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<div id="form_top">
<h1>Visa* Intake Form</h1>
<!-- <p class="top_text"></p>-->
<form action="#" method="post">
<!--form info-->
<input type="hidden" id="form_name" name="form_name" value="visa_intake_form">
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<!---------------------------------APPLICANT DETAILS-------------------------------->
<h3>APPLICANT DETAILS</h3>
<!--applicant name-->
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<label for="email" class="placeholder_sub">Email</label>
</div>
<!---------------------------------ABOUT YOUR BUSINESS-------------------------->
<h3>ABOUT YOUR BUSINESS</h3>
<!-- existing client-->
<label class="with_checkbox less_mt"><input id="existing_client" name="existing_client"
type="checkbox">Existing VCIB Client</label>
<!--business type-->
<div class="input_wrap half" tabindex="0">
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<li class="init select_label">Business Type<span>*</span></li>
<!-- -->
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Organization
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</div>
<!--Business Since-->
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<!--Number of Employees-->
<!-- todo: make number validation work-->
<div class="input_wrap half">
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required>
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<!--Business phone number-->
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<li data-value="BC">BC</li>
<li data-value="MB">MB</li>
<li data-value="NB">NB</li>
<li data-value="NL">NL</li>
<li data-value="NS">NS</li>
<li data-value="NT">NT</li>
<li data-value="NU">NU</li>
<li data-value="ON">ON</li>
<li data-value="PE">PE</li>
<li data-value="SK">SK</li>
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</ul>
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class="hidden_input required_hidden" value=""/>
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<input type="text" name="business_country" id="business_country" required>
<label for="business_country" class="placeholder_sub">Business Country</label>
</div>
<!--------------------------- YOUR BUSINESS’S IMPACT ------------------------->
<h3>YOUR BUSINESS’S IMPACT</h3>
<!-- addressing issues-->
<p class="section_description">As Canada’s first values-driven bank, VCIB partners with
businesses and organizations making a difference in their communities. The following
questions will help us understand the impact you’re having through your products, services
or operational practices.</p>
<div class="with_multiple_checkboxes">
<p class="question_description">VCIB seeks to support businesses and organizations
addressing a wide range of social, environmental and economic issues.
Please check all that apply to your business or organization: </p>
<div class="checkboxes_wrap two">
<label class="with_checkbox"><input id="poverty_reduction" type="checkbox"
name="poverty_reduction" value="Poverty reduction">Poverty
reduction</label>
<label class="with_checkbox"><input id="good_food_and_nutrition" type="checkbox"
name="good_food_and_nutrition"
value="Good food and nutrition">Good food and
nutrition</label>
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name="health_and_well_being"
value="Health and well-being">Health and well-being</label>
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value="Education">Education</label>
<label class="with_checkbox"><input id="gender_equality" type="checkbox"
name="gender_equality" value="Gender equality">Gender
equality</label>
<label class="with_checkbox"><input id="economic_inequality" type="checkbox"
name="economic_inequality"
value="Economic inequality">Economic
inequality</label>
<label class="with_checkbox"><input id="decent_work_and_economic_opportunity"
type="checkbox"
name="decent_work_and_economic_opportunity"
value="Decent work & economic opportunity">Decent
work & economic opportunity</label>
<label class="with_checkbox"><input id="responsible_consumption" type="checkbox"
name="responsible_consumption"
value="Responsible consumption">Responsible
consumption</label>
<label class="with_checkbox"><input id="clean_water_and_sanitation" type="checkbox"
name="clean_water_and_sanitation"
value="Clean water and sanitation">Clean water and
sanitation</label>
<label class="with_checkbox"><input id="clean_energy" type="checkbox"
name="clean_energy" value="Clean energy">Clean
energy</label>
<label class="with_checkbox"><input id="climate_action" type="checkbox"
name="climate_action" value="Climate action">Climate
action</label>
<label class="with_checkbox"><input id="sustainable_cities_and_communities"
type="checkbox"
name="sustainable_cities_and_communities"
value="Sustainable cities and communities">Sustainable
cities and communities</label>
<label class="with_checkbox"><input id="land_based_conservation" type="checkbox"
name="land_based_conservation"
value="Land based conservation">Land based
conservation</label>
<label class="with_checkbox"><input id="ocean_or_freshwater_conservation"
type="checkbox"
name="ocean_or_freshwater_conservation"
value="Ocean or freshwater conservation">Ocean or
freshwater conservation</label>
<label class="with_checkbox"><input id="peace_building_and_justice" type="checkbox"
name="peace_building_and_justice"
value="Peace building and justice">Peace building
and justice</label>
<div>
<label class="with_checkbox"><input id="addressing_issues_other"
class="with_toggled_text" type="checkbox"
name="addressing_issues_other" value="Other">Other</label>
<input class="toggled_text" id="addressing_issues_other_text"
name="addressing_issues_other_text" type="text">
</div>
</div><!-- .checkboxes_wrap-->
</div><!-- .with_multiple_checkboxes-->
<!-- underserved demographic-->
<div class="with_multiple_checkboxes">
<p class="question_description">Where possible, VCIB seeks to support businesses
historically underserved by mainstream finance. Please check all that apply to your
business or organization: </p>
<div class="checkboxes_wrap two">
<label class="with_checkbox"><input id="person_of_colour" type="checkbox"
name="person_of_colour"
value="Person of colour leadership or ownership">Person
of colour leadership or ownership</label>
<label class="with_checkbox"><input id="new_immigrant" type="checkbox"
name="new_immigrant"
value="New immigrant leadership or ownership">New
immigrant leadership or ownership</label>
<label class="with_checkbox"><input id="female" type="checkbox" name="female"
value="Female leadership or ownership">Female
leadership or ownership</label>
<label class="with_checkbox"><input id="indigenous" type="checkbox" name="indigenous"
value="Leadership or ownership by an Indigenous individual or community">Leadership
or ownership by an Indigenous individual or community</label>
<label class="with_checkbox"><input id="incarcerated" type="checkbox"
name="incarcerated"
value="Leadership or ownership by a formerly incarcerated individual">Leadership
or ownership by a formerly incarcerated individual</label>
<label class="with_checkbox"><input id="community" type="checkbox" name="community"
value="Partial or full community ownership">Partial
or full community ownership </label>
<label class="with_checkbox"><input id="underserved_demographic_none" type="checkbox"
name="underserved_demographic_none"
value="None of the above">None of the above</label>
</div><!-- .checkboxes_wrap-->
</div><!-- .with_multiple_checkboxes-->
<!-- steps_to -->
<div class="with_multiple_checkboxes">
<p class="question_description">Where possible, VCIB seeks to support businesses that
demonstrate leadership for the environment, workers and communities. Please check all
that apply to your business: </p>
<div class="checkboxes_wrap two">
<div>
<label class="with_checkbox">
<input id="environmental" class="with_toggled_text" type="checkbox"
name="environmental"
value="My organization is taking or has taken significant steps to track and reduce its environmental footprint">
My organization is taking or has taken significant steps to track and reduce its
environmental footprint (e.g. energy retrofits).
</label>
<label for="environmental_desc" class="toggled_text">Please describe in 1-2
sentences. (Optional)</label>
<textarea class="toggled_text" id="environmental_desc" name="environmental_desc"
maxlength="2000"></textarea>
</div>
<div>
<label class="with_checkbox">
<input id="job_quality" class="with_toggled_text" type="checkbox"
name="job_quality"
value="My organization is taking or has taken significant steps to improve job quality for workers">
My organization is taking or has taken significant steps to improve job quality
for workers (e.g. living wage provider)
</label>
<label for="job_quality_desc" class="toggled_text">Please describe in 1-2 sentences.
(Optional)</label>
<textarea id="job_quality_desc" class="toggled_text" name="job_quality_desc"
maxlength="2000"></textarea>
</div>
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