{"id":1453,"date":"2023-11-17T02:00:49","date_gmt":"2023-11-17T02:00:49","guid":{"rendered":"https:\/\/upcog.in\/?page_id=1453"},"modified":"2023-12-24T11:29:28","modified_gmt":"2023-12-24T11:29:28","slug":"form-demo","status":"publish","type":"page","link":"https:\/\/upcog.in\/?page_id=1453","title":{"rendered":"Membership Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1453\" class=\"elementor elementor-1453\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-588e65d5 e-flex e-con-boxed e-con e-parent\" data-id=\"588e65d5\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-23dfd57f elementor-widget elementor-widget-text-editor\" data-id=\"23dfd57f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"wpforms-container wpforms-container-full wpforms-block wpforms-block-c8c1a79b-a573-48ab-9d68-4dfa31f70195 wpforms-render-modern\" id=\"wpforms-1450\"><form id=\"wpforms-form-1450\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"1450\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F1453&#038;wpforms_form_id=1450\" data-token=\"3ee906aa0e9b50ec1a5582a1e3a2ee5f\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-1450-field_3-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-1450-field_3\">Dear Madam\/Sir<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-1450-field_3\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"F j, Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][3][date]\" placeholder=\"Submission Date\" aria-errormessage=\"wpforms-1450-field_3-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-1450-field_2-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-1450-field_2\">I here apply to be enrolled as a life Member of the U.P. Chapter of Obstetrics &amp; Gynaecology.<\/label><input type=\"text\" id=\"wpforms-1450-field_2\" class=\"wpforms-field-large\" name=\"wpforms[fields][2]\" placeholder=\"Name (in block letters)\" aria-errormessage=\"wpforms-1450-field_2-error\" ><\/div><div id=\"wpforms-1450-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1450-field_4\" aria-hidden=\"false\">Father&#039;s\/Husband\/Wife Name<\/label><input type=\"text\" id=\"wpforms-1450-field_4\" class=\"wpforms-field-large\" name=\"wpforms[fields][4]\" placeholder=\"Father&#039;s\/Husband\/Wife Name\" aria-errormessage=\"wpforms-1450-field_4-error\" ><\/div><div id=\"wpforms-1450-field_6-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"6\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1450-field_6\" aria-hidden=\"false\">Current Address<\/label><input type=\"text\" id=\"wpforms-1450-field_6\" class=\"wpforms-field-large\" name=\"wpforms[fields][6]\" placeholder=\"Current Address\" aria-errormessage=\"wpforms-1450-field_6-error\" ><\/div><div id=\"wpforms-1450-field_7-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"7\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1450-field_7\" aria-hidden=\"false\">Permanent Address <\/label><input type=\"text\" id=\"wpforms-1450-field_7\" class=\"wpforms-field-large\" name=\"wpforms[fields][7]\" placeholder=\"Permanent Address \" aria-errormessage=\"wpforms-1450-field_7-error\" ><\/div><div id=\"wpforms-1450-field_10-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"10\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1450-field_10\" aria-hidden=\"false\">Contact Information<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-1450-field_8-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-1450-field_8\">Contact Details<\/label><input type=\"tel\" id=\"wpforms-1450-field_8\" class=\"wpforms-field-large wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][8]\" placeholder=\"Contact Number\" aria-errormessage=\"wpforms-1450-field_8-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-1450-field_9-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-1450-field_9\">Email<\/label><input type=\"email\" id=\"wpforms-1450-field_9\" class=\"wpforms-field-large\" name=\"wpforms[fields][9]\" placeholder=\"Email \" spellcheck=\"false\" aria-errormessage=\"wpforms-1450-field_9-error\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-1450-field_11-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"11\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1450-field_11\" aria-hidden=\"false\">Qualification<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-1450-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-1450-field_12\">Qualification<\/label><input type=\"text\" id=\"wpforms-1450-field_12\" class=\"wpforms-field-medium\" name=\"wpforms[fields][12]\" placeholder=\"College\" aria-errormessage=\"wpforms-1450-field_12-error\" ><\/div><div id=\"wpforms-1450-field_13-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-1450-field_13\">University<\/label><input type=\"text\" id=\"wpforms-1450-field_13\" class=\"wpforms-field-medium\" name=\"wpforms[fields][13]\" placeholder=\"University\" aria-errormessage=\"wpforms-1450-field_13-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-1450-field_14-container\" class=\"wpforms-field wpforms-field-date-time disable-future-dates\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-1450-field_14\">Year of Admission<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-1450-field_14\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][14][date]\" placeholder=\"Year of Admission\" aria-errormessage=\"wpforms-1450-field_14-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-1450-field_15-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-1450-field_15\">Year of Passing<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-1450-field_15\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][15][date]\" placeholder=\"Year of Passing\" aria-errormessage=\"wpforms-1450-field_15-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-1450-field_32-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"32\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1450-field_32\" aria-hidden=\"false\">Layout<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-1450-field_49-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"49\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1450-field_49\" aria-hidden=\"false\">Registration Number<\/label><input type=\"text\" id=\"wpforms-1450-field_49\" class=\"wpforms-field-medium\" name=\"wpforms[fields][49]\" placeholder=\"Registration Number\" aria-errormessage=\"wpforms-1450-field_49-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-1450-field_18-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"18\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1450-field_18\" aria-hidden=\"false\">Name of Council Registration<\/label><input type=\"text\" id=\"wpforms-1450-field_18\" class=\"wpforms-field-medium\" name=\"wpforms[fields][18]\" placeholder=\"Name of Council Registration\" aria-errormessage=\"wpforms-1450-field_18-error\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-1450-field_31-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"31\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1450-field_31\" aria-hidden=\"false\">Layout<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-1450-field_19-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"19\"><fieldset><legend class=\"wpforms-field-label\">Are you in service?<\/legend><ul id=\"wpforms-1450-field_19\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1450-field_19_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][19][]\" value=\"Yes\" aria-errormessage=\"wpforms-1450-field_19_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1450-field_19_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1450-field_19_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][19][]\" value=\"No\" aria-errormessage=\"wpforms-1450-field_19_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1450-field_19_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1450-field_33-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"33\"><fieldset><legend class=\"wpforms-field-label\">Choose Membership<\/legend><ul id=\"wpforms-1450-field_33\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1450-field_33_1\" name=\"wpforms[fields][33]\" value=\"Life Membership + Journal for 3 years =(5000+1500=6500)\" aria-errormessage=\"wpforms-1450-field_33_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1450-field_33_1\">Life Membership + Journal for 3 years =(5000+1500=6500)<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1450-field_33_2\" name=\"wpforms[fields][33]\" value=\"Annual membership + journal = (1500+500=2000)\" aria-errormessage=\"wpforms-1450-field_33_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1450-field_33_2\">Annual membership + journal = (1500+500=2000)<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1450-field_36-container\" class=\"wpforms-field wpforms-field-file-upload wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"36\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1450-field_36\">Upload Screenshot of Payment<\/label><div\n\t\tclass=\"wpforms-uploader\"\n\t\tdata-field-id=\"36\"\n\t\tdata-form-id=\"1450\"\n\t\tdata-input-name=\"wpforms_1450_36\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,x-wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages,pls,m3u8,json\"\n\t\tdata-max-size=\"1073741824\"\n\t\tdata-max-file-number=\"1\"\n\t\tdata-post-max-size=\"1073741824\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg viewBox=\"0 0 1024 1024\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M885.2 446.3l-.2-.8-112.2-285.1c-5-16.1-19.9-27.2-36.8-27.2H281.2c-17 0-32.1 11.3-36.9 27.6L139.4 443l-.3.7-.2.8c-1.3 4.9-1.7 9.9-1 14.8-.1 1.6-.2 3.2-.2 4.8V830a60.9 60.9 0 0 0 60.8 60.8h627.2c33.5 0 60.8-27.3 60.9-60.8V464.1c0-1.3 0-2.6-.1-3.7.4-4.9 0-9.6-1.3-14.1zm-295.8-43l-.3 15.7c-.8 44.9-31.8 75.1-77.1 75.1-22.1 0-41.1-7.1-54.8-20.6S436 441.2 435.6 419l-.3-15.7H229.5L309 210h399.2l81.7 193.3H589.4zm-375 76.8h157.3c24.3 57.1 76 90.8 140.4 90.8 33.7 0 65-9.4 90.3-27.2 22.2-15.6 39.5-37.4 50.7-63.6h156.5V814H214.4V480.1z\"><\/path>\n\t\t<\/svg>\n\t\t<span class=\"modern-title\">Click or drag a file to this area to upload.<\/span>\n\n\t\t\t<\/div>\n<\/div>\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-1450-field_36\"\n\t\tname=\"wpforms_1450_36\" \t\tvalue=\"\">\n<\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-1450-field_20-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"20\"><fieldset><legend class=\"wpforms-field-label\">Status<\/legend><ul id=\"wpforms-1450-field_20\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1450-field_20_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][20][]\" value=\"GP\" aria-errormessage=\"wpforms-1450-field_20_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1450-field_20_1\">GP<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1450-field_20_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][20][]\" value=\"Consultant Hospital Practices\" aria-errormessage=\"wpforms-1450-field_20_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1450-field_20_2\">Consultant Hospital Practices<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1450-field_35-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"35\"><fieldset><legend class=\"wpforms-field-label\">Payment<\/legend><ul id=\"wpforms-1450-field_35\"><li class=\"choice-2 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-1450-field_35_2\" name=\"wpforms[fields][35]\" value=\"Paid Offline\" aria-errormessage=\"wpforms-1450-field_35_2-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-1450-field_35_2\">Paid Offline<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1450-field_30-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"30\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1450-field_30\" aria-hidden=\"false\">Layout<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-1450-field_23-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"23\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1450-field_23\">Payment Details<\/label><input type=\"text\" id=\"wpforms-1450-field_23\" class=\"wpforms-field-large\" name=\"wpforms[fields][23]\" aria-errormessage=\"wpforms-1450-field_23-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><\/div><div id=\"wpforms-1450-field_25-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"25\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1450-field_25\" aria-hidden=\"false\">Total Amount<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-33-33-33\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-1450-field_26-container\" class=\"wpforms-field wpforms-field-number wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"26\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1450-field_26\">Total Amount<\/label><input type=\"number\" pattern=\"\\d*\" id=\"wpforms-1450-field_26\" class=\"wpforms-field-medium\" name=\"wpforms[fields][26]\" value=\"6500\" placeholder=\"Total Amount\" aria-errormessage=\"wpforms-1450-field_26-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-1450-field_48-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"48\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1450-field_48\">Bank Txn\/Ref No.<\/label><input type=\"text\" id=\"wpforms-1450-field_48\" class=\"wpforms-field-medium\" name=\"wpforms[fields][48]\" placeholder=\"Bank Txn\/Ref No.\" aria-errormessage=\"wpforms-1450-field_48-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-1450-field_29-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"29\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1450-field_29\">Date<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-1450-field_29\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][29][date]\" placeholder=\"Date\" aria-errormessage=\"wpforms-1450-field_29-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-1450-field_50-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"50\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1450-field_50\" aria-hidden=\"false\">Total Amount (copy)<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-33-33-33\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><\/div><\/div><\/div><div id=\"wpforms-1450-field_42-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"42\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1450-field_42\" aria-hidden=\"false\">Total Amount (copy)<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-33-33-33\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-1450-field_43-container\" class=\"wpforms-field wpforms-field-number wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"43\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1450-field_43\">Total Amount<\/label><input type=\"number\" pattern=\"\\d*\" id=\"wpforms-1450-field_43\" class=\"wpforms-field-medium\" name=\"wpforms[fields][43]\" value=\"2000\" placeholder=\"Total Amount\" aria-errormessage=\"wpforms-1450-field_43-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-1450-field_47-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"47\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1450-field_47\">Bank Txn\/Ref No.<\/label><input type=\"text\" id=\"wpforms-1450-field_47\" class=\"wpforms-field-medium\" name=\"wpforms[fields][47]\" placeholder=\"Bank Txn\/Ref No.\" aria-errormessage=\"wpforms-1450-field_47-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-1450-field_46-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"46\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1450-field_46\">Date<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-1450-field_46\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][46][date]\" placeholder=\"Date\" aria-errormessage=\"wpforms-1450-field_46-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"1450\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"1\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-1450\" class=\"wpforms-submit\" data-alt-text=\"Sending\u2026\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img decoding=\"async\" src=\"https:\/\/upcog.in\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-c795f43 e-flex e-con-boxed e-con e-parent\" data-id=\"c795f43\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-d399971 e-con-full e-flex e-con e-child\" data-id=\"d399971\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-9e1fc7d elementor-widget elementor-widget-image\" data-id=\"9e1fc7d\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" width=\"1000\" height=\"1000\" src=\"https:\/\/upcog.in\/wp-content\/uploads\/2023\/11\/20231115_063315-1024x1024.png\" class=\"attachment-large size-large wp-image-976\" alt=\"\" srcset=\"https:\/\/upcog.in\/wp-content\/uploads\/2023\/11\/20231115_063315-1024x1024.png 1024w, https:\/\/upcog.in\/wp-content\/uploads\/2023\/11\/20231115_063315-300x300.png 300w, https:\/\/upcog.in\/wp-content\/uploads\/2023\/11\/20231115_063315-150x150.png 150w, https:\/\/upcog.in\/wp-content\/uploads\/2023\/11\/20231115_063315-768x768.png 768w, https:\/\/upcog.in\/wp-content\/uploads\/2023\/11\/20231115_063315-650x650.png 650w, https:\/\/upcog.in\/wp-content\/uploads\/2023\/11\/20231115_063315.png 1280w\" sizes=\"(max-width: 1000px) 100vw, 1000px\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-ac5e549 e-con-full e-flex e-con e-child\" data-id=\"ac5e549\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-6ef189f elementor-widget elementor-widget-heading\" data-id=\"6ef189f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">UP Chapters of Obstetrics &amp; GynAecology<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-4aeec22 e-con-full e-flex e-con e-child\" data-id=\"4aeec22\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-689cfdc elementor-widget elementor-widget-image\" data-id=\"689cfdc\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" width=\"1000\" height=\"1000\" src=\"https:\/\/upcog.in\/wp-content\/uploads\/2023\/11\/20231115_063315-1024x1024.png\" class=\"attachment-large size-large wp-image-976\" alt=\"\" srcset=\"https:\/\/upcog.in\/wp-content\/uploads\/2023\/11\/20231115_063315-1024x1024.png 1024w, https:\/\/upcog.in\/wp-content\/uploads\/2023\/11\/20231115_063315-300x300.png 300w, https:\/\/upcog.in\/wp-content\/uploads\/2023\/11\/20231115_063315-150x150.png 150w, https:\/\/upcog.in\/wp-content\/uploads\/2023\/11\/20231115_063315-768x768.png 768w, https:\/\/upcog.in\/wp-content\/uploads\/2023\/11\/20231115_063315-650x650.png 650w, https:\/\/upcog.in\/wp-content\/uploads\/2023\/11\/20231115_063315.png 1280w\" sizes=\"(max-width: 1000px) 100vw, 1000px\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-3fb421f e-con-full e-flex e-con e-parent\" data-id=\"3fb421f\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-e776caf elementor-widget__width-initial elementor-widget elementor-widget-bdt-wp-forms\" data-id=\"e776caf\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"bdt-wp-forms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-1450\"><form id=\"wpforms-form-1450\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"1450\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F1453&#038;wpforms_form_id=1450\" data-token=\"3ee906aa0e9b50ec1a5582a1e3a2ee5f\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-1450-field_3-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-1450-field_3\">Dear Madam\/Sir<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-1450-field_3\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"F j, Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][3][date]\" placeholder=\"Submission Date\" aria-errormessage=\"wpforms-1450-field_3-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-1450-field_2-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-1450-field_2\">I here apply to be enrolled as a life Member of the U.P. Chapter of Obstetrics &amp; Gynaecology.<\/label><input type=\"text\" id=\"wpforms-1450-field_2\" class=\"wpforms-field-large\" name=\"wpforms[fields][2]\" placeholder=\"Name (in block letters)\" aria-errormessage=\"wpforms-1450-field_2-error\" ><\/div><div id=\"wpforms-1450-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1450-field_4\" aria-hidden=\"false\">Father&#039;s\/Husband\/Wife Name<\/label><input type=\"text\" id=\"wpforms-1450-field_4\" class=\"wpforms-field-large\" name=\"wpforms[fields][4]\" placeholder=\"Father&#039;s\/Husband\/Wife Name\" aria-errormessage=\"wpforms-1450-field_4-error\" ><\/div><div id=\"wpforms-1450-field_6-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"6\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1450-field_6\" aria-hidden=\"false\">Current Address<\/label><input type=\"text\" id=\"wpforms-1450-field_6\" class=\"wpforms-field-large\" name=\"wpforms[fields][6]\" placeholder=\"Current Address\" aria-errormessage=\"wpforms-1450-field_6-error\" ><\/div><div id=\"wpforms-1450-field_7-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"7\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1450-field_7\" aria-hidden=\"false\">Permanent Address <\/label><input type=\"text\" id=\"wpforms-1450-field_7\" class=\"wpforms-field-large\" name=\"wpforms[fields][7]\" placeholder=\"Permanent Address \" aria-errormessage=\"wpforms-1450-field_7-error\" ><\/div><div id=\"wpforms-1450-field_10-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"10\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1450-field_10\" aria-hidden=\"false\">Contact Information<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-1450-field_8-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-1450-field_8\">Contact Details<\/label><input type=\"tel\" id=\"wpforms-1450-field_8\" class=\"wpforms-field-large wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][8]\" placeholder=\"Contact Number\" aria-errormessage=\"wpforms-1450-field_8-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-1450-field_9-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-1450-field_9\">Email<\/label><input type=\"email\" id=\"wpforms-1450-field_9\" class=\"wpforms-field-large\" name=\"wpforms[fields][9]\" placeholder=\"Email \" spellcheck=\"false\" aria-errormessage=\"wpforms-1450-field_9-error\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-1450-field_11-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"11\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1450-field_11\" aria-hidden=\"false\">Qualification<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-1450-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-1450-field_12\">Qualification<\/label><input type=\"text\" id=\"wpforms-1450-field_12\" class=\"wpforms-field-medium\" name=\"wpforms[fields][12]\" placeholder=\"College\" aria-errormessage=\"wpforms-1450-field_12-error\" ><\/div><div id=\"wpforms-1450-field_13-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-1450-field_13\">University<\/label><input type=\"text\" id=\"wpforms-1450-field_13\" class=\"wpforms-field-medium\" name=\"wpforms[fields][13]\" placeholder=\"University\" aria-errormessage=\"wpforms-1450-field_13-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-1450-field_14-container\" class=\"wpforms-field wpforms-field-date-time disable-future-dates\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-1450-field_14\">Year of Admission<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-1450-field_14\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][14][date]\" placeholder=\"Year of Admission\" aria-errormessage=\"wpforms-1450-field_14-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-1450-field_15-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-1450-field_15\">Year of Passing<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-1450-field_15\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][15][date]\" placeholder=\"Year of Passing\" aria-errormessage=\"wpforms-1450-field_15-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-1450-field_32-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"32\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1450-field_32\" aria-hidden=\"false\">Layout<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-1450-field_49-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"49\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1450-field_49\" aria-hidden=\"false\">Registration Number<\/label><input type=\"text\" id=\"wpforms-1450-field_49\" class=\"wpforms-field-medium\" name=\"wpforms[fields][49]\" placeholder=\"Registration Number\" aria-errormessage=\"wpforms-1450-field_49-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-1450-field_18-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"18\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1450-field_18\" aria-hidden=\"false\">Name of Council Registration<\/label><input type=\"text\" id=\"wpforms-1450-field_18\" class=\"wpforms-field-medium\" name=\"wpforms[fields][18]\" placeholder=\"Name of Council Registration\" aria-errormessage=\"wpforms-1450-field_18-error\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-1450-field_31-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"31\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1450-field_31\" aria-hidden=\"false\">Layout<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-1450-field_19-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"19\"><fieldset><legend class=\"wpforms-field-label\">Are you in service?<\/legend><ul id=\"wpforms-1450-field_19\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1450-field_19_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][19][]\" value=\"Yes\" aria-errormessage=\"wpforms-1450-field_19_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1450-field_19_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1450-field_19_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][19][]\" value=\"No\" aria-errormessage=\"wpforms-1450-field_19_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1450-field_19_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1450-field_33-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"33\"><fieldset><legend class=\"wpforms-field-label\">Choose Membership<\/legend><ul id=\"wpforms-1450-field_33\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1450-field_33_1\" name=\"wpforms[fields][33]\" value=\"Life Membership + Journal for 3 years =(5000+1500=6500)\" aria-errormessage=\"wpforms-1450-field_33_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1450-field_33_1\">Life Membership + Journal for 3 years =(5000+1500=6500)<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1450-field_33_2\" name=\"wpforms[fields][33]\" value=\"Annual membership + journal = (1500+500=2000)\" aria-errormessage=\"wpforms-1450-field_33_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1450-field_33_2\">Annual membership + journal = (1500+500=2000)<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1450-field_36-container\" class=\"wpforms-field wpforms-field-file-upload wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"36\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1450-field_36\">Upload Screenshot of 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upload.<\/span>\n\n\t\t\t<\/div>\n<\/div>\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-1450-field_36\"\n\t\tname=\"wpforms_1450_36\" \t\tvalue=\"\">\n<\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-1450-field_20-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"20\"><fieldset><legend class=\"wpforms-field-label\">Status<\/legend><ul id=\"wpforms-1450-field_20\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1450-field_20_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][20][]\" value=\"GP\" aria-errormessage=\"wpforms-1450-field_20_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1450-field_20_1\">GP<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1450-field_20_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][20][]\" value=\"Consultant Hospital Practices\" aria-errormessage=\"wpforms-1450-field_20_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1450-field_20_2\">Consultant Hospital Practices<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1450-field_35-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"35\"><fieldset><legend class=\"wpforms-field-label\">Payment<\/legend><ul id=\"wpforms-1450-field_35\"><li class=\"choice-2 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-1450-field_35_2\" name=\"wpforms[fields][35]\" value=\"Paid Offline\" aria-errormessage=\"wpforms-1450-field_35_2-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-1450-field_35_2\">Paid Offline<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1450-field_30-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"30\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1450-field_30\" aria-hidden=\"false\">Layout<\/label><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-1450-field_23-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"23\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1450-field_23\">Payment Details<\/label><input type=\"text\" id=\"wpforms-1450-field_23\" class=\"wpforms-field-large\" name=\"wpforms[fields][23]\" aria-errormessage=\"wpforms-1450-field_23-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><\/div><div 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