{"id":5144,"date":"2021-01-08T06:41:39","date_gmt":"2021-01-08T06:41:39","guid":{"rendered":"http:\/\/cfpcstate.iseo.biz\/?page_id=5144"},"modified":"2021-03-16T07:35:24","modified_gmt":"2021-03-16T07:35:24","slug":"request-for-emergency-transfer-of-entry-permit","status":"publish","type":"page","link":"https:\/\/commercialfishingpermits.us\/state\/alaska\/transfer-forms\/request-for-emergency-transfer-of-entry-permit\/","title":{"rendered":"Request for Emergency Transfer of Entry Permit"},"content":{"rendered":"<p><p class=\"mt-25\">This form is for an Emergency Transfer of Entry Permit Request.<\/p><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_270' style='display:none'>\n                        <div class='gform_heading'>\n                            <p class='gform_description'>A brief description of the form or Application to be filled out here.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_270'  action='\/state\/wp-json\/wp\/v2\/pages\/5144' data-formid='270' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_270' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_270_1\" class=\"gfield gfield--type-text vessel-name gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_1'>Vessel Name<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_1' id='input_270_1' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_39\" class=\"gfield gfield--type-checkbox gfield--type-choice vessel-use gf_right_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Vessel Use \/ Endorsement<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_270_39'><li class='checkbox gchoice gchoice_270_39_1'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_39.1' type='checkbox'  value='Pleasure'  id='choice_270_39_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_39_1' id='label_270_39_1' class='gform-field-label gform-field-label--type-inline'>Pleasure<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_39_2'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_39.2' type='checkbox'  value='Commercial'  id='choice_270_39_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_39_2' id='label_270_39_2' class='gform-field-label gform-field-label--type-inline'>Commercial<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_9\" class=\"gfield gfield--type-text gf_left_half official-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_9'>Official Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_9' id='input_270_9' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_17\" class=\"gfield gfield--type-text gf_right_half official-number-confirm gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_17'>Confirm Official Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_17' id='input_270_17' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_10\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Please allow up to 2 weeks for processing.<\/h2><div class='gsection_description' id='gfield_description_270_10'>Please complete all sections of this form and submit with the $50.00 transfer processing fee, the current year permit card (if it has been issued) and a copy of the \u201ctransfer agreement\u201d or \u201cbill of sale\u201d outlining all terms and conditions of this transfer as required by CFEC regulation 20 AAC 05.1712(c). If any of the information is not submitted, or if the form is incomplete, there will be delays in processing the request. <\/div><\/li><li id=\"field_270_48\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">PERMIT HOLDER INFORMATION<\/h2><div class='gsection_description' id='gfield_description_270_48'>Must be completed by the current permit holder<\/div><\/li><li id=\"field_270_132\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_132'>Name<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_132' id='input_270_132' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_41\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_41'>Permit Number<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_41' id='input_270_41' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_133\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_133'>CFEC ID Number<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_133' id='input_270_133' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_42\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_42'>Social Security Number<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_42' id='input_270_42' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_43\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_43'>Date of Birth<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_43' id='input_270_43' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_44\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Permanent Mailing Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_270_44' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_270_44_1_container' >\n                                        <input class='form-control' type='text' name='input_44.1' id='input_270_44_1' value=''    aria-required='false'    \/>\n                                        <label for='input_270_44_1' id='input_270_44_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_270_44_2_container' >\n                                        <input class='form-control' type='text' name='input_44.2' id='input_270_44_2' value=''     aria-required='false'   \/>\n                                        <label for='input_270_44_2' id='input_270_44_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_270_44_3_container' >\n                                    <input class='form-control' type='text' name='input_44.3' id='input_270_44_3' value=''    aria-required='false'    \/>\n                                    <label for='input_270_44_3' id='input_270_44_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_270_44_4_container' >\n                                        <input class='form-control' type='text' name='input_44.4' id='input_270_44_4' value=''      aria-required='false'    \/>\n                                        <label for='input_270_44_4' id='input_270_44_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_270_44_5_container' >\n                                    <input class='form-control' type='text' name='input_44.5' id='input_270_44_5' value=''    aria-required='false'    \/>\n                                    <label for='input_270_44_5' id='input_270_44_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_270_44_6_container' >\n                                        <select class='form-control' class='form-control' name='input_44.6' id='input_270_44_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_270_44_6' id='input_270_44_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_270_45\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_45'>Phone<\/label><div class='ginput_container ginput_container_phone'><input class='form-control' name='input_45' id='input_270_45' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_46\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_270_46'><li class='checkbox gchoice gchoice_270_46_1'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_46.1' type='checkbox'  value='Check1'  id='choice_270_46_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_46_1' id='label_270_46_1' class='gform-field-label gform-field-label--type-inline'>Check if unlisted<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_47\" class=\"gfield gfield--type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_47'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input class='form-control' name='input_47' id='input_270_47' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_270_64\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">PERMIT RENEWAL INFORMATION:<\/h2><div class='gsection_description' id='gfield_description_270_64'>If this permit has already been renewed for the year, you may skip the following questions about residency. Please carefully review the following definition of residency: \"For the purpose of assessing fees for the application for, annual issuance of, or renewal of entry and interim-use permits, an individual is a resident of this state if, on the date of permit application, issuance, or renewal, and throughout the 12-month period before that date, that individual maintained their domicile in this state and neither claimed residency in another state, territory, or country nor obtained benefits under a claim of residency in another state, territory, or country.\"  20 AAC 05.290.<\/div><\/li><li id=\"field_270_134\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Do you qualify as an Alaska resident under this definition?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_270_134'><li class='checkbox gchoice gchoice_270_134_1'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_134.1' type='checkbox'  value='Yes'  id='choice_270_134_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_134_1' id='label_270_134_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_134_2'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_134.2' type='checkbox'  value='No'  id='choice_270_134_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_134_2' id='label_270_134_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_135\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >1. What is your current physical address? (no PO boxes)<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_270_135' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_270_135_1_container' >\n                                        <input class='form-control' type='text' name='input_135.1' id='input_270_135_1' value=''    aria-required='false'    \/>\n                                        <label for='input_270_135_1' id='input_270_135_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_270_135_2_container' >\n                                        <input class='form-control' type='text' name='input_135.2' id='input_270_135_2' value=''     aria-required='false'   \/>\n                                        <label for='input_270_135_2' id='input_270_135_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_270_135_3_container' >\n                                    <input class='form-control' type='text' name='input_135.3' id='input_270_135_3' value=''    aria-required='false'    \/>\n                                    <label for='input_270_135_3' id='input_270_135_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_270_135_4_container' >\n                                        <input class='form-control' type='text' name='input_135.4' id='input_270_135_4' value=''      aria-required='false'    \/>\n                                        <label for='input_270_135_4' id='input_270_135_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_270_135_5_container' >\n                                    <input class='form-control' type='text' name='input_135.5' id='input_270_135_5' value=''    aria-required='false'    \/>\n                                    <label for='input_270_135_5' id='input_270_135_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_270_135_6_container' >\n                                        <select class='form-control' class='form-control' name='input_135.6' id='input_270_135_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_270_135_6' id='input_270_135_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_270_68\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >2. Within the previous 365 days, have you resided anywhere else?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_270_68'><li class='checkbox gchoice gchoice_270_68_1'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_68.1' type='checkbox'  value='Check11'  id='choice_270_68_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_68_1' id='label_270_68_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_68_2'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_68.2' type='checkbox'  value='Check12'  id='choice_270_68_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_68_2' id='label_270_68_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_70\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_70'>If yes, where?<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_70' id='input_270_70' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_71\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >3. Do you have a current Alaska driver&#039;s license or other Alaska ID?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_270_71'><li class='checkbox gchoice gchoice_270_71_1'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_71.1' type='checkbox'  value='Check13'  id='choice_270_71_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_71_1' id='label_270_71_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_71_2'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_71.2' type='checkbox'  value='Check14'  id='choice_270_71_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_71_2' id='label_270_71_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_72\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_72'>If yes, provide number:<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_72' id='input_270_72' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_73\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >4. Are you registered to vote in Alaska?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_270_73'><li class='checkbox gchoice gchoice_270_73_1'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_73.1' type='checkbox'  value='Check15'  id='choice_270_73_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_73_1' id='label_270_73_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_73_2'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_73.2' type='checkbox'  value='Check16'  id='choice_270_73_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_73_2' id='label_270_73_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_74\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_74'>**NOTE: If you answered &#039;no&#039; to question 3 or 4, please provide a brief explanation of why you qualify as an Alaska resident<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_74' id='input_270_74' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_49\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">PROPOSED TRANSFEREE INFORMATION<\/h2><div class='gsection_description' id='gfield_description_270_49'>Must be Completed by the Proposed Transferee<\/div><\/li><li id=\"field_270_50\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_270_50'>\n                            \n                            <span id='input_270_50_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input class='form-control' type='text' name='input_50.3' id='input_270_50_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_270_50_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_270_50_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input class='form-control' type='text' name='input_50.4' id='input_270_50_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_270_50_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_270_50_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input class='form-control' type='text' name='input_50.6' id='input_270_50_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_270_50_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_270_51\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_51'>Social Security Number<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_51' id='input_270_51' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_52\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_52'>Date of Birth<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_52' id='input_270_52' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_53\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_53'>ADFG Number<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_53' id='input_270_53' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_54\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Permanent Mailing Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_270_54' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_270_54_1_container' >\n                                        <input class='form-control' type='text' name='input_54.1' id='input_270_54_1' value=''    aria-required='false'    \/>\n                                        <label for='input_270_54_1' id='input_270_54_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_270_54_2_container' >\n                                        <input class='form-control' type='text' name='input_54.2' id='input_270_54_2' value=''     aria-required='false'   \/>\n                                        <label for='input_270_54_2' id='input_270_54_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_270_54_3_container' >\n                                    <input class='form-control' type='text' name='input_54.3' id='input_270_54_3' value=''    aria-required='false'    \/>\n                                    <label for='input_270_54_3' id='input_270_54_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_270_54_4_container' >\n                                        <input class='form-control' type='text' name='input_54.4' id='input_270_54_4' value=''      aria-required='false'    \/>\n                                        <label for='input_270_54_4' id='input_270_54_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_270_54_5_container' >\n                                    <input class='form-control' type='text' name='input_54.5' id='input_270_54_5' value=''    aria-required='false'    \/>\n                                    <label for='input_270_54_5' id='input_270_54_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_270_54_6_container' >\n                                        <select class='form-control' class='form-control' name='input_54.6' id='input_270_54_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_270_54_6' id='input_270_54_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_270_55\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Temporary Mailing Address (for mailing of this permit)<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_270_55' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_270_55_1_container' >\n                                        <input class='form-control' type='text' name='input_55.1' id='input_270_55_1' value=''    aria-required='false'    \/>\n                                        <label for='input_270_55_1' id='input_270_55_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_270_55_2_container' >\n                                        <input class='form-control' type='text' name='input_55.2' id='input_270_55_2' value=''     aria-required='false'   \/>\n                                        <label for='input_270_55_2' id='input_270_55_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_270_55_3_container' >\n                                    <input class='form-control' type='text' name='input_55.3' id='input_270_55_3' value=''    aria-required='false'    \/>\n                                    <label for='input_270_55_3' id='input_270_55_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_270_55_4_container' >\n                                        <input class='form-control' type='text' name='input_55.4' id='input_270_55_4' value=''      aria-required='false'    \/>\n                                        <label for='input_270_55_4' id='input_270_55_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_270_55_5_container' >\n                                    <input class='form-control' type='text' name='input_55.5' id='input_270_55_5' value=''    aria-required='false'    \/>\n                                    <label for='input_270_55_5' id='input_270_55_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_270_55_6_container' >\n                                        <select class='form-control' class='form-control' name='input_55.6' id='input_270_55_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_270_55_6' id='input_270_55_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_270_56\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_56'>Phone Number<\/label><div class='ginput_container ginput_container_phone'><input class='form-control' name='input_56' id='input_270_56' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_57\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_270_57'><li class='checkbox gchoice gchoice_270_57_1'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_57.1' type='checkbox'  value='Check2'  id='choice_270_57_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_57_1' id='label_270_57_1' class='gform-field-label gform-field-label--type-inline'>Check if unlisted<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_58\" class=\"gfield gfield--type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_58'>Email Address<\/label><div class='ginput_container ginput_container_email'>\n                            <input class='form-control' name='input_58' id='input_270_58' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_270_69\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Citizenship<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_270_69'><li class='checkbox gchoice gchoice_270_69_1'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_69.1' type='checkbox'  value='Check3'  id='choice_270_69_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_69_1' id='label_270_69_1' class='gform-field-label gform-field-label--type-inline'>U.S. Citizen<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_69_2'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_69.2' type='checkbox'  value='Check4'  id='choice_270_69_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_69_2' id='label_270_69_2' class='gform-field-label gform-field-label--type-inline'>Alien<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_60\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_60'>Alien Reg#<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_60' id='input_270_60' type='text' value='' class='medium'  aria-describedby=\"gfield_description_270_60\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_270_60'>(Aliens must enclose copy of green card)<\/div><\/li><li id=\"field_270_16\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">REQUIRED EMERGENCY TRANSFER INFORMATION: MUST BE FILLED OUT BY PERMIT HOLDER<\/h2><\/li><li id=\"field_270_136\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >1. Is this request due to an illness, injury, or other unavoidable hardship that began, or death that occurred, within the last 14 days? (If no, please proceed to question #2)<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_270_136'><li class='checkbox gchoice gchoice_270_136_1'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_136.1' type='checkbox'  value='Yes'  id='choice_270_136_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_136_1' id='label_270_136_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_136_2'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_136.2' type='checkbox'  value='No'  id='choice_270_136_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_136_2' id='label_270_136_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_137\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_137'>If yes, please explain how the incident occurred.  Please also indicate when the fishery involved is expected to open.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_137' id='input_270_137' class='form-control textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_270_138\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >2. Is your permit a nontransferable permit? (If your permit is transferable, please proceed to question #3).<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_270_138'><li class='checkbox gchoice gchoice_270_138_1'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_138.1' type='checkbox'  value='First Choice'  id='choice_270_138_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_138_1' id='label_270_138_1' class='gform-field-label gform-field-label--type-inline'>First Choice<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_138_2'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_138.2' type='checkbox'  value='Second Choice'  id='choice_270_138_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_138_2' id='label_270_138_2' class='gform-field-label gform-field-label--type-inline'>Second Choice<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_138_3'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_138.3' type='checkbox'  value='Third Choice'  id='choice_270_138_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_138_3' id='label_270_138_3' class='gform-field-label gform-field-label--type-inline'>Third Choice<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_139\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_139'>If your permit is &#039;nontransferable&#039;, how would a transfer help to &#039;continue&#039; your fishing operation?  For example, whose vessel, gear, setnet site, or dive operation will be used if the transfer is granted?  Will former crew members remain engaged in the operation if the transfer is granted?  Please explain.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_139' id='input_270_139' class='form-control textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_270_140\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >3. Is the transfer request due to a physical limitation such as an injury or illness?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_270_140'><li class='checkbox gchoice gchoice_270_140_1'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_140.1' type='checkbox'  value='Yes'  id='choice_270_140_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_140_1' id='label_270_140_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_140_2'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_140.2' type='checkbox'  value='No'  id='choice_270_140_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_140_2' id='label_270_140_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_141\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_141'>If yes, when did the injury\/illness first occur?  Please explain how your current physical condition prevents you from being able to participate in the upcoming fishing season.  If you are dealing with multiple injuries or illnesses, please mention and describe all conditions that currently prevent you from fishing.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_141' id='input_270_141' class='form-control textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_270_142\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_142'>If no, please describe your unavoidable hardship.  Please specifically explain how the hardship prevents you from being able to participate in the upcoming fishing season.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_142' id='input_270_142' class='form-control textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_270_143\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >4. Did your illness\/injury\/hardship also prevent you from participating in the fishery in a previous fishing season?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_270_143'><li class='checkbox gchoice gchoice_270_143_1'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_143.1' type='checkbox'  value='Yes'  id='choice_270_143_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_143_1' id='label_270_143_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_143_2'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_143.2' type='checkbox'  value='No'  id='choice_270_143_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_143_2' id='label_270_143_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_144\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_144'>If yes, in which years?  Has the nature of the illness\/injury\/hardship changed or worsened over the years?  Please describe what, if any, steps you have taken to overcome the situation or manage the problem.  Please be specific.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_144' id='input_270_144' class='form-control textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_270_145\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >5.   At any point in the preceding 365 days did you intend to participate in the upcoming season?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_270_145'><li class='checkbox gchoice gchoice_270_145_1'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_145.1' type='checkbox'  value='Yes'  id='choice_270_145_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_145_1' id='label_270_145_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_145_2'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_145.2' type='checkbox'  value='No'  id='choice_270_145_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_145_2' id='label_270_145_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_146\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_146'>If yes, please describe the nature of your intention and what, if any, preparations you made to participate in the upcoming fishing season. Please be as specific as possible.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_146' id='input_270_146' class='form-control textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_270_147\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_147'>If no, what is your long-term plan for this fishing permit? If you intend to participate in future seasons, please describe your plan to return to the fishery and any efforts you have made towards that goal. Please be specific.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_147' id='input_270_147' class='form-control textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_270_148\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >6. Have you participated in any commercial fishery (in Alaska or other state) in the preceding 365 days?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_270_148'><li class='checkbox gchoice gchoice_270_148_1'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_148.1' type='checkbox'  value='Yes'  id='choice_270_148_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_148_1' id='label_270_148_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_148_2'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_148.2' type='checkbox'  value='No'  id='choice_270_148_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_148_2' id='label_270_148_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_149\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_149'>If yes, please name the fishery (or fisheries) and describe the nature of your involvement, including any physical labor that was performed.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_149' id='input_270_149' class='form-control textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_270_150\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_150'>If no, when was the last time you participated in a commercial fishery (in Alaska or any other state)? Please name the fishery and describe the nature of your involvement. During your absence from commercial fishing have you worked other jobs? If yes, please describe the nature of work performed at the job(s).<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_150' id='input_270_150' class='form-control textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_270_151\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >7. Will you be working at another job during the upcoming fishing season?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_270_151'><li class='checkbox gchoice gchoice_270_151_1'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_151.1' type='checkbox'  value='Yes'  id='choice_270_151_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_151_1' id='label_270_151_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_151_2'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_151.2' type='checkbox'  value='No'  id='choice_270_151_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_151_2' id='label_270_151_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_152\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_152'>If yes, where will you be working? Please provide name and address of employer. Please describe the nature of the work, including any physical labor to be performed.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_152' id='input_270_152' class='form-control textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_270_153\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_153'>If no, what will you be doing during the fishing season? Where will you be?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_153' id='input_270_153' class='form-control textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_270_75\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">TO BE COMPLETED BY THE PROPOSED TRANSFEREE<\/h2><\/li><li id=\"field_270_154\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >1. How did you locate this permit for emergency transfer? (select one answer)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_270_154'>\n\t\t\t<li class='radio gchoice gchoice_270_154_0'>\n\t\t\t\t<input style='margin-left:1px;' name='input_154' type='radio' value='Relative or personal friend'  id='choice_270_154_0'    \/>\n\t\t\t\t<label for='choice_270_154_0' id='label_270_154_0' class='gform-field-label gform-field-label--type-inline'>Relative or personal friend<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_154_1'>\n\t\t\t\t<input style='margin-left:1px;' name='input_154' type='radio' value='Casual acquaintance'  id='choice_270_154_1'    \/>\n\t\t\t\t<label for='choice_270_154_1' id='label_270_154_1' class='gform-field-label gform-field-label--type-inline'>Casual acquaintance<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_154_2'>\n\t\t\t\t<input style='margin-left:1px;' name='input_154' type='radio' value='Permit Broker'  id='choice_270_154_2'    \/>\n\t\t\t\t<label for='choice_270_154_2' id='label_270_154_2' class='gform-field-label gform-field-label--type-inline'>Permit Broker<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_154_3'>\n\t\t\t\t<input style='margin-left:1px;' name='input_154' type='radio' value='Fish Processor'  id='choice_270_154_3'    \/>\n\t\t\t\t<label for='choice_270_154_3' id='label_270_154_3' class='gform-field-label gform-field-label--type-inline'>Fish Processor<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_154_4'>\n\t\t\t\t<input style='margin-left:1px;' name='input_154' type='radio' value='Advertisement'  id='choice_270_154_4'    \/>\n\t\t\t\t<label for='choice_270_154_4' id='label_270_154_4' class='gform-field-label gform-field-label--type-inline'>Advertisement<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_154_5'>\n\t\t\t\t<input style='margin-left:1px;' name='input_154' type='radio' value='Other'  id='choice_270_154_5'    \/>\n\t\t\t\t<label for='choice_270_154_5' id='label_270_154_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_155\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_155'>If other, explain<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_155' id='input_270_155' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_156\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >2. What is your relationship to the permit holder?  (select one answer)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_270_156'>\n\t\t\t<li class='radio gchoice gchoice_270_156_0'>\n\t\t\t\t<input style='margin-left:1px;' name='input_156' type='radio' value='None'  id='choice_270_156_0'    \/>\n\t\t\t\t<label for='choice_270_156_0' id='label_270_156_0' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_156_1'>\n\t\t\t\t<input style='margin-left:1px;' name='input_156' type='radio' value='Business partner\/crewmember'  id='choice_270_156_1'    \/>\n\t\t\t\t<label for='choice_270_156_1' id='label_270_156_1' class='gform-field-label gform-field-label--type-inline'>Business partner\/crewmember<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_156_2'>\n\t\t\t\t<input style='margin-left:1px;' name='input_156' type='radio' value='Personal friend'  id='choice_270_156_2'    \/>\n\t\t\t\t<label for='choice_270_156_2' id='label_270_156_2' class='gform-field-label gform-field-label--type-inline'>Personal friend<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_156_3'>\n\t\t\t\t<input style='margin-left:1px;' name='input_156' type='radio' value='Member of immediate family'  id='choice_270_156_3'    \/>\n\t\t\t\t<label for='choice_270_156_3' id='label_270_156_3' class='gform-field-label gform-field-label--type-inline'>Member of immediate family<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_156_4'>\n\t\t\t\t<input style='margin-left:1px;' name='input_156' type='radio' value='Other relative'  id='choice_270_156_4'    \/>\n\t\t\t\t<label for='choice_270_156_4' id='label_270_156_4' class='gform-field-label gform-field-label--type-inline'>Other relative<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_156_5'>\n\t\t\t\t<input style='margin-left:1px;' name='input_156' type='radio' value='Other'  id='choice_270_156_5'    \/>\n\t\t\t\t<label for='choice_270_156_5' id='label_270_156_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_79\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_79'>If other, explain<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_79' id='input_270_79' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_157\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >3. Who owns the vessel or site that you will be fishing? (select one answer)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_270_157'>\n\t\t\t<li class='radio gchoice gchoice_270_157_0'>\n\t\t\t\t<input style='margin-left:1px;' name='input_157' type='radio' value='Myself'  id='choice_270_157_0'    \/>\n\t\t\t\t<label for='choice_270_157_0' id='label_270_157_0' class='gform-field-label gform-field-label--type-inline'>Myself<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_157_1'>\n\t\t\t\t<input style='margin-left:1px;' name='input_157' type='radio' value='Permit Holder'  id='choice_270_157_1'    \/>\n\t\t\t\t<label for='choice_270_157_1' id='label_270_157_1' class='gform-field-label gform-field-label--type-inline'>Permit Holder<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_157_2'>\n\t\t\t\t<input style='margin-left:1px;' name='input_157' type='radio' value='Fish Company or Processor'  id='choice_270_157_2'    \/>\n\t\t\t\t<label for='choice_270_157_2' id='label_270_157_2' class='gform-field-label gform-field-label--type-inline'>Fish Company or Processor<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_157_3'>\n\t\t\t\t<input style='margin-left:1px;' name='input_157' type='radio' value='Other'  id='choice_270_157_3'    \/>\n\t\t\t\t<label for='choice_270_157_3' id='label_270_157_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_81\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_81'>If other, explain<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_81' id='input_270_81' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_97\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class=\"gfield_label\">4. What are the agreed upon terms for the use of the permit?<\/legend><\/li><li id=\"field_270_158\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_158'>Flat fee of $ ______ paid to the permit holder<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_158' id='input_270_158' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_159\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_159'>Percentage of gross earnings, ______ %<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_159' id='input_270_159' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_86\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_86'>Combination of flat fee and percentage, the flat fee $ ______<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_86' id='input_270_86' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_87\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_87'>and a percentage _____ %<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_87' id='input_270_87' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_88\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_88'>Payment in Trade, indicate what is being traded and its estimated value:<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_88' id='input_270_88' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_89\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_89'>Value $<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_89' id='input_270_89' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_161\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >5. Are you paying a commission or fee to a broker or other agent?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_270_161'>\n\t\t\t<li class='radio gchoice gchoice_270_161_0'>\n\t\t\t\t<input style='margin-left:1px;' name='input_161' type='radio' value='No'  id='choice_270_161_0'    \/>\n\t\t\t\t<label for='choice_270_161_0' id='label_270_161_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_161_1'>\n\t\t\t\t<input style='margin-left:1px;' name='input_161' type='radio' value='Yes'  id='choice_270_161_1'    \/>\n\t\t\t\t<label for='choice_270_161_1' id='label_270_161_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_160\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_160'>If yes, indicate which firm or person is acting as broker:<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_160' id='input_270_160' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_162\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_162'>6. How much are you paying in brokers\u2019 fees or commissions?<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_162' id='input_270_162' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_163\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >7. Is there any agreement concerning future transfers of this permit?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_270_163'>\n\t\t\t<li class='radio gchoice gchoice_270_163_0'>\n\t\t\t\t<input style='margin-left:1px;' name='input_163' type='radio' value='No'  id='choice_270_163_0'    \/>\n\t\t\t\t<label for='choice_270_163_0' id='label_270_163_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_163_1'>\n\t\t\t\t<input style='margin-left:1px;' name='input_163' type='radio' value='Yes'  id='choice_270_163_1'    \/>\n\t\t\t\t<label for='choice_270_163_1' id='label_270_163_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_164\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_164'>If yes, explain<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_164' id='input_270_164' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_165\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">TO BE COMPLETED ONLY BY THE PERMIT HOLDER<\/h2><\/li><li id=\"field_270_166\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >1. Are you using the service of a broker or other agent to assist with this transfer?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_270_166'>\n\t\t\t<li class='radio gchoice gchoice_270_166_0'>\n\t\t\t\t<input style='margin-left:1px;' name='input_166' type='radio' value='No'  id='choice_270_166_0'    \/>\n\t\t\t\t<label for='choice_270_166_0' id='label_270_166_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_166_1'>\n\t\t\t\t<input style='margin-left:1px;' name='input_166' type='radio' value='Yes'  id='choice_270_166_1'    \/>\n\t\t\t\t<label for='choice_270_166_1' id='label_270_166_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_167\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_167'>If yes, which firm or person is acting as broker?<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_167' id='input_270_167' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_168\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_168'>2. How much are you paying in brokers\u2019 fees or commissions?<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_168' id='input_270_168' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_170\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >3. Who advised you to seek an emergency transfer of your permit? (select one answer)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_270_170'>\n\t\t\t<li class='radio gchoice gchoice_270_170_0'>\n\t\t\t\t<input style='margin-left:1px;' name='input_170' type='radio' value='Entry Commission staff'  id='choice_270_170_0'    \/>\n\t\t\t\t<label for='choice_270_170_0' id='label_270_170_0' class='gform-field-label gform-field-label--type-inline'>Entry Commission staff<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_170_1'>\n\t\t\t\t<input style='margin-left:1px;' name='input_170' type='radio' value='Dept. of Fish and Game staff'  id='choice_270_170_1'    \/>\n\t\t\t\t<label for='choice_270_170_1' id='label_270_170_1' class='gform-field-label gform-field-label--type-inline'>Dept. of Fish and Game staff<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_170_2'>\n\t\t\t\t<input style='margin-left:1px;' name='input_170' type='radio' value='Permit Broker'  id='choice_270_170_2'    \/>\n\t\t\t\t<label for='choice_270_170_2' id='label_270_170_2' class='gform-field-label gform-field-label--type-inline'>Permit Broker<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_170_3'>\n\t\t\t\t<input style='margin-left:1px;' name='input_170' type='radio' value='Fish Processor'  id='choice_270_170_3'    \/>\n\t\t\t\t<label for='choice_270_170_3' id='label_270_170_3' class='gform-field-label gform-field-label--type-inline'>Fish Processor<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_170_4'>\n\t\t\t\t<input style='margin-left:1px;' name='input_170' type='radio' value='Business partner\/crewmember'  id='choice_270_170_4'    \/>\n\t\t\t\t<label for='choice_270_170_4' id='label_270_170_4' class='gform-field-label gform-field-label--type-inline'>Business partner\/crewmember<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_170_5'>\n\t\t\t\t<input style='margin-left:1px;' name='input_170' type='radio' value='Myself'  id='choice_270_170_5'    \/>\n\t\t\t\t<label for='choice_270_170_5' id='label_270_170_5' class='gform-field-label gform-field-label--type-inline'>Myself<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_170_6'>\n\t\t\t\t<input style='margin-left:1px;' name='input_170' type='radio' value='Other'  id='choice_270_170_6'    \/>\n\t\t\t\t<label for='choice_270_170_6' id='label_270_170_6' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_95\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_95'>If other, specify<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_95' id='input_270_95' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_171\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >4. If you are receiving payment for the use of the permit, when is to be paid? (select one answer)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_270_171'>\n\t\t\t<li class='radio gchoice gchoice_270_171_0'>\n\t\t\t\t<input style='margin-left:1px;' name='input_171' type='radio' value='At the time of transfer'  id='choice_270_171_0'    \/>\n\t\t\t\t<label for='choice_270_171_0' id='label_270_171_0' class='gform-field-label gform-field-label--type-inline'>At the time of transfer<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_171_1'>\n\t\t\t\t<input style='margin-left:1px;' name='input_171' type='radio' value='At the end of the season'  id='choice_270_171_1'    \/>\n\t\t\t\t<label for='choice_270_171_1' id='label_270_171_1' class='gform-field-label gform-field-label--type-inline'>At the end of the season<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_171_2'>\n\t\t\t\t<input style='margin-left:1px;' name='input_171' type='radio' value='In periodic payments during the season'  id='choice_270_171_2'    \/>\n\t\t\t\t<label for='choice_270_171_2' id='label_270_171_2' class='gform-field-label gform-field-label--type-inline'>In periodic payments during the season<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_171_3'>\n\t\t\t\t<input style='margin-left:1px;' name='input_171' type='radio' value='Other'  id='choice_270_171_3'    \/>\n\t\t\t\t<label for='choice_270_171_3' id='label_270_171_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_96\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_96'>If other, explain<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_96' id='input_270_96' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_172\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >5. What is your reason for transferring this permit? (select one answer)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_270_172'>\n\t\t\t<li class='radio gchoice gchoice_270_172_0'>\n\t\t\t\t<input style='margin-left:1px;' name='input_172' type='radio' value='Injury or accident'  id='choice_270_172_0'    \/>\n\t\t\t\t<label for='choice_270_172_0' id='label_270_172_0' class='gform-field-label gform-field-label--type-inline'>Injury or accident<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_172_1'>\n\t\t\t\t<input style='margin-left:1px;' name='input_172' type='radio' value='Illness or other health problem'  id='choice_270_172_1'    \/>\n\t\t\t\t<label for='choice_270_172_1' id='label_270_172_1' class='gform-field-label gform-field-label--type-inline'>Illness or other health problem<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_172_2'>\n\t\t\t\t<input style='margin-left:1px;' name='input_172' type='radio' value='Immediate family illness or death'  id='choice_270_172_2'    \/>\n\t\t\t\t<label for='choice_270_172_2' id='label_270_172_2' class='gform-field-label gform-field-label--type-inline'>Immediate family illness or death<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_172_3'>\n\t\t\t\t<input style='margin-left:1px;' name='input_172' type='radio' value='School or Training'  id='choice_270_172_3'    \/>\n\t\t\t\t<label for='choice_270_172_3' id='label_270_172_3' class='gform-field-label gform-field-label--type-inline'>School or Training<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_172_4'>\n\t\t\t\t<input style='margin-left:1px;' name='input_172' type='radio' value='Death of permit holder'  id='choice_270_172_4'    \/>\n\t\t\t\t<label for='choice_270_172_4' id='label_270_172_4' class='gform-field-label gform-field-label--type-inline'>Death of permit holder<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_172_5'>\n\t\t\t\t<input style='margin-left:1px;' name='input_172' type='radio' value='Incarceration'  id='choice_270_172_5'    \/>\n\t\t\t\t<label for='choice_270_172_5' id='label_270_172_5' class='gform-field-label gform-field-label--type-inline'>Incarceration<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_172_6'>\n\t\t\t\t<input style='margin-left:1px;' name='input_172' type='radio' value='Pregnancy'  id='choice_270_172_6'    \/>\n\t\t\t\t<label for='choice_270_172_6' id='label_270_172_6' class='gform-field-label gform-field-label--type-inline'>Pregnancy<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_172_7'>\n\t\t\t\t<input style='margin-left:1px;' name='input_172' type='radio' value='Government\/Military service'  id='choice_270_172_7'    \/>\n\t\t\t\t<label for='choice_270_172_7' id='label_270_172_7' class='gform-field-label gform-field-label--type-inline'>Government\/Military service<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_172_8'>\n\t\t\t\t<input style='margin-left:1px;' name='input_172' type='radio' value='Financial or economic hardship'  id='choice_270_172_8'    \/>\n\t\t\t\t<label for='choice_270_172_8' id='label_270_172_8' class='gform-field-label gform-field-label--type-inline'>Financial or economic hardship<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_172_9'>\n\t\t\t\t<input style='margin-left:1px;' name='input_172' type='radio' value='Working at alternate employment'  id='choice_270_172_9'    \/>\n\t\t\t\t<label for='choice_270_172_9' id='label_270_172_9' class='gform-field-label gform-field-label--type-inline'>Working at alternate employment<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_270_172_10'>\n\t\t\t\t<input style='margin-left:1px;' name='input_172' type='radio' value='Other'  id='choice_270_172_10'    \/>\n\t\t\t\t<label for='choice_270_172_10' id='label_270_172_10' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_98\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_98'>If other, specify<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_98' id='input_270_98' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_118\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">THIS SECTION IS OPTIONAL AND IS NOT REQUIRED<\/h2><div class='gsection_description' id='gfield_description_270_118'>The section is protected by the Alaska Human Rights Law AS 18.80.255.<\/div><\/li><li id=\"field_270_119\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >What is your ethnic origin for Permit Holder: (check your answers)<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_270_119'><li class='checkbox gchoice gchoice_270_119_1'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_119.1' type='checkbox'  value='Alaska Native'  id='choice_270_119_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_119_1' id='label_270_119_1' class='gform-field-label gform-field-label--type-inline'>Alaska Native<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_119_2'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_119.2' type='checkbox'  value='Caucasian'  id='choice_270_119_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_119_2' id='label_270_119_2' class='gform-field-label gform-field-label--type-inline'>Caucasian<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_119_3'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_119.3' type='checkbox'  value='Black'  id='choice_270_119_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_119_3' id='label_270_119_3' class='gform-field-label gform-field-label--type-inline'>Black<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_119_4'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_119.4' type='checkbox'  value='Asian'  id='choice_270_119_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_119_4' id='label_270_119_4' class='gform-field-label gform-field-label--type-inline'>Asian<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_119_5'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_119.5' type='checkbox'  value='Hispanic'  id='choice_270_119_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_119_5' id='label_270_119_5' class='gform-field-label gform-field-label--type-inline'>Hispanic<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_119_6'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_119.6' type='checkbox'  value='Other'  id='choice_270_119_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_119_6' id='label_270_119_6' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_117\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_117'>If other, please share<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_117' id='input_270_117' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_121\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >What is your ethnic origin for Permit Holder: (check your answers)<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_270_121'><li class='checkbox gchoice gchoice_270_121_1'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_121.1' type='checkbox'  value='Alaska Native'  id='choice_270_121_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_121_1' id='label_270_121_1' class='gform-field-label gform-field-label--type-inline'>Alaska Native<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_121_2'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_121.2' type='checkbox'  value='Caucasian'  id='choice_270_121_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_121_2' id='label_270_121_2' class='gform-field-label gform-field-label--type-inline'>Caucasian<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_121_3'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_121.3' type='checkbox'  value='Black'  id='choice_270_121_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_121_3' id='label_270_121_3' class='gform-field-label gform-field-label--type-inline'>Black<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_121_4'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_121.4' type='checkbox'  value='Asian'  id='choice_270_121_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_121_4' id='label_270_121_4' class='gform-field-label gform-field-label--type-inline'>Asian<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_121_5'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_121.5' type='checkbox'  value='Hispanic'  id='choice_270_121_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_121_5' id='label_270_121_5' class='gform-field-label gform-field-label--type-inline'>Hispanic<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_121_6'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_121.6' type='checkbox'  value='Other'  id='choice_270_121_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_121_6' id='label_270_121_6' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_122\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_122'>If other, please share<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_122' id='input_270_122' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_173\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">REQUIRED PHYSICIAN STATEMENT:<\/h2><\/li><li id=\"field_270_99\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_99'>By signing this form, I _______(permit holder) authorize the examining physician, clinic and\/or hospital to release confidential information regarding his or her medical records to the Entry Commission.<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_99' id='input_270_99' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_174\" class=\"gfield gfield--type-signature field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_174'>Signature of permit holder<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_270_174_Container' class='gfield_signature_container ginput_container' style='height:180px; width:500px; ' ><input type='hidden' class='gform_hidden' name='input_270_174_valid' id='input_270_174_valid' \/><canvas id='input_270_174' width='500' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/commercialfishingpermits.us\/state\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_270_174_toolbar' style='margin:5px 0;position:relative;height:20px;width:500px;max-width:100%;'><img id = 'input_270_174_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_270_174_data' name='input_270_174_data' value=''><\/div><\/li><li id=\"field_270_175\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_175'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_175' id='input_270_175' type='text' value='' class='datepicker form-control gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_270_175_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_270_175_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_270_175' class='gform_hidden' value='https:\/\/commercialfishingpermits.us\/state\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_270_100\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_100'>Physician&#039;s Name:<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_100' id='input_270_100' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_176\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_270_176' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_270_176_1_container' >\n                                        <input class='form-control' type='text' name='input_176.1' id='input_270_176_1' value=''    aria-required='false'    \/>\n                                        <label for='input_270_176_1' id='input_270_176_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_270_176_2_container' >\n                                        <input class='form-control' type='text' name='input_176.2' id='input_270_176_2' value=''     aria-required='false'   \/>\n                                        <label for='input_270_176_2' id='input_270_176_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_270_176_3_container' >\n                                    <input class='form-control' type='text' name='input_176.3' id='input_270_176_3' value=''    aria-required='false'    \/>\n                                    <label for='input_270_176_3' id='input_270_176_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_270_176_4_container' >\n                                        <input class='form-control' type='text' name='input_176.4' id='input_270_176_4' value=''      aria-required='false'    \/>\n                                        <label for='input_270_176_4' id='input_270_176_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_270_176_5_container' >\n                                    <input class='form-control' type='text' name='input_176.5' id='input_270_176_5' value=''    aria-required='false'    \/>\n                                    <label for='input_270_176_5' id='input_270_176_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input class='form-control' type='hidden' class='gform_hidden' name='input_176.6' id='input_270_176_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_270_177\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_177'>Telephone Number:<\/label><div class='ginput_container ginput_container_phone'><input class='form-control' name='input_177' id='input_270_177' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_179\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_179'>Fax Number<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_179' id='input_270_179' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_180\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >You are the Patient\u2019s:<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_270_180'><li class='checkbox gchoice gchoice_270_180_1'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_180.1' type='checkbox'  value='Regular physician'  id='choice_270_180_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_180_1' id='label_270_180_1' class='gform-field-label gform-field-label--type-inline'>Regular physician<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_180_2'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_180.2' type='checkbox'  value='Specialist'  id='choice_270_180_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_180_2' id='label_270_180_2' class='gform-field-label gform-field-label--type-inline'>Specialist<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_180_3'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_180.3' type='checkbox'  value='Village Health Aide'  id='choice_270_180_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_180_3' id='label_270_180_3' class='gform-field-label gform-field-label--type-inline'>Village Health Aide<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_180_4'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_180.4' type='checkbox'  value='Emergency medical care provider'  id='choice_270_180_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_180_4' id='label_270_180_4' class='gform-field-label gform-field-label--type-inline'>Emergency medical care provider<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_180_5'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_180.5' type='checkbox'  value='Other'  id='choice_270_180_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_180_5' id='label_270_180_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_101\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_101'>If other, specify<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_101' id='input_270_101' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_102\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_102'>1. What date did you examine the patient:<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_102' id='input_270_102' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_103\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_103'>2. What complaint did the patient present and what was the date of onset:<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_103' id='input_270_103' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_104\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_104'>3. What did your examination consist of:<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_104' id='input_270_104' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_105\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_105'>4. What is your diagnosis of the illness or disability:<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_105' id='input_270_105' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_181\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >5. The diagnosis is based upon:<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_270_181'><li class='checkbox gchoice gchoice_270_181_1'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_181.1' type='checkbox'  value='Information provided verbally by patient'  id='choice_270_181_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_181_1' id='label_270_181_1' class='gform-field-label gform-field-label--type-inline'>Information provided verbally by patient<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_181_2'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_181.2' type='checkbox'  value='Medical records and history'  id='choice_270_181_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_181_2' id='label_270_181_2' class='gform-field-label gform-field-label--type-inline'>Medical records and history<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_181_3'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_181.3' type='checkbox'  value='Examination and observation'  id='choice_270_181_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_181_3' id='label_270_181_3' class='gform-field-label gform-field-label--type-inline'>Examination and observation<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_181_4'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_181.4' type='checkbox'  value='Blood work, X-rays'  id='choice_270_181_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_181_4' id='label_270_181_4' class='gform-field-label gform-field-label--type-inline'>Blood work, X-rays<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_181_5'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_181.5' type='checkbox'  value='Other tests or procedures'  id='choice_270_181_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_181_5' id='label_270_181_5' class='gform-field-label gform-field-label--type-inline'>Other tests or procedures<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_106\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_106'>If other, please explain<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_106' id='input_270_106' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_182\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_182'>6. If the diagnosis is back pain or injury to the back, attach clinical notes describing the tests performed and their results:<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_182' id='input_270_182' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_183\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_183'>7. Describe the patient\u2019s current physical limitations:<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_183' id='input_270_183' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_184\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >8. Have you previously seen the patient for the same or a related problem?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_270_184'><li class='checkbox gchoice gchoice_270_184_1'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_184.1' type='checkbox'  value='No'  id='choice_270_184_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_184_1' id='label_270_184_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_270_184_2'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_184.2' type='checkbox'  value='Yes'  id='choice_270_184_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_184_2' id='label_270_184_2' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_185\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_185'>If yes, indicate when and provide relevant history:<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_185' id='input_270_185' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_186\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_186'>9. What treatment(s) have you been prescribed (including prescribed medications, recommendations regarding physical activity, dietary recommendations, etc.)?<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_186' id='input_270_186' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_187\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_187'>10. What is the prognosis and expected duration of the problem?<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_187' id='input_270_187' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_188\" class=\"gfield gfield--type-signature field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_188'>Signature of Physician or Medical Examiner<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_270_188_Container' class='gfield_signature_container ginput_container' style='height:180px; width:500px; ' ><input type='hidden' class='gform_hidden' name='input_270_188_valid' id='input_270_188_valid' \/><canvas id='input_270_188' width='500' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/commercialfishingpermits.us\/state\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_270_188_toolbar' style='margin:5px 0;position:relative;height:20px;width:500px;max-width:100%;'><img id = 'input_270_188_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_270_188_data' name='input_270_188_data' value=''><\/div><\/li><li id=\"field_270_189\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_189'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_189' id='input_270_189' type='text' value='' class='datepicker form-control gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_270_189_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_270_189_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_270_189' class='gform_hidden' value='https:\/\/commercialfishingpermits.us\/state\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_270_123\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Commercial Fisheries Entry Commission Credit Card Authorization<\/h2><div class='gsection_description' id='gfield_description_270_123'>Please indicate the permit and\/or vessel numbers in the space provided and the total amount you are\nauthorizing your card to be charged.<\/div><\/li><li id=\"field_270_124\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_124'>Enter Permit(s)<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_124' id='input_270_124' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_125\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_125'>Fee amount for Permit(s)<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_125' id='input_270_125' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_126\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_126'>Enter Vessel(s)<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_126' id='input_270_126' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_127\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_127'>Fee amount for Vessel(s)<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_127' id='input_270_127' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_128\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_128'>Transfer Fees ($50):<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_128' id='input_270_128' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_129\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_129'>Immediate Fishing ($80):<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_129' id='input_270_129' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_130\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_270_130'><li class='checkbox gchoice gchoice_270_130_1'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_130.1' type='checkbox'  value='Check here to have your licenses express mailed and that you agree to pay the current USPS express mail rate PLUS the CFEC service fee of $15.00.'  id='choice_270_130_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_270_130_1' id='label_270_130_1' class='gform-field-label gform-field-label--type-inline'>Check here to have your licenses express mailed and that you agree to pay the current USPS express mail rate PLUS the CFEC service fee of $15.00.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_131\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_131'>Total amount to be charged.<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_131' id='input_270_131' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_14\" class=\"gfield gfield--type-product gfield--input-type-singleproduct base-product gfield_price gfield_price_270_14 gfield_product_270_14 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_270_14_1'>Application Fee<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_14.1' value='Application Fee' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_270_14' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_14.2' id='ginput_base_price_270_14' value='$450.00' aria-label='Application Fee Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_14.3' value='1' class='ginput_quantity_270_14 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_270_36\" class=\"gfield gfield--type-option gfield--type-choice gfield--input-type-radio advanced-renewal gfield_price gfield_price_270_14 gfield_option_270_14 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >RENEWAL ADVANCED PAYMENT OPTION<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_270_36'>\n\t\t\t<li class='gchoice gchoice_270_36_0'>\n\t\t\t\t<input name='input_36' type='radio' value='No Additional Years|0'  id='choice_270_36_0'    \/>\n\t\t\t\t<label for='choice_270_36_0' id='label_270_36_0' class='gform-field-label gform-field-label--type-inline'>No Additional Years<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_270_36_1'>\n\t\t\t\t<input name='input_36' type='radio' value='2 year renewal|75'  id='choice_270_36_1'    \/>\n\t\t\t\t<label for='choice_270_36_1' id='label_270_36_1' class='gform-field-label gform-field-label--type-inline'>2 year renewal<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_270_36_2'>\n\t\t\t\t<input name='input_36' type='radio' value='3 year renewal|150'  id='choice_270_36_2'    \/>\n\t\t\t\t<label for='choice_270_36_2' id='label_270_36_2' class='gform-field-label gform-field-label--type-inline'>3 year renewal<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_270_36_3'>\n\t\t\t\t<input name='input_36' type='radio' value='4 year renewal|225'  id='choice_270_36_3'    \/>\n\t\t\t\t<label for='choice_270_36_3' id='label_270_36_3' class='gform-field-label gform-field-label--type-inline'>4 year renewal<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_270_36_4'>\n\t\t\t\t<input name='input_36' type='radio' value='5 year renewal|300'  id='choice_270_36_4'    \/>\n\t\t\t\t<label for='choice_270_36_4' id='label_270_36_4' class='gform-field-label gform-field-label--type-inline'>5 year renewal<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_270_18\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_270_19\" class=\"gfield gfield--type-total pricing-total gfield_price gfield_price_270_ gfield_total gfield_total_270_ field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  aria-atomic=\"true\" aria-live=\"polite\" ><label class='gfield_label gform-field-label' for='input_270_19'>Total<\/label><div class='ginput_container ginput_container_total'>\n\t\t\t\t\t\t\t<span class='ginput_total ginput_total_270'>$0.00<\/span>\n\t\t\t\t\t\t\t<input type='hidden' name='input_19' id='input_270_19' class='gform_hidden'\/>\n\t\t\t\t\t\t<\/div><\/li><li id=\"field_270_21\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_270_22\" class=\"gfield gfield--type-consent gfield--type-choice consent-agree gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_22.1' id='input_270_22_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_270_22\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_270_22_1' >I agree<\/label><input type='hidden' name='input_22.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_22.3' value='1561' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_270_22' tabindex='0'>I CERTIFY THAT THE RECITATIONS CONCERNING THE VESSEL: NAME, TONNAGE, DIMENSIONS, PROPULSION, OWNERSHIP, HAILING PORT, RESTRICTIONS, ENTITLEMENTS, REMARKS AND ENDORSEMENTS CONTAINED IN THE CERTIFICATE OF DOCUMENTATION REMAIN ABSOLUTELY THE SAME.<\/div><\/li><li id=\"field_270_20\" class=\"gfield gfield--type-text typed-name-for-signature gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_20'>NAME:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_20' id='input_270_20' type='text' value='' class='medium'  aria-describedby=\"gfield_description_270_20\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_270_20'>Type your full name to sign this secure webform<\/div><\/li><li id=\"field_270_27\" class=\"gfield gfield--type-signature signature field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_27'>Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_270_27_Container' class='gfield_signature_container ginput_container' style='height:180px; width:500px; ' ><input type='hidden' class='gform_hidden' name='input_270_27_valid' id='input_270_27_valid' \/><canvas id='input_270_27' width='500' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/commercialfishingpermits.us\/state\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_270_27_toolbar' style='margin:5px 0;position:relative;height:20px;width:500px;max-width:100%;'><img id = 'input_270_27_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_270_27_data' name='input_270_27_data' value=''><\/div><\/li><li id=\"field_270_23\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_23'>CAPACITY OF PERSON SIGNING (E.G., OWNER, AGENT, TRUSTEE, GENERAL PARTNER, CORPORATE OFFICER, MEMBER)<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_23' id='input_270_23' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_270_24\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon signed-date field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_270_24'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_24' id='input_270_24' type='text' value='04\/16\/2026' class='datepicker form-control gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_270_24_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_270_24_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_270_24' class='gform_hidden' value='https:\/\/commercialfishingpermits.us\/state\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_270_25\" class=\"gfield gfield--type-consent gfield--type-choice consent_authorization gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Authorization<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_25.1' id='input_270_25_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_270_25\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_270_25_1' >I agree<\/label><input type='hidden' name='input_25.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_25.3' value='1561' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_270_25' tabindex='0'>I agree to pay the above total amount according to the card issuer agreement and hereby authorize the charge for the total amount above for the processing of selected permits. I understand that my application will be processed in the order in which it is received by Commercial Fishing Permits Center, a private fee-for-service documentation company, not owned or operated by any governmental agency. I understand that application and processing fees are non-refundable as per Commercial Fishing Permits Center's no refund policy. I understand that submitting another application for a license or permit will supersede the current\/pending application for that license or permit. I understand that Commercial Fishing Permits Center does not issue or sell any licenses or permits.<\/div><\/li><li id=\"field_270_26\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_270_193\" class=\"gfield gfield--type-stripe_creditcard field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--type-stripe_creditcard-card\"  ><label class='gfield_label gfield_label_before_complex gform-field-label' for='input_270_193_1'>Credit Card<\/label><div class='ginput_complex ginput_container ginput_container_creditcard ginput_stripe_creditcard gform-grid-row' id='input_270_193'><div class='ginput_full gform-grid-col' id='input_270_193_1_container' data-payment-element='false'><div id='input_270_193_1' class='gform-theme-field-control StripeElement--card'><\/div><label for='input_270_193_1' id='input_270_193_1_label' class='gform-field-label gform-field-label--type-sub'>Card Details<\/label><\/div><!-- .ginput_full --><div class='ginput_full gform-grid-col' id='input_270_193_5_container'>\r\n\t\t\t\t\t<input type='text' name='input_193.5' id='input_270_193_5' value=''>\r\n\t\t\t\t\t<label for='input_270_193_5' id='input_270_193_5_label' class='gform-field-label gform-field-label--type-sub'>Cardholder Name<\/label>\r\n\t\t\t\t<\/div><\/div><!-- .ginput_container -->\r\n\t\t\t<style type=\"text\/css\">\r\n\t\t\t\t:root {\r\n  \t\t\t\t\t--link-login-string: \"Link login\"\r\n\t\t\t\t}\r\n\t\t\t<\/style><\/li><li id=\"field_270_29\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_270_33\" class=\"gfield gfield--type-consent gfield--type-choice payment_not_working field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Having Trouble with your card?<\/label><div class='ginput_container ginput_container_consent'><input name='input_33.1' id='input_270_33_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_270_33\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_270_33_1' >My card information is not working<\/label><input type='hidden' name='input_33.2' value='My card information is not working' class='gform_hidden' \/><input type='hidden' name='input_33.3' value='1561' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_270_33' tabindex='0'>Check this box to move forward without your Credit Card.<\/div><\/li><li id=\"field_270_40\" class=\"gfield gfield--type-address billing-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >BILLING ADDRESS<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_270_40' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_270_40_1_container' >\n                                        <input class='form-control' type='text' name='input_40.1' id='input_270_40_1' value=''    aria-required='false'    \/>\n                                        <label for='input_270_40_1' id='input_270_40_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_270_40_2_container' >\n                                        <input class='form-control' type='text' name='input_40.2' id='input_270_40_2' value=''     aria-required='false'   \/>\n                                        <label for='input_270_40_2' id='input_270_40_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_270_40_3_container' >\n                                    <input class='form-control' type='text' name='input_40.3' id='input_270_40_3' value=''    aria-required='false'    \/>\n                                    <label for='input_270_40_3' id='input_270_40_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_270_40_4_container' >\n                                        <input class='form-control' type='text' name='input_40.4' id='input_270_40_4' value=''      aria-required='false'    \/>\n                                        <label for='input_270_40_4' id='input_270_40_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_270_40_5_container' >\n                                    <input class='form-control' type='text' name='input_40.5' id='input_270_40_5' value=''    aria-required='false'    \/>\n                                    <label for='input_270_40_5' id='input_270_40_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_270_40_6_container' >\n                                        <select class='form-control' class='form-control' name='input_40.6' id='input_270_40_6'   aria-required='false'    ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy 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