if (window.location.protocol != "https:" && window.location.href.indexOf("formulate") == -1 && "False" === "True") { window.location.href = "https:" + window.location.href.substring(window.location.protocol.length); } var fbScriptTag = document.getElementsByClassName("a661d466-feab-4ad5-ac99-13b97d995aa6"), fbBodyTag = document.body, fbHeadTag = document.head, fbIsTestResponse = 'False', fbEnableInstaMedScript = 'False', fbRenderContainer = document.createElement("div"), fbRenderedCssContainer = document.createElement("div"), fbConfigScript = document.createElement("script"), fbRequireJSScript = document.createElement("script"), fbInstaMedJSScript = document.createElement("script"), fbGeoCaptchaCallback = document.createElement("script"), fbGeoReCaptchaCallback = document.createElement("script"), fbFormulateRenderer = document.createElement("script"), fbRenderedIntegrations = document.createElement("script"), fbRenderedScripts = document.createElement("script"), fbAutoPopulateFromQueryString = document.createElement("script"), fbEmbeddedCss = "", renderedScripts = ''; if(fbScriptTag.length === 0) { fbScriptTag = document.querySelector("script[src*='a661d466-feab-4ad5-ac99-13b97d995aa6']"); } else { fbScriptTag = fbScriptTag[0]; } fbRenderContainer.id = "formRenderContainer"; fbRenderContainer.className = " fbRenderContainer fbRenderContainer_a661d466-feab-4ad5-ac99-13b97d995aa6"; fbRenderedCssContainer.id = "fbRenderedCssContainer"; fbConfigScript.type = "text/javascript"; fbRequireJSScript.type = "text/javascript"; fbInstaMedJSScript.type = "text/javascript"; fbGeoCaptchaCallback.type = "text/javascript"; fbGeoReCaptchaCallback.type = "text/javascript"; fbFormulateRenderer.type = "text/javascript"; fbRenderedIntegrations.type = "text/javascript"; fbRenderedScripts.type = "text/javascript"; fbAutoPopulateFromQueryString.type = "text/javascript"; fbRequireJSScript.src = "https://formulate.geonetric.com/Scripts/require.min.js"; fbInstaMedJSScript.src = "https://formulate.geonetric.com/Scripts/vendor/instamed/token.js"; fbInstaMedJSScript.id = "instamed-sdk"; fbGeoCaptchaCallback.src = "https://formulate.geonetric.com/Scripts/geo-captcha-callback.js"; fbGeoReCaptchaCallback.src = "https://www.google.com/recaptcha/api.js?onload=geoFbCaptchaCallback&render=6LdxkTEpAAAAAMKbkhz8-INpQis_mvSaIXnoyC2V"; fbFormulateRenderer.src = "https://formulate.geonetric.com/Scripts/require/formulate-renderer.js?embeddedCssType=0&isTestResponse=False&hasGoogleAnalytics=False"; fbFormulateRenderer.id = "formulateRendererScript"; fbAutoPopulateFromQueryString.src = "https://formulate.geonetric.com/Scripts/auto-populate-from-query-string.js"; if (fbEnableInstaMedScript === 'True') { fbInstaMedJSScript.setAttribute("data-displaymode", "embedded"); fbInstaMedJSScript.setAttribute("data-environment", "UAT"); fbInstaMedJSScript.setAttribute("data-mobiledisplaymode", "embedded"); } fbGeoCaptchaCallback.onload = function() { if(document.querySelectorAll('.geo-fb-recaptcha').length > 0) { fbBodyTag.appendChild(fbGeoReCaptchaCallback); } } fbRequireJSScript.addEventListener("load", function() { fbBodyTag.appendChild(fbFormulateRenderer); fbBodyTag.appendChild(fbAutoPopulateFromQueryString); }); fbFormulateRenderer.addEventListener("load", function () { initFormBuilderForm(); }); var embeddedCssType = 0 switch (embeddedCssType) { case 1: fbEmbeddedCss = ''; break; case 2: fbEmbeddedCss = ''; break; default: fbEmbeddedCss = ''; } if (fbIsTestResponse === 'True') { fbRenderContainer.setAttribute('data-test-mode', 'true'); } else { fbRenderContainer.setAttribute('data-test-mode', 'false'); } fbRenderContainer.innerHTML = "
Required fields are marked with *
\ \ \ \ \ \ \ \ \ \