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Submitted URL: http://forms.zohopublic.com/accrediteddrugtesting/form/NewAccountSetUpSecureScreenings/formperma/Bntgfs1mf5YFORd7T1Jq-9tvZvi...
Effective URL: https://forms.zohopublic.com/accrediteddrugtesting/form/NewAccountSetUpSecureScreenings/formperma/Bntgfs1mf5YFORd7T1Jq-9tvZvi...
Submission: On July 13 via manual from US — Scanned from DE
Effective URL: https://forms.zohopublic.com/accrediteddrugtesting/form/NewAccountSetUpSecureScreenings/formperma/Bntgfs1mf5YFORd7T1Jq-9tvZvi...
Submission: On July 13 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
Name: test —
<form name="test" id="test"><input type="hidden" name="formName" value="NewAccountSetUpSecureScreenings" id="formName"><input type="hidden" name="verifyPerma" value="" id="verifyPerma"><!-- Form Perma will be sent only for PermaUrls -->
<input type="hidden" name="formPerma" value="Bntgfs1mf5YFORd7T1Jq-9tvZviXEnjqnrzH6Vtue7A" id="formPerma"><input type="hidden" name="referrerName" id="referrerName" value="null"><input type="hidden" name="isPaymentForm" value="false"
id="isPaymentForm"><input type="hidden" name="formType" value="0" id="formType">
<input type="hidden" id="zf_date_format" datelocale="en-GB" name="date_format" value="MM/dd/yyyy"><input type="hidden" name="isDocsPublicForm" value="false" id="isDocsPublicForm">
<input type="hidden" name="formrid" value="" id="formrid">
<input type="hidden" name="resizeform" value="0" id="resizeform">
<div id="zf_utmTrack" style="display: none;"></div>
<div class="templateWrapper" id="formRedirectURL" style="min-height:1070px;">
<ul class="tempHeadBdr formRelative">
<li class="tempHeadContBdr"><span id="logo-formheader" class="formLogo" style="display: none"><img id="logo-formheader-img" src=""></span>
<h2 class="frmTitle"><em>New Account Set Up-Secure Screenings</em></h2>
<p class="frmDesc"></p>
<div class="clearBoth"></div>
</li>
</ul>
<!-- 'FieldElement' class is imported in order to get the key for display name of the component of 'Address' field.
'FormField' class is used to get field type of Zoho CRM field.-->
<div id="formBodyDiv" class="formRelative subContWrap topAlign"><!-- <button elname="openPopUpSubForm" onclick="openPopUp();event.preventDefault()"> Open subform pop up </button> -->
<div class="pBarWrapper bar">
<table id="navigBar" width="100%" border="0" cellspacing="0" cellpadding="0" pagecount="3" navigtype="2" currentpage="1">
<tbody>
<tr class="pBarHeader">
<td onclick="goTo(1);" class="selected currentPTab">
<div class="pBar"></div><em class="pArrow"></em>
</td>
<td onclick="goTo(2);" class="unselected">
<div class="pBar"></div><em class="pArrow"></em>
</td>
<td onclick="goTo(3);" class="unselected">
<div class="pBar"></div><em class="pArrow"></em>
</td>
</tr>
</tbody>
</table>
</div>
<!-- formFieldWrapper class is used to differantiate form fields and subform fields in themes. Direct children (li) are considered as form fields. Dont change the order of class used. -->
<ul elname="formBodyULName" class="ulNoStyle formFieldWrapper" page_no="1" needpagedata="true">
<!-- i) Private form, ii) Perma, iii) Shared form, iv) Theme preview, v) Current Theme -->
<!-- "isVisible"="false": This 'Admin Only' field must not be shown to user. -->
<!-- "isVisible"="true": Case 1: This is not an 'Admin Only' field. Case 2: This 'Admin Only' field must be shown to user. -->
<!-- Theme Preview, Current Theme - Admin Only fields will be shown. Formula won't be calculated. Field Rules won't be executed. -->
<!-- formMetaData.key=Field link name -->
<!-- Zoho CRM field : "FIELD_LIST" key won't be present. -->
<li elname="livefield-elem" comptype="1" id="SingleLine-li" needdata="true" compname="SingleLine" linkname="SingleLine" isvisible="true" class="tempFrmWrapper small" mandatory="true" page_no="1" page_link_name="Page" showlabel="true">
<label class="labelName">
<span>Company Name</span>
<em class="important">*</em>
</label>
<div class="tempContDiv">
<span><input onkeyup="ZFLive.configureInputMask(this);" onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="off" type="text" maxlength="255" name="SingleLine" value="" placeholder=""></span>
<p class="errorMessage" elname="error" id="error-SingleLine"></p>
</div>
<div class="clearBoth"></div>
</li>
<li class="tempFrmWrapper small" elname="livefield-elem" comptype="3" id="Number-li" needdata="true" compname="Number" linkname="Number" isvisible="true" mandatory="true" unit_position="2" page_no="1" page_link_name="Page" summary_type="0"
showlabel="true">
<label class="labelName">
<span>Contact Phone</span>
<em class="important">*</em>
</label>
<div elname="tempContDiv" class="tempContDiv">
<span><input onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="off" type="text" maxlength="18" name="Number" value="" placeholder=""> </span>
<span class="symbol" name="field_unit_after" elname="field_unit_span"></span>
<p class="errorMessage" elname="error" id="error-Number"></p>
</div>
<div class="clearBoth"></div>
</li>
<li class="tempFrmWrapper small" elname="livefield-elem" comptype="3" id="Number1-li" needdata="true" compname="Number1" linkname="Number1" isvisible="true" mandatory="true" unit_position="2" page_no="1" page_link_name="Page" summary_type="0"
showlabel="true">
<label class="labelName">
<span>Number of Employees</span>
<em class="important">*</em>
</label>
<div elname="tempContDiv" class="tempContDiv">
<span><input onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="off" type="text" maxlength="18" name="Number1" value="" placeholder=""> </span>
<span class="symbol" name="field_unit_after" elname="field_unit_span"></span>
<p class="errorMessage" elname="error" id="error-Number1"></p>
</div>
<div class="clearBoth"></div>
</li>
<li class="tempFrmWrapper name namemedium zfSelect2CustomCont" elname="livefield-elem" comptype="7" needdata="true" id="Name-li" compname="Name" linkname="Name" isvisible="true" mandatory="true" page_no="1" page_link_name="Page"
regex_type="0" showlabel="true">
<label class="labelName">
<span>Contact Person/Designated Employer Representative</span>
<em class="important">*</em>
</label>
<div class="tempContDiv twoType">
<div class="nameWrapper">
<span> <input onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="auto-off" type="text" maxlength="255" elname="First" name="Name" complink="Name_First" value="" mandatory="true" placeholder="">
<label class="formSubInfoText">First</label>
</span>
<span> <input onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="auto-off" type="text" maxlength="255" elname="Last" name="Name" complink="Name_Last" value="" mandatory="true" placeholder="">
<label class="formSubInfoText">Last</label>
</span>
<div class="clearBoth"></div>
</div>
<p class="errorMessage" elname="error" id="error-Name"></p>
</div>
<div class="clearBoth"></div>
</li>
<li class="tempFrmWrapper small" elname="livefield-elem" comptype="10" id="Website-li" needdata="true" compname="Website" linkname="Website" isvisible="true" mandatory="false" page_no="1" page_link_name="Page" showlabel="true">
<label class="labelName">
<span>Website</span>
</label>
<div class="tempContDiv">
<span> <input autocomplete="off" onfocusout="ZFLive.validateFieldConstraint(this);" type="text" maxlength="2083" name="Website" value="" placeholder=""></span>
<p class="errorMessage" elname="error" id="error-Website"></p>
</div>
<div class="clearBoth"></div>
</li>
<li class="tempFrmWrapper dropdown small zfSelect2CustomCont" elname="livefield-elem" comptype="12" id="Dropdown-li" needdata="true" compname="Dropdown" linkname="Dropdown" isvisible="true" mandatory="true" page_no="1" page_link_name="Page"
showlabel="true">
<label class="labelName">
<span>Industry</span>
<em class="important">*</em>
</label>
<div class="tempContDiv">
<div class="form_selectBox">
<div class="selectArrow"></div><select name="Dropdown" onchange="ZFLive.prefillFieldLabel(this); ZFLive.hideClosestFieldElemErrorDiv(this); ZFLive.checkUniqueChoiceFld(this);
" tabindex="-1" class="select2-hidden-accessible" aria-hidden="true">
<option selected="true" value="-Select-">-Select-</option>
<option value="Please Choose|" formula_val="">Please Choose|</option>
<option value="Automotive" formula_val="">Automotive</option>
<option value="Attorney / Legal" formula_val="">Attorney / Legal</option>
<option value="Bar / Restaurant" formula_val="">Bar / Restaurant</option>
<option value="Construction" formula_val="">Construction</option>
<option value="Energy / Power Plant" formula_val="">Energy / Power Plant</option>
<option value="Healthcare" formula_val="">Healthcare</option>
<option value="Hotel / Lodging" formula_val="">Hotel / Lodging</option>
<option value="Manufacturing" formula_val="">Manufacturing</option>
<option value="Oil and gas" formula_val="">Oil and gas</option>
<option value="Pharmaceuticals" formula_val="">Pharmaceuticals</option>
<option value="Retail" formula_val="">Retail</option>
<option value="Technology" formula_val="">Technology</option>
<option value="Transportation" formula_val="">Transportation</option>
<option value="Other" formula_val="">Other</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" style="width: 364px;"><span class="selection"><span class="select2-selection select2-selection--single select2FormCont" role="combobox"
aria-haspopup="true" aria-expanded="false" tabindex="0" aria-labelledby="select2-Dropdown-hy-container"><span class="select2-selection__rendered" id="select2-Dropdown-hy-container" title="-Select-">
<div class="select2FormFont drpDwnPlaceholder">-Select-</div>
</span><span class="select2-selection__arrow select2FormArrow" role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
</div>
<div elname="liveFieldTempChoiceCont" style="display: none;"></div>
<p class="errorMessage" elname="error" id="error-Dropdown"></p>
</div>
<div class="clearBoth"></div>
</li>
<li elname="livefield-elem" comptype="1" id="SingleLine1-li" needdata="true" compname="SingleLine1" linkname="SingleLine1" isvisible="false" class="tempFrmWrapper small" style="display:none;" mandatory="false" page_no="1"
page_link_name="Page" showlabel="true">
<label class="labelName">
<span>Staff Name</span>
</label>
<div class="tempContDiv">
<span><input onkeyup="ZFLive.configureInputMask(this);" onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="off" type="text" maxlength="255" name="SingleLine1" value="" placeholder=""></span>
<p class="errorMessage" elname="error" id="error-SingleLine1"></p>
</div>
<div class="clearBoth"></div>
</li>
<li class="tempFrmWrapper email small" elname="livefield-elem" comptype="9" id="Email-li" needdata="true" compname="Email" linkname="Email" isvisible="true" mandatory="true" page_no="1" page_link_name="Page" showlabel="true" domain_option="0"
need_reconf="false">
<label class="labelName">
<span>Contact Email</span>
<em class="important">*</em>
</label>
<div class="tempContDiv">
<span elname="livefield-email-elem"><input onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="off" type="text" maxlength="255" name="Email" value="" placeholder="">
<p class="errorMessage" elname="error" id="error-Email"></p>
</span>
</div>
<div class="clearBoth"></div>
</li>
<li class="tempFrmWrapper address addrlarge zfSelect2CustomCont" elname="livefield-elem" comptype="8" needdata="true" id="Address-li" compname="Address" linkname="Address" isvisible="true" mandatory="true" page_no="1" page_link_name="Page"
showlabel="true">
<div class="arrowNav"></div>
<label class="labelName">
<span>Company Address</span>
<em class="important">*</em>
</label>
<div class="tempContDiv address">
<div class="addrCont">
<!-- <input value=>-->
<span class="addOne">
<input name="Address" onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="auto-off" type="text" maxlength="255" complink="Address_AddressLine1" value="" mandatory="true" placeholder="">
<!-- Display name of 'AddressLine1' component of 'Address' field. -->
<label class="formSubInfoText">Street Address</label>
</span>
<!-- <input value=>-->
<!-- <input value=>-->
<span class="flLeft addtwo">
<input name="Address" onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="auto-off" type="text" maxlength="255" complink="Address_City" value="" mandatory="true" placeholder="">
<!-- Display name of 'City' component of 'Address' field. -->
<label class="formSubInfoText">City</label>
</span>
<!-- <input value=>-->
<span class="flLeft addtwo">
<input name="Address" onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="auto-off" type="text" maxlength="255" complink="Address_Region" value="" mandatory="true" placeholder="">
<!-- Display name of 'Region' component of 'Address' field. -->
<label class="formSubInfoText">State/Region/Province</label>
</span>
<!-- <input value=>-->
<span class="flLeft addtwo">
<input name="Address" onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="auto-off" type="text" maxlength="255" complink="Address_ZipCode" value="" mandatory="true" placeholder="">
<!-- Display name of 'ZipCode' component of 'Address' field. -->
<label class="formSubInfoText">Postal / Zip Code</label>
</span>
<!-- <input value=>-->
<span class="flLeft addtwo">
<div class="form_selectBox">
<div class="selectArrow"></div><select onchange="ZFLive.validateFieldConstraint(this);" onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="auto-off" name="Address" complink="Address_Country" id="Address_Country"
mandatory="true" tabindex="-1" class="select2-hidden-accessible" aria-hidden="true">
<option value="-Select-">-Select-</option>
<option value="Åland Islands">Åland Islands</option>
<option value="Afghanistan">Afghanistan</option>
<option value="Akrotiri">Akrotiri</option>
<option value="Albania">Albania</option>
<option value="Algeria">Algeria</option>
<option value="American Samoa">American Samoa</option>
<option value="Andorra">Andorra</option>
<option value="Angola">Angola</option>
<option value="Anguilla">Anguilla</option>
<option value="Antarctica">Antarctica</option>
<option value="Antigua and Barbuda">Antigua and Barbuda</option>
<option value="Argentina">Argentina</option>
<option value="Armenia">Armenia</option>
<option value="Aruba">Aruba</option>
<option value="Ashmore and Cartier Islands">Ashmore and Cartier Islands</option>
<option value="Australia">Australia</option>
<option value="Austria">Austria</option>
<option value="Azerbaijan">Azerbaijan</option>
<option value="Bahrain">Bahrain</option>
<option value="Bangladesh">Bangladesh</option>
<option value="Barbados">Barbados</option>
<option value="Bassas Da India">Bassas Da India</option>
<option value="Belarus">Belarus</option>
<option value="Belgium">Belgium</option>
<option value="Belize">Belize</option>
<option value="Benin">Benin</option>
<option value="Bermuda">Bermuda</option>
<option value="Bhutan">Bhutan</option>
<option value="Bolivia">Bolivia</option>
<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
<option value="Botswana">Botswana</option>
<option value="Bouvet Island">Bouvet Island</option>
<option value="Brazil">Brazil</option>
<option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
<option value="British Virgin Islands">British Virgin Islands</option>
<option value="Brunei">Brunei</option>
<option value="Bulgaria">Bulgaria</option>
<option value="Burkina Faso">Burkina Faso</option>
<option value="Burma">Burma</option>
<option value="Burundi">Burundi</option>
<option value="Cambodia">Cambodia</option>
<option value="Cameroon">Cameroon</option>
<option value="Canada">Canada</option>
<option value="Cape Verde">Cape Verde</option>
<option value="Caribbean Netherlands">Caribbean Netherlands</option>
<option value="Cayman Islands">Cayman Islands</option>
<option value="Central African Republic">Central African Republic</option>
<option value="Chad">Chad</option>
<option value="Chile">Chile</option>
<option value="China">China</option>
<option value="Christmas Island">Christmas Island</option>
<option value="Clipperton Island">Clipperton Island</option>
<option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option>
<option value="Colombia">Colombia</option>
<option value="Comoros">Comoros</option>
<option value="Cook Islands">Cook Islands</option>
<option value="Coral Sea Islands">Coral Sea Islands</option>
<option value="Costa Rica">Costa Rica</option>
<option value="Cote D'Ivoire">Cote D'Ivoire</option>
<option value="Croatia">Croatia</option>
<option value="Cuba">Cuba</option>
<option value="Curaçao">Curaçao</option>
<option value="Cyprus">Cyprus</option>
<option value="Czech Republic">Czech Republic</option>
<option value="Democratic Republic of the Congo">Democratic Republic of the Congo</option>
<option value="Denmark">Denmark</option>
<option value="Dhekelia">Dhekelia</option>
<option value="Djibouti">Djibouti</option>
<option value="Dominica">Dominica</option>
<option value="Dominican Republic">Dominican Republic</option>
<option value="Ecuador">Ecuador</option>
<option value="Egypt">Egypt</option>
<option value="El Salvador">El Salvador</option>
<option value="Equatorial Guinea">Equatorial Guinea</option>
<option value="Eritrea">Eritrea</option>
<option value="Estonia">Estonia</option>
<option value="Ethiopia">Ethiopia</option>
<option value="Europa Island">Europa Island</option>
<option value="Falkland Islands (Islas Malvinas)">Falkland Islands (Islas Malvinas)</option>
<option value="Faroe Islands">Faroe Islands</option>
<option value="Federated States of Micronesia">Federated States of Micronesia</option>
<option value="Fiji">Fiji</option>
<option value="Finland">Finland</option>
<option value="France">France</option>
<option value="French Guiana">French Guiana</option>
<option value="French Polynesia">French Polynesia</option>
<option value="French Southern and Antarctic Lands">French Southern and Antarctic Lands</option>
<option value="Gabon">Gabon</option>
<option value="Gaza Strip">Gaza Strip</option>
<option value="Georgia">Georgia</option>
<option value="Germany">Germany</option>
<option value="Ghana">Ghana</option>
<option value="Gibraltar">Gibraltar</option>
<option value="Glorioso Islands">Glorioso Islands</option>
<option value="Greece">Greece</option>
<option value="Greenland">Greenland</option>
<option value="Grenada">Grenada</option>
<option value="Guadeloupe">Guadeloupe</option>
<option value="Guam">Guam</option>
<option value="Guatemala">Guatemala</option>
<option value="Guernsey">Guernsey</option>
<option value="Guinea">Guinea</option>
<option value="Guinea-bissau">Guinea-bissau</option>
<option value="Guyana">Guyana</option>
<option value="Haiti">Haiti</option>
<option value="Heard Island and Mcdonald Islands">Heard Island and Mcdonald Islands</option>
<option value="Holy See (Vatican City)">Holy See (Vatican City)</option>
<option value="Honduras">Honduras</option>
<option value="Hong Kong">Hong Kong</option>
<option value="Hungary">Hungary</option>
<option value="Iceland">Iceland</option>
<option value="India">India</option>
<option value="Indonesia">Indonesia</option>
<option value="Iran">Iran</option>
<option value="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Isle of Man">Isle of Man</option>
<option value="Israel">Israel</option>
<option value="Italy">Italy</option>
<option value="Jamaica">Jamaica</option>
<option value="Jan Mayen">Jan Mayen</option>
<option value="Japan">Japan</option>
<option value="Jersey">Jersey</option>
<option value="Jordan">Jordan</option>
<option value="Juan De Nova Island">Juan De Nova Island</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kiribati">Kiribati</option>
<option value="Kuwait">Kuwait</option>
<option value="Kyrgyzstan">Kyrgyzstan</option>
<option value="Laos">Laos</option>
<option value="Latvia">Latvia</option>
<option value="Lebanon">Lebanon</option>
<option value="Lesotho">Lesotho</option>
<option value="Liberia">Liberia</option>
<option value="Libya">Libya</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lithuania">Lithuania</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macau">Macau</option>
<option value="Macedonia">Macedonia</option>
<option value="Madagascar">Madagascar</option>
<option value="Malawi">Malawi</option>
<option value="Malaysia">Malaysia</option>
<option value="Maldives">Maldives</option>
<option value="Mali">Mali</option>
<option value="Malta">Malta</option>
<option value="Marshall Islands">Marshall Islands</option>
<option value="Martinique">Martinique</option>
<option value="Mauritania">Mauritania</option>
<option value="Mauritius">Mauritius</option>
<option value="Mayotte">Mayotte</option>
<option value="Mexico">Mexico</option>
<option value="Moldova">Moldova</option>
<option value="Monaco">Monaco</option>
<option value="Mongolia">Mongolia</option>
<option value="Montenegro">Montenegro</option>
<option value="Montserrat">Montserrat</option>
<option value="Morocco">Morocco</option>
<option value="Mozambique">Mozambique</option>
<option value="Myanmar">Myanmar</option>
<option value="Namibia">Namibia</option>
<option value="Nauru">Nauru</option>
<option value="Navassa Island">Navassa Island</option>
<option value="Nepal">Nepal</option>
<option value="Netherlands">Netherlands</option>
<option value="Netherlands Antilles">Netherlands Antilles</option>
<option value="New Caledonia">New Caledonia</option>
<option value="New Zealand">New Zealand</option>
<option value="Nicaragua">Nicaragua</option>
<option value="Niger">Niger</option>
<option value="Nigeria">Nigeria</option>
<option value="Niue">Niue</option>
<option value="Norfolk Island">Norfolk Island</option>
<option value="North Korea">North Korea</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Norway">Norway</option>
<option value="Oman">Oman</option>
<option value="Pakistan">Pakistan</option>
<option value="Palau">Palau</option>
<option value="Palestine">Palestine</option>
<option value="Panama">Panama</option>
<option value="Papua New Guinea">Papua New Guinea</option>
<option value="Paracel Islands">Paracel Islands</option>
<option value="Paraguay">Paraguay</option>
<option value="Peru">Peru</option>
<option value="Philippines">Philippines</option>
<option value="Pitcairn Islands">Pitcairn Islands</option>
<option value="Poland">Poland</option>
<option value="Portugal">Portugal</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Qatar">Qatar</option>
<option value="Republic of the Congo">Republic of the Congo</option>
<option value="Reunion">Reunion</option>
<option value="Romania">Romania</option>
<option value="Russia">Russia</option>
<option value="Rwanda">Rwanda</option>
<option value="Saint Barthélemy">Saint Barthélemy</option>
<option value="Saint Helena">Saint Helena</option>
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
<option value="Saint Lucia">Saint Lucia</option>
<option value="Saint Martin">Saint Martin</option>
<option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option>
<option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option>
<option value="Samoa">Samoa</option>
<option value="San Marino">San Marino</option>
<option value="Sao Tome and Principe">Sao Tome and Principe</option>
<option value="Saudi Arabia">Saudi Arabia</option>
<option value="Senegal">Senegal</option>
<option value="Serbia">Serbia</option>
<option value="Seychelles">Seychelles</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapore">Singapore</option>
<option value="Sint Maarten">Sint Maarten</option>
<option value="Slovakia">Slovakia</option>
<option value="Slovenia">Slovenia</option>
<option value="Solomon Islands">Solomon Islands</option>
<option value="Somalia">Somalia</option>
<option value="South Africa">South Africa</option>
<option value="South Georgia and the South Sandwich Islands">South Georgia and the South Sandwich Islands</option>
<option value="South Korea">South Korea</option>
<option value="South Sudan">South Sudan</option>
<option value="Spain">Spain</option>
<option value="Spratly Islands">Spratly Islands</option>
<option value="Sri Lanka">Sri Lanka</option>
<option value="Sudan">Sudan</option>
<option value="Suriname">Suriname</option>
<option value="Svalbard">Svalbard</option>
<option value="Swaziland">Swaziland</option>
<option value="Sweden">Sweden</option>
<option value="Switzerland">Switzerland</option>
<option value="Syria">Syria</option>
<option value="Taiwan">Taiwan</option>
<option value="Tajikistan">Tajikistan</option>
<option value="Tanzania">Tanzania</option>
<option value="Thailand">Thailand</option>
<option value="The Bahamas">The Bahamas</option>
<option value="The Gambia">The Gambia</option>
<option value="Timor-leste">Timor-leste</option>
<option value="Togo">Togo</option>
<option value="Tokelau">Tokelau</option>
<option value="Tonga">Tonga</option>
<option value="Trinidad and Tobago">Trinidad and Tobago</option>
<option value="Tromelin Island">Tromelin Island</option>
<option value="Tunisia">Tunisia</option>
<option value="Turkey">Turkey</option>
<option value="Turkmenistan">Turkmenistan</option>
<option value="Turks and Caicos Islands">Turks and Caicos Islands</option>
<option value="Tuvalu">Tuvalu</option>
<option value="Uganda">Uganda</option>
<option value="Ukraine">Ukraine</option>
<option value="United Arab Emirates">United Arab Emirates</option>
<option value="United Kingdom">United Kingdom</option>
<option value="United States" selected="true">United States</option>
<option value="Uruguay">Uruguay</option>
<option value="Uzbekistan">Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Venezuela">Venezuela</option>
<option value="Vietnam">Vietnam</option>
<option value="Virgin Islands">Virgin Islands</option>
<option value="Wake Island">Wake Island</option>
<option value="Wallis and Futuna">Wallis and Futuna</option>
<option value="West Bank">West Bank</option>
<option value="Western Sahara">Western Sahara</option>
<option value="Yemen">Yemen</option>
<option value="Zambia">Zambia</option>
<option value="Zimbabwe">Zimbabwe</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" style="width: 347.438px;"><span class="selection"><span class="select2-selection select2-selection--single select2FormCont" role="combobox"
aria-haspopup="true" aria-expanded="false" tabindex="0" aria-labelledby="select2-Address_Country-container"><span class="select2-selection__rendered" id="select2-Address_Country-container" title="United States">
<div class="select2FormFont">United States</div>
</span><span class="select2-selection__arrow select2FormArrow" role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
</div><!-- Display name of 'Country' component of 'Address' field. -->
<label class="formSubInfoText formSubInfoAlign">Country</label>
</span>
<div class="clearBoth"></div>
<p class="errorMessage" elname="error" id="error-Address"></p>
</div>
</div>
<div class="clearBoth"></div>
<script type="module">
$(function() {
var mode = "live"; // No I18N
if (mode == "edit") { // No I18N
var selectedCountry = ""; // No I18N
var selectedCountryNonEncoded = ""; // No I18N
var countryDropdown = $("#Address-li").find('select');
if (selectedCountry.length > 0 && (typeof($(countryDropdown).find('option:selected').val()) == 'undefined' || $(countryDropdown).find('option:selected').val().toLowerCase() != selectedCountryNonEncoded.toLowerCase())) { // No I18N
$(countryDropdown).append($("<option></option>").attr("value", selectedCountryNonEncoded).html(selectedCountry).hide()); // No I18N
$(countryDropdown).val(selectedCountryNonEncoded).change();
}
}
});
</script>
</li>
<li class="tempFrmWrapper dropdown small zfSelect2CustomCont" elname="livefield-elem" comptype="12" id="Dropdown1-li" needdata="true" compname="Dropdown1" linkname="Dropdown1" isvisible="true" mandatory="true" page_no="1"
page_link_name="Page" showlabel="true">
<label class="labelName">
<span>Regulated by DOT- Part 40?</span>
<em class="important">*</em>
</label>
<div class="tempContDiv">
<div class="form_selectBox">
<div class="selectArrow"></div><select name="Dropdown1" onchange="ZFLive.prefillFieldLabel(this); ZFLive.hideClosestFieldElemErrorDiv(this); ZFLive.checkUniqueChoiceFld(this);
" tabindex="-1" class="select2-hidden-accessible" aria-hidden="true">
<option selected="true" value="-Select-">-Select-</option>
<option value="Yes" formula_val="">Yes</option>
<option value="no" formula_val="">no</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" style="width: 364px;"><span class="selection"><span class="select2-selection select2-selection--single select2FormCont" role="combobox"
aria-haspopup="true" aria-expanded="false" tabindex="0" aria-labelledby="select2-Dropdown1-y0-container"><span class="select2-selection__rendered" id="select2-Dropdown1-y0-container" title="-Select-">
<div class="select2FormFont drpDwnPlaceholder">-Select-</div>
</span><span class="select2-selection__arrow select2FormArrow" role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
</div>
<div elname="liveFieldTempChoiceCont" style="display: none;"></div>
<p class="errorMessage" elname="error" id="error-Dropdown1"></p>
</div>
<div class="clearBoth"></div>
</li>
<li class="tempFrmWrapper dropdown small zfSelect2CustomCont" elname="livefield-elem" comptype="12" id="Dropdown2-li" needdata="true" compname="Dropdown2" linkname="Dropdown2" isvisible="true" mandatory="false" page_no="1"
page_link_name="Page" showlabel="true">
<label class="labelName">
<span>DOT Agency (mode)</span>
</label>
<div class="tempContDiv">
<div class="form_selectBox">
<div class="selectArrow"></div><select name="Dropdown2" onchange="ZFLive.prefillFieldLabel(this); ZFLive.hideClosestFieldElemErrorDiv(this); ZFLive.checkUniqueChoiceFld(this);
" tabindex="-1" class="select2-hidden-accessible" aria-hidden="true">
<option selected="true" value="-Select-">-Select-</option>
<option value="Please Select|" formula_val="">Please Select|</option>
<option value="FMCSA" formula_val="">FMCSA</option>
<option value="PHMSA" formula_val="">PHMSA</option>
<option value="USCG" formula_val="">USCG</option>
<option value="FAA" formula_val="">FAA</option>
<option value="FRA" formula_val="">FRA</option>
<option value="FTA" formula_val="">FTA</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" style="width: 364px;"><span class="selection"><span class="select2-selection select2-selection--single select2FormCont" role="combobox"
aria-haspopup="true" aria-expanded="false" tabindex="0" aria-labelledby="select2-Dropdown2-by-container"><span class="select2-selection__rendered" id="select2-Dropdown2-by-container" title="-Select-">
<div class="select2FormFont drpDwnPlaceholder">-Select-</div>
</span><span class="select2-selection__arrow select2FormArrow" role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
</div>
<div elname="liveFieldTempChoiceCont" style="display: none;"></div>
<p class="errorMessage" elname="error" id="error-Dropdown2"></p>
</div>
<div class="clearBoth"></div>
</li>
<li class="tempFrmWrapper small" elname="livefield-elem" comptype="15" id="MultipleChoice-li" needdata="true" compname="MultipleChoice" linkname="MultipleChoice" isvisible="true" mandatory="true" page_no="1" page_link_name="Page">
<label class="labelName"><span>How do you wish to schedule test/service*</span>
<em class="important">*</em>
</label>
<div class="tempContDiv mSelect">
<select name="MultipleChoice" id="MultipleChoice-multiple-id" multiple="multiple" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);">
<option value="Schedule/order test through your personalized portal yourself" formula_val="">Schedule/order test through your personalized portal yourself</option>
<option value="Phone (800)488-5350" formula_val="">Phone (800)488-5350</option>
<option value="Email orders@securescreenings.com" formula_val="">Email orders@securescreenings.com</option>
<option value="ALL" formula_val="">ALL</option>
</select>
<p class="errorMessage" elname="error" id="error-MultipleChoice"></p>
</div>
<div class="clearBoth"></div>
</li>
</ul>
<!-- formFieldWrapper class is used to differantiate form fields and subform fields in themes. Direct children (li) are considered as form fields. Dont change the order of class used. -->
<ul elname="formBodyULName" class="ulNoStyle formFieldWrapper" page_no="2" needpagedata="true" style="display:none;">
<!-- i) Private form, ii) Perma, iii) Shared form, iv) Theme preview, v) Current Theme -->
<!-- "isVisible"="false": This 'Admin Only' field must not be shown to user. -->
<!-- "isVisible"="true": Case 1: This is not an 'Admin Only' field. Case 2: This 'Admin Only' field must be shown to user. -->
<!-- Theme Preview, Current Theme - Admin Only fields will be shown. Formula won't be calculated. Field Rules won't be executed. -->
<!-- formMetaData.key=Field link name -->
<!-- Zoho CRM field : "FIELD_LIST" key won't be present. -->
<li class="tempFrmWrapper small" elname="livefield-elem" comptype="15" id="MultipleChoice1-li" needdata="true" compname="MultipleChoice1" linkname="MultipleChoice1" isvisible="true" mandatory="true" page_no="2" page_link_name="Page1">
<label class="labelName"><span>Testing Purpose</span>
<em class="important">*</em>
</label>
<div class="tempContDiv mSelect">
<select name="MultipleChoice1" id="MultipleChoice1-multiple-id" multiple="multiple" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);">
<option value="Pre Employment" formula_val="">Pre Employment</option>
<option value="Random" formula_val="">Random</option>
<option value="Post Accident" formula_val="">Post Accident</option>
<option value="Reasonable Suspicion" formula_val="">Reasonable Suspicion</option>
<option value="Other" formula_val="">Other</option>
</select>
<p class="errorMessage" elname="error" id="error-MultipleChoice1"></p>
</div>
<div class="clearBoth"></div>
</li>
<li class="tempFrmWrapper small" elname="livefield-elem" comptype="15" id="MultipleChoice2-li" needdata="true" compname="MultipleChoice2" linkname="MultipleChoice2" isvisible="true" mandatory="true" page_no="2" page_link_name="Page1">
<label class="labelName"><span>Testing Services</span>
<em class="important">*</em>
</label>
<div class="tempContDiv mSelect">
<select name="MultipleChoice2" id="MultipleChoice2-multiple-id" multiple="multiple" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);">
<option value="Urine Testing" formula_val="">Urine Testing</option>
<option value="Alcohol Testing" formula_val="">Alcohol Testing</option>
<option value="Hair Testing" formula_val="">Hair Testing</option>
<option value="Oral Fluid Testing" formula_val="">Oral Fluid Testing</option>
<option value="Blood Testing" formula_val="">Blood Testing</option>
</select>
<p class="errorMessage" elname="error" id="error-MultipleChoice2"></p>
</div>
<div class="clearBoth"></div>
</li>
<li class="zfcheckbox tempFrmWrapper oneColumns " elname="livefield-elem" comptype="14" needdata="true" id="Checkbox-li" compname="Checkbox" linkname="Checkbox" isvisible="true" mandatory="true" page_no="2" page_link_name="Page1"
choice_type="checkbox">
<label class="labelName"><span>Testing Panel</span>
<em class="important">*</em>
</label>
<div class="tempContDiv">
<div class="overflow customCheckBox">
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" type="checkbox" id="Checkbox_1" class="checkBoxType" name="Checkbox" elname="Checkbox" value="5 panel DOT" formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);
">
<label for="Checkbox_1" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">5 panel DOT</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" type="checkbox" id="Checkbox_2" class="checkBoxType" name="Checkbox" elname="Checkbox" value="5 panel" formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);
">
<label for="Checkbox_2" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">5 panel</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" type="checkbox" id="Checkbox_3" class="checkBoxType" name="Checkbox" elname="Checkbox" value="5 Panel Instant" formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);
">
<label for="Checkbox_3" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">5 Panel Instant</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" type="checkbox" id="Checkbox_4" class="checkBoxType" name="Checkbox" elname="Checkbox" value="5 panel + expanded opiates" formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);
">
<label for="Checkbox_4" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">5 panel + expanded opiates</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" type="checkbox" id="Checkbox_5" class="checkBoxType" name="Checkbox" elname="Checkbox" value="10 panel" formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);
">
<label for="Checkbox_5" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">10 panel</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" type="checkbox" id="Checkbox_6" class="checkBoxType" name="Checkbox" elname="Checkbox" value="10 Panel Instant" formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);
">
<label for="Checkbox_6" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">10 Panel Instant</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" type="checkbox" id="Checkbox_7" class="checkBoxType" name="Checkbox" elname="Checkbox" value="10 panel + expanded opiates" formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);
">
<label for="Checkbox_7" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">10 panel + expanded opiates</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" type="checkbox" id="Checkbox_8" class="checkBoxType" name="Checkbox" elname="Checkbox" value="12 panel" formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);
">
<label for="Checkbox_8" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">12 panel</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" type="checkbox" id="Checkbox_9" class="checkBoxType" name="Checkbox" elname="Checkbox" value="14 panel" formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);
">
<label for="Checkbox_9" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">14 panel</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" type="checkbox" id="Checkbox_10" class="checkBoxType" name="Checkbox" elname="Checkbox" value="Customized test" formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);
">
<label for="Checkbox_10" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">Customized test</em>
</label> </span>
<div class="clearBoth"></div>
</div>
<p class="errorMessage" elname="error" id="error-Checkbox"></p>
</div>
<div class="clearBoth"></div>
</li>
<li class="zfcheckbox tempFrmWrapper oneColumns " elname="livefield-elem" comptype="14" needdata="true" id="Checkbox1-li" compname="Checkbox1" linkname="Checkbox1" isvisible="true" mandatory="true" page_no="2" page_link_name="Page1"
choice_type="checkbox">
<label class="labelName"><span>Additional Services</span>
<em class="important">*</em>
</label>
<div class="tempContDiv">
<div class="overflow customCheckBox">
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" type="checkbox" id="Checkbox1_1" class="checkBoxType" name="Checkbox1" elname="Checkbox1" value="DOT Consortium Membership" formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);
">
<label for="Checkbox1_1" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">DOT Consortium Membership</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" type="checkbox" id="Checkbox1_2" class="checkBoxType" name="Checkbox1" elname="Checkbox1" value="Physicals" formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);
">
<label for="Checkbox1_2" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">Physicals</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" type="checkbox" id="Checkbox1_3" class="checkBoxType" name="Checkbox1" elname="Checkbox1" value="Background Checks" formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);
">
<label for="Checkbox1_3" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">Background Checks</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" type="checkbox" id="Checkbox1_4" class="checkBoxType" name="Checkbox1" elname="Checkbox1" value="Drug Free Work Place Program" formula_val=""
onchange="ZFLive.hideClosestFieldElemErrorDiv(this);
">
<label for="Checkbox1_4" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">Drug Free Work Place Program</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" type="checkbox" id="Checkbox1_5" class="checkBoxType" name="Checkbox1" elname="Checkbox1" value="Random Testing Program" formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);
">
<label for="Checkbox1_5" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">Random Testing Program</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" type="checkbox" id="Checkbox1_6" class="checkBoxType" name="Checkbox1" elname="Checkbox1" value="Drug Free Work Place Policy" formula_val=""
onchange="ZFLive.hideClosestFieldElemErrorDiv(this);
">
<label for="Checkbox1_6" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">Drug Free Work Place Policy</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" type="checkbox" id="Checkbox1_7" class="checkBoxType" name="Checkbox1" elname="Checkbox1" value="Reasonable Suspicion Supervisor Training"
formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);
">
<label for="Checkbox1_7" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">Reasonable Suspicion Supervisor Training</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" type="checkbox" id="Checkbox1_8" class="checkBoxType" name="Checkbox1" elname="Checkbox1" value="On Site / Mobile Testing" formula_val="" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);
">
<label for="Checkbox1_8" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">On Site / Mobile Testing</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" type="checkbox" id="Checkbox1_9" class="checkBoxType" name="Checkbox1" elname="Checkbox1" value="TPA / Third Party Administrator" formula_val=""
onchange="ZFLive.hideClosestFieldElemErrorDiv(this);
">
<label for="Checkbox1_9" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">TPA / Third Party Administrator</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" type="checkbox" id="Checkbox1_10" class="checkBoxType" name="Checkbox1" elname="Checkbox1" value="Motor Vehicle Reports / MVR" formula_val=""
onchange="ZFLive.hideClosestFieldElemErrorDiv(this);
">
<label for="Checkbox1_10" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">Motor Vehicle Reports / MVR</em>
</label> </span>
<span class="multiAttType cusChoiceSpan"> <input onmousedown="event.preventDefault();" type="checkbox" id="Checkbox1_11" class="checkBoxType" name="Checkbox1" elname="Checkbox1" value="None Required At This Time" formula_val=""
onchange="ZFLive.hideClosestFieldElemErrorDiv(this);
">
<label for="Checkbox1_11" class="checkChoice cusChoiceLabel">
<div class="checker"></div><em class="cusChoiceEm">None Required At This Time</em>
</label> </span>
<div class="clearBoth"></div>
</div>
<p class="errorMessage" elname="error" id="error-Checkbox1"></p>
</div>
<div class="clearBoth"></div>
</li>
<li elname="livefield-elem" linkname="TermsConditions" comptype="34" id="TermsConditions-li" needdata="true" compname="TermsConditions" statustext="Agreed" class="tempFrmWrapper termsWrapper" mandatory="false" page_no="2"
page_link_name="Page1" choice_type="checkbox" tabindex="1" showlabel="true">
<label class="labelName">
<span>Terms and Conditions</span>
</label>
<div class="tempContDiv">
<div class="termsContainer">
<div class="termsMsg descFld">
<div><b>I am authorized to establish an account with Secure Screenings and authorize Secure Screenings to activate an account for drug, alcohol or additional testing services.</b><br></div>
</div>
<div class="termsAccept customCheckBox">
<input onmousedown="event.preventDefault();" elname="statusCB" id="TermsConditions-input" class="checkBoxType flLeft" name="TermsConditions" type="checkbox" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);">
<!-- declaration content moved to div from label to make custom choices work -->
<label class="cusChoiceLabel" for="TermsConditions-input">
<div class="checker"></div>
</label>
<div class="descFld">I accept the Terms and Conditions.</div>
</div>
</div>
<p class="errorMessage" elname="error" id="error-TermsConditions"></p>
</div>
<div class="clearBoth"></div>
</li>
<li class="sign tempFrmWrapper" tabindex="1" elname="livefield-elem" comptype="25" id="Signature-li" needdata="true" compname="Signature" linkname="Signature" isvisible="true" mandatory="false" page_no="2" page_link_name="Page1">
<label class="labelName"><span>Signature</span>
</label>
<div class="tempContDiv">
<div class="signContainer" elname="signContainer" id="signContainer-Signature"><canvas id="drawingCanvas-Signature" tabindex="-1" width="0"></canvas>
<div class="signArea" elname="signArea" id="sign-area-Signature" style="display:none"></div>
<a id="clearSign" elname="clearSign" class="instrSpace" href="javascript:void(0);" onclick="clearSignature('drawingCanvas-Signature');">Clear</a>
</div>
<p class="errorMessage" elname="error" id="error-Signature"></p>
</div>
<div class="clearBoth"></div>
<script type="module">
setCanvasElemWidth("Signature"); //No I18N
$("#drawingCanvas-Signature").mousedown(function(event) {
var inputField = $("#formBodyDiv").find(".tempContDiv input[type=text]:first")[0];
var fontColor = "#000000";
if (typeof inputField != "undefined") {
fontColor = $(inputField).css("color"); // No I18N
} else {
var textArea = $("#formBodyDiv").find(".tempContDiv textarea:first")[0];
if (typeof inputField != "undefined") {
fontColor = $(textArea).css("color"); // No I18N
}
}
var canvasElem = document.getElementById("drawingCanvas-Signature");
var context = canvasElem.getContext("2d"); // No I18N
var position = getXYCoords(event, canvasElem, false);
context.moveTo(position.X, position.Y);
context.beginPath();
$(this).mousemove(function(event) {
startScribbling(event, canvasElem, context, false, fontColor);
}).mouseup(function(event) {
endScribbling(event, canvasElem, context, fontColor);
var fieldElem = getClosestFieldElemLi(canvasElem); // No I18N
removeErrorFromLiElem(fieldElem); // No I18N
}).mouseout(function(event) {
endScribbling(event, canvasElem, context, fontColor);
var fieldElem = getClosestFieldElemLi(canvasElem); // No I18N
removeErrorFromLiElem(fieldElem); // No I18N
});
this.addEventListener('touchstart', function(event) {
position = getXYCoords(event, canvasElem, true);
context.moveTo(position.X, position.Y);
context.beginPath();
event.preventDefault();
}, false);
this.addEventListener('touchmove', function(event) {
startScribbling(event, canvasElem, context, true, fontColor);
event.preventDefault();
}, false);
});
var userAgent = window.navigator.userAgent;
var msie = userAgent.indexOf("MSIE ");
if (msie > 0) {
$("#drawingCanvas-Signature").keypress(function(event) {
if (event.keyCode === 13) {
event.preventDefault();
}
});
}
if (false == true) //No I18N
{
$("#drawingCanvas-Signature").css("pointer-events", "none"); //No I18N
$("#drawingCanvas-Signature").css("cursor", "default"); //No I18N
}
</script>
</li>
</ul>
<!-- formFieldWrapper class is used to differantiate form fields and subform fields in themes. Direct children (li) are considered as form fields. Dont change the order of class used. -->
<ul elname="formBodyULName" class="ulNoStyle formFieldWrapper" page_no="3" needpagedata="true" style="display:none;">
<!-- i) Private form, ii) Perma, iii) Shared form, iv) Theme preview, v) Current Theme -->
<!-- "isVisible"="false": This 'Admin Only' field must not be shown to user. -->
<!-- "isVisible"="true": Case 1: This is not an 'Admin Only' field. Case 2: This 'Admin Only' field must be shown to user. -->
<!-- Theme Preview, Current Theme - Admin Only fields will be shown. Formula won't be calculated. Field Rules won't be executed. -->
<!-- formMetaData.key=Field link name -->
<!-- Zoho CRM field : "FIELD_LIST" key won't be present. -->
<li class="tempFrmWrapper name namemedium zfSelect2CustomCont" elname="livefield-elem" comptype="7" needdata="true" id="Name1-li" compname="Name1" linkname="Name1" isvisible="true" mandatory="true" page_no="3" page_link_name="Page2"
regex_type="0" showlabel="true">
<label class="labelName">
<span>Credit Card Authorization</span>
<em class="important">*</em>
</label>
<div class="tempContDiv twoType">
<div class="nameWrapper">
<span> <input onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="auto-off" type="text" maxlength="255" elname="First" name="Name1" complink="Name1_First" value="" mandatory="true" placeholder="">
<label class="formSubInfoText">First</label>
</span>
<span> <input onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="auto-off" type="text" maxlength="255" elname="Last" name="Name1" complink="Name1_Last" value="" mandatory="true" placeholder="">
<label class="formSubInfoText">Last</label>
</span>
<div class="clearBoth"></div>
</div>
<p class="errorMessage" elname="error" id="error-Name1"></p>
<p class="instruction instrLeftSpace" elname="hint" id="hint-Name1"> A valid credit card must be maintained on file and will only be charged for invoices that are 30 days past due. Accredited Drug Testing members will automatically
receive a 5% discount on all tests and services. Invoices due within 30 days</p>
</div>
<div class="clearBoth"></div>
</li>
<li class="tempFrmWrapper small" elname="livefield-elem" comptype="3" id="Number2-li" needdata="true" compname="Number2" linkname="Number2" isvisible="true" mandatory="true" unit_position="2" page_no="3" page_link_name="Page2"
summary_type="0" showlabel="true">
<label class="labelName">
<span>CC Number</span>
<em class="important">*</em>
</label>
<div elname="tempContDiv" class="tempContDiv">
<span><input onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="off" type="text" maxlength="18" name="Number2" value="" placeholder=""> </span>
<span class="symbol" name="field_unit_after" elname="field_unit_span"></span>
<p class="errorMessage" elname="error" id="error-Number2"></p>
</div>
<div class="clearBoth"></div>
</li>
<li class="tempFrmWrapper small" elname="livefield-elem" comptype="3" id="Number3-li" needdata="true" compname="Number3" linkname="Number3" isvisible="true" mandatory="true" unit_position="2" page_no="3" page_link_name="Page2"
summary_type="0" showlabel="true">
<label class="labelName">
<span>Expiration Date</span>
<em class="important">*</em>
</label>
<div elname="tempContDiv" class="tempContDiv">
<span><input onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="off" type="text" maxlength="18" name="Number3" value="" placeholder=""> </span>
<span class="symbol" name="field_unit_after" elname="field_unit_span"></span>
<p class="errorMessage" elname="error" id="error-Number3"></p>
</div>
<div class="clearBoth"></div>
</li>
<li class="tempFrmWrapper small" elname="livefield-elem" comptype="3" id="Number4-li" needdata="true" compname="Number4" linkname="Number4" isvisible="true" mandatory="true" unit_position="2" page_no="3" page_link_name="Page2"
summary_type="0" showlabel="true">
<label class="labelName">
<span>Sec Code</span>
<em class="important">*</em>
</label>
<div elname="tempContDiv" class="tempContDiv">
<span><input onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="off" type="text" maxlength="18" name="Number4" value="" placeholder=""> </span>
<span class="symbol" name="field_unit_after" elname="field_unit_span"></span>
<p class="errorMessage" elname="error" id="error-Number4"></p>
</div>
<div class="clearBoth"></div>
</li>
<li class="tempFrmWrapper small" elname="livefield-elem" comptype="3" id="Number5-li" needdata="true" compname="Number5" linkname="Number5" isvisible="true" mandatory="true" unit_position="2" page_no="3" page_link_name="Page2"
summary_type="0" showlabel="true">
<label class="labelName">
<span>Billing Zip Code</span>
<em class="important">*</em>
</label>
<div elname="tempContDiv" class="tempContDiv">
<span><input onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="off" type="text" maxlength="18" name="Number5" value="" placeholder=""> </span>
<span class="symbol" name="field_unit_after" elname="field_unit_span"></span>
<p class="errorMessage" elname="error" id="error-Number5"></p>
</div>
<div class="clearBoth"></div>
</li>
<li class="tempFrmWrapper phone small" elname="livefield-elem" comptype="11" id="PhoneNumber-li" needdata="true" compname="PhoneNumber" linkname="PhoneNumber" isvisible="true" mandatory="true" page_no="3" page_link_name="Page2"
showlabel="true" need_reconf="false">
<label class="labelName">
<span>Billing Phone</span>
<em class="important">*</em>
</label>
<div class="tempContDiv" elname="phoneFormatElem" phoneformat="INTERNATIONAL">
<div elname="phoneFld" name="phone-elements">
<input name="PhoneNumber" onfocusout="ZFLive.validateFieldConstraint(this);" autocomplete="off" id="PhoneNumber" type="text" elname="countrycode" maxlength="20" value="" iscodeenabled="false" phoneformattype="1" placeholder="">
</div>
<p class="errorMessage" elname="error" id="error-PhoneNumber"></p>
<script type="module">
if (false == true && (true)) {
var allowedCountryList = [];
var ipBasedCurrentCountry = null;
var defaultCountry = ""; // No I18N
var keyId = $("#PhoneNumber");
var keyIdConf = ("#" + "PhoneNumber" + "-reconf"); // No I18N
var listofcountries = [],
hasCode = false;
var initialCountry = "auto"; // No I18N
var countryCodeProps = jQuery.extend(true, {}, ZFPhone.countryCodeProps);
var isRtlEnabled = false;
var txtDir = "1"; // No I18N
if (txtDir != null && txtDir != undefined) {
if (txtDir == 2) {
isRtlEnabled = true;
}
}
countryCodeProps.isRtl = isRtlEnabled;
if (defaultCountry != "") {
defaultCountry = countryUniqueCode[""]; // No I18N
}
if (allowedCountryList.length > 0) {
var phoneVal = ""; // No I18N
var codeVal = ""; // No I18N
for (var itr = 0; itr < allowedCountryList.length; itr++) {
if (codeVal != "" && codelist[allowedCountryList[itr]] == codeVal && !hasCode) {
phoneVal = codeVal + phoneVal;
hasCode = true;
}
listofcountries[itr] = countryUniqueCode[allowedCountryList[itr]];
}
countryCodeProps.onlyCountries = listofcountries;
if ("live" == 'live') {
if (jQuery.inArray(defaultCountry, listofcountries) !== -1) {
initialCountry = defaultCountry;
} else if (ipBasedCurrentCountry !== null && ipBasedCurrentCountry != "null" && ipBasedCurrentCountry != "-" && jQuery.inArray(ipBasedCurrentCountry, listofcountries) != -1) { // No I18N
initialCountry = ipBasedCurrentCountry;
}
} else {
$("#PhoneNumber").val(phoneVal);
if ("false" == "true") {
$(keyIdConf).val(phoneVal); // No I18N
}
}
} else if ("live" == 'live') { // No I18N
if (defaultCountry != "") {
initialCountry = defaultCountry;
} else if (ipBasedCurrentCountry !== null && ipBasedCurrentCountry != "null" && ipBasedCurrentCountry != "-") { // No I18N
initialCountry = ipBasedCurrentCountry;
}
}
if ($(keyId).parents("ul").attr("elname") != "subFormFieldsCloneUl") {
countryCodeProps.initialCountry = initialCountry;
$(keyId).intlTelInput(countryCodeProps);
$(keyIdConf).intlTelInput(countryCodeProps); // No I18N
if ("live" == 'live') {
$(keyId).intlTelInput("setNumber", ""); // No I18N
}
}
$(keyId).attr({
"initCountry": initialCountry,
"countryList": listofcountries
}); // No I18N
//$("#PhoneNumber") is used instead of variable keyId, since event get attached only to the last dom element instead of all elements.
setCountryCodePropsForFlds(("#" + "PhoneNumber"), isRtlEnabled); // No I18N
if ("false" == "true") {
setCountryCodePropsForFlds(("#" + "PhoneNumber" + "-reconf"), isRtlEnabled); // No I18N
}
}
</script>
</div>
<div class="clearBoth"></div>
</li>
<li class="tempFrmWrapper dropdown small zfSelect2CustomCont" elname="livefield-elem" comptype="12" id="Dropdown3-li" needdata="true" compname="Dropdown3" linkname="Dropdown3" isvisible="true" mandatory="true" page_no="3"
page_link_name="Page2" showlabel="true">
<label class="labelName">
<span>Invoice Method</span>
<em class="important">*</em>
</label>
<div class="tempContDiv">
<div class="form_selectBox">
<div class="selectArrow"></div><select name="Dropdown3" onchange="ZFLive.prefillFieldLabel(this); ZFLive.hideClosestFieldElemErrorDiv(this); ZFLive.checkUniqueChoiceFld(this);
" tabindex="-1" class="select2-hidden-accessible" aria-hidden="true">
<option selected="true" value="-Select-">-Select-</option>
<option value="Invoice My Company (net 30 days)" formula_val="">Invoice My Company (net 30 days)</option>
<option value="Charge Card on File 1st of each month" formula_val="">Charge Card on File 1st of each month</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" style="width: auto;"><span class="selection"><span class="select2-selection select2-selection--single select2FormCont" role="combobox"
aria-haspopup="true" aria-expanded="false" tabindex="0" aria-labelledby="select2-Dropdown3-71-container"><span class="select2-selection__rendered" id="select2-Dropdown3-71-container" title="-Select-">
<div class="select2FormFont drpDwnPlaceholder">-Select-</div>
</span><span class="select2-selection__arrow select2FormArrow" role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
</div>
<div elname="liveFieldTempChoiceCont" style="display: none;"></div>
<p class="errorMessage" elname="error" id="error-Dropdown3"></p>
</div>
<div class="clearBoth"></div>
</li>
<li class="tempFrmWrapper decesion " style="display:none;" elname="livefield-elem" comptype="18" needdata="true" id="DecisionBox-li" compname="DecisionBox" linkname="DecisionBox" isvisible="false" mandatory="false" page_no="3"
page_link_name="Page2" choice_type="checkbox">
<div class="tempContDiv customCheckBox">
<input onmousedown="event.preventDefault();" type="checkbox" checked="true" id="DecisionBox" name="DecisionBox" onchange="ZFLive.hideClosestFieldElemErrorDiv(this);">
<label class="labelName cusChoiceLabel" for="DecisionBox">
<div class="checker"></div><span elname="display_name" class="cusChoiceSpanWrap"> Form Completed </span>
</label>
<p class="errorMessage" elname="error" id="error-DecisionBox"></p>
</div>
<div class="clearBoth"></div>
</li>
</ul>
</div>
<ul elname="footer" class="footerWrapper formRelative" page_no="1" page_count="3" page_link_name="Page">
<li style="overflow:visible; position: relative;" class="btnAllign fmFooter page" id="formAccess" elname="0">
<div class="pageFotDef">
<div class="alignNext">
<div class="inlineBlock nextAlign" elname="next"><button class="fmSmtButton next_previous navWrapper" type="button" elname="next" onclick="gotoNextPage(this);">
<em> Next </em>
</button></div>
</div>
</div>
<div class="clearBoth"></div>
<div class="footerPgNum">1/3</div>
</li>
</ul>
<ul elname="footer" class="footerWrapper formRelative" page_no="2" page_count="3" page_link_name="Page1" style="display:none;">
<li style="overflow:visible; position: relative;" class="btnAllign fmFooter page" id="formAccess" elname="0">
<div class="pageFotDef">
<div class="inlineBlock prevAlign" elname="back"><button class="fmSmtButton next_previous navWrapper" type="button" elname="back" onclick="gotoPrev(this);">
<em> Back </em>
</button></div>
<div class="alignNext">
<div class="inlineBlock nextAlign" elname="next"><button class="fmSmtButton next_previous navWrapper" type="button" elname="next" onclick="gotoNextPage(this);">
<em> Next </em>
</button></div>
</div>
</div>
<div class="clearBoth"></div>
<div class="footerPgNum">2/3</div>
</li>
</ul>
<ul elname="footer" class="footerWrapper formRelative" page_no="3" page_count="3" page_link_name="Page2" style="display:none;">
<li style="overflow:visible; position: relative;" class="btnAllign fmFooter page" id="formAccess" elname="0">
<div class="pageFotDef">
<div class="inlineBlock prevAlign" elname="back"><button class="fmSmtButton next_previous navWrapper" type="button" elname="back" onclick="gotoPrev(this);">
<em> Back </em>
</button></div>
<div class="alignSubmit">
<div class="formRelative inlineBlock submitBtnCont"><button class="fmSmtButton submitColor submitWrapper fmSmtButtom" elname="submit" value="submit">
<em>Submit</em>
</button></div>
</div>
</div>
<div class="clearBoth"></div>
<div class="footerPgNum">3/3</div>
</li>
</ul>
<!-- Uncomment the following Code to enable automation location based value filling for GeoLocation Fields -->
<!-- Set the mapquestURL from zohoforms.properties -->
<!-- -->
<!--Div to show error for unconfirmed users -->
<div id="errorDiv" style="display:none" class="errorMsgWrapper">
<div class="flLeft errorIcon"></div>
<div class="errorMsgCont">
<h2>Error Occurred!</h2>
<span id="errorMsgSpan">You haven't verified your email yet, click<a href="javascript:;" onclick="ZFUtil.resendMail('0');"> here </a> to receive a verification email.</span>
</div>
<div class="clearBoth"></div>
</div>
</div><!-- 'formRedirectURL' ends -->
<div id="popupdiv" class="dim-div2" style="display:none;">
<div id="imageChoiceDiv-cont" class="popUpOuter imageTypeZoom">
<div class="popUpInnerWrapper">
<div class="popupHeader removeBdr"><a class="flRight ppDeleteIcon" onclick="ZFLive.hideZoomedImage();" href="javascript:;"></a>
<div class="clearBoth"></div>
</div>
<div class="popupMainCont"><img src=""></div>
</div>
</div>
</div>
</form>Text Content
* NEW ACCOUNT SET UP-SECURE SCREENINGS * Company Name * * Contact Phone * * Number of Employees * * Contact Person/Designated Employer Representative * First Last * Website * Industry * -Select- Please Choose| Automotive Attorney / Legal Bar / Restaurant Construction Energy / Power Plant Healthcare Hotel / Lodging Manufacturing Oil and gas Pharmaceuticals Retail Technology Transportation Other -Select- * Staff Name * Contact Email * * Company Address * Street Address City State/Region/Province Postal / Zip Code -Select- Åland Islands Afghanistan Akrotiri Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Ashmore and Cartier Islands Australia Austria Azerbaijan Bahrain Bangladesh Barbados Bassas Da India Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Caribbean Netherlands Cayman Islands Central African Republic Chad Chile China Christmas Island Clipperton Island Cocos (Keeling) Islands Colombia Comoros Cook Islands Coral Sea Islands Costa Rica Cote D'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Democratic Republic of the Congo Denmark Dhekelia Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Europa Island Falkland Islands (Islas Malvinas) Faroe Islands Federated States of Micronesia Fiji Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gaza Strip Georgia Germany Ghana Gibraltar Glorioso Islands Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-bissau Guyana Haiti Heard Island and Mcdonald Islands Holy See (Vatican City) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Jan Mayen Japan Jersey Jordan Juan De Nova Island Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Navassa Island Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paracel Islands Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Republic of the Congo Reunion Romania Russia Rwanda Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Spratly Islands Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Timor-leste Togo Tokelau Tonga Trinidad and Tobago Tromelin Island Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands Wake Island Wallis and Futuna West Bank Western Sahara Yemen Zambia Zimbabwe United States Country * Regulated by DOT- Part 40? * -Select- Yes no -Select- * DOT Agency (mode) -Select- Please Select| FMCSA PHMSA USCG FAA FRA FTA -Select- * How do you wish to schedule test/service* * Schedule/order test through your personalized portal yourself Phone (800)488-5350 Email orders@securescreenings.com ALL * Testing Purpose * Pre Employment Random Post Accident Reasonable Suspicion Other * Testing Services * Urine Testing Alcohol Testing Hair Testing Oral Fluid Testing Blood Testing * Testing Panel * 5 panel DOT 5 panel 5 Panel Instant 5 panel + expanded opiates 10 panel 10 Panel Instant 10 panel + expanded opiates 12 panel 14 panel Customized test * Additional Services * DOT Consortium Membership Physicals Background Checks Drug Free Work Place Program Random Testing Program Drug Free Work Place Policy Reasonable Suspicion Supervisor Training On Site / Mobile Testing TPA / Third Party Administrator Motor Vehicle Reports / MVR None Required At This Time * Terms and Conditions I am authorized to establish an account with Secure Screenings and authorize Secure Screenings to activate an account for drug, alcohol or additional testing services. I accept the Terms and Conditions. * Signature Clear * Credit Card Authorization * First Last A valid credit card must be maintained on file and will only be charged for invoices that are 30 days past due. Accredited Drug Testing members will automatically receive a 5% discount on all tests and services. Invoices due within 30 days * CC Number * * Expiration Date * * Sec Code * * Billing Zip Code * * Billing Phone * * Invoice Method * -Select- Invoice My Company (net 30 days) Charge Card on File 1st of each month -Select- * Form Completed * Next 1/3 * Back Next 2/3 * Back Submit 3/3 ERROR OCCURRED! You haven't verified your email yet, click here to receive a verification email. OK OK Retry Cancel That CAPTCHA was incorrect. Your form has been deactivated. Contact support@zohoforms.com for further information. Submitting... Please Wait... Saving... Redirecting to Merchant Website.. Verifying Credit Card Details... Please wait... Verification Code Enter the text in the box below Continue Verification mail sent. LINK TO RESUME THIS FORM LATER: Email Link to Send Please enter a valid email address to configure Zoho Sign settings. Copy Link Copied to clipboard. * * * Done TURN ON THE CAMERA PERMISSION IN YOUR BROWSER TO CONTINUE FURTHER