var uvFormLoadAction;
	uvFormLoadAction = function(e) {
		var topMessage = document.getElementById('uv_top_message');
		topMessage.className = '';
		topMessage.innerHTML = '';
					    var top = document.getElementById('uv_top_message');

	    //create a form
		var f = document.createElement("form");
		f.setAttribute('name',"Raise Grievance");
		f.setAttribute('method',"POST");
		f.setAttribute('class',"uv_form");
		f.setAttribute('id',"form_submit");
		f.setAttribute('enctype',"multipart/form-data");
		f.setAttribute('action',"https://portal-tickets.ondc.org/en/settings/formbuilder/update/JS/1");

		var sideHead = document.createElement("h2");
		var boldHead = document.createElement("b");
        boldHead.innerHTML = "Raise Grievance";
        sideHead.appendChild(boldHead);
		f.appendChild(sideHead);

                
        		var div_input_filed = document.createElement("div");
		div_input_filed.setAttribute('class',"uv_form-group");
		var field_label = document.createElement("label");
		field_label.setAttribute('class',"uv_required");
		field_label.innerHTML = "Email*";
		var input_field = document.createElement("input");
        input_field.type = "text";
        input_field.name = "email";
		input_field.id = 'uv_' + '102';
		input_field.value = "";
		input_field.setAttribute('class',"uv_form-control");
		input_field.setAttribute('required',"required");

		var child_div_span = document.createElement("span");
		child_div_span.setAttribute('class',"uv-field-info email");
		
		var main_div_span = document.createElement("span");
		main_div_span.setAttribute('class',"uv-field-info");
		main_div_span.innerHTML = "Enter valid email address";


		div_input_filed.appendChild(field_label);
		div_input_filed.appendChild(input_field);
		div_input_filed.appendChild(child_div_span);
		div_input_filed.appendChild(main_div_span);
		f.appendChild(div_input_filed);

		
        
		
		
		
		                
        
        
		
				var div_input_filed = document.createElement("div");
		div_input_filed.setAttribute('class',"uv_form-group");
		var field_label = document.createElement("label");
		field_label.setAttribute('class',"uv_required");
		field_label.innerHTML = "Grievance text*";
		var input_field = document.createElement("textarea");
        input_field.type = "reply";
        input_field.name = "reply";
		input_field.id = 'uv_' + '105';
		input_field.value = "";
		input_field.setAttribute('class',"uv_form-control");
		input_field.setAttribute('required',"required");
		
		var main_div_span = document.createElement("span");
		main_div_span.setAttribute('class',"uv-field-info");
		main_div_span.innerHTML = "Provide details of the grievance faced by you";

		div_input_filed.appendChild(field_label);
		div_input_filed.appendChild(input_field);
		div_input_filed.appendChild(main_div_span);
		f.appendChild(div_input_filed);

		
		
		                		var div_input_filed = document.createElement("div");
		div_input_filed.setAttribute('class',"uv_form-group");
		var field_label = document.createElement("label");
		field_label.setAttribute('class',"uv_required");
		field_label.innerHTML = "Name*";
		var input_field = document.createElement("input");
		input_field.id = 'uv_' + '101';
        input_field.type = "text";
        input_field.name = "name";
		input_field.value = "";
		input_field.setAttribute('class',"uv_form-control");
		input_field.setAttribute('required',"required");
		
		var main_div_span = document.createElement("span");
		main_div_span.setAttribute('class',"uv-field-info");
		main_div_span.innerHTML = "Your full name";

		div_input_filed.appendChild(field_label);
		div_input_filed.appendChild(input_field);
		div_input_filed.appendChild(main_div_span);
		f.appendChild(div_input_filed);

        
		
        
        
		
		
		
		                
        
        
		
		
		
		                
        
        
		
		
		
		                
        
        
		
		
		
		                
        
        
		
		
		
		                
        
        
		
		
		
		                
        
        
		
		
		
		                
        
        
		
		
		
		                
        
        
		
		
		
		                
        
        
		
		
		
		                
        
        
		
		
		
		                
        
        
		
		
		
		                
        
        
				var div_input_filed = document.createElement("div");
		div_input_filed.setAttribute('class',"uv_form-group");
		var field_label = document.createElement("label");
		field_label.setAttribute('class',"uv_required");
		field_label.innerHTML = "Type*";

        var select_input = document.createElement("select");
		select_input.setAttribute('class',"uv_selectpicker");
		select_input.setAttribute('name',"type");
		select_input.setAttribute('id','uv_' + '104');
		select_input.type = "type";

        var select_input_option = document.createElement("option");
		select_input_option.setAttribute('value'," ");
		select_input_option.innerHTML = "Choose query Type";
		select_input.appendChild(select_input_option);

				    var select_input_option = document.createElement("option");
		    select_input_option.setAttribute('value',"3");
		    select_input_option.innerHTML = "compliance";
			select_input.appendChild(select_input_option);
			
				    var select_input_option = document.createElement("option");
		    select_input_option.setAttribute('value',"4");
		    select_input_option.innerHTML = "Grievance";
			select_input.appendChild(select_input_option);
			
				    var select_input_option = document.createElement("option");
		    select_input_option.setAttribute('value',"1");
		    select_input_option.innerHTML = "network-operations";
			select_input.appendChild(select_input_option);
			
				    var select_input_option = document.createElement("option");
		    select_input_option.setAttribute('value',"2");
		    select_input_option.innerHTML = "portal-support";
			select_input.appendChild(select_input_option);
			
		
		var main_div_span = document.createElement("span");
		main_div_span.setAttribute('class',"uv-field-info");
		main_div_span.innerHTML = "Choose ticket type";

		div_input_filed.appendChild(field_label);
		div_input_filed.appendChild(select_input);
		div_input_filed.appendChild(main_div_span);
		f.appendChild(div_input_filed);

		
		
		
		                
        
        
		
		
		
		        
		                            				    						
						
                        
                        							var div_input_filed = document.createElement("div");
							div_input_filed.setAttribute('class',"uv_form-group  ");
							div_input_filed.setAttribute('style',"position: relative; ");
							var field_label = document.createElement("label");
							field_label.setAttribute('class',"uv_required");
							field_label.innerHTML = "Category (product / service as available on ONDC)*";

							var input_select = document.createElement("select");
        					input_select.setAttribute('class',"uv_form-control");
							input_select.name = "customFields[1]";
							input_select.value = "1";
							input_select.id = "forCategory (product / service as available on ONDC)*1";
														input_select.setAttribute('required',"required");
							
							var select_input_option = document.createElement("option");
		                    select_input_option.innerHTML = "Default";
			                input_select.appendChild(select_input_option);


                            		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"1");
		                    select_input_option.innerHTML = "Grocery";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"10");
		                    select_input_option.innerHTML = "Pharma";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"11");
		                    select_input_option.innerHTML = "Autoparts & Components";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"12");
		                    select_input_option.innerHTML = "Hardware and Industrial";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"13");
		                    select_input_option.innerHTML = "Building & Construction Supplies";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"14");
		                    select_input_option.innerHTML = "Chemicals";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"2");
		                    select_input_option.innerHTML = "Food & Beverage";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"3");
		                    select_input_option.innerHTML = "Fashion";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"4");
		                    select_input_option.innerHTML = "Beauty & Personal Care";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"5");
		                    select_input_option.innerHTML = "Electronics";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"6");
		                    select_input_option.innerHTML = "Appliances";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"7");
		                    select_input_option.innerHTML = "Home & Decor";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"8");
		                    select_input_option.innerHTML = "Agriculture";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"9");
		                    select_input_option.innerHTML = "Health & Wellness";
			                input_select.appendChild(select_input_option);
			
		                    


                            div_input_filed.appendChild(field_label);
							div_input_filed.appendChild(input_select);
							f.appendChild(div_input_filed);
   

						
                        
                        

						
						
						



					                                            				    						
						
                        
                        							var div_input_filed = document.createElement("div");
							div_input_filed.setAttribute('class',"uv_form-group  ");
							div_input_filed.setAttribute('style',"position: relative; ");
							var field_label = document.createElement("label");
							field_label.setAttribute('class',"uv_required");
							field_label.innerHTML = "Type of Grievance*";

							var input_select = document.createElement("select");
        					input_select.setAttribute('class',"uv_form-control");
							input_select.name = "customFields[2]";
							input_select.value = "2";
							input_select.id = "forType of Grievance*2";
														input_select.setAttribute('required',"required");
							
							var select_input_option = document.createElement("option");
		                    select_input_option.innerHTML = "Default";
			                input_select.appendChild(select_input_option);


                            		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"15");
		                    select_input_option.innerHTML = "Issue with ordering and/or payment";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"16");
		                    select_input_option.innerHTML = "Issue with delivery or fulfilment";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"17");
		                    select_input_option.innerHTML = "Issue with quality of product/service";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"18");
		                    select_input_option.innerHTML = "Issue with refunds";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"19");
		                    select_input_option.innerHTML = "Other";
			                input_select.appendChild(select_input_option);
			
		                    


                            div_input_filed.appendChild(field_label);
							div_input_filed.appendChild(input_select);
							f.appendChild(div_input_filed);
   

						
                        
                        

						
						
						



					                                            				    						
						
                        
                        							var div_input_filed = document.createElement("div");
							div_input_filed.setAttribute('class',"uv_form-group  ");
							div_input_filed.setAttribute('style',"position: relative; ");
							var field_label = document.createElement("label");
							field_label.setAttribute('class',"uv_required");
							field_label.innerHTML = "App where order was placed*";

							var input_select = document.createElement("select");
        					input_select.setAttribute('class',"uv_form-control");
							input_select.name = "customFields[3]";
							input_select.value = "3";
							input_select.id = "forApp where order was placed*3";
														input_select.setAttribute('required',"required");
							
							var select_input_option = document.createElement("option");
		                    select_input_option.innerHTML = "Default";
			                input_select.appendChild(select_input_option);


                            		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"20");
		                    select_input_option.innerHTML = "ninjacart.com";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"29");
		                    select_input_option.innerHTML = "Meesho";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"30");
		                    select_input_option.innerHTML = "GupShup";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"31");
		                    select_input_option.innerHTML = "Mystore";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"32");
		                    select_input_option.innerHTML = "magicpin";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"33");
		                    select_input_option.innerHTML = "Mappls Mall";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"34");
		                    select_input_option.innerHTML = "Marico";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"35");
		                    select_input_option.innerHTML = "Khojle.com";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"36");
		                    select_input_option.innerHTML = "MOS-World";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"37");
		                    select_input_option.innerHTML = "Nobrokerhood";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"38");
		                    select_input_option.innerHTML = "Novopay";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"21");
		                    select_input_option.innerHTML = "airpay";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"39");
		                    select_input_option.innerHTML = "nStore";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"40");
		                    select_input_option.innerHTML = "OLA";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"41");
		                    select_input_option.innerHTML = "Otipy";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"42");
		                    select_input_option.innerHTML = "Paytm";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"43");
		                    select_input_option.innerHTML = "Pincode";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"44");
		                    select_input_option.innerHTML = "Samhita Good CSR Ventures Private Limited";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"45");
		                    select_input_option.innerHTML = "Qaddoo.com";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"46");
		                    select_input_option.innerHTML = "OrderDe";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"47");
		                    select_input_option.innerHTML = "Spice Smart Shop";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"48");
		                    select_input_option.innerHTML = "Tata Neu";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"22");
		                    select_input_option.innerHTML = "Snapdeal";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"49");
		                    select_input_option.innerHTML = "rubaru";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"50");
		                    select_input_option.innerHTML = "placeorder.com";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"51");
		                    select_input_option.innerHTML = "Zionmart";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"23");
		                    select_input_option.innerHTML = "BharatPe";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"24");
		                    select_input_option.innerHTML = "gonuclei";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"25");
		                    select_input_option.innerHTML = "Craftsvilla";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"26");
		                    select_input_option.innerHTML = "eStore VLE App";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"27");
		                    select_input_option.innerHTML = "Easy Pay";
			                input_select.appendChild(select_input_option);
			
		                    		                    var select_input_option = document.createElement("option");
		                    select_input_option.setAttribute('value',"28");
		                    select_input_option.innerHTML = "oze";
			                input_select.appendChild(select_input_option);
			
		                    


                            div_input_filed.appendChild(field_label);
							div_input_filed.appendChild(input_select);
							f.appendChild(div_input_filed);
   

						
                        
                        

						
						
						



					                                            				    						
						
                        
                        
                        
                        							var div_input_filed = document.createElement("div");
							div_input_filed.setAttribute('class',"uv_form-group");
							var field_label = document.createElement("label");
							div_input_filed.setAttribute('class',"uv_required  ");
							div_input_filed.setAttribute('style',"position: relative; ");
							field_label.innerHTML = "Date of Order*";
							var input_field = document.createElement("input");
        					input_field.type = "date";
							input_field.id   ="4";
        					input_field.name = "customFields[4]";
							input_field.value = "";
							input_field.setAttribute('class',"uv_form-control");
														input_field.setAttribute('required',"required");
									
							div_input_filed.appendChild(field_label);
							div_input_filed.appendChild(input_field);
							f.appendChild(div_input_filed);

						

						
						
						



					                                            				    													var div_input_filed = document.createElement("div");
							div_input_filed.setAttribute('class',"uv_form-group  "  );
							div_input_filed.setAttribute('style',"position: relative; ");
							var field_label = document.createElement("label");
							field_label.setAttribute('class',"uv_required ");
							field_label.innerHTML = "Order ID*";
							var input_field = document.createElement("input");
        					input_field.type = "text";
							input_field.id   ="5";
        					input_field.name = "customFields[ 5 ]";
							input_field.value = "";
							input_field.setAttribute('class',"uv_form-control");
														input_field.setAttribute('required',"required");
									
							div_input_filed.appendChild(field_label);
							div_input_filed.appendChild(input_field);
							f.appendChild(div_input_filed);

						
						
                        
                        
                        
                        

						
						
						



					                                            				    													var div_input_filed = document.createElement("div");
							div_input_filed.setAttribute('class',"uv_form-group  "  );
							div_input_filed.setAttribute('style',"position: relative; ");
							var field_label = document.createElement("label");
							field_label.setAttribute('class',"uv_required ");
							field_label.innerHTML = "Grievance / Ticket number as received from App where you had placed order*";
							var input_field = document.createElement("input");
        					input_field.type = "text";
							input_field.id   ="6";
        					input_field.name = "customFields[ 6 ]";
							input_field.value = "";
							input_field.setAttribute('class',"uv_form-control");
														input_field.setAttribute('required',"required");
									
							div_input_filed.appendChild(field_label);
							div_input_filed.appendChild(input_field);
							f.appendChild(div_input_filed);

						
						
                        
                        
                        
                        

						
						
						



					                                                                        				    						
													var div_input_filed = document.createElement("div");
							div_input_filed.setAttribute('class',"uv_form-group");
							var field_label = document.createElement("label");
							div_input_filed.setAttribute('class',"uv_required  ");
							div_input_filed.setAttribute('style',"position: relative; ");
							field_label.innerHTML = "Any additional details that you may want to provide*";
							var input_field = document.createElement("textarea");
        					input_field.type = "textarea";
							input_field.id   ="8";
        					input_field.name = "customFields[ 8]";
							input_field.value = "";
							input_field.setAttribute('class',"uv_form-control");
									
							div_input_filed.appendChild(field_label);
							div_input_filed.appendChild(input_field);
							f.appendChild(div_input_filed);

						
                        
                        
                        
                        

						
						
						



					                                            				    													var div_input_filed = document.createElement("div");
							div_input_filed.setAttribute('class',"uv_form-group  "  );
							div_input_filed.setAttribute('style',"position: relative; ");
							var field_label = document.createElement("label");
							field_label.setAttribute('class',"uv_required ");
							field_label.innerHTML = "Item / services purchased";
							var input_field = document.createElement("input");
        					input_field.type = "text";
							input_field.id   ="9";
        					input_field.name = "customFields[ 9 ]";
							input_field.value = "";
							input_field.setAttribute('class',"uv_form-control");
									
							div_input_filed.appendChild(field_label);
							div_input_filed.appendChild(input_field);
							f.appendChild(div_input_filed);

						
						
                        
                        
                        
                        

						
						
						



					                                            				    													var div_input_filed = document.createElement("div");
							div_input_filed.setAttribute('class',"uv_form-group  "  );
							div_input_filed.setAttribute('style',"position: relative; ");
							var field_label = document.createElement("label");
							field_label.setAttribute('class',"uv_required ");
							field_label.innerHTML = "Name of Seller ";
							var input_field = document.createElement("input");
        					input_field.type = "text";
							input_field.id   ="10";
        					input_field.name = "customFields[ 10 ]";
							input_field.value = "";
							input_field.setAttribute('class',"uv_form-control");
									
							div_input_filed.appendChild(field_label);
							div_input_filed.appendChild(input_field);
							f.appendChild(div_input_filed);

						
						
                        
                        
                        
                        

						
						
						



					                                            				    													var div_input_filed = document.createElement("div");
							div_input_filed.setAttribute('class',"uv_form-group  "  );
							div_input_filed.setAttribute('style',"position: relative; ");
							var field_label = document.createElement("label");
							field_label.setAttribute('class',"uv_required ");
							field_label.innerHTML = "Order Value";
							var input_field = document.createElement("input");
        					input_field.type = "text";
							input_field.id   ="11";
        					input_field.name = "customFields[ 11 ]";
							input_field.value = "";
							input_field.setAttribute('class',"uv_form-control");
									
							div_input_filed.appendChild(field_label);
							div_input_filed.appendChild(input_field);
							f.appendChild(div_input_filed);

						
						
                        
                        
                        
                        

						
						
						



					                                            				    													var div_input_filed = document.createElement("div");
							div_input_filed.setAttribute('class',"uv_form-group  "  );
							div_input_filed.setAttribute('style',"position: relative; ");
							var field_label = document.createElement("label");
							field_label.setAttribute('class',"uv_required ");
							field_label.innerHTML = "Phone Number";
							var input_field = document.createElement("input");
        					input_field.type = "text";
							input_field.id   ="12";
        					input_field.name = "customFields[ 12 ]";
							input_field.value = "";
							input_field.setAttribute('class',"uv_form-control");
									
							div_input_filed.appendChild(field_label);
							div_input_filed.appendChild(input_field);
							f.appendChild(div_input_filed);

						
						
                        
                        
                        
                        

						
						
						



					                                    


		var submit_button = document.createElement("button");
        submit_button.type = "submit";
		submit_button.id   ="uv_submit";
		submit_button.value   = "Create Ticket";
        submit_button.name = "submit";
		submit_button.setAttribute('class',"btn btn-md btn-info");
        submit_button.innerHTML = "Create Ticket";
		
		f.appendChild(submit_button);


top.appendChild(f); //pure javascript

if(document.getElementById('uv_104')) {
	document.getElementById('uv_104').addEventListener('change', function(event) {
		selectedVal = event.currentTarget.value;
		if((allDependent = document.getElementsByClassName('dependent')) && (len = allDependent.length)) {
			for(i=0;i<len;i++) {
				allDependent[i].style.display = 'none';
				}
			}
		if((dependent = document.getElementsByClassName('dependency'+selectedVal)) && (leng = dependent.length)) {
			for(j=0;j<leng;j++) {
				dependent[j].style.display = 'block';
			    }
			}
	});
}

var checkboxes = $('.input-checkbox');
checkboxes.change(function(){
    if($('.checkboxes:checked').length > 0) {
        checkboxes.removeAttr('required');
    }
});

function validateEmail(email) {
  const re = /^(([^<>()[\]\\.,;:\s@\"]+(\.[^<>()[\]\\.,;:\s@\"]+)*)|(\".+\"))@((\[[0-9]{1,3}\.[0-9]{1,3}\.[0-9]{1,3}\.[0-9]{1,3}\])|(([a-zA-Z\-0-9]+\.)+[a-zA-Z]{2,}))$/;
  return re.test(email);
}

function validate() {
  const $result = $(".email");
  const email = $('#uv_102').val();
  $result.text("");

  if (validateEmail(email)) {
    $result.text(""); 
	$("#uv_102").closest("div").removeClass('uv_has_error') ;
	return true;
  } else {
	if(email != ""){
    		$result.text(email + " is not valid");
    		$result.css("color", "red");
		$("#uv_102").closest("div").addClass('uv_has_error') ;
	}else{
		$result.text( "email field must not be empty !!! ");
    		$result.css("color", "red");
		$("#uv_102").closest("div").addClass('uv_has_error') ;
	}
  }
  return false;
}

$("#uv_submit").on("click", validate);

function checkhidden() {

        	    			        								        	    	    			        								        	    	    			        								        	    	    			        								        	    	    			        								        	    	    			        								        	    	    		    	    			        								        	    	    			        								        	    	    			        								        	    	    			        								        	    	    			        								        	    	    
  return true;
}

$("#uv_submit").on("click", checkhidden);


};

window.addEventListener('load', function() {
	if(typeof(uvFormLoadAction) === 'function') {
		uvFormLoadAction();
	}
});