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Form.html
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<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01//EN" "http://www.w3.org/TR/html4/strict.dtd">
<html class="supernova"><head>
<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
<link rel="alternate" type="application/json+oembed" href="https://www.jotform.com/oembed/?format=json&url=https%3A%2F%2Fform.jotform.com%2F210574655894467" title="oEmbed Form">
<link rel="alternate" type="text/xml+oembed" href="https://www.jotform.com/oembed/?format=xml&url=https%3A%2F%2Fform.jotform.com%2F210574655894467" title="oEmbed Form">
<meta property="og:title" content="Samyak's Complaint Form" >
<meta property="og:url" content="https://form.jotform.com/210574655894467" >
<meta property="og:description" content="Please click the link to complete this form." >
<meta name="slack-app-id" content="AHNMASS8M">
<link rel="shortcut icon" href="https://cdn.jotfor.ms/favicon.ico">
<link rel="canonical" href="https://form.jotform.com/210574655894467" />
<meta name="viewport" content="width=device-width, initial-scale=1.0, maximum-scale=2.0, user-scalable=1" />
<meta name="HandheldFriendly" content="true" />
<title>Samyak's Complaint Form</title>
<link type="text/css" media="print" rel="stylesheet" href="https://cdn.jotfor.ms/css/printForm.css?3.3.23566" />
<link id="custom-font" type="text/css" rel="stylesheet" href="https://cdn.jotfor.ms/opt/google-fonts/Comic Sans MS/fontface.css" />
<link type="text/css" rel="stylesheet" href="https://cdn.jotfor.ms/themes/CSS/5e6b428acc8c4e222d1beb91.css?themeRevisionID=5f7ed99c2c2c7240ba580251"/>
<link type="text/css" rel="stylesheet" href="https://cdn.jotfor.ms/css/styles/payment/payment_styles.css?3.3.23566" />
<link type="text/css" rel="stylesheet" href="https://cdn.jotfor.ms/css/styles/payment/payment_feature.css?3.3.23566" />
<style type="text/css" id="form-designer-style">
/* Injected CSS Code */
/*PREFERENCES STYLE*/
/* NEW THEME STYLE */
/* colors */
.form-textbox, .form-textarea {
color: #2c3345;
}
.rating-item input:hover+label {
color: rgba(0, 112, 141, 0.75);
}
li[data-type=control_fileupload] .qq-upload-button,
.until-text,
.form-submit-reset {
color: rgba(0, 112, 141, 0.75);
}
.stageEmpty.isSmall{
color: rgba(0, 112, 141, 0.75);
}
.rating-item label {
color: rgba(0, 112, 141, 0.75);
}
.currentDate,
.pickerItem select,
.appointmentCalendar .calendarDay,
.calendar.popup th,
.calendar.popup table tbody td,
.calendar-new-header>*,
.form-collapse-table {
color: #00708D;
}
.appointmentCalendar .dayOfWeek {
color: #00708D;
}
.appointmentSlotsContainer > * {
color: rgba(0, 112, 141, 0.75);
}
li[data-type=control_fileupload] .jfUpload-heading,
::placeholder,
.form-dropdown.is-active,
.form-dropdown:first-child,
.form-spinner-input {
color: #83D0E4;
}
.appointmentCalendar .calendarWeek .calendarDay.isUnavailable,
.calendar tr.days td.otherDay,
.calendar tr.days td:hover:not(.unselectable) {
color: #83D0E4;
}
span.form-sub-label, label.form-sub-label, div.form-header-group .form-subHeader,
.rating-item-title.for-to > label:first-child,
.rating-item-title.for-from > label:first-child,
.rating-item-title .editor-container * {
color: #00708D;
}
.form-pagebreak-back{
color: #FFFFFF;
}
.rating-item input:checked+label,
.rating-item input:focus+label {
color: #FFFFFF;
}
.clear-pad-btn {
color: #FFFFFF;
}
.form-textbox::placeholder,
.form-dropdown:not(.time-dropdown):not(:required),
.form-dropdown:not(:required),
.form-dropdown:required:invalid {
color: #83D0E4;
}
/* border-colors */
.form-dropdown,
.form-textarea,
.form-textbox,
li[data-type=control_fileupload] .qq-upload-button,
.rating-item label,
.rating-item input:focus+label,
.rating-item input:checked+label,
.jf-form-buttons,
.form-checkbox+label:before, .form-checkbox+span:before, .form-radio+label:before, .form-radio+span:before,
.signature-pad-passive,
.signature-wrapper,
.appointmentCalendarContainer,
.appointmentField .timezonePickerName,
.appointmentDayPickerButton,
.appointmentCalendarContainer .monthYearPicker .pickerItem+.pickerItem,
.appointmentCalendarContainer .monthYearPicker,
.appointmentCalendar .calendarDay.isActive .calendarDayEach, .appointmentCalendar .calendarDay.isToday .calendarDayEach, .appointmentCalendar .calendarDay:not(.empty):hover .calendarDayEach,
.calendar.popup:before,
.calendar-new-month,
.form-matrix-column-headers, .form-matrix-table td, .form-matrix-table td:last-child,
.form-matrix-table th, .form-matrix-table th:last-child, .form-matrix-table tr:last-child td, .form-matrix-table tr:last-child th, .form-matrix-table tr:not([role=group])+tr[role=group] th,
.form-matrix-headers.form-matrix-column-headers,
.isSelected .form-matrix-column-headers:nth-last-of-type(2),
li[data-type=control_inline] input[type=email], li[data-type=control_inline] input[type=number],
li[data-type=control_inline] input[type=tel], li[data-type=control_inline] input[type=text],
.stageEmpty.isSmall {
border-color: rgba(0, 112, 141, 0.75);
}
.rating-item input:hover+label {
border-color: rgba(0, 112, 141, 0.75);
}
.appointmentSlot,
.form-checkbox:checked+label:before, .form-checkbox:checked+span:before, .form-checkbox:checked+span label:before,
.form-radio:checked+label:before, .form-radio:checked+span:before,
.form-dropdown:focus, .form-textarea:focus, .form-textbox:focus, .signature-wrapper:focus,
.form-line[data-payment="true"] .form-product-item .p_checkbox .checked,
.form-dropdown:hover, .form-textarea:hover, .form-textbox:hover, .signature-wrapper:hover {
border-color: rgba(0, 112, 141, 0.75);
}
.calendar tr.days td:hover:not(.unselectable):after {
border-color: #83D0E4;
}
.form-header-group,
.form-buttons-wrapper, .form-pagebreak, .form-submit-clear-wrapper,
.form-pagebreak-next,
.form-pagebreak-back,
.form-checkbox:hover+label:before, .form-checkbox:hover+span:before, .form-radio:hover+label:before, .form-radio:hover+span:before{
border-color: #83D0E4;
}
.form-pagebreak-back:focus, .form-pagebreak-next:focus, .form-submit-button:focus {
border-color: rgba(0, 112, 141, 1);
}
/* background-colors */
.form-line-active {
background-color: #DAF3FA;
}
.form-line-error {
background-color: #FFEDED;
}
.form-matrix-column-headers, .form-matrix-row-headers,
.form-spinner-button-container>*,
.form-collapse-table,
.form-collapse-table:hover,
.appointmentDayPickerButton {
background-color: #83D0E4;
}
.calendar.popup, .calendar.popup table,
.calendar.popup table tbody td:after{
background-color: #F0FCFF;
}
.appointmentCalendar .calendarDay.isActive .calendarDayEach,
.appointmentFieldRow.forSelectedDate,
.calendar.popup tr.days td.selected:after,
.calendar.popup:after,
.submit-button,
.form-checkbox:checked+label:before, .form-checkbox:checked+span:before, .form-checkbox:checked+span label:before,
.form-radio+label:after, .form-radio+span:after,
.rating-item input:checked+label,
.appointmentCalendar .calendarDay:after,
.form-line[data-payment="true"] .form-product-item .p_checkbox .checked,
.rating-item input:focus+label {
background-color: #01485A;
}
.appointmentSlot.active {
background-color: #01485A !important;
}
.clear-pad-btn,
.appointmentCalendar .dayOfWeek,
.calendar.popup th {
background-color: #83D0E4 !important;
}
.appointmentField .timezonePicker:hover+.timezonePickerName,
.form-spinner-button-container>*:hover {
background-color: #86C8D9;
}
.form-matrix-values,
.form-matrix-values,
.signature-wrapper,
.signature-pad-passive,
.rating-item label,
.form-checkbox+label:before, .form-checkbox+span:before,
.form-radio+label:before, .form-radio+span:before {
background-color: #FFFFFF;
}
li[data-type=control_fileupload] .qq-upload-button {
background-color: #FFFFFF;
}
.JotFormBuilder .appContainer #app li.form-line[data-type=control_matrix].isSelected
.questionLine-editButton.forRemove:after,
.JotFormBuilder .appContainer #app li.form-line[data-type=control_matrix].isSelected .questionLine-editButton.forRemove:before {
background-color: #FFFFFF;
}
.appointmentCalendarContainer, .appointmentSlot,
.rating-item-title.for-to > label:first-child,
.rating-item-title.for-from > label:first-child,
.rating-item-title .editor-container *,
.calendar-opened {
background-color: transparent;
}
.page-section li.form-line-active[data-type="control_button"] {
background-color: #DAF3FA;
}
.appointmentCalendar .calendarDay.isSelected:after {
color: #FFFFFF;
}
/* shadow */
.form-dropdown:hover, .form-textarea:hover, .form-textbox:hover, .signature-wrapper:hover,
.calendar.popup:before,
.jSignature:hover,
li[data-type=control_fileupload] .qq-upload-button-hover,
.form-line[data-payment="true"] .form-product-item .p_checkbox .checked,
.form-line[data-payment="true"] .form-product-item .p_checkbox:hover .select_border,
.form-checkbox:hover+label:before, .form-checkbox:hover+span:before, .form-radio:hover+label:before, .form-radio:hover+span:before,
.calendar.popup:before {
border-color: rgba(0, 112, 141, 0.5);
box-shadow: 0 0 0 2px rgba(0, 112, 141, 0.25);
}
.form-dropdown:focus, .form-textarea:focus, .form-textbox:focus, .signature-wrapper:focus,
li[data-type=control_fileupload] .qq-upload-button-focus,
.form-checkbox:focus+label:before, .form-checkbox:focus+span:before, .form-radio:focus+label:before, .form-radio:focus+span:before,
.calendar.popup:before {
border-color: rgba(0, 112, 141, 1);
box-shadow: 0 0 0 3px rgba(0, 112, 141, 0.25);
}
.calendar.popup table tbody td{
box-shadow: none;
}
/* button colors */
.submit-button {
background-color: #00708D;
border-color: #00708D;
}
.submit-button:hover {
background-color: #004355;
border-color: #004355;
}
.form-pagebreak-next {
background-color: #83D0E4;
}
.form-pagebreak-back {
background-color: #83D0E4;
}
.form-pagebreak-back:hover {
background-color: #4F7D89;
border-color: #4F7D89;
}
.form-pagebreak-next:hover {
background-color: #4F7D89;
border-color: #4F7D89;
}
.form-sacl-button, .form-submit-print {
background-color: transparent;
color: rgba(0, 112, 141, 0.75);
border-color: rgba(0, 112, 141, 0.75);
}
.form-sacl-button:hover, .form-submit-print:hover,
.appointmentSlot:not(.disabled):not(.active):hover,
.appointmentDayPickerButton:hover,
.rating-item input:hover+label {
background-color: #86C8D9;
}
/* payment styles */
.form-line[data-payment=true] .form-textbox,
.form-line[data-payment=true] .select-area,
.form-line[data-payment=true] #coupon-input,
.form-line[data-payment=true] #coupon-container input,
.form-line[data-payment=true] input#productSearch-input,
.form-line[data-payment=true] .form-product-category-item:after,
.form-line[data-payment=true] .filter-container .dropdown-container .select-content,
.form-line[data-payment=true] .form-textbox.form-product-custom_quantity,
.form-line[data-payment="true"] .form-product-item .p_checkbox .select_border,
.form-line[data-payment="true"] .form-product-item .form-product-container .form-sub-label-container span.select_cont,
.form-line[data-payment=true] select.form-dropdown {
border-color: rgba(0, 112, 141, 0.75);
border-color: rgba(0,112,141,.4);
}
.form-line[data-payment="true"] hr,
.form-line[data-payment=true] .p_item_separator,
.form-line[data-payment="true"] .payment_footer.new_ui,
.form-line.card-3col .form-product-item.new_ui,
.form-line.card-2col .form-product-item.new_ui {
border-color: rgba(0, 112, 141, 0.75);
border-color: rgba(0,112,141,.2);
}
.form-line[data-payment=true] .form-product-category-item {
border-color: rgba(0, 112, 141, 0.75);
border-color: rgba(0,112,141,.3);
}
.form-line[data-payment=true] #coupon-input,
.form-line[data-payment=true] .form-textbox.form-product-custom_quantity,
.form-line[data-payment=true] input#productSearch-input,
.form-line[data-payment=true] .select-area,
.form-line[data-payment=true] .custom_quantity,
.form-line[data-payment=true] .filter-container .select-content,
.form-line[data-payment=true] .p_checkbox .select_border {
background-color: #FFFFFF;
}
.form-product-category-item:after {
background-color: rgba(0,112,141,.7);
border-color: rgba(0,112,141,.7);
}
.form-line[data-payment=true].form-line.card-3col .form-product-item,
.form-line[data-payment=true].form-line.card-2col .form-product-item {
background-color: rgba(0,0,0,.05);
}
.form-line[data-payment=true] .payment-form-table input.form-textbox,
.form-line[data-payment=true] .payment-form-table input.form-dropdown,
.form-line[data-payment=true] .payment-form-table .form-sub-label-container > div,
.form-line[data-payment=true] .payment-form-table span.form-sub-label-container iframe,
.form-line[data-type=control_square] .payment-form-table span.form-sub-label-container iframe {
border-color: rgba(0, 112, 141, 0.75);
}
/* icons */
.appointmentField .timezonePickerName:before {
background-image: url(data:image/svg+xml;base64,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);
}
.appointmentCalendarContainer .monthYearPicker .pickerArrow.prev:after {
background-image: url(data:image/svg+xml;base64,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);
}
.appointmentCalendarContainer .monthYearPicker .pickerArrow.next:after {
background-image: url(data:image/svg+xml;base64,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);
}
.appointmentField .timezonePickerName:after {
background-image: url(data:image/svg+xml;base64,PHN2ZyB3aWR0aD0iMTAiIGhlaWdodD0iNiIgdmlld0JveD0iMCAwIDEwIDYiIGZpbGw9Im5vbmUiIHhtbG5zPSJodHRwOi8vd3d3LnczLm9yZy8yMDAwL3N2ZyI+CjxwYXRoIGQ9Ik0xIDFMNSA1TDkgMSIgc3Ryb2tlPSIjMDA3MDhEIiBzdHJva2Utd2lkdGg9IjIiIHN0cm9rZS1saW5lY2FwPSJyb3VuZCIgc3Ryb2tlLWxpbmVqb2luPSJyb3VuZCIvPgo8L3N2Zz4K);
width: 11px;
}
li[data-type=control_datetime] [data-wrapper-react=true].extended>div+.form-sub-label-container .form-textbox:placeholder-shown,
li[data-type=control_datetime] [data-wrapper-react=true]:not(.extended) .form-textbox:not(.time-dropdown):placeholder-shown,
.appointmentCalendarContainer .currentDate {
background-image: url(data:image/svg+xml;base64,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);
}
.form-star-rating-star.Stars {
background-image: 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}
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background-image: 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}
.form-spinner-button.form-spinner-up:before {
background-image: url(data:image/svg+xml;base64,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);
}
.form-spinner-button.form-spinner-down:before {
background-image: url(data:image/svg+xml;base64,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);
}
.form-collapse-table:after{
background-image: url(data:image/svg+xml;base64,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);
}
li[data-type=control_fileupload] .qq-upload-button:before {
background-image: url(data:image/svg+xml;base64,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);
}
.appointmentDayPickerButton {
background-image: url(data:image/svg+xml;base64,PHN2ZyB3aWR0aD0iNiIgaGVpZ2h0PSIxMCIgdmlld0JveD0iMCAwIDYgMTAiIGZpbGw9Im5vbmUiIHhtbG5zPSJodHRwOi8vd3d3LnczLm9yZy8yMDAwL3N2ZyI+CjxwYXRoIGQ9Ik0xIDlMNSA1TDEgMSIgc3Ryb2tlPSIjMDA3MDhEIiBzdHJva2Utd2lkdGg9IjIiIHN0cm9rZS1saW5lY2FwPSJyb3VuZCIgc3Ryb2tlLWxpbmVqb2luPSJyb3VuZCIvPgo8L3N2Zz4K);
}
/* NEW THEME STYLE */
/*PREFERENCES STYLE*/
*,
*:after,
*:before {
box-sizing: border-box;
}
.form-all {
font-family: "Comic Sans MS", sans-serif;
}
.main .jotform-form {
width: 100%;
padding: 0 3%;
}
.form-all {
display: flex;
flex-direction: column;
width: 100%;
max-width: 758px;
}
.form-line-active {
background-color: #daf3fa;
}
.form-all {
font-size: 18px;
}
li.form-line {
margin-top: 12px;
margin-bottom: 12px;
}
.form-line {
padding: 12px 10px;
}
.form-all .form-textbox,
.form-all .form-radio-other-input,
.form-all .form-checkbox-other-input,
.form-all .form-captcha input,
.form-all .form-spinner input,
.form-all .form-pagebreak-back,
.form-all .form-pagebreak-next,
.form-all .qq-upload-button,
.form-all .signature-wrapper,
.form-all .form-error-message {
border-radius: 20px;
}
.form-all .form-sub-label {
margin-left: 3px;
}
.form-all .form-textarea {
border-radius: 20px;
padding: 10px;
}
.supernova .form-all,
.form-all {
border-radius: 3px;
}
.form-section:first-child {
border-radius: 3px 3px 0 0;
}
.form-section:last-child {
border-radius: 0 0 3px 3px;
}
.form-section {
padding: 0px 38px;
}
.form-textbox,
.form-textarea {
border-width: 4px;
width: 100% !important;
border-color: rgba(0, 185, 233, 0.75);
color: #0b831b;
}
.form-textbox,
.form-textarea,
.form-radio-other-input,
.form-checkbox-other-input,
.form-captcha input,
.form-spinner input {
background-color: #ffffff;
}
li[data-type="control_textbox"] div[data-layout="half"],
li[data-type="control_dropdown"] div[data-layout="half"],
li[data-type="control_email"] div[data-layout="half"],
li[data-type="control_number"] div[data-layout="half"],
li[data-type="control_phone"] div[data-layout="half"],
li[data-type="control_datetime"] div[data-layout="half"],
li[data-type="control_signature"] div[data-layout="half"] {
width: 100% !important;
max-width: 313px;
}
.form-label {
font-family: "Comic Sans MS", sans-serif;
}
.form-line-column {
width: calc(50% - 8px);
}
.form-dropdown {
border-color: rgba(0, 112, 141, 0.75);
color: #83d0e4;
background-color: #ffffff;
}
[data-type="control_dropdown"] .form-input,
[data-type="control_birthdate"] .form-input,
[data-type="control_time"] .form-input,
[data-type="control_dropdown"] .form-input-wide,
[data-type="control_birthdate"] .form-input-wide,
[data-type="control_time"] .form-input-wide {
width: 100% !important;
max-width: 313px;
}
[data-type="control_dropdown"] .form-dropdown {
width: 100% !important;
max-width: 313px;
}
.form-checkbox-item label,
.form-checkbox-item span,
.form-radio-item label,
.form-radio-item span {
color: #0099c0;
}
.form-radio-item,
.form-checkbox-item {
padding-bottom: 0px !important;
}
.form-radio-item:last-child,
.form-checkbox-item:last-child {
padding-bottom: 0;
}
.form-single-column .form-checkbox-item,
.form-single-column .form-radio-item {
width: 100%;
}
.form-checkbox-item .editor-container div,
.form-radio-item .editor-container div {
position: relative;
}
.form-checkbox-item .editor-container div:before,
.form-radio-item .editor-container div:before {
display: inline-block;
vertical-align: middle;
left: 0;
width: 20px;
height: 20px;
}
.form-checkbox-item input,
.form-radio-item input {
margin-top: 2px;
}
.form-checkbox-item .form-checkbox:checked + label:before,
.form-checkbox-item .form-checkbox:checked + span:before {
background-color: rgba(0, 6, 141, 0.75);
border-color: rgba(0, 6, 141, 0.75);
}
.form-radio-item .form-radio:checked + label:before,
.form-radio-item .form-radio:checked + span:before {
border-color: rgba(0, 6, 141, 0.75);
}
.form-radio-item .form-radio:checked + label:after,
.form-radio-item .form-radio:checked + span:after {
background-color: rgba(0, 6, 141, 0.75);
}
.form-all .form-submit-button,
.form-all .form-submit-print {
font-size: 18px;
font-weight: normal;
font-family: "Comic Sans MS", sans-serif;
border-color: rgba(0, 112, 141, 0.75);
}
.form-all .form-submit-button {
min-width: 180px;
}
.form-all .form-submit-button.js-new-sacl-button,
.form-all .form-submit-print {
min-width: 98px;
}
.form-all .form-pagebreak-back,
.form-all .form-pagebreak-next {
font-family: "Comic Sans MS", sans-serif;
font-size: 18px;
font-weight: normal;
}
.form-all .form-pagebreak-back,
.form-all .form-pagebreak-next {
min-width: 128px;
}
li[data-type="control_image"] div {
text-align: left;
}
li[data-type="control_image"] img {
border: none;
border-width: 0px !important;
border-style: solid !important;
border-color: false !important;
}
.supernova {
height: 100%;
background-repeat: no-repeat;
background-attachment: scroll;
background-position: center top;
background-repeat: repeat;
}
.supernova {
background-image: none;
}
#stage {
background-image: none;
}
/* | */
.form-all {
background-repeat: no-repeat;
background-attachment: scroll;
background-position: center top;
background-repeat: repeat;
}
.form-header-group {
background-repeat: no-repeat;
background-attachment: scroll;
background-position: center top;
}
.header-large h1.form-header {
font-size: 2em;
}
.header-large h2.form-header {
font-size: 1.5em;
}
.header-large h3.form-header {
font-size: 1.17em;
}
.header-large h1 + .form-subHeader {
font-size: 1em;
}
.header-large h2 + .form-subHeader {
font-size: .875em;
}
.header-large h3 + .form-subHeader {
font-size: .75em;
}
.header-default h1.form-header {
font-size: 2em;
}
.header-default h2.form-header {
font-size: 1.5em;
}
.header-default h3.form-header {
font-size: 1.17em;
}
.header-default h1 + .form-subHeader {
font-size: 1em;
}
.header-default h2 + .form-subHeader {
font-size: .875em;
}
.header-default h3 + .form-subHeader {
font-size: .75em;
}
.header-small h1.form-header {
font-size: 2em;
}
.header-small h2.form-header {
font-size: 1.5em;
}
.header-small h3.form-header {
font-size: 1.17em;
}
.header-small h1 + .form-subHeader {
font-size: 1em;
}
.header-small h2 + .form-subHeader {
font-size: .875em;
}
.header-small h3 + .form-subHeader {
font-size: .75em;
}
.form-header-group {
text-align: left;
}
.form-header-group {
font-family: "Comic Sans MS", sans-serif;
}
div.form-header-group.header-large {
margin: 0px -38px;
}
div.form-header-group.header-large {
padding: 40px 52px;
}
.form-header-group .form-header,
.form-header-group .form-subHeader {
color: #00708d;
}
.form-collapse-table {
border: 1px solid rgba(0, 0, 0, 0.2);
background-color: #83d0e4;
box-shadow: 0 1px 0 rgba(255,255,255,0.5) inset, 0 1px 0 rgba(0,0,0,0.2);
color: #00708d;
}
.form-collapse-table .form-collapse-mid {
text-shadow: none;
}
.form-line-error {
overflow: hidden;
-webkit-transition-property: none;
-moz-transition-property: none;
-ms-transition-property: none;
-o-transition-property: none;
transition-property: none;
-webkit-transition-duration: 0.3s;
-moz-transition-duration: 0.3s;
-ms-transition-duration: 0.3s;
-o-transition-duration: 0.3s;
transition-duration: 0.3s;
-webkit-transition-timing-function: ease;
-moz-transition-timing-function: ease;
-ms-transition-timing-function: ease;
-o-transition-timing-function: ease;
transition-timing-function: ease;
background-color: #ffeded;
}
.form-line-error .form-error-message {
background-color: #f23a3c;
clear: both;
float: none;
}
.form-line-error .form-error-message .form-error-arrow {
border-bottom-color: #f23a3c;
}
.form-line-error input:not(#coupon-input),
.form-line-error textarea,
.form-line-error .form-validation-error {
border: 1px solid #f23a3c;
box-shadow: 0 0 3px #f23a3c;
}
.supernova {
background-color: #f0fcff;
background-color: #83d0e4;
}
.supernova body {
background-color: transparent;
}
.supernova .form-all,
.form-all {
background-color: #f0fcff;
}
.form-textbox,
.form-textarea,
.form-radio-other-input,
.form-checkbox-other-input,
.form-captcha input,
.form-spinner input {
background-color: #ffffff;
}
.form-matrix-table tr {
border-color: #bdf2ff;
}
.form-matrix-table tr:nth-child(2n) {
background-color: #d7f7ff;
}
.form-all {
color: #00708d;
}
.form-label-top,
.form-label-left,
.form-label-right,
.form-html {
color: #00708d;
}
.form-line-error {
overflow: hidden;
-webkit-transition-property: none;
-moz-transition-property: none;
-ms-transition-property: none;
-o-transition-property: none;
transition-property: none;
-webkit-transition-duration: 0.3s;
-moz-transition-duration: 0.3s;
-ms-transition-duration: 0.3s;
-o-transition-duration: 0.3s;
transition-duration: 0.3s;
-webkit-transition-timing-function: ease;
-moz-transition-timing-function: ease;
-ms-transition-timing-function: ease;
-o-transition-timing-function: ease;
transition-timing-function: ease;
background-color: #ffeded;
}
/*__INSPECT_SEPERATOR__*/
.form-line {
}
.form-textbox {
}
.form-sub-label {
}
#label_5 {
}
#id_5 {
}
.form-section.page-section {
}
#210574655894467 ul.form-section {
}
.form-textarea {
}
.form-label.form-label-auto {
display : block;
float : none;
text-align : left;
width : 100%;
}
/* Injected CSS Code */
</style>
<script src="https://cdn.jotfor.ms/js/vendor/jquery-1.8.0.min.js?v=3.3.23566" type="text/javascript"></script>
<script src="https://cdn.jotfor.ms/js/vendor/maskedinput.min.js?v=3.3.23566" type="text/javascript"></script>
<script src="https://cdn.jotfor.ms/js/vendor/jquery.maskedinput.min.js?v=3.3.23566" type="text/javascript"></script>
<script src="https://cdn.jotfor.ms/js/vendor/imageinfo.js?v=3.3.23566" type="text/javascript"></script>
<script src="https://cdn.jotfor.ms/file-uploader/fileuploader.js?v=3.3.23566"></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?3.3.23566" 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("3", 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("3", 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.formatDate({date:(new Date()), dateField:$("id_"+3)});
JotForm.displayLocalTime("input_3_hourSelect", "input_3_minuteSelect","input_3_ampm", "input_3_timeInput", false);
if (window.JotForm && JotForm.accessible) $('input_4').setAttribute('tabindex',0);
setTimeout(function() {
$('input_4').hint(' Name');
}, 20);
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("15", 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("15", 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_11').setAttribute('tabindex',0);
if (window.JotForm && JotForm.accessible) $('input_8').setAttribute('tabindex',0);
setTimeout(function() {
$('input_27').hint('ex: 23');
}, 20);
JotForm.newDefaultTheme = true;
JotForm.extendsNewTheme = false;
JotForm.newPaymentUIForNewCreatedForms = false;
JotForm.newPaymentUI = true;
setTimeout(function() {
JotForm.initMultipleUploads();
}, 2);
/*INIT-END*/
});
JotForm.prepareCalculationsOnTheFly([null,{"name":"clickTo","qid":"1","text":"We are here to assist you!","type":"control_head"},{"name":"submit","qid":"2","text":"Send","type":"control_button"},{"name":"dateOf","qid":"3","text":"Date of filling the form:","type":"control_datetime"},{"description":"","name":"complainantsName","qid":"4","subLabel":"","text":"Complainant's Name:","type":"control_textbox"},null,{"name":"clickTo6","qid":"6","text":"","type":"control_text"},null,{"name":"hasAny","qid":"8","text":"Has any authorities have been reported too? If yes, which all and what actions have been taken so far?","type":"control_textarea"},null,null,{"name":"theSpecific","qid":"11","text":"The specific details of the complaint:","type":"control_textarea"},null,null,null,{"description":"","name":"whenDid","qid":"15","text":"When did this incident occur?","type":"control_datetime"},null,null,{"description":"","name":"whereDid18","qid":"18","subLabel":"","text":"Where did this incident occur?","type":"control_dropdown"},{"description":"","name":"anyFiles","qid":"19","subLabel":"","text":"Any files as a proof","type":"control_fileupload"},null,{"description":"","name":"whichAge","qid":"21","text":"Which age group do you belong","type":"control_checkbox"},{"description":"","name":"whatsYour","qid":"22","text":"Whats your gender?","type":"control_radio"},null,null,null,null,{"description":"","name":"yourContact","qid":"27","subLabel":"","text":"Your Contact Number (with the country code)","type":"control_number"}]);
setTimeout(function() {
JotForm.paymentExtrasOnTheFly([null,{"name":"clickTo","qid":"1","text":"We are here to assist you!","type":"control_head"},{"name":"submit","qid":"2","text":"Send","type":"control_button"},{"name":"dateOf","qid":"3","text":"Date of filling the form:","type":"control_datetime"},{"description":"","name":"complainantsName","qid":"4","subLabel":"","text":"Complainant's Name:","type":"control_textbox"},null,{"name":"clickTo6","qid":"6","text":"","type":"control_text"},null,{"name":"hasAny","qid":"8","text":"Has any authorities have been reported too? If yes, which all and what actions have been taken so far?","type":"control_textarea"},null,null,{"name":"theSpecific","qid":"11","text":"The specific details of the complaint:","type":"control_textarea"},null,null,null,{"description":"","name":"whenDid","qid":"15","text":"When did this incident occur?","type":"control_datetime"},null,null,{"description":"","name":"whereDid18","qid":"18","subLabel":"","text":"Where did this incident occur?","type":"control_dropdown"},{"description":"","name":"anyFiles","qid":"19","subLabel":"","text":"Any files as a proof","type":"control_fileupload"},null,{"description":"","name":"whichAge","qid":"21","text":"Which age group do you belong","type":"control_checkbox"},{"description":"","name":"whatsYour","qid":"22","text":"Whats your gender?","type":"control_radio"},null,null,null,null,{"description":"","name":"yourContact","qid":"27","subLabel":"","text":"Your Contact Number (with the country code)","type":"control_number"}]);}, 20);
</script>
</head>
<body>
<form class="jotform-form" action="https://submit.jotform.com/submit/210574655894467/" method="post" enctype="multipart/form-data" name="form_210574655894467" id="210574655894467" accept-charset="utf-8" autocomplete="on">
<input type="hidden" name="formID" value="210574655894467" />
<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_1" class="form-input-wide" data-type="control_head">
<div class="form-header-group header-large">
<div class="header-text httal htvam">
<h1 id="header_1" class="form-header" data-component="header">
We are here to assist you!
</h1>
<div id="subHeader_1" class="form-subHeader">
Please complete the form below for your complaints.
</div>
</div>
</div>
</li>
<li class="form-line" data-type="control_datetime" id="id_3">
<label class="form-label form-label-top form-label-auto" id="label_3" for="lite_mode_3"> Date of filling the form: </label>
<div id="cid_3" class="form-input-wide" data-layout="half">
<div data-wrapper-react="true">
<div style="display:none">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" class="form-textbox validate[limitDate]" id="month_3" name="q3_dateOf[month]" size="2" data-maxlength="2" data-age="" maxLength="2" value="02" autoComplete="off" aria-labelledby="label_3 sublabel_3_month" />
<span class="date-separate" aria-hidden="true">
-
</span>
<label class="form-sub-label" for="month_3" id="sublabel_3_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="currentDate form-textbox validate[limitDate]" id="day_3" name="q3_dateOf[day]" size="2" data-maxlength="2" data-age="" maxLength="2" value="27" autoComplete="off" aria-labelledby="label_3 sublabel_3_day" />
<span class="date-separate" aria-hidden="true">
-
</span>
<label class="form-sub-label" for="day_3" id="sublabel_3_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_3" name="q3_dateOf[year]" size="4" data-maxlength="4" data-age="" maxLength="4" value="2021" autoComplete="off" aria-labelledby="label_3 sublabel_3_year" />
<label class="form-sub-label" for="year_3" id="sublabel_3_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_3" size="12" data-maxlength="12" maxLength="12" data-age="" value="02-27-2021" data-format="mmddyyyy" data-seperator="-" placeholder="MM-DD-YYYY" autoComplete="off" aria-labelledby="label_3" />
<img class=" newDefaultTheme-dateIcon icon-liteMode" alt="Pick a Date" id="input_3_pick" src="https://cdn.jotfor.ms/images/calendar.png" data-component="datetime" aria-hidden="true" data-allow-time="No" data-version="v2" />
<label class="form-sub-label is-empty" for="lite_mode_3" id="sublabel_3_litemode" style="min-height:13px" aria-hidden="false"> </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_textbox" id="id_4">
<label class="form-label form-label-top form-label-auto" id="label_4" for="input_4"> Complainant's Name: </label>
<div id="cid_4" class="form-input-wide" data-layout="half">
<input type="text" id="input_4" name="q4_complainantsName" data-type="input-textbox" class="form-textbox" style="width:310px" size="310" value="" placeholder=" Name" data-component="textbox" aria-labelledby="label_4" />
</div>
</li>
<li class="form-line jf-required" data-type="control_radio" id="id_22">
<label class="form-label form-label-top form-label-auto" id="label_22" for="input_22">
Whats your gender?
<span class="form-required">
*
</span>
</label>
<div id="cid_22" class="form-input-wide jf-required" data-layout="full">
<div class="form-single-column" role="group" aria-labelledby="label_22" data-component="radio">
<span class="form-radio-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="radio" class="form-radio validate[required]" id="input_22_0" name="q22_whatsYour" value="Male" required="" />
<label id="label_input_22_0" for="input_22_0"> Male </label>
</span>
<span class="form-radio-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="radio" class="form-radio validate[required]" id="input_22_1" name="q22_whatsYour" value="Female" required="" />
<label id="label_input_22_1" for="input_22_1"> Female </label>
</span>
</div>
</div>
</li>
<li class="form-line jf-required" data-type="control_checkbox" id="id_21">
<label class="form-label form-label-top form-label-auto" id="label_21" for="input_21">
Which age group do you belong
<span class="form-required">
*
</span>
</label>
<div id="cid_21" class="form-input-wide jf-required" data-layout="full">
<div class="form-single-column" role="group" aria-labelledby="label_21" 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_21_0" name="q21_whichAge[]" value="Below 18" required="" />
<label id="label_input_21_0" for="input_21_0"> Below 18 </label>
</span>
<span class="form-checkbox-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="checkbox" class="form-checkbox validate[required]" id="input_21_1" name="q21_whichAge[]" value="18 to 25" required="" />
<label id="label_input_21_1" for="input_21_1"> 18 to 25 </label>
</span>
<span class="form-checkbox-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="checkbox" class="form-checkbox validate[required]" id="input_21_2" name="q21_whichAge[]" value="25-35" required="" />
<label id="label_input_21_2" for="input_21_2"> 25-35 </label>
</span>
<span class="form-checkbox-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="checkbox" class="form-checkbox validate[required]" id="input_21_3" name="q21_whichAge[]" value="35 and above" required="" />
<label id="label_input_21_3" for="input_21_3"> 35 and above </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_text" id="id_6">
<div id="cid_6" class="form-input-wide" data-layout="full">
<div id="text_6" class="form-html" data-component="text">
<hr />
</div>
</div>
</li>
<li class="form-line jf-required" data-type="control_datetime" id="id_15">
<label class="form-label form-label-top form-label-auto" id="label_15" for="lite_mode_15">
When did this incident occur?
<span class="form-required">
*
</span>
</label>
<div id="cid_15" class="form-input-wide jf-required" data-layout="half">
<div data-wrapper-react="true">
<div style="display:none">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="tel" class="form-textbox validate[required, limitDate]" id="month_15" name="q15_whenDid[month]" size="2" data-maxlength="2" data-age="" maxLength="2" value="" required="" autoComplete="off" aria-labelledby="label_15 sublabel_15_month" />
<span class="date-separate" aria-hidden="true">
-
</span>
<label class="form-sub-label" for="month_15" id="sublabel_15_month" style="min-height:13px" aria-hidden="false"> Month </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top">