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URL:
https://www.emailmeform.com/builder/form/04bfmc0f8BqpR8WAv6PFajZ0
Submission: On September 10 via manual from CA — Scanned from CA
Submission: On September 10 via manual from CA — Scanned from CA
Form analysis 1 forms found in the DOM
POST https://www.emailmeform.com/builder/form/04bfmc0f8BqpR8WAv6PFajZ0
<form id="emf-form" target="_self" class="leftLabel" enctype="multipart/form-data" method="post" action="https://www.emailmeform.com/builder/form/04bfmc0f8BqpR8WAv6PFajZ0">
<div id="emf-form-instruction" class="emf-head-widget">
<div id="emf-form-description">3rd Annual Tax Liability Insurance ExecuSummit<br> October 8 & 9, 2024<br> Mohegan Sun Hotel & Convention Center, Uncasville, CT</div>
</div>
<ul>
<li id="emf-li-0" class="emf-li-field emf-field-Image cell_align_left">
<label class="emf-label-desc" for="element_0">Welcome! Register online with our Secure 256-bit SSL Encryption. If you have any questions please feel free to contact us at 800-905-9357 x 705</label>
<div class="emf-div-field"><img id="element_0" name="element_0" src="https://files.emailmeform.com/1021530/UT4qfCF0/ES-LOGO-2015-FORM.jpg" style="width:413px;height:171px;border:0;" title="" alt="" class="validate[optional]"></div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-1" class="emf-li-field emf-field-section_break cell_align_left">
<div class="emf-div-field-section">
<div class="emf-section-separator"></div>
<h3 id="element_1" name="element_1"></h3>
<div class="emf-section-text">The Earlier Your Register the More You Save:</div>
</div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-2" class="emf-li-field emf-field-new_checkbox data_container cell_align_left">
<label class="emf-label-desc" for="element_2"> <span>*</span></label>
<div class="emf-div-field">
<div my_choice_order_type="">
<div class="one_column"><input id="element_2_0" name="element_2[]" value="Please Register Me for the 3rd Annual Tax Liability Insurance ExecuSummit *** October 8 & 9, 2024 *** Mohegan Sun Hotel & Convention Center, Uncasville, CT"
class="validate[required]" checked="checked" type="checkbox"><label class="padleft-w5" for="element_2_0">Please Register Me for the 3rd Annual Tax Liability Insurance ExecuSummit *** October 8 & 9, 2024 *** Mohegan Sun Hotel &
Convention Center, Uncasville, CT</label></div>
</div>
</div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-3" class="emf-li-field emf-field-new_checkbox data_container cell_align_left">
<label class="emf-label-desc" for="element_3"> <span>*</span></label>
<div class="emf-div-field">
<div my_choice_order_type="">
<div class="one_column"><input id="element_3_0" name="element_3[]" value="Early-Bird Promotion: Register through September 10, 2024 .........................$ 849.00" class="validate[required]" checked="checked" type="checkbox"><label
class="padleft-w5" for="element_3_0">Early-Bird Promotion: Register through September 10, 2024 .........................$ 849.00</label></div>
</div>
<div class="emf-div-instruction">You Save $146 of Regular Registration.</div>
</div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-4" class="emf-li-field emf-field-new_checkbox data_container cell_align_left">
<label class="emf-label-desc" for="element_4"></label>
<div class="emf-div-field">
<div my_choice_order_type="">
<div class="one_column"><input id="element_4_0" name="element_4[]" value=" Register September 11, 2024 through Conference: Regular ExecuSummit Registration: $ 995.00" class="validate[optional]" type="checkbox"><label class="padleft-w5"
for="element_4_0"> Register September 11, 2024 through Conference: Regular ExecuSummit Registration: $ 995.00</label></div>
</div>
<div class="emf-div-instruction">Regular Registration Rate</div>
</div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-5" class="emf-li-field emf-field-section_break cell_align_left">
<div class="emf-div-field-section">
<div class="emf-section-separator"></div>
<h3 id="element_5" name="element_5">Attendee Information:</h3>
</div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-6" class="emf-li-field emf-field-email data_container cell_align_left">
<label class="emf-label-desc" for="element_6">Email: <span>*</span></label>
<div class="emf-div-field"><input id="element_6" name="element_6" class="validate[required,custom[email]]" value="" size="60" type="text"></div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-7" class="emf-li-field emf-field-text data_container cell_align_left">
<label class="emf-label-desc" for="element_7">First Name: <span>*</span></label>
<div class="emf-div-field"><input id="element_7" name="element_7" value="" size="60" type="text" class="validate[required]"></div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-8" class="emf-li-field emf-field-text data_container cell_align_left">
<label class="emf-label-desc" for="element_8">Last Name: <span>*</span></label>
<div class="emf-div-field"><input id="element_8" name="element_8" value="" size="60" type="text" class="validate[required]"></div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-9" class="emf-li-field emf-field-text data_container cell_align_left">
<label class="emf-label-desc" for="element_9">Title/Position: <span>*</span></label>
<div class="emf-div-field"><input id="element_9" name="element_9" value="" size="60" type="text" class="validate[required]"></div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-10" class="emf-li-field emf-field-text data_container cell_align_left">
<label class="emf-label-desc" for="element_10">Company Name: <span>*</span></label>
<div class="emf-div-field"><input id="element_10" name="element_10" value="" size="60" type="text" class="validate[required]"></div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-11" class="emf-li-field emf-field-text data_container ">
<label class="emf-label-desc" for="element_11">Office Address: <span>*</span></label>
<div class="emf-div-field"><input id="element_11" name="element_11" value="" size="60" type="text" class="validate[required]"></div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-12" class="emf-li-field emf-field-text data_container ">
<label class="emf-label-desc" for="element_12">City: <span>*</span></label>
<div class="emf-div-field"><input id="element_12" name="element_12" value="" size="60" type="text" class="validate[required]"></div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-13" class="emf-li-field emf-field-text data_container ">
<label class="emf-label-desc" for="element_13">State / Province /Region: <span>*</span></label>
<div class="emf-div-field"><input id="element_13" name="element_13" value="" size="60" type="text" class="validate[required]"></div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-14" class="emf-li-field emf-field-text data_container ">
<label class="emf-label-desc" for="element_14">Postal / ZIP Code: <span>*</span></label>
<div class="emf-div-field"><input id="element_14" name="element_14" value="" size="30" type="text" class="validate[required]"></div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-15" class="emf-li-field emf-field-text data_container ">
<label class="emf-label-desc" for="element_15">Country / Region: <span>*</span></label>
<div class="emf-div-field"><input id="element_15" name="element_15" value="" size="30" type="text" class="validate[required]"></div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-16" class="emf-li-field emf-field-phone data_container cell_align_left">
<label class="emf-label-desc" for="element_16">Phone: <span>*</span></label>
<div class="emf-div-field">
<span>
<input maxlength="3" value="" id="element_16_1" name="element_16[]" type="text" class="emf-input-w30 validate[required,custom[onlyNumber],length[3,3]]">
<label for="element_16_1" class="emf-bottom-label">###</label>
</span><span class="emf-sep">-</span><span>
<input maxlength="3" value="" id="element_16_2" name="element_16[]" type="text" class="emf-input-w30 validate[required,custom[onlyNumber],length[3,3]]">
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</span><span class="emf-sep">-</span><span>
<input maxlength="4" value="" id="element_16_3" name="element_16[]" type="text" class="emf-input-w40 validate[required,custom[onlyNumber],length[4,4]]">
<label for="element_16_3" class="emf-bottom-label">####</label>
</span>
</div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-17" class="emf-li-field emf-field-email data_container cell_align_left">
<label class="emf-label-desc" for="element_17">CC this e-mail on Confirmation:</label>
<div class="emf-div-field"><input id="element_17" name="element_17" class="validate[optional,custom[email]]" value="" size="60" type="text">
<div class="emf-div-instruction">Enter a different e-mail here if you would like to be cc'd on e-confirmation</div>
</div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-18" class="emf-li-field emf-field-section_break cell_align_left">
<div class="emf-div-field-section">
<div class="emf-section-separator"></div>
<h3 id="element_18" name="element_18">Select Method of Payment:</h3>
</div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-19" class="emf-li-field emf-field-credit_card data_container ">
<label class="emf-label-desc" for="element_19">Credit Card <span>*</span></label>
<div class="emf-div-field" onclick="">
<link href="/builder/css/vendor/validation.css" rel="stylesheet">
<link href="/builder/css/vault/form.css" rel="stylesheet">
<script src="/builder/js/vendor/validation.min.js"></script>
<script src="https://vault.emailmeform.com/vault.js?rls=master"></script>
<script type="text/javascript">
window.VAULT_PRIMARY_TOKENIZATION_PROVIDER = "tokenex-0";
</script>
<script type="text/javascript">
window.VAULT_FALLBACK_TOKENIZATION_PROVIDER = "undefined";
</script>
<script type="text/javascript">
window.VAULT_ENABLE_FALLBACK_PROVIDER = false;
</script>
<script src="/builder/js/vault/form.js"></script>
<script id="tpl-vault-loader" type="text/template"> <div id="vault-loader" class="hidden">
<div class="indicator">
<img src="/images/small-loading-animation-4.gif"/>
<span class="message">Encrypting form data.</span>
</div>
</div>
</script>
<!-- REVIEW: [Mousetraps] CC fields after vault is disabled -->
<script id="tpl-vault-warning" type="text/template"> <div id="vault-warning" class="hidden">
<div class="overlay-content">
<div class="message-warning">
It is no longer safe to submit credit card information through this form as Vault:PCI has been disabled on this account.<br>
Please contact the form owner and ask to enable Vault on this form.
</div>
<div style="margin-top: 30px; text-align: center;">
<button class="btn btn-primary" onclick="javascript:document.getElementById('vault-warning').classList.add('hidden');">Continue at your own risk</button>
</div>
</div>
</div>
</script>
<div id="vault_19" class="widget-form--vault vault-widget" data-type="card" data-title="Credit Card" data-required="1" data-index="19" data-mode="create" data-styles="{"input":[]}"
data-errors="{"required":"This field is required"}" data-hide-exp="0" data-hide-cvv="0">
<input id="element_19" name="element_19" value="" type="hidden">
<div class="widget-form--vault">
<div class="two_column">
<label class="emf-label-desc" for="">Card Number</label>
<div class="number fake--input hf--md validate-class vault-field" data-type="number" data-error="Invalid card number">
<span class="creditcard--logo"></span>
<iframe src="https://vault.emailmeform.com/frame.html#0ffe8dea-237b-4947-a609-dabbf3b36b76" frameborder="0" allowtransparency="true" scrolling="no" name="emf-vault-number" type="number" id="emf-vault-number"></iframe>
</div>
</div>
<div class="two_column">
<span class="elin exp-block" style="visibility: visible;">
<label class="emf-label-desc" for=""> Expiration </label>
<span class="emf-field-datetime-month elin">
<div class="exp-month fake--input emf-input-w30 validate-class vault-field" data-type="expMonth" data-error="Invalid expiration date">
<iframe src="https://vault.emailmeform.com/frame.html#0ffe8dea-237b-4947-a609-dabbf3b36b76" frameborder="0" allowtransparency="true" scrolling="no" name="emf-vault-expMonth" type="expMonth" id="emf-vault-expMonth"></iframe>
</div>
<label for="element_1_year-mm" class="emf-bottom-label">MM</label>
</span>
<span class="emf-sep elin">/</span>
<span class="emf-field-datetime-year elin">
<div class="exp-year fake--input emf-input-w30 validate-class vault-field" data-type="expYear" data-error="Invalid expiration date">
<iframe src="https://vault.emailmeform.com/frame.html#0ffe8dea-237b-4947-a609-dabbf3b36b76" frameborder="0" allowtransparency="true" scrolling="no" name="emf-vault-expYear" type="expYear" id="emf-vault-expYear"></iframe>
</div>
<label for="element_1_year" class="emf-bottom-label">YY</label>
</span>
</span>
<span class="elin cvv-block" style="visibility: visible;">
<label class="emf-label-desc" for=""> CVV </label>
<div class="cvv fake--input emf-input-w40 validate-class vault-field" data-type="cvv" data-error="Invalid CVV">
<iframe src="https://vault.emailmeform.com/frame.html#0ffe8dea-237b-4947-a609-dabbf3b36b76" frameborder="0" allowtransparency="true" scrolling="no" name="emf-vault-cvv" type="cvv" id="emf-vault-cvv"></iframe>
</div>
<a href="javascript:void(0);" class="link--wtf has-tooltip">
What is this? <i class="tooltip--custom bl">3 or 4 digit number printed on the back/front of your credit card</i>
</a>
</span>
</div>
<div class="emf-clear"></div>
</div>
</div>
<div class="vault-protected has-tooltip">
<svg style="width:16px;height:16px" viewBox="0 0 24 24">
<path fill="#666"
d="M12,17A2,2 0 0,0 14,15C14,13.89 13.1,13 12,13A2,2 0 0,0 10,15A2,2 0 0,0 12,17M18,8A2,2 0 0,1 20,10V20A2,2 0 0,1 18,22H6A2,2 0 0,1 4,20V10C4,8.89 4.9,8 6,8H7V6A5,5 0 0,1 12,1A5,5 0 0,1 17,6V8H18M12,3A3,3 0 0,0 9,6V8H15V6A3,3 0 0,0 12,3Z">
</path>
</svg>
<span>Protected in vault</span>
<i class="tooltip--custom" style="width: 200px;">Data collected via fields that have our security seal are encrypted and stored with the highest global security standard — PCI compliance. Your data is absolutely safe in Vault.</i>
</div>
</div>
</li>
<li id="emf-li-20" class="emf-li-field emf-field-text data_container cell_align_left">
<label class="emf-label-desc" for="element_20">Name as Appears on Card: <span>*</span></label>
<div class="emf-div-field"><input id="element_20" name="element_20" value="" size="60" type="text" class="validate[required]"></div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-21" class="emf-li-field emf-field-text data_container cell_align_left">
<label class="emf-label-desc" for="element_21">Card Billing Address: <span>*</span></label>
<div class="emf-div-field"><input id="element_21" name="element_21" value="" size="60" type="text" class="validate[required]"></div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-22" class="emf-li-field emf-field-text data_container cell_align_left">
<label class="emf-label-desc" for="element_22">Card Billing Address Line 2:</label>
<div class="emf-div-field"><input id="element_22" name="element_22" value="" size="60" type="text" class="validate[optional]"></div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-23" class="emf-li-field emf-field-text data_container cell_align_left">
<label class="emf-label-desc" for="element_23">City: <span>*</span></label>
<div class="emf-div-field"><input id="element_23" name="element_23" value="" size="60" type="text" class="validate[required]"></div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-24" class="emf-li-field emf-field-text data_container cell_align_left">
<label class="emf-label-desc" for="element_24">State / Province /Region: <span>*</span></label>
<div class="emf-div-field"><input id="element_24" name="element_24" value="" size="60" type="text" class="validate[required]"></div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-25" class="emf-li-field emf-field-text data_container cell_align_left">
<label class="emf-label-desc" for="element_25">Postal / ZIP Code: <span>*</span></label>
<div class="emf-div-field"><input id="element_25" name="element_25" value="" size="60" type="text" class="validate[required]"></div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-26" class="emf-li-field emf-field-text data_container cell_align_left">
<label class="emf-label-desc" for="element_26">Country / Region: <span>*</span></label>
<div class="emf-div-field"><input id="element_26" name="element_26" value="" size="60" type="text" class="validate[required]"></div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-27" class="emf-li-field emf-field-section_break cell_align_left">
<div class="emf-div-field-section">
<div class="emf-section-separator"></div>
<h3 id="element_27" name="element_27">EVENT VENUE - LOCATION INFORMATION:</h3>
<div class="emf-section-text">Mohegan Sun<br> 1 Mohegan Sun Blvd<br> Uncasville, CT 06382<br>
<br> Your confirmation will provide our preferred rate code and phone number as well as a link to book your room online.
</div>
</div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-28" class="emf-li-field emf-field-section_break cell_align_left">
<div class="emf-div-field-section">
<div class="emf-section-separator"></div>
<h3 id="element_28" name="element_28">Group Rates Available</h3>
<div class="emf-section-text">SAVE!!! Special Promotional Pricing for groups of 4 or more.<br> Register 3 delegates and Receive a 4th registration for the same event at no charge<br>
</div>
</div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-29" class="emf-li-field emf-field-section_break cell_align_left">
<div class="emf-div-field-section">
<div class="emf-section-separator"></div>
<h3 id="element_29" name="element_29"></h3>
<div class="emf-section-text">Registration for this ExecuSummit includes presentation documentation provided by speakers and presented in PDF form, on the event attendee website,Post Summit-Materials, breakfast, Networking luncheon &
refreshment breaks & cocktail reception.<br>
<br> Dress Attire: Business Casual.
</div>
</div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-30" class="emf-li-field emf-field-new_checkbox data_container cell_align_left">
<label class="emf-label-desc" for="element_30">Should you be unable to attend, a prompt refund less an administrative fee of $150 will be made for cancellations received in writing by September 9, 2024. There will be no refunds due to
cancellations received after September 9, 2024. Non-Payment does not constitute a cancellation. You may transfer your registration anytime without admin fee. ExecuSummit event name badges must be worn at all times to attend our general
session, event networking functions and/or exhibit area. In the unlikely event this program is cancelled, ExecuSummit is not responsible for any airfare, hotel or other costs incurred by registrants. Every effort is made to ensure the
speakers in our agenda appear, but speakers, agenda & other events are subject to change without notice. <span>*</span></label>
<div class="emf-div-field">
<div my_choice_order_type="">
<div class="one_column"><input id="element_30_0" name="element_30[]" value="By checking this box I have reviewed, agree to all terms and conditions above and authorize you to charge the credit card info above for the registration fee. "
class="validate[required]" type="checkbox"><label class="padleft-w5" for="element_30_0">By checking this box I have reviewed, agree to all terms and conditions above and authorize you to charge the credit card info above for the
registration fee. </label></div>
</div>
<div class="emf-div-instruction">This box must be checked for your registration to be processed. </div>
</div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-31" class="emf-li-field emf-field-section_break cell_align_left">
<div class="emf-div-field-section">
<div class="emf-section-separator"></div>
<h3 id="element_31" name="element_31"></h3>
<div class="emf-section-text">Please fill in the field below and click the submit button. <br>
<br> A confirmation will be e-mailed back to you shortly. <br>
<br> Please only hit submit once to avoid duplicate registrations.<br>
<br> Thank you for registering!
</div>
</div>
<div class="emf-clear"></div>
</li>
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EmailMeForm 3rd Annual Tax Liability Insurance ExecuSummit October 8 & 9, 2024 Mohegan Sun Hotel & Convention Center, Uncasville, CT * Welcome! Register online with our Secure 256-bit SSL Encryption. If you have any questions please feel free to contact us at 800-905-9357 x 705 * The Earlier Your Register the More You Save: * * Please Register Me for the 3rd Annual Tax Liability Insurance ExecuSummit *** October 8 & 9, 2024 *** Mohegan Sun Hotel & Convention Center, Uncasville, CT * * Early-Bird Promotion: Register through September 10, 2024 .........................$ 849.00 You Save $146 of Regular Registration. * Register September 11, 2024 through Conference: Regular ExecuSummit Registration: $ 995.00 Regular Registration Rate * ATTENDEE INFORMATION: * Email: * * First Name: * * Last Name: * * Title/Position: * * Company Name: * * Office Address: * * City: * * State / Province /Region: * * Postal / ZIP Code: * * Country / Region: * * Phone: * ### - ### - #### * CC this e-mail on Confirmation: Enter a different e-mail here if you would like to be cc'd on e-confirmation * SELECT METHOD OF PAYMENT: * Credit Card * Card Number Expiration MM / YY CVV What is this? 3 or 4 digit number printed on the back/front of your credit card Protected in vault Data collected via fields that have our security seal are encrypted and stored with the highest global security standard — PCI compliance. Your data is absolutely safe in Vault. * Name as Appears on Card: * * Card Billing Address: * * Card Billing Address Line 2: * City: * * State / Province /Region: * * Postal / ZIP Code: * * Country / Region: * * EVENT VENUE - LOCATION INFORMATION: Mohegan Sun 1 Mohegan Sun Blvd Uncasville, CT 06382 Your confirmation will provide our preferred rate code and phone number as well as a link to book your room online. * GROUP RATES AVAILABLE SAVE!!! Special Promotional Pricing for groups of 4 or more. Register 3 delegates and Receive a 4th registration for the same event at no charge * Registration for this ExecuSummit includes presentation documentation provided by speakers and presented in PDF form, on the event attendee website,Post Summit-Materials, breakfast, Networking luncheon & refreshment breaks & cocktail reception. Dress Attire: Business Casual. * Should you be unable to attend, a prompt refund less an administrative fee of $150 will be made for cancellations received in writing by September 9, 2024. There will be no refunds due to cancellations received after September 9, 2024. Non-Payment does not constitute a cancellation. You may transfer your registration anytime without admin fee. ExecuSummit event name badges must be worn at all times to attend our general session, event networking functions and/or exhibit area. In the unlikely event this program is cancelled, ExecuSummit is not responsible for any airfare, hotel or other costs incurred by registrants. Every effort is made to ensure the speakers in our agenda appear, but speakers, agenda & other events are subject to change without notice. * By checking this box I have reviewed, agree to all terms and conditions above and authorize you to charge the credit card info above for the registration fee. This box must be checked for your registration to be processed. * Please fill in the field below and click the submit button. A confirmation will be e-mailed back to you shortly. Please only hit submit once to avoid duplicate registrations. Thank you for registering! * * Encrypting form data.