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			<h1 class="article-header__title js-article-title js-page-title">The JBN Giving Pledge Form</h1>
		
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<form class="userform-form" action="" method="post" name="form_7210055" id="7210055" accept-charset="utf-8"><input type="hidden" name="formID" value="7210055" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li class="form-line" id="id_15"><div id="cid_15" class="form-input-wide"> <div id="text_15" class="form-html"><p>Partner with fellow Long Island businesses in the Giving Pledge.<br />
Join a monumental change for good in the world.</p>
</div> </div></li><li class="form-line" id="id_3"><div class="form-label-left" id="label_3"><label for="input_3"> Full Name </label><label class="label-message" for="input_3"> </label></div><div id="cid_3" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q3_fullName[first]" id="first_3" autocomplete="given-name" />  <label class="form-sub-label" for="first_3" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q3_fullName[last]" id="last_3" autocomplete="family-name" />  <label class="form-sub-label" for="last_3" 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"> Business Name </label><label class="label-message" for="input_6"> </label></div><div id="cid_6" class="form-input"> <input type="email" class=" form-textbox validate[Email]" id="input_6" name="q6_email6" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_14"><div class="form-label-left" id="label_14"><label for="input_14"> Website </label><label class="label-message" for="input_14"> </label></div><div id="cid_14" class="form-input"> <input type="email" class=" form-textbox validate[Email]" id="input_14" name="q14_email14" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_13"><div class="form-label-left" id="label_13"><label for="input_13"> E-mail </label><label class="label-message" for="input_13"> </label></div><div id="cid_13" class="form-input"> <input type="email" class=" form-textbox validate[Email]" id="input_13" name="q13_email13" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_8"><div class="form-label-left" id="label_8"><label for="input_8"> Phone Number </label><label class="label-message" for="input_8"> </label></div><div id="cid_8" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input data-type="mask-number" class="mask-phone-number form-textbox" type="tel" name="q8_phoneNumber[full]" id="input_8_full" autocomplete="tel" />  <label class="form-sub-label" for="input_8_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_7"><div class="form-label-left" id="label_7"><label for="input_7"> Number of team members, employees, and associates who will receive an additional dollar or more per paycheck for charitable giving </label><label class="label-message" for="input_7"> </label></div><div id="cid_7" class="form-input"> <input type="number" class="form-number-input  form-textbox" id="input_7" name="q7_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_10"><div class="form-label-left" id="label_10"><label for="input_10"> How would you like to be listed on the JBN Giving Pledge? </label><label class="label-message" for="input_10"> </label></div><div id="cid_10" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_10_0" name="q10_input10" value="Business Name" /><label id="label_input_10_0" for="input_10_0"><span>Business Name</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_10_1" name="q10_input10" value="Business Name &amp; Personal Name" /><label id="label_input_10_1" for="input_10_1"><span>Business Name &amp; Personal Name</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_10_2" name="q10_input10" value="Personal Name Only" /><label id="label_input_10_2" for="input_10_2"><span>Personal Name Only</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_10_3" name="q10_input10" value="Would like to join anonymously" /><label id="label_input_10_3" for="input_10_3"><span>Would like to join anonymously</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"> JBN Giving Pledge Amount at each pay check </label><label class="label-message" for="input_17"> </label></div><div id="cid_17" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_17_0" name="q17_input17" value="$1" /><label id="label_input_17_0" for="input_17_0"><span>$1</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_17_1" name="q17_input17" value="$5" /><label id="label_input_17_1" for="input_17_1"><span>$5</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_17_2" name="q17_input17" value="Other" /><label id="label_input_17_2" for="input_17_2"><span>Other</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_18"><div class="form-label-left" id="label_18"><label for="input_18"> If other, please specify the amount your business plans to contribute per paycheck for charitable giving. </label><label class="label-message" for="input_18"> </label></div><div id="cid_18" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_18" name="q18_input18" size="20" value="" /> </div></li><li class="form-line" id="id_19"><div class="form-label-left" id="label_19"><label for="input_19"> Please let us know how long you plan to commit to the JBN Giving Pledge. Many participants begin with a 12-month commitment and renew afterward. </label><label class="label-message" for="input_19"> </label></div><div id="cid_19" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="month_19" name="q19_input19[month]" type="tel" size="2" maxlength="2" value="01" />  <label class="form-sub-label" for="month_19" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="day_19" name="q19_input19[day]" type="tel" size="2" maxlength="2" value="14" />  <label class="form-sub-label" for="day_19" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input autocomplete="nope" class="form-textbox" id="year_19" name="q19_input19[year]" type="tel" size="4" maxlength="4" value="2026" />  <label class="form-sub-label" for="year_19" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_19_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_19_pick"><span> </span></label></span></div><span class="dir_ltr inline_block time-fields" style="white-space: nowrap;"><span class="form-sub-label-container"><span id="at_19" class="form-control-static at-label">at</span>  <label class="form-sub-label" for="at_19"><span> </span></label></span><span class="form-sub-label-container"><select autocomplete="nope" class="form-dropdown" id="hour_19" name="q19_input19[hour]"><option></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option selected="selected" value="12">12</option></select>  <label class="form-sub-label" for="hour_19" id="sublabel_hour">Hour</label></span><span class="form-sub-label-container"><select class="form-dropdown" id="min_19" name="q19_input19[min]"><option></option><option value="00">00</option><option value="10">10</option><option value="20">20</option><option selected="selected" value="30">30</option><option value="40">40</option><option value="50">50</option></select>  <label class="form-sub-label" for="min_19" id="sublabel_minutes">Minutes</label></span><span class="form-sub-label-container"><select class="form-dropdown" id="ampm_19" name="q19_input19[ampm]"><option value="AM">AM</option><option selected="selected" value="PM">PM</option></select>  <label class="form-sub-label" for="ampm_19"><span> </span></label></span></span></div> </div></li><li class="form-line" id="id_16"><div class="form-label-left" id="label_16"><label for="input_16"> Please share any comments and, if you wish, a brief statement on why you are joining the JBN Giving Pledge. We would be happy to include your message on the JBN Giving Pledge list. </label><label class="label-message" for="input_16"> </label></div><div id="cid_16" class="form-input"> <textarea id="input_16" class="form-textarea" name="q16_input16" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_2"><div id="cid_2" class="form-input-wide"> <div style="text-align: center; text-indent:156px;" class="form-buttons-wrapper button-align-auto"><button id="input_2" type="submit" class="form-submit-button  form-submit-button-none;">Submit</button></div> </div></li><li style="display:none">Should be Empty: <input type="text" name="website" value="" /></li></ul></div><input type="hidden" id="simple_spc" name="simple_spc" value="7210055" /><script type="text/javascript">document.getElementById("si"+"mple"+"_spc").value = "7210055-7210055";</script></form></div>
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