{"id":10736,"date":"2025-05-14T10:15:18","date_gmt":"2025-05-14T10:15:18","guid":{"rendered":"https:\/\/tmckolkata.com\/in\/events\/registration-iapc-nurse-copy\/"},"modified":"2025-05-14T10:28:55","modified_gmt":"2025-05-14T10:28:55","slug":"registration-iapc-student","status":"publish","type":"page","link":"https:\/\/tmckolkata.com\/in\/events\/registration-iapc-student\/","title":{"rendered":"Registration &#8211; IAPC &#8211; Student"},"content":{"rendered":"<div id='av-layout-grid-1'  class='av-layout-grid-container av-2jft0b-35fca6f06f34b2d032652cbdb5fcd422 entry-content-wrapper main_color av-flex-cells  avia-builder-el-0  el_before_av_layout_row  avia-builder-el-first   container_wrap sidebar_right'  >\n\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-jsohstnf-a341e83612e197f5825bf744f289da81\">\n.flex_cell.av-jsohstnf-a341e83612e197f5825bf744f289da81{\nvertical-align:top;\nbackground-color:#037cc1;\n}\n.responsive #top #wrap_all .flex_cell.av-jsohstnf-a341e83612e197f5825bf744f289da81{\npadding:15px 15px 15px 15px !important;\n}\n<\/style>\n<div class='flex_cell av-jsohstnf-a341e83612e197f5825bf744f289da81 av-gridrow-cell av_one_fourth no_margin  avia-builder-el-1  el_before_av_cell_one_fourth  avia-builder-el-first  content-align-top'  ><div class='flex_cell_inner'><\/div><\/div>\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-jsoht6rm-5acb80f13026ac411bd2199030f0a8e2\">\n.flex_cell.av-jsoht6rm-5acb80f13026ac411bd2199030f0a8e2{\nvertical-align:top;\nbackground-color:#379cd6;\n}\n.responsive #top #wrap_all .flex_cell.av-jsoht6rm-5acb80f13026ac411bd2199030f0a8e2{\npadding:15px 15px 15px 15px !important;\n}\n<\/style>\n<div class='flex_cell av-jsoht6rm-5acb80f13026ac411bd2199030f0a8e2 av-gridrow-cell av_one_fourth no_margin  avia-builder-el-2  el_after_av_cell_one_fourth  el_before_av_cell_one_fourth  content-align-top'  ><div class='flex_cell_inner'><\/div><\/div>\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-jsohtkcx-66808317f389c9d0bce4a7e90e9dfbf4\">\n.flex_cell.av-jsohtkcx-66808317f389c9d0bce4a7e90e9dfbf4{\nvertical-align:top;\nbackground-color:#5fb4e4;\n}\n.responsive #top #wrap_all .flex_cell.av-jsohtkcx-66808317f389c9d0bce4a7e90e9dfbf4{\npadding:15px 15px 15px 15px !important;\n}\n<\/style>\n<div class='flex_cell av-jsohtkcx-66808317f389c9d0bce4a7e90e9dfbf4 av-gridrow-cell av_one_fourth no_margin  avia-builder-el-3  el_after_av_cell_one_fourth  el_before_av_cell_one_fourth  content-align-top'  ><div class='flex_cell_inner'><\/div><\/div>\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-jsohtx7c-b26bd84e15bdf8da0acc2af71a827000\">\n.flex_cell.av-jsohtx7c-b26bd84e15bdf8da0acc2af71a827000{\nvertical-align:top;\nbackground-color:#80c7ef;\n}\n.responsive #top #wrap_all .flex_cell.av-jsohtx7c-b26bd84e15bdf8da0acc2af71a827000{\npadding:15px 15px 15px 15px !important;\n}\n<\/style>\n<div class='flex_cell av-jsohtx7c-b26bd84e15bdf8da0acc2af71a827000 av-gridrow-cell av_one_fourth no_margin  avia-builder-el-4  el_after_av_cell_one_fourth  avia-builder-el-last  content-align-top'  ><div class='flex_cell_inner'><\/div><\/div>\n<\/div>\n<div id='av-layout-grid-2'  class='av-layout-grid-container av-3znmz6-f261ea6a19a67a36367cd24bf4acbbb7 entry-content-wrapper main_color av-fixed-cells  avia-builder-el-5  el_after_av_layout_row  el_before_av_heading  grid-row-not-first  container_wrap sidebar_right'  >\n\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-3tm3yi-14f4b76a14e11b52c2f8f5f9efbecab7\">\n.flex_cell.av-3tm3yi-14f4b76a14e11b52c2f8f5f9efbecab7{\nvertical-align:middle;\nbackground:url(https:\/\/tmckolkata.com\/in\/wp-content\/uploads\/2025\/05\/iapc_header1.jpg) 50% 50% no-repeat scroll ;\n}\n.responsive #top #wrap_all .flex_cell.av-3tm3yi-14f4b76a14e11b52c2f8f5f9efbecab7{\npadding:80px 80px 80px 80px !important;\n}\n<\/style>\n<div class='flex_cell av-3tm3yi-14f4b76a14e11b52c2f8f5f9efbecab7 av-gridrow-cell av_one_full no_margin  avia-builder-el-6  avia-builder-el-no-sibling  content-align-middle avia-full-contain'  ><div class='flex_cell_inner'><\/div><\/div><\/div><div id='after_grid_row_2'  class='main_color av_default_container_wrap container_wrap sidebar_right'  ><div class='container av-section-cont-open' ><div class='template-page content  av-content-small alpha units'><div class='post-entry post-entry-type-page post-entry-10736'><div class='entry-content-wrapper clearfix'>\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-l2fn2wa1-c6d8794748f1a83f27601c1742f9a296\">\n#top .av-special-heading.av-l2fn2wa1-c6d8794748f1a83f27601c1742f9a296{\npadding-bottom:-10px;\n}\nbody .av-special-heading.av-l2fn2wa1-c6d8794748f1a83f27601c1742f9a296 .av-special-heading-tag .heading-char{\nfont-size:25px;\n}\n.av-special-heading.av-l2fn2wa1-c6d8794748f1a83f27601c1742f9a296 .av-subheading{\nfont-size:15px;\n}\n<\/style>\n<div  class='av-special-heading av-l2fn2wa1-c6d8794748f1a83f27601c1742f9a296 av-special-heading-h3  avia-builder-el-7  el_after_av_layout_row  el_before_av_textblock  avia-builder-el-first  av-thin-font'><h3 class='av-special-heading-tag '  itemprop=\"headline\"  ><strong>Registration fees for conference<\/strong><\/h3><div class=\"special-heading-border\"><div class=\"special-heading-inner-border\"><\/div><\/div><\/div><\/p>\n<section  class='av_textblock_section av-lzxoyi6t-4d222a0ddd687b26d0377636a00562c2 '   itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div class='avia_textblock'  itemprop=\"text\" ><p>Choose either NEFT , UPI or CARD option for payment (Rs. 500)<\/p>\n<\/div><\/section>\n\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-lzxov1qm-b7d8bd1cba52ae964d8be5b4ed486b58\">\n#top .hr.hr-invisible.av-lzxov1qm-b7d8bd1cba52ae964d8be5b4ed486b58{\nheight:10px;\n}\n<\/style>\n<div  class='hr av-lzxov1qm-b7d8bd1cba52ae964d8be5b4ed486b58 hr-invisible  avia-builder-el-9  el_after_av_textblock  el_before_av_one_half '><span class='hr-inner '><span class=\"hr-inner-style\"><\/span><\/span><\/div>\n\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-3lsepqy-dcc1952921c15de1c63d81c148aefe54\">\n.flex_column.av-3lsepqy-dcc1952921c15de1c63d81c148aefe54{\nborder-radius:0px 0px 0px 0px;\npadding:0px 0px 0px 0px;\n}\n<\/style>\n<div  class='flex_column av-3lsepqy-dcc1952921c15de1c63d81c148aefe54 av_one_half  avia-builder-el-10  el_after_av_hr  el_before_av_one_half  first flex_column_div av-zero-column-padding  '     ><p>\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-shf8y3-3680911654ad89df1d2a72f586e56fef\">\n#top .av-special-heading.av-shf8y3-3680911654ad89df1d2a72f586e56fef{\npadding-bottom:10px;\n}\nbody .av-special-heading.av-shf8y3-3680911654ad89df1d2a72f586e56fef .av-special-heading-tag .heading-char{\nfont-size:25px;\n}\n.av-special-heading.av-shf8y3-3680911654ad89df1d2a72f586e56fef .av-subheading{\nfont-size:16px;\n}\n<\/style>\n<div  class='av-special-heading av-shf8y3-3680911654ad89df1d2a72f586e56fef av-special-heading-h2 blockquote modern-quote  avia-builder-el-11  el_before_av_contact  avia-builder-el-first  av-linked-heading'><h2 class='av-special-heading-tag '  itemprop=\"headline\"  >Registration Form<\/h2><div class='av-subheading av-subheading_below'><p>WITH <strong>NEFT <\/strong>, <strong>UPI <\/strong>PAYMENT OPTION<\/p>\n<\/div><div class=\"special-heading-border\"><div class=\"special-heading-inner-border\"><\/div><\/div><\/div><br \/>\n<form action=\"https:\/\/tmckolkata.com\/in\/events\/registration-iapc-student\/\" method=\"post\" data-fields-with-error=\"Found errors in the following field(s):\" class=\"avia_ajax_form av-form-labels-visible   avia-builder-el-12  el_after_av_heading  el_before_av_heading   \" data-avia-form-id=\"1\" data-avia-redirect='' ><fieldset><div id='avia_1_1' class='av-form-text'><p>\n<strong>Personal Information:<\/strong><\/p>\n<\/div><p class='  first_form  form_element form_fullwidth' id='element_avia_2_1'><label for=\"avia_2_1\">Name : <abbr class=\"required\" title=\"required\">*<\/abbr><\/label> <input name=\"avia_2_1\" class=\"text_input is_empty\" type=\"text\" id=\"avia_2_1\" value=\"\" \/><\/p><p class='  first_form  form_element form_fullwidth' id='element_avia_3_1'><label for=\"avia_3_1\">Address : <abbr class=\"required\" title=\"required\">*<\/abbr><\/label> <input name=\"avia_3_1\" class=\"text_input is_empty\" type=\"text\" id=\"avia_3_1\" value=\"\" \/><\/p><p class='  first_form  form_element form_fullwidth' id='element_avia_4_1'><label for=\"avia_4_1\">Country:<\/label> <input name=\"avia_4_1\" class=\"text_input \" type=\"text\" id=\"avia_4_1\" value=\"\" \/><\/p><p class='  first_form  form_element form_element_third' id='element_avia_5_1'><label for=\"avia_5_1\">Mobile Number : <abbr class=\"required\" title=\"required\">*<\/abbr><\/label> <input name=\"avia_5_1\" class=\"text_input is_empty\" type=\"text\" id=\"avia_5_1\" value=\"\" \/><\/p><p class='  form_element form_element_two_third' id='element_avia_6_1'><label for=\"avia_6_1\">Email : <abbr class=\"required\" title=\"required\">*<\/abbr><\/label> <input name=\"avia_6_1\" class=\"text_input is_email\" type=\"text\" id=\"avia_6_1\" value=\"\" \/><\/p><p class='  first_form  form_element form_fullwidth' id='element_avia_7_1'><label for=\"avia_7_1\">Place of Work (Name of Hospital\/Institution) :<\/label> <input name=\"avia_7_1\" class=\"text_input \" type=\"text\" id=\"avia_7_1\" value=\"\" \/><\/p><p class='  first_form  form_element form_fullwidth' id='element_avia_8_1'><label for=\"avia_8_1\">Type of Institution: <abbr class=\"required\" title=\"required\">*<\/abbr><\/label><select  name=\"avia_8_1\" class=\"select is_empty\" id=\"avia_8_1\"><option   value='Government Hospital'>Government Hospital<\/option><option   value='Private or Corporate Hospital'>Private or Corporate Hospital<\/option><option   value='Other'>Other<\/option><\/select><\/p><p class='  first_form  form_element form_fullwidth' id='element_avia_9_1'><label for=\"avia_9_1\">Professional Position:<\/label> <input name=\"avia_9_1\" class=\"text_input \" type=\"text\" id=\"avia_9_1\" value=\"\" \/><\/p><p class='  first_form  form_element form_fullwidth' id='element_avia_10_1'><label for=\"avia_10_1\">Department: <abbr class=\"required\" title=\"required\">*<\/abbr><\/label> <input name=\"avia_10_1\" class=\"text_input is_empty\" type=\"text\" id=\"avia_10_1\" value=\"\" \/><\/p><p class='  first_form  form_element form_fullwidth' id='element_avia_11_1'><label for=\"avia_11_1\">Meal Preference<\/label><select  name=\"avia_11_1\" class=\"select \" id=\"avia_11_1\"><option   value='Veg'>Veg<\/option><option   value='Non-Veg'>Non-Veg<\/option><\/select><\/p><div id='avia_12_1' class='av-form-text'><p>\n<strong>Payment:<\/strong><\/p>\n<\/div><p class='  first_form  form_element form_fullwidth' id='element_avia_13_1'><label for=\"avia_13_1\">Mode of Payment : (Amount Rs. 500) <abbr class=\"required\" title=\"required\">*<\/abbr><\/label><select  name=\"avia_13_1\" class=\"select is_empty\" id=\"avia_13_1\"><option   value='NEFT'>NEFT<\/option><option   value='UPI or QR-Code'>UPI or QR-Code<\/option><\/select><\/p><p class='  first_form  form_element form_fullwidth' id='element_avia_14_1'><label for=\"avia_14_1\">NEFT \/ Cheque \/ Draft \/ UPI Transaction ID <abbr class=\"required\" title=\"required\">*<\/abbr><\/label> <input name=\"avia_14_1\" class=\"text_input is_empty\" type=\"text\" id=\"avia_14_1\" value=\"\" \/><\/p><p class='  first_form  form_element form_fullwidth' id='element_avia_15_1'><label for=\"avia_15_1\">NEFT \/ Cheque \/ Draft \/ UPI Date <abbr class=\"required\" title=\"required\">*<\/abbr><\/label> <input name=\"avia_15_1\" class=\"text_input is_empty\" type=\"text\" id=\"avia_15_1\" value=\"\" \/><\/p><p class='  first_form  form_element form_fullwidth' id='element_avia_16_1'><label for=\"avia_16_1\">NEFT \/ Cheque \/ Draft \/ UPI Amount <abbr class=\"required\" title=\"required\">*<\/abbr><\/label><select  name=\"avia_16_1\" class=\"select is_empty\" id=\"avia_16_1\"><option   value='Rs. 500'>Rs. 500<\/option><\/select><\/p><p class='  first_form  form_element form_fullwidth' id='element_avia_17_1'><label for=\"avia_17_1\" class=\"textare_label hidden textare_label_avia_17_1\">Any other information<\/label><textarea  name=\"avia_17_1\" class=\"text_area \" cols=\"40\" rows=\"7\" id=\"avia_17_1\" ><\/textarea><\/p><p class=\"hidden\"><input type=\"text\" name=\"avia_18_1\" class=\"hidden \" id=\"avia_18_1\" value=\"\" \/><\/p><p class='   form_element form_fullwidth' id='element_avia_19_1'><span class='value_verifier_label'>3 + 5 = ?<\/span><input name=\"avia_19_1_verifier\" type=\"hidden\" id=\"avia_19_1_verifier\" value=\"744633856\"\/><label for=\"avia_19_1\">Please prove that you are human by solving the equation <abbr class=\"required\" title=\"required\">*<\/abbr><\/label><input name=\"avia_19_1\" class=\"text_input captcha\" type=\"text\" id=\"avia_19_1\" value=\"\"\/><\/p><p class=\"form_element \"><input type=\"hidden\" value=\"1\" name=\"avia_generated_form1\" \/><input type=\"submit\" value=\"Submit\" class=\"button\"  data-sending-label=\"Sending\"\/><\/p><\/fieldset><\/form><div id=\"ajaxresponse_1\" class=\"ajaxresponse ajaxresponse_1 hidden\"><\/div><br \/>\n\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-2haghu-faf5cb9f2ccae959f81f360ced04ce31\">\n#top .av-special-heading.av-2haghu-faf5cb9f2ccae959f81f360ced04ce31{\npadding-bottom:10px;\n}\nbody .av-special-heading.av-2haghu-faf5cb9f2ccae959f81f360ced04ce31 .av-special-heading-tag .heading-char{\nfont-size:25px;\n}\n.av-special-heading.av-2haghu-faf5cb9f2ccae959f81f360ced04ce31 .av-subheading{\nfont-size:15px;\n}\n<\/style>\n<div  class='av-special-heading av-2haghu-faf5cb9f2ccae959f81f360ced04ce31 av-special-heading-h3  avia-builder-el-13  el_after_av_contact  el_before_av_textblock '><h3 class='av-special-heading-tag '  itemprop=\"headline\"  >Bank Detail for Offline Payment<\/h3><div class=\"special-heading-border\"><div class=\"special-heading-inner-border\"><\/div><\/div><\/div><br \/>\n<section  class='av_textblock_section av-jt2kkpc0-f6e7f84301a801dfe5f8c7bea76939b7 '   itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div class='avia_textblock'  itemprop=\"text\" ><p style=\"text-align: justify;\"><strong>Hospital Name:<\/strong> Tata Medical Center<br \/>\n<strong>Payee \/ Cheque Name:<\/strong> Tata Medical Centre Trust<br \/>\n<strong>Hospital Address:<\/strong> 14 Major Arterial Road (EW), New Town, Rajarhat, Kolkata-700160<br \/>\n<strong>Bank Name:<\/strong> HDFC Bank Limited<br \/>\n<strong>Bank Account Number:<\/strong> 00601-6600-00021<br \/>\n<strong>Bank Account Type:<\/strong> Savings Account<br \/>\n<strong>Bank Branch:<\/strong> Fort Mumbai<br \/>\n<strong>Bank Address:<\/strong> Fort Mumbai, Manekji Wadia Building, Groung Floor, Nanik Motwani Marg, Mumbai &#8211; 400001<br \/>\n<strong>IFSC :<\/strong> HDFC0000060<\/p>\n<\/div><\/section><\/p><\/div>\n<div  class='flex_column av-215oph-a1bda063f0a73bb3fd5a9cabcd7069d1 av_one_half  avia-builder-el-15  el_after_av_one_half  el_before_av_layout_row  avia-builder-el-last  flex_column_div  '     ><p>\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-14ghgi-de2c87847ab6bf6546e590716b26c2de\">\n#top .av-special-heading.av-14ghgi-de2c87847ab6bf6546e590716b26c2de{\npadding-bottom:10px;\n}\nbody .av-special-heading.av-14ghgi-de2c87847ab6bf6546e590716b26c2de .av-special-heading-tag .heading-char{\nfont-size:25px;\n}\n.av-special-heading.av-14ghgi-de2c87847ab6bf6546e590716b26c2de .av-subheading{\nfont-size:16px;\n}\n<\/style>\n<div  class='av-special-heading av-14ghgi-de2c87847ab6bf6546e590716b26c2de av-special-heading-h2 blockquote modern-quote  avia-builder-el-16  el_before_av_contact  avia-builder-el-first  av-linked-heading'><h2 class='av-special-heading-tag '  itemprop=\"headline\"  >Registration Form<\/h2><div class='av-subheading av-subheading_below'><p>WITH <strong>Card <\/strong>PAYMENT OPTION<\/p>\n<\/div><div class=\"special-heading-border\"><div class=\"special-heading-inner-border\"><\/div><\/div><\/div><br \/>\n<form action=\"https:\/\/tmckolkata.com\/in\/events\/registration-iapc-student\/\" method=\"post\" data-fields-with-error=\"Found errors in the following field(s):\" class=\"avia_ajax_form av-form-labels-visible   avia-builder-el-17  el_after_av_heading  el_before_av_image   \" data-avia-form-id=\"2\" data-avia-redirect='https:\/\/www.tmckolkata.com\/apps\/events\/1117' ><fieldset><div id='avia_1_2' class='av-form-text'><p>\n<strong>Personal Information:<\/strong><\/p>\n<\/div><p class='  first_form  form_element form_fullwidth' id='element_avia_2_2'><label for=\"avia_2_2\">Name : <abbr class=\"required\" title=\"required\">*<\/abbr><\/label> <input name=\"avia_2_2\" class=\"text_input is_empty\" type=\"text\" id=\"avia_2_2\" value=\"\" \/><\/p><p class='  first_form  form_element form_fullwidth' id='element_avia_3_2'><label for=\"avia_3_2\">Address : <abbr class=\"required\" title=\"required\">*<\/abbr><\/label> <input name=\"avia_3_2\" class=\"text_input is_empty\" type=\"text\" id=\"avia_3_2\" value=\"\" \/><\/p><p class='  first_form  form_element form_fullwidth' id='element_avia_4_2'><label for=\"avia_4_2\">Country:<\/label> <input name=\"avia_4_2\" class=\"text_input \" type=\"text\" id=\"avia_4_2\" value=\"\" \/><\/p><p class='  first_form  form_element form_element_third' id='element_avia_5_2'><label for=\"avia_5_2\">Mobile Number : <abbr class=\"required\" title=\"required\">*<\/abbr><\/label> <input name=\"avia_5_2\" class=\"text_input is_empty\" type=\"text\" id=\"avia_5_2\" value=\"\" \/><\/p><p class='  form_element form_element_two_third' id='element_avia_6_2'><label for=\"avia_6_2\">Email : <abbr class=\"required\" title=\"required\">*<\/abbr><\/label> <input name=\"avia_6_2\" class=\"text_input is_email\" type=\"text\" id=\"avia_6_2\" value=\"\" \/><\/p><p class='  first_form  form_element form_fullwidth' id='element_avia_7_2'><label for=\"avia_7_2\">Place of Work (Name of Hospital\/Institution) :<\/label> <input name=\"avia_7_2\" class=\"text_input \" type=\"text\" id=\"avia_7_2\" value=\"\" \/><\/p><p class='  first_form  form_element form_fullwidth' id='element_avia_8_2'><label for=\"avia_8_2\">Type of Institution: <abbr class=\"required\" title=\"required\">*<\/abbr><\/label><select  name=\"avia_8_2\" class=\"select is_empty\" id=\"avia_8_2\"><option   value='Government Hospital'>Government Hospital<\/option><option   value='Private or Corporate Hospital'>Private or Corporate Hospital<\/option><option   value='Other'>Other<\/option><\/select><\/p><p class='  first_form  form_element form_fullwidth' id='element_avia_9_2'><label for=\"avia_9_2\">Professional Position:<\/label> <input name=\"avia_9_2\" class=\"text_input \" type=\"text\" id=\"avia_9_2\" value=\"\" \/><\/p><p class='  first_form  form_element form_fullwidth' id='element_avia_10_2'><label for=\"avia_10_2\">Department: <abbr class=\"required\" title=\"required\">*<\/abbr><\/label> <input name=\"avia_10_2\" class=\"text_input is_empty\" type=\"text\" id=\"avia_10_2\" value=\"\" \/><\/p><p class='  first_form  form_element form_fullwidth' id='element_avia_11_2'><label for=\"avia_11_2\">Meal Preference<\/label><select  name=\"avia_11_2\" class=\"select \" id=\"avia_11_2\"><option   value='Veg'>Veg<\/option><option   value='Non-Veg'>Non-Veg<\/option><\/select><\/p><div id='avia_12_2' class='av-form-text'><p>\n<strong>Payment:<\/strong><\/p>\n<\/div><p class='  first_form  form_element form_fullwidth' id='element_avia_13_2'><label for=\"avia_13_2\">Mode of Payment : (Amount Rs. 500) <abbr class=\"required\" title=\"required\">*<\/abbr><\/label><select  name=\"avia_13_2\" class=\"select is_empty\" id=\"avia_13_2\"><option   value='Credit Card'>Credit Card<\/option><option   value='Debit Card'>Debit Card<\/option><\/select><\/p><p class='  first_form  form_element form_fullwidth' id='element_avia_14_2'><label for=\"avia_14_2\" class=\"textare_label hidden textare_label_avia_14_2\">Any other information<\/label><textarea  name=\"avia_14_2\" class=\"text_area \" cols=\"40\" rows=\"7\" id=\"avia_14_2\" ><\/textarea><\/p><p class=\"hidden\"><input type=\"text\" name=\"avia_15_2\" class=\"hidden \" id=\"avia_15_2\" value=\"\" \/><\/p><p class='   form_element form_fullwidth' id='element_avia_16_2'><span class='value_verifier_label'>5 + 2 = ?<\/span><input name=\"avia_16_2_verifier\" type=\"hidden\" id=\"avia_16_2_verifier\" value=\"717115726\"\/><label for=\"avia_16_2\">Please prove that you are human by solving the equation <abbr class=\"required\" title=\"required\">*<\/abbr><\/label><input name=\"avia_16_2\" class=\"text_input captcha\" type=\"text\" id=\"avia_16_2\" value=\"\"\/><\/p><p class=\"form_element \"><input type=\"hidden\" value=\"1\" name=\"avia_generated_form2\" \/><input type=\"submit\" value=\"Submit\" class=\"button\"  data-sending-label=\"Sending\"\/><\/p><\/fieldset><\/form><div id=\"ajaxresponse_2\" class=\"ajaxresponse ajaxresponse_2 hidden\"><\/div><br \/>\n\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-lsa7kjf0-de76abfd6060088993a3aee14862c16a\">\n.avia-image-container.av-lsa7kjf0-de76abfd6060088993a3aee14862c16a 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type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-yqesyp-9fc6763342d8739002b168f6891fbf9f\">\n.flex_cell.av-yqesyp-9fc6763342d8739002b168f6891fbf9f{\nvertical-align:top;\nbackground-color:#5fb4e4;\n}\n.responsive #top #wrap_all .flex_cell.av-yqesyp-9fc6763342d8739002b168f6891fbf9f{\npadding:15px 15px 15px 15px !important;\n}\n<\/style>\n<div class='flex_cell av-yqesyp-9fc6763342d8739002b168f6891fbf9f av-gridrow-cell av_one_fourth no_margin  avia-builder-el-22  el_after_av_cell_one_fourth  el_before_av_cell_one_fourth  content-align-top'  ><div class='flex_cell_inner'><\/div><\/div>\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-ir5s9t-1e8f78cdc75cb433e224d24d337c8201\">\n.flex_cell.av-ir5s9t-1e8f78cdc75cb433e224d24d337c8201{\nvertical-align:top;\nbackground-color:#80c7ef;\n}\n.responsive #top #wrap_all .flex_cell.av-ir5s9t-1e8f78cdc75cb433e224d24d337c8201{\npadding:15px 15px 15px 15px !important;\n}\n<\/style>\n<div 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