1" autocomplete="given-name" />  <label class="form-sub-label" for="first_1" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q1_fullName[last]" id="last_1" autocomplete="family-name" />  <label class="form-sub-label" for="last_1" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_29"><div class="form-label-left" id="label_29"><label for="input_29"> Groom's Cell Phone Number:<span class="form-required">*</span> </label><label class="label-message" for="input_29"> </label></div><div id="cid_29" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q29_phoneNumber29[area]" id="input_29_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_29_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q29_phoneNumber29[phone]" id="input_29_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_29_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_3"><div class="form-label-left" id="label_3"><label for="input_3"> Groom's E-mail Address:<span class="form-required">*</span> </label><label class="label-message" for="input_3"> </label></div><div id="cid_3" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_3" name="q3_email" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_6"><div class="form-label-left" id="label_6"><label for="input_6"> Groom's Address:<span class="form-required">*</span> </label><label class="label-message" for="input_6"> </label></div><div id="cid_6" 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="q6_address[addr_line1]" id="input_6_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_6_addr_line1" id="sublabel_6_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="q6_address[addr_line2]" id="input_6_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_6_addr_line2" id="sublabel_6_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="q6_address[city]" id="input_6_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_6_city" id="sublabel_6_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q6_address[state]" id="input_6_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_6_state" id="sublabel_6_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="q6_address[postal]" id="input_6_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_6_postal" id="sublabel_6_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q6_address[country]" id="input_6_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 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_6_country" id="sublabel_6_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_7"><div class="form-label-left" id="label_7"><label for="input_7"> Groom's Birth Date:<span class="form-required">*</span> </label><label class="label-message" for="input_7"> </label></div><div id="cid_7" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q7_birthDate[month]" id="input_7_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_7_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q7_birthDate[day]" id="input_7_day"><option></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>  <label class="form-sub-label" for="input_7_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q7_birthDate[year]" id="input_7_year"><option></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>  <label class="form-sub-label" for="input_7_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_8"><div class="form-label-left" id="label_8"><label for="input_8"> Groom's Time of Birth:<span class="form-required">*</span> </label><label class="label-message" for="input_8"> </label></div><div id="cid_8" class="form-input"> <span class="dir_ltr inline_block"><span class="form-sub-label-container"><select class="noDefault form-dropdown validate[required]" id="input_8_hourSelect" name="q8_input8[hourSelect]"><option></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>  <label class="form-sub-label" for="input_8_hourSelect" id="sublabel_hour">Hour</label></span><span class="form-sub-label-container"><select class="form-dropdown validate[required]" id="input_8_minuteSelect" name="q8_input8[minuteSelect]"><option></option><option value="00">00</option><option value="10">10</option><option value="20">20</option><option value="30">30</option><option value="40">40</option><option value="50">50</option></select>  <label class="form-sub-label" for="input_8_minuteSelect" id="sublabel_minutes">Minutes</label></span><span class="form-sub-label-container"><select class="form-dropdown validate[required]" id="input_8_ampm" name="q8_input8[ampm]"><option></option><option value="AM">AM</option><option value="PM">PM</option></select>  <label class="form-sub-label" for="input_8_ampm"><span> </span></label></span></span> </div></li><li class="form-line" id="id_9"><div class="form-label-left" id="label_9"><label for="input_9"> Groom's Place of Birth:<span class="form-required">*</span> </label><label class="label-message" for="input_9"> </label></div><div id="cid_9" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_9" name="q9_input9" size="20" value="" /> </div></li><li class="form-line" id="id_20"><div class="form-label-left" id="label_20"><label for="input_20"> Groom's Hebrew Name:<span class="form-required">*</span> </label><label class="label-message" for="input_20"> </label></div><div id="cid_20" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_20" name="q20_input20" size="20" value="" /> </div></li><li class="form-line" id="id_14"><div class="form-label-left" id="label_14"><label for="input_14"> What is the groom's Jewish Status:<span class="form-required">*</span> </label><label class="label-message" for="input_14"> </label></div><div id="cid_14" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_14_0" name="q14_input14[]" value="Cohen" /><label id="label_input_14_0" for="input_14_0"><span>Cohen</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_14_1" name="q14_input14[]" value="Levi" /><label id="label_input_14_1" for="input_14_1"><span>Levi</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_14_2" name="q14_input14[]" value="Yisroel" /><label id="label_input_14_2" for="input_14_2"><span>Yisroel</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_14_3" name="q14_input14[]" value="Not Sure" /><label id="label_input_14_3" for="input_14_3"><span>Not Sure</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_13"><div class="form-label-left" id="label_13"><label for="input_13"> Groom's Father's Name:<span class="form-required">*</span> </label><label class="label-message" for="input_13"> </label></div><div id="cid_13" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q13_fullName13[first]" id="first_13" autocomplete="given-name" />  <label class="form-sub-label" for="first_13" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q13_fullName13[last]" id="last_13" autocomplete="family-name" />  <label class="form-sub-label" for="last_13" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_21"><div class="form-label-left" id="label_21"><label for="input_21"> Groom's Father's Hebrew Name:<span class="form-required">*</span> </label><label class="label-message" for="input_21"> </label></div><div id="cid_21" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_21" name="q21_input21" size="20" value="" /> </div></li><li class="form-line" id="id_30"><div class="form-label-left" id="label_30"><label for="input_30"> Groom's Mother's Name:<span class="form-required">*</span> </label><label class="label-message" for="input_30"> </label></div><div id="cid_30" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q30_fullName30[first]" id="first_30" autocomplete="given-name" />  <label class="form-sub-label" for="first_30" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q30_fullName30[last]" id="last_30" autocomplete="family-name" />  <label class="form-sub-label" for="last_30" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_12"><div class="form-label-left" id="label_12"><label for="input_12"> Groom's Maternal Grandmother's  Hebrew Name:<span class="form-required">*</span> </label><label class="label-message" for="input_12"> </label></div><div id="cid_12" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_12" name="q12_input12" size="20" value="" /> </div></li><li class="form-line" id="id_48"><div class="form-label-left" id="label_48"><label for="input_48"> Groom's Mother's Full Name:<span class="form-required">*</span> </label><label class="label-message" for="input_48"> </label></div><div id="cid_48" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q48_fullName48[first]" id="first_48" autocomplete="given-name" />  <label class="form-sub-label" for="first_48" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q48_fullName48[last]" id="last_48" autocomplete="family-name" />  <label class="form-sub-label" for="last_48" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_31"><div class="form-label-left" id="label_31"><label for="input_31"> Groom's Mother's Hebrew Name:<span class="form-required">*</span> </label><label class="label-message" for="input_31"> </label></div><div id="cid_31" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_31" name="q31_input31" size="20" value="" /> </div></li><li class="form-line" id="id_28"><div id="cid_28" class="form-input-wide"> <div id="text_28" class="form-html"><p><span style="color: rgb(153, 51, 0); font-size: 20px;"><strong>Section 2 - Marriageable Status</strong></span></p><p> This section only applies to those that have conversions in the family, are widowed, or are divorced. If section 2 does not apply, you can continue from section 3.</p><p><span style="color: rgb(153, 51, 0); font-size: 20px;"></span><span style="color: rgb(153, 51, 102);"></span></p></div> </div></li><li class="form-line" id="id_15"><div class="form-label-left" id="label_15"><label for="input_15"> Are there any conversions on the groom's side:<span class="form-required">*</span> </label><label class="label-message" for="input_15"> </label></div><div id="cid_15" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_15_0" name="q15_input15[]" value="Yes on the groom's fathers side" /><label id="label_input_15_0" for="input_15_0"><span>Yes on the groom's fathers side</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_15_1" name="q15_input15[]" value="Yes on the groom's Mothers side" /><label id="label_input_15_1" for="input_15_1"><span>Yes on the groom's Mothers side</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_15_2" name="q15_input15[]" value="No conversions on either side" /><label id="label_input_15_2" for="input_15_2"><span>No conversions on either side</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"> Conversion details </label><label class="label-message" for="input_16"> If there are conversions on either side please provide the name of the Beth Din that completed the conversion process and the date of conversion</label></div><div id="cid_16" class="form-input"> <textarea id="input_16" class="form-textarea" name="q16_input16" cols="40" rows="2"></textarea> </div></li><li class="form-line" id="id_22"><div class="form-label-left" id="label_22"><label for="input_22"> Has the groom been previously married?<span class="form-required">*</span> </label><label class="label-message" for="input_22"> </label></div><div id="cid_22" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_22_0" name="q22_input22[]" value="This will be the groom's first marriage" /><label id="label_input_22_0" for="input_22_0"><span>This will be the groom's first marriage</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_22_1" name="q22_input22[]" value="Divorced" /><label id="label_input_22_1" for="input_22_1"><span>Divorced</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_22_2" name="q22_input22[]" value="Widowed" /><label id="label_input_22_2" for="input_22_2"><span>Widowed</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_23"><div class="form-label-left" id="label_23"><label for="input_23"> Date of previous marriage </label><label class="label-message" for="input_23"> If applies</label></div><div id="cid_23" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="month_23" name="q23_input23[month]" type="tel" size="2" maxlength="2" value="01" />  <label class="form-sub-label" for="month_23" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="day_23" name="q23_input23[day]" type="tel" size="2" maxlength="2" value="28" />  <label class="form-sub-label" for="day_23" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="year_23" name="q23_input23[year]" type="tel" size="4" maxlength="4" value="2026" />  <label class="form-sub-label" for="year_23" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_23_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_23_pick"><span> </span></label></span></div></div> </div></li><li class="form-line" id="id_24"><div class="form-label-left" id="label_24"><label for="input_24"> Location of previous marriage </label><label class="label-message" for="input_24"> If applies</label></div><div id="cid_24" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_24" name="q24_input24" size="20" value="" /> </div></li><li class="form-line" id="id_25"><div class="form-label-left" id="label_25"><label for="input_25"> Date of divorce </label><label class="label-message" for="input_25"> If applies</label></div><div id="cid_25" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="month_25" name="q25_input25[month]" type="tel" size="2" maxlength="2" value="01" />  <label class="form-sub-label" for="month_25" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="day_25" name="q25_input25[day]" type="tel" size="2" maxlength="2" value="28" />  <label class="form-sub-label" for="day_25" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="year_25" name="q25_input25[year]" type="tel" size="4" maxlength="4" value="2026" />  <label class="form-sub-label" for="year_25" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_25_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_25_pick"><span> </span></label></span></div></div> </div></li><li class="form-line" id="id_26"><div class="form-label-left" id="label_26"><label for="input_26"> In the case of Divorce, Was a Get given? </label><label class="label-message" for="input_26"> </label></div><div id="cid_26" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_26_0" name="q26_input26[]" value="Yes" /><label id="label_input_26_0" for="input_26_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_26_1" name="q26_input26[]" value="No" /><label id="label_input_26_1" for="input_26_1"><span>No</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_26_2" name="q26_input26[]" value="Previous spouse was not Jewish" /><label id="label_input_26_2" for="input_26_2"><span>Previous spouse was not Jewish</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_33"><div class="form-label-left" id="label_33"><label for="input_33"> Date "The Get" was given </label><label class="label-message" for="input_33"> If applies</label></div><div id="cid_33" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="month_33" name="q33_input33[month]" type="tel" size="2" maxlength="2" value="01" />  <label class="form-sub-label" for="month_33" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="day_33" name="q33_input33[day]" type="tel" size="2" maxlength="2" value="28" />  <label class="form-sub-label" for="day_33" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="year_33" name="q33_input33[year]" type="tel" size="4" maxlength="4" value="2026" />  <label class="form-sub-label" for="year_33" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_33_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_33_pick"><span> </span></label></span></div></div> </div></li><li class="form-line" id="id_70"><div class="form-label-left" id="label_70"><label for="input_70"> Name of the Beth Din that performed the Get Ceremony </label><label class="label-message" for="input_70"> If applies</label></div><div id="cid_70" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_70" name="q70_input70" size="20" value="" /> </div></li><li class="form-line" id="id_34"><div class="form-label-left" id="label_34"><label for="input_34"> Address of Beth Din </label><label class="label-message" for="input_34"> </label></div><div id="cid_34" 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 form-address-line" type="text" name="q34_address34[addr_line1]" id="input_34_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_34_addr_line1" id="sublabel_34_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="q34_address34[addr_line2]" id="input_34_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_34_addr_line2" id="sublabel_34_addr_line2">Street Address Line 2</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-city" type="text" name="q34_address34[city]" id="input_34_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_34_city" id="sublabel_34_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q34_address34[state]" id="input_34_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_34_state" id="sublabel_34_state">State / Province</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-postal" type="text" name="q34_address34[postal]" id="input_34_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_34_postal" id="sublabel_34_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q34_address34[country]" id="input_34_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 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_34_country" id="sublabel_34_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_35"><div class="form-label-left" id="label_35"><label for="input_35"> Phone Number of Beth Din </label><label class="label-message" for="input_35"> </label></div><div id="cid_35" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q35_phoneNumber35[area]" id="input_35_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_35_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q35_phoneNumber35[phone]" id="input_35_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_35_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_36"><div id="cid_36" class="form-input-wide"> <div id="text_36" class="form-html"><p><span style="color: rgb(153, 51, 0); font-size: 20px;"><strong>Section 3 - Wedding Details</strong></span></p><p><span style="color: rgb(153, 51, 0); font-size: 20px;"></span><span style="color: rgb(153, 51, 102);"></span></p></div> </div></li><li class="form-line" id="id_37"><div class="form-label-left" id="label_37"><label for="input_37"> Date and Time of the Wedding<span class="form-required">*</span> </label><label class="label-message" for="input_37"> </label></div><div id="cid_37" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox validate[required]" id="month_37" name="q37_input37[month]" type="tel" size="2" maxlength="2" value="01" />  <label class="form-sub-label" for="month_37" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox validate[required]" id="day_37" name="q37_input37[day]" type="tel" size="2" maxlength="2" value="28" />  <label class="form-sub-label" for="day_37" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox validate[required]" id="year_37" name="q37_input37[year]" type="tel" size="4" maxlength="4" value="2026" />  <label class="form-sub-label" for="year_37" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_37_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_37_pick"><span> </span></label></span></div><span class="dir_ltr inline_block time-fields" style="white-space: nowrap;"><span class="form-sub-label-container"><span id="at_37" class="form-control-static at-label">at</span>  <label class="form-sub-label" for="at_37"><span> </span></label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" id="hour_37" name="q37_input37[hour]"><option></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 selected="selected" value="12">12</option></select>  <label class="form-sub-label" for="hour_37" id="sublabel_hour">Hour</label></span><span class="form-sub-label-container"><select class="form-dropdown validate[required]" id="min_37" name="q37_input37[min]"><option></option><option value="00">00</option><option value="10">10</option><option selected="selected" value="20">20</option><option value="30">30</option><option value="40">40</option><option value="50">50</option></select>  <label class="form-sub-label" for="min_37" id="sublabel_minutes">Minutes</label></span><span class="form-sub-label-container"><select class="form-dropdown validate[required]" id="ampm_37" name="q37_input37[ampm]"><option value="AM">AM</option><option selected="selected" value="PM">PM</option></select>  <label class="form-sub-label" for="ampm_37"><span> </span></label></span></span></div> </div></li><li class="form-line" id="id_74"><div class="form-label-left" id="label_74"><label for="input_74"> Venue address<span class="form-required">*</span> </label><label class="label-message" for="input_74"> Exact location how it is listed</label></div><div id="cid_74" 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="q74_address74[addr_line1]" id="input_74_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_74_addr_line1" id="sublabel_74_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="q74_address74[addr_line2]" id="input_74_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_74_addr_line2" id="sublabel_74_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="q74_address74[city]" id="input_74_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_74_city" id="sublabel_74_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q74_address74[state]" id="input_74_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_74_state" id="sublabel_74_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="q74_address74[postal]" id="input_74_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_74_postal" id="sublabel_74_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q74_address74[country]" id="input_74_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 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_74_country" id="sublabel_74_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_41"><div class="form-label-left" id="label_41"><label for="input_41"> Will there be a custom Ketuba being prepared?<span class="form-required">*</span> </label><label class="label-message" for="input_41"> </label></div><div id="cid_41" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_41_0" name="q41_input41[]" value="Yes" /><label id="label_input_41_0" for="input_41_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_41_1" name="q41_input41[]" value="No" /><label id="label_input_41_1" for="input_41_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_83"><div id="cid_83" class="form-input-wide"> <div id="text_83" class="form-html"><p><span style="color: rgb(153, 51, 0); font-size: 20px;"><strong>Section 4 - Agreement</strong></span></p><p><span style="color: rgb(153, 51, 0); font-size: 20px;"></span><span style="color: rgb(153, 51, 102);"></span></p></div> </div></li><li class="form-line" id="id_42"><div class="form-label-left" id="label_42"><label for="input_42"> Declaration for the groom<span class="form-required">*</span> </label><label class="label-message" for="input_42"> Please check box. A checked box is considered as a signature</label></div><div id="cid_42" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_42_0" name="q42_input42[]" value="I herby declare that all the details above were given with goodwill and are correct. I, therefore, request a marriage to be conducted according to the laws of Moses and Israel." /><label id="label_input_42_0" for="input_42_0"><span>I herby declare that all the details above were given with goodwill and are correct. I, therefore, request a marriage to be conducted according to the laws of Moses and Israel.</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_42_1" name="q42_input42[]" value="Decline" /><label id="label_input_42_1" for="input_42_1"><span>Decline</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_43"><div class="form-label-left" id="label_43"><label for="input_43"> Classes<span class="form-required">*</span> </label><label class="label-message" for="input_43"> Please check box. A checked box is considered as a signature</label></div><div id="cid_43" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_43_0" name="q43_input43[]" value="I agree to have at least 4 marriage classes with Rabbi Adi before the wedding" /><label id="label_input_43_0" for="input_43_0"><span>I agree to have at least 4 marriage classes with Rabbi Adi before the wedding</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_43_1" name="q43_input43[]" value="Decline" /><label id="label_input_43_1" for="input_43_1"><span>Decline</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_84"><div id="cid_84" class="form-input-wide"> <div id="text_84" class="form-html"><p><span style="color: rgb(153, 51, 0); font-size: 20px;"><strong>Section 1 - Bride Questionnaire </strong></span></p><p>General information about the Groom</p><p><span style="color: rgb(153, 51, 0); font-size: 20px;"></span><span style="color: rgb(153, 51, 102);"></span></p></div> </div></li><li class="form-line" id="id_85"><div class="form-label-left" id="label_85"><label for="input_85"> Bride's Full Name:<span class="form-required">*</span> </label><label class="label-message" for="input_85"> </label></div><div id="cid_85" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q85_fullName85[first]" id="first_85" autocomplete="given-name" />  <label class="form-sub-label" for="first_85" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q85_fullName85[last]" id="last_85" autocomplete="family-name" />  <label class="form-sub-label" for="last_85" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_49"><div class="form-label-left" id="label_49"><label for="input_49"> Bride's Cell Phone:<span class="form-required">*</span> </label><label class="label-message" for="input_49"> </label></div><div id="cid_49" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q49_phoneNumber49[area]" id="input_49_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_49_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q49_phoneNumber49[phone]" id="input_49_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_49_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_50"><div class="form-label-left" id="label_50"><label for="input_50"> Bride's E-mail:<span class="form-required">*</span> </label><label class="label-message" for="input_50"> </label></div><div id="cid_50" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_50" name="q50_email50" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_51"><div class="form-label-left" id="label_51"><label for="input_51"> Bride's Address:<span class="form-required">*</span> </label><label class="label-message" for="input_51"> </label></div><div id="cid_51" 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="q51_address51[addr_line1]" id="input_51_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_51_addr_line1" id="sublabel_51_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="q51_address51[addr_line2]" id="input_51_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_51_addr_line2" id="sublabel_51_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="q51_address51[city]" id="input_51_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_51_city" id="sublabel_51_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q51_address51[state]" id="input_51_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_51_state" id="sublabel_51_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="q51_address51[postal]" id="input_51_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_51_postal" id="sublabel_51_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q51_address51[country]" id="input_51_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 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_51_country" id="sublabel_51_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_52"><div class="form-label-left" id="label_52"><label for="input_52"> Bride's Birth Date:<span class="form-required">*</span> </label><label class="label-message" for="input_52"> </label></div><div id="cid_52" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q52_birthDate52[month]" id="input_52_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_52_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q52_birthDate52[day]" id="input_52_day"><option></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>  <label class="form-sub-label" for="input_52_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" name="q52_birthDate52[year]" id="input_52_year"><option></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>  <label class="form-sub-label" for="input_52_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_53"><div class="form-label-left" id="label_53"><label for="input_53"> Bride's Time of Birth:<span class="form-required">*</span> </label><label class="label-message" for="input_53"> </label></div><div id="cid_53" class="form-input"> <span class="dir_ltr inline_block"><span class="form-sub-label-container"><select class="noDefault form-dropdown validate[required]" id="input_53_hourSelect" name="q53_input53[hourSelect]"><option></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>  <label class="form-sub-label" for="input_53_hourSelect" id="sublabel_hour">Hour</label></span><span class="form-sub-label-container"><select class="form-dropdown validate[required]" id="input_53_minuteSelect" name="q53_input53[minuteSelect]"><option></option><option value="00">00</option><option value="10">10</option><option value="20">20</option><option value="30">30</option><option value="40">40</option><option value="50">50</option></select>  <label class="form-sub-label" for="input_53_minuteSelect" id="sublabel_minutes">Minutes</label></span><span class="form-sub-label-container"><select class="form-dropdown validate[required]" id="input_53_ampm" name="q53_input53[ampm]"><option></option><option value="AM">AM</option><option value="PM">PM</option></select>  <label class="form-sub-label" for="input_53_ampm"><span> </span></label></span></span> </div></li><li class="form-line" id="id_54"><div class="form-label-left" id="label_54"><label for="input_54"> Bride's Place of Birth:<span class="form-required">*</span> </label><label class="label-message" for="input_54"> </label></div><div id="cid_54" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_54" name="q54_input54" size="20" value="" /> </div></li><li class="form-line" id="id_55"><div class="form-label-left" id="label_55"><label for="input_55"> Bride's Hebrew Name:<span class="form-required">*</span> </label><label class="label-message" for="input_55"> </label></div><div id="cid_55" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_55" name="q55_input55" size="20" value="" /> </div></li><li class="form-line" id="id_56"><div class="form-label-left" id="label_56"><label for="input_56"> What is the bride's Jewish Status:<span class="form-required">*</span> </label><label class="label-message" for="input_56"> </label></div><div id="cid_56" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_56_0" name="q56_input56[]" value="Cohen" /><label id="label_input_56_0" for="input_56_0"><span>Cohen</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_56_1" name="q56_input56[]" value="Levi" /><label id="label_input_56_1" for="input_56_1"><span>Levi</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_56_2" name="q56_input56[]" value="Yisroel" /><label id="label_input_56_2" for="input_56_2"><span>Yisroel</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_56_3" name="q56_input56[]" value="Not Sure" /><label id="label_input_56_3" for="input_56_3"><span>Not Sure</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_57"><div class="form-label-left" id="label_57"><label for="input_57"> Bride's Father's Name:<span class="form-required">*</span> </label><label class="label-message" for="input_57"> </label></div><div id="cid_57" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q57_fullName57[first]" id="first_57" autocomplete="given-name" />  <label class="form-sub-label" for="first_57" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q57_fullName57[last]" id="last_57" autocomplete="family-name" />  <label class="form-sub-label" for="last_57" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_58"><div class="form-label-left" id="label_58"><label for="input_58"> Bride's Father's Hebrew Name:<span class="form-required">*</span> </label><label class="label-message" for="input_58"> </label></div><div id="cid_58" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_58" name="q58_input58" size="20" value="" /> </div></li><li class="form-line" id="id_59"><div class="form-label-left" id="label_59"><label for="input_59"> Bride's Mother's Name:<span class="form-required">*</span> </label><label class="label-message" for="input_59"> </label></div><div id="cid_59" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q59_fullName59[first]" id="first_59" autocomplete="given-name" />  <label class="form-sub-label" for="first_59" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q59_fullName59[last]" id="last_59" autocomplete="family-name" />  <label class="form-sub-label" for="last_59" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_60"><div class="form-label-left" id="label_60"><label for="input_60"> Bride's Mother's Hebrew Name:<span class="form-required">*</span> </label><label class="label-message" for="input_60"> </label></div><div id="cid_60" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_60" name="q60_input60" size="20" value="" /> </div></li><li class="form-line" id="id_61"><div class="form-label-left" id="label_61"><label for="input_61"> Bride's Maternal Grandmother's  Hebrew Name:<span class="form-required">*</span> </label><label class="label-message" for="input_61"> </label></div><div id="cid_61" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_61" name="q61_input61" size="20" value="" /> </div></li><li class="form-line" id="id_80"><div id="cid_80" class="form-input-wide"> <div id="text_80" class="form-html"><p><span style="color: rgb(153, 51, 0); font-size: 20px;"><strong>Section 2 - Marriageable Status</strong></span></p><p> This section only applies to those that have conversions in the family, are widowed, or are divorced. If section 2 does not apply, you can continue from section 3.</p><p><span style="color: rgb(153, 51, 0); font-size: 20px;"></span><span style="color: rgb(153, 51, 102);"></span></p></div> </div></li><li class="form-line" id="id_62"><div class="form-label-left" id="label_62"><label for="input_62"> Are there any conversions on the bride's side<span class="form-required">*</span> </label><label class="label-message" for="input_62"> </label></div><div id="cid_62" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_62_0" name="q62_input62[]" value="Yes on the bride's fathers side" /><label id="label_input_62_0" for="input_62_0"><span>Yes on the bride's fathers side</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_62_1" name="q62_input62[]" value="Yes on the bride's Mothers side" /><label id="label_input_62_1" for="input_62_1"><span>Yes on the bride's Mothers side</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_62_2" name="q62_input62[]" value="No conversions on either side" /><label id="label_input_62_2" for="input_62_2"><span>No conversions on either side</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_63"><div class="form-label-left" id="label_63"><label for="input_63"> Conversion details </label><label class="label-message" for="input_63"> If there are conversions on either side please provide the name of the Beth Din that completed the conversion process and the date of conversion</label></div><div id="cid_63" class="form-input"> <textarea id="input_63" class="form-textarea" name="q63_input63" cols="40" rows="2"></textarea> </div></li><li class="form-line" id="id_64"><div class="form-label-left" id="label_64"><label for="input_64"> Has the bride been previously married? </label><label class="label-message" for="input_64"> </label></div><div id="cid_64" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_64_0" name="q64_input64[]" value="This will be the bride's first marriage" /><label id="label_input_64_0" for="input_64_0"><span>This will be the bride's first marriage</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_64_1" name="q64_input64[]" value="Divorced" /><label id="label_input_64_1" for="input_64_1"><span>Divorced</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_64_2" name="q64_input64[]" value="Widowed" /><label id="label_input_64_2" for="input_64_2"><span>Widowed</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_66"><div class="form-label-left" id="label_66"><label for="input_66"> Date of previous marriage </label><label class="label-message" for="input_66"> If applies</label></div><div id="cid_66" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="month_66" name="q66_input66[month]" type="tel" size="2" maxlength="2" value="01" />  <label class="form-sub-label" for="month_66" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="day_66" name="q66_input66[day]" type="tel" size="2" maxlength="2" value="28" />  <label class="form-sub-label" for="day_66" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="year_66" name="q66_input66[year]" type="tel" size="4" maxlength="4" value="2026" />  <label class="form-sub-label" for="year_66" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_66_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_66_pick"><span> </span></label></span></div></div> </div></li><li class="form-line" id="id_67"><div class="form-label-left" id="label_67"><label for="input_67"> Location of previous marriage </label><label class="label-message" for="input_67"> If applies</label></div><div id="cid_67" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_67" name="q67_input67" size="20" value="" /> </div></li><li class="form-line" id="id_68"><div class="form-label-left" id="label_68"><label for="input_68"> Date of divorce </label><label class="label-message" for="input_68"> If applies</label></div><div id="cid_68" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="month_68" name="q68_input68[month]" type="tel" size="2" maxlength="2" value="01" />  <label class="form-sub-label" for="month_68" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="day_68" name="q68_input68[day]" type="tel" size="2" maxlength="2" value="28" />  <label class="form-sub-label" for="day_68" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="year_68" name="q68_input68[year]" type="tel" size="4" maxlength="4" value="2026" />  <label class="form-sub-label" for="year_68" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_68_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_68_pick"><span> </span></label></span></div></div> </div></li><li class="form-line" id="id_69"><div class="form-label-left" id="label_69"><label for="input_69"> In the case of Divorce, Was a Get given? </label><label class="label-message" for="input_69"> </label></div><div id="cid_69" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_69_0" name="q69_input69[]" value="Yes" /><label id="label_input_69_0" for="input_69_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_69_1" name="q69_input69[]" value="No" /><label id="label_input_69_1" for="input_69_1"><span>No</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_69_2" name="q69_input69[]" value="Previous spouse was not Jewish" /><label id="label_input_69_2" for="input_69_2"><span>Previous spouse was not Jewish</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_81"><div class="form-label-left" id="label_81"><label for="input_81"> Date "The Get" was given </label><label class="label-message" for="input_81"> If applies</label></div><div id="cid_81" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="month_81" name="q81_input81[month]" type="tel" size="2" maxlength="2" value="01" />  <label class="form-sub-label" for="month_81" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="day_81" name="q81_input81[day]" type="tel" size="2" maxlength="2" value="28" />  <label class="form-sub-label" for="day_81" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="year_81" name="q81_input81[year]" type="tel" size="4" maxlength="4" value="2026" />  <label class="form-sub-label" for="year_81" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_81_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_81_pick"><span> </span></label></span></div></div> </div></li><li class="form-line" id="id_32"><div class="form-label-left" id="label_32"><label for="input_32"> Name of the Beth Din that performed the Get Ceremony </label><label class="label-message" for="input_32"> If applies</label></div><div id="cid_32" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_32" name="q32_input32" size="20" value="" /> </div></li><li class="form-line" id="id_71"><div class="form-label-left" id="label_71"><label for="input_71"> Address of Beth Din </label><label class="label-message" for="input_71"> </label></div><div id="cid_71" 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 form-address-line" type="text" name="q71_address71[addr_line1]" id="input_71_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_71_addr_line1" id="sublabel_71_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="q71_address71[addr_line2]" id="input_71_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_71_addr_line2" id="sublabel_71_addr_line2">Street Address Line 2</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-city" type="text" name="q71_address71[city]" id="input_71_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_71_city" id="sublabel_71_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q71_address71[state]" id="input_71_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_71_state" id="sublabel_71_state">State / Province</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-postal" type="text" name="q71_address71[postal]" id="input_71_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_71_postal" id="sublabel_71_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q71_address71[country]" id="input_71_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 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_71_country" id="sublabel_71_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_72"><div class="form-label-left" id="label_72"><label for="input_72"> Phone Number of Beth Din </label><label class="label-message" for="input_72"> </label></div><div id="cid_72" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q72_phoneNumber72[area]" id="input_72_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_72_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q72_phoneNumber72[phone]" id="input_72_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_72_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_82"><div id="cid_82" class="form-input-wide"> <div id="text_82" class="form-html"><p><span style="color: rgb(153, 51, 0); font-size: 20px;"><strong>Section 3 - Wedding Details</strong></span></p><p><span style="color: rgb(153, 51, 0); font-size: 20px;"></span><span style="color: rgb(153, 51, 102);"></span></p></div> </div></li><li class="form-line" id="id_73"><div class="form-label-left" id="label_73"><label for="input_73"> Date and Time of the Wedding:<span class="form-required">*</span> </label><label class="label-message" for="input_73"> </label></div><div id="cid_73" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox validate[required]" id="month_73" name="q73_input73[month]" type="tel" size="2" maxlength="2" value="01" />  <label class="form-sub-label" for="month_73" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox validate[required]" id="day_73" name="q73_input73[day]" type="tel" size="2" maxlength="2" value="28" />  <label class="form-sub-label" for="day_73" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox validate[required]" id="year_73" name="q73_input73[year]" type="tel" size="4" maxlength="4" value="2026" />  <label class="form-sub-label" for="year_73" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_73_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_73_pick"><span> </span></label></span></div><span class="dir_ltr inline_block time-fields" style="white-space: nowrap;"><span class="form-sub-label-container"><span id="at_73" class="form-control-static at-label">at</span>  <label class="form-sub-label" for="at_73"><span> </span></label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown validate[required]" id="hour_73" name="q73_input73[hour]"><option></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 selected="selected" value="12">12</option></select>  <label class="form-sub-label" for="hour_73" id="sublabel_hour">Hour</label></span><span class="form-sub-label-container"><select class="form-dropdown validate[required]" id="min_73" name="q73_input73[min]"><option></option><option value="00">00</option><option value="10">10</option><option selected="selected" value="20">20</option><option value="30">30</option><option value="40">40</option><option value="50">50</option></select>  <label class="form-sub-label" for="min_73" id="sublabel_minutes">Minutes</label></span><span class="form-sub-label-container"><select class="form-dropdown validate[required]" id="ampm_73" name="q73_input73[ampm]"><option value="AM">AM</option><option selected="selected" value="PM">PM</option></select>  <label class="form-sub-label" for="ampm_73"><span> </span></label></span></span></div> </div></li><li class="form-line" id="id_38"><div class="form-label-left" id="label_38"><label for="input_38"> Venue address:<span class="form-required">*</span> </label><label class="label-message" for="input_38"> Exact location how it is listed</label></div><div id="cid_38" 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="q38_address38[addr_line1]" id="input_38_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_38_addr_line1" id="sublabel_38_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="q38_address38[addr_line2]" id="input_38_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_38_addr_line2" id="sublabel_38_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="q38_address38[city]" id="input_38_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_38_city" id="sublabel_38_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q38_address38[state]" id="input_38_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_38_state" id="sublabel_38_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="q38_address38[postal]" id="input_38_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_38_postal" id="sublabel_38_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q38_address38[country]" id="input_38_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 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_38_country" id="sublabel_38_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_75"><div class="form-label-left" id="label_75"><label for="input_75"> Will there be a custom Ketuba being prepared?<span class="form-required">*</span> </label><label class="label-message" for="input_75"> </label></div><div id="cid_75" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_75_0" name="q75_input75[]" value="Yes" /><label id="label_input_75_0" for="input_75_0"><span>Yes</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_75_1" name="q75_input75[]" value="No" /><label id="label_input_75_1" for="input_75_1"><span>No</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_40"><div id="cid_40" class="form-input-wide"> <div id="text_40" class="form-html"><p><span style="color: rgb(153, 51, 0); font-size: 20px;"><strong>Section 4 - Agreement</strong></span></p><p><span style="color: rgb(153, 51, 0); font-size: 20px;"></span><span style="color: rgb(153, 51, 102);"></span></p></div> </div></li><li class="form-line" id="id_76"><div class="form-label-left" id="label_76"><label for="input_76"> Declaration for the bride<span class="form-required">*</span> </label><label class="label-message" for="input_76"> Please check box. A checked box is considered as a signature</label></div><div id="cid_76" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_76_0" name="q76_input76[]" value="I herby declare that all the details above were given with goodwill and are correct. I, therefore, request a marriage to be conducted according to the laws of Moses and Israel." /><label id="label_input_76_0" for="input_76_0"><span>I herby declare that all the details above were given with goodwill and are correct. I, therefore, request a marriage to be conducted according to the laws of Moses and Israel.</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_76_1" name="q76_input76[]" value="Decline" /><label id="label_input_76_1" for="input_76_1"><span>Decline</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_77"><div class="form-label-left" id="label_77"><label for="input_77"> Classes<span class="form-required">*</span> </label><label class="label-message" for="input_77"> Please check box. A checked box is considered as a signature</label></div><div id="cid_77" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_77_0" name="q77_input77[]" value="I agree to have at least 4 marriage classes with Rabbi Adi before the wedding" /><label id="label_input_77_0" for="input_77_0"><span>I agree to have at least 4 marriage classes with Rabbi Adi before the wedding</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_77_1" name="q77_input77[]" value="Decline" /><label id="label_input_77_1" for="input_77_1"><span>Decline</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_86"><div id="cid_86" class="form-input-wide"> <div id="text_86" class="form-html"><p><span style="color: rgb(153, 51, 0); font-size: 20px;"><strong>Section 5 - Deposit </strong></span></p><p><span style="color: rgb(153, 51, 0); font-size: 20px;"></span><span style="color: rgb(153, 51, 102);"></span></p></div> </div></li><li class="form-line" id="id_78"><div class="form-label-left" id="label_78"><label for="input_78"> Fees<span class="form-required">*</span> </label><label class="label-message" for="input_78"> Please check box. A checked box is considered as a signature</label></div><div id="cid_78" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_78_0" name="q78_input78[]" value="I understand that the fee to perform the marriage ceremony is $1,800.00" /><label id="label_input_78_0" for="input_78_0"><span>I understand that the fee to perform the marriage ceremony is $1,800.00</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_78_1" name="q78_input78[]" value="I agree that if the wedding will be outside of the south florida tri-county area, (Dade, Broward, Palm Beach)the family is responsible to reimburse all travel costs, and expenses this includes:  Flights/Travel expenses for both Rabbi Adi and Malky, Kosher food, Trasportation / Car Rental all other related expenses" /><label id="label_input_78_1" for="input_78_1"><span>I agree that if the wedding will be outside of the south florida tri-county area, (Dade, Broward, Palm Beach)the family is responsible to reimburse all travel costs, and expenses this includes:  Flights/Travel expenses for both Rabbi Adi and Malky, Kosher food, Trasportation / Car Rental all other related expenses</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_78_2" name="q78_input78[]" value="I understand that there is a $200.00 non-refundable deposit to hold the date. The deposit will be deducted from the total wedding fee of $1,800.00" /><label id="label_input_78_2" for="input_78_2"><span>I understand that there is a $200.00 non-refundable deposit to hold the date. The deposit will be deducted from the total wedding fee of $1,800.00</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_78_3" name="q78_input78[]" value="The final $1,600.00 balance is due 14 days prior to the wedding date" /><label id="label_input_78_3" for="input_78_3"><span>The final $1,600.00 balance is due 14 days prior to the wedding date</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_79"><div class="form-label-left" id="label_79"><label for="input_79"> Deposit Charge<span class="form-required">*</span> </label><label class="label-message" for="input_79"> Please check box. A checked box is considered as a signature</label></div><div id="cid_79" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_79_0" name="q79_input79[]" value="$200.00 Deposit Fee" /><label id="label_input_79_0" for="input_79_0"><span>$200.00 Deposit Fee</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox-other form-checkbox validate[required, other]" name="q79_input79[other]" id="other_79" value="" /><span><input type="text" class="form-checkbox-other-input form-textbox form-checkbox validate[required, other]" name="q79_input79[other][text]" data-otherhint="Other" size="15" id="input_79" disabled="disabled" /></span><br /></span></div> </div></li><li class="form-line" id="id_87"><div class="form-label-left" id="label_87"><label for="input_87"> Total </label></div><div id="cid_87" class="form-input"> <div id="total_amount">$0.00 </div><div class="form-single-column form-checkbox-item" id="div_offset_gift_87" style="padding-top: 10px">		<input type="checkbox" id="input_87" class="form-checkbox" name="q87_offsetGiftPercent" value="3" />		<label id="label_87" for="input_87">Yes, I'd like to donate the cost of processing this transaction by adding 3%</label>		<input type="hidden" id="hidden_87" name="q87_offsetGiftAmount" />		<div class="clearfix"></div>		</div> </div></li><li class="form-line" id="id_47"><div class="form-label-left" id="label_47"><label for="input_47"> Payment<span class="form-required">*</span> </label><label class="label-message" for="input_47"> </label></div><div id="cid_47" 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[required, paymentMethod] form-radio" type="radio" id="input_47_creditCard" name="q47_payment[payment_method]" value="creditCard" onclick="BuildSource.creditCard(this)" /><label for="input_47_creditCard">Credit Card</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[required, paymentMethod] form-radio" type="radio" id="input_47_paypal" name="q47_payment[payment_method]" value="paypal" onclick="BuildSource.paypal(this)" /><label for="input_47_paypal">Paypal</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[required, paymentMethod] form-radio" type="radio" id="input_47_other" name="q47_payment[payment_method]" value="other" onclick="BuildSource.other(this)" /><label for="input_47_other">Zelle: Rabbi@jewishmonterra.com / Venmo: @Chabadatmonterra.com</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="q47_payment[cc_type]" id="input_47_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[required, visible, creditcard]" type="text" name="q47_payment[cc_number]" id="input_47_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_47_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[required, visible]" type="text" name="q47_payment[cc_ccv]" id="input_47_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_47_cc_ccv" id="sublabel_cc_ccv">Security Code</label></span></td></tr><tr><td colspan="2" class="cc_name_on_card "><span class="form-sub-label-container"><input class="form-textbox validate[required, visible]" type="text" name="q47_payment[cc_nameOnCard]" id="input_47_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_47_cc_nameOnCard" id="sublabel_cc_nameOnCard">Name on Card</label></span></td></tr><tr class="credit_card hide"><td colspan=""><span class="form-sub-label-container"><select class="form-textbox validate[required, visible]" name="q47_payment[cc_exp_month]" id="input_47_cc_exp_month" autocomplete="cc-exp-month"><option></option><option value="1">1 - 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