-
Notifications
You must be signed in to change notification settings - Fork 0
/
Complaint.html
112 lines (100 loc) · 31.3 KB
/
Complaint.html
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<!-- Bootstrap CSS -->
<link
href="https://cdn.jsdelivr.net/npm/[email protected]/dist/css/bootstrap.min.css"
rel="stylesheet"
integrity="sha384-giJF6kkoqNQ00vy+HMDP7azOuL0xtbfIcaT9wjKHr8RbDVddVHyTfAAsrekwKmP1"
crossorigin="anonymous"
/>
<!-- style.css file -->
<link rel="stylesheet" href="style.css">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<title>Document</title>
</head>
<body>
<!-- navbar -->
<nav class="navbar fixed-top navbar-expand-lg navbar-dark bg-dark">
<div class="container-fluid">
<a class="navbar-brand" href="#"><h3>WooCare</h3></a>
<button
class="navbar-toggler"
type="button"
data-bs-toggle="collapse"
data-bs-target="#navbarSupportedContent"
aria-controls="navbarSupportedContent"
aria-expanded="false"
aria-label="Toggle navigation"
>
<span class="navbar-toggler-icon"></span>
</button>
<div class="collapse navbar-collapse" id="navbarSupportedContent">
<ul class="navbar-nav me-auto mb-2 mb-lg-0">
<li class="nav-item">
<a class="nav-link active" aria-current="page" href="index.html" color=white>Home</a>
</li>
<li class="nav-item">
<a class="nav-link" href="#">About Us</a>
</li>
<li class="nav-item dropdown">
<a
class="nav-link dropdown-toggle"
href="#"
id="navbarDropdown"
role="button"
data-bs-toggle="dropdown"
aria-expanded="false"
>
Take Action
</a>
<ul class="dropdown-menu" aria-labelledby="navbarDropdown">
<li><a class="dropdown-item" href="Complaint.html" target="_blank">File a Complaint</a></li>
<li><a class="dropdown-item" href="#">How to file a complaint</a></li>
<li><hr class="dropdown-divider" /></li>
</ul>
</li>
<li class="nav-item">
<a
class="nav-link enable"
href="#"
tabindex="-1"
aria-disabled="true"
>Get Involved</a
>
</li>
</ul>
<li class="nav-item">
<button type="button" class="btn btn-primary"><a href="/login-form/login-form/login-form.html" class="sin " id="sin1">Sign in</a></button>
</li>
<li class="nav-item">
<button type="button" class="btn btn-primary"><a href="/Register/register/reg-form.html" class="sin " id="sin1" > Register</a></button>
</li>
<li class="nav-item">
<button type="button" class="btn btn-warning">Donate</button>
</li>
</form>
</div>
</div>
</nav>
<script src="https://cdn.jotfor.ms/js/vendor/jquery-1.8.0.min.js?v=3.3.22857" type="text/javascript"></script>
<script src="https://cdn.jotfor.ms/js/vendor/maskedinput.min.js?v=3.3.22857" type="text/javascript"></script>
<script src="https://cdn.jotfor.ms/js/vendor/jquery.maskedinput.min.js?v=3.3.22857" type="text/javascript"></script>
<script src="https://cdn.jotfor.ms/static/prototype.forms.js" type="text/javascript"></script>
<script src="https://cdn.jotfor.ms/static/jotform.forms.js?3.3.22857" type="text/javascript"></script>
<script type="text/javascript"> JotForm.init(function(){ JotForm.calendarMonths = ["January","February","March","April","May","June","July","August","September","October","November","December"]; JotForm.calendarDays = ["Sunday","Monday","Tuesday","Wednesday","Thursday","Friday","Saturday","Sunday"]; JotForm.calendarOther = {"today":"Today"}; var languageOptions = document.querySelectorAll('#langList li'); for(var langIndex = 0; langIndex < languageOptions.length; langIndex++) { languageOptions[langIndex].on('click', function(e) { setTimeout(function(){ JotForm.setCalendar("12", false, {"days":{"monday":true,"tuesday":true,"wednesday":true,"thursday":true,"friday":true,"saturday":true,"sunday":true},"future":true,"past":true,"custom":false,"ranges":false,"start":"","end":""}); }, 0); }); } JotForm.setCalendar("12", false, {"days":{"monday":true,"tuesday":true,"wednesday":true,"thursday":true,"friday":true,"saturday":true,"sunday":true},"future":true,"past":true,"custom":false,"ranges":false,"start":"","end":""}); JotForm.calendarMonths = ["January","February","March","April","May","June","July","August","September","October","November","December"]; JotForm.calendarDays = ["Sunday","Monday","Tuesday","Wednesday","Thursday","Friday","Saturday","Sunday"]; JotForm.calendarOther = {"today":"Today"}; var languageOptions = document.querySelectorAll('#langList li'); for(var langIndex = 0; langIndex < languageOptions.length; langIndex++) { languageOptions[langIndex].on('click', function(e) { setTimeout(function(){ JotForm.setCalendar("13", false, {"days":{"monday":true,"tuesday":true,"wednesday":true,"thursday":true,"friday":true,"saturday":true,"sunday":true},"future":true,"past":true,"custom":false,"ranges":false,"start":"","end":""}); }, 0); }); } JotForm.setCalendar("13", false, {"days":{"monday":true,"tuesday":true,"wednesday":true,"thursday":true,"friday":true,"saturday":true,"sunday":true},"future":true,"past":true,"custom":false,"ranges":false,"start":"","end":""});
if (window.JotForm && JotForm.accessible) $('input_24').setAttribute('tabindex',0); JotForm.newDefaultTheme = true; JotForm.extendsNewTheme = false; JotForm.newPaymentUIForNewCreatedForms = false; JotForm.newPaymentUI = true; /*INIT-END*/ }); JotForm.prepareCalculationsOnTheFly([null,null,{"name":"submit","qid":"2","text":"Report Now!","type":"control_button"},null,{"name":"clickTo","qid":"4","text":"Police Incident Report","type":"control_head"},null,{"name":"incidentReport6","qid":"6","text":"Incident report issued by:","type":"control_fullname"},null,null,null,null,{"name":"incidentLocation","qid":"11","text":"Incident Location (Please provide specific details):","type":"control_textarea"},{"name":"reportDate","qid":"12","text":"Report date and time:","type":"control_datetime"},{"name":"dateAnd","qid":"13","text":"Date and time when incident occurred:","type":"control_datetime"},{"name":"natureOf14","qid":"14","text":"Nature of incident","type":"control_textarea"},{"name":"incidentDetails15","qid":"15","text":"Incident details","type":"control_textarea"},{"name":"whatMotivated16","qid":"16","text":"What motivated the incident?","type":"control_textarea"},{"name":"wasA","qid":"17","text":"Was a report of the incident issued to the police?","type":"control_textarea"},{"name":"hasAnyone","qid":"18","text":"Has anyone been arrested so far in relation to the incident?","type":"control_textarea"},{"name":"clickTo19","qid":"19","text":"","type":"control_text"},{"name":"fullName20","qid":"20","text":"Full Name","type":"control_fullname"},{"name":"phoneNumber21","qid":"21","text":"Phone Number","type":"control_phone"},{"name":"address22","qid":"22","text":"Address","type":"control_address"},{"name":"doYou","qid":"23","text":"Do you want the police to get in touch with you?","type":"control_radio"},{"name":"furtherComments","qid":"24","text":"Further Comments","type":"control_textarea"},{"name":"clickTo25","qid":"25","text":"","type":"control_text"},{"name":"terms","qid":"26","type":"control_checkbox"}]); setTimeout(function() {
JotForm.paymentExtrasOnTheFly([null,null,{"name":"submit","qid":"2","text":"Report Now!","type":"control_button"},null,{"name":"clickTo","qid":"4","text":"Police Incident Report","type":"control_head"},null,{"name":"incidentReport6","qid":"6","text":"Incident report issued by:","type":"control_fullname"},null,null,null,null,{"name":"incidentLocation","qid":"11","text":"Incident Location (Please provide specific details):","type":"control_textarea"},{"name":"reportDate","qid":"12","text":"Report date and time:","type":"control_datetime"},{"name":"dateAnd","qid":"13","text":"Date and time when incident occurred:","type":"control_datetime"},{"name":"natureOf14","qid":"14","text":"Nature of incident","type":"control_textarea"},{"name":"incidentDetails15","qid":"15","text":"Incident details","type":"control_textarea"},{"name":"whatMotivated16","qid":"16","text":"What motivated the incident?","type":"control_textarea"},{"name":"wasA","qid":"17","text":"Was a report of the incident issued to the police?","type":"control_textarea"},{"name":"hasAnyone","qid":"18","text":"Has anyone been arrested so far in relation to the incident?","type":"control_textarea"},{"name":"clickTo19","qid":"19","text":"","type":"control_text"},{"name":"fullName20","qid":"20","text":"Full Name","type":"control_fullname"},{"name":"phoneNumber21","qid":"21","text":"Phone Number","type":"control_phone"},{"name":"address22","qid":"22","text":"Address","type":"control_address"},{"name":"doYou","qid":"23","text":"Do you want the police to get in touch with you?","type":"control_radio"},{"name":"furtherComments","qid":"24","text":"Further Comments","type":"control_textarea"},{"name":"clickTo25","qid":"25","text":"","type":"control_text"},{"name":"terms","qid":"26","type":"control_checkbox"}]);}, 20); </script>
<link type="text/css" media="print" rel="stylesheet" href="https://cdn.jotfor.ms/css/printForm.css?3.3.22857" />
<link type="text/css" rel="stylesheet" href="https://cdn.jotfor.ms/themes/CSS/5e6b428acc8c4e222d1beb91.css?themeRevisionID=5f30e2a790832f3e96009402"/>
<link type="text/css" rel="stylesheet" href="https://cdn.jotfor.ms/css/styles/payment/payment_styles.css?3.3.22857" />
<link type="text/css" rel="stylesheet" href="https://cdn.jotfor.ms/css/styles/payment/payment_feature.css?3.3.22857" />
<form class="jotform-form" action="https://submit.jotform.com/submit/210272370100436/" method="post" name="form_210272370100436" id="210272370100436" accept-charset="utf-8" autocomplete="on"> <input type="hidden" name="formID" value="210272370100436" /> <input type="hidden" id="JWTContainer" value="" /> <input type="hidden" id="cardinalOrderNumber" value="" /> <div role="main" class="form-all"> <ul class="form-section page-section"> <li id="cid_4" class="form-input-wide" data-type="control_head"> <div class="form-header-group header-large"> <div class="header-text httal htvam"> <h1 id="header_4" class="form-header" data-component="header"> Incident Report </h1> <div id="subHeader_4" class="form-subHeader"> To report and incident, please provide the following information's </div> </div> </div> </li> <li class="form-line allowTime" data-type="control_datetime" id="id_12"> <label class="form-label form-label-top form-label-auto" id="label_12" for="lite_mode_12"> Report date and time: </label> <div id="cid_12" class="form-input-wide" data-layout="full"> <div data-wrapper-react="true" class="extended"> <div style="display:none"> <span class="form-sub-label-container" style="vertical-align:top"> <input type="tel" class="form-textbox validate[limitDate]" id="month_12" name="q12_reportDate[month]" size="2" data-maxlength="2" data-age="" maxLength="2" value="" autoComplete="off" aria-labelledby="label_12 sublabel_12_month" /> <span class="date-separate" aria-hidden="true"> - </span> <label class="form-sub-label" for="month_12" id="sublabel_12_month" style="min-height:13px" aria-hidden="false"> Month </label> </span> <span class="form-sub-label-container" style="vertical-align:top"> <input type="tel" class="form-textbox validate[limitDate]" id="day_12" name="q12_reportDate[day]" size="2" data-maxlength="2" data-age="" maxLength="2" value="" autoComplete="off" aria-labelledby="label_12 sublabel_12_day" /> <span class="date-separate" aria-hidden="true"> - </span> <label class="form-sub-label" for="day_12" id="sublabel_12_day" style="min-height:13px" aria-hidden="false"> Day </label> </span> <span class="form-sub-label-container" style="vertical-align:top"> <input type="tel" class="form-textbox validate[limitDate]" id="year_12" name="q12_reportDate[year]" size="4" data-maxlength="4" data-age="" maxLength="4" value="" autoComplete="off" aria-labelledby="label_12 sublabel_12_year" /> <label class="form-sub-label" for="year_12" id="sublabel_12_year" style="min-height:13px" aria-hidden="false"> Year </label> </span> </div> <span class="form-sub-label-container" style="vertical-align:top"> <input type="text" class="form-textbox validate[limitDate, validateLiteDate]" id="lite_mode_12" size="12" data-maxlength="12" maxLength="12" data-age="" value="" data-format="mmddyyyy" data-seperator="-" placeholder="MM-DD-YYYY" autoComplete="off" aria-labelledby="label_12 sublabel_12_litemode" /> <img class=" newDefaultTheme-dateIcon icon-liteMode" alt="Pick a Date" id="input_12_pick" src="https://cdn.jotfor.ms/images/calendar.png" data-component="datetime" aria-hidden="true" data-allow-time="Yes" data-version="v2" /> <label class="form-sub-label" for="lite_mode_12" id="sublabel_12_litemode" style="min-height:13px" aria-hidden="false"> Date </label> </span> <span class="allowTime-container timeAMPM"> <div data-wrapper-react="true"> <span class="form-sub-label-container hasAMPM" style="vertical-align:top"> <input type="text" class="time-dropdown form-textbox" id="input_12_timeInput" name="q12_reportDate[timeInput]" placeholder="HH : MM" aria-labelledby="label_12 sublabel_12_hour" data-mask="hh:MM" value="" data-version="v2" /> <input type="hidden" id="input_12_hourSelect" name="q12_reportDate[hour]" /> <input type="hidden" id="input_12_minuteSelect" name="q12_reportDate[min]" /> <label class="form-sub-label" for="input_12_timeInput" style="min-height:13px" aria-hidden="false"> Hour Minutes </label> </span> <span class="form-sub-label-container" style="vertical-align:top"> <select class="time-dropdown form-dropdown" id="input_12_ampm" name="q12_reportDate[ampm]" data-component="time-ampm" aria-labelledby="label_12 sublabel_12_ampm"> <option selected="" value="AM"> AM </option> <option value="PM"> PM </option> </select> <label class="form-sub-label" for="input_12_ampm" id="sublabel_12_ampm" style="border:0;clip:rect(0 0 0 0);height:1px;margin:-1px;overflow:hidden;padding:0;position:absolute;width:1px;white-space:nowrap" aria-hidden="false"> AM/PM Option </label> </span> </div> </span> </div> </div> </li> <li class="form-line allowTime" data-type="control_datetime" id="id_13"> <label class="form-label form-label-top form-label-auto" id="label_13" for="lite_mode_13"> Date and time when incident occurred: </label> <div id="cid_13" class="form-input-wide" data-layout="full"> <div data-wrapper-react="true" class="extended"> <div style="display:none"> <span class="form-sub-label-container" style="vertical-align:top"> <input type="tel" class="form-textbox validate[limitDate]" id="month_13" name="q13_dateAnd[month]" size="2" data-maxlength="2" data-age="" maxLength="2" value="" autoComplete="off" aria-labelledby="label_13 sublabel_13_month" /> <span class="date-separate" aria-hidden="true"> - </span> <label class="form-sub-label" for="month_13" id="sublabel_13_month" style="min-height:13px" aria-hidden="false"> Month </label> </span> <span class="form-sub-label-container" style="vertical-align:top"> <input type="tel" class="form-textbox validate[limitDate]" id="day_13" name="q13_dateAnd[day]" size="2" data-maxlength="2" data-age="" maxLength="2" value="" autoComplete="off" aria-labelledby="label_13 sublabel_13_day" /> <span class="date-separate" aria-hidden="true"> - </span> <label class="form-sub-label" for="day_13" id="sublabel_13_day" style="min-height:13px" aria-hidden="false"> Day </label> </span> <span class="form-sub-label-container" style="vertical-align:top"> <input type="tel" class="form-textbox validate[limitDate]" id="year_13" name="q13_dateAnd[year]" size="4" data-maxlength="4" data-age="" maxLength="4" value="" autoComplete="off" aria-labelledby="label_13 sublabel_13_year" /> <label class="form-sub-label" for="year_13" id="sublabel_13_year" style="min-height:13px" aria-hidden="false"> Year </label> </span> </div> <span class="form-sub-label-container" style="vertical-align:top"> <input type="text" class="form-textbox validate[limitDate, validateLiteDate]" id="lite_mode_13" size="12" data-maxlength="12" maxLength="12" data-age="" value="" data-format="mmddyyyy" data-seperator="-" placeholder="MM-DD-YYYY" autoComplete="off" aria-labelledby="label_13 sublabel_13_litemode" /> <img class=" newDefaultTheme-dateIcon icon-liteMode" alt="Pick a Date" id="input_13_pick" src="https://cdn.jotfor.ms/images/calendar.png" data-component="datetime" aria-hidden="true" data-allow-time="Yes" data-version="v2" /> <label class="form-sub-label" for="lite_mode_13" id="sublabel_13_litemode" style="min-height:13px" aria-hidden="false"> Date </label> </span> <span class="allowTime-container timeAMPM"> <div data-wrapper-react="true"> <span class="form-sub-label-container hasAMPM" style="vertical-align:top"> <input type="text" class="time-dropdown form-textbox" id="input_13_timeInput" name="q13_dateAnd[timeInput]" placeholder="HH : MM" aria-labelledby="label_13 sublabel_13_hour" data-mask="hh:MM" value="" data-version="v2" /> <input type="hidden" id="input_13_hourSelect" name="q13_dateAnd[hour]" /> <input type="hidden" id="input_13_minuteSelect" name="q13_dateAnd[min]" /> <label class="form-sub-label" for="input_13_timeInput" style="min-height:13px" aria-hidden="false"> Hour Minutes </label> </span> <span class="form-sub-label-container" style="vertical-align:top"> <select class="time-dropdown form-dropdown" id="input_13_ampm" name="q13_dateAnd[ampm]" data-component="time-ampm" aria-labelledby="label_13 sublabel_13_ampm"> <option selected="" value="AM"> AM </option> <option value="PM"> PM </option> </select> <label class="form-sub-label" for="input_13_ampm" id="sublabel_13_ampm" style="border:0;clip:rect(0 0 0 0);height:1px;margin:-1px;overflow:hidden;padding:0;position:absolute;width:1px;white-space:nowrap" aria-hidden="false"> AM/PM Option </label> </span> </div> </span> </div> </div> </li> <li class="form-line" data-type="control_fullname" id="id_6"> <label class="form-label form-label-top form-label-extended form-label-auto" id="label_6" for="prefix_6"> Incident report issued by: </label> <div id="cid_6" class="form-input-wide" data-layout="full"> <div data-wrapper-react="true" class="extended"> <span class="form-sub-label-container" style="vertical-align:top" data-input-type="prefix"> <input type="text" id="prefix_6" name="q6_incidentReport6[prefix]" class="form-textbox" size="4" value="" data-component="prefix" aria-labelledby="label_6 sublabel_6_prefix" /> <label class="form-sub-label" for="prefix_6" id="sublabel_6_prefix" style="min-height:13px" aria-hidden="false"> Mr/Ms/Mrs </label> </span> <span class="form-sub-label-container" style="vertical-align:top" data-input-type="first"> <input type="text" id="first_6" name="q6_incidentReport6[first]" class="form-textbox" size="10" value="" data-component="first" aria-labelledby="label_6 sublabel_6_first" /> <label class="form-sub-label" for="first_6" id="sublabel_6_first" style="min-height:13px" aria-hidden="false"> First Name </label> </span> <span class="form-sub-label-container" style="vertical-align:top" data-input-type="middle"> <input type="text" id="middle_6" name="q6_incidentReport6[middle]" class="form-textbox" size="10" value="" data-component="middle" aria-labelledby="label_6 sublabel_6_middle" /> <label class="form-sub-label" for="middle_6" id="sublabel_6_middle" style="min-height:13px" aria-hidden="false"> Middle Name </label> </span> <span class="form-sub-label-container" style="vertical-align:top" data-input-type="last"> <input type="text" id="last_6" name="q6_incidentReport6[last]" class="form-textbox" size="15" value="" data-component="last" aria-labelledby="label_6 sublabel_6_last" /> <label class="form-sub-label" for="last_6" id="sublabel_6_last" style="min-height:13px" aria-hidden="false"> Last Name </label> </span> </div> </div> </li> <li class="form-line" data-type="control_textarea" id="id_11"> <label class="form-label form-label-top form-label-auto" id="label_11" for="input_11"> Incident Location (Please provide specific details): </label> <div id="cid_11" class="form-input-wide" data-layout="full"> <textarea id="input_11" class="form-textarea" name="q11_incidentLocation" style="width:648px;height:163px" data-component="textarea" aria-labelledby="label_11"></textarea> </div> </li> <li class="form-line" data-type="control_textarea" id="id_14"> <label class="form-label form-label-top form-label-auto" id="label_14" for="input_14"> Nature of incident </label> <div id="cid_14" class="form-input-wide" data-layout="full"> <textarea id="input_14" class="form-textarea" name="q14_natureOf14" style="width:648px;height:163px" data-component="textarea" aria-labelledby="label_14"></textarea> </div> </li> <li class="form-line" data-type="control_textarea" id="id_15"> <label class="form-label form-label-top form-label-auto" id="label_15" for="input_15"> Incident details </label> <div id="cid_15" class="form-input-wide" data-layout="full"> <textarea id="input_15" class="form-textarea" name="q15_incidentDetails15" style="width:648px;height:163px" data-component="textarea" aria-labelledby="label_15"></textarea> </div> </li> <li class="form-line" data-type="control_textarea" id="id_16"> <label class="form-label form-label-top form-label-auto" id="label_16" for="input_16"> What motivated the incident? </label> <div id="cid_16" class="form-input-wide" data-layout="full"> <textarea id="input_16" class="form-textarea" name="q16_whatMotivated16" style="width:648px;height:163px" data-component="textarea" aria-labelledby="label_16"></textarea> </div> </li> <li class="form-line" data-type="control_textarea" id="id_17"> <label class="form-label form-label-top form-label-auto" id="label_17" for="input_17"> Was a report of the incident issued to the police? </label> <div id="cid_17" class="form-input-wide" data-layout="full"> <textarea id="input_17" class="form-textarea" name="q17_wasA" style="width:648px;height:163px" data-component="textarea" aria-labelledby="label_17"></textarea> </div> </li> <li class="form-line" data-type="control_textarea" id="id_18"> <label class="form-label form-label-top form-label-auto" id="label_18" for="input_18"> Has anyone been arrested so far in relation to the incident? </label> <div id="cid_18" class="form-input-wide" data-layout="full"> <textarea id="input_18" class="form-textarea" name="q18_hasAnyone" style="width:648px;height:163px" data-component="textarea" aria-labelledby="label_18"></textarea> </div> </li> <li class="form-line" data-type="control_text" id="id_19"> <div id="cid_19" class="form-input-wide" data-layout="full"> <div id="text_19" class="form-html" data-component="text"> <hr /> </div> </div> </li> <li class="form-line" data-type="control_fullname" id="id_20"> <label class="form-label form-label-top form-label-auto" id="label_20" for="first_20"> Full Name </label> <div id="cid_20" class="form-input-wide" data-layout="full"> <div data-wrapper-react="true"> <span class="form-sub-label-container" style="vertical-align:top" data-input-type="first"> <input type="text" id="first_20" name="q20_fullName20[first]" class="form-textbox" size="10" value="" data-component="first" aria-labelledby="label_20 sublabel_20_first" /> <label class="form-sub-label" for="first_20" id="sublabel_20_first" style="min-height:13px" aria-hidden="false"> First Name </label> </span> <span class="form-sub-label-container" style="vertical-align:top" data-input-type="last"> <input type="text" id="last_20" name="q20_fullName20[last]" class="form-textbox" size="15" value="" data-component="last" aria-labelledby="label_20 sublabel_20_last" /> <label class="form-sub-label" for="last_20" id="sublabel_20_last" style="min-height:13px" aria-hidden="false"> Last Name </label> </span> </div> </div> </li> <li class="form-line" data-type="control_phone" id="id_21"> <label class="form-label form-label-top form-label-auto" id="label_21" for="input_21_full"> Phone Number </label> <div id="cid_21" class="form-input-wide" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"> <input type="tel" id="input_21_full" name="q21_phoneNumber21[full]" data-type="mask-number" class="mask-phone-number form-textbox validate[Fill Mask]" style="width:310px" data-masked="true" value="" placeholder="(000) 000-0000" data-component="phone" aria-labelledby="label_21" /> <label class="form-sub-label is-empty" for="input_21_full" id="sublabel_21_masked" style="min-height:13px" aria-hidden="false"> </label> </span> </div> </li> <li class="form-line" data-type="control_address" id="id_22"> <label class="form-label form-label-top form-label-auto" id="label_22" for="input_22_addr_line1"> Address </label> <div id="cid_22" class="form-input-wide" data-layout="full"> <div summary="" class="form-address-table jsTest-addressField"> <div class="form-address-line-wrapper jsTest-address-line-wrapperField"> <span class="form-address-line form-address-street-line jsTest-address-lineField"> <span class="form-sub-label-container" style="vertical-align:top"> <input type="text" id="input_22_addr_line1" name="q22_address22[addr_line1]" class="form-textbox form-address-line" value="" data-component="address_line_1" aria-labelledby="label_22 sublabel_22_addr_line1" required="" /> <label class="form-sub-label" for="input_22_addr_line1" id="sublabel_22_addr_line1" style="min-height:13px" aria-hidden="false"> Street Address </label> </span> </span> </div> <div class="form-address-line-wrapper jsTest-address-line-wrapperField"> <span class="form-address-line form-address-street-line jsTest-address-lineField"> <span class="form-sub-label-container" style="vertical-align:top"> <input type="text" id="input_22_addr_line2" name="q22_address22[addr_line2]" class="form-textbox form-address-line" value="" data-component="address_line_2" aria-labelledby="label_22 sublabel_22_addr_line2" /> <label class="form-sub-label" for="input_22_addr_line2" id="sublabel_22_addr_line2" style="min-height:13px" aria-hidden="false"> Street Address Line 2 </label> </span> </span> </div> <div class="form-address-line-wrapper jsTest-address-line-wrapperField"> <span class="form-address-line form-address-city-line jsTest-address-lineField "> <span class="form-sub-label-container" style="vertical-align:top"> <input type="text" id="input_22_city" name="q22_address22[city]" class="form-textbox form-address-city" value="" data-component="city" aria-labelledby="label_22 sublabel_22_city" required="" /> <label class="form-sub-label" for="input_22_city" id="sublabel_22_city" style="min-height:13px" aria-hidden="false"> City </label> </span> </span> <span class="form-address-line form-address-state-line jsTest-address-lineField "> <span class="form-sub-label-container" style="vertical-align:top"> <input type="text" id="input_22_state" name="q22_address22[state]" class="form-textbox form-address-state" value="" data-component="state" aria-labelledby="label_22 sublabel_22_state" required="" /> <label class="form-sub-label" for="input_22_state" id="sublabel_22_state" style="min-height:13px" aria-hidden="false"> State / Province </label> </span> </span> </div> <div class="form-address-line-wrapper jsTest-address-line-wrapperField"> <span class="form-address-line form-address-zip-line jsTest-address-lineField "> <span class="form-sub-label-container" style="vertical-align:top"> <input type="text" id="input_22_postal" name="q22_address22[postal]" class="form-textbox form-address-postal" value="" data-component="zip" aria-labelledby="label_22 sublabel_22_postal" required="" /> <label class="form-sub-label" for="input_22_postal" id="sublabel_22_postal" style="min-height:13px" aria-hidden="false"> Postal / Zip Code </label> </span> </span> </div> </div> </div> </li> <li class="form-line" data-type="control_radio" id="id_23"> <label class="form-label form-label-top form-label-auto" id="label_23" for="input_23"> Do you want the police to get in touch with you? </label> <div id="cid_23" class="form-input-wide" data-layout="full"> <div class="form-single-column" role="group" aria-labelledby="label_23" data-component="radio"> <span class="form-radio-item" style="clear:left"> <span class="dragger-item"> </span> <input type="radio" class="form-radio" id="input_23_0" name="q23_doYou" value="Yes" /> <label id="label_input_23_0" for="input_23_0"> Yes </label> </span> <span class="form-radio-item" style="clear:left"> <span class="dragger-item"> </span> <input type="radio" class="form-radio" id="input_23_1" name="q23_doYou" value="No" /> <label id="label_input_23_1" for="input_23_1"> No </label> </span> </div> </div> </li> <li class="form-line" data-type="control_textarea" id="id_24"> <label class="form-label form-label-top form-label-auto" id="label_24" for="input_24"> Further Comments </label> <div id="cid_24" class="form-input-wide" data-layout="full"> <textarea id="input_24" class="form-textarea" name="q24_furtherComments" style="width:648px;height:163px" data-component="textarea" aria-labelledby="label_24"></textarea> </div> </li> <li class="form-line" data-type="control_text" id="id_25"> <div id="cid_25" class="form-input-wide" data-layout="full"> <div id="text_25" class="form-html" data-component="text"> <hr /> </div> </div> </li> <li class="form-line jf-required" data-type="control_checkbox" id="id_26"> <label class="form-label form-label-top form-label-auto" id="label_26" for="input_26"> <span class="form-required"> * </span> </label> <div id="cid_26" class="form-input-wide jf-required" data-layout="full"> <div class="form-single-column" role="group" aria-labelledby="label_26" data-component="checkbox"> <span class="form-checkbox-item" style="clear:left"> <span class="dragger-item"> </span> <input type="checkbox" class="form-checkbox validate[required]" id="input_26_0" name="q26_terms[]" value="I certify that the above information is true and correct." required="" /> <label id="label_input_26_0" for="input_26_0"> I certify that the above information is true and correct. </label> </span> </div> </div> </li> <li class="form-line" data-type="control_button" id="id_2"> <div id="cid_2" class="form-input-wide" data-layout="full"> <div data-align="left" class="form-buttons-wrapper form-buttons-left jsTest-button-wrapperField"> <button id="input" type="submit" class="formsubmit-button submit-button jf-form-buttons jsTest-submitField" data-component="button" data-content=""> Report Now! </button> </div> </div> </li> <li style="display:none"> Should be Empty: <input type="text" name="website" value="" /> </li> </ul> </div> <script> JotForm.showJotFormPowered = "new_footer"; </script> <script> JotForm.poweredByText = "Powered by JotForm"; </script> <input type="hidden" class="simple_spc" id="simple_spc" name="simple_spc" value="210272370100436" /> <script type="text/javascript"> var all_spc = document.querySelectorAll("form[id='210272370100436'] .si" + "mple" + "_spc");
<!-- for (var i = 0; i < all_spc.length; i++)
{ all_spc[i].value = "210272370100436-210272370100436"; -->
<!-- } </script> <div class="formFooter-heightMask"> </div> <div class="formFooter f6"> <div class="formFooter-wrapper formFooter-leftSide"> <a href="https://www.jotform.com/?utm_source=formfooter&utm_medium=banner&utm_term=210272370100436&utm_content=jotform_logo&utm_campaign=powered_by_jotform_le" target="_blank" class="formFooter-logoLink"> -->
<!-- <script src="https://cdn.jotfor.ms//js/vendor/smoothscroll.min.js?v=3.3.22857"></script>
<script src="https://cdn.jotfor.ms//js/errorNavigation.js?v=3.3.22857"></script> -->
</body>
</html>