{"id":102283,"date":"2019-01-23T11:11:35","date_gmt":"2019-01-23T16:11:35","guid":{"rendered":"https:\/\/www.samaritanspurse.org\/?p=102283"},"modified":"2025-06-06T09:53:56","modified_gmt":"2025-06-06T13:53:56","slug":"ohop-application-private-view","status":"publish","type":"post","link":"https:\/\/samaritanspurse.org\/es\/our-ministry\/ohop-application-private-view\/","title":{"rendered":"OHOP Application"},"content":{"rendered":"<!--  THIS IS A PRIVATE VIEW OF THIS APPLICATION. THIS IS NOT THE APPLICATION THAT WE USE FOR THE SEASON. -->\r\n\r\n\r\n<span class=\"alt-title\"><strong>THIS IS A PRIVATE VIEW OF THIS APPLICATION - NOT INTENDED FOR PUBLIC&nbsp;USE<\/strong><br><br> Encounter God\u2019s Healing Love<\/span>\r\n\r\n<p>&nbsp;<\/p>\r\n\r\n<!-- <blockquote style=\"position: relative;padding-left: 1em;border-left: 0.2em solid #b17b08;display: block;\r\n    margin-block-start: 1em;\r\n    margin-block-end: 1em;\r\n    margin-inline-start: 40px;\r\n    margin-inline-end: 40px;\"><strong>Applications will be accepted for the 2023 season beginning 1 Feb. 2023<\/strong>.<\/blockquote> -->\r\n\r\n\r\n<p>This summer 170 military couples will be invited to experience a week of marriage enrichment at our lodge in wilderness Alaska. Apply now to be one of them! <\/p>\r\n\r\n<p>Operation Heal Our Patriots gives wounded veterans and their spouses an opportunity to strengthen their marriage and find physical and spiritual refreshment. Couples enjoy the beauty of God\u2019s creation and participate in Biblically based marriage classes that help build their relationship with each other and with Jesus Christ. Through our robust Family Care program, we continue to support participants long after their initial stay, keeping their spiritual needs and marriages a priority.<\/p>\r\n\r\n<p><em>Before you begin filling out this application, be sure you have a digital photo of you and your spouse ready to attach, as well as your DD-214 (or service record, if you are active duty and spouse DD-214 if applicable). Applications cannot be submitted without both a photo and DD-214 attached. Please note: this application may not work properly with some older browsers and mobile devices. If you have technical difficulties, please call 828-278-1625.<\/em><\/p>\r\n\r\n<div style=\"height: 20px;\"> <\/div>\r\n\r\n<div style=\"padding-left:45px;\">\r\n\r\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 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d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_104' style='display:none'><div id='gf_104' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_104'  action='\/es\/wp-json\/wp\/v2\/posts\/102283#gf_104' data-formid='104' novalidate> \r\n <input type='hidden' class='gforms-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/>\n        <div id='gf_progressbar_wrapper_104' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<h3 class=\"gf_progressbar_title\">Paso <span class='gf_step_current_page'>1<\/span> de <span class='gf_step_page_count'>8<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_12' style='width:12%;'><span>12%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_104_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_104' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_104_180\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_180'>Comments<\/label><div class='ginput_container'><input name='input_180' id='input_104_180' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_104_180'>Este campo es un campo de validaci\u00f3n y debe quedar sin cambios.<\/div><\/li><li id=\"field_104_175\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you or your spouse ever participated in our marriage enrichment training at Samaritan Lodge Alaska?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_104_175'>\n\t\t\t<li class='gchoice gchoice_104_175_0'>\n\t\t\t\t<input name='input_175' type='radio' value='Yes'  id='choice_104_175_0'    \/>\n\t\t\t\t<label for='choice_104_175_0' id='label_104_175_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_104_175_1'>\n\t\t\t\t<input name='input_175' type='radio' value='No'  id='choice_104_175_1'    \/>\n\t\t\t\t<label for='choice_104_175_1' id='label_104_175_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_104_176\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>Operation Heal Our Patriots is honored to serve our veteran couples. To ensure we serve as many veteran couples as possible, alumni couples and\/or remarried participants are only allowed one opportunity to participate in training at Samaritan Lodge Alaska.<\/strong><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_104_178' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_104_2_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Save and Continue Later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_104_2' class='gform_page' data-js='page-field-id-178' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_104_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_104_122\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you and\/or your spouse a post-9\/11 Veteran?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_104_122'>\n\t\t\t<li class='gchoice gchoice_104_122_0'>\n\t\t\t\t<input name='input_122' type='radio' value='Yes'  id='choice_104_122_0'    \/>\n\t\t\t\t<label for='choice_104_122_0' id='label_104_122_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_104_122_1'>\n\t\t\t\t<input name='input_122' type='radio' value='No'  id='choice_104_122_1'    \/>\n\t\t\t\t<label for='choice_104_122_1' id='label_104_122_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_104_121\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you currently married? (Proof of marriage may be requested in some cases prior to attendance.)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_104_121'>\n\t\t\t<li class='gchoice gchoice_104_121_0'>\n\t\t\t\t<input name='input_121' type='radio' value='Yes'  id='choice_104_121_0'    \/>\n\t\t\t\t<label for='choice_104_121_0' id='label_104_121_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_104_121_1'>\n\t\t\t\t<input name='input_121' type='radio' value='No'  id='choice_104_121_1'    \/>\n\t\t\t\t<label for='choice_104_121_1' id='label_104_121_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_104_131\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_131'>Please list the city, county, and state that you were married.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_131' id='input_104_131' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_104_15\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Marriage Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_104_15' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_104_15_1_container'><label for='input_104_15_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_15[]' id='input_104_15_1'   aria-required='true'  ><option value=''>Month<\/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><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_104_15_2_container'><label for='input_104_15_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_15[]' id='input_104_15_2'   aria-required='true'  ><option value=''>Day<\/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><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_104_15_3_container'><label for='input_104_15_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_15[]' id='input_104_15_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_104_165\" class=\"gfield gfield--type-sp_attachment_upload gfield--input-type-sp_attachment_upload gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_165'>Add Photo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_104_165'><p style='font-size:14px !important;padding-left:0 !important;'><i><label>Please attach a recent photo of you and your spouse.<\/label>\n<p style=\"font-size:14px !important;padding-left:0 !important;\"><i>Images should be no larger than 5MB, and may be in one of the following formats: JPG, GIF, or PDF<\/i><\/p><\/div><div class='ginput_container ginput_container_text large'>\t\t\t<div class='spau-content-wrapper'>\n\t\t\t\t<span id='input_104_165_btn-photo' data-photobutton class='btn btn-success fileinput-button'>\n\t\t\t\t<i class='glyphicon glyphicon-plus'><\/i>\n\t\t\t\t<span>Add file...<\/span>\n\t\t\t\t<!-- The file input field used as target for the file upload widget -->\n\t\t\t\t\t\t\t\t<input id='input_104_165_fileupload' data-file-upload type='file' name='input_104_165_files[]'>\n\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t<span id='input_104_165_fileUploadedBool' data-uploadbutton>Your file has not been uploaded.<\/span>\n\t\t\t\t<br>\n\t\t\t\t<br>\n\t\t\t\t<!-- The global progress bar -->\n\t\t\t\t<div id='input_104_165_progress' data-progress-bar class='progress'>\n\t\t\t\t\t<div class='progress-bar progress-bar-success'><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<!-- The container for the uploaded files -->\n\t\t\t\t<div id='input_104_165_files' data-file-wrapper class='input_104_165_files'><\/div>\n\t\t\t\t<br>\n\t\t\t\t\t\t\t\t\t\t<input type=hidden name='input_165' id='input_104_165_field' value='' \/>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div><\/li><li id=\"field_104_179\" class=\"gfield gfield--type-sp_attachment_upload gfield--input-type-sp_attachment_upload gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_179'>Marriage Certificate<\/label><div class='gfield_description' id='gfield_description_104_179'><p style='font-size:14px !important;padding-left:0 !important;'><i>Images should be no larger than 5MB, and may be in one of the following formats: JPG, GIF, or PDF<\/i><\/p><\/div><div class='ginput_container ginput_container_text large'>\t\t\t<div class='spau-content-wrapper'>\n\t\t\t\t<span id='input_104_179_btn-photo' data-photobutton class='btn btn-success fileinput-button'>\n\t\t\t\t<i class='glyphicon glyphicon-plus'><\/i>\n\t\t\t\t<span>Add file...<\/span>\n\t\t\t\t<!-- The file input field used as target for the file upload widget -->\n\t\t\t\t\t\t\t\t<input id='input_104_179_fileupload' data-file-upload type='file' name='input_104_179_files[]'>\n\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t<span id='input_104_179_fileUploadedBool' data-uploadbutton>Your file has not been uploaded.<\/span>\n\t\t\t\t<br>\n\t\t\t\t<br>\n\t\t\t\t<!-- The global progress bar -->\n\t\t\t\t<div id='input_104_179_progress' data-progress-bar class='progress'>\n\t\t\t\t\t<div class='progress-bar progress-bar-success'><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<!-- The container for the uploaded files -->\n\t\t\t\t<div id='input_104_179_files' data-file-wrapper class='input_104_179_files'><\/div>\n\t\t\t\t<br>\n\t\t\t\t\t\t\t\t\t\t<input type=hidden name='input_179' id='input_104_179_field' value='' \/>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div><\/li><li id=\"field_104_127\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Note Program Requirements<\/h2><\/li><li id=\"field_104_125\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >\n<strong>Thank you for your service and your interest in Operation Heal Our Patriots!\n<br><br>\nThis project is only open to married veterans who sustained combat-related injuries after Sept 11, 2001.<\/strong><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_104_150' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_104_150' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_104_3_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Save and Continue Later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_104_3' class='gform_page' data-js='page-field-id-150' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_104_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_104_98\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p style=\"font-size:22px;font-weight:900;padding:0;\">Name of Wounded Veteran:<\/p>\n\n<p style=\"font-size:14px; font-weight:bold\">If both are veterans please use most qualified applicant based on post-9\/11 service.<\/p><\/li><li id=\"field_104_3\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_3'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_104_3' type='text' value='' class='medium' maxlength='20'    aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_104_1\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_1'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_104_1' type='text' value='' class='medium' maxlength='20'    aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_104_2\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_2'>Middle Name<\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_104_2' type='text' value='' class='medium' maxlength='20'     aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_104_78\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_78'>Preferred Name<\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_104_78' type='text' value='' class='medium' maxlength='20'     aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_104_16\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_104_16' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_104_16_1_container'><label for='input_104_16_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_16[]' id='input_104_16_1'   aria-required='true'  ><option value=''>Month<\/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><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_104_16_2_container'><label for='input_104_16_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_16[]' id='input_104_16_2'   aria-required='true'  ><option value=''>Day<\/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><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_104_16_3_container'><label for='input_104_16_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_16[]' id='input_104_16_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_104_10\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Current Physical Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_104_10' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_104_10_1_container' >\n                                        <input type='text' name='input_10.1' id='input_104_10_1' value=''    aria-required='true'    \/>\n                                        <label for='input_104_10_1' id='input_104_10_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_104_10_2_container' >\n                                        <input type='text' name='input_10.2' id='input_104_10_2' value=''     aria-required='false'   \/>\n                                        <label for='input_104_10_2' id='input_104_10_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_104_10_3_container' >\n                                    <input type='text' name='input_10.3' id='input_104_10_3' value=''    aria-required='true'    \/>\n                                    <label for='input_104_10_3' id='input_104_10_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_104_10_4_container' >\n                                        <select name='input_10.4' id='input_104_10_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='AL' >Alabama<\/option><option value='AK' >Alaska<\/option><option value='AZ' >Arizona<\/option><option value='AR' >Arkansas<\/option><option value='CA' >California<\/option><option value='CO' >Colorado<\/option><option value='CT' >Connecticut<\/option><option value='DE' >Delaware<\/option><option value='DC' >District of Columbia<\/option><option value='FL' >Florida<\/option><option value='GA' >Georgia<\/option><option value='GU' >Guam<\/option><option value='HI' >Hawaii<\/option><option value='ID' >Idaho<\/option><option value='IL' >Illinois<\/option><option value='IN' >Indiana<\/option><option value='IA' >Iowa<\/option><option value='KS' >Kansas<\/option><option value='KY' >Kentucky<\/option><option value='LA' >Louisiana<\/option><option value='ME' >Maine<\/option><option value='MD' >Maryland<\/option><option value='MA' >Massachusetts<\/option><option value='MI' >Michigan<\/option><option value='MN' >Minnesota<\/option><option value='MS' >Mississippi<\/option><option value='MO' >Missouri<\/option><option value='MT' >Montana<\/option><option value='NE' >Nebraska<\/option><option value='NV' >Nevada<\/option><option value='NH' >New Hampshire<\/option><option value='NJ' >New Jersey<\/option><option value='NM' >New Mexico<\/option><option value='NY' >New York<\/option><option value='NC' >North Carolina<\/option><option value='ND' >North Dakota<\/option><option value='OH' >Ohio<\/option><option value='OK' >Oklahoma<\/option><option value='OR' >Oregon<\/option><option value='PA' >Pennsylvania<\/option><option value='PR' >Puerto Rico<\/option><option value='RI' >Rhode Island<\/option><option value='SC' >South Carolina<\/option><option value='SD' >South Dakota<\/option><option value='TN' >Tennessee<\/option><option value='TX' >Texas<\/option><option value='UT' >Utah<\/option><option value='VT' >Vermont<\/option><option value='VA' >Virginia<\/option><option value='WA' >Washington<\/option><option value='WV' >West Virginia<\/option><option value='WI' >Wisconsin<\/option><option value='WY' >Wyoming<\/option><\/select>\n                                        <label for='input_104_10_4' id='input_104_10_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_104_10_5_container' >\n                                    <input type='text' name='input_10.5' id='input_104_10_5' value=''    aria-required='true'    \/>\n                                    <label for='input_104_10_5' id='input_104_10_5_label' class='gform-field-label gform-field-label--type-sub '>Zip Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_10.6' id='input_104_10_6' value='USAB' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_104_132\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Is your mailing address the same as your physical address?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_104_132'>\n\t\t\t<li class='gchoice gchoice_104_132_0'>\n\t\t\t\t<input name='input_132' type='radio' value='Yes'  id='choice_104_132_0'    \/>\n\t\t\t\t<label for='choice_104_132_0' id='label_104_132_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_104_132_1'>\n\t\t\t\t<input name='input_132' type='radio' value='No'  id='choice_104_132_1'    \/>\n\t\t\t\t<label for='choice_104_132_1' id='label_104_132_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_104_133\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Mailing Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_104_133' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_104_133_1_container' >\n                                        <input type='text' name='input_133.1' id='input_104_133_1' value=''    aria-required='true'    \/>\n                                        <label for='input_104_133_1' id='input_104_133_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_104_133_2_container' >\n                                        <input type='text' name='input_133.2' id='input_104_133_2' value=''     aria-required='false'   \/>\n                                        <label for='input_104_133_2' id='input_104_133_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_104_133_3_container' >\n                                    <input type='text' name='input_133.3' id='input_104_133_3' value=''    aria-required='true'    \/>\n                                    <label for='input_104_133_3' id='input_104_133_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_104_133_4_container' >\n                                        <select name='input_133.4' id='input_104_133_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='AL' >Alabama<\/option><option value='AK' >Alaska<\/option><option value='AZ' >Arizona<\/option><option value='AR' >Arkansas<\/option><option value='CA' >California<\/option><option value='CO' >Colorado<\/option><option value='CT' >Connecticut<\/option><option value='DE' >Delaware<\/option><option value='DC' >District of Columbia<\/option><option value='FL' >Florida<\/option><option value='GA' >Georgia<\/option><option value='GU' >Guam<\/option><option value='HI' >Hawaii<\/option><option value='ID' >Idaho<\/option><option value='IL' >Illinois<\/option><option value='IN' >Indiana<\/option><option value='IA' >Iowa<\/option><option value='KS' >Kansas<\/option><option value='KY' >Kentucky<\/option><option value='LA' >Louisiana<\/option><option value='ME' >Maine<\/option><option value='MD' >Maryland<\/option><option value='MA' >Massachusetts<\/option><option value='MI' >Michigan<\/option><option value='MN' >Minnesota<\/option><option value='MS' >Mississippi<\/option><option value='MO' >Missouri<\/option><option value='MT' >Montana<\/option><option value='NE' >Nebraska<\/option><option value='NV' >Nevada<\/option><option value='NH' >New Hampshire<\/option><option value='NJ' >New Jersey<\/option><option value='NM' >New Mexico<\/option><option value='NY' >New York<\/option><option value='NC' >North Carolina<\/option><option value='ND' >North Dakota<\/option><option value='OH' >Ohio<\/option><option value='OK' >Oklahoma<\/option><option value='OR' >Oregon<\/option><option value='PA' >Pennsylvania<\/option><option value='PR' >Puerto Rico<\/option><option value='RI' >Rhode Island<\/option><option value='SC' >South Carolina<\/option><option value='SD' >South Dakota<\/option><option value='TN' >Tennessee<\/option><option value='TX' >Texas<\/option><option value='UT' >Utah<\/option><option value='VT' >Vermont<\/option><option value='VA' >Virginia<\/option><option value='WA' >Washington<\/option><option value='WV' >West Virginia<\/option><option value='WI' >Wisconsin<\/option><option value='WY' >Wyoming<\/option><\/select>\n                                        <label for='input_104_133_4' id='input_104_133_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_104_133_5_container' >\n                                    <input type='text' name='input_133.5' id='input_104_133_5' value=''    aria-required='true'    \/>\n                                    <label for='input_104_133_5' id='input_104_133_5_label' class='gform-field-label gform-field-label--type-sub '>Zip Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_133.6' id='input_104_133_6' value='USAB' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_104_46\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_46'>Cell Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_104_46' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_104_45\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_45'>Additional Contact Number<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_104_45' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_104_13\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_13'>Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_13' id='input_104_13' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_104_149' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_104_149' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_104_4_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Save and Continue Later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_104_4' class='gform_page' data-js='page-field-id-149' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_104_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_104_126\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Service Details<\/h2><\/li><li id=\"field_104_4\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_4'>Branch of Service<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_4' id='input_104_4' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Air Force' >Air Force<\/option><option value='Army' >Army<\/option><option value='Coast Guard' >Coast Guard<\/option><option value='Marines' >Marines<\/option><option value='Navy' >Navy<\/option><option value='Space Force' >Space Force<\/option><\/select><\/div><\/li><li id=\"field_104_6\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_6'>Status<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_6' id='input_104_6' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Active Duty' >Active Duty<\/option><option value='Reserve' >Reserve<\/option><option value='Retired' >Retired<\/option><option value='Medically Retired' >Medically Retired<\/option><option value='Former' >Former<\/option><option value='National Guard' >National Guard<\/option><\/select><\/div><\/li><li id=\"field_104_5\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_5'>Current rank or rank at time of separation\/retirement<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_5' id='input_104_5' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Admiral' >Admiral<\/option><option value='Airman' >Airman<\/option><option value='Airman Basic' >Airman Basic<\/option><option value='Airman First Class' >Airman First Class<\/option><option value='Brigadier General' >Brigadier General<\/option><option value='Captain' >Captain<\/option><option value='Chief Master Sergeant' >Chief Master Sergeant<\/option><option value='Chief Petty Officer' >Chief Petty Officer<\/option><option value='Chief Warrant Officer 2' >Chief Warrant Officer 2<\/option><option value='Chief Warrant Officer 3' >Chief Warrant Officer 3<\/option><option value='Chief Warrant Officer 4' >Chief Warrant Officer 4<\/option><option value='Chief Warrant Officer 5' >Chief Warrant Officer 5<\/option><option value='Command Sergeant Major' >Command Sergeant Major<\/option><option value='Colonel' >Colonel<\/option><option value='Corporal' >Corporal<\/option><option value='Ensign' >Ensign<\/option><option value='First Lieutenant' >First Lieutenant<\/option><option value='First Sergeant' >First Sergeant<\/option><option value='Fleet\/Command Master Chief' >Fleet\/Command Master Chief<\/option><option value='General' >General<\/option><option value='Gunnery Sergeant' >Gunnery Sergeant<\/option><option value='Lance Corporal' >Lance Corporal<\/option><option value='Lieutenant' >Lieutenant<\/option><option value='Lieutenant Colonel' >Lieutenant Colonel<\/option><option value='Lieutenant Commander' >Lieutenant Commander<\/option><option value='Lieutenant General' >Lieutenant General<\/option><option value='Lieutenant Junior Grade' >Lieutenant Junior Grade<\/option><option value='Major' >Major<\/option><option value='Master Chief Petty Officer' >Master Chief Petty Officer<\/option><option value='Major General' >Major General<\/option><option value='Master Gunnery Sergeant' >Master Gunnery Sergeant<\/option><option value='Master Sergeant' >Master Sergeant<\/option><option value='Petty Officer 1st Class' >Petty Officer 1st Class<\/option><option value='Petty Officer 2nd Class' >Petty Officer 2nd Class<\/option><option value='Petty Officer 3rd Class' >Petty Officer 3rd Class<\/option><option value='Private 2' >Private 2<\/option><option value='Private' >Private<\/option><option value='Private First Class' >Private First Class<\/option><option value='Rear Admiral Lower Half' >Rear Admiral Lower Half<\/option><option value='Rear Admiral Upper Half' >Rear Admiral Upper Half<\/option><option value='Seaman' >Seaman<\/option><option value='Seaman Apprentice' >Seaman Apprentice<\/option><option value='Seaman Recruit' >Seaman Recruit<\/option><option value='Second Lieutenant' >Second Lieutenant<\/option><option value='Senior Airman' >Senior Airman<\/option><option value='Senior Chief Petty Officer' >Senior Chief Petty Officer<\/option><option value='Senior Master Sergeant' >Senior Master Sergeant<\/option><option value='Sergeant' >Sergeant<\/option><option value='Sergeant First Class' >Sergeant First Class<\/option><option value='Sergeant Major' >Sergeant Major<\/option><option value='Specialist' >Specialist<\/option><option value='Specialist 1' >Specialist 1<\/option><option value='Specialist 2' >Specialist 2<\/option><option value='Specialist 3' >Specialist 3<\/option><option value='Specialist 4' >Specialist 4<\/option><option value='Staff Sergeant' >Staff Sergeant<\/option><option value='Technical Sergeant' >Technical Sergeant<\/option><option value='Vice Admiral' >Vice Admiral<\/option><option value='Warrant Officer' >Warrant Officer<\/option><option value='Warrant Officer 1' >Warrant Officer 1<\/option><\/select><\/div><\/li><li id=\"field_104_7\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-full gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Military Service From Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_104_7' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_104_7_1_container'><label for='input_104_7_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_7[]' id='input_104_7_1'   aria-required='true'  ><option value=''>Month<\/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><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_104_7_2_container'><label for='input_104_7_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_7[]' id='input_104_7_2'   aria-required='true'  ><option value=''>Day<\/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><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_104_7_3_container'><label for='input_104_7_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_7[]' id='input_104_7_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_104_8\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-full gf_right_half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Military Service To Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_104_8' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_104_8_1_container'><label for='input_104_8_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_8[]' id='input_104_8_1'   aria-required='true'  ><option value=''>Month<\/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><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_104_8_2_container'><label for='input_104_8_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_8[]' id='input_104_8_2'   aria-required='true'  ><option value=''>Day<\/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><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_104_8_3_container'><label for='input_104_8_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_8[]' id='input_104_8_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_104_8'>(If currently on active duty, use today's date.)<\/div><\/li><li id=\"field_104_118\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_118'>Number of Combat Deployments<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_118' id='input_104_118' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='0' >0<\/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><\/select><\/div><\/li><li id=\"field_104_100\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_100'>List of Combat Deployment(s)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_100' id='input_104_100' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_104_162\" class=\"gfield gfield--type-sp_attachment_upload gfield--input-type-sp_attachment_upload gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_162'>Add DD-214<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_104_162'><p style='font-size:14px !important;padding-left:0 !important;'><i><label class=\"gfield_label\">Please attach your DD-214 or service record for active duty.<\/label>\n<p style=\"font-size:14px !important;padding-left:0 !important;\"><i>Images should be no larger than 5MB, and may be in one of the following formats: JPG, GIF, or PDF.  Please note: we do not use your Social Security number for any reason so please redact it.<\/i><\/p><\/i><\/p><\/div><div class='ginput_container ginput_container_text large'>\t\t\t<div class='spau-content-wrapper'>\n\t\t\t\t<span id='input_104_162_btn-photo' data-photobutton class='btn btn-success fileinput-button'>\n\t\t\t\t<i class='glyphicon glyphicon-plus'><\/i>\n\t\t\t\t<span>Add file...<\/span>\n\t\t\t\t<!-- The file input field used as target for the file upload widget -->\n\t\t\t\t\t\t\t\t<input id='input_104_162_fileupload' data-file-upload type='file' name='input_104_162_files[]'>\n\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t<span id='input_104_162_fileUploadedBool' data-uploadbutton>Your file has not been uploaded.<\/span>\n\t\t\t\t<br>\n\t\t\t\t<br>\n\t\t\t\t<!-- The global progress bar -->\n\t\t\t\t<div id='input_104_162_progress' data-progress-bar class='progress'>\n\t\t\t\t\t<div class='progress-bar progress-bar-success'><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<!-- The container for the uploaded files -->\n\t\t\t\t<div id='input_104_162_files' data-file-wrapper class='input_104_162_files'><\/div>\n\t\t\t\t<br>\n\t\t\t\t\t\t\t\t\t\t<input type=hidden name='input_162' id='input_104_162_field' value='' \/>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div><\/li><li id=\"field_104_163\" class=\"gfield gfield--type-sp_attachment_upload gfield--input-type-sp_attachment_upload gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_163'>Please attach any additional service documents (ex: combat citations, etc.).<\/label><div class='gfield_description' id='gfield_description_104_163'><p style='font-size:14px !important;padding-left:0 !important;'><i><!--<label class=\"gfield_label\">Please attach additional documents.<\/label>-->\n<p style=\"font-size:14px !important;padding-left:0 !important;\"><i>Images should be no larger than 5MB, and may be in one of the following formats: JPG, GIF, or PDF.\n\nPlease note: we do not use your Social Security number for any reason so please redact it.<\/i><\/p><\/i><\/p><\/div><div class='ginput_container ginput_container_text large'>\t\t\t<div class='spau-content-wrapper'>\n\t\t\t\t<span id='input_104_163_btn-photo' data-photobutton class='btn btn-success fileinput-button'>\n\t\t\t\t<i class='glyphicon glyphicon-plus'><\/i>\n\t\t\t\t<span>Add file...<\/span>\n\t\t\t\t<!-- The file input field used as target for the file upload widget -->\n\t\t\t\t\t\t\t\t<input id='input_104_163_fileupload' data-file-upload type='file' name='input_104_163_files[]'>\n\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t<span id='input_104_163_fileUploadedBool' data-uploadbutton>Your file has not been uploaded.<\/span>\n\t\t\t\t<br>\n\t\t\t\t<br>\n\t\t\t\t<!-- The global progress bar -->\n\t\t\t\t<div id='input_104_163_progress' data-progress-bar class='progress'>\n\t\t\t\t\t<div class='progress-bar progress-bar-success'><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<!-- The container for the uploaded files -->\n\t\t\t\t<div id='input_104_163_files' data-file-wrapper class='input_104_163_files'><\/div>\n\t\t\t\t<br>\n\t\t\t\t\t\t\t\t\t\t<input type=hidden name='input_163[]' id='input_104_163_field' value='' \/>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_104_160' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_104_160' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_104_5_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Save and Continue Later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_104_5' class='gform_page' data-js='page-field-id-160' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_104_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_104_17\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Combat or Service Related Injury Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_104_17' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_104_17_1_container'><label for='input_104_17_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_17[]' id='input_104_17_1'   aria-required='true'  ><option value=''>Month<\/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><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_104_17_2_container'><label for='input_104_17_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_17[]' id='input_104_17_2'   aria-required='true'  ><option value=''>Day<\/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><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_104_17_3_container'><label for='input_104_17_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_17[]' id='input_104_17_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_104_17'>Approximate date of injury if PTSD\/TBI\/cumulative musculoskeletal injury.<\/div><\/li><li id=\"field_104_18\" class=\"gfield gfield--type-multiselect gfield--input-type-multiselect gfield--width-full ohop_multi_select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_18'>Please select one or more entries that best describe your injury\/injuries.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple' data-placeholder='Clic para seleccionar...' size='7' name='input_18[]' id='input_104_18' class='medium gfield_select'   aria-invalid=\"false\" aria-required=\"true\" ><option value='Amputee (arm)' >Amputee (arm)<\/option><option value='Amputee (leg)' >Amputee (leg)<\/option><option value='Burn Wound' >Burn Wound<\/option><option value='Shrapnel or bullet wound' >Shrapnel or bullet wound<\/option><option value='Vision loss' >Vision loss<\/option><option value='Hearing loss' >Hearing loss<\/option><option value='PTSD' >PTSD<\/option><option value='TBI' >TBI<\/option><option value='Debilitating organ injury' >Debilitating organ injury<\/option><option value='Paralysis' >Paralysis<\/option><option value='Chronic pain from broken bones and\/or torn muscle' >Chronic pain from broken bones and\/or torn muscle<\/option><\/select><\/div><\/li><li id=\"field_104_166\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Did you receive a Purple Heart for your injury?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_104_166'>\n\t\t\t<li class='gchoice gchoice_104_166_0'>\n\t\t\t\t<input name='input_166' type='radio' value='Yes'  id='choice_104_166_0'    \/>\n\t\t\t\t<label for='choice_104_166_0' id='label_104_166_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_104_166_1'>\n\t\t\t\t<input name='input_166' type='radio' value='No'  id='choice_104_166_1'    \/>\n\t\t\t\t<label for='choice_104_166_1' id='label_104_166_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_104_167\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_167'>Please describe the incident for which you were awarded the Purple Heart.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_167' id='input_104_167' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_104_19\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_19'>Please provide a detailed description of your injury (or injuries), including how, and where your injuries occurred.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_19' id='input_104_19' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_104_29\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_29'>Are you currently receiving medical treatment? If so, please describe, and include any special medical needs.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_29' id='input_104_29' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_104_93\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_93'>Operation Heal Our Patriots operates in a remote region of the Alaskan wilderness. Do you rely on any specialized medical equipment? If so, please describe. (eg. Wheelchair, prosthetics, CPAP)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_93' id='input_104_93' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_104_172\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_172'>Please provide a physical description of your injuries and limitations.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_172' id='input_104_172' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_104_87' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_104_87' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_104_6_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Save and Continue Later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_104_6' class='gform_page' data-js='page-field-id-87' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_104_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_104_168\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p style=\"font-size:22px;font-weight:900;padding:0;\">Spouse Information:<\/p><\/li><li id=\"field_104_82\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><b>Please enter your spouse's name exactly as it appears on their driver's license.<\/b><\/li><li id=\"field_104_32\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_32'>Spouse Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_104_32' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_104_33\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_33'>Spouse First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_104_33' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_104_34\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_34'>Middle Name<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_104_34' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_104_79\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_79'>Preferred Name<\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_104_79' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_104_38\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Spouse Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_104_38' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_104_38_1_container'><label for='input_104_38_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_38[]' id='input_104_38_1'   aria-required='true'  ><option value=''>Month<\/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><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_104_38_2_container'><label for='input_104_38_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_38[]' id='input_104_38_2'   aria-required='true'  ><option value=''>Day<\/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><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_104_38_3_container'><label for='input_104_38_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_38[]' id='input_104_38_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_104_50\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Is your physical address the same as your spouse?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_104_50'>\n\t\t\t<li class='gchoice gchoice_104_50_0'>\n\t\t\t\t<input name='input_50' type='radio' value='Yes'  id='choice_104_50_0'    \/>\n\t\t\t\t<label for='choice_104_50_0' id='label_104_50_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_104_50_1'>\n\t\t\t\t<input name='input_50' type='radio' value='No'  id='choice_104_50_1'    \/>\n\t\t\t\t<label for='choice_104_50_1' id='label_104_50_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_104_51\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Current Physical Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_104_51' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_104_51_1_container' >\n                                        <input type='text' name='input_51.1' id='input_104_51_1' value=''    aria-required='true'    \/>\n                                        <label for='input_104_51_1' id='input_104_51_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_104_51_2_container' >\n                                        <input type='text' name='input_51.2' id='input_104_51_2' value=''     aria-required='false'   \/>\n                                        <label for='input_104_51_2' id='input_104_51_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_104_51_3_container' >\n                                    <input type='text' name='input_51.3' id='input_104_51_3' value=''    aria-required='true'    \/>\n                                    <label for='input_104_51_3' id='input_104_51_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_104_51_4_container' >\n                                        <select name='input_51.4' id='input_104_51_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='AL' >Alabama<\/option><option value='AK' >Alaska<\/option><option value='AZ' >Arizona<\/option><option value='AR' >Arkansas<\/option><option value='CA' >California<\/option><option value='CO' >Colorado<\/option><option value='CT' >Connecticut<\/option><option value='DE' >Delaware<\/option><option value='DC' >District of Columbia<\/option><option value='FL' >Florida<\/option><option value='GA' >Georgia<\/option><option value='GU' >Guam<\/option><option value='HI' >Hawaii<\/option><option value='ID' >Idaho<\/option><option value='IL' >Illinois<\/option><option value='IN' >Indiana<\/option><option value='IA' >Iowa<\/option><option value='KS' >Kansas<\/option><option value='KY' >Kentucky<\/option><option value='LA' >Louisiana<\/option><option value='ME' >Maine<\/option><option value='MD' >Maryland<\/option><option value='MA' >Massachusetts<\/option><option value='MI' >Michigan<\/option><option value='MN' >Minnesota<\/option><option value='MS' >Mississippi<\/option><option value='MO' >Missouri<\/option><option value='MT' >Montana<\/option><option value='NE' >Nebraska<\/option><option value='NV' >Nevada<\/option><option value='NH' >New Hampshire<\/option><option value='NJ' >New Jersey<\/option><option value='NM' >New Mexico<\/option><option value='NY' >New York<\/option><option value='NC' >North Carolina<\/option><option value='ND' >North Dakota<\/option><option value='OH' >Ohio<\/option><option value='OK' >Oklahoma<\/option><option value='OR' >Oregon<\/option><option value='PA' >Pennsylvania<\/option><option value='PR' >Puerto Rico<\/option><option value='RI' >Rhode Island<\/option><option value='SC' >South Carolina<\/option><option value='SD' >South Dakota<\/option><option value='TN' >Tennessee<\/option><option value='TX' >Texas<\/option><option value='UT' >Utah<\/option><option value='VT' >Vermont<\/option><option value='VA' >Virginia<\/option><option value='WA' >Washington<\/option><option value='WV' >West Virginia<\/option><option value='WI' >Wisconsin<\/option><option value='WY' >Wyoming<\/option><\/select>\n                                        <label for='input_104_51_4' id='input_104_51_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_104_51_5_container' >\n                                    <input type='text' name='input_51.5' id='input_104_51_5' value=''    aria-required='true'    \/>\n                                    <label for='input_104_51_5' id='input_104_51_5_label' class='gform-field-label gform-field-label--type-sub '>Zip Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_51.6' id='input_104_51_6' value='USAB' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_104_49\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_49'>Spouse Cell Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_104_49' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_104_48\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_48'>Spouse Additional Number<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_104_48' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_104_37\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_37'>Spouse Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_37' id='input_104_37' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_104_151' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_104_151' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_104_7_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Save and Continue Later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_104_7' class='gform_page' data-js='page-field-id-151' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_104_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_104_63\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Spouse Military Information<\/h2><\/li><li id=\"field_104_39\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >As the spouse of the primary applicant, are you also a post-9\/11 veteran?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_104_39'>\n\t\t\t<li class='gchoice gchoice_104_39_0'>\n\t\t\t\t<input name='input_39' type='radio' value='Yes'  id='choice_104_39_0'    \/>\n\t\t\t\t<label for='choice_104_39_0' id='label_104_39_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_104_39_1'>\n\t\t\t\t<input name='input_39' type='radio' value='No'  id='choice_104_39_1'    \/>\n\t\t\t\t<label for='choice_104_39_1' id='label_104_39_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_104_40\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_40'>Branch of Service<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_40' id='input_104_40' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Air Force' >Air Force<\/option><option value='Army' >Army<\/option><option value='Coast Guard' >Coast Guard<\/option><option value='Marines' >Marines<\/option><option value='Navy' >Navy<\/option><option value='Space Force' >Space Force<\/option><\/select><\/div><\/li><li id=\"field_104_42\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_42'>Status<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_42' id='input_104_42' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Active Duty' >Active Duty<\/option><option value='Reserve' >Reserve<\/option><option value='Retired' >Retired<\/option><option value='Medically Retired' >Medically Retired<\/option><option value='Former' >Former<\/option><\/select><\/div><\/li><li id=\"field_104_41\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_41'>Current rank or rank at time of separation\/retirement<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_41' id='input_104_41' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Admiral' >Admiral<\/option><option value='Airman' >Airman<\/option><option value='Airman Basic' >Airman Basic<\/option><option value='Airman First Class' >Airman First Class<\/option><option value='Brigadier General' >Brigadier General<\/option><option value='Captain' >Captain<\/option><option value='Chief Master Sergeant' >Chief Master Sergeant<\/option><option value='Chief Petty Officer' >Chief Petty Officer<\/option><option value='Chief Warrant Officer 2' >Chief Warrant Officer 2<\/option><option value='Chief Warrant Officer 3' >Chief Warrant Officer 3<\/option><option value='Chief Warrant Officer 4' >Chief Warrant Officer 4<\/option><option value='Chief Warrant Officer 5' >Chief Warrant Officer 5<\/option><option value='Colonel' >Colonel<\/option><option value='Command Sergeant Major' >Command Sergeant Major<\/option><option value='Corporal' >Corporal<\/option><option value='Ensign' >Ensign<\/option><option value='Fist Lieutenant' >Fist Lieutenant<\/option><option value='First Sergeant' >First Sergeant<\/option><option value='Fleet\/Command Master Chief' >Fleet\/Command Master Chief<\/option><option value='General' >General<\/option><option value='Gunnery Sergeant' >Gunnery Sergeant<\/option><option value='Lance Corporal' >Lance Corporal<\/option><option value='Lieutenant' >Lieutenant<\/option><option value='Lieutenant Colonel' >Lieutenant Colonel<\/option><option value='Lieutenant Commander' >Lieutenant Commander<\/option><option value='Lieutenant General' >Lieutenant General<\/option><option value='Lieutenant Junior Grade' >Lieutenant Junior Grade<\/option><option value='Major' >Major<\/option><option value='Major General' >Major General<\/option><option value='Master Chief Petty Officer' >Master Chief Petty Officer<\/option><option value='Master Gunnery Sergeant' >Master Gunnery Sergeant<\/option><option value='Master Sergeant' >Master Sergeant<\/option><option value='Petty Officer 1st Class' >Petty Officer 1st Class<\/option><option value='Petty Officer 2nd Class' >Petty Officer 2nd Class<\/option><option value='Petty Officer 3rd Class' >Petty Officer 3rd Class<\/option><option value='Private' >Private<\/option><option value='Private 2' >Private 2<\/option><option value='Private First Class' >Private First Class<\/option><option value='Rear Admiral Lower Half' >Rear Admiral Lower Half<\/option><option value='Rear Admiral Upper Half' >Rear Admiral Upper Half<\/option><option value='Seaman' >Seaman<\/option><option value='Seaman Apprentice' >Seaman Apprentice<\/option><option value='Seaman Recruit' >Seaman Recruit<\/option><option value='Second Lieutenant' >Second Lieutenant<\/option><option value='Senior Airman' >Senior Airman<\/option><option value='Senior Chief Petty Officer' >Senior Chief Petty Officer<\/option><option value='Senior Master Sergeant' >Senior Master Sergeant<\/option><option value='Sergeant' >Sergeant<\/option><option value='Sergeant First Class' >Sergeant First Class<\/option><option value='Sergeant Major' >Sergeant Major<\/option><option value='Specialist' >Specialist<\/option><option value='Specialist 1' >Specialist 1<\/option><option value='Specialist 2' >Specialist 2<\/option><option value='Specialist 3' >Specialist 3<\/option><option value='Specialist 4' >Specialist 4<\/option><option value='Staff Sergeant' >Staff Sergeant<\/option><option value='Technical Sergeant' >Technical Sergeant<\/option><option value='Vice Admiral' >Vice Admiral<\/option><option value='Warrant Officer' >Warrant Officer<\/option><option value='Warrant Officer 1' >Warrant Officer 1<\/option><\/select><\/div><\/li><li id=\"field_104_43\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Military Service From Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_104_43' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_104_43_1_container'><label for='input_104_43_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_43[]' id='input_104_43_1'   aria-required='true'  ><option value=''>Month<\/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><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_104_43_2_container'><label for='input_104_43_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_43[]' id='input_104_43_2'   aria-required='true'  ><option value=''>Day<\/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><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_104_43_3_container'><label for='input_104_43_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_43[]' id='input_104_43_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_104_44\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gf_right_half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Military Service To Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_104_44' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_104_44_1_container'><label for='input_104_44_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_44[]' id='input_104_44_1'   aria-required='true'  ><option value=''>Month<\/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><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_104_44_2_container'><label for='input_104_44_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_44[]' id='input_104_44_2'   aria-required='true'  ><option value=''>Day<\/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><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_104_44_3_container'><label for='input_104_44_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_44[]' id='input_104_44_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_104_44'>If currently on active duty, use today's date.<\/div><\/li><li id=\"field_104_119\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_119'>Number of Combat Deployments<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_119' id='input_104_119' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='0' >0<\/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><\/select><\/div><\/li><li id=\"field_104_109\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_109'>List of Combat Deployment(s)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_109' id='input_104_109' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_104_146\" class=\"gfield gfield--type-sp_attachment_upload gfield--input-type-sp_attachment_upload gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_146'>Please attach a copy of your spouse DD-214 or service record for active duty.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_104_146'><p style='font-size:14px !important;padding-left:0 !important;'><i><label class=\"gfield_label\">Please attach your DD-214 or service record for active duty. <\/label>\n<p style=\"font-size:14px !important;padding-left:0 !important;\"><i>Images should be no larger than 5MB, and may be in one of the following formats: JPG, GIF, or PDF.  Please note: we do not use your Social Security number for any reason so please redact it.<\/i><\/p><\/i><\/p><\/div><div class='ginput_container ginput_container_text large'>\t\t\t<div class='spau-content-wrapper'>\n\t\t\t\t<span id='input_104_146_btn-photo' data-photobutton class='btn btn-success fileinput-button'>\n\t\t\t\t<i class='glyphicon glyphicon-plus'><\/i>\n\t\t\t\t<span>Add file...<\/span>\n\t\t\t\t<!-- The file input field used as target for the file upload widget -->\n\t\t\t\t\t\t\t\t<input id='input_104_146_fileupload' data-file-upload type='file' name='input_104_146_files[]'>\n\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t<span id='input_104_146_fileUploadedBool' data-uploadbutton>Your file has not been uploaded.<\/span>\n\t\t\t\t<br>\n\t\t\t\t<br>\n\t\t\t\t<!-- The global progress bar -->\n\t\t\t\t<div id='input_104_146_progress' data-progress-bar class='progress'>\n\t\t\t\t\t<div class='progress-bar progress-bar-success'><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<!-- The container for the uploaded files -->\n\t\t\t\t<div id='input_104_146_files' data-file-wrapper class='input_104_146_files'><\/div>\n\t\t\t\t<br>\n\t\t\t\t\t\t\t\t\t\t<input type=hidden name='input_146' id='input_104_146_field' value='' \/>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div><\/li><li id=\"field_104_147\" class=\"gfield gfield--type-sp_attachment_upload gfield--input-type-sp_attachment_upload gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_147'>Please attach any additional spouse service documents (ex: combat citations, etc.).<\/label><div class='gfield_description' id='gfield_description_104_147'><p style='font-size:14px !important;padding-left:0 !important;'><i><!--<label class=\"gfield_label\">Please attach additional documents.<\/label>-->\n<p style=\"font-size:14px !important;padding-left:0 !important;\"><i>Images should be no larger than 5MB, and may be in one of the following formats: JPG, GIF, or PDF.\n\nPlease note: we do not use your Social Security number for any reason so please redact it.<\/i><\/p><\/i><\/p><\/div><div class='ginput_container ginput_container_text large'>\t\t\t<div class='spau-content-wrapper'>\n\t\t\t\t<span id='input_104_147_btn-photo' data-photobutton class='btn btn-success fileinput-button'>\n\t\t\t\t<i class='glyphicon glyphicon-plus'><\/i>\n\t\t\t\t<span>Add file...<\/span>\n\t\t\t\t<!-- The file input field used as target for the file upload widget -->\n\t\t\t\t\t\t\t\t<input id='input_104_147_fileupload' data-file-upload type='file' name='input_104_147_files[]'>\n\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t<span id='input_104_147_fileUploadedBool' data-uploadbutton>Your file has not been uploaded.<\/span>\n\t\t\t\t<br>\n\t\t\t\t<br>\n\t\t\t\t<!-- The global progress bar -->\n\t\t\t\t<div id='input_104_147_progress' data-progress-bar class='progress'>\n\t\t\t\t\t<div class='progress-bar progress-bar-success'><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<!-- The container for the uploaded files -->\n\t\t\t\t<div id='input_104_147_files' data-file-wrapper class='input_104_147_files'><\/div>\n\t\t\t\t<br>\n\t\t\t\t\t\t\t\t\t\t<input type=hidden name='input_147[]' id='input_104_147_field' value='' \/>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div><\/li><li id=\"field_104_171\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Were you injured during post-9\/11 military service?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_104_171'>\n\t\t\t<li class='gchoice gchoice_104_171_0'>\n\t\t\t\t<input name='input_171' type='radio' value='Yes'  id='choice_104_171_0'    \/>\n\t\t\t\t<label for='choice_104_171_0' id='label_104_171_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_104_171_1'>\n\t\t\t\t<input name='input_171' type='radio' value='No'  id='choice_104_171_1'    \/>\n\t\t\t\t<label for='choice_104_171_1' id='label_104_171_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_104_155\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Combat or Service Related Injury Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_104_155' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_104_155_1_container'><label for='input_104_155_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_155[]' id='input_104_155_1'   aria-required='true'  ><option value=''>Month<\/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><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_104_155_2_container'><label for='input_104_155_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_155[]' id='input_104_155_2'   aria-required='true'  ><option value=''>Day<\/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><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_104_155_3_container'><label for='input_104_155_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_155[]' id='input_104_155_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_104_155'>Approximate date of injury if PTSD\/TBI\/cumulative musculoskeletal injury.<\/div><\/li><li id=\"field_104_156\" class=\"gfield gfield--type-multiselect gfield--input-type-multiselect gfield--width-full ohop_multi_select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_156'>Please select one or more entries that best describe your injury\/injuries.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple' data-placeholder='Clic para seleccionar...' size='7' name='input_156[]' id='input_104_156' class='medium gfield_select'   aria-invalid=\"false\" aria-required=\"true\" ><option value='Amputee (arm)' >Amputee (arm)<\/option><option value='Amputee (leg)' >Amputee (leg)<\/option><option value='Burn Wound' >Burn Wound<\/option><option value='Shrapnel or bullet wound' >Shrapnel or bullet wound<\/option><option value='Vision loss' >Vision loss<\/option><option value='Hearing loss' >Hearing loss<\/option><option value='PTSD' >PTSD<\/option><option value='TBI' >TBI<\/option><option value='Debilitating organ injury' >Debilitating organ injury<\/option><option value='Paralysis' >Paralysis<\/option><option value='Chronic pain from broken bones and\/or torn muscle' >Chronic pain from broken bones and\/or torn muscle<\/option><\/select><\/div><\/li><li id=\"field_104_170\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Did you receive a Purple Heart for your injury<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_104_170'>\n\t\t\t<li class='gchoice gchoice_104_170_0'>\n\t\t\t\t<input name='input_170' type='radio' value='Yes'  id='choice_104_170_0'    \/>\n\t\t\t\t<label for='choice_104_170_0' id='label_104_170_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_104_170_1'>\n\t\t\t\t<input name='input_170' type='radio' value='No'  id='choice_104_170_1'    \/>\n\t\t\t\t<label for='choice_104_170_1' id='label_104_170_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_104_123\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_123'>Please describe the incident for which you were awarded the Purple Heart.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_123' id='input_104_123' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_104_158\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_158'>Please provide a detailed description of your injury (or injuries), including how, and where your injuries occurred.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_158' id='input_104_158' class='textarea medium'  aria-describedby=\"gfield_description_104_158\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_104_158'>If no injuries, please list \u201cnone\u201d<\/div><\/li><li id=\"field_104_64\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_64'>Are you currently receiving medical treatment? If so, please describe and include any special medical needs.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_64' id='input_104_64' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_104_159\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_159'>Operation Heal Our Patriots operates in a remote region of the Alaskan wilderness. Do you rely on any specialized medical equipment? If so, please describe.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_159' id='input_104_159' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_104_173\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_173'>Please provide a physical description of your injuries or limitations.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_173' id='input_104_173' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_104_88' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_104_88' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_104_8_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Save and Continue Later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_104_8' class='gform_page' data-js='page-field-id-88' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_104_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_104_174\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p style=\"font-size:22px;font-weight:900;padding:0;\">Describe Your Marriage<\/p>\n<\/li><li id=\"field_104_104\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_104'>Marital Status?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_104' id='input_104_104' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected'><\/option><option value='Great' >Great<\/option><option value='Average' >Average<\/option><option value='Troubled' >Troubled<\/option><option value='Separated' >Separated<\/option><\/select><\/div><\/li><li id=\"field_104_129\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_129'>Please describe your marriage and the reason for the marital status:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_129' id='input_104_129' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_104_139\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_139'>Has military service\/injuries affected your marriage? Please tell us how.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_139' id='input_104_139' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_104_73\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_73'>Why are you applying for Operation Heal Our Patriots and what do you hope to get out of participation?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_73' id='input_104_73' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_104_140\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you have a faith background?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_104_140'>\n\t\t\t<li class='gchoice gchoice_104_140_0'>\n\t\t\t\t<input name='input_140' type='radio' value='Yes'  id='choice_104_140_0'    \/>\n\t\t\t\t<label for='choice_104_140_0' id='label_104_140_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_104_140_1'>\n\t\t\t\t<input name='input_140' type='radio' value='No'  id='choice_104_140_1'    \/>\n\t\t\t\t<label for='choice_104_140_1' id='label_104_140_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_104_143\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_143'>Please describe your faith background.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_143' id='input_104_143' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_104_128\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you regularly attend a church?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_104_128'>\n\t\t\t<li class='gchoice gchoice_104_128_0'>\n\t\t\t\t<input name='input_128' type='radio' value='Yes'  id='choice_104_128_0'    \/>\n\t\t\t\t<label for='choice_104_128_0' id='label_104_128_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_104_128_1'>\n\t\t\t\t<input name='input_128' type='radio' value='No'  id='choice_104_128_1'    \/>\n\t\t\t\t<label for='choice_104_128_1' id='label_104_128_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_104_107\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_107'>Please provide the church name and address and briefly describe your level of involvement.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_107' id='input_104_107' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_104_106\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_106'>List any marriage counseling\/programs previously attended.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_106' id='input_104_106' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_104_76\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_76'>If you have been recommended by a previous Operation Heal Our Patriots participant, please provide their name.<\/label><div class='ginput_container ginput_container_text'><input name='input_76' id='input_104_76' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_104_85\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_104_85'>How did you learn about Operation Heal Our Patriots?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_85' id='input_104_85' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_104_142\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >If there is a last minute cancellation would you be able to attend on a short notice (72 hours)?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_104_142'>\n\t\t\t<li class='gchoice gchoice_104_142_0'>\n\t\t\t\t<input name='input_142' type='radio' value='Yes'  id='choice_104_142_0'    \/>\n\t\t\t\t<label for='choice_104_142_0' id='label_104_142_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_104_142_1'>\n\t\t\t\t<input name='input_142' type='radio' value='No'  id='choice_104_142_1'    \/>\n\t\t\t\t<label for='choice_104_142_1' id='label_104_142_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_104_135\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br \/>\n<br \/><\/li><li id=\"field_104_95\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br \/>\n<br \/>\n\n<p style=\"font-weight:700;\">To effectively deliver this program, Samaritan\u2019s Purse, through Operation Heal Our Patriots, may collect, process, store, and\/or disclose your personal data in accordance with our <a href=\"https:\/\/www.samaritanspurse.org\/our-ministry\/privacy-policy\/\" target=\"_blank\">Privacy Policy<\/a>.<\/p>\n\n<p style=\"font-weight:700;\">Operation Heal Our Patriots cares deeply about protecting your personal information. Any injury information provided on this application will be used for the sole purpose of determining eligibility to the program and may be used by our staff in supporting you at Samaritan Lodge Alaska if you are selected for the program.\n<\/p>\n\n<p>All teaching and correspondence will be in English.<\/p>\n\n<br \/><\/li><li id=\"field_104_96\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Operation Heal Our Patriots Consent:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_104_96'><li class='gchoice gchoice_104_96_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' 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PUBLIC&nbsp;USE Encounter God\u2019s Healing Love &nbsp; This summer 170 military couples will be invited to experience a week of marriage enrichment at our lodge in wilderness Alaska. Apply now to be one of them! 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