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https://formstack.io/ffbDz1IbTzzNdbhm86CBmjre92euLYKuicfh9qYvfX2vXC4r5yUOe17crnGVS-FORrOxUdJ33mzztP9Lyv7DWg
Submission: On October 27 via manual from US — Scanned from DE
Submission: On October 27 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST https://sfapi.formstack.io/FormEngine/EngineFrame/UploadFile
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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."
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value="{"ResultText":"[{\"objectName\":\"Lead\",\"objectFieldRootIdentifier\":\"Lead.\",\"jsonListResults\":\"[{\\\"attributes\\\":{\\\"type\\\":\\\"Lead\\\",\\\"url\\\":\\\"/services/data/v56.0/sobjects/Lead/B8mOKIVoVty7JOwim7d2rlUeQSuWedrzYQz2zYwfCNQ\\\"},\\\"Manager_Name__c\\\":\\\"-\\\",\\\"Company\\\":\\\"SURGE STAFFING\\\",\\\"Citi_Form_Question_2__c\\\":\\\"Yes\\\",\\\"Email\\\":\\\"ldarks@surgeforcegroup.com\\\",\\\"Payment_Remittance_Email__c\\\":\\\"adriscall@surgestaffing.com\\\",\\\"PostalCode\\\":\\\"43229\\\",\\\"Legal_Entity__c\\\":\\\"LLC\\\",\\\"Business_Description__c\\\":\\\"-\\\",\\\"Original_Address__c\\\":\\\"1110 MORSE RD\\\",\\\"Original_Postal_Code__c\\\":\\\"43229\\\",\\\"Street\\\":\\\"1110 MORSE RD\\\",\\\"Original_City__c\\\":\\\"COLUMBUS\\\",\\\"Original_State__c\\\":\\\"OH\\\",\\\"Citi_Form_Question_3__c\\\":\\\"Yes\\\",\\\"ABA_Routing_Number__c\\\":\\\"-\\\",\\\"FirstName\\\":null,\\\"Tax_ID__c\\\":null,\\\"Title\\\":null,\\\"City\\\":\\\"COLUMBUS\\\",\\\"ABA_Account_Number__c\\\":\\\"-\\\",\\\"MID_Closed_Date__c\\\":null,\\\"Blank_Column_01__c\\\":\\\"-\\\",\\\"State\\\":\\\"OH\\\",\\\"Universal_Acceptor__c\\\":\\\"No\\\",\\\"Id\\\":\\\"B8mOKIVoVty7JOwim7d2rlUeQSuWedrzYQz2zYwfCNQ\\\",\\\"LastName\\\":\\\"Valued Supplier\\\",\\\"Citi_Form_Question_1__c\\\":\\\"Yes\\\"}]\"}]","ResultSObject":null,"OtherText":"{\"primary\":\"Lead\"}","IsValid":true}"><input
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function evaluateRules(lstRules, source) {
if (arguments.length > 0) {
for (var i = 0; i < lstRules.length; i++) {
switch (lstRules[i]) {
case 1:
if ((FFEqualTo('Lead.Citi_Form_Question_2__c', 'I will process the payment (SIP).', false, source)) || (FFEqualTo('Lead.Citi_Form_Question_2__c', 'I would like Priority to process my payments (BIP).', false, source))) {
FFShowPage('ffPage11738', source);
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<div>
<style>
.ff-form {
background-color: #1c2729;
background-attachment: fixed;
background-repeat: no-repeat;
background-repeat: repeat;
}
#dvFastForms .ff-page-header {
font-family: Arial;
font-weight: bold;
color: #564d4d;
font-size: 19px;
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#dvFastForms .ff-page-header-row {
border-style: solid;
border-radius: 5px;
border-color: #dfdbdb;
border-width: 0px;
padding: 10px;
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.ff-logo {
background-color: #ffffff;
background-image: url(https://epayables--visualantidote.visualforce.com/servlet/servlet.ImageServer?id=0152I000009XkXzQAK&oid=00DA0000000JA2rMAG);
width: 127px;
height: 150px;
margin: auto;
padding: 20px;
}
.ff-header {
background-color: #ffffff;
background-image: url(https://na10.salesforce.com/servlet/servlet.ImageServer?id=015F00000067Fi1IAE&oid=00DA0000000JA2rMAG);
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background-repeat: no-repeat;
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.ff-form-main {
background-color: #fcfcfc;
margin: auto;
max-width: 1000px;
border-style: none;
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border-color: #f5f2f5;
border-width: 0px;
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#dvFastForms .ff-group-row {
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border-radius: 5px;
border-color: #000509;
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margin: 0px;
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#dvFastForms .ff-section-header {
font-family: Arial, Tahoma;
color: #030303;
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#dvFastForms .ff-footer-group {
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background-attachment: fixed;
background-repeat: no-repeat;
background-repeat: repeat;
padding: 56px;
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#dvFastForms .ff-col-2.ff-field-col {
clear: none;
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#dvFastForms .ff-label,
#dvFastForms .ff-footnote-label {
font-family: Tahoma;
font-weight: bold;
font-size: 14px;
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#dvFastForms .ff-label {
color: #0a0a0a;
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#dvFastForms .ff-label-col {
text-align: left;
padding: 10px;
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#dvFastForms .ff-field-col {
font-family: Tahoma;
font-weight: bold;
font-size: 14px;
text-align: left;
padding: 5px;
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#dvFastForms .ff-field-col,
#dvFastForms .ff-rating-widget a {
color: #000000;
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#dvFastForms .ff-type-text,
#dvFastForms .ff-textarea,
#dvFastForms select.ff-select-type,
#dvFastForms .ff-fileupload-drop-area,
#dvFastForms .select2-container {
background-color: #c9c3c3;
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#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;
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#dvFastForms .ff-textarea {
height: 25px;
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#dvFastForms .ff-item-row .ff-type-text:not(.ff-creditcard),
#dvFastForms .ff-textarea,
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width: 358px;
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#dvFastForms div.ff-select-to-radiobtn-list {
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#dvFastForms .ff-invalid-msg {
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font-weight: bold;
color: #aea9a9;
font-size: 10px;
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#dvFastForms .ff-required-mark {
font-family: Tahoma;
font-weight: bold;
color: #ff0000;
font-size: 14px;
}
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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;
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<div class="ff-form-main">
<div class="ff-page-bread-header">
<div class="ff-page-bread-prev ff-page-bread-item" style="visibility: hidden;"><</div>
<div class="ff-page-bread-wrapper" style="width: 936.75px;">
<div class="ff-page-bread" style="width: 979.843px;">
<div data-pageid="ffPage11737" class="ff-page-bread-item item-selected" data-pagenumber="0">1. D&H Distributing Enrollment Form</div>
<div data-pageid="ffPage11738" class="ff-page-bread-item" data-pagenumber="1">2. Enrollment Form</div>
<div data-pageid="ffPage11739" class="ff-page-bread-item" data-pagenumber="2">3. Quick Start Application</div>
<div data-pageid="ffPage11740" class="ff-page-bread-item" data-pagenumber="3">4. Thank you for your submission!</div>
</div>
</div>
<div class="ff-page-bread-next ff-page-bread-item" style="visibility: visible;">></div>
</div>
<div id="ffOverlay"></div>
<div id="ffPage11737" class="ff-page-row page-1" data-pagetitle="D&amp;H Distributing Enrollment Form" data-page-ishidden="false">
<div class="ff-page-header-row">
<div class="ff-item-row">
<div class="ff-col-1 ff-page-col"><label class="ff-page-header">D&H Distributing Enrollment Form</label></div>
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</div>
<div class="ff-group-row group-0" id="ffSection1">
<div class="ff-item-row">
<div class="ff-col-1 ff-section-col"><label class="ff-section-header" id="sectionLabel1"></label></div>
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<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">How would you like your virtual card processed?</label><span
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aria-labelledby="select2-chosen-1" id="s2id_autogen1">
<div class="select2-drop select2-display-none select2-with-searchbox">
<div class="select2-search"> <label for="s2id_autogen1_search" class="select2-offscreen">How would you like your virtual card processed?</label> <input type="text" autocomplete="off" autocorrect="off" autocapitalize="off"
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<ul class="select2-results" role="listbox" id="select2-results-1"> </ul>
</div>
</div><select name="Lead.Citi_Form_Question_2__c" id="Lead.Citi_Form_Question_2__c" vatt="PICKLIST" class="ff-select-type ff-singlepicklist select2-offscreen" data-flexcontrol="picklist-combobox" data-requiredmessage="required"
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title="How would you like your virtual card processed?">
<option value="" selected="selected">--select an item--</option>
<option value="I will process the payment (SIP).">I will process the payment (SIP).</option>
<option value="I would like Priority to process my payments (BIP).">I would like Priority to process my payments (BIP).</option>
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</div>
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<div id="ffPage11738" class="ff-page-row page-2" data-pagetitle="Enrollment Form" data-page-ishidden="false" style="display: none;">
<div class="ff-page-header-row">
<div class="ff-item-row">
<div class="ff-col-1 ff-page-col"><label class="ff-page-header">Enrollment Form</label></div>
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</div>
<div class="ff-group-row group-0" id="ffSection2">
<div class="ff-item-row">
<div class="ff-col-1 ff-section-col"><label class="ff-section-header" id="sectionLabel2"></label></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="" aria-placeholder="" name="Lead.Company" vatt="STRING" class="ff-input-type ff-type-text" data-maxlengthmessage="Maximum 255 characters"
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</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="" aria-placeholder="" name="Lead.FirstName" vatt="STRING" class="ff-input-type ff-type-text" data-maxlengthmessage="Maximum 40 characters"
maxlength="40" data-validatefieldtype="" value="" data-requiredmessage="required" data-isrequired="true" aria-required="true" data-isupsert="false" 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="" aria-placeholder="" name="Lead.LastName" 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" aria-required="true" data-isupsert="false" 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="" aria-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" aria-required="true" data-isupsert="false" 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="" aria-placeholder="" name="Lead.Email" 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" aria-required="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="TEXTAREA" for="Lead.Street" class="ff-label" id="lblLeadStreet">Street (Physical Address Preferred)</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><textarea id="Lead.Street" placeholder="" aria-placeholder="" name="Lead.Street" vatt="TEXTAREA" class="ff-textarea" data-maxlengthmessage="Maximum 255 characters" maxlength="255"
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</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>
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data-validatefieldtype="" value="" data-requiredmessage="required" data-isrequired="true" aria-required="true" data-isupsert="false" 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.State" class="ff-label" id="lblLeadState">State/Province (Abbreviation)</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.State" placeholder="" aria-placeholder="" name="Lead.State" 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" aria-required="true" data-isupsert="false" 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.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="" aria-placeholder="" name="Lead.PostalCode" 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" aria-required="true" data-isupsert="false" 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.Payment_Remittance_Email__c" class="ff-label" id="lblLeadPayment_Remittance_Email__c">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.Payment_Remittance_Email__c" placeholder="" aria-placeholder="" name="Lead.Payment_Remittance_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" aria-required="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></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.Tax_ID__c" placeholder="" aria-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-isupsert="false" 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.Universal_Acceptor__c" class="ff-label" id="lblLeadUniversal_Acceptor__c">Our company accepts virtual card payments from all buyers, There are no fees or stipulations
to this acceptance. </label></div>
<div class="ff-col-2 ff-field-col"><select name="Lead.Universal_Acceptor__c" id="Lead.Universal_Acceptor__c" vatt="PICKLIST" class="ff-select-type ff-singlepicklist" data-flexcontrol="" data-requiredmessage="required"
data-isupsert="false" data-ishidden="false" data-vatt="PICKLIST">
<option value="" selected="selected">--select an item--</option>
<option value="No">No </option>
<option value="Yes">Yes </option>
</select></div>
</div>
</div>
</div>
<div id="ffPage11739" class="ff-page-row page-3" data-pagetitle="Quick Start Application" data-page-ishidden="false" style="display: none;">
<div class="ff-page-header-row">
<div class="ff-item-row">
<div class="ff-col-1 ff-page-col"><label class="ff-page-header">Quick Start Application</label></div>
</div>
</div>
<div class="ff-group-row group-0" id="ffSection3">
<div class="ff-item-row">
<div class="ff-col-1 ff-section-col"><label class="ff-section-header" id="sectionLabel3">Add'l Data Requirements for Priority Processing Option</label></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="PICKLIST" for="Lead.Legal_Entity__c" class="ff-label" id="lblLeadLegal_Entity__c">Legal Entity</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><select name="Lead.Legal_Entity__c" id="Lead.Legal_Entity__c" vatt="PICKLIST" class="ff-select-type ff-singlepicklist" data-flexcontrol="" data-requiredmessage="required" data-isrequired="true"
aria-required="true" data-isupsert="false" data-ishidden="false" data-vatt="PICKLIST">
<option value="">--select an item--</option>
<option value="501C-3">501C-3 </option>
<option value="C Corporation">C Corporation </option>
<option value="LLC" selected="selected">LLC </option>
<option value="Partnership">Partnership </option>
<option value="S Corporation">S Corporation </option>
<option value="Sole Proprietor">Sole Proprietor </option>
</select></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="STRING" for="Lead.Business_Description__c" class="ff-label" id="lblLeadBusiness_Description__c">Business Description</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.Business_Description__c" placeholder="" aria-placeholder="" name="Lead.Business_Description__c" vatt="STRING" class="ff-input-type ff-type-text"
data-maxlengthmessage="Maximum 100 characters" maxlength="100" data-validatefieldtype="" value="" data-requiredmessage="required" data-isrequired="true" aria-required="true" data-isupsert="false" 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_Name__c" class="ff-label" id="lblLeadManager_Name__c">Owner 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="" aria-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" aria-required="true" data-isupsert="false" data-ishidden="false"
data-vatt="STRING"></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="TEXTAREA" for="Lead.Original_Address__c" class="ff-label" id="lblLeadOriginal_Address__c">Owner Home Address</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><textarea id="Lead.Original_Address__c" placeholder="" aria-placeholder="" name="Lead.Original_Address__c" vatt="TEXTAREA" class="ff-textarea" data-maxlengthmessage="Maximum 255 characters"
maxlength="255" data-ishtmlformatted="false" value="" data-requiredmessage="required" data-isrequired="true" aria-required="true" data-isupsert="false" data-ishidden="false" data-vatt="TEXTAREA"></textarea></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="TEXTAREA" for="Lead.Original_City__c" class="ff-label" id="lblLeadOriginal_City__c">Owner City</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><textarea id="Lead.Original_City__c" placeholder="" aria-placeholder="" name="Lead.Original_City__c" vatt="TEXTAREA" class="ff-textarea" data-maxlengthmessage="Maximum 255 characters" maxlength="255"
data-ishtmlformatted="false" value="" data-requiredmessage="required" data-isrequired="true" aria-required="true" data-isupsert="false" data-ishidden="false" data-vatt="TEXTAREA"></textarea></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="TEXTAREA" for="Lead.Original_State__c" class="ff-label" id="lblLeadOriginal_State__c">Owner State</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><textarea id="Lead.Original_State__c" placeholder="" aria-placeholder="" name="Lead.Original_State__c" vatt="TEXTAREA" class="ff-textarea" data-maxlengthmessage="Maximum 255 characters" maxlength="255"
data-ishtmlformatted="false" value="" data-requiredmessage="required" data-isrequired="true" aria-required="true" data-isupsert="false" data-ishidden="false" data-vatt="TEXTAREA"></textarea></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="TEXTAREA" for="Lead.Original_Postal_Code__c" class="ff-label" id="lblLeadOriginal_Postal_Code__c">Owner Zip Code</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><textarea id="Lead.Original_Postal_Code__c" placeholder="" aria-placeholder="" name="Lead.Original_Postal_Code__c" vatt="TEXTAREA" class="ff-textarea" data-maxlengthmessage="Maximum 255 characters"
maxlength="255" data-ishtmlformatted="false" value="" data-requiredmessage="required" data-isrequired="true" aria-required="true" data-isupsert="false" data-ishidden="false" data-vatt="TEXTAREA"></textarea></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="STRING" for="Lead.Blank_Column_01__c" class="ff-label" id="lblLeadBlank_Column_01__c">Owner/Officer SSN </label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.Blank_Column_01__c" placeholder="000-00-0000" aria-placeholder="000-00-0000" name="Lead.Blank_Column_01__c" vatt="STRING" class="ff-input-type ff-type-text"
data-maxlengthmessage="Maximum 30 characters" maxlength="30" data-validatefieldtype="" value="000-00-0000" data-requiredmessage="required" data-isrequired="true" aria-required="true" data-isupsert="false" data-ishidden="false"
data-vatt="STRING"></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="DATE" for="Lead.MID_Closed_Date__c" class="ff-label" id="lblLeadMID_Closed_Date__c">Date of Birth</label></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.MID_Closed_Date__c" placeholder="" aria-placeholder="" name="Lead.MID_Closed_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="false" data-ishidden="false" data-vatt="DATE"></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="STRING" for="Lead.ABA_Routing_Number__c" class="ff-label" id="lblLeadABA_Routing_Number__c">ABA Routing Number</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.ABA_Routing_Number__c" placeholder="" aria-placeholder="" name="Lead.ABA_Routing_Number__c" vatt="STRING" class="ff-input-type ff-type-text"
data-maxlengthmessage="Maximum 9 characters" maxlength="9" data-validatefieldtype="" value="" data-requiredmessage="required" data-isrequired="true" aria-required="true" data-isupsert="false" 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.ABA_Account_Number__c" class="ff-label" id="lblLeadABA_Account_Number__c">ABA Account Number</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.ABA_Account_Number__c" placeholder="" aria-placeholder="" name="Lead.ABA_Account_Number__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" aria-required="true" data-isupsert="false" data-ishidden="false"
data-vatt="STRING"></div>
</div>
<div class="ff-item-row fw-row">
<div class="ff-col-1 ff-label-col"><label id="GENERALTEXT151" class="ff-label ff-general-text-label" vatt="STRING" data-ishidden="false">*NOTE: The fees below are not in addition to your current merchant processing fees.</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">I accept the following pricing from Priority Payment Systems: 1.80- 2.58%. Fees will be
taken at the time payments are processed.</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>
</ul>
</div><select name="Lead.Citi_Form_Question_1__c" id="Lead.Citi_Form_Question_1__c" vatt="PICKLIST" class="ff-select-type ff-singlepicklist custom-select-offscreen" data-flexcontrol="picklist-radiobutton-vertical"
data-requiredmessage="required" data-isrequired="true" aria-required="true" data-isupsert="false" data-ishidden="false" data-vatt="PICKLIST">
<option value="">--select an item--</option>
<option value="Yes" selected="selected">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">I accept the Merchant Services Program Guide</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 ff-ext-selected" role="radio" aria-checked="true" 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="true"></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" aria-required="true" data-isupsert="false" data-ishidden="false" data-vatt="PICKLIST">
<option value="">--select an item--</option>
<option value="Yes" selected="selected">Yes </option>
<option value="No">No </option>
</select>
</div>
</div>
</div>
<div class="ff-group-row group-1" id="ffSection4">
<div class="ff-item-row">
<div class="ff-col-1 ff-section-col"><label class="ff-section-header" id="sectionLabel4"></label></div>
</div>
<div class="ff-esignature-wrapper ff-item-row"><input id="inputESIGNATURE213" type="hidden" lblname="Signature" class="ffd-esignature-input" data-signtype="full" data-signoptions="typed" data-signlabel="Full Name" data-signdate="Date"
data-signdatehide="false" data-signagree="I agree to terms and services" data-signagreehide="true" data-emailenabled="false" data-emaillabel="Email">
<div class="main-docsign-wrapper ffs-typed ffs-full" id="elemESIGNATURE213">
<div class="ff-sign-div">
<div class="ffclearButton ff-label" style="visibility:hidden">
<a class="ff-alink">clear</a>
</div>
<ul class="ff-sign-ul">
<li class="fftypeIt">
<a class="ff-label current" data-signed="typed">Typed</a>
</li>
<li class="ffdrawIt">
<a class="ff-label" data-signed="drawn">Drawn</a>
</li>
</ul>
</div>
<div class="ff-signwrapper-outer">
<div class="ff-chkagree ff-col-1" style="display: none;">
<input data-isrequired="false" type="checkbox" id="chkffsignagree213" name="chkffsignagree213" value="on">
<label class="ff-label" for="chkffsignagree213">I agree to terms and services</label>
</div>
<div class="ff-email-verification ff-sign-block" style="display: none;">
<div class="ff-label-col ffsign-label ff-col-1">
<label class="ff-label" for="ffsignEmail213">Email</label>
</div>
<div class="ff-col-2 ff-field-col">
<input class="ff-input-type ff-type-text" data-isrequired="false" type="textbox" id="ffsignEmail213" name="ffsignEmail213">
</div>
</div>
<div class="ff-signwrapper ff-typed">
<div class="doc-sign-name ff-sign-block">
<div class="ff-label-col ffsign-label ff-col-1">
<label class="ff-label" for="signTffsignature213">Full Name</label>
<span class="ff-required-mark ffs-req">*</span>
</div>
<div class="docsignWrapper ff-col-2 ff-field-col">
<input class="ffsignature ff-input-type ff-type-text" type="text" id="signTffsignature213" name="signTffsignature213" data-isrequired="true" aria-required="true">
<div class="typedSignName" style="font-size: 20px;"></div>
<canvas class="signPadName" height="55" width="232"></canvas>
<input class="outputSignedName" type="hidden" id="signTffSignedName213" name="signTffSignedName213" data-isrequired="true" aria-required="true" value="">
</div>
</div>
<div class="doc-sign-date ff-sign-block">
<div class="ff-label-col ffsign-label ff-col-1">
<label class="ff-label" for="signTffdate213">Date</label>
<span class="ff-required-mark ffs-req">*</span>
</div>
<div class="docsignWrapper ff-col-2 ff-field-col">
<input class="ffdate ff-input-type ff-type-text hasDate hasDatepicker" type="textbox" vatt="DATE" id="signTffdate213" name="signTffdate213" data-vatt="DATE" data-isrequired="true" aria-required="true">
<div class="typedSignDate" style="font-size: 20px;"></div>
<canvas class="signPadDate" height="55" width="232"></canvas>
<input class="outputSignedDate" id="signTffSignedDate213" type="hidden" name="signTffSignedDate213" value="" data-isrequired="true" aria-required="true">
</div>
</div>
</div>
<div class="ff-signwrapper ff-drawn display-none">
<div class="doc-sign-name ff-sign-block">
<div class="ff-label-col ffsign-label ff-col-1">
<label class="ff-label">Full Name</label>
<span class="ff-required-mark ffs-req">*</span>
</div>
<div class="docsignWrapper ff-col-2 ff-field-col">
<canvas class="signPadName" height="55" width="232"></canvas>
<input class="outputSignedName" type="hidden" id="signDffSignedName213" name="signDffSignedName213" data-isrequired="true" aria-required="true" value="">
</div>
</div>
<div class="doc-sign-date ff-sign-block">
<div class="ff-label-col ffsign-label ff-col-1">
<label class="ff-label">Date</label>
<span class="ff-required-mark ffs-req">*</span>
</div>
<div class="docsignWrapper ff-col-2 ff-field-col">
<canvas class="signPadDate" height="55" width="232"></canvas>
<input class="outputSignedDate" type="hidden" id="signDffSignedDate213" name="signDffSignedDate213" value="" data-isrequired="true" aria-required="true">
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div id="ffPage11740" class="ff-page-row page-4" data-pagetitle="Thank you for your submission!" data-page-ishidden="false" style="display: none;">
<div class="ff-page-header-row">
<div class="ff-item-row">
<div class="ff-col-1 ff-page-col"><label class="ff-page-header">Thank you for your submission!</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" data-btnmessage="Thank you for your submission!" data-btnurl="" style="display: none;"><input type="button"
class="sectionHeader ff-btn-submit ff-btn-prev" id="btnprev" value="Back" style="display: none;"><input type="button" class="sectionHeader ff-btn-submit ff-btn-next" id="btnnext" value="Next" style=""></div>
</div>
</div>
</div>
</div>
</div>
</div>
<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
< 1. D&H Distributing Enrollment Form 2. Enrollment Form 3. Quick Start Application 4. Thank you for your submission! > D&H Distributing Enrollment Form How would you like your virtual card processed?* How would you like your virtual card processed? How would you like your virtual card processed? --select an item--I will process the payment (SIP).I would like Priority to process my payments (BIP). Enrollment Form Company* First Name* Last Name* Title* Email* Street (Physical Address Preferred)* City* State/Province (Abbreviation)* Postal Code* Payment Remittance Email* Tax ID Our company accepts virtual card payments from all buyers, There are no fees or stipulations to this acceptance. --select an item--No Yes Quick Start Application Add'l Data Requirements for Priority Processing Option Legal Entity* --select an item--501C-3 C Corporation LLC Partnership S Corporation Sole Proprietor Business Description* Owner Name* Owner Home Address* Owner City* Owner State* Owner Zip Code* Owner/Officer SSN * Date of Birth ABA Routing Number* ABA Account Number* *NOTE: The fees below are not in addition to your current merchant processing fees. I accept the following pricing from Priority Payment Systems: 1.80- 2.58%. Fees will be taken at the time payments are processed.* * Yes * No --select an item--Yes No I accept the Merchant Services Program Guide* * Yes * No --select an item--Yes No clear * Typed * Drawn I agree to terms and services Email Full Name * Date * Full Name * Date * Thank you for your submission! *- required