Advantis Widget

Requester

What do you want

<div class="control-group ticket_section">
                 <label class=" required control-label cf_last_name_767862-label " for="helpdesk_ticket_cf_last_name_767862">Last Name</label>
            <div class="controls   ">
              <input class=" required text section_field span12" id="helpdesk_ticket_custom_field_cf_last_name_767862" name="helpdesk_ticket[custom_field][cf_last_name_767862]" size="30" type="text" />
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class=" required control-label cf_occupation_767862-label " for="helpdesk_ticket_cf_occupation_767862">Occupation</label>
            <div class="controls   ">
              <select class=" required dropdown_blank section_field dynamic_sections" id="helpdesk_ticket_custom_field_cf_occupation_767862" name="helpdesk_ticket[custom_field][cf_occupation_767862]"><option value="">...</option>
<option value="Physician" data-id="35000677596">Physician</option>
<option value="Medical Technologist" data-id="35000677597">Medical Technologist</option>
<option value="Healthcare IT" data-id="35000677598">Healthcare IT</option>
<option value="Healthcare Management" data-id="35000677599">Healthcare Management</option>
<option value="Student/Researcher" data-id="35000677600">Student/Researcher</option>
<option value="Other" data-id="35000677601">Other</option></select>
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class=" required control-label cf_company_institution_767862-label " for="helpdesk_ticket_cf_company_institution_767862">Company / Institution</label>
            <div class="controls   ">
              <input class=" required text section_field span12" id="helpdesk_ticket_custom_field_cf_company_institution_767862" name="helpdesk_ticket[custom_field][cf_company_institution_767862]" size="30" type="text" />
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class="  control-label cf_phone_number_767862-label " for="helpdesk_ticket_cf_phone_number_767862">Phone Number</label>
            <div class="controls   ">
              <input class="  text section_field span12" id="helpdesk_ticket_custom_field_cf_phone_number_767862" name="helpdesk_ticket[custom_field][cf_phone_number_767862]" size="30" type="text" />
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class=" required control-label cf_productservice_767862-label " for="helpdesk_ticket_cf_productservice_767862">Product/Service</label>
            <div class="controls   ">
              <select class=" required dropdown_blank section_field dynamic_sections" id="helpdesk_ticket_custom_field_cf_productservice_767862" name="helpdesk_ticket[custom_field][cf_productservice_767862]"><option value="">...</option>
<option value="Brainance MD" data-id="35000677602">Brainance MD</option>
<option value="Brainance Academy" data-id="35000677603">Brainance Academy</option>
<option value="Website" data-id="35000677604">Website</option>
<option value="Other" data-id="35000677605">Other</option></select>
            </div> 
                </div>

<div class="control-group ticket_section">
                 <label class=" required control-label cf_last_name_767862-label " for="helpdesk_ticket_cf_last_name_767862">Last Name</label>
            <div class="controls   ">
              <input class=" required text section_field span12" id="helpdesk_ticket_custom_field_cf_last_name_767862" name="helpdesk_ticket[custom_field][cf_last_name_767862]" size="30" type="text" />
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class="  control-label cf_date_767862-label " for="helpdesk_ticket_cf_date_767862">Date for demo</label>
            <div class="controls  support-date-field ">
              <input class="  date section_field datepicker_popover" data-date-format="d M, yy" data-show-image="true" id="helpdesk_ticket_custom_field_cf_date_767862" name="helpdesk_ticket[custom_field][cf_date_767862]" readonly="readonly" type="text" />
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class=" required control-label cf_occupation_767862-label " for="helpdesk_ticket_cf_occupation_767862">Occupation</label>
            <div class="controls   ">
              <select class=" required dropdown_blank section_field dynamic_sections" id="helpdesk_ticket_custom_field_cf_occupation_767862" name="helpdesk_ticket[custom_field][cf_occupation_767862]"><option value="">...</option>
<option value="Physician" data-id="35000677596">Physician</option>
<option value="Medical Technologist" data-id="35000677597">Medical Technologist</option>
<option value="Healthcare IT" data-id="35000677598">Healthcare IT</option>
<option value="Healthcare Management" data-id="35000677599">Healthcare Management</option>
<option value="Student/Researcher" data-id="35000677600">Student/Researcher</option>
<option value="Other" data-id="35000677601">Other</option></select>
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class=" required control-label cf_company_institution_767862-label " for="helpdesk_ticket_cf_company_institution_767862">Company / Institution</label>
            <div class="controls   ">
              <input class=" required text section_field span12" id="helpdesk_ticket_custom_field_cf_company_institution_767862" name="helpdesk_ticket[custom_field][cf_company_institution_767862]" size="30" type="text" />
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class="  control-label cf_phone_number_767862-label " for="helpdesk_ticket_cf_phone_number_767862">Phone Number</label>
            <div class="controls   ">
              <input class="  text section_field span12" id="helpdesk_ticket_custom_field_cf_phone_number_767862" name="helpdesk_ticket[custom_field][cf_phone_number_767862]" size="30" type="text" />
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class=" required control-label cf_country_767862-label " for="helpdesk_ticket_cf_country_767862">Country</label>
            <div class="controls   ">
              <input class=" required text section_field span12" id="helpdesk_ticket_custom_field_cf_country_767862" name="helpdesk_ticket[custom_field][cf_country_767862]" size="30" type="text" />
            </div> 
                </div>

<div class="control-group ticket_section">
                 <label class=" required control-label cf_last_name_767862-label " for="helpdesk_ticket_cf_last_name_767862">Last Name</label>
            <div class="controls   ">
              <input class=" required text section_field span12" id="helpdesk_ticket_custom_field_cf_last_name_767862" name="helpdesk_ticket[custom_field][cf_last_name_767862]" size="30" type="text" />
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class="  control-label cf_product_767862-label " for="helpdesk_ticket_cf_product_767862">Product</label>
            <div class="controls   ">
              <select class="  dropdown_blank section_field dynamic_sections" id="helpdesk_ticket_custom_field_cf_product_767862" name="helpdesk_ticket[custom_field][cf_product_767862]"><option value="">...</option>
<option value="Brainance MD" data-id="35000465929">Brainance MD</option>
<option value="Brainance Academy" data-id="35000465930">Brainance Academy</option></select>
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class=" required control-label cf_country_767862-label " for="helpdesk_ticket_cf_country_767862">Country</label>
            <div class="controls   ">
              <input class=" required text section_field span12" id="helpdesk_ticket_custom_field_cf_country_767862" name="helpdesk_ticket[custom_field][cf_country_767862]" size="30" type="text" />
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class=" required control-label cf_occupation_767862-label " for="helpdesk_ticket_cf_occupation_767862">Occupation</label>
            <div class="controls   ">
              <select class=" required dropdown_blank section_field dynamic_sections" id="helpdesk_ticket_custom_field_cf_occupation_767862" name="helpdesk_ticket[custom_field][cf_occupation_767862]"><option value="">...</option>
<option value="Physician" data-id="35000677596">Physician</option>
<option value="Medical Technologist" data-id="35000677597">Medical Technologist</option>
<option value="Healthcare IT" data-id="35000677598">Healthcare IT</option>
<option value="Healthcare Management" data-id="35000677599">Healthcare Management</option>
<option value="Student/Researcher" data-id="35000677600">Student/Researcher</option>
<option value="Other" data-id="35000677601">Other</option></select>
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class=" required control-label cf_company_institution_767862-label " for="helpdesk_ticket_cf_company_institution_767862">Company / Institution</label>
            <div class="controls   ">
              <input class=" required text section_field span12" id="helpdesk_ticket_custom_field_cf_company_institution_767862" name="helpdesk_ticket[custom_field][cf_company_institution_767862]" size="30" type="text" />
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class="  control-label cf_phone_number_767862-label " for="helpdesk_ticket_cf_phone_number_767862">Phone Number</label>
            <div class="controls   ">
              <input class="  text section_field span12" id="helpdesk_ticket_custom_field_cf_phone_number_767862" name="helpdesk_ticket[custom_field][cf_phone_number_767862]" size="30" type="text" />
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class="  control-label cf_number_of_exam_month_767862-label " for="helpdesk_ticket_cf_number_of_exam_month_767862">Number of exams / month</label>
            <div class="controls   ">
              <input class="  text section_field span12" id="helpdesk_ticket_custom_field_cf_number_of_exam_month_767862" name="helpdesk_ticket[custom_field][cf_number_of_exam_month_767862]" size="30" type="text" />
            </div> 
                </div>
      <div class="control-group ticket_section">
                 <label class="  control-label cf_number_of_users_767862-label " for="helpdesk_ticket_cf_number_of_users_767862">Number of users</label>
            <div class="controls   ">
              <input class="  text section_field span12" id="helpdesk_ticket_custom_field_cf_number_of_users_767862" name="helpdesk_ticket[custom_field][cf_number_of_users_767862]" size="30" type="text" />
            </div> 
                </div>

Subject

Description

Contact Form⊂mitTitle=Submit⊂mitThanks=Thank you

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