{"id":3155,"date":"2022-04-27T07:23:54","date_gmt":"2022-04-27T07:23:54","guid":{"rendered":"https:\/\/www.alianzatelecom.org\/solicitud-de-ingreso\/"},"modified":"2022-05-17T10:36:37","modified_gmt":"2022-05-17T10:36:37","slug":"solicitud-de-ingreso","status":"publish","type":"page","link":"https:\/\/www.alianzatelecom.org\/en\/solicitud-de-ingreso\/","title":{"rendered":"Membership Application"},"content":{"rendered":"<div id=\"pl-3155\"  class=\"panel-layout\" ><div id=\"pg-3155-0\"  class=\"panel-grid panel-no-style\" ><div id=\"pgc-3155-0-0\"  class=\"panel-grid-cell\" ><div id=\"panel-3155-0-0-0\" class=\"widget_text so-panel widget widget_custom_html panel-first-child panel-last-child\" data-index=\"0\" ><div class=\"textwidget custom-html-widget\"><div class='fluentform ff-default fluentform_wrapper_5 ffs_bootstrap_wrap'><form data-form_id=\"5\" id=\"fluentform_5\" class=\"frm-fluent-form fluent_form_5 ff-el-form-top ff_form_instance_5_1 ff-form-loading ffs_bootstrap\" data-form_instance=\"ff_form_instance_5_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Membership Application<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='' \/><input type=\"hidden\" id=\"_fluentform_5_fluentformnonce\" name=\"_fluentform_5_fluentformnonce\" value=\"3730fb4c16\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/3155\" \/><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-5_1\" ><h3><span style=\"color: #299cc5\">Company information<\/span><\/h3><\/div><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_input_text' id='label_ff_5_input_text' aria-label=\"Organization\u2019s name\">Organization\u2019s name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" data-name=\"input_text\" id=\"ff_5_input_text\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_input_text_1' id='label_ff_5_input_text_1' aria-label=\"Main Representative\">Main Representative<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" data-name=\"input_text_1\" id=\"ff_5_input_text_1\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_input_text_2' id='label_ff_5_input_text_2' aria-label=\"Representative title\">Representative title<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_2\" class=\"ff-el-form-control\" data-name=\"input_text_2\" id=\"ff_5_input_text_2\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_input_text_3' id='label_ff_5_input_text_3' aria-label=\"Address\">Address<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_3\" class=\"ff-el-form-control\" data-name=\"input_text_3\" id=\"ff_5_input_text_3\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_dropdown' id='label_ff_5_dropdown' aria-label=\"State\">State<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown\" id=\"ff_5_dropdown\" class=\"ff-el-form-control\" data-name=\"dropdown\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_5_dropdown\"><option value=\"\">- Select -<\/option><option value=\"Alabama\"  >Alabama<\/option><option value=\"Alaska\"  >Alaska<\/option><option value=\"Arizona\"  >Arizona<\/option><option value=\"Arkansas\"  >Arkansas<\/option><option value=\"California\"  >California<\/option><option value=\"Colorado\"  >Colorado<\/option><option value=\"Connecticut\"  >Connecticut<\/option><option value=\"Delaware\"  >Delaware<\/option><option value=\"District of Columbia\"  >District of Columbia<\/option><option value=\"Florida\"  >Florida<\/option><option value=\"Georgia\"  >Georgia<\/option><option value=\"Hawaii\"  >Hawaii<\/option><option value=\"Idaho\"  >Idaho<\/option><option value=\"Illinois\"  >Illinois<\/option><option value=\"Indiana\"  >Indiana<\/option><option value=\"Iowa\"  >Iowa<\/option><option value=\"Kansas\"  >Kansas<\/option><option value=\"Kentucky\"  >Kentucky<\/option><option value=\"Louisiana\"  >Louisiana<\/option><option value=\"Maine\"  >Maine<\/option><option value=\"Maryland\"  >Maryland<\/option><option value=\"Massachusetts\"  >Massachusetts<\/option><option value=\"Michigan\"  >Michigan<\/option><option value=\"Minnesota\"  >Minnesota<\/option><option value=\"Mississippi\"  >Mississippi<\/option><option value=\"Missouri\"  >Missouri<\/option><option value=\"Montana\"  >Montana<\/option><option value=\"Nebraska\"  >Nebraska<\/option><option value=\"Nevada\"  >Nevada<\/option><option value=\"New Hampshire\"  >New Hampshire<\/option><option value=\"New Jersey\"  >New Jersey<\/option><option value=\"New Mexico\"  >New Mexico<\/option><option value=\"New York\"  >New York<\/option><option value=\"North Carolina\"  >North Carolina<\/option><option value=\"North Dakota\"  >North Dakota<\/option><option value=\"Ohio\"  >Ohio<\/option><option value=\"Oklahoma\"  >Oklahoma<\/option><option value=\"Oregon\"  >Oregon<\/option><option value=\"Pennsylvania\"  >Pennsylvania<\/option><option value=\"Puerto Rico\"  >Puerto Rico<\/option><option value=\"Rhode Island\"  >Rhode Island<\/option><option value=\"South Carolina\"  >South Carolina<\/option><option value=\"South Dakota\"  >South Dakota<\/option><option value=\"Tennessee\"  >Tennessee<\/option><option value=\"Texas\"  >Texas<\/option><option value=\"Utah\"  >Utah<\/option><option value=\"Vermont\"  >Vermont<\/option><option value=\"Virginia\"  >Virginia<\/option><option value=\"Washington\"  >Washington<\/option><option value=\"West Virginia\"  >West Virginia<\/option><option value=\"Wisconsin\"  >Wisconsin<\/option><option value=\"Wyoming\"  >Wyoming<\/option><option value=\"Armed Forces Americas\"  >Armed Forces Americas<\/option><option value=\"Armed Forces Europe\"  >Armed Forces Europe<\/option><option value=\"Armed Forces Pacific\"  >Armed Forces Pacific<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_dropdown_2' id='label_ff_5_dropdown_2' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_2\" id=\"ff_5_dropdown_2\" class=\"ff-el-form-control\" data-name=\"dropdown_2\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_5_dropdown_2\"><option value=\"\">- Select -<\/option><option value=\"Adjuntas\"  >Adjuntas<\/option><option value=\"Aguada\"  >Aguada<\/option><option value=\"Aguadilla\"  >Aguadilla<\/option><option value=\"Aguas Buenas\"  >Aguas Buenas<\/option><option value=\"Aibonito\"  >Aibonito<\/option><option value=\"Arecibo\"  >Arecibo<\/option><option value=\"Arroyo\"  >Arroyo<\/option><option value=\"A\u00f1asco\"  >A\u00f1asco<\/option><option value=\"Barceloneta\"  >Barceloneta<\/option><option value=\"Barranquitas\"  >Barranquitas<\/option><option value=\"Bayam\u00f3n\"  >Bayam\u00f3n<\/option><option value=\"Cabo Rojo\"  >Cabo Rojo<\/option><option value=\"Caguas\"  >Caguas<\/option><option value=\"Camuy\"  >Camuy<\/option><option value=\"Can\u00f3vanas\"  >Can\u00f3vanas<\/option><option value=\"Carolina\"  >Carolina<\/option><option value=\"Cata\u00f1o\"  >Cata\u00f1o<\/option><option value=\"Cayey\"  >Cayey<\/option><option value=\"Ceiba\"  >Ceiba<\/option><option value=\"Ciales\"  >Ciales<\/option><option value=\"Cidra\"  >Cidra<\/option><option value=\"Coamo\"  >Coamo<\/option><option value=\"Comer\u00edo\"  >Comer\u00edo<\/option><option value=\"Corozal\"  >Corozal<\/option><option value=\"Culebra\"  >Culebra<\/option><option value=\"Dorado\"  >Dorado<\/option><option value=\"Fajardo\"  >Fajardo<\/option><option value=\"Florida\"  >Florida<\/option><option value=\"Guayama\"  >Guayama<\/option><option value=\"Guayanilla\"  >Guayanilla<\/option><option value=\"Guaynabo\"  >Guaynabo<\/option><option value=\"Gurabo\"  >Gurabo<\/option><option value=\"Gu\u00e1nica\"  >Gu\u00e1nica<\/option><option value=\"Hatillo\"  >Hatillo<\/option><option value=\"Hormigueros\"  >Hormigueros<\/option><option value=\"Humacao\"  >Humacao<\/option><option value=\"Isabela\"  >Isabela<\/option><option value=\"Jayuya\"  >Jayuya<\/option><option value=\"Juana D\u00edaz\"  >Juana D\u00edaz<\/option><option value=\"Juncos\"  >Juncos<\/option><option value=\"Lajas\"  >Lajas<\/option><option value=\"Lares\"  >Lares<\/option><option value=\"Las Mar\u00edas\"  >Las Mar\u00edas<\/option><option value=\"Las Piedras\"  >Las Piedras<\/option><option value=\"Loiza\"  >Loiza<\/option><option value=\"Luquillo\"  >Luquillo<\/option><option value=\"Manat\u00ed\"  >Manat\u00ed<\/option><option value=\"Maricao\"  >Maricao<\/option><option value=\"Maunabo\"  >Maunabo<\/option><option value=\"Mayag\u00fcez\"  >Mayag\u00fcez<\/option><option value=\"Moca\"  >Moca<\/option><option value=\"Morovis\"  >Morovis<\/option><option value=\"Naguabo\"  >Naguabo<\/option><option value=\"Naranjito\"  >Naranjito<\/option><option value=\"Orocovis\"  >Orocovis<\/option><option value=\"Patillas\"  >Patillas<\/option><option value=\"Pe\u00f1uelas\"  >Pe\u00f1uelas<\/option><option value=\"Ponce\"  >Ponce<\/option><option value=\"Quebradillas\"  >Quebradillas<\/option><option value=\"Rinc\u00f3n\"  >Rinc\u00f3n<\/option><option value=\"Rio Grande\"  >Rio Grande<\/option><option value=\"Sabana Grande\"  >Sabana Grande<\/option><option value=\"Salinas\"  >Salinas<\/option><option value=\"San Germ\u00e1n\"  >San Germ\u00e1n<\/option><option value=\"San Juan\"  >San Juan<\/option><option value=\"San Lorenzo\"  >San Lorenzo<\/option><option value=\"San Sebasti\u00e1n\"  >San Sebasti\u00e1n<\/option><option value=\"Santa Isabel\"  >Santa Isabel<\/option><option value=\"Toa Alta\"  >Toa Alta<\/option><option value=\"Toa Baja\"  >Toa Baja<\/option><option value=\"Trujillo Alto\"  >Trujillo Alto<\/option><option value=\"Utuado\"  >Utuado<\/option><option value=\"Vega Alta\"  >Vega Alta<\/option><option value=\"Vega Baja\"  >Vega Baja<\/option><option value=\"Vieques\"  >Vieques<\/option><option value=\"Villalba\"  >Villalba<\/option><option value=\"Yabucoa\"  >Yabucoa<\/option><option value=\"Yauco\"  >Yauco<\/option><option value=\"other\"  >other<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_input_text_6' id='label_ff_5_input_text_6' aria-label=\"Zip Code\">Zip Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_6\" class=\"ff-el-form-control\" data-name=\"input_text_6\" id=\"ff_5_input_text_6\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_14' id='label_ff_5_input_text_14' aria-label=\"Company physical address\">Company physical address<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_14\" class=\"ff-el-form-control\" data-name=\"input_text_14\" id=\"ff_5_input_text_14\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_dropdown_1' id='label_ff_5_dropdown_1' aria-label=\"State\">State<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_1\" id=\"ff_5_dropdown_1\" class=\"ff-el-form-control\" data-name=\"dropdown_1\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_5_dropdown_1\"><option value=\"\">- Select -<\/option><option value=\"Alabama\"  >Alabama<\/option><option value=\"Alaska\"  >Alaska<\/option><option value=\"Arizona\"  >Arizona<\/option><option value=\"Arkansas\"  >Arkansas<\/option><option value=\"California\"  >California<\/option><option value=\"Colorado\"  >Colorado<\/option><option value=\"Connecticut\"  >Connecticut<\/option><option value=\"Delaware\"  >Delaware<\/option><option value=\"District of Columbia\"  >District of Columbia<\/option><option value=\"Florida\"  >Florida<\/option><option value=\"Georgia\"  >Georgia<\/option><option value=\"Hawaii\"  >Hawaii<\/option><option value=\"Idaho\"  >Idaho<\/option><option value=\"Illinois\"  >Illinois<\/option><option value=\"Indiana\"  >Indiana<\/option><option value=\"Iowa\"  >Iowa<\/option><option value=\"Kansas\"  >Kansas<\/option><option value=\"Kentucky\"  >Kentucky<\/option><option value=\"Louisiana\"  >Louisiana<\/option><option value=\"Maine\"  >Maine<\/option><option value=\"Maryland\"  >Maryland<\/option><option value=\"Massachusetts\"  >Massachusetts<\/option><option value=\"Michigan\"  >Michigan<\/option><option value=\"Minnesota\"  >Minnesota<\/option><option value=\"Mississippi\"  >Mississippi<\/option><option value=\"Missouri\"  >Missouri<\/option><option value=\"Montana\"  >Montana<\/option><option value=\"Nebraska\"  >Nebraska<\/option><option value=\"Nevada\"  >Nevada<\/option><option value=\"New Hampshire\"  >New Hampshire<\/option><option value=\"New Jersey\"  >New Jersey<\/option><option value=\"New Mexico\"  >New Mexico<\/option><option value=\"New York\"  >New York<\/option><option value=\"North Carolina\"  >North Carolina<\/option><option value=\"North Dakota\"  >North Dakota<\/option><option value=\"Ohio\"  >Ohio<\/option><option value=\"Oklahoma\"  >Oklahoma<\/option><option value=\"Oregon\"  >Oregon<\/option><option value=\"Pennsylvania\"  >Pennsylvania<\/option><option value=\"Puerto Rico\"  >Puerto Rico<\/option><option value=\"Rhode Island\"  >Rhode Island<\/option><option value=\"South Carolina\"  >South Carolina<\/option><option value=\"South Dakota\"  >South Dakota<\/option><option value=\"Tennessee\"  >Tennessee<\/option><option value=\"Texas\"  >Texas<\/option><option value=\"Utah\"  >Utah<\/option><option value=\"Vermont\"  >Vermont<\/option><option value=\"Virginia\"  >Virginia<\/option><option value=\"Washington\"  >Washington<\/option><option value=\"West Virginia\"  >West Virginia<\/option><option value=\"Wisconsin\"  >Wisconsin<\/option><option value=\"Wyoming\"  >Wyoming<\/option><option value=\"Armed Forces Americas\"  >Armed Forces Americas<\/option><option value=\"Armed Forces Europe\"  >Armed Forces Europe<\/option><option value=\"Armed Forces Pacific\"  >Armed Forces Pacific<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_dropdown_3' id='label_ff_5_dropdown_3' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_3\" id=\"ff_5_dropdown_3\" class=\"ff-el-form-control\" data-name=\"dropdown_3\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_5_dropdown_3\"><option value=\"\">- Select -<\/option><option value=\"Adjuntas\"  >Adjuntas<\/option><option value=\"Aguada\"  >Aguada<\/option><option value=\"Aguadilla\"  >Aguadilla<\/option><option value=\"Aguas Buenas\"  >Aguas Buenas<\/option><option value=\"Aibonito\"  >Aibonito<\/option><option value=\"Arecibo\"  >Arecibo<\/option><option value=\"Arroyo\"  >Arroyo<\/option><option value=\"A\u00f1asco\"  >A\u00f1asco<\/option><option value=\"Barceloneta\"  >Barceloneta<\/option><option value=\"Barranquitas\"  >Barranquitas<\/option><option value=\"Bayam\u00f3n\"  >Bayam\u00f3n<\/option><option value=\"Cabo Rojo\"  >Cabo Rojo<\/option><option value=\"Caguas\"  >Caguas<\/option><option value=\"Camuy\"  >Camuy<\/option><option value=\"Can\u00f3vanas\"  >Can\u00f3vanas<\/option><option value=\"Carolina\"  >Carolina<\/option><option value=\"Cata\u00f1o\"  >Cata\u00f1o<\/option><option value=\"Cayey\"  >Cayey<\/option><option value=\"Ceiba\"  >Ceiba<\/option><option value=\"Ciales\"  >Ciales<\/option><option value=\"Cidra\"  >Cidra<\/option><option value=\"Coamo\"  >Coamo<\/option><option value=\"Comer\u00edo\"  >Comer\u00edo<\/option><option value=\"Corozal\"  >Corozal<\/option><option value=\"Culebra\"  >Culebra<\/option><option value=\"Dorado\"  >Dorado<\/option><option value=\"Fajardo\"  >Fajardo<\/option><option value=\"Florida\"  >Florida<\/option><option value=\"Guayama\"  >Guayama<\/option><option value=\"Guayanilla\"  >Guayanilla<\/option><option value=\"Guaynabo\"  >Guaynabo<\/option><option value=\"Gurabo\"  >Gurabo<\/option><option value=\"Gu\u00e1nica\"  >Gu\u00e1nica<\/option><option value=\"Hatillo\"  >Hatillo<\/option><option value=\"Hormigueros\"  >Hormigueros<\/option><option value=\"Humacao\"  >Humacao<\/option><option value=\"Isabela\"  >Isabela<\/option><option value=\"Jayuya\"  >Jayuya<\/option><option value=\"Juana D\u00edaz\"  >Juana D\u00edaz<\/option><option value=\"Juncos\"  >Juncos<\/option><option value=\"Lajas\"  >Lajas<\/option><option value=\"Lares\"  >Lares<\/option><option value=\"Las Mar\u00edas\"  >Las Mar\u00edas<\/option><option value=\"Las Piedras\"  >Las Piedras<\/option><option value=\"Loiza\"  >Loiza<\/option><option value=\"Luquillo\"  >Luquillo<\/option><option value=\"Manat\u00ed\"  >Manat\u00ed<\/option><option value=\"Maricao\"  >Maricao<\/option><option value=\"Maunabo\"  >Maunabo<\/option><option value=\"Mayag\u00fcez\"  >Mayag\u00fcez<\/option><option value=\"Moca\"  >Moca<\/option><option value=\"Morovis\"  >Morovis<\/option><option value=\"Naguabo\"  >Naguabo<\/option><option value=\"Naranjito\"  >Naranjito<\/option><option value=\"Orocovis\"  >Orocovis<\/option><option value=\"Patillas\"  >Patillas<\/option><option value=\"Pe\u00f1uelas\"  >Pe\u00f1uelas<\/option><option value=\"Ponce\"  >Ponce<\/option><option value=\"Quebradillas\"  >Quebradillas<\/option><option value=\"Rinc\u00f3n\"  >Rinc\u00f3n<\/option><option value=\"Rio Grande\"  >Rio Grande<\/option><option value=\"Sabana Grande\"  >Sabana Grande<\/option><option value=\"Salinas\"  >Salinas<\/option><option value=\"San Germ\u00e1n\"  >San Germ\u00e1n<\/option><option value=\"San Juan\"  >San Juan<\/option><option value=\"San Lorenzo\"  >San Lorenzo<\/option><option value=\"San Sebasti\u00e1n\"  >San Sebasti\u00e1n<\/option><option value=\"Santa Isabel\"  >Santa Isabel<\/option><option value=\"Toa Alta\"  >Toa Alta<\/option><option value=\"Toa Baja\"  >Toa Baja<\/option><option value=\"Trujillo Alto\"  >Trujillo Alto<\/option><option value=\"Utuado\"  >Utuado<\/option><option value=\"Vega Alta\"  >Vega Alta<\/option><option value=\"Vega Baja\"  >Vega Baja<\/option><option value=\"Vieques\"  >Vieques<\/option><option value=\"Villalba\"  >Villalba<\/option><option value=\"Yabucoa\"  >Yabucoa<\/option><option value=\"Yauco\"  >Yauco<\/option><option value=\"other\"  >other<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_17' id='label_ff_5_input_text_17' aria-label=\"Zip Code\">Zip Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_17\" class=\"ff-el-form-control\" data-name=\"input_text_17\" id=\"ff_5_input_text_17\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_phone' id='label_ff_5_phone' aria-label=\"Phone number\">Phone number<\/label><\/div><div class='ff-el-input--content'><input name=\"phone\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" data-name=\"phone\" id=\"ff_5_phone\" inputmode=\"tel\"  aria-invalid='false' aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_phone_1' id='label_ff_5_phone_1' aria-label=\"Mobile number\">Mobile number<\/label><\/div><div class='ff-el-input--content'><input name=\"phone_1\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" data-name=\"phone_1\" id=\"ff_5_phone_1\" inputmode=\"tel\"  aria-invalid='false' aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_input_text_8' id='label_ff_5_input_text_8' aria-label=\"Email address\">Email address<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_8\" class=\"ff-el-form-control\" data-name=\"input_text_8\" id=\"ff_5_input_text_8\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_47' id='label_ff_5_input_text_47' aria-label=\"Extension number\">Extension number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_47\" class=\"ff-el-form-control\" data-name=\"input_text_47\" id=\"ff_5_input_text_47\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_7' id='label_ff_5_input_text_7' aria-label=\"Fax Number\">Fax Number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_7\" class=\"ff-el-form-control\" data-name=\"input_text_7\" id=\"ff_5_input_text_7\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_9' id='label_ff_5_input_text_9' aria-label=\"Website\">Website<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_9\" class=\"ff-el-form-control\" data-name=\"input_text_9\" id=\"ff_5_input_text_9\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-5_2\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div data-name=\"ff_cn_id_5\"  class='ff-t-container ff-column-container ff_columns_total_1 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_dropdown_4' id='label_ff_5_dropdown_4' aria-label=\"Membership and applicable annual fee\">Membership and applicable annual fee<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_4\" id=\"ff_5_dropdown_4\" class=\"ff-el-form-control\" data-name=\"dropdown_4\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_5_dropdown_4\"><option value=\"\">- Select -<\/option><option value=\"VOTING MEMBER (operating company)\"  >VOTING MEMBER (operating company)<\/option><option value=\"JUNIOR CHAPTER MEMBER\"  >JUNIOR CHAPTER MEMBER<\/option><option value=\"TELECOMMUNICATIONS INFRASTRUCTURE MEMBER\"  >TELECOMMUNICATIONS INFRASTRUCTURE MEMBER<\/option><option value=\"VENDOR MEMBER\"  >VENDOR MEMBER<\/option><option value=\"AFFILIATE MEMBER\"  >AFFILIATE MEMBER<\/option><\/select><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_dropdown_5' id='label_ff_5_dropdown_5' aria-label=\"Desplegable-Miembro Votante\">Desplegable-Miembro Votante<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_5\" id=\"ff_5_dropdown_5\" class=\"ff-el-form-control\" data-name=\"dropdown_5\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_5_dropdown_5\"><option value=\"\">- Select -<\/option><option value=\"More than $100 million in annual revenue\"  >More than $100 million in annual revenue<\/option><option value=\"More than $10 million in annual revenue\"  >More than $10 million in annual revenue<\/option><option value=\"Between $5 million to $10 million in annual revenue\"  >Between $5 million to $10 million in annual revenue<\/option><option value=\"Between $1 million to $5 million in annual revenue\"  >Between $1 million to $5 million in annual revenue<\/option><\/select><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_dropdown_6' id='label_ff_5_dropdown_6' aria-label=\"Desplegable- Associate Member\">Desplegable- Associate Member<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_6\" id=\"ff_5_dropdown_6\" class=\"ff-el-form-control\" data-name=\"dropdown_6\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_5_dropdown_6\"><option value=\"\">- Select -<\/option><option value=\"Tower Co.\"  >Tower Co.<\/option><option value=\"Other\"  >Other<\/option><\/select><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_dropdown_7' id='label_ff_5_dropdown_7' aria-label=\"Desplegable-Junior Chapter Member\">Desplegable-Junior Chapter Member<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_7\" id=\"ff_5_dropdown_7\" class=\"ff-el-form-control\" data-name=\"dropdown_7\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_5_dropdown_7\"><option value=\"\">- Select -<\/option><option value=\"An annual revenue below  $1,000,000.0\"  >An annual revenue below  $1,000,000.0<\/option><\/select><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_dropdown_9' id='label_ff_5_dropdown_9' aria-label=\"Desplegable - comapnia torres\">Desplegable - comapnia torres<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_9\" id=\"ff_5_dropdown_9\" class=\"ff-el-form-control\" data-name=\"dropdown_9\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"false\" aria-labelledby=\"label_ff_5_dropdown_9\"><option value=\"\">- Select -<\/option><option value=\"Company with 21 or more towers\"  >Company with 21 or more towers<\/option><option value=\"Company  with 20 towers or less\"  >Company  with 20 towers or less<\/option><\/select><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Annual fee\">Annual fee<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for='input_radio_c2b2101fb763f8f2ddea48d4df0a0daf'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" checked=\"1\" value=\"$40,000\"  id='input_radio_c2b2101fb763f8f2ddea48d4df0a0daf' aria-label='$40,000' aria-invalid='false' aria-required=false> <span>$40,000<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Annual fee\">Annual fee<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for='input_radio_7_ad1462369fdc49f1aa85582478ff5145'><input  type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" checked=\"1\" value=\"$8,000\"  id='input_radio_7_ad1462369fdc49f1aa85582478ff5145' aria-label='$8,000' aria-invalid='false' aria-required=false> <span>$8,000<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Annual fee\">Annual fee<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for='input_radio_8_a4832f6aa51157154c93b8e9270e378c'><input  type=\"radio\" name=\"input_radio_8\" data-name=\"input_radio_8\" class=\"ff-el-form-check-input ff-el-form-check-radio\" checked=\"1\" value=\"$6,000\"  id='input_radio_8_a4832f6aa51157154c93b8e9270e378c' aria-label='$6,000' aria-invalid='false' aria-required=false> <span>$6,000<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Annual fee\">Annual fee<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for='input_radio_10_67596fcd8a402e9422183429cb7bc9e8'><input  type=\"radio\" name=\"input_radio_10\" data-name=\"input_radio_10\" class=\"ff-el-form-check-input ff-el-form-check-radio\" checked=\"1\" value=\"$3,000\"  id='input_radio_10_67596fcd8a402e9422183429cb7bc9e8' aria-label='$3,000' aria-invalid='false' aria-required=false> <span>$3,000<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Annual fee\">Annual fee<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for='input_radio_9_a8ace710a41240c97a5f1ee000c1877c'><input  type=\"radio\" name=\"input_radio_9\" data-name=\"input_radio_9\" class=\"ff-el-form-check-input ff-el-form-check-radio\" checked=\"1\" value=\"$7,500 (voting right)\"  id='input_radio_9_a8ace710a41240c97a5f1ee000c1877c' aria-label='$7,500 (voting right)' aria-invalid='false' aria-required=false> <span>$7,500 (voting right)<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Annual fee\">Annual fee<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for='input_radio_11_2bf0740fb3e71fa05396f5936dcdc94f'><input  type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" checked=\"1\" value=\"$3,000\"  id='input_radio_11_2bf0740fb3e71fa05396f5936dcdc94f' aria-label='$3,000' aria-invalid='false' aria-required=false> <span>$3,000<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Annual fee\">Annual fee<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for='input_radio_15_210182a7a50ad3a804269cef873fd85b'><input  type=\"radio\" name=\"input_radio_15\" data-name=\"input_radio_15\" class=\"ff-el-form-check-input ff-el-form-check-radio\" checked=\"1\" value=\"$3,000\"  id='input_radio_15_210182a7a50ad3a804269cef873fd85b' aria-label='$3,000' aria-invalid='false' aria-required=false> <span>$3,000<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Annual fee\">Annual fee<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for='input_radio_14_82d5e31d88ccf5b2f8b2cdfe8e59bea0'><input  type=\"radio\" name=\"input_radio_14\" data-name=\"input_radio_14\" class=\"ff-el-form-check-input ff-el-form-check-radio\" checked=\"1\" value=\"$3,000\"  id='input_radio_14_82d5e31d88ccf5b2f8b2cdfe8e59bea0' aria-label='$3,000' aria-invalid='false' aria-required=false> <span>$3,000<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Annual fee\">Annual fee<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for='input_radio_16_74aee02b3922c7ed761575b6f7b496bc'><input  type=\"radio\" name=\"input_radio_16\" data-name=\"input_radio_16\" class=\"ff-el-form-check-input ff-el-form-check-radio\" checked=\"1\" value=\"$3,000\"  id='input_radio_16_74aee02b3922c7ed761575b6f7b496bc' aria-label='$3,000' aria-invalid='false' aria-required=false> <span>$3,000<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Annual fee\">Annual fee<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for='input_radio_12_376a1f15cd63814bb19b11a55ce1f097'><input  type=\"radio\" name=\"input_radio_12\" data-name=\"input_radio_12\" class=\"ff-el-form-check-input ff-el-form-check-radio\" checked=\"1\" value=\"$500\"  id='input_radio_12_376a1f15cd63814bb19b11a55ce1f097' aria-label='$500' aria-invalid='false' aria-required=false> <span>$500<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Annual fee\">Annual fee<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for='input_radio_13_0c2d88ef9f4aebdb1cc45056ffb0b1a8'><input  type=\"radio\" name=\"input_radio_13\" data-name=\"input_radio_13\" class=\"ff-el-form-check-input ff-el-form-check-radio\" checked=\"1\" value=\"$1,000\"  id='input_radio_13_0c2d88ef9f4aebdb1cc45056ffb0b1a8' aria-label='$1,000' aria-invalid='false' aria-required=false> <span>$1,000<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_6\"  class='ff-t-container ff-column-container ff_columns_total_1 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: %;'><div class='ff-el-group  ff-custom_html has-conditions' tabindex='-1' data-name=\"custom_html-5_3\" ><p>Along with the application for admission, you must submit evidence of: Be registered as a certified business before the NET (by its Spanish acronym), CMRS, ETC, cable TV or interconnected VoIP, or possess an FCC-spectrum license, or be a tenant of an FCC-approved spectrum, or a better bidder for a license at the closing of any FCC-spectrum auction, which provides or plans to provide a bidirectional wireless service or owns participation in a submarine cable.<\/p><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_file-upload_1' id='label_ff_5_file-upload_1' aria-label=\"File Upload\">File Upload<\/label><\/div><div class='ff-el-input--content'><label for='ff_5_file-upload_1' class='ff_file_upload_holder'><span class='ff_upload_btn ff-btn' tabindex='0'>Choose File<\/span> <input type=\"file\" name=\"file-upload\" id=\"ff_5_file-upload_1\" class=\"ff-el-form-control  ff-screen-reader-element\" data-name=\"file-upload\" multiple=\"1\"  aria-invalid='false' aria-required=false><\/label><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_7\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_input_text_10' id='label_ff_5_input_text_10' aria-label=\"Name\">Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_10\" class=\"ff-el-form-control\" data-name=\"input_text_10\" id=\"ff_5_input_text_10\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_input_text_46' id='label_ff_5_input_text_46' aria-label=\"Title\">Title<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_46\" class=\"ff-el-form-control\" data-name=\"input_text_46\" id=\"ff_5_input_text_46\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_input_text_11' id='label_ff_5_input_text_11' aria-label=\"Company\">Company<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_11\" class=\"ff-el-form-control\" data-name=\"input_text_11\" id=\"ff_5_input_text_11\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-5_4\" ><p>APT\u2019s fiscal year and membership runs from January 1 st to December 31 st of each year.<\/p>\n<p>PAYMENT INFORMATION: Payment must be issued in dollars, via check payable to Alianza Puertorrique\u00f1a de Telecomunicaciones.<\/p>\n<p>Send check payment by regular mail to: Membres\u00edas APT, P.O. Box 11345, San Juan, PR 00922-1345<\/p>\n<p>Your APT membership will become effective when the Board of Directors and the Membership Committee approve your application.<\/p><\/div><div data-name=\"ff_cn_id_8\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_12' id='label_ff_5_input_text_12' aria-label=\"Alternative Representative\">Alternative Representative<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_12\" class=\"ff-el-form-control\" data-name=\"input_text_12\" id=\"ff_5_input_text_12\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_13' id='label_ff_5_input_text_13' aria-label=\"Title\">Title<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_13\" class=\"ff-el-form-control\" data-name=\"input_text_13\" id=\"ff_5_input_text_13\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_9\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_18' id='label_ff_5_input_text_18' aria-label=\"Phone Number\">Phone Number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_18\" class=\"ff-el-form-control\" data-name=\"input_text_18\" id=\"ff_5_input_text_18\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_20' id='label_ff_5_input_text_20' aria-label=\"Email Address\">Email Address<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_20\" class=\"ff-el-form-control\" data-name=\"input_text_20\" id=\"ff_5_input_text_20\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_19' id='label_ff_5_input_text_19' aria-label=\"Fax Number\">Fax Number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_19\" class=\"ff-el-form-control\" data-name=\"input_text_19\" id=\"ff_5_input_text_19\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-5_5\" ><h3><span style=\"color: #299cc5\">CEO\/President Contact Information<\/span><\/h3><\/div><div data-name=\"ff_cn_id_10\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_21' id='label_ff_5_input_text_21' aria-label=\"Name\">Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_21\" class=\"ff-el-form-control\" data-name=\"input_text_21\" id=\"ff_5_input_text_21\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_23' id='label_ff_5_input_text_23' aria-label=\"Contact\u2019s Phone\">Contact\u2019s Phone<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_23\" class=\"ff-el-form-control\" data-name=\"input_text_23\" id=\"ff_5_input_text_23\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_22' id='label_ff_5_input_text_22' aria-label=\"Title\">Title<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_22\" class=\"ff-el-form-control\" data-name=\"input_text_22\" id=\"ff_5_input_text_22\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_24' id='label_ff_5_input_text_24' aria-label=\"Contact\u2019s email\">Contact\u2019s email<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_24\" class=\"ff-el-form-control\" data-name=\"input_text_24\" id=\"ff_5_input_text_24\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-5_6\" ><h3><span style=\"color: #299cc5\">Contact information for state government affairs<\/span><\/h3><\/div><div data-name=\"ff_cn_id_11\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_25' id='label_ff_5_input_text_25' aria-label=\"Name\">Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_25\" class=\"ff-el-form-control\" data-name=\"input_text_25\" id=\"ff_5_input_text_25\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_26' id='label_ff_5_input_text_26' aria-label=\"Contact\u2019s Phone\">Contact\u2019s Phone<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_26\" class=\"ff-el-form-control\" data-name=\"input_text_26\" id=\"ff_5_input_text_26\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_27' id='label_ff_5_input_text_27' aria-label=\"Title\">Title<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_27\" class=\"ff-el-form-control\" data-name=\"input_text_27\" id=\"ff_5_input_text_27\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_28' id='label_ff_5_input_text_28' aria-label=\"Contact\u2019s email\">Contact\u2019s email<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_28\" class=\"ff-el-form-control\" data-name=\"input_text_28\" id=\"ff_5_input_text_28\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-5_7\" ><h3><span style=\"color: #299cc5\">Billing Contact Information<\/span><\/h3><\/div><div data-name=\"ff_cn_id_12\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_29' id='label_ff_5_input_text_29' aria-label=\"Name\">Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_29\" class=\"ff-el-form-control\" data-name=\"input_text_29\" id=\"ff_5_input_text_29\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_30' id='label_ff_5_input_text_30' aria-label=\"Contact\u2019s Phone\">Contact\u2019s Phone<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_30\" class=\"ff-el-form-control\" data-name=\"input_text_30\" id=\"ff_5_input_text_30\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_31' id='label_ff_5_input_text_31' aria-label=\"Title\">Title<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_31\" class=\"ff-el-form-control\" data-name=\"input_text_31\" id=\"ff_5_input_text_31\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_32' id='label_ff_5_input_text_32' aria-label=\"Contact\u2019s email\">Contact\u2019s email<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_32\" class=\"ff-el-form-control\" data-name=\"input_text_32\" id=\"ff_5_input_text_32\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-5_8\" ><h3><span style=\"color: #299cc5\">Lawyer Contact Information<\/span><\/h3><\/div><div data-name=\"ff_cn_id_13\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_33' id='label_ff_5_input_text_33' aria-label=\"Name\">Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_33\" class=\"ff-el-form-control\" data-name=\"input_text_33\" id=\"ff_5_input_text_33\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_34' id='label_ff_5_input_text_34' aria-label=\"Contact\u2019s Phone\">Contact\u2019s Phone<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_34\" class=\"ff-el-form-control\" data-name=\"input_text_34\" id=\"ff_5_input_text_34\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_35' id='label_ff_5_input_text_35' aria-label=\"Title\">Title<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_35\" class=\"ff-el-form-control\" data-name=\"input_text_35\" id=\"ff_5_input_text_35\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_36' id='label_ff_5_input_text_36' aria-label=\"Contact\u2019s email\">Contact\u2019s email<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_36\" class=\"ff-el-form-control\" data-name=\"input_text_36\" id=\"ff_5_input_text_36\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-5_9\" ><h3><span style=\"color: #299cc5\">Public Policy Contact<\/span><\/h3><\/div><div data-name=\"ff_cn_id_14\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_37' id='label_ff_5_input_text_37' aria-label=\"Name\">Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_37\" class=\"ff-el-form-control\" data-name=\"input_text_37\" id=\"ff_5_input_text_37\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_38' id='label_ff_5_input_text_38' aria-label=\"Contact\u2019s Phone\">Contact\u2019s Phone<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_38\" class=\"ff-el-form-control\" data-name=\"input_text_38\" id=\"ff_5_input_text_38\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_39' id='label_ff_5_input_text_39' aria-label=\"Title\">Title<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_39\" class=\"ff-el-form-control\" data-name=\"input_text_39\" id=\"ff_5_input_text_39\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_40' id='label_ff_5_input_text_40' aria-label=\"Contact\u2019s email\">Contact\u2019s email<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_40\" class=\"ff-el-form-control\" data-name=\"input_text_40\" id=\"ff_5_input_text_40\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-5_10\" ><h3><span style=\"color: #299cc5\">Public Relations Contact<\/span><\/h3><\/div><div data-name=\"ff_cn_id_15\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_41' id='label_ff_5_input_text_41' aria-label=\"Name\">Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_41\" class=\"ff-el-form-control\" data-name=\"input_text_41\" id=\"ff_5_input_text_41\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_42' id='label_ff_5_input_text_42' aria-label=\"Contact\u2019s Phone\">Contact\u2019s Phone<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_42\" class=\"ff-el-form-control\" data-name=\"input_text_42\" id=\"ff_5_input_text_42\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_43' id='label_ff_5_input_text_43' aria-label=\"Title\">Title<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_43\" class=\"ff-el-form-control\" data-name=\"input_text_43\" id=\"ff_5_input_text_43\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_44' id='label_ff_5_input_text_44' aria-label=\"Contact\u2019s email\">Contact\u2019s email<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_44\" class=\"ff-el-form-control\" data-name=\"input_text_44\" id=\"ff_5_input_text_44\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"# of Employees:\"># of Employees:<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_ee069c1203ad6d068fb400523f9cd545'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"1 \u2013 50\"  id='input_radio_1_ee069c1203ad6d068fb400523f9cd545' aria-label='1 \u2013 50' aria-invalid='false' aria-required=false> <span>1 \u2013 50<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_dd2c6fb21dc51e394a88c21808574120'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"51 \u2013 100\"  id='input_radio_1_dd2c6fb21dc51e394a88c21808574120' aria-label='51 \u2013 100' aria-invalid='false' aria-required=false> <span>51 \u2013 100<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_57ca3e55d0a50d9478ced17c0b356eca'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"101 \u2013 250\"  id='input_radio_1_57ca3e55d0a50d9478ced17c0b356eca' aria-label='101 \u2013 250' aria-invalid='false' aria-required=false> <span>101 \u2013 250<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_6e943b1d1e45315bc253e409dbacdb86'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"251 \u2013 500\"  id='input_radio_1_6e943b1d1e45315bc253e409dbacdb86' aria-label='251 \u2013 500' aria-invalid='false' aria-required=false> <span>251 \u2013 500<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_dfd160bc163d114097b96a369d1bfcc0'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"501 \u2013 1,000\"  id='input_radio_1_dfd160bc163d114097b96a369d1bfcc0' aria-label='501 \u2013 1,000' aria-invalid='false' aria-required=false> <span>501 \u2013 1,000<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_400aee9e6bc774c195506bc35e35403c'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"1,001 or more\"  id='input_radio_1_400aee9e6bc774c195506bc35e35403c' aria-label='1,001 or more' aria-invalid='false' aria-required=false> <span>1,001 or more<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff_list_2col'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Services provided\">Services provided<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_4f7c5637a7e47f6332fba1d9c02f86fc'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Broadband Internet\"  id='checkbox_4f7c5637a7e47f6332fba1d9c02f86fc' aria-label='Broadband Internet' aria-invalid='false' aria-required=true> <span>Broadband Internet<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_3066cbfc5b50925e1c5c377bbe184097'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Dedicated Internet\"  id='checkbox_3066cbfc5b50925e1c5c377bbe184097' aria-label='Dedicated Internet' aria-invalid='false' aria-required=true> <span>Dedicated Internet<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_83a8cb1bea1934bdd7047d39d781be43'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Voice Over IP (VOIP)\"  id='checkbox_83a8cb1bea1934bdd7047d39d781be43' aria-label='Voice Over IP (VOIP)' aria-invalid='false' aria-required=true> <span>Voice Over IP (VOIP)<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_0c6726a32e8e5722c0e6d541b43a6ef2'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"IPTV\"  id='checkbox_0c6726a32e8e5722c0e6d541b43a6ef2' aria-label='IPTV' aria-invalid='false' aria-required=true> <span>IPTV<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_a3256fcd7c1dc108e6e32b09e9918e7f'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Cable TV\"  id='checkbox_a3256fcd7c1dc108e6e32b09e9918e7f' aria-label='Cable TV' aria-invalid='false' aria-required=true> <span>Cable TV<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2bc4b6cd61dd71ae916edfaab9b87beb'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Satellite TV\"  id='checkbox_2bc4b6cd61dd71ae916edfaab9b87beb' aria-label='Satellite TV' aria-invalid='false' aria-required=true> <span>Satellite TV<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_f723964c8d853ade0adc738bf8f38518'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Satellite Internet\"  id='checkbox_f723964c8d853ade0adc738bf8f38518' aria-label='Satellite Internet' aria-invalid='false' aria-required=true> <span>Satellite Internet<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_da3cbd97be0881902967a36bac4dc1ff'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Mobile Internet\"  id='checkbox_da3cbd97be0881902967a36bac4dc1ff' aria-label='Mobile Internet' aria-invalid='false' aria-required=true> <span>Mobile Internet<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_8af4e24fcc7ad60b212967bf71c1f6bf'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Telephone Services\"  id='checkbox_8af4e24fcc7ad60b212967bf71c1f6bf' aria-label='Telephone Services' aria-invalid='false' aria-required=true> <span>Telephone Services<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_e2a4d28218f137d037acca0011a6ef48'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Mobile Telephone Services\"  id='checkbox_e2a4d28218f137d037acca0011a6ef48' aria-label='Mobile Telephone Services' aria-invalid='false' aria-required=true> <span>Mobile Telephone Services<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_0df5abf5114a04bc36e8a3096799727d'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Data Transfer (Metro Ethernet, MPLS)\"  id='checkbox_0df5abf5114a04bc36e8a3096799727d' aria-label='Data Transfer (Metro Ethernet, MPLS)' aria-invalid='false' aria-required=true> <span>Data Transfer (Metro Ethernet, MPLS)<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_74abe80332a0058b5947f796cf3e19ff'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Data Center\"  id='checkbox_74abe80332a0058b5947f796cf3e19ff' aria-label='Data Center' aria-invalid='false' aria-required=true> <span>Data Center<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_f1855b682c955e38e1e17f2c69bf949b'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Internet Exchange\"  id='checkbox_f1855b682c955e38e1e17f2c69bf949b' aria-label='Internet Exchange' aria-invalid='false' aria-required=true> <span>Internet Exchange<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_description' id='label_ff_5_description' aria-label=\"Brief description of what the company does\">Brief description of what the company does<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"true\" aria-labelledby=\"label_ff_5_description\" name=\"description\" id=\"ff_5_description\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"description\" ><\/textarea><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Sale or service\">Sale or service<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_9d6136dfe7509c5294f85450b4adb977'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Retail\"  id='input_radio_2_9d6136dfe7509c5294f85450b4adb977' aria-label='Retail' aria-invalid='false' aria-required=true> <span>Retail<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_a84320ee1b4127c8b68ef3fb02ccd9a0'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Commercial\"  id='input_radio_2_a84320ee1b4127c8b68ef3fb02ccd9a0' aria-label='Commercial' aria-invalid='false' aria-required=true> <span>Commercial<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_451386506634d7ddfc4c7dc1102b42ec'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Both\"  id='input_radio_2_451386506634d7ddfc4c7dc1102b42ec' aria-label='Both' aria-invalid='false' aria-required=true> <span>Both<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Coverage Area\">Coverage Area<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_3_aa072d70aa64b576c1c09f31fb39a7e3'><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"All the island\"  id='input_radio_3_aa072d70aa64b576c1c09f31fb39a7e3' aria-label='All the island' aria-invalid='false' aria-required=true> <span>All the island<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_3_2d663c9608f6b3f49e767cce24c0be4d'><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Select towns \/ municipalities\"  id='input_radio_3_2d663c9608f6b3f49e767cce24c0be4d' aria-label='Select towns \/ municipalities' aria-invalid='false' aria-required=true> <span>Select towns \/ municipalities<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions  ff_list_4col'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Seleccione Pueblo \/ Municipio\">Seleccione Pueblo \/ Municipio<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_d2a2c541bcd360b5825bb669efc4c586'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Adjuntas\"  id='checkbox_2_d2a2c541bcd360b5825bb669efc4c586' aria-label='Adjuntas' aria-invalid='false' aria-required=true> <span>Adjuntas<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_c78c798b9c8ce704d5357e065126b56c'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Aguada\"  id='checkbox_2_c78c798b9c8ce704d5357e065126b56c' aria-label='Aguada' aria-invalid='false' aria-required=true> <span>Aguada<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_104f6a587da6085c51b446cbfa969011'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Aguadilla\"  id='checkbox_2_104f6a587da6085c51b446cbfa969011' aria-label='Aguadilla' aria-invalid='false' aria-required=true> <span>Aguadilla<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_e9950eb6aec6e3a9c5cc5af1ece46aa2'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Aguas Buenas\"  id='checkbox_2_e9950eb6aec6e3a9c5cc5af1ece46aa2' aria-label='Aguas Buenas' aria-invalid='false' aria-required=true> <span>Aguas Buenas<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_192c1003fd28e59b3c4208a8632e6d72'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Aibonito\"  id='checkbox_2_192c1003fd28e59b3c4208a8632e6d72' aria-label='Aibonito' aria-invalid='false' aria-required=true> <span>Aibonito<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_c5372b1c074fd25300570df4b8871a6f'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Arecibo\"  id='checkbox_2_c5372b1c074fd25300570df4b8871a6f' aria-label='Arecibo' aria-invalid='false' aria-required=true> <span>Arecibo<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_1a2e071179d17f1aa0028293c30962db'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Arroyo\"  id='checkbox_2_1a2e071179d17f1aa0028293c30962db' aria-label='Arroyo' aria-invalid='false' aria-required=true> <span>Arroyo<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_d7f82432b912358527723e9095a2a4fc'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"A\u00f1asco\"  id='checkbox_2_d7f82432b912358527723e9095a2a4fc' aria-label='A\u00f1asco' aria-invalid='false' aria-required=true> <span>A\u00f1asco<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_828536247716edcecefbe74a4411813b'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Barceloneta\"  id='checkbox_2_828536247716edcecefbe74a4411813b' aria-label='Barceloneta' aria-invalid='false' aria-required=true> <span>Barceloneta<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_edc8ef541096d9b326740401548be170'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Barranquitas\"  id='checkbox_2_edc8ef541096d9b326740401548be170' aria-label='Barranquitas' aria-invalid='false' aria-required=true> <span>Barranquitas<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_77ab88621c4fdf07837082471d783896'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Bayam\u00f3n\"  id='checkbox_2_77ab88621c4fdf07837082471d783896' aria-label='Bayam\u00f3n' aria-invalid='false' aria-required=true> <span>Bayam\u00f3n<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_1595c4e265d6c41d4ffe1496b744f03b'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Cabo Rojo\"  id='checkbox_2_1595c4e265d6c41d4ffe1496b744f03b' aria-label='Cabo Rojo' aria-invalid='false' aria-required=true> <span>Cabo Rojo<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_d2c00e46f590cc17ea874b95f1e2fd2a'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Caguas\"  id='checkbox_2_d2c00e46f590cc17ea874b95f1e2fd2a' aria-label='Caguas' aria-invalid='false' aria-required=true> <span>Caguas<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_f76abc85eaf8e1981e111e11cfaac7a3'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Camuy\"  id='checkbox_2_f76abc85eaf8e1981e111e11cfaac7a3' aria-label='Camuy' aria-invalid='false' aria-required=true> <span>Camuy<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_8577f71466386ce348f822c15c3136af'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Can\u00f3vanas\"  id='checkbox_2_8577f71466386ce348f822c15c3136af' aria-label='Can\u00f3vanas' aria-invalid='false' aria-required=true> <span>Can\u00f3vanas<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_5456b34ef17a7cf71138fe331cb0720f'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Carolina\"  id='checkbox_2_5456b34ef17a7cf71138fe331cb0720f' aria-label='Carolina' aria-invalid='false' aria-required=true> <span>Carolina<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_9507052b2669a629f5ee44818e660f72'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Cata\u00f1o\"  id='checkbox_2_9507052b2669a629f5ee44818e660f72' aria-label='Cata\u00f1o' aria-invalid='false' aria-required=true> <span>Cata\u00f1o<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_06e91d539ce45fbdda359debe4fee96c'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Cayey\"  id='checkbox_2_06e91d539ce45fbdda359debe4fee96c' aria-label='Cayey' aria-invalid='false' aria-required=true> <span>Cayey<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_9b16be9b4ff844623033156fc1318110'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ceiba\"  id='checkbox_2_9b16be9b4ff844623033156fc1318110' aria-label='Ceiba' aria-invalid='false' aria-required=true> <span>Ceiba<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_795178e1363c083dadabac9559c044ba'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ciales\"  id='checkbox_2_795178e1363c083dadabac9559c044ba' aria-label='Ciales' aria-invalid='false' aria-required=true> <span>Ciales<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_8f9d1789e99d19a00623f988a26d605b'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Cidra\"  id='checkbox_2_8f9d1789e99d19a00623f988a26d605b' aria-label='Cidra' aria-invalid='false' aria-required=true> <span>Cidra<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_01e934278dd6b8cbcd24b12f670e84a7'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Coamo\"  id='checkbox_2_01e934278dd6b8cbcd24b12f670e84a7' aria-label='Coamo' aria-invalid='false' aria-required=true> <span>Coamo<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_8744acd3c72c8d6a14da95d9582b3413'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Comer\u00edo\"  id='checkbox_2_8744acd3c72c8d6a14da95d9582b3413' aria-label='Comer\u00edo' aria-invalid='false' aria-required=true> <span>Comer\u00edo<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_15ddf1fcbce644322f36915d0699c4f6'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Corozal\"  id='checkbox_2_15ddf1fcbce644322f36915d0699c4f6' aria-label='Corozal' aria-invalid='false' aria-required=true> <span>Corozal<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_2d75e9687877348f97051c6b145afb40'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Culebra\"  id='checkbox_2_2d75e9687877348f97051c6b145afb40' aria-label='Culebra' aria-invalid='false' aria-required=true> <span>Culebra<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_66fcdd955b29d13694f8e1b87b2078f9'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Dorado\"  id='checkbox_2_66fcdd955b29d13694f8e1b87b2078f9' aria-label='Dorado' aria-invalid='false' aria-required=true> <span>Dorado<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_f319aa63af7214d3b5f3b7a6428bc767'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Fajardo\"  id='checkbox_2_f319aa63af7214d3b5f3b7a6428bc767' aria-label='Fajardo' aria-invalid='false' aria-required=true> <span>Fajardo<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_8404715ad0e034ab78742086571a9a0a'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Florida\"  id='checkbox_2_8404715ad0e034ab78742086571a9a0a' aria-label='Florida' aria-invalid='false' aria-required=true> <span>Florida<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_767221060fa5b4e562758194792cb946'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Guayama\"  id='checkbox_2_767221060fa5b4e562758194792cb946' aria-label='Guayama' aria-invalid='false' aria-required=true> <span>Guayama<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_d84d0c4c6e0f7e90e35abbaf3dacb290'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Guayanilla\"  id='checkbox_2_d84d0c4c6e0f7e90e35abbaf3dacb290' aria-label='Guayanilla' aria-invalid='false' aria-required=true> <span>Guayanilla<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_c61ca1b083c31bf99e1ecc7c99f77b9b'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Guaynabo\"  id='checkbox_2_c61ca1b083c31bf99e1ecc7c99f77b9b' aria-label='Guaynabo' aria-invalid='false' aria-required=true> <span>Guaynabo<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_7153c6f0066d02b6e9a504afa673882a'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Gurabo\"  id='checkbox_2_7153c6f0066d02b6e9a504afa673882a' aria-label='Gurabo' aria-invalid='false' aria-required=true> <span>Gurabo<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_4442949b94dbf60d9a9488a534538d29'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Gu\u00e1nica\"  id='checkbox_2_4442949b94dbf60d9a9488a534538d29' aria-label='Gu\u00e1nica' aria-invalid='false' aria-required=true> <span>Gu\u00e1nica<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_76974e4632aca84fa8377f2fa3d23b65'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Hatillo\"  id='checkbox_2_76974e4632aca84fa8377f2fa3d23b65' aria-label='Hatillo' aria-invalid='false' aria-required=true> <span>Hatillo<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_ce838e5d2bfcbbfab8cd9bdc3ca3eb8e'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Hormigueros\"  id='checkbox_2_ce838e5d2bfcbbfab8cd9bdc3ca3eb8e' aria-label='Hormigueros' aria-invalid='false' aria-required=true> <span>Hormigueros<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_02b4a19fa91eb5ac257a5c4889884b86'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Humacao\"  id='checkbox_2_02b4a19fa91eb5ac257a5c4889884b86' aria-label='Humacao' aria-invalid='false' aria-required=true> <span>Humacao<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_941282283bbd13591c843d7c38a59fc3'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Isabela\"  id='checkbox_2_941282283bbd13591c843d7c38a59fc3' aria-label='Isabela' aria-invalid='false' aria-required=true> <span>Isabela<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_4aeceae1f8fcb571604be53a4cce81fe'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Jayuya\"  id='checkbox_2_4aeceae1f8fcb571604be53a4cce81fe' aria-label='Jayuya' aria-invalid='false' aria-required=true> <span>Jayuya<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_018b48dceac8a9725e34005e0c1a376b'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Juana D\u00edaz\"  id='checkbox_2_018b48dceac8a9725e34005e0c1a376b' aria-label='Juana D\u00edaz' aria-invalid='false' aria-required=true> <span>Juana D\u00edaz<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_0abec3052711b7655f85b7c9ef1a6a61'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Juncos\"  id='checkbox_2_0abec3052711b7655f85b7c9ef1a6a61' aria-label='Juncos' aria-invalid='false' aria-required=true> <span>Juncos<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_4dd7d079271bd3d989e6f21682212383'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Lajas\"  id='checkbox_2_4dd7d079271bd3d989e6f21682212383' aria-label='Lajas' aria-invalid='false' aria-required=true> <span>Lajas<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_6167d352241b7ee06c5064b809d3c36d'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Lares\"  id='checkbox_2_6167d352241b7ee06c5064b809d3c36d' aria-label='Lares' aria-invalid='false' aria-required=true> <span>Lares<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_343cea70f0bfe2951037aeeb0d2752a3'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Las Mar\u00edas\"  id='checkbox_2_343cea70f0bfe2951037aeeb0d2752a3' aria-label='Las Mar\u00edas' aria-invalid='false' aria-required=true> <span>Las Mar\u00edas<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_d5272797313e8b3d3999da781c4a1d4d'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Las Piedras\"  id='checkbox_2_d5272797313e8b3d3999da781c4a1d4d' aria-label='Las Piedras' aria-invalid='false' aria-required=true> <span>Las Piedras<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_1344795706baec47622a5fc51ae1ae3b'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Loiza\"  id='checkbox_2_1344795706baec47622a5fc51ae1ae3b' aria-label='Loiza' aria-invalid='false' aria-required=true> <span>Loiza<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_845d9f88668bc9b8c5614b8dbd5cfeed'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Luquillo\"  id='checkbox_2_845d9f88668bc9b8c5614b8dbd5cfeed' aria-label='Luquillo' aria-invalid='false' aria-required=true> <span>Luquillo<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_58908fd073906eb699a8403fa45a7e7b'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Manat\u00ed\"  id='checkbox_2_58908fd073906eb699a8403fa45a7e7b' aria-label='Manat\u00ed' aria-invalid='false' aria-required=true> <span>Manat\u00ed<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_8da0ba70845d8508ea514a502aad18a8'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Maricao\"  id='checkbox_2_8da0ba70845d8508ea514a502aad18a8' aria-label='Maricao' aria-invalid='false' aria-required=true> <span>Maricao<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_d8a9ed92a652d004f4d95c5f9092a7f4'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Maunabo\"  id='checkbox_2_d8a9ed92a652d004f4d95c5f9092a7f4' aria-label='Maunabo' aria-invalid='false' aria-required=true> <span>Maunabo<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_0ba53cbdadcdaba2e6937b0fce97fca3'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Mayag\u00fcez\"  id='checkbox_2_0ba53cbdadcdaba2e6937b0fce97fca3' aria-label='Mayag\u00fcez' aria-invalid='false' aria-required=true> <span>Mayag\u00fcez<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_0595bf798a8a508ead627fa460b6fe6e'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Moca\"  id='checkbox_2_0595bf798a8a508ead627fa460b6fe6e' aria-label='Moca' aria-invalid='false' aria-required=true> <span>Moca<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_8f47d88754b1fbdcb6760b229d287eac'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Morovis\"  id='checkbox_2_8f47d88754b1fbdcb6760b229d287eac' aria-label='Morovis' aria-invalid='false' aria-required=true> <span>Morovis<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_58d57d018241ee3f47d72777cdc8d154'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Naguabo\"  id='checkbox_2_58d57d018241ee3f47d72777cdc8d154' aria-label='Naguabo' aria-invalid='false' aria-required=true> <span>Naguabo<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_ae22d604a10853f85f10153512c5b244'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Naranjito\"  id='checkbox_2_ae22d604a10853f85f10153512c5b244' aria-label='Naranjito' aria-invalid='false' aria-required=true> <span>Naranjito<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_23dfb014144806a9a0b06c1980f75861'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Orocovis\"  id='checkbox_2_23dfb014144806a9a0b06c1980f75861' aria-label='Orocovis' aria-invalid='false' aria-required=true> <span>Orocovis<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_8c0a868403815b0c583a630b3d6d810d'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Patillas\"  id='checkbox_2_8c0a868403815b0c583a630b3d6d810d' aria-label='Patillas' aria-invalid='false' aria-required=true> <span>Patillas<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_060862017b223b6e238f0c6076d13850'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Pe\u00f1uelas\"  id='checkbox_2_060862017b223b6e238f0c6076d13850' aria-label='Pe\u00f1uelas' aria-invalid='false' aria-required=true> <span>Pe\u00f1uelas<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_4372969edec1845c5e596c34d79064fe'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ponce\"  id='checkbox_2_4372969edec1845c5e596c34d79064fe' aria-label='Ponce' aria-invalid='false' aria-required=true> <span>Ponce<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_49466885e707f44f6d801e714b085fd8'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Quebradillas\"  id='checkbox_2_49466885e707f44f6d801e714b085fd8' aria-label='Quebradillas' aria-invalid='false' aria-required=true> <span>Quebradillas<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_7019e6791c7dff42e98a65640a5cf662'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Rinc\u00f3n\"  id='checkbox_2_7019e6791c7dff42e98a65640a5cf662' aria-label='Rinc\u00f3n' aria-invalid='false' aria-required=true> <span>Rinc\u00f3n<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_341b612592e12cd6c9b3032ca8342022'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Rio Grande\"  id='checkbox_2_341b612592e12cd6c9b3032ca8342022' aria-label='Rio Grande' aria-invalid='false' aria-required=true> <span>Rio Grande<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_6a2df23c983e08b4d21a68a2e9c0eb71'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Sabana Grande\"  id='checkbox_2_6a2df23c983e08b4d21a68a2e9c0eb71' aria-label='Sabana Grande' aria-invalid='false' aria-required=true> <span>Sabana Grande<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_507e241cbc5e96c4ab9c4232b69de8fa'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Salinas\"  id='checkbox_2_507e241cbc5e96c4ab9c4232b69de8fa' aria-label='Salinas' aria-invalid='false' aria-required=true> <span>Salinas<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_baee4a0560e8d8c0b0314490b11720a2'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"San Germ\u00e1n\"  id='checkbox_2_baee4a0560e8d8c0b0314490b11720a2' aria-label='San Germ\u00e1n' aria-invalid='false' aria-required=true> <span>San Germ\u00e1n<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_f3c193c0406043aab127ed4d6255cc3f'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"San Juan\"  id='checkbox_2_f3c193c0406043aab127ed4d6255cc3f' aria-label='San Juan' aria-invalid='false' aria-required=true> <span>San Juan<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_ca7d9bb093055f419dacef178b8fda1f'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"San Lorenzo\"  id='checkbox_2_ca7d9bb093055f419dacef178b8fda1f' aria-label='San Lorenzo' aria-invalid='false' aria-required=true> <span>San Lorenzo<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_f19116beda7ab41f68e74259e9f1748c'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"San Sebasti\u00e1n\"  id='checkbox_2_f19116beda7ab41f68e74259e9f1748c' aria-label='San Sebasti\u00e1n' aria-invalid='false' aria-required=true> <span>San Sebasti\u00e1n<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_4d6cc6919d92ceda9f952fb31390809e'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Santa Isabel\"  id='checkbox_2_4d6cc6919d92ceda9f952fb31390809e' aria-label='Santa Isabel' aria-invalid='false' aria-required=true> <span>Santa Isabel<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_65e086b946c167c779e95b895ad771e9'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Toa Alta\"  id='checkbox_2_65e086b946c167c779e95b895ad771e9' aria-label='Toa Alta' aria-invalid='false' aria-required=true> <span>Toa Alta<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_cb080df0077a5dbad38c5bde607acdce'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Toa Baja\"  id='checkbox_2_cb080df0077a5dbad38c5bde607acdce' aria-label='Toa Baja' aria-invalid='false' aria-required=true> <span>Toa Baja<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_4b2b57b8fa732d54e0beabf6afdc62f5'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Trujillo Alto\"  id='checkbox_2_4b2b57b8fa732d54e0beabf6afdc62f5' aria-label='Trujillo Alto' aria-invalid='false' aria-required=true> <span>Trujillo Alto<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_f66a8bacd0fb65ba0a4ecfb035ade0d2'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Utuado\"  id='checkbox_2_f66a8bacd0fb65ba0a4ecfb035ade0d2' aria-label='Utuado' aria-invalid='false' aria-required=true> <span>Utuado<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_f32c8eb93756cfe2ea7c4669c510eb58'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Vega Alta\"  id='checkbox_2_f32c8eb93756cfe2ea7c4669c510eb58' aria-label='Vega Alta' aria-invalid='false' aria-required=true> <span>Vega Alta<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_ad4500ecf2f63d41bd722c1635f0a819'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Vega Baja\"  id='checkbox_2_ad4500ecf2f63d41bd722c1635f0a819' aria-label='Vega Baja' aria-invalid='false' aria-required=true> <span>Vega Baja<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_325bacd41e8aad888d90f0cb11208313'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Vieques\"  id='checkbox_2_325bacd41e8aad888d90f0cb11208313' aria-label='Vieques' aria-invalid='false' aria-required=true> <span>Vieques<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_4cff24c24a0fe5bd8f2641feaf857d7a'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Villalba\"  id='checkbox_2_4cff24c24a0fe5bd8f2641feaf857d7a' aria-label='Villalba' aria-invalid='false' aria-required=true> <span>Villalba<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_f3cce5a44a20eb2fe834ba4783459bbd'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yabucoa\"  id='checkbox_2_f3cce5a44a20eb2fe834ba4783459bbd' aria-label='Yabucoa' aria-invalid='false' aria-required=true> <span>Yabucoa<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_c0e421c12da4f2a71d9c8abeb4aeff17'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yauco\"  id='checkbox_2_c0e421c12da4f2a71d9c8abeb4aeff17' aria-label='Yauco' aria-invalid='false' aria-required=true> <span>Yauco<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Type of Organization\">Type of Organization<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_4116960f3838d12fb4e0c7a8d3c7ae25'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Corporation\"  id='input_radio_4_4116960f3838d12fb4e0c7a8d3c7ae25' aria-label='Corporation' aria-invalid='false' aria-required=true> <span>Corporation<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_67e7ee6f3021f89ce1129b1b32d586c9'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Company\"  id='input_radio_4_67e7ee6f3021f89ce1129b1b32d586c9' aria-label='Company' aria-invalid='false' aria-required=true> <span>Company<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_0c538bde3fea00ab4ff8a30163d22126'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Individual\"  id='input_radio_4_0c538bde3fea00ab4ff8a30163d22126' aria-label='Individual' aria-invalid='false' aria-required=true> <span>Individual<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Annual Income\">Annual Income<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_5_88cbeb91d7c3df0fa57cfc604ce20082'><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\" An annual revenue below $1,000,000.00\"  id='input_radio_5_88cbeb91d7c3df0fa57cfc604ce20082' aria-label='An annual revenue below $1,000,000.00' aria-invalid='false' aria-required=false> <span> An annual revenue below $1,000,000.00<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_5_cda2326d9c148216a886a6ec5eff6236'><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Between $1 million to $5 million in annual revenue\"  id='input_radio_5_cda2326d9c148216a886a6ec5eff6236' aria-label='Between $1 million to $5 million in annual revenue' aria-invalid='false' aria-required=false> <span>Between $1 million to $5 million in annual revenue<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_5_da0696598f6fb12389a46f7589aad441'><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Between $5 million to $10 million in annual revenue\"  id='input_radio_5_da0696598f6fb12389a46f7589aad441' aria-label='Between $5 million to $10 million in annual revenue' aria-invalid='false' aria-required=false> <span>Between $5 million to $10 million in annual revenue<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_5_78a0621a30c5111a1a82f5386a7fcff7'><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"More than $10 million in annual revenue\"  id='input_radio_5_78a0621a30c5111a1a82f5386a7fcff7' aria-label='More than $10 million in annual revenue' aria-invalid='false' aria-required=false> <span>More than $10 million in annual revenue<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_5_128b0fa7a1094e2a5178c13a45d51889'><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"More than $100 million in annual revenue\"  id='input_radio_5_128b0fa7a1094e2a5178c13a45d51889' aria-label='More than $100 million in annual revenue' aria-invalid='false' aria-required=false> <span>More than $100 million in annual revenue<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Committees\">Committees<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_6_634bfe3d7237c76ab11ba0880f539a36'><input  type=\"radio\" name=\"input_radio_6\" data-name=\"input_radio_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Legislative and Governmental Affairs Committee\"  id='input_radio_6_634bfe3d7237c76ab11ba0880f539a36' aria-label='Legislative and Governmental Affairs Committee' aria-invalid='false' aria-required=false> <span>Legislative and Governmental Affairs Committee<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_6_038bdaf8fca5160131aa9b9d6d18a267'><input  type=\"radio\" name=\"input_radio_6\" data-name=\"input_radio_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Communications Committee (the representative must work in Marketing and Public Relations)\"  id='input_radio_6_038bdaf8fca5160131aa9b9d6d18a267' aria-label='Communications Committee (the representative must work in Marketing and Public Relations)' aria-invalid='false' aria-required=false> <span>Communications Committee (the representative must work in Marketing and Public Relations)<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_6_02a0f758ad1265474a2476c2c55e354d'><input  type=\"radio\" name=\"input_radio_6\" data-name=\"input_radio_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Membership Committee\"  id='input_radio_6_02a0f758ad1265474a2476c2c55e354d' aria-label='Membership Committee' aria-invalid='false' aria-required=false> <span>Membership Committee<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-5_11\" ><p><strong>Recommended by:<\/strong><\/p>\n<p>\u201cThis application for membership must be recommended by at least 2 members of the PRTA, who should be either members of the Membership Committee or members of the Board of Directors.<\/p><\/div><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_48' id='label_ff_5_input_text_48' aria-label=\"Recommended by\">Recommended by<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_48\" class=\"ff-el-form-control\" data-name=\"input_text_48\" id=\"ff_5_input_text_48\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div data-name=\"ff_cn_id_16\"  class='ff-t-container ff-column-container ff_columns_total_1 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='I certify that I am authorized to complete this application and that the above information is true and correct.' class='ff-el-form-check-label ff_tc_label' for=terms-n-condition_a0dcffff6ede197a5f63fc7889fa7cd5><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"terms-n-condition\" class=\"ff-el-form-check-input\" data-name=\"terms-n-condition\" id=\"terms-n-condition_a0dcffff6ede197a5f63fc7889fa7cd5\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'><p>I certify that I am authorized to complete this application and that the above information is true and correct.<\/p><\/div><\/label><\/div><\/div><\/div><\/div><div class='ff-el-group ff-text-left ff_submit_btn_wrapper'><button type=\"submit\" class=\"ff-btn ff-btn-submit ff-btn-md ff_btn_style\"  aria-label=\"Submit\"> Submit<\/button><\/div><\/fieldset><\/form><div id='fluentform_5_errors' class='ff-errors-in-stack ff_form_instance_5_1 ff-form-loading_errors ff_form_instance_5_1_errors'><\/div><\/div>            <script type=\"text\/javascript\">\n                window.fluent_form_ff_form_instance_5_1 = {\"id\":\"5\",\"ajaxUrl\":\"https:\\\/\\\/www.alianzatelecom.org\\\/wp-admin\\\/admin-ajax.php\",\"settings\":{\"layout\":{\"labelPlacement\":\"top\",\"helpMessagePlacement\":\"with_label\",\"errorMessagePlacement\":\"inline\",\"asteriskPlacement\":\"asterisk-right\"},\"restrictions\":{\"denyEmptySubmission\":{\"enabled\":false}}},\"form_instance\":\"ff_form_instance_5_1\",\"form_id_selector\":\"fluentform_5\",\"rules\":{\"input_text\":{\"required\":{\"value\":true,\"message\":\" Required field\",\"global\":false,\"global_message\":\"This field is required\"}},\"input_text_1\":{\"required\":{\"value\":true,\"message\":\" Required field\",\"global\":false,\"global_message\":\"This field is required\"}},\"input_text_2\":{\"required\":{\"value\":true,\"message\":\" Required field\",\"global\":false,\"global_message\":\"This field is required\"}},\"input_text_3\":{\"required\":{\"value\":true,\"message\":\" Required field\",\"global\":false,\"global_message\":\"This field is 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