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	Shaina's Torah Dedications - Chabad Lubavitch of Arizona
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<form class="userform-form" action="" method="post" name="form_5711123" id="5711123" accept-charset="utf-8"><input type="hidden" name="formID" value="5711123" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li id="cid_1" class="form-input-wide"> <div class="form-header-group"><h2 id="header_1" class="form-header">Shaina's Hakhel - Unity Torah</h2></div> </li><li class="form-line" id="id_4"><div id="cid_4" class="form-input-wide"> <div id="text_4" class="form-html"><p>Be a part of Unity, Healing and History!</p>

<p>The Goal of this unique unity project is to be a blessing for our community and for the precious neshama of Shaina bas yl"t Yaakov Chaim, who brought so much unity in her short life. It is an opportunity for every single person to participate and to own a letter or part in the Holy Torah.  The Campaign will Run throughout the year giving everyone the chance to participate. </p>

<p>This is a very unique opportunity to dedicate a part in honor or in loving memory of someone. </p>

<p>The scribe, pious and skilled in his field, will transcribe the letters of the Torah’s final verse, finishing our Torah, the latest link in the eternal, holy chain, in the presence of our entire community.</p>
</div> </div></li><li class="form-line" id="id_3"><div id="cid_3" class="form-input-wide"> <img alt="" class="form-image" border="0" src="https://w2.chabad.org/media/images/1120/Dmwe11203394.jpg" height="245" width="650" /> </div></li><li class="form-line" id="id_23"><div id="cid_23" class="form-input-wide"> <img alt="" class="form-image" border="0" src="https://w2.chabad.org/media/images/1243/ZkMB12438956.jpeg" height="1050.45" width="745" /> </div></li><li class="form-line" id="id_24"><div class="form-label-left" id="label_24"><label for="input_24"> ADULTS ATTENDING </label><label class="label-message" for="input_24"> </label></div><div id="cid_24" class="form-input"> <input type="number" autocomplete="nope" id="input_24" name="q24_input24" data-type="input-spinner" class="form-spinner-input form-textbox" /> </div></li><li class="form-line" id="id_25"><div class="form-label-left" id="label_25"><label for="input_25"> CHILDREN ATTENDING </label><label class="label-message" for="input_25"> </label></div><div id="cid_25" class="form-input"> <input type="number" autocomplete="nope" id="input_25" name="q25_input25" data-type="input-spinner" class="form-spinner-input form-textbox" /> </div></li><li class="form-line" id="id_26"><div class="form-label-left" id="label_26"><label for="input_26"> We Plan On Participating For: EX The Procession, Entire Event, Letter Completion </label><label class="label-message" for="input_26"> </label></div><div id="cid_26" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_26" name="q26_input26" size="20" value="" /> </div></li><li class="form-line" id="id_27"><div class="form-label-left" id="label_27"><label for="input_27"> I would Like to Fill In One of the Final Letter  </label><label class="label-message" for="input_27"> </label></div><div id="cid_27" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_27_0" name="q27_input27[]" value="$1800 - Fill In One of The Final Letters" /><label id="label_input_27_0" for="input_27_0"><span>$1800 - Fill In One of The Final Letters</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_5"><div class="form-label-left" id="label_5"><label for="input_5"> Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_5"> </label></div><div id="cid_5" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q5_fullName[first]" id="first_5" autocomplete="given-name" />  <label class="form-sub-label" for="first_5" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q5_fullName[last]" id="last_5" autocomplete="family-name" />  <label class="form-sub-label" for="last_5" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_6"><div class="form-label-left" id="label_6"><label for="input_6"> E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_6"> </label></div><div id="cid_6" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_6" name="q6_email" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_7"><div class="form-label-left form-label-hidden" id="label_7"></div><div id="cid_7" class="form-input"> <div class="form-single-column form-checkbox-item"><input name="optin" value="true" type="checkbox" checked="checked" class="form-checkbox" id="input_7" /><label id="label_input_7" for="input_7">I would like to receive news and updates by email</label></div> </div></li><li class="form-line" id="id_8"><div class="form-label-left" id="label_8"><label for="input_8"> Address </label><label class="label-message" for="input_8"> </label></div><div id="cid_8" class="form-input"> <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line" type="text" name="q8_address[addr_line1]" id="input_8_addr_line1" size="46" autocomplete="address-line1" />  <label class="form-sub-label" for="input_8_addr_line1" id="sublabel_8_addr_line1">Street Address</label></span></td></tr><tr><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line no-validation" type="text" name="q8_address[addr_line2]" id="input_8_addr_line2" size="46" autocomplete="address-line2" />  <label class="form-sub-label" for="input_8_addr_line2" id="sublabel_8_addr_line2">Street Address Line 2</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-city" type="text" name="q8_address[city]" id="input_8_city" size="21" autocomplete="address-level2" />  <label class="form-sub-label" for="input_8_city" id="sublabel_8_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q8_address[state]" id="input_8_state" size="22" autocomplete="address-level1" />  <label class="form-sub-label" for="input_8_state" id="sublabel_8_state">State / Province</label></span></td></tr><tr><td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-postal" type="text" name="q8_address[postal]" id="input_8_postal" size="10" autocomplete="postal-code" />  <label class="form-sub-label" for="input_8_postal" id="sublabel_8_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q8_address[country]" id="input_8_country" autocomplete="country-name"><option value="" selected="selected">Please 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value="Benin">Benin</option><option value="Bermuda">Bermuda</option><option value="Bhutan">Bhutan</option><option value="Bolivia">Bolivia</option><option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option><option value="Botswana">Botswana</option><option value="Brazil">Brazil</option><option value="Brunei">Brunei</option><option value="Bulgaria">Bulgaria</option><option value="Burkina Faso">Burkina Faso</option><option value="Burundi">Burundi</option><option value="Cambodia">Cambodia</option><option value="Cameroon">Cameroon</option><option value="Canada">Canada</option><option value="Cape Verde">Cape Verde</option><option value="Cayman Islands">Cayman Islands</option><option value="Central African Republic">Central African Republic</option><option value="Chad">Chad</option><option value="Chile">Chile</option><option value="People's Republic of China">People's Republic of China</option><option value="Republic of China">Republic of China</option><option value="Christmas Island">Christmas Island</option><option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option><option value="Colombia">Colombia</option><option value="Comoros">Comoros</option><option value="Congo">Congo</option><option value="Cook Islands">Cook Islands</option><option value="Costa Rica">Costa Rica</option><option value="Cote d'Ivoire">Cote d'Ivoire</option><option value="Croatia">Croatia</option><option value="Cuba">Cuba</option><option value="Cyprus">Cyprus</option><option value="Czech Republic">Czech Republic</option><option value="Denmark">Denmark</option><option value="Djibouti">Djibouti</option><option value="Dominica">Dominica</option><option value="Dominican Republic">Dominican Republic</option><option value="Ecuador">Ecuador</option><option value="Egypt">Egypt</option><option value="El Salvador">El Salvador</option><option value="Equatorial Guinea">Equatorial Guinea</option><option value="Eritrea">Eritrea</option><option value="Estonia">Estonia</option><option value="Eswatini">Eswatini</option><option value="Ethiopia">Ethiopia</option><option value="Falkland Islands">Falkland Islands</option><option value="Faroe Islands">Faroe Islands</option><option value="Fiji">Fiji</option><option value="Finland">Finland</option><option value="France">France</option><option value="French Polynesia">French Polynesia</option><option value="Gabon">Gabon</option><option value="The Gambia">The Gambia</option><option value="Georgia">Georgia</option><option value="Germany">Germany</option><option value="Ghana">Ghana</option><option value="Gibraltar">Gibraltar</option><option value="Greece">Greece</option><option value="Greenland">Greenland</option><option value="Grenada">Grenada</option><option value="Guadeloupe">Guadeloupe</option><option value="Guam">Guam</option><option value="Guatemala">Guatemala</option><option value="Guernsey">Guernsey</option><option value="Guinea">Guinea</option><option value="Guinea-Bissau">Guinea-Bissau</option><option value="Guyana">Guyana</option><option value="Haiti">Haiti</option><option value="Honduras">Honduras</option><option value="Hong Kong">Hong Kong</option><option value="Hungary">Hungary</option><option value="Iceland">Iceland</option><option value="India">India</option><option value="Indonesia">Indonesia</option><option value="Iran">Iran</option><option value="Iraq">Iraq</option><option value="Ireland">Ireland</option><option value="Israel">Israel</option><option value="Italy">Italy</option><option value="Jamaica">Jamaica</option><option value="Japan">Japan</option><option value="Jersey">Jersey</option><option value="Jordan">Jordan</option><option value="Kazakhstan">Kazakhstan</option><option value="Kenya">Kenya</option><option value="Kiribati">Kiribati</option><option value="North Korea">North Korea</option><option value="South Korea">South Korea</option><option value="Kosovo">Kosovo</option><option value="Kuwait">Kuwait</option><option value="Kyrgyzstan">Kyrgyzstan</option><option value="Laos">Laos</option><option value="Latvia">Latvia</option><option value="Lebanon">Lebanon</option><option value="Lesotho">Lesotho</option><option value="Liberia">Liberia</option><option value="Libya">Libya</option><option value="Liechtenstein">Liechtenstein</option><option value="Lithuania">Lithuania</option><option value="Luxembourg">Luxembourg</option><option value="Macau">Macau</option><option value="Macedonia">Macedonia</option><option value="Madagascar">Madagascar</option><option value="Malawi">Malawi</option><option value="Malaysia">Malaysia</option><option value="Maldives">Maldives</option><option value="Mali">Mali</option><option value="Malta">Malta</option><option value="Marshall Islands">Marshall Islands</option><option value="Martinique">Martinique</option><option value="Mauritania">Mauritania</option><option value="Mauritius">Mauritius</option><option value="Mayotte">Mayotte</option><option value="Mexico">Mexico</option><option value="Micronesia">Micronesia</option><option value="Moldova">Moldova</option><option value="Monaco">Monaco</option><option value="Mongolia">Mongolia</option><option value="Montenegro">Montenegro</option><option value="Montserrat">Montserrat</option><option value="Morocco">Morocco</option><option value="Mozambique">Mozambique</option><option value="Myanmar">Myanmar</option><option value="Namibia">Namibia</option><option value="Nauru">Nauru</option><option value="Nepal">Nepal</option><option value="Netherlands">Netherlands</option><option value="New Caledonia">New Caledonia</option><option value="New Zealand">New Zealand</option><option value="Nicaragua">Nicaragua</option><option value="Niger">Niger</option><option value="Nigeria">Nigeria</option><option value="Niue">Niue</option><option value="Norfolk Island">Norfolk Island</option><option value="Northern Mariana">Northern Mariana</option><option value="Norway">Norway</option><option value="Oman">Oman</option><option value="Pakistan">Pakistan</option><option value="Palau">Palau</option><option value="Panama">Panama</option><option value="Papua New Guinea">Papua New Guinea</option><option value="Paraguay">Paraguay</option><option value="Peru">Peru</option><option value="Philippines">Philippines</option><option value="Pitcairn Islands">Pitcairn Islands</option><option value="Poland">Poland</option><option value="Portugal">Portugal</option><option value="Puerto Rico">Puerto Rico</option><option value="Qatar">Qatar</option><option value="Romania">Romania</option><option value="Russia">Russia</option><option value="Rwanda">Rwanda</option><option value="Saint Barthelemy">Saint Barthelemy</option><option value="Saint Helena">Saint Helena</option><option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option><option value="Saint Lucia">Saint Lucia</option><option value="Saint Martin">Saint Martin</option><option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option><option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option><option value="Samoa">Samoa</option><option value="San Marino">San Marino</option><option value="Sao Tome and Principe">Sao Tome and Principe</option><option value="Saudi Arabia">Saudi Arabia</option><option value="Senegal">Senegal</option><option value="Serbia">Serbia</option><option value="Seychelles">Seychelles</option><option value="Sierra Leone">Sierra Leone</option><option value="Singapore">Singapore</option><option value="Slovakia">Slovakia</option><option value="Slovenia">Slovenia</option><option value="Solomon Islands">Solomon Islands</option><option value="Somalia">Somalia</option><option value="Somaliland">Somaliland</option><option value="South Africa">South Africa</option><option value="South Ossetia">South Ossetia</option><option value="Spain">Spain</option><option value="Sri Lanka">Sri Lanka</option><option value="Sudan">Sudan</option><option value="Suriname">Suriname</option><option value="Svalbard">Svalbard</option><option value="Sweden">Sweden</option><option value="Switzerland">Switzerland</option><option value="Syria">Syria</option><option value="Taiwan">Taiwan</option><option value="Tajikistan">Tajikistan</option><option value="Tanzania">Tanzania</option><option value="Thailand">Thailand</option><option value="Timor-Leste">Timor-Leste</option><option value="Togo">Togo</option><option value="Tokelau">Tokelau</option><option value="Tonga">Tonga</option><option value="Trinidad and Tobago">Trinidad and Tobago</option><option value="Tristan da Cunha">Tristan da Cunha</option><option value="Tunisia">Tunisia</option><option value="Turkey">Turkey</option><option value="Turkmenistan">Turkmenistan</option><option value="Turks and Caicos Islands">Turks and Caicos Islands</option><option value="Tuvalu">Tuvalu</option><option value="Uganda">Uganda</option><option value="Ukraine">Ukraine</option><option value="United Arab Emirates">United Arab Emirates</option><option value="United Kingdom">United Kingdom</option><option value="Uruguay">Uruguay</option><option value="Uzbekistan">Uzbekistan</option><option value="Vanuatu">Vanuatu</option><option value="Vatican City">Vatican City</option><option value="Venezuela">Venezuela</option><option value="Vietnam">Vietnam</option><option value="British Virgin Islands">British Virgin Islands</option><option value="US Virgin Islands">US Virgin Islands</option><option value="Wallis and Futuna">Wallis and Futuna</option><option value="Western Sahara">Western Sahara</option><option value="Yemen">Yemen</option><option value="Zambia">Zambia</option><option value="Zimbabwe">Zimbabwe</option><option value="other">Other</option></select>  <label class="form-sub-label" for="input_8_country" id="sublabel_8_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_10"><div class="form-label-left" id="label_10"><label for="input_10"> Torah Sponsor: $65,000 </label><label class="label-message" for="input_10"> The Shaina Hakhel Unity Torah Sponsored by ___ In honor of ___. Your dedication will be embroidered for eternity on the front cover of the Torah scroll.</label></div><div id="cid_10" class="form-input"> <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="Sponsor with Front Everlasting Dedication" /><label id="label_input_10_0" for="input_10_0"><span>Sponsor with Front Everlasting Dedication</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_11"><div class="form-label-left" id="label_11"><label for="input_11"> Sefer (One of the 5 books of Moses) $13,600 </label><label class="label-message" for="input_11"> Endow one of the five books. Your family name and or tribute will be inscribed on the back cover of the Torah.</label></div><div id="cid_11" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_11" name="q11_input11"><option value=""></option><option value="Book of Bereishit - Genesis">Book of Bereishit - Genesis</option><option value="Book of Shemot - Exodus">Book of Shemot - Exodus</option><option value="Book of Vayikra - Levitucus">Book of Vayikra - Levitucus</option><option value="Book of Bamidbar - Numbers">Book of Bamidbar - Numbers</option><option value="Book of Devarim - Deuteronomy">Book of Devarim - Deuteronomy</option></select> </div></li><li class="form-line" id="id_12"><div class="form-label-left" id="label_12"><label for="input_12"> Torah Beautifications </label><label class="label-message" for="input_12"> Sponsor one of the implements of the Torah created with beautiful, traditional craftsmanship Your family name and or a tribute will be engraved (embroidered) on the item</label></div><div id="cid_12" class="form-input"> <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="RESERVED Kesser (Crown)" /><label id="label_input_12_0" for="input_12_0"><span>RESERVED Kesser (Crown)</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="$8,000 Atzei Chaim (Wooden Torah Rollers)" /><label id="label_input_12_1" for="input_12_1"><span>$8,000 Atzei Chaim (Wooden Torah Rollers)</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="$3,000 Breast Plate" /><label id="label_input_12_2" for="input_12_2"><span>$3,000 Breast Plate</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_12_3" name="q12_input12[]" value="RESERVED Yad (Pointer)" /><label id="label_input_12_3" for="input_12_3"><span>RESERVED Yad (Pointer)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_12_4" name="q12_input12[]" value="RESERVED Belt (Gartel)" /><label id="label_input_12_4" for="input_12_4"><span>RESERVED Belt (Gartel)</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_13"><div class="form-label-left" id="label_13"><label for="input_13"> Special sections $3,600 </label><label class="label-message" for="input_13"> Endow a special blessing in the Torah that has special meaning to you and/or a friend</label></div><div id="cid_13" class="form-input"> <select class="form-dropdown" style="width:150px" id="input_13" name="q13_input13"><option value=""></option><option value="Ten Commandments (2 Available)">Ten Commandments (2 Available)</option><option value="Birchat Cohanim - The Priestly Blessing">Birchat Cohanim - The Priestly Blessing</option><option value="Parshat Haman - The Portion of the Heavenly Manna Bread">Parshat Haman - The Portion of the Heavenly Manna Bread</option><option value="Vayehi Binsoa - The section we recite when opening the Ark">Vayehi Binsoa - The section we recite when opening the Ark</option><option value="Hashem Hashem - The 13 Attributes of Mercy">Hashem Hashem - The 13 Attributes of Mercy</option><option value="Shema">Shema</option><option value="Shirat HaBe'er - Song of the Well of Miriyam">Shirat HaBe'er - Song of the Well of Miriyam</option><option value="Shirat Hayam - Song of the Splitting of the Sea">Shirat Hayam - Song of the Splitting of the Sea</option></select> </div></li><li class="form-line" id="id_14"><div class="form-label-left" id="label_14"><label for="input_14"> Parsha -Torah Portion Dedication - $1800 </label><label class="label-message" for="input_14"> Endow a Torah portion for yourself and/or a friend by choosing a Bar/Bat Mitzvah or wedding anniversary Torah portion.</label></div><div id="cid_14" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_14_0" name="q14_input14[]" value="1 Parsha" /><label id="label_input_14_0" for="input_14_0"><span>1 Parsha</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_14_1" name="q14_input14[]" value="2 Parshas" /><label id="label_input_14_1" for="input_14_1"><span>2 Parshas</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_14_2" name="q14_input14[]" value="3 Parsha" /><label id="label_input_14_2" for="input_14_2"><span>3 Parsha</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_15"><div class="form-label-left" id="label_15"><label for="input_15"> Which Parsha/s </label><label class="label-message" for="input_15"> Already Reserved: Ki Teitzei</label></div><div id="cid_15" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_15" name="q15_input15" size="20" value="" /> </div></li><li class="form-line" id="id_16"><div class="form-label-left" id="label_16"><label for="input_16"> Aliya Dedication - $540 </label><label class="label-message" for="input_16"> Endow an Aliya - Dedicate the writing of a section of the Parsha that you connect to.</label></div><div id="cid_16" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_16_0" name="q16_input16[]" value="1 Aliya" /><label id="label_input_16_0" for="input_16_0"><span>1 Aliya</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_16_1" name="q16_input16[]" value="2 Aliyot" /><label id="label_input_16_1" for="input_16_1"><span>2 Aliyot</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_16_2" name="q16_input16[]" value="3 Aliyot" /><label id="label_input_16_2" for="input_16_2"><span>3 Aliyot</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_17"><div class="form-label-left" id="label_17"><label for="input_17"> Which Aliya/s </label><label class="label-message" for="input_17"> </label></div><div id="cid_17" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_17" name="q17_input17" size="20" value="" /> </div></li><li class="form-line" id="id_18"><div class="form-label-left" id="label_18"><label for="input_18"> Word Dedication - $180 </label><label class="label-message" for="input_18"> Endow a word in the Torah that has special meaning to you and/or a friend</label></div><div id="cid_18" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_18_0" name="q18_input18[]" value="1 Word" /><label id="label_input_18_0" for="input_18_0"><span>1 Word</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_18_1" name="q18_input18[]" value="2 Words" /><label id="label_input_18_1" for="input_18_1"><span>2 Words</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_18_2" name="q18_input18[]" value="3 Words" /><label id="label_input_18_2" for="input_18_2"><span>3 Words</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_19"><div class="form-label-left" id="label_19"><label for="input_19"> Which Word/s </label><label class="label-message" for="input_19"> For example . Kavod- Honor. Chaim - life</label></div><div id="cid_19" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_19" name="q19_input19" size="20" value="" /> </div></li><li class="form-line" id="id_20"><div class="form-label-left" id="label_20"><label for="input_20"> Letter Dedications - $18 Each </label><label class="label-message" for="input_20"> Dedicate a letter for each family member and as a gift to a friend</label></div><div id="cid_20" class="form-input"> <input type="number" class="form-number-input  form-textbox" id="input_20" name="q20_number" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" /> </div></li><li class="form-line" id="id_21"><div class="form-label-left" id="label_21"><label for="input_21"> Total </label></div><div id="cid_21" class="form-input"> <div id="total_amount">$0.00 </div> </div></li><li class="form-line" id="id_22"><div id="cid_22" class="form-input-wide"> <div id="text_22" class="form-html"><p><strong>Please note:</strong>  This project is an additional large expense to our annual budget. Please consider donation to our Our Year End and Annual Gala fundraisers to help cover the annual operating budget.</p><p>If you would like to send a check, please make it out to Chabad of Arizona - 2110 E Lincoln Dr, Phoenix, AZ 85016</p><p>Thank you very much!</p></div> </div></li><li class="form-line" id="id_9"><div class="form-label-left" id="label_9"><label for="input_9"> Payment<span class="form-required">*</span> </label><label class="label-message" for="input_9"> </label></div><div id="cid_9" class="form-input"> <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2" class="form-payment-methods form-multiple-column"><span class="form-radio-item"><input class="paymentMethod form-radio validate[required, paymentMethod] form-radio" type="radio" id="input_9_creditCard" name="q9_payment[payment_method]" value="creditCard" onclick="BuildSource.creditCard(this)" /><label for="input_9_creditCard">Credit Card</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[required, paymentMethod] form-radio" type="radio" id="input_9_other" name="q9_payment[payment_method]" value="other" onclick="BuildSource.other(this)" /><label for="input_9_other">Check</label> </span></td></tr><tr class="credit_card hide"><th colspan="2">Credit Card</th></tr><tr class="credit_card hide"><td colspan="2" style="padding:0"><table cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"><span class="form-sub-label-container">  <label class="form-sub-label">We accept Visa, MasterCard, American Express, Discover</label></span><div class="cc-icons"><div class="cc-icon visa-icon"></div><div class="cc-icon mastercard-icon"></div><div class="cc-icon amex-icon"></div><div class="cc-icon discover-icon"></div></div><input type="hidden" name="q9_payment[cc_type]" id="input_9_cc_type" value="" /></td></tr><tr><td><div class="cc-field-wrapper"><span class="form-sub-label-container"><input class="form-textbox form-creditcard js-cc-number validate[required, visible, creditcard]" type="text" name="q9_payment[cc_number]" id="input_9_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_9_cc_number" id="sublabel_cc_number">Credit Card Number</label></span></div></td><td class="cc_ccv "><span class="form-sub-label-container"><input class="form-textbox validate[required, visible]" type="text" name="q9_payment[cc_ccv]" id="input_9_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_9_cc_ccv" id="sublabel_cc_ccv">Security Code</label></span></td></tr><tr><td colspan="2" class="cc_name_on_card "><span class="form-sub-label-container"><input class="form-textbox validate[required, visible]" type="text" name="q9_payment[cc_nameOnCard]" id="input_9_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_9_cc_nameOnCard" id="sublabel_cc_nameOnCard">Name on Card</label></span></td></tr><tr class="credit_card hide"><td colspan=""><span class="form-sub-label-container"><select class="form-textbox validate[required, visible]" name="q9_payment[cc_exp_month]" id="input_9_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 class="form-sub-label" for="input_9_cc_exp_month" id="sublabel_cc_exp_month">Expiration Month</label></span></td><td><span class="form-sub-label-container"><select class="form-textbox validate[required, visible]" name="q9_payment[cc_exp_year]" id="input_9_cc_exp_year" autocomplete="cc-exp-year"><option></option><option value="2023">2023</option><option value="2024">2024</option><option value="2025">2025</option><option value="2026">2026</option><option value="2027">2027</option><option value="2028">2028</option><option value="2029">2029</option><option value="2030">2030</option><option value="2031">2031</option><option value="2032">2032</option></select>  <label class="form-sub-label" for="input_9_cc_exp_year" id="sublabel_cc_exp_year">Expiration Year</label></span></td></tr></tbody></table></td></tr><tr class="other hide"><td colspan="2"></td></tr><tr class="billing_address hide"><th colspan="2">Billing Address</th></tr><tr class="billing_address hide"><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-line" type="text" name="q9_payment[addr_line1]" id="input_9_addr_line1" autocomplete="billing address-line1" />  <label class="form-sub-label" for="input_9_addr_line1" id="sublabel_9_addr_line1">Street Address</label></span></td></tr><tr class="billing_address hide"><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line no-validation" type="text" name="q9_payment[addr_line2]" id="input_9_addr_line2" size="46" autocomplete="billing address-line2" />  <label class="form-sub-label" for="input_9_addr_line2" id="sublabel_9_addr_line2">Street Address Line 2</label></span></td></tr><tr class="billing_address hide"><td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-city" type="text" name="q9_payment[city]" id="input_9_city" autocomplete="billing address-level2" />  <label class="form-sub-label" for="input_9_city" id="sublabel_9_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q9_payment[state]" id="input_9_state" autocomplete="billing address-level1" />  <label class="form-sub-label" for="input_9_state" id="sublabel_9_state">State / Province</label></span></td></tr><tr class="billing_address hide"><td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-postal" type="text" name="q9_payment[postal]" id="input_9_postal" size="10" autocomplete="billing postal-code" />  <label class="form-sub-label" for="input_9_postal" id="sublabel_9_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q9_payment[country]" id="input_9_country" autocomplete="billing country-name"><option value="" selected="selected">Please Select</option><option value="United States">United States</option><option value="Afghanistan">Afghanistan</option><option value="Albania">Albania</option><option value="Algeria">Algeria</option><option value="American Samoa">American Samoa</option><option value="Andorra">Andorra</option><option value="Angola">Angola</option><option value="Anguilla">Anguilla</option><option value="Antigua and Barbuda">Antigua and Barbuda</option><option value="Argentina">Argentina</option><option value="Armenia">Armenia</option><option value="Aruba">Aruba</option><option value="Australia">Australia</option><option value="Austria">Austria</option><option value="Azerbaijan">Azerbaijan</option><option value="The Bahamas">The Bahamas</option><option value="Bahrain">Bahrain</option><option value="Bangladesh">Bangladesh</option><option value="Barbados">Barbados</option><option value="Belarus">Belarus</option><option value="Belgium">Belgium</option><option value="Belize">Belize</option><option value="Benin">Benin</option><option value="Bermuda">Bermuda</option><option value="Bhutan">Bhutan</option><option value="Bolivia">Bolivia</option><option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option><option value="Botswana">Botswana</option><option value="Brazil">Brazil</option><option value="Brunei">Brunei</option><option value="Bulgaria">Bulgaria</option><option value="Burkina Faso">Burkina Faso</option><option value="Burundi">Burundi</option><option value="Cambodia">Cambodia</option><option value="Cameroon">Cameroon</option><option value="Canada">Canada</option><option value="Cape Verde">Cape Verde</option><option value="Cayman Islands">Cayman Islands</option><option value="Central African Republic">Central African Republic</option><option value="Chad">Chad</option><option value="Chile">Chile</option><option value="People's Republic of China">People's Republic of China</option><option value="Republic of China">Republic of China</option><option value="Christmas Island">Christmas Island</option><option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option><option value="Colombia">Colombia</option><option value="Comoros">Comoros</option><option value="Congo">Congo</option><option value="Cook Islands">Cook Islands</option><option value="Costa Rica">Costa Rica</option><option value="Cote d'Ivoire">Cote d'Ivoire</option><option value="Croatia">Croatia</option><option value="Cuba">Cuba</option><option value="Cyprus">Cyprus</option><option value="Czech Republic">Czech Republic</option><option value="Denmark">Denmark</option><option value="Djibouti">Djibouti</option><option value="Dominica">Dominica</option><option value="Dominican Republic">Dominican Republic</option><option value="Ecuador">Ecuador</option><option value="Egypt">Egypt</option><option value="El Salvador">El Salvador</option><option value="Equatorial Guinea">Equatorial Guinea</option><option value="Eritrea">Eritrea</option><option value="Estonia">Estonia</option><option value="Eswatini">Eswatini</option><option value="Ethiopia">Ethiopia</option><option value="Falkland Islands">Falkland Islands</option><option value="Faroe Islands">Faroe Islands</option><option value="Fiji">Fiji</option><option value="Finland">Finland</option><option value="France">France</option><option value="French Polynesia">French Polynesia</option><option value="Gabon">Gabon</option><option value="The Gambia">The Gambia</option><option value="Georgia">Georgia</option><option value="Germany">Germany</option><option value="Ghana">Ghana</option><option value="Gibraltar">Gibraltar</option><option value="Greece">Greece</option><option value="Greenland">Greenland</option><option value="Grenada">Grenada</option><option value="Guadeloupe">Guadeloupe</option><option value="Guam">Guam</option><option value="Guatemala">Guatemala</option><option value="Guernsey">Guernsey</option><option value="Guinea">Guinea</option><option value="Guinea-Bissau">Guinea-Bissau</option><option value="Guyana">Guyana</option><option value="Haiti">Haiti</option><option value="Honduras">Honduras</option><option value="Hong Kong">Hong Kong</option><option value="Hungary">Hungary</option><option value="Iceland">Iceland</option><option value="India">India</option><option value="Indonesia">Indonesia</option><option value="Iran">Iran</option><option value="Iraq">Iraq</option><option value="Ireland">Ireland</option><option value="Israel">Israel</option><option value="Italy">Italy</option><option value="Jamaica">Jamaica</option><option value="Japan">Japan</option><option value="Jersey">Jersey</option><option value="Jordan">Jordan</option><option value="Kazakhstan">Kazakhstan</option><option value="Kenya">Kenya</option><option value="Kiribati">Kiribati</option><option value="North Korea">North Korea</option><option value="South Korea">South Korea</option><option value="Kosovo">Kosovo</option><option value="Kuwait">Kuwait</option><option value="Kyrgyzstan">Kyrgyzstan</option><option value="Laos">Laos</option><option value="Latvia">Latvia</option><option value="Lebanon">Lebanon</option><option value="Lesotho">Lesotho</option><option value="Liberia">Liberia</option><option value="Libya">Libya</option><option value="Liechtenstein">Liechtenstein</option><option value="Lithuania">Lithuania</option><option value="Luxembourg">Luxembourg</option><option value="Macau">Macau</option><option value="Macedonia">Macedonia</option><option value="Madagascar">Madagascar</option><option value="Malawi">Malawi</option><option value="Malaysia">Malaysia</option><option value="Maldives">Maldives</option><option value="Mali">Mali</option><option value="Malta">Malta</option><option value="Marshall Islands">Marshall Islands</option><option value="Martinique">Martinique</option><option value="Mauritania">Mauritania</option><option value="Mauritius">Mauritius</option><option value="Mayotte">Mayotte</option><option value="Mexico">Mexico</option><option value="Micronesia">Micronesia</option><option value="Moldova">Moldova</option><option value="Monaco">Monaco</option><option value="Mongolia">Mongolia</option><option value="Montenegro">Montenegro</option><option value="Montserrat">Montserrat</option><option value="Morocco">Morocco</option><option value="Mozambique">Mozambique</option><option value="Myanmar">Myanmar</option><option value="Namibia">Namibia</option><option value="Nauru">Nauru</option><option value="Nepal">Nepal</option><option value="Netherlands">Netherlands</option><option value="New Caledonia">New Caledonia</option><option value="New Zealand">New Zealand</option><option value="Nicaragua">Nicaragua</option><option value="Niger">Niger</option><option value="Nigeria">Nigeria</option><option value="Niue">Niue</option><option value="Norfolk Island">Norfolk Island</option><option value="Northern Mariana">Northern Mariana</option><option value="Norway">Norway</option><option value="Oman">Oman</option><option value="Pakistan">Pakistan</option><option value="Palau">Palau</option><option value="Panama">Panama</option><option value="Papua New Guinea">Papua New Guinea</option><option value="Paraguay">Paraguay</option><option value="Peru">Peru</option><option value="Philippines">Philippines</option><option value="Pitcairn Islands">Pitcairn Islands</option><option value="Poland">Poland</option><option value="Portugal">Portugal</option><option value="Puerto Rico">Puerto Rico</option><option value="Qatar">Qatar</option><option value="Romania">Romania</option><option value="Russia">Russia</option><option value="Rwanda">Rwanda</option><option value="Saint Barthelemy">Saint Barthelemy</option><option value="Saint Helena">Saint Helena</option><option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option><option value="Saint Lucia">Saint Lucia</option><option value="Saint Martin">Saint Martin</option><option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option><option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option><option value="Samoa">Samoa</option><option value="San Marino">San Marino</option><option value="Sao Tome and Principe">Sao Tome and Principe</option><option value="Saudi Arabia">Saudi Arabia</option><option value="Senegal">Senegal</option><option value="Serbia">Serbia</option><option value="Seychelles">Seychelles</option><option value="Sierra Leone">Sierra Leone</option><option value="Singapore">Singapore</option><option value="Slovakia">Slovakia</option><option value="Slovenia">Slovenia</option><option value="Solomon Islands">Solomon Islands</option><option value="Somalia">Somalia</option><option value="Somaliland">Somaliland</option><option value="South Africa">South Africa</option><option value="South Ossetia">South Ossetia</option><option value="Spain">Spain</option><option value="Sri Lanka">Sri Lanka</option><option value="Sudan">Sudan</option><option value="Suriname">Suriname</option><option value="Svalbard">Svalbard</option><option value="Sweden">Sweden</option><option value="Switzerland">Switzerland</option><option value="Syria">Syria</option><option value="Taiwan">Taiwan</option><option 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