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				Semicha Program
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			<h1 class="article-header__title js-article-title js-page-title">Semicha Application Form</h1>
		
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                <option value="1932"> 1932 </option>
                <option value="1931"> 1931 </option>
                <option value="1930"> 1930 </option>
                <option value="1929"> 1929 </option>
                <option value="1928"> 1928 </option>
                <option value="1927"> 1927 </option>
                <option value="1926"> 1926 </option>
                <option value="1925"> 1925 </option>
                <option value="1924"> 1924 </option>
                <option value="1923"> 1923 </option>
                <option value="1922"> 1922 </option>
                <option value="1921"> 1921 </option>
                <option value="1920"> 1920 </option>
              </select>
              <label class="form-sub-label" for="input_15_year" id="sublabel_year"> Year </label></span>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_3">
        <div class="form-label-left" id="label_3">
          <label for="input_3"> Address </label>
          <label class="label-message" for="input_3">  </label>
        </div>
        <div id="cid_3" class="form-input">
          <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0">
            <tbody><tr>
              <td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line" type="text" name="q3_address[addr_line1]" id="input_3_addr_line1" size="46" />
                  <label class="form-sub-label" for="input_3_addr_line1" id="sublabel_3_addr_line1"> Street Address </label></span>
              </td>
            </tr>
            <tr>
              <td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line no-validation" type="text" name="q3_address[addr_line2]" id="input_3_addr_line2" size="46" />
                  <label class="form-sub-label" for="input_3_addr_line2" id="sublabel_3_addr_line2"> Street Address Line 2 </label></span>
              </td>
            </tr>
            <tr>
              <td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-city" type="text" name="q3_address[city]" id="input_3_city" size="21" />
                  <label class="form-sub-label" for="input_3_city" id="sublabel_3_city"> City </label></span>
              </td>
              <td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q3_address[state]" id="input_3_state" size="22" />
                  <label class="form-sub-label" for="input_3_state" id="sublabel_3_state"> State / Province </label></span>
              </td>
            </tr>
            <tr>
              <td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-postal" type="text" name="q3_address[postal]" id="input_3_postal" size="10" />
                  <label class="form-sub-label" for="input_3_postal" id="sublabel_3_postal"> Postal / Zip Code </label></span>
              </td>
              <td><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q3_address[country]" id="input_3_country">
                    <option value="" selected="selected"> Please Select </option>
                    <option value="United States"> United States </option>
                    <option value="Afghanistan"> Afghanistan </option>
                    <option value="Albania"> Albania </option>
                    <option value="Algeria"> Algeria </option>
                    <option value="American Samoa"> American Samoa </option>
                    <option value="Andorra"> Andorra </option>
                    <option value="Angola"> Angola </option>
                    <option value="Anguilla"> Anguilla </option>
                    <option value="Antigua and Barbuda"> Antigua and Barbuda </option>
                    <option value="Argentina"> Argentina </option>
                    <option value="Armenia"> Armenia </option>
                    <option value="Aruba"> Aruba </option>
                    <option value="Australia"> Australia </option>
                    <option value="Austria"> Austria </option>
                    <option value="Azerbaijan"> Azerbaijan </option>
                    <option value="The Bahamas"> The Bahamas </option>
                    <option value="Bahrain"> Bahrain </option>
                    <option value="Bangladesh"> Bangladesh </option>
                    <option value="Barbados"> Barbados </option>
                    <option value="Belarus"> Belarus </option>
                    <option value="Belgium"> Belgium </option>
                    <option value="Belize"> Belize </option>
                    <option value="Benin"> Benin </option>
                    <option value="Bermuda"> Bermuda </option>
                    <option value="Bhutan"> Bhutan </option>
                    <option value="Bolivia"> Bolivia </option>
                    <option value="Bosnia and Herzegovina"> Bosnia and Herzegovina </option>
                    <option value="Botswana"> Botswana </option>
                    <option value="Brazil"> Brazil </option>
                    <option value="Brunei"> Brunei </option>
                    <option value="Bulgaria"> Bulgaria </option>
                    <option value="Burkina Faso"> Burkina Faso </option>
                    <option value="Burundi"> Burundi </option>
                    <option value="Cambodia"> Cambodia </option>
                    <option value="Cameroon"> Cameroon </option>
                    <option value="Canada"> Canada </option>
                    <option value="Cape Verde"> Cape Verde </option>
                    <option value="Cayman Islands"> Cayman Islands </option>
                    <option value="Central African Republic"> Central African Republic </option>
                    <option value="Chad"> Chad </option>
                    <option value="Chile"> Chile </option>
                    <option value="People's Republic of China"> People's Republic of China </option>
                    <option value="Republic of China"> Republic of China </option>
                    <option value="Christmas Island"> Christmas Island </option>
                    <option value="Cocos (Keeling) Islands"> Cocos (Keeling) Islands </option>
                    <option value="Colombia"> Colombia </option>
                    <option value="Comoros"> Comoros </option>
                    <option value="Congo"> Congo </option>
                    <option value="Cook Islands"> Cook Islands </option>
                    <option value="Costa Rica"> Costa Rica </option>
                    <option value="Cote d'Ivoire"> Cote d'Ivoire </option>
                    <option value="Croatia"> Croatia </option>
                    <option value="Cuba"> Cuba </option>
                    <option value="Cyprus"> Cyprus </option>
                    <option value="Czech Republic"> Czech Republic </option>
                    <option value="Denmark"> Denmark </option>
                    <option value="Djibouti"> Djibouti </option>
                    <option value="Dominica"> Dominica </option>
                    <option value="Dominican Republic"> Dominican Republic </option>
                    <option value="Ecuador"> Ecuador </option>
                    <option value="Egypt"> Egypt </option>
                    <option value="El Salvador"> El Salvador </option>
                    <option value="Equatorial Guinea"> Equatorial Guinea </option>
                    <option value="Eritrea"> Eritrea </option>
                    <option value="Estonia"> Estonia </option>
                    <option value="Eswatini"> Eswatini </option>
                    <option value="Ethiopia"> Ethiopia </option>
                    <option value="Falkland Islands"> Falkland Islands </option>
                    <option value="Faroe Islands"> Faroe Islands </option>
                    <option value="Fiji"> Fiji </option>
                    <option value="Finland"> Finland </option>
                    <option value="France"> France </option>
                    <option value="French Polynesia"> French Polynesia </option>
                    <option value="Gabon"> Gabon </option>
                    <option value="The Gambia"> The Gambia </option>
                    <option value="Georgia"> Georgia </option>
                    <option value="Germany"> Germany </option>
                    <option value="Ghana"> Ghana </option>
                    <option value="Gibraltar"> Gibraltar </option>
                    <option value="Greece"> Greece </option>
                    <option value="Greenland"> Greenland </option>
                    <option value="Grenada"> Grenada </option>
                    <option value="Guadeloupe"> Guadeloupe </option>
                    <option value="Guam"> Guam </option>
                    <option value="Guatemala"> Guatemala </option>
                    <option value="Guernsey"> Guernsey </option>
                    <option value="Guinea"> Guinea </option>
                    <option value="Guinea-Bissau"> Guinea-Bissau </option>
                    <option value="Guyana"> Guyana </option>
                    <option value="Haiti"> Haiti </option>
                    <option value="Honduras"> Honduras </option>
                    <option value="Hong Kong"> Hong Kong </option>
                    <option value="Hungary"> Hungary </option>
                    <option value="Iceland"> Iceland </option>
                    <option value="India"> India </option>
                    <option value="Indonesia"> Indonesia </option>
                    <option value="Iran"> Iran </option>
                    <option value="Iraq"> Iraq </option>
                    <option value="Ireland"> Ireland </option>
                    <option value="Israel"> Israel </option>
                    <option value="Italy"> Italy </option>
                    <option value="Jamaica"> Jamaica </option>
                    <option value="Japan"> Japan </option>
                    <option value="Jersey"> Jersey </option>
                    <option value="Jordan"> Jordan </option>
                    <option value="Kazakhstan"> Kazakhstan </option>
                    <option value="Kenya"> Kenya </option>
                    <option value="Kiribati"> Kiribati </option>
                    <option value="North Korea"> North Korea </option>
                    <option value="South Korea"> South Korea </option>
                    <option value="Kosovo"> Kosovo </option>
                    <option value="Kuwait"> Kuwait </option>
                    <option value="Kyrgyzstan"> Kyrgyzstan </option>
                    <option value="Laos"> Laos </option>
                    <option value="Latvia"> Latvia </option>
                    <option value="Lebanon"> Lebanon </option>
                    <option value="Lesotho"> Lesotho </option>
                    <option value="Liberia"> Liberia </option>
                    <option value="Libya"> Libya </option>
                    <option value="Liechtenstein"> Liechtenstein </option>
                    <option value="Lithuania"> Lithuania </option>
                    <option value="Luxembourg"> Luxembourg </option>
                    <option value="Macau"> Macau </option>
                    <option value="Macedonia"> Macedonia </option>
                    <option value="Madagascar"> Madagascar </option>
                    <option value="Malawi"> Malawi </option>
                    <option value="Malaysia"> Malaysia </option>
                    <option value="Maldives"> Maldives </option>
                    <option value="Mali"> Mali </option>
                    <option value="Malta"> Malta </option>
                    <option value="Marshall Islands"> Marshall Islands </option>
                    <option value="Martinique"> Martinique </option>
                    <option value="Mauritania"> Mauritania </option>
                    <option value="Mauritius"> Mauritius </option>
                    <option value="Mayotte"> Mayotte </option>
                    <option value="Mexico"> Mexico </option>
                    <option value="Micronesia"> Micronesia </option>
                    <option value="Moldova"> Moldova </option>
                    <option value="Monaco"> Monaco </option>
                    <option value="Mongolia"> Mongolia </option>
                    <option value="Montenegro"> Montenegro </option>
                    <option value="Montserrat"> Montserrat </option>
                    <option value="Morocco"> Morocco </option>
                    <option value="Mozambique"> Mozambique </option>
                    <option value="Myanmar"> Myanmar </option>
                    <option value="Namibia"> Namibia </option>
                    <option value="Nauru"> Nauru </option>
                    <option value="Nepal"> Nepal </option>
                    <option value="Netherlands"> Netherlands </option>
                    <option value="New Caledonia"> New Caledonia </option>
                    <option value="New Zealand"> New Zealand </option>
                    <option value="Nicaragua"> Nicaragua </option>
                    <option value="Niger"> Niger </option>
                    <option value="Nigeria"> Nigeria </option>
                    <option value="Niue"> Niue </option>
                    <option value="Norfolk Island"> Norfolk Island </option>
                    <option value="Northern Mariana"> Northern Mariana </option>
                    <option value="Norway"> Norway </option>
                    <option value="Oman"> Oman </option>
                    <option value="Pakistan"> Pakistan </option>
                    <option value="Palau"> Palau </option>
                    <option value="Panama"> Panama </option>
                    <option value="Papua New Guinea"> Papua New Guinea </option>
                    <option value="Paraguay"> Paraguay </option>
                    <option value="Peru"> Peru </option>
                    <option value="Philippines"> Philippines </option>
                    <option value="Pitcairn Islands"> Pitcairn Islands </option>
                    <option value="Poland"> Poland </option>
                    <option value="Portugal"> Portugal </option>
                    <option value="Puerto Rico"> Puerto Rico </option>
                    <option value="Qatar"> Qatar </option>
                    <option value="Romania"> Romania </option>
                    <option value="Russia"> Russia </option>
                    <option value="Rwanda"> Rwanda </option>
                    <option value="Saint Barthelemy"> Saint Barthelemy </option>
                    <option value="Saint Helena"> Saint Helena </option>
                    <option value="Saint Kitts and Nevis"> Saint Kitts and Nevis </option>
                    <option value="Saint Lucia"> Saint Lucia </option>
                    <option value="Saint Martin"> Saint Martin </option>
                    <option value="Saint Pierre and Miquelon"> Saint Pierre and Miquelon </option>
                    <option value="Saint Vincent and the Grenadines"> Saint Vincent and the Grenadines </option>
                    <option value="Samoa"> Samoa </option>
                    <option value="San Marino"> San Marino </option>
                    <option value="Sao Tome and Principe"> Sao Tome and Principe </option>
                    <option value="Saudi Arabia"> Saudi Arabia </option>
                    <option value="Senegal"> Senegal </option>
                    <option value="Serbia"> Serbia </option>
                    <option value="Seychelles"> Seychelles </option>
                    <option value="Sierra Leone"> Sierra Leone </option>
                    <option value="Singapore"> Singapore </option>
                    <option value="Slovakia"> Slovakia </option>
                    <option value="Slovenia"> Slovenia </option>
                    <option value="Solomon Islands"> Solomon Islands </option>
                    <option value="Somalia"> Somalia </option>
                    <option value="Somaliland"> Somaliland </option>
                    <option value="South Africa"> South Africa </option>
                    <option value="South Ossetia"> South Ossetia </option>
                    <option value="Spain"> Spain </option>
                    <option value="Sri Lanka"> Sri Lanka </option>
                    <option value="Sudan"> Sudan </option>
                    <option value="Suriname"> Suriname </option>
                    <option value="Svalbard"> Svalbard </option>
                    <option value="Sweden"> Sweden </option>
                    <option value="Switzerland"> Switzerland </option>
                    <option value="Syria"> Syria </option>
                    <option value="Taiwan"> Taiwan </option>
                    <option value="Tajikistan"> Tajikistan </option>
                    <option value="Tanzania"> Tanzania </option>
                    <option value="Thailand"> Thailand </option>
                    <option value="Timor-Leste"> Timor-Leste </option>
                    <option value="Togo"> Togo </option>
                    <option value="Tokelau"> Tokelau </option>
                    <option value="Tonga"> Tonga </option>
                    <option value="Trinidad and Tobago"> Trinidad and Tobago </option>
                    <option value="Tristan da Cunha"> Tristan da Cunha </option>
                    <option value="Tunisia"> Tunisia </option>
                    <option value="Turkey"> Turkey </option>
                    <option value="Turkmenistan"> Turkmenistan </option>
                    <option value="Turks and Caicos Islands"> Turks and Caicos Islands </option>
                    <option value="Tuvalu"> Tuvalu </option>
                    <option value="Uganda"> Uganda </option>
                    <option value="Ukraine"> Ukraine </option>
                    <option value="United Arab Emirates"> United Arab Emirates </option>
                    <option value="United Kingdom"> United Kingdom </option>
                    <option value="Uruguay"> Uruguay </option>
                    <option value="Uzbekistan"> Uzbekistan </option>
                    <option value="Vanuatu"> Vanuatu </option>
                    <option value="Vatican City"> Vatican City </option>
                    <option value="Venezuela"> Venezuela </option>
                    <option value="Vietnam"> Vietnam </option>
                    <option value="British Virgin Islands"> British Virgin Islands </option>
                    <option value="US Virgin Islands"> US Virgin Islands </option>
                    <option value="Wallis and Futuna"> Wallis and Futuna </option>
                    <option value="Western Sahara"> Western Sahara </option>
                    <option value="Yemen"> Yemen </option>
                    <option value="Zambia"> Zambia </option>
                    <option value="Zimbabwe"> Zimbabwe </option>
                    <option value="other"> Other </option>
                  </select>
                  <label class="form-sub-label" for="input_3_country" id="sublabel_3_country"> Country </label></span>
              </td>
            </tr>
          </tbody></table>
        </div>
      </li>
      <li class="form-line" id="id_4">
        <div class="form-label-left" id="label_4">
          <label for="input_4"> Phone Number </label>
          <label class="label-message" for="input_4">  </label>
        </div>
        <div id="cid_4" class="form-input">
          <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q4_phoneNumber[area]" id="input_4_area" size="3" />
              <label class="form-sub-label" for="input_4_area" id="sublabel_area"> Area Code </label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q4_phoneNumber[phone]" id="input_4_phone" size="8" />
              <label class="form-sub-label" for="input_4_phone" id="sublabel_phone"> Phone Number </label></span>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_5">
        <div class="form-label-left" id="label_5">
          <label for="input_5">
            E-mail<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_5">  </label>
        </div>
        <div id="cid_5" class="form-input">
          <input type="email" class=" form-textbox validate[required, Email]" id="input_5" name="q5_email" size="30" value="" />
        </div>
      </li>
      <li class="form-line" id="id_6">
        <div class="form-label-left" id="label_6">
          <label for="input_6">
            Father's Full Name<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_6">  </label>
        </div>
        <div id="cid_6" class="form-input"><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q6_fullName6[first]" id="first_6" />
            <label class="form-sub-label" for="first_6" id="sublabel_first"> First Name </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q6_fullName6[last]" id="last_6" />
            <label class="form-sub-label" for="last_6" id="sublabel_last"> Last Name </label></span>
        </div>
      </li>
      <li class="form-line" id="id_7">
        <div class="form-label-left" id="label_7">
          <label for="input_7">
            Father's Phone Number<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_7">  </label>
        </div>
        <div id="cid_7" class="form-input">
          <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q7_phoneNumber7[area]" id="input_7_area" size="3" />
              <label class="form-sub-label" for="input_7_area" id="sublabel_area"> Area Code </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q7_phoneNumber7[phone]" id="input_7_phone" size="8" />
              <label class="form-sub-label" for="input_7_phone" id="sublabel_phone"> Phone Number </label></span>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_8">
        <div class="form-label-left" id="label_8">
          <label for="input_8"> Father's E-mail </label>
          <label class="label-message" for="input_8">  </label>
        </div>
        <div id="cid_8" class="form-input">
          <input type="email" class=" form-textbox validate[Email]" id="input_8" name="q8_email8" size="30" value="" />
        </div>
      </li>
      <li class="form-line" id="id_9">
        <div class="form-label-left" id="label_9">
          <label for="input_9">
            Mother's Full Name<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_9">  </label>
        </div>
        <div id="cid_9" class="form-input"><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q9_fullName9[first]" id="first_9" />
            <label class="form-sub-label" for="first_9" id="sublabel_first"> First Name </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q9_fullName9[last]" id="last_9" />
            <label class="form-sub-label" for="last_9" id="sublabel_last"> Last Name </label></span>
        </div>
      </li>
      <li class="form-line" id="id_10">
        <div class="form-label-left" id="label_10">
          <label for="input_10"> Mother's Phone Number </label>
          <label class="label-message" for="input_10">  </label>
        </div>
        <div id="cid_10" class="form-input">
          <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q10_phoneNumber10[area]" id="input_10_area" size="3" />
              <label class="form-sub-label" for="input_10_area" id="sublabel_area"> Area Code </label></span><span class="form-sub-label-container"><input class="form-textbox validate[Numeric]" type="tel" name="q10_phoneNumber10[phone]" id="input_10_phone" size="8" />
              <label class="form-sub-label" for="input_10_phone" id="sublabel_phone"> Phone Number </label></span>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_11">
        <div class="form-label-left" id="label_11">
          <label for="input_11"> Mother's E-mail </label>
          <label class="label-message" for="input_11">  </label>
        </div>
        <div id="cid_11" class="form-input">
          <input type="email" class=" form-textbox validate[Email]" id="input_11" name="q11_email11" size="30" value="" />
        </div>
      </li>
      <li class="form-line" id="id_12">
        <div class="form-label-left" id="label_12">
          <label for="input_12">
            Best person to discuss administrative issues with<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_12">  </label>
        </div>
        <div id="cid_12" class="form-input">
          <select class="form-dropdown validate[required]" style="width:150px" id="input_12" name="q12_input12">
            <option value="">  </option>
            <option value="Father"> Father </option>
            <option value="Mother"> Mother </option>
            <option value="Other"> Other </option>
          </select>
        </div>
      </li>
      <li class="form-line" id="id_13">
        <div class="form-label-left" id="label_13">
          <label for="input_13"> If you have selected "Other" please give us the contact information for that person </label>
          <label class="label-message" for="input_13">  </label>
        </div>
        <div id="cid_13" class="form-input">
          <input type="text" class=" form-textbox" data-type="input-textbox" id="input_13" name="q13_input13" size="20" value="" />
        </div>
      </li>
      <li class="form-line" id="id_16">
        <div class="form-label-left" id="label_16">
          <label for="input_16">
            Yeshiva attended last year<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_16">  </label>
        </div>
        <div id="cid_16" class="form-input">
          <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_16" name="q16_input16" size="20" value="" />
        </div>
      </li>
      <li class="form-line" id="id_21">
        <div class="form-label-left" id="label_21">
          <label for="input_21">
            Name and phone number of the Rosh Yeshiva<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_21">  </label>
        </div>
        <div id="cid_21" class="form-input">
          <textarea id="input_21" class="form-textarea validate[required]" name="q21_input21" cols="40" rows="6"></textarea>
        </div>
      </li>
      <li class="form-line" id="id_18">
        <div class="form-label-left" id="label_18">
          <label for="input_18">
            Yeshiva attended two years ago<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_18">  </label>
        </div>
        <div id="cid_18" class="form-input">
          <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_18" name="q18_input18" size="20" value="" />
        </div>
      </li>
      <li class="form-line" id="id_19">
        <div class="form-label-left" id="label_19">
          <label for="input_19">
            Name and phone number of the Rosh Yeshiva<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_19">  </label>
        </div>
        <div id="cid_19" class="form-input">
          <textarea id="input_19" class="form-textarea validate[required]" name="q19_input19" cols="40" rows="6"></textarea>
        </div>
      </li>
      <li class="form-line" id="id_22">
        <div class="form-label-left" id="label_22">
          <label for="input_22">
            Reference #1: Name and contact information<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_22">  </label>
        </div>
        <div id="cid_22" class="form-input">
          <textarea id="input_22" class="form-textarea validate[required]" name="q22_input22" cols="40" rows="6"></textarea>
        </div>
      </li>
      <li class="form-line" id="id_24">
        <div class="form-label-left" id="label_24">
          <label for="input_24">
            Reference #2: Name and contact information<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_24">  </label>
        </div>
        <div id="cid_24" class="form-input">
          <textarea id="input_24" class="form-textarea validate[required]" name="q24_input24" cols="40" rows="6"></textarea>
        </div>
      </li>
      <li class="form-line" id="id_23">
        <div class="form-label-left" id="label_23">
          <label for="input_23">
            Reference #3: Name and contact information<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_23">  </label>
        </div>
        <div id="cid_23" class="form-input">
          <textarea id="input_23" class="form-textarea validate[required]" name="q23_input23" cols="40" rows="6"></textarea>
        </div>
      </li>
      <li class="form-line" id="id_25">
        <div class="form-label-left" id="label_25">
          <label for="input_25">
            Who is your Chavrusa for Semicha<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_25">  </label>
        </div>
        <div id="cid_25" class="form-input">
          <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_25" name="q25_input25" size="20" value="" />
        </div>
      </li>
      <li class="form-line" id="id_26">
        <div class="form-label-left" id="label_26">
          <label for="input_26">
            What is your reason for choosing our program?<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_26">  </label>
        </div>
        <div id="cid_26" class="form-input">
          <textarea id="input_26" class="form-textarea validate[required]" name="q26_input26" cols="40" rows="6"></textarea>
        </div>
      </li>
      <li class="form-line" id="id_27">
        <div id="cid_27" class="form-input-wide">
          <div id="text_27" class="form-html">
            <p>
              Send in one recent picture and two letters of recommendations. One of them from your Rosh Yeshiva that includes your scholastic grades, level of shmiras hasdorim and level of yiras shomayim
            </p>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_28">
        <div id="cid_28" class="form-input-wide">
          <div id="text_28" class="form-html">
             There is a $150 application fee. Full time and dormitory tuition is set at $15,000. (Not yet available for 5782) Half day program tuition is set at $3,000 Online program tuition is set at $2,500 
          </div>
        </div>
      </li>
      <li class="form-line" id="id_31">
        <div class="form-label-left" id="label_31">
          <label for="input_31"> Choose your program </label>
          <label class="label-message" for="input_31">  </label>
        </div>
        <div id="cid_31" class="form-input">
          <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_31_0" name="q31_input31[]" value="On site" />
              <label id="label_input_31_0" for="input_31_0"><span>On site</span>
              </label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_31_1" name="q31_input31[]" value="Online" />
              <label id="label_input_31_1" for="input_31_1"><span>Online</span>
              </label></span><span class="clearfix"></span>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_30">
        <div class="form-label-left" id="label_30">
          <label for="input_30"> Click to edit </label>
          <label class="label-message" for="input_30">  </label>
        </div>
        <div id="cid_30" class="form-input">
          <div class="form-multiple-column" data-columns="3"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_30_0" name="q30_input30" value="150" />
              <label for="input_30_0"><span>$150</span>
              </label></span><span class="clearfix"></span>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_29">
        <div class="form-label-left" id="label_29">
          <label for="input_29"> Payment </label>
          <label class="label-message" for="input_29">  </label>
        </div>
        <div id="cid_29" class="form-input">
          <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0">
            <tbody><tr>
              <td colspan="2" class="form-payment-methods form-multiple-column">
              </td>
            </tr>
            <tr class="credit_card ">
              <th colspan="2">
                Credit Card
              </th>
            </tr>
            <tr class="credit_card ">
              <td colspan="2" style="padding:0">
                <table cellpadding="0" cellspacing="0">
                  <tbody><tr>
                    <td colspan="2"><span class="form-sub-label-container"><select class="form-textbox validate[visible]" name="q29_payment[cc_type]" id="input_29_cc_type">
                          <option value="Visa"> Visa </option>
                          <option value="Mastercard"> MasterCard </option>
                          <option value="Amex"> American Express </option>
                          <option value="Discover"> Discover </option>
                        </select>
                        <label class="form-sub-label" for="input_29_cc_type" id="sublabel_cc_type"> Credit Card Type </label></span>
                    </td>
                  </tr>
                  <tr>
                    <td><span class="form-sub-label-container"><input class="form-textbox form-creditcard js-cc-number validate[visible, creditcard]" type="text" name="q29_payment[cc_number]" id="input_29_cc_number" size="20" autocomplete="off" />
                        <label class="form-sub-label" for="input_29_cc_number" id="sublabel_cc_number"> Credit Card Number </label></span>
                    </td>
                    <td class="cc_ccv hide"><span class="form-sub-label-container"><input class="form-textbox validate[visible]" type="text" name="q29_payment[cc_ccv]" id="input_29_cc_ccv" size="6" autocomplete="off" />
                        <label class="form-sub-label" for="input_29_cc_ccv" id="sublabel_cc_ccv"> Security Code </label></span>
                    </td>
                  </tr>
                  <tr>
                    <td colspan="2" class="cc_name_on_card "><span class="form-sub-label-container"><input class="form-textbox validate[visible]" type="text" name="q29_payment[cc_nameOnCard]" id="input_29_cc_nameOnCard" size="33" autocomplete="off" />
                        <label class="form-sub-label" for="input_29_cc_nameOnCard" id="sublabel_cc_nameOnCard"> Name on Card </label></span>
                    </td>
                  </tr>
                  <tr class="credit_card ">
                    <td colspan=""><span class="form-sub-label-container"><select class="form-textbox validate[visible]" name="q29_payment[cc_exp_month]" id="input_29_cc_exp_month">
                          <option>  </option>
                          <option value="1"> 1 - January </option>
                          <option value="2"> 2 - February </option>
                          <option value="3"> 3 - March </option>
                          <option value="4"> 4 - April </option>
                          <option value="5"> 5 - May </option>
                          <option value="6"> 6 - June </option>
                          <option value="7"> 7 - July </option>
                          <option value="8"> 8 - August </option>
                          <option value="9"> 9 - September </option>
                          <option value="10"> 10 - October </option>
                          <option value="11"> 11 - November </option>
                          <option value="12"> 12 - December </option>
                        </select>
                        <label class="form-sub-label" for="input_29_cc_exp_month" id="sublabel_cc_exp_month"> Expiration Month </label></span>
                    </td>
                    <td><span class="form-sub-label-container"><select class="form-textbox validate[visible]" name="q29_payment[cc_exp_year]" id="input_29_cc_exp_year">
                          <option>  </option>
                          <option value="2021"> 2021 </option>
                          <option value="2022"> 2022 </option>
                          <option value="2023"> 2023 </option>
                          <option value="2024"> 2024 </option>
                          <option value="2025"> 2025 </option>
                          <option value="2026"> 2026 </option>
                          <option value="2027"> 2027 </option>
                          <option value="2028"> 2028 </option>
                          <option value="2029"> 2029 </option>
                          <option value="2030"> 2030 </option>
                        </select>
                        <label class="form-sub-label" for="input_29_cc_exp_year" id="sublabel_cc_exp_year"> Expiration Year </label></span>
                    </td>
                  </tr>
                </tbody></table>
              </td>
            </tr>
            <tr class="billing_address ">
              <th colspan="2">
                Billing Address
              </th>
            </tr>
            <tr class="billing_address ">
              <td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line" type="text" name="q29_payment[addr_line1]" id="input_29_addr_line1" />
                  <label class="form-sub-label" for="input_29_addr_line1" id="sublabel_29_addr_line1"> Street Address </label></span>
              </td>
            </tr>
            <tr class="billing_address ">
              <td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line no-validation" type="text" name="q29_payment[addr_line2]" id="input_29_addr_line2" size="46" />
                  <label class="form-sub-label" for="input_29_addr_line2" id="sublabel_29_addr_line2"> Street Address Line 2 </label></span>
              </td>
            </tr>
            <tr class="billing_address ">
              <td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-city" type="text" name="q29_payment[city]" id="input_29_city" />
                  <label class="form-sub-label" for="input_29_city" id="sublabel_29_city"> City </label></span>
              </td>
              <td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q29_payment[state]" id="input_29_state" />
                  <label class="form-sub-label" for="input_29_state" id="sublabel_29_state"> State / Province </label></span>
              </td>
            </tr>
            <tr class="billing_address ">
              <td width="50%"><span class="form-sub-label-container"><input class="form-textbox form-address-postal" type="text" name="q29_payment[postal]" id="input_29_postal" size="10" />
                  <label class="form-sub-label" for="input_29_postal" id="sublabel_29_postal"> Postal / Zip Code </label></span>
              </td>
              <td><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q29_payment[country]" id="input_29_country">
                    <option value="" selected="selected"> Please Select </option>
                    <option value="United States"> United States </option>
                    <option value="Afghanistan"> Afghanistan </option>
                    <option value="Albania"> Albania </option>
                    <option value="Algeria"> Algeria </option>
                    <option value="American Samoa"> American Samoa </option>
                    <option value="Andorra"> Andorra </option>
                    <option value="Angola"> Angola </option>
                    <option value="Anguilla"> Anguilla </option>
                    <option value="Antigua and Barbuda"> Antigua and Barbuda </option>
                    <option value="Argentina"> Argentina </option>
                    <option value="Armenia"> Armenia </option>
                    <option value="Aruba"> Aruba </option>
                    <option value="Australia"> Australia </option>
                    <option value="Austria"> Austria </option>
                    <option value="Azerbaijan"> Azerbaijan </option>
                    <option value="The Bahamas"> The Bahamas </option>
                    <option value="Bahrain"> Bahrain </option>
                    <option value="Bangladesh"> Bangladesh </option>
                    <option value="Barbados"> Barbados </option>
                    <option value="Belarus"> Belarus </option>
                    <option value="Belgium"> Belgium </option>
                    <option value="Belize"> Belize </option>
                    <option value="Benin"> Benin </option>
                    <option value="Bermuda"> Bermuda </option>
                    <option value="Bhutan"> Bhutan </option>
                    <option value="Bolivia"> Bolivia </option>
                    <option value="Bosnia and Herzegovina"> Bosnia and Herzegovina </option>
                    <option value="Botswana"> Botswana </option>
                    <option value="Brazil"> Brazil </option>
                    <option value="Brunei"> Brunei </option>
                    <option value="Bulgaria"> Bulgaria </option>
                    <option value="Burkina Faso"> Burkina Faso </option>
                    <option value="Burundi"> Burundi </option>
                    <option value="Cambodia"> Cambodia </option>
                    <option value="Cameroon"> Cameroon </option>
                    <option value="Canada"> Canada </option>
                    <option value="Cape Verde"> Cape Verde </option>
                    <option value="Cayman Islands"> Cayman Islands </option>
                    <option value="Central African Republic"> Central African Republic </option>
                    <option value="Chad"> Chad </option>
                    <option value="Chile"> Chile </option>
                    <option value="People's Republic of China"> People's Republic of China </option>
                    <option value="Republic of China"> Republic of China </option>
                    <option value="Christmas Island"> Christmas Island </option>
                    <option value="Cocos (Keeling) Islands"> Cocos (Keeling) Islands </option>
                    <option value="Colombia"> Colombia </option>
                    <option value="Comoros"> Comoros </option>
                    <option value="Congo"> Congo </option>
                    <option value="Cook Islands"> Cook Islands </option>
                    <option value="Costa Rica"> Costa Rica </option>
                    <option value="Cote d'Ivoire"> Cote d'Ivoire </option>
                    <option value="Croatia"> Croatia </option>
                    <option value="Cuba"> Cuba </option>
                    <option value="Cyprus"> Cyprus </option>
                    <option value="Czech Republic"> Czech Republic </option>
                    <option value="Denmark"> Denmark </option>
                    <option value="Djibouti"> Djibouti </option>
                    <option value="Dominica"> Dominica </option>
                    <option value="Dominican Republic"> Dominican Republic </option>
                    <option value="Ecuador"> Ecuador </option>
                    <option value="Egypt"> Egypt </option>
                    <option value="El Salvador"> El Salvador </option>
                    <option value="Equatorial Guinea"> Equatorial Guinea </option>
                    <option value="Eritrea"> Eritrea </option>
                    <option value="Estonia"> Estonia </option>
                    <option value="Eswatini"> Eswatini </option>
                    <option value="Ethiopia"> Ethiopia </option>
                    <option value="Falkland Islands"> Falkland Islands </option>
                    <option value="Faroe Islands"> Faroe Islands </option>
                    <option value="Fiji"> Fiji </option>
                    <option value="Finland"> Finland </option>
                    <option value="France"> France </option>
                    <option value="French Polynesia"> French Polynesia </option>
                    <option value="Gabon"> Gabon </option>
                    <option value="The Gambia"> The Gambia </option>
                    <option value="Georgia"> Georgia </option>
                    <option value="Germany"> Germany </option>
                    <option value="Ghana"> Ghana </option>
                    <option value="Gibraltar"> Gibraltar </option>
                    <option value="Greece"> Greece </option>
                    <option value="Greenland"> Greenland </option>
                    <option value="Grenada"> Grenada </option>
                    <option value="Guadeloupe"> Guadeloupe </option>
                    <option value="Guam"> Guam </option>
                    <option value="Guatemala"> Guatemala </option>
                    <option value="Guernsey"> Guernsey </option>
                    <option value="Guinea"> Guinea </option>
                    <option value="Guinea-Bissau"> Guinea-Bissau </option>
                    <option value="Guyana"> Guyana </option>
                    <option value="Haiti"> Haiti </option>
                    <option value="Honduras"> Honduras </option>
                    <option value="Hong Kong"> Hong Kong </option>
                    <option value="Hungary"> Hungary </option>
                    <option value="Iceland"> Iceland </option>
                    <option value="India"> India </option>
                    <option value="Indonesia"> Indonesia </option>
                    <option value="Iran"> Iran </option>
                    <option value="Iraq"> Iraq </option>
                    <option value="Ireland"> Ireland </option>
                    <option value="Israel"> Israel </option>
                    <option value="Italy"> Italy </option>
                    <option value="Jamaica"> Jamaica </option>
                    <option value="Japan"> Japan </option>
                    <option value="Jersey"> Jersey </option>
                    <option value="Jordan"> Jordan </option>
                    <option value="Kazakhstan"> Kazakhstan </option>
                    <option value="Kenya"> Kenya </option>
                    <option value="Kiribati"> Kiribati </option>
                    <option value="North Korea"> North Korea </option>
                    <option value="South Korea"> South Korea </option>
                    <option value="Kosovo"> Kosovo </option>
                    <option value="Kuwait"> Kuwait </option>
                    <option value="Kyrgyzstan"> Kyrgyzstan </option>
                    <option value="Laos"> Laos </option>
                    <option value="Latvia"> Latvia </option>
                    <option value="Lebanon"> Lebanon </option>
                    <option value="Lesotho"> Lesotho </option>
                    <option value="Liberia"> Liberia </option>
                    <option value="Libya"> Libya </option>
                    <option value="Liechtenstein"> Liechtenstein </option>
                    <option value="Lithuania"> Lithuania </option>
                    <option value="Luxembourg"> Luxembourg </option>
                    <option value="Macau"> Macau </option>
                    <option value="Macedonia"> Macedonia </option>
                    <option value="Madagascar"> Madagascar </option>
                    <option value="Malawi"> Malawi </option>
                    <option value="Malaysia"> Malaysia </option>
                    <option value="Maldives"> Maldives </option>
                    <option value="Mali"> Mali </option>
                    <option value="Malta"> Malta </option>
                    <option value="Marshall Islands"> Marshall Islands </option>
                    <option value="Martinique"> Martinique </option>
                    <option value="Mauritania"> Mauritania </option>
                    <option value="Mauritius"> Mauritius </option>
                    <option value="Mayotte"> Mayotte </option>
                    <option value="Mexico"> Mexico </option>
                    <option value="Micronesia"> Micronesia </option>
                    <option value="Moldova"> Moldova </option>
                    <option value="Monaco"> Monaco </option>
                    <option value="Mongolia"> Mongolia </option>
                    <option value="Montenegro"> Montenegro </option>
                    <option value="Montserrat"> Montserrat </option>
                    <option value="Morocco"> Morocco </option>
                    <option value="Mozambique"> Mozambique </option>
                    <option value="Myanmar"> Myanmar </option>
                    <option value="Namibia"> Namibia </option>
                    <option value="Nauru"> Nauru </option>
                    <option value="Nepal"> Nepal </option>
                    <option value="Netherlands"> Netherlands </option>
                    <option value="New Caledonia"> New Caledonia </option>
                    <option value="New Zealand"> New Zealand </option>
                    <option value="Nicaragua"> Nicaragua </option>
                    <option value="Niger"> Niger </option>
                    <option value="Nigeria"> Nigeria </option>
                    <option value="Niue"> Niue </option>
                    <option value="Norfolk Island"> Norfolk Island </option>
                    <option value="Northern Mariana"> Northern Mariana </option>
                    <option value="Norway"> Norway </option>
                    <option value="Oman"> Oman </option>
                    <option value="Pakistan"> Pakistan </option>
                    <option value="Palau"> Palau </option>
                    <option value="Panama"> Panama </option>
                    <option value="Papua New Guinea"> Papua New Guinea </option>
                    <option value="Paraguay"> Paraguay </option>
                    <option value="Peru"> Peru </option>
                    <option value="Philippines"> Philippines </option>
                    <option value="Pitcairn Islands"> Pitcairn Islands </option>
                    <option value="Poland"> Poland </option>
                    <option value="Portugal"> Portugal </option>
                    <option value="Puerto Rico"> Puerto Rico </option>
                    <option value="Qatar"> Qatar </option>
                    <option value="Romania"> Romania </option>
                    <option value="Russia"> Russia </option>
                    <option value="Rwanda"> Rwanda </option>
                    <option value="Saint Barthelemy"> Saint Barthelemy </option>
                    <option value="Saint Helena"> Saint Helena </option>
                    <option value="Saint Kitts and Nevis"> Saint Kitts and Nevis </option>
                    <option value="Saint Lucia"> Saint Lucia </option>
                    <option value="Saint Martin"> Saint Martin </option>
                    <option value="Saint Pierre and Miquelon"> Saint Pierre and Miquelon </option>
                    <option value="Saint Vincent and the Grenadines"> Saint Vincent and the Grenadines </option>
                    <option value="Samoa"> Samoa </option>
                    <option value="San Marino"> San Marino </option>
                    <option value="Sao Tome and Principe"> Sao Tome and Principe </option>
                    <option value="Saudi Arabia"> Saudi Arabia </option>
                    <option value="Senegal"> Senegal </option>
                    <option value="Serbia"> Serbia </option>
                    <option value="Seychelles"> Seychelles </option>
                    <option value="Sierra Leone"> Sierra Leone </option>
                    <option value="Singapore"> Singapore </option>
                    <option value="Slovakia"> Slovakia </option>
                    <option value="Slovenia"> Slovenia </option>
                    <option value="Solomon Islands"> Solomon Islands </option>
                    <option value="Somalia"> Somalia </option>
                    <option value="Somaliland"> Somaliland </option>
                    <option value="South Africa"> South Africa </option>
                    <option value="South Ossetia"> South Ossetia </option>
                    <option value="Spain"> Spain </option>
                    <option value="Sri Lanka"> Sri Lanka </option>
                    <option value="Sudan"> Sudan </option>
                    <option value="Suriname"> Suriname </option>
                    <option value="Svalbard"> Svalbard </option>
                    <option value="Sweden"> Sweden </option>
                    <option value="Switzerland"> Switzerland </option>
                    <option value="Syria"> Syria </option>
                    <option value="Taiwan"> Taiwan </option>
                    <option value="Tajikistan"> Tajikistan </option>
                    <option value="Tanzania"> Tanzania </option>
                    <option value="Thailand"> Thailand </option>
                    <option value="Timor-Leste"> Timor-Leste </option>
                    <option value="Togo"> Togo </option>
                    <option value="Tokelau"> Tokelau </option>
                    <option value="Tonga"> Tonga </option>
                    <option value="Trinidad and Tobago"> Trinidad and Tobago </option>
                    <option value="Tristan da Cunha"> Tristan da Cunha </option>
                    <option value="Tunisia"> Tunisia </option>
                    <option value="Turkey"> Turkey </option>
                    <option value="Turkmenistan"> Turkmenistan </option>
                    <option value="Turks and Caicos Islands"> Turks and Caicos Islands </option>
                    <option value="Tuvalu"> Tuvalu </option>
                    <option value="Uganda"> Uganda </option>
                    <option value="Ukraine"> Ukraine </option>
                    <option value="United Arab Emirates"> United Arab Emirates </option>
                    <option value="United Kingdom"> United Kingdom </option>
                    <option value="Uruguay"> Uruguay </option>
                    <option value="Uzbekistan"> Uzbekistan </option>
                    <option value="Vanuatu"> Vanuatu </option>
                    <option value="Vatican City"> Vatican City </option>
                    <option value="Venezuela"> Venezuela </option>
                    <option value="Vietnam"> Vietnam </option>
                    <option value="British Virgin Islands"> British Virgin Islands </option>
                    <option value="US Virgin Islands"> US Virgin Islands </option>
                    <option value="Wallis and Futuna"> Wallis and Futuna </option>
                    <option value="Western Sahara"> Western Sahara </option>
                    <option value="Yemen"> Yemen </option>
                    <option value="Zambia"> Zambia </option>
                    <option value="Zimbabwe"> Zimbabwe </option>
                    <option value="other"> Other </option>
                  </select>
                  <label class="form-sub-label" for="input_29_country" id="sublabel_29_country"> Country </label></span>
              </td>
          </tr></tbody></table>
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