Personal Information
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="mf-first-name"
as=${html``}
/>
${ parent.decodeEntities(`Enter your first name here`) }
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="mf-middle-name"
as=${html``}
/>
${ parent.decodeEntities(`Enter your first name here`) }
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="mf-last-name"
as=${html``}
/>
${ parent.decodeEntities(`Enter your last name here`) }
<${props.Select}
className=${"mf-input mf-input-select " + ( validation.errors['mf-select'] ? 'mf-invalid' : '' )}
classNamePrefix="mf_select"
name="mf-select"
placeholder="${ parent.decodeEntities(`Select`) } "
isSearchable=${false}
options=${[{"label":"Sr.","value":"value-1","isDisabled":false},{"label":"II","value":"value-2","isDisabled":false},{"label":"III","value":"value-3","isDisabled":false},{"label":"IV","value":"value-4","isDisabled":false},{"label":"V","value":"value-5","isDisabled":false},{"label":"Jr.","value":"value-6","isDisabled":false}]}
value=${parent.getValue("mf-select") ? [{"label":"Sr.","value":"value-1","isDisabled":false},{"label":"II","value":"value-2","isDisabled":false},{"label":"III","value":"value-3","isDisabled":false},{"label":"IV","value":"value-4","isDisabled":false},{"label":"V","value":"value-5","isDisabled":false},{"label":"Jr.","value":"value-6","isDisabled":false}].filter(item => item.value === parent.getValue("mf-select"))[0] : []}
onChange=${(e)=> parent.handleSelect(e, "mf-select")}
ref=${() => {
register({ name: "mf-select" }, parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false}));
if ( parent.getValue("mf-select") === '' && false ) {
parent.setValue( 'mf-select', '', true );
parent.handleChange({
target: {
name: 'mf-select',
value: ''
}
});
}
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="mf-select"
as=${html``}
/>
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="mf-number"
as=${html``}
/>
<${props.Flatpickr}
name="mf-date"
className="mf-input mf-date-input mf-left-parent "
placeholder="${ parent.decodeEntities(`Date`) } "
options=${{"minDate":"","maxDate":"","dateFormat":"m-d-Y","enableTime":"","disable":[],"mode":"single","static":true,"disableMobile":true,"time_24hr":false}}
value=${parent.getValue('mf-date')}
onInput=${parent.handleDateTime}
aria-invalid=${validation.errors['mf-date'] ? 'true' : 'false'}
ref=${el => props.DateWidget(
el,
'',
{"message":"This field is required.","required":true},
register,
parent
)}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="mf-date"
as=${html``}
/>
<${props.ReactPhoneInput}
inputProps=${{
name: "mf-mobile"
}}
inputExtraProps=${{
required: true,
autoFocus: true,
}}
searchPlaceholder="Search"
inputClass="mf-input mf-input-mobile"
country="us"
enableSearch=${true}
countryCodeEditable=${false}
enableAreaCodes=${false}
value=${parent.state.mobileWidget["mf-mobile"] ? parent.state.mobileWidget["mf-mobile"] :
(parent.state.formData["mf-mobile"] ? parent.state.formData["mf-mobile"] : '')}
}
name="mf-mobile"
id="mf-input-mobile-7791807"
onChange=${(value, country) => parent.handleOnChangePhoneInput(value, "mf-mobile", country) }
/>
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false}, el) }
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="mf-mobile"
as=${html``}
/>
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="mf-telephone"
as=${html``}
/>
If your cell phone is similar to primary phone, enter it in both fields.
parent.activateValidation({"message":"This field is required.","emailMessage":"Please enter a valid Email address","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="mf-email"
as=${html``}
/>
parent.activateValidation({"message":"This field is required.","emailMessage":"Please enter a valid Email address","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="mf-email"
as=${html``}
/>
<${props.Flatpickr}
name="mf-date"
className="mf-input mf-date-input mf-left-parent "
placeholder="${ parent.decodeEntities(`Date`) } "
options=${{"minDate":"","maxDate":"","dateFormat":"m-d-Y","enableTime":"","disable":[],"mode":"single","static":true,"disableMobile":true,"time_24hr":false}}
value=${parent.getValue('mf-date')}
onInput=${parent.handleDateTime}
aria-invalid=${validation.errors['mf-date'] ? 'true' : 'false'}
ref=${el => props.DateWidget(
el,
'',
{"message":"This field is required.","required":false},
register,
parent
)}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="mf-date"
as=${html``}
/>
Enter your last 3 years address(es)
<${props.Flatpickr}
name="mf-date"
className="mf-input mf-date-input mf-left-parent "
placeholder="${ parent.decodeEntities(`Date`) } "
options=${{"minDate":"","maxDate":"","dateFormat":"m-d-Y","enableTime":"","disable":[],"mode":"single","static":true,"disableMobile":true,"time_24hr":false}}
value=${parent.getValue('mf-date')}
onInput=${parent.handleDateTime}
aria-invalid=${validation.errors['mf-date'] ? 'true' : 'false'}
ref=${el => props.DateWidget(
el,
'',
{"message":"This field is required.","required":false},
register,
parent
)}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="mf-date"
as=${html``}
/>
<${props.Flatpickr}
name="mf-date"
className="mf-input mf-date-input mf-left-parent mf-conditional-input"
placeholder="${ parent.decodeEntities(`Date`) } "
options=${{"minDate":"","maxDate":"","dateFormat":"m-d-Y","enableTime":"","disable":[],"mode":"single","static":true,"disableMobile":true,"time_24hr":false}}
value=${parent.getValue('mf-date')}
onInput=${parent.handleDateTime}
aria-invalid=${validation.errors['mf-date'] ? 'true' : 'false'}
ref=${el => props.DateWidget(
el,
'',
{"message":"This field is required.","required":false},
register,
parent
)}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="mf-date"
as=${html``}
/>
parent.handleCheckbox(el, 'onLoad')}
class="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-aa33371">
<${validation.ErrorMessage}
errors=${validation.errors}
name="presentcheckbox"
as=${html``}
/>
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Street"
as=${html``}
/>
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="Country"
as=${html``}
/>
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="City"
as=${html``}
/>
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="State"
as=${html``}
/>
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false,"expression":"null"}, el)}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="mf-number"
as=${html``}
/>
Yes, I want to receive information and communications from Safeway Truck Lines, LLC concerning future opportunities or promotions.
parent.handleCheckbox(el, 'onLoad')}
class="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-b93f5ed">
<${validation.ErrorMessage}
errors=${validation.errors}
name="mf-checkbox"
as=${html``}
/>
Would you like to receive communication from Safeway Truck Lines, LLC via text message?
parent.handleCheckbox(el, 'onLoad')}
class="mf-checkbox multi-option-input-type"
id="mf-input-checkbox-795538a">
<${validation.ErrorMessage}
errors=${validation.errors}
name="mf-checkbox"
as=${html``}
/>
