document.write('<script type=\"text/javascript\" src=\"https://assets.bravenet.com/bn/js/emailfwd/bn_email_forms.min.js\"></script><link rel=\"stylesheet\" href=\"https://pub39.bravenet.com/emailfwd/v2/bnet-form.css.php?usernum=3265496703&formid=4150&formpadding=0\"><form method=\"post\" class=\"bnet-form\" enctype=\"multipart/form-data\" action=\"#bn-ajax-post:3265496703:39:4150\"><div class=\"bn-form-header\"><div class=\"bn-form-legend\"><div>Contact Chilean Mission Reunion Committee</div></div> <div class=\"bn-form-desc\"><p>Please fill out the fields below.</p></div></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">Given name(s) <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-1\" placeholder=\"your first and last name\" validator=\"\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">Surname <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-148976957248552\" placeholder=\"\" validator=\"\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">Maiden Name </span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-148976920750596\" placeholder=\"\" validator=\"\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">Your email address <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-2\" placeholder=\"you must enter a valid email address\" validator=\"email\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">Your phone number <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-148973230350065\" placeholder=\"xxx-xxx-xxxx\" validator=\"\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">Complete mailing address (including city, state, Zip/postal code, and country <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-148973315922342\" placeholder=\"\" validator=\"\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><div class=\"bn-row rowcb\"><span class=\"bn-label\">Were you an LDS missionary or LDS member in Chile? (mark all that apply) <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-148977070877474[]\" value=\"LDS missionary in Chile 1975 or earlier\" required=\"required\"> LDS missionary in Chile 1975 or earlier</label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-148977070877474[]\" value=\"LDS missionary in Chile after 1975\" required=\"required\"> LDS missionary in Chile after 1975</label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-148977070877474[]\" value=\"LDS member in Chile 1975 or earlier\" required=\"required\"> LDS member in Chile 1975 or earlier</label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-148977070877474[]\" value=\"LDS member in Chile after 1975\" required=\"required\"> LDS member in Chile after 1975</label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-148977070877474[]\" value=\"Non-LDS resident in Chile 1975 or earlier\" required=\"required\"> Non-LDS resident in Chile 1975 or earlier</label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-148977070877474[]\" value=\"Non-LDS resident in Chile after 1975\" required=\"required\"> Non-LDS resident in Chile after 1975</label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-148977070877474[]\" value=\"Never been in Chile\" required=\"required\"> Never been in Chile</label></span></span></div></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">When did you serve or live in Chile? <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-1489768865252109\" placeholder=\"\" validator=\"\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">Comments <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><textarea name=\"Field-3\" placeholder=\"enter your comments here\" validator=\"\" required=\"required\"></textarea></span></label></div>  <input type=\"hidden\" name=\"carboncopy\" value=\"gvdavis@comcast.net,gvdavis@byu.net,chileanmission@yahoo.com,chileanmission@gmail.com,gordonirv48@gmail.com,x4nservice@hotmail.com,joe@jmtmlt.com,sivasparachile@msn.com,ttyler4434@gmail.com\"> <input type=\"hidden\" name=\"thankyou\" value=\"http://www.chileanmission.org\"> <input type=\"hidden\" name=\"thankyoutext\" value=\"\"> <input type=\"hidden\" name=\"subject\" value=\"Message for Chilean Mission Reunion Committee\"><div class=\"bn-form-submit\"><button type=\"submit\" class=\"formbtn\">Submit Form</button></div> <style type=\"text/css\">.bnet-form ::-webkit-input-placeholder {');
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