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| <form action="email" id="TfacsSubmission" no_submit_on_return mwreturn="Thank you for your submission!" enctype="multipart/form-data">
| | {{ApplicationForm}} |
| <_email template="SubmissionEmailTemplate"></_email>
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| <_create mwwrite="Admin:{{CURRENTTIMESTAMP}} [firstname] [lastname]" mwtemplate="Submission" />
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| {| class="smwtable-clean th-top-right border"
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| |-
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| ! <label for="firstname">Name {{r|*}}</label>
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| | <input style="width: 50%;" type="text" name="firstname" placeholder="first name" required="required" />
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| <input style="width: 50%;" type="text" name="lastname" placeholder="last name" required="required" />
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| ! <label for="birthdate">Date of birth {{r|*}}</label>
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| | <input type="date" name="birthdate" value="{{CURRENTYEAR}}-{{CURRENTMONTH}}-{{CURRENTDAY}}" min="1900-01-01" max="2999-12-31" required="required" />
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| |-
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| ! <label for="birthcountry">Country of birth {{r|*}}</label>
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| | <select name="birthcountry" selected="" placeholder="select" options="{{ListOfCountries}}" />
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| ! <label for="street">Address {{r|*}}</label>
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| | <input style="width: 100%;" type="text" name="street" placeholder="street address" required="required" /><br>
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| <input style="width: 100%;" type="text" name="street2" placeholder="address line 2" /><br>
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| <input style="width: 50%;" type="text" name="city" placeholder="city" required="required" /><input style="width: 50%;" type="text" name="stateprov" placeholder="state / province" /><br>
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| <input style="width: 50%;" type="text" name="postalcode" placeholder="zip/postal code" required="required" /><select style="width: 50%;" name="country" selected="" options="{{ListOfCountries}}" required="required" />
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| ! <label for="email">Contact {{r|*}}</label>
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| | <input style="width: 100%;" type="email" name="email" placeholder="email" required="required" />
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| <input style="width: 100%;" type="tel" id="phone" name="telephone" placeholder="phone number" required="required" /><br>
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| Include [https://en.wikipedia.org/wiki/List_of_country_calling_codes#Ordered_by_code an international code] if applicable.
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| ! <label for="fileupload">Upload file {{r|*}}</label>
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| | <input type="file" target="[firstname]_[lastname]_-_Test.pdf" id="TestFileUpload" name="fileupload" accept="application/pdf" parsecontent />
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| {{r|PDF ONLY!}}
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| |}
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| {| class="smwtable-clean th-top-right border"
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| |-
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| |}
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| <input type="submit" value="submit" />
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| </form>{{#widget:FlexForm.css}}
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