| Server IP : 10.200.247.200 / Your IP : 216.73.217.19 Web Server : Apache System : Linux synergy-usa-sites 6.8.0-138-generic #138-Ubuntu SMP PREEMPT_DYNAMIC Fri Jul 31 22:41:49 UTC 2026 x86_64 User : jeremy ( 1001) PHP Version : 8.4.25 Disable Function : NONE MySQL : OFF | cURL : ON | WGET : ON | Perl : ON | Python : OFF | Sudo : ON | Pkexec : OFF Directory : /var/www/usa_sites/fundingapplications.com/ |
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<?php
require_once($_SERVER['DOCUMENT_ROOT'].'/inc/php_header.php');
if(!empty($_GET['prm'])) {
$prm_arr = explode('|',UnCryptify($_GET['prm']));
$prm = array();
$prm['cid'] = $prm_arr[0];
$prm['sid'] = $prm_arr[1];
$prm['initial'] = $prm_arr[2];
$prm['monthly'] = $prm_arr[3];
$_SESSION['prm'] = $prm;
}
//echo '<!-- https://fundingapplications.com/order.php?s=1&prm='.Cryptify('Chat|Alesha|'.($_INITIAL_FEE*0.8).'|'.($_MONTHLY_FEE)).' -->';
$categories = get_categories();
$business_questions = get_business_questions();
$trackerformparams = $tracker->FormParameters();
$title = 'Choose Application';
$body_id = 'index';
require_once("header.php") ?>
<script type="text/javascript" src="/js/jquery.formatter.min.js"></script>
<script type="text/javascript">
function checkZip(zip,me) {
zip = zip.replace(/[^0-9]/g,'');
if(zip.length==5) {
var str = 'zip='+encodeURIComponent(zip);
$.ajax
({
cache: false,
type: "POST",
dataType:"json",
data: str,
url: "/php/ZipToCity.php",
success: function(data)
{
if(!data.error) {
$('[name=cc_city]').val(data.city);
$('[name=cc_state]').val(data.state);
}
},error: function(jqXHR, textStatus, errorThrown) {
}
});
}
}
$(document).ready( function() {
$('.subcategory,.subtext,#education_questions,#business_questions').hide().find('input,select,textarea').attr('disabled','disabled');
$('input[name=category_id]').click( function() {
var show_class = $(this).attr('class');
var subcat_elements = $('.subcategory[class~='+show_class+']');
$('.subcategory').hide().find('input,select,textarea').attr('disabled', 'disabled');
if(subcat_elements.length > 0) {
$('#subcategories').show();
subcat_elements.show().find('input,select,textarea').removeAttr('disabled');
} else {
$('#subcategories').hide().find('input,select,textarea').attr('disabled', 'disabled');
}
var granttype = $(this).parents('td:first').attr('id');
$('#granttype_input').val(granttype);
var amount_needed = $('select[name=app_amount_needed]').val();
if(granttype == 'business') {
$('#amount_needed').html('<select name="app_amount_needed"><option selected>Select</option><option value="$500 - $10,000">$500 - $10,000</option><option value="$10,000 - $25,000">$10,000 - $25,000</option><option value="$25,000 - $50,000">$25,000 - $50,000</option><option value="$50,000 - $100,000">$50,000 - $100,000</option><option value="$100,000 - $250,000">$100,000 - $250,000</option><option value="$250,000 - $500,000">$250,000 - $500,000</option><option value="$500,000 - $1,000,000">$500,000 - $1,000,000</option><option value="$1,000,000 +">$1,000,000 +</option></select>');
$('#business_questions').show('slow').find('input,select,textarea').removeAttr('disabled');
} else {
$('#amount_needed').html('<select name="app_amount_needed"><option selected>Select</option><option value="$500 - $10,000">$500 - $10,000</option><option value="$10,000 - $25,000">$10,000 - $25,000</option><option value="$25,000 - $50,000">$25,000 - $50,000</option><option value="$50,000 - $100,000">$50,000 - $100,000</option><option value="$100,000 or More">$100,000 or More</option></select>');
$('#business_questions').hide('slow').find('input,select,textarea').attr('disabled','disabled');
}
/*if($(this).val() == '2') { //education
$('#education_questions').show().find('input,select,textarea').removeAttr('disabled');
} else {
$('#education_questions').hide().find('input,select,textarea').attr('disabled','disabled');
}*/
});
$('input[name=phone_full]').formatter({
'pattern': '({{999}}) {{999}}-{{9999}}',
'persistent': false
});
<?php
if(!empty($_REQUEST)) {
echo "$('input:radio[name=category_id]').filter(function() { return $(this).val()=='{$_REQUEST['category_id']}'; }).click();\n";
}
?>
});
var prettynames = {
category_id:"Funding Category",
cc_fname:"First Name",
cc_lname:"Last Name",
cc_addr:"Address",
cc_city:"City",
cc_state:"State",
cc_zip:"Zip",
cc_phonearea:"Phone Number Area Code",
cc_phoneprefix:"Phone Number Prefix",
cc_phoneextension:"Phone Number Ending",
cc_email:"Email Address",
app_gender:"Gender",
app_citizenship:"Citizenship",
app_age:"Your age",
app_amount_needed:"The amount needed",
app_usedescription:"Describe what you will use the money for",
app_uniqueness:"Uniqueness",
own_business:"Do you own your own business?",
name_of_business:"What is the Name of your Business?",
has_website:"Do you have a website?",
website:"What is your website?",
business_structured:"How is your business structured?",
how_many_employees:"How many employees do you have?",
annual_revenue:"What is the Total Gross Income of your business?",
defendant_lawsuit:"Have you or your business every been a defendant in a lawsuit?",
sued_protected:"Do you feel if you were sued, you are properly protected so you wouldn't lose any of your assets like your home, cars, building, etc?",
living_trust:"Do you have a living trust?"
};
function verify(f) {
// Loop through each element of the form and validate each item
//
// Set the parameters for each field to be valid
// If a field doesn't have any modifiers it is assumed to be
// a text field that can not be blank.
var msg;
var empty_fields = "";
var errors = "";
var required_fields = ['category_id','app_amount_needed','cc_fname','cc_lname','cc_zip','cc_email','phone_full','cc_addr','app_usedescription','app_uniqueness','cc_city','cc_state','app_age','app_gender'];
$(f).find('input,tel,textarea,select,number').each(function()
{
//only check for required fields
var element = $(this)[0];
var is_required = required_fields.indexOf(element.name);
if(is_required=='-1') {
//Not Required
} else {
//Required
if($(element).is(':hidden')) {
//Ignore
}
else if((element.name == 'cc_email')) {
if(/(.+)@(.+){2,}\.(.+){2,}/.test(element.value)) {
//valid email
} else {
errors += "- Please enter a valid email address\n";
}
}
else if ((element.name == 'phone_full')) {
var real_phone = element.value;
real_phone = real_phone.replace(/[^0-9]/g,'');
if(real_phone.length==10) {
//valid phone
} else {
errors += "- Please enter a valid phone number\n";
}
}
else if ((element.name == 'cc_zip')) {
var real_phone = element.value;
real_phone = real_phone.replace(/[^0-9]/g,'');
if(real_phone.length==5) {
//valid phone
} else {
empty_fields += "\n Zip Code";
}
}
else if ((element.type == 'text' || element.type == 'textarea') && (element.name != 'granttype_other'))
{
if ( (element.value == null || element.value == "") || isblank(element.value) )
{
empty_fields += "\n " + prettynames[element.name];
}
else
{
if (element.numeric)
{
var v = parseFloat(element.value);
if (isNaN(v))
{
errors +="- The field " + prettynames[element.name] + " must be a number\n";
}
}
if ( (element.requiredlength > 0) && (element.value.length != element.requiredlength) )
{
errors += "- The field " + prettynames[element.name] + " must be " + element.requiredlength + " digits long\n";
}
}
}
else if (element.type == 'select-one')
{
// The first option, option[0] can not be selected
if ( (element.value == null || element.value == "" || element.selectedIndex == 0) || isblank(element.value) )
{
empty_fields += "\n " + prettynames[element.name];
}
}
else if (element.type == 'radio')
{
if (!$('[name='+element.name+']').filter(':checked').val() && empty_fields.indexOf(prettynames[element.name]) == -1)
{
empty_fields += "\n " + prettynames[element.name];
}
}
}
});
if (!empty_fields && !errors) { return true; }
msg = "__________________________________\n\n";
msg += "The form was not submitted because of the following error(s).\n";
msg += "Please correct these error(s) and re-submit.\n";
msg += "__________________________________\n\n";
if (empty_fields)
{
msg += "- The following required field(s) are empty:" + empty_fields + "\n";
if (errors) { msg += "\n"; }
}
msg += errors;
alert(msg);
return false;
}
function validate_form(me) {
return verify(me);
}
</script>
<? include("assets/sidebar.php") ?>
<h1>New Funding Applications Are Available Now!</h1>
<p class="text">Want to take advantage of all the Free Funding out there, but don't know HOW? Truth is, there are Billions of dollars in free funding awaiting those who qualify and those who know how to apply. This money is awarded to individuals, businesses, researchers, and non-profit organizations through various lenders, including state agencies, federal agencies, private corporations and foundations. We've done the research and THE MONEY EXISTS! Let us show you how and where to apply and how much you may qualify for!</p>
<p class="text">The amount of money and the time of year the money is given away varies. No two funding application deadlines are alike. Therefore, you need to get started as soon as you can so you can take advantage of all those you qualify for and not miss their due dates. Apply all year long.</p>
<p class="text">No need to procrastinate now that we have found the applications for you. No excuses. Get started applying today. "FundingApplications.com" was created for people like you who need help finding the applications. That seems to be one of the hardest things people have to do in the funding seeking process.</p>
<p class="text">Most will miss out on the opportunity to receive such funds because they just don't know where to start. Thousands of private corporations and foundations are just waiting to help provide programs to help individuals and small businesses or organizations throughout the country now more than ever before because more people and businesses need help more than ever before.</p>
<?php if(!empty($_SESSION['prm'])) { ?>
<p class="text" style="color:#33aa66">Thanks to <?= $_SESSION['prm']['sid']; ?>, you can get access to these funding opportunities for only <span style='text-decoration:line-through'>$<?= $_INITIAL_FEE; ?></span> $<?= $_SESSION['prm']['initial']; ?>.</p>
<?php } ?>
<a name="form"></a>
<form action='order.php' method='post' onsubmit="return validate_form(this);">
<table id="form" cellspacing="0" cellpadding="0">
<tr>
<td class="form_top">Funding Application Registration</td>
</tr>
<tr>
<td class="form_in" height="400px">
<table cellpadding="0" cellspacing="0" id="select">
<tr>
<td id="personal" class="personal">
<img src="images/select_tl.png" style="float:left" />
<img src="images/select_tr.png" style="float:right" />
<div>
<label><input type="radio" name="category_id" id="inp_personal" value="3" onclick="test();" />PERSONAL</label>
</div>
</td>
<td id="education" class="education">
<img src="images/select_tl.png" style="float:left" />
<img src="images/select_tr.png" style="float:right" />
<div>
<label><input type="radio" name="category_id" id="inp_education" value="11" onclick="test();" />EDUCATION</label>
</div>
</td>
<td id="realestate" class="realestate">
<img src="images/select_tl.png" style="float:left" />
<img src="images/select_tr.png" style="float:right" />
<div>
<label><input type="radio" name="category_id" id="inp_realestate" value="13" onclick="test();" />REAL ESTATE</label>
</div>
</td>
<td id="business" class="business">
<img src="images/select_tl.png" style="float:left" />
<img src="images/select_tr.png" style="float:right" />
<div>
<label><input type="radio" name="category_id" id="inp_business" value="10" onclick="test();" />BUSINESSES</label>
</div>
</td>
</tr>
</table>
<table cellpadding="0" cellspacing="0" class="select" id="a1">
<tr>
<td></td>
<td></td>
<td class="tr"></td>
<tr>
</tr>
<td></td>
<td>
<?php $counter = 0; if(!empty($categories['subcategories'])) {
echo '<ul>';
foreach($categories['subcategories'] as $subcats) {
if(isset($subcats['categories'][4])) { $counter++;
if($counter > 5) { $counter=0; echo '</ul><ul>'; }
?><li><label><input type="checkbox" class="check" name="subcategories[]" value="<?= $subcats['id'];?>" /><?= $subcats['name']; ?></label></li><?php
}
}
echo '</ul>';
}?>
<span><img src="images/arrow_up.png" />Highlight All Applicable Personal Sub-Categories<img src="images/arrow_up.png" /></span>
</td>
<td></td>
</tr>
<tr>
<td class="bl"></td>
<td></td>
<td class="br"></td>
</tr>
</table>
<table cellpadding="0" cellspacing="0" class="select" id="a2">
<tr>
<td class="tl"></td>
<td></td>
<td class="tr"></td>
<tr>
<tr>
<td></td>
<td>
<?php $counter = 0; if(!empty($categories['subcategories'])) {
echo '<ul>';
foreach($categories['subcategories'] as $subcats) {
if(isset($subcats['categories'][2])) { $counter++;
if($counter > 5) { $counter=0; echo '</ul><ul>'; }
?><li><label><input type="checkbox" class="check" name="subcategories[]" value="<?= $subcats['id'];?>" /><?= $subcats['name']; ?></label></li><?php
}
}
echo '</ul>';
}?>
<span><img src="images/arrow_up.png" />Highlight All Applicable Education Sub-Categories<img src="images/arrow_up.png" /></span>
</td>
<td></td>
</tr>
<tr>
<td class="bl"></td>
<td></td>
<td class="br"></td>
</tr>
</table>
<table cellpadding="0" cellspacing="0" class="select" id="a3">
<tr>
<td class="tl"></td>
<td></td>
<td class="tr"></td>
<tr>
<tr>
<td></td>
<td>
<?php $counter = 0; if(!empty($categories['subcategories'])) {
echo '<ul>';
foreach($categories['subcategories'] as $subcats) {
if(isset($subcats['categories'][5])) { $counter++;
if($counter > 5) { $counter=0; echo '</ul><ul>'; }
?><li><label><input type="checkbox" class="check" name="subcategories[]" value="<?= $subcats['id'];?>" /><?= $subcats['name']; ?></label></li><?php
}
}
echo '</ul>';
}?>
<span><img src="images/arrow_up.png" />Highlight All Applicable Real Estate Sub-Categories<img src="images/arrow_up.png" /></span>
</td>
<td></td>
</tr>
<tr>
<td class="bl"></td>
<td></td>
<td class="br"></td>
</tr>
</table>
<table cellpadding="0" cellspacing="0" class="select" id="a4">
<tr>
<td class="tl"></td>
<td></td>
<td></td>
<tr>
<tr>
<td></td>
<td>
<?php $counter = 0; if(!empty($categories['subcategories'])) {
echo '<ul>';
foreach($categories['subcategories'] as $subcats) {
if(isset($subcats['categories'][1])) { $counter++;
if($counter > 5) { $counter=0; echo '</ul><ul>'; }
?><li><label><input type="checkbox" class="check" name="subcategories[]" value="<?= $subcats['id'];?>" /><?= $subcats['name']; ?></label></li><?php
}
}
echo '</ul>';
}?>
<span><img src="images/arrow_up.png" />Highlight All Applicable Business Sub-Categories<img src="images/arrow_up.png" /></span>
</td>
<td></td>
</tr>
<tr>
<td class="bl"></td>
<td></td>
<td class="br"></td>
</tr>
</table>
<script language="JavaScript">
function test() {
if (document.getElementById('inp_personal').checked == true) {
document.getElementById('personal').className = 'personal_';
document.getElementById('education').className = 'education';
document.getElementById('realestate').className = 'realestate';
document.getElementById('business').className = 'business';
switchid('a1');
}
if (document.getElementById('inp_education').checked == true) {
document.getElementById('personal').className = 'personal';
document.getElementById('education').className = 'education_';
document.getElementById('realestate').className = 'realestate';
document.getElementById('business').className = 'business';
switchid('a2');
}
if (document.getElementById('inp_realestate').checked == true) {
document.getElementById('personal').className = 'personal';
document.getElementById('education').className = 'education';
document.getElementById('realestate').className = 'realestate_';
document.getElementById('business').className = 'business';
switchid('a3');
}
if (document.getElementById('inp_business').checked == true) {
document.getElementById('personal').className = 'personal';
document.getElementById('education').className = 'education';
document.getElementById('realestate').className = 'realestate';
document.getElementById('business').className = 'business_';
switchid('a4');
}
}
//here you place the ids of every element you want.
var ids=new Array('a1','a2','a3','a4');
function switchid(id){
hideallids();
showdiv(id);
}
function hideallids(){
//loop through the array and hide each element by id
for (var i=0;i<ids.length;i++){
hidediv(ids[i]);
}
}
function hidediv(id) {
//safe function to hide an element with a specified id
if (document.getElementById) { // DOM3 = IE5, NS6
document.getElementById(id).style.display = 'none';
}
else {
if (document.layers) { // Netscape 4
document.id.display = 'none';
}
else { // IE 4
document.all.id.style.display = 'none';
}
}
}
function showdiv(id) {
//safe function to show an element with a specified id
if (document.getElementById) { // DOM3 = IE5, NS6
document.getElementById(id).style.display = 'block';
}
else {
if (document.layers) { // Netscape 4
document.id.display = 'block';
}
else { // IE 4
document.all.id.style.display = 'block';
}
}
}
</script>
<table cellpadding="0" cellspacing="0" border="0" class="form_table">
<tr>
<td>citizenship</td>
<td>age</td>
<td colspan="2">gender</td>
</tr>
<tr>
<td><select class="third_" name="app_citizenship">
<option value="" >Select</option>
<option value="citizen" >U.S. Citizen</option>
<option value="resident" >Resident Alien</option>
<option value="greencard" >Green Card Holder</option>
<option value="permanent" >Permanent Resident</option>
<option value="unsure" >Not Sure</option>
</select></td>
<td><input type="tel" maxlength="3" class="third" name="app_age" value="" /></td>
<td colspan="2">
<label><input type="radio" name="app_gender" class="radio" value="male" />male</label>
<label><input type="radio" name="app_gender" class="radio" value="female" />female</label>
</td>
</tr>
</table>
<table cellpadding="0" cellspacing="0" border="0" class="form_table">
<tr>
<td>ethnicity</td>
<td>employment status</td>
</tr>
<tr>
<td><select name="ethnicity">
<option value="">Select</option>
<option value="White">White</option>
<option value="Black or African American">Black or African American</option>
<option value="Native American">Native American</option>
<option value="Asian American">Asian American</option>
<option value="Native Hawaiian">Native Hawaiian</option>
<option value="Pacific Islander">Pacific Islander</option>
<option value="Middle Eastern American">Middle Eastern American</option>
<option value="Hispanic">Hispanic</option>
<option value="Latino">Latino</option>
<option value="Multi-racial">Multi-racial</option>
<option value="Other">Other</option>
</select></td>
<td>
<select name="employment_status">
<option value="">Select</option>
<option value="Employed Full-time">Employed Full-time</option>
<option value="Employed Part-time">Employed Part-time</option>
<option value="Self Employed">Self Employed</option>
<option value="Unemployed">Unemployed</option>
<option value="Retired">Retired</option>
<option value="Collecting Social Security">Collecting Social Security</option>
<option value="Disabled">Disabled</option>
</select>
</td>
</tr>
</table>
<?php /*
<table cellpadding="0" cellspacing="0" border="0" class="form_table" id="disability_questions">
<?php foreach($disability_questions['questions'] as $slug=>$data) {?>
<tr>
<td><?= $data['name'];?></td>
</tr>
<tr>
<td>
<?php if($data['type']=='bool') {?>
<label><input type="radio" value="1" name="<?= $slug;?>" id="<?= $slug;?>_yes" /> Yes</label>
<label><input type="radio" value="0" name="<?= $slug;?>" id="<?= $slug;?>_no" /> No</label>
<?php } elseif(strpos($data['type'],'range') > -1) {
$range = array();
$pieces = explode(':',$data['type']);
$range_limits = explode('-',$pieces[1]);
if($range_limits[0] > $range_limits[1]) {
for($i=$range_limits[0]; $i>=$range_limits[1]; $i--) {
$range[$i] = $i;
}
} else {
for($i=$range_limits[0]; $i<=$range_limits[1]; $i++) {
$range[$i] = $i;
}
}
?>
<select name="<?= $slug;?>" id="<?= $slug;?>">
<option value="">Select</option>
<?php foreach($range as $i=>$j) {?>
<option value="<?= $i;?>"><?= $j;?></option>
<?php }?>
</select>
<?php } elseif($data['type']=='textarea') {
?>
<textarea name="<?= $slug;?>" id="<?= $slug;?>"></textarea>
<?php
}
sub_question_recursive_disability($slug);
?>
</td>
</tr>
<?php } ?>
</table>
*/?>
<?php /*<table cellpadding="0" cellspacing="0" border="0" class="form_table" id="education_questions">
<?php foreach($education_questions['questions'] as $slug=>$data) {?>
<tr>
<td><?= $data['name'];?></td>
</tr>
<tr>
<td>
<?php if($data['type']=='bool') {?>
<label><input type="radio" value="1" name="<?= $slug;?>" id="<?= $slug;?>_yes" /> Yes</label>
<label><input type="radio" value="0" name="<?= $slug;?>" id="<?= $slug;?>_no" /> No</label>
<?php } elseif(strpos($data['type'],'range') > -1) {
$range = array();
$pieces = explode(':',$data['type']);
$range_limits = explode('-',$pieces[1]);
if($range_limits[0] > $range_limits[1]) {
for($i=$range_limits[0]; $i>=$range_limits[1]; $i--) {
$range[$i] = $i;
}
} else {
for($i=$range_limits[0]; $i<=$range_limits[1]; $i++) {
$range[$i] = $i;
}
}
?>
<select name="<?= $slug;?>" id="<?= $slug;?>">
<option value="">Select</option>
<?php foreach($range as $i=>$j) {?>
<option value="<?= $i;?>"><?= $j;?></option>
<?php }?>
</select>
<?php }
sub_question_recursive($slug);
?>
</td>
</tr>
<?php } ?>
</table>*/?>
<?php /*
<table cellpadding="0" cellspacing="0" border="0" class="form_table" id="business_questions">
<tr>
<td>What are the major financial needs for your business? <i>(Check all that apply)</i></td>
</tr>
<?php foreach($business_questions['questions'] as $slug=>$data) {?>
<tr>
<td>
<label><input type="checkbox" value="1" name="<?= $slug;?>" id="<?= $slug;?>_yes" style="vertical-align:middle;" /> <?= $data['name'];?></label>
</td>
</tr>
<?php } ?>
<tr>
<td>
Do you own your own business?
<label style="display:inline-block;width:auto;">Yes <input type="radio" name="own_business" value="yes" style="vertical-align:middle;" onclick="$('.has_business_show').show();" /></label>
<label style="display:inline-block;width:auto;">No <input type="radio" name="own_business" value="no" style="vertical-align:middle;" onclick="$('.has_business_show').hide();" /></label>
</td>
</tr>
<tr class="has_business_show" style="display:none;">
<td>
<label>What is the Name of your Business? <input type="text" name="name_of_business" value="" /></label>
</td>
</tr>
<tr class="has_business_show" style="display:none;">
<td>
Do you have a website?
<label style="display:inline-block;width:auto;">Yes <input type="radio" name="has_website" value="yes" style="vertical-align:middle;" onclick="$('.has_website_show').show();" /></label>
<label style="display:inline-block;width:auto;">No <input type="radio" name="has_website" value="no" style="vertical-align:middle;" onclick="$('.has_website_show').hide();" /></label>
</td>
</tr>
<tr class="has_website_show" style="display:none;">
<td>
<label>What is your website? <input type="text" name="website" value="" /></label>
</td>
</tr>
<tr class="has_business_show" style="display:none;">
<td>
<label>
How is your business structured?
<select name="business_structured" style="vertical-align:middle;">
<option value=""></option>
<option value="Sole Proprietor">Sole Proprietor</option>
<option value="Corporation">Corporation</option>
<option value="LLC">LLC</option>
</select>
</label>
</td>
</tr>
<tr class="has_business_show" style="display:none;">
<td>
<label>How many employees do you have? <input type="number" name="how_many_employees" value="" /></label>
</td>
</tr>
<tr class="has_business_show" style="display:none;">
<td>
<label>What is the Total Gross Income of your business? <small><i>(Total money received before any deductions like rent, cost of goods, and taxes)</i></small> <input type="number" name="annual_revenue" value="" /></label>
</td>
</tr>
<tr class="has_business_show" style="display:none;">
<td>
Have you or your business every been a defendant in a lawsuit?
<label style="display:inline-block;width:auto;">Yes <input type="radio" name="defendant_lawsuit" value="yes" style="vertical-align:middle;" /></label>
<label style="display:inline-block;width:auto;">No <input type="radio" name="defendant_lawsuit" value="no" style="vertical-align:middle;" /></label>
</td>
</tr>
<tr class="has_business_show" style="display:none;">
<td>
Do you feel if you were sued, you are properly protected so you wouldn't lose any of your assets like your home, cars, building, etc?
<label style="display:inline-block;width:auto;">Yes <input type="radio" name="sued_protected" value="yes" style="vertical-align:middle;" /></label>
<label style="display:inline-block;width:auto;">No <input type="radio" name="sued_protected" value="no" style="vertical-align:middle;" /></label>
</td>
</tr>
<tr class="has_business_show" style="display:none;">
<td>
Are you putting money into the business?
<label style="display:inline-block;width:auto;">Yes <input type="radio" name="putting_money_into_business" value="yes" style="vertical-align:middle;" onclick="$('.putting_money_into_business_show').show();" /></label>
<label style="display:inline-block;width:auto;">No <input type="radio" name="putting_money_into_business" value="no" style="vertical-align:middle;" onclick="$('.putting_money_into_business_show').hide();" /></label>
</td>
</tr>
<tr class="putting_money_into_business_show" style="display:none;">
<td>
<label>How much? <input type="number" name="putting_money_how_much" placeholder="$0.00" /></label>
</td>
</tr>
<tr>
<td>
Do you have a living trust?
<label style="display:inline-block;width:auto;">Yes <input type="radio" name="living_trust" value="yes" style="vertical-align:middle;" /></label>
<label style="display:inline-block;width:auto;">No <input type="radio" name="living_trust" value="no" style="vertical-align:middle;" /></label>
</td>
</tr>
</table>
*/ ?>
<?php /*
<div id="bankruptcy_questions" style="padding:0px 10px;">
<div style="padding:5px 0px;">
Have you filed a prior bankruptcy:<br />
<label>
<input type="radio" name="filed_bankruptcy" value="Yes" <?= $_REQUEST['filed_bankruptcy']=='Yes' ? 'checked' : '';?> onclick="if($(this).is(':checked')) { $('#filed_bankruptcy_yes').show(); } else { $('#filed_bankruptcy_yes').hide(); }" style="vertical-align:middle;margin:0px;" />
Yes
</label>
<label>
<input type="radio" name="filed_bankruptcy" value="No" <?= $_REQUEST['filed_bankruptcy']=='No' ? 'checked' : '';?> onclick="if($(this).is(':checked')) { $('#filed_bankruptcy_yes').hide(); } else { $('#filed_bankruptcy_yes').show(); }" style="vertical-align:middle;margin:0px;" />
No
</label>
</div>
<div id="filed_bankruptcy_yes" style="padding-left:40px;display:<?= $_REQUEST['filed_bankruptcy']=='Yes' ? 'block' : 'none';?>;">
<div style="padding:5px 0px;">
What chapter was it?<br />
<label>
<input type="radio" name="what_chapter" value="Chapter 7" <?= $_REQUEST['what_chapter']=='Chapter 7' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
Chapter 7
</label>
<label>
<input type="radio" name="what_chapter" value="Chapter 13" <?= $_REQUEST['what_chapter']=='Chapter 13' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
Chapter 13
</label>
</div>
<div style="padding:5px 0px;">
<label>
Date Filed:
<input type="date" name="date_filed" value="<?= $_REQUEST['date_filed'];?>" />
</label>
</div>
<div style="padding:5px 0px;">
Result:<br />
<label>
<input type="radio" name="bankruptcy_result" value="Dismissed" <?= $_REQUEST['bankruptcy_result']=='Dismissed' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
Dismissed
</label>
<label>
<input type="radio" name="bankruptcy_result" value="Discharged" <?= $_REQUEST['bankruptcy_result']=='Discharged' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
Discharged
</label>
<label>
<input type="radio" name="bankruptcy_result" value="In the middle of the process" <?= $_REQUEST['bankruptcy_result']=='In the middle of the process' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
In the middle of the process
</label>
</div>
</div>
<div style="padding:5px 0px;">
Have you considered bankruptcy?<br />
<label>
<input type="radio" name="considered_bankruptcy" value="Yes" <?= $_REQUEST['considered_bankruptcy']=='Yes' ? 'checked' : '';?> onclick="if($(this).is(':checked')) { $('#considered_bankruptcy_yes').show(); } else { $('#considered_bankruptcy_yes').hide(); }" style="vertical-align:middle;margin:0px;" />
Yes
</label>
<label>
<input type="radio" name="considered_bankruptcy" value="No" <?= $_REQUEST['considered_bankruptcy']=='No' ? 'checked' : '';?> onclick="if($(this).is(':checked')) { $('#considered_bankruptcy_yes').hide(); } else { $('#considered_bankruptcy_yes').show(); }" style="vertical-align:middle;margin:0px;" />
No
</label>
</div>
<div id="considered_bankruptcy_yes" style="padding-left:40px;display:<?= $_REQUEST['considered_bankruptcy']=='Yes' ? 'block' : 'none';?>;">
<div style="padding:5px 0px;">
<label>
Why?
<textarea name="considered_why"><?= $_REQUEST['considered_why'];?></textarea>
</label>
</div>
</div>
<div style="padding:5px 0px;">
Are you behind on ANY of your payments/bills including credit cards, car loans, mortgage, or tax payments?<br />
<label>
<input type="radio" name="behind_on_bills" value="Yes" <?= $_REQUEST['behind_on_bills']=='Yes' ? 'checked' : '';?> onclick="if($(this).is(':checked')) { $('#behind_on_bills_yes').show(); } else { $('#behind_on_bills_yes').hide(); }" style="vertical-align:middle;margin:0px;" />
Yes
</label>
<label>
<input type="radio" name="behind_on_bills" value="No" <?= $_REQUEST['behind_on_bills']=='No' ? 'checked' : '';?> onclick="if($(this).is(':checked')) { $('#behind_on_bills_yes').hide(); } else { $('#behind_on_bills_yes').show(); }" style="vertical-align:middle;margin:0px;" />
No
</label>
</div>
<div id="behind_on_bills_yes" style="padding-left:40px;display:<?= $_REQUEST['behind_on_bills']=='Yes' ? 'block' : 'none';?>;">
<div style="padding:5px 0px;">
<label>
How far behind are you?<br />
<label>
<input type="radio" name="how_far_behind" value="1 Month" <?= $_REQUEST['how_far_behind']=='1 Month' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
1 Month
</label>
<label>
<input type="radio" name="how_far_behind" value="2-3 Months" <?= $_REQUEST['how_far_behind']=='2-3 Months' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
2-3 Months
</label>
<label>
<input type="radio" name="how_far_behind" value="3-6 Months" <?= $_REQUEST['how_far_behind']=='3-6 Months' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
3-6 Months
</label>
<label>
<input type="radio" name="how_far_behind" value="Over 6 Months" <?= $_REQUEST['how_far_behind']=='Over 6 Months' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
Over 6 Months
</label>
</label>
</div>
<div style="padding:5px 0px;">
<label>
What is the approximate amount of your total unsecured debt <i>(credit cards)</i>:<br />
<input type="number" name="amount_of_unsecured_debt" value="<?= $_REQUEST['amount_of_unsecured_debt'];?>" />
</label>
</div>
<div style="padding:5px 0px;">
Do you owe past due taxes?<br />
<label>
<input type="radio" name="owe_backtaxes" value="Yes" <?= $_REQUEST['owe_backtaxes']=='Yes' ? 'checked' : '';?> onclick="if($(this).is(':checked')) { $('#owe_backtaxes_yes').show(); } else { $('#owe_backtaxes_yes').hide(); }" style="vertical-align:middle;margin:0px;" />
Yes
</label>
<label>
<input type="radio" name="owe_backtaxes" value="No" <?= $_REQUEST['owe_backtaxes']=='No' ? 'checked' : '';?> onclick="if($(this).is(':checked')) { $('#owe_backtaxes_yes').hide(); } else { $('#owe_backtaxes_yes').show(); }" style="vertical-align:middle;margin:0px;" />
No
</label>
</div>
<div id="owe_backtaxes_yes" style="padding-left:40px;display:<?= $_REQUEST['owe_backtaxes']=='Yes' ? 'block' : 'none';?>;">
<?php if(!empty($_REQUEST['bankruptcy_which_year'])) { ?>
<?php foreach($_REQUEST['bankruptcy_which_year'] as $k=>$v) { ?>
<div>
<label>
Which Tax Year?
<input type="number" name="bankruptcy_which_year[]" value="<?= $v;?>" />
</label><br />
<label>
Amount Owed?
<input type="number" name="bankruptcy_amount_owed[]" value="<?= $_REQUEST['bankruptcy_amount_owed'][$k];?>" />
</label>
</div>
<?php } ?>
<?php } ?>
<div onclick="$(this).clone().insertAfter(this); $(this).attr('onclick','');">
<label>
Which Tax Year?
<input type="number" name="bankruptcy_which_year[]" />
</label><br />
<label>
Amount Owed?
<input type="number" name="bankruptcy_amount_owed[]" />
</label>
</div>
</div>
<div style="padding:5px 0px;">
Are your wages being garnished or are any garnishments pending?<br />
<label>
<input type="radio" name="wages_garnished" value="Yes" <?= $_REQUEST['wages_garnished']=='Yes' ? 'checked' : '';?> onclick="if($(this).is(':checked')) { $('#wages_garnished_yes').show(); } else { $('#wages_garnished_yes').hide(); }" style="vertical-align:middle;margin:0px;" />
Yes
</label>
<label>
<input type="radio" name="wages_garnished" value="No" <?= $_REQUEST['wages_garnished']=='No' ? 'checked' : '';?> onclick="if($(this).is(':checked')) { $('#wages_garnished_yes').hide(); } else { $('#wages_garnished_yes').show(); }" style="vertical-align:middle;margin:0px;" />
No
</label>
</div>
<div id="wages_garnished_yes" style="padding-left:40px;display:<?= $_REQUEST['wages_garnished']=='Yes' ? 'block' : 'none';?>;">
<div style="padding:5px 0px;">
<label>
How much do you have in garnishments?
<input type="number" name="garnished_amount" value="<?= $_REQUEST['garnished_amount'];?>" />
</label>
</div>
</div>
<div style="padding:5px 0px;">
Do you have any judgments?<br />
<label>
<input type="radio" name="have_judgements" value="Yes" <?= $_REQUEST['have_judgements']=='Yes' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
Yes
</label>
<label>
<input type="radio" name="have_judgements" value="No" <?= $_REQUEST['have_judgements']=='No' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
No
</label>
</div>
<div style="padding:5px 0px;">
Are you being harassed by creditors?<br />
<label>
<input type="radio" name="harrased_by_creditors" value="Yes" <?= $_REQUEST['harrased_by_creditors']=='Yes' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
Yes
</label>
<label>
<input type="radio" name="harrased_by_creditors" value="No" <?= $_REQUEST['harrased_by_creditors']=='No' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
No
</label>
</div>
<div style="padding:5px 0px;">
Do you Own or Rent your Home?<br />
<label>
<input type="radio" name="rent_or_own" value="Own" <?= $_REQUEST['rent_or_own']=='Own' ? 'checked' : '';?> onclick="if($(this).is(':checked')) { $('#own_yes').show(); } else { $('#own_yes').hide(); }" style="vertical-align:middle;margin:0px;" />
Own
</label>
<label>
<input type="radio" name="rent_or_own" value="Rent" <?= $_REQUEST['rent_or_own']=='Rent' ? 'checked' : '';?> onclick="if($(this).is(':checked')) { $('#own_yes').hide(); } else { $('#own_yes').show(); }" style="vertical-align:middle;margin:0px;" />
Rent
</label>
</div>
<div id="own_yes" style="padding-left:40px;display:<?= $_REQUEST['rent_or_own']=='Own' ? 'block' : 'none';?>;">
<div style="padding:5px 0px;">
<label>
Current assessed value your home:<br />
<input type="number" name="value_of_home" value="<?= $_REQUEST['value_of_home'];?>" />
</label>
</div>
<div style="padding:5px 0px;">
Are you delinquent on your mortgage?<br />
<label>
<input type="radio" name="deliquent_on_mortgage" value="Yes" <?= $_REQUEST['deliquent_on_mortgage']=='Yes' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
Yes
</label>
<label>
<input type="radio" name="deliquent_on_mortgage" value="No" <?= $_REQUEST['deliquent_on_mortgage']=='No' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
No
</label>
</div>
</div>
<div style="padding:5px 0px;">
<label>
How many dependants are in your home?<br />
<input type="number" name="dependents_in_home" value="<?= $_REQUEST['dependents_in_home'];?>" />
</label>
</div>
<div style="padding:5px 0px;">
<label>
What is your average monthly household income?<br />
<input type="number" name="average_monthly_income" value="<?= $_REQUEST['average_monthly_income'];?>" />
</label>
</div>
<div style="padding:5px 0px;">
Any other income contributed to the household?<br />
<label>
<input type="radio" name="other_income_sources" value="Yes" <?= $_REQUEST['other_income_sources']=='Yes' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
Yes
</label>
<label>
<input type="radio" name="other_income_sources" value="No" <?= $_REQUEST['other_income_sources']=='No' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
No
</label>
</div>
<div style="padding:5px 0px;">
Are you currently in the middle of a lawsuit/injury settlement?<br />
<label>
<input type="radio" name="in_lawsuit" value="Own" <?= $_REQUEST['in_lawsuit']=='Yes' ? 'checked' : '';?> onclick="if($(this).is(':checked')) { $('#in_lawsuit_yes').show(); } else { $('#in_lawsuit_yes').hide(); }" style="vertical-align:middle;margin:0px;" />
Yes
</label>
<label>
<input type="radio" name="in_lawsuit" value="Rent" <?= $_REQUEST['in_lawsuit']=='No' ? 'checked' : '';?> onclick="if($(this).is(':checked')) { $('#in_lawsuit_yes').hide(); } else { $('#in_lawsuit_yes').show(); }" style="vertical-align:middle;margin:0px;" />
No
</label>
</div>
<div id="in_lawsuit_yes" style="padding-left:40px;display:<?= $_REQUEST['in_lawsuit']=='Yes' ? 'block' : 'none';?>;">
<div style="padding:5px 0px;">
<label>
Please Explain:
<textarea name="lawsuit_explain"><?= $_REQUEST['lawsuit_explain'];?></textarea>
</label>
</div>
</div>
<div style="padding:5px 0px;">
Would you be open to visiting with a debt relief consultant to help you improve your situation?<br />
<label>
<input type="radio" name="open_to_debt_relief" value="Yes" <?= $_REQUEST['open_to_debt_relief']=='Yes' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
Yes
</label>
<label>
<input type="radio" name="open_to_debt_relief" value="No" <?= $_REQUEST['open_to_debt_relief']=='No' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
No
</label>
</div>
</div>
</div>
*/?>
<div id="credit_questions" style="padding:0px 5px;">
<div style="padding:5px 0px;">
How would you describe your credit?<br />
<label>
<input type="radio" name="describe_credit" value="Excellent" <?= $_REQUEST['describe_credit']=='Excellent' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
Excellent
</label>
<label>
<input type="radio" name="describe_credit" value="Good" <?= $_REQUEST['describe_credit']=='Good' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
Good
</label>
<label>
<input type="radio" name="describe_credit" value="Fair" <?= $_REQUEST['describe_credit']=='Fair' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
Fair
</label>
<label>
<input type="radio" name="describe_credit" value="Poor" <?= $_REQUEST['describe_credit']=='Poor' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
Poor
</label>
</div>
<div style="padding:5px 0px;">
Do you want to improve your credit?<br />
<label>
<input type="radio" name="want_to_improve_credit" value="Yes" <?= $_REQUEST['want_to_improve_credit']=='Yes' ? 'checked' : '';?> onclick="if($(this).is(':checked')) { $('#want_to_improve_credit_yes').show(); } else { $('#want_to_improve_credit_yes').hide(); }" style="vertical-align:middle;margin:0px;" />
Yes
</label>
<label>
<input type="radio" name="want_to_improve_credit" value="No" <?= $_REQUEST['want_to_improve_credit']=='No' ? 'checked' : '';?> onclick="if($(this).is(':checked')) { $('#want_to_improve_credit_yes').hide(); } else { $('#want_to_improve_credit_yes').show(); }" style="vertical-align:middle;margin:0px;" />
No
</label>
</div>
<div id="want_to_improve_credit_yes" style="padding-left:40px;display:<?= $_REQUEST['want_to_improve_credit']=='Yes' ? 'block' : 'none';?>;">
<div style="padding:5px 0px;">
Have you been turned down for a loan in the last 60 days?<br />
<label>
<input type="radio" name="turned_down_for_loan" value="Yes" <?= $_REQUEST['turned_down_for_loan']=='Yes' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
Yes
</label>
<label>
<input type="radio" name="turned_down_for_loan" value="No" <?= $_REQUEST['turned_down_for_loan']=='No' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
No
</label>
</div>
<div style="padding:5px 0px;">
What is your main goal or reason to have good credit?<br />
<label>
<input type="radio" name="main_goal_for_good_credit" value="Buy a home" <?= $_REQUEST['main_goal_for_good_credit']=='Buy a home' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
Buy a home
</label>
<label>
<input type="radio" name="main_goal_for_good_credit" value="Buy a car" <?= $_REQUEST['main_goal_for_good_credit']=='Buy a car' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
Buy a car
</label>
<label>
<input type="radio" name="main_goal_for_good_credit" value="Other" <?= $_REQUEST['main_goal_for_good_credit']=='Other' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
Other
</label>
</div>
<div style="padding:5px 0px;">
What is your time frame for accomplishing your goal?<br />
<label>
<input type="radio" name="goal_time_frame" value="1-3 Months" <?= $_REQUEST['goal_time_frame']=='1-3 Months' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
1-3 Months
</label>
<label>
<input type="radio" name="goal_time_frame" value="4-6 Months" <?= $_REQUEST['goal_time_frame']=='4-6 Months' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
4-6 Months
</label>
<label>
<input type="radio" name="goal_time_frame" value="6-12 Months" <?= $_REQUEST['goal_time_frame']=='6-12 Months' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
6-12 Months
</label>
</div>
<div style="padding:5px 0px;">
How serious are you about fixing your credit?<br />
<div>
<label>
<input type="radio" name="how_serious" value="Very interested!" <?= $_REQUEST['how_serious']=='Very interested!' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
<strong>Very interested!</strong> I need to make a large purchase soon and need to improve it.
</label>
</div>
<div>
<label>
<input type="radio" name="how_serious" value="No Rush." <?= $_REQUEST['how_serious']=='No Rush.' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
<strong>No Rush.</strong> I'm just looking for options.
</label>
</div>
</div>
<div style="padding:5px 0px;">
Would you like to talk to a specialist to improve your credit?<br />
<label>
<input type="radio" name="talk_to_specialist" value="Yes" <?= $_REQUEST['talk_to_specialist']=='Yes' ? 'checked' : '';?> onclick="$('#talk_to_specialist_yes').show();" style="vertical-align:middle;margin:0px;" />
Yes
</label>
<label>
<input type="radio" name="talk_to_specialist" value="No" <?= $_REQUEST['talk_to_specialist']=='No' ? 'checked' : '';?> onclick="$('#talk_to_specialist_yes').hide();" style="vertical-align:middle;margin:0px;" />
No
</label>
</div>
<div id="talk_to_specialist_yes" style="display:<?= $_REQUEST['talk_to_specialist']=='Yes' ? 'block' : 'none';?>;">
<div style="padding:5px 0px;">
I give permission to have a credit pro from Pinnacle Credit Pros contact me.<br />
<label>
<input type="radio" name="give_permission_for_specialist" value="Yes" <?= $_REQUEST['give_permission_for_specialist']=='Yes' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
Yes
</label>
<label>
<input type="radio" name="give_permission_for_specialist" value="No" <?= $_REQUEST['give_permission_for_specialist']=='No' ? 'checked' : '';?> style="vertical-align:middle;margin:0px;" />
No
</label>
</div>
</div>
</div>
</div>
<table cellpadding="0" cellspacing="0" border="0" class="form_table">
<tr>
<td>How much funding are you looking for?</td>
</tr>
<tr>
<td id="amount_needed"><select name="app_amount_needed">
<option selected>Select</option>
<option value="$500 - $10,000" >$500 - $10,000</option>
<option value="$10,000 - $25,000" >$10,000 - $25,000</option>
<option value="$25,000 - $50,000" >$25,000 - $50,000</option>
<option value="$50,000 - $100,000" >$50,000 - $100,000</option>
<option value="$100,000 or More" >$100,000 or More</option>
</select></td>
</tr>
<tr>
<td>Describe in detail how you'll use the money:</td>
</tr>
<tr>
<td><textarea name="app_usedescription"></textarea></td>
</tr>
<tr>
<td>What makes you the ideal candidate for this funding?</td>
</tr>
<tr>
<td><textarea name="app_uniqueness"></textarea></td>
</tr>
</table>
<table cellpadding="0" cellspacing="0" border="0" class="form_table">
<tr>
<td colspan="2">first name</td>
<td colspan="2">last name</td>
</tr>
<tr>
<td colspan="2"><input type="text" class="full" name="cc_fname" value="" required pattern="[a-zA-Z']+" title="Please use only letters" /></td>
<td colspan="2"><input type="text" class="full" name="cc_lname" value="" required pattern="[a-zA-Z']+" title="Please use only letters" /></td>
</tr>
<tr>
<td colspan="2">street address</td>
<td colspan="2">zip</td>
</tr>
<tr>
<td colspan="2"><input type="text" class="full" name="cc_addr" value="" /></td>
<td colspan="2"><input type="tel" class="full" maxlength="5" id="id-cc-zip" name="cc_zip" onkeyup="checkZip($(this).val(),this);" value="<?= isset($_REQUEST['cc_zip']) ? $_REQUEST['cc_zip'] : null;?>" /></td>
</tr>
<tr>
<td colspan="2">city</td>
<td colspan="2">state</td>
</tr>
<tr>
<td colspan="2">
<input type="text" name="cc_city" class="full" value="<?=$_POST['cc_city']?>" />
</td>
<td colspan="2">
<select name="cc_state" class="full">
<?php
$_STATES = array(''=>'','AL'=>'Alabama','AK'=>'Alaska','AS'=>'American Samoa','AZ'=>'Arizona','AR'=>'Arkansas','CA'=>'California','CO'=>'Colorado','CT'=>'Connecticut','DE'=>'Delaware','DC'=>'District of Columbia','FM'=>'Federated States of Micronesia','FL'=>'Florida','GA'=>'Georgia','GU'=>'Guam','HI'=>'Hawaii','ID'=>'Idaho','IL'=>'Illinois','IN'=>'Indiana','IA'=>'Iowa','KS'=>'Kansas','KY'=>'Kentucky','LA'=>'Louisiana','ME'=>'Maine','MD'=>'Maryland','MH'=>'Marshall Islands','MA'=>'Massachusetts','MI'=>'Michigan','MN'=>'Minnesota','MS'=>'Mississippi','MO'=>'Missouri','MT'=>'Montana','NE'=>'Nebraska','NV'=>'Nevada','NH'=>'New Hampshire','NJ'=>'New Jersey','NM'=>'New Mexico','NY'=>'New York','NC'=>'North Carolina','ND'=>'North Dakota','MP'=>'Northern Mariana Islands','OH'=>'Ohio','OK'=>'Oklahoma','OR'=>'Oregon','PW'=>'Palau','PA'=>'Pennsylvania','PR'=>'Puerto Rico','RI'=>'Rhode Island','SC'=>'South Carolina','SD'=>'South Dakota','TN'=>'Tennessee','TX'=>'Texas','UT'=>'Utah','VT'=>'Vermont','VI'=>'Virgin Islands','VA'=>'Virginia','WA'=>'Washington','WV'=>'West Virginia','WI'=>'Wisconsin','WY'=>'Wyoming');
foreach($_STATES as $k=>$v)
{
?><option value="<?= $k;?>" <?= ($_POST['cc_state']==$k) ? 'selected' : '';?>><?= $v;?></option><?php
}
?>
</select>
</td>
</tr>
<tr>
<td colspan="2">phone</td>
<td colspan="2">email</td>
</tr>
<tr>
<td colspan="2" class="phoneBox">
<input type="tel" class="full" name="phone_full" value="<?= $_REQUEST['phone_full'];?>" />
</td>
<td colspan="2"><input type="text" class="full" name="cc_email" value="" /></td>
</tr>
<tr>
<td colspan="4"><label><input id="inform_me" type="checkbox" name="inform_me" value="1" checked="checked" />Yes, inform me of new funding opportunities!</label></td>
</tr>
<tr>
<td colspan="4">
<input type="hidden" name="application" value="application">
<input type="hidden" name="tc" value="<?= $tc; ?>">
<input type="hidden" name="form_filled_out" value="index.php" />
<?= $trackerformparams; ?>
<input type="submit" class="submit" value="" />
<br />
<br />
<center>
<img src="/vx/usa/pci_form/ssl_logo.png" style="vertical-align:middle;" />
<a href="//www.securitymetrics.com/site_certificate?id=1889711&tk=b09e62c4cae0d777a4ffbb2d08faa4b0"
target="_blank" rel="noopener noreferrer" style="vertical-align:middle;">
<img src="https://www.securitymetrics.com/portal/app/ngsm/assets/img/BlueContent_Credit_Card_Safe_White_Sqr.png"
alt="SecurityMetrics Credit Card Safe" />
</a>
</center>
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td class="form_bot"></td>
</tr>
</table>
</form>
<p class="text">In order to pay the online advertising we have to do to get this information out to you, we need to charge a small registration fee of <?= (!empty($_SESSION['prm'])) ? '<span style="text-decoration:line-through">$'.$_INITIAL_FEE.'</span> <span style="color:#33aa66">$'.$_SESSION['prm']['initial'].'</span>' : '$'.$_INITIAL_FEE; ?>. We hope you understand. Remember, this information is updated on a regular basis so you should always have the most current information! Our membership registration fee also comes with a RISK FREE GUARANTEE: If you apply and don't qualify for one of the funding programs on our site, your fee will be refunded to you on the spot! All you have to do is send us the application and response you received from the funding agency, and we will refund you the <?= (!empty($_SESSION['prm'])) ? '<span style="text-decoration:line-through">$'.$_INITIAL_FEE.'</span> <span style="color:#33aa66">$'.$_SESSION['prm']['initial'].'</span>' : '$'.$_INITIAL_FEE; ?>! You have nothing to lose--either you qualify for Free Funding or you get your money back, GUARANTEED! You will have 90 days from the date of this transaction to submit your refund request along with your denial letter. You will have instant access to the online training program through our exclusive members-only application website.</p>
<p style="font:bold italic 14pt/140% SegoeUI; color:#DA912E; padding:5px 0 0 10px">What are you waiting for?</p>
<p class="text">Fill out the <a href="#form">Registration Form</a> above and start your Funding Applications today!</p>
<img src="https://www.surfcrm.com/lcapi/FormImpressionTracking.php?site=fa&ip_address=<?= $_SERVER['REMOTE_ADDR'];?>&form_url=index.php" />
<script type="text/javascript">
window.setTimeout(function() {
var form_session = new Image();
form_session.src = "https://www.surfcrm.com/lcapi/FormSessionTracking.php?site=fa&ip_address=<?= $_SERVER['REMOTE_ADDR'];?>&form_url=<?= urlencode($_SERVER['REQUEST_URI']);?>";
},10000);
</script>
<? require_once("footer.php")?>