{"id":15690,"date":"2023-11-22T18:39:56","date_gmt":"2023-11-22T23:39:56","guid":{"rendered":"https:\/\/perupowersports.pe\/tienda\/?page_id=15690"},"modified":"2024-04-25T21:19:36","modified_gmt":"2024-04-26T02:19:36","slug":"libro-de-reclamaciones","status":"publish","type":"page","link":"https:\/\/perupowersports.pe\/tienda\/libro-de-reclamaciones\/","title":{"rendered":"Libro de reclamaciones"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"15690\" class=\"elementor elementor-15690\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-4ad48446 elementor-section-stretched elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"4ad48446\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;,&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-no\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-6f5bff27\" data-id=\"6f5bff27\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-681b7c16 elementor-widget elementor-widget-heading\" data-id=\"681b7c16\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Libro de reclamaciones<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-5dac9a5b elementor-widget elementor-widget-text-editor\" data-id=\"5dac9a5b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<a style=\"color: #ffffff;\" href=\"https:\/\/perupowersports.pe\/tienda\/\">Inicio<\/a> &gt; Libro de reclamaciones\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-5e1eacb elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"5e1eacb\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-36cb740\" data-id=\"36cb740\" data-element_type=\"column\" 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.formcraft-css .fc-pagination > div.active\n\t\t\t\t{\n\t\t\t\t\tbackground: url(https:\/\/hanzo.com.pe\/website2\/wp-content\/plugins\/formcraft3\/views\/..\/assets\/images\/backgrounds\/white-linen.png);\n\t\t\t\t}\n\t\t\t}\n\t\t<\/style>\n\t\t<div class=\"form-cover\">\n\t\t\t<form data-auto-scroll=\"\" data-no-message-redirect=\"\" data-thousand=\"\" data-decimal=\".\" data-delay=\"10\" data-id=\"1\" class=\"fc-form fc-form-1 align- fc-temp-class save-form- disable-enter- label-floating field-border-visible frame-visible dont-submit-hidden-true remove-asterisk-true icons-hide-false field-alignment-left options-fade ng-submitted  \" style=\"width: 720px; color: #222222; font-size: 105%; background: url(https:\/\/hanzo.com.pe\/website2\/wp-content\/plugins\/formcraft3\/views\/..\/assets\/images\/backgrounds\/white-linen.png)\">\n\t\t\t\t<!-- ngRepeat: page in Builder.FormElements track by $index --><div class=\"form-page form-page-0\" data-index=\"0\">\n\t\t\t\t\t\n\t\t\t\t\t<div class=\"form-page-content      ng-not-empty\">\n\t\t\t\t\t\t<div data-identifier=\"field16\" data-index=\"0\" style=\"width: 100%\" class=\" form-element form-element-field16 options-false form-element-0 default-false form-element-type-datepicker is-required-true odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"datepicker-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >FECHA DE REGISTRO:<\/span><\/span><span class=\"sub-label\"><span >Seleccionar el D\u00eda-Mes-A\u00f1o de la solicitud<\/span><\/span><\/span><div><span class=\"error\"><\/span><input autocomplete=\"off\" data-field-id=\"field16\" placeholder=\"\" type=\"text\" class=\"validation-lenient    hasDatepicker ng-empty\" data-is-required=\"true\" datepicker=\"\" data-date-min-range=\"\" data-date-format=\"d M yy\" data-date-days=\"{&quot;0&quot;:true,&quot;1&quot;:true,&quot;2&quot;:true,&quot;3&quot;:true,&quot;4&quot;:true,&quot;5&quot;:true,&quot;6&quot;:true}\" data-date-min=\"-30\" data-date-min-alt=\"2026\/03\/17\" data-date-max-alt=\"\" data-date-max=\"0\" data-date-lang=\"es\" name=\"field16\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-original-title=\"\"><i class=\"formcraft-icon\">date_range<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field72\" data-index=\"1\" style=\"width: 100%\" class=\" even form-element form-element-field72 form-element-1 default-false form-element-type-customText is-required-false -handle options-true\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><p style=\"font-size: 14px\" ><b>Raz\u00f3n Social:<\/b> PPS PARTS S.A.C.<br><b>RUC:<\/b> 20614807629<br><b>Domicilio Legal:<\/b>&nbsp;<span id=\"selectionBoundary_1776394942334_47312373796488283\" class=\"rangySelectionBoundary\">\ufeff<\/span><!--StartFragment-->Lote 7, <span id=\"selectionBoundary_1776394978113_8619842734289466\" class=\"rangySelectionBoundary\">\ufeff<\/span>MZ 4B, Urbanizaci\u00f3n Defensores de Marques de Corpac, Chorrillos, Lima.<span id=\"selectionBoundary_1776394961212_6676423420205295\" class=\"rangySelectionBoundary\">\ufeff<\/span><span id=\"selectionBoundary_1776394948575_8033448720995875\" class=\"rangySelectionBoundary\">\ufeff<\/span><!--EndFragment--><br><br><span id=\"selectionBoundary_1776394933361_31987850955780783\" class=\"rangySelectionBoundary\">\ufeff<\/span><\/p><\/div><input type=\"hidden\" name=\"field72\" data-field-id=\"field72\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field21\" data-index=\"2\" style=\"width: 100%\" class=\" form-element form-element-field21 options-false form-element-2 default-false form-element-type-heading is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div style=\"background-color: #000000\" class=\"heading-cover field-cover \"><div style=\"text-align: left; font-size: 1.0999999999999996em; padding-top: 15px; padding-bottom: 5px; color: #eeeeee\" class=\"bold-true\"><span >1.- IDENTIFICACI\u00d3N DEL USUARIO<\/span><\/div><input type=\"hidden\" data-field-id=\"field21\" name=\"field21[]\" value=\"1.- IDENTIFICACI\u00d3N DEL USUARIO\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field15\" data-index=\"3\" style=\"width: 50%\" class=\" even form-element form-element-field15 options-false form-element-3 default-false form-element-type-oneLineText is-required-true -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >NOMBRES:<\/span><\/span><span class=\"sub-label\"><span >Ingrese sus Nombres<\/span><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"\" make-read-only=\"\" data-field-id=\"field15\" name=\"field15[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"true\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-person\">person<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field73\" data-index=\"4\" style=\"width: 50%\" class=\" form-element form-element-field73 options-false form-element-4 default-false form-element-type-oneLineText is-required-true odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >APELLIDOS:<\/span><\/span><span class=\"sub-label\"><span >Ingrese sus Apellidos<\/span><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"\" make-read-only=\"\" data-field-id=\"field73\" name=\"field73[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"true\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-person\">person<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field43\" data-index=\"5\" style=\"width: 50%\" class=\" even form-element form-element-field43 options-false form-element-5 default-false form-element-type-dropdown is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type-false\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >DEPARTAMENTO:<\/span><\/span><span class=\"sub-label\"><span >Ingrese su distrito de residencia<\/span><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"false\" class=\"validation-lenient\" data-field-id=\"field43\" name=\"field43\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \"><\/option><option value=\"Amazonas\" class=\" \">Amazonas<\/option><option value=\"\u00c1ncash\" class=\" \">\u00c1ncash<\/option><option value=\"Apur\u00edmac\" class=\" \">Apur\u00edmac<\/option><option value=\"Arequipa\" class=\" \">Arequipa<\/option><option value=\"Ayacucho\" class=\" \">Ayacucho<\/option><option value=\"Cajamarca\" class=\" \">Cajamarca<\/option><option value=\"Cusco\" class=\" \">Cusco<\/option><option value=\"Huancavelica\" class=\" \">Huancavelica<\/option><option value=\"Hu\u00e1nuco\" class=\" \">Hu\u00e1nuco<\/option><option value=\"Ica\" class=\" \">Ica<\/option><option value=\"Jun\u00edn\" class=\" \">Jun\u00edn<\/option><option value=\"La Libertad\" class=\" \">La Libertad<\/option><option value=\"Lambayeque\" class=\" \">Lambayeque<\/option><option value=\"Lima\" class=\" \">Lima<\/option><option value=\"Loreto\" class=\" \">Loreto<\/option><option value=\"Madre de Dios\" class=\" \">Madre de Dios<\/option><option value=\"Moquegua\" class=\" \">Moquegua<\/option><option value=\"Pasco\" class=\" \">Pasco<\/option><option value=\"Piura\" class=\" \">Piura<\/option><option value=\"Puno\" class=\" \">Puno<\/option><option value=\"San Mart\u00edn\" class=\" \">San Mart\u00edn<\/option><option value=\"Tacna\" class=\" \">Tacna<\/option><option value=\"Tumbes\" class=\" \">Tumbes<\/option><option value=\"Ucayali\" class=\" \">Ucayali<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field106\" data-index=\"6\" style=\"width: 50%\" class=\" form-element form-element-field106 options-false form-element-6 default-true form-element-type-dropdown is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type-false\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >PROVINCIA de Amazonas<\/span><\/span><span class=\"sub-label\"><span >Seleccione su Provincia<\/span><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"false\" class=\"validation-lenient\" data-field-id=\"field106\" name=\"field106\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \"><\/option><option value=\"Chachapoyas\" class=\" \">Chachapoyas<\/option><option value=\"Bagua\" class=\" \">Bagua<\/option><option value=\"Bongar\u00e1\" class=\" \">Bongar\u00e1<\/option><option value=\"Condorcanqui\" class=\" \">Condorcanqui<\/option><option value=\"Luya\" class=\" \">Luya<\/option><option value=\"Rodr\u00edguez de Mendoza\" class=\" \">Rodr\u00edguez de Mendoza<\/option><option value=\"Utcubamba\" class=\" \">Utcubamba<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field108\" data-index=\"7\" style=\"width: 50%\" class=\" even form-element form-element-field108 options-false form-element-7 default-true form-element-type-dropdown is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type-false\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >PROVINCIA de \u00c1ncash<\/span><\/span><span class=\"sub-label\"><span >Seleccione su Provincia<\/span><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"false\" class=\"validation-lenient\" data-field-id=\"field108\" name=\"field108\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \"><\/option><option value=\"Aija\" class=\" \">Aija<\/option><option value=\"Antonio Raymondi\" class=\" \">Antonio Raymondi<\/option><option value=\"Asunci\u00f3n\" class=\" \">Asunci\u00f3n<\/option><option value=\"Bolognesi\" class=\" \">Bolognesi<\/option><option value=\"Carhuaz\" class=\" \">Carhuaz<\/option><option value=\"Carlos F. Fitzcarrald\" class=\" \">Carlos F. Fitzcarrald<\/option><option value=\"Casma\" class=\" \">Casma<\/option><option value=\"Corongo\" class=\" \">Corongo<\/option><option value=\"Huaraz\" class=\" \">Huaraz<\/option><option value=\"Huari\" class=\" \">Huari<\/option><option value=\"Huarmey\" class=\" \">Huarmey<\/option><option value=\"Huaylas\" class=\" \">Huaylas<\/option><option value=\"Mariscal Luzuriaga\" class=\" \">Mariscal Luzuriaga<\/option><option value=\"Ocros\" class=\" \">Ocros<\/option><option value=\"Pallasca\" class=\" \">Pallasca<\/option><option value=\"Pomabamba\" class=\" \">Pomabamba<\/option><option value=\"Recuay\" class=\" \">Recuay<\/option><option value=\"Santa\" class=\" \">Santa<\/option><option value=\"Sihuas\" class=\" \">Sihuas<\/option><option value=\"Yungay\" class=\" \">Yungay<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field109\" data-index=\"8\" style=\"width: 50%\" class=\" form-element form-element-field109 options-false form-element-8 default-true form-element-type-dropdown is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type-false\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >PROVINCIA de Apur\u00edmac<\/span><\/span><span class=\"sub-label\"><span >Seleccione su Provincia<\/span><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"false\" class=\"validation-lenient\" data-field-id=\"field109\" name=\"field109\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \"><\/option><option value=\"Abancay\" class=\" \">Abancay<\/option><option value=\"Antabamba\" class=\" \">Antabamba<\/option><option value=\"Aymaraes\" class=\" \">Aymaraes<\/option><option value=\"Cotabambas\" class=\" \">Cotabambas<\/option><option value=\"Grau\" class=\" \">Grau<\/option><option value=\"Chincheros\" class=\" \">Chincheros<\/option><option value=\"Andahuaylas\" class=\" \">Andahuaylas<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field107\" data-index=\"9\" style=\"width: 50%\" class=\" even form-element form-element-field107 options-false form-element-9 default-true form-element-type-dropdown is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type-false\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >PROVINCIA de Arequipa<\/span><\/span><span class=\"sub-label\"><span >Seleccione su Provincia<\/span><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"false\" class=\"validation-lenient\" data-field-id=\"field107\" name=\"field107\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \"><\/option><option value=\"Arequipa\" class=\" \">Arequipa<\/option><option value=\"Caman\u00e1\" class=\" \">Caman\u00e1<\/option><option value=\"Caravel\u00ed\" class=\" \">Caravel\u00ed<\/option><option value=\"Castilla\" class=\" \">Castilla<\/option><option value=\"Caylloma\" class=\" \">Caylloma<\/option><option value=\"Condesuyos\" class=\" \">Condesuyos<\/option><option value=\"Islay\" class=\" \">Islay<\/option><option value=\"La Uni\u00f3n\" class=\" \">La Uni\u00f3n<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field110\" data-index=\"10\" style=\"width: 50%\" class=\" form-element form-element-field110 options-false form-element-10 default-true form-element-type-dropdown is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type-false\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >PROVINCIA de Ayacucho<\/span><\/span><span class=\"sub-label\"><span >Seleccione su Provincia<\/span><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"false\" class=\"validation-lenient\" data-field-id=\"field110\" name=\"field110\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \"><\/option><option value=\"Cangallo\" class=\" \">Cangallo<\/option><option value=\"Huanta\" class=\" \">Huanta<\/option><option value=\"Huamanga\" class=\" \">Huamanga<\/option><option value=\"Huanca Sancos\" class=\" \">Huanca Sancos<\/option><option value=\"La Mar\" class=\" \">La Mar<\/option><option value=\"Lucanas\" class=\" \">Lucanas<\/option><option value=\"Parinacochas\" class=\" \">Parinacochas<\/option><option value=\"P\u00e1ucar del Sara Sara\" class=\" \">P\u00e1ucar del Sara Sara<\/option><option value=\"Sucre\" class=\" \">Sucre<\/option><option value=\"V\u00edctor Fajardo\" class=\" \">V\u00edctor Fajardo<\/option><option value=\"Vilcashuam\u00e1n\" class=\" \">Vilcashuam\u00e1n<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field111\" data-index=\"11\" style=\"width: 50%\" class=\" even form-element form-element-field111 options-false form-element-11 default-true form-element-type-dropdown is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type-false\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >PROVINCIA de Cajamarca<\/span><\/span><span class=\"sub-label\"><span >Seleccione su Provincia<\/span><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"false\" class=\"validation-lenient\" data-field-id=\"field111\" name=\"field111\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \"><\/option><option value=\"Cajamarca\" class=\" \">Cajamarca<\/option><option value=\"Cajabamba\" class=\" \">Cajabamba<\/option><option value=\"Celend\u00edn\" class=\" \">Celend\u00edn<\/option><option value=\"Chota\" class=\" \">Chota<\/option><option value=\"Contumaz\u00e1\" class=\" \">Contumaz\u00e1<\/option><option value=\"Cutervo\" class=\" \">Cutervo<\/option><option value=\"Hualg\u00e1yoc\" class=\" \">Hualg\u00e1yoc<\/option><option value=\"Ja\u00e9n\" class=\" \">Ja\u00e9n<\/option><option value=\"San Ignacio\" class=\" \">San Ignacio<\/option><option value=\"San Marcos\" class=\" \">San Marcos<\/option><option value=\"San Miguel\" class=\" \">San Miguel<\/option><option value=\"San Pablo\" class=\" \">San Pablo<\/option><option value=\"Santa Cruz\" class=\" \">Santa Cruz<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field112\" data-index=\"12\" style=\"width: 50%\" class=\" form-element form-element-field112 options-false form-element-12 default-true form-element-type-dropdown is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type-false\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >PROVINCIA de Cusco<\/span><\/span><span class=\"sub-label\"><span >Seleccione su Provincia<\/span><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"false\" class=\"validation-lenient\" data-field-id=\"field112\" name=\"field112\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \"><\/option><option value=\"Cusco\" class=\" \">Cusco<\/option><option value=\"Acomayo\" class=\" \">Acomayo<\/option><option value=\"Anta\" class=\" \">Anta<\/option><option value=\"Calca\" class=\" \">Calca<\/option><option value=\"Canas\" class=\" \">Canas<\/option><option value=\"Canchis\" class=\" \">Canchis<\/option><option value=\"Chumbivilcas\" class=\" \">Chumbivilcas<\/option><option value=\"Espinar\" class=\" \">Espinar<\/option><option value=\"La Convenci\u00f3n\" class=\" \">La Convenci\u00f3n<\/option><option value=\"Paruro\" class=\" \">Paruro<\/option><option value=\"Paucartambo\" class=\" \">Paucartambo<\/option><option value=\"Quispicanchi\" class=\" \">Quispicanchi<\/option><option value=\"Urubamba\" class=\" \">Urubamba<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field113\" data-index=\"13\" style=\"width: 50%\" class=\" even form-element form-element-field113 options-false form-element-13 default-true form-element-type-dropdown is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type-false\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >PROVINCIA de Huancavelica<\/span><\/span><span class=\"sub-label\"><span >Seleccione su Provincia<\/span><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"false\" class=\"validation-lenient\" data-field-id=\"field113\" name=\"field113\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \"><\/option><option value=\"Huancavelica\" class=\" \">Huancavelica<\/option><option value=\"Acobamba\" class=\" \">Acobamba<\/option><option value=\"Angaraes\" class=\" \">Angaraes<\/option><option value=\"Castrovirreyna\" class=\" \">Castrovirreyna<\/option><option value=\"Churcampa\" class=\" \">Churcampa<\/option><option value=\"Huaytar\u00e1\" class=\" \">Huaytar\u00e1<\/option><option value=\"Tayacaja\" class=\" \">Tayacaja<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field114\" data-index=\"14\" style=\"width: 50%\" class=\" form-element form-element-field114 options-false form-element-14 default-true form-element-type-dropdown is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type-false\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >PROVINCIA de Hu\u00e1nuco<\/span><\/span><span class=\"sub-label\"><span >Seleccione su Provincia<\/span><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"false\" class=\"validation-lenient\" data-field-id=\"field114\" name=\"field114\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \"><\/option><option value=\"Hu\u00e1nuco\" class=\" \">Hu\u00e1nuco<\/option><option value=\"Ambo\" class=\" \">Ambo<\/option><option value=\"Dos de Mayo\" class=\" \">Dos de Mayo<\/option><option value=\"Huacaybamba\" class=\" \">Huacaybamba<\/option><option value=\"Huamal\u00edes\" class=\" \">Huamal\u00edes<\/option><option value=\"Leoncio Prado\" class=\" \">Leoncio Prado<\/option><option value=\"Mara\u00f1\u00f3n\" class=\" \">Mara\u00f1\u00f3n<\/option><option value=\"Pachitea\" class=\" \">Pachitea<\/option><option value=\"Puerto Inca\" class=\" \">Puerto Inca<\/option><option value=\"Lauricocha\" class=\" \">Lauricocha<\/option><option value=\"Yarowilca\" class=\" \">Yarowilca<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field115\" data-index=\"15\" style=\"width: 50%\" class=\" even form-element form-element-field115 options-false form-element-15 default-true form-element-type-dropdown is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type-false\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >PROVINCIA de Ica<\/span><\/span><span class=\"sub-label\"><span >Seleccione su Provincia<\/span><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"false\" class=\"validation-lenient\" data-field-id=\"field115\" name=\"field115\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \"><\/option><option value=\"Ica\" class=\" \">Ica<\/option><option value=\"Chincha\" class=\" \">Chincha<\/option><option value=\"Nazca\" class=\" \">Nazca<\/option><option value=\"Palpa\" class=\" \">Palpa<\/option><option value=\"Pisco\" class=\" \">Pisco<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field116\" data-index=\"16\" style=\"width: 50%\" class=\" form-element form-element-field116 options-false form-element-16 default-true form-element-type-dropdown is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type-false\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >PROVINCIA de Jun\u00edn<\/span><\/span><span class=\"sub-label\"><span >Seleccione su Provincia<\/span><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"false\" class=\"validation-lenient\" data-field-id=\"field116\" name=\"field116\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \"><\/option><option value=\"Chanchamayo\" class=\" \">Chanchamayo<\/option><option value=\"Chupaca\" class=\" \">Chupaca<\/option><option value=\"Concepci\u00f3n\" class=\" \">Concepci\u00f3n<\/option><option value=\"Huancayo\" class=\" \">Huancayo<\/option><option value=\"Jauja\" class=\" \">Jauja<\/option><option value=\"Jun\u00edn\" class=\" \">Jun\u00edn<\/option><option value=\"Satipo\" class=\" \">Satipo<\/option><option value=\"Tarma\" class=\" \">Tarma<\/option><option value=\"Yauli\" class=\" \">Yauli<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field117\" data-index=\"17\" style=\"width: 50%\" class=\" even form-element form-element-field117 options-false form-element-17 default-true form-element-type-dropdown is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type-false\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >PROVINCIA de La Libertad<\/span><\/span><span class=\"sub-label\"><span >Seleccione su Provincia<\/span><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"false\" class=\"validation-lenient\" data-field-id=\"field117\" name=\"field117\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \"><\/option><option value=\"Ascope\" class=\" \">Ascope<\/option><option value=\"Bol\u00edvar\" class=\" \">Bol\u00edvar<\/option><option value=\"Chep\u00e9n\" class=\" \">Chep\u00e9n<\/option><option value=\"Gran Chim\u00fa\" class=\" \">Gran Chim\u00fa<\/option><option value=\"Julc\u00e1n\" class=\" \">Julc\u00e1n<\/option><option value=\"Otuzco\" class=\" \">Otuzco<\/option><option value=\"Pacasmayo\" class=\" \">Pacasmayo<\/option><option value=\"Pataz\" class=\" \">Pataz<\/option><option value=\"S\u00e1nchez Carri\u00f3n\" class=\" \">S\u00e1nchez Carri\u00f3n<\/option><option value=\"Santiago de Chuco\" class=\" \">Santiago de Chuco<\/option><option value=\"Trujillo\" class=\" \">Trujillo<\/option><option value=\"Vir\u00fa\" class=\" \">Vir\u00fa<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field118\" data-index=\"18\" style=\"width: 50%\" class=\" form-element form-element-field118 options-false form-element-18 default-true form-element-type-dropdown is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type-false\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >PROVINCIA de Lambayeque<\/span><\/span><span class=\"sub-label\"><span >Seleccione su Provincia<\/span><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"false\" class=\"validation-lenient\" data-field-id=\"field118\" name=\"field118\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \"><\/option><option value=\"Chiclayo\" class=\" \">Chiclayo<\/option><option value=\"Ferre\u00f1afe\" class=\" \">Ferre\u00f1afe<\/option><option value=\"Lambayeque\" class=\" \">Lambayeque<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field119\" data-index=\"19\" style=\"width: 50%\" class=\" even form-element form-element-field119 options-false form-element-19 default-true form-element-type-dropdown is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type-false\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >PROVINCIA de Lima<\/span><\/span><span class=\"sub-label\"><span >Seleccione su Provincia<\/span><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"false\" class=\"validation-lenient\" data-field-id=\"field119\" name=\"field119\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \"><\/option><option value=\"Barranca\" class=\" \">Barranca<\/option><option value=\"Cajatambo\" class=\" \">Cajatambo<\/option><option value=\"Callao\" class=\" \">Callao<\/option><option value=\"Canta\" class=\" \">Canta<\/option><option value=\"Ca\u00f1ete\" class=\" \">Ca\u00f1ete<\/option><option value=\"Huaral\" class=\" \">Huaral<\/option><option value=\"Huarochir\u00ed\" class=\" \">Huarochir\u00ed<\/option><option value=\"Huaura\" class=\" \">Huaura<\/option><option value=\"Lima Metropolitana\" class=\" \">Lima Metropolitana<\/option><option value=\"Oy\u00f3n\" class=\" \">Oy\u00f3n<\/option><option value=\"Yauyos\" class=\" \">Yauyos<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field120\" data-index=\"20\" style=\"width: 50%\" class=\" form-element form-element-field120 options-false form-element-20 default-true form-element-type-dropdown is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type-false\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >PROVINCIA de Loreto<\/span><\/span><span class=\"sub-label\"><span >Seleccione su Provincia<\/span><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"false\" class=\"validation-lenient\" data-field-id=\"field120\" name=\"field120\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \"><\/option><option value=\"Putumayo\" class=\" \">Putumayo<\/option><option value=\"Alto Amazonas\" class=\" \">Alto Amazonas<\/option><option value=\"Datem del Mara\u00f1\u00f3n\" class=\" \">Datem del Mara\u00f1\u00f3n<\/option><option value=\"Loreto\" class=\" \">Loreto<\/option><option value=\"Mariscal Ram\u00f3n Castilla\" class=\" \">Mariscal Ram\u00f3n Castilla<\/option><option value=\"Maynas\" class=\" \">Maynas<\/option><option value=\"Requena\" class=\" \">Requena<\/option><option value=\"Ucayali\" class=\" \">Ucayali<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field121\" data-index=\"21\" style=\"width: 50%\" class=\" even form-element form-element-field121 options-false form-element-21 default-true form-element-type-dropdown is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type-false\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >PROVINCIA de Madre de Dios<\/span><\/span><span class=\"sub-label\"><span >Seleccione su Provincia<\/span><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"false\" class=\"validation-lenient\" data-field-id=\"field121\" name=\"field121\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \"><\/option><option value=\"Tambopata\" class=\" \">Tambopata<\/option><option value=\"Manu\" class=\" \">Manu<\/option><option value=\"Tahuamanu\" class=\" \">Tahuamanu<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field122\" data-index=\"22\" style=\"width: 50%\" class=\" form-element form-element-field122 options-false form-element-22 default-true form-element-type-dropdown is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type-false\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >PROVINCIA de Moquegua<\/span><\/span><span class=\"sub-label\"><span >Seleccione su Provincia<\/span><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"false\" class=\"validation-lenient\" data-field-id=\"field122\" name=\"field122\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \"><\/option><option value=\"General S\u00e1nchez Cerro\" class=\" \">General S\u00e1nchez Cerro<\/option><option value=\"Ilo\" class=\" \">Ilo<\/option><option value=\"Mariscal Nieto\" class=\" \">Mariscal Nieto<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field123\" data-index=\"23\" style=\"width: 50%\" class=\" even form-element form-element-field123 options-false form-element-23 default-true form-element-type-dropdown is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type-false\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >PROVINCIA de Pasco<\/span><\/span><span class=\"sub-label\"><span >Seleccione su Provincia<\/span><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"false\" class=\"validation-lenient\" data-field-id=\"field123\" name=\"field123\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \"><\/option><option value=\"Pasco\" class=\" \">Pasco<\/option><option value=\"Daniel A. Carri\u00f3n\" class=\" \">Daniel A. Carri\u00f3n<\/option><option value=\"Oxapampa\" class=\" \">Oxapampa<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field124\" data-index=\"24\" style=\"width: 50%\" class=\" form-element form-element-field124 options-false form-element-24 default-true form-element-type-dropdown is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type-false\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >PROVINCIA de Piura<\/span><\/span><span class=\"sub-label\"><span >Seleccione su Provincia<\/span><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"false\" class=\"validation-lenient\" data-field-id=\"field124\" name=\"field124\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \"><\/option><option value=\"Ayabaca\" class=\" \">Ayabaca<\/option><option value=\"Huancabamba\" class=\" \">Huancabamba<\/option><option value=\"Morrop\u00f3n\" class=\" \">Morrop\u00f3n<\/option><option value=\"Paita\" class=\" \">Paita<\/option><option value=\"Piura\" class=\" \">Piura<\/option><option value=\"Sechura\" class=\" \">Sechura<\/option><option value=\"Sullana\" class=\" \">Sullana<\/option><option value=\"Talara\" class=\" \">Talara<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field125\" data-index=\"25\" style=\"width: 50%\" class=\" even form-element form-element-field125 options-false form-element-25 default-true form-element-type-dropdown is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type-false\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >PROVINCIA de Puno<\/span><\/span><span class=\"sub-label\"><span >Seleccione su Provincia<\/span><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"false\" class=\"validation-lenient\" data-field-id=\"field125\" name=\"field125\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \"><\/option><option value=\"Puno\" class=\" \">Puno<\/option><option value=\"Az\u00e1ngaro\" class=\" \">Az\u00e1ngaro<\/option><option value=\"Carabaya\" class=\" \">Carabaya<\/option><option value=\"Chucuito\" class=\" \">Chucuito<\/option><option value=\"El Collao\" class=\" \">El Collao<\/option><option value=\"Huancan\u00e9\" class=\" \">Huancan\u00e9<\/option><option value=\"Lampa\" class=\" \">Lampa<\/option><option value=\"Melgar\" class=\" \">Melgar<\/option><option value=\"San Antonio de Putina\" class=\" \">San Antonio de Putina<\/option><option value=\"San Rom\u00e1n\" class=\" \">San Rom\u00e1n<\/option><option value=\"Sandia\" class=\" \">Sandia<\/option><option value=\"Yunguyo\" class=\" \">Yunguyo<\/option><option value=\"Moho\" class=\" \">Moho<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field126\" data-index=\"26\" style=\"width: 50%\" class=\" form-element form-element-field126 options-false form-element-26 default-true form-element-type-dropdown is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type-false\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >PROVINCIA de San Mart\u00edn<\/span><\/span><span class=\"sub-label\"><span >Seleccione su Provincia<\/span><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"false\" class=\"validation-lenient\" data-field-id=\"field126\" name=\"field126\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \"><\/option><option value=\"Bellavista\" class=\" \">Bellavista<\/option><option value=\"El Dorado\" class=\" \">El Dorado<\/option><option value=\"Huallaga\" class=\" \">Huallaga<\/option><option value=\"Lamas\" class=\" \">Lamas<\/option><option value=\"Mariscal C\u00e1ceres\" class=\" \">Mariscal C\u00e1ceres<\/option><option value=\"Moyobamba\" class=\" \">Moyobamba<\/option><option value=\"Picota\" class=\" \">Picota<\/option><option value=\"Rioja\" class=\" \">Rioja<\/option><option value=\"San Mart\u00edn\" class=\" \">San Mart\u00edn<\/option><option value=\"Tocache\" class=\" \">Tocache<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field127\" data-index=\"27\" style=\"width: 50%\" class=\" even form-element form-element-field127 options-false form-element-27 default-true form-element-type-dropdown is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type-false\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >PROVINCIA de Tacna<\/span><\/span><span class=\"sub-label\"><span >Seleccione su Provincia<\/span><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"false\" class=\"validation-lenient\" data-field-id=\"field127\" name=\"field127\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \"><\/option><option value=\"Tacna\" class=\" \">Tacna<\/option><option value=\"Candarave\" class=\" \">Candarave<\/option><option value=\"Jorge Basadre\" class=\" \">Jorge Basadre<\/option><option value=\"Tarata\" class=\" \">Tarata<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field128\" data-index=\"28\" style=\"width: 50%\" class=\" form-element form-element-field128 options-false form-element-28 default-true form-element-type-dropdown is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type-false\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >PROVINCIA de Tumbes<\/span><\/span><span class=\"sub-label\"><span >Seleccione su Provincia<\/span><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"false\" class=\"validation-lenient\" data-field-id=\"field128\" name=\"field128\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \"><\/option><option value=\"Tumbes\" class=\" \">Tumbes<\/option><option value=\"Zarumilla\" class=\" \">Zarumilla<\/option><option value=\"Contralmirante Villar\" class=\" \">Contralmirante Villar<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field129\" data-index=\"29\" style=\"width: 50%\" class=\" even form-element form-element-field129 options-false form-element-29 default-true form-element-type-dropdown is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type-false\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >PROVINCIA de Ucayali<\/span><\/span><span class=\"sub-label\"><span >Seleccione su Provincia<\/span><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"false\" class=\"validation-lenient\" data-field-id=\"field129\" name=\"field129\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \"><\/option><option value=\"Coronel Portillo\" class=\" \">Coronel Portillo<\/option><option value=\"Atalaya\" class=\" \">Atalaya<\/option><option value=\"Padre Abad\" class=\" \">Padre Abad<\/option><option value=\"Pur\u00fas\" class=\" \">Pur\u00fas<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field105\" data-index=\"30\" style=\"width: 50%\" class=\" form-element form-element-field105 options-false form-element-30 default-true form-element-type-dropdown is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type-false\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >DISTRITO de Lima Metropolitana:<\/span><\/span><span class=\"sub-label\"><span >Ingrese su distrito de residencia<\/span><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"false\" class=\"validation-lenient\" data-field-id=\"field105\" name=\"field105\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \"><\/option><option value=\"Anc\u00f3n\" class=\" \">Anc\u00f3n<\/option><option value=\"Ate\" class=\" \">Ate<\/option><option value=\"Barranco\" class=\" \">Barranco<\/option><option value=\"Bre\u00f1a\" class=\" \">Bre\u00f1a<\/option><option value=\"Carabayllo\" class=\" \">Carabayllo<\/option><option value=\"Chaclacayo\" class=\" \">Chaclacayo<\/option><option value=\"Chorrillos\" class=\" \">Chorrillos<\/option><option value=\"Cieneguilla\" class=\" \">Cieneguilla<\/option><option value=\"Comas\" class=\" \">Comas<\/option><option value=\"El Agustino\" class=\" \">El Agustino<\/option><option value=\"Independencia\" class=\" \">Independencia<\/option><option value=\"Jes\u00fas Mar\u00eda\" class=\" \">Jes\u00fas Mar\u00eda<\/option><option value=\"La Molina\" class=\" \">La Molina<\/option><option value=\"La Victoria\" class=\" \">La Victoria<\/option><option value=\"Lima Cercado\" class=\" \">Lima Cercado<\/option><option value=\"Lince\" class=\" \">Lince<\/option><option value=\"Los Olivos\" class=\" \">Los Olivos<\/option><option value=\"Lurigancho\" class=\" \">Lurigancho<\/option><option value=\"Lur\u00edn\" class=\" \">Lur\u00edn<\/option><option value=\"Magdalena del Mar\" class=\" \">Magdalena del Mar<\/option><option value=\"Miraflores\" class=\" \">Miraflores<\/option><option value=\"Pachacamac\" class=\" \">Pachacamac<\/option><option value=\"Pucusuna\" class=\" \">Pucusuna<\/option><option value=\"Pueblo Libre\" class=\" \">Pueblo Libre<\/option><option value=\"Puente Piedra\" class=\" \">Puente Piedra<\/option><option value=\"Punta Hermosa\" class=\" \">Punta Hermosa<\/option><option value=\"Punta Negra\" class=\" \">Punta Negra<\/option><option value=\"R\u00edmac\" class=\" \">R\u00edmac<\/option><option value=\"San Bartolo\" class=\" \">San Bartolo<\/option><option value=\"San Borja\" class=\" \">San Borja<\/option><option value=\"San Isidro\" class=\" \">San Isidro<\/option><option value=\"San Juan de Lurigancho\" class=\" \">San Juan de Lurigancho<\/option><option value=\"San Juan de Miraflores\" class=\" \">San Juan de Miraflores<\/option><option value=\"San Luis\" class=\" \">San Luis<\/option><option value=\"San Martin de Porres\" class=\" \">San Martin de Porres<\/option><option value=\"San Miguel\" class=\" \">San Miguel<\/option><option value=\"Santa Anita\" class=\" \">Santa Anita<\/option><option value=\"Santa Mar\u00eda del Mar\" class=\" \">Santa Mar\u00eda del Mar<\/option><option value=\"Santa Rosa\" class=\" \">Santa Rosa<\/option><option value=\"Santiago de Surco\" class=\" \">Santiago de Surco<\/option><option value=\"Surquillo\" class=\" \">Surquillo<\/option><option value=\"Villa El Salvador\" class=\" \">Villa El Salvador<\/option><option value=\"Villa Mar\u00eda del Triunfo\" class=\" \">Villa Mar\u00eda del Triunfo<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field130\" data-index=\"31\" style=\"width: 50%\" class=\" even form-element form-element-field130 options-false form-element-31 default-true form-element-type-dropdown is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"dropdown-cover field-cover autocomplete-type-false\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >DISTRITO del Callao<\/span><\/span><span class=\"sub-label\"><span >Ingrese su distrito de residencia<\/span><\/span><\/span><div><span class=\"error\"><\/span><select data-is-required=\"false\" class=\"validation-lenient\" data-field-id=\"field130\" name=\"field130\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><option value=\"\" class=\" \"><\/option><option value=\"Bellavista\" class=\" \">Bellavista<\/option><option value=\"Callao Cercado\" class=\" \">Callao Cercado<\/option><option value=\"Carmen de La Legua-Reynoso\" class=\" \">Carmen de La Legua-Reynoso<\/option><option value=\"La Perla\" class=\" \">La Perla<\/option><option value=\"La Punta\" class=\" \">La Punta<\/option><option value=\"Ventanilla\" class=\" \">Ventanilla<\/option><option value=\"Mi Per\u00fa\" class=\" \">Mi Per\u00fa<\/option><\/select><input type=\"text\"><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field40\" data-index=\"32\" style=\"width: 100%\" class=\" form-element form-element-field40 options-false form-element-32 default-false form-element-type-oneLineText is-required-true odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >DIRECCI\u00d3N:<\/span><\/span><span class=\"sub-label\"><span >Ingrese su direcci\u00f3n<\/span><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"\" make-read-only=\"\" data-field-id=\"field40\" name=\"field40[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"true\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-home\">home<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field20\" data-index=\"33\" style=\"width: 100%\" class=\" even form-element form-element-field20 options-false form-element-33 default-false form-element-type-oneLineText is-required-true -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >TEL\u00c9FONO:<\/span><\/span><span class=\"sub-label\"><span >Ingrese un tel\u00e9fono fijo o m\u00f3vil<\/span><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"\" make-read-only=\"\" data-field-id=\"field20\" name=\"field20[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"numbers\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"true\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-phone\">phone<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field38\" data-index=\"34\" style=\"width: 100%\" class=\" form-element form-element-field38 options-false form-element-34 default-false form-element-type-email is-required-true odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"email-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >E-MAIL:<\/span><\/span><span class=\"sub-label\"><span >Ingrese su correo electr\u00f3nico<\/span><\/span><\/span><div><span class=\"error\"><\/span><input placeholder=\"\" data-field-id=\"field38\" type=\"text\" data-val-type=\"email\" make-read-only=\"\" data-is-required=\"true\" name=\"field38\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-original-title=\"\"><i class=\"formcraft-icon\">email<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field74\" data-index=\"35\" style=\"width: 100%\" class=\" even form-element form-element-field74 options-false form-element-35 default-false form-element-type-oneLineText is-required-true -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >TIPO DE DOCUMENTO: DNI\/CE\/RUC<\/span><\/span><span class=\"sub-label\"><span >Ingrese un tipo de documento<\/span><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"\" make-read-only=\"\" data-field-id=\"field74\" name=\"field74[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"numbers\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"true\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-call_to_action\">call_to_action<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field131\" data-index=\"36\" style=\"width: 100%\" class=\" form-element form-element-field131 options-false form-element-36 default-false form-element-type-checkbox is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images-false checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >SOY MENOR DE EDAD<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field131\" type=\"checkbox\" data-is-required=\"false\" name=\"field131[]\" value=\"Completar datos del Apoderado (Padre\/Madre)\" class=\"validation-lenient\"><span><span >Completar datos del Apoderado (Padre\/Madre)<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field75\" data-index=\"37\" style=\"width: 50%\" class=\" even form-element form-element-field75 options-false form-element-37 default-true form-element-type-oneLineText is-required-true -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >NOMBRES (Padre\/Madre):<\/span><\/span><span class=\"sub-label\"><span >Ingresar nombres del Padre\/Madre<\/span><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"\" make-read-only=\"\" data-field-id=\"field75\" name=\"field75[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"true\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-person\">person<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field76\" data-index=\"38\" style=\"width: 50%\" class=\" form-element form-element-field76 options-false form-element-38 default-true form-element-type-oneLineText is-required-true odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >APELLIDOS (Padre\/Madre):<\/span><\/span><span class=\"sub-label\"><span >Ingresar apellidosnombres del Padre\/Madre<\/span><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"\" make-read-only=\"\" data-field-id=\"field76\" name=\"field76[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"true\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-person\">person<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field37\" data-index=\"39\" style=\"width: 100%\" class=\" even form-element form-element-field37 options-false form-element-39 default-false form-element-type-heading is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div style=\"background-color: #000000\" class=\"heading-cover field-cover \"><div style=\"text-align: left; font-size: 1.0999999999999996em; padding-top: 15px; padding-bottom: 5px; color: #eeeeee\" class=\"bold-true\"><span >2.- DETALLE DEL PRODUCTO\/SERVICIO<\/span><\/div><input type=\"hidden\" data-field-id=\"field37\" name=\"field37[]\" value=\"2.- DETALLE DEL PRODUCTO\/SERVICIO\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field103\" data-index=\"40\" style=\"width: 100%\" class=\" form-element form-element-field103 options-false form-element-40 default-false form-element-type-checkbox is-required-true odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >TIPO DE BIEN:<\/span><\/span><span class=\"sub-label\"><span >Tipo de bien<\/span><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field103\" type=\"radio\" data-is-required=\"true\" name=\"field103[]\" value=\"Producto\" class=\"validation-lenient\"><span><span >Producto<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field103\" type=\"radio\" data-is-required=\"true\" name=\"field103[]\" value=\"Servicio\" class=\"validation-lenient\"><span><span >Servicio<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field85\" data-index=\"41\" style=\"width: 100%\" class=\" even form-element form-element-field85 options-false form-element-41 default-false form-element-type-oneLineText is-required-true -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >N\u00daMERO DEL PEDIDO:<\/span><\/span><span class=\"sub-label\"><span >Ingrese el n\u00famero del pedido<\/span><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"\" make-read-only=\"\" data-field-id=\"field85\" name=\"field85[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"alphanumeric\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"true\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-local_grocery_store\">local_grocery_store<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field89\" data-index=\"42\" style=\"width: 100%\" class=\" form-element form-element-field89 options-false form-element-42 default-false form-element-type-checkbox is-required-true odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >CANAL DEL PEDIDO<\/span><\/span><span class=\"sub-label\"><span >Selecciones el canal del pedido<\/span><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field89\" type=\"checkbox\" data-is-required=\"true\" name=\"field89[]\" value=\"Redes Sociales\" class=\"validation-lenient\"><span><span >Redes Sociales<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field89\" type=\"checkbox\" data-is-required=\"true\" name=\"field89[]\" value=\"WhatsApp\" class=\"validation-lenient\"><span><span >WhatsApp<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field89\" type=\"checkbox\" data-is-required=\"true\" name=\"field89[]\" value=\"Sitio Web\" class=\"validation-lenient\"><span><span >Sitio Web<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field83\" data-index=\"43\" style=\"width: 100%\" class=\" even form-element form-element-field83 options-false form-element-43 default-false form-element-type-oneLineText is-required-true -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >MONTO RECLAMADO:<\/span><\/span><span class=\"sub-label\"><span >Ingrese el monto reclamado<\/span><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"\" make-read-only=\"\" data-field-id=\"field83\" name=\"field83[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"true\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-monetization_on\">monetization_on<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field84\" data-index=\"44\" style=\"width: 100%\" class=\" form-element form-element-field84 options-false form-element-44 default-false form-element-type-textarea is-required-true odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"textarea-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >DESCRIPCI\u00d3N:<\/span><\/span><span class=\"sub-label\"><span >Ingrese la descripci\u00f3n del producto\/servicio<\/span><\/span><\/span><div><span class=\"error\"><\/span><textarea data-field-id=\"field84\" placeholder=\"\" class=\"validation-lenient\" name=\"field84\" value=\"\" rows=\"6\" data-min-char=\"\" data-max-char=\"4000\" data-is-required=\"true\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-original-title=\"\" style=\"min-height: 131.7px\"><\/textarea><div class=\"count-true\"><span class=\"current-count\">0<\/span> \/ <span class=\"max-count \">4000<\/span><\/div><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field90\" data-index=\"45\" style=\"width: 100%\" class=\" even form-element form-element-field90 options-false form-element-45 default-false form-element-type-heading is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div style=\"background-color: #000000\" class=\"heading-cover field-cover \"><div style=\"text-align: left; font-size: 1.0999999999999996em; padding-top: 15px; padding-bottom: 5px; color: #eeeeee\" class=\"bold-true\"><span >3.- DETALLE DEL RECLAMO\/QUEJA<\/span><\/div><input type=\"hidden\" data-field-id=\"field90\" name=\"field90[]\" value=\"3.- DETALLE DEL RECLAMO\/QUEJA\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field91\" data-index=\"46\" style=\"width: 100%\" class=\" form-element form-element-field91 options-false form-element-46 default-false form-element-type-checkbox is-required-true odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >RECLAMO\/QUEJA<\/span><\/span><span class=\"sub-label\"><span >Reclamo\/Queja<\/span><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width: 100%\" ><img alt=\"\"><input data-field-id=\"field91\" type=\"radio\" data-is-required=\"true\" name=\"field91[]\" value=\"RECLAMO: Disconformidad relacionada a los productos o servicios.\" class=\"validation-lenient\"><span><span >RECLAMO: Disconformidad relacionada a los productos o servicios.<\/span><\/span><\/label><label style=\"width: 100%\" ><img alt=\"\"><input data-field-id=\"field91\" type=\"radio\" data-is-required=\"true\" name=\"field91[]\" value=\"QUEJA: Disconformidad, malestar o descontento respecto a la atenci\u00f3n al p\u00fablico.\" class=\"validation-lenient\"><span><span >QUEJA: Disconformidad, malestar o descontento respecto a la atenci\u00f3n al p\u00fablico.<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field92\" data-index=\"47\" style=\"width: 100%\" class=\" even form-element form-element-field92 options-false form-element-47 default-false form-element-type-textarea is-required-true -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"textarea-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >DESCRIPCI\u00d3N:<\/span><\/span><span class=\"sub-label\"><span >Ingrese la descripci\u00f3n del reclamo\/queja<\/span><\/span><\/span><div><span class=\"error\"><\/span><textarea data-field-id=\"field92\" placeholder=\"\" class=\"validation-lenient\" name=\"field92\" value=\"\" rows=\"6\" data-min-char=\"\" data-max-char=\"4000\" data-is-required=\"true\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-original-title=\"\" style=\"min-height: 131.7px\"><\/textarea><div class=\"count-true\"><span class=\"current-count\">0<\/span> \/ <span class=\"max-count \">4000<\/span><\/div><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field95\" data-index=\"48\" style=\"width: 100%\" class=\" form-element form-element-field95 options-false form-element-48 default-false form-element-type-heading is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div style=\"background-color: #000000\" class=\"heading-cover field-cover \"><div style=\"text-align: left; font-size: 1.0999999999999996em; padding-top: 15px; padding-bottom: 5px; color: #eeeeee\" class=\"bold-true\"><span >4.- OBSERVACIONES\/ACCIONES DEL PROVEEDOR<\/span><\/div><input type=\"hidden\" data-field-id=\"field95\" name=\"field95[]\" value=\"4.- OBSERVACIONES\/ACCIONES DEL PROVEEDOR\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field96\" data-index=\"49\" style=\"width: 100%\" class=\" even form-element form-element-field96 options-false form-element-49 default-false form-element-type-textarea is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"textarea-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >DETALLE:<\/span><\/span><span class=\"sub-label\"><span >Ingrese las observaciones\/acciones del proveedor<\/span><\/span><\/span><div><span class=\"error\"><\/span><textarea data-field-id=\"field96\" placeholder=\"\" class=\"validation-lenient\" name=\"field96\" value=\"\" rows=\"6\" data-min-char=\"\" data-max-char=\"4000\" data-is-required=\"false\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-original-title=\"\" style=\"min-height: 131.7px\"><\/textarea><div class=\"count-true\"><span class=\"current-count\">0<\/span> \/ <span class=\"max-count \">4000<\/span><\/div><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field97\" data-index=\"50\" style=\"width: 100%\" class=\" form-element form-element-field97 options-false form-element-50 default-false form-element-type-customText is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><p ><img decoding=\"async\" src=\"https:\/\/perupowersports.pe\/tienda\/wp-content\/uploads\/2023\/11\/linea_negra_800x10.jpg\" width=\"100%\" border=\"0\"><\/p><\/div><input type=\"hidden\" name=\"field97\" data-field-id=\"field97\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field98\" data-index=\"51\" style=\"width: 100%\" class=\" even form-element form-element-field98 options-false form-element-51 default-false form-element-type-customText is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><p ><\/p><ul ><li style=\"padding: 0px\">La formulaci\u00f3n del reclamo no impide acudir a otras v\u00edas de soluci\u00f3n de controversias ni es requisito previo para interponer una denuncia ante el INDECOPI.<\/li><li style=\"padding: 0px\">El proveedor deber\u00e1 dar respuesta al reclamo en un plazo no mayor a treinta (30) d\u00edas calendario, pudiendo ampliar el plazo hasta por treinta (30) d\u00edas m\u00e1s, previa comunicaci\u00f3n al consumidor.<\/li><\/ul><p ><\/p><\/div><input type=\"hidden\" name=\"field98\" data-field-id=\"field98\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field94\" data-index=\"52\" style=\"width: 100%\" class=\" form-element form-element-field94 options-false form-element-52 default-false form-element-type-checkbox is-required-true odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >CONFORMIDAD:<\/span><\/span><span class=\"sub-label\"><span >Seleccionar la pol\u00edtica de privacidad<\/span><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field94\" type=\"checkbox\" data-is-required=\"true\" name=\"field94[]\" value=\"He le\u00eddo y acepto las Pol\u00edticas de Privacidad de Per\u00fa PowerSports\" class=\"validation-lenient\"><span><span >He le\u00eddo y acepto las Pol\u00edticas de Privacidad de Per\u00fa PowerSports<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field45\" data-index=\"53\" style=\"width: 100%\" class=\" even form-element form-element-field45 options-false form-element-53 default-false form-element-type-submit is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"align-center wide-true submit-cover field-cover\"><button type=\"submit\" class=\"button submit-button\"><span class=\"text \">ENVIAR<\/span><span class=\"spin-cover\"><i style=\"color:\" class=\"loading-icon icon-cog animate-spin\"><\/i><\/span><\/button><\/div><div class=\"submit-response \"><\/div><label ><input type=\"text\" class=\"required_field\" name=\"website\" 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