<div class="wpforms-container wpforms-container-full" id="wpforms-7913"><form id="wpforms-form-7913" class="wpforms-validate wpforms-form" data-formid="7913" method="post" enctype="multipart/form-data" action="/2018-2/"><noscript class="wpforms-error-noscript">Please enable JavaScript in your browser to complete this form.</noscript><div class="wpforms-field-container"><div id="wpforms-7913-field_2-container" class="wpforms-field wpforms-field-text" data-field-id="2"><label class="wpforms-field-label" for="wpforms-7913-field_2">Name <span class="wpforms-required-label">*</span></label><input type="text" id="wpforms-7913-field_2" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][2]" required></div><div id="wpforms-7913-field_3-container" class="wpforms-field wpforms-field-text" data-field-id="3"><label class="wpforms-field-label" for="wpforms-7913-field_3">Age <span class="wpforms-required-label">*</span></label><input type="text" id="wpforms-7913-field_3" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][3]" required></div><div id="wpforms-7913-field_4-container" class="wpforms-field wpforms-field-text" data-field-id="4"><label class="wpforms-field-label" for="wpforms-7913-field_4">Birthdate <span class="wpforms-required-label">*</span></label><input type="text" id="wpforms-7913-field_4" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][4]" placeholder="mm/dd/yyyy" required></div><div id="wpforms-7913-field_5-container" class="wpforms-field wpforms-field-text" data-field-id="5"><label class="wpforms-field-label" for="wpforms-7913-field_5">Address <span class="wpforms-required-label">*</span></label><input type="text" id="wpforms-7913-field_5" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][5]" required></div><div id="wpforms-7913-field_7-container" class="wpforms-field wpforms-field-email" data-field-id="7"><label class="wpforms-field-label" for="wpforms-7913-field_7">Email <span class="wpforms-required-label">*</span></label><input type="email" id="wpforms-7913-field_7" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][7]" placeholder="myemail@email.com" required></div><div id="wpforms-7913-field_9-container" class="wpforms-field wpforms-field-number" data-field-id="9"><label class="wpforms-field-label" for="wpforms-7913-field_9">Mobile Number <span class="wpforms-required-label">*</span></label><input type="number" pattern="\d*" id="wpforms-7913-field_9" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][9]" placeholder="+639" required></div><div id="wpforms-7913-field_10-container" class="wpforms-field wpforms-field-select wpforms-field-select-style-classic" data-field-id="10"><label class="wpforms-field-label" for="wpforms-7913-field_10">Civil Status <span class="wpforms-required-label">*</span></label><select id="wpforms-7913-field_10" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][10]" required="required"><option value="Single" >Single</option><option value="Married" >Married</option><option value="Divorced" >Divorced</option><option value="Separated" >Separated</option><option value="Widowed" >Widowed</option></select></div><div id="wpforms-7913-field_11-container" class="wpforms-field wpforms-field-select wpforms-field-select-style-classic" data-field-id="11"><label class="wpforms-field-label" for="wpforms-7913-field_11">Sex <span class="wpforms-required-label">*</span></label><select id="wpforms-7913-field_11" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][11]" required="required"><option value="Male" >Male</option><option value="Female" >Female</option></select></div><div id="wpforms-7913-field_13-container" class="wpforms-field wpforms-field-text" data-field-id="13"><label class="wpforms-field-label" for="wpforms-7913-field_13">Educational Attainment <span class="wpforms-required-label">*</span></label><input type="text" id="wpforms-7913-field_13" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][13]" required></div><div id="wpforms-7913-field_14-container" class="wpforms-field wpforms-field-select wpforms-field-select-style-classic" data-field-id="14"><label class="wpforms-field-label" for="wpforms-7913-field_14">Occupation <span class="wpforms-required-label">*</span></label><select id="wpforms-7913-field_14" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][14]" required="required"><option value="OFW" >OFW</option><option value="OFW Dependent" >OFW Dependent</option></select></div><div id="wpforms-7913-field_15-container" class="wpforms-field wpforms-field-text" data-field-id="15"><label class="wpforms-field-label" for="wpforms-7913-field_15">Host Country of OFW <span class="wpforms-required-label">*</span></label><input type="text" id="wpforms-7913-field_15" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][15]" required></div><div id="wpforms-7913-field_16-container" class="wpforms-field wpforms-field-select wpforms-field-select-style-classic" data-field-id="16"><label class="wpforms-field-label" for="wpforms-7913-field_16">Migration Status <span class="wpforms-required-label">*</span></label><select id="wpforms-7913-field_16" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][16]" required="required"><option value="Active OFW" >Active OFW</option><option value="Ex-OFW" >Ex-OFW</option></select></div><div id="wpforms-7913-field_17-container" class="wpforms-field wpforms-field-radio" data-field-id="17"><label class="wpforms-field-label" for="wpforms-7913-field_17">Are you an OWWA member? <span class="wpforms-required-label">*</span></label><ul id="wpforms-7913-field_17" class="wpforms-field-required"><li class="choice-1 depth-1"><input type="radio" id="wpforms-7913-field_17_1" name="wpforms[fields][17]" value="Yes" required ><label class="wpforms-field-label-inline" for="wpforms-7913-field_17_1">Yes</label></li><li class="choice-2 depth-1"><input type="radio" id="wpforms-7913-field_17_2" name="wpforms[fields][17]" value="No" required ><label class="wpforms-field-label-inline" for="wpforms-7913-field_17_2">No</label></li></ul></div><div id="wpforms-7913-field_18-container" class="wpforms-field wpforms-field-textarea" data-field-id="18"><label class="wpforms-field-label" for="wpforms-7913-field_18">What is your purpose in visiting the Region 1 Kabayan e-Konek? <span class="wpforms-required-label">*</span></label><textarea id="wpforms-7913-field_18" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][18]" required></textarea></div><div id="wpforms-7913-field_19-container" class="wpforms-field wpforms-field-text" data-field-id="19"><label class="wpforms-field-label" for="wpforms-7913-field_19">What agency do you want to transact with? <span class="wpforms-required-label">*</span></label><input type="text" id="wpforms-7913-field_19" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][19]" required></div><div id="wpforms-7913-field_20-container" class="wpforms-field wpforms-field-checkbox" data-field-id="20"><label class="wpforms-field-label" for="wpforms-7913-field_20">Assistance / Services needed (please check all that apply) <span class="wpforms-required-label">*</span></label><ul id="wpforms-7913-field_20" class="wpforms-field-required"><li class="choice-1 depth-1"><input type="checkbox" id="wpforms-7913-field_20_1" name="wpforms[fields][20][]" value="Birth Certificate " required ><label class="wpforms-field-label-inline" for="wpforms-7913-field_20_1">Birth Certificate </label></li><li class="choice-2 depth-1"><input type="checkbox" id="wpforms-7913-field_20_2" name="wpforms[fields][20][]" value="Marriage Certificate" required ><label class="wpforms-field-label-inline" for="wpforms-7913-field_20_2">Marriage Certificate</label></li><li class="choice-3 depth-1"><input type="checkbox" id="wpforms-7913-field_20_3" name="wpforms[fields][20][]" value="Overseas Employment Certificate (OEC)" required ><label class="wpforms-field-label-inline" for="wpforms-7913-field_20_3">Overseas Employment Certificate (OEC)</label></li><li class="choice-4 depth-1"><input type="checkbox" id="wpforms-7913-field_20_4" name="wpforms[fields][20][]" value="Passport" required ><label class="wpforms-field-label-inline" for="wpforms-7913-field_20_4">Passport</label></li><li class="choice-5 depth-1"><input type="checkbox" id="wpforms-7913-field_20_5" name="wpforms[fields][20][]" value="Livelihood assistance" required ><label class="wpforms-field-label-inline" for="wpforms-7913-field_20_5">Livelihood assistance</label></li><li class="choice-6 depth-1"><input type="checkbox" id="wpforms-7913-field_20_6" name="wpforms[fields][20][]" value="Educational Assistance" required ><label class="wpforms-field-label-inline" for="wpforms-7913-field_20_6">Educational Assistance</label></li><li class="choice-7 depth-1"><input type="checkbox" id="wpforms-7913-field_20_7" name="wpforms[fields][20][]" value="Online trainings for employment" required ><label class="wpforms-field-label-inline" for="wpforms-7913-field_20_7">Online trainings for employment</label></li><li class="choice-8 depth-1"><input type="checkbox" id="wpforms-7913-field_20_8" name="wpforms[fields][20][]" value="Employment/ Job referral" required ><label class="wpforms-field-label-inline" for="wpforms-7913-field_20_8">Employment/ Job referral</label></li></ul></div><div id="wpforms-7913-field_21-container" class="wpforms-field wpforms-field-text" data-field-id="21"><label class="wpforms-field-label" for="wpforms-7913-field_21">For other assistance/services, please specify</label><input type="text" id="wpforms-7913-field_21" class="wpforms-field-medium" name="wpforms[fields][21]" ></div></div><div class="wpforms-field wpforms-field-hp"><label for="wpforms-7913-field-hp" class="wpforms-field-label">Phone</label><input type="text" name="wpforms[hp]" id="wpforms-7913-field-hp" class="wpforms-field-medium"></div><div class="wpforms-submit-container" ><input type="hidden" name="wpforms[id]" value="7913"><input type="hidden" name="wpforms[author]" value="7"><input type="hidden" name="wpforms[post_id]" value="3526"><button type="submit" name="wpforms[submit]" class="wpforms-submit om-trigger-conversion" id="wpforms-submit-7913" value="wpforms-submit" aria-live="assertive" data-alt-text="Your response is being recorded." data-submit-text="Submit">Submit</button></div></form></div> <!-- .wpforms-container -->