@axos-web-dev/shared-components 0.0.117 → 0.0.118

package/dist/Forms/CpraRequest.js

@@ -125,608 +125,600 @@ const CpraRequest = ({
       setValue("Axos_Financial_interaction_outlet", updatedValues.join(";"));
     }
   };
-  return /* @__PURE__ */ jsx(
-    "section",
-    {
-      id: `id_${id}`,
-      className: clsx(formContainer({ variant })),
-      children: /* @__PURE__ */ jsx("div", { className: clsx("containment"), children: /* @__PURE__ */ jsxs(FormProvider, { ...methods, children: [
-        icon && /* @__PURE__ */ jsx("div", { className: clsx("text_center", iconForm), children: ["primary", "secondary"].includes(variant) ? /* @__PURE__ */ jsx(SvgComponent, {}) : /* @__PURE__ */ jsx(SvgAxosX, {}) }),
-        /* @__PURE__ */ jsxs("div", { className: `${headerContainer}`, children: [
-          /* @__PURE__ */ jsx("h2", { className: `header_2 ${form} ${descriptionField({ variant })}`, children: headline }),
-          description && /* @__PURE__ */ jsx("div", { className: `${form} ${descriptionField({ variant })}`, children: description })
-        ] }),
-        /* @__PURE__ */ jsxs("div", { className: `${headerContainer}`, children: [
-          /* @__PURE__ */ jsx("h2", { className: `header_2 ${form} ${descriptionField({ variant })}`, children: "Step 1: Please identify which privacy right(s) you would like to exercise." }),
-          /* @__PURE__ */ jsxs("div", { className: `${form} ${descriptionField({ variant })}`, children: [
-            /* @__PURE__ */ jsx("u", { children: "Right to Access:" }),
-            " You have the right to send Axos Financial a verifiable request, twice in a 12-month period, asking that we disclose to you the personal information Axos Financial has collected, used, disclosed and sold about you during the past 12 months. Please check the box below relating to the information you would like Axos Financial to disclose to you:"
-          ] })
-        ] }),
-        /* @__PURE__ */ jsxs("form", { className: form, onSubmit: handleSubmit(submitForm), children: [
-          /* @__PURE__ */ jsxs("div", { className: clsx(formWrapper({ variant })), children: [
-            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
-              RadioButtonSet,
-              {
-                id: "California_Resident",
-                label: "* Are you a California resident?",
-                sizes: "medium",
-                required: true,
-                error: !!errors.California_Resident,
-                helperText: errors.California_Resident?.message,
-                variant,
-                children: [
-                  /* @__PURE__ */ jsx(
-                    RadioButton,
-                    {
-                      ...register("California_Resident", {}),
-                      value: "Yes",
-                      radioText: "Yes",
-                      groupName: "California_Resident"
-                    }
-                  ),
-                  /* @__PURE__ */ jsx(
-                    RadioButton,
-                    {
-                      ...register("California_Resident", {}),
-                      value: "No",
-                      radioText: "No",
-                      groupName: "California_Resident"
-                    }
-                  )
-                ]
-              }
-            ) }),
-            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
-              RadioButtonSet,
-              {
-                id: "Categories_of_personal_info",
-                label: "* The categories of personal information Axos Financial has collected about you.",
-                sizes: "medium",
-                required: true,
-                error: !!errors.Categories_of_personal_info,
-                helperText: errors.Categories_of_personal_info?.message,
-                variant,
-                children: [
-                  /* @__PURE__ */ jsx(
-                    RadioButton,
-                    {
-                      ...register("Categories_of_personal_info", {}),
-                      value: "Yes",
-                      radioText: "Yes",
-                      groupName: "Categories_of_personal_info"
-                    }
-                  ),
-                  /* @__PURE__ */ jsx(
-                    RadioButton,
-                    {
-                      ...register("Categories_of_personal_info", {}),
-                      value: "No",
-                      radioText: "No",
-                      groupName: "Categories_of_personal_info"
-                    }
-                  )
-                ]
-              }
-            ) }),
-            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
-              RadioButtonSet,
-              {
-                id: "Pieces_of_personal_information",
-                label: "* The specific pieces of personal information Axos Financial has collected about you.",
-                sizes: "medium",
-                required: true,
-                error: !!errors.Pieces_of_personal_information,
-                helperText: errors.Pieces_of_personal_information?.message,
-                variant,
-                children: [
-                  /* @__PURE__ */ jsx(
-                    RadioButton,
-                    {
-                      ...register("Pieces_of_personal_information", {}),
-                      value: "Yes",
-                      radioText: "Yes",
-                      groupName: "Pieces_of_personal_information"
-                    }
-                  ),
-                  /* @__PURE__ */ jsx(
-                    RadioButton,
-                    {
-                      ...register("Pieces_of_personal_information", {}),
-                      value: "No",
-                      radioText: "No",
-                      groupName: "Pieces_of_personal_information"
-                    }
-                  )
-                ]
-              }
-            ) }),
-            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx("div", { className: `${form} ${descriptionField({ variant })}`, children: "By selecting specific pieces of personal information Axos Financial has collected about you, you are required to sign a declaration, under penalty of perjury, that you are the individual whose information is provided above. We will provide you with the form and instructions at your preferred contact method. If you do not return the completed form, we will not be able to provide you with the specific pieces of personal information Axos Financial has collected about you." }) }),
-            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
-              RadioButtonSet,
-              {
-                id: "Request_Correction_of_Information",
-                label: "Request correction of information?",
-                sizes: "medium",
-                required: true,
-                error: !!errors.Request_Correction_of_Information,
-                helperText: errors.Request_Correction_of_Information?.message,
-                variant,
-                children: [
-                  /* @__PURE__ */ jsx(
-                    RadioButton,
-                    {
-                      ...register("Request_Correction_of_Information", {}),
-                      value: "Yes",
-                      radioText: "Yes",
-                      groupName: "Request_Correction_of_Information"
-                    }
-                  ),
-                  /* @__PURE__ */ jsx(
-                    RadioButton,
-                    {
-                      ...register("Request_Correction_of_Information", {}),
-                      value: "No",
-                      radioText: "No",
-                      groupName: "Request_Correction_of_Information"
-                    }
-                  )
-                ]
-              }
-            ) }),
-            requestCorrectionOfInfo === "Yes" && /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
-              CheckboxGroup,
-              {
-                options,
-                selectedValues,
-                error: !!errors.Corrected_Information,
-                onChange: handleSelectedValues
-              }
-            ) }),
-            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs("div", { className: `${form} ${descriptionField({ variant })}`, children: [
-              /* @__PURE__ */ jsx("u", { children: "Right to Delete:" }),
-              " You have the right to submit a verifiable request asking that Axos Financial delete certain personal information Axos Financial has collected from you, subject to certain exceptions as permitted by law."
-            ] }) }),
-            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
-              RadioButtonSet,
-              {
-                id: "Delete_personal_info",
-                label: "* Would you like Axos Financial to delete the personal information we have collected from you?",
-                sizes: "medium",
-                required: true,
-                error: !!errors.Delete_personal_info,
-                helperText: errors.Delete_personal_info?.message,
-                variant,
-                children: [
-                  /* @__PURE__ */ jsx(
-                    RadioButton,
-                    {
-                      ...register("Delete_personal_info", {}),
-                      value: "Yes",
-                      radioText: "Yes",
-                      groupName: "Delete_personal_info"
-                    }
-                  ),
-                  /* @__PURE__ */ jsx(
-                    RadioButton,
-                    {
-                      ...register("Delete_personal_info", {}),
-                      value: "No",
-                      radioText: "No",
-                      groupName: "Delete_personal_info"
-                    }
-                  )
-                ]
-              }
-            ) }),
-            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs("div", { className: `${form} ${descriptionField({ variant })}`, children: [
-              /* @__PURE__ */ jsx("u", { children: "Right to Opt-Out of Sale:" }),
-              " You have the right to opt-out of the sale of your personal information we collect on our websites, such as to enhance the ability to serve you content and advertisements that may be of interest to you."
-            ] }) }),
-            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
-              RadioButtonSet,
-              {
-                id: "Opt_out_of_sale_of_info",
-                label: "* Would you like to opt out of the sale of your personal information by Axos Financial?",
-                sizes: "medium",
-                required: true,
-                error: !!errors.Opt_out_of_sale_of_info,
-                helperText: errors.Opt_out_of_sale_of_info?.message,
-                variant,
-                children: [
-                  /* @__PURE__ */ jsx(
-                    RadioButton,
-                    {
-                      ...register("Opt_out_of_sale_of_info", {}),
-                      value: "Yes",
-                      radioText: "Yes",
-                      groupName: "Opt_out_of_sale_of_info"
-                    }
+  return /* @__PURE__ */ jsx("section", { id, className: clsx(formContainer({ variant })), children: /* @__PURE__ */ jsx("div", { className: clsx("containment"), children: /* @__PURE__ */ jsxs(FormProvider, { ...methods, children: [
+    icon && /* @__PURE__ */ jsx("div", { className: clsx("text_center", iconForm), children: ["primary", "secondary"].includes(variant) ? /* @__PURE__ */ jsx(SvgComponent, {}) : /* @__PURE__ */ jsx(SvgAxosX, {}) }),
+    /* @__PURE__ */ jsxs("div", { className: `${headerContainer}`, children: [
+      /* @__PURE__ */ jsx("h2", { className: `header_2 ${form} ${descriptionField({ variant })}`, children: headline }),
+      description && /* @__PURE__ */ jsx("div", { className: `${form} ${descriptionField({ variant })}`, children: description })
+    ] }),
+    /* @__PURE__ */ jsxs("div", { className: `${headerContainer}`, children: [
+      /* @__PURE__ */ jsx("h2", { className: `header_2 ${form} ${descriptionField({ variant })}`, children: "Step 1: Please identify which privacy right(s) you would like to exercise." }),
+      /* @__PURE__ */ jsxs("div", { className: `${form} ${descriptionField({ variant })}`, children: [
+        /* @__PURE__ */ jsx("u", { children: "Right to Access:" }),
+        " You have the right to send Axos Financial a verifiable request, twice in a 12-month period, asking that we disclose to you the personal information Axos Financial has collected, used, disclosed and sold about you during the past 12 months. Please check the box below relating to the information you would like Axos Financial to disclose to you:"
+      ] })
+    ] }),
+    /* @__PURE__ */ jsxs("form", { className: form, onSubmit: handleSubmit(submitForm), children: [
+      /* @__PURE__ */ jsxs("div", { className: clsx(formWrapper({ variant })), children: [
+        /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
+          RadioButtonSet,
+          {
+            id: "California_Resident",
+            label: "* Are you a California resident?",
+            sizes: "medium",
+            required: true,
+            error: !!errors.California_Resident,
+            helperText: errors.California_Resident?.message,
+            variant,
+            children: [
+              /* @__PURE__ */ jsx(
+                RadioButton,
+                {
+                  ...register("California_Resident", {}),
+                  value: "Yes",
+                  radioText: "Yes",
+                  groupName: "California_Resident"
+                }
+              ),
+              /* @__PURE__ */ jsx(
+                RadioButton,
+                {
+                  ...register("California_Resident", {}),
+                  value: "No",
+                  radioText: "No",
+                  groupName: "California_Resident"
+                }
+              )
+            ]
+          }
+        ) }),
+        /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
+          RadioButtonSet,
+          {
+            id: "Categories_of_personal_info",
+            label: "* The categories of personal information Axos Financial has collected about you.",
+            sizes: "medium",
+            required: true,
+            error: !!errors.Categories_of_personal_info,
+            helperText: errors.Categories_of_personal_info?.message,
+            variant,
+            children: [
+              /* @__PURE__ */ jsx(
+                RadioButton,
+                {
+                  ...register("Categories_of_personal_info", {}),
+                  value: "Yes",
+                  radioText: "Yes",
+                  groupName: "Categories_of_personal_info"
+                }
+              ),
+              /* @__PURE__ */ jsx(
+                RadioButton,
+                {
+                  ...register("Categories_of_personal_info", {}),
+                  value: "No",
+                  radioText: "No",
+                  groupName: "Categories_of_personal_info"
+                }
+              )
+            ]
+          }
+        ) }),
+        /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
+          RadioButtonSet,
+          {
+            id: "Pieces_of_personal_information",
+            label: "* The specific pieces of personal information Axos Financial has collected about you.",
+            sizes: "medium",
+            required: true,
+            error: !!errors.Pieces_of_personal_information,
+            helperText: errors.Pieces_of_personal_information?.message,
+            variant,
+            children: [
+              /* @__PURE__ */ jsx(
+                RadioButton,
+                {
+                  ...register("Pieces_of_personal_information", {}),
+                  value: "Yes",
+                  radioText: "Yes",
+                  groupName: "Pieces_of_personal_information"
+                }
+              ),
+              /* @__PURE__ */ jsx(
+                RadioButton,
+                {
+                  ...register("Pieces_of_personal_information", {}),
+                  value: "No",
+                  radioText: "No",
+                  groupName: "Pieces_of_personal_information"
+                }
+              )
+            ]
+          }
+        ) }),
+        /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx("div", { className: `${form} ${descriptionField({ variant })}`, children: "By selecting specific pieces of personal information Axos Financial has collected about you, you are required to sign a declaration, under penalty of perjury, that you are the individual whose information is provided above. We will provide you with the form and instructions at your preferred contact method. If you do not return the completed form, we will not be able to provide you with the specific pieces of personal information Axos Financial has collected about you." }) }),
+        /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
+          RadioButtonSet,
+          {
+            id: "Request_Correction_of_Information",
+            label: "Request correction of information?",
+            sizes: "medium",
+            required: true,
+            error: !!errors.Request_Correction_of_Information,
+            helperText: errors.Request_Correction_of_Information?.message,
+            variant,
+            children: [
+              /* @__PURE__ */ jsx(
+                RadioButton,
+                {
+                  ...register("Request_Correction_of_Information", {}),
+                  value: "Yes",
+                  radioText: "Yes",
+                  groupName: "Request_Correction_of_Information"
+                }
+              ),
+              /* @__PURE__ */ jsx(
+                RadioButton,
+                {
+                  ...register("Request_Correction_of_Information", {}),
+                  value: "No",
+                  radioText: "No",
+                  groupName: "Request_Correction_of_Information"
+                }
+              )
+            ]
+          }
+        ) }),
+        requestCorrectionOfInfo === "Yes" && /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
+          CheckboxGroup,
+          {
+            options,
+            selectedValues,
+            error: !!errors.Corrected_Information,
+            onChange: handleSelectedValues
+          }
+        ) }),
+        /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs("div", { className: `${form} ${descriptionField({ variant })}`, children: [
+          /* @__PURE__ */ jsx("u", { children: "Right to Delete:" }),
+          " You have the right to submit a verifiable request asking that Axos Financial delete certain personal information Axos Financial has collected from you, subject to certain exceptions as permitted by law."
+        ] }) }),
+        /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
+          RadioButtonSet,
+          {
+            id: "Delete_personal_info",
+            label: "* Would you like Axos Financial to delete the personal information we have collected from you?",
+            sizes: "medium",
+            required: true,
+            error: !!errors.Delete_personal_info,
+            helperText: errors.Delete_personal_info?.message,
+            variant,
+            children: [
+              /* @__PURE__ */ jsx(
+                RadioButton,
+                {
+                  ...register("Delete_personal_info", {}),
+                  value: "Yes",
+                  radioText: "Yes",
+                  groupName: "Delete_personal_info"
+                }
+              ),
+              /* @__PURE__ */ jsx(
+                RadioButton,
+                {
+                  ...register("Delete_personal_info", {}),
+                  value: "No",
+                  radioText: "No",
+                  groupName: "Delete_personal_info"
+                }
+              )
+            ]
+          }
+        ) }),
+        /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs("div", { className: `${form} ${descriptionField({ variant })}`, children: [
+          /* @__PURE__ */ jsx("u", { children: "Right to Opt-Out of Sale:" }),
+          " You have the right to opt-out of the sale of your personal information we collect on our websites, such as to enhance the ability to serve you content and advertisements that may be of interest to you."
+        ] }) }),
+        /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
+          RadioButtonSet,
+          {
+            id: "Opt_out_of_sale_of_info",
+            label: "* Would you like to opt out of the sale of your personal information by Axos Financial?",
+            sizes: "medium",
+            required: true,
+            error: !!errors.Opt_out_of_sale_of_info,
+            helperText: errors.Opt_out_of_sale_of_info?.message,
+            variant,
+            children: [
+              /* @__PURE__ */ jsx(
+                RadioButton,
+                {
+                  ...register("Opt_out_of_sale_of_info", {}),
+                  value: "Yes",
+                  radioText: "Yes",
+                  groupName: "Opt_out_of_sale_of_info"
+                }
+              ),
+              /* @__PURE__ */ jsx(
+                RadioButton,
+                {
+                  ...register("Opt_out_of_sale_of_info", {}),
+                  value: "No",
+                  radioText: "No",
+                  groupName: "Opt_out_of_sale_of_info"
+                }
+              )
+            ]
+          }
+        ) }),
+        /* @__PURE__ */ jsx("div", { className: `${headerContainer} ${fullRowForm}`, children: /* @__PURE__ */ jsx("h2", { className: `header_2 ${descriptionField({ variant })}`, children: "Step 2: Please provide the following information so that we can verify your identity and respond to your request." }) }),
+        /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
+          RadioButtonSet,
+          {
+            id: "Current_client",
+            label: "* I am a current or former client or customer.",
+            sizes: "medium",
+            required: true,
+            error: !!errors.Current_client,
+            helperText: errors.Current_client?.message,
+            variant,
+            children: [
+              /* @__PURE__ */ jsx(
+                RadioButton,
+                {
+                  ...register("Current_client", {}),
+                  value: "Yes",
+                  radioText: "Yes",
+                  groupName: "Current_client"
+                }
+              ),
+              /* @__PURE__ */ jsx(
+                RadioButton,
+                {
+                  ...register("Current_client", {}),
+                  value: "No",
+                  radioText: "No",
+                  groupName: "Current_client"
+                }
+              )
+            ]
+          }
+        ) }),
+        /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
+          RadioButtonSet,
+          {
+            id: "Currently_Employed_by_Axos_Financial",
+            label: "* Are you currently employed by Axos Financial?",
+            sizes: "medium",
+            required: true,
+            error: !!errors.Currently_Employed_by_Axos_Financial,
+            helperText: errors.Currently_Employed_by_Axos_Financial?.message,
+            variant,
+            children: [
+              /* @__PURE__ */ jsx(
+                RadioButton,
+                {
+                  ...register("Currently_Employed_by_Axos_Financial", {}),
+                  value: "Yes",
+                  radioText: "Yes",
+                  groupName: "Currently_Employed_by_Axos_Financial"
+                }
+              ),
+              /* @__PURE__ */ jsx(
+                RadioButton,
+                {
+                  ...register("Currently_Employed_by_Axos_Financial", {}),
+                  value: "No",
+                  radioText: "No",
+                  groupName: "Currently_Employed_by_Axos_Financial"
+                }
+              )
+            ]
+          }
+        ) }),
+        /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
+          RadioButtonSet,
+          {
+            id: "Previously_Employed_by_Axos_Financial",
+            label: "* Have you previously been employed by Axos Financial?",
+            sizes: "medium",
+            required: true,
+            error: !!errors.Previously_Employed_by_Axos_Financial,
+            helperText: errors.Previously_Employed_by_Axos_Financial?.message,
+            variant,
+            children: [
+              /* @__PURE__ */ jsx(
+                RadioButton,
+                {
+                  ...register("Previously_Employed_by_Axos_Financial", {}),
+                  value: "Yes",
+                  radioText: "Yes",
+                  groupName: "Previously_Employed_by_Axos_Financial"
+                }
+              ),
+              /* @__PURE__ */ jsx(
+                RadioButton,
+                {
+                  ...register("Previously_Employed_by_Axos_Financial", {}),
+                  value: "No",
+                  radioText: "No",
+                  groupName: "Previously_Employed_by_Axos_Financial"
+                }
+              )
+            ]
+          }
+        ) }),
+        /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
+          RadioButtonSet,
+          {
+            id: "Ever_Applied_for_Employment_with_Axos_Financial",
+            label: "* Have you ever applied for employment with Axos Financial?",
+            sizes: "medium",
+            required: true,
+            error: !!errors.Ever_Applied_for_Employment_with_Axos_Financial,
+            helperText: errors.Ever_Applied_for_Employment_with_Axos_Financial?.message,
+            variant,
+            children: [
+              /* @__PURE__ */ jsx(
+                RadioButton,
+                {
+                  ...register(
+                    "Ever_Applied_for_Employment_with_Axos_Financial",
+                    {}
                   ),
-                  /* @__PURE__ */ jsx(
-                    RadioButton,
-                    {
-                      ...register("Opt_out_of_sale_of_info", {}),
-                      value: "No",
-                      radioText: "No",
-                      groupName: "Opt_out_of_sale_of_info"
-                    }
-                  )
-                ]
-              }
-            ) }),
-            /* @__PURE__ */ jsx("div", { className: `${headerContainer} ${fullRowForm}`, children: /* @__PURE__ */ jsx("h2", { className: `header_2 ${descriptionField({ variant })}`, children: "Step 2: Please provide the following information so that we can verify your identity and respond to your request." }) }),
-            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
-              RadioButtonSet,
-              {
-                id: "Current_client",
-                label: "* I am a current or former client or customer.",
-                sizes: "medium",
-                required: true,
-                error: !!errors.Current_client,
-                helperText: errors.Current_client?.message,
-                variant,
-                children: [
-                  /* @__PURE__ */ jsx(
-                    RadioButton,
-                    {
-                      ...register("Current_client", {}),
-                      value: "Yes",
-                      radioText: "Yes",
-                      groupName: "Current_client"
-                    }
+                  value: "Yes",
+                  radioText: "Yes",
+                  groupName: "Ever_Applied_for_Employment_with_Axos_Financial"
+                }
+              ),
+              /* @__PURE__ */ jsx(
+                RadioButton,
+                {
+                  ...register(
+                    "Ever_Applied_for_Employment_with_Axos_Financial",
+                    {}
                   ),
-                  /* @__PURE__ */ jsx(
-                    RadioButton,
-                    {
-                      ...register("Current_client", {}),
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-                      radioText: "No",
-                      groupName: "Current_client"
-                    }
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-                ]
-              }
-            ) }),
-            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
-              RadioButtonSet,
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-                id: "Currently_Employed_by_Axos_Financial",
-                label: "* Are you currently employed by Axos Financial?",
-                sizes: "medium",
-                required: true,
-                error: !!errors.Currently_Employed_by_Axos_Financial,
-                helperText: errors.Currently_Employed_by_Axos_Financial?.message,
-                variant,
-                children: [
-                  /* @__PURE__ */ jsx(
-                    RadioButton,
-                    {
-                      ...register("Currently_Employed_by_Axos_Financial", {}),
-                      value: "Yes",
-                      radioText: "Yes",
-                      groupName: "Currently_Employed_by_Axos_Financial"
-                    }
-                  ),
-                  /* @__PURE__ */ jsx(
-                    RadioButton,
-                    {
-                      ...register("Currently_Employed_by_Axos_Financial", {}),
-                      value: "No",
-                      radioText: "No",
-                      groupName: "Currently_Employed_by_Axos_Financial"
-                    }
-                  )
-                ]
-              }
-            ) }),
-            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
-              RadioButtonSet,
-              {
-                id: "Previously_Employed_by_Axos_Financial",
-                label: "* Have you previously been employed by Axos Financial?",
-                sizes: "medium",
-                required: true,
-                error: !!errors.Previously_Employed_by_Axos_Financial,
-                helperText: errors.Previously_Employed_by_Axos_Financial?.message,
-                variant,
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-                  /* @__PURE__ */ jsx(
-                    RadioButton,
-                    {
-                      ...register("Previously_Employed_by_Axos_Financial", {}),
-                      value: "Yes",
-                      radioText: "Yes",
-                      groupName: "Previously_Employed_by_Axos_Financial"
-                    }
-                  ),
-                  /* @__PURE__ */ jsx(
-                    RadioButton,
-                    {
-                      ...register("Previously_Employed_by_Axos_Financial", {}),
-                      value: "No",
-                      radioText: "No",
-                      groupName: "Previously_Employed_by_Axos_Financial"
-                    }
-                  )
-                ]
-              }
-            ) }),
-            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
-              RadioButtonSet,
-              {
-                id: "Ever_Applied_for_Employment_with_Axos_Financial",
-                label: "* Have you ever applied for employment with Axos Financial?",
-                sizes: "medium",
-                required: true,
-                error: !!errors.Ever_Applied_for_Employment_with_Axos_Financial,
-                helperText: errors.Ever_Applied_for_Employment_with_Axos_Financial?.message,
-                variant,
-                children: [
-                  /* @__PURE__ */ jsx(
-                    RadioButton,
-                    {
-                      ...register(
-                        "Ever_Applied_for_Employment_with_Axos_Financial",
-                        {}
-                      ),
-                      value: "Yes",
-                      radioText: "Yes",
-                      groupName: "Ever_Applied_for_Employment_with_Axos_Financial"
-                    }
-                  ),
-                  /* @__PURE__ */ jsx(
-                    RadioButton,
-                    {
-                      ...register(
-                        "Ever_Applied_for_Employment_with_Axos_Financial",
-                        {}
-                      ),
-                      value: "No",
-                      radioText: "No",
-                      groupName: "Ever_Applied_for_Employment_with_Axos_Financial"
-                    }
-                  )
-                ]
-              }
-            ) }),
-            /* @__PURE__ */ jsx("div", { className: `${headerContainer} ${fullRowForm}`, children: /* @__PURE__ */ jsx("h2", { className: `header_2 ${descriptionField({ variant })}`, children: "Step 3: Where have you interacted with Axos Financial?" }) }),
-            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
-              CheckboxGroup,
-              {
-                options: options2,
-                selectedValues: selectedValues2,
-                error: !!errors.Axos_Financial_interaction_outlet,
-                onChange: handleSelectedValues2
-              }
-            ) }),
-            /* @__PURE__ */ jsx("div", { className: `${headerContainer} ${fullRowForm}`, children: /* @__PURE__ */ jsx("h2", { className: `header_2 ${descriptionField({ variant })}`, children: "Step 4: Please provide your contact details." }) }),
-            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
-              Input,
-              {
-                id: "First_Name",
-                ...register("First_Name", { required: true }),
-                label: "First Name",
-                sizes: "medium",
-                placeholder: "First Name",
-                required: true,
-                error: !!errors.First_Name,
-                helperText: errors.First_Name?.message,
-                variant
-              }
-            ) }),
-            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
-              Input,
-              {
-                id: "Last_Name",
-                ...register("Last_Name", { required: true }),
-                label: "Last Name",
-                sizes: "medium",
-                required: true,
-                error: !!errors.Last_Name,
-                helperText: errors.Last_Name?.message,
-                variant
-              }
-            ) }),
-            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
-              Input,
-              {
-                id: "DOB",
-                ...register("DOB", {
-                  required: true
-                }),
-                type: "date",
-                label: "Date of Birth",
-                sizes: "medium",
-                placeholder: "Date of Birth",
-                required: true,
-                error: !!errors.DOB,
-                helperText: errors.DOB?.message,
-                variant
-              }
-            ) }),
-            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
-              Input,
-              {
-                id: "email",
-                ...register("email", {
-                  required: true
-                  // validate: {
-                  //   isValid: associatedEmail,
-                  // },
-                }),
-                label: "Email",
-                sizes: "medium",
-                required: true,
-                error: !!errors.email,
-                helperText: errors.email?.message,
-                variant
-              }
-            ) }),
-            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
-              InputPhone,
-              {
-                id: "Telephone",
-                ...register("Telephone", { required: true, maxLength: 12 }),
-                label: "Preferred Phone",
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-                required: true,
-                error: !!errors.Telephone,
-                helperText: errors.Telephone?.message,
-                variant
-              }
-            ) }),
-            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
-              Input,
-              {
-                id: "Street_Address",
-                ...register("Street Address", { required: true }),
-                label: "Street Address",
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-                required: true,
-                variant
-              }
-            ) }),
-            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
-              Input,
-              {
-                id: "City",
-                ...register("City", { required: true }),
-                label: "City",
-                sizes: "medium",
-                required: true,
-                variant
-              }
-            ) }),
-            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
-              Dropdown,
-              {
-                id: "State",
-                ...register("State", {
-                  required: true
-                }),
-                label: "Assets Under Management",
-                sizes: "medium",
-                required: true,
-                error: !!errors.State,
-                helperText: errors.State?.message,
-                variant,
-                children: [
-                  /* @__PURE__ */ jsx("option", { value: "Alabama - AL", children: "Alabama - AL" }),
-                  /* @__PURE__ */ jsx("option", { value: "Alaska - AK", children: "Alaska - AK" }),
-                  /* @__PURE__ */ jsx("option", { value: "Arizona - AZ", children: "Arizona - AZ" }),
-                  /* @__PURE__ */ jsx("option", { value: "Arkansas - AR", children: "Arkansas - AR" }),
-                  /* @__PURE__ */ jsx("option", { value: "California - CA", children: "California - CA" }),
-                  /* @__PURE__ */ jsx("option", { value: "Colorado - CO", children: "Colorado - CO" }),
-                  /* @__PURE__ */ jsx("option", { value: "Connecticut - CT", children: "Connecticut - CT" }),
-                  /* @__PURE__ */ jsx("option", { value: "Delaware - DE", children: "Delaware - DE" }),
-                  /* @__PURE__ */ jsx("option", { value: "Florida - FL", children: "Florida - FL" }),
-                  /* @__PURE__ */ jsx("option", { value: "Georgia - GA", children: "Georgia - GA" }),
-                  /* @__PURE__ */ jsx("option", { value: "Hawaii - HI", children: "Hawaii - HI" }),
-                  /* @__PURE__ */ jsx("option", { value: "Idaho - ID", children: "Idaho - ID" }),
-                  /* @__PURE__ */ jsx("option", { value: "Illinois - IL", children: "Illinois - IL" }),
-                  /* @__PURE__ */ jsx("option", { value: "Indiana - IN", children: "Indiana - IN" }),
-                  /* @__PURE__ */ jsx("option", { value: "Iowa - IA", children: "Iowa - IA" }),
-                  /* @__PURE__ */ jsx("option", { value: "Kansas - KS", children: "Kansas - KS" }),
-                  /* @__PURE__ */ jsx("option", { value: "Kentucky - KY", children: "Kentucky - KY" }),
-                  /* @__PURE__ */ jsx("option", { value: "Louisiana - LA", children: "Louisiana - LA" }),
-                  /* @__PURE__ */ jsx("option", { value: "Maine - ME", children: "Maine - ME" }),
-                  /* @__PURE__ */ jsx("option", { value: "Maryland - MD", children: "Maryland - MD" }),
-                  /* @__PURE__ */ jsx("option", { value: "Massachusetts - MA", children: "Massachusetts - MA" }),
-                  /* @__PURE__ */ jsx("option", { value: "Michigan - MI", children: "Michigan - MI" }),
-                  /* @__PURE__ */ jsx("option", { value: "Minnesota - MN", children: "Minnesota - MN" }),
-                  /* @__PURE__ */ jsx("option", { value: "Mississippi - MS", children: "Mississippi - MS" }),
-                  /* @__PURE__ */ jsx("option", { value: "Missouri - MO", children: "Missouri - MO" }),
-                  /* @__PURE__ */ jsx("option", { value: "Montana - MT", children: "Montana - MT" }),
-                  /* @__PURE__ */ jsx("option", { value: "Nebraska - NE", children: "Nebraska - NE" }),
-                  /* @__PURE__ */ jsx("option", { value: "Nevada - NV", children: "Nevada - NV" }),
-                  /* @__PURE__ */ jsx("option", { value: "New Hampshire - NH", children: "New Hampshire - NH" }),
-                  /* @__PURE__ */ jsx("option", { value: "New Jersey - NJ", children: "New Jersey - NJ" }),
-                  /* @__PURE__ */ jsx("option", { value: "New Mexico - NM", children: "New Mexico - NM" }),
-                  /* @__PURE__ */ jsx("option", { value: "New York - NY", children: "New York - NY" }),
-                  /* @__PURE__ */ jsx("option", { value: "North Carolina - NC", children: "North Carolina - NC" }),
-                  /* @__PURE__ */ jsx("option", { value: "North Dakota - ND", children: "North Dakota - ND" }),
-                  /* @__PURE__ */ jsx("option", { value: "Ohio - OH", children: "Ohio - OH" }),
-                  /* @__PURE__ */ jsx("option", { value: "Oklahoma - OK", children: "Oklahoma - OK" }),
-                  /* @__PURE__ */ jsx("option", { value: "Oregon - OR", children: "Oregon - OR" }),
-                  /* @__PURE__ */ jsx("option", { value: "Pennsylvania - PA", children: "Pennsylvania - PA" }),
-                  /* @__PURE__ */ jsx("option", { value: "Rhode Island - RI", children: "Rhode Island - RI" }),
-                  /* @__PURE__ */ jsx("option", { value: "South Carolina - SC", children: "South Carolina - SC" }),
-                  /* @__PURE__ */ jsx("option", { value: "South Dakota - SD", children: "South Dakota - SD" }),
-                  /* @__PURE__ */ jsx("option", { value: "Tennessee - TN", children: "Tennessee - TN" }),
-                  /* @__PURE__ */ jsx("option", { value: "Texas - TX", children: "Texas - TX" }),
-                  /* @__PURE__ */ jsx("option", { value: "Utah - UT", children: "Utah - UT" }),
-                  /* @__PURE__ */ jsx("option", { value: "Vermont - VT", children: "Vermont - VT" }),
-                  /* @__PURE__ */ jsx("option", { value: "Virginia - VA", children: "Virginia - VA" }),
-                  /* @__PURE__ */ jsx("option", { value: "Washington - WA", children: "Washington - WA" }),
-                  /* @__PURE__ */ jsx("option", { value: "West Virginia - WV", children: "West Virginia - WV" }),
-                  /* @__PURE__ */ jsx("option", { value: "Wisconsin - WI", children: "Wisconsin - WI" }),
-                  /* @__PURE__ */ jsx("option", { value: "Wyoming - WY", children: "Wyoming - WY" })
-                ]
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-            ) }),
-            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
-              Input,
-              {
-                id: "Zip_Code",
-                ...register("Zip Code", { required: true }),
-                label: "Zip Code",
-                sizes: "medium",
-                required: true,
-                variant
-              }
-            ) }),
-            /* @__PURE__ */ jsx("div", { className: `${headerContainer} ${fullRowForm}`, children: /* @__PURE__ */ jsx("h2", { className: `header_2 ${descriptionField({ variant })}`, children: "Step 5: Please select how you would like to receive our response." }) }),
-            /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
-              RadioButtonSet,
-              {
-                id: "Contact_Method",
-                label: "* We will contact you using the information provided above:",
-                sizes: "medium",
-                required: true,
-                error: !!errors.Contact_Method,
-                helperText: errors.Contact_Method?.message,
-                variant,
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-                  /* @__PURE__ */ jsx(
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-                    {
-                      ...register("Contact_Method", {}),
-                      value: "Email",
-                      radioText: "Email",
-                      groupName: "Contact_Method"
-                    }
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-                  /* @__PURE__ */ jsx(
-                    RadioButton,
-                    {
-                      ...register("Contact_Method", {}),
-                      value: "Postal Mail",
-                      radioText: "Postal Mail",
-                      groupName: "Contact_Method"
-                    }
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-                ]
-              }
-            ) })
-          ] }),
-          children,
-          /* @__PURE__ */ jsx("div", { className: disclosureForm({ variant }), children: disclosure }),
-          /* @__PURE__ */ jsx("div", { className: actions, children: /* @__PURE__ */ jsx(
-            Button,
-            {
-              color: getVariant(callToAction?.variant),
-              as: "button",
-              type: "submit",
-              disabled: !isValid || isSubmitting,
-              children: callToAction?.displayText
-            }
-          ) })
-        ] })
-      ] }) })
-    },
-    id
-  );
+                  value: "No",
+                  radioText: "No",
+                  groupName: "Ever_Applied_for_Employment_with_Axos_Financial"
+                }
+              )
+            ]
+          }
+        ) }),
+        /* @__PURE__ */ jsx("div", { className: `${headerContainer} ${fullRowForm}`, children: /* @__PURE__ */ jsx("h2", { className: `header_2 ${descriptionField({ variant })}`, children: "Step 3: Where have you interacted with Axos Financial?" }) }),
+        /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
+          CheckboxGroup,
+          {
+            options: options2,
+            selectedValues: selectedValues2,
+            error: !!errors.Axos_Financial_interaction_outlet,
+            onChange: handleSelectedValues2
+          }
+        ) }),
+        /* @__PURE__ */ jsx("div", { className: `${headerContainer} ${fullRowForm}`, children: /* @__PURE__ */ jsx("h2", { className: `header_2 ${descriptionField({ variant })}`, children: "Step 4: Please provide your contact details." }) }),
+        /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
+          Input,
+          {
+            id: "First_Name",
+            ...register("First_Name", { required: true }),
+            label: "First Name",
+            sizes: "medium",
+            placeholder: "First Name",
+            required: true,
+            error: !!errors.First_Name,
+            helperText: errors.First_Name?.message,
+            variant
+          }
+        ) }),
+        /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
+          Input,
+          {
+            id: "Last_Name",
+            ...register("Last_Name", { required: true }),
+            label: "Last Name",
+            sizes: "medium",
+            required: true,
+            error: !!errors.Last_Name,
+            helperText: errors.Last_Name?.message,
+            variant
+          }
+        ) }),
+        /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
+          Input,
+          {
+            id: "DOB",
+            ...register("DOB", {
+              required: true
+            }),
+            type: "date",
+            label: "Date of Birth",
+            sizes: "medium",
+            placeholder: "Date of Birth",
+            required: true,
+            error: !!errors.DOB,
+            helperText: errors.DOB?.message,
+            variant
+          }
+        ) }),
+        /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
+          Input,
+          {
+            id: "email",
+            ...register("email", {
+              required: true
+              // validate: {
+              //   isValid: associatedEmail,
+              // },
+            }),
+            label: "Email",
+            sizes: "medium",
+            required: true,
+            error: !!errors.email,
+            helperText: errors.email?.message,
+            variant
+          }
+        ) }),
+        /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
+          InputPhone,
+          {
+            id: "Telephone",
+            ...register("Telephone", { required: true, maxLength: 12 }),
+            label: "Preferred Phone",
+            sizes: "medium",
+            required: true,
+            error: !!errors.Telephone,
+            helperText: errors.Telephone?.message,
+            variant
+          }
+        ) }),
+        /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
+          Input,
+          {
+            id: "Street_Address",
+            ...register("Street Address", { required: true }),
+            label: "Street Address",
+            sizes: "medium",
+            required: true,
+            variant
+          }
+        ) }),
+        /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
+          Input,
+          {
+            id: "City",
+            ...register("City", { required: true }),
+            label: "City",
+            sizes: "medium",
+            required: true,
+            variant
+          }
+        ) }),
+        /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
+          Dropdown,
+          {
+            id: "State",
+            ...register("State", {
+              required: true
+            }),
+            label: "Assets Under Management",
+            sizes: "medium",
+            required: true,
+            error: !!errors.State,
+            helperText: errors.State?.message,
+            variant,
+            children: [
+              /* @__PURE__ */ jsx("option", { value: "Alabama - AL", children: "Alabama - AL" }),
+              /* @__PURE__ */ jsx("option", { value: "Alaska - AK", children: "Alaska - AK" }),
+              /* @__PURE__ */ jsx("option", { value: "Arizona - AZ", children: "Arizona - AZ" }),
+              /* @__PURE__ */ jsx("option", { value: "Arkansas - AR", children: "Arkansas - AR" }),
+              /* @__PURE__ */ jsx("option", { value: "California - CA", children: "California - CA" }),
+              /* @__PURE__ */ jsx("option", { value: "Colorado - CO", children: "Colorado - CO" }),
+              /* @__PURE__ */ jsx("option", { value: "Connecticut - CT", children: "Connecticut - CT" }),
+              /* @__PURE__ */ jsx("option", { value: "Delaware - DE", children: "Delaware - DE" }),
+              /* @__PURE__ */ jsx("option", { value: "Florida - FL", children: "Florida - FL" }),
+              /* @__PURE__ */ jsx("option", { value: "Georgia - GA", children: "Georgia - GA" }),
+              /* @__PURE__ */ jsx("option", { value: "Hawaii - HI", children: "Hawaii - HI" }),
+              /* @__PURE__ */ jsx("option", { value: "Idaho - ID", children: "Idaho - ID" }),
+              /* @__PURE__ */ jsx("option", { value: "Illinois - IL", children: "Illinois - IL" }),
+              /* @__PURE__ */ jsx("option", { value: "Indiana - IN", children: "Indiana - IN" }),
+              /* @__PURE__ */ jsx("option", { value: "Iowa - IA", children: "Iowa - IA" }),
+              /* @__PURE__ */ jsx("option", { value: "Kansas - KS", children: "Kansas - KS" }),
+              /* @__PURE__ */ jsx("option", { value: "Kentucky - KY", children: "Kentucky - KY" }),
+              /* @__PURE__ */ jsx("option", { value: "Louisiana - LA", children: "Louisiana - LA" }),
+              /* @__PURE__ */ jsx("option", { value: "Maine - ME", children: "Maine - ME" }),
+              /* @__PURE__ */ jsx("option", { value: "Maryland - MD", children: "Maryland - MD" }),
+              /* @__PURE__ */ jsx("option", { value: "Massachusetts - MA", children: "Massachusetts - MA" }),
+              /* @__PURE__ */ jsx("option", { value: "Michigan - MI", children: "Michigan - MI" }),
+              /* @__PURE__ */ jsx("option", { value: "Minnesota - MN", children: "Minnesota - MN" }),
+              /* @__PURE__ */ jsx("option", { value: "Mississippi - MS", children: "Mississippi - MS" }),
+              /* @__PURE__ */ jsx("option", { value: "Missouri - MO", children: "Missouri - MO" }),
+              /* @__PURE__ */ jsx("option", { value: "Montana - MT", children: "Montana - MT" }),
+              /* @__PURE__ */ jsx("option", { value: "Nebraska - NE", children: "Nebraska - NE" }),
+              /* @__PURE__ */ jsx("option", { value: "Nevada - NV", children: "Nevada - NV" }),
+              /* @__PURE__ */ jsx("option", { value: "New Hampshire - NH", children: "New Hampshire - NH" }),
+              /* @__PURE__ */ jsx("option", { value: "New Jersey - NJ", children: "New Jersey - NJ" }),
+              /* @__PURE__ */ jsx("option", { value: "New Mexico - NM", children: "New Mexico - NM" }),
+              /* @__PURE__ */ jsx("option", { value: "New York - NY", children: "New York - NY" }),
+              /* @__PURE__ */ jsx("option", { value: "North Carolina - NC", children: "North Carolina - NC" }),
+              /* @__PURE__ */ jsx("option", { value: "North Dakota - ND", children: "North Dakota - ND" }),
+              /* @__PURE__ */ jsx("option", { value: "Ohio - OH", children: "Ohio - OH" }),
+              /* @__PURE__ */ jsx("option", { value: "Oklahoma - OK", children: "Oklahoma - OK" }),
+              /* @__PURE__ */ jsx("option", { value: "Oregon - OR", children: "Oregon - OR" }),
+              /* @__PURE__ */ jsx("option", { value: "Pennsylvania - PA", children: "Pennsylvania - PA" }),
+              /* @__PURE__ */ jsx("option", { value: "Rhode Island - RI", children: "Rhode Island - RI" }),
+              /* @__PURE__ */ jsx("option", { value: "South Carolina - SC", children: "South Carolina - SC" }),
+              /* @__PURE__ */ jsx("option", { value: "South Dakota - SD", children: "South Dakota - SD" }),
+              /* @__PURE__ */ jsx("option", { value: "Tennessee - TN", children: "Tennessee - TN" }),
+              /* @__PURE__ */ jsx("option", { value: "Texas - TX", children: "Texas - TX" }),
+              /* @__PURE__ */ jsx("option", { value: "Utah - UT", children: "Utah - UT" }),
+              /* @__PURE__ */ jsx("option", { value: "Vermont - VT", children: "Vermont - VT" }),
+              /* @__PURE__ */ jsx("option", { value: "Virginia - VA", children: "Virginia - VA" }),
+              /* @__PURE__ */ jsx("option", { value: "Washington - WA", children: "Washington - WA" }),
+              /* @__PURE__ */ jsx("option", { value: "West Virginia - WV", children: "West Virginia - WV" }),
+              /* @__PURE__ */ jsx("option", { value: "Wisconsin - WI", children: "Wisconsin - WI" }),
+              /* @__PURE__ */ jsx("option", { value: "Wyoming - WY", children: "Wyoming - WY" })
+            ]
+          }
+        ) }),
+        /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
+          Input,
+          {
+            id: "Zip_Code",
+            ...register("Zip Code", { required: true }),
+            label: "Zip Code",
+            sizes: "medium",
+            required: true,
+            variant
+          }
+        ) }),
+        /* @__PURE__ */ jsx("div", { className: `${headerContainer} ${fullRowForm}`, children: /* @__PURE__ */ jsx("h2", { className: `header_2 ${descriptionField({ variant })}`, children: "Step 5: Please select how you would like to receive our response." }) }),
+        /* @__PURE__ */ jsx("div", { className: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
+          RadioButtonSet,
+          {
+            id: "Contact_Method",
+            label: "* We will contact you using the information provided above:",
+            sizes: "medium",
+            required: true,
+            error: !!errors.Contact_Method,
+            helperText: errors.Contact_Method?.message,
+            variant,
+            children: [
+              /* @__PURE__ */ jsx(
+                RadioButton,
+                {
+                  ...register("Contact_Method", {}),
+                  value: "Email",
+                  radioText: "Email",
+                  groupName: "Contact_Method"
+                }
+              ),
+              /* @__PURE__ */ jsx(
+                RadioButton,
+                {
+                  ...register("Contact_Method", {}),
+                  value: "Postal Mail",
+                  radioText: "Postal Mail",
+                  groupName: "Contact_Method"
+                }
+              )
+            ]
+          }
+        ) })
+      ] }),
+      children,
+      /* @__PURE__ */ jsx("div", { className: disclosureForm({ variant }), children: disclosure }),
+      /* @__PURE__ */ jsx("div", { className: actions, children: /* @__PURE__ */ jsx(
+        Button,
+        {
+          color: getVariant(callToAction?.variant),
+          as: "button",
+          type: "submit",
+          disabled: !isValid || isSubmitting,
+          children: callToAction?.displayText
+        }
+      ) })
+    ] })
+  ] }) }) }, id);
 };
 export {
   CpraRequest