<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<title>Sample Title</title>
<link rel="stylesheet" href="css/all.css">
<style>
body {
font-family: Arial, Helvetica, sans-serif;
font-size: 12px
}
fieldset {
border: none;
margin: 0;
padding: 0;
}
legend {
float: left;
}
h2 {
margin: 10px 0;
font-size: 13px;
margin: 20px 0 0 0;
}
h3 {
margin: 0;
font-size: 12px;
}
ul {
margin: 0;
}
li {
margin-bottom: 3px;
padding-left: 5px;
}
p {
margin: 4px 0;
}
.header {
border-bottom: 2px solid #000;
margin: 0 5px 15px 5px;
}
.header h1 {
font-weight: 700;
margin: 0;
font-size: 15px;
}
.body {
border: 1px solid #000;
padding: 0 5px 10px 5px;
}
.page {
padding: 0 25px;
margin: 0 auto;
}
.txt_logo {
font-size: 30px;
color:blue;
font-style:oblique
}
.textTag {
padding: 9px 0;
border-bottom: 2px solid #000;
margin: 0 -4px 5px 0
}
.underline {
text-decoration: underline;
font-weight: 700;
font-size: 12px
}
.columns-2 .item {
width: 49%
}
.columns-3 .item {
width: 33%
}
.item {
display: inline-block
}
.address .item {
width: 16%
}
.item.big {
width: 30%
}
.checkbox {
margin: 15px 0
}
.checkbox span {
font-weight: 700;
font-size: 11px
}
.card-info label {
width: 12%;
font-size: 11px;
text-transform: capitalize
}
.card-info p {
border-bottom: 1px solid #000;
margin-right: 10px;
padding-bottom:5px;
display: inline-block
}
.card-number {
width: 40%;
}
.expiry-date {
width: 25%;
}
.radio-button label {
width: 55%
}
.radio-button .item {
width: 16%
}
.note {
font-size: 12px
}
.footer {
padding: 0 10px;
font-size: 11px;
}
</style>
</head>
<body>
<div class="page">
<div class="header">
<h2 class="txt_logo"><b>SAMPLE COMPANY</b></h2>
<h1 class="h1_header">SAMPLE REQUEST TO OBTAIN MY FREE CREDIT REPORT </h1>
</div>
<div class="body">
<h3>Sample Important Information & Instructions:</h3>
<p>In order to protect your personal information we will validate your identity before mailing your credit report to your <u>confirmed</u>
home address. You must provide a photocopy of the front and back of:</p>
<ul class="info">
<li class="info__item">Two pieces of government-issued identification</li>
<li class="info__item">Si la dirección no está actualizada en ninguna de las identificaciones, <u>también debe</u> facilitar un documento adicional que muestre su <u>dirección postal actual</u> (por ejemplo, una factura de suministros públicos).</li>
<li class="info__item">If you provide your <b>Social Insurance Number</b>, we will cross-reference it with our records to ensure that we disclose the correct information to you. Saberlo nos ayuda a evitar retrasos y confusiones en caso de que la información identificativa de otra persona (como el nombre y la dirección) sea similar a la que usted nos ha facilitado.</li>
<li class="info__item">Si facilita un extracto de una <b>tarjeta de crédito </b> o una copia de su <b>tarjeta de crédito</b> como prueba, asegúrese de <b>tachar</b> su información privada.</li>
</ul>
<p>The information you provide on the form will be used to confirm your identity and may also be used to update your credit report. Such updated information will be stored, safeguarded, used and/or disclosed in the normal course as part of your credit file. For more information about SAMPLE COMPANY’s privacy practices, please see our Privacy Policy at https://www.adobe.com/privacy/policy.html. For clarity, in any case, we will keep a copy of the information you provide to demonstrate that we complied with our obligation to obtain reasonable identification from you.
</p>
<p>Envíe el formulario completado con un documento acreditativo a: <b>Lorem inseam dolor sit amen, consenttetur</b>o por fax a: <b>XXX-XX-XXXX. </b>Espere entre X e Y días para la entrega. If any corrections to your credit report are necessary you must complete the Credit Report Update form enclosed with your package, or visit <a href="http://sampleurl">SampleURL</a> and click on “How to File a Something” under Our Sample Assistance.
</p>
</div>
<div class="form">
<div class="columns-3">
<div class="item">
<p class="textTag">{{*LastName_es_:signer1}}</p>
<label for="LastName">APELLIDOS </label>
</div>
<div class="item">
<p class="textTag">{{*FirstName_es_:signer1}}</p>
<label for="FirstName">FIRST NAME, INITIAL</label>
</div>
<div class="item">
<p class="textTag">{{Suffix_es_:signer1}}</p>
<label for="Suffix">SUFFIX (Sr., Jr., etc.)</label>
</div>
</div>
<div class="address">
<div class="item big">
<p class="textTag">{{*StreetAddress_es_:signer1 }}</p>
<label for="StreetAddress">CURRENT STREET ADDRESS </label>
</div>
<div class="item">
<p class="textTag">{{*Apt_es_:signer1}}</p>
<label for="Apt">APT.</label>
</div>
<div class="item">
<p class="textTag">{{*City_es_:signer1}}</p>
<label for="City">CIUDAD</label>
</div>
<div class="item">
<p class="textTag">{{*Prov_es_:signer1}}</p>
<label for="Prov">PROVINCE</label>
</div>
<div class="item">
<p class="textTag">{{*Zip_es_:signer1:zip}}</p>
<label for="Zip">POSTAL CODE</label>
</div>
</div>
<h2>PREVIOUS ADDRESS(ES) WITHIN LAST 3 YEARS</h2>
<div class="address">
<div class="item big">
<p class="textTag">{{*StreetAddressPr_es_:signer1 }}</p>
<label for="StreetAddressPr">PREVIOUS STREET ADDRESS </label>
</div>
<div class="item">
<p class="textTag">{{*AptPr_es_:signer1}}</p>
<label for="AptPr">APT.</label>
</div>
<div class="item">
<p class="textTag">{{*CityPr_es_:signer1}}</p>
<label for="CityPr">CIUDAD</label>
</div>
<div class="item">
<p class="textTag">{{*PrvPr_es_:signer1}}</p>
<label for="PrvPr">PROVINCE</label>
</div>
<div class="item">
<p class="textTag">{{*ZipPr_es_:signer1:zip}}</p>
<label for="ZipPr">POSTAL CODE</label>
</div>
</div>
<div>
<p class="textTag">{{*EmailAddress_es_:signer1:isemail}}</p>
<label for="EmailAddress">CORREO ELECTRÓNICO</label>
</div>
<div class="columns-2">
<div class="item">
<p class="textTag">{{$DATEOFBIRTH}}</p>
<label for="Date">DATE OF BIRTH </label>
</div>
<div class="item">
<p class="textTag">{{SocialSecurityNumber_es_:signer1:ssn}}</p>
<label for="SocialSecurityNumber">S.I.N.:</label>
</div>
</div>
<div class="columns-2">
<div class="item">
<p class="textTag">{{$NAMEMAJORCARD}}</p>
<label for="NameMajorCard">NAME OF MAJOR CREDIT CARD:</label>
</div>
<div class="item">
<p class="textTag">{{$LAST4}}</p> <label for="Last4">LAST 4 DIGITS OF MAJOR CREDIT CARD:</label>
</div>
</div>
<div class="columns-2">
<div class="item">
<p class="textTag">{{*Signature_es_:signer1:signature}}</p><label for="Signature">Signature</label>
</div>
<div class="item">
<p class="textTag">{{*DateOfSignature_es_:signer1:date}}</p><label for="DateOfSignature">Date</label>
</div>
</div>
<div class="checkbox">
<label class="underline">{{$PAY}} YES, I WOULD ALSO LIKE TO PURCHASE MY Sample Company SCORE* FOR $X.XX (tax included)</label>
</div>
<fieldset>
<legend> Autorizo a la empresa Sample a cargar el pago en mi tarjeta de crédito:</legend>
<div class="radio-button">
<div class="item"><label>{{$V}}Visa</label></div>
<div class="item"><label>{{$M}}MasterCard</label></div>
<div class="item"><label>{{$A}}AMEX</label></div>
</div>
</legend>
<div class="card-info">
<label for="CardholderName">Cardholder Name:</label>
<p>{{$CALCULATEDCARDHOLDERNAME}}</p>
</div>
<div class="card-info">
<label for="CardNumber">Card Number:</label>
<p class="card-number">{{*CardNumber_es_:signer1}}</p> <label for="ExpiryDate">Expiry Date:</label>
<p class="expiry-date">{{$EXPIRYDATE}}</p>
</div>
<div class="note">
<p>Note: Cheque and cash payments are not accepted. El nombre del titular de la tarjeta debe ser el mismo que el nombre del solicitante.</p>
</div>
</div>
<div class="footer">
<p>*Sample company’s XY is a product some service providers use when assessing applications for credit and services. It is not part of your sample credit report, but is based on the particular information in your credit file at the time it is calculated. Lorem Ipsem is not the same as the Lorem Ipsem, which is also used by some lenders. Sample Company will provide your sample report free of charge, whether or not you purchase your Lorem Ipsem. <b>Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Sample company can provide more sample services:</b> Sample Address Telephone: 1-XXX-XXX-XXXX Telephone in Sample: 1-XXX-XXX-XXXX</p>
</div>
</div>
<!-- PAGE BREAK -->
<div style="page-break-after:always"></div>
<!-- SIGN Text Tag Definitions -->
{{#REMOVE_PAGE_FROM_OUTPUT}}
<!-- check box -->
<p>{{#PAY=*Pay_es_:signer1:checkbox}}</p>
<!-- radio button and conditional rule to enable if Pay is checked -->
<p>{{#V=(Visa)CCard_es_:signer1:enableif(Pay=checked)}}</p>
<p>{{#M=(MasterCard)CCard_es_:signer1:enableif(Pay=checked)}}</p>
<p>{{#A=(AMEX)CCard_es_:signer1:enableif(Pay=checked)}}</p>
<!-- drop down -->
{{#NAMEMAJORCARD=*NameMajorCard_es_:dropdown(options="Visa,MasterCard,AMEX,Discover")}}
<!-- calculated field -->
<p>{{#CALCULATEDCARDHOLDERNAME=*CardholderName_es_:signer1:calc([FirstName]+" "+[LastName]+" "+[Suffix])}}
<!-- regular expression fromatting validation -->
<p>{{#LAST4=*Last4_es_:signer1:custom(regexp="^[0-9]{4}$")}}
<p>{{#CREDITCARDNUMBER=*CardNumber_es_:signer1:custom(regexp="^[0-9]{16}$")}}</p>
<!-- date validations -->
<p>{{#EXPIRYDATE=*ExpiryDate_es_:isdate(format=mm/yy)}}</p>
<p>{{#DATEOFBIRTH=*Date_es_:signer1:isdate(format=mm/dd/yyyy)}}</p>
</body>
</html>