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clear-left"><input type="checkbox" class="form-checkbox" id="input_3_0" name="q3_input3[]" value="$150 - Podium" /><label id="label_input_3_0" for="input_3_0"><span>$150 - Podium</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_7"><div id="cid_7" class="form-input-wide"> <img alt="" class="form-image" border="0" src="https://w2.chabad.org/media/images/1080/wbfz10808719.jpg" height="150" width="150" /> </div></li><li class="form-line" id="id_8"><div class="form-label-top" id="label_8"><label for="input_8"> Parochet - Ark Covering  </label><label class="label-message" for="input_8"> </label></div><div id="cid_8" class="form-input-wide"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_8_0" name="q8_input8[]" value="$1800 - Parochet" /><label id="label_input_8_0" for="input_8_0"><span>$1800 - Parochet</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_9"><div id="cid_9" class="form-input-wide"> <img alt="" class="form-image" border="0" src="https://w2.chabad.org/media/images/1096/kYhB10968159.png" height="150" width="150" /> </div></li><li class="form-line" id="id_10"><div class="form-label-top" id="label_10"><label for="input_10"> Large Clock for Shul </label><label class="label-message" for="input_10"> </label></div><div id="cid_10" class="form-input-wide"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_10_0" name="q10_input10[]" value="$75 - Clock" /><label id="label_input_10_0" for="input_10_0"><span>$75 - Clock</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_11"><div id="cid_11" class="form-input-wide"> <img alt="" class="form-image" border="0" src="https://w2.chabad.org/media/images/1096/zJvm10960250.png" height="150" width="150" /> </div></li><li class="form-line" id="id_12"><div class="form-label-top" id="label_12"><label for="input_12"> New Mechitza for Shul </label><label class="label-message" for="input_12"> </label></div><div id="cid_12" class="form-input-wide"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_12_0" name="q12_input12[]" value="$190 - 1 Mechitza" /><label id="label_input_12_0" for="input_12_0"><span>$190 - 1 Mechitza</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_12_1" name="q12_input12[]" value="$380 - 2 Mechitzas" /><label id="label_input_12_1" for="input_12_1"><span>$380 - 2 Mechitzas</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_12_2" name="q12_input12[]" value="$570 - 3 Mechitzas" /><label id="label_input_12_2" for="input_12_2"><span>$570 - 3 Mechitzas</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_4"><div class="form-label-top" id="label_4"><label for="input_4"> Total </label></div><div id="cid_4" class="form-input-wide"> <div id="total_amount">$0.00 </div> </div></li><li class="form-line" id="id_16"><div class="form-label-top" id="label_16"><label for="input_16"> Full Name </label><label class="label-message" for="input_16"> </label></div><div id="cid_16" class="form-input-wide"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q16_fullName[first]" id="first_16" autocomplete="given-name" />  <label class="form-sub-label" for="first_16" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q16_fullName[last]" id="last_16" autocomplete="family-name" />  <label class="form-sub-label" for="last_16" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_17"><div class="form-label-top" id="label_17"><label for="input_17"> E-mail </label><label class="label-message" for="input_17"> </label></div><div id="cid_17" class="form-input-wide"> <input type="email" class=" form-textbox validate[Email]" id="input_17" name="q17_email" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_18"><div class="form-label-top" id="label_18"><label for="input_18"> Phone Number </label><label class="label-message" for="input_18"> </label></div><div id="cid_18" class="form-input-wide"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q18_phoneNumber[area]" id="input_18_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_18_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input 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mastercard-icon"></div><div class="cc-icon amex-icon"></div><div class="cc-icon discover-icon"></div></div><input type="hidden" name="q15_payment[cc_type]" id="input_15_cc_type" value="" /></td></tr><tr><td><div class="cc-field-wrapper"><span class="form-sub-label-container"><input class="form-textbox form-creditcard js-cc-number validate[visible, creditcard]" type="text" name="q15_payment[cc_number]" id="input_15_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_15_cc_number" id="sublabel_cc_number">Credit Card Number</label></span></div></td><td class="cc_ccv "><span class="form-sub-label-container"><input class="form-textbox validate[visible]" type="text" name="q15_payment[cc_ccv]" id="input_15_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_15_cc_ccv" id="sublabel_cc_ccv">Security Code</label></span></td></tr><tr><td colspan="2" class="cc_name_on_card "><span class="form-sub-label-container"><input class="form-textbox validate[visible]" type="text" name="q15_payment[cc_nameOnCard]" id="input_15_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_15_cc_nameOnCard" id="sublabel_cc_nameOnCard">Name on Card</label></span></td></tr><tr class="credit_card hide"><td colspan=""><span class="form-sub-label-container"><select class="form-textbox validate[visible]" name="q15_payment[cc_exp_month]" id="input_15_cc_exp_month" autocomplete="cc-exp-month"><option></option><option value="1">1 - January</option><option value="2">2 - February</option><option value="3">3 - March</option><option value="4">4 - April</option><option value="5">5 - May</option><option value="6">6 - June</option><option value="7">7 - July</option><option value="8">8 - August</option><option value="9">9 - September</option><option value="10">10 - October</option><option value="11">11 - November</option><option value="12">12 - December</option></select>  <label 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