{"id":103,"date":"2026-02-15T09:09:49","date_gmt":"2026-02-15T09:09:49","guid":{"rendered":"https:\/\/iclrauthority.org\/?page_id=103"},"modified":"2026-03-15T08:21:16","modified_gmt":"2026-03-15T08:21:16","slug":"new-license-application","status":"publish","type":"page","link":"https:\/\/iclrauthority.org\/?page_id=103","title":{"rendered":"New License Application"},"content":{"rendered":"<style id=\"wpforms-css-vars-96\">\n\t\t\t\t#wpforms-96 {\n\t\t\t\t--wpforms-field-border-style: none;\n--wpforms-field-border-radius: 0px;\n--wpforms-field-background-color: rgba(14, 15, 50, 0.1);\n--wpforms-field-border-color: rgba(0, 0, 0, 0.25);\n--wpforms-field-border-color-spare: rgba(0, 0, 0, 0.25);\n--wpforms-field-text-color: #0e0f32;\n--wpforms-label-color: #0e0f32;\n--wpforms-label-sublabel-color: #64647f;\n--wpforms-label-error-color: #de0000;\n--wpforms-button-border-radius: 0px;\n--wpforms-button-background-color: #0e0f32;\n--wpforms-button-border-color: #0e0f32;\n--wpforms-container-padding: 60px;\n--wpforms-container-border-radius: 0px;\n--wpforms-background-color: #e1e5ee;\n--wpforms-background-image: stock;\n--wpforms-background-position: bottom center;\n--wpforms-background-url: url( https:\/\/iclrauthority.org\/wp-content\/uploads\/wpforms\/themes\/stock-photos\/jean-philippe-delberghe-75xPHEQBmvA-unsplash.jpg );\n--wpforms-field-menu-color: #e1e5ee;\n--wpforms-page-break-color: #0e0f32;\n--wpforms-field-border-size: 0px;\n--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-container-quiz wpforms-stripe wpforms-container-save-resume wpforms-render-modern\" id=\"wpforms-96\"><form id=\"wpforms-form-96\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"96\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F103&#038;wpforms_form_id=96\" data-token=\"eca89bf44c33ef035de3108b3f17d6fd\" data-token-time=\"1776345996\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-page-indicator progress\" data-indicator=\"progress\" data-indicator-color=\"#066aab\" data-scroll=\"1\" role=\"progressbar\" aria-valuenow=\"1\" aria-valuemin=\"1\" aria-valuemax=\"3\" tabindex=\"-1\"><span class=\"wpforms-page-indicator-page-title\" ><\/span><span class=\"wpforms-page-indicator-page-title-sep\" style=\"display:none;\"> - <\/span><span class=\"wpforms-page-indicator-steps\">Step <span class=\"wpforms-page-indicator-steps-current\">1<\/span> of 3<\/span><div class=\"wpforms-page-indicator-page-progress-wrap\"><div class=\"wpforms-page-indicator-page-progress\" style=\"width:33.333333333333%;background-color:#066aab\"><\/div><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \" data-page=\"1\"><div id=\"wpforms-96-field_15-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"15\"><\/div><div id=\"wpforms-96-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"1\"><fieldset><legend class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-96-field_1\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][1][first]\" placeholder=\"Given Name\" aria-errormessage=\"wpforms-96-field_1-error\" required><label for=\"wpforms-96-field_1\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-fifth\"><input type=\"text\" id=\"wpforms-96-field_1-middle\" class=\"wpforms-field-name-middle\" name=\"wpforms[fields][1][middle]\" placeholder=\"Middle Name\" aria-errormessage=\"wpforms-96-field_1-middle-error\" ><label for=\"wpforms-96-field_1-middle\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Middle<\/label><\/div><div class=\"wpforms-field-row-block wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-96-field_1-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][1][last]\" placeholder=\"Family Name\" aria-errormessage=\"wpforms-96-field_1-last-error\" required><label for=\"wpforms-96-field_1-last\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-96-field_32-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"32\"><fieldset><legend class=\"wpforms-field-label\">Gender <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-96-field_32\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-96-field_32_1\" name=\"wpforms[fields][32]\" value=\"Male\" aria-errormessage=\"wpforms-96-field_32_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-96-field_32_1\">Male<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-96-field_32_2\" name=\"wpforms[fields][32]\" value=\"Female\" aria-errormessage=\"wpforms-96-field_32_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-96-field_32_2\">Female<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-96-field_21-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-96-field_21\">Date Born <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-96-field_21\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][21]\" value=\"DD\/MM\/YYYY\" aria-errormessage=\"wpforms-96-field_21-error\" required><\/div>\t\t<div id=\"wpforms-96-field_7-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"7\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-96-field_7\" >Application Name for:<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-96-field_7\" class=\"wpforms-field-medium\" name=\"wpforms[fields][7]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-96-field_31-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-96-field_31\">Birth Certificate Registration Number: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-96-field_31\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][31]\" aria-errormessage=\"wpforms-96-field_31-error\" required><\/div><div id=\"wpforms-96-field_6-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-96-field_6\">Phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-96-field_6\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][6]\" aria-label=\"Phone\" aria-errormessage=\"wpforms-96-field_6-error\" required><\/div><div id=\"wpforms-96-field_4-container\" class=\"wpforms-field wpforms-field-email\" data-field-type=\"email\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-96-field_4\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-96-field_4\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][4]\" spellcheck=\"false\" aria-errormessage=\"wpforms-96-field_4-error\" required><\/div><div id=\"wpforms-96-field_2-container\" class=\"wpforms-field wpforms-field-address\" data-field-type=\"address\" data-field-id=\"2\"><fieldset><legend class=\"wpforms-field-label\">Residential Address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-96-field_2\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][2][address1]\" aria-errormessage=\"wpforms-96-field_2-error\" required><label for=\"wpforms-96-field_2\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-96-field_2-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][2][address2]\" aria-errormessage=\"wpforms-96-field_2-address2-error\" ><label for=\"wpforms-96-field_2-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-96-field_2-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][2][city]\" aria-errormessage=\"wpforms-96-field_2-city-error\" required><label for=\"wpforms-96-field_2-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-96-field_2-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][2][state]\" aria-errormessage=\"wpforms-96-field_2-state-error\" required><label for=\"wpforms-96-field_2-state\" class=\"wpforms-field-sublabel after\">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-96-field_2-postal\" class=\"wpforms-field-address-postal wpforms-field-required\" name=\"wpforms[fields][2][postal]\" aria-errormessage=\"wpforms-96-field_2-postal-error\" required><label for=\"wpforms-96-field_2-postal\" class=\"wpforms-field-sublabel after\">Postal Code<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-96-field_2-country\" class=\"wpforms-field-address-country wpforms-field-required\" name=\"wpforms[fields][2][country]\" aria-errormessage=\"wpforms-96-field_2-country-error\" required><option class=\"placeholder\" value=\"\" selected disabled>--- Select country ---<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia (Plurinational State of)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Democratic Republic of the)<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"SZ\" >Eswatini (Kingdom of)<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran (Islamic Republic of)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republic of)<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea (Democratic People&#039;s Republic of)<\/option><option value=\"KR\" >Korea (Republic of)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia (Federated States of)<\/option><option value=\"MD\" >Moldova (Republic of)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MK\" >North Macedonia (Republic of)<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (State of)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Republic of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (United Republic of)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"TR\" >T\u00fcrkiye<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"US\" >United States of America<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican City State<\/option><option value=\"VE\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (U.S.)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AX\" >\u00c5land Islands<\/option><\/select><label for=\"wpforms-96-field_2-country\" class=\"wpforms-field-sublabel after\">Country<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-96-field_3-container\" class=\"wpforms-field wpforms-field-address\" data-field-type=\"address\" data-field-id=\"3\"><fieldset><legend class=\"wpforms-field-label\">Postal Address- if different to above<\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-96-field_3\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][3][address1]\" aria-errormessage=\"wpforms-96-field_3-error\" ><label for=\"wpforms-96-field_3\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-96-field_3-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][3][address2]\" aria-errormessage=\"wpforms-96-field_3-address2-error\" ><label for=\"wpforms-96-field_3-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-96-field_3-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][3][city]\" aria-errormessage=\"wpforms-96-field_3-city-error\" ><label for=\"wpforms-96-field_3-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-96-field_3-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][3][state]\" aria-errormessage=\"wpforms-96-field_3-state-error\" ><label for=\"wpforms-96-field_3-state\" class=\"wpforms-field-sublabel after\">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-96-field_3-postal\" class=\"wpforms-field-address-postal\" name=\"wpforms[fields][3][postal]\" aria-errormessage=\"wpforms-96-field_3-postal-error\" ><label for=\"wpforms-96-field_3-postal\" class=\"wpforms-field-sublabel after\">Postal Code<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-96-field_3-country\" class=\"wpforms-field-address-country\" name=\"wpforms[fields][3][country]\" aria-errormessage=\"wpforms-96-field_3-country-error\" ><option class=\"placeholder\" value=\"\" selected disabled>--- Select country ---<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia (Plurinational State of)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Democratic Republic of the)<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"SZ\" >Eswatini (Kingdom of)<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran (Islamic Republic of)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republic of)<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea (Democratic People&#039;s Republic of)<\/option><option value=\"KR\" >Korea (Republic of)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia (Federated States of)<\/option><option value=\"MD\" >Moldova (Republic of)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MK\" >North Macedonia (Republic of)<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (State of)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Republic of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (United Republic of)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"TR\" >T\u00fcrkiye<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"US\" >United States of America<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican City State<\/option><option value=\"VE\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (U.S.)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AX\" >\u00c5land Islands<\/option><\/select><label for=\"wpforms-96-field_3-country\" class=\"wpforms-field-sublabel after\">Country<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-96-field_5-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"5\"><fieldset><legend class=\"wpforms-field-label\">License Application for: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-96-field_5\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-96-field_5_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][5][]\" value=\"Motorbike- Learner\" aria-errormessage=\"wpforms-96-field_5_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-96-field_5_1\">Motorbike- Learner<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-96-field_5_8\" data-rule-check-limit=\"true\" name=\"wpforms[fields][5][]\" value=\"Motorbike\" aria-errormessage=\"wpforms-96-field_5_8-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-96-field_5_8\">Motorbike<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-96-field_5_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][5][]\" value=\"Car- Learner\" aria-errormessage=\"wpforms-96-field_5_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-96-field_5_2\">Car- Learner<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-96-field_5_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][5][]\" value=\"Car- P (red) Manual\" aria-errormessage=\"wpforms-96-field_5_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-96-field_5_3\">Car- P (red) Manual<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-96-field_5_4\" data-rule-check-limit=\"true\" name=\"wpforms[fields][5][]\" value=\"Car- P (red)\" aria-errormessage=\"wpforms-96-field_5_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-96-field_5_4\">Car- P (red)<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-96-field_5_5\" data-rule-check-limit=\"true\" name=\"wpforms[fields][5][]\" value=\"Car- P (green)\" aria-errormessage=\"wpforms-96-field_5_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-96-field_5_5\">Car- P (green)<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-96-field_5_6\" data-rule-check-limit=\"true\" name=\"wpforms[fields][5][]\" value=\"Car- Open\" aria-errormessage=\"wpforms-96-field_5_6-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-96-field_5_6\">Car- Open<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-96-field_18-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"18\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"1\" data-formid=\"96\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2  \" data-page=\"2\" style=\"display:none;\"><div id=\"wpforms-96-field_8-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"8\"><fieldset><legend class=\"wpforms-field-label\">I hereby confirm; <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-96-field_8\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-96-field_8_1\" name=\"wpforms[fields][8][]\" value=\"I have no medical conditions that may affect my ability to drive safely\" aria-errormessage=\"wpforms-96-field_8_1-error\" aria-describedby=\"wpforms-96-field_8-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-96-field_8_1\">I have no medical conditions that may affect my ability to drive safely<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-96-field_8_2\" name=\"wpforms[fields][8][]\" value=\"I have medical conditions that may affect my ability to drive safely, and I have included relevant Medical evidence\" aria-errormessage=\"wpforms-96-field_8_2-error\" aria-describedby=\"wpforms-96-field_8-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-96-field_8_2\">I have medical conditions that may affect my ability to drive safely, and I have included relevant Medical evidence<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-96-field_8_4\" name=\"wpforms[fields][8][]\" value=\"I require prescription glasses to drive\" aria-errormessage=\"wpforms-96-field_8_4-error\" aria-describedby=\"wpforms-96-field_8-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-96-field_8_4\">I require prescription glasses to drive<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-96-field_8_5\" name=\"wpforms[fields][8][]\" value=\"I am restricted to an automatic transmission only\" aria-errormessage=\"wpforms-96-field_8_5-error\" aria-describedby=\"wpforms-96-field_8-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-96-field_8_5\">I am restricted to an automatic transmission only<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-96-field_8_6\" name=\"wpforms[fields][8][]\" value=\"I am restricted to daylight driving conditions only\" aria-errormessage=\"wpforms-96-field_8_6-error\" aria-describedby=\"wpforms-96-field_8-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-96-field_8_6\">I am restricted to daylight driving conditions only<\/label><\/li><\/ul><div id=\"wpforms-96-field_8-description\" class=\"wpforms-field-description\">tick all that apply<\/div><\/fieldset><\/div><div id=\"wpforms-96-field_10-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-type=\"file-upload\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-96-field_10\">Medical File Upload<\/label><div\n\t\tclass=\"wpforms-uploader \"\n\t\tdata-field-id=\"10\"\n\t\tdata-form-id=\"96\"\n\t\tdata-input-name=\"wpforms_96_10\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,x-wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages\"\n\t\tdata-max-size=\"536870912\"\n\t\tdata-max-file-number=\"2\"\n\t\tdata-post-max-size=\"536870912\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg  viewBox=\"0 0 640 640\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M352 173.3L352 384C352 401.7 337.7 416 320 416C302.3 416 288 401.7 288 384L288 173.3L246.6 214.7C234.1 227.2 213.8 227.2 201.3 214.7C188.8 202.2 188.8 181.9 201.3 169.4L297.3 73.4C309.8 60.9 330.1 60.9 342.6 73.4L438.6 169.4C451.1 181.9 451.1 202.2 438.6 214.7C426.1 227.2 405.8 227.2 393.3 214.7L352 173.3zM320 464C364.2 464 400 428.2 400 384L480 384C515.3 384 544 412.7 544 448L544 480C544 515.3 515.3 544 480 544L160 544C124.7 544 96 515.3 96 480L96 448C96 412.7 124.7 384 160 384L240 384C240 428.2 275.8 464 320 464zM464 488C477.3 488 488 477.3 488 464C488 450.7 477.3 440 464 440C450.7 440 440 450.7 440 464C440 477.3 450.7 488 464 488z\"\/>\n\t\t<\/svg>\n\n\t\t<span class=\"modern-title\">\n\t\t\t\t\t\t\tDrag &amp; Drop Files, \t\t\t\t<span>Choose Files to Upload<\/span>\n\t\t\t\t\t<\/span>\n\n\t\t\t\t\t<span class=\"modern-hint\">You can upload up to 2 files.<\/span>\n\t\t\t<\/div>\n<\/div>\n\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-96-field_10\"\n\t\tname=\"wpforms_96_10\" \t\tvalue=\"\">\n<\/div><div id=\"wpforms-96-field_9-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"9\"><fieldset><legend class=\"wpforms-field-label\">I hereby confirm; <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-96-field_9\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-96-field_9_1\" name=\"wpforms[fields][9]\" value=\"I agree to donate my organs in the event of an accident and my next of kin is aware\" aria-errormessage=\"wpforms-96-field_9_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-96-field_9_1\">I agree to donate my organs in the event of an accident and my next of kin is aware<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-96-field_9_2\" name=\"wpforms[fields][9]\" value=\"I do not agree to donate my organs in the event of an accident and my next of kin is aware\" aria-errormessage=\"wpforms-96-field_9_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-96-field_9_2\">I do not agree to donate my organs in the event of an accident and my next of kin is aware<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-96-field_11-container\" class=\"wpforms-field wpforms-field-camera\" data-field-type=\"camera\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-96-field_11\">ID Photograph <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><button type=\"button\" class=\"wpforms-camera-button wpforms-btn-secondary\" id=\"11\"><svg width=\"16\" height=\"14\" viewBox=\"0 0 16 14\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M4.65625 1.03125C4.875 0.40625 5.4375 0 6.09375 0H9.90625C10.5625 0 11.125 0.40625 11.3438 1.03125L11.6562 2H14C15.0938 2 16 2.90625 16 4V12C16 13.0938 15.0938 14 14 14H2C0.90625 14 0 13.0938 0 12V4C0 2.90625 0.90625 2 2 2H4.34375L4.65625 1.03125ZM8 5C6.34375 5 5 6.34375 5 8C5 9.65625 6.34375 11 8 11C9.65625 11 11 9.65625 11 8C11 6.34375 9.65625 5 8 5Z\"\/><\/svg> Capture With Your Camera<\/button><div class=\"wpforms-camera-selected-file\"><span><\/span> <button class=\"wpforms-camera-remove-file\" title=\"Remove file\"><svg width=\"13\" height=\"15\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M4.121.914a.853.853 0 0 1 .82-.602H8.06c.382 0 .71.247.82.602l.246.711h2.625c.492 0 .875.383.875.875a.864.864 0 0 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height=\"11\" fill=\"none\">\n\t\t\t\t\t<path d=\"M10.688 2.219 7.405 5.5l3.282 3.313a.964.964 0 0 1 0 1.406.964.964 0 0 1-1.407 0L6 6.938l-3.313 3.28a.964.964 0 0 1-1.406 0 .964.964 0 0 1 0-1.405L4.563 5.5 1.28 2.219a.964.964 0 0 1 0-1.406.964.964 0 0 1 1.407 0L6 4.092 9.281.814a.964.964 0 0 1 1.406 0 .964.964 0 0 1 0 1.406Z\"\/>\n\t\t\t\t<\/svg>\n\t\t\t<\/div>\n\t\t<\/div>\n\n\t\t<div class=\"wpforms-camera-modal-content\">\n\t\t\t<div class=\"wpforms-camera-preview\">\n\t\t\t\t<video id=\"wpforms-camera-video-96-11\" autoplay playsinline muted disablepictureinpicture><\/video>\n\t\t\t<\/div>\n\t\t\t<div class=\"wpforms-camera-error\"><\/div>\n\t\t<\/div>\n\n\t\t\t\t\t<div class=\"wpforms-camera-modal-footer\">\n\t\t\t\t<div class=\"wpforms-camera-modal-actions\">\n\t\t\t\t\t<button class=\"wpforms-camera-capture\" title=\"Capture Photo\" disabled>\n\t\t\t\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"24\" height=\"22\" fill=\"none\">\n\t\t\t\t\t\t\t\t<path fill=\"#fff\" d=\"M6.984 2.047C7.313 1.109 8.156.5 9.141.5h5.718c.985 0 1.829.61 2.157 1.547l.468 1.453H21c1.64 0 3 1.36 3 3v12c0 1.64-1.36 3-3 3H3c-1.64 0-3-1.36-3-3v-12c0-1.64 1.36-3 3-3h3.516l.468-1.453ZM12 8a4.501 4.501 0 0 0 0 9 4.501 4.501 0 0 0 0-9Z\"\/>\n\t\t\t\t\t\t\t<\/svg>\n\t\t\t\t\t<\/button>\n\t\t\t\t\t<button class=\"wpforms-camera-stop\" style=\"display:none;\">O<\/button>\n\t\t\t\t\t<div class=\"wpforms-camera-countdown\" style=\"display: none;\">\n\t\t\t\t\t\t<svg>\n\t\t\t\t\t\t\t<circle class=\"bg\" r=\"22\"><\/circle>\n\t\t\t\t\t\t\t<circle class=\"progress\" r=\"22\"><\/circle>\n\t\t\t\t\t\t<\/svg>\n\t\t\t\t\t\t<span>3<\/span>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"wpforms-camera-flip\"><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"wpforms-camera-modal-buttons\" style=\"display: none;\">\n\t\t\t\t\t<button class=\"wpforms-camera-cancel\" title=\"Retake Photo\"><\/button>\n\t\t\t\t\t<button class=\"wpforms-camera-accept\">Use Photo<\/button>\n\t\t\t\t\t<button class=\"wpforms-camera-accept-crop\" style=\"display: none;\">Apply Crop<\/button>\n\t\t\t\t\t<button class=\"wpforms-camera-crop\" title=\"Crop Photo\"><\/button>\n\t\t\t\t\t<button class=\"wpforms-camera-crop-cancel\" title=\"Cancel Crop\" style=\"display: none;\"><\/button>\n\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\n\t\t<canvas id=\"wpforms-camera-canvas-96-11\" style=\"display:none;\"><\/canvas>\n\t<\/div>\n<\/div>\n<div id=\"wpforms-96-field_11-description\" class=\"wpforms-field-description\">Disclaimer:\nUse a bright lit area with a blank\/solid background\nAny and all incomplete images will not be accepted and you may not be refunded your application fee<\/div><\/div><div id=\"wpforms-96-field_22-container\" class=\"wpforms-field wpforms-field-payment-select wpforms-field-select-style-classic\" data-field-type=\"payment-select\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-96-field_22\">License Term <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-96-field_22\" class=\"wpforms-payment-price wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][22]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>--- Select Choice ---<\/option><option value=\"1\" data-amount=\"100.00\" >1 Year - &#036;100.00<\/option><option value=\"2\" data-amount=\"250.00\" >3 Year - &#036;250.00<\/option><option value=\"3\" data-amount=\"350.00\" >5 Year - &#036;350.00<\/option><option value=\"4\" data-amount=\"50.00\" >Learner- Car or Motorbike 2 years - &#036;50.00<\/option><\/select><\/div><div id=\"wpforms-96-field_27-container\" class=\"wpforms-field wpforms-field-payment-multiple\" data-field-type=\"payment-multiple\" data-field-id=\"27\"><fieldset><legend class=\"wpforms-field-label\">Shipping <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-96-field_27\" class=\"wpforms-field-required\"><li class=\"choice-1\"><input type=\"radio\" id=\"wpforms-96-field_27_1\" class=\"wpforms-payment-price\" data-amount=\"10.00\" name=\"wpforms[fields][27]\" value=\"1\" aria-errormessage=\"wpforms-96-field_27_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-96-field_27_1\">Australia<\/label><\/li><li class=\"choice-2\"><input type=\"radio\" id=\"wpforms-96-field_27_2\" class=\"wpforms-payment-price\" data-amount=\"10.00\" name=\"wpforms[fields][27]\" value=\"2\" aria-errormessage=\"wpforms-96-field_27_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-96-field_27_2\">International- no tracking<\/label><\/li><li class=\"choice-4\"><input type=\"radio\" id=\"wpforms-96-field_27_4\" class=\"wpforms-payment-price\" data-amount=\"35.00\" name=\"wpforms[fields][27]\" value=\"4\" aria-errormessage=\"wpforms-96-field_27_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-96-field_27_4\">International-with tracking<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-96-field_12-container\" class=\"wpforms-field wpforms-field-signature\" data-field-type=\"signature\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-96-field_12\">Signature <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-96-field_12\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][12]\" autocomplete=\"off\" inputmode=\"none\" aria-errormessage=\"wpforms-96-field_12-error\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-96-field_12-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Clear Signature\" tabindex=\"0\">\n\t\t\t\t<svg 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class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-96-field_25\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-96-field_25_1\" name=\"wpforms[fields][25][]\" value=\"I, the applicant, do hereby confirm that the details as provided in this application are true and correct to the best of my ability and consent to the Crown Licensing Regulatory Authority verifying my information and using my private information contained herein and existing on the Crown Licensing Regulatory Authority database, including but not limited to my digital photograph and autograph and consent for the Crown Licensing Regulatory Authority to conduct enquires necessary to assess this application for the purposes associated with approval of this application, including but not limited to criminal and driving history checks\" aria-errormessage=\"wpforms-96-field_25_1-error\" aria-describedby=\"wpforms-96-field_25-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-96-field_25_1\">I, the applicant, do hereby confirm that the details as provided in this application are true and correct to the best of my ability and consent to the Crown Licensing Regulatory Authority verifying my information and using my private information contained herein and existing on the Crown Licensing Regulatory Authority database, including but not limited to my digital photograph and autograph and consent for the Crown Licensing Regulatory Authority to conduct enquires necessary to assess this application for the purposes associated with approval of this application, including but not limited to criminal and driving history checks<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-96-field_25_2\" name=\"wpforms[fields][25][]\" value=\"I, the applicant, understand that by providing any false or misleading information to the Crown Licensing Regulatory Authority may result in this application being refused and if applicable the cancellation of the International Driver license\" aria-errormessage=\"wpforms-96-field_25_2-error\" aria-describedby=\"wpforms-96-field_25-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-96-field_25_2\">I, the applicant, understand that by providing any false or misleading information to the Crown Licensing Regulatory Authority may result in this application being refused and if applicable the cancellation of the International Driver license<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-96-field_25_3\" name=\"wpforms[fields][25][]\" value=\"I, the applicant, understand the responsibilities of holding an International Driver License and will comply with requirements under the International Crown Licensing Regulatory Authority, as found under the Legal Compliance section\" aria-errormessage=\"wpforms-96-field_25_3-error\" aria-describedby=\"wpforms-96-field_25-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-96-field_25_3\">I, the applicant, understand the responsibilities of holding an International Driver License and will comply with requirements under the International Crown Licensing Regulatory Authority, as found under the Legal Compliance section<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-96-field_25_4\" name=\"wpforms[fields][25][]\" value=\"I, the applicant, do hereby confirm that I have not had a driver&#039;s license, held by the International Crown Licensing Regulatory Authority or any other licensing agency and\/or court, previously or currently suspended, cancelled or restricted due to a serious at fault vehicle accident\" aria-errormessage=\"wpforms-96-field_25_4-error\" aria-describedby=\"wpforms-96-field_25-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-96-field_25_4\">I, the applicant, do hereby confirm that I have not had a driver's license, held by the International Crown Licensing Regulatory Authority or any other licensing agency and\/or court, previously or currently suspended, cancelled or restricted due to a serious at fault vehicle accident<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-96-field_25_5\" name=\"wpforms[fields][25][]\" value=\"I, the applicant, understand that the International Crown Licensing Regulatory Authority is not a govenment agency and that I have read and understand the legal policy\" aria-errormessage=\"wpforms-96-field_25_5-error\" aria-describedby=\"wpforms-96-field_25-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-96-field_25_5\">I, the applicant, understand that the International Crown Licensing Regulatory Authority is not a govenment agency and that I have read and understand the legal policy<\/label><\/li><\/ul><div id=\"wpforms-96-field_25-description\" class=\"wpforms-field-description wpforms-disclaimer-description\">**LEGAL DISCLAIMER \u2013 LIMITATION OF RESPONSIBILITY FOR LICENSE HOLDERS**<br \/>\n<br \/>\n**International Crown Licensing Regulatory Authority (ICLRA)**<br \/>\n<br \/>\nThis disclaimer defines the relationship between the International Crown Licensing Regulatory Authority (\u201cICLRA\u201d) and individuals or entities who obtain licenses, and\/or registrations issued by ICLRA (\u201cLicense Holders\u201d).<br \/>\n<br \/>\n1. Independent Status of License Holders<br \/>\n<br \/>\nAll License Holders operate as independent people or entities.<br \/>\nNothing contained in any license, certificate, or registration issued by ICLRA shall be interpreted as creating:<br \/>\n<br \/>\n* an agency relationship<br \/>\n* a partnership<br \/>\n* an employment relationship<br \/>\n* a joint venture<br \/>\n* or any representation authority<br \/>\n<br \/>\nbetween ICLRA and the License Holder.<br \/>\n<br \/>\n2. No Operational Control<br \/>\n<br \/>\nICLRA, as a new incoming licensing and registration authority, does not control, supervise, or direct the activities, services, business practices, or conduct of License Holders.<br \/>\nAll operational decisions and actions are undertaken solely by the License Holder.<br \/>\n<br \/>\n3. Assumption of Responsibility<br \/>\n<br \/>\nEach License Holder accepts full responsibility for:<br \/>\n<br \/>\n* their professional activities<br \/>\n* business operations<br \/>\n* representations made to third parties<br \/>\n* compliance with applicable laws and regulations in their jurisdiction.<br \/>\n<br \/>\nICLRA bears no responsibility for the acts, omissions, or representations of License Holders.<br \/>\n<br \/>\n4. No Guarantee or Endorsement<br \/>\n<br \/>\nIssuance of an ICLRA license or registration does not constitute a guarantee, warranty, endorsement, or certification of competence, legality, or regulatory compliance of the License Holder within federal or state jurisdictions that fall outside the Crown jurisdiction.<br \/>\n<br \/>\n5. Limitation of Liability<br \/>\n<br \/>\nTo the maximum extent permitted by law, ICLRA shall not be liable for any loss, damage, claim, liability, or expense arising from or related to:<br \/>\n<br \/>\n* actions or omissions of License Holders<br \/>\n* reliance upon licenses or certifications issued by ICLRA<br \/>\n* services, products, or activities conducted by License Holders.<br \/>\n<br \/>\n6. Indemnification<br \/>\n<br \/>\nLicense Holders agree to indemnify and hold harmless ICLRA, its officers, administrators, and representatives from any claims, damages, liabilities, or legal proceedings arising from the License Holder\u2019s activities, conduct, and\/or representations.<br \/>\n<br \/>\n7. Non-Excludable Rights<br \/>\n<br \/>\nNothing in this disclaimer shall exclude or limit liability where such exclusion is prohibited by applicable law under Crown jurisdiction.<br \/>\n<br \/>\n8. Acceptance<br \/>\n<br \/>\nBy accepting, using, or representing possession of an ICLRA license, certification, or registration, the License Holder acknowledges and agrees to the terms of this disclaimer.<br \/>\n<\/div><\/fieldset><\/div><div id=\"wpforms-96-field_14-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"14\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"2\" data-formid=\"96\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"2\" data-formid=\"96\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-3 last \" data-page=\"3\" style=\"display:none;\"><div id=\"wpforms-96-field_17-container\" class=\"wpforms-field wpforms-field-entry-preview\" data-field-type=\"entry-preview\" data-field-id=\"17\"><div class=\"wpforms-entry-preview-updating-message\">Updating preview\u2026<\/div><div class=\"wpforms-entry-preview-notice\" style=\"display: none;\"><strong>This is a preview of your submission. 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You can also go back to make changes.<\/div><div class=\"wpforms-entry-preview-wrapper\" style=\"display: none;\"><\/div><\/div><div id=\"wpforms-96-field_23-container\" class=\"wpforms-field wpforms-field-payment-total wpforms-field-medium\" data-field-type=\"payment-total\" data-field-id=\"23\" aria-live=\"polite\" aria-atomic=\"true\"><label class=\"wpforms-field-label\">Total<\/label><div class=\"wpforms-payment-total\" style=\"\">&#036;0.00<\/div><input type=\"hidden\" id=\"wpforms-96-field_23\" class=\"wpforms-field-medium wpforms-payment-total\" name=\"wpforms[fields][23]\" value=\"0\"><\/div><div id=\"wpforms-96-field_30-container\" class=\"wpforms-field wpforms-field-content\" data-field-type=\"content\" data-field-id=\"30\"><div id=\"wpforms-96-field_30\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-96-field_30-error\"><p>International Transfers:<\/p>\n<p>Please be advised that your bank may charge transaction and exchange fees may apply<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-96-field_24-container\" class=\"wpforms-field wpforms-field-stripe-credit-card\" data-field-type=\"stripe-credit-card\" data-field-id=\"24\"><label class=\"wpforms-field-label\">Stripe Credit Card<\/label><div class=\"wpforms-field-row wpforms-no-columns wpforms-field-medium \" data-sublabel-position=\"above\" data-link-email=\"\" data-required=\"0\"><div id=\"wpforms-field-stripe-link-element-96\"><\/div><div id=\"wpforms-field-stripe-payment-element-96\"><\/div><input type=\"text\" class=\"wpforms-stripe-credit-card-hidden-input\" name=\"wpforms[stripe-credit-card-hidden-input-96]\" disabled style=\"display: none;\"><\/div><\/div><div id=\"wpforms-96-field_16-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"16\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"3\" data-formid=\"96\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><\/div><\/div><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-96-field_7-container { position: absolute !important; 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