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=3271421378&formid=4169&formpadding=0\"><form method=\"post\" class=\"bnet-form\" enctype=\"multipart/form-data\" action=\"#bn-ajax-post:3271421378:39:4169\"><div class=\"bn-form-header\"><div class=\"bn-form-legend\"><div>Subscription Request Form (Grade 11)</div></div> </div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">First Name: <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-1\" placeholder=\"your first name\" validator=\"\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">Last Name: <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-1498026095754107\" placeholder=\"your last name\" validator=\"\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">Email ID: <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\">City: </span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-149802629924978\" placeholder=\"\" validator=\"\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">Country: </span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-149802630339357\" placeholder=\"\" validator=\"\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">Phone: </span> <span class=\"bn-input\"><input type=\"text\" name=\"Field-149802639541067\" placeholder=\"optional\" validator=\"\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><div class=\"bn-row\"><span class=\"bn-label\">I am a </span> <span class=\"bn-input\"><span class=\"bn-select\"><select name=\"Field-149802654511317[]\"><option value=\"Student\" selected=\"selected\">Student</option><option value=\"Parent\">Parent</option><option value=\"Teacher\">Teacher</option></select></span></span></div></div><div class=\"fields-wrapper ui-sortable-handle\"><div class=\"bn-row rowcb\"><span class=\"bn-label\">Select your Package(s): <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-149802682748893[]\" value=\"P11A: Comprehension/Reading - INR 1,000.00\" required=\"required\"> <span class=\"bn-inner-label\">P11A: Comprehension/Reading - INR 1,000.00</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-149802682748893[]\" value=\"P11B: Writing Skills / Compositions - INR 1,500.00\" required=\"required\"> <span class=\"bn-inner-label\">P11B: Writing Skills / Compositions - INR 1,500.00</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-149802682748893[]\" value=\"P11C: Applied Grammar - INR 2,000.00\" required=\"required\"> <span class=\"bn-inner-label\">P11C: Applied Grammar - INR 2,000.00</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-149802682748893[]\" value=\"P11D: Literature - INR 2,000.00\" required=\"required\"> <span class=\"bn-inner-label\">P11D: Literature - INR 2,000.00</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-149802682748893[]\" value=\"P11E : Extra Worksheets - INR 2,000.00\" required=\"required\"> <span class=\"bn-inner-label\">P11E : Extra Worksheets - INR 2,000.00</span></label></span></span></div></div><div class=\"fields-wrapper ui-sortable-handle\"><div class=\"bn-row rowcb\"><span class=\"bn-label\">I\'ll pay by <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-149802722697765[]\" value=\"Bank Transfer / Netbanking\" required=\"required\"> <span class=\"bn-inner-label\">Bank Transfer / Netbanking</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-149802722697765[]\" value=\"Credit Card (in US$ only)\" required=\"required\"> <span class=\"bn-inner-label\">Credit Card (in US$ only)</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-149802722697765[]\" value=\"Paypal (in US$ only)\" required=\"required\"> <span class=\"bn-inner-label\">Paypal (in US$ only)</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-149802722697765[]\" value=\"Bank Cheque (this option is available only to subscribers in India)\" required=\"required\"> <span class=\"bn-inner-label\">Bank Cheque (this option is available only to subscribers in India)</span></label></span></span></div></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">Additional queries (if any): </span> <span class=\"bn-input\"><textarea name=\"Field-3\" placeholder=\"jot down any queries/concerns that you may have\" validator=\"\"></textarea></span></label></div>  <input type=\"hidden\" name=\"carboncopy\" value=\"\"> <input type=\"hidden\" name=\"thankyou\" value=\"\"> <input type=\"hidden\" name=\"thankyoutext\" value=\"\"> <input type=\"hidden\" name=\"subject\" value=\"Subscription Request P11\"><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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