fs23.formsite.com Open in urlscan Pro
54.89.35.75  Public Scan

URL: https://fs23.formsite.com/GYLA1E/xcw1eamci8/index.html
Submission: On October 19 via api from US — Scanned from DE

Form analysis 1 forms found in the DOM

POST https://fs23.formsite.com/res/submit

<form method="post" id="FSForm" action="https://fs23.formsite.com/res/submit" enctype="application/x-www-form-urlencoded" onsubmit="return Vromansys.Form.processSubmit(this);">
  <div style="display:none;">
    <input type="hidden" name="locid" value="GYLA1E/xcw1eamci8">
    <input type="hidden" name="EParam" value="AT1kKIiyxDwjf6UwFcKBhKeLTfEDMMCu_MHkKNaFXyobqWxQDn-KfkJMs3M5cHo0M-Rbnf7MqWc">
    <input type="hidden" name="ElapsedTime" id="ElapsedTime" value="0">
    <input type="hidden" name="Referrer" id="Referrer" value="">
    <input type="text" name="subject_line" id="subject_line" autocomplete="off"><label for="subject_line">subject_line</label>
  </div>
  <!-- BEGIN_ITEMS -->
  <div class="form_table">
    <div class="clear"></div>
    <div id="q0" class="q full_width">
      <a class="item_anchor" name="ItemAnchor0"></a>
      <div class="segment_header"
        style="color:#FFFFFF;width:auto;text-align:Center;background-repeat:repeat;background-color:transparent;background-image:url(&quot;/images/stock/2015/BusinessAndTechnology/Business42.jpg&quot;);background-size: cover;background-position: 50% 50%;">
        <h1 style="font-size:30px;padding:20px 1em ;background-color:rgba(0, 0, 0, 0.55)">Delegate Registration Form</h1>
      </div>
    </div>
    <div class="clear"></div>
    <div id="q45" class="q full_width">
      <a class="item_anchor" name="ItemAnchor1"></a>
      <div class="segment_header" style="width:auto;text-align:Left;background-size: auto;background-position: 0% 0%;">
        <h1 style="font-size:30px;padding:20px 1em ;">On Demand 2021 Virtual European Medical Device and Diagnostic Reimbursement &amp; Market Access Conference</h1>
      </div>
    </div>
    <div class="clear"></div>
    <div id="q26" class="q full_width">
      <a class="item_anchor" name="ItemAnchor2"></a>
      <div class="segment_header" style="background:#000080;width:auto;text-align:Left;">
        <h1 style="font-size:30px;padding:20px 1em ;">Attendee Details</h1>
      </div>
    </div>
    <div class="clear"></div>
    <div id="q49" class="q required">
      <a class="item_anchor" name="ItemAnchor3"></a>
      <label class="question top_question" for="RESULT_TextField-3">First Name&nbsp;<b class="icon_required">*</b></label>
      <input type="text" name="RESULT_TextField-3" class="text_field" id="RESULT_TextField-3" size="23" value="">
    </div>
    <div id="q50" class="q required">
      <a class="item_anchor" name="ItemAnchor4"></a>
      <label class="question top_question" for="RESULT_TextField-4">Last Name&nbsp;<b class="icon_required">*</b></label>
      <input type="text" name="RESULT_TextField-4" class="text_field" id="RESULT_TextField-4" size="23" value="">
    </div>
    <div class="clear"></div>
    <div id="q58" class="q required">
      <a class="item_anchor" name="ItemAnchor5"></a>
      <label class="question top_question" for="RESULT_TextField-5">Email Address&nbsp;<b class="icon_required">*</b></label>
      <input type="email" name="RESULT_TextField-5" class="text_field" id="RESULT_TextField-5" size="54" value="">
      <div class="clear" style="padding:1px"></div>
      <label class="question top_question" for="RESULT_TextField-5">Confirm Email Address&nbsp;<b class="icon_required">*</b></label>
      <input type="email" name="CONFIRM_TextField-5" class="text_field" id="CONFIRM_TextField-5" size="54" value="">
    </div>
    <div class="clear"></div>
    <div id="q79" class="q required">
      <a class="item_anchor" name="ItemAnchor6"></a>
      <label class="question top_question" for="RESULT_TextField-6">Mobile Number&nbsp;<b class="icon_required">*</b></label>
      <input type="text" name="RESULT_TextField-6" class="text_field number_field" id="RESULT_TextField-6" size="25" value="">
    </div>
    <div class="clear"></div>
    <div id="q59" class="q required">
      <a class="item_anchor" name="ItemAnchor7"></a>
      <label class="question top_question" for="RESULT_TextField-7">Job Title&nbsp;<b class="icon_required">*</b></label>
      <input type="text" name="RESULT_TextField-7" class="text_field" id="RESULT_TextField-7" size="25" value="">
    </div>
    <div class="clear"></div>
    <div id="q25" class="q full_width">
      <a class="item_anchor" name="ItemAnchor8"></a>
      <div class="segment_header" style="background:#000080;width:auto;text-align:Left;">
        <h1 style="font-size:30px;padding:20px 1em ;">Company Details</h1>
      </div>
    </div>
    <div class="clear"></div>
    <div id="q1" class="q required">
      <a class="item_anchor" name="ItemAnchor9"></a>
      <label class="question top_question" for="RESULT_TextField-9">Name Of Organization&nbsp;<b class="icon_required">*</b></label>
      <input type="text" name="RESULT_TextField-9" class="text_field" id="RESULT_TextField-9" size="52" value="">
    </div>
    <div class="clear"></div>
    <div id="q5" class="q required">
      <a class="item_anchor" name="ItemAnchor10"></a>
      <label class="question top_question" for="RESULT_TextField-10">City&nbsp;<b class="icon_required">*</b></label>
      <input type="text" name="RESULT_TextField-10" class="text_field" id="RESULT_TextField-10" size="52" value="">
    </div>
    <div class="clear"></div>
    <div id="q10" class="q required">
      <a class="item_anchor" name="ItemAnchor11"></a>
      <label class="question top_question" for="RESULT_RadioButton-11">Country&nbsp;<b class="icon_required">*</b></label>
      <select id="RESULT_RadioButton-11" name="RESULT_RadioButton-11" class="drop_down">
        <option></option>
        <option value="Radio-0">Afghanistan</option>
        <option value="Radio-1">Albania</option>
        <option value="Radio-2">Algeria</option>
        <option value="Radio-3">Andorra</option>
        <option value="Radio-4">Angola</option>
        <option value="Radio-5">Antigua and Barbuda</option>
        <option value="Radio-6">Argentina</option>
        <option value="Radio-7">Armenia</option>
        <option value="Radio-8">Aruba</option>
        <option value="Radio-9">Australia</option>
        <option value="Radio-10">Austria</option>
        <option value="Radio-11">Azerbaijan</option>
        <option value="Radio-12">Bahamas, The</option>
        <option value="Radio-13">Bahrain</option>
        <option value="Radio-14">Bangladesh</option>
        <option value="Radio-15">Barbados</option>
        <option value="Radio-16">Belarus</option>
        <option value="Radio-17">Belgium</option>
        <option value="Radio-18">Belize</option>
        <option value="Radio-19">Benin</option>
        <option value="Radio-20">Bhutan</option>
        <option value="Radio-21">Bolivia</option>
        <option value="Radio-22">Bosnia and Herzegovina</option>
        <option value="Radio-23">Botswana</option>
        <option value="Radio-24">Brazil</option>
        <option value="Radio-25">Brunei</option>
        <option value="Radio-26">Bulgaria</option>
        <option value="Radio-27">Burkina Faso</option>
        <option value="Radio-28">Burma</option>
        <option value="Radio-29">Burundi</option>
        <option value="Radio-30">Cambodia</option>
        <option value="Radio-31">Cameroon</option>
        <option value="Radio-32">Canada</option>
        <option value="Radio-33">Cabo Verde</option>
        <option value="Radio-34">Central African Republic</option>
        <option value="Radio-35">Chad</option>
        <option value="Radio-36">Chile</option>
        <option value="Radio-37">China</option>
        <option value="Radio-38">Colombia</option>
        <option value="Radio-39">Comoros</option>
        <option value="Radio-40">Congo, Democratic Republic of the</option>
        <option value="Radio-41">Congo, Republic of the</option>
        <option value="Radio-42">Costa Rica</option>
        <option value="Radio-43">Cote d'Ivoire</option>
        <option value="Radio-44">Croatia</option>
        <option value="Radio-45">Cuba</option>
        <option value="Radio-46">Curacao</option>
        <option value="Radio-47">Cyprus</option>
        <option value="Radio-48">Czechia</option>
        <option value="Radio-49">Denmark</option>
        <option value="Radio-50">Djibouti</option>
        <option value="Radio-51">Dominica</option>
        <option value="Radio-52">Dominican Republic</option>
        <option value="Radio-53">East Timor</option>
        <option value="Radio-54">Ecuador</option>
        <option value="Radio-55">Egypt</option>
        <option value="Radio-56">El Salvador</option>
        <option value="Radio-57">Equatorial Guinea</option>
        <option value="Radio-58">Eritrea</option>
        <option value="Radio-59">Estonia</option>
        <option value="Radio-60">Ethiopia</option>
        <option value="Radio-61">Fiji</option>
        <option value="Radio-62">Finland</option>
        <option value="Radio-63">France</option>
        <option value="Radio-64">Gabon</option>
        <option value="Radio-65">Gambia, The</option>
        <option value="Radio-66">Georgia</option>
        <option value="Radio-67">Germany</option>
        <option value="Radio-68">Ghana</option>
        <option value="Radio-69">Greece</option>
        <option value="Radio-70">Grenada</option>
        <option value="Radio-71">Guatemala</option>
        <option value="Radio-72">Guinea</option>
        <option value="Radio-73">Guinea-Bissau</option>
        <option value="Radio-74">Guyana</option>
        <option value="Radio-75">Haiti</option>
        <option value="Radio-76">Holy See</option>
        <option value="Radio-77">Honduras</option>
        <option value="Radio-78">Hong Kong</option>
        <option value="Radio-79">Hungary</option>
        <option value="Radio-80">Iceland</option>
        <option value="Radio-81">India</option>
        <option value="Radio-82">Indonesia</option>
        <option value="Radio-83">Iran</option>
        <option value="Radio-84">Iraq</option>
        <option value="Radio-85">Ireland</option>
        <option value="Radio-86">Israel</option>
        <option value="Radio-87">Italy</option>
        <option value="Radio-88">Jamaica</option>
        <option value="Radio-89">Japan</option>
        <option value="Radio-90">Jordan</option>
        <option value="Radio-91">Kazakhstan</option>
        <option value="Radio-92">Kenya</option>
        <option value="Radio-93">Kiribati</option>
        <option value="Radio-94">Korea, North</option>
        <option value="Radio-95">Korea, South</option>
        <option value="Radio-96">Kosovo</option>
        <option value="Radio-97">Kuwait</option>
        <option value="Radio-98">Kyrgyzstan</option>
        <option value="Radio-99">Laos</option>
        <option value="Radio-100">Latvia</option>
        <option value="Radio-101">Lebanon</option>
        <option value="Radio-102">Lesotho</option>
        <option value="Radio-103">Liberia</option>
        <option value="Radio-104">Libya</option>
        <option value="Radio-105">Liechtenstein</option>
        <option value="Radio-106">Lithuania</option>
        <option value="Radio-107">Luxembourg</option>
        <option value="Radio-108">Macau</option>
        <option value="Radio-109">Macedonia</option>
        <option value="Radio-110">Madagascar</option>
        <option value="Radio-111">Malawi</option>
        <option value="Radio-112">Malaysia</option>
        <option value="Radio-113">Maldives</option>
        <option value="Radio-114">Mali</option>
        <option value="Radio-115">Malta</option>
        <option value="Radio-116">Marshall Islands</option>
        <option value="Radio-117">Mauritania</option>
        <option value="Radio-118">Mauritius</option>
        <option value="Radio-119">Mexico</option>
        <option value="Radio-120">Micronesia</option>
        <option value="Radio-121">Moldova</option>
        <option value="Radio-122">Monaco</option>
        <option value="Radio-123">Mongolia</option>
        <option value="Radio-124">Montenegro</option>
        <option value="Radio-125">Morocco</option>
        <option value="Radio-126">Mozambique</option>
        <option value="Radio-127">Namibia</option>
        <option value="Radio-128">Nauru</option>
        <option value="Radio-129">Nepal</option>
        <option value="Radio-130">Netherlands</option>
        <option value="Radio-131">New Zealand</option>
        <option value="Radio-132">Nicaragua</option>
        <option value="Radio-133">Niger</option>
        <option value="Radio-134">Nigeria</option>
        <option value="Radio-135">North Korea</option>
        <option value="Radio-136">Norway</option>
        <option value="Radio-137">Oman</option>
        <option value="Radio-138">Pakistan</option>
        <option value="Radio-139">Palau</option>
        <option value="Radio-140">Palestinian Territories</option>
        <option value="Radio-141">Panama</option>
        <option value="Radio-142">Papua New Guinea</option>
        <option value="Radio-143">Paraguay</option>
        <option value="Radio-144">Peru</option>
        <option value="Radio-145">Philippines</option>
        <option value="Radio-146">Poland</option>
        <option value="Radio-147">Portugal</option>
        <option value="Radio-148">Qatar</option>
        <option value="Radio-149">Romania</option>
        <option value="Radio-150">Russia</option>
        <option value="Radio-151">Rwanda</option>
        <option value="Radio-152">Saint Kitts and Nevis</option>
        <option value="Radio-153">Saint Lucia</option>
        <option value="Radio-154">Saint Vincent and the Grenadines</option>
        <option value="Radio-155">Samoa</option>
        <option value="Radio-156">San Marino</option>
        <option value="Radio-157">Sao Tome and Principe</option>
        <option value="Radio-158">Saudi Arabia</option>
        <option value="Radio-159">Senegal</option>
        <option value="Radio-160">Serbia</option>
        <option value="Radio-161">Seychelles</option>
        <option value="Radio-162">Sierra Leone</option>
        <option value="Radio-163">Singapore</option>
        <option value="Radio-164">Sint Maarten</option>
        <option value="Radio-165">Slovakia</option>
        <option value="Radio-166">Slovenia</option>
        <option value="Radio-167">Solomon Islands</option>
        <option value="Radio-168">Somalia</option>
        <option value="Radio-169">South Africa</option>
        <option value="Radio-170">South Korea</option>
        <option value="Radio-171">South Sudan</option>
        <option value="Radio-172">Spain</option>
        <option value="Radio-173">Sri Lanka</option>
        <option value="Radio-174">Sudan</option>
        <option value="Radio-175">Suriname</option>
        <option value="Radio-176">Swaziland</option>
        <option value="Radio-177">Sweden</option>
        <option value="Radio-178">Switzerland</option>
        <option value="Radio-179">Syria</option>
        <option value="Radio-180">Taiwan</option>
        <option value="Radio-181">Tajikistan</option>
        <option value="Radio-182">Tanzania</option>
        <option value="Radio-183">Thailand</option>
        <option value="Radio-184">Timor-Leste</option>
        <option value="Radio-185">Togo</option>
        <option value="Radio-186">Tonga</option>
        <option value="Radio-187">Trinidad and Tobago</option>
        <option value="Radio-188">Tunisia</option>
        <option value="Radio-189">Turkey</option>
        <option value="Radio-190">Turkmenistan</option>
        <option value="Radio-191">Tuvalu</option>
        <option value="Radio-192">Uganda</option>
        <option value="Radio-193">Ukraine</option>
        <option value="Radio-194">United Arab Emirates</option>
        <option value="Radio-195">United Kingdom</option>
        <option value="Radio-196">United States</option>
        <option value="Radio-197">Uruguay</option>
        <option value="Radio-198">Uzbekistan</option>
        <option value="Radio-199">Vanuatu</option>
        <option value="Radio-200">Venezuela</option>
        <option value="Radio-201">Vietnam</option>
        <option value="Radio-202">Yemen</option>
        <option value="Radio-203">Zambia</option>
        <option value="Radio-204">Zimbabwe</option>
      </select>
    </div>
    <div class="clear"></div>
    <div id="q12" class="q full_width">
      <a class="item_anchor" name="ItemAnchor12"></a>
      <div class="segment_header" style="background:#000080;width:auto;text-align:Left;">
        <h1 style="font-size:30px;padding:20px 1em ;">Passes</h1>
      </div>
    </div>
    <div class="clear"></div>
    <div id="q32" class="q required">
      <a class="item_anchor" name="ItemAnchor13"></a>
      <label class="question top_question" for="RESULT_RadioButton-13">How many passes would you like to secure?&nbsp;<b class="icon_required">*</b></label>
      <select id="RESULT_RadioButton-13" name="RESULT_RadioButton-13" class="drop_down">
        <option></option>
        <option value="Radio-0">1 (£594)</option>
        <option value="Radio-1">2 (£1,188)</option>
        <option value="Radio-2">3 (£1,784)</option>
        <option value="Radio-3">4 (£2,376)</option>
        <option value="Radio-4">5 (£2,970)</option>
        <option value="Radio-5">Other</option>
      </select>
    </div>
    <div id="q72" class="q">
      <a class="item_anchor" name="ItemAnchor14"></a>
      <span class="question top_question">Add Additional Team Members (Name, Email ID &amp; Job Title)&nbsp;<span class="instructions">🛈</span></span>
      <table class="text_list">
        <tbody>
          <tr class="matrix_row_light">
            <td><input type="text" name="RESULT_MatrixTextField-14-0" class="text_field" size="25" maxlength="255" value=""></td>
            <td><span class="icon_add"><span class="accessibility_hidden">+</span></span><span class="icon_del"><span class="accessibility_hidden">-</span></span></td>
          </tr>
        </tbody>
      </table>
      <input type="hidden" name="MaxAnswers" value="25">
    </div>
    <div class="clear"></div>
    <div id="q60" class="q full_width">
      <a class="item_anchor" name="ItemAnchor15"></a>
      <div class="full_width_space">
        <div>Please note, all registrations will be subjected to our final approval process and a confirmation of your registration will be emailed directly to you once approved. For addtional enquiries, please contact accounts@ttgw.co.uk</div>
      </div>
    </div>
    <div class="clear"></div>
    <div id="q18" class="q full_width">
      <a class="item_anchor" name="ItemAnchor16"></a>
      <div class="segment_header" style="background:#000080;width:auto;text-align:Left;">
        <h1 style="font-size:30px;padding:20px 1em ;">Payment</h1>
      </div>
    </div>
    <div class="clear"></div>
    <div id="q37" class="q required">
      <a class="item_anchor" name="ItemAnchor17"></a>
      <label class="question top_question" for="RESULT_RadioButton-17">Card Type&nbsp;<b class="icon_required">*</b></label>
      <select id="RESULT_RadioButton-17" name="RESULT_RadioButton-17" class="drop_down">
        <option></option>
        <option value="Radio-0">Amex</option>
        <option value="Radio-1">Visa</option>
        <option value="Radio-2">Mastercard</option>
        <option value="Radio-3">Other</option>
      </select>
    </div>
    <div id="q38" class="q required">
      <a class="item_anchor" name="ItemAnchor18"></a>
      <label class="question top_question" for="RESULT_TextField-18">Name on Card&nbsp;<b class="icon_required">*</b></label>
      <input type="text" name="RESULT_TextField-18" class="text_field" id="RESULT_TextField-18" size="25" value="">
    </div>
    <div id="q33" class="q required">
      <a class="item_anchor" name="ItemAnchor19"></a>
      <label class="question top_question" for="RESULT_TextField-19">Card Number&nbsp;<b class="icon_required">*</b></label>
      <input type="text" name="RESULT_TextField-19" class="text_field" id="RESULT_TextField-19" size="25" maxlength="19" autocomplete="off" value="">
    </div>
    <div class="clear"></div>
    <div id="q39" class="q required">
      <a class="item_anchor" name="ItemAnchor20"></a>
      <label class="question top_question" for="RESULT_TextField-20">Expiry&nbsp;<b class="icon_required">*</b></label>
      <input type="text" name="RESULT_TextField-20" class="text_field" id="RESULT_TextField-20" size="25" value="">
    </div>
    <div id="q40" class="q required">
      <a class="item_anchor" name="ItemAnchor21"></a>
      <label class="question top_question" for="RESULT_TextField-21">CSV&nbsp;<b class="icon_required">*</b></label>
      <input type="text" name="RESULT_TextField-21" class="text_field" id="RESULT_TextField-21" size="25" value="">
    </div>
    <div class="clear"></div>
    <div id="q63" class="q required">
      <a class="item_anchor" name="ItemAnchor22"></a>
      <label class="question top_question" for="RESULT_TextField-22">Billing Address&nbsp;<b class="icon_required">*</b></label>
      <input type="text" name="RESULT_TextField-22" class="text_field" id="RESULT_TextField-22" size="54" value="">
    </div>
    <div class="clear"></div>
    <div id="q64" class="q">
      <a class="item_anchor" name="ItemAnchor23"></a>
      <label class="question top_question" for="RESULT_TextField-23">Address Line 2</label>
      <input type="text" name="RESULT_TextField-23" class="text_field" id="RESULT_TextField-23" size="54" value="">
    </div>
    <div class="clear"></div>
    <div id="q65" class="q required">
      <a class="item_anchor" name="ItemAnchor24"></a>
      <label class="question top_question" for="RESULT_TextField-24">City&nbsp;<b class="icon_required">*</b></label>
      <input type="text" name="RESULT_TextField-24" class="text_field" id="RESULT_TextField-24" size="22" value="">
    </div>
    <div id="q66" class="q required">
      <a class="item_anchor" name="ItemAnchor25"></a>
      <label class="question top_question" for="RESULT_TextField-25">State/Province/Region&nbsp;<b class="icon_required">*</b></label>
      <input type="text" name="RESULT_TextField-25" class="text_field" id="RESULT_TextField-25" size="24" value="">
    </div>
    <div class="clear"></div>
    <div id="q67" class="q required">
      <a class="item_anchor" name="ItemAnchor26"></a>
      <label class="question top_question" for="RESULT_TextField-26">Zip/Postal Code&nbsp;<b class="icon_required">*</b></label>
      <input type="text" name="RESULT_TextField-26" class="text_field" id="RESULT_TextField-26" size="22" value="">
    </div>
    <div class="clear"></div>
    <div id="q69" class="q required">
      <a class="item_anchor" name="ItemAnchor27"></a>
      <label class="question top_question" for="RESULT_TextField-27">Country&nbsp;<b class="icon_required">*</b></label>
      <input type="text" name="RESULT_TextField-27" class="text_field" id="RESULT_TextField-27" size="54" value="">
    </div>
    <div class="clear"></div>
    <div id="q74" class="q full_width">
      <a class="item_anchor" name="ItemAnchor28"></a>
      <div class="segment_header"
        style="width:auto;text-align:Left;background-repeat:repeat;background-color:transparent;background-image:url(&quot;/images/stock/2015/BusinessAndTechnology/Business03.jpg&quot;);background-size: cover;background-position: 50% 50%;">
        <h1 style="font-size:30px;padding:20px 1em ;">Confirmation</h1>
      </div>
    </div>
    <div class="clear"></div>
    <div id="q44" class="q full_width">
      <a class="item_anchor" name="ItemAnchor29"></a>
      <div class="full_width_space" style="text-align:center"><a href="https://www.ttgroupworldwide.com/terms-and-conditions.php" class="link" target="_blank">Terms &amp; Conditions</a></div>
    </div>
    <div class="clear"></div>
    <div id="q78" class="q required">
      <a class="item_anchor" name="ItemAnchor30"></a>
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Text Content

subject_line


DELEGATE REGISTRATION FORM




ON DEMAND 2021 VIRTUAL EUROPEAN MEDICAL DEVICE AND DIAGNOSTIC REIMBURSEMENT &
MARKET ACCESS CONFERENCE




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