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\
        fbRequire([\'jquery\', \'AutoNumeric\', \'cost\', \'he\'], function ($, AutoNumeric, cost, he) {\
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};\
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fbRequireJSScript.addEventListener("load", optionRateCostJs);var totalCostElementJs = function () {\
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\
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\
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\
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};\
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fbRequireJSScript.addEventListener("load", totalCostElementJs);var overridePaymentJS = function () {\
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\
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                    $formElementsContainer.find(\'div.instaMedPaymentElement\').show();\
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            \
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                && window.location.href.indexOf(\'submittableFormTest\') === -1\
                && window.location.href.indexOf(\'registrations/add\') === -1) {\
                $(\'.fbFormContainer_\' + formId + \' div.overridePayment\').remove();\
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        });\
    });\
};\
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fbRequireJSScript.addEventListener(\'load\', overridePaymentJS);var processStripePaymentJs = function () {\
    requirejs([window.formHost + \'/Scripts/require/fbRequire.config.js\'], function (fbRequireConfig) {\
        var fbRequire = fbRequireConfig.fbRequire;\
\
        fbRequire([\'jquery\'], function ($) {\
            $(function () {\
                var jsElm = document.createElement(\'script\');\
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                jsElm.src = \'https://js.authorize.net/v1/Accept.js\';\
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                document.body.appendChild(jsElm);\
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\
            window.getAuthorizeDotNetToken = function (container, successCallBack, failureCallBack) {\
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                var authData = {\
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                var cardData = {\
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                    year: cardExpiration[1].trim(),\
                    cardCode: container.find(\'.cardCvc\').val(),\
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                };\
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                var secureData = {\
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                    cardData: cardData\
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                        var errorMessages = [];\
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                        for (var i = 0; i < response.messages.message.length; i++) {\
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                        failureCallBack(container, errorMessages);\
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\
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                        };\
\
                        successCallBack(token, customer, address);\
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};\
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fbRequireJSScript.addEventListener("load", processStripePaymentJs);';

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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";

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fbFormulateRenderer.addEventListener("load", function () {
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var embeddedCssType = 0
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        fbEmbeddedCss = '';
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fbRenderContainer.innerHTML = "<div id=\'formContainer_c5ed1ff0-d4be-4681-b4da-16481faeae88\' class=\'fbFormContainer fbFormContainer_c5ed1ff0-d4be-4681-b4da-16481faeae88 BlockLabels hidden\'>\
<p>Required fields are marked with <span class=\'fb-required\'>*</span></p>\
<input type=\'hidden\' name=\'formId\' id=\'formId\' value=\'c5ed1ff0-d4be-4681-b4da-16481faeae88\' />\
<input type=\'hidden\' name=\'formName\' id=\'formName\' value=\'Sheila R. Veloz Fund/ Bustin Breast Cancer\' />\
<input type=\'hidden\' name=\'formVersion\' value=\'9\' id=\'formVersion\' />\
<input type=\'hidden\' name=\'organizationId\' id=\'organizationId\' value=\'16be16de-ad40-4f41-885c-f3bf8045e577\' />\
<input type=\'hidden\' name=\'responseId\' id=\'responseId\' value=\'db7777f0-c009-4d7e-b967-e5f6b8bcd13b\' />\
<input type=\'hidden\' name=\'formBaseUrl\' id=\'formBaseUrl\' value=\'https://formulate.geonetric.com\' />\
\
<input type=\'hidden\' name=\'totalCost\' id=\'totalCost\' data-export-label=\'total_cost\' value=\'0\'><input type=\'hidden\' name=\'subTotalCost\' id=\'subTotalCost\' data-export-label=\'subtotal_cost\' value=\'0\'>\
\
                        <fieldset class=\'fb-fieldset \'>\
                            <legend class=\'fb-legend \'>Name</legend>\
                            \
                            <div class=\'row\'>\
                                <div class=\'col-sm-6\'>\
                                    \
                <div class=\'form-group fb-form-group\'>\
                    <label class=\'control-label  \' for=\'FormField1_a6371461-6bd4-4cf9-81d7-98de40196252First\'>First Name<span class=\'fb-required\'>*</span></label>\
                    <div >\
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                        \
                    </div>\
                </div>\
                                </div>\
                                <div class=\'col-sm-6\'>\
                                    \
                <div class=\'form-group fb-form-group\'>\
                    <label class=\'control-label  \' for=\'FormField1_a6371461-6bd4-4cf9-81d7-98de40196252Last\'>Last Name<span class=\'fb-required\'>*</span></label>\
                    <div >\
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                        \
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                </div>\
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                        </fieldset><div class=\'form-group\'><label for=\'FormField2_a6371461-6bd4-4cf9-81d7-98de40196252\' class=\'control-label  \'>Email<span class=\'fb-required\'>*</span></label><div><input type=\'email\' name=\'FormField2_a6371461-6bd4-4cf9-81d7-98de40196252\' id=\'FormField2_a6371461-6bd4-4cf9-81d7-98de40196252\' class=\'form-control input-medium \' value=\'\' required data-msg-required=\'Email is required.\' data-export-label=\'Email\'  data-msg-email=\'Please specify a valid email.\' />\
</div></div><div class=\'form-group\'><label for=\'FormField3_a6371461-6bd4-4cf9-81d7-98de40196252\' class=\'control-label  \'>Phone Number<span class=\'fb-required\'>*</span></label><div><input type=\'text\' name=\'FormField3_a6371461-6bd4-4cf9-81d7-98de40196252\' id=\'FormField3_a6371461-6bd4-4cf9-81d7-98de40196252\' class=\'form-control input-medium \' value=\'\' required data-msg-required=\'Phone Number is required.\' data-export-label=\'Phone_Number\'  data-rule-phoneUS=\'true\' data-msg-phoneUS=\'Please specify a valid phone number.\' />\
</div></div><div class=\'form-group\'><label for=\'FormField5_c5ed1ff0-d4be-4681-b4da-16481faeae88\' class=\'control-label  \'>Donation Amount<span class=\'fb-required\'>*</span></label><div><select name=\'FormField5_c5ed1ff0-d4be-4681-b4da-16481faeae88_selected_item\' id=\'FormField5_c5ed1ff0-d4be-4681-b4da-16481faeae88_selected_item\' class=\'form-control \' style=\'width: auto\' required data-msg-required=\'Donation Amount is required.\' data-export-label=\'DonationAmount_selected_item\' ><option value=\'\' selected=\'selected\'>( Please Select )</option><option value=\'$20\'>$20</option><option value=\'$50\'>$50</option><option value=\'$100\'>$100</option><option value=\'$250\'>$250</option><option value=\'$500\'>$500</option><option id=\'FormField5_c5ed1ff0-d4be-4681-b4da-16481faeae88_other_selected_item\' value=\'Custom Donation\'>Custom Donation</option></select><input type=\'hidden\' name=\'FormField5_c5ed1ff0-d4be-4681-b4da-16481faeae88_description\' id=\'FormField5_c5ed1ff0-d4be-4681-b4da-16481faeae88_description\' data-export-label=\'DonationAmount_description\' value=\'SheilaR.VelozDonation\'><input type=\'hidden\' name=\'FormField5_c5ed1ff0-d4be-4681-b4da-16481faeae88_quantity\' id=\'FormField5_c5ed1ff0-d4be-4681-b4da-16481faeae88_quantity\' value=\'1\'><input type=\'hidden\' name=\'FormField5_c5ed1ff0-d4be-4681-b4da-16481faeae88_amount\' id=\'FormField5_c5ed1ff0-d4be-4681-b4da-16481faeae88_amount\' data-export-label=\'DonationAmount_amount\' value=\'0\'></div></div><div class=\'\'><div class=\'form-group\' style=\'display:none\'><label class=\'control-label\'><strong>Subtotal:</strong></label><span class=\'subtotalCostAmount\'></span></div><div class=\'form-group\' style=\'display:none\'><label class=\'control-label\'><strong>Discount:</strong></label><span class=\'promoCodeDiscount\'></span>&nbsp;&#40;<span class=\'appliedPromoCode\'></span>&#41;</div><div class=\'form-group\'><label class=\'control-label  \'><strong>Total Cost:</strong></label><span class=\'totalCostAmount\'></span></div></div><div class=\'overridePayment\'>\
    <div class=\'flow Chkbx\'>\
        <input type=\'checkbox\' value=\'Override Payment\' name=\'OverridePaymentCheckbox\' id=\'OverridePaymentCheckbox\' class=\'fo-right-margin-5\' data-export-label=\'Checkbox\'>\
        <label for=\'OverridePaymentCheckbox\'>Override Payment</label>\
    </div>\
</div><div class=\'authorizeDotNetPaymentElement\'>\
    <div class=\'form-group\' style=\'display:none\'>\
        <label class=\'control-label\' for=\'customerId\'><span class=\'fb-required\'>*</span></label>\
        <div class=\'\'>\
            <input data-msg-required=\' is required\' class=\'form-control input-large customerId no-partials\' type=\'text\' name=\'customerId\' id=\'customerId\' autocorrect=\'off\' spellcheck=\'false\' value=\'\' required=\'required\' maxlength=\'64\' />\
        </div>\
    </div>\
    <div class=\'form-group\'>\
        <label class=\'control-label\' for=\'firstNameCard\'>First Name on Card<span class=\'fb-required\'>*</span></label>\
        <div class=\'\'>\
            <input data-msg-required=\'Card First Name is required\' class=\'form-control input-large firstNameCard no-partials\' type=\'text\' name=\'firstNameCard\' id=\'firstNameCard\' autocomplete=\'cc-name\' autocorrect=\'off\' spellcheck=\'false\' value=\'\' required=\'required\' maxlength=\'64\' />\
        </div>\
    </div>\
    <div class=\'form-group\'>\
        <label class=\'control-label\' for=\'lastNameCard\'>Last Name on Card<span class=\'fb-required\'>*</span></label>\
        <div class=\'\'>\
            <input data-msg-required=\'Card Last Name is required\' class=\'form-control input-large lastNameCard no-partials\' type=\'text\' name=\'lastNameCard\' id=\'lastNameCard\' autocomplete=\'cc-name\' autocorrect=\'off\' spellcheck=\'false\' value=\'\' required=\'required\' maxlength=\'64\' />\
        </div>\
    </div>\
    <div class=\'form-group\'>\
        <label class=\'control-label\' for=\'cardNumber\'>Card Number<span class=\'fb-required\'>*</span></label>\
        <div class=\'\'>\
            <input data-msg-required=\'Card Number is required\' class=\'form-control input-large cardNumber no-partials\' type=\'text\' name=\'cardNumber\' id=\'cardNumber\' autocomplete=\'cc-number\' autocorrect=\'off\' spellcheck=\'false\' value=\'\' required=\'required\' />\
        </div>\
    </div>\
    <div class=\'form-group\'>\
        <label class=\'control-label\' for=\'cardExpiration\'>Expiration<span class=\'fb-required\'>*</span></label>\
        <div class=\'\'>\
            <input data-msg-required=\'Card Expiration is required\' class=\'form-control input-small cardExpiration no-partials\' type=\'text\' name=\'cardExpiration\' id=\'cardExpiration\' autocomplete=\'cc-exp\' autocorrect=\'off\' spellcheck=\'false\' value=\'\' required=\'required\' />\
        </div>\
    </div>\
    <div class=\'form-group\'>\
        <label class=\'control-label\' for=\'cardCvc\'>CVC<span class=\'fb-required\'>*</span></label>\
        <div class=\'\'>\
            <input data-msg-required=\'Card CVC is required\' class=\'form-control input-small cardCvc no-partials\' type=\'text\' name=\'cardCvc\' id=\'cardCvc\' autocomplete=\'cc-csc\' autocorrect=\'off\' spellcheck=\'false\' value=\'\' required=\'required\' minlength=\'3\' />\
        </div>\
    </div>\
    <div class=\'form-group\'>\
        <label class=\'control-label\' for=\'billingStreetAddress\'>Street Address<span class=\'fb-required\'>*</span></label>\
        <div class=\'\'>\
            <input data-msg-required=\'Card Street Address is required\' class=\'form-control input-large billingStreetAddress no-partials\' type=\'text\' name=\'billingStreetAddress\' id=\'billingStreetAddress\' autocomplete=\'billing street-address\' autocorrect=\'off\' spellcheck=\'false\' value=\'\' required=\'required\' maxlength=\'60\' />\
        </div>\
    </div>\
    <div class=\'form-group\'>\
        <label class=\'control-label\' for=\'billingCity\'>City<span class=\'fb-required\'>*</span></label>\
        <div class=\'\'>\
            <input data-msg-required=\'Card City is required\' class=\'form-control input-large billingCity no-partials\' type=\'text\' name=\'billingCity\' id=\'billingCity\' autocomplete=\'billing locality\' autocorrect=\'off\' spellcheck=\'false\' value=\'\' required=\'required\' maxlength=\'40\' />\
        </div>\
    </div>\
    <div class=\'form-group\'>\
        <label class=\'control-label\' for=\'billingState\'>State<span class=\'fb-required\'>*</span></label>\
        <div class=\'\'>\
            <select data-msg-required=\'Card State is required\' class=\'form-control billingState no-partials\' name=\'billingState\' id=\'billingState\' autocomplete=\'billing region\' required=\'required\'>\
                <option value=\'\'>( Please Select )</option>\
                <option value=\'AL\'>Alabama</option>\
                <option value=\'AK\'>Alaska</option>\
                <option value=\'AZ\'>Arizona</option>\
                <option value=\'AR\'>Arkansas</option>\
                <option value=\'CA\'>California</option>\
                <option value=\'CO\'>Colorado</option>\
                <option value=\'CT\'>Connecticut</option>\
                <option value=\'DE\'>Delaware</option>\
                <option value=\'DC\'>District Of Columbia</option>\
                <option value=\'FL\'>Florida</option>\
                <option value=\'GA\'>Georgia</option>\
                <option value=\'HI\'>Hawaii</option>\
                <option value=\'ID\'>Idaho</option>\
                <option value=\'IL\'>Illinois</option>\
                <option value=\'IN\'>Indiana</option>\
                <option value=\'IA\'>Iowa</option>\
                <option value=\'KS\'>Kansas</option>\
                <option value=\'KY\'>Kentucky</option>\
                <option value=\'LA\'>Louisiana</option>\
                <option value=\'ME\'>Maine</option>\
                <option value=\'MD\'>Maryland</option>\
                <option value=\'MA\'>Massachusetts</option>\
                <option value=\'MI\'>Michigan</option>\
                <option value=\'MN\'>Minnesota</option>\
                <option value=\'MS\'>Mississippi</option>\
                <option value=\'MO\'>Missouri</option>\
                <option value=\'MT\'>Montana</option>\
                <option value=\'NE\'>Nebraska</option>\
                <option value=\'NV\'>Nevada</option>\
                <option value=\'NH\'>New Hampshire</option>\
                <option value=\'NJ\'>New Jersey</option>\
                <option value=\'NM\'>New Mexico</option>\
                <option value=\'NY\'>New York</option>\
                <option value=\'NC\'>North Carolina</option>\
                <option value=\'ND\'>North Dakota</option>\
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                <option value=\'OK\'>Oklahoma</option>\
                <option value=\'OR\'>Oregon</option>\
                <option value=\'PA\'>Pennsylvania</option>\
                <option value=\'RI\'>Rhode Island</option>\
                <option value=\'SC\'>South Carolina</option>\
                <option value=\'SD\'>South Dakota</option>\
                <option value=\'TN\'>Tennessee</option>\
                <option value=\'TX\'>Texas</option>\
                <option value=\'UT\'>Utah</option>\
                <option value=\'VT\'>Vermont</option>\
                <option value=\'VA\'>Virginia</option>\
                <option value=\'WA\'>Washington</option>\
                <option value=\'WV\'>West Virginia</option>\
                <option value=\'WI\'>Wisconsin</option>\
                <option value=\'WY\'>Wyoming</option>\
            </select>\
        </div>\
    </div>\
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        </div>\
    </div>\
    <input type=\'hidden\' class=\'authorizeCardDataValue\' />\
    <input type=\'hidden\' class=\'authorizeCardDataDescriptor\' />\
    <div class=\'paymentTotalCost\'>\
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    </div>\
</div>\
\
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