{"id":37505,"date":"2022-07-19T11:11:07","date_gmt":"2022-07-19T15:11:07","guid":{"rendered":"https:\/\/www.equilibar.com\/?page_id=37505"},"modified":"2024-12-05T10:31:55","modified_gmt":"2024-12-05T14:31:55","slug":"end-user-form","status":"publish","type":"page","link":"https:\/\/www.equilibar.com\/fr\/end-user-form\/","title":{"rendered":"End User Form"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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ginput_container_text'><input name='input_86' id='input_23_86' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='04\/10\/2026' \/><\/div><\/div><div id=\"field_23_87\" class=\"gfield gfield--type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_87' id='input_23_87' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='216.73.216.85' \/><\/div><\/div><div id=\"field_23_88\" class=\"gfield gfield--type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_88' id='input_23_88' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_23_102\" class=\"gfield gfield--type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_102' id='input_23_102' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_23_100\" class=\"gfield gfield--type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_100' id='input_23_100' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='false' \/><\/div><\/div><div id=\"field_23_18\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><div class='gsection_description' id='gfield_description_23_18'>Equilibar must obtain a certification from its customers that they will not ship products to certain individuals, foreign nationals or to companies who do business with these individuals.  These individuals or companies are classified as \u201cdenied parties\u201d or \u201crestricted parties\u201d by the U.S. government.  Equilibar is required by federal law to collect and maintain the information requested below, and Equilibar will use such information solely to ensure compliance with applicable export laws, rules, and regulations.  All information will be kept strictly confidential except where required by US law.  If you have further questions regarding this law, please contact me at 828-650-6590 or at julie@equilibar.com or go to www.bis.doc.gov for further information.<br><br>Equilibar ensures that all shipments are done in accordance with Export Administration Regulations (EAR) and any diversion contrary to U.S. Law is prohibited. To maintain this compliance, we must have the following on file for every order for each application. If your order is for the same application, please contact the Sales Department and request a blanket export compliance form.<br><br>** ALL LINES MUST BE FULLY ANSWERED IN ORDER FOR EQUILIBAR TO SHIP YOUR ORDER **<\/div><\/div><div id=\"field_23_91\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 style=\"background-color: #edf8fc; text-align: center;\">ORDER INFORMATION<\/h2><\/div><div id=\"field_23_57\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_57'>Purchasing Company<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_23_57' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_59\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_59'>Contact Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_23_59' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_60\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_60'>Contact Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_23_60' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_61\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_61'>Contact Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_23_61' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_62\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_62'>Purchase Order #<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_23_62' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_92\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 style=\"background-color: #edf8fc; text-align: center;\">USER INFORMATION<\/h2><\/div><div id=\"field_23_64\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_64'>End User&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_23_64' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_65\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_65'>End User&#039;s Company<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_23_65' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_66\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_66'>End User&#039;s Website<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_23_66' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_93\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 style=\"background-color: #edf8fc; text-align: center;\">Address Where Product Will Be Used<\/h2><\/div><div id=\"field_23_68\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_68'>Street Address 1<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_23_68' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_69\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_69'>Street Address 2<\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_23_69' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_70\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_70'>City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_23_70' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_71\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_71'>State or Province<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_23_71' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_72\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_72'>Zipcode<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_23_72' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_73\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_73'>Country<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_23_73' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_94\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 style=\"background-color: #edf8fc; text-align: center;\">End Use Information<\/h2><\/div><div id=\"field_23_81\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_81'>Will this be re-exported in the form it is received?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_81' id='input_23_81' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='YES' >YES<\/option><option value='NO' >NO<\/option><option value='' selected='selected'><\/option><\/select><\/div><\/div><div id=\"field_23_77\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_77'>Address where it will be Re-Exported? (Street, City, State\/Province, Country, Zipcode)<\/label><div class='ginput_container ginput_container_text'><input name='input_77' id='input_23_77' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_78\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_78'>What is the End User\u2019s Primary Business Activity?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_23_78' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_79\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_79'>What is the Application of the Product? (1-2 sentences)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_23_79' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_76\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_76'>Will the items in this shipment be used in any non-commercial application (e.g. military or nuclear)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_76' id='input_23_76' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='YES' >YES<\/option><option value='NO' >NO<\/option><option value='' selected='selected'><\/option><\/select><\/div><\/div><div id=\"field_23_82\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_82'>Please list all Government Affiliations for non-commercial applications.<\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_23_82' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_101\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_101'>Please list all military or nuclear non commercial uses.<\/label><div class='ginput_container ginput_container_text'><input name='input_101' id='input_23_101' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_90\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><div class='gsection_description' id='gfield_description_23_90'>If the above information were to change, for example, items will be re-exported to a different End User or used for a different application, you agree to provide Equilibar written notification of the changes and a new end user \/ end use form. <br><br>\nYou are required to comply with the Equilibar, LLC. Standard Terms and Conditions of Quotation and Sale, including but not limited to, the requirement to comply with all applicable U.S. import, export control and sanctions laws, regulations, orders and requirements.  By electronically signing, you certify that you have reviewed, understand and agree to abide by these terms and conditions that apply to quotations and sales. By electronically signing, you also certify that, to the best of your knowledge, the information provided is accurate and complete. \n<\/div><\/div><div id=\"field_23_99\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 style=\"background-color: #edf8fc; text-align: center;\">Sign and Consent<\/h2><\/div><fieldset id=\"field_23_95\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Click to Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_95.1' id='input_23_95_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_23_95_1' >By clicking this box I confirm that all data entered on this form is accurate and correct to the best of my understanding.  I will immediately notify Equilibar with any changes as soon as I become aware of them.<\/label><input type='hidden' name='input_95.2' value='By clicking this box I confirm that all data entered on this form is accurate and correct to the best of my understanding.  I will immediately notify Equilibar with any changes as soon as I become aware of them.' class='gform_hidden' \/><input type='hidden' name='input_95.3' value='2' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_23_96\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_96'>Your Full Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_96' id='input_23_96' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_23_97\" class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Your Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_23_97_container'>\n                                <span id='input_23_97_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_97' id='input_23_97' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_23_97' class='gform-field-label gform-field-label--type-sub '>Saisissez un e-mail<\/label>\n                                <\/span>\n                                <span id='input_23_97_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_97_2' id='input_23_97_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_23_97_2' class='gform-field-label gform-field-label--type-sub '>Confirmez l\u2019e-mail<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_23_98\" class=\"gfield gfield--type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_23_98'>Your Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><input type='hidden' value='' name='input_98' id='input_23_98_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_23_98_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_23_98' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/www.equilibar.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_23_98_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_23_98_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_23_98_data' name='input_23_98_data' value=''><\/div><\/div><div id=\"field_23_105\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><div class='gsection_description' id='gfield_description_23_105'>\nYou should receive an email with a PDF confirmation of your submission.  This confirmation email should arrive within a few minutes.<\/div><\/div><div id=\"field_23_104\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><div class='gsection_description' id='gfield_description_23_104'>Please click SUBMIT just one time.  Page takes about 15 seconds to refresh to confirmation page.<\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_23' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_23' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_23' id='gform_theme_23' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_23' id='gform_style_settings_23' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_23' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='23' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='iuH4wqBTlNGEXXpi6l9rMU7zeOCgr6ZYTYIZhuVrlTbKMNE9bTS+k+w0qchnxOtiPMNb9TSQJ4Twfdkr\/Zs1Crsuj3HFPUCtXTmEhNeEKkZArlY=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_23' value='WyJ7XCI5NS4xXCI6XCI4ZDczZTA3N2IzMDcyOWQ4YjRlZjg1NzlmNTQxYTJhNVwiLFwiOTUuMlwiOlwiNWQzMGU5ZDgyYTJlMWQ5MjRjN2U2MTEwOTFjZGJiYmZcIixcIjk1LjNcIjpcImU2NGMzMzU5YTgwNTYxZjVhM2Q0NjAxYTU5Y2ZlYWVkXCJ9IiwiOThmZTEyZjdiZDYwMzIwYjU4OGY2MDYzYjcyZGYxOWIiXQ==' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_23' id='gform_target_page_number_23' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_23' id='gform_source_page_number_23' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 23, 'https:\/\/www.equilibar.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', false );jQuery('#gform_ajax_frame_23').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_23');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_23').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_23').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_23').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_23').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/  }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_23').val();gformInitSpinner( 23, 'https:\/\/www.equilibar.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', false );jQuery(document).trigger('gform_page_loaded', [23, current_page]);window['gf_submitting_23'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_23').replaceWith(confirmation_content);jQuery(document).trigger('gform_confirmation_loaded', [23]);window['gf_submitting_23'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_23').text());}else{jQuery('#gform_23').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"23\", currentPage: \"current_page\", abort: function() { this.preventDefault(); 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