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Submitted URL: https://wainscot.omeclk.com/portal/wts/ucmcnt2c|Paq|DDdorycB9F|e
Effective URL: https://wainscot.dragonforms.com/loading.do?omedasite=DIC_new&pk=WKNW19
Submission: On June 02 via api from US — Scanned from DE
Effective URL: https://wainscot.dragonforms.com/loading.do?omedasite=DIC_new&pk=WKNW19
Submission: On June 02 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST saveNewSubscription.do;jsessionid=621DCDBE8FCC006B2F320D0605358876
<form method="post" accept-charset="utf-8" action="saveNewSubscription.do;jsessionid=621DCDBE8FCC006B2F320D0605358876" id="standardForm"><input type="hidden" name="14" id="14" value="1"><input type="hidden" id="dragonjsessionid"
name="dragonjsessionid" value="621DCDBE8FCC006B2F320D0605358876"><input type="hidden" id="shippingaddresscountry" name="shippingaddresscountry" value="7">
<nav class="drgNav nav" style="display: none;"><select>
<option selected="selected" value="">Go to...</option>
</select></nav>
<div class="container">
<span id="logo" class="eight columns"><img src="https://hostedcontent.dragonforms.com/hosted/images/dragon/12426/141.jpg" alt="DIClogo"></span><span id="cover" class="eight columns"></span>
<div>
<span class="validation">
<ul>
</ul>
</span>
</div>
<div id="content1" class="sixteen columns">
<h2>New Subscription</h2>Please complete the information below to start your subscription.
<hr><input name="demo13093" type="hidden" value="WKNW19" id="demo13093">
<p id="p1" class="drg-element-type-standard-field drg-element-sub-type-fieldname-FIRSTNAME addresslabel"><span class="questionlabel "><label for="id1">First Name <font color="red">*</font></label> </span><input class="drg-field-address-normal"
name="demo13094" type="text" value="" id="id1" maxlength="40" size="40"></p>
<p id="p2" class="drg-element-type-standard-field drg-element-sub-type-fieldname-LASTNAME addresslabel"><span class="questionlabel "><label for="id2">Last Name <font color="red">*</font></label> </span><input class="drg-field-address-normal"
name="demo13095" type="text" value="" id="id2" maxlength="40" size="40"></p>
<p id="p10" class="drg-element-type-standard-field drg-element-sub-type-fieldname-TITLE addresslabel"><span class="questionlabel "><label for="id10">Title <font color="red">*</font></label> </span><input class="drg-field-address-normal"
name="demo13096" type="text" value="" id="id10" maxlength="40" size="40"></p>
<p id="p3" class="drg-element-type-standard-field drg-element-sub-type-fieldname-COMPANY addresslabel"><span class="questionlabel "><label for="id3">Company <font color="red">*</font></label> </span><input class="drg-field-address-normal"
name="demo13097" type="text" value="" id="id3" maxlength="40" size="40"></p>
<p id="p13" class="drg-element-type-standard-field drg-element-sub-type-fieldname-EMAILADDR addresslabel"><span class="questionlabel "><label for="id13">Email <font color="red">*</font></label> </span><input class="drg-field-address-normal"
name="demo13107" type="text" value="" id="id13" maxlength="50" size="50"></p>
<p id="p4" class="drg-element-type-standard-field drg-element-sub-type-fieldname-ADDRESS addresslabel"><span class="questionlabel "><label for="id4">Address 1 <font color="red">*</font></label> </span><input class="drg-field-address-normal"
name="demo13098" type="text" value="" id="id4" maxlength="255" size="255"></p>
<p id="p5" class="drg-element-type-standard-field drg-element-sub-type-fieldname-DEPARTMENT addresslabel"><span class="questionlabel "><label for="id5">Address 2</label> </span><input class="drg-field-address-normal" name="demo13099"
type="text" value="" id="id5" maxlength="255" size="255"></p>
<p id="p6" class="drg-element-type-standard-field drg-element-sub-type-fieldname-CITY addresslabel"><span class="questionlabel "><label for="id6">City <font color="red">*</font></label> </span><input class="drg-field-address-normal"
name="demo13100" type="text" value="" id="id6" maxlength="100" size="100"></p><span class="spanc8 drg-element-type-standard-field drg-element-sub-type-fieldname-STATE">
<p id="p8" class="drg-element-type-standard-field drg-element-sub-type-fieldname-STATE addresslabel"><span class="questionlabel "><label for="id8">State/Province (USA and Canada only) <font color="red">*</font></label> </span><select
name="demo13101" id="id8">
<option value="">Select One</option>
<option value="1" [-selected13101_r1-]="">ALABAMA</option>
<option value="2" [-selected13101_r2-]="">ALASKA</option>
<option value="3" [-selected13101_r3-]="">ARIZONA</option>
<option value="4" [-selected13101_r4-]="">ARKANSAS</option>
<option value="5" [-selected13101_r5-]="">CALIFORNIA</option>
<option value="6" [-selected13101_r6-]="">COLORADO</option>
<option value="7" [-selected13101_r7-]="">CONNECTICUT</option>
<option value="8" [-selected13101_r8-]="">DELAWARE</option>
<option value="9" [-selected13101_r9-]="">DISTRICT OF COLUMBIA</option>
<option value="10" [-selected13101_r10-]="">FLORIDA</option>
<option value="11" [-selected13101_r11-]="">GEORGIA</option>
<option value="12" [-selected13101_r12-]="">HAWAII</option>
<option value="13" [-selected13101_r13-]="">IDAHO</option>
<option value="14" [-selected13101_r14-]="">ILLINOIS</option>
<option value="15" [-selected13101_r15-]="">INDIANA</option>
<option value="16" [-selected13101_r16-]="">IOWA</option>
<option value="17" [-selected13101_r17-]="">KANSAS</option>
<option value="18" [-selected13101_r18-]="">KENTUCKY</option>
<option value="19" [-selected13101_r19-]="">LOUISIANA</option>
<option value="20" [-selected13101_r20-]="">MAINE</option>
<option value="21" [-selected13101_r21-]="">MARYLAND</option>
<option value="22" [-selected13101_r22-]="">MASSACHUSETTS</option>
<option value="23" [-selected13101_r23-]="">MICHIGAN</option>
<option value="24" [-selected13101_r24-]="">MINNESOTA</option>
<option value="25" [-selected13101_r25-]="">MISSISSIPPI</option>
<option value="26" [-selected13101_r26-]="">MISSOURI</option>
<option value="27" [-selected13101_r27-]="">MONTANA</option>
<option value="28" [-selected13101_r28-]="">NEBRASKA</option>
<option value="29" [-selected13101_r29-]="">NEVADA</option>
<option value="30" [-selected13101_r30-]="">NEW HAMPSHIRE</option>
<option value="31" [-selected13101_r31-]="">NEW JERSEY</option>
<option value="32" [-selected13101_r32-]="">NEW MEXICO</option>
<option value="33" [-selected13101_r33-]="">NEW YORK</option>
<option value="34" [-selected13101_r34-]="">NORTH CAROLINA</option>
<option value="35" [-selected13101_r35-]="">NORTH DAKOTA</option>
<option value="36" [-selected13101_r36-]="">OHIO</option>
<option value="37" [-selected13101_r37-]="">OKLAHOMA</option>
<option value="38" [-selected13101_r38-]="">OREGON</option>
<option value="39" [-selected13101_r39-]="">PENNSYLVANIA</option>
<option value="40" [-selected13101_r40-]="">RHODE ISLAND</option>
<option value="41" [-selected13101_r41-]="">SOUTH CAROLINA</option>
<option value="42" [-selected13101_r42-]="">SOUTH DAKOTA</option>
<option value="43" [-selected13101_r43-]="">TENNESSEE</option>
<option value="44" [-selected13101_r44-]="">TEXAS</option>
<option value="45" [-selected13101_r45-]="">UTAH</option>
<option value="46" [-selected13101_r46-]="">VERMONT</option>
<option value="47" [-selected13101_r47-]="">VIRGIN ISLANDS</option>
<option value="48" [-selected13101_r48-]="">VIRGINIA</option>
<option value="49" [-selected13101_r49-]="">WASHINGTON</option>
<option value="50" [-selected13101_r50-]="">WEST VIRGINIA</option>
<option value="51" [-selected13101_r51-]="">WISCONSIN</option>
<option value="52" [-selected13101_r52-]="">WYOMING</option>
<option value="53" [-selected13101_r53-]="">American Samoa</option>
<option value="54" [-selected13101_r54-]="">Guam</option>
<option value="56" [-selected13101_r56-]="">Micronesia (Federated States of)</option>
<option value="58" [-selected13101_r58-]="">Puerto Rico</option>
<option value="59" [-selected13101_r59-]="">U.S. Minor Outlying Islands</option>
<option value="60" [-selected13101_r60-]="">NORTHERN MARIANA ISLANDS</option>
<option value="61" [-selected13101_r61-]="">Armed Forces Africa</option>
<option value="62" [-selected13101_r62-]="">Armed Forces Americas AA (except Canada)</option>
<option value="63" [-selected13101_r63-]="">Armed Forces Canada</option>
<option value="64" [-selected13101_r64-]="">Armed Forces Europe AE</option>
<option value="65" [-selected13101_r65-]="">Armed Forces Middle East AE</option>
<option value="66" [-selected13101_r66-]="">Armed Forces Pacific AP</option>
<option value="67" [-selected13101_r67-]="">ALBERTA</option>
<option value="68" [-selected13101_r68-]="">NOVA SCOTIA</option>
<option value="69" [-selected13101_r69-]="">BRITISH COLUMBIA</option>
<option value="70" [-selected13101_r70-]="">ONTARIO</option>
<option value="71" [-selected13101_r71-]="">MANITOBA</option>
<option value="72" [-selected13101_r72-]="">PRINCE EDWARD ISLAND</option>
<option value="73" [-selected13101_r73-]="">NEW BRUNSWICK</option>
<option value="74" [-selected13101_r74-]="">QUEBEC</option>
<option value="75" [-selected13101_r75-]="">NEWFOUNDLAND</option>
<option value="76" [-selected13101_r76-]="">SASKATCHEWAN</option>
<option value="77" [-selected13101_r77-]="">NORTHWEST TERRITORIES</option>
<option value="78" [-selected13101_r78-]="">YUKON TERRITORY</option>
<option value="79" [-selected13101_r79-]="">NUNAVUT</option>
<option value="1002" [-selected13101_r1002-]="">FOREIGN</option>
</select></p>
</span>
<p id="p9" class="drg-element-type-standard-field drg-element-sub-type-fieldname-ZIP addresslabel"><span class="questionlabel "><label for="id9">Zip <font color="red">*</font></label> </span><input class="drg-field-address-normal"
name="demo13102" type="text" value="" id="id9" maxlength="9" size="9"></p><span class="spanc7 drg-element-type-standard-field drg-element-sub-type-fieldname-COUNTRY">
<p id="p7" class="drg-element-type-standard-field drg-element-sub-type-fieldname-COUNTRY addresslabel"><span class="questionlabel "><label for="id7">Country <font color="red">*</font></label> </span><select name="demo13103" id="id7">
<option value="">Select One</option>
<option value="80" [-selected13103_r80-]="">UNITED STATES</option>
<option value="81" [-selected13103_r81-]="">CANADA</option>
<option value="84" [-selected13103_r84-]="">AFGHANISTAN</option>
<option value="86" [-selected13103_r86-]="">ALBANIA</option>
<option value="87" [-selected13103_r87-]="">ALGERIA</option>
<option value="89" [-selected13103_r89-]="">ANDORRA</option>
<option value="90" [-selected13103_r90-]="">ANGOLA</option>
<option value="91" [-selected13103_r91-]="">ANGUILLA</option>
<option value="350" [-selected13103_r350-]="">ANTARCTICA</option>
<option value="92" [-selected13103_r92-]="">ANTIGUA</option>
<option value="93" [-selected13103_r93-]="">ARGENTINA</option>
<option value="94" [-selected13103_r94-]="">ARMENIA</option>
<option value="95" [-selected13103_r95-]="">ARUBA</option>
<option value="96" [-selected13103_r96-]="">ASCENSION IS</option>
<option value="97" [-selected13103_r97-]="">AUSTRALIA</option>
<option value="98" [-selected13103_r98-]="">AUSTRIA</option>
<option value="99" [-selected13103_r99-]="">AZERBAIJAN</option>
<option value="101" [-selected13103_r101-]="">BAHAMAS</option>
<option value="102" [-selected13103_r102-]="">BAHRAIN</option>
<option value="103" [-selected13103_r103-]="">BANGLADESH</option>
<option value="104" [-selected13103_r104-]="">BARBADOS</option>
<option value="106" [-selected13103_r106-]="">BELARUS</option>
<option value="108" [-selected13103_r108-]="">BELGIUM</option>
<option value="109" [-selected13103_r109-]="">BELIZE</option>
<option value="110" [-selected13103_r110-]="">BENIN</option>
<option value="111" [-selected13103_r111-]="">BERMUDA</option>
<option value="112" [-selected13103_r112-]="">BHUTAN</option>
<option value="113" [-selected13103_r113-]="">BOLIVIA</option>
<option value="115" [-selected13103_r115-]="">BOSNIA-HERZEGOVINA</option>
<option value="116" [-selected13103_r116-]="">BOTSWANA</option>
<option value="117" [-selected13103_r117-]="">BRAZIL</option>
<option value="351" [-selected13103_r351-]="">BRITISH INDIAN OCEAN TERRITORY</option>
<option value="118" [-selected13103_r118-]="">BRITISH VIRGIN IS</option>
<option value="120" [-selected13103_r120-]="">BRUNEI</option>
<option value="121" [-selected13103_r121-]="">BULGARIA</option>
<option value="122" [-selected13103_r122-]="">BURKINA FASO</option>
<option value="123" [-selected13103_r123-]="">BURUNDI</option>
<option value="124" [-selected13103_r124-]="">CAMBODIA</option>
<option value="125" [-selected13103_r125-]="">CAMEROON</option>
<option value="127" [-selected13103_r127-]="">CAPE VERDE ISLANDS</option>
<option value="128" [-selected13103_r128-]="">CAYMAN ISLANDS</option>
<option value="129" [-selected13103_r129-]="">CENTRAL AFRICAN REP</option>
<option value="130" [-selected13103_r130-]="">CHAD</option>
<option value="134" [-selected13103_r134-]="">CHILE</option>
<option value="135" [-selected13103_r135-]="">CHINA</option>
<option value="136" [-selected13103_r136-]="">COCO ISLAND</option>
<option value="137" [-selected13103_r137-]="">COLOMBIA</option>
<option value="138" [-selected13103_r138-]="">COMOROS</option>
<option value="139" [-selected13103_r139-]="">CONGO</option>
<option value="141" [-selected13103_r141-]="">COOK ISLANDS</option>
<option value="142" [-selected13103_r142-]="">COSTA RICA</option>
<option value="143" [-selected13103_r143-]="">CROATIA</option>
<option value="144" [-selected13103_r144-]="">CUBA</option>
<option value="145" [-selected13103_r145-]="">CYPRUS</option>
<option value="146" [-selected13103_r146-]="">CZECH REPUBLIC</option>
<option value="147" [-selected13103_r147-]="">DENMARK</option>
<option value="148" [-selected13103_r148-]="">DJIBOUTI</option>
<option value="149" [-selected13103_r149-]="">DOMINICA</option>
<option value="150" [-selected13103_r150-]="">DOMINICAN REPUBLIC</option>
<option value="151" [-selected13103_r151-]="">EAST TIMOR</option>
<option value="152" [-selected13103_r152-]="">ECUADOR</option>
<option value="153" [-selected13103_r153-]="">EGYPT</option>
<option value="154" [-selected13103_r154-]="">EL SALVADOR</option>
<option value="156" [-selected13103_r156-]="">ERITREA</option>
<option value="157" [-selected13103_r157-]="">ESTONIA</option>
<option value="158" [-selected13103_r158-]="">ETHIOPIA</option>
<option value="159" [-selected13103_r159-]="">FAEROE ISLANDS</option>
<option value="160" [-selected13103_r160-]="">FALKLAND ISLANDS</option>
<option value="161" [-selected13103_r161-]="">FIJI</option>
<option value="162" [-selected13103_r162-]="">FINLAND</option>
<option value="163" [-selected13103_r163-]="">FRANCE</option>
<option value="164" [-selected13103_r164-]="">FRENCH GUIANA</option>
<option value="165" [-selected13103_r165-]="">FRENCH POLYNESIA</option>
<option value="168" [-selected13103_r168-]="">GABON</option>
<option value="169" [-selected13103_r169-]="">GAMBIA</option>
<option value="171" [-selected13103_r171-]="">GEORGIA</option>
<option value="172" [-selected13103_r172-]="">GERMANY</option>
<option value="173" [-selected13103_r173-]="">GHANA</option>
<option value="174" [-selected13103_r174-]="">GIBRALTAR</option>
<option value="176" [-selected13103_r176-]="">GREECE</option>
<option value="177" [-selected13103_r177-]="">GREENLAND</option>
<option value="178" [-selected13103_r178-]="">GRENADA</option>
<option value="179" [-selected13103_r179-]="">GUADELOUPE</option>
<option value="180" [-selected13103_r180-]="">GUATEMALA</option>
<option value="181" [-selected13103_r181-]="">GUERNSEY</option>
<option value="182" [-selected13103_r182-]="">GUINEA</option>
<option value="183" [-selected13103_r183-]="">GUYANA</option>
<option value="184" [-selected13103_r184-]="">HAITI</option>
<option value="185" [-selected13103_r185-]="">HONDURAS</option>
<option value="186" [-selected13103_r186-]="">HONG KONG</option>
<option value="187" [-selected13103_r187-]="">HUNGARY</option>
<option value="188" [-selected13103_r188-]="">ICELAND</option>
<option value="189" [-selected13103_r189-]="">INDIA</option>
<option value="190" [-selected13103_r190-]="">INDONESIA</option>
<option value="191" [-selected13103_r191-]="">IRAN</option>
<option value="192" [-selected13103_r192-]="">IRAQ</option>
<option value="193" [-selected13103_r193-]="">IRELAND</option>
<option value="194" [-selected13103_r194-]="">ISLE OF MAN</option>
<option value="195" [-selected13103_r195-]="">ISRAEL</option>
<option value="196" [-selected13103_r196-]="">ITALY</option>
<option value="197" [-selected13103_r197-]="">IVORY COAST</option>
<option value="198" [-selected13103_r198-]="">JAMAICA</option>
<option value="199" [-selected13103_r199-]="">JAPAN</option>
<option value="200" [-selected13103_r200-]="">JORDAN</option>
<option value="201" [-selected13103_r201-]="">KAZAKHSTAN</option>
<option value="202" [-selected13103_r202-]="">KENYA</option>
<option value="204" [-selected13103_r204-]="">KIRIBATI</option>
<option value="206" [-selected13103_r206-]="">KUWAIT</option>
<option value="207" [-selected13103_r207-]="">KYRGYZSTAN</option>
<option value="208" [-selected13103_r208-]="">LAOS</option>
<option value="209" [-selected13103_r209-]="">LATVIA</option>
<option value="210" [-selected13103_r210-]="">LEBANON</option>
<option value="211" [-selected13103_r211-]="">LESOTHO</option>
<option value="212" [-selected13103_r212-]="">LIBERIA</option>
<option value="213" [-selected13103_r213-]="">LIBYA</option>
<option value="214" [-selected13103_r214-]="">LIECHTENSTEIN</option>
<option value="215" [-selected13103_r215-]="">LITHUANIA</option>
<option value="216" [-selected13103_r216-]="">LUXEMBOURG</option>
<option value="217" [-selected13103_r217-]="">MACAO</option>
<option value="218" [-selected13103_r218-]="">MACEDONIA</option>
<option value="219" [-selected13103_r219-]="">MADAGASCAR</option>
<option value="221" [-selected13103_r221-]="">MALAWI</option>
<option value="222" [-selected13103_r222-]="">MALAYSIA</option>
<option value="223" [-selected13103_r223-]="">MALDIVES</option>
<option value="224" [-selected13103_r224-]="">MALI</option>
<option value="225" [-selected13103_r225-]="">MALTA</option>
<option value="226" [-selected13103_r226-]="">MARSHALL ISLANDS</option>
<option value="227" [-selected13103_r227-]="">MARTINIQUE</option>
<option value="228" [-selected13103_r228-]="">MAURITANIA</option>
<option value="229" [-selected13103_r229-]="">MAURITIUS</option>
<option value="230" [-selected13103_r230-]="">MAYOTTE</option>
<option value="231" [-selected13103_r231-]="">MEXICO</option>
<option value="232" [-selected13103_r232-]="">MICRONESIA</option>
<option value="233" [-selected13103_r233-]="">MOLDOVA</option>
<option value="235" [-selected13103_r235-]="">MONACO</option>
<option value="236" [-selected13103_r236-]="">MONGOLIA</option>
<option value="237" [-selected13103_r237-]="">MONTENEGRO</option>
<option value="238" [-selected13103_r238-]="">MONTSERRAT</option>
<option value="239" [-selected13103_r239-]="">MOROCCO</option>
<option value="240" [-selected13103_r240-]="">MOZAMBIQUE</option>
<option value="241" [-selected13103_r241-]="">MYANMAR</option>
<option value="242" [-selected13103_r242-]="">NAMIBIA</option>
<option value="243" [-selected13103_r243-]="">NAURU</option>
<option value="244" [-selected13103_r244-]="">NEPAL</option>
<option value="245" [-selected13103_r245-]="">NETHERLAND ANTILLES</option>
<option value="246" [-selected13103_r246-]="">NETHERLANDS</option>
<option value="248" [-selected13103_r248-]="">NEW CALEDONIA</option>
<option value="249" [-selected13103_r249-]="">NEW GUINEA</option>
<option value="250" [-selected13103_r250-]="">NEW ZEALAND</option>
<option value="251" [-selected13103_r251-]="">NICARAGUA</option>
<option value="252" [-selected13103_r252-]="">NIGER</option>
<option value="253" [-selected13103_r253-]="">NIGERIA</option>
<option value="254" [-selected13103_r254-]="">NORTH KOREA</option>
<option value="256" [-selected13103_r256-]="">NORWAY</option>
<option value="257" [-selected13103_r257-]="">OMAN</option>
<option value="259" [-selected13103_r259-]="">PAKISTAN</option>
<option value="260" [-selected13103_r260-]="">PALAU</option>
<option value="261" [-selected13103_r261-]="">PALESTINE</option>
<option value="262" [-selected13103_r262-]="">PANAMA</option>
<option value="264" [-selected13103_r264-]="">PARAGUAY</option>
<option value="265" [-selected13103_r265-]="">PERU</option>
<option value="266" [-selected13103_r266-]="">PHILIPPINES</option>
<option value="268" [-selected13103_r268-]="">PITCAIRN IS</option>
<option value="269" [-selected13103_r269-]="">POLAND</option>
<option value="270" [-selected13103_r270-]="">PORTUGAL</option>
<option value="271" [-selected13103_r271-]="">QATAR</option>
<option value="272" [-selected13103_r272-]="">REUNION</option>
<option value="273" [-selected13103_r273-]="">ROMANIA</option>
<option value="274" [-selected13103_r274-]="">RUSSIA</option>
<option value="275" [-selected13103_r275-]="">RWANDA</option>
<option value="276" [-selected13103_r276-]="">SAN MARINO</option>
<option value="277" [-selected13103_r277-]="">SAO TOME E PRINCIPE</option>
<option value="279" [-selected13103_r279-]="">SAUDI ARABIA</option>
<option value="281" [-selected13103_r281-]="">SENEGAL</option>
<option value="282" [-selected13103_r282-]="">SERBIA</option>
<option value="283" [-selected13103_r283-]="">SEYCHELLES</option>
<option value="284" [-selected13103_r284-]="">SIERRA LEONE</option>
<option value="285" [-selected13103_r285-]="">SINGAPORE</option>
<option value="286" [-selected13103_r286-]="">SLOVAK REPUBLIC</option>
<option value="287" [-selected13103_r287-]="">SLOVENIA</option>
<option value="288" [-selected13103_r288-]="">SOLOMON ISLANDS</option>
<option value="289" [-selected13103_r289-]="">SOMALIA</option>
<option value="290" [-selected13103_r290-]="">SOUTH AFRICA</option>
<option value="291" [-selected13103_r291-]="">SOUTH KOREA</option>
<option value="292" [-selected13103_r292-]="">SPAIN</option>
<option value="293" [-selected13103_r293-]="">SRI LANKA</option>
<option value="294" [-selected13103_r294-]="">ST CROIX</option>
<option value="295" [-selected13103_r295-]="">ST KITTS</option>
<option value="296" [-selected13103_r296-]="">ST LUCIA</option>
<option value="298" [-selected13103_r298-]="">ST MARTIN</option>
<option value="299" [-selected13103_r299-]="">ST PIERRE</option>
<option value="300" [-selected13103_r300-]="">ST VINCENT</option>
<option value="301" [-selected13103_r301-]="">SUDAN</option>
<option value="302" [-selected13103_r302-]="">SURINAME</option>
<option value="303" [-selected13103_r303-]="">SWAZILAND</option>
<option value="304" [-selected13103_r304-]="">SWEDEN</option>
<option value="305" [-selected13103_r305-]="">SWITZERLAND</option>
<option value="306" [-selected13103_r306-]="">SYRIA</option>
<option value="308" [-selected13103_r308-]="">TAIWAN</option>
<option value="309" [-selected13103_r309-]="">TAJIKISTAN</option>
<option value="310" [-selected13103_r310-]="">TANZANIA</option>
<option value="312" [-selected13103_r312-]="">THAILAND</option>
<option value="314" [-selected13103_r314-]="">TOGO</option>
<option value="315" [-selected13103_r315-]="">TONGA</option>
<option value="316" [-selected13103_r316-]="">TRINIDAD AND TOBAGO</option>
<option value="317" [-selected13103_r317-]="">TUNISIA</option>
<option value="318" [-selected13103_r318-]="">TURKEY</option>
<option value="319" [-selected13103_r319-]="">TURKMENISTAN</option>
<option value="320" [-selected13103_r320-]="">TURKS ISLAND</option>
<option value="321" [-selected13103_r321-]="">TUVALU</option>
<option value="322" [-selected13103_r322-]="">UGANDA</option>
<option value="323" [-selected13103_r323-]="">UKRAINE</option>
<option value="324" [-selected13103_r324-]="">UNITED ARAB EMIRATES</option>
<option value="749" [-selected13103_r749-]="">UNITED KINGDOM</option>
<option value="325" [-selected13103_r325-]="">URUGUAY</option>
<option value="326" [-selected13103_r326-]="">UZBEKISTAN</option>
<option value="327" [-selected13103_r327-]="">VANUATU</option>
<option value="328" [-selected13103_r328-]="">VATICAN CITY</option>
<option value="329" [-selected13103_r329-]="">VENEZUELA</option>
<option value="330" [-selected13103_r330-]="">VIETNAM</option>
<option value="332" [-selected13103_r332-]="">WALLIS ISLAND</option>
<option value="333" [-selected13103_r333-]="">WESTERN SAHARA</option>
<option value="334" [-selected13103_r334-]="">WESTERN SAMOA</option>
<option value="335" [-selected13103_r335-]="">YEMEN</option>
<option value="336" [-selected13103_r336-]="">ZAIRE</option>
<option value="337" [-selected13103_r337-]="">ZAMBIA</option>
<option value="338" [-selected13103_r338-]="">ZIMBABWE</option>
</select></p>
</span>
<p id="p11" class="drg-element-type-standard-field drg-element-sub-type-fieldname-PHONE addresslabel"><span class="questionlabel "><label for="id11">Phone <font color="red">*</font></label> </span><input class="drg-field-address-normal"
name="demo13104" type="text" value="" id="id11" maxlength="32" size="32"></p>
<p id="p12" class="drg-element-type-standard-field drg-element-sub-type-fieldname-FAX addresslabel"><span class="questionlabel "><label for="id12">Fax</label> </span><input class="drg-field-address-normal" name="demo13105" type="text" value=""
id="id12" maxlength="32" size="32"></p>
</div>
<span id="content2" class="eight columns"></span><span id="content3" class="eight columns"></span>
<div id="content4" class="sixteen columns">
<p id="p124" class="drg-element-type-standard-field drg-element-sub-type-fieldname-PHONE_MOBILE addresslabel"><span class="questionlabel "><label for="id124">Cell Phone</label> </span><input class="drg-field-address-normal" name="demo13106"
type="text" value="" id="id124" maxlength="20" size="20"></p>
<hr><span class="spanc24 drg-element-type-standard-field drg-element-sub-type-fieldname-SIGNATURE">
<p id="p24" class="drg-element-type-standard-field drg-element-sub-type-fieldname-SIGNATURE"><span class="questionlabel ">Do you wish to receive/continue receiving DAIC/Diagnostic and Interventional Cardiology eMagazine? Note: Your email is
required to receive DAIC, now only available in digital format <font color="red">*</font> </span></p>
<ul>
<li class="licr24_343 lier13110_343 "><input name="demo13110" type="radio" value="343" id="id24_343" [-checked13110_r343-]=""><span class="radiolabel"><label for="id24_343">Yes</label></span></li>
<li class="licr24_344 lier13110_344 "><input name="demo13110" type="radio" value="344" id="id24_344" [-checked13110_r344-]=""><span class="radiolabel"><label for="id24_344">No</label></span></li>
</ul>
</span><input name="demo13111" type="hidden" value="999" id="demo13111">
<hr><span class="spanc6 drg-element-type-demographic drg-element-sub-type-type-1">
<p id="p6" class="drg-element-type-demographic drg-element-sub-type-type-1"><span class="questionlabel "><label for="id6">What is your Type of Facility? <font color="red">*</font></label> </span><select name="demo13113" id="id6">
<option value="">Select...</option>
<option value="53">Cardiac Catheterization Lab</option>
<option value="48">Clinic</option>
<option value="47">Group Practice</option>
<option value="50">Group Purchasing Organization</option>
<option value="57">Heart Center</option>
<option value="54">Hospital</option>
<option value="49">Hospital - Affiliate/Satellite</option>
<option value="46">Integrated Healthcare Delivery Network</option>
<option value="59">Medical/Health Center</option>
<option value="52">Other (please specifiy)</option>
</select></p>
</span>
<div id="other52" class="otherfillin" style="display: none;">
<p id="p52"><span id="otherfillinid_r52" class="otherfillinlabelomeda">Other (please specifiy)</span><input name="demo13113_r52" type="text" value="" id="id_r52" maxlength="50" size="50"></p>
</div>
<hr><span class="spanc4 drg-element-type-demographic drg-element-sub-type-type-1">
<p id="p4" class="drg-element-type-demographic drg-element-sub-type-type-1"><span class="questionlabel "><label for="id4">What is your Primary Responsibility? <font color="red">*</font></label> </span><select name="demo13115" id="id4">
<option value="">Select...</option>
<option value="25">PACS Administrator</option>
<option value="28">Cardiologist - Chief</option>
<option value="20">Cardiologist</option>
<option value="19">Cardiologist - Interventional</option>
<option value="18">Cardiology Administrator/Director</option>
<option value="17">Cardiology - Other (Please Specify)</option>
<option value="24">Electrophysiologist</option>
<option value="21">Cath Lab - Administrator</option>
<option value="23">Cath Lab - Chief/Director</option>
<option value="15">Cath Lab - Manager</option>
<option value="40">Cath Lab - Nurse</option>
<option value="16">Cath Lab - Supervisor</option>
<option value="22">Cath Lab - Technologist</option>
<option value="33">CEO/President</option>
<option value="31">Chief Financial Officer</option>
<option value="39">Chief Information Officer</option>
<option value="36">Chief Technical Officer</option>
<option value="32">Chief Operating Officer</option>
<option value="38">HIS/MIS Director/Manager</option>
<option value="30">Hospital Administrator</option>
<option value="37">Materials Management/Purchasing - Chief/Director</option>
<option value="35">Other, Medical (please specify)</option>
<option value="29">Other, Non-Medical (please specify)</option>
</select></p>
</span>
<div id="other17" class="otherfillin" style="display: none;">
<p id="p17"><span id="otherfillinid_r17" class="otherfillinlabelomeda">Cardiology - Other (Please Specify)</span><input name="demo13115_r17" type="text" value="" id="id_r17" maxlength="50" size="50"></p>
</div>
<div id="other35" class="otherfillin" style="display: none;">
<p id="p35"><span id="otherfillinid_r35" class="otherfillinlabelomeda">Other, Medical (please specify)</span><input name="demo13115_r35" type="text" value="" id="id_r35" maxlength="50" size="50"></p>
</div>
<div id="other29" class="otherfillin" style="display: none;">
<p id="p29"><span id="otherfillinid_r29" class="otherfillinlabelomeda">Other, Non-Medical (please specify)</span><input name="demo13115_r29" type="text" value="" id="id_r29" maxlength="50" size="50"></p>
</div>
<hr><span class="spanc20 drg-element-type-demographic drg-element-sub-type-type-2">
<p id="p20" class="drg-element-type-demographic drg-element-sub-type-type-2"><span class="questionlabel ">Do you have any responsibilities for these areas: (check all that apply) </span></p>
<ul>
<li class="licr20_258 lier13207_258 "><input name="demo13207" type="checkbox" value="258" id="id20_258"><span class="checkboxlabel"><label for="id20_258">Electrophysiology (EP)</label></span></li>
<li class="licr20_257 lier13207_257 "><input name="demo13207" type="checkbox" value="257" id="id20_257"><span class="checkboxlabel"><label for="id20_257">Interventional radiology (IR)</label></span></li>
<li class="licr20_255 lier13207_255 "><input name="demo13207" type="checkbox" value="255" id="id20_255"><span class="checkboxlabel"><label for="id20_255">Interventional neurology</label></span></li>
<li class="licr20_253 lier13207_253 "><input name="demo13207" type="checkbox" value="253" id="id20_253"><span class="checkboxlabel"><label for="id20_253">Vascular surgery</label></span></li>
<li class="licr20_260 lier13207_260 "><input name="demo13207" type="checkbox" value="260" id="id20_260"><span class="checkboxlabel"><label for="id20_260">Cardiovascular surgery</label></span></li>
<li class="licr20_259 lier13207_259 "><input name="demo13207" type="checkbox" value="259" id="id20_259"><span class="checkboxlabel"><label for="id20_259">Structural Heart</label></span></li>
</ul>
</span>
<hr><span class="spanc2 drg-element-type-demographic drg-element-sub-type-type-1">
<p id="p2" class="drg-element-type-demographic drg-element-sub-type-type-1"><span class="questionlabel "><label for="id2">Hospital Bed Size</label> </span><select name="demo13117" id="id2">
<option value="">Select...</option>
<option value="6">1000+</option>
<option value="4">500-999</option>
<option value="3">200-499</option>
<option value="2">100-199</option>
<option value="8">1-99</option>
<option value="7">0</option>
</select></p>
</span>
<hr><span class="spanc3 drg-element-type-demographic drg-element-sub-type-type-1">
<p id="p3" class="drg-element-type-demographic drg-element-sub-type-type-1"><span class="questionlabel "><label for="id3">Are you planning any construction in your department or facility?</label> </span><select name="demo13119" id="id3">
<option value="">Select...</option>
<option value="12">New Facility</option>
<option value="14">Expansion/Remodeling/Renovation</option>
<option value="13">None</option>
</select></p>
</span>
<hr>
<div id="disp13121" style=""><span class="spanc90 drg-element-type-cms-content drg-element-sub-type-category-1">
<p id="p90" class="drg-element-type-cms-content drg-element-sub-type-category-1"><span class="questionlabel ">Is there another individual at the location listed above you would like to send a complimentary subscription to? </span></p>
<ul>
<li class="licr90_25 lier13121_25 "><input name="demo13121" type="radio" value="25" id="id90_25"><span class="radiolabel"><label for="id90_25">Yes</label></span></li>
<li class="licr90_26 lier13121_26 "><input name="demo13121" type="radio" value="26" id="id90_26"><span class="radiolabel"><label for="id90_26">No</label></span></li>
</ul>
</span></div>
<div id="disp13122" style="display:none;">Please also send Diagnostics & Interventional Cardiology Magazine completely free to the following individuals employed at the location listed above:<br><br></div>
<ul class="groupul">
<li class="groupinline">
<div id="disp13123_1" style="display:none;">
<p id="p1" class="drg-element-type-standard-field drg-element-sub-type-fieldname-FIRSTNAME addresslabel"><span class="questionlabel "><label for="id1">First Name</label> </span><input class="drg-field-address-normal" name="demo13123_1"
type="text" value="" id="id1" maxlength="40" size="40"></p>
</div>
</li>
<li class="groupinline">
<div id="disp13124_1" style="display:none;">
<p id="p2" class="drg-element-type-standard-field drg-element-sub-type-fieldname-LASTNAME addresslabel"><span class="questionlabel "><label for="id2">Last Name</label> </span><input class="drg-field-address-normal" name="demo13124_1"
type="text" value="" id="id2" maxlength="40" size="40"></p>
</div>
</li>
<li class="groupinline">
<div id="disp13125_1" style="display:none;">
<p id="p10" class="drg-element-type-standard-field drg-element-sub-type-fieldname-TITLE addresslabel"><span class="questionlabel "><label for="id10">Title</label> </span><input class="drg-field-address-normal" name="demo13125_1"
type="text" value="" id="id10" maxlength="40" size="40"></p>
</div>
</li>
<li class="groupinline">
<div id="disp13126_1" style="display:none;"><span class="spanc4 drg-element-type-demographic drg-element-sub-type-type-1">
<p id="p4" class="drg-element-type-demographic drg-element-sub-type-type-1"><span class="questionlabel "><label for="id4">Primary Responsibility</label> </span><select name="demo13126_1" id="id4">
<option value="">Select...</option>
<option value="25_1" [-selected13126_r25_1-]="">PACS Administrator</option>
<option value="28_1" [-selected13126_r28_1-]="">Cardiologist - Chief</option>
<option value="20_1" [-selected13126_r20_1-]="">Cardiologist</option>
<option value="19_1" [-selected13126_r19_1-]="">Cardiologist - Interventional</option>
<option value="18_1" [-selected13126_r18_1-]="">Cardiology Administrator/Director</option>
<option value="17_1" [-selected13126_r17_1-]="">Cardiology - Other (Please Specify)</option>
<option value="24_1" [-selected13126_r24_1-]="">Electrophysiologist</option>
<option value="23_1" [-selected13126_r23_1-]="">Cath Lab - Chief/Director</option>
<option value="22_1" [-selected13126_r22_1-]="">Cath Lab - Technologist</option>
<option value="21_1" [-selected13126_r21_1-]="">Cath Lab - Administrator</option>
<option value="16_1" [-selected13126_r16_1-]="">Cath Lab - Supervisor</option>
<option value="15_1" [-selected13126_r15_1-]="">Cath Lab - Manager</option>
<option value="40_1" [-selected13126_r40_1-]="">Cath Lab - Nurse</option>
<option value="33_1" [-selected13126_r33_1-]="">CEO/President</option>
<option value="31_1" [-selected13126_r31_1-]="">Chief Financial Officer</option>
<option value="39_1" [-selected13126_r39_1-]="">Chief Information Officer</option>
<option value="36_1" [-selected13126_r36_1-]="">Chief Technical Officer</option>
<option value="32_1" [-selected13126_r32_1-]="">Chief Operating Officer</option>
<option value="38_1" [-selected13126_r38_1-]="">HIS/MIS Director/Manager</option>
<option value="30_1" [-selected13126_r30_1-]="">Hospital Administrator</option>
<option value="37_1" [-selected13126_r37_1-]="">Materials Management/Purchasing - Chief/Director</option>
<option value="35_1" [-selected13126_r35_1-]="">Other, Medical (please specify)</option>
<option value="29_1" [-selected13126_r29_1-]="">Other, Non-Medical (please specify)</option>
</select></p>
</span></div>
</li>
<li class="groupinline">
<div>
<div id="other17_1" class="otherfillin" style="display: none;">
<p id="p17_1"><span id="otherfillinid_r17_1" class="otherfillinlabelomeda">Cardiology - Other (Please Specify)</span><input name="demo13126_r17_1" type="text" value="" id="id_r17_1" maxlength="50" size="50"></p>
</div>
</div>
</li>
<li class="groupinline">
<div>
<div id="other35_1" class="otherfillin" style="display: none;">
<p id="p35_1"><span id="otherfillinid_r35_1" class="otherfillinlabelomeda">Other, Medical (please specify)</span><input name="demo13126_r35_1" type="text" value="" id="id_r35_1" maxlength="50" size="50"></p>
</div>
</div>
</li>
<li class="groupinline">
<div>
<div id="other29_1" class="otherfillin" style="display: none;">
<p id="p29_1"><span id="otherfillinid_r29_1" class="otherfillinlabelomeda">Other, Non-Medical (please specify)</span><input name="demo13126_r29_1" type="text" value="" id="id_r29_1" maxlength="50" size="50"></p>
</div>
</div>
</li>
<li>
<div id="disp13127_1" style="display:none;"><input name="demo13127_1" type="hidden" value="" id="demo13127_1"></div>
</li>
</ul>
<div id="disp13128" style="">
<hr>
</div>
<p><strong>Subscribe to Diagnostic & Interventional Cardiology newsletters:</strong></p>
<div id="pp26" class="drg-element-type-product drg-element-sub-type-type-2 opt"><input name="opt13130" type="checkbox" value="1" id="optp26" [-checkedopt13130-]=""><span class="questionlabel optlabel"><label for="optp26"><strong>DAIC Top
5</strong> (weekly)<br>Top cardiology headlines, plus videos, podcasts, webinars, comparison charts, trade show coverage and more!</label> </span>
<div id="longp26" class="longdescopt" style="display:none"></div>
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