app.smartsheet.com
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34.238.65.53
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Submitted URL: https://track.govresource.com/z.z?l=aHR0cHM6Ly9hcHAuc21hcnRzaGVldC5jb20vYi9mb3JtL2RmNTIwODZhNjg4OTRiYzBhZTU4N2RjOTQ3MTU0NDcw&j...
Effective URL: https://app.smartsheet.com/b/form/df52086a68894bc0ae587dc947154470?MassEmailID=363318095&email_id=646&emailaddress=dhosmer%...
Submission: On June 26 via api from US — Scanned from DE
Effective URL: https://app.smartsheet.com/b/form/df52086a68894bc0ae587dc947154470?MassEmailID=363318095&email_id=646&emailaddress=dhosmer%...
Submission: On June 26 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
<form>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Name" data-client-type="text" id="GjNlX9b" class="css-1e3khfm ef83ajd0"><label for="text_box_Name" data-client-id="label_Name" class="css-1xl1v40 ekxsfat0">Name<span data-client-id="required_indicator"
class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Name" data-client-id="text_box_Name" data-client-type="" name="GjNlX9b" maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Employer/Agency" data-client-type="text" id="6drMK7r" class="css-1e3khfm ef83ajd0"><label for="text_box_Employer/Agency" data-client-id="label_Employer/Agency" class="css-1xl1v40 ekxsfat0">Employer/Agency<span
data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Employer/Agency" data-client-id="text_box_Employer/Agency" data-client-type="" name="6drMK7r" maxlength="4000" class="css-1p0590h e1407lhe0" value="">
</div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div role="application" title="" data-client-id="container_State" data-client-type="dropdown" id="3nrOAog" class="css-u3yn36 ef83ajd0"><label for="select_input_State" id="5f18fbd8-eb36-4068-9628-f735df8ad9e6" data-client-id="label_State"
class="css-1xl1v40 ekxsfat0">State<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div class="css-t8xanh-container">
<div class="css-kf2egt-control react-select__control">
<div class="css-11ksah1 react-select__value-container">
<div class="css-1i5h0xy-placeholder react-select__placeholder">Select or enter value</div>
<div class="css-1g6gooi">
<div class="react-select__input" style="display: inline-block;"><input autocapitalize="none" autocomplete="off" autocorrect="off" id="select_input_State" spellcheck="false" tabindex="0" type="text" aria-label="Select or enter value"
aria-labelledby="5f18fbd8-eb36-4068-9628-f735df8ad9e6" value="" style="box-sizing: content-box; width: 2px; background: 0px center; border: 0px; font-size: inherit; opacity: 1; outline: 0px; padding: 0px; color: inherit;">
<div
style="position: absolute; top: 0px; left: 0px; visibility: hidden; height: 0px; overflow: scroll; white-space: pre; font-size: 13px; font-family: Arial; font-weight: 400; font-style: normal; letter-spacing: normal; text-transform: none;">
</div>
</div>
</div>
</div>
<div class="css-1wy0on6 react-select__indicators"><span class="css-9lpq22-indicatorSeparator react-select__indicator-separator"></span><span style="margin-right: 6px;"><svg data-client-id="caret_icon" width="16px" height="16px"
viewBox="0 0 16 16" version="1.1" role="img" xmlns="http://www.w3.org/2000/svg">
<title>Caret Icon</title>
<desc>Caret symbol</desc>
<g stroke="none" stroke-width="1" fill="none" fill-rule="evenodd">
<g fill="#161616">
<path
d="M8.38951287,9.81740951 C8.3743818,9.83527284 8.35811596,9.85207547 8.34082332,9.86770589 C8.12569934,10.0621513 7.79871352,10.0396329 7.61048004,9.81740951 L5.12806062,6.88673235 C5.04550447,6.78926879 5,6.66416424 5,6.53465776 C5,6.23937443 5.23172713,6 5.51757703,6 L10.4824159,6 C10.607785,6 10.7288928,6.04700617 10.8232427,6.13228679 C11.0383667,6.32673222 11.0601658,6.664509 10.8719323,6.88673235 L8.38951287,9.81740951 Z">
</path>
</g>
</g>
</svg></span></div>
</div>
</div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div role="application" title="" data-client-id="container_Type of Plan(s)" data-client-type="dropdown" id="aj2ORkX" class="css-u3yn36 ef83ajd0"><label for="select_input_Type of Plan(s)" id="63f8fa9b-8134-479f-877a-b25f362882ac"
data-client-id="label_Type of Plan(s)" class="css-1xl1v40 ekxsfat0">Type of Plan(s)<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div class="css-t8xanh-container">
<div class="css-kf2egt-control react-select__control">
<div class="css-11ksah1 react-select__value-container react-select__value-container--is-multi">
<div class="css-1i5h0xy-placeholder react-select__placeholder">Select or enter value</div>
<div class="css-1g6gooi">
<div class="react-select__input" style="display: inline-block;"><input autocapitalize="none" autocomplete="off" autocorrect="off" id="select_input_Type of Plan(s)" spellcheck="false" tabindex="0" type="text"
aria-label="Select or enter value" aria-labelledby="63f8fa9b-8134-479f-877a-b25f362882ac" value=""
style="box-sizing: content-box; width: 2px; background: 0px center; border: 0px; font-size: inherit; opacity: 1; outline: 0px; padding: 0px; color: inherit;">
<div
style="position: absolute; top: 0px; left: 0px; visibility: hidden; height: 0px; overflow: scroll; white-space: pre; font-size: 13px; font-family: Arial; font-weight: 400; font-style: normal; letter-spacing: normal; text-transform: none;">
</div>
</div>
</div>
</div>
<div class="css-1wy0on6 react-select__indicators"><span class="css-9lpq22-indicatorSeparator react-select__indicator-separator"></span><span style="margin-right: 6px;"><svg data-client-id="caret_icon" width="16px" height="16px"
viewBox="0 0 16 16" version="1.1" role="img" xmlns="http://www.w3.org/2000/svg">
<title>Caret Icon</title>
<desc>Caret symbol</desc>
<g stroke="none" stroke-width="1" fill="none" fill-rule="evenodd">
<g fill="#161616">
<path
d="M8.38951287,9.81740951 C8.3743818,9.83527284 8.35811596,9.85207547 8.34082332,9.86770589 C8.12569934,10.0621513 7.79871352,10.0396329 7.61048004,9.81740951 L5.12806062,6.88673235 C5.04550447,6.78926879 5,6.66416424 5,6.53465776 C5,6.23937443 5.23172713,6 5.51757703,6 L10.4824159,6 C10.607785,6 10.7288928,6.04700617 10.8232427,6.13228679 C11.0383667,6.32673222 11.0601658,6.664509 10.8719323,6.88673235 L8.38951287,9.81740951 Z">
</path>
</g>
</g>
</svg></span></div>
</div>
</div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div role="application" title="" data-client-id="container_Your Pension System (and Tier if Applicable)" data-client-type="dropdown" id="eOLg122" class="css-u3yn36 ef83ajd0"><label for="select_input_Your Pension System (and Tier if Applicable)"
id="be67082b-7001-4818-9a75-56dae943dc3b" data-client-id="label_Your Pension System (and Tier if Applicable)" class="css-1xl1v40 ekxsfat0">Your Pension System (and Tier if Applicable)</label>
<div class="css-t8xanh-container">
<div class="css-kf2egt-control react-select__control">
<div class="css-11ksah1 react-select__value-container react-select__value-container--is-multi">
<div class="css-1i5h0xy-placeholder react-select__placeholder">Select or enter value</div>
<div class="css-1g6gooi">
<div class="react-select__input" style="display: inline-block;"><input autocapitalize="none" autocomplete="off" autocorrect="off" id="select_input_Your Pension System (and Tier if Applicable)" spellcheck="false" tabindex="0" type="text"
aria-label="Select or enter value" aria-labelledby="be67082b-7001-4818-9a75-56dae943dc3b" value=""
style="box-sizing: content-box; width: 2px; background: 0px center; border: 0px; font-size: inherit; opacity: 1; outline: 0px; padding: 0px; color: inherit;">
<div
style="position: absolute; top: 0px; left: 0px; visibility: hidden; height: 0px; overflow: scroll; white-space: pre; font-size: 13px; font-family: Arial; font-weight: 400; font-style: normal; letter-spacing: normal; text-transform: none;">
</div>
</div>
</div>
</div>
<div class="css-1wy0on6 react-select__indicators"><span class="css-9lpq22-indicatorSeparator react-select__indicator-separator"></span><span style="margin-right: 6px;"><svg data-client-id="caret_icon" width="16px" height="16px"
viewBox="0 0 16 16" version="1.1" role="img" xmlns="http://www.w3.org/2000/svg">
<title>Caret Icon</title>
<desc>Caret symbol</desc>
<g stroke="none" stroke-width="1" fill="none" fill-rule="evenodd">
<g fill="#161616">
<path
d="M8.38951287,9.81740951 C8.3743818,9.83527284 8.35811596,9.85207547 8.34082332,9.86770589 C8.12569934,10.0621513 7.79871352,10.0396329 7.61048004,9.81740951 L5.12806062,6.88673235 C5.04550447,6.78926879 5,6.66416424 5,6.53465776 C5,6.23937443 5.23172713,6 5.51757703,6 L10.4824159,6 C10.607785,6 10.7288928,6.04700617 10.8232427,6.13228679 C11.0383667,6.32673222 11.0601658,6.664509 10.8719323,6.88673235 L8.38951287,9.81740951 Z">
</path>
</g>
</g>
</svg></span></div>
</div>
</div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Other Pension Option (Ex. DROP/ORP)" data-client-type="text" id="7kOG202" class="css-1e3khfm ef83ajd0"><label for="text_box_Other Pension Option (Ex. DROP/ORP)"
data-client-id="label_Other Pension Option (Ex. DROP/ORP)" class="css-1xl1v40 ekxsfat0">Other Pension Option (Ex. DROP/ORP)</label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Other Pension Option (Ex. DROP/ORP)" data-client-id="text_box_Other Pension Option (Ex. DROP/ORP)" data-client-type="" name="7kOG202" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Date of Birth" data-client-type="date" id="MeGjRpy" class="css-gbq6lm ef83ajd0"><label for="date_Date of Birth" data-client-id="label_Date of Birth" class="css-1xl1v40 ekxsfat0">Date of Birth<span
data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div class="css-1f92r3b"><input data-client-id="date_Date of Birth" id="date_Date of Birth" aria-label="Date of Birth" tabindex="0" name="Date of Birth" maxlength="100" class="css-1dpiipj epidubd0" value=""><button tabindex="0" type="button"
aria-label="Choose" class="css-17q24xo"><span title="Choose a date" class="css-14atay6 e1yrjtds0"><svg xmlns="http://www.w3.org/2000/svg" role="img" width="16" height="16" viewBox="0 0 16 16">
<title>Calendar Icon</title>
<desc>Calendar</desc>
<g fill="none" fill-rule="evenodd">
<rect width="13" height="13" x="2" y="2" fill="#005EE0" rx="1"></rect>
<path fill="#FFF"
d="M11.648 12h-.96V8.38c-.351.328-.765.571-1.241.728v-.871c.25-.082.523-.238.817-.467.294-.229.495-.496.605-.801h.779V12zm-6.385-1.33l.93-.112c.03.237.11.418.24.543.129.125.286.188.47.188a.648.648 0 0 0 .502-.226c.135-.15.203-.353.203-.608 0-.241-.065-.433-.195-.574a.621.621 0 0 0-.475-.212c-.123 0-.27.024-.44.072l.105-.783c.26.007.458-.05.595-.17a.602.602 0 0 0 .205-.476.545.545 0 0 0-.15-.403.54.54 0 0 0-.4-.15.579.579 0 0 0-.42.17c-.117.114-.188.28-.213.5l-.885-.151c.061-.303.154-.545.279-.726.124-.182.297-.324.52-.428.221-.103.47-.155.746-.155.472 0 .85.15 1.135.45.234.247.352.525.352.835 0 .44-.24.79-.721 1.053.287.061.516.199.688.413a1.2 1.2 0 0 1 .258.776c0 .44-.16.815-.482 1.125-.32.31-.72.464-1.2.464-.453 0-.829-.13-1.127-.39a1.538 1.538 0 0 1-.52-1.025zM11 5a1 1 0 1 1 0-2 1 1 0 0 1 0 2zM6 5a1 1 0 1 1 0-2 1 1 0 0 1 0 2z">
</path>
</g>
</svg></span></button></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Customer phone" data-client-type="text" id="PqaRXN1" class="css-1e3khfm ef83ajd0"><label for="text_box_Customer phone" data-client-id="label_Customer phone" class="css-1xl1v40 ekxsfat0">Customer phone<span
data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Customer phone" data-client-id="text_box_Customer phone" data-client-type="" name="PqaRXN1" maxlength="4000" class="css-1p0590h e1407lhe0" value="">
</div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Customer email" data-client-type="text" id="o6ednzO" class="css-1e3khfm ef83ajd0"><label for="text_box_Customer email" data-client-id="label_Customer email" class="css-1xl1v40 ekxsfat0">Customer email<span
data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Customer email" data-client-id="text_box_Customer email" data-client-type="" name="o6ednzO" maxlength="4000" class="css-1p0590h e1407lhe0" value="">
</div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Specific Questions" data-client-type="text" id="5dre9aG" class="css-1e3khfm ef83ajd0"><label for="text_box_Specific Questions" data-client-id="label_Specific Questions" class="css-1xl1v40 ekxsfat0">Specific
Questions<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Specific Questions" data-client-id="text_box_Specific Questions" data-client-type="" name="5dre9aG" maxlength="4000" class="css-1p0590h e1407lhe0"
value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Job Title" data-client-type="text" id="9n0RJjM" class="css-1e3khfm ef83ajd0"><label for="text_box_Job Title" data-client-id="label_Job Title" class="css-1xl1v40 ekxsfat0">Job Title<span
data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Job Title" data-client-id="text_box_Job Title" data-client-type="" name="9n0RJjM" maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="email_receipt_section">
<div data-client-id="container_email_receipt" data-client-type="divider" class="css-1e2fy0l e14sboee0">
<hr data-client-id="email_receipt" class="css-1xs1ymt e14sboee2">
</div>
<div class="css-1gl0c9l excyp8g0"><label class="css-1y93uaa excyp8g1"><input data-client-id="email_receipt_checkbox" name="EMAIL_RECEIPT_CHECKBOX" type="checkbox" class="css-1czgm8r excyp8g2" value="false"><span>Send me a copy of my
responses</span></label></div>
</div>
</div>
<div class="css-1ock8o4 e1xpzprc2"><button data-client-id="form_submit_btn" disabled="" type="submit" value="submit" class="css-oltpmt e1xpzprc0"><span>Submit</span></button></div>
<div data-client-id="footer" class="css-ybae4b e8i4qwl0">
<div class="css-1kw6mnl e8i4qwl1">
<div class="css-qoiejo e8i4qwl3"><span>Powered by
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