document.write('<script type=\"text/javascript\" src=\"https://assets.bravenet.com/bn/js/emailfwd/bn_email_forms.min.js\"></script><link rel=\"stylesheet\" href=\"https://pub27.bravenet.com/emailfwd/v2/bnet-form.css.php?usernum=2285354722&formid=1587&formpadding=0\"><form method=\"post\" class=\"bnet-form\" enctype=\"multipart/form-data\" action=\"#bn-ajax-post:2285354722:27:1587\"><div class=\"bn-form-header\"><div class=\"bn-form-legend\"><div>Wowos Club Order Form</div></div> </div><div class=\"fields-wrapper ui-sortable-handle\"><div class=\"bn-row rowcb\"><span class=\"bn-label\">Payment Method <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><span class=\"bn-optionwrapper\"><label class=\"bn-radio\"><input type=\"radio\" name=\"Field-169962951827579\" value=\"Wowos Club Account\" checked=\"checked\"> <span class=\"bn-inner-label\">Wowos Club Account</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-radio\"><input type=\"radio\" name=\"Field-169962951827579\" value=\"EFT\"> <span class=\"bn-inner-label\">EFT</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-radio\"><input type=\"radio\" name=\"Field-169962951827579\" value=\"Cash Sent\"> <span class=\"bn-inner-label\">Cash Sent</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-radio\"><input type=\"radio\" name=\"Field-169962951827579\" value=\"Crypto Currency\"> <span class=\"bn-inner-label\">Crypto Currency</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-radio\"><input type=\"radio\" name=\"Field-169962951827579\" value=\"PayShap\"> <span class=\"bn-inner-label\">PayShap</span></label></span></span></div></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">First Name: <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"FirstName\" placeholder=\"\" validator=\"\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">Last Name: <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"LastName\" placeholder=\"\" validator=\"\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">Phone Number: <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"PhoneNumber\" placeholder=\"\" validator=\"\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">E-mail Address: <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"PhoneNumber-167726740289436\" placeholder=\"\" validator=\"email\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">Address Line 1: <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"AddressLineOne\" placeholder=\"\" validator=\"\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">Address Line 2: <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"AddressLineTwo\" placeholder=\"\" validator=\"\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">City: <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"City\" placeholder=\"\" validator=\"\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">State/Province: <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"StateProvince\" placeholder=\"\" validator=\"\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">Country: <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"Country\" placeholder=\"\" validator=\"\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">Zip/Postal Code: <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><input type=\"text\" name=\"ZipPostalCode\" placeholder=\"\" validator=\"\" required=\"required\" value=\"\"></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><div class=\"bn-row rowcb\"><span class=\"bn-label\">Should we add you in our Wowos Store Club Newsletter?  </span> <span class=\"bn-input\"><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-167734854247171[]\" value=\"Yes\" checked=\"checked\"> <span class=\"bn-inner-label\">Yes</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-167734854247171[]\" value=\"No\"> <span class=\"bn-inner-label\">No</span></label></span></span></div></div><div class=\"fields-wrapper ui-sortable-handle\"><div class=\"bn-row rowcb\"><span class=\"bn-label\">Wowos Kids Club </span> <span class=\"bn-input\"><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-170223101509240[]\" value=\"Wowos\' Kids T-Shirt = R80 each\"> <span class=\"bn-inner-label\">Wowos\' Kids T-Shirt = R80 each</span></label></span></span></div></div><div class=\"fields-wrapper ui-sortable-handle\"><div class=\"bn-row rowcb\"><span class=\"bn-label\">Item (2024 Prices) <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-160243163819595[]\" value=\"Morning Thoughts By Zibuse L Kunene = R250.00 each\" required=\"required\"> <span class=\"bn-inner-label\">Morning Thoughts By Zibuse L Kunene = R250.00 each</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-160243163819595[]\" value=\"Wowos Club Hoodie = R350.00 each\" required=\"required\"> <span class=\"bn-inner-label\">Wowos Club Hoodie = R350.00 each</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-160243163819595[]\" value=\"Mask = R57.20 each\" required=\"required\"> <span class=\"bn-inner-label\">Mask = R57.20 each</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-160243163819595[]\" value=\"Mug = R90.00 each \" required=\"required\"> <span class=\"bn-inner-label\">Mug = R90.00 each </span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-160243163819595[]\" value=\"Slazenger Ladies Hacker Golf Shirt = R531.50 each\" required=\"required\"> <span class=\"bn-inner-label\">Slazenger Ladies Hacker Golf Shirt = R531.50 each</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-160243163819595[]\" value=\"Slazenger Mens Hacker Golf Shirt = R531.50 each\" required=\"required\"> <span class=\"bn-inner-label\">Slazenger Mens Hacker Golf Shirt = R531.50 each</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-160243163819595[]\" value=\"Mouse Pad = R57.20 each \" required=\"required\"> <span class=\"bn-inner-label\">Mouse Pad = R57.20 each </span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-160243163819595[]\" value=\"Key Holder = R57.20 each\" required=\"required\"> <span class=\"bn-inner-label\">Key Holder = R57.20 each</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-160243163819595[]\" value=\"Slippers (80mm w x 30 mm h) = R105.00 each\" required=\"required\"> <span class=\"bn-inner-label\">Slippers (80mm w x 30 mm h) = R105.00 each</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-160243163819595[]\" value=\"A5 Notebook (100 mm x 160 mm) = R100.00 each\" required=\"required\"> <span class=\"bn-inner-label\">A5 Notebook (100 mm x 160 mm) = R100.00 each</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-160243163819595[]\" value=\"Aria Eye Mask = R70.50 each\" required=\"required\"> <span class=\"bn-inner-label\">Aria Eye Mask = R70.50 each</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-160243163819595[]\" value=\"Ladies Hacker Golf Shirt = R531.50 each\" required=\"required\"> <span class=\"bn-inner-label\">Ladies Hacker Golf Shirt = R531.50 each</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-160243163819595[]\" value=\"US Basic Mens T-Shirt = R250 each\" required=\"required\"> <span class=\"bn-inner-label\">US Basic Mens T-Shirt = R250 each</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-160243163819595[]\" value=\"Combo 1 - Slippers, A5 Notebook, Arial Eye Mask, Ladies Hacker Golf Shirt = R720 each\" required=\"required\"> <span class=\"bn-inner-label\">Combo 1 - Slippers, A5 Notebook, Arial Eye Mask, Ladies Hacker Golf Shirt = R720 each</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-160243163819595[]\" value=\"Combo 2 - Keep Going - Journal, Slippers, Eye mask = R247.95\" required=\"required\"> <span class=\"bn-inner-label\">Combo 2 - Keep Going - Journal, Slippers, Eye mask = R247.95</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-160243163819595[]\" value=\"Combo 3 - A5 Notebook, Mug, Mouse Paid, Slippers = R352.20\" required=\"required\"> <span class=\"bn-inner-label\">Combo 3 - A5 Notebook, Mug, Mouse Paid, Slippers = R352.20</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-160243163819595[]\" value=\"Combo 4 - Hoodie, Mug, Journal = R486.00\" required=\"required\"> <span class=\"bn-inner-label\">Combo 4 - Hoodie, Mug, Journal = R486.00</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-160243163819595[]\" value=\"Combo 5 - Keep Going Mug and Journal  R170.00\" required=\"required\"> <span class=\"bn-inner-label\">Combo 5 - Keep Going Mug and Journal  R170.00</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-160243163819595[]\" value=\"Cap = R90.00 each\" required=\"required\"> <span class=\"bn-inner-label\">Cap = R90.00 each</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-160243163819595[]\" value=\"Only Mom Can Storage Box = R316.00 each\" required=\"required\"> <span class=\"bn-inner-label\">Only Mom Can Storage Box = R316.00 each</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-160243163819595[]\" value=\"Mask = R57.20 each\" required=\"required\"> <span class=\"bn-inner-label\">Mask = R57.20 each</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-160243163819595[]\" value=\"Combo 4 - Wowos A5 Notebook, Mug = R352.20\" required=\"required\"> <span class=\"bn-inner-label\">Combo 4 - Wowos A5 Notebook, Mug = R352.20</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-160243163819595[]\" value=\"Wowos Club Mens T-Shirt (Don\'t be a number be a member) = R345 each\" required=\"required\"> <span class=\"bn-inner-label\">Wowos Club Mens T-Shirt (Don\'t be a number be a member) = R345 each</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-160243163819595[]\" value=\"Pick n Pay  (Door Delivery) = R119.99 \" required=\"required\"> <span class=\"bn-inner-label\">Pick n Pay  (Door Delivery) = R119.99 </span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-160243163819595[]\" value=\"Pep Delivery (3 to 5 days Collection at Pep stores) = R99.95\" required=\"required\"> <span class=\"bn-inner-label\">Pep Delivery (3 to 5 days Collection at Pep stores) = R99.95</span></label></span><span class=\"bn-optionwrapper\"><label class=\"bn-checkbox\"><input type=\"checkbox\" name=\"Field-160243163819595[]\" value=\"Pep Delivery (7 to 9 days Collection at Pep stores) = R69.95  \" required=\"required\" checked=\"checked\"> <span class=\"bn-inner-label\">Pep Delivery (7 to 9 days Collection at Pep stores) = R69.95  </span></label></span></span></div></div><div class=\"fields-wrapper ui-sortable-handle\"><div class=\"bn-row\"><span class=\"bn-label\">Size of the T-Shirt(s) - where applicable </span> <span class=\"bn-input\"><span class=\"bn-select\"><select name=\"Field-160243172134378[]\"><option value=\"Small\" selected=\"selected\">Small</option><option value=\"Medium\">Medium</option><option value=\"Large\">Large</option></select></span></span></div></div><div class=\"fields-wrapper ui-sortable-handle\"><div class=\"bn-row\"><span class=\"bn-label\">Quantity of the order <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><span class=\"bn-select\"><select name=\"Field-160243216358493[]\" required=\"required\"><option value=\"1\" selected=\"selected\">1</option><option value=\"2\">2</option><option value=\"3\">3</option><option value=\"4\">4</option><option value=\"5\">5</option></select></span></span></div></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span class=\"bn-label\">Delivery Instructions: <span class=\"bn-required\">*</span></span> <span class=\"bn-input\"><textarea name=\"SpecialDeliveryInstructions\" placeholder=\"\" validator=\"\" required=\"required\"></textarea></span></label></div><div class=\"fields-wrapper ui-sortable-handle\"><label class=\"bn-row\"><span 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