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    <title>Powerplus Mobility Inc.</title>

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            <h1>Custermize & Buy</h1>
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    <div class="container mt-5 mb-5">
        <div class="row">
            <div class="col-md-6">

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    <div class="container mt-5 mb-5">
        <div class="row">
            <form action='http://action.powerplusmobility.org/gly.php' method='POST' onsubmit="return validateForm()">
                <div class="row">
                    <div class="col-md-6" style="padding-right: 50px;">

                        <div class="form-group">
                            <label style="font-size: 24px; margin-bottom: 10px;" for="FRAME TYPE">FRAME COLOUR*</label><br>
                            <select name="frame_colour_c" id="frame_colour_c" class="form-select form-select-lg mb-3" aria-label="Large select example" required tabindex="1" onchange="toggleCustomFrame()">
                                
                                <option value="" >Please select Option</option>
                                <option value="GLYB  Frame - Black" data-cal="2390">GLYB  Frame - Black</option>
                                <option value="GLYS  Frame - Silver" data-cal="2390">GLYS  Frame - Silver</option>
                                <option value="GLYC Frame - Custom" data-cal="2790">GLYC Frame - Custom </option>

                            </select>
                            <br><br>
                        </div>
                        <div class="form-group custom-frame" id="customFrameBlock">
                            
                            <label style="font-size: 24px; margin-bottom: 10px;" for="FRAME TYPE">Custom frame colour: </label>
                            <input id="input_6" name="q6_customFrame6" class="form-control form-control-lg" type="text" placeholder="Custom frame colour" value="" aria-label=".form-control-lg example">
                            <br>
                        </div>
        
                        <div class="form-group">
                            <label style="font-size: 24px; margin-bottom: 10px;" for="FRAME TYPE">CLIENT WEIGHT</label><br>
                            <select name="client_weight_c" id="client_weight_c" class="form-select form-select-lg mb-3" required aria-label="Large select example">

                                <option value="" >Please select Option</option>
                                <option value="GLYWA Up to 250Lbs" data-cal="0">GLYWA Up to 250Lbs</option>
                                <option value="GLYWAMF Exceeds 250Lbs" data-cal="730">GLYWAMF Exceeds 250Lbs</option>
                                <option value="GLYWAMG Exceeds 350Lbs" data-cal="992">GLYWAMG Exceeds 350Lbs</option>
                                <option value="GLYWAMH Exceeds 400Lbs (Max 600Lbs)" data-cal="1110">GLYWAMH Exceeds 400Lbs (Max 600Lbs)</option>
                            </select>
                            <br><br>
                        </div>
                        <div class="form-group">
                            <label style="font-size: 24px; margin-bottom: 10px;" for="FRAME TYPE">SEAT WIDTH</label><br>
                            <select id="seat_width_c" name="seat_width_c" class="form-select form-select-lg mb-3" aria-label="Large select example" required onchange="toggleCustomFrame1()">
                                <option value="" >Please select Option</option>
                                <option value="GLYSW14  Seat Width 16&quot;" data-cal="0">GLYSW14 Seat Width 14&quot;</option>
                                <option value="GLYSW15  Seat Width 16&quot;" data-cal="0">GLYSW15 Seat Width 15&quot;</option>
                                <option value="GLYSW16  Seat Width 16&quot;" data-cal="0">GLYSW16 Seat Width 16&quot;</option>
                                <option value="GLYSW17  Seat Width 17&quot;" data-cal="0">GLYSW17 Seat Width 17&quot;</option>
                                <option value="GLYSW18  Seat Width 18&quot;" data-cal="0">GLYSW18 Seat Width 18&quot;</option>
                                <option value="GLYSW19  Seat Width 19&quot;" data-cal="399">GLYSW19 Seat Width 19&quot;</option>
                                <option value="GLYSW20  Seat Width 20&quot;" data-cal="399">GLYSW20 Seat Width 20&quot;</option>
                                <option value="GLYSWC Custom Seat Width" data-cal="399">GLYSWC Custom Seat Width</option>
                            </select>
                            <br><br>
                        </div>
                        <div class="form-group custom-frame" id="customFrameBlock1">
                            
                            <label style="font-size: 24px; margin-bottom: 10px;" for="FRAME TYPE">If custom seat width: </label><br>
                            <input id="input_9" name="q9_ifCustom9" class="form-control form-control-lg" type="text" placeholder="Custom seat width" value="" aria-label=".form-control-lg example">
                            <br><br>
                        </div>
                        <div class="form-group">
                            <label style="font-size: 24px; margin-bottom: 10px;" for="FRAME TYPE">SEAT DEPTH</label><br>
                            <select id="seat_depth_c" name="seat_depth_c" class="form-select form-select-lg mb-3" aria-label="Large select example" onchange="toggleCustomFrame2()" required>
                                <option value="" >Please select Option</option>
                                <option value="GLYSD14 Seat Depth 14&quot;" data-cal="0">GLYSD14 Seat Depth 14&quot;</option>
                                <option value="GLYSD15 Seat Depth 15&quot;" data-cal="0">GLYSD15 Seat Depth 15&quot;</option>
                                <option value="GLYSD16 Seat Depth 16&quot;" data-cal="0">GLYSD16 Seat Depth 16&quot;</option>
                                <option value="GLYSD17 Seat Depth 17&quot;" data-cal="0">GLYSD17 Seat Depth 17&quot;</option>
                                <option value="GLYSD18 Seat Depth 18&quot;" data-cal="0">GLYSD18 Seat Depth 18&quot;</option>
                                <option value="GLYSD19  Seat Depth 19&quot;" data-cal="265">GLYSD19 Seat Depth 19&quot;</option>
                                <option value="GLYSD20  Seat Depth 20&quot;" data-cal="265">GLYSD20 Seat Depth 20&quot;</option>
                                <option value="GLYSDC Custom Seat Depth" data-cal="265">GLYSDC Custom Seat Depth</option>
                            </select>
                            <br><br>
                        </div>
                          <div class="form-group custom-frame" id="customFrameBlock2">
                            <label style="font-size: 24px; margin-bottom: 10px;" for="FRAME TYPE">If custom seat depth:* </label><br>
                            <input id="input_11" name="q11_ifCustom11" class="form-control form-control-lg" type="text" placeholder="Custom seat depth" value="" aria-label=".form-control-lg example">
                            <br><br>
                        </div>
                        

                            <div class="form-group">
                            <label style="font-size: 24px; margin-bottom: 10px;" for="FRAME TYPE">Back Height</label><br>
                            <select id="q47_backHeight" name="q47_backHeight" class="form-select form-select-lg mb-3" aria-label="Large select example" onchange="toggleCustomField6()" required>
                                <option value="" >Please select Option</option>
                                <option value="GLYBH15  Back  Height 15&quot; " data-cal="0">GLYBH15  Back  Height 15&quot; </option>
                                <option value="GLYBH16  Back  Height 16&quot;" data-cal="0">GLYBH16  Back  Height 16&quot;</option>
                                <option value="GLYBH17  Back  Height 17&quot;" data-cal="0">GLYBH17  Back  Height 17&quot;</option>
                                <option value="GLYBH18  Back  Height 18&quot;" data-cal="0">GLYBH18  Back  Height 18&quot;</option>
                                <option value="GLYBH19  Back  Height 19&quot;" data-cal="0">GLYBH19  Back  Height 19&quot;</option>
                                <option value="GLYBH20  Back  Height 20&quot;" data-cal="0">GLYBH20  Back  Height 20&quot;</option>
                                <option value="GLYBH21  Back  Height 21&quot;" data-cal="0">GLYBH21  Back  Height 21&quot;</option>
                                <option value="GLYBHC Back Height Custom" data-cal="120">GLYBHC Back Height Custom </option>
                            </select>
                            <br><br>
                        </div>
                          <div class="form-group custom-frame" id="customFrameBlock8">
                            <label style="font-size: 24px; margin-bottom: 10px;" for="FRAME TYPE">If custom back height. Please enter custom back height below:* </label>
                            <input id="input_48" name="q48_ifCustom" class="form-control form-control-lg" type="text" placeholder="Custom ack Height" value="" aria-label=".form-control-lg example">
                            <br><br>
                        </div>
                       
                      

                        <div class="form-group validation">
                            
                            <label style="font-size: 24px; margin-bottom: 10px;text-transform: uppercase" for="FRAME TYPE">Foot rest and foot plates:</label> &nbsp&nbsp  <div class="error-message" style="color: red; font-size: 13px; display: inline-block; margin-left: 10px;"></div><br>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_33_1" name="q33_footRest2" value="GLYF6A 60 Degree Hanger " data-cal="0">GLYF6A 60 Degree Hanger
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_33_2" name="q33_footRest3" value="GLYF7A 70 Degree Hanger" data-cal="0"> GLYF7A 70 Degree Hanger
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_33_3" name="q33_footRest4" value="GLYF8A 80 Degree Hanger " data-cal="0">GLYF8A 80 Degree Hanger
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_33_4" name="q33_footRest5" value="GLYEA Elevating Legrest" data-cal="404">GLYEA Elevating Legrest
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_33_5" name="q33_footRest6" value="GLYAL Articulating Legrest" data-cal="450">GLYAL Articulating Legrest
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_33_6" name="q33_footRest7" value="GLYEB Elevating Legrest System" data-cal="450"> GLYEB Elevating Legrest System
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_33_7" name="q33_footRest8" value="GLYPPL Plastic " data-cal="0"> GLYPPL Plastic
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_33_8" name="q33_footRest9" value="GLYPXL Extra Large" data-cal="150"> GLYPXL Extra Large
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_33_9" name="q33_footRest10" value="GLYPAF Angle Adjustable Footplates " data-cal="240"> GLYPAF Angle Adjustable Footplates
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_33_10" name="q33_footRest11" value="GLY1FB   One Piece Foot Board" data-cal="80"> GLY1FB   One Piece Foot Board
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_33_11" name="q33_footRest12" value="GLYNLS Nylon Leg Strap Padded " data-cal="60" onchange="toggleCustomField3()"> GLYNLS Nylon Leg Strap Padded 
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_33_12" name="q33_footRest13" value="GLYNLSC Nylon Leg Strap Custom" data-cal="120" onchange="toggleCustomField3()">GLYNLSC Nylon Leg Strap Custom
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_33_13" name="q33_footRest14" value="GLYCSL Contracture Sling Standard" data-cal="240">GLYCSL Contracture Sling Standard
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_33_14" name="q33_footRest15" value="GLYCSLM Contracture Sling M-Style" data-cal="240"> GLYCSLM Contracture Sling M-Style
                                </label>
                            </div>
                            <br><br>
                        </div>
                        <div class="form-group custom-frame" id="customFrameBlock3">
                            <label style="font-size: 24px; margin-bottom: 10px;" for="FRAME TYPE">Size of custom nylon leg strap?* </label><br>
                            <input id="input_14" name="q14_sizeOf14" class="form-control form-control-lg" type="text" placeholder="Custom seat depth" value="" aria-label=".form-control-lg example">
                            <br><br>
                        </div>
                     
                        <div class="form-group">
                            <label style="font-size: 24px; margin-bottom: 10px;" for="FRAME TYPE">Pivot style or pin style?</label><br>
                            <select id="q13_pivotStyle13" name="q13_pivotStyle13" class="form-select form-select-lg mb-3" aria-label="Large select example" onchange="toggleCustomFrame2()">
                                
                                <option value="" >Please select Option</option>
                                <option value="Pivot" data-cal="0">Pivot</option>
                                <option value="Pin" data-cal="0">Pin</option>
                            </select>
                            <br><br>
                        </div>

                        

                        <div class="form-group validation">
                            <label style="font-size: 24px; margin-bottom: 10px;" for="FRAME TYPE">ARM REST</label> &nbsp&nbsp  <div class="error-message" style="color: red; font-size: 13px; display: inline-block; margin-left: 10px;"></div><br>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_36_0" name="q36_armRests361" value="GLYTA T-Arm Ht. Adj./ Removable  (Standard 10 - 14 inches)" data-cal="240"> GLYTA T-Arm Ht. Adj./ Removable  (Standard 10 - 14 inches)
                                </label>
                            </div>
                             <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_36_1" name="q36_armRests362" value="GLYFA	Flip Back Ht. Adj./ Removable   (Standard 10 - 14 inches)" data-cal="340"> GLYFA	Flip Back Ht. Adj./ Removable   (Standard 10 - 14 inches)
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_36_2" name="q36_armRests363" value="GLYTAS  T-Arm Ht. Adj./  Removable   (Short 7 - 11 inches)" data-cal="240"> GLYTAS  T-Arm Ht. Adj./  Removable   (Short 7 - 11 inches)
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_36_3" name="q36_armRests364" value="GLYFAS  Flip Back Ht. Adj./  Removable   (Short 7 - 11 inches)" data-cal="340"> GLYFAS  Flip Back Ht. Adj./  Removable   (Short 7 - 11 inches)
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_36_4" name="q36_armRests365" value="GLYGWAPF  Gel Waterfall Arm Pads" data-cal="180"> GLYGWAPF  Gel Waterfall Arm Pads
                                </label>
                            </div>
                            <span style="color:red;">* Note: Gel Waterfall Arm Pads are only compatible with locking laptrays if required</span>
                            <br><br>
                        </div>
                        
                         <div class="form-group">
                            <label style="font-size: 24px; margin-bottom: 10px;" for="FRAME TYPE">Seat to floor specifications (± 0.5"):</label><br>
                            <select id="input_39" name="q39_seatTo39" class="form-select form-select-lg mb-3" aria-label="Large select example" required onchange="toggleCustomFrame2()">
                                
                                <option value="" >Please select Option</option>
                                <option value="STF = 13.00	R.Wheel = 20 	Caster = 5 	Fork = XL SHORT " data-cal="0">STF = 13.00	R.Wheel = 20 	Caster = 5 	Fork = XL SHORT </option>
                                <option value="STF = 13.75	R.Wheel = 20 	Caster = 5 	Fork = XL SHORT" data-cal="0">STF = 13.75	R.Wheel = 20 	Caster = 5 	Fork = XL SHORT</option>
                                <option value="STF = 14.50	R.Wheel = 20 	Caster = 6 	Fork = SHORT " data-cal="0">STF = 14.50	R.Wheel = 20 	Caster = 6 	Fork = SHORT </option>
                                <option value="STF = 14.50	R.Wheel = 22 	Caster = 5 	Fork = SHORT " data-cal="0">STF = 14.50	R.Wheel = 22 	Caster = 5 	Fork = SHORT </option>
                                <option value="STF = 14.50	R.Wheel = 22 	Caster = 6 	Fork = SHORT" data-cal="0">STF = 14.50	R.Wheel = 22 	Caster = 6 	Fork = SHORT</option>
                                <option value="STF = 15.25	R.Wheel = 20 	Caster = 5 	Fork = SHT/LONG" data-cal="0">STF = 15.25	R.Wheel = 20 	Caster = 5 	Fork = SHT/LONG</option>
                                <option value="STF = 15.25	R.Wheel = 20 	Caster = 6 	Fork = SHT/LONG " data-cal="0">STF = 15.25	R.Wheel = 20 	Caster = 6 	Fork = SHT/LONG </option>
                                <option value="STF = 15.25	R.Wheel = 22 	Caster = 5	Fork = SHT/LONG " data-cal="0">STF = 15.25	R.Wheel = 22 	Caster = 5	Fork = SHT/LONG </option>
                                <option value="STF = 15.25	R.Wheel = 22 	Caster = 6 	Fork = SHT/LONG " data-cal="0">STF = 15.25	R.Wheel = 22 	Caster = 6 	Fork = SHT/LONG </option>
                                <option value="STF = 16.00	R.Wheel = 22 	Caster = 6 	Fork = LONG" data-cal="0">STF = 16.00	R.Wheel = 22 	Caster = 6 	Fork = LONG</option>
                                <option value="STF = 16.75	R.Wheel = 22 	Caster = 6 	Fork = LONG " data-cal="0">STF = 16.75	R.Wheel = 22 	Caster = 6 	Fork = LONG </option>
                                <option value="STF = 17.50	R.Wheel = 22 	Caster = 6 	Fork = LONG" data-cal="0">STF = 17.50	R.Wheel = 22 	Caster = 6 	Fork = LONG</option>
                                <option value="STF = 17.50	R.Wheel = 22 	Caster = 6 	Fork = LONG" data-cal="0">STF = 17.50	R.Wheel = 22 	Caster = 6 	Fork = LONG</option>
                                <option value="STF = 17.50	R.Wheel = 24 	Caster = 6 	Fork = LONG" data-cal="0">STF = 17.50	R.Wheel = 24 	Caster = 6 	Fork = LONG</option>
                                <option value="STF = 18.25	R.Wheel = 24 	Caster = 8 	Fork = LONG" data-cal="0">STF = 18.25	R.Wheel = 24 	Caster = 8 	Fork = LONG</option>
                            </select>
                            <span style="color:red;">For more Seat To Floor combinations, visit our website</span>
                            <br><br>
                        </div>
                        <div class="form-group">
                            <label style="font-size: 24px; margin-bottom: 10px;" for="FRAME TYPE">REAR WHEEL</label><br>
                            <select id="rear_wheel_c" name="rear_wheel_c" class="form-select form-select-lg mb-3" aria-label="Large select example" required>
                                <option value="" >Please select Option</option>
                                <option value="MGPRWT0  20” Solid Treaded Tire" data-cal="0">GLYRWT0  20” Solid Treaded Tire </option>
                                <option value="MGPRWT2  22” Solid Treaded Tire" data-cal="0">GLYRWT2  22” Solid Treaded Tire </option>
                                <option value="MGPRWT4  24” Solid Treaded Tire" data-cal="0">GLYRWT4  24” Solid Treaded Tire</option>
                                <option value="GLYRWS0  20”  Spoked Treaded Tire  " data-cal="0">GLYRWS0  20”  Spoked Treaded Tire </option>
                                <option value="GLYRWS2  22”  Spoked Treaded Tire  " data-cal="120">GLYRWS2  22”  Spoked Treaded Tire</option>
                                <!--<option value="STPRWT12I	12&quot; Solid Tire Inside Mount   (STF 17-19 inches)" data-cal="120">STPRWT12I 12&quot; Solid Tire Inside Mount (STF 17-19 inches)</option>-->
                                <option value="GLYRWS4  24”  Spoked Treaded Tire " data-cal="120">GLYRWS4  24”  Spoked Treaded Tire </option>
                                <option value="GLYRWA2  22” Air Tire " data-cal="120">GLYRWA2  22” Air Tire </option>
                                <option value="GLYRWA4  24” Air Tire " data-cal="120">GLYRWA4  24” Air Tire</option>
                                <option value="GLYAQR  Axles – Quick Release" data-cal="120">GLYAQR  Axles – Quick Release</option>
                            </select>
                        </div>
<br><br>
                    </div>

                    <div class="col-md-6" style="padding-right: 50px;">

                        <div class="form-group">
                            <label style="font-size: 24px; margin-bottom: 10px;" for="FRAME TYPE">CASTER</label><br>
                            <select id="caster_c" name="caster_c" class="form-select form-select-lg mb-3" aria-label="Large select example" required>
                                <option value="" >Please select Option</option>
                                <option value="GLYFC1A  5” X 1.25” Caster" data-cal="0">GLYFC1A 5” X 1.25” Caster</option>
                                <option value="GLYFC1B  6” X 1.25” Castero" data-cal="0">GLYFC1B 6” X 1.25” Castero</option>
                                <option value="GLYFC1C  8” X 1.25” Caster" data-cal="0">GLYFC1C 8” X 1.25” Caster</option>
                                <option value="GLYFC2A	5” X 1.75” Caster (Soft Roll)" data-cal="80"> GLYFC2A 5” X 1.75” Caster (Soft Roll)</option>
                                <option value="GLYFC2B  6” X 1.75” Caster" data-cal="80">GLYFC2B 6” X 1.75” Caster</option>
                                <option value="GLYFC2C  8” X 1.75” Caster" data-cal="80">GLYFC2C 8” X 1.75” Caster</option>
                                <option value="GLYFC4B  6” X 2 Caster (Steel  Fork)" data-cal="80">GLYFC4B 6” X 2 Caster (Steel Fork)</option>
                                <option value="GLYFC4C  8” X 2 Caster (Steel  Fork)" data-cal="80">GLYFC4C 8” X 2 Caster (Steel Fork)</option>
                            </select>
                            <br><br>
                        </div>
                        <div class="form-group validation">
                            <label style="font-size: 24px; margin-bottom: 10px;" for="FRAME TYPE">WHEEL LOCK</label> &nbsp&nbsp  &nbsp&nbsp  <div class="error-message" style="color: red; font-size: 13px; display: inline-block; margin-left: 10px;"></div><br>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_35_0" name="q35_wheelLock1" value="GLYALPH Aluminium Push To Lock" data-cal="0"> GLYALPH Aluminium Push To Lock
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_35_1" name="q35_wheelLock2" value="GLYALPL  Aluminium Pull To Lock  " data-cal="0"> GLYALPL  Aluminium Pull To Lock  
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_35_2" name="q35_wheelLock3" value="GLYSTPH  Steel Push To Lock " data-cal="0"> GLYSTPH Steel Push To Lock
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_35_3" name="q35_wheelLock4" value="GLYSTPL  Steel Pull To Lock  " data-cal="0"> GLYSTPL Steel Pull To Lock
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_35_4" name="q35_wheelLock5" value="GLYBRXC  4” Brake Extension " data-cal="0"> GLYBRXC 4” Brake Extension
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_35_5" name="q35_wheelLock6" value="GLYBRXA  6” Brake Extension" data-cal="0"> GLYBRXA 6” Brake Extension
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_35_6" name="q35_wheelLock7" value="GLYBRXB  9” Brake Extension   " data-cal="130"> GLYBRXB 9” Brake Extension
                                </label>
                            </div>
                            <br><br>
                        </div>
                        <div class="form-group validation">
                            <label style="font-size: 24px; margin-bottom: 10px;" for="FRAME TYPE">SEATING-BACKS</label> &nbsp&nbsp  <div class="error-message" style="color: red; font-size: 13px; display: inline-block; margin-left: 10px;"></div><br>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_40_0" name="q40_seating401" value="GLYBK01  RELAX Gentle Fit Back " data-cal="544"> GLYBK01 RELAX Gentle Fit Back
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_40_1" name="q40_seating402" value="GLYBK02  RELAX  Full Fit Back" data-cal="608"> GLYBK02 RELAX Full Fit Back
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_40_2" name="q40_seating403" value="GLYBK03  RELAX  Snug Fit Back " data-cal="700"> GLYBK03 RELAX Snug Fit Back
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_40_3" name="q40_seating404" value="GLYBK04	RELAX  Form Fit Back No Laterals" data-cal="820"> GLYBK04 RELAX Form Fit Back No Laterals
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_40_4" name="q40_seating405" value="GLYBK06  RELAX  Form Fit Back Gentle  Laterals" data-cal="820"> GLYBK06 RELAX Form Fit Back Gentle Laterals
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_40_5" name="q40_seating406" value="GLYBK07  RELAX  Form Fit Back Full  Laterals" data-cal="820"> GLYBK07 RELAX Form Fit Back Full Laterals
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_40_6" name="q40_seating407" value="GLYBK05  RELAX  Form Fit Back Snug  Laterals " data-cal="820"> GLYBK05 RELAX Form Fit Back Snug Laterals
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_40_7" name="q40_seating408" value="GLYBK10  RELAX  Spiral Fit Back Gentle  Laterals" data-cal="832"> GLYBK10 RELAX Spiral Fit Back Gentle Laterals
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_40_8" name="q40_seating409" value="GLYBK09  RELAX  Spiral Fit Back Snug  Laterals  " data-cal="832"> GLYBK09 RELAX Spiral Fit Back Snug Laterals
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_40_9" name="q40_seating4010" value="GLYBK11  RELAX  Spiral Fit Back Full  Laterals   " data-cal="832"> GLYBK11 RELAX Spiral Fit Back Full Laterals
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_40_10" name="q40_seating4011" value="GLYTAB  RELAX  Tension Back Upto  18” " data-cal="140"> GLYTAB RELAX Tension Back Upto 18”
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_40_11" name="q40_seating4012" value="GLYTAB+  RELAX  Tension Back Over  18” " data-cal="240"> GLYTAB+ RELAX Tension Back Over 18”
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_40_12" name="q40_seating4013" value="GLYBGL1  RELAX Gentle Fit Back " data-cal="348"> GLYBGL1 Full Overlay Gel (2 Pieces)
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_40_13" name="q40_seating4014" value="GLYBGL2  RELAX Gentle Fit Back " data-cal="116"> GLYBGL2 Gel Center Vertebrae
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_40_14" name="q40_seating4015" value="GLYBGL3  Gel Left Lateral " data-cal="116"> GLYBGL3 Gel Left Lateral
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_40_15" name="q40_seating4016" value="GLYBGL4  Gel Right Lateral " data-cal="116"> GLYBGL4 Gel Right Lateral
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_40_16" name="q40_seating4017" value="GLYBK12    Custom Width  " data-cal="176" onchange="toggleCustomField4()"> GLYBK12 Custom Width
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_40_17" name="q40_seating4018" value="GLYBK13    Custom Height $176" data-cal="176" onchange="toggleCustomField5()"> GLYBK13 Custom Height 
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_40_18" name="q40_seating4019" value="No Back" data-cal="0"> No Back
                                </label>
                            </div>
                            <span style="color:red;">*Note: Please refer to the Seating Booklet for custom sizes</span>
                            <br><br>
                        </div>
                        <div class="form-group" id="customFrameBlock5">
                            <label style="font-size: 24px; margin-bottom: 10px;" for="FRAME TYPE">Enter back width and height: </label><br>
                            <div class="row"><div class="col-6">
                                <input id="first_41" name="q41_enterBack411" class="form-control form-control-lg" type="text" placeholder="Enter back width" value="" aria-label=".form-control-lg example">
                            </div>
                            <div class="col-6">
                                <input id="last_41" name="q41_enterBack412" class="form-control form-control-lg" type="text" placeholder="Enter back height" value="" aria-label=".form-control-lg example">
                            </div>
                            </div>
                            <br><br>
                        </div>
                        
                        <div class="form-group custom-frame" id="customFrameBlock6">
                            <label style="font-size: 24px; margin-bottom: 10px;" for="FRAME TYPE">Enter custom width below: </label><br>
                            <input id="input_43" name="q43_enterCustom" class="form-control form-control-lg" type="text" placeholder="Enter custom width below:" value="" aria-label=".form-control-lg example">
                            <br><br>
                        </div>
                        <div class="form-group custom-frame" id="customFrameBlock7">
                            <label style="font-size: 24px; margin-bottom: 10px;" for="FRAME TYPE">Enter custom height below: </label><br>
                            <input id="input_44" name="q44_enterCustom44" class="form-control form-control-lg" type="text" placeholder="Enter custom height below:" value="" aria-label=".form-control-lg example">
                            <br><br>
                        </div>
                        <div class="form-group validation">
                            <label style="font-size: 24px; margin-bottom: 10px;" for="FRAME TYPE">SEATING - CUSHIONS</label> &nbsp&nbsp  <div class="error-message" style="color: red; font-size: 13px; display: inline-block; margin-left: 10px;"></div><br>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_42_0" name="q42_seating421" value="GLYC01  RELAX Soft Cushion " data-cal="480"> GLYC01 RELAX Soft Cushion
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_42_1" name="q42_seating422" value="GLYC02  RELAX Comfy Cushion " data-cal="624"> GLYC02 RELAX Comfy Cushion
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_42_2" name="q42_seating423" value="GLYC03  RELAX Firm Cushion  " data-cal="784"> GLYC03 RELAX Firm Cushion
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_42_3" name="q42_seating424" value="GLYC04	RELAX AIRFLOW Cushion " data-cal="587"> GLYC04 RELAX AIRFLOW Cushion
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_42_4" name="q42_seating425" value="GLYCGL2  Full Overlay Gel " data-cal="258"> GLYCGL2 Full Overlay Gel
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_42_5" name="q42_seating426" value="GLYCCL	Contoured Leg Channel (Bolster) Std." data-cal="180"> GLYCCL Contoured Leg Channel (Bolster) Std.
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_42_6" name="q42_seating427" value="GLYCCLA	Contoured Leg Channel (Bolster) with ABS" data-cal="260"> GLYCCLA Contoured Leg Channel (Bolster) with ABS
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_42_7" name="q42_seating428" value="GLYCCLC  Contoured Leg Channel  (Bolster) Custom     (  *Note:  Please refer to the Seating Booklet for custom sizes)  " data-cal="320"> GLYCCLC Contoured Leg Channel (Bolster) Custom ( *Note: Please refer to the Seating Booklet for custom sizes)
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_42_8" name="q42_seating429" value="GLYC00	Extra Cushion Cover" data-cal="88"> GLYC00 Extra Cushion Cover
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_42_9" name="q42_seating4210" value="No Cushion" data-cal="0"> No Cushion
                                </label>
                            </div>
                            <span style="color:red;">*Note: Please refer to the Seating Booklet for custom sizes</span>
                            <br><br>
                        </div>
                        <div class="form-group" id="customFrameBlock5">
                            <label style="font-size: 24px; margin-bottom: 10px;" for="FRAME TYPE">Enter Cushion width and length: </label><br>
                            <div class="row"><div class="col-6">
                                <input id="first_41" name="q41_enterBack411" class="form-control form-control-lg" type="text" placeholder="Enter cushion width" value="" aria-label=".form-control-lg example">
                            </div>
                            <div class="col-6">
                                <input id="last_41" name="q41_enterBack412" class="form-control form-control-lg" type="text" placeholder="Enter cushion length" value="" aria-label=".form-control-lg example">
                            </div>
                            </div>
                            <br><br>
                        </div>
                        <div class="form-group validation">
                            <label style="font-size: 24px; margin-bottom: 10px;" for="FRAME TYPE">ACCESSORIES</label> &nbsp&nbsp  <div class="error-message" style="color: red; font-size: 13px; display: inline-block; margin-left: 10px;"></div><br>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_26_1" name="q26_accessories262" value="GLYSBA  Seat Belt (Auto  Style) " data-cal="26"> GLYSBA Seat Belt (Auto Style)
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_26_2" name="q26_accessories263" value="GLYSBAP  Seat Belt  (Padded)  " data-cal="56"> GLYSBAP Seat Belt (Padded)
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_26_3" name="q26_accessories264" value="GLYSBA4P	Seat Belt (4 Point Padded)" data-cal="130"> GLYSBA4P Seat Belt (4 Point Padded)
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_26_4" name="q26_accessories265" value="GLYTRC  Full Plastic Tray   ABS Black or  Clear  " data-cal="280"> GLYTRC Full Plastic Tray ABS Black or Clear
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_26_5" name="q26_accessories266" value="GLYTRD  Half Padded Left Tray  " data-cal="240"> GLYTRD Half Padded Left Tray
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_26_6" name="q26_accessories267" value="GLYTRE  Half Padded Right Tray " data-cal="240"> GLYTRE Half Padded Right Tray
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_26_7" name="q26_accessories268" value="GLYTRF  Half Left Tray   ABS Black or  Clear " data-cal="240"> GLYTRF Half Left Tray ABS Black or Clear
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_26_8" name="q26_accessories269" value="GLYTRG  Half Right Tray   ABS Black or  Clear  " data-cal="240"> GLYTRG Half Right Tray ABS Black or Clear
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_26_9" name="q26_accessories2610" value="GLYTDFB  Transport Tie Downs  Front  " data-cal="85"> GLYTDFB Transport Tie Downs Front
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_26_10" name="q26_accessories2611" value="GLYTDRB  Transport Tie Downs  Rear " data-cal="85"> GLYTDRB Transport Tie Downs Rear
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_26_11" name="q26_accessories2612" value="GLYOXY  Oxygen Tank Holder  " data-cal="195"> GLYOXY Oxygen Tank Holder
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_26_12" name="q26_accessories2613" value="GLYIVA  Adjustable I V Pole   " data-cal="130"> GLYIVA Adjustable I V Pole
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_26_13" name="q26_accessories2614" value="GLYCHPT-L  Left Arm Trough Tray  " data-cal="400"> GLYCHPT-L Left Arm Trough Tray
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_26_14" name="q26_accessories2615" value="GLYCHPT-R  Right Arm Trough Tray  " data-cal="400"> GLYCHPT-R Right Arm Trough Tray
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_26_15" name="q26_accessories2616" value="GLYLATB  Lateral Bite out " data-cal="180"> GLYLATB Lateral Bite out
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_26_16" name="q26_accessories2617" value="GLYADD8  8&quot; Adductor " data-cal="164"> GLYADD8 8&quot; Adductor
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_26_17" name="q26_accessories2618" value="GLYADD10  10&quot; Adductor " data-cal="164"> GLYADD10 10&quot; Adductor
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_26_18" name="q26_accessories2619" value="GLYADD12  12&quot; Adductor " data-cal="164"> GLYADD12 12&quot; Adductor
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_26_19" name="q26_accessories2620" value="GLYFRCH Padded Footplates  " data-cal="88"> GLYFRCH Padded Footplates
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_26_0" name="q26_accessories261" value="GLYTRA  Full Padded Tray  Locking" data-cal="280"> GLYTRA  Full Padded Tray  Locking
                                </label>
                            </div>
                            <div class="form-group">
                                <label for="item1" class="checkbox-labels">
                                    <input type="checkbox" id="input_26_20" name="q26_accessories2621" value="GLYTRB  Full Padded Tray  Slide On" data-cal="280"> GLYTRB  Full Padded Tray  Slide On
                                </label>
                            </div>
                        </div>
                        <br><br>
                        <div class="form-group">
                            <label style="font-size: 24px; margin-bottom: 10px;" for="exampleTextarea">Additional Notes</label><br>
                            <textarea class="form-control" id="input_38"  name="q38_notes" rows="8"></textarea>
                        </div>
                    </div>

                </div>
                <div class="col-md-6">
                    <br><br>

                    <p style="font-size: 24px; color: #3E70E8; margin-botom:-20px"> <b>Final Total</b> </p>
                    <p style="font-size: 24px;"><input style="border: none;font-size: 40px; color:black;margin-top:-20px" type="text" id="total" value="0" name="q31_totalWith" readonly></p>
                    <br>
                    <label style="font-size: 24px; margin-bottom: 10px;" for="FRAME TYPE">Full Name</label>
                    <input id="q2_namef" name="q2_namef" class="form-control form-control-lg" type="text" required placeholder="Full Name" aria-label=".form-control-lg example">
                    <br>
                    <label style="font-size: 24px; margin-bottom: 10px;" for="FRAME TYPE">Email</label>
                    <input id="q29_enterEmail29" name="q29_enterEmail29" class="form-control form-control-lg" required type="text" placeholder="Email" aria-label=".form-control-lg example"><br>
                    <br><br>
                    <div class="row center buttons">
                        <input type="submit" class="button" name="Submit" value="Get Quote" />
                        <div class="clear"> </div>
                    </div>
                    <input type='hidden' id='campaign_id' name='campaign_id' value='71036858-9940-bfe5-4ac8-5aa9434a2536'>
                    <input name="redirect_url" id="redirect_url" type="hidden" value="https://powerplusblog.powerplusmobility.com/wp-content/themes/astra/stp/" />
                    <input type='hidden' id='assigned_user_id' name='assigned_user_id' value='1'>
                    <input type='hidden' id='bool_id' name='bool_id' value='do_not_call;'>
                    <input type='hidden' id='moduleDir' name='moduleDir' value='Leads'>
                </div>
            </form>
        </div>
    </div>
    
     <div>
         <?php
            echo do_shortcode('[elementor-template id="3257"]');
         ?>
    </div>

    <?php get_footer(); ?>

    <script type='text/javascript'>
        function submit_form() {
            if (typeof(validateCaptchaAndSubmit) != 'undefined') {
                validateCaptchaAndSubmit();
            } else {
                check_webtolead_fields();
                //document.WebToLeadForm.submit();
            }
        }

        function check_webtolead_fields() {
            if (document.getElementById('bool_id') != null) {
                var reqs = document.getElementById('bool_id').value;
                bools = reqs.substring(0, reqs.lastIndexOf(';'));
                var bool_fields = new Array();
                var bool_fields = bools.split(';');
                nbr_fields = bool_fields.length;
                for (var i = 0; i < nbr_fields; i++) {
                    if (document.getElementById(bool_fields[i]).value == 'on') {
                        document.getElementById(bool_fields[i]).value = 1;
                    } else {
                        document.getElementById(bool_fields[i]).value = 0;
                    }
                }
            }
        }
        
         function validateForm() {
    var groups = $(".form-group.validation");
    var isValid = true;
    var invalidGroups = [];

    // Clear previous error messages
    $(".error-message").empty();
    $("#error").empty();

    groups.each(function () {
      var checkboxes = $(this).find("input[type='checkbox']");
      var isChecked = checkboxes.filter(":checked").length > 0;

      if (!isChecked) {
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