{"id":3283,"date":"2025-05-15T11:42:35","date_gmt":"2025-05-15T15:42:35","guid":{"rendered":"https:\/\/pmbhuissiers.com\/?page_id=3283"},"modified":"2025-06-04T13:54:27","modified_gmt":"2025-06-04T17:54:27","slug":"screening-form","status":"publish","type":"page","link":"https:\/\/pmbhuissiers.com\/en\/screening-form\/","title":{"rendered":"Screening Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3283\" class=\"elementor elementor-3283 elementor-3282\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-6a01afd0 elementor-section-stretched elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"6a01afd0\" data-element_type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;,&quot;background_background&quot;:&quot;classic&quot;,&quot;jet_parallax_layout_list&quot;:[{&quot;jet_parallax_layout_image&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;,&quot;size&quot;:&quot;&quot;},&quot;_id&quot;:&quot;603df3d&quot;,&quot;jet_parallax_layout_image_tablet&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;,&quot;size&quot;:&quot;&quot;},&quot;jet_parallax_layout_image_mobile&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;,&quot;size&quot;:&quot;&quot;},&quot;jet_parallax_layout_speed&quot;:{&quot;unit&quot;:&quot;%&quot;,&quot;size&quot;:50,&quot;sizes&quot;:[]},&quot;jet_parallax_layout_type&quot;:&quot;scroll&quot;,&quot;jet_parallax_layout_direction&quot;:&quot;1&quot;,&quot;jet_parallax_layout_fx_direction&quot;:null,&quot;jet_parallax_layout_z_index&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_x&quot;:50,&quot;jet_parallax_layout_bg_x_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_x_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_y&quot;:50,&quot;jet_parallax_layout_bg_y_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_y_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_size&quot;:&quot;auto&quot;,&quot;jet_parallax_layout_bg_size_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_size_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_animation_prop&quot;:&quot;transform&quot;,&quot;jet_parallax_layout_on&quot;:[&quot;desktop&quot;,&quot;tablet&quot;]}]}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-413599b9 title_head\" data-id=\"413599b9\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-175037ec elementor-widget elementor-widget-heading\" data-id=\"175037ec\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Service Request Form<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-20b04b51 elementor-section-stretched elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"20b04b51\" data-element_type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;,&quot;jet_parallax_layout_list&quot;:[{&quot;jet_parallax_layout_image&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;,&quot;size&quot;:&quot;&quot;},&quot;_id&quot;:&quot;a06b6cd&quot;,&quot;jet_parallax_layout_image_tablet&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;,&quot;size&quot;:&quot;&quot;},&quot;jet_parallax_layout_image_mobile&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;,&quot;size&quot;:&quot;&quot;},&quot;jet_parallax_layout_speed&quot;:{&quot;unit&quot;:&quot;%&quot;,&quot;size&quot;:50,&quot;sizes&quot;:[]},&quot;jet_parallax_layout_type&quot;:&quot;scroll&quot;,&quot;jet_parallax_layout_direction&quot;:&quot;1&quot;,&quot;jet_parallax_layout_fx_direction&quot;:null,&quot;jet_parallax_layout_z_index&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_x&quot;:50,&quot;jet_parallax_layout_bg_x_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_x_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_y&quot;:50,&quot;jet_parallax_layout_bg_y_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_y_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_size&quot;:&quot;auto&quot;,&quot;jet_parallax_layout_bg_size_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_size_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_animation_prop&quot;:&quot;transform&quot;,&quot;jet_parallax_layout_on&quot;:[&quot;desktop&quot;,&quot;tablet&quot;]}],&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-256e9cc8\" data-id=\"256e9cc8\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-4b4a0d4c elementor-widget elementor-widget-heading\" data-id=\"4b4a0d4c\" data-element_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\">Screening form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-be6829f elementor-widget elementor-widget-text-editor\" data-id=\"be6829f\" data-element_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 id=\"field_11_47\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" data-js-reload=\"field_11_47\">Please note that requests received after 4:15 p.m. will be received and processed the next working day.<\/div>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-565a29e9 form-execution elementor-widget elementor-widget-shortcode\" data-id=\"565a29e9\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><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 gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_21' style='display:none'>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_21'  action='\/en\/wp-json\/wp\/v2\/pages\/3283' data-formid='21' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_21' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_21_113\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Client<\/h3><\/div><div id=\"field_21_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half orange-field gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_11'>Client Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_21_11' type='text' value='' class='large'    placeholder='Name*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_21_19\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half orange-field gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_19'>Client E-mail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_19' id='input_21_19' type='email' value='' class='large'   placeholder='Email*' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_21_126\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full orange-field gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Client Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \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_21_126' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_21_126_1_container' >\n                                        <input type='text' name='input_126.1' id='input_21_126_1' value=''   placeholder='Adresse postale*' aria-required='true'    \/>\n                                        <label for='input_21_126_1' id='input_21_126_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_21_126_2_container' >\n                                        <input type='text' name='input_126.2' id='input_21_126_2' value=''   placeholder='Adresse ligne 2'  aria-required='false'   \/>\n                                        <label for='input_21_126_2' id='input_21_126_2_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Address 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_21_126_3_container' >\n                                    <input type='text' name='input_126.3' id='input_21_126_3' value=''   placeholder='Ville*' aria-required='true'    \/>\n                                    <label for='input_21_126_3' id='input_21_126_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_21_126_4_container' >\n                                        <select name='input_126.4' id='input_21_126_4'     aria-required='true'    ><option value='' selected='selected'>Province*<\/option><option value='Alberta' >Alberta<\/option><option value='British Columbia' >British Columbia<\/option><option value='Manitoba' >Manitoba<\/option><option value='New Brunswick' >New Brunswick<\/option><option value='Newfoundland and Labrador' >Newfoundland and Labrador<\/option><option value='Northwest Territories' >Northwest Territories<\/option><option value='Nova Scotia' >Nova Scotia<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='Prince Edward Island' >Prince Edward Island<\/option><option value='Quebec' >Quebec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_21_126_4' id='input_21_126_4_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_21_126_5_container' >\n                                    <input type='text' name='input_126.5' id='input_21_126_5' value=''   placeholder='Code postal*' aria-required='true'    \/>\n                                    <label for='input_21_126_5' id='input_21_126_5_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_126.6' id='input_21_126_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><input type=\"hidden\" name=\"gpaa_place_126\" class=\"gform_hidden\" value=\"\"><\/fieldset><div id=\"field_21_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half orange-field gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_14'>Client Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_21_14' type='text' value='' class='large'    placeholder='Phone Number*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_21_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half orange-field field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_18'>Client Cellphone Number<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_21_18' type='text' value='' class='large'    placeholder='Cellphone Number'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_21_115\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Wanted Person<\/h3><\/div><div id=\"field_21_23\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half orange-field gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_23'>Wanted Person&#039;s Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_21_23' type='text' value='' class='large'    placeholder='Last Name*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_21_135\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half orange-field gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_135'>Wanted Person&#039;s First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_135' id='input_21_135' type='text' value='' class='large'    placeholder='First Name*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_21_32\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half orange-field field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_32'>Wanted Person&#039;s E-mail<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_32' id='input_21_32' type='email' value='' class='large'   placeholder='E-mail'  aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_21_136\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half orange-field field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_136'>Wanted Person&#039;s Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_136' id='input_21_136' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='Date of Birth' aria-describedby=\"input_21_136_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_21_136_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_21_136' class='gform_hidden' value='https:\/\/pmbhuissiers.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_21_128\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full orange-field field_sublabel_hidden_label gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Wanted Person&#039;s Address or Last Known Address<\/legend>    \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_21_128' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_21_128_1_container' >\n                                        <input type='text' name='input_128.1' id='input_21_128_1' value=''   placeholder='Address or Last Known Address' aria-required='false'    \/>\n                                        <label for='input_21_128_1' id='input_21_128_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_21_128_2_container' >\n                                        <input type='text' name='input_128.2' id='input_21_128_2' value=''   placeholder='App \/ Office \/ Suite'  aria-required='false'   \/>\n                                        <label for='input_21_128_2' id='input_21_128_2_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Address 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_21_128_3_container' >\n                                    <input type='text' name='input_128.3' id='input_21_128_3' value=''   placeholder='City' aria-required='false'    \/>\n                                    <label for='input_21_128_3' id='input_21_128_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_21_128_4_container' >\n                                        <select name='input_128.4' id='input_21_128_4'     aria-required='false'    ><option value='' selected='selected'>Province<\/option><option value='Alberta' >Alberta<\/option><option value='British Columbia' >British Columbia<\/option><option value='Manitoba' >Manitoba<\/option><option value='New Brunswick' >New Brunswick<\/option><option value='Newfoundland and Labrador' >Newfoundland and Labrador<\/option><option value='Northwest Territories' >Northwest Territories<\/option><option value='Nova Scotia' >Nova Scotia<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='Prince Edward Island' >Prince Edward Island<\/option><option value='Quebec' >Quebec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_21_128_4' id='input_21_128_4_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_21_128_5_container' >\n                                    <input type='text' name='input_128.5' id='input_21_128_5' value=''   placeholder='Postal code' aria-required='false'    \/>\n                                    <label for='input_21_128_5' id='input_21_128_5_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_128.6' id='input_21_128_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><input type=\"hidden\" name=\"gpaa_place_128\" class=\"gform_hidden\" value=\"\"><\/fieldset><div id=\"field_21_30\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third orange-field field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_30'>Wanted Person&#039;s Phone Number<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_21_30' type='text' value='' class='large'    placeholder='Phone Number'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_21_137\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third orange-field field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_137'>Wanted Person&#039;s SSN<\/label><div class='ginput_container ginput_container_text'><input name='input_137' id='input_21_137' type='text' value='' class='large'    placeholder='SSN'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_21_31\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third orange-field field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_31'>Wanted Person&#039;s Cellphone Number<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_21_31' type='text' value='' class='large'    placeholder='N\u00b0 de cellulaire'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_21_150\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_150'>Additional Information<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_150' id='input_21_150' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_21_117\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Deposit required for screening service <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/h3><\/div><fieldset id=\"field_21_146\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-full price-radio gfield_price gfield_price_21_146 gfield_product_21_146 gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Service<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_21_146'>\n\t\t\t<div class='gchoice gchoice_21_146_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_146' type='radio' value='Identity + address and\/or income|215'  id='choice_21_146_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_21_146_0' id='label_21_146_0' class='gform-field-label gform-field-label--type-inline'>Identity + address and\/or income <span>$215.00<\/span><\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_21_146_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_146' type='radio' value='Summary solvency (address, job and bank)|340'  id='choice_21_146_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_21_146_1' id='label_21_146_1' class='gform-field-label gform-field-label--type-inline'>Summary solvency (address, job and bank) <span>$340.00<\/span><\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_21_146_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_146' type='radio' value='Full report (complete solvency and asset search)|485'  id='choice_21_146_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_21_146_2' id='label_21_146_2' class='gform-field-label gform-field-label--type-inline'>Full report (complete solvency and asset search) <span>$485.00<\/span><\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_21_153\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_153'>Reason for the request<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_153' id='input_21_153' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_21_139\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-quarter fix-inline-text gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>City: <\/h4><\/div><div id=\"field_21_140\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter fix-inline-input gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_140'>Signed City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_140' id='input_21_140' type='text' value='' class='large'    placeholder='City*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_21_141\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-quarter fix-inline-text-center gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4> Date: <\/h4><\/div><div id=\"field_21_142\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter fix-inline-input gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_142'>Signed Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_142' id='input_21_142' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='Date*' aria-describedby=\"input_21_142_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_21_142_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_21_142' class='gform_hidden' value='https:\/\/pmbhuissiers.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_21_144\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full 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_21_144'>Signature of the customer or representative<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><input type='hidden' value='' name='input_144' id='input_21_144_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_21_144_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_21_144' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/pmbhuissiers.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_21_144_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_21_144_resetbutton' src='data:image\/png;base64,iVBORw0KGgoAAAANSUhEUgAAABgAAAAYCAYAAADgdz34AAAAGXRFWHRTb2Z0d2FyZQBBZG9iZSBJbWFnZVJlYWR5ccllPAAAAtRJREFUeNrsld9rklEYx32nc7i2GulGtZg6XJbJyBeJzbGZJJVuAyFD7D8QumiG7nLXQuw6dtHN7oYwFtIgDG+2CGQtGf1grBpWIkPHaDpJZvZ95F2cqfPHRTfRgY\/H85znfb7nPc85z8sVi0XR32zcf4GmBTiOk8GWY8YSdEpwHpwG7eAA\/ABJsA3\/w5MEJOUGi8VyCUFFeCiGvlcsFvOFQqGtzK1d4Bzmr8DvDfy\/NyTgcDj6I5GIGA91YdiN4CW7RqNp83g8fZ2dna17e3v5ubm5r1tbWz8F8WH4v4PIh7oCTOumH4VCIQkGg6axsTElgkRhyoJTXq\/33srKStzpdL5KpVK0RVcxvw+Rb40KlNr09LTSbDZH8HcJ\/DqyY2sksE9Go1GHVqsN5fP5Yk9Pz3WIJNmctNQT8Pl8n\/DQZza40CjIokqlerywsMCTYWdnpwVjTb0kF1dXVy2sLR6Pn4HIJnu6mLZht9s3KUeUE7VarYPt459ZOqZlKMFEFRRVfI+QzMzMeBHOOTAw4GbnKt4AK6Vte0\/nHA6pBu\/T4ejoqAgnS4dTlT82U74aJOourYTn+ds1VlyNm+AReMjaK5LsdrvpxoqSyWSX8DbVSwDHtYJ+hi9gETxl\/SoCWK1WGfWJRKLQ0dGhO0kAq5MGAoFB\/OVZXC6XtqYAzvamwWCgMiDK5XKXsSL5CRpZv98vnp+fH2SNJpPpYk0BlIIXSJaB\/lOZkEqlNyCi4ahAHd8iajGUj41a2a+2xzmj0fgsFAoN0QA3lAJfAxMISDeVpx7jSbJnMplSOZ6amuptVIBaZHx8\/G0sFruj1+tlgo2KWh\/oF3opGWl+bW3t1uzsrHJ5eXm42Q+OGW\/wADc7gYe3w+Fwen19\/YByhMMgt9lsqpGRkQvYxifwfQnup9PprFwuX2rmi0ZvYAdDwurPgl1A9ek1eE7byqYR7P873+TfAgwATQiKdubVli0AAAAASUVORK5CYII=' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_21_144_data' name='input_21_144_data' value=''><\/div><\/div><fieldset id=\"field_21_155\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Acknowledgement for professional services<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_155.1' id='input_21_155_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_21_155_1' >I hereby acknowledge that I have read and understood the <a href=\"\/en\/general-terms-conditions-professional-services-agreement\" target=\"_blank\">professional services form and agreement<\/a>.<span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/label><input type='hidden' name='input_155.2' value='I hereby acknowledge that I have read and understood the &lt;a href=&quot;\/en\/general-terms-conditions-professional-services-agreement&quot; target=&quot;_blank&quot;&gt;professional services form and agreement&lt;\/a&gt;.' class='gform_hidden' \/><input type='hidden' name='input_155.3' value='21' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_21_154\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Agree to abide terms and conditions for professional services<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_154.1' id='input_21_154_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_21_154_1' >I hereby agree to abide by the terms and conditions set forth in the <a href=\"\/en\/general-terms-conditions-professional-services-agreement\" target=\"_blank\">professional services form and agreement<\/a>.<span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/label><input type='hidden' name='input_154.2' value='I hereby agree to abide by the terms and conditions set forth in the &lt;a href=&quot;\/en\/general-terms-conditions-professional-services-agreement&quot; target=&quot;_blank&quot;&gt;professional services form and agreement&lt;\/a&gt;.' class='gform_hidden' \/><input type='hidden' name='input_154.3' value='21' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_21_145\" class=\"gfield gfield--type-total gfield--input-type-total gfield--width-full gfield_price gfield_price_21_ gfield_total gfield_total_21_ 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_21_145'>Total<\/label><div class='ginput_container ginput_container_total'>\n\t\t\t\t\t\t\t<input type='text' readonly name='input_145' id='input_21_145' value='$ 0.00 CAD' class='gform-text-input-reset ginput_total ginput_total_21' \/>\n\t\t\t\t\t\t<\/div><\/div><fieldset id=\"field_21_156\" class=\"gfield gfield--type-creditcard gfield--input-type-creditcard gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Credit card<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_creditcard gform-grid-row' id='input_21_156'><span class='ginput_full gform-grid-col' id='input_21_156_1_container' >\n                                    <div class='gform_card_icon_container'><div class='gform_card_icon gform_card_icon_amex' >American Express<\/div><div class='gform_card_icon gform_card_icon_discover' >Discover<\/div><div class='gform_card_icon gform_card_icon_mastercard' >MasterCard<\/div><div class='gform_card_icon gform_card_icon_visa' >Visa<\/div><span class='screen-reader-text' id='field_21_156_supported_creditcards'>Supported Credit Cards: American Express, Discover, MasterCard, Visa<\/span><\/div>\n                                    <label for='input_21_156_1' id='input_21_156_1_label' class='gform-field-label gform-field-label--type-sub '>Card Number<\/label>\n                                    <input type='text' name='input_156.1' id='input_21_156_1' value=''   onchange='gformMatchCard(\"input_21_156_1\");' onkeyup='gformMatchCard(\"input_21_156_1\");' autocomplete='off' pattern='[0-9]*' title='Only digits are allowed'  aria-required='true'  \/>\n                                 <\/span><span class='ginput_full ginput_cardextras gform-grid-col gform-grid-row' id='input_21_156_2_container'>\n                                            <fieldset class='ginput_cardinfo_left gform-grid-col' id='input_21_156_2_cardinfo_left'>\n                                            <legend class='gform-field-label gform-field-label--type-sub '>Expiration Date<\/legend>\n                                                <span class='ginput_card_expiration_container ginput_card_field gform-grid-row'>\n                                                   <span class='ginput_card_expiration_month_container gform-grid-col'>\n                                                       <label for='input_21_156_2_month' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                                       <select name='input_156.2[]' id='input_21_156_2_month'   class='ginput_card_expiration ginput_card_expiration_month' aria-required='true'  >\n                                                           <option value=''>Month<\/option><option value='1' >01<\/option><option value='2' >02<\/option><option value='3' >03<\/option><option value='4' >04<\/option><option value='5' >05<\/option><option value='6' >06<\/option><option value='7' >07<\/option><option value='8' >08<\/option><option value='9' >09<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option>\n                                                       <\/select>\n                                                   <\/span>\n                                                   <span class='ginput_card_expiration_year_container gform-grid-col'>\n                                                       <label for='input_21_156_2_year' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                                       <select name='input_156.2[]' id='input_21_156_2_year'   class='ginput_card_expiration ginput_card_expiration_year' aria-required='true'  >\n                                                           <option value=''>Year<\/option><option value='2026' >2026<\/option><option value='2027' >2027<\/option><option value='2028' >2028<\/option><option value='2029' >2029<\/option><option value='2030' >2030<\/option><option value='2031' >2031<\/option><option value='2032' >2032<\/option><option value='2033' >2033<\/option><option value='2034' >2034<\/option><option value='2035' >2035<\/option><option value='2036' >2036<\/option><option value='2037' >2037<\/option><option value='2038' >2038<\/option><option value='2039' >2039<\/option><option value='2040' >2040<\/option><option value='2041' >2041<\/option><option value='2042' >2042<\/option><option value='2043' >2043<\/option><option value='2044' >2044<\/option><option value='2045' >2045<\/option>\n                                                       <\/select>\n                                                   <\/span>\n                                                <\/span>\n                                            <\/fieldset><span class='ginput_cardinfo_right gform-grid-col' id='input_21_156_2_cardinfo_right'>\n                                                <label for='input_21_156_3' class='gform-field-label gform-field-label--type-sub '>Security Code<\/label>\n                                                <input type='text' name='input_156.3' id='input_21_156_3'   class='ginput_card_security_code' value='' autocomplete='off' pattern='[0-9]*' title='Only digits are allowed'  aria-required='true'  \/>\n                                                <span class='ginput_card_security_code_icon'>&nbsp;<\/span>\n                                             <\/span>\n                                        <\/span><span class='ginput_full gform-grid-col' id='input_21_156_5_container'>\n                                            <label for='input_21_156_5' id='input_21_156_5_label' class='gform-field-label gform-field-label--type-sub '>Cardholder Name<\/label>\n                                            <input type='text' name='input_156.5' id='input_21_156_5' value=''    aria-required='false'  \/>\n                                        <\/span> <\/div><\/fieldset><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_21' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Soumettre le formulaire'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_21' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_21' id='gform_theme_21' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_21' id='gform_style_settings_21' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_21' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='21' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='CAD' 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