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<?php
require_once($_SERVER['DOCUMENT_ROOT'].'/assets/includes/php_header.php');
$granttype = (isset($_GET['apptype'])) ? $_GET['apptype'] : 'business_funding';
$tc = (isset($_GET['tc'])) ? $_GET['tc'] : 'none' ;
$title = $_SITE_NAME." : Application";
switch ($granttype)
{
case "business_funding":
$grants = $businessgrants;
break;
case "1st_time_home":
case "real_estate_funding":
$grants = $realestategrants;
break;
case "education_tuition_funding":
$grants = $educationgrants;
break;
case "personal_assistance":
$grants = $personalgrants;
break;
case "women":
$grants = $women;
break;
case "seniors":
$grants = $seniors;
break;
case "minorities":
$grants = $minorities;
break;
case "faith":
$grants = $faith;
break;
case "non_profit":
$grants = $nonprofit;
break;
case "disabled":
$grants = $disabled;
break;
default:
$grants = $businessgrants;
break;
}
include('assets/includes/header2.php'); ?>
<script type="text/javascript">
// Create an associative array of 'pretty name' values
var prettynames = {
cc_fname:"First Name",
cc_lname:"Last Name",
cc_addr:"Address",
cc_city:"City",
cc_state:"State",
cc_country:"Country",
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_age:"Your age",
app_citizenship:"Citizenship",
app_funding_type:"What type of funding you are looking for?",
app_amount_needed:"How much money are you going to need?",
app_usedescription:"How do you want to use the money?",
app_uniqueness:"Why should the funder select you?",
app_married:"What is your martial status?",
app_dual_income:"Do you have a dual income household?",
app_employ: "What is your current employment status?",
app_house_income: "What is your total household income?",
app_previous_experience: "Tell us about any previous funding application experience you've had.",
app_community: "How will your project help in your community?",
app_hear: "How did you hear about us?",
app_refr: "Who referred you?"
};
var optional =[ "app_married", "app_dual_income", "app_employ", "app_house_income",
"app_previous_experience", "app_community", "app_hear", "app_refr"];
// Utility function that returns true if a string contains only
// whitespace characters
// Taken from "Javascript: The Definitive Guide" pg. 264
function isblank(s)
{
for (var i=0; i < s.length; i++)
{
var c = s.charAt(i);
if ((c!=' ') && (c != '\n') && (c != ''))
{
return false;
}
}
return true;
}
// Credit Card Validation Javascript
// copyright 12th May 2003, by Stephen Chapman, Felgall Pty Ltd
// You have permission to copy and use this javascript provided that
// the content of the script is not changed in any way.
function validateCreditCard(s) {
// remove non-numerics
var v = "0123456789";
var w = "";
for (i=0; i < s.length; i++) {
x = s.charAt(i);
if (v.indexOf(x,0) != -1)
w += x;
}
// validate number
j = w.length / 2;
if (j < 6.5 || j > 8 || j == 7) return false;
k = Math.floor(j);
m = Math.ceil(j) - k;
c = 0;
for (i=0; i<k; i++) {
a = w.charAt(i*2+m) * 2;
c += a > 9 ? Math.floor(a/10 + a%10) : a;
}
for (i=0; i<k+m; i++) c += w.charAt(i*2+1-m) * 1;
return (c%10 == 0);
}
function verify(f)
{
// Taken from "Javascript: The Definitive Guide" pg. 264.
// Modified heavily to suit our needs
// 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.
f.cc_phonearea.requiredlength = 3;
f.cc_phonearea.numeric = true;
f.cc_phoneprefix.requiredlength = 3;
f.cc_phoneprefix.numeric = true;
f.cc_phoneextension.requiredlength = 4;
f.cc_phoneextension.numeric = true;
f.cc_zip.requiredlength = 5;
f.cc_zip.numeric = true;
var msg;
var empty_fields = "";
var errors = "";
var required = true;
for (var i=0; i < f.length; i++)
{
var element = f.elements[i];
for(var j=0; j < optional.length; j++) {
if(element.name == optional[j]) {
required = false;
}
}
//document.getElementById('errorconsole').innerHTML += element.name + ":" + element.type + "<br>";
if(required) {
if ((element.type == 'text' || element.type == 'textarea'))
{
if ( (element.value == null || element.value == "") || isblank(element.value) )
{
empty_fields += "\n " + prettynames[element.name];
continue;
}
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];
continue;
}
}
}
}
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;
}
</script>
<script language="javascript">
var ids=new Array();
ids[0]="busgrants";
ids[1]="edugrants";
ids[2]="comgrants";
ids[3]="pergrants";
ids[4]="reagrants";
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>
<!--INFO AREA + BOX MIDDLE-->
<div style="background:url(assets/images/box_middle.png) repeat-y; width:1000px; float:left">
<h2><?=$_SITE_NAME;?> Registration Form</h2>
<!--COLUMN-->
<div id="one_column" class="terms">
<div style="padding:0px; margin:0px;">
<style type="text/css">
h2 { font-family:Arial, Helvetica, sans-serif; font-size:18px; font-weight:bold; margin:0px; }
fieldset {border:3px double #ccc; float:left; margin:3px 0px; padding:0px;}
fieldset table {width: 600px; margin:10px}
fieldset td {font:8.5pt/120% verdana}
fieldset input, fieldset select {font:8.5pt/120% verdana}
.text {font:8.5pt/120% verdan; border:1px solid #ccc}
legend {background: url(assets/images/ttl_bg.png) top left no-repeat; width:217px; height:18px; padding:1px 0px 0px 5px; margin:0px 6px; font:bold 8pt/120% verdana; text-transform:uppercase;}
label {cursor:pointer;margin:2px}
container {border:1px solid #cccccc; width:650px; text-align:center; padding:10px 20px}
.wht {border:1px solid #fff;}
.grant_category {margin-bottom:15px; width:95%}
.grant_category .txt {cursor:pointer; border-bottom:1px dotted #333333; margin-bottom:5px}
.grant_category .txt p {float:left; clear:both; width:100%; font-size:9px !important; text-transform:none; text-indent:24px; white-space:nowrap; padding:3px 0px}
.grant_category .txt label {font-weight:normal; text-transform:uppercase}
.grant_category .txt input {margin:3px 3px -4px 0}
.grant_category .img {background-repeat:no-repeat; background-position:0px 2px; padding-left:50px; height:41px !important}
.grant_category .col {width:33%}
.grant_category .hrd {font-weight:bold; text-transform:uppercase; border-bottom:1px solid #333333; height:15px}
.grant_category .hrd span {font-weight:normal; text-transform:none; font-style:italic}
</style>
<form action="https://<?= $_SERVER['SERVER_NAME'].'/order.php'?>" method="post" name="apply" onsubmit="return verify(this);">
<div class="container" style="width:900px">
<div style="background-color:#f2f2f2; text-align:left; font:9pt/120% verdana; height:1500px; width:240px; float:left;padding:10px; margin:15px 5px">Please fill out the information to the right. Try to be as detailed as possible for each of the questions. Your information is confidential and will only be used in researching new funding opportunities for you to apply. We want to provide the most up-to-date information to you to help you succeed in your funding endeavors.</div>
<fieldset>
<legend>PERSONAL PROFILE</legend>
<table cellpadding="3" cellspacing="0" border="0">
<tr>
<td colspan="2">First Name</td>
<td colspan="2">Last Name</td>
</tr>
<tr>
<td colspan="2"><input type="text" class="text" size="30" name="cc_fname" value="<?= ($_REQUEST['cc_fname']) ? $_REQUEST['cc_fname'] : null; ?>" /></td>
<td colspan="2"><input type="text" class="text" size="54" name="cc_lname" value="<?= ($_REQUEST['cc_lname']) ? $_REQUEST['cc_lname'] : null; ?>" /></td>
</tr>
<tr>
<td colspan="4">Address</td>
</tr>
<tr>
<td colspan="4"><input type="text" class="text" size="90" name="cc_addr" value="<?= ($_REQUEST['cc_addr']) ? $_REQUEST['cc_addr'] : null; ?>" /></td>
</tr>
<tr>
<td>City</td>
<td colspan="2">State</td>
<td style="display:inline" nowrap="nowrap">Zip Country</td>
</tr>
<tr>
<td colspan="2"><input type="text" class="text" size="15" name="cc_city" value="<?= ($_REQUEST['cc_city']) ? $_REQUEST['cc_city'] : null; ?>" /></td>
<td>
<select name="cc_state">
<option value="">Select</option>
<?php foreach($STATES as $abbr=>$name) : ?>
<option value="<?=$abbr;?>" <?= (isset($_POST['cc_state']) && $_POST['cc_state'] == $abbr) ? "selected" : null; ?>><?=$name;?></option>
<?php endforeach; ?>
</select>
</td>
<td style="display:inline" nowrap="nowrap">
<input type="text" class="text" size="6" name="cc_zip" value="<?= ($_REQUEST['cc_zip']) ? $_REQUEST['cc_zip'] : null; ?>" />
<select name="cc_country">
<option>Select...</option>
<option value="US" selected>U.S.A.</option>
</select>
</td>
</tr>
<tr>
<td colspan="2">Email</td>
<td colspan="2">Phone Number</td>
</tr>
<tr>
<td colspan="2"><input type="text" class="text" size="30" name="cc_email" value="<?= ($_REQUEST['cc_email']) ? $_REQUEST['cc_email'] : null; ?>" /></td>
<td colspan="2">(<input type="text" class="text" size="4" name="cc_phonearea" maxlength="3" value="<?= ($_REQUEST['cc_phonearea']) ? $_REQUEST['cc_phonearea'] : null; ?>" />)
<input type="text" class="text" size="4" name="cc_phoneprefix" maxlength="3" value="<?= ($_REQUEST['cc_phoneprefix']) ? $_REQUEST['cc_phoneprefix'] : null; ?>" /> -
<input type="text" class="text" size="4" name="cc_phoneextension" maxlength="4" value="<?= ($_REQUEST['cc_phoneextension']) ? $_REQUEST['cc_phoneextension'] : null; ?>" />
</td>
</tr>
</table>
</fieldset>
<fieldset>
<legend>TELL US ABOUT YOURSELF</legend>
<table cellpadding="4" cellspacing="4" border="0" style="border-collapse:separate">
<tr>
<td>Citizenship</td>
<td>Gender</td>
<td>Age</td>
<td>Married</td>
<td>Dual Income</td>
<td></td>
</tr>
<tr>
<td>
<select name="app_citizenship">
<option>Select...</option>
<option value="U.S. Citizen">U.S. Citizen</option>
<option value="Resident Alien">Resident Alien</option>
<option value="Green Card Holder">Green Card Holder</option>
<option value="Permanent Resident">Permanent Resident</option>
<option value="Not Sure">Not Sure</option>
</select>
</td>
<td>
<select name="app_gender">
<option>Select...</option>
<option value="M">Male</option>
<option value="F">Female</option>
</select>
</td>
<td>
<select name="app_age">
<option>Select...</option>
<option value="18-25">18-25</option>
<option value="26-34">26-34</option>
<option value="35-49">35-49</option>
<option value="50-65">50-65</option>
<option value="66-80">66-80</option>
<option value="80+">80 +</option>
</select>
</td>
<td>
<select name="app_married">
<option>Select...</option>
<option value="R">Married</option>
<option value="U">Unmarried</option>
</select>
</td>
<td>
<select name="app_dual_income">
<option>Select...</option>
<option value="Y">Yes</option>
<option value="N">No</option>
</select>
</td>
<td width="50%"></td>
</tr>
<tr>
<td colspan="6">Employment Status</td>
</tr>
<tr>
<td colspan="6" style="margin-left:30px">
<label><input type="radio" name="app_employ" value="full" />Full Time</label>
<label><input type="radio" name="app_employ" value="part" />Part Time</label>
<label><input type="radio" name="app_employ" value="self" />Self Employed</label>
<label><input type="radio" name="app_employ" value="unem" />Unemployed</label>
<label><input type="radio" name="app_employ" value="stud" />Student</label>
<label><input type="radio" name="app_employ" value="retr" />Retired</label>
</td>
</tr>
<tr>
<td colspan="6">Household Income:</td>
</tr>
<tr>
<td colspan="6">
<select name="app_house_income">
<option>Select...</option>
<option>10,000</option>
<option>$10,000 - $25,000</option>
<option>$25,000 - $50,000</option>
<option>$50,000 - $75,000</option>
<option>$75,000 - $100,000</option>
<option>$100,000 - $150,000</option>
<option>$150,000 +</option>
</select>
</td>
</tr>
</table>
</fieldset>
<fieldset>
<legend>FUNDING</legend>
<table cellpadding="3" cellspacing="0" border="0">
<tr>
<td nowrap>How much money are you looking for?</td>
<td>
<select name="app_amount_needed">
<option>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 - $100,000</option>
<?
if ($granttype != 'business_funding')
{
echo "<option value=\"$100,000 or More\">\$100,000 or More</option>";
}
else
{
?>
<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>
</td>
</tr>
<tr>
<td colspan="2"> </td>
</tr>
<tr>
<td colspan="2">Choose which funding category you are interested in</td>
</tr>
<tr>
<td colspan="2">
<table cellpadding="2" cellspacing="0" class="grant_category">
<tr>
<td class="txt img" style="border-top:1px dotted #333333; background-image:url(assets/images/cat_business.png)" id="bus_grant">
<label title="Business Funding">
<input type="radio" name="granttypes" id="granttype_bus" value="Business Funding" onclick="switchid('busgrants');">Business Funding
<p>Statup Capital, Expand Business, Private Money, Venture Capital, Inventions</p></label>
</td>
</tr>
<tr>
<td class="txt img" style="background-image:url(assets/images/cat_education.png)" id="edu_grant">
<label title="Education Funding">
<input type="radio" name="granttypes" id="granttype_edu" value="Education Funding" onclick="switchid('edugrants');">Education Funding
<p>Tuition, Student Financial Aid, Stafford Loans, Scholarships, Research</p></label>
</td>
</tr>
<tr>
<td class="txt img" style="background-image:url(assets/images/cat_community.png)" id="com_grant">
<label title="Community Funding">
<input type="radio" name="granttypes" id="granttype_com" value="Community Funding" onclick="switchid('comgrants');">Community Funding
<p>Performing Arts, Humanities, Crime Prevention, Disaster Relief / Prevention</p></label>
</td>
</tr>
<tr>
<td class="txt img" style="background-image:url(assets/images/cat_personal.png)" id="per_grant">
<label title="Personal Funding">
<input type="radio" name="granttypes" id="granttype_per" value="Personal Funding" onclick="switchid('pergrants');">Personal Funding
<p>Medical Expenses, Food Stamps, Child Care, Rent Assistance, Veterans</p></label>
</td>
</tr>
<tr>
<td class="txt img" style="background-image:url(assets/images/cat_realestate.png)" id="rea_grant">
<label title="Real Estate Funding">
<input type="radio" name="granttypes" id="granttype_rea" value="Real Estate Funding" onclick="switchid('reagrants');">Real Estate Funding
<p>1st Time Home Buyers, New Construction, Rental Properties, Commercial, Repairs</p></label>
</td>
</tr>
</table>
<table cellpadding="2" cellspacing="0" class="grant_category" id="busgrants" style="display:none">
<tr>
<td colspan="3" class="hrd">Suggested "Business" Sub-Categories <span>(Check all that apply)</span></td>
</tr>
<tr>
<td class="txt col">
<label for="busgrant_0" title="Startup Capital">
<input type="checkbox" name="busgrant_0" id="busgrant_0" value="Startup Capital">Startup Capital</label>
</td>
<td class="txt col">
<label for="busgrant_1" title="Green Business">
<input type="checkbox" name="busgrant_1" id="busgrant_1" value="Green Business">Green Business</label>
</td>
<td class="txt col">
<label for="busgrant_2" title="Minority Owned">
<input type="checkbox" name="busgrant_2" id="busgrant_2" value="Minority Owned">Minority Owned</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="busgrant_3" title="Expand Business">
<input type="checkbox" name="busgrant_3" id="busgrant_3" value="Expand">Expand Business</label>
</td>
<td class="txt col">
<label for="busgrant_4" title="Training">
<input type="checkbox" name="busgrant_4" id="busgrant_4" value="Training">Training</label>
</td>
<td class="txt col">
<label for="busgrant_5" title="Invention">
<input type="checkbox" name="busgrant_5" id="busgrant_5" value="Invention">Invention</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="busgrant_6" title="Women Owned">
<input type="checkbox" name="busgrant_6" id="busgrant_6" value="Women Owned">Women Owned</label>
</td>
<td class="txt col">
<label for="busgrant_7" title="Technology">
<input type="checkbox" name="busgrant_7" id="busgrant_7" value="Technology">Technology</label>
</td>
<td class="txt col"> </td>
</tr>
</table>
<table cellpadding="2" cellspacing="0" class="grant_category" id="edugrants" style="display:none">
<tr>
<td colspan="3" class="hrd">Suggested "Education" Sub-Categories <span>(Check all that apply)</span></td>
</tr>
<tr>
<td class="txt col">
<label for="edugrant_0" title="Tuition">
<input type="checkbox" name="edugrant_0" id="edugrant_0" value="Tuition">Tuition</label>
</td>
<td class="txt col">
<label for="edugrant_1" title="Interships">
<input type="checkbox" name="edugrant_1" id="edugrant_1" value="Interships">Interships</label>
</td>
<td class="txt col">
<label for="edugrant_2" title="Training">
<input type="checkbox" name="edugrant_2" id="edugrant_2" value="Training">Training</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="edugrant_3" title="Scholarships">
<input type="checkbox" name="edugrant_3" id="edugrant_3" value="Scholarships">Scholarships</label>
</td>
<td class="txt col">
<label for="edugrant_4" title="Housing / Boarding">
<input type="checkbox" name="edugrant_4" id="edugrant_4" value="Housing / Boarding">Housing / Boarding</label>
</td>
<td class="txt col">
<label for="edugrant_5" title="Research Grants">
<input type="checkbox" name="edugrant_5" id="edugrant_5" value="Research Grants">Research Grants</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="edugrant_6" title="University Grants">
<input type="checkbox" name="edugrant_6" id="edugrant_6" value="University Grants">University Grants</label>
</td>
<td class="txt col">
<label for="edugrant_7" title="Teacher / Staff">
<input type="checkbox" name="edugrant_7" id="edugrant_7" value="Teacher / Staff">Teacher / Staff</label>
</td>
<td class="txt col">
<label for="edugrant_8" title="Science">
<input type="checkbox" name="edugrant_8" id="edugrant_8" value="Science">Science</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="edugrant_9" title="Technology">
<input type="checkbox" name="edugrant_9" id="edugrant_9" value="Technology">Technology</label>
</td>
<td class="txt col"> </td>
<td class="txt col"> </td>
</tr>
</table>
<table cellpadding="2" cellspacing="0" class="grant_category" id="comgrants" style="display:none">
<tr>
<td colspan="3" class="hrd">Suggested "Community" Sub-Categories <span>(Check all that apply)</span></td>
</tr>
<tr>
<td class="txt col">
<label for="comgrant_0" title="Disaster Relief">
<input type="checkbox" name="comgrant_0" id="comgrant_0" value="Disaster Relief">Disaster Relief</label>
</td>
<td class="txt col">
<label for="comgrant_1" title="Disaster Prevention">
<input type="checkbox" name="comgrant_1" id="comgrant_1" value="Disaster Prevention">Disaster Prevention</label>
</td>
<td class="txt col">
<label for="comgrant_2" title="Crime Prevention">
<input type="checkbox" name="comgrant_2" id="comgrant_2" value="Crime Prevention">Crime Prevention</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="comgrant_3" title="Performing Arts">
<input type="checkbox" name="comgrant_3" id="comgrant_3" value="Performing Arts">Performing Arts</label>
</td>
<td class="txt col">
<label for="comgrant_4" title="Historical Sites">
<input type="checkbox" name="comgrant_4" id="comgrant_4" value="Historical Sites">Historical Sites</label>
</td>
<td class="txt col">
<label for="comgrant_5" title="Humanities">
<input type="checkbox" name="comgrant_5" id="comgrant_5" value="Humanities">Humanities</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="comgrant_6" title="Non Profit">
<input type="checkbox" name="comgrant_6" id="comgrant_6" value="Non Profit">Non Profit</label>
</td>
<td class="txt col">
<label for="comgrant_7" title="Arts">
<input type="checkbox" name="comgrant_7" id="comgrant_7" value="Arts">Arts</label>
</td>
<td class="txt col">
<label for="comgrant_8" title="Transportation">
<input type="checkbox" name="comgrant_8" id="comgrant_8" value="Transportation">Transportation</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="comgrant_9" title="Green Community">
<input type="checkbox" name="comgrant_9" id="comgrant_9" value="Green Community">Green Community</label>
</td>
<td class="txt col">
<label for="comgrant_a" title="Senior">
<input type="checkbox" name="comgrant_a" id="comgrant_a" value="Senior">Senior</label>
</td>
<td class="txt col">
<label for="comgrant_b" title="Social Services">
<input type="checkbox" name="comgrant_b" id="comgrant_b" value="Social Services">Social Services</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="comgrant_c" title="Environmental">
<input type="checkbox" name="comgrant_c" id="comgrant_c" value="Environmental">Environmental</label>
</td>
<td class="txt col"> </td>
<td class="txt col"> </td>
</tr>
</table>
<table cellpadding="2" cellspacing="0" class="grant_category" id="pergrants" style="display:none">
<tr>
<td colspan="3" class="hrd">Suggested "Personal" Sub-Categories <span>(Check all that apply)</span></td>
</tr>
<tr>
<td class="txt col">
<label for="pergrant_0" title="Bills">
<input type="checkbox" name="pergrant_0" id="pergrant_0" value="Bills">Bills</label>
</td>
<td class="txt col">
<label for="pergrant_1" title="Medical Expenses">
<input type="checkbox" name="pergrant_1" id="pergrant_1" value="Medical Expenses">Medical Expenses</label>
</td>
<td class="txt col">
<label for="pergrant_2" title="Child Care">
<input type="checkbox" name="pergrant_2" id="pergrant_2" value="Child Care">Child Care</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="pergrant_3" title="Utility Bills">
<input type="checkbox" name="pergrant_3" id="pergrant_3" value="Utility Bills">Utility Bills</label>
</td>
<td class="txt col">
<label for="pergrant_4" title="Rent Assistance">
<input type="checkbox" name="pergrant_4" id="pergrant_4" value="Rent Assistance">Rent Assistance</label>
</td>
<td class="txt col">
<label for="pergrant_5" title="Food Stamps">
<input type="checkbox" name="pergrant_5" id="pergrant_5" value="Food Stamps">Food Stamps</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="pergrant_6" title="Drug Abuse Treatment">
<input type="checkbox" name="pergrant_6" id="pergrant_6" value="Drug Abuse Treatment">Drug Abuse Treatment</label>
</td>
<td class="txt col">
<label for="pergrant_7" title="Veterans">
<input type="checkbox" name="pergrant_7" id="pergrant_7" value="Veterans">Veterans</label>
</td>
<td class="txt col">
<label for="pergrant_8" title="Low Income">
<input type="checkbox" name="pergrant_8" id="pergrant_8" value="Low Income">Low Income</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="pergrant_9" title="Senior">
<input type="checkbox" name="pergrant_9" id="pergrant_9" value="Senior">Senior</label>
</td>
<td class="txt col">
<label for="pergrant_a" title="Food / Nutrition">
<input type="checkbox" name="pergrant_a" id="pergrant_a" value="Food / Nutrition">Food / Nutrition</label>
</td>
<td class="txt col"> </td>
</tr>
</table>
<table cellpadding="2" cellspacing="0" class="grant_category" id="reagrants" style="display:none">
<tr>
<td colspan="3" class="hrd">Suggested "Real Estate" Sub-Categories <span>(Check all that apply)</span></td>
</tr>
<tr>
<td class="txt col">
<label for="reagrant0" title="Rental Properties">
<input type="checkbox" name="reagrant0" id="reagrant0" value="Rental Properties">Rental Properties</label>
</td>
<td class="txt col">
<label for="reagrant1" title="1st Time Home Buyers">
<input type="checkbox" name="reagrant1" id="reagrant1" value="1st Time Home Buyers">1st Time Home Buyers</label>
</td>
<td class="txt col">
<label for="reagrant2" title="Apartment Buildings">
<input type="checkbox" name="reagrant2" id="reagrant2" value="Apartment Buildings">Apartment Buildings</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="reagrant3" title="RV Parks">
<input type="checkbox" name="reagrant3" id="reagrant3" value="RV Parks">RV Parks</label>
</td>
<td class="txt col">
<label for="reagrant4" title="Mobile Home Parks">
<input type="checkbox" name="reagrant4" id="reagrant4" value="Mobile Home Parks">Mobile Home Parks</label>
</td>
<td class="txt col">
<label for="reagrant5" title="Commerical">
<input type="checkbox" name="reagrant5" id="reagrant5" value="Commerical">Commerical</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="reagrant6" title="Land Development">
<input type="checkbox" name="reagrant6" id="reagrant6" value="Land Development">Land Development</label>
</td>
<td class="txt col">
<label for="reagrant7" title="New Construction">
<input type="checkbox" name="reagrant7" id="reagrant7" value="New Construction">New Construction</label>
</td>
<td class="txt col">
<label for="reagrant8" title="Property Repair">
<input type="checkbox" name="reagrant8" id="reagrant8" value="Property Repair">Property Repair</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="reagrant9" title="Historic Renovation">
<input type="checkbox" name="reagrant9" id="reagrant9" value="Historic Renovation">Historic Renovation</label>
</td>
<td class="txt col">
<label for="reagranta" title="Home Improvements">
<input type="checkbox" name="reagranta" id="reagranta" value="Home Improvements">Home Improvements</label>
</td>
<td class="txt col"> </td>
</tr>
</table>
</td>
</tr>
<tr>
<td colspan="2">What are you looking to do with the money?</td>
</tr>
<tr>
<td colspan="2"><textarea name="app_usedescription" style="width:600px; height:125px;"></textarea></td>
</tr>
<tr>
<td colspan="2">Have you applied for funding before? Please tell us about your experience.</td>
</tr>
<tr>
<td colspan="2"><textarea name="app_previous_experience" style="width:600px; height:125px;"></textarea></td>
</tr>
</table>
</fieldset>
<fieldset>
<legend>YOUR FUNDING NEEDS</legend>
<table cellpadding="3" cellspacing="0" border="0">
<tr>
<td nowrap>Does your project fulfill a need in your community? If so, how?</td>
</tr>
<tr>
<td><textarea name="app_community" style="width:600px; height:125px;"></textarea></td>
</tr>
<tr>
<td nowrap>Why would a funder pick you instead of someone else? What sets you apart from other funders?</td>
</tr>
<tr>
<td><textarea name="app_uniqueness" style="width:600px; height:125px;"></textarea></td>
</tr>
</table>
</fieldset>
<fieldset>
<legend>OTHER</legend>
<table cellpadding="3" cellspacing="0" border="0">
<tr>
<td>How did you hear about us?</td>
</tr>
<tr>
<td valign="top" style="margin-left:30px">
<label><input type="radio" name="app_hear" value="internet" />Search Engine</label>
<label><input type="radio" name="app_hear" value="email" />Email</label>
<label><input type="radio" name="app_hear" value="phone" />Phone</label>
<label><input type="radio" name="app_hear" value="radio" />Radio</label>
<label><input type="radio" name="app_hear" value="other" />Other</label>
</td>
</tr>
<tr>
<td>Who referred you?</td>
</tr>
<tr>
<td valign="top" style="margin-left:30px">
<label><input type="radio" name="app_refr" value="google" />Google</label>
<label><input type="radio" name="app_refr" value="yahoo" />Yahoo</label>
<label><input type="radio" name="app_refr" value="msn" />MSN</label>
<label><input type="radio" name="app_refr" value="bing" />Bing</label>
<label><input type="radio" name="app_refr" value="other" />Other</label>
</td>
</tr>
</table>
</fieldset>
<fieldset class="wht" style="float:right">
<table cellpadding="3" cellspacing="0" border="0">
<?php /*
<tr>
<td>
<div style="width:600px; margin:20px 0px; text-align:left;"><p><input type="checkbox" checked name="" value="" /> Yes, please keep me up-to-date on new funding opportunities via email as they are found by the <?=$_SITE_NAME;?> Research Team. Your email will only be used by <?=$_SITE_NAME;?> to help you in your research and application needs. You will receive an email to help us confirm your registration to our research team. Please reply back to it and add us to your contacts! We look forward to working with you!</p></div>
</td>
</tr>
*/ ?>
<tr>
<td align="center">
<input type="submit" style="background:url('/assets/images/b_applytoday.png') no-repeat scroll center top transparent; border:0px none; cursor:pointer; width:200px; height:50px;" value="" />
<input type="hidden" name="granttype" value="<? echo $granttype; ?>" />
<input type="hidden" name="application" value="application" />
<input type="hidden" name="tc" value="<?= $tc; ?>" />
<?= $trackerformparams; ?>
</td>
</tr>
</table>
</fieldset>
</div>
</form>
</div> <!--end centered div-->
</div> <!--end one column-->
<div style="clear:both;"></div>
</div> <!--end info area-->
<!--INCLUDE FOOTER-->
<?php include('assets/includes/footer.php'); ?>