{"id":235721,"date":"2023-12-19T11:22:20","date_gmt":"2023-12-19T16:22:20","guid":{"rendered":"https:\/\/wcc-tech.ca\/home\/?page_id=235721"},"modified":"2023-12-19T13:24:24","modified_gmt":"2023-12-19T18:24:24","slug":"sign-up-referral","status":"publish","type":"page","link":"https:\/\/wcc-tech.ca\/home\/sign-up-referral\/","title":{"rendered":"Sign Up &#8211; Referral"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; fullwidth=&#8221;on&#8221; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_fullwidth_menu menu_id=&#8221;4&#8243; active_link_color=&#8221;#f7f9ff&#8221; logo=&#8221;https:\/\/wcc-tech.ca\/home\/wp-content\/uploads\/2020\/12\/WCCT.png&#8221; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; menu_text_color=&#8221;#ffffff&#8221; background_color=&#8221;#201c44&#8243; text_orientation=&#8221;right&#8221; background_layout=&#8221;dark&#8221; menu_font_tablet=&#8221;&#8221; menu_font_phone=&#8221;&#8221; menu_font_last_edited=&#8221;on|desktop&#8221; box_shadow_style=&#8221;preset2&#8243; global_colors_info=&#8221;{}&#8221;][\/et_pb_fullwidth_menu][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; background_image=&#8221;https:\/\/wcc-tech.ca\/home\/wp-content\/uploads\/2020\/12\/communication-tower-design-02.png&#8221; custom_padding=&#8221;54px||54px||false|&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#201c44&#8243; custom_padding=&#8221;|30px||30px|false|true&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#201c44&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.23.1&#8243; _module_preset=&#8221;default&#8221; text_line_height=&#8221;1.4em&#8221; header_font=&#8221;|600|||||||&#8221; header_font_size=&#8221;42px&#8221; header_line_height=&#8221;3em&#8221; background_image=&#8221;https:\/\/wcc-tech.ca\/home\/wp-content\/uploads\/2021\/01\/Sign-up-Image.jpeg&#8221; min_height=&#8221;54px&#8221; min_height_tablet=&#8221;&#8221; min_height_phone=&#8221;&#8221; min_height_last_edited=&#8221;on|desktop&#8221; custom_margin=&#8221;0px||||false|true&#8221; custom_padding=&#8221;|10px||10px|false|true&#8221; custom_padding_tablet=&#8221;&#8221; custom_padding_phone=&#8221;&#8221; custom_padding_last_edited=&#8221;on|phone&#8221; hover_enabled=&#8221;0&#8243; header_font_size_tablet=&#8221;30px&#8221; header_font_size_phone=&#8221;&#8221; header_font_size_last_edited=&#8221;on|desktop&#8221; background_last_edited=&#8221;on|tablet&#8221; text_text_shadow_style=&#8221;preset2&#8243; text_text_shadow_color=&#8221;#201c44&#8243; header_text_shadow_style=&#8221;preset2&#8243; header_text_shadow_color=&#8221;#201c44&#8243; global_colors_info=&#8221;{}&#8221; title_text=&#8221;Sign-up-Image&#8221; sticky_enabled=&#8221;0&#8243;]<\/p>\n<h1 style=\"text-align: center;\"><strong><span style=\"color: #ffffff;\">Referral Special &#8211; Sign Up<\/span><\/strong><\/h1>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#d7deed&#8221; box_shadow_style=&#8221;preset6&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.23.1&#8243; _module_preset=&#8221;default&#8221; min_height=&#8221;190px&#8221; custom_padding=&#8221;|20px||20px|false|true&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<div id=\"quform-2fe80b\" class=\"quform quform-8 quform-support-page-caching\"><form id=\"quform-form-2fe80b\" class=\"quform-form quform-form-8\" action=\"\/home\/wp-json\/wp\/v2\/pages\/235721#quform-2fe80b\" method=\"post\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-options=\"{&quot;id&quot;:8,&quot;uniqueId&quot;:&quot;2fe80b&quot;,&quot;theme&quot;:&quot;&quot;,&quot;ajax&quot;:true,&quot;logic&quot;:{&quot;logic&quot;:[],&quot;dependents&quot;:[],&quot;elementIds&quot;:[],&quot;dependentElementIds&quot;:[],&quot;animate&quot;:true},&quot;currentPageId&quot;:1,&quot;errorsIcon&quot;:&quot;&quot;,&quot;updateFancybox&quot;:true,&quot;hasPages&quot;:false,&quot;pages&quot;:[1],&quot;pageProgressType&quot;:&quot;numbers&quot;,&quot;tooltipsEnabled&quot;:true,&quot;tooltipClasses&quot;:&quot;qtip-quform-dark qtip-shadow&quot;,&quot;tooltipMy&quot;:&quot;left center&quot;,&quot;tooltipAt&quot;:&quot;right center&quot;,&quot;isRtl&quot;:false,&quot;scrollOffset&quot;:-50,&quot;scrollSpeed&quot;:800}\"><button class=\"quform-default-submit\" name=\"quform_submit\" type=\"submit\" value=\"submit\" aria-hidden=\"true\" tabindex=\"-1\"><\/button><div class=\"quform-form-inner quform-form-inner-8\"><input type=\"hidden\" name=\"quform_form_id\" value=\"8\" \/><input type=\"hidden\" name=\"quform_form_uid\" value=\"2fe80b\" \/><input type=\"hidden\" name=\"quform_count\" value=\"1\" \/><input type=\"hidden\" name=\"form_url\" value=\"https:\/\/wcc-tech.ca\/home\/wp-json\/wp\/v2\/pages\/235721\" \/><input type=\"hidden\" name=\"referring_url\" value=\"\" \/><input type=\"hidden\" name=\"post_id\" value=\"\" \/><input type=\"hidden\" name=\"post_title\" value=\"\" \/><input type=\"hidden\" name=\"quform_current_page_id\" value=\"1\" \/><input type=\"hidden\" name=\"quform_csrf_token\" value=\"SoL7ET6lLj8kH1c2XjvqbHjAYGrTJOgPYTtMEWRf\" \/><div class=\"quform-elements quform-elements-8 quform-cf quform-responsive-elements-phone-landscape\"><div class=\"quform-element quform-element-page quform-page-1 quform-page-8_1 quform-cf quform-group-style-plain quform-first-page quform-last-page quform-current-page\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-group quform-element-8_3 quform-cf quform-group-style-plain\"><div class=\"quform-spacer\"><div class=\"quform-group-title-description\"><h4 class=\"quform-group-title\">Current Customer Information<\/h4><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-row quform-element-row-8_4 quform-3-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-8_5\"><div class=\"quform-element quform-element-text quform-element-8_8 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_8\"><label class=\"quform-label-text\" for=\"quform_8_8_2fe80b\">Customer ID (Rxxxx or Bxxxx)<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_8\"><div class=\"quform-input quform-input-text quform-input-8_8 quform-cf\"><input type=\"text\" id=\"quform_8_8_2fe80b\" name=\"quform_8_8\" class=\"quform-field quform-field-text quform-field-8_8\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-8_6\"><div class=\"quform-element quform-element-text quform-element-8_9 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_9\"><label class=\"quform-label-text\" for=\"quform_8_9_2fe80b\">First Name<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_9\"><div class=\"quform-input quform-input-text quform-input-8_9 quform-cf\"><input type=\"text\" id=\"quform_8_9_2fe80b\" name=\"quform_8_9\" class=\"quform-field quform-field-text quform-field-8_9\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-8_7\"><div class=\"quform-element quform-element-text quform-element-8_10 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_10\"><label class=\"quform-label-text\" for=\"quform_8_10_2fe80b\">Last Name<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_10\"><div class=\"quform-input quform-input-text quform-input-8_10 quform-cf\"><input type=\"text\" id=\"quform_8_10_2fe80b\" name=\"quform_8_10\" class=\"quform-field quform-field-text quform-field-8_10\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-8_12 quform-1-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-8_13\"><div class=\"quform-element quform-element-email quform-element-8_43 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_43\"><label class=\"quform-label-text\" for=\"quform_8_43_2fe80b\">Email address<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-email quform-inner-8_43\"><div class=\"quform-input quform-input-email quform-input-8_43 quform-cf\"><input type=\"email\" id=\"quform_8_43_2fe80b\" name=\"quform_8_43\" class=\"quform-field quform-field-email quform-field-8_43\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-8_14 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_14\"><label class=\"quform-label-text\" for=\"quform_8_14_2fe80b\">Address - Street Number and Name<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_14\"><div class=\"quform-input quform-input-text quform-input-8_14 quform-cf\"><input type=\"text\" id=\"quform_8_14_2fe80b\" name=\"quform_8_14\" class=\"quform-field quform-field-text quform-field-8_14\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-8_44 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_44\"><label class=\"quform-label-text\" for=\"quform_8_44_2fe80b\">Instructions \/ Comments<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-8_44\"><div class=\"quform-input quform-input-textarea quform-input-8_44 quform-cf\"><textarea id=\"quform_8_44_2fe80b\" name=\"quform_8_44\" class=\"quform-field quform-field-textarea quform-field-8_44\"><\/textarea><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-8_19 quform-cf quform-group-style-plain\"><div class=\"quform-spacer\"><div class=\"quform-group-title-description\"><h4 class=\"quform-group-title\">Referred Person<\/h4><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-row quform-element-row-8_20 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-8_21\"><div class=\"quform-element quform-element-text quform-element-8_23 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_23\"><label class=\"quform-label-text\" for=\"quform_8_23_2fe80b\">First Name<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_23\"><div class=\"quform-input quform-input-text quform-input-8_23 quform-cf\"><input type=\"text\" id=\"quform_8_23_2fe80b\" name=\"quform_8_23\" class=\"quform-field quform-field-text quform-field-8_23\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-8_22\"><div class=\"quform-element quform-element-text quform-element-8_24 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_24\"><label class=\"quform-label-text\" for=\"quform_8_24_2fe80b\">Last Name<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_24\"><div class=\"quform-input quform-input-text quform-input-8_24 quform-cf\"><input type=\"text\" id=\"quform_8_24_2fe80b\" name=\"quform_8_24\" class=\"quform-field quform-field-text quform-field-8_24\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-8_37 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-8_38\"><div class=\"quform-element quform-element-text quform-element-8_39 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_39\"><label class=\"quform-label-text\" for=\"quform_8_39_2fe80b\">Phone<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_39\"><div class=\"quform-input quform-input-text quform-input-8_39 quform-cf\"><input type=\"text\" id=\"quform_8_39_2fe80b\" name=\"quform_8_39\" class=\"quform-field quform-field-text quform-field-8_39\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-8_40\"><div class=\"quform-element quform-element-text quform-element-8_41 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_41\"><label class=\"quform-label-text\" for=\"quform_8_41_2fe80b\">Email<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_41\"><div class=\"quform-input quform-input-text quform-input-8_41 quform-cf\"><input type=\"text\" id=\"quform_8_41_2fe80b\" name=\"quform_8_41\" class=\"quform-field quform-field-text quform-field-8_41\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-8_25 quform-1-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-8_26\"><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-8_2 quform-cf quform-button-style-classic\"><div class=\"quform-button-submit quform-button-submit-default quform-button-submit-8_2\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-submit\" value=\"submit\"><span class=\"quform-button-text quform-button-submit-text\">Submit<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element-tree\"><label for=\"quform_8_0_2fe80b\">This field should be left blank<\/label><input type=\"text\" id=\"quform_8_0_2fe80b\" name=\"quform_8_0\" class=\"quform-field quform-field-tree quform-field-8_0\" tabindex=\"-1\" autocomplete=\"off\" \/><\/div><\/div><\/div><\/div><\/div><\/form><\/div>\n<p>[\/et_pb_text][et_pb_code _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;]<script><!-- [et_pb_line_break_holder] -->$( document ).ready(function() { <!-- [et_pb_line_break_holder] -->    $( \"a\" ).click(function( event ) {<!-- [et_pb_line_break_holder] -->        alert( \"Thanks for visiting!\" );<!-- [et_pb_line_break_holder] -->    }); <!-- [et_pb_line_break_holder] -->});<\/script>[\/et_pb_code][et_pb_code _builder_version=&#8221;4.16&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;]<script>jQuery(function ($) {<!-- [et_pb_line_break_holder] -->    var calculate = function () {<!-- [et_pb_line_break_holder] -->        var install=75;<!-- [et_pb_line_break_holder] -->        var mrc=0;<!-- [et_pb_line_break_holder] -->        var bundle=0;<!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] -->        \/\/ Add router rent<!-- [et_pb_line_break_holder] -->        mrc += 5;<!-- [et_pb_line_break_holder] -->        \/\/ Process internet choice<!-- [et_pb_line_break_holder] -->        var val1 = $('.quform-field-7_274').val();<!-- [et_pb_line_break_holder] -->        if (val1 == '5\/1') {<!-- [et_pb_line_break_holder] -->            mrc += 49;<!-- [et_pb_line_break_holder] -->        } else if (val1 == '10\/5') {<!-- [et_pb_line_break_holder] -->            mrc += 64;<!-- [et_pb_line_break_holder] -->        } else if (val1 == '25\/5') {<!-- [et_pb_line_break_holder] -->            mrc += 79;<!-- [et_pb_line_break_holder] -->        } else if (val1 == '50\/10') {<!-- [et_pb_line_break_holder] -->            mrc += 99;<!-- [et_pb_line_break_holder] -->        }<!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] -->        \/\/ Process phone choice<!-- [et_pb_line_break_holder] -->        var val2 = $('.quform-field-7_273').val();<!-- [et_pb_line_break_holder] -->        if (val2 == 'Yes') {<!-- [et_pb_line_break_holder] -->           mrc += 20;<!-- [et_pb_line_break_holder] -->           bundle += 1;<!-- [et_pb_line_break_holder] -->        }<!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] -->        \/\/ Process TV choice<!-- [et_pb_line_break_holder] -->        var val3 = $('.quform-field-7_275').val();<!-- [et_pb_line_break_holder] -->        if (val3 > 0) {<!-- [et_pb_line_break_holder] -->        \tmrc += 50 + (val3-1)*5;<!-- [et_pb_line_break_holder] -->                bundle += 1;<!-- [et_pb_line_break_holder] -->            }<!-- [et_pb_line_break_holder] -->        }<!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] -->        \/\/ Apply bundle savings<!-- [et_pb_line_break_holder] -->        mrc = mrc - (bundle*10);<!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] -->        \/\/ A text input field with numeric value<!-- [et_pb_line_break_holder] -->        \/\/var val4 = $('.quform-field-1_8').val();<!-- [et_pb_line_break_holder] -->        \/\/if (val4 && val4.length && $.isNumeric(val4)) {<!-- [et_pb_line_break_holder] -->        \/\/    total += parseFloat(val4);<!-- [et_pb_line_break_holder] -->        \/\/}<!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] -->        \/\/ Display the result to the user<!-- [et_pb_line_break_holder] -->        $('#cost-estimate').text('On-Time Installation Fee: $' + install + '  ' + 'Monthly Service Fee: $' + mrc);<!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] -->        \/\/ Set the value of the hidden field<!-- [et_pb_line_break_holder] -->        $('.quform-field-7_293').val('$' + mrc);<!-- [et_pb_line_break_holder] -->    };<!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] -->    \/\/ Calculate on page load<!-- [et_pb_line_break_holder] -->    calculate();<!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] -->    \/\/ Recalculate when these checkboxes\/radio buttons are clicked<!-- [et_pb_line_break_holder] -->    $('.quform-field-7_273, .quform-field-7_274, .quform-field-7_275').click(calculate);<!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] -->  });<\/script>[\/et_pb_code][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Referral Special &#8211; Sign Up<div id=\"quform-835ee3\" class=\"quform quform-8 quform-support-page-caching\"><form id=\"quform-form-835ee3\" class=\"quform-form quform-form-8\" action=\"\/home\/wp-json\/wp\/v2\/pages\/235721#quform-835ee3\" method=\"post\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-options=\"{&quot;id&quot;:8,&quot;uniqueId&quot;:&quot;835ee3&quot;,&quot;theme&quot;:&quot;&quot;,&quot;ajax&quot;:true,&quot;logic&quot;:{&quot;logic&quot;:[],&quot;dependents&quot;:[],&quot;elementIds&quot;:[],&quot;dependentElementIds&quot;:[],&quot;animate&quot;:true},&quot;currentPageId&quot;:1,&quot;errorsIcon&quot;:&quot;&quot;,&quot;updateFancybox&quot;:true,&quot;hasPages&quot;:false,&quot;pages&quot;:[1],&quot;pageProgressType&quot;:&quot;numbers&quot;,&quot;tooltipsEnabled&quot;:true,&quot;tooltipClasses&quot;:&quot;qtip-quform-dark qtip-shadow&quot;,&quot;tooltipMy&quot;:&quot;left center&quot;,&quot;tooltipAt&quot;:&quot;right center&quot;,&quot;isRtl&quot;:false,&quot;scrollOffset&quot;:-50,&quot;scrollSpeed&quot;:800}\"><button class=\"quform-default-submit\" name=\"quform_submit\" type=\"submit\" value=\"submit\" aria-hidden=\"true\" tabindex=\"-1\"><\/button><div class=\"quform-form-inner quform-form-inner-8\"><input type=\"hidden\" name=\"quform_form_id\" value=\"8\" \/><input type=\"hidden\" name=\"quform_form_uid\" value=\"835ee3\" \/><input type=\"hidden\" name=\"quform_count\" value=\"2\" \/><input type=\"hidden\" name=\"form_url\" value=\"https:\/\/wcc-tech.ca\/home\/wp-json\/wp\/v2\/pages\/235721\" \/><input type=\"hidden\" name=\"referring_url\" value=\"\" \/><input type=\"hidden\" name=\"post_id\" value=\"\" \/><input type=\"hidden\" name=\"post_title\" value=\"\" \/><input type=\"hidden\" name=\"quform_current_page_id\" value=\"1\" \/><input type=\"hidden\" name=\"quform_csrf_token\" value=\"SoL7ET6lLj8kH1c2XjvqbHjAYGrTJOgPYTtMEWRf\" \/><div class=\"quform-elements quform-elements-8 quform-cf quform-responsive-elements-phone-landscape\"><div class=\"quform-element quform-element-page quform-page-1 quform-page-8_1 quform-cf quform-group-style-plain quform-first-page quform-last-page quform-current-page\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-group quform-element-8_3 quform-cf quform-group-style-plain\"><div class=\"quform-spacer\"><div class=\"quform-group-title-description\"><h4 class=\"quform-group-title\">Current Customer Information<\/h4><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-row quform-element-row-8_4 quform-3-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-8_5\"><div class=\"quform-element quform-element-text quform-element-8_8 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_8\"><label class=\"quform-label-text\" for=\"quform_8_8_835ee3\">Customer ID (Rxxxx or Bxxxx)<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_8\"><div class=\"quform-input quform-input-text quform-input-8_8 quform-cf\"><input type=\"text\" id=\"quform_8_8_835ee3\" name=\"quform_8_8\" class=\"quform-field quform-field-text quform-field-8_8\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-8_6\"><div class=\"quform-element quform-element-text quform-element-8_9 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_9\"><label class=\"quform-label-text\" for=\"quform_8_9_835ee3\">First Name<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_9\"><div class=\"quform-input quform-input-text quform-input-8_9 quform-cf\"><input type=\"text\" id=\"quform_8_9_835ee3\" name=\"quform_8_9\" class=\"quform-field quform-field-text quform-field-8_9\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-8_7\"><div class=\"quform-element quform-element-text quform-element-8_10 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_10\"><label class=\"quform-label-text\" for=\"quform_8_10_835ee3\">Last Name<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_10\"><div class=\"quform-input quform-input-text quform-input-8_10 quform-cf\"><input type=\"text\" id=\"quform_8_10_835ee3\" name=\"quform_8_10\" class=\"quform-field quform-field-text quform-field-8_10\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-8_12 quform-1-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-8_13\"><div class=\"quform-element quform-element-email quform-element-8_43 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_43\"><label class=\"quform-label-text\" for=\"quform_8_43_835ee3\">Email address<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-email quform-inner-8_43\"><div class=\"quform-input quform-input-email quform-input-8_43 quform-cf\"><input type=\"email\" id=\"quform_8_43_835ee3\" name=\"quform_8_43\" class=\"quform-field quform-field-email quform-field-8_43\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-8_14 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_14\"><label class=\"quform-label-text\" for=\"quform_8_14_835ee3\">Address - Street Number and Name<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_14\"><div class=\"quform-input quform-input-text quform-input-8_14 quform-cf\"><input type=\"text\" id=\"quform_8_14_835ee3\" name=\"quform_8_14\" class=\"quform-field quform-field-text quform-field-8_14\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-8_44 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_44\"><label class=\"quform-label-text\" for=\"quform_8_44_835ee3\">Instructions \/ Comments<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-8_44\"><div class=\"quform-input quform-input-textarea quform-input-8_44 quform-cf\"><textarea id=\"quform_8_44_835ee3\" name=\"quform_8_44\" class=\"quform-field quform-field-textarea quform-field-8_44\"><\/textarea><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-8_19 quform-cf quform-group-style-plain\"><div class=\"quform-spacer\"><div class=\"quform-group-title-description\"><h4 class=\"quform-group-title\">Referred Person<\/h4><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-row quform-element-row-8_20 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-8_21\"><div class=\"quform-element quform-element-text quform-element-8_23 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_23\"><label class=\"quform-label-text\" for=\"quform_8_23_835ee3\">First Name<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_23\"><div class=\"quform-input quform-input-text quform-input-8_23 quform-cf\"><input type=\"text\" id=\"quform_8_23_835ee3\" name=\"quform_8_23\" class=\"quform-field quform-field-text quform-field-8_23\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-8_22\"><div class=\"quform-element quform-element-text quform-element-8_24 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_24\"><label class=\"quform-label-text\" for=\"quform_8_24_835ee3\">Last Name<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_24\"><div class=\"quform-input quform-input-text quform-input-8_24 quform-cf\"><input type=\"text\" id=\"quform_8_24_835ee3\" name=\"quform_8_24\" class=\"quform-field quform-field-text quform-field-8_24\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-8_37 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-8_38\"><div class=\"quform-element quform-element-text quform-element-8_39 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_39\"><label class=\"quform-label-text\" for=\"quform_8_39_835ee3\">Phone<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_39\"><div class=\"quform-input quform-input-text quform-input-8_39 quform-cf\"><input type=\"text\" id=\"quform_8_39_835ee3\" name=\"quform_8_39\" class=\"quform-field quform-field-text quform-field-8_39\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-8_40\"><div class=\"quform-element quform-element-text quform-element-8_41 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_41\"><label class=\"quform-label-text\" for=\"quform_8_41_835ee3\">Email<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_41\"><div class=\"quform-input quform-input-text quform-input-8_41 quform-cf\"><input type=\"text\" id=\"quform_8_41_835ee3\" name=\"quform_8_41\" class=\"quform-field quform-field-text quform-field-8_41\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-8_25 quform-1-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-8_26\"><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-8_2 quform-cf quform-button-style-classic\"><div class=\"quform-button-submit quform-button-submit-default quform-button-submit-8_2\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-submit\" value=\"submit\"><span class=\"quform-button-text quform-button-submit-text\">Submit<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element-tree\"><label for=\"quform_8_0_835ee3\">This field should be left blank<\/label><input type=\"text\" id=\"quform_8_0_835ee3\" name=\"quform_8_0\" class=\"quform-field quform-field-tree quform-field-8_0\" tabindex=\"-1\" autocomplete=\"off\" 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