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<form class="userform-form" action="" method="post" name="form_6380063" id="6380063" accept-charset="utf-8"><input type="hidden" name="formID" value="6380063" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li class="form-line" id="id_1"><div id="cid_1" class="form-input-wide"> <img alt="" class="form-image" border="0" src="https://w2.chabad.org/media/images/1045/TIkp10456675.jpg" height="259.35" width="665" /> </div></li><li class="form-line" id="id_3"><div id="cid_3" class="form-input-wide"> <img alt="" class="form-image" border="0" src="https://w2.chabad.org/media/images/1045/wyxb10456677.jpg" height="63" width="213" /> </div></li><li class="form-line" id="id_4"><div id="cid_4" class="form-input-wide"> <div id="text_4" class="form-html"><p>It is written in the Kabbalah that Matzah is a Superfood. When you eat <b>specifically the hand made Shmurah Matzah </b> on the first night of Passover it gives us greater faith in G-d. When we eat it on the second night of Passover, it is a blessing for health. </p>

<p dir="auto"><i>Friends make sure their friends have hand made Matzah. </i></p>

<p dir="auto">So please send a package to your friend. Even better...come pick up a bunch of boxes and give the ultimate Passover gift. </p>

<p dir="auto">Share the gift of faith and health! Be an Ambassador of Freedom!</p>

<p>Help us reach 800 households.</p>

<p>The cost is $15 for each gift box</p>

<p>Your donation will help us reach our goal</p>
</div> </div></li><li class="form-line" id="id_5"><div class="form-label-left" id="label_5"><label for="input_5"> Count me in for: </label><label class="label-message" for="input_5"> </label></div><div id="cid_5" class="form-input"> <div class="form-multiple-column"><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_5_0" name="q5_input5[]" value="$1800=120" /><label id="label_input_5_0" for="input_5_0"><span>$1800=120</span></label></span><span class="clearfix"></span><span class="form-checkbox-item"><input type="checkbox" class="form-checkbox" id="input_5_1" name="q5_input5[]" value="$1080=72" /><label id="label_input_5_1" for="input_5_1"><span>$1080=72</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_5_2" name="q5_input5[]" value="$540-36" /><label id="label_input_5_2" for="input_5_2"><span>$540-36</span></label></span><span 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class="form-checkbox-other-input form-textbox undefined" name="q5_input5[other][text]" data-otherhint="Other" size="15" id="input_5" disabled="disabled" /></span><br /></span></div> </div></li><li class="form-line" id="id_14"><div class="form-label-left" id="label_14"><label for="input_14"> Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_14"> </label></div><div id="cid_14" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q14_fullName14[first]" id="first_14" autocomplete="given-name" />  <label class="form-sub-label" for="first_14" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q14_fullName14[last]" id="last_14" autocomplete="family-name" />  <label class="form-sub-label" for="last_14" id="sublabel_last">Last Name</label></span> </div></li><li 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Payment will take place on the next page.</td></tr><tr class="other hide"><td colspan="2">Please send check to:<br />Chabad of Islip<br />49 Union Ave<br />Islip, NY 11751</td></tr></tbody></table> </div></li><li class="form-line" id="id_13"><div class="form-label-left" id="label_13"><label for="input_13"> Total </label></div><div id="cid_13" class="form-input"> <div id="total_amount">$0.00 </div><div class="form-single-column form-checkbox-item" id="div_offset_gift_13" style="padding-top: 10px">		<input type="checkbox" id="input_13" class="form-checkbox" name="q13_offsetGiftPercent" value="3" />		<label id="label_13" for="input_13">Yes, I'd like to donate the cost of processing this transaction by adding 3%</label>		<input type="hidden" id="hidden_13" name="q13_offsetGiftAmount" />		<div class="clearfix"></div>		</div> </div></li><li class="form-line" id="id_2"><div id="cid_2" class="form-input-wide"> <div style="text-align: center; text-indent:156px;" class="form-buttons-wrapper button-align-auto"><button id="input_2" type="submit" class="form-submit-button  form-submit-button-none;">Submit</button></div> </div></li><li style="display:none">Should be Empty: <input type="text" name="website" value="" /></li></ul></div><input type="hidden" id="simple_spc" name="simple_spc" value="6380063" /><script type="text/javascript">document.getElementById("si"+"mple"+"_spc").value = "6380063-6380063";</script><div>


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