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\/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_4' id='label_3_7_4' class='gform-field-label gform-field-label--type-inline'>\u140a\u14ef\u140a\u148d\u1466<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_59\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_59'>\u140a\u14ef\u140a\u148d\u1466:<\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_3_59' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u1403\u14c4\u1450\u1403\u14d0\u14c7\u1405\u1556\u1466 \u14c4\u14c7\u1555\u14bb\u14a5\u1405\u1591\u1466\u14f1\u144e\u1466?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_9'>\n\t\t\t<div class='gchoice gchoice_3_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='\u140b'  id='choice_3_9_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_9_0' id='label_3_9_0' class='gform-field-label gform-field-label--type-inline'>\u140b<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='\u140a\u1405\u1472'  id='choice_3_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_9_1' id='label_3_9_1' class='gform-field-label gform-field-label--type-inline'>\u140a\u1405\u1472<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_12\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u140a\u1405\u1473\u1548\u1555\u1466, \u14c4\u14c7\u1555\u14bb\u14a5\u1405\u1591\u1555\u1466 \u140a\u1550\u154c\u148e\u1449 \u1405\u1593\u1456\u14c4\u1466? <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_12'>\n\t\t\t<div class='gchoice gchoice_3_12_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='\u140b'  id='choice_3_12_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_12_0' id='label_3_12_0' class='gform-field-label gform-field-label--type-inline'>\u140b<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_12_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='\u140a\u1405\u1472'  id='choice_3_12_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_12_1' id='label_3_12_1' class='gform-field-label gform-field-label--type-inline'>\u140a\u1405\u1472<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_11'>\u140a\u158f\u1548\u1555\u1466, \u1403\u14da\u1405\u152b\u148d\u144e\u1449\u1431\u1466 \u146d\u14ef\u1466\u14ef\u148d\u144e\u1593 (JBNQA\/\u14aa\u146d\u155d\u1555\u1483)<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_3_11' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_67\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full acx-stop-form gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Ce programme est destin\u00e9 exclusivement aux personnes Inuit ou aux r\u00e9sidents du Nunavik. Contactez-nous au info@ajurisarvik.org pour plus d\u2019informations<\/p><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_3_61' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u146d\u1591\u14ea\u14d5\u1585'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_2' class='gform_page' data-js='page-field-id-61' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_3\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">\u1403\u14d5\u14d0\u14c5\u14d5\u1593\u152a\u1466 \u1450\u14f4\u1405\u14aa\u152d\u1405\u148b\u140a\u14d6\u1466<\/h3><\/div><fieldset id=\"field_3_13\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u140a\u144f\u1466<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_13'>\n                            \n                            <span id='input_3_13_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_13.3' id='input_3_13_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_13_3' class='gform-field-label gform-field-label--type-sub '>\u140a\u144f\u1466<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_13_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_13.6' id='input_3_13_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_13_6' class='gform-field-label gform-field-label--type-sub '>\u140a\u144e\u14d5\u1550\u1580\u1466 <\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_3_14\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u140a\u144f\u1466<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_14'>\n                            \n                            <span id='input_3_14_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_14.3' id='input_3_14_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_14_3' class='gform-field-label gform-field-label--type-sub '>\u140a\u144e\u148b\u140a\u14ea\u14d3\u1466 \u140a\u144e\u1449\u1431\u1466 \u140a\u14ef\u140a<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_14_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_14.6' id='input_3_14_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_14_6' class='gform-field-label gform-field-label--type-sub '>\u140a\u144e\u14d5\u1550\u157f\u148b\u140a\u14ea\u14d3\u1466 \u140a\u14ef\u140a <\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_3_16\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u14f1\u14c7\u1405\u14c3\u1466<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_16'>\n\t\t\t<div class='gchoice gchoice_3_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='\u140a\u1591\u144e'  id='choice_3_16_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_16_0' id='label_3_16_0' class='gform-field-label gform-field-label--type-inline'>\u140a\u1591\u144e<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='\u140a\u1550\u14c7\u1585'  id='choice_3_16_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_16_1' id='label_3_16_1' class='gform-field-label gform-field-label--type-inline'>\u140a\u1550\u14c7\u1585<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_16_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='\u140a\u14ef\u140a\u148d\u1466'  id='choice_3_16_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_16_2' id='label_3_16_2' class='gform-field-label gform-field-label--type-inline'>\u140a\u14ef\u140a\u148d\u1466<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_21\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u1401\u1449\u1438\u1583\u1550\u14c2\u146f\u1466 \u1583\u14c4\u1403\u1466\u1451\u14c2\u1585<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_21'><div class='gchoice gchoice_3_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='\u1401\u1449\u1438\u1583\u1595\u158f\u1450\u1585'  id='choice_3_21_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_21_1' id='label_3_21_1' class='gform-field-label gform-field-label--type-inline'>\u1401\u1449\u1438\u1583\u1595\u158f\u1450\u1585<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='\u1472\u144e\u144e\u1455\u1405\u14aa\u152a\u1585 \/ \u1401\u1449\u1438\u14d5\u1483'  id='choice_3_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_21_2' id='label_3_21_2' class='gform-field-label gform-field-label--type-inline'>\u1472\u144e\u144e\u1455\u1405\u14aa\u152a\u1585 \/ \u1401\u1449\u1438\u14d5\u1483<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_21_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.3' type='checkbox'  value='\u140a\u1555\u1466\u14ef\u14aa\u152a\u1585'  id='choice_3_21_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_21_3' id='label_3_21_3' class='gform-field-label gform-field-label--type-inline'>\u140a\u1555\u1466\u14ef\u14aa\u152a\u1585<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_21_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.4' type='checkbox'  value='\u1405\u1403\u14a1\u1490\u14c2\u1585'  id='choice_3_21_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_21_4' id='label_3_21_4' class='gform-field-label gform-field-label--type-inline'>\u1405\u1403\u14a1\u1490\u14c2\u1585<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_19\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_19'>\u1403\u14c5\u14d5\u1550\u1556\u1466<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_19' id='input_3_19' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='\u1455\u1550\u157f\u1593 \/ \u1405\u14ea\u14d7\u1593 \/ \u140a\u1550\u154c\u148d\u1593' aria-describedby=\"input_3_19_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_19_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_19' class='gform_hidden' value='https:\/\/www.ajurisarvik.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_18'>\u1431\u14c7\u14f1\u148d\u14d0\u14c7\u1405\u144f\u1466 \u146d\u14ef\u1466\u152a\u14ef\u1593 (SIN)<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_3_18' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_62' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u14ef\u1557\u14ea\u14d5\u1585'  \/> <input type='button' id='gform_next_button_3_62' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u146d\u1591\u14ea\u14d5\u1585'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_3' class='gform_page' data-js='page-field-id-62' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_5\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">\u1405\u1584\u14da\u1555\u1405\u148d\u14d0\u14c7\u14c2\u1550\u14a7\u1466 \u1450\u14f4\u1405\u14aa\u152d\u1405\u148b\u140a\u14d6\u1466<\/h3><\/div><fieldset id=\"field_3_31\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u140a\u14ea\u14da\u1456\u1550\u1555\u146f\u1466 \u1450\u154c\u1548\u144f\u1466<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_3_31' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_31_1_container' >\n                                        <input type='text' name='input_31.1' id='input_3_31_1' value=''    aria-required='false'    \/>\n                                        <label for='input_3_31_1' id='input_3_31_1_label' class='gform-field-label gform-field-label--type-sub '>\u1403\u14ea\u14d7\u1431\u1466 \u146d\u14ef\u1466\u152a\u144e\u1593 \u140a\u1550\u1581\u144e\u1405\u14ea\u14d7 \u140a\u144e\u1593<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_3_31_2_container' >\n                                        <input type='text' name='input_31.2' id='input_3_31_2' value=''     aria-required='false'   \/>\n                                        <label for='input_3_31_2' id='input_3_31_2_label' class='gform-field-label gform-field-label--type-sub '>\u140a\u14ea\u14da\u1456\u1550\u1555\u146f\u1466 \u1403\u1466\u14ef\u1555\u140a\u1432\u1483<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_31_3_container' >\n                                    <input type='text' name='input_31.3' id='input_3_31_3' value=''    aria-required='false'    \/>\n                                    <label for='input_3_31_3' id='input_3_31_3_label' class='gform-field-label gform-field-label--type-sub '>\u14c4\u14c7\u14d6\u1466<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_3_31_4_container' >\n                                        <input type='text' name='input_31.4' id='input_3_31_4' value=''      aria-required='false'    \/>\n                                        <label for='input_3_31_4' id='input_3_31_4_label' class='gform-field-label gform-field-label--type-sub '>\u14c4\u14c7\u1405\u1449 \u140a\u1555\u1466\u1450\u14ef\u14aa\u1405\u144e\u1593<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_3_31_5_container' >\n                                    <input type='text' name='input_31.5' id='input_3_31_5' value=''    aria-required='false'    \/>\n                                    <label for='input_3_31_5' id='input_3_31_5_label' class='gform-field-label gform-field-label--type-sub '>\u1450\u154c\u1548\u144e\u1449\u1431\u1466 \u14c7\u14d7\u14c0\u1483\u146f\u1455\u1593<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_31.6' id='input_3_31_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_3_26\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u1583\u1593\u1405\u144e\u14ea\u14d7\u148d \u1405\u1584\u14da\u1555\u1405\u1548\u14d0\u14c7\u14c3\u1466<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_26'><div class='gchoice gchoice_3_26_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.1' type='checkbox'  value='\u1405\u14ea\u14db\u146f\u1466'  id='choice_3_26_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_26_1' id='label_3_26_1' class='gform-field-label gform-field-label--type-inline'>\u1405\u14ea\u14db\u146f\u1466<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_26_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.2' type='checkbox'  value='\u157f\u144e\u154b\u14d5\u1547\u14a5'  id='choice_3_26_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_26_2' id='label_3_26_2' class='gform-field-label gform-field-label--type-inline'>\u157f\u144e\u154b\u14d5\u1547\u14a5<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_26_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.3' type='checkbox'  value='\u1405\u14d0\u14c4\u146f\u1466'  id='choice_3_26_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_26_3' id='label_3_26_3' class='gform-field-label gform-field-label--type-inline'>\u1405\u14d0\u14c4\u146f\u1466<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_27\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u1405\u1584\u1555\u1405\u148d\u14aa\u1450\u140a\u1548\u1555\u1466 \u1403\u14f1\u140a\u1546\u14c2\u1550\u1439\u1466<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_3_27'>(\u1583\u1546\u1455\u1405\u152d\u1483\u146f\u1466 \u140a\u14ea\u14da\u1583\u1466\u1455\u1405\u144e\u148d\u144e\u1405\u1449\u1438\u1466, \u140a\u144f\u1466 Facebook-\u14a5 \u140a\u14ea\u14da\u14d7\u148d \u140a\u14ea\u14da\u1555\u1405\u1490\u14f1\u140a\u1550\u1555\u144e\u14ea\u14d7 \u1583\u1405\u1528\u148b\u140a\u1466\u14ef\u140a\u1583\u1466\u1455\u14d7\u148b\u1466)<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_27'><div class='gchoice gchoice_3_27_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.1' type='checkbox'  value='\u1405\u1584\u14da\u1405\u144e\u1483\u146f\u1466\u1405\u1584\u14da\u1405\u144e\u1483\u146f\u1466'  id='choice_3_27_1'   aria-describedby=\"gfield_description_3_27\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_3_27_1' id='label_3_27_1' class='gform-field-label gform-field-label--type-inline'>\u1405\u1584\u14da\u1405\u144e\u1483\u146f\u1466<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_27_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.2' type='checkbox'  value='\u1583\u1546\u1455\u1405\u152d\u1483\u146f\u1466 \u140a\u14ea\u14da\u1456\u1550\u1555\u146f\u1466'  id='choice_3_27_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_27_2' id='label_3_27_2' class='gform-field-label gform-field-label--type-inline'>\u1583\u1546\u1455\u1405\u152d\u1483\u146f\u1466 \u140a\u14ea\u14da\u1456\u1550\u1555\u146f\u1466<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_27_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.3' type='checkbox'  value='\u1583\u1546\u1455\u1405\u152d\u1483\u146f\u1466 \u140a\u14ea\u14da\u1583\u1466\u1455\u1405\u144e\u148d\u144e\u1483\u146f\u1466 \u140a\u14ef\u140a\u148d\u14ea\u14d8\u14c3\u1466'  id='choice_3_27_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_27_3' id='label_3_27_3' class='gform-field-label gform-field-label--type-inline'>\u1583\u1546\u1455\u1405\u152d\u1483\u146f\u1466 \u140a\u14ea\u14da\u1583\u1466\u1455\u1405\u144e\u148d\u144e\u1483\u146f\u1466 \u140a\u14ef\u140a\u148d\u14ea\u14d8\u14c3\u1466<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_28'>Autre moyen de contact<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_3_28' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_25\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_25'>\u1583\u1546\u1455\u1405\u152d\u1483\u146f\u1466 \u140a\u14ea\u14da\u1456\u1550\u1555\u146f\u1466<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_25' id='input_3_25' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_3_23\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_23'>\u140a\u14ef\u140a \u1405\u1584\u14da\u1405\u144e\u1593<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_23' id='input_3_23' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_60\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_60'>\u140a\u14ef\u140a\u148d\u1466<\/label><div class='ginput_container ginput_container_phone'><input name='input_60' id='input_3_60' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_37\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">\u1405\u1403\u14aa\u14c7\u1550\u1450\u146f\u1466 \u1405\u1584\u14da\u1555\u1466\u14f4\u1585<\/h3><\/div><fieldset id=\"field_3_32\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u1405\u1403\u14aa\u14c7\u1550\u1450\u146f\u1466 \u1405\u1584\u14da\u1555\u1466\u14f4\u1585<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_32'>\n                            \n                            <span id='input_3_32_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_32.3' id='input_3_32_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_32_3' class='gform-field-label gform-field-label--type-sub '>\u140a\u144f\u1466<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_32_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_32.6' id='input_3_32_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_32_6' class='gform-field-label gform-field-label--type-sub '>\u140a\u144e\u14d5\u1550\u1580\u1466 <\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_33'>\u1431\u152a\u1466\u14f4\u1405\u152e\u1550\u1451\u1449 \u146d\u14c7\u1593<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_3_33' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_36\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_36'>\u140a\u14c2\u1550\u154b\u14a5 \u1405\u1584\u14da\u1405\u144e\u1593<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_36' id='input_3_36' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_3_34\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_34'>\u140a\u14ef\u140a \u1405\u1584\u14da\u1405\u144e\u1593<\/label><div class='ginput_container ginput_container_phone'><input name='input_34' id='input_3_34' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_35\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_35'>\u1583\u1546\u1455\u1405\u152d\u1483\u146f\u1466 \u140a\u14ea\u14da\u1456\u1550\u1555\u1593<\/label><div class='ginput_container ginput_container_phone'><input name='input_35' id='input_3_35' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_64' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u14ef\u1557\u14ea\u14d5\u1585'  \/> <input type='button' id='gform_next_button_3_64' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u146d\u1591\u14ea\u14d5\u1585'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_4' class='gform_page' data-js='page-field-id-64' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_40\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">\u1431\u1581\u152d\u144e\u148d\u1466 \u1431\u14c2\u1550\u14d7\u14ef\u14aa\u1405\u144e\u1583\u1550\u14c2\u1585<\/h3><\/div><fieldset id=\"field_3_70\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you have a criminal record? * By completing this form, I agree to have my criminal record checked.<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_70'><div class='gchoice gchoice_3_70_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_70.1' type='checkbox'  value='Oui'  id='choice_3_70_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_70_1' id='label_3_70_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_70_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_70.2' type='checkbox'  value='Non'  id='choice_3_70_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_70_2' id='label_3_70_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_70_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_70.3' type='checkbox'  value='Je ne sais pas'  id='choice_3_70_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_70_3' id='label_3_70_3' class='gform-field-label gform-field-label--type-inline'>Je ne sais pas<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_43\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">\u140a\u1405\u14da\u148d\u14d0\u14c7\u14c2\u1550\u14a7\u1466 \u1450\u14f4\u1405\u14aa\u152d\u1405\u148b\u140a\u14d6\u1466<\/h3><\/div><fieldset id=\"field_3_42\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u1455\u14aa\u1466\u14f1\u14a5\u1593 \u140a\u1451\u144e\u14c2\u1550\u14a7\u1466 \u1403\u14c4\u1483\u152a\u140a\u14a6\u1548\u14d0\u14c7\u157f\u1466 (\u1431\u14c7\u14f1\u140a\u1548\u14ef\u1550\u14c2 15-\u14c2 \u1405\u1593\u1456\u14c4\u14ea\u14d8\u14c3\u1466)?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_42'>\n\t\t\t<div class='gchoice gchoice_3_42_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='\u140b'  id='choice_3_42_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_42_0' id='label_3_42_0' class='gform-field-label gform-field-label--type-inline'>\u140b<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_42_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='\u140a\u1405\u1472'  id='choice_3_42_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_42_1' id='label_3_42_1' class='gform-field-label gform-field-label--type-inline'>\u140a\u1405\u1472<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_6\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">\u14ab\u14d0\u14c7\u1405\u144e\u14ea\u14d7\u148d \u1583\u14c4\u1403\u1466\u1450\u14a6\u14d0\u14c2\u1585<\/h3><\/div><fieldset id=\"field_3_44\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u1431\u14c7\u14f1\u1490\u1583\u1550\u1431\u1466?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_44'>\n\t\t\t<div class='gchoice gchoice_3_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='\u140b'  id='choice_3_44_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_44_0' id='label_3_44_0' class='gform-field-label gform-field-label--type-inline'>\u140b<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='\u140a\u1405\u1472'  id='choice_3_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_44_1' id='label_3_44_1' class='gform-field-label gform-field-label--type-inline'>\u140a\u1405\u1472<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_68\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_68'>\u140a\u158f\u1548\u1555\u1466, \u1431\u14c7\u14f1\u1489\u1466 \u14f1\u14c7\u1405\u14bb\u14aa\u1594\u1466 \u1431\u14c7\u14f1\u155d\u1556\u14d7<\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_3_68' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_48\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u1431\u14c7\u14f1\u1490\u1583\u1550\u14c2\u14a5 \u1583\u14c4\u1403\u1466\u1450\u14a6\u14d0\u14c3\u1466<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_48'><div class='gchoice gchoice_3_48_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.1' type='checkbox'  value='\u1405\u14ea\u14d7\u14d5\u14ab\u1550\u1450\u14a5\u1483'  id='choice_3_48_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_48_1' id='label_3_48_1' class='gform-field-label gform-field-label--type-inline'>\u1405\u14ea\u14d7\u14d5\u14ab\u1550\u1450\u14a5\u1483<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_48_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.2' type='checkbox'  value='\u1405\u14ea\u14d7\u14d5\u14ab\u1595\u158f\u1450\u14a5\u1483'  id='choice_3_48_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_48_2' id='label_3_48_2' class='gform-field-label gform-field-label--type-inline'>\u1405\u14ea\u14d7\u14d5\u14ab\u1595\u158f\u1450\u14a5\u1483<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_48_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.3' type='checkbox'  value='\u140a\u144c\u14d0\u14c7\u1450\u1585'  id='choice_3_48_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_48_3' id='label_3_48_3' class='gform-field-label gform-field-label--type-inline'>\u140a\u144c\u14d0\u14c7\u1450\u1585<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_48_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.4' type='checkbox'  value='\u1403\u14c7\u158f\u1550\u14ef\u14ef\u14aa\u152a\u1585'  id='choice_3_48_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_48_4' id='label_3_48_4' class='gform-field-label gform-field-label--type-inline'>\u1403\u14c7\u158f\u1550\u14ef\u14ef\u14aa\u152a\u1585<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_48_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.5' type='checkbox'  value='\u14c7\u14bb\u14a5\u14c2\u1581\u144e\u14a5 '  id='choice_3_48_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_48_5' id='label_3_48_5' class='gform-field-label gform-field-label--type-inline'>\u14c7\u14bb\u14a5\u14c2\u1581\u144e\u14a5 <\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_50\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u1403\u14d7\u14ef\u1550\u14f2\u144f\u1466 \u1583\u14c4\u1403\u1595\u158f\u14aa\u1466 \u1431\u14c7\u14f1\u148d\u14d0\u14c7\u1431\u1466?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_50'>\n\t\t\t<div class='gchoice gchoice_3_50_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='\u140b, \u1403\u14d7\u14ef\u154b \u1583\u14c4\u1403\u1595\u158f\u14aa\u1466 \u1431\u14c7\u14f1\u148d\u14d0\u14c7\u1433\u1593'  id='choice_3_50_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_50_0' id='label_3_50_0' class='gform-field-label gform-field-label--type-inline'>\u140b, \u1403\u14d7\u14ef\u154b \u1583\u14c4\u1403\u1595\u158f\u14aa\u1466 \u1431\u14c7\u14f1\u148d\u14d0\u14c7\u1433\u1593<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_50_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='\u140a\u1405\u1472, \u1403\u14d7\u14ef\u1550\u14f1\u14ef\u140a\u1595\u158f\u14c7\u14aa \u1431\u14c7\u14f1\u1550\u1583\u152d\u1595\u158f\u1450\u1593'  id='choice_3_50_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_50_1' id='label_3_50_1' class='gform-field-label gform-field-label--type-inline'>\u140a\u1405\u1472, \u1403\u14d7\u14ef\u1550\u14f1\u14ef\u140a\u1595\u158f\u14c7\u14aa \u1431\u14c7\u14f1\u1550\u1583\u152d\u1595\u158f\u1450\u1593<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_51\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_51'>Pourquoi ne vous permet-elle pas de travailler?<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_3_51' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_52\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u1406\u14aa\u1455\u1583\u1550\u1431\u1466?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_52'>\n\t\t\t<div class='gchoice gchoice_3_52_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='\u140b, \u1406\u14aa\u1455\u1583\u1550\u1433\u1593 (\u1431\u140a\u154b\u1483\u1472, \u1401\u1449\u1438\u154b \u1431\u14c7\u14f1\u1595\u158f\u1450\u1585, \u140a\u14ef\u158f\u14ea\u14d7)'  id='choice_3_52_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_52_0' id='label_3_52_0' class='gform-field-label gform-field-label--type-inline'>\u140b, \u1406\u14aa\u1455\u1583\u1550\u1433\u1593 (\u1431\u140a\u154b\u1483\u1472, \u1401\u1449\u1438\u154b \u1431\u14c7\u14f1\u1595\u158f\u1450\u1585, \u140a\u14ef\u158f\u14ea\u14d7)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_52_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='\u140a\u1405\u1472'  id='choice_3_52_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_52_1' id='label_3_52_1' class='gform-field-label gform-field-label--type-inline'>\u140a\u1405\u1472<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_54\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_54'>\u140a\u158f\u1548\u1555\u1466, \u1583\u1466\u14f0\u1466 \u1406\u14aa\u1455\u144e\u1466<\/label><div class='ginput_container ginput_container_number'><input name='input_54' id='input_3_54' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_3_55\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u140a\u158f\u1548\u1555\u1466, \u142f\u1546\u1466\u14ef\u1555\u14bb\u14a6\u14f2\u1466<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_55'>\n\t\t\t<div class='gchoice gchoice_3_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='\u140b'  id='choice_3_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_55_0' id='label_3_55_0' class='gform-field-label gform-field-label--type-inline'>\u140b<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='\u140a\u1405\u1472'  id='choice_3_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_55_1' id='label_3_55_1' class='gform-field-label gform-field-label--type-inline'>\u140a\u1405\u1472<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_58\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u140a\u158f\u1548\u144f\u1466 \u1583\u14c4\u1403\u1466\u1450\u14a6\u14d0\u14c2\u1583\u1548\u144f\u14ea\u14d7<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_58.1' id='input_3_58_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_58_1' >\u1456\u14d0\u14c7 \u1455\u1455\u1550\u14f4\u1490\u1585 \u140a\u1405\u14ea\u14da\u144e\u1466\u14f1\u148d, \u14f1\u14d5\u14c2\u1543\u1557\u1593 \u1450\u14f4\u1405\u14aa\u152d\u1405\u148b\u140a\u14d6\u1466 \u14c8\u14bb\u14aa\u14ef\u140a\u1550\u14c2\u158f\u14d0\u14c2\u1483 \u14f1\u14c7\u14a5\u1466\u1450\u144e\u14d7, \u1450\u146d\u14ef\u1466\u14f1\u1593\u14d7 \u1583\u1405\u1528\u14f4\u1546\u140a\u1548\u144e\u1405\u148d\u14d0\u14c7\u14aa\u1455. \u140a\u158f\u1550\u1433\u1593 \u1450\u14f4\u1550\u144e\u14ef\u14c2\u1550\u14a7\u1466 \u140a\u152a\u1546\u14f4\u1550\u1555\u14a5\u1483 \u140a\u14ef\u1466\u1528\u148d\u144e\u14d5\u14ab\u14c2\u1483 \u1405\u1559\u14d0\u14c5\u14d5\u1593\u152a\u14c2\u1483 \u1450\u14f4\u1405\u14aa\u152d\u1405\u148b\u140a\u14d5\u14d0\u14c2\u1483 \u140a\u1405\u14da\u1466\u14ef\u14c2\u14d5\u1546\u14c2\u1550\u14a7\u1466 \u1431\u1466\u152a\u144e\u14d5\u14d0\u14c2\u1483 \u140a\u158f\u1548\u144e\u148b\u1466\u14f1\u148d\u14d7 \u1450\u14f4\u1405\u14aa\u152d\u1405\u148b\u140a\u14d6\u1466 \u1455\u14aa\u1483\u146f\u140a \u140a\u14a5\u1550\u1584\u1583\u144e\u1405\u14da\u1593\u144e\u14ea\u14d7\u148b\u1466 \u140a\u1466\u1528\u148c\u1595\u158f\u1450\u14c4\u1466 \u1431\u14c7\u14f1\u155d\u1555\u14c4\u1466 \u1472\u1559\u14aa\u14d5\u1546\u1555\u14d0\u14c4\u14d7.<\/label><input type='hidden' name='input_58.2' value='\u1456\u14d0\u14c7 \u1455\u1455\u1550\u14f4\u1490\u1585 \u140a\u1405\u14ea\u14da\u144e\u1466\u14f1\u148d, \u14f1\u14d5\u14c2\u1543\u1557\u1593 \u1450\u14f4\u1405\u14aa\u152d\u1405\u148b\u140a\u14d6\u1466 \u14c8\u14bb\u14aa\u14ef\u140a\u1550\u14c2\u158f\u14d0\u14c2\u1483 \u14f1\u14c7\u14a5\u1466\u1450\u144e\u14d7, \u1450\u146d\u14ef\u1466\u14f1\u1593\u14d7 \u1583\u1405\u1528\u14f4\u1546\u140a\u1548\u144e\u1405\u148d\u14d0\u14c7\u14aa\u1455. \u140a\u158f\u1550\u1433\u1593 \u1450\u14f4\u1550\u144e\u14ef\u14c2\u1550\u14a7\u1466 \u140a\u152a\u1546\u14f4\u1550\u1555\u14a5\u1483 \u140a\u14ef\u1466\u1528\u148d\u144e\u14d5\u14ab\u14c2\u1483 \u1405\u1559\u14d0\u14c5\u14d5\u1593\u152a\u14c2\u1483 \u1450\u14f4\u1405\u14aa\u152d\u1405\u148b\u140a\u14d5\u14d0\u14c2\u1483 \u140a\u1405\u14da\u1466\u14ef\u14c2\u14d5\u1546\u14c2\u1550\u14a7\u1466 \u1431\u1466\u152a\u144e\u14d5\u14d0\u14c2\u1483 \u140a\u158f\u1548\u144e\u148b\u1466\u14f1\u148d\u14d7 \u1450\u14f4\u1405\u14aa\u152d\u1405\u148b\u140a\u14d6\u1466 \u1455\u14aa\u1483\u146f\u140a \u140a\u14a5\u1550\u1584\u1583\u144e\u1405\u14da\u1593\u144e\u14ea\u14d7\u148b\u1466 \u140a\u1466\u1528\u148c\u1595\u158f\u1450\u14c4\u1466 \u1431\u14c7\u14f1\u155d\u1555\u14c4\u1466 \u1472\u1559\u14aa\u14d5\u1546\u1555\u14d0\u14c4\u14d7.' class='gform_hidden' \/><input type='hidden' name='input_58.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_3' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u14ef\u1557\u14ea\u14d5\u1585'  \/> <input type='submit' id='gform_submit_button_3' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='\u140a\u1405\u14ea\u14da\u144e\u14d7\u148d'  \/> <input type='hidden' name='gform_ajax' value='form_id=3&amp;title=&amp;description=&amp;tabindex=0&amp;theme=gravity-theme&amp;styles=[]&amp;hash=4e8232cfc37903bb3ed0febcaf3de50e' \/><input type='hidden' class='gform_hidden' name='gform_submission_speeds' value='{&quot;pages&quot;:[]}' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_3' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_3' id='gform_theme_3' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_3' id='gform_style_settings_3' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_3' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='3' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='CAD' value='KOzuKDvnQ3I5LZpuSJowOdTPbpy3pNecSV03hzvQIWYSiGTEnNWeGY+v9G1A8nU6QOqjCnPKlV9462CDj3L0EDV1w3+cQsRva2Sm7DF\/7EPyT3o=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_3' 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\/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_3' id='gform_target_page_number_3' value='2' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_3' id='gform_source_page_number_3' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n             <\/div><\/div>\n                        <\/form>\n                        <\/div>\n\t\t                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_3' id='gform_ajax_frame_3' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n\t\t                <script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 3, 'https:\/\/www.ajurisarvik.org\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true 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{gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"3\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_3\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_3\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_3\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 3, current_page );            if ( visibilityTestDiv ) {                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\u1405\u146d\u1405\u1583\u1550\u14d7\u144e\u1466 \u1450\u146d\u14ef\u140a\u1466\u14ef\u140a\u1548\u14d0\u14c7\u14d7\u144e\u1483 \u1583\u14ea\u14d7\u14c8\u144e\u1450\u1466 (\u1405\u1584\u14c2\u1483\u146f\u1466, \u140a\u14ea\u14da\u14c2\u140a\u1550\u14c2\u146f\u1466 \u140a\u14ea\u14da\u14c2\u1483\u146f\u14d7\u1466) \u1405\u146f\u140a \u14c7\u14ea\u14d5\u158f\u14d0\u14c2\u1483 \u1472\u1590\u14f1\u14ea\u14d7\u144e\u1466 \u140a\u14ea\u14da\u1555\u14bb\u14a5 \u1431\u14c7\u14f1\u1490\u1550\u14c2\u1483: \u140a\u14ea\u14da\u1555\u14bb\u14a5 \u1431\u14c7\u14f1\u1466\u144e-\u140a\u14ea\u14da\u144e\/\u146d\u1405\u1528-\u146e\u14c7\u1405\u152d\u14d5\u1546\u14c2\u1550\u14a5 \u1431\u14c7\u14f1\u1466\u144e \u1431\u152a\u1466\u14f4\u1405\u152e\u1550\u14c2\u14a7\u1466 \u140a\u14ea\u14da\u1555\u1405\u148b\u140a\u14d5\u1483\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_3' style='display:none'><div id='gf_3' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_3' id='gform_3'  action='\/es\/wp-json\/wp\/v2\/pages\/802#gf_3' data-formid='3' novalidate>\n        <div id='gf_progressbar_wrapper_3' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">\u140a\u14ea\u14d7\u1546\u140a\u1548\u144e <span class='gf_step_current_page'>1<\/span> \u1406\u14aa <span class='gf_step_page_count'>4<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_25' style='width:25%;'><span>25%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_3_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_71\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_71'>Name<\/label><div class='ginput_container'><input name='input_71' id='input_3_71' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_3_71'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_3_1\" class=\"gfield gfield--type-section 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value='\u1583\u1546\u1455\u1405\u152d\u1483\u146f\u1466'  id='choice_3_7_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_1' id='label_3_7_1' class='gform-field-label gform-field-label--type-inline'>\u1583\u1546\u1455\u1405\u152d\u1483\u146f\u1466<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_7_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.2' type='checkbox'  value='YES\/LEO'  id='choice_3_7_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_2' id='label_3_7_2' class='gform-field-label gform-field-label--type-inline'>YES\/LEO<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_7_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.3' type='checkbox'  value='\u1431\u152a\u14d0\u14c7\u1581\u1593'  id='choice_3_7_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_7_3' id='label_3_7_3' class='gform-field-label gform-field-label--type-inline'>\u1431\u152a\u14d0\u14c7\u1581\u1593<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice 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value='\u140a\u1405\u1472'  id='choice_3_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_9_1' id='label_3_9_1' class='gform-field-label gform-field-label--type-inline'>\u140a\u1405\u1472<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_12\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u140a\u1405\u1473\u1548\u1555\u1466, \u14c4\u14c7\u1555\u14bb\u14a5\u1405\u1591\u1555\u1466 \u140a\u1550\u154c\u148e\u1449 \u1405\u1593\u1456\u14c4\u1466? <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_12'>\n\t\t\t<div class='gchoice gchoice_3_12_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='\u140b'  id='choice_3_12_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_12_0' id='label_3_12_0' class='gform-field-label gform-field-label--type-inline'>\u140b<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_12_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='\u140a\u1405\u1472'  id='choice_3_12_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_12_1' id='label_3_12_1' class='gform-field-label gform-field-label--type-inline'>\u140a\u1405\u1472<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_11'>\u140a\u158f\u1548\u1555\u1466, \u1403\u14da\u1405\u152b\u148d\u144e\u1449\u1431\u1466 \u146d\u14ef\u1466\u14ef\u148d\u144e\u1593 (JBNQA\/\u14aa\u146d\u155d\u1555\u1483)<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_3_11' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_67\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full acx-stop-form gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Ce programme est destin\u00e9 exclusivement aux personnes Inuit ou aux r\u00e9sidents du Nunavik. Contactez-nous au info@ajurisarvik.org pour plus d\u2019informations<\/p><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_3_61' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u146d\u1591\u14ea\u14d5\u1585'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_2' class='gform_page' data-js='page-field-id-61' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_3\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">\u1403\u14d5\u14d0\u14c5\u14d5\u1593\u152a\u1466 \u1450\u14f4\u1405\u14aa\u152d\u1405\u148b\u140a\u14d6\u1466<\/h3><\/div><fieldset id=\"field_3_13\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u140a\u144f\u1466<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_13'>\n                            \n                            <span id='input_3_13_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_13.3' id='input_3_13_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_13_3' class='gform-field-label gform-field-label--type-sub '>\u140a\u144f\u1466<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_13_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_13.6' id='input_3_13_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_13_6' class='gform-field-label gform-field-label--type-sub '>\u140a\u144e\u14d5\u1550\u1580\u1466 <\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_3_14\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u140a\u144f\u1466<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_14'>\n                            \n                            <span id='input_3_14_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_14.3' id='input_3_14_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_14_3' class='gform-field-label gform-field-label--type-sub '>\u140a\u144e\u148b\u140a\u14ea\u14d3\u1466 \u140a\u144e\u1449\u1431\u1466 \u140a\u14ef\u140a<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_14_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_14.6' id='input_3_14_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_14_6' class='gform-field-label gform-field-label--type-sub '>\u140a\u144e\u14d5\u1550\u157f\u148b\u140a\u14ea\u14d3\u1466 \u140a\u14ef\u140a <\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_3_16\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u14f1\u14c7\u1405\u14c3\u1466<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_16'>\n\t\t\t<div class='gchoice gchoice_3_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='\u140a\u1591\u144e'  id='choice_3_16_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_16_0' id='label_3_16_0' class='gform-field-label gform-field-label--type-inline'>\u140a\u1591\u144e<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='\u140a\u1550\u14c7\u1585'  id='choice_3_16_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_16_1' id='label_3_16_1' class='gform-field-label gform-field-label--type-inline'>\u140a\u1550\u14c7\u1585<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_16_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='\u140a\u14ef\u140a\u148d\u1466'  id='choice_3_16_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_16_2' id='label_3_16_2' class='gform-field-label gform-field-label--type-inline'>\u140a\u14ef\u140a\u148d\u1466<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_21\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u1401\u1449\u1438\u1583\u1550\u14c2\u146f\u1466 \u1583\u14c4\u1403\u1466\u1451\u14c2\u1585<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_21'><div class='gchoice gchoice_3_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='\u1401\u1449\u1438\u1583\u1595\u158f\u1450\u1585'  id='choice_3_21_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_21_1' id='label_3_21_1' class='gform-field-label gform-field-label--type-inline'>\u1401\u1449\u1438\u1583\u1595\u158f\u1450\u1585<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='\u1472\u144e\u144e\u1455\u1405\u14aa\u152a\u1585 \/ \u1401\u1449\u1438\u14d5\u1483'  id='choice_3_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_21_2' id='label_3_21_2' class='gform-field-label gform-field-label--type-inline'>\u1472\u144e\u144e\u1455\u1405\u14aa\u152a\u1585 \/ \u1401\u1449\u1438\u14d5\u1483<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_21_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.3' type='checkbox'  value='\u140a\u1555\u1466\u14ef\u14aa\u152a\u1585'  id='choice_3_21_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_21_3' id='label_3_21_3' class='gform-field-label gform-field-label--type-inline'>\u140a\u1555\u1466\u14ef\u14aa\u152a\u1585<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_21_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.4' type='checkbox'  value='\u1405\u1403\u14a1\u1490\u14c2\u1585'  id='choice_3_21_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_21_4' id='label_3_21_4' class='gform-field-label gform-field-label--type-inline'>\u1405\u1403\u14a1\u1490\u14c2\u1585<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_19\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_19'>\u1403\u14c5\u14d5\u1550\u1556\u1466<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_19' id='input_3_19' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='\u1455\u1550\u157f\u1593 \/ \u1405\u14ea\u14d7\u1593 \/ \u140a\u1550\u154c\u148d\u1593' aria-describedby=\"input_3_19_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_19_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_19' class='gform_hidden' value='https:\/\/www.ajurisarvik.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_18'>\u1431\u14c7\u14f1\u148d\u14d0\u14c7\u1405\u144f\u1466 \u146d\u14ef\u1466\u152a\u14ef\u1593 (SIN)<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_3_18' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_62' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u14ef\u1557\u14ea\u14d5\u1585'  \/> <input type='button' id='gform_next_button_3_62' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u146d\u1591\u14ea\u14d5\u1585'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_3' class='gform_page' data-js='page-field-id-62' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_5\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">\u1405\u1584\u14da\u1555\u1405\u148d\u14d0\u14c7\u14c2\u1550\u14a7\u1466 \u1450\u14f4\u1405\u14aa\u152d\u1405\u148b\u140a\u14d6\u1466<\/h3><\/div><fieldset id=\"field_3_31\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u140a\u14ea\u14da\u1456\u1550\u1555\u146f\u1466 \u1450\u154c\u1548\u144f\u1466<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_3_31' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_31_1_container' >\n                                        <input type='text' name='input_31.1' id='input_3_31_1' value=''    aria-required='false'    \/>\n                                        <label for='input_3_31_1' id='input_3_31_1_label' class='gform-field-label gform-field-label--type-sub '>\u1403\u14ea\u14d7\u1431\u1466 \u146d\u14ef\u1466\u152a\u144e\u1593 \u140a\u1550\u1581\u144e\u1405\u14ea\u14d7 \u140a\u144e\u1593<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_3_31_2_container' >\n                                        <input type='text' name='input_31.2' id='input_3_31_2' value=''     aria-required='false'   \/>\n                                        <label for='input_3_31_2' id='input_3_31_2_label' class='gform-field-label gform-field-label--type-sub '>\u140a\u14ea\u14da\u1456\u1550\u1555\u146f\u1466 \u1403\u1466\u14ef\u1555\u140a\u1432\u1483<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_31_3_container' >\n                                    <input type='text' name='input_31.3' id='input_3_31_3' value=''    aria-required='false'    \/>\n                                    <label for='input_3_31_3' id='input_3_31_3_label' class='gform-field-label gform-field-label--type-sub '>\u14c4\u14c7\u14d6\u1466<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_3_31_4_container' >\n                                        <input type='text' name='input_31.4' id='input_3_31_4' value=''      aria-required='false'    \/>\n                                        <label for='input_3_31_4' id='input_3_31_4_label' class='gform-field-label gform-field-label--type-sub '>\u14c4\u14c7\u1405\u1449 \u140a\u1555\u1466\u1450\u14ef\u14aa\u1405\u144e\u1593<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_3_31_5_container' >\n                                    <input type='text' name='input_31.5' id='input_3_31_5' value=''    aria-required='false'    \/>\n                                    <label for='input_3_31_5' id='input_3_31_5_label' class='gform-field-label gform-field-label--type-sub '>\u1450\u154c\u1548\u144e\u1449\u1431\u1466 \u14c7\u14d7\u14c0\u1483\u146f\u1455\u1593<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_31.6' id='input_3_31_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_3_26\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u1583\u1593\u1405\u144e\u14ea\u14d7\u148d \u1405\u1584\u14da\u1555\u1405\u1548\u14d0\u14c7\u14c3\u1466<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_26'><div class='gchoice gchoice_3_26_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.1' type='checkbox'  value='\u1405\u14ea\u14db\u146f\u1466'  id='choice_3_26_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_26_1' id='label_3_26_1' class='gform-field-label gform-field-label--type-inline'>\u1405\u14ea\u14db\u146f\u1466<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_26_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.2' type='checkbox'  value='\u157f\u144e\u154b\u14d5\u1547\u14a5'  id='choice_3_26_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_26_2' id='label_3_26_2' class='gform-field-label gform-field-label--type-inline'>\u157f\u144e\u154b\u14d5\u1547\u14a5<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_26_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.3' type='checkbox'  value='\u1405\u14d0\u14c4\u146f\u1466'  id='choice_3_26_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_26_3' id='label_3_26_3' class='gform-field-label gform-field-label--type-inline'>\u1405\u14d0\u14c4\u146f\u1466<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_27\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u1405\u1584\u1555\u1405\u148d\u14aa\u1450\u140a\u1548\u1555\u1466 \u1403\u14f1\u140a\u1546\u14c2\u1550\u1439\u1466<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_3_27'>(\u1583\u1546\u1455\u1405\u152d\u1483\u146f\u1466 \u140a\u14ea\u14da\u1583\u1466\u1455\u1405\u144e\u148d\u144e\u1405\u1449\u1438\u1466, \u140a\u144f\u1466 Facebook-\u14a5 \u140a\u14ea\u14da\u14d7\u148d \u140a\u14ea\u14da\u1555\u1405\u1490\u14f1\u140a\u1550\u1555\u144e\u14ea\u14d7 \u1583\u1405\u1528\u148b\u140a\u1466\u14ef\u140a\u1583\u1466\u1455\u14d7\u148b\u1466)<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_27'><div class='gchoice gchoice_3_27_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.1' type='checkbox'  value='\u1405\u1584\u14da\u1405\u144e\u1483\u146f\u1466\u1405\u1584\u14da\u1405\u144e\u1483\u146f\u1466'  id='choice_3_27_1'   aria-describedby=\"gfield_description_3_27\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_3_27_1' id='label_3_27_1' class='gform-field-label gform-field-label--type-inline'>\u1405\u1584\u14da\u1405\u144e\u1483\u146f\u1466<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_27_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.2' type='checkbox'  value='\u1583\u1546\u1455\u1405\u152d\u1483\u146f\u1466 \u140a\u14ea\u14da\u1456\u1550\u1555\u146f\u1466'  id='choice_3_27_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_27_2' id='label_3_27_2' class='gform-field-label gform-field-label--type-inline'>\u1583\u1546\u1455\u1405\u152d\u1483\u146f\u1466 \u140a\u14ea\u14da\u1456\u1550\u1555\u146f\u1466<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_27_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.3' type='checkbox'  value='\u1583\u1546\u1455\u1405\u152d\u1483\u146f\u1466 \u140a\u14ea\u14da\u1583\u1466\u1455\u1405\u144e\u148d\u144e\u1483\u146f\u1466 \u140a\u14ef\u140a\u148d\u14ea\u14d8\u14c3\u1466'  id='choice_3_27_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_27_3' id='label_3_27_3' class='gform-field-label gform-field-label--type-inline'>\u1583\u1546\u1455\u1405\u152d\u1483\u146f\u1466 \u140a\u14ea\u14da\u1583\u1466\u1455\u1405\u144e\u148d\u144e\u1483\u146f\u1466 \u140a\u14ef\u140a\u148d\u14ea\u14d8\u14c3\u1466<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_28'>Autre moyen de contact<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_3_28' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_25\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_25'>\u1583\u1546\u1455\u1405\u152d\u1483\u146f\u1466 \u140a\u14ea\u14da\u1456\u1550\u1555\u146f\u1466<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_25' id='input_3_25' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_3_23\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_23'>\u140a\u14ef\u140a \u1405\u1584\u14da\u1405\u144e\u1593<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_23' id='input_3_23' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_60\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_60'>\u140a\u14ef\u140a\u148d\u1466<\/label><div class='ginput_container ginput_container_phone'><input name='input_60' id='input_3_60' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_37\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">\u1405\u1403\u14aa\u14c7\u1550\u1450\u146f\u1466 \u1405\u1584\u14da\u1555\u1466\u14f4\u1585<\/h3><\/div><fieldset id=\"field_3_32\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u1405\u1403\u14aa\u14c7\u1550\u1450\u146f\u1466 \u1405\u1584\u14da\u1555\u1466\u14f4\u1585<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_32'>\n                            \n                            <span id='input_3_32_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_32.3' id='input_3_32_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_32_3' class='gform-field-label gform-field-label--type-sub '>\u140a\u144f\u1466<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_32_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_32.6' id='input_3_32_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_32_6' class='gform-field-label gform-field-label--type-sub '>\u140a\u144e\u14d5\u1550\u1580\u1466 <\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_33'>\u1431\u152a\u1466\u14f4\u1405\u152e\u1550\u1451\u1449 \u146d\u14c7\u1593<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_3_33' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_36\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_36'>\u140a\u14c2\u1550\u154b\u14a5 \u1405\u1584\u14da\u1405\u144e\u1593<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_36' id='input_3_36' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_3_34\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_34'>\u140a\u14ef\u140a \u1405\u1584\u14da\u1405\u144e\u1593<\/label><div class='ginput_container ginput_container_phone'><input name='input_34' id='input_3_34' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_35\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_35'>\u1583\u1546\u1455\u1405\u152d\u1483\u146f\u1466 \u140a\u14ea\u14da\u1456\u1550\u1555\u1593<\/label><div class='ginput_container ginput_container_phone'><input name='input_35' id='input_3_35' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_64' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u14ef\u1557\u14ea\u14d5\u1585'  \/> <input type='button' id='gform_next_button_3_64' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u146d\u1591\u14ea\u14d5\u1585'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_4' class='gform_page' data-js='page-field-id-64' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_40\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">\u1431\u1581\u152d\u144e\u148d\u1466 \u1431\u14c2\u1550\u14d7\u14ef\u14aa\u1405\u144e\u1583\u1550\u14c2\u1585<\/h3><\/div><fieldset id=\"field_3_70\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you have a criminal record? * By completing this form, I agree to have my criminal record checked.<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_70'><div class='gchoice gchoice_3_70_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_70.1' type='checkbox'  value='Oui'  id='choice_3_70_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_70_1' id='label_3_70_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_70_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_70.2' type='checkbox'  value='Non'  id='choice_3_70_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_70_2' id='label_3_70_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_70_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_70.3' type='checkbox'  value='Je ne sais pas'  id='choice_3_70_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_70_3' id='label_3_70_3' class='gform-field-label gform-field-label--type-inline'>Je ne sais pas<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_43\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">\u140a\u1405\u14da\u148d\u14d0\u14c7\u14c2\u1550\u14a7\u1466 \u1450\u14f4\u1405\u14aa\u152d\u1405\u148b\u140a\u14d6\u1466<\/h3><\/div><fieldset id=\"field_3_42\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u1455\u14aa\u1466\u14f1\u14a5\u1593 \u140a\u1451\u144e\u14c2\u1550\u14a7\u1466 \u1403\u14c4\u1483\u152a\u140a\u14a6\u1548\u14d0\u14c7\u157f\u1466 (\u1431\u14c7\u14f1\u140a\u1548\u14ef\u1550\u14c2 15-\u14c2 \u1405\u1593\u1456\u14c4\u14ea\u14d8\u14c3\u1466)?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_42'>\n\t\t\t<div class='gchoice gchoice_3_42_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='\u140b'  id='choice_3_42_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_42_0' id='label_3_42_0' class='gform-field-label gform-field-label--type-inline'>\u140b<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_42_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='\u140a\u1405\u1472'  id='choice_3_42_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_42_1' id='label_3_42_1' class='gform-field-label gform-field-label--type-inline'>\u140a\u1405\u1472<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_6\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">\u14ab\u14d0\u14c7\u1405\u144e\u14ea\u14d7\u148d \u1583\u14c4\u1403\u1466\u1450\u14a6\u14d0\u14c2\u1585<\/h3><\/div><fieldset id=\"field_3_44\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u1431\u14c7\u14f1\u1490\u1583\u1550\u1431\u1466?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_44'>\n\t\t\t<div class='gchoice gchoice_3_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='\u140b'  id='choice_3_44_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_44_0' id='label_3_44_0' class='gform-field-label gform-field-label--type-inline'>\u140b<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='\u140a\u1405\u1472'  id='choice_3_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_44_1' id='label_3_44_1' class='gform-field-label gform-field-label--type-inline'>\u140a\u1405\u1472<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_68\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_68'>\u140a\u158f\u1548\u1555\u1466, \u1431\u14c7\u14f1\u1489\u1466 \u14f1\u14c7\u1405\u14bb\u14aa\u1594\u1466 \u1431\u14c7\u14f1\u155d\u1556\u14d7<\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_3_68' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_48\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u1431\u14c7\u14f1\u1490\u1583\u1550\u14c2\u14a5 \u1583\u14c4\u1403\u1466\u1450\u14a6\u14d0\u14c3\u1466<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_48'><div class='gchoice gchoice_3_48_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.1' type='checkbox'  value='\u1405\u14ea\u14d7\u14d5\u14ab\u1550\u1450\u14a5\u1483'  id='choice_3_48_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_48_1' id='label_3_48_1' class='gform-field-label gform-field-label--type-inline'>\u1405\u14ea\u14d7\u14d5\u14ab\u1550\u1450\u14a5\u1483<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_48_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.2' type='checkbox'  value='\u1405\u14ea\u14d7\u14d5\u14ab\u1595\u158f\u1450\u14a5\u1483'  id='choice_3_48_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_48_2' id='label_3_48_2' class='gform-field-label gform-field-label--type-inline'>\u1405\u14ea\u14d7\u14d5\u14ab\u1595\u158f\u1450\u14a5\u1483<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_48_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.3' type='checkbox'  value='\u140a\u144c\u14d0\u14c7\u1450\u1585'  id='choice_3_48_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_48_3' id='label_3_48_3' class='gform-field-label gform-field-label--type-inline'>\u140a\u144c\u14d0\u14c7\u1450\u1585<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_48_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.4' type='checkbox'  value='\u1403\u14c7\u158f\u1550\u14ef\u14ef\u14aa\u152a\u1585'  id='choice_3_48_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_48_4' id='label_3_48_4' class='gform-field-label gform-field-label--type-inline'>\u1403\u14c7\u158f\u1550\u14ef\u14ef\u14aa\u152a\u1585<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_48_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.5' type='checkbox'  value='\u14c7\u14bb\u14a5\u14c2\u1581\u144e\u14a5 '  id='choice_3_48_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_48_5' id='label_3_48_5' class='gform-field-label gform-field-label--type-inline'>\u14c7\u14bb\u14a5\u14c2\u1581\u144e\u14a5 <\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_50\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u1403\u14d7\u14ef\u1550\u14f2\u144f\u1466 \u1583\u14c4\u1403\u1595\u158f\u14aa\u1466 \u1431\u14c7\u14f1\u148d\u14d0\u14c7\u1431\u1466?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_50'>\n\t\t\t<div class='gchoice gchoice_3_50_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='\u140b, \u1403\u14d7\u14ef\u154b \u1583\u14c4\u1403\u1595\u158f\u14aa\u1466 \u1431\u14c7\u14f1\u148d\u14d0\u14c7\u1433\u1593'  id='choice_3_50_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_50_0' id='label_3_50_0' class='gform-field-label gform-field-label--type-inline'>\u140b, \u1403\u14d7\u14ef\u154b \u1583\u14c4\u1403\u1595\u158f\u14aa\u1466 \u1431\u14c7\u14f1\u148d\u14d0\u14c7\u1433\u1593<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_50_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='\u140a\u1405\u1472, \u1403\u14d7\u14ef\u1550\u14f1\u14ef\u140a\u1595\u158f\u14c7\u14aa \u1431\u14c7\u14f1\u1550\u1583\u152d\u1595\u158f\u1450\u1593'  id='choice_3_50_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_50_1' id='label_3_50_1' class='gform-field-label gform-field-label--type-inline'>\u140a\u1405\u1472, \u1403\u14d7\u14ef\u1550\u14f1\u14ef\u140a\u1595\u158f\u14c7\u14aa \u1431\u14c7\u14f1\u1550\u1583\u152d\u1595\u158f\u1450\u1593<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_51\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_51'>Pourquoi ne vous permet-elle pas de travailler?<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_3_51' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_52\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u1406\u14aa\u1455\u1583\u1550\u1431\u1466?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_52'>\n\t\t\t<div class='gchoice gchoice_3_52_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='\u140b, \u1406\u14aa\u1455\u1583\u1550\u1433\u1593 (\u1431\u140a\u154b\u1483\u1472, \u1401\u1449\u1438\u154b \u1431\u14c7\u14f1\u1595\u158f\u1450\u1585, \u140a\u14ef\u158f\u14ea\u14d7)'  id='choice_3_52_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_52_0' id='label_3_52_0' class='gform-field-label gform-field-label--type-inline'>\u140b, \u1406\u14aa\u1455\u1583\u1550\u1433\u1593 (\u1431\u140a\u154b\u1483\u1472, \u1401\u1449\u1438\u154b \u1431\u14c7\u14f1\u1595\u158f\u1450\u1585, \u140a\u14ef\u158f\u14ea\u14d7)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_52_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='\u140a\u1405\u1472'  id='choice_3_52_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_52_1' id='label_3_52_1' class='gform-field-label gform-field-label--type-inline'>\u140a\u1405\u1472<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_54\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_54'>\u140a\u158f\u1548\u1555\u1466, \u1583\u1466\u14f0\u1466 \u1406\u14aa\u1455\u144e\u1466<\/label><div class='ginput_container ginput_container_number'><input name='input_54' id='input_3_54' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_3_55\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u140a\u158f\u1548\u1555\u1466, \u142f\u1546\u1466\u14ef\u1555\u14bb\u14a6\u14f2\u1466<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_55'>\n\t\t\t<div class='gchoice gchoice_3_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='\u140b'  id='choice_3_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_55_0' id='label_3_55_0' class='gform-field-label gform-field-label--type-inline'>\u140b<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='\u140a\u1405\u1472'  id='choice_3_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_55_1' id='label_3_55_1' class='gform-field-label gform-field-label--type-inline'>\u140a\u1405\u1472<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_58\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u140a\u158f\u1548\u144f\u1466 \u1583\u14c4\u1403\u1466\u1450\u14a6\u14d0\u14c2\u1583\u1548\u144f\u14ea\u14d7<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_58.1' id='input_3_58_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_58_1' >\u1456\u14d0\u14c7 \u1455\u1455\u1550\u14f4\u1490\u1585 \u140a\u1405\u14ea\u14da\u144e\u1466\u14f1\u148d, \u14f1\u14d5\u14c2\u1543\u1557\u1593 \u1450\u14f4\u1405\u14aa\u152d\u1405\u148b\u140a\u14d6\u1466 \u14c8\u14bb\u14aa\u14ef\u140a\u1550\u14c2\u158f\u14d0\u14c2\u1483 \u14f1\u14c7\u14a5\u1466\u1450\u144e\u14d7, \u1450\u146d\u14ef\u1466\u14f1\u1593\u14d7 \u1583\u1405\u1528\u14f4\u1546\u140a\u1548\u144e\u1405\u148d\u14d0\u14c7\u14aa\u1455. \u140a\u158f\u1550\u1433\u1593 \u1450\u14f4\u1550\u144e\u14ef\u14c2\u1550\u14a7\u1466 \u140a\u152a\u1546\u14f4\u1550\u1555\u14a5\u1483 \u140a\u14ef\u1466\u1528\u148d\u144e\u14d5\u14ab\u14c2\u1483 \u1405\u1559\u14d0\u14c5\u14d5\u1593\u152a\u14c2\u1483 \u1450\u14f4\u1405\u14aa\u152d\u1405\u148b\u140a\u14d5\u14d0\u14c2\u1483 \u140a\u1405\u14da\u1466\u14ef\u14c2\u14d5\u1546\u14c2\u1550\u14a7\u1466 \u1431\u1466\u152a\u144e\u14d5\u14d0\u14c2\u1483 \u140a\u158f\u1548\u144e\u148b\u1466\u14f1\u148d\u14d7 \u1450\u14f4\u1405\u14aa\u152d\u1405\u148b\u140a\u14d6\u1466 \u1455\u14aa\u1483\u146f\u140a \u140a\u14a5\u1550\u1584\u1583\u144e\u1405\u14da\u1593\u144e\u14ea\u14d7\u148b\u1466 \u140a\u1466\u1528\u148c\u1595\u158f\u1450\u14c4\u1466 \u1431\u14c7\u14f1\u155d\u1555\u14c4\u1466 \u1472\u1559\u14aa\u14d5\u1546\u1555\u14d0\u14c4\u14d7.<\/label><input type='hidden' name='input_58.2' value='\u1456\u14d0\u14c7 \u1455\u1455\u1550\u14f4\u1490\u1585 \u140a\u1405\u14ea\u14da\u144e\u1466\u14f1\u148d, \u14f1\u14d5\u14c2\u1543\u1557\u1593 \u1450\u14f4\u1405\u14aa\u152d\u1405\u148b\u140a\u14d6\u1466 \u14c8\u14bb\u14aa\u14ef\u140a\u1550\u14c2\u158f\u14d0\u14c2\u1483 \u14f1\u14c7\u14a5\u1466\u1450\u144e\u14d7, \u1450\u146d\u14ef\u1466\u14f1\u1593\u14d7 \u1583\u1405\u1528\u14f4\u1546\u140a\u1548\u144e\u1405\u148d\u14d0\u14c7\u14aa\u1455. \u140a\u158f\u1550\u1433\u1593 \u1450\u14f4\u1550\u144e\u14ef\u14c2\u1550\u14a7\u1466 \u140a\u152a\u1546\u14f4\u1550\u1555\u14a5\u1483 \u140a\u14ef\u1466\u1528\u148d\u144e\u14d5\u14ab\u14c2\u1483 \u1405\u1559\u14d0\u14c5\u14d5\u1593\u152a\u14c2\u1483 \u1450\u14f4\u1405\u14aa\u152d\u1405\u148b\u140a\u14d5\u14d0\u14c2\u1483 \u140a\u1405\u14da\u1466\u14ef\u14c2\u14d5\u1546\u14c2\u1550\u14a7\u1466 \u1431\u1466\u152a\u144e\u14d5\u14d0\u14c2\u1483 \u140a\u158f\u1548\u144e\u148b\u1466\u14f1\u148d\u14d7 \u1450\u14f4\u1405\u14aa\u152d\u1405\u148b\u140a\u14d6\u1466 \u1455\u14aa\u1483\u146f\u140a \u140a\u14a5\u1550\u1584\u1583\u144e\u1405\u14da\u1593\u144e\u14ea\u14d7\u148b\u1466 \u140a\u1466\u1528\u148c\u1595\u158f\u1450\u14c4\u1466 \u1431\u14c7\u14f1\u155d\u1555\u14c4\u1466 \u1472\u1559\u14aa\u14d5\u1546\u1555\u14d0\u14c4\u14d7.' class='gform_hidden' \/><input type='hidden' name='input_58.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_3' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u14ef\u1557\u14ea\u14d5\u1585'  \/> <input type='submit' id='gform_submit_button_3' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='\u140a\u1405\u14ea\u14da\u144e\u14d7\u148d'  \/> <input type='hidden' name='gform_ajax' value='form_id=3&amp;title=&amp;description=&amp;tabindex=0&amp;theme=gravity-theme&amp;styles=[]&amp;hash=4e8232cfc37903bb3ed0febcaf3de50e' \/><input type='hidden' class='gform_hidden' name='gform_submission_speeds' 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