{"id":812,"date":"2024-12-14T12:04:11","date_gmt":"2024-12-14T12:04:11","guid":{"rendered":"https:\/\/www.debtcontrolagency.com\/?page_id=812"},"modified":"2025-08-12T23:49:01","modified_gmt":"2025-08-12T23:49:01","slug":"subscription-form","status":"publish","type":"page","link":"https:\/\/www.debtcontrolagency.com\/fr\/subscription-form\/","title":{"rendered":"Subscription Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"812\" class=\"elementor elementor-812\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-e70860c elementor-section-height-min-height elementor-section-boxed elementor-section-height-default elementor-section-items-middle\" data-id=\"e70860c\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-005965c\" data-id=\"005965c\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-07dd31c elementor-widget elementor-widget-text-editor\" data-id=\"07dd31c\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>DCA<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-bb2b7b7 elementor-widget elementor-widget-heading\" data-id=\"bb2b7b7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h6 class=\"elementor-heading-title elementor-size-default\">Schedule your recurring payments<\/h6>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-d1db4dc elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"d1db4dc\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-0465938\" data-id=\"0465938\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-463ca32 elementor-invisible elementor-widget elementor-widget-heading\" data-id=\"463ca32\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;fadeInUp&quot;}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Schedule your recurring payments<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-88f6659 elementor-widget__width-initial elementor-widget elementor-widget-text-editor\" data-id=\"88f6659\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Simplify Managing Your Debt<\/p><p>Recurring payments make it easy to manage your outstanding debt by automatically scheduling payments. This helps you pay off your balance in smaller, manageable amounts without the stress of missed deadlines or additional fees. It\u2019s a hassle-free way to stay on track and regain control of your financial obligations.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-e64af02 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"e64af02\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-b581a2d\" data-id=\"b581a2d\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-99016d9 elementor-widget elementor-widget-toggle\" data-id=\"99016d9\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"toggle.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-toggle\">\n\t\t\t\t\t\t\t<div class=\"elementor-toggle-item\">\n\t\t\t\t\t<div id=\"elementor-tab-title-1601\" class=\"elementor-tab-title\" data-tab=\"1\" role=\"button\" aria-controls=\"elementor-tab-content-1601\" aria-expanded=\"false\">\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-toggle-icon elementor-toggle-icon-left\" aria-hidden=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-toggle-icon-closed\"><i class=\"fas fa-caret-right\"><\/i><\/span>\n\t\t\t\t\t\t\t\t<span class=\"elementor-toggle-icon-opened\"><i class=\"elementor-toggle-icon-opened fas fa-caret-up\"><\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t<a class=\"elementor-toggle-title\" tabindex=\"0\">Recurring Payment<\/a>\n\t\t\t\t\t<\/div>\n\n\t\t\t\t\t<div id=\"elementor-tab-content-1601\" class=\"elementor-tab-content elementor-clearfix\" data-tab=\"1\" role=\"region\" aria-labelledby=\"elementor-tab-title-1601\"><h6>Getting Started<\/h6>\n<p>To set up your recurring payments, follow the questions below carefully and have your DCA (your file number) ready\u2014this is essential to proceed. Your DCA Number, which begins with two letters followed by six digits (e.g., DD123456), can be found on the letter, email, or text message you received from us. If you\u2019re unsure about any step, don\u2019t hesitate to contact us at 1-866-307-5322 or email us at customercare@debtcontrolagency.com, and our team will gladly assist you.<\/p>\n<p>By completing this transaction, you agree to fulfill recurring payment obligations. A $50 fee may apply for defaults. Contact us with any concerns<\/p>\n<p><strong>Enter Cardholder\u2019s information<br><\/strong><script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_5' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Schedule your recurring payments<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/fr\/wp-json\/wp\/v2\/pages\/812' data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_5_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_1'>\n                            \n                            <span id='input_5_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_5_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_1_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_5_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_1_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_5_3\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_3'><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_5_3' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_5_4\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_4'><span class='gform-field-label__text'>Phone<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_5_4' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"    \/><\/div><\/div><fieldset id=\"field_5_5\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_5_5' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_5_1_container' >\n                                        <input type='text' name='input_5.1' id='input_5_5_1' value=''    aria-required='true'    \/>\n                                        <label for='input_5_5_1' id='input_5_5_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse postale<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_5_2_container' >\n                                        <input type='text' name='input_5.2' id='input_5_5_2' value=''     aria-required='false'   \/>\n                                        <label for='input_5_5_2' id='input_5_5_2_label' class='gform-field-label gform-field-label--type-sub '>Adresse ligne 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_5_3_container' >\n                                    <input type='text' name='input_5.3' id='input_5_5_3' value=''    aria-required='true'    \/>\n                                    <label for='input_5_5_3' id='input_5_5_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_5_4_container' >\n                                        <input type='text' name='input_5.4' id='input_5_5_4' value=''      aria-required='true'    \/>\n                                        <label for='input_5_5_4' id='input_5_5_4_label' class='gform-field-label gform-field-label--type-sub '>\u00c9tat \/ Province \/ R\u00e9gion<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_5_5_container' >\n                                    <input type='text' name='input_5.5' id='input_5_5_5' value=''    aria-required='true'    \/>\n                                    <label for='input_5_5_5' id='input_5_5_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Code postal<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_5_5_6_container' >\n                                        <select name='input_5.6' id='input_5_5_6'   aria-required='true'    ><option value='' ><\/option><option value='AF' >Afghanistan<\/option><option value='ZA' >Afrique du Sud<\/option><option value='AL' >Albanie<\/option><option value='DZ' >Alg\u00e9rie<\/option><option value='DE' >Allemagne<\/option><option value='AD' >Andorre<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctique<\/option><option value='AG' >Antigua-et-Barbuda<\/option><option value='SA' >Arabie Saoudite<\/option><option value='AR' >Argentine<\/option><option value='AM' >Arm\u00e9nie<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australie<\/option><option value='AT' >Autriche<\/option><option value='AZ' >Azerba\u00efdjan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahre\u00efn<\/option><option value='BD' >Bangladesh<\/option><option value='BY' >Belarus<\/option><option value='BE' >Belgique<\/option><option value='BZ' >Belize<\/option><option value='BJ' >B\u00e9nin<\/option><option value='BM' >Bermudes<\/option><option value='BT' >Bhoutan<\/option><option value='BO' >Bolivie<\/option><option value='BQ' >Bonaire, Saint-Eustache et Saba<\/option><option value='BA' >Bosnie-Herz\u00e9govine<\/option><option value='BW' >Botswana<\/option><option value='BR' >Br\u00e9sil<\/option><option value='BN' >Brunei Darussalam<\/option><option value='BG' >Bulgarie<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='KH' >Cambodge<\/option><option value='CM' >Cameroun<\/option><option value='CA' >Canada<\/option><option value='CV' >Cap-Vert<\/option><option value='CL' >Chili<\/option><option value='CN' >Chine<\/option><option value='CY' >Chypre<\/option><option value='CO' >Colombie<\/option><option value='KM' >Comores<\/option><option value='CG' >Congo<\/option><option value='CR' >Costa Rica<\/option><option value='CI' >C\u00f4te d\u2019Ivoire<\/option><option value='HR' >Croatie<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='CZ' >Czechia<\/option><option value='DK' >Danemark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominique<\/option><option value='EG' >\u00c9gypte<\/option><option value='AE' >\u00c9mirats arabes unis<\/option><option value='EC' >\u00c9quateur<\/option><option value='ER' >\u00c9rythr\u00e9e<\/option><option value='ES' >Espagne<\/option><option value='EE' >Estonie<\/option><option value='SZ' >Eswatini<\/option><option value='PS' >\u00c9tat palestinien<\/option><option value='US' >\u00c9tats-Unis<\/option><option value='ET' >\u00c9thiopie<\/option><option value='FJ' >Fidji<\/option><option value='FI' >Finlande<\/option><option value='FR' >France<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambie<\/option><option value='GE' >G\u00e9orgie<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GR' >Gr\u00e8ce<\/option><option value='GD' >Grenade<\/option><option value='GL' >Groenland<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernesey<\/option><option value='GN' >Guin\u00e9e<\/option><option value='GQ' >Guin\u00e9e \u00e9quatoriale<\/option><option value='GF' >Guin\u00e9e Fran\u00e7aise<\/option><option value='GW' >Guin\u00e9e-Bissau<\/option><option value='GY' >Guyane<\/option><option value='HT' >Ha\u00efti<\/option><option value='HM' >Heard Island and McDonald Islands<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hongrie<\/option><option value='BV' >\u00cele Bouvet<\/option><option value='IM' >\u00cele de Man<\/option><option value='CX' >\u00cele de No\u00ebl<\/option><option value='NF' >\u00cele de Norfolk<\/option><option value='MU' >\u00cele Maurice<\/option><option value='AX' >Iles Aland<\/option><option value='KY' >\u00celes Cayman<\/option><option value='CC' >\u00celes Cocos<\/option><option value='CK' >\u00celes Cook<\/option><option value='FK' >\u00celes Falkland<\/option><option value='FO' >\u00celes F\u00e9ro\u00e9<\/option><option value='MP' >\u00celes Mariannes du Nord<\/option><option value='MH' >\u00celes Marshall<\/option><option value='UM' >\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis<\/option><option value='SB' >\u00celes Salomon<\/option><option value='TC' >\u00celes Turques-et-Ca\u00efques<\/option><option value='VI' >\u00celes Vierges am\u00e9ricaines<\/option><option value='VG' >\u00celes Vierges britanniques<\/option><option value='IN' >Inde<\/option><option value='ID' >Indon\u00e9sie<\/option><option value='IQ' >Irak<\/option><option value='IR' >Iran<\/option><option value='IE' >Irlande<\/option><option value='IS' >Islande<\/option><option value='IL' >Isra\u00ebl<\/option><option value='IT' >Italie<\/option><option value='JM' >Jama\u00efque<\/option><option value='JP' >Japon<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordanie<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KG' >Kirghizistan<\/option><option value='KI' >Kiribati<\/option><option value='KP' >Korea, Democratic People&#039;s Republic of<\/option><option value='KR' >Korea, Republic of<\/option><option value='KW' >Kowe\u00eft<\/option><option value='BB' >La Barbade<\/option><option value='RE' >La R\u00e9union<\/option><option value='LS' >Lesotho<\/option><option value='LV' >Lettonie<\/option><option value='LB' >Liban<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libye<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lituanie<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao<\/option><option value='MG' >Madagascar<\/option><option value='MY' >Malaisie<\/option><option value='MW' >Malawi<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malte<\/option><option value='MA' >Maroc<\/option><option value='MQ' >Martinique<\/option><option value='MR' >Mauritanie<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexique<\/option><option value='FM' >Micron\u00e9sie<\/option><option value='MD' >Moldavie<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolie<\/option><option value='ME' >Mont\u00e9n\u00e9gro<\/option><option value='MS' >Montserrat<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibie<\/option><option value='NR' >Nauru<\/option><option value='NP' >N\u00e9pal<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nig\u00e9ria<\/option><option value='NU' >Niue<\/option><option value='MK' >North Macedonia<\/option><option value='NO' >Norv\u00e8ge<\/option><option value='NC' >Nouvelle Cal\u00e9donie<\/option><option value='NZ' >Nouvelle-Z\u00e9lande<\/option><option value='OM' >Oman<\/option><option value='UG' >Ouganda<\/option><option value='UZ' >Ouzb\u00e9kistan<\/option><option value='PK' >Pakistan<\/option><option value='PW' >Palau<\/option><option value='PA' >Panama<\/option><option value='PG' >Papouasie-Nouvelle-Guin\u00e9e<\/option><option value='PY' >Paraguay<\/option><option value='NL' >Pays-Bas<\/option><option value='PE' >P\u00e9rou<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Pologne<\/option><option value='PF' >Polyn\u00e9sie fran\u00e7aise<\/option><option value='PR' >Porto Rico<\/option><option value='PT' >Portugal<\/option><option value='QA' >Qatar<\/option><option value='CF' >R\u00e9publique centrafricaine<\/option><option value='CD' >R\u00e9publique d\u00e9mocratique du Congo<\/option><option value='LA' >R\u00e9publique d\u00e9mocratique populaire Lao<\/option><option value='DO' >R\u00e9publique Dominicaine<\/option><option value='RO' >Roumanie<\/option><option value='GB' >Royaume-Uni<\/option><option value='RU' >Russian Federation<\/option><option value='RW' >Rwanda<\/option><option value='EH' >Sahara occidental<\/option><option value='BL' >Saint Barth\u00e9lemy<\/option><option value='SH' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='MF' >Saint Martin<\/option><option value='KN' >Saint-Christophe-et-Nevis<\/option><option value='SM' >Saint-Marin<\/option><option value='SX' >Saint-Martin<\/option><option value='PM' >Saint-Pierre-et-Miquelon<\/option><option value='VA' >Saint-Si\u00e8ge<\/option><option value='VC' >Saint-Vincent-et-les Grenadines<\/option><option value='LC' >Sainte-Lucie<\/option><option value='SV' >Salvador<\/option><option value='WS' >Samoa<\/option><option value='AS' >Samoa am\u00e9ricaines<\/option><option value='ST' >Sao Tom\u00e9 et Principe<\/option><option value='SN' >S\u00e9n\u00e9gal<\/option><option value='RS' >Serbie<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapour<\/option><option value='SK' >Slovaquie<\/option><option value='SI' >Slov\u00e9nie<\/option><option value='SO' >Somalie<\/option><option value='SD' >Soudan<\/option><option value='SS' >Soudan du Sud<\/option><option value='GS' >South Georgia and the South Sandwich Islands<\/option><option value='LK' >Sri Lanka<\/option><option value='SE' >Su\u00e8de<\/option><option value='CH' >Suisse<\/option><option value='SR' >Suriname<\/option><option value='SJ' >Svalbard and Jan Mayen<\/option><option value='SY' >Syria Arab Republic<\/option><option value='TJ' >Tadjikistan<\/option><option value='TW' >Ta\u00efwan<\/option><option value='TZ' >Tanzania, the United Republic of<\/option><option value='TD' >Tchad<\/option><option value='TF' >Terres australes Fran\u00e7aises<\/option><option value='IO' >Territoire britannique de l&#039;oc\u00e9an Indien<\/option><option value='TH' >Tha\u00eflande<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinit\u00e9 et Tobago<\/option><option value='TN' >Tunisie<\/option><option value='TR' >T\u00fcrkiye<\/option><option value='TM' >Turkm\u00e9nistan<\/option><option value='TV' >Tuvalu<\/option><option value='UA' >Ukraine<\/option><option value='UY' >Uruguay<\/option><option value='VU' >Vanuatu<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Viet Nam<\/option><option value='WF' >Wallis et Futuna<\/option><option value='YE' >Y\u00e9men<\/option><option value='ZM' >Zambie<\/option><option value='ZW' >Zimbabwe<\/option><\/select>\n                                        <label for='input_5_5_6' id='input_5_5_6_label' class='gform-field-label gform-field-label--type-sub '>Pays<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_5_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_6'><span class='gform-field-label__text'>DCA#<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_5_6' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_6\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_5_6'>This file number can be found in the text message, e-mail or letter you received from us \u2013 it begins with two letters, followed by six digits (ex. DD123456)<\/div><\/div><div id=\"field_5_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_7'><span class='gform-field-label__text'>Customer Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_5_7' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_18\" class=\"gfield gfield--type-product gfield--input-type-price gfield--width-half recurring-amount-nmi gfield_price gfield_price_5_18 gfield_product_5_18 gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_18'><span class='gform-field-label__text'>Total amount you wish to pay<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_product_price'>\n\t\t\t\t\t<input name='input_18' id='input_5_18' type='text' value='' class='large ginput_amount'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n\t\t\t\t<\/div><\/div><div id=\"field_5_19\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half payment-count-nmi gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_19'><span class='gform-field-label__text'>Number of recurring payments<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_19' id='input_5_19' type='number' step='any' min='1'  value='1' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_19 gfield_description_5_19\" \/><div class='gfield_description instruction ' id='gfield_instruction_5_19'>Veuillez entrer un nombre plus grand ou \u00e9gal \u00e0 <strong>1<\/strong>.<\/div><\/div><div class='gfield_description' id='gfield_description_5_19'>\nTotal number of payments before the recurring plan is complete.<\/div><\/div><div id=\"field_5_20\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half calculated-amount-nmi gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_20'><span class='gform-field-label__text'>Recurring Payment Installment(s)<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_20' id='input_5_20' type='text' step='any'   value='' class='large gform-text-input-reset'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_5_17\" class=\"gfield gfield--type-total gfield--input-type-total gfield--width-half total-nmi gfield_price gfield_price_5_ gfield_total gfield_total_5_ field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  aria-atomic=\"true\" aria-live=\"polite\" ><label class='gfield_label gform-field-label' for='input_5_17'><span class='gform-field-label__text'>Total Amount<\/span><\/label><div class='ginput_container ginput_container_total'>\n\t\t\t\t\t\t\t<input type='text' readonly name='input_17' id='input_5_17' value='$ 0.00 CAD' class='gform-text-input-reset ginput_total ginput_total_5' \/>\n\t\t\t\t\t\t<\/div><\/div><div id=\"field_5_11\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-seven-twelfths gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_11'><span class='gform-field-label__text'>Billing Frequency Type<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_11' id='input_5_11' class='large gfield_select'  aria-describedby=\"gfield_description_5_11\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='day_frequency' >Daily Frequency<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_5_11'>Choose how often you would like to be billed for this subscription. <\/div><\/div><div id=\"field_5_12\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_12'><span class='gform-field-label__text'>Daily Frequency<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_12' id='input_5_12' type='number' step='any' min='1' max='31' value='7' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_12 gfield_description_5_12\" \/><div class='gfield_description instruction ' id='gfield_instruction_5_12'>Veuillez saisir un nombre entre <strong>1<\/strong> et <strong>31<\/strong>.<\/div><\/div><div class='gfield_description' id='gfield_description_5_12'>If you would like to make a payment every 2 days, (enter 2) once every 7 days, (enter 7) or any interval between 1 and 31 days.<\/div><\/div><div id=\"field_5_13\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_13'><span class='gform-field-label__text'>Monthly Frequency<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_13' id='input_5_13' type='number' step='any' min='1' max='12' value='1' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_13\" \/><div class='gfield_description instruction ' id='gfield_instruction_5_13'>Veuillez saisir un nombre entre <strong>1<\/strong> et <strong>12<\/strong>.<\/div><\/div><\/div><div data-fieldId=\"13\" class=\"spacer gfield\" style=\"grid-column: span 7;\" data-groupId=\"64efbf64\"><\/div><div id=\"field_5_14\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_14'><span class='gform-field-label__text'>Day of the Month for Billing<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_14' id='input_5_14' type='number' step='any' min='1' max='31' value='1' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_5_14 gfield_description_5_14\" \/><div class='gfield_description instruction ' id='gfield_instruction_5_14'>Veuillez saisir un nombre entre <strong>1<\/strong> et <strong>31<\/strong>.<\/div><\/div><div class='gfield_description' id='gfield_description_5_14'>Select the specific day of the month on which you would like to be billed (e.g., 1 for the 1st of the month, 15 for the 15th of the month).<\/div><\/div><div id=\"field_5_15\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_15'><span class='gform-field-label__text'>Recurring Start Date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='yyyy\/mm\/dd'\n\t\t\t\t\tid='input_5_15'\n\t\t\t\t\tclass='datepicker gform-datepicker ymd_slash datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_15'\n\t\t\t\t\tvalue=''\n\t\t\t\t\taria-describedby=\"gfield_description_5_15\" \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"9999\/99\/99\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_15' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_15' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_15' aria-label='Recurring Start Date: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><div class='gfield_description' id='gfield_description_5_15'>Select the date on which you would like your subscription billing to begin. This determines when the first payment will be processed and the recurring schedule will start.<\/div><\/div><fieldset id=\"field_5_16\" class=\"gfield gfield--type-creditcard gfield--input-type-creditcard gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Credit Card<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_creditcard gform-grid-row' id='input_5_16'><span class='ginput_full gform-grid-col' id='input_5_16_1_container' >\n                                    <div class='gform_card_icon_container'><div class='gform_card_icon gform_card_icon_amex' >American Express<\/div><div class='gform_card_icon gform_card_icon_discover' >Discover<\/div><div class='gform_card_icon gform_card_icon_mastercard' >MasterCard<\/div><div class='gform_card_icon gform_card_icon_visa' >Visa<\/div><span class='screen-reader-text' id='field_5_16_supported_creditcards'>Cartes de cr\u00e9dit prises en charge\u00a0: American Express, Discover, MasterCard, Visa<\/span><\/div>\n                                    <input type='text' name='input_16.1' id='input_5_16_1' value=''   onchange='gformMatchCard(\"input_5_16_1\");' onkeyup='gformMatchCard(\"input_5_16_1\");' autocomplete='off' pattern='[0-9]*' title='Seuls les chiffres sont autoris\u00e9s'  aria-required='true'  \/>\n                                    <label for='input_5_16_1' id='input_5_16_1_label' class='gform-field-label gform-field-label--type-sub '>Num\u00e9ro de carte<\/label>\n                                 <\/span><span class='ginput_full ginput_cardextras gform-grid-col gform-grid-row' id='input_5_16_2_container'>\n                                            <fieldset class='ginput_cardinfo_left gform-grid-col' id='input_5_16_2_cardinfo_left'>\n                                            <legend class='gform-field-label gform-field-label--type-sub '>Date d\u2019expiration<\/legend>\n                                                <span class='ginput_card_expiration_container ginput_card_field gform-grid-row'>\n                                                   <span class='ginput_card_expiration_month_container gform-grid-col'>\n                                                       <label for='input_5_16_2_month' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mois<\/label>\n                                                       <select name='input_16.2[]' id='input_5_16_2_month'   class='ginput_card_expiration ginput_card_expiration_month' aria-required='true'  >\n                                                           <option value=''>Mois<\/option><option value='1' >01<\/option><option value='2' >02<\/option><option value='3' >03<\/option><option value='4' >04<\/option><option value='5' >05<\/option><option value='6' >06<\/option><option value='7' >07<\/option><option value='8' >08<\/option><option value='9' >09<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option>\n                                                       <\/select>\n                                                   <\/span>\n                                                   <span class='ginput_card_expiration_year_container gform-grid-col'>\n                                                       <label for='input_5_16_2_year' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Ann\u00e9e<\/label>\n                                                       <select name='input_16.2[]' id='input_5_16_2_year'   class='ginput_card_expiration ginput_card_expiration_year' aria-required='true'  >\n                                                           <option value=''>Ann\u00e9e<\/option><option value='2026' >2026<\/option><option value='2027' >2027<\/option><option value='2028' >2028<\/option><option value='2029' >2029<\/option><option value='2030' >2030<\/option><option value='2031' >2031<\/option><option value='2032' >2032<\/option><option value='2033' >2033<\/option><option value='2034' >2034<\/option><option value='2035' >2035<\/option><option value='2036' >2036<\/option><option value='2037' >2037<\/option><option value='2038' >2038<\/option><option value='2039' >2039<\/option><option value='2040' >2040<\/option><option value='2041' >2041<\/option><option value='2042' >2042<\/option><option value='2043' >2043<\/option><option value='2044' >2044<\/option><option value='2045' >2045<\/option>\n                                                       <\/select>\n                                                   <\/span>\n                                                <\/span>\n                                            <\/fieldset><span class='ginput_cardinfo_right gform-grid-col' id='input_5_16_2_cardinfo_right'>\n                                                <input type='text' name='input_16.3' id='input_5_16_3'   class='ginput_card_security_code' value='' autocomplete='off' pattern='[0-9]*' title='Seuls les chiffres sont autoris\u00e9s'  aria-required='true'  \/>\n                                                <span class='ginput_card_security_code_icon'>&nbsp;<\/span>\n                                                <label for='input_5_16_3' class='gform-field-label gform-field-label--type-sub '>Code de s\u00e9curit\u00e9 (CSV)<\/label>\n                                             <\/span>\n                                        <\/span><span class='ginput_full gform-grid-col' id='input_5_16_5_container'>\n                                            <input type='text' name='input_16.5' id='input_5_16_5' value=''    aria-required='false'  \/>\n                                            <label for='input_5_16_5' id='input_5_16_5_label' class='gform-field-label gform-field-label--type-sub '>Nom du d\u00e9tenteur de la carte<\/label>\n                                        <\/span> <\/div><\/fieldset><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_5' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Submit<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_5' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_5' id='gform_theme_5' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_5' id='gform_style_settings_5' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_5' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='5' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='CAD' value='xYuZDTYKH82MuEuuuOIDUm4jERRQhNHzES3aQwIhQ0GZkm6Q6K324A\/Omf3+H9p4Rgyu3pAQ+ujHJZVrz\/rPMz+ndbLFiigGctsx+nDUP1vSgIY=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_5' 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