@axos-web-dev/shared-components 1.0.77-patch.6 → 1.0.77-patch.60

package/dist/Forms/CpraRequest.js

@@ -16,23 +16,26 @@ import { InputPhone } from "../Input/InputPhone.js";
 import "../Input/InputTextArea.js";
 import "../Input/DownPaymentInput.js";
 import { RadioButtonSet, RadioButton } from "../Input/RadioButton.js";
+import CheckboxGroup from "../Input/CheckboxGroup.js";
 import "../icons/ArrowIcon/ArrowIcon.css.js";
 import SvgAxosX from "../icons/AxosX/index.js";
 import SvgComponent from "../icons/AxosX/Blue.js";
 import "../icons/CheckIcon/CheckIcon.css.js";
-import '../assets/icons/FollowIcon/FollowIcon.css';import '../assets/icons/DownloadIcon/DownloadIcon.css';import '../assets/themes/victorie.css';import '../assets/themes/premier.css';import '../assets/themes/axos.css';/* empty css                                */
+import '../assets/icons/FollowIcon/FollowIcon.css';import '../assets/icons/DownloadIcon/DownloadIcon.css';import '../assets/themes/victorie.css';import '../assets/themes/ufb.css';import '../assets/themes/premier.css';import '../assets/themes/axos.css';/* empty css                                */
 /* empty css                                   */
+/* empty css                               */
 /* empty css                                    */
 /* empty css                                                    */
 /* empty css                                                */
 import { findMoreAxosDomains } from "../utils/allowedAxosDomains.js";
+import * as z from "zod";
 import { associatedEmail } from "../utils/EverestValidity.js";
 import { getVariant } from "../utils/getVariant.js";
-import CheckboxGroup from "../Input/CheckboxGroup.js";
+import { useCachedEmailValidator } from "../utils/useCachedValidators.js";
 import clsx from "clsx";
 import { useForm, FormProvider } from "react-hook-form";
-import * as z from "zod";
 import { iconForm, headerContainer, form, descriptionField, fullRowForm, formWrapper, disclosureForm, actions, formContainer } from "./Forms.css.js";
+import { honeyPotSchema, isValidHoneyPot, HoneyPot } from "./HoneyPot/index.js";
 const CpraRequest = ({
   icon = false,
   children,
@@ -44,8 +47,11 @@ const CpraRequest = ({
   headline,
   description,
   callToAction,
+  validateEmail,
+  onValidate,
   id
 }) => {
+  const cachedEmailValidator = useCachedEmailValidator(validateEmail);
   const schema = z.object({
     California_Resident: z.string(),
     Categories_of_personal_info: z.string(),
@@ -71,7 +77,7 @@ const CpraRequest = ({
     Last_Name: z.string().regex(/^[A-Za-z][^0-9_!¡?÷?¿/\\+=@#$%ˆ&*,.^(){}|~<>;:[\]]{1,}$/g, {
       message: "Last Name is required."
     }).trim().min(1, { message: "Last Name is required." }),
-    email: z.string().email({ message: "Email is required." }),
+    email: z.string().email({ message: "Email is required." }).refine(cachedEmailValidator, { message: "Invalid email address." }),
     Telephone: z.string({ message: "Phone is required." }).regex(/[\d-]{10}/, "Invalid phone number.").min(10, { message: "Phone is required." }).max(12, { message: "Phone is required." }).transform((val, ctx) => {
       const removeDashes = val.replace(/-/gi, "");
       if (removeDashes.length !== 10) {
@@ -91,8 +97,16 @@ const CpraRequest = ({
       return removeDashes;
     })
   });
+  const gen_schema = schema.merge(honeyPotSchema).superRefine((data, ctx) => {
+    if (!isValidHoneyPot(data)) {
+      ctx.addIssue({
+        code: z.ZodIssueCode.custom,
+        message: "fields are not valid."
+      });
+    }
+  });
   const methods = useForm({
-    resolver: zodResolver(schema, {
+    resolver: zodResolver(gen_schema, {
       async: true
     }),
     mode: "all"
@@ -136,626 +150,638 @@ const CpraRequest = ({
         " You have the right to send Axos Financial a verifiable request, twice in a 12-month period, asking that we disclose to you the personal information Axos Financial has collected, used, disclosed and sold about you during the past 12 months. Please check the box below relating to the information you would like Axos Financial to disclose to you:"
       ] })
     ] }),
-    /* @__PURE__ */ jsxs("form", { className: form, onSubmit: handleSubmit(submitForm), children: [
-      /* @__PURE__ */ jsxs("div", { className: clsx(formWrapper({ variant })), children: [
-        /* @__PURE__ */ jsx("div", { className: `${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} ${descriptionField({ variant })}`, children: "By selecting specific pieces of personal information Axos Financial has collected about you, you are required to sign a declaration, under penalty of perjury, that you are the individual whose information is provided above." }) }),
-        /* @__PURE__ */ jsx("div", { className: `${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"
-                }
-              )
-            ]
-          }
-        ) }),
-        /* @__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 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: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
-          RadioButtonSet,
-          {
-            id: "Former_client",
-            label: "* I am a former client or customer.",
-            sizes: "medium",
-            required: true,
-            error: !!errors.Former_client,
-            helperText: errors.Former_client?.message,
-            variant,
-            children: [
-              /* @__PURE__ */ jsx(
-                RadioButton,
-                {
-                  ...register("Former_client", {}),
-                  value: "Yes",
-                  radioText: "Yes",
-                  groupName: "Former_client"
-                }
-              ),
-              /* @__PURE__ */ jsx(
-                RadioButton,
-                {
-                  ...register("Former_client", {}),
-                  value: "No",
-                  radioText: "No",
-                  groupName: "Former_client"
-                }
-              )
-            ]
-          }
-        ) }),
-        /* @__PURE__ */ jsx("div", { className: `${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__ */ jsxs(
+      "form",
+      {
+        className: form,
+        onSubmit: async (e) => {
+          onValidate && onValidate(e);
+          await handleSubmit(submitForm)(e);
+          e.preventDefault();
+        },
+        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} ${descriptionField({ variant })}`, children: "By selecting specific pieces of personal information Axos Financial has collected about you, you are required to sign a declaration, under penalty of perjury, that you are the individual whose information is provided above." }) }),
+            /* @__PURE__ */ jsx("div", { className: `${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"
+                    }
+                  )
+                ]
+              }
+            ) }),
+            /* @__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 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: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
+              RadioButtonSet,
+              {
+                id: "Former_client",
+                label: "* I am a former client or customer.",
+                sizes: "medium",
+                required: true,
+                error: !!errors.Former_client,
+                helperText: errors.Former_client?.message,
+                variant,
+                children: [
+                  /* @__PURE__ */ jsx(
+                    RadioButton,
+                    {
+                      ...register("Former_client", {}),
+                      value: "Yes",
+                      radioText: "Yes",
+                      groupName: "Former_client"
+                    }
+                  ),
+                  /* @__PURE__ */ jsx(
+                    RadioButton,
+                    {
+                      ...register("Former_client", {}),
+                      value: "No",
+                      radioText: "No",
+                      groupName: "Former_client"
+                    }
+                  )
+                ]
+              }
+            ) }),
+            /* @__PURE__ */ jsx("div", { className: `${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: `${fullRowForm}`, children: /* @__PURE__ */ jsxs(
+              RadioButtonSet,
+              {
+                id: "Previously_Employed_by_Axos_Financial",
+                label: "* Have you previously been employed by Axos Financial?",
+                sizes: "medium",
+                required: true,
+                error: !!errors.Previously_Employed_by_Axos_Financial,
+                helperText: errors.Previously_Employed_by_Axos_Financial?.message,
+                variant,
+                children: [
+                  /* @__PURE__ */ jsx(
+                    RadioButton,
+                    {
+                      ...register("Previously_Employed_by_Axos_Financial", {}),
+                      value: "Yes",
+                      radioText: "Yes",
+                      groupName: "Previously_Employed_by_Axos_Financial"
+                    }
                   ),
-                  value: "Yes",
-                  radioText: "Yes",
-                  groupName: "Ever_Applied_for_Employment_with_Axos_Financial"
-                }
-              ),
-              /* @__PURE__ */ jsx(
-                RadioButton,
-                {
-                  ...register(
-                    "Ever_Applied_for_Employment_with_Axos_Financial",
-                    {}
+                  /* @__PURE__ */ jsx(
+                    RadioButton,
+                    {
+                      ...register("Previously_Employed_by_Axos_Financial", {}),
+                      value: "No",
+                      radioText: "No",
+                      groupName: "Previously_Employed_by_Axos_Financial"
+                    }
+                  )
+                ]
+              }
+            ) }),
+            /* @__PURE__ */ jsx("div", { className: `${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"
+                    }
                   ),
-                  value: "No",
-                  radioText: "No",
-                  groupName: "Ever_Applied_for_Employment_with_Axos_Financial"
-                }
-              )
-            ]
-          }
-        ) }),
-        /* @__PURE__ */ jsxs("div", { className: `${fullRowForm}`, children: [
-          /* @__PURE__ */ jsx("h2", { className: `header_2 ${descriptionField({ variant })}`, children: "Step 3: Where have you interacted with Axos Financial?" }),
-          /* @__PURE__ */ jsx("div", { className: `${form} ${descriptionField({ variant })}`, children: "* Please select all that apply." })
-        ] }),
-        /* @__PURE__ */ jsx("div", { className: `${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",
-            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: `${fullRowForm}`, children: /* @__PURE__ */ jsx(
-          Input,
-          {
-            id: "email",
-            ...register("email", {
-              required: true,
-              validate: {
-                isValid: associatedEmail
+                  /* @__PURE__ */ jsx(
+                    RadioButton,
+                    {
+                      ...register(
+                        "Ever_Applied_for_Employment_with_Axos_Financial",
+                        {}
+                      ),
+                      value: "No",
+                      radioText: "No",
+                      groupName: "Ever_Applied_for_Employment_with_Axos_Financial"
+                    }
+                  )
+                ]
+              }
+            ) }),
+            /* @__PURE__ */ jsxs("div", { className: `${fullRowForm}`, children: [
+              /* @__PURE__ */ jsx("h2", { className: `header_2 ${descriptionField({ variant })}`, children: "Step 3: Where have you interacted with Axos Financial?" }),
+              /* @__PURE__ */ jsx("div", { className: `${form} ${descriptionField({ variant })}`, children: "* Please select all that apply." })
+            ] }),
+            /* @__PURE__ */ jsx("div", { className: `${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",
+                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
               }
-            }),
-            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: "* State",
-            sizes: "medium",
-            required: true,
-            error: !!errors.State_,
-            helperText: errors.State_?.message,
-            variant,
-            children: [
-              /* @__PURE__ */ jsx("option", { value: "AL", children: "Alabama - AL" }),
-              /* @__PURE__ */ jsx("option", { value: "AK", children: "Alaska - AK" }),
-              /* @__PURE__ */ jsx("option", { value: "AZ", children: "Arizona - AZ" }),
-              /* @__PURE__ */ jsx("option", { value: "AR", children: "Arkansas - AR" }),
-              /* @__PURE__ */ jsx("option", { value: "CA", children: "California - CA" }),
-              /* @__PURE__ */ jsx("option", { value: "CO", children: "Colorado - CO" }),
-              /* @__PURE__ */ jsx("option", { value: "CT", children: "Connecticut - CT" }),
-              /* @__PURE__ */ jsx("option", { value: "DE", children: "Delaware - DE" }),
-              /* @__PURE__ */ jsx("option", { value: "FL", children: "Florida - FL" }),
-              /* @__PURE__ */ jsx("option", { value: "GA", children: "Georgia - GA" }),
-              /* @__PURE__ */ jsx("option", { value: "HI", children: "Hawaii - HI" }),
-              /* @__PURE__ */ jsx("option", { value: "ID", children: "Idaho - ID" }),
-              /* @__PURE__ */ jsx("option", { value: "IL", children: "Illinois - IL" }),
-              /* @__PURE__ */ jsx("option", { value: "IN", children: "Indiana - IN" }),
-              /* @__PURE__ */ jsx("option", { value: "IA", children: "Iowa - IA" }),
-              /* @__PURE__ */ jsx("option", { value: "KS", children: "Kansas - KS" }),
-              /* @__PURE__ */ jsx("option", { value: "KY", children: "Kentucky - KY" }),
-              /* @__PURE__ */ jsx("option", { value: "LA", children: "Louisiana - LA" }),
-              /* @__PURE__ */ jsx("option", { value: "ME", children: "Maine - ME" }),
-              /* @__PURE__ */ jsx("option", { value: "MD", children: "Maryland - MD" }),
-              /* @__PURE__ */ jsx("option", { value: "MA", children: "Massachusetts - MA" }),
-              /* @__PURE__ */ jsx("option", { value: "MI", children: "Michigan - MI" }),
-              /* @__PURE__ */ jsx("option", { value: "MN", children: "Minnesota - MN" }),
-              /* @__PURE__ */ jsx("option", { value: "MS", children: "Mississippi - MS" }),
-              /* @__PURE__ */ jsx("option", { value: "MO", children: "Missouri - MO" }),
-              /* @__PURE__ */ jsx("option", { value: "MT", children: "Montana - MT" }),
-              /* @__PURE__ */ jsx("option", { value: "NE", children: "Nebraska - NE" }),
-              /* @__PURE__ */ jsx("option", { value: "NV", children: "Nevada - NV" }),
-              /* @__PURE__ */ jsx("option", { value: "NH", children: "New Hampshire - NH" }),
-              /* @__PURE__ */ jsx("option", { value: "NJ", children: "New Jersey - NJ" }),
-              /* @__PURE__ */ jsx("option", { value: "NM", children: "New Mexico - NM" }),
-              /* @__PURE__ */ jsx("option", { value: "NY", children: "New York - NY" }),
-              /* @__PURE__ */ jsx("option", { value: "NC", children: "North Carolina - NC" }),
-              /* @__PURE__ */ jsx("option", { value: "ND", children: "North Dakota - ND" }),
-              /* @__PURE__ */ jsx("option", { value: "OH", children: "Ohio - OH" }),
-              /* @__PURE__ */ jsx("option", { value: "OK", children: "Oklahoma - OK" }),
-              /* @__PURE__ */ jsx("option", { value: "OR", children: "Oregon - OR" }),
-              /* @__PURE__ */ jsx("option", { value: "PA", children: "Pennsylvania - PA" }),
-              /* @__PURE__ */ jsx("option", { value: "RI", children: "Rhode Island - RI" }),
-              /* @__PURE__ */ jsx("option", { value: "SC", children: "South Carolina - SC" }),
-              /* @__PURE__ */ jsx("option", { value: "SD", children: "South Dakota - SD" }),
-              /* @__PURE__ */ jsx("option", { value: "TN", children: "Tennessee - TN" }),
-              /* @__PURE__ */ jsx("option", { value: "TX", children: "Texas - TX" }),
-              /* @__PURE__ */ jsx("option", { value: "UT", children: "Utah - UT" }),
-              /* @__PURE__ */ jsx("option", { value: "VT", children: "Vermont - VT" }),
-              /* @__PURE__ */ jsx("option", { value: "VA", children: "Virginia - VA" }),
-              /* @__PURE__ */ jsx("option", { value: "WA", children: "Washington - WA" }),
-              /* @__PURE__ */ jsx("option", { value: "WV", children: "West Virginia - WV" }),
-              /* @__PURE__ */ jsx("option", { value: "WI", children: "Wisconsin - WI" }),
-              /* @__PURE__ */ jsx("option", { value: "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: `${headerContainer}`, children: /* @__PURE__ */ jsxs("div", { className: `${form} ${descriptionField({ variant })}`, children: [
-        "For additional questions or concerns, please",
-        " ",
-        /* @__PURE__ */ jsx("a", { href: findMoreAxosDomains("{ONLINEBANKING}/Messages/Inbox"), children: "log in to online banking" }),
-        " ",
-        "and send us a secure message."
-      ] }) }),
-      /* @__PURE__ */ jsx("div", { className: actions, children: /* @__PURE__ */ jsx(
-        Button,
-        {
-          color: getVariant(callToAction?.variant),
-          as: "button",
-          type: "submit",
-          disabled: !isValid || isSubmitting,
-          children: callToAction?.displayText
-        }
-      ) }),
-      /* @__PURE__ */ jsx("div", { className: `${headerContainer}`, children: /* @__PURE__ */ jsx(
-        "div",
-        {
-          id: "test",
-          className: `${form} ${descriptionField({ variant })}`,
-          children: "* = Required Field"
-        }
-      ) })
-    ] })
+            ) }),
+            /* @__PURE__ */ jsx("div", { className: `${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: "* State",
+                sizes: "medium",
+                required: true,
+                error: !!errors.State_,
+                helperText: errors.State_?.message,
+                variant,
+                children: [
+                  /* @__PURE__ */ jsx("option", { value: "AL", children: "Alabama - AL" }),
+                  /* @__PURE__ */ jsx("option", { value: "AK", children: "Alaska - AK" }),
+                  /* @__PURE__ */ jsx("option", { value: "AZ", children: "Arizona - AZ" }),
+                  /* @__PURE__ */ jsx("option", { value: "AR", children: "Arkansas - AR" }),
+                  /* @__PURE__ */ jsx("option", { value: "CA", children: "California - CA" }),
+                  /* @__PURE__ */ jsx("option", { value: "CO", children: "Colorado - CO" }),
+                  /* @__PURE__ */ jsx("option", { value: "CT", children: "Connecticut - CT" }),
+                  /* @__PURE__ */ jsx("option", { value: "DE", children: "Delaware - DE" }),
+                  /* @__PURE__ */ jsx("option", { value: "FL", children: "Florida - FL" }),
+                  /* @__PURE__ */ jsx("option", { value: "GA", children: "Georgia - GA" }),
+                  /* @__PURE__ */ jsx("option", { value: "HI", children: "Hawaii - HI" }),
+                  /* @__PURE__ */ jsx("option", { value: "ID", children: "Idaho - ID" }),
+                  /* @__PURE__ */ jsx("option", { value: "IL", children: "Illinois - IL" }),
+                  /* @__PURE__ */ jsx("option", { value: "IN", children: "Indiana - IN" }),
+                  /* @__PURE__ */ jsx("option", { value: "IA", children: "Iowa - IA" }),
+                  /* @__PURE__ */ jsx("option", { value: "KS", children: "Kansas - KS" }),
+                  /* @__PURE__ */ jsx("option", { value: "KY", children: "Kentucky - KY" }),
+                  /* @__PURE__ */ jsx("option", { value: "LA", children: "Louisiana - LA" }),
+                  /* @__PURE__ */ jsx("option", { value: "ME", children: "Maine - ME" }),
+                  /* @__PURE__ */ jsx("option", { value: "MD", children: "Maryland - MD" }),
+                  /* @__PURE__ */ jsx("option", { value: "MA", children: "Massachusetts - MA" }),
+                  /* @__PURE__ */ jsx("option", { value: "MI", children: "Michigan - MI" }),
+                  /* @__PURE__ */ jsx("option", { value: "MN", children: "Minnesota - MN" }),
+                  /* @__PURE__ */ jsx("option", { value: "MS", children: "Mississippi - MS" }),
+                  /* @__PURE__ */ jsx("option", { value: "MO", children: "Missouri - MO" }),
+                  /* @__PURE__ */ jsx("option", { value: "MT", children: "Montana - MT" }),
+                  /* @__PURE__ */ jsx("option", { value: "NE", children: "Nebraska - NE" }),
+                  /* @__PURE__ */ jsx("option", { value: "NV", children: "Nevada - NV" }),
+                  /* @__PURE__ */ jsx("option", { value: "NH", children: "New Hampshire - NH" }),
+                  /* @__PURE__ */ jsx("option", { value: "NJ", children: "New Jersey - NJ" }),
+                  /* @__PURE__ */ jsx("option", { value: "NM", children: "New Mexico - NM" }),
+                  /* @__PURE__ */ jsx("option", { value: "NY", children: "New York - NY" }),
+                  /* @__PURE__ */ jsx("option", { value: "NC", children: "North Carolina - NC" }),
+                  /* @__PURE__ */ jsx("option", { value: "ND", children: "North Dakota - ND" }),
+                  /* @__PURE__ */ jsx("option", { value: "OH", children: "Ohio - OH" }),
+                  /* @__PURE__ */ jsx("option", { value: "OK", children: "Oklahoma - OK" }),
+                  /* @__PURE__ */ jsx("option", { value: "OR", children: "Oregon - OR" }),
+                  /* @__PURE__ */ jsx("option", { value: "PA", children: "Pennsylvania - PA" }),
+                  /* @__PURE__ */ jsx("option", { value: "RI", children: "Rhode Island - RI" }),
+                  /* @__PURE__ */ jsx("option", { value: "SC", children: "South Carolina - SC" }),
+                  /* @__PURE__ */ jsx("option", { value: "SD", children: "South Dakota - SD" }),
+                  /* @__PURE__ */ jsx("option", { value: "TN", children: "Tennessee - TN" }),
+                  /* @__PURE__ */ jsx("option", { value: "TX", children: "Texas - TX" }),
+                  /* @__PURE__ */ jsx("option", { value: "UT", children: "Utah - UT" }),
+                  /* @__PURE__ */ jsx("option", { value: "VT", children: "Vermont - VT" }),
+                  /* @__PURE__ */ jsx("option", { value: "VA", children: "Virginia - VA" }),
+                  /* @__PURE__ */ jsx("option", { value: "WA", children: "Washington - WA" }),
+                  /* @__PURE__ */ jsx("option", { value: "WV", children: "West Virginia - WV" }),
+                  /* @__PURE__ */ jsx("option", { value: "WI", children: "Wisconsin - WI" }),
+                  /* @__PURE__ */ jsx("option", { value: "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"
+                    }
+                  )
+                ]
+              }
+            ) }),
+            /* @__PURE__ */ jsx(HoneyPot, { register, variant })
+          ] }),
+          children,
+          /* @__PURE__ */ jsx("div", { className: disclosureForm({ variant }), children: disclosure }),
+          /* @__PURE__ */ jsx("div", { className: `${headerContainer}`, children: /* @__PURE__ */ jsxs("div", { className: `${form} ${descriptionField({ variant })}`, children: [
+            "For additional questions or concerns, please",
+            " ",
+            /* @__PURE__ */ jsx("a", { href: findMoreAxosDomains("{ONLINEBANKING}/Messages/Inbox"), children: "log in to online banking" }),
+            " ",
+            "and send us a secure message."
+          ] }) }),
+          /* @__PURE__ */ jsx("div", { className: actions, children: /* @__PURE__ */ jsx(
+            Button,
+            {
+              color: getVariant(callToAction?.variant),
+              as: "button",
+              type: "submit",
+              disabled: !isValid || isSubmitting,
+              children: callToAction?.displayText
+            }
+          ) }),
+          /* @__PURE__ */ jsx("div", { className: `${headerContainer}`, children: /* @__PURE__ */ jsx(
+            "div",
+            {
+              id: "test",
+              className: `${form} ${descriptionField({ variant })}`,
+              children: "* = Required Field"
+            }
+          ) })
+        ]
+      }
+    )
   ] }) }) }, id);
 };
 export {