{"id":7,"date":"2023-03-13T17:09:28","date_gmt":"2023-03-13T17:09:28","guid":{"rendered":"https:\/\/orderform.weborderscys.com\/?page_id=7"},"modified":"2023-03-13T20:34:01","modified_gmt":"2023-03-13T20:34:01","slug":"order-form","status":"publish","type":"page","link":"https:\/\/orderform.weborderscys.com\/","title":{"rendered":"Order Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"7\" class=\"elementor elementor-7\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-1eed613 elementor-section-stretched elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"1eed613\" data-element_type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;,&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-a07e96c\" data-id=\"a07e96c\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-25adfd3 elementor-widget elementor-widget-image\" data-id=\"25adfd3\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.21.0 - 25-04-2024 *\/\n.elementor-widget-image{text-align:center}.elementor-widget-image a{display:inline-block}.elementor-widget-image a img[src$=\".svg\"]{width:48px}.elementor-widget-image img{vertical-align:middle;display:inline-block}<\/style>\t\t\t\t\t\t\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" width=\"800\" height=\"691\" src=\"https:\/\/orderform.weborderscys.com\/wp-content\/uploads\/2023\/03\/cys-logo-png-1024x884.png\" class=\"attachment-large size-large wp-image-10\" alt=\"\" srcset=\"https:\/\/orderform.weborderscys.com\/wp-content\/uploads\/2023\/03\/cys-logo-png-1024x884.png 1024w, https:\/\/orderform.weborderscys.com\/wp-content\/uploads\/2023\/03\/cys-logo-png-300x259.png 300w, https:\/\/orderform.weborderscys.com\/wp-content\/uploads\/2023\/03\/cys-logo-png-768x663.png 768w, https:\/\/orderform.weborderscys.com\/wp-content\/uploads\/2023\/03\/cys-logo-png-1536x1326.png 1536w, https:\/\/orderform.weborderscys.com\/wp-content\/uploads\/2023\/03\/cys-logo-png-2048x1768.png 2048w\" sizes=\"(max-width: 800px) 100vw, 800px\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-f857daf elementor-section-stretched elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"f857daf\" data-element_type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;,&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-36f5493\" data-id=\"36f5493\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-45e0420 elementor-widget elementor-widget-wpforms\" data-id=\"45e0420\" data-element_type=\"widget\" data-widget_type=\"wpforms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-19\"><form id=\"wpforms-form-19\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"19\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/7\" data-token=\"d14f12aca1afb860ff43016b8228f66a\" data-token-time=\"1776422021\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-19-field_2-container\" class=\"wpforms-field wpforms-field-name wpforms-one-half wpforms-first\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-19-field_2\">Customer Name  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-19-field_2\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][2]\" placeholder=\"Customer Name \" required><\/div><div id=\"wpforms-19-field_4-container\" class=\"wpforms-field wpforms-field-number wpforms-one-half\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-19-field_4\">Customer Phone Number <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" id=\"wpforms-19-field_4\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][4]\" placeholder=\"Phone Number\" required><\/div><div id=\"wpforms-19-field_5-container\" class=\"wpforms-field wpforms-field-email wpforms-one-half wpforms-first\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-19-field_5\"> Customer Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-19-field_5\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][5]\" placeholder=\" Customer Email\" spellcheck=\"false\" required><\/div><div id=\"wpforms-19-field_31-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-19-field_31\">Customer Date of Birth <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-19-field_31\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][31]\" placeholder=\"10-jan-1990\" required><\/div><div id=\"wpforms-19-field_8-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-19-field_8\">Last 4 digit of your Social Security Number <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" id=\"wpforms-19-field_8\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][8]\" placeholder=\"0000\" required><\/div><div id=\"wpforms-19-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-19-field_9\">  Service Address<\/label><input type=\"text\" id=\"wpforms-19-field_9\" class=\"wpforms-field-large\" name=\"wpforms[fields][9]\" ><\/div><div id=\"wpforms-19-field_10-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-19-field_10\">Street Address: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-19-field_10\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][10]\" placeholder=\"Street Address\" required><\/div><div id=\"wpforms-19-field_11-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-19-field_11\">City: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-19-field_11\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][11]\" placeholder=\"City\" required><\/div><div id=\"wpforms-19-field_13-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-19-field_13\">State \/ Province: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-19-field_13\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][13]\" placeholder=\"State \/ Province\" required><\/div><div id=\"wpforms-19-field_16-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-19-field_16\">Postal \/ Zip Code: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" id=\"wpforms-19-field_16\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][16]\" placeholder=\"Postal \/ Zip Code\" required><\/div><div id=\"wpforms-19-field_17-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-19-field_17\">Previous Address (If you lived less than 2 years at current address)<\/label><input type=\"text\" id=\"wpforms-19-field_17\" class=\"wpforms-field-large\" name=\"wpforms[fields][17]\" ><\/div><div id=\"wpforms-19-field_18-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-19-field_18\">Street Address:<\/label><input type=\"text\" id=\"wpforms-19-field_18\" class=\"wpforms-field-large\" name=\"wpforms[fields][18]\" placeholder=\"Street Address\" ><\/div><div id=\"wpforms-19-field_19-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-19-field_19\">City:<\/label><input type=\"text\" id=\"wpforms-19-field_19\" class=\"wpforms-field-large\" name=\"wpforms[fields][19]\" placeholder=\"City\" ><\/div><div id=\"wpforms-19-field_28-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-19-field_28\">State \/ Province:<\/label><input type=\"text\" id=\"wpforms-19-field_28\" class=\"wpforms-field-large\" name=\"wpforms[fields][28]\" placeholder=\"State \/ Province\" ><\/div><div id=\"wpforms-19-field_27-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-19-field_27\">Postal \/ Zip Code: (copy)<\/label><input type=\"text\" id=\"wpforms-19-field_27\" class=\"wpforms-field-large\" name=\"wpforms[fields][27]\" placeholder=\"Postal \/ Zip Code\" ><\/div><div id=\"wpforms-19-field_22-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-19-field_22\">Please select which option best describes your household income  <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-19-field_22\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-19-field_22_1\" name=\"wpforms[fields][22][]\" value=\"Under $1000 per month\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-19-field_22_1\">Under $1000 per month<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-19-field_22_3\" name=\"wpforms[fields][22][]\" value=\"more than $1000\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-19-field_22_3\">more than $1000<\/label><\/li><\/ul><\/div><div id=\"wpforms-19-field_29-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-19-field_29\">Please, select the state or federal program&#039;s you participate in: <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-19-field_29\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-19-field_29_1\" name=\"wpforms[fields][29][]\" value=\"Supplemental Nutrition Assistance (SNAP\/Food Stamps)                      \" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-19-field_29_1\">Supplemental Nutrition Assistance (SNAP\/Food Stamps)<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-19-field_29_2\" name=\"wpforms[fields][29][]\" value=\"Medicaid                     \" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-19-field_29_2\">Medicaid<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-19-field_29_3\" name=\"wpforms[fields][29][]\" value=\"Social Security (SSI)                     \" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-19-field_29_3\">Social Security (SSI)<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-19-field_29_4\" name=\"wpforms[fields][29][]\" value=\"Section 8 Housing\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-19-field_29_4\">Section 8 Housing<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-19-field_29_5\" name=\"wpforms[fields][29][]\" value=\"(Veterans Pension and Survivors Benefit Program)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-19-field_29_5\">(Veterans Pension and Survivors Benefit Program)<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-19-field_29_6\" name=\"wpforms[fields][29][]\" value=\"(WIC) supplemental nutrition program for woman and infants, children\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-19-field_29_6\">(WIC) supplemental nutrition program for woman and infants, children<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-19-field_29_7\" name=\"wpforms[fields][29][]\" value=\"Free School Lunch\/Breakfast program\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-19-field_29_7\">Free School Lunch\/Breakfast program<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-19-field_29_8\" name=\"wpforms[fields][29][]\" value=\"Federal Pell Grant Program\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-19-field_29_8\">Federal Pell Grant Program<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-19-field_29_9\" name=\"wpforms[fields][29][]\" value=\"None of the above\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-19-field_29_9\">None of the above<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-19-field_29_10\" name=\"wpforms[fields][29][]\" value=\"Other\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-19-field_29_10\">Other<\/label><\/li><\/ul><\/div><div id=\"wpforms-19-field_30-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"30\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-19-field_30\">Other<\/label><input type=\"text\" id=\"wpforms-19-field_30\" class=\"wpforms-field-large\" name=\"wpforms[fields][30]\" ><\/div><div id=\"wpforms-19-field_23-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-19-field_23\">How many adults live in your household? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-19-field_23\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][23]\" required><\/div><div id=\"wpforms-19-field_25-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-modern\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-19-field_25\"> Do you reside on Federally-recognized tribal lands? <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-19-field_25\" class=\"wpforms-field-large wpforms-field-required choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-large\" data-search-enabled=\"\" name=\"wpforms[fields][25]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled >NO<\/option><option value=\"NO\"  selected='selected'>NO<\/option><option value=\"YES\" >YES<\/option><\/select><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"19\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/orderform.weborderscys.com\/index.php\/wp-json\/wp\/v2\/pages\/7\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-19\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img decoding=\"async\" src=\"https:\/\/orderform.weborderscys.com\/wp-content\/plugins\/wpforms-lite\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_canvas","meta":{"footnotes":""},"_links":{"self":[{"href":"https:\/\/orderform.weborderscys.com\/index.php\/wp-json\/wp\/v2\/pages\/7"}],"collection":[{"href":"https:\/\/orderform.weborderscys.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/orderform.weborderscys.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/orderform.weborderscys.com\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/orderform.weborderscys.com\/index.php\/wp-json\/wp\/v2\/comments?post=7"}],"version-history":[{"count":16,"href":"https:\/\/orderform.weborderscys.com\/index.php\/wp-json\/wp\/v2\/pages\/7\/revisions"}],"predecessor-version":[{"id":81,"href":"https:\/\/orderform.weborderscys.com\/index.php\/wp-json\/wp\/v2\/pages\/7\/revisions\/81"}],"wp:attachment":[{"href":"https:\/\/orderform.weborderscys.com\/index.php\/wp-json\/wp\/v2\/media?parent=7"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}