Wesprzyj

[et_pb_wp360_donate_form_donation goal_id="4728" style="divi" _builder_version="3.0.106"]

<p><p><p><p><p><p><p><p><p><p><p><p><div class="et_pb_contact"><br /> <form class="blocked wp360-donation-form js--wp360-donate-form et_pb_contact_form clearfix" action="" method="POST" data-field_type="select"><br /> <fieldset><br /> <div class="js--field-to-remove"><input name="action" type="hidden" value="register_donation" /><br /> <input name="goal_id" type="hidden" value="4594" /><br /> <input id="_wpnonce" name="_wpnonce" type="hidden" value="06ec5205a4" /><input name="_wp_http_referer" type="hidden" value="/wp-admin/admin-ajax.php" /></div><br /> <div class="wp360-row"><br /> <div class="wp360-form-field wp360-form-field-amounts-container wp360-form-field-amounts-container--select js--field-to-remove js--defined-type et_pb_contact_field et_pb_contact_field_0 et_pb_contact_field_half js--field-container" data-type="select"><label class="et_pb_contact_form_label">Kwota dotacji *</label><br /><select class="js--choose-amount" name="amount" required="required"><option value="">wybierz kwotę</option><option value="30"></option></select><br /><select class="js--choose-amount" name="amount" required="required"><option value="30">30 zł</option><option value="50"></option></select><br /><select class="js--choose-amount" name="amount" required="required"><option value="50">50 zł</option><option selected="selected" value="100"></option></select><br /><select class="js--choose-amount" name="amount" required="required"><option selected="selected" value="100">100 zł</option><option value="custom"></option></select><br /><select class="js--choose-amount" name="amount" required="required"><option value="custom">Własna kwota</option></select></div><br /> <p class="wp360-form-field js--custom-amount-container js--field-to-remove et_pb_contact_field et_pb_contact_field_0 et_pb_contact_field_half et_pb_contact_field_last js--field-container" style="display: none;"> </p><br /> <p><label class="et_pb_contact_form_label">Wprowadź kwotę*</label></p><br /> <p><input class="input" name="custom_amount" required="required" type="text" placeholder="Kwota dotacji*" /></p><br /> </div><br /> <p><!-- .wp360-row --></p><br /> <div class="wp360-row"><br /> <p class="wp360-form-field js--field-to-remove et_pb_contact_field et_pb_contact_field_0 et_pb_contact_field_half js--field-container"><label class="et_pb_contact_form_label">Imię*</label></p><br /> <p><input class="input" name="firstname" required="required" type="text" value="" placeholder="Imię*" /></p><br /> <p class="wp360-form-field js--field-to-remove et_pb_contact_field et_pb_contact_field_0 et_pb_contact_field_half et_pb_contact_field_last js--field-container"><label class="et_pb_contact_form_label">Nazwisko*</label></p><br /> <p><input class="input" name="lastname" required="required" type="text" value="" placeholder="Nazwisko*" /></p><br /> <p class="wp360-form-field js--field-to-remove et_pb_contact_field et_pb_contact_field_0 et_pb_contact_field_half js--field-container"><label class="et_pb_contact_form_label">E-mail*</label></p><br /> <p><input class="input" name="email" required="required" type="email" value="" placeholder="E-mail*" /></p><br /> <p class="wp360-form-field js--field-container js--field-to-remove"><label>Ulica </label></p><br /> <p><input class="input" name="ulica" type="text" value="" placeholder="Ulica" /></p><br /> <p class="wp360-form-field js--field-container js--field-to-remove"><label>Miejscowość </label></p><br /> <p><input class="input" name="Miejscowość" type="text" value="" placeholder="Miejscowość" /></p><br /> <p class="wp360-form-field js--field-container js--field-to-remove"><label>Telefon </label></p><br /> <p><input class="input" name="Telefon" type="text" value="" placeholder="Telefon" /></p><br /> <div class="js--field-container js--field-to-remove" style="display: none;"><input name="payment_method" type="hidden" value="przelewy24" /></div><br /> <div class="wp360-row"><br /> <p class="wp360-form-field wp360-checkbox-field js--field-container js--field-to-remove"><input id="fundrising-consents-0" name="anonim" type="checkbox" value="1" /> <label for="fundrising-consents-0"><i></i>Chcę pozostać Anonimowym Darczyńcą</label></p><br /> </div><br /> <div class="wp360-row"><br /> <p class="wp360-form-field wp360-checkbox-field js--field-container js--field-to-remove"><input id="fundrising-consents-1" name="newsletter-agreement" type="checkbox" value="1" /> <label for="fundrising-consents-1"><i></i>Chcę dostawać informacje o akcji i młodych naukowcach.</label></p><br /> </div><br /> <div class="wp360-row"><br /> <p class="wp360-form-field wp360-checkbox-field js--field-container js--field-to-remove"><input id="fundrising-consents-2" name="przetwarzanie_danych" required="required" type="checkbox" value="1" /> <label for="fundrising-consents-2"><i></i>Wyrażam zgodę na przetwarzanie podanego przeze mnie adresu e-mail przez Fundację na rzecz Nauki Polskiej z siedzibą w Warszawie przy ul. Krasickiego 20/22 w celu otrzymywania newslettera Fundacji. Przyjmuję do wiadomości, że zgodnie z ustawą z dnia 29 sierpnia 1997 r. o ochronie danych osobowych (Dz. U. z 2014 r. poz. 1182 ze zm.) mam prawo do dostępu do podanego przeze mnie adresu oraz jego poprawiania. Podanie adresu e-mail jest dobrowolne.</label></p><br /> </div><br /> <div class="et_contact_bottom_container"><br /> <p class="form-field et_pb_contact_right"><button class="et_pb_contact_submit et_pb_button" name="register_donation" type="submit"><br /> Wpłać </button></p><br /> </div><br /> </div><br /> <p><!-- .wp360-row --></p><br /> </fieldset><br /> </form><br /> </div></p></p></p></p></p></p></p></p></p></p></p></p>

[/et_pb_wp360_donate_form_donation]