<div class="widget_wysija_cont html_wysija"><div id="msg-form-wysija-html5a8c95a3c7d4d-3" class="wysija-msg ajax"></div><form id="form-wysija-html5a8c95a3c7d4d-3" method="post" action="#wysija" class="widget_wysija html_wysija"><!-- [et_pb_line_break_holder] --><hr /><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><h2>Contact Info</h2><!-- [et_pb_line_break_holder] --><div class="wrapper2col" ><!-- [et_pb_line_break_holder] --><p class="wysija-paragraph"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <input type="text" name="wysija[user][firstname]" class="wysija-input validate[required]" title="First name" placeholder="First name" value="" /><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <span class="abs-req"><!-- [et_pb_line_break_holder] --> <input type="text" name="wysija[user][abs][firstname]" class="wysija-input validated[abs][firstname]" value="" /><!-- [et_pb_line_break_holder] --> </span><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><p class="wysija-paragraph"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <input type="text" name="wysija[user][lastname]" class="wysija-input validate[required]" title="Last name" placeholder="Last name" value="" /><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <span class="abs-req"><!-- [et_pb_line_break_holder] --> <input type="text" name="wysija[user][abs][lastname]" class="wysija-input validated[abs][lastname]" value="" /><!-- [et_pb_line_break_holder] --> </span><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><p class="wysija-paragraph"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <input type="text" name="wysija[field][cf_2]" class="wysija-input validate[required]" title="Address" placeholder="Address" value="" /><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <span class="abs-req"><!-- [et_pb_line_break_holder] --> <input type="text" name="wysija[field][abs][cf_2]" class="wysija-input validated[abs][cf_2]" value="" /><!-- [et_pb_line_break_holder] --> </span><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><div class="wrapper3col12x"><!-- [et_pb_line_break_holder] --><p class="wysija-paragraph"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <input type="text" name="wysija[field][cf_3]" class="wysija-input validate[required]" title="City" placeholder="City" value="" /><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <span class="abs-req"><!-- [et_pb_line_break_holder] --> <input type="text" name="wysija[field][abs][cf_3]" class="wysija-input validated[abs][cf_3]" value="" /><!-- [et_pb_line_break_holder] --> </span><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><p class="wysija-paragraph"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <input type="text" name="wysija[field][cf_7]" class="wysija-input validate[required]" title="State" placeholder="State" value="" /><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <span class="abs-req"><!-- [et_pb_line_break_holder] --> <input type="text" name="wysija[field][abs][cf_7]" class="wysija-input validated[abs][cf_7]" value="" /><!-- [et_pb_line_break_holder] --> </span><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><p class="wysija-paragraph"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <input type="text" name="wysija[field][cf_20]" class="wysija-input validate[required,custom[onlyNumberSp]]" title="ZipCode" placeholder="ZipCode" value="" /><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <span class="abs-req"><!-- [et_pb_line_break_holder] --> <input type="text" name="wysija[field][abs][cf_20]" class="wysija-input validated[abs][cf_20]" value="" /><!-- [et_pb_line_break_holder] --> </span><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="wrapper2col" ><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><p class="wysija-paragraph"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <input type="text" name="wysija[field][cf_1]" class="wysija-input validate[required,custom[phone]]" title="Mobile Phone" placeholder="Mobile Phone" value="" /><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <span class="abs-req"><!-- [et_pb_line_break_holder] --> <input type="text" name="wysija[field][abs][cf_1]" class="wysija-input validated[abs][cf_1]" value="" /><!-- [et_pb_line_break_holder] --> </span><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><p class="wysija-paragraph"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <input type="text" name="wysija[field][cf_9]" class="wysija-input validate[custom[phone]]" title="Home Phone" placeholder="Home Phone" value="" /><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <span class="abs-req"><!-- [et_pb_line_break_holder] --> <input type="text" name="wysija[field][abs][cf_9]" class="wysija-input validated[abs][cf_9]" value="" /><!-- [et_pb_line_break_holder] --> </span><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><p class="wysija-paragraph"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <input type="text" name="wysija[user][email]" class="wysija-input validate[required,custom[email]]" title="Email" placeholder="Email" value="" /><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <span class="abs-req"><!-- [et_pb_line_break_holder] --> <input type="text" name="wysija[user][abs][email]" class="wysija-input validated[abs][email]" value="" /><!-- [et_pb_line_break_holder] --> </span><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><hr /><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><h2>Tell us About Yourself</h2><!-- [et_pb_line_break_holder] --><p class="wysija-paragraph"><!-- [et_pb_line_break_holder] --> <label>What year did you get your first Keeshond?</label><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <input type="text" name="wysija[field][cf_21]" class="wysija-input validate[custom[onlyNumberSp]]" title="What year did you get your first Keeshond?" value="" /><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <span class="abs-req"><!-- [et_pb_line_break_holder] --> <input type="text" name="wysija[field][abs][cf_21]" class="wysija-input validated[abs][cf_21]" value="" /><!-- [et_pb_line_break_holder] --> </span><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><p class="wysija-paragraph"><!-- [et_pb_line_break_holder] --> <label> Are you a member of any other All-breed, breed club including agility/obedience and/or other dog sport clubs</label><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <label class="wysija-radio-label"><input type="radio" class="wysija-radio validate[required]" name="wysija[field][cf_22]" value="Yes" checked="checked" />Yes</label><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <label class="wysija-radio-label"><input type="radio" class="wysija-radio validate[required]" name="wysija[field][cf_22]" value="No" />No</label><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><hr /><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><h3>Select your Areas of Interest </h3><!-- [et_pb_line_break_holder] --><p>Check all that apply</p><!-- [et_pb_line_break_holder] --><div class="wrapper3col"><!-- [et_pb_line_break_holder] --><p class="wysija-paragraph"><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <input type="hidden" name="wysija[field][cf_4]" value="0" /><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <label class="wysija-checkbox-label"> <input type="checkbox" class="wysija-checkbox " name="wysija[field][cf_4]" value="1" />Companion</label><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><p class="wysija-paragraph"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <input type="hidden" name="wysija[field][cf_5]" value="0" /><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <label class="wysija-checkbox-label"><input type="checkbox" class="wysija-checkbox " name="wysija[field][cf_5]" value="1" />Conformation</label><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><p class="wysija-paragraph"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <input type="hidden" name="wysija[field][cf_8]" value="0" /><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <label class="wysija-checkbox-label"><input type="checkbox" class="wysija-checkbox " name="wysija[field][cf_8]" value="1" />Agility</label><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><p class="wysija-paragraph"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <input type="hidden" name="wysija[field][cf_25]" value="0" /><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <label class="wysija-checkbox-label"><input type="checkbox" class="wysija-checkbox " name="wysija[field][cf_25]" value="1" />Rally</label><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><p class="wysija-paragraph"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <input type="hidden" name="wysija[field][cf_24]" value="0" /><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <label class="wysija-checkbox-label"><input type="checkbox" class="wysija-checkbox " name="wysija[field][cf_24]" value="1" />Obedience</label><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><p class="wysija-paragraph"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <input type="hidden" name="wysija[field][cf_11]" value="0" /><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <label class="wysija-checkbox-label"><input type="checkbox" class="wysija-checkbox " name="wysija[field][cf_11]" value="1" />Nose Work</label><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><p class="wysija-paragraph"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <input type="hidden" name="wysija[field][cf_10]" value="0" /><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <label class="wysija-checkbox-label"><input type="checkbox" class="wysija-checkbox " name="wysija[field][cf_10]" value="1" />Barn Hunt</label><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><p class="wysija-paragraph"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <input type="hidden" name="wysija[field][cf_23]" value="0" /><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <label class="wysija-checkbox-label"><input type="checkbox" class="wysija-checkbox " name="wysija[field][cf_23]" value="1" />Fly Ball</label><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><p class="wysija-paragraph"><!-- [et_pb_line_break_holder] --> <label>Other Area of Interest</label><!-- [et_pb_line_break_holder] --> <textarea name="wysija[field][cf_12]" class="wysija-textarea " rows="1" placeholder=""></textarea><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <span class="abs-req"><!-- [et_pb_line_break_holder] --> <input type="text" name="wysija[field][abs][cf_12]" class="wysija-input validated[abs][cf_12]" value="" /><!-- [et_pb_line_break_holder] --> </span><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><hr /><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><h3>Breeder Area</h3><!-- [et_pb_line_break_holder] --><p class="wysija-paragraph"><!-- [et_pb_line_break_holder] --> <label class="wysija-select-label">Are you a Keeshond Breeder?</label><!-- [et_pb_line_break_holder] --> <select class="wysija-select validate[required]" name="wysija[field][cf_13]"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <option value="No">No</option><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <option value="Yes">Yes</option><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> </select><!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><p>If Yes, please answer the next two questions</p><!-- [et_pb_line_break_holder] --><p class="wysija-paragraph"><!-- [et_pb_line_break_holder] --> <label class="wysija-select-label">Are you following the Keeshond Club of America’s Code of Ethics?</label><!-- [et_pb_line_break_holder] --> <select class="wysija-select " name="wysija[field][cf_15]"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <option value="No">No</option><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <option value="Yes">Yes</option><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> </select><!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><p class="wysija-paragraph"><!-- [et_pb_line_break_holder] --> <label class="wysija-select-label">Are you familiar with CHIC health test requirements for Keeshond? </label><!-- [et_pb_line_break_holder] --> <select class="wysija-select " name="wysija[field][cf_14]"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <option value="No">No</option><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <option value="Yes">Yes</option><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> </select><!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><hr /><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><h3>Membership Participation</h3><!-- [et_pb_line_break_holder] --><p class="wysija-paragraph"><!-- [et_pb_line_break_holder] --> <label class="wysija-select-label">Would you be able to attend at least 2 of 6 annual Meetings?</label><!-- [et_pb_line_break_holder] --> <select class="wysija-select " name="wysija[field][cf_16]"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <option value="No">No</option><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <option value="Yes">Yes</option><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> </select><!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><p class="wysija-paragraph"><!-- [et_pb_line_break_holder] --> <label class="wysija-select-label">Would you be interested in serving as an officer?</label><!-- [et_pb_line_break_holder] --> <select class="wysija-select " name="wysija[field][cf_17]"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <option value="No">No</option><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <option value="Yes">Yes</option><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> </select><!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><p class="wysija-paragraph"><!-- [et_pb_line_break_holder] --> <label class="wysija-select-label">Would you be interested in working on a committee? </label><!-- [et_pb_line_break_holder] --> <select class="wysija-select " name="wysija[field][cf_18]"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <option value="No">No</option><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <option value="Yes">Yes</option><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> </select><!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><hr /><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><h2>Sponsorship</h2><!-- [et_pb_line_break_holder] --><p>Any member of CCKC and/or KCA can sponsor your membership </p><!-- [et_pb_line_break_holder] --><p class="wysija-paragraph"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <input type="text" name="wysija[field][cf_6]" class="wysija-input validate[required,custom[onlyLetterSp]]" title="Name" placeholder="Name" value="" /><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <span class="abs-req"><!-- [et_pb_line_break_holder] --> <input type="text" name="wysija[field][abs][cf_6]" class="wysija-input validated[abs][cf_6]" value="" /><!-- [et_pb_line_break_holder] --> </span><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><hr /><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><h3>Dues:</h3><!-- [et_pb_line_break_holder] --><p>Family Single </p><!-- [et_pb_line_break_holder] --><p>Once approved, you will be provided a payment link. Annual Club Dues are due March 1st, so the first year will be prorated according to the following: </p><!-- [et_pb_line_break_holder] --><ul><!-- [et_pb_line_break_holder] --><li>1st quarter - fee waived. Dues paid for following year!</li><!-- [et_pb_line_break_holder] --><li>2nd and 3rd quarter - full rate</li><!-- [et_pb_line_break_holder] --><li>4th quarter - 1/2 off</li><!-- [et_pb_line_break_holder] --></ul><!-- [et_pb_line_break_holder] --><p>If you have any questions, please email: carolinakeeshondclub@gmail.com</p><!-- [et_pb_line_break_holder] --><p>A Sponsor is required, feel free to ask for assistance in acquiring a sponsor if needed. Applications are reviewed by the Membership Coordinator, and the CCKC Board at it's next meeting. Once approved, you will be contacted. Thank you for your interest in our club!</p><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><hr /><!-- [et_pb_line_break_holder] --><p class="wysija-paragraph"><!-- [et_pb_line_break_holder] --> <label>By Submitting this Application, I agree that all information is accurate, and that I will abide by CCKC Club Rules and ByLaws</label><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <label class="wysija-radio-label"><input type="radio" class="wysija-radio validate[required]" name="wysija[field][cf_26]" value="Yes" />Yes</label><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <label class="wysija-radio-label"><input type="radio" class="wysija-radio validate[required]" name="wysija[field][cf_26]" value="No" />No</label><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --></p><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><input class="wysija-submit wysija-submit-field" type="submit" value="Submit Application" /><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <input type="hidden" name="form_id" value="3" /><!-- [et_pb_line_break_holder] --> <input type="hidden" name="action" value="save" /><!-- [et_pb_line_break_holder] --> <input type="hidden" name="controller" value="subscribers" /><!-- [et_pb_line_break_holder] --> <input type="hidden" value="1" name="wysija-page" /><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <input type="hidden" name="wysija[user_list][list_ids]" value="5" /><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> </form></div>