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https://formstack.io/ffbDz1IbTzzNdbhm86CBmjre92euLYKuicfh9qYvfX1pjmvFdshNkp1xEMePWWbm1sMtlq5msoXrRCmxAD3g3g
Submission Tags: falconsandbox
Submission: On January 29 via api from US — Scanned from DE
Submission Tags: falconsandbox
Submission: On January 29 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST https://sfapi.formstack.io/FormEngine/EngineFrame/UploadFile
<form action="https://sfapi.formstack.io/FormEngine/EngineFrame/UploadFile" enctype="multipart/form-data" id="form1" method="post" target="ffIframe"><input id="userTimeZone" name="userTimeZone" type="hidden" value="0"><input id="txtHtmlId"
name="txtHtmlId" type="hidden" value="qbPpKOXJz_XpGFvXbBVc3w"><input id="txtSendSizeChange" name="txtSendSizeChange" type="hidden" value=""><input id="txtObjId" name="txtObjId" type="hidden"
value="wFJDL-30ykZVziWipS8byGHF12RFtlMhptM02dtPIDI"><input id="txtOrgId" name="txtOrgId" type="hidden" value="c58IKteAtKgb2MrI5cKMmYWxZKDuB5g62TPtrDd-CLc"><input id="txtAuthToken" name="txtAuthToken" type="hidden"
value="p9Houyv4WEFWeqzCz1O2_8QIcCgl8Ure2XnclepsV0BAZxXyMpdXifnmokRMt8zqw4BrSsGiCoquAwIIwOiMSQejQOMstC417fA54YKQjJUFMIVc1d8BUZjhAeetpTONmyj6hWBdoOPL_2KgCV8LPk8V2g-mVqxfA5sdiXbX9xs"><input id="txtRefreshToken" name="txtRefreshToken" type="hidden"
value="JAoZswkhw8ZcznpiHrnsWGYBb3Vz19u2xTLA59zSViqCvR07CO3_x22CHk47d9YQUP5k3nZY-P5k3koE9sEClivIiz-dZnXh5IpF9JowM7XXx21irpTX2AnfzoR-IzKG"><input id="txtAccessURI" name="txtAccessURI" type="hidden"
value="XgWospRAWwpEjJUV6xYuL_LIHuXXSD7EMaG1G24VBE6lSfCzfBIcxCWqmKvXohvs"><input id="txtSessionID" name="txtSessionID" type="hidden" value="K6GhCBWJg8Hc29ifm-yQDWXeUohjDAckTjJGUnkc3IQrAc3sKWOE9Qyhmjb_pjSQ"><input id="txtSubmittedData"
name="txtSubmittedData" type="hidden" value=""><input id="formHtml" name="formHtml" type="hidden" value=""><input data-val="true" data-val-required="The Boolean field is required." id="multipageEnabled" name="multipageEnabled" type="hidden"
value="False"><input data-val="true" data-val-required="The Boolean field is required." id="breadcrumbEnabled" name="breadcrumbEnabled" type="hidden" value="False"><input data-val="true" data-val-required="The Boolean field is required."
id="breadcrumbNumbered" name="breadcrumbNumbered" type="hidden" value="False"><input id="breadcrumbPrefix" name="breadcrumbPrefix" type="hidden" value=""><input id="submitMessage" name="submitMessage" type="hidden" value="Thank you for enrolling in our Virtual Credit Card payment program. Please consider the following when processing a Virtual Card payment:
The size of the transaction(s) received via Virtual Credit Card will vary. Please confirm with your current merchant acquirer if you have the ability to process the size of these individual transaction(s).
Virtual Credit Cards are single-use only cards. The single use card may apply to several invoices. Keep in mind you will not be able to charge the card for each individual invoice. It must be processed as the total amount sent on the remittance email.
For questions related to processing the card, or how to lower your cost of accepting cards in a business to business environment, please reach out to our Business Services Desk at 844-295-9858."><input id="submitUrl" name="submitUrl"
type="hidden" value=""><input id="submitBtnText" name="submitBtnText" type="hidden" value="Submit Enrollment Form"><input id="prevBtnText" name="prevBtnText" type="hidden" value="Back"><input id="nextBtnText" name="nextBtnText" type="hidden"
value="Next"><input id="pageValType" name="pageValType" type="hidden" value="form"><input id="txtUserContentId" name="txtUserContentId" type="hidden" value=""><input data-val="true" data-val-required="The Boolean field is required."
id="hasCustomCSS" name="hasCustomCSS" type="hidden" value="True"><input id="isCurrentForm" name="isCurrentForm" type="hidden" value=""><input id="packageTier" name="packageTier" type="hidden" value=""><input data-val="true"
data-val-required="The Boolean field is required." id="isDraft" name="isDraft" type="hidden" value="False"><input data-val="true" data-val-required="The Boolean field is required." id="saveForLaterEnabled" name="saveForLaterEnabled" type="hidden"
value="False"><input id="saveBtnText" name="saveBtnText" type="hidden" value="Save"><input id="discardBtnText" name="discardBtnText" type="hidden" value="Discard"><input id="draftSaved" name="draftSaved" type="hidden" value=""><input
id="draftEmail" name="draftEmail" type="hidden" value=""><input id="paymentType" name="paymentType" type="hidden" value=""><input id="formName" name="formName" type="hidden" value="Becton Dickinson W7"><input id="CommunityInstanceURL"
name="CommunityInstanceURL" type="hidden" value=""><input id="CommunitySessioID" name="CommunitySessioID" type="hidden" value=""><input id="CommunityUserId" name="CommunityUserId" type="hidden" value=""><input id="CommunityUserType"
name="CommunityUserType" type="hidden" value=""><input id="CommunityViewMode" name="CommunityViewMode" type="hidden" value=""><input id="comPrefillDataset" name="comPrefillDataset" type="hidden" value=""><input id="prefillDataset"
name="prefillDataset" type="hidden" value=""><input id="comPrefillObj" name="comPrefillObj" type="hidden" value=""><input id="hfFileServiceEndpoint" name="hfFileServiceEndpoint" type="hidden" value="https://sfapi.formstack.io"><input
id="hfFileServiceApiKey" name="hfFileServiceApiKey" type="hidden" value="8fc5982e-6eca-4d73-a3ff-997902b163b0-20212151122"><input id="reCaptchaV3token" name="reCaptchaV3token" type="hidden" value=""><input id="submissionWorkflowId"
name="submissionWorkflowId" type="hidden" value="">
<div id="dvBannerHTML" runat="server">
<div>
<style>
.ff-form {
background-color: rgba(253, 255, 255, 1);
background-attachment: fixed;
background-repeat: no-repeat;
background-repeat: repeat;
}
#dvFastForms .ff-page-header {
font-family: Arial;
font-weight: bold;
color: rgba(255, 255, 255, 1);
font-size: 100px;
}
#dvFastForms .ff-page-header-row {
border-style: solid;
border-radius: 5px;
border-color: rgba(255, 255, 255, 1);
border-width: 100px;
padding: 8px;
}
.ff-logo {
background-color: #ffffff;
background-image: url(https://na43.salesforce.com/servlet/servlet.ImageServer?id=0150G0000075T9JQAU&oid=00DA0000000JA2rMAG);
width: 525px;
height: 69px;
margin: auto;
padding: 0px;
}
.ff-header {
background-color: #ffffff;
background-attachment: fixed;
background-repeat: no-repeat;
padding: 11px;
}
.ff-form-main {
background-color: #fcfcfc;
margin: auto;
max-width: 1000px;
border-style: solid;
border-radius: 10px;
border-color: rgba(0, 0, 0, 1);
border-width: 4px;
padding: 5px;
}
#dvFastForms .ff-group-row {
background-color: #ffffff;
border-style: solid;
border-radius: 5px;
border-color: rgba(255, 255, 255, 1);
border-width: 3px;
max-width: 1000px;
padding: 10px;
margin: 0px;
}
#dvFastForms .ff-section-header {
font-family: Tahoma;
font-weight: bold;
color: rgba(255, 255, 255, 1);
font-size: 33px;
}
#dvFastForms .ff-footer-group {
background-color: #ffffff;
background-attachment: fixed;
background-repeat: no-repeat;
background-repeat: repeat;
padding: 56px;
}
#dvFastForms .ff-col-2.ff-field-col {
clear: none;
}
#dvFastForms .ff-label,
#dvFastForms .ff-footnote-label {
font-family: Tahoma;
font-weight: bold;
font-size: 14px;
}
#dvFastForms .ff-label {
color: #0a0a0a;
}
#dvFastForms .ff-label-col {
text-align: left;
padding: 10px;
}
#dvFastForms .ff-field-col {
font-family: Tahoma;
font-weight: bold;
font-size: 14px;
text-align: left;
padding: 5px;
}
#dvFastForms .ff-field-col,
#dvFastForms .ff-rating-widget a {
color: #000000;
}
#dvFastForms .ff-type-text,
#dvFastForms .ff-textarea,
#dvFastForms select.ff-select-type,
#dvFastForms .ff-fileupload-drop-area,
#dvFastForms .select2-container {
background-color: #c9c3c3;
}
#dvFastForms .ff-type-text,
#dvFastForms .ff-textarea,
#dvFastForms select.ff-select-type,
#dvFastForms .ff-fileupload-drop-area,
#dvFastForms .select2-container .select2-choice,
#dvFastForms .select2-container .select2-choices {
border-style: solid;
border-radius: 5px;
border-color: #000609;
border-width: 1px;
padding: 5px;
}
#dvFastForms .ff-textarea {
height: 22px;
}
#dvFastForms .ff-item-row .ff-type-text:not(.ff-creditcard),
#dvFastForms .ff-textarea,
#dvFastForms .ff-fileupload-drop-area {
width: 358px;
}
#dvFastForms div.ff-select-to-checkbox-list,
#dvFastForms div.ff-select-to-radiobtn-list {
width: 100%;
}
#dvFastForms .ff-invalid-msg {
font-family: Tahoma;
font-weight: bold;
color: #aea9a9;
font-size: 10px;
}
#dvFastForms .ff-required-mark {
font-family: Tahoma;
font-weight: bold;
color: #ff0000;
font-size: 14px;
}
#dvFastForms .ff-btn-submit {
background-color: #a0a2a3;
font-family: Tahoma;
font-weight: bold;
color: #070000;
font-size: 15px;
border-style: solid;
border-radius: 5px;
border-color: #010000;
border-width: 3px;
padding: 10px;
}
#dvFastForms .ff-btn-submit:hover {
background-color: #004f87;
}
</style>
<div class="ff-form-main">
<div id="ffOverlay"></div>
<div id="ffPage4722" class="ff-page-row page-1" data-pagetitle="Page Title">
<div class="ff-group-row group-0" id="ffSection0">
<div class="ff-item-row">
<div class="ff-col-1 ff-section-col"><label class="ff-section-header" id="sectionLabel0">Becton Dickinson Enrollment Form</label></div>
</div>
<div class="ff-item-row fw-row">
<div class="ff-col-1 ff-label-col"><label id="GENERALTEXT683" lblname="text" class="ff-label ff-general-text-label" data-ishidden="false"></label></div>
</div>
<div class="ff-item-row" style="display: none;">
<div class="ff-col-1 ff-label-col"><label vatt="PICKLIST" for="Lead.Status" class="ff-label" id="lblLeadStatus">Status</label></div>
<div class="ff-col-2 ff-field-col"><select name="Lead.Status" id="Lead.Status" vatt="PICKLIST" class="ff-select-type ff-singlepicklist" data-flexcontrol="" data-requiredmessage="required" data-isupsert="true" data-ishidden="true"
data-vatt="PICKLIST">
<option value=""></option>
<option value="Won">Won</option>
<option value="Lost">Lost</option>
<option value="Supplier Remorse">Supplier Remorse</option>
<option value="Open">Open</option>
<option value="Return" selected="selected">Return</option>
<option value="Won/Converted">Won/Converted</option>
</select></div>
</div>
<div class="ff-item-row" style="display: none;">
<div class="ff-col-1 ff-label-col"><label vatt="PICKLIST" for="Lead.Reason__c" class="ff-label" id="lblLeadReason__c">Reason</label></div>
<div class="ff-col-2 ff-field-col"><select name="Lead.Reason__c" id="Lead.Reason__c" vatt="PICKLIST" class="ff-select-type ff-singlepicklist" data-flexcontrol="" data-requiredmessage="required" data-isupsert="true" data-ishidden="true"
data-vatt="PICKLIST">
<option value=""></option>
<option value="Acquiring Prospect">Acquiring Prospect</option>
<option value="Alt Pmt Method">Alt Pmt Method</option>
<option value="App In Progress">App In Progress</option>
<option value="Auto Enroll">Auto Enroll</option>
<option value="Better Contact Information">Better Contact Information</option>
<option value="BIP Full Acquiring">BIP Full Acquiring</option>
<option value="BIP MID">BIP MID</option>
<option value="BIP No MID">BIP No MID</option>
<option value="Call">Call</option>
<option value="CANCELLED">CANCELLED</option>
<option value="Client Discount">Client Discount</option>
<option value="Contractual Term">Contractual Term</option>
<option value="Customer Acct #">Customer Acct #</option>
<option value="Do Not Call">Do Not Call</option>
<option value="Email">Email</option>
<option value="Enroll Email">Enroll Email</option>
<option value="Enroll Form">Enroll Form</option>
<option value="Full Acquiring">Full Acquiring</option>
<option value="Inactive Client">Inactive Client</option>
<option value="Max Attempts">Max Attempts</option>
<option value="No Discounts Accepted">No Discounts Accepted</option>
<option value="No Longer in Business">No Longer in Business</option>
<option value="Non Acceptor">Non Acceptor</option>
<option value="Not Preferred">Not Preferred</option>
<option value="Not Started">Not Started</option>
<option value="ON HOLD" selected="selected">ON HOLD</option>
<option value="Processing Limit">Processing Limit</option>
<option value="Require Invoice #">Require Invoice #</option>
<option value="Research">Research</option>
<option value="Rework Lead">Rework Lead</option>
<option value="SE ENROLL">SE ENROLL</option>
<option value="SE FULL ACQUIRING">SE FULL ACQUIRING</option>
<option value="SE MID">SE MID</option>
<option value="Supplier Remorse">Supplier Remorse</option>
<option value="Surcharge/Fees">Surcharge/Fees</option>
<option value="Validate with Client">Validate with Client</option>
<option value="Verbal">Verbal</option>
<option value="Voicemail">Voicemail</option>
</select></div>
</div>
<div class="ff-item-row" style="display: none;">
<div class="ff-col-1 ff-label-col"><label vatt="DATE" for="Lead.Enroll_Date__c" class="ff-label" id="lblLeadEnroll_Date__c">Enroll Date</label></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.Enroll_Date__c" placeholder="" name="Lead.Enroll_Date__c" vatt="DATE" class="ff-input-type ff-type-text hasDatepicker" data-maxlengthmessage="Maximum 10 characters"
maxlength="10" data-validatefieldtype="" value="" data-requiredmessage="required" data-isupsert="true" data-ishidden="true" data-vatt="DATE"></div>
</div>
<div class="ff-item-row" style="display: none;">
<div class="ff-col-1 ff-label-col"><label vatt="DATE" for="Lead.Win_Date__c" class="ff-label" id="lblLeadWin_Date__c">Win Date</label></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.Win_Date__c" placeholder="" name="Lead.Win_Date__c" vatt="DATE" class="ff-input-type ff-type-text hasDatepicker" data-maxlengthmessage="Maximum 10 characters"
maxlength="10" data-validatefieldtype="" value="" data-requiredmessage="required" data-isupsert="true" data-ishidden="true" data-vatt="DATE"></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="STRING" for="Lead.Company" class="ff-label" id="lblLeadCompany">Company</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.Company" placeholder="" name="Lead.Company" vatt="STRING" class="ff-input-type ff-type-text" data-maxlengthmessage="Maximum 255 characters" maxlength="255"
data-validatefieldtype="" value="CATHERINE M BURZIK" data-requiredmessage="required" data-isrequired="true" data-isupsert="true" data-ishidden="false" data-vatt="STRING"></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="STRING" for="Lead.FirstName" class="ff-label" id="lblLeadFirstName">First Name</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.FirstName" placeholder="" name="Lead.FirstName" vatt="STRING" class="ff-input-type ff-type-text" data-maxlengthmessage="Maximum 40 characters" maxlength="40"
data-validatefieldtype="" value="Cathy" data-requiredmessage="required" data-isrequired="true" data-isupsert="true" data-ishidden="false" data-vatt="STRING"></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="STRING" for="Lead.LastName" class="ff-label" id="lblLeadLastName">Last Name</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.LastName" placeholder="" name="Lead.LastName" vatt="STRING" class="ff-input-type ff-type-text" data-maxlengthmessage="Maximum 80 characters" maxlength="80"
data-validatefieldtype="" value="Burzik" data-requiredmessage="required" data-isrequired="true" data-isupsert="true" data-ishidden="false" data-vatt="STRING"></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="STRING" for="Lead.Title" class="ff-label" id="lblLeadTitle">Title</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.Title" placeholder="" name="Lead.Title" vatt="STRING" class="ff-input-type ff-type-text" data-maxlengthmessage="Maximum 128 characters" maxlength="128"
data-validatefieldtype="" value="" data-requiredmessage="required" data-isrequired="true" data-isupsert="true" data-ishidden="false" data-vatt="STRING"></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="EMAIL" for="Lead.Email" class="ff-label" id="lblLeadEmail">Email</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.Email" placeholder="" name="Lead.Email" vatt="EMAIL" class="ff-input-type ff-type-text" data-maxlengthmessage="Maximum 80 characters" maxlength="80"
data-validatefieldtype="" value="cathy.burzik@cfboffice.com" data-requiredmessage="required" data-isrequired="true" data-isupsert="true" data-ishidden="false" data-vatt="EMAIL"></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="TEXTAREA" for="Lead.Street" class="ff-label" id="lblLeadStreet">Street</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><textarea id="Lead.Street" placeholder="" name="Lead.Street" vatt="TEXTAREA" class="ff-textarea" data-maxlengthmessage="Maximum 255 characters" maxlength="255" data-ishtmlformatted="false" value=""
data-requiredmessage="required" data-isrequired="true" data-isupsert="true" data-ishidden="false" data-vatt="TEXTAREA">222 PRIMROSE PLACE</textarea></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="STRING" for="Lead.City" class="ff-label" id="lblLeadCity">City</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.City" placeholder="" name="Lead.City" vatt="STRING" class="ff-input-type ff-type-text" data-maxlengthmessage="Maximum 40 characters" maxlength="40"
data-validatefieldtype="" value="SAN ANTONIO" data-requiredmessage="required" data-isrequired="true" data-isupsert="true" data-ishidden="false" data-vatt="STRING"></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="PICKLIST" for="Lead.StateCode" class="ff-label" id="lblLeadStateCode">State/Province Code</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><select name="Lead.StateCode" id="Lead.StateCode" vatt="PICKLIST" class="ff-select-type ff-singlepicklist" data-flexcontrol="" data-requiredmessage="required" data-isrequired="true"
data-isupsert="false" data-ishidden="false" data-vatt="PICKLIST">
<option value=""></option>
<option value="AK">AK</option>
<option value="AL">AL</option>
<option value="AB">AB</option>
<option value="AR">AR</option>
<option value="ACT">ACT</option>
<option value="AZ">AZ</option>
<option value="BC">BC</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DC">DC</option>
<option value="DE">DE</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="GU">GU</option>
<option value="HI">HI</option>
<option value="IA">IA</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="MA">MA</option>
<option value="MB">MB</option>
<option value="MD">MD</option>
<option value="ME">ME</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MO">MO</option>
<option value="MS">MS</option>
<option value="MT">MT</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="NE">NE</option>
<option value="NB">NB</option>
<option value="NL">NL</option>
<option value="NSW">NSW</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NT">NT</option>
<option value="NT">NT</option>
<option value="NS">NS</option>
<option value="NU">NU</option>
<option value="NV">NV</option>
<option value="NY">NY</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="ON">ON</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="PR">PR</option>
<option value="PE">PE</option>
<option value="QC">QC</option>
<option value="QLD">QLD</option>
<option value="RI">RI</option>
<option value="SK">SK</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="SA">SA</option>
<option value="TAS">TAS</option>
<option value="TN">TN</option>
<option value="TX" selected="selected">TX</option>
<option value="UT">UT</option>
<option value="VA">VA</option>
<option value="VI">VI</option>
<option value="VIC">VIC</option>
<option value="VT">VT</option>
<option value="WA">WA</option>
<option value="WA">WA</option>
<option value="WI">WI</option>
<option value="WV">WV</option>
<option value="WY">WY</option>
<option value="YT">YT</option>
</select></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="STRING" for="Lead.PostalCode" class="ff-label" id="lblLeadPostalCode">Postal Code</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.PostalCode" placeholder="" name="Lead.PostalCode" vatt="STRING" class="ff-input-type ff-type-text" data-maxlengthmessage="Maximum 20 characters" maxlength="20"
data-validatefieldtype="" value="78209" data-requiredmessage="required" data-isrequired="true" data-isupsert="true" data-ishidden="false" data-vatt="STRING"></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="PHONE" for="Lead.Phone" class="ff-label" id="lblLeadPhone">Phone</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.Phone" placeholder="" name="Lead.Phone" vatt="PHONE" class="ff-input-type ff-type-text" data-maxlengthmessage="Maximum 40 characters" maxlength="40"
data-validatefieldtype="" value="(210) 826-1149" data-requiredmessage="required" data-isrequired="true" data-isupsert="false" data-ishidden="false" data-vatt="PHONE"></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="STRING" for="Lead.Manager_Name__c" class="ff-label" id="lblLeadManager_Name__c">Manager Name</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.Manager_Name__c" placeholder="" name="Lead.Manager_Name__c" vatt="STRING" class="ff-input-type ff-type-text" data-maxlengthmessage="Maximum 80 characters" maxlength="80"
data-validatefieldtype="" value="" data-requiredmessage="required" data-isrequired="true" data-isupsert="true" data-ishidden="false" data-vatt="STRING"></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="STRING" for="Lead.Manager_Title__c" class="ff-label" id="lblLeadManager_Title__c">Manager Title</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.Manager_Title__c" placeholder="" name="Lead.Manager_Title__c" vatt="STRING" class="ff-input-type ff-type-text" data-maxlengthmessage="Maximum 80 characters"
maxlength="80" data-validatefieldtype="" value="" data-requiredmessage="required" data-isrequired="true" data-isupsert="true" data-ishidden="false" data-vatt="STRING"></div>
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<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="EMAIL" for="Lead.Manager_Email__c" class="ff-label" id="lblLeadManager_Email__c">Manager Email</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.Manager_Email__c" placeholder="" name="Lead.Manager_Email__c" vatt="EMAIL" class="ff-input-type ff-type-text" data-maxlengthmessage="Maximum 80 characters" maxlength="80"
data-validatefieldtype="" value="cathy.burzik@cfboffice.com" data-requiredmessage="required" data-isrequired="true" data-isupsert="true" data-ishidden="false" data-vatt="EMAIL"></div>
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<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="EMAIL" for="Lead.Payment_Remittance_Email__c" class="ff-label" id="lblLeadPayment_Remittance_Email__c">Payment Remittance Email</label><span class="requiredSpan ff-required-mark">*</span>
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<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.Payment_Remittance_Email__c" placeholder="" name="Lead.Payment_Remittance_Email__c" vatt="EMAIL" class="ff-input-type ff-type-text"
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</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="EMAIL" for="Lead.Unsubscribe_Email__c" class="ff-label" id="lblLeadUnsubscribe_Email__c">Confirm Payment Remittance Email</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.Unsubscribe_Email__c" placeholder="" name="Lead.Unsubscribe_Email__c" vatt="EMAIL" class="ff-input-type ff-type-text" data-maxlengthmessage="Maximum 80 characters"
maxlength="80" data-validatefieldtype="" value="" data-requiredmessage="required" data-isrequired="true" data-isupsert="false" data-ishidden="false" data-vatt="EMAIL"></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="STRING" for="Lead.Tax_ID__c" class="ff-label" id="lblLeadTax_ID__c">Tax ID</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.Tax_ID__c" placeholder="" name="Lead.Tax_ID__c" vatt="STRING" class="ff-input-type ff-type-text" data-maxlengthmessage="Maximum 20 characters" maxlength="20"
data-validatefieldtype="" value="" data-requiredmessage="required" data-isrequired="true" data-isupsert="true" data-ishidden="false" data-vatt="STRING"></div>
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<div class="ff-item-row fw-row">
<div class="ff-col-1 ff-label-col"><label id="GENERALTEXT375" lblname="text" class="ff-label ff-general-text-label" data-ishidden="false">Please answer the questions below:</label></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="PICKLIST" for="Lead.Citi_Form_Question_1__c" class="ff-label" id="lblLeadCiti_Form_Question_1__c">Our company is able to process all credit card transactions with our merchant processor
with NO processing limits and/or restrictions on the size of the credit card transaction received. We have the ability to process transactions over $99,999.</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col">
<div class="ff-select-to-radiobtn-list custom-flex-control-container">
<ul id="ulLead.Citi_Form_Question_1__c" class="ff-select-to-radiobtn-ul ff-ext-vertical" role="radiogroup" aria-labelledby="lblLeadCiti_Form_Question_1__c">
<li class="ff-radio-li"><span class="ff-ext-radio-css ff-ext-selected" role="radio" aria-checked="true" aria-labelledby="lblLead.Citi_Form_Question_1__c__1" tabindex="0" name="Lead.Citi_Form_Question_1__c"
id="Lead.Citi_Form_Question_1__c__1" data-value="Yes" data-ff-ext-radio-checked="true"></span><label for="Lead.Citi_Form_Question_1__c__1" id="lblLead.Citi_Form_Question_1__c__1">Yes</label></li>
<li class="ff-radio-li"><span class="ff-ext-radio-css" role="radio" aria-checked="false" aria-labelledby="lblLead.Citi_Form_Question_1__c__2" tabindex="0" name="Lead.Citi_Form_Question_1__c" id="Lead.Citi_Form_Question_1__c__2"
data-value="No" data-ff-ext-radio-checked="false"></span><label for="Lead.Citi_Form_Question_1__c__2" id="lblLead.Citi_Form_Question_1__c__2">No</label></li>
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<option value="Yes" selected="selected">Yes</option>
<option value="No">No</option>
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</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="PICKLIST" for="Lead.Citi_Form_Question_2__c" class="ff-label" id="lblLeadCiti_Form_Question_2__c">Our company agrees to accept all payments to our Company's Tax ID via credit card, in
United States Dollars (USD).</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col">
<div class="ff-select-to-radiobtn-list custom-flex-control-container">
<ul id="ulLead.Citi_Form_Question_2__c" class="ff-select-to-radiobtn-ul ff-ext-vertical" role="radiogroup" aria-labelledby="lblLeadCiti_Form_Question_2__c">
<li class="ff-radio-li"><span class="ff-ext-radio-css" role="radio" aria-checked="false" aria-labelledby="lblLead.Citi_Form_Question_2__c__1" tabindex="0" name="Lead.Citi_Form_Question_2__c" id="Lead.Citi_Form_Question_2__c__1"
data-value="Yes" data-ff-ext-radio-checked="false"></span><label for="Lead.Citi_Form_Question_2__c__1" id="lblLead.Citi_Form_Question_2__c__1">Yes</label></li>
<li class="ff-radio-li"><span class="ff-ext-radio-css" role="radio" aria-checked="false" aria-labelledby="lblLead.Citi_Form_Question_2__c__2" tabindex="0" name="Lead.Citi_Form_Question_2__c" id="Lead.Citi_Form_Question_2__c__2"
data-value="No" data-ff-ext-radio-checked="false"></span><label for="Lead.Citi_Form_Question_2__c__2" id="lblLead.Citi_Form_Question_2__c__2">No</label></li>
</ul>
</div><select name="Lead.Citi_Form_Question_2__c" id="Lead.Citi_Form_Question_2__c" vatt="PICKLIST" class="ff-select-type ff-singlepicklist custom-select-offscreen" data-flexcontrol="picklist-radiobutton-vertical"
data-requiredmessage="required" data-isrequired="true" data-isupsert="true" data-ishidden="false" data-vatt="PICKLIST">
<option value="" selected="selected"></option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="PICKLIST" for="Lead.Citi_Form_Question_3__c" class="ff-label" id="lblLeadCiti_Form_Question_3__c">Our company agrees to accept card payments via email from incontrol@mastercard.com and
process them in a timely manner.</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col">
<div class="ff-select-to-radiobtn-list custom-flex-control-container">
<ul id="ulLead.Citi_Form_Question_3__c" class="ff-select-to-radiobtn-ul ff-ext-vertical" role="radiogroup" aria-labelledby="lblLeadCiti_Form_Question_3__c">
<li class="ff-radio-li"><span class="ff-ext-radio-css" role="radio" aria-checked="false" aria-labelledby="lblLead.Citi_Form_Question_3__c__1" tabindex="0" name="Lead.Citi_Form_Question_3__c" id="Lead.Citi_Form_Question_3__c__1"
data-value="Yes" data-ff-ext-radio-checked="false"></span><label for="Lead.Citi_Form_Question_3__c__1" id="lblLead.Citi_Form_Question_3__c__1">Yes</label></li>
<li class="ff-radio-li"><span class="ff-ext-radio-css" role="radio" aria-checked="false" aria-labelledby="lblLead.Citi_Form_Question_3__c__2" tabindex="0" name="Lead.Citi_Form_Question_3__c" id="Lead.Citi_Form_Question_3__c__2"
data-value="No" data-ff-ext-radio-checked="false"></span><label for="Lead.Citi_Form_Question_3__c__2" id="lblLead.Citi_Form_Question_3__c__2">No</label></li>
</ul>
</div><select name="Lead.Citi_Form_Question_3__c" id="Lead.Citi_Form_Question_3__c" vatt="PICKLIST" class="ff-select-type ff-singlepicklist custom-select-offscreen" data-flexcontrol="picklist-radiobutton-vertical"
data-requiredmessage="required" data-isrequired="true" data-isupsert="true" data-ishidden="false" data-vatt="PICKLIST">
<option value="" selected="selected"></option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="PICKLIST" for="Lead.Citi_Form_Question_4__c" class="ff-label" id="lblLeadCiti_Form_Question_4__c">Our company agrees to accept a single credit card payment (single-use card) which may
apply to multiple invoices in ready-to-pay status.</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col">
<div class="ff-select-to-radiobtn-list custom-flex-control-container">
<ul id="ulLead.Citi_Form_Question_4__c" class="ff-select-to-radiobtn-ul ff-ext-vertical" role="radiogroup" aria-labelledby="lblLeadCiti_Form_Question_4__c">
<li class="ff-radio-li"><span class="ff-ext-radio-css" role="radio" aria-checked="false" aria-labelledby="lblLead.Citi_Form_Question_4__c__1" tabindex="0" name="Lead.Citi_Form_Question_4__c" id="Lead.Citi_Form_Question_4__c__1"
data-value="Yes" data-ff-ext-radio-checked="false"></span><label for="Lead.Citi_Form_Question_4__c__1" id="lblLead.Citi_Form_Question_4__c__1">Yes</label></li>
<li class="ff-radio-li"><span class="ff-ext-radio-css" role="radio" aria-checked="false" aria-labelledby="lblLead.Citi_Form_Question_4__c__2" tabindex="0" name="Lead.Citi_Form_Question_4__c" id="Lead.Citi_Form_Question_4__c__2"
data-value="No" data-ff-ext-radio-checked="false"></span><label for="Lead.Citi_Form_Question_4__c__2" id="lblLead.Citi_Form_Question_4__c__2">No</label></li>
</ul>
</div><select name="Lead.Citi_Form_Question_4__c" id="Lead.Citi_Form_Question_4__c" vatt="PICKLIST" class="ff-select-type ff-singlepicklist custom-select-offscreen" data-flexcontrol="picklist-radiobutton-vertical"
data-requiredmessage="required" data-isrequired="true" data-isupsert="true" data-ishidden="false" data-vatt="PICKLIST">
<option value="" selected="selected"></option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="ff-item-row fw-row">
<div class="ff-col-1 ff-label-col"><label id="GENERALTEXT500" lblname="text" class="ff-label ff-general-text-label" data-ishidden="false">
<center>* Becton Dickinson will not agree to a surcharge or a fee for paying with a virtual credit card.</center>
</label></div>
</div>
<div class="ff-item-row fw-row">
<div class="ff-col-1 ff-label-col"><label id="GENERALTEXT793" lblname="text" class="ff-label ff-general-text-label" data-ishidden="false">* Contact us at BectonDickinson@info14.citi.com or call us at 877-345-6923. Our fax number is
855-859-6873.</label></div>
</div>
</div>
</div>
<div class="ff-footer-group">
<div class="ff-item-row ff-footer-row">
<div class="ff-submit-btn">
<div class="footnoteDiv"><span class="requiredSpan ff-footnote ff-required-mark">*</span><label class="ff-footnote-label ff-label">- required</label></div>
<div class="btnDiv"><input type="button" class="sectionHeader ff-btn-submit" id="btnsubmit" value="Submit Enrollment Form" data-btnmessage="Thank you for enrolling in our Virtual Credit Card payment program. Please consider the following when processing a Virtual Card payment:
The size of the transaction(s) received via Virtual Credit Card will vary. Please confirm with your current merchant acquirer if you have the ability to process the size of these individual transaction(s).
Virtual Credit Cards are single-use only cards. The single use card may apply to several invoices. Keep in mind you will not be able to charge the card for each individual invoice. It must be processed as the total amount sent on the remittance email.
For questions related to processing the card, or how to lower your cost of accepting cards in a business to business environment, please reach out to our Business Services Desk at 844-295-9858." data-btnurl=""></div>
</div>
</div>
</div>
</div>
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<iframe id="ffIframe" name="ffIframe" style="display:none"></iframe>
<div id="dialog">
</div>
<div id="paymentDialog" style="display:none;overflow:hidden;">
<iframe id="paymentDialogIFrame" style="width:100%;height:100%;margin:0px;padding:0px;border:0" scrolling="no"></iframe>
</div>
<div id="ffLookupDialog" style="overflow:hidden">
</div>
<input type="hidden" id="selectedId" value="">
</form>Text Content
Becton Dickinson Enrollment Form Status WonLostSupplier RemorseOpenReturnWon/Converted Reason Acquiring ProspectAlt Pmt MethodApp In ProgressAuto EnrollBetter Contact InformationBIP Full AcquiringBIP MIDBIP No MIDCallCANCELLEDClient DiscountContractual TermCustomer Acct #Do Not CallEmailEnroll EmailEnroll FormFull AcquiringInactive ClientMax AttemptsNo Discounts AcceptedNo Longer in BusinessNon AcceptorNot PreferredNot StartedON HOLDProcessing LimitRequire Invoice #ResearchRework LeadSE ENROLLSE FULL ACQUIRINGSE MIDSupplier RemorseSurcharge/FeesValidate with ClientVerbalVoicemail Enroll Date Win Date Company* First Name* Last Name* Title* Email* Street* 222 PRIMROSE PLACE City* State/Province Code* AKALABARACTAZBCCACOCTDCDEFLGAGUHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNCNDNENBNLNSWNHNJNMNTNTNSNUNVNYOHOKONORPAPRPEQCQLDRISKSCSDSATASTNTXUTVAVIVICVTWAWAWIWVWYYT Postal Code* Phone* Manager Name* Manager Title* Manager Email* Payment Remittance Email* Confirm Payment Remittance Email* Tax ID* Please answer the questions below: Our company is able to process all credit card transactions with our merchant processor with NO processing limits and/or restrictions on the size of the credit card transaction received. We have the ability to process transactions over $99,999.* * Yes * No YesNo Our company agrees to accept all payments to our Company's Tax ID via credit card, in United States Dollars (USD).* * Yes * No YesNo Our company agrees to accept card payments via email from incontrol@mastercard.com and process them in a timely manner.* * Yes * No YesNo Our company agrees to accept a single credit card payment (single-use card) which may apply to multiple invoices in ready-to-pay status.* * Yes * No YesNo * Becton Dickinson will not agree to a surcharge or a fee for paying with a virtual credit card. * Contact us at BectonDickinson@info14.citi.com or call us at 877-345-6923. Our fax number is 855-859-6873. *- required PrevNext JanFebMarAprMayJunJulAugSepOctNovDec192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027202820292030203120322033 SuMoTuWeThFrSa12345678910111213141516171819202122232425262728293031 NowDone