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Submitted URL: https://cegroups.com/
Effective URL: https://www.netce.com/
Submission: On August 21 via api from US — Scanned from DE
Effective URL: https://www.netce.com/
Submission: On August 21 via api from US — Scanned from DE
Form analysis 3 forms found in the DOM
POST /search.php
<form novalidate="novalidate" class="search_form" id="search_form" method="post" action="/search.php">
<fieldset data-form-section="">
<div class="rdo-iln">
<span class="tp-lbl">Search by: </span>
<label for="optionsRadios1" class="radio lbl-txt">
<input type="radio" name="type" id="optionsRadios1" value="specials" class="chkb-lrg value-added" tabindex="7" data-ignored="" checked="checked" data-old-val="specials"> Special Offer </label>
<label for="optionsRadios2" class="radio lbl-txt">
<input type="radio" name="type" id="optionsRadios2" value="courses" data-ignored="" class="chkb-lrg value-added" data-old-val="courses"> Course List </label>
</div>
<!-- Start Error Section for State and Profession validation -->
<div class="error-placeholder" id="error_2"><!----></div>
<!-- End Error Section for State and Profession validation -->
<div class="control-group">
<!-- |||||| -->
<div class="select2-container ga_s" id="s2id_state_select" style="width: 100%;">
<a href="javascript:void(0)" class="select2-choice select2-default" tabindex="-1"> <span class="select2-chosen" id="select2-chosen-1">Select Your State or Jurisdiction</span><abbr class="select2-search-choice-close"></abbr> <span class="select2-arrow" role="presentation"><b role="presentation"></b></span></a><label
for="s2id_autogen1" class="select2-offscreen"></label><input class="select2-focusser select2-offscreen" type="text" aria-haspopup="true" role="button" aria-labelledby="select2-chosen-1" id="s2id_autogen1" tabindex="8">
<div class="select2-drop select2-display-none select2-with-searchbox">
<div class="select2-search"> <label for="s2id_autogen1_search" class="select2-offscreen"></label> <input type="text" autocomplete="off" autocorrect="off" autocapitalize="off" spellcheck="false" class="select2-input" role="combobox"
aria-expanded="true" aria-autocomplete="list" aria-owns="select2-results-1" id="s2id_autogen1_search" placeholder=""> </div>
<ul class="select2-results" role="listbox" id="select2-results-1"> </ul>
</div>
</div><select name="jurisdiction" id="state_select" class="ga_s select2-offscreen" tabindex="-1" data-placeholder="Select Your State or Jurisdiction" data-field-type="state" required="required" title="">
<option value="" disabled="disabled" selected="selected"><!----></option>
<option value="AL" data-match="AL">Alabama</option>
<option value="AK" data-match="AK">Alaska</option>
<option value="AS" data-match="AS">American Samoa</option>
<option value="AZ" data-match="AZ">Arizona</option>
<option value="AR" data-match="AR">Arkansas</option>
<option value="BS" data-match="BS">Bahamas</option>
<option value="CA" data-match="CA">California</option>
<option value="CO" data-match="CO">Colorado</option>
<option value="CT" data-match="CT">Connecticut</option>
<option value="DE" data-match="DE">Delaware</option>
<option value="DC" data-match="DC">District of Columbia</option>
<option value="FL" data-match="FL">Florida</option>
<option value="GA" data-match="GA">Georgia</option>
<option value="GU" data-match="GU">Guam</option>
<option value="HI" data-match="HI">Hawaii</option>
<option value="ID" data-match="ID">Idaho</option>
<option value="IL" data-match="IL">Illinois</option>
<option value="IN" data-match="IN">Indiana</option>
<option value="IA" data-match="IA">Iowa</option>
<option value="KS" data-match="KS">Kansas</option>
<option value="KY" data-match="KY">Kentucky</option>
<option value="LA" data-match="LA">Louisiana</option>
<option value="ME" data-match="ME">Maine</option>
<option value="MH" data-match="MH">Marshall Islands</option>
<option value="MD" data-match="MD">Maryland</option>
<option value="MA" data-match="MA">Massachusetts</option>
<option value="MI" data-match="MI">Michigan</option>
<option value="FM" data-match="FM">Micronesia</option>
<option value="MN" data-match="MN">Minnesota</option>
<option value="MS" data-match="MS">Mississippi</option>
<option value="MO" data-match="MO">Missouri</option>
<option value="MT" data-match="MT">Montana</option>
<option value="NE" data-match="NE">Nebraska</option>
<option value="NV" data-match="NV">Nevada</option>
<option value="NH" data-match="NH">New Hampshire</option>
<option value="NJ" data-match="NJ">New Jersey</option>
<option value="NM" data-match="NM">New Mexico</option>
<option value="NY" data-match="NY">New York</option>
<option value="XX" data-match="XX">Non-US</option>
<option value="NC" data-match="NC">North Carolina</option>
<option value="ND" data-match="ND">North Dakota</option>
<option value="MP" data-match="MP">Northern Marianas</option>
<option value="OH" data-match="OH">Ohio</option>
<option value="OK" data-match="OK">Oklahoma</option>
<option value="OR" data-match="OR">Oregon</option>
<option value="PW" data-match="PW">Palau</option>
<option value="PA" data-match="PA">Pennsylvania</option>
<option value="PR" data-match="PR">Puerto Rico</option>
<option value="RI" data-match="RI">Rhode Island</option>
<option value="SC" data-match="SC">South Carolina</option>
<option value="SD" data-match="SD">South Dakota</option>
<option value="TN" data-match="TN">Tennessee</option>
<option value="TX" data-match="TX">Texas</option>
<option value="US" data-match="US">US Nationally-Certified</option>
<option value="UT" data-match="UT">Utah</option>
<option value="VT" data-match="VT">Vermont</option>
<option value="VA" data-match="VA">Virginia</option>
<option value="VI" data-match="VI">Virgin Islands</option>
<option value="WA" data-match="WA">Washington</option>
<option value="WV" data-match="WV">West Virginia</option>
<option value="WI" data-match="WI">Wisconsin</option>
<option value="WY" data-match="WY">Wyoming</option>
</select>
</div>
<!-- Profession Message Area -->
<div id="prof-mes"><!----></div>
<div class="control-group">
<div class="professionid_block">
<div class="select2-container" id="s2id_professionid" style="width: 100%;">
<a href="javascript:void(0)" class="select2-choice select2-default" tabindex="-1"> <span class="select2-chosen" id="select2-chosen-2">Select Your Profession or Title</span><abbr class="select2-search-choice-close"></abbr> <span class="select2-arrow" role="presentation"><b role="presentation"></b></span></a><label
for="s2id_autogen2" class="select2-offscreen"></label><input class="select2-focusser select2-offscreen" type="text" aria-haspopup="true" role="button" aria-labelledby="select2-chosen-2" id="s2id_autogen2" tabindex="9">
<div class="select2-drop select2-display-none select2-with-searchbox">
<div class="select2-search"> <label for="s2id_autogen2_search" class="select2-offscreen"></label> <input type="text" autocomplete="off" autocorrect="off" autocapitalize="off" spellcheck="false" class="select2-input" role="combobox"
aria-expanded="true" aria-autocomplete="list" aria-owns="select2-results-2" id="s2id_autogen2_search" placeholder=""> </div>
<ul class="select2-results" role="listbox" id="select2-results-2"> </ul>
</div>
</div><select data-field-type="profession" data-placeholder="Select Your Profession or Title" tabindex="-1" required="required" name="professionid" id="professionid" title="" class="select2-offscreen">
<option value="" disabled="disabled" selected="selected" data-certifications="[]"></option>
<option value="1" data-match="Nurses" data-certifications="[]">Nurse</option>
<option value="10" data-match="Advanced Practice Registered Nurses" data-certifications="[]">Advanced Practice Nurse</option>
<option value="2" data-match="Physicians" data-certifications="[]">Physician</option>
<option value="11" data-match="Physician Assistants" data-certifications="[]">Physician Assistant</option>
<option value="26" data-match="Pharmacists" data-certifications="[]">Pharmacist</option>
<option value="27" data-match="Pharmacy Technicians" data-certifications="[]">Pharmacy Technician</option>
<option value="4" data-match="Social Workers" data-certifications="[]">Social Worker</option>
<option value="16" data-match="Counselors/Therapists" data-certifications="[]">Counselor/Therapist</option>
<option value="5" data-match="Psychologists" data-certifications="[]">Psychologist</option>
<option value="7" data-match="Case Managers" data-certifications="[]">Certified Case Manager</option>
<option value="25" data-match="Certified Diabetes Educators" data-certifications="[]">Certified Diabetes Educator</option>
<option value="17" data-match="Nursing Assistants" data-certifications="[]">Nursing Assistant</option>
<option value="24" data-match="Certified Surgical Assistant" data-certifications="[]">Certified Surgical Assistant</option>
<option value="6" data-match="CSTs/CSFAs" data-certifications="[]">CST/CSFA</option>
<option value="23" data-match="Dental Assistants" data-certifications="[]">Dental Assistant</option>
<option value="22" data-match="Dental Hygienists" data-certifications="[]">Dental Hygienist</option>
<option value="3" data-match="Dentists" data-certifications="[]">Dentist</option>
<option value="9" data-match="Nursing Home Administrators" data-certifications="[]">Nursing Home Administrator</option>
<option value="20" data-match="Other/IACET" data-certifications="[]">Other/IACET</option>
<option value="-1"> Select By Title </option>
</select>
</div>
</div>
<!-- Start Qualification Select -->
<!-- Qualification Message Area -->
<div id="qual-mes"><!-- --></div>
<div class="control-group">
<div class="qualificationid_block hidden">
<div class="select2-container select2-container-disabled" id="s2id_qualificationid" style="width: 100%;">
<a href="javascript:void(0)" class="select2-choice select2-default" tabindex="-1"> <span class="select2-chosen" id="select2-chosen-3">Select Your Professional Title</span><abbr class="select2-search-choice-close"></abbr> <span class="select2-arrow" role="presentation"><b role="presentation"></b></span></a><label
for="s2id_autogen3" class="select2-offscreen"></label><input class="select2-focusser select2-offscreen" type="text" aria-haspopup="true" role="button" aria-labelledby="select2-chosen-3" id="s2id_autogen3" tabindex="10" disabled="">
<div class="select2-drop select2-display-none select2-with-searchbox">
<div class="select2-search"> <label for="s2id_autogen3_search" class="select2-offscreen"></label> <input type="text" autocomplete="off" autocorrect="off" autocapitalize="off" spellcheck="false" class="select2-input" role="combobox"
aria-expanded="true" aria-autocomplete="list" aria-owns="select2-results-3" id="s2id_autogen3_search" placeholder=""> </div>
<ul class="select2-results" role="listbox" id="select2-results-3"> </ul>
</div>
</div><select data-field-type="qualification" data-placeholder="Select Your Professional Title" tabindex="-1" data-jurisdiction-selector="#state_select" required="required" name="qualificationid" id="qualificationid" disabled="" title=""
class="select2-offscreen">
<option value="" selected="selected"></option>
<option value="-1" id="backtoprofession"> Go back to profession list </option>
<optgroup label="Nurse" data-professionid="1">
<option value="106" data-match="APRN" data-professionid="1" data-allowed-jurisdictions="["GA"]">APRN - Advanced Practice Registered Nurse</option>
<option value="6" data-match="CAPT" data-professionid="1" data-allowed-jurisdictions="["CA","NY"]">CAPT - California Psychiatric Technician</option>
<option value="55" data-match="FLSLP" data-professionid="1" data-allowed-jurisdictions="["FL"]">FLSLP - Florida Speech/Language Pathologist</option>
<option value="268" data-match="LPNV" data-professionid="1" data-allowed-jurisdictions="["MI"]">LPNV - Licensed Practical Nurse Volunteer</option>
<option value="267" data-match="RNV" data-professionid="1" data-allowed-jurisdictions="["MI"]">RNV - Registered Nurse Volunteer</option>
<option value="1" data-match="RN" data-professionid="1">RN - Registered Nurse</option>
<option value="3" data-match="LPN" data-professionid="1" data-hidden-jurisdictions="["CA","TX"]">LPN - Licensed Practical Nurse</option>
<option value="2" data-match="LVN" data-professionid="1" data-allowed-jurisdictions="["TX","CA"]">LVN - Licensed Vocational Nurse</option>
<option value="45" data-match="CHT" data-professionid="1" data-allowed-jurisdictions="["US"]">CHT - Certified Hemodialysis Technician</option>
<option value="54" data-match="CLP" data-professionid="1" data-allowed-jurisdictions="["US"]">CLP - Clinical Laboratory Personnel</option>
<option value="57" data-match="CCT" data-professionid="1" data-allowed-jurisdictions="["US"]">CCT - Certified Cardiographic Technician</option>
<option value="199" data-match="LMHT" data-professionid="1" data-allowed-jurisdictions="["KS"]">LMHT - Licensed Mental Health Technician</option>
<option value="91" data-match="TPN" data-professionid="1" data-hidden-jurisdictions="["US"]">TPN - Temporary Nurse Permit</option>
<option value="147" data-match="PHN" data-professionid="1" data-allowed-jurisdictions="["CA"]">PHN - Public Health Nurse</option>
<option value="157" data-match="PMH" data-professionid="1" data-allowed-jurisdictions="["CA"]">PMH - Psychiatric Mental Health Nurse</option>
</optgroup>
<optgroup label="Advanced Practice Nurse" data-professionid="10">
<option value="49" data-match="APRN" data-professionid="10" data-allowed-jurisdictions="["GA"]"
data-hidden-jurisdictions="["TX","MI","CO","AL","PA","AZ","NJ","MN","NM","DE"]">APRN - Advanced Practice Registered Nurse</option>
<option value="5" data-match="ARNP" data-professionid="10" data-allowed-jurisdictions="["US"]">ARNP - Advanced Registered Nurse Practitioner</option>
<option value="88" data-match="CRNP" data-professionid="10" data-allowed-jurisdictions="["PA","AL"]">CRNP - Certified Registered Nurse Practitioner</option>
<option value="61" data-match="DTR" data-professionid="10" data-allowed-jurisdictions="["US"]">DTR - Dietetic Technician, Registered</option>
<option value="67" data-match="FLAP" data-professionid="10" data-allowed-jurisdictions="["FL"]">FLAP - Florida Acupuncturist</option>
<option value="77" data-match="FNP" data-professionid="10" data-allowed-jurisdictions="["US"]">FNP - Family Nurse Practitioner</option>
<option value="164" data-match="ND" data-professionid="10" data-allowed-jurisdictions="["US"]">ND - Nutritionist, Dietician, Nutrition Counselor</option>
<option value="60" data-match="RD" data-professionid="10" data-allowed-jurisdictions="["US"]">RD - Registered Dietician</option>
<option value="90" data-match="SA" data-professionid="10" data-allowed-jurisdictions="["US"]">SA - Surgical Assistant</option>
<option value="158" data-match="CNP" data-professionid="10"
data-hidden-jurisdictions="["GA","KS","TX","WV","MI","CO","PA","MS","SC","FL","AZ","NJ","AK","DE","AL"]">
CNP - Certified Nurse Practitioner</option>
<option value="53" data-match="NP" data-professionid="10" data-allowed-jurisdictions="["NY","KS","MS","TX","VA","MI"]"
data-hidden-jurisdictions="["WV","AK","PA","FL","NJ","MN"]">NP - Nurse Practitioner</option>
<option value="44" data-match="RCP" data-professionid="10" data-allowed-jurisdictions="["GA","US"]">RCP - Respiratory Care Practitioner</option>
<option value="59" data-match="CNS" data-professionid="10" data-hidden-jurisdictions="["GA","WV","FL","AK","NJ"]">CNS - Clinical Nurse Specialist</option>
<option value="69" data-match="CRNA" data-professionid="10" data-hidden-jurisdictions="["GA","WV","PA","FL","NJ","MI"]">CRNA - Certified Registered Nurse Anesthetist</option>
<option value="151" data-match="CNM" data-professionid="10" data-hidden-jurisdictions="["GA","WV","PA","KS","FL","AK","MI"]">CNM - Certified Nurse Midwife</option>
<option value="7" data-match="CCRN" data-professionid="10" data-allowed-jurisdictions="["US"]">CCRN - Critical Care Registered Nurse</option>
<option value="254" data-match="NA" data-professionid="10" data-allowed-jurisdictions="["MI"]">NA - Nurse Anesthetist</option>
<option value="214" data-match="NMW" data-professionid="10" data-allowed-jurisdictions="["WA","PA","KS","IN","MD","MO","TN","VT","WI"]">NMW - Nurse
Midwife</option>
<option value="8" data-match="RNC" data-professionid="10" data-allowed-jurisdictions="["US"]">RNC - Certified Registered Nurse</option>
<option value="43" data-match="CNOR" data-professionid="10" data-allowed-jurisdictions="["US"]">CNOR - Certified Nurse in the Operating Room</option>
<option value="255" data-match="NM" data-professionid="10" data-allowed-jurisdictions="["MI"]">NM - Nurse Midwife</option>
<option value="261" data-match="ACL" data-professionid="10" data-allowed-jurisdictions="["GA"]">ACL - Assistant Cosmetic Laser Practitioner</option>
<option value="262" data-match="SCL" data-professionid="10" data-allowed-jurisdictions="["GA"]">SCL - Senior Cosmetic Laser Practitioner</option>
<option value="70" data-match="APN" data-professionid="10" data-allowed-jurisdictions="["WI","NJ"]">APN - Advanced Practice Nurse</option>
<option value="170" data-match="CPM" data-professionid="10" data-allowed-jurisdictions="["NJ","DE","AZ"]">CPM - Certified Professional Midwife</option>
<option value="42" data-match="CM" data-professionid="10" data-allowed-jurisdictions="["NJ","AK"]">CM - Certified Midwife</option>
<option value="206" data-match="LM" data-professionid="10" data-allowed-jurisdictions="["FL","CO","AZ","CT","CA"]">LM - Licensed Midwife</option>
<option value="215" data-match="RXA" data-professionid="10" data-allowed-jurisdictions="["CA","CO"]">RXA - Prescribing Authority</option>
<option value="99" data-match="TPNP" data-professionid="10" data-hidden-jurisdictions="["US"]">TPNP - Temporary Nurse Practitioner Permit</option>
</optgroup>
<optgroup label="Physician" data-professionid="2">
<option value="269" data-match="DOCL" data-professionid="2" data-allowed-jurisdictions="["MI"]">DOCL - Osteopathic Doctor Compact License</option>
<option value="51" data-match="FP" data-professionid="2" data-allowed-jurisdictions="["US"]">FP - Family Physician</option>
<option value="265" data-match="MDCL" data-professionid="2" data-allowed-jurisdictions="["MI"]">MDCL - Medical Doctor Compact License</option>
<option value="230" data-match="TPDO" data-professionid="2" data-allowed-jurisdictions="["FM"]">TPDO - Temporary Osteopathic Physician Permit</option>
<option value="11" data-match="MD" data-professionid="2" data-hidden-jurisdictions="["BS"]">MD - Medical Doctor</option>
<option value="237" data-match="MP" data-professionid="2" data-allowed-jurisdictions="["BS"]">MP - Medical Practitioner</option>
<option value="12" data-match="DO" data-professionid="2" data-hidden-jurisdictions="["BS"]">DO - Osteopathic Doctor</option>
<option value="238" data-match="SMP" data-professionid="2" data-allowed-jurisdictions="["BS"]">SMP - Specialty Medical Practitioner</option>
<option value="68" data-match="DC" data-professionid="2" data-hidden-jurisdictions="["BS"]">DC - Doctor of Chiropractic</option>
<option value="169" data-match="DNM" data-professionid="2" data-hidden-jurisdictions="["BS","FL"]">DNM - Doctor of Naturopathic Medicine</option>
<option value="48" data-match="DPM" data-professionid="2" data-hidden-jurisdictions="["BS"]">DPM - Doctor of Podiatric Medicine</option>
<option value="92" data-match="TPMD" data-professionid="2" data-hidden-jurisdictions="["BS"]">TPMD - Temporary Physician Permit</option>
</optgroup>
<optgroup label="Physician Assistant" data-professionid="11">
<option value="165" data-match="OPA" data-professionid="11" data-allowed-jurisdictions="["PA","ME","NM","NV","WV"]">OPA - Osteopathic Physician Assistant</option>
<option value="13" data-match="PA" data-professionid="11">PA - Physician Assistant</option>
<option value="100" data-match="TPPA" data-professionid="11">TPPA - Temporary Physician Assistant Permit</option>
<option value="103" data-match="AA" data-professionid="11"
data-allowed-jurisdictions="["FL","MO","WI","CO","DC","IN","SC","NC","AL","VT","OK","OH","GA"]">AA -
Anesthesiologist Assistant</option>
<option value="46" data-match="MP" data-professionid="11" data-allowed-jurisdictions="["FL"]">MP - Medical Physicist</option>
</optgroup>
<optgroup label="Pharmacist" data-professionid="26">
<option value="288" data-match="ADV" data-professionid="26" data-allowed-jurisdictions="["ME"]">ADV - Administration of Drugs and Vaccines Approval</option>
<option value="287" data-match="CA" data-professionid="26" data-allowed-jurisdictions="["ME"]">CA - Contraceptive Administration Approval</option>
<option value="283" data-match="CPA" data-professionid="26" data-allowed-jurisdictions="["ME","NJ"]">CPA - Collaborative Practice Approval</option>
<option value="285" data-match="DTMP" data-professionid="26" data-allowed-jurisdictions="["GA"]">DTMP - Drug Therapy Modification Protocol Approval</option>
<option value="284" data-match="IA" data-professionid="26" data-allowed-jurisdictions="["NJ"]">IA - Immunization Administration Approval</option>
<option value="281" data-match="PIC" data-professionid="26" data-allowed-jurisdictions="["LA","ME","SC"]">PIC - Pharmacist in Charge</option>
<option value="195" data-match="PH" data-professionid="26"
data-hidden-jurisdictions="["WV","CA","GA","ND","OH","OK","OR","PA","RI","MT"]">PH - Pharmacist</option>
<option value="205" data-match="RPH" data-professionid="26"
data-allowed-jurisdictions="["WV","CA","GA","ND","OH","OK","OR","PA","RI","MT"]">RPH - Registered Pharmacist</option>
<option value="286" data-match="APH" data-professionid="26" data-allowed-jurisdictions="["CA"]">APH - Advanced Practice Pharmacist</option>
<option value="274" data-match="CPH" data-professionid="26" data-allowed-jurisdictions="["FL"]">CPH - Consultant Pharmacist</option>
<option value="278" data-match="CPP" data-professionid="26" data-allowed-jurisdictions="["NC","NC","MT"]">CPP - Clinical Pharmacist Practitioner</option>
<option value="275" data-match="NPH" data-professionid="26" data-allowed-jurisdictions="["GA","FL"]">NPH - Nuclear Pharmacist</option>
<option value="279" data-match="TPPH" data-professionid="26">TPPH - Temporary Pharmacist</option>
</optgroup>
<optgroup label="Pharmacy Technician" data-professionid="27">
<option value="196" data-match="CPHT" data-professionid="27"
data-allowed-jurisdictions="["ID","NH","OR","KY","KS","LA","MT","OH","SC","SD"]">CPHT - Certified Pharmacy Technician</option>
<option value="282" data-match="PHA" data-professionid="27" data-allowed-jurisdictions="["WA"]">PHA - Pharmacy Assistant</option>
<option value="229" data-match="RPHT" data-professionid="27" data-allowed-jurisdictions="["FL","ND","NH","NY","OH","WY"]">RPHT - Registered Pharmacy Technician</option>
<option value="277" data-match="PHT" data-professionid="27"
data-hidden-jurisdictions="["FL","KS","LA","MT","ND","NH","NY","SD","WY","OH"]">PHT - Pharmacy Technician</option>
<option value="276" data-match="NPHT" data-professionid="27" data-allowed-jurisdictions="["FL","WV"]">NPHT - Nuclear Pharmacy Technician</option>
<option value="280" data-match="TPPHT" data-professionid="27">TPPHT - Temporary Pharmacy Technician</option>
</optgroup>
<optgroup label="Social Worker" data-professionid="4">
<option value="249" data-match="BSW" data-professionid="4" data-allowed-jurisdictions="["PA"]">BSW - Bachelor Social Worker</option>
<option value="144" data-match="CMSW" data-professionid="4" data-allowed-jurisdictions="["NC","NE","FL"]">CMSW - Certified Master Social Worker</option>
<option value="63" data-match="CSW" data-professionid="4"
data-allowed-jurisdictions="["NC","RI","UT","WY","MS","NJ","GA","KY","LA","SD","US","NE"]">CSW - Certified Social
Worker</option>
<option value="248" data-match="CSW" data-professionid="4" data-allowed-jurisdictions="["??","AK","PA","NH"]">CSW - Clinical Social Worker</option>
<option value="233" data-match="CSWA" data-professionid="4" data-allowed-jurisdictions="["CA","OR"]">CSWA - Clinical Social Work Associate</option>
<option value="84" data-match="CSWI" data-professionid="4" data-allowed-jurisdictions="["FM"]">CSWI - Registered Clinical Social Work Intern</option>
<option value="247" data-match="LCSW" data-professionid="4" data-allowed-jurisdictions="["AR","??","MA","MS","WV"]">LCSW - Licensed Certified Social Worker</option>
<option value="245" data-match="LCSWC" data-professionid="4" data-allowed-jurisdictions="["MD"]">LCSWC - Licensed Certified Social Worker Clinical</option>
<option value="135" data-match="LGSW" data-professionid="4" data-allowed-jurisdictions="["MN","WV","DC"]">LGSW - Licensed Graduate Social Worker</option>
<option value="250" data-match="LISWCP" data-professionid="4" data-allowed-jurisdictions="["SC"]">LISWCP - Licensed Independent Social Worker Clinical Practice</option>
<option value="21" data-match="LSW" data-professionid="4"
data-allowed-jurisdictions="["AR","HI","CO","NV","MN","IN","MA","MS","OH","VA","IL","WV","NJ","KY","ME","ND","OK"]">
LSW - Licensed Social Worker</option>
<option value="258" data-match="LSWI" data-professionid="4" data-allowed-jurisdictions="["ID"]">LSWI - Licensed Social Worker Independent</option>
<option value="138" data-match="MSW" data-professionid="4" data-allowed-jurisdictions="["AK","GA","ME","US"]">MSW - Master Social Worker</option>
<option value="149" data-match="RSW" data-professionid="4" data-allowed-jurisdictions="["OR","VA","LA"]">RSW - Registered Social Worker</option>
<option value="30" data-match="SW" data-professionid="4"
data-allowed-jurisdictions="["UT","VA","WI","PA","SD","AS","GU","MH","FM","MP","XX","PW","PR","VI"]">
SW - Social Worker</option>
<option value="139" data-match="SWA" data-professionid="4" data-allowed-jurisdictions="["WA","VA"]">SWA - Social Work Associate</option>
<option value="257" data-match="SWS" data-professionid="4">SWS - Social Worker Supervisor</option>
<option value="94" data-match="TPSW" data-professionid="4" data-allowed-jurisdictions="["FM"]">TPSW - Temporary Social Worker Permit</option>
<option value="218" data-match="APSW" data-professionid="4" data-allowed-jurisdictions="["WA","WI","WI"]">APSW - Advanced Practice Social Worker</option>
<option value="152" data-match="ASW" data-professionid="4">ASW - Associate Social Worker</option>
<option value="17" data-match="LCSW" data-professionid="4"
data-allowed-jurisdictions="["MO","AZ","HI","CO","IN","MD","MT","ID","NV","DE","NC","NM","NY","OR","TX","UT","VA","WI","WY","CA","IL","NJ","CT","FL","KY","LA","ME","ND","TN","OK","VT"]">
LCSW - Licensed Clinical Social Worker</option>
<option value="66" data-match="LISW" data-professionid="4" data-allowed-jurisdictions="["SC","NV","MN","NM","OH","WI","WV","IA","DC"]">LISW -
Licensed Independent Social Worker</option>
<option value="228" data-match="LAPSW" data-professionid="4" data-allowed-jurisdictions="["TN"]">LAPSW - Licensed Advanced Practitioner Social Worker</option>
<option value="244" data-match="LISWD" data-professionid="4" data-allowed-jurisdictions="["SC"]">LISWD - Licensed Independent Social Worker Dual Practice</option>
<option value="73" data-match="LBSW" data-professionid="4"
data-allowed-jurisdictions="["AL","AZ","HI","SC","MD","AK","KS","MI","MT","ID","DE","IN","NM","TX","VA","IA","MO","US","TN"]">
LBSW - Licensed Bachelor Social Worker</option>
<option value="75" data-match="LICSW" data-professionid="4" data-allowed-jurisdictions="["AL","WA","MN","MA","DC","RI","ND"]">LICSW - Licensed Independent Clinical
Social Worker</option>
<option value="289" data-match="LCSWA" data-professionid="4" data-allowed-jurisdictions="["NC"]">LCSWA - Licensed Clinical Social Worker Associate</option>
<option value="29" data-match="LMSW" data-professionid="4"
data-allowed-jurisdictions="["AL","CT","MI","AR","AZ","NV","SC","MD","KS","ND","MT","ID","MN","DE","MS","NM","NY","OR","TX","IA","LA","US","TN","MO","OK"]">
LMSW - Licensed Master Social Worker</option>
<option value="212" data-match="LMSWI" data-professionid="4" data-allowed-jurisdictions="["ID","CA"]">LMSWI - Licensed Independent Master Social Worker</option>
<option value="232" data-match="LSCSW" data-professionid="4" data-allowed-jurisdictions="["KS"]">LSCSW - Licensed Specialist Clinical Social Worker</option>
<option value="76" data-match="LSWA" data-professionid="4" data-allowed-jurisdictions="["KS","OH","NV","MA","DC","OK"]">LSWA - Licensed Social Worker Associate</option>
</optgroup>
<optgroup label="Counselor/Therapist" data-professionid="16">
<option value="162" data-match="AT" data-professionid="16" data-allowed-jurisdictions="["FM"]">AT - Art Therapist</option>
<option value="234" data-match="CMHC" data-professionid="16" data-allowed-jurisdictions="["NH"]">CMHC - Clinical Mental Health Counselor</option>
<option value="150" data-match="IMHP" data-professionid="16" data-allowed-jurisdictions="["NE"]">IMHP - Independent Mental Health Practitioner</option>
<option value="163" data-match="LMHA" data-professionid="16" data-allowed-jurisdictions="["WA","IN"]">LMHA - Licensed Mental Health Counselor Associate</option>
<option value="128" data-match="LPCI" data-professionid="16" data-allowed-jurisdictions="["FM"]">LPCI - Licensed Professional Counselor Intern</option>
<option value="19" data-match="MFC" data-professionid="16" data-allowed-jurisdictions="["FM"]">MFC - Marriage and Family Counselor</option>
<option value="83" data-match="MFTI" data-professionid="16" data-allowed-jurisdictions="["FM"]">MFTI - Marriage and Family Therapist Intern</option>
<option value="82" data-match="MHCI" data-professionid="16" data-allowed-jurisdictions="["FM"]">MHCI - Mental Health Counselor Intern</option>
<option value="142" data-match="MHP" data-professionid="16" data-allowed-jurisdictions="["NE","VA"]">MHP - Mental Health Practitioner</option>
<option value="159" data-match="MTBC" data-professionid="16" data-allowed-jurisdictions="["FM"]">MTBC - Music Therapist-Board Certified</option>
<option value="130" data-match="NCC" data-professionid="16" data-allowed-jurisdictions="["FM","US"]">NCC - National Certified Counselor</option>
<option value="141" data-match="PAC" data-professionid="16" data-allowed-jurisdictions="["ME"]">PAC - Pastoral Counselor</option>
<option value="160" data-match="PC" data-professionid="16"
data-allowed-jurisdictions="["PA","GU","AS","MH","MP","XX","PW","PR","VI","GA"]">PC - Professional Counselor</option>
<option value="129" data-match="RC" data-professionid="16" data-allowed-jurisdictions="["ME","NJ","MA"]">RC - Registered Counselor</option>
<option value="101" data-match="TPCT" data-professionid="16" data-allowed-jurisdictions="["ME"]">TPCT - Temporary Counselor/Therapist Permit</option>
<option value="64" data-match="AP" data-professionid="16"
data-allowed-jurisdictions="["WV","WY","UT","DC","IN","LA","AL","CO","MA","RI","CA","FL","KY","XX","US"]">
AP - Addiction Professional</option>
<option value="179" data-match="CDP" data-professionid="16" data-allowed-jurisdictions="["FM","AK","WA"]">CDP - Chemical Dependency Professional</option>
<option value="211" data-match="LADC" data-professionid="16" data-allowed-jurisdictions="["FM","MN","CT","ME","NE","NH","NM","NV","OK"]">LADC -
Licensed Alcohol and Drug Counselor</option>
<option value="140" data-match="CPC" data-professionid="16" data-allowed-jurisdictions="["NV","AR","NE","WA"]">CPC - Certified Professional Counselor</option>
<option value="58" data-match="CADC" data-professionid="16"
data-allowed-jurisdictions="["CT","MD","AR","DC","NJ","SD","AZ","IA","IL","ME","MO","MS","RI","TX","VT","WV","CA","FL","GA","ID","NV","PA","XX","MI","OR"]">
CADC - Certified Alcohol/Drug Counselor</option>
<option value="145" data-match="LCADC" data-professionid="16" data-allowed-jurisdictions="["AR","ND","NJ","NC","MD"]">LCADC - Licensed Clinical Alcohol and Drug Counselor</option>
<option value="71" data-match="SAC" data-professionid="16" data-allowed-jurisdictions="["AK","VA","HI","NM","RI","WI","NY","TN"]">SAC - Substance Abuse
Counselor</option>
<option value="143" data-match="AC" data-professionid="16" data-allowed-jurisdictions="["CA","SC","GA","MD","AR","NJ","DE"]">AC - Associate Counselor</option>
<option value="148" data-match="LISAC" data-professionid="16" data-allowed-jurisdictions="["AZ"]">LISAC - Licensed Independent Substance Abuse Counselor</option>
<option value="74" data-match="MFTA" data-professionid="16" data-allowed-jurisdictions="["CA","WA","GA","IN","TX","AL","NM","XX","KY"]">MFTA -
Marriage and Family Therapist Associate</option>
<option value="146" data-match="LMHC" data-professionid="16" data-allowed-jurisdictions="["FL","AR","NY","NM","MA"]">LMHC - Licensed Mental Health Counselor</option>
<option value="178" data-match="LPCA" data-professionid="16" data-allowed-jurisdictions="["AR","AL"]">LPCA - Licensed Professional Counselor Associate</option>
<option value="161" data-match="LSAT" data-professionid="16" data-allowed-jurisdictions="["AZ"]">LSAT - Licensed Substance Abuse Technician</option>
<option value="18" data-match="MFT" data-professionid="16"
data-allowed-jurisdictions="["UT","WA","WI","GA","KY","NV","OK","PA","MI","AK","AR","HI","IA","IN","ME","MO","NE","NH","NJ","RI","AL","IL","CT","DC","VT","XX","US","OH","MS"]">
MFT - Marriage and Family Therapist</option>
<option value="219" data-match="CAC" data-professionid="16" data-allowed-jurisdictions="["IN"]">CAC - Clinical Addiction Counselor</option>
<option value="50" data-match="MHC" data-professionid="16" data-allowed-jurisdictions="["WA","WY","UT","AR","HI","IA","IN","RI","VT"]">MHC - Mental
Health Counselor</option>
<option value="220" data-match="CACA" data-professionid="16" data-allowed-jurisdictions="["IN"]">CACA - Clinical Addiction Counselor Associate</option>
<option value="259" data-match="IMFT" data-professionid="16" data-allowed-jurisdictions="["OH"]">IMFT - Independent Marriage and Family Therapist</option>
<option value="65" data-match="LEP" data-professionid="16" data-allowed-jurisdictions="["CA","SC","MA"]">LEP - Licensed Educational Psychologist</option>
<option value="260" data-match="IMFTS" data-professionid="16" data-allowed-jurisdictions="["OH"]">IMFTS - Independent Marriage and Family Therapist Supervisor</option>
<option value="177" data-match="LCPC" data-professionid="16" data-allowed-jurisdictions="["TN","IL","MT","KS","ID","MD"]">LCPC - Licensed Clinical Professional Counselor</option>
<option value="20" data-match="LPC" data-professionid="16"
data-allowed-jurisdictions="["MI","SD","WI","WY","GA","ID","KY","MD","WV","OK","OR","SC","OH","AK","AR","AZ","CO","DC","IL","KS","LA","MO","MS","ND","NJ","TX","CT","NM","AL","MN","VA","XX"]">
LPC - Licensed Professional Counselor</option>
<option value="127" data-match="LPCS" data-professionid="16" data-allowed-jurisdictions="["OH","AR","MS","NC","SC"]">LPCS - Licensed Professional Counselor Supervisor</option>
<option value="224" data-match="LAMFT" data-professionid="16" data-allowed-jurisdictions="["MN","AZ","ND","AR"]">LAMFT - Licensed Associate Marriage and Family Therapist</option>
<option value="223" data-match="LAC" data-professionid="16" data-allowed-jurisdictions="["AZ"]">LAC - Licensed Associate Counselor</option>
<option value="225" data-match="LASAC" data-professionid="16" data-allowed-jurisdictions="["AZ"]">LASAC - Licensed Associate Substance Abuse Counselor</option>
<option value="72" data-match="LPCC" data-professionid="16"
data-allowed-jurisdictions="["CA","ID","KY","MD","CO","ME","ND","NM","XX","OH"]">LPCC - Licensed Professional Clinical Counselor
</option>
<option value="222" data-match="LPCCS" data-professionid="16" data-allowed-jurisdictions="["OH"]">LPCCS - Licensed Professional Clinical Counselor Supervisor</option>
<option value="186" data-match="LCDC" data-professionid="16" data-allowed-jurisdictions="["TX","DE","OH"]">LCDC - Licensed Chemical Dependency Counselor</option>
<option value="221" data-match="LCMFT" data-professionid="16" data-allowed-jurisdictions="["KS"]">LCMFT - Licensed Clinical Marriage and Family Therapist</option>
<option value="136" data-match="LMFT" data-professionid="16"
data-allowed-jurisdictions="["WV","LA","MN","WY","CA","DE","FL","ID","MD","NY","TN","OR","SC","TX","AZ","MT","NC","KS","SD","VA","CO","NM","MA","ND","XX"]">
LMFT - Licensed Marriage and Family Therapist</option>
<option value="208" data-match="LCMHC" data-professionid="16" data-allowed-jurisdictions="["NC"]">LCMHC - Licensed Clinical Mental Health Counselor</option>
<option value="213" data-match="LPCMH" data-professionid="16" data-allowed-jurisdictions="["SD","DE"]">LPCMH - Licensed Professional Counselor Mental Health</option>
<option value="210" data-match="LCMHCS" data-professionid="16" data-allowed-jurisdictions="["NC"]">LCMHCS - Licensed Clinical Mental Health Counselor Supervisor</option>
<option value="263" data-match="LCAC" data-professionid="16" data-allowed-jurisdictions="["KS"]">LCAC - Licensed Clinical Addiction Counselor</option>
<option value="264" data-match="LMAC" data-professionid="16" data-allowed-jurisdictions="["KS"]">LMAC - Licensed Master Addiction Counselor</option>
<option value="270" data-match="LMFS" data-professionid="16" data-allowed-jurisdictions="["XX"]">LMFS - Licensed Marriage and Family Therapist Supervisor</option>
<option value="236" data-match="MFTS" data-professionid="16" data-allowed-jurisdictions="["SC"]">MFTS - Marriage and Family Therapy Supervisor</option>
<option value="246" data-match="MHA" data-professionid="16" data-allowed-jurisdictions="["IN"]">MHA - Mental Health Associate</option>
<option value="235" data-match="LACS" data-professionid="16" data-allowed-jurisdictions="["SC"]">LACS - Licensed Addiction Counselor Supervisor</option>
<option value="226" data-match="LAC" data-professionid="16" data-allowed-jurisdictions="["SC","MT","CO","KS"]">LAC - Licensed Addiction Counselor</option>
<option value="271" data-match="LACA" data-professionid="16" data-allowed-jurisdictions="["SC"]">LACA - Licensed Addiction Counselor Associate</option>
<option value="209" data-match="LCMHCA" data-professionid="16" data-allowed-jurisdictions="["NC"]">LCMHCA - Licensed Clinical Mental Health Counselor Associate</option>
<option value="266" data-match="LRC" data-professionid="16" data-allowed-jurisdictions="["NJ"]">LRC - Licensed Rehabilitation Counselor</option>
</optgroup>
<optgroup label="Psychologist" data-professionid="5">
<option value="52" data-match="PHD" data-professionid="5">PHD - Psychologist PhD</option>
<option value="23" data-match="PSYD" data-professionid="5">PSYD - Doctor of Psychology</option>
<option value="89" data-match="PSYM" data-professionid="5">PSYM - Master of Psychology</option>
<option value="217" data-match="MPsy" data-professionid="5" data-allowed-jurisdictions="["LA"]">MPsy - Medical Psychologist</option>
<option value="95" data-match="TPPS" data-professionid="5">TPPS - Temporary Psychologist Permit</option>
<option value="272" data-match="PP" data-professionid="5" data-allowed-jurisdictions="["WY"]">PP - Psychological Practitioner</option>
<option value="273" data-match="SSP" data-professionid="5" data-allowed-jurisdictions="["WY"]">SSP - Specialist in School Psychology</option>
</optgroup>
<optgroup label="Certified Case Manager" data-professionid="7">
<option value="26" data-match="CCM" data-professionid="7">CCM - Certified Case Manager</option>
</optgroup>
<optgroup label="Certified Diabetes Educator" data-professionid="25">
<option value="62" data-match="CDE" data-professionid="25">CDE - Certified Diabetes Educator</option>
</optgroup>
<optgroup label="Nursing Assistant" data-professionid="17">
<option value="4" data-match="CNA" data-professionid="17">CNA - Certified Nurse Assistant</option>
<option value="137" data-match="TPCNA" data-professionid="17">TPCNA - Temporary Certified Nurse Assistant</option>
</optgroup>
<optgroup label="Certified Surgical Assistant" data-professionid="24">
<option value="155" data-match="CSA" data-professionid="24">CSA - Certified Surgical Assistant</option>
</optgroup>
<optgroup label="CST/CSFA" data-professionid="6">
<option value="25" data-match="CSFA" data-professionid="6">CSFA - Certified Surgical First Assistant</option>
<option value="24" data-match="CST" data-professionid="6">CST - Certified Surgical Technician</option>
<option value="96" data-match="TPCST" data-professionid="6">TPCST - Temporary CST Permit</option>
</optgroup>
<optgroup label="Dental Assistant" data-professionid="23">
<option value="36" data-match="CDA" data-professionid="23" data-allowed-jurisdictions="["US"]">CDA - Certified Dental Assistant</option>
<option value="185" data-match="DSA" data-professionid="23" data-allowed-jurisdictions="["CA"]">DSA - Dental Sedation Assistant</option>
<option value="253" data-match="DT" data-professionid="23" data-allowed-jurisdictions="["SC"]">DT - Dental Technician</option>
<option value="252" data-match="LDA" data-professionid="23" data-allowed-jurisdictions="["MN"]">LDA - Licensed Dental Assistant</option>
<option value="184" data-match="OA" data-professionid="23" data-allowed-jurisdictions="["CA"]">OA - Orthodontic Assistant</option>
<option value="15" data-match="RDA" data-professionid="23" data-allowed-jurisdictions="["CA","PA","MA","MI"]">RDA - Registered Dental Assistant</option>
<option value="167" data-match="RDAEF" data-professionid="23" data-allowed-jurisdictions="["CA","PA"]">RDAEF - Registered Dental Assistant Extended Function</option>
<option value="251" data-match="DA" data-professionid="23" data-hidden-jurisdictions="["CA","MA","SC","PA","MI","MN"]">DA - Dental Assistant</option>
</optgroup>
<optgroup label="Dental Hygienist" data-professionid="22">
<option value="14" data-match="RDH" data-professionid="22" data-allowed-jurisdictions="["OK","CA","PA","MI"]">RDH - Registered Dental Hygienist</option>
<option value="168" data-match="RDHEF" data-professionid="22" data-allowed-jurisdictions="["CA"]">RDHEF - Registered Dental Hygienist Extended Function</option>
<option value="154" data-match="DH" data-professionid="22" data-hidden-jurisdictions="["CA","PA","MI","OK"]">DH - Dental Hygienist</option>
<option value="207" data-match="RDHAP" data-professionid="22" data-allowed-jurisdictions="["CA"]">RDHAP - Registered Dental Hygienist Alternative Practice</option>
</optgroup>
<optgroup label="Dentist" data-professionid="3">
<option value="241" data-match="CSED" data-professionid="3" data-allowed-jurisdictions="["CA"]">CSED - Conscious Sedation</option>
<option value="239" data-match="DGA" data-professionid="3" data-allowed-jurisdictions="["CA"]">DGA - Dental General Anesthesia</option>
<option value="35" data-match="DMD" data-professionid="3" data-allowed-jurisdictions="["US"]">DMD - Doctor of Dental Medicine</option>
<option value="240" data-match="MGA" data-professionid="3" data-allowed-jurisdictions="["CA"]">MGA - Medical General Anesthesia</option>
<option value="256" data-match="MSED" data-professionid="3" data-allowed-jurisdictions="["CA"]">MSED - Moderate Sedation</option>
<option value="243" data-match="OMS" data-professionid="3" data-allowed-jurisdictions="["CA"]">OMS - Oral Maxillofacial Surgery</option>
<option value="242" data-match="OSED" data-professionid="3" data-allowed-jurisdictions="["CA"]">OSED - Oral Conscious Sedation</option>
<option value="31" data-match="DDS" data-professionid="3">DDS - Doctor of Dental Surgery</option>
<option value="93" data-match="TPD" data-professionid="3" data-hidden-jurisdictions="["FL","SC","OK"]">TPD - Temporary Dental Permit</option>
</optgroup>
<optgroup label="Nursing Home Administrator" data-professionid="9">
<option value="28" data-match="NHA" data-professionid="9">NHA - Nursing Home Administrator</option>
<option value="98" data-match="TPNHA" data-professionid="9">TPNHA - Temporary Nursing Home Administrator</option>
</optgroup>
<optgroup label="Respiratory Therapist" data-professionid="13">
<option value="33" data-match="RT" data-professionid="13">RT - Respiratory Therapist</option>
</optgroup>
<optgroup label="Research Professional" data-professionid="14">
<option value="38" data-match="CCRA" data-professionid="14">CCRA - Certified Clinical Research Associate</option>
<option value="37" data-match="CCRC" data-professionid="14">CCRC - Certified Clinical Research Coordinator</option>
<option value="39" data-match="CCRI" data-professionid="14">CCRI - Certified Clinical Research Investigator</option>
</optgroup>
<optgroup label="Other/IACET" data-professionid="20">
<option value="34" data-match="OTH" data-professionid="20">OTH - Other IACET qualification</option>
</optgroup>
<optgroup label="Medical Assistant" data-professionid="15">
<option value="41" data-match="CMA" data-professionid="15">CMA - Certified Medical Assistant</option>
<option value="40" data-match="MA" data-professionid="15">MA - Medical Assistant</option>
</optgroup>
</select>
</div>
</div>
<!-- End Qualification Select -->
<button type="submit" class="btn btn-green btn-gts" tabindex="11" data-search="1" data-loading-text="Start Now <i class='icon-spinner icon-spin'></i>">Start Now</button>
</fieldset>
</form>Name: quickcode — POST /quickcode.php
<form novalidate="novalidate" name="quickcode" class="ajax-form base-forms" id="quickcode" method="post" action="/quickcode.php">
<fieldset data-form-section="">
<p class="wc_booklettext">The back of your booklet contains your <span class="ignore-grid">Quick Code</span> and <span class="ignore-grid">Customer ID</span>. Enter your information here to get started!</p>
<!-- Start Error Section for Quick Code & Customer ID validation -->
<div class="error-placeholder" id="error_1"><!----></div>
<!-- End Error Section for Quick Code & Customer ID validation -->
<div class="control-group">
<label class="hidden" for="code_field">Quick Code</label>
<div class="controls prepend_icon large">
<input id="code_field" type="text" name="code" maxlength="20" placeholder="Quick Code" tabindex="2" autocomplete="off" data-field-type="code" required="required" value="">
<i class="icon-barcode"><!-- --></i>
</div>
</div>
<div class="control-group">
<label class="hidden" for="customer_id">Customer ID</label>
<div class="controls prepend_icon large">
<input id="customer_id" type="text" name="customerid" maxlength="20" placeholder="Customer ID" tabindex="3" autocomplete="off" pattern="[0-9]*" data-field-type="customerid" required="required" value="">
<i class="icon-user"><!-- --></i>
</div>
</div>
<p><a title="Don't have a quick code? Find your CE." id="no_qc" href="#new_visitor#new_visitor">Don't have a Quick Code?</a></p>
<button type="submit" class="btn btn-green btn-gts" tabindex="5" data-loading-text="Start Now <i class='icon-spinner icon-spin'></i>">Start Now</button>
</fieldset>
</form>Name: request-booklet — POST /register.php
<form class="span6 base-forms base-select ajax-form" novalidate="novalidate" name="request-booklet" id="request-booklet" method="post" action="/register.php">
<input type="hidden" name="action" value="e8b98bea7c42f258de51854cb5e7590e">
<input type="hidden" name="dest" value="booklet">
<fieldset data-form-section="">
<div class="error-placeholder" id="error_4"><!----></div>
<div class="row-fluid">
<!-- First Name -->
<div class="span4 register_fn">
<div class="control-group">
<label class="hidden" for="first_name">First Name</label>
<div class="controls prepend_icon">
<input type="text" id="first_name" placeholder="First Name" class="input-block-level" tabindex="13" name="firstname" maxlength="20" data-field-type="firstname" required="required" value="">
<i class="icon-user"><!-- --></i>
</div>
</div>
</div>
<!-- MI -->
<div class="span3 register_mi">
<div class="control-group">
<label class="hidden" for="middle_initial">Middle Name</label>
<div class="controls">
<input type="text" id="middle_initial" placeholder="Middle" name="middlename" class="input-block-level" tabindex="14" maxlength="20" data-field-type="middlename" value="">
</div>
</div>
</div>
<div class="clearfix visible-phone"><!-- --></div>
<!-- Last Name -->
<div class="span5 register_ln">
<div class="control-group">
<label class="hidden" for="last_name">Last Name</label>
<div class="controls prepend_icon">
<input type="text" id="last_name" placeholder="Last Name" class="input-block-level" tabindex="15" name="lastname" maxlength="30" data-field-type="lastname" required="required" value="">
<i class="icon-user"><!-- --></i>
</div>
</div>
</div>
</div>
<div class="row-fluid">
<div class="control-group">
<div class="span12 bsl-wrap">
<!-- End Error Section for State and Profession validation -->
<!-- |||||| -->
<div class="select2-container ga_s" id="s2id_state_select_small" style="width: 100%;">
<a href="javascript:void(0)" class="select2-choice select2-default" tabindex="-1"> <span class="select2-chosen" id="select2-chosen-4">Select Your State or Jurisdiction</span><abbr class="select2-search-choice-close"></abbr> <span class="select2-arrow" role="presentation"><b role="presentation"></b></span></a><label
for="s2id_autogen4" class="select2-offscreen"></label><input class="select2-focusser select2-offscreen" type="text" aria-haspopup="true" role="button" aria-labelledby="select2-chosen-4" id="s2id_autogen4" tabindex="16">
<div class="select2-drop select2-display-none target_id_state_select_small select2-small select2-with-searchbox">
<div class="select2-search"> <label for="s2id_autogen4_search" class="select2-offscreen"></label> <input type="text" autocomplete="off" autocorrect="off" autocapitalize="off" spellcheck="false" class="select2-input" role="combobox"
aria-expanded="true" aria-autocomplete="list" aria-owns="select2-results-4" id="s2id_autogen4_search" placeholder=""> </div>
<ul class="select2-results" role="listbox" id="select2-results-4"> </ul>
</div>
</div><select tabindex="-1" name="jurisdiction" id="state_select_small" class="ga_s select2-small select2-offscreen" data-placeholder="Select Your State or Jurisdiction" data-connected-fields="license" data-field-type="state"
required="required" title="">
<option><!-- --></option>
<option value="AL" data-match="AL">Alabama</option>
<option value="AK" data-match="AK">Alaska</option>
<option value="AS" data-match="AS">American Samoa</option>
<option value="AZ" data-match="AZ">Arizona</option>
<option value="AR" data-match="AR">Arkansas</option>
<option value="BS" data-match="BS">Bahamas</option>
<option value="CA" data-match="CA">California</option>
<option value="CO" data-match="CO">Colorado</option>
<option value="CT" data-match="CT">Connecticut</option>
<option value="DE" data-match="DE">Delaware</option>
<option value="DC" data-match="DC">District of Columbia</option>
<option value="FL" data-match="FL">Florida</option>
<option value="GA" data-match="GA">Georgia</option>
<option value="GU" data-match="GU">Guam</option>
<option value="HI" data-match="HI">Hawaii</option>
<option value="ID" data-match="ID">Idaho</option>
<option value="IL" data-match="IL">Illinois</option>
<option value="IN" data-match="IN">Indiana</option>
<option value="IA" data-match="IA">Iowa</option>
<option value="KS" data-match="KS">Kansas</option>
<option value="KY" data-match="KY">Kentucky</option>
<option value="LA" data-match="LA">Louisiana</option>
<option value="ME" data-match="ME">Maine</option>
<option value="MH" data-match="MH">Marshall Islands</option>
<option value="MD" data-match="MD">Maryland</option>
<option value="MA" data-match="MA">Massachusetts</option>
<option value="MI" data-match="MI">Michigan</option>
<option value="FM" data-match="FM">Micronesia</option>
<option value="MN" data-match="MN">Minnesota</option>
<option value="MS" data-match="MS">Mississippi</option>
<option value="MO" data-match="MO">Missouri</option>
<option value="MT" data-match="MT">Montana</option>
<option value="NE" data-match="NE">Nebraska</option>
<option value="NV" data-match="NV">Nevada</option>
<option value="NH" data-match="NH">New Hampshire</option>
<option value="NJ" data-match="NJ">New Jersey</option>
<option value="NM" data-match="NM">New Mexico</option>
<option value="NY" data-match="NY">New York</option>
<option value="XX" data-match="XX">Non-US</option>
<option value="NC" data-match="NC">North Carolina</option>
<option value="ND" data-match="ND">North Dakota</option>
<option value="MP" data-match="MP">Northern Marianas</option>
<option value="OH" data-match="OH">Ohio</option>
<option value="OK" data-match="OK">Oklahoma</option>
<option value="OR" data-match="OR">Oregon</option>
<option value="PW" data-match="PW">Palau</option>
<option value="PA" data-match="PA">Pennsylvania</option>
<option value="PR" data-match="PR">Puerto Rico</option>
<option value="RI" data-match="RI">Rhode Island</option>
<option value="SC" data-match="SC">South Carolina</option>
<option value="SD" data-match="SD">South Dakota</option>
<option value="TN" data-match="TN">Tennessee</option>
<option value="TX" data-match="TX">Texas</option>
<option value="US" data-match="US">US Nationally-Certified</option>
<option value="UT" data-match="UT">Utah</option>
<option value="VT" data-match="VT">Vermont</option>
<option value="VA" data-match="VA">Virginia</option>
<option value="VI" data-match="VI">Virgin Islands</option>
<option value="WA" data-match="WA">Washington</option>
<option value="WV" data-match="WV">West Virginia</option>
<option value="WI" data-match="WI">Wisconsin</option>
<option value="WY" data-match="WY">Wyoming</option>
</select>
</div>
</div>
</div>
<div class="row-fluid">
<!-- Profession Message Area -->
<div id="prof-mes"><!-- --></div>
<!-- Qualification Message Area -->
<div id="qual-mes"><!-- --></div>
</div>
<div class="row-fluid">
<div class="control-group">
<div class="span12 bsl-wrap ">
<div class="select2-container" id="s2id_professionid_small" style="width: 100%;">
<a href="javascript:void(0)" class="select2-choice select2-default" tabindex="-1"> <span class="select2-chosen" id="select2-chosen-5">Select Your Profession</span><abbr class="select2-search-choice-close"></abbr> <span class="select2-arrow" role="presentation"><b role="presentation"></b></span></a><label
for="s2id_autogen5" class="select2-offscreen"></label><input class="select2-focusser select2-offscreen" type="text" aria-haspopup="true" role="button" aria-labelledby="select2-chosen-5" id="s2id_autogen5" tabindex="17">
<div class="select2-drop select2-display-none target_id_professionid_small select2-small select2-with-searchbox">
<div class="select2-search"> <label for="s2id_autogen5_search" class="select2-offscreen"></label> <input type="text" autocomplete="off" autocorrect="off" autocapitalize="off" spellcheck="false" class="select2-input" role="combobox"
aria-expanded="true" aria-autocomplete="list" aria-owns="select2-results-5" id="s2id_autogen5_search" placeholder=""> </div>
<ul class="select2-results" role="listbox" id="select2-results-5"> </ul>
</div>
</div><select data-field-type="profession" id="professionid_small" class="select2-small select2-offscreen" data-independent="true" data-placeholder="Select Your Profession" tabindex="-1" data-connected-fields="license" required="required"
name="professionid" title="">
<option value="" disabled="disabled" selected="selected" data-certifications="[]"></option>
<option value="1" data-match="Nurses" data-certifications="[]">Nurse</option>
<option value="10" data-match="Advanced Practice Registered Nurses" data-certifications="[]">Advanced Practice Nurse</option>
<option value="2" data-match="Physicians" data-certifications="[]">Physician</option>
<option value="11" data-match="Physician Assistants" data-certifications="[]">Physician Assistant</option>
<option value="26" data-match="Pharmacists" data-certifications="[]">Pharmacist</option>
<option value="27" data-match="Pharmacy Technicians" data-certifications="[]">Pharmacy Technician</option>
<option value="4" data-match="Social Workers" data-certifications="[]">Social Worker</option>
<option value="16" data-match="Counselors/Therapists" data-certifications="[]">Counselor/Therapist</option>
<option value="5" data-match="Psychologists" data-certifications="[]">Psychologist</option>
<option value="7" data-match="Case Managers" data-certifications="[]">Certified Case Manager</option>
<option value="25" data-match="Certified Diabetes Educators" data-certifications="[]">Certified Diabetes Educator</option>
<option value="17" data-match="Nursing Assistants" data-certifications="[]">Nursing Assistant</option>
<option value="24" data-match="Certified Surgical Assistant" data-certifications="[]">Certified Surgical Assistant</option>
<option value="6" data-match="CSTs/CSFAs" data-certifications="[]">CST/CSFA</option>
<option value="23" data-match="Dental Assistants" data-certifications="[]">Dental Assistant</option>
<option value="22" data-match="Dental Hygienists" data-certifications="[]">Dental Hygienist</option>
<option value="3" data-match="Dentists" data-certifications="[]">Dentist</option>
<option value="9" data-match="Nursing Home Administrators" data-certifications="[]">Nursing Home Administrator</option>
<option value="20" data-match="Other/IACET" data-certifications="[]">Other/IACET</option>
</select>
</div>
</div>
</div>
<div class="row-fluid">
<div class="control-group">
<div class="span12 bsl-wrap">
<div class="select2-container" id="s2id_qualificationid_small" style="width: 100%;">
<a href="javascript:void(0)" class="select2-choice select2-default" tabindex="-1"> <span class="select2-chosen" id="select2-chosen-6">Select Your Professional Title</span><abbr class="select2-search-choice-close"></abbr> <span class="select2-arrow" role="presentation"><b role="presentation"></b></span></a><label
for="s2id_autogen6" class="select2-offscreen"></label><input class="select2-focusser select2-offscreen" type="text" aria-haspopup="true" role="button" aria-labelledby="select2-chosen-6" id="s2id_autogen6" tabindex="18">
<div class="select2-drop select2-display-none target_id_qualificationid_small select2-small select2-with-searchbox">
<div class="select2-search"> <label for="s2id_autogen6_search" class="select2-offscreen"></label> <input type="text" autocomplete="off" autocorrect="off" autocapitalize="off" spellcheck="false" class="select2-input" role="combobox"
aria-expanded="true" aria-autocomplete="list" aria-owns="select2-results-6" id="s2id_autogen6_search" placeholder=""> </div>
<ul class="select2-results" role="listbox" id="select2-results-6"> </ul>
</div>
</div><select data-field-type="qualification" id="qualificationid_small" class="select2-small select2-offscreen" tabindex="-1" data-independent="1" data-placeholder="Select Your Professional Title"
data-jurisdiction-selector="#state_select_small" data-connected-fields="license" required="required" name="qualificationid" title="">
<option value="" selected="selected"></option>
<optgroup label="Nurse" data-professionid="1">
<option value="106" data-match="APRN" data-professionid="1" data-allowed-jurisdictions="["GA"]">APRN - Advanced Practice Registered Nurse</option>
<option value="6" data-match="CAPT" data-professionid="1" data-allowed-jurisdictions="["CA","NY"]">CAPT - California Psychiatric Technician</option>
<option value="55" data-match="FLSLP" data-professionid="1" data-allowed-jurisdictions="["FL"]">FLSLP - Florida Speech/Language Pathologist</option>
<option value="268" data-match="LPNV" data-professionid="1" data-allowed-jurisdictions="["MI"]">LPNV - Licensed Practical Nurse Volunteer</option>
<option value="267" data-match="RNV" data-professionid="1" data-allowed-jurisdictions="["MI"]">RNV - Registered Nurse Volunteer</option>
<option value="1" data-match="RN" data-professionid="1">RN - Registered Nurse</option>
<option value="3" data-match="LPN" data-professionid="1" data-hidden-jurisdictions="["CA","TX"]">LPN - Licensed Practical Nurse</option>
<option value="2" data-match="LVN" data-professionid="1" data-allowed-jurisdictions="["TX","CA"]">LVN - Licensed Vocational Nurse</option>
<option value="45" data-match="CHT" data-professionid="1" data-allowed-jurisdictions="["US"]">CHT - Certified Hemodialysis Technician</option>
<option value="54" data-match="CLP" data-professionid="1" data-allowed-jurisdictions="["US"]">CLP - Clinical Laboratory Personnel</option>
<option value="57" data-match="CCT" data-professionid="1" data-allowed-jurisdictions="["US"]">CCT - Certified Cardiographic Technician</option>
<option value="199" data-match="LMHT" data-professionid="1" data-allowed-jurisdictions="["KS"]">LMHT - Licensed Mental Health Technician</option>
<option value="91" data-match="TPN" data-professionid="1" data-hidden-jurisdictions="["US"]">TPN - Temporary Nurse Permit</option>
<option value="147" data-match="PHN" data-professionid="1" data-allowed-jurisdictions="["CA"]">PHN - Public Health Nurse</option>
<option value="157" data-match="PMH" data-professionid="1" data-allowed-jurisdictions="["CA"]">PMH - Psychiatric Mental Health Nurse</option>
</optgroup>
<optgroup label="Advanced Practice Nurse" data-professionid="10">
<option value="49" data-match="APRN" data-professionid="10" data-allowed-jurisdictions="["GA"]"
data-hidden-jurisdictions="["TX","MI","CO","AL","PA","AZ","NJ","MN","NM","DE"]">APRN - Advanced Practice Registered Nurse</option>
<option value="5" data-match="ARNP" data-professionid="10" data-allowed-jurisdictions="["US"]">ARNP - Advanced Registered Nurse Practitioner</option>
<option value="88" data-match="CRNP" data-professionid="10" data-allowed-jurisdictions="["PA","AL"]">CRNP - Certified Registered Nurse Practitioner</option>
<option value="61" data-match="DTR" data-professionid="10" data-allowed-jurisdictions="["US"]">DTR - Dietetic Technician, Registered</option>
<option value="67" data-match="FLAP" data-professionid="10" data-allowed-jurisdictions="["FL"]">FLAP - Florida Acupuncturist</option>
<option value="77" data-match="FNP" data-professionid="10" data-allowed-jurisdictions="["US"]">FNP - Family Nurse Practitioner</option>
<option value="164" data-match="ND" data-professionid="10" data-allowed-jurisdictions="["US"]">ND - Nutritionist, Dietician, Nutrition Counselor</option>
<option value="60" data-match="RD" data-professionid="10" data-allowed-jurisdictions="["US"]">RD - Registered Dietician</option>
<option value="90" data-match="SA" data-professionid="10" data-allowed-jurisdictions="["US"]">SA - Surgical Assistant</option>
<option value="158" data-match="CNP" data-professionid="10"
data-hidden-jurisdictions="["GA","KS","TX","WV","MI","CO","PA","MS","SC","FL","AZ","NJ","AK","DE","AL"]">
CNP - Certified Nurse Practitioner</option>
<option value="53" data-match="NP" data-professionid="10" data-allowed-jurisdictions="["NY","KS","MS","TX","VA","MI"]"
data-hidden-jurisdictions="["WV","AK","PA","FL","NJ","MN"]">NP - Nurse Practitioner</option>
<option value="44" data-match="RCP" data-professionid="10" data-allowed-jurisdictions="["GA","US"]">RCP - Respiratory Care Practitioner</option>
<option value="59" data-match="CNS" data-professionid="10" data-hidden-jurisdictions="["GA","WV","FL","AK","NJ"]">CNS - Clinical Nurse Specialist</option>
<option value="69" data-match="CRNA" data-professionid="10" data-hidden-jurisdictions="["GA","WV","PA","FL","NJ","MI"]">CRNA - Certified Registered Nurse Anesthetist</option>
<option value="151" data-match="CNM" data-professionid="10" data-hidden-jurisdictions="["GA","WV","PA","KS","FL","AK","MI"]">CNM - Certified Nurse Midwife</option>
<option value="7" data-match="CCRN" data-professionid="10" data-allowed-jurisdictions="["US"]">CCRN - Critical Care Registered Nurse</option>
<option value="254" data-match="NA" data-professionid="10" data-allowed-jurisdictions="["MI"]">NA - Nurse Anesthetist</option>
<option value="214" data-match="NMW" data-professionid="10" data-allowed-jurisdictions="["WA","PA","KS","IN","MD","MO","TN","VT","WI"]">NMW -
Nurse Midwife</option>
<option value="8" data-match="RNC" data-professionid="10" data-allowed-jurisdictions="["US"]">RNC - Certified Registered Nurse</option>
<option value="43" data-match="CNOR" data-professionid="10" data-allowed-jurisdictions="["US"]">CNOR - Certified Nurse in the Operating Room</option>
<option value="255" data-match="NM" data-professionid="10" data-allowed-jurisdictions="["MI"]">NM - Nurse Midwife</option>
<option value="261" data-match="ACL" data-professionid="10" data-allowed-jurisdictions="["GA"]">ACL - Assistant Cosmetic Laser Practitioner</option>
<option value="262" data-match="SCL" data-professionid="10" data-allowed-jurisdictions="["GA"]">SCL - Senior Cosmetic Laser Practitioner</option>
<option value="70" data-match="APN" data-professionid="10" data-allowed-jurisdictions="["WI","NJ"]">APN - Advanced Practice Nurse</option>
<option value="170" data-match="CPM" data-professionid="10" data-allowed-jurisdictions="["NJ","DE","AZ"]">CPM - Certified Professional Midwife</option>
<option value="42" data-match="CM" data-professionid="10" data-allowed-jurisdictions="["NJ","AK"]">CM - Certified Midwife</option>
<option value="206" data-match="LM" data-professionid="10" data-allowed-jurisdictions="["FL","CO","AZ","CT","CA"]">LM - Licensed Midwife</option>
<option value="215" data-match="RXA" data-professionid="10" data-allowed-jurisdictions="["CA","CO"]">RXA - Prescribing Authority</option>
<option value="99" data-match="TPNP" data-professionid="10" data-hidden-jurisdictions="["US"]">TPNP - Temporary Nurse Practitioner Permit</option>
</optgroup>
<optgroup label="Physician" data-professionid="2">
<option value="269" data-match="DOCL" data-professionid="2" data-allowed-jurisdictions="["MI"]">DOCL - Osteopathic Doctor Compact License</option>
<option value="51" data-match="FP" data-professionid="2" data-allowed-jurisdictions="["US"]">FP - Family Physician</option>
<option value="265" data-match="MDCL" data-professionid="2" data-allowed-jurisdictions="["MI"]">MDCL - Medical Doctor Compact License</option>
<option value="230" data-match="TPDO" data-professionid="2" data-allowed-jurisdictions="["FM"]">TPDO - Temporary Osteopathic Physician Permit</option>
<option value="11" data-match="MD" data-professionid="2" data-hidden-jurisdictions="["BS"]">MD - Medical Doctor</option>
<option value="237" data-match="MP" data-professionid="2" data-allowed-jurisdictions="["BS"]">MP - Medical Practitioner</option>
<option value="12" data-match="DO" data-professionid="2" data-hidden-jurisdictions="["BS"]">DO - Osteopathic Doctor</option>
<option value="238" data-match="SMP" data-professionid="2" data-allowed-jurisdictions="["BS"]">SMP - Specialty Medical Practitioner</option>
<option value="68" data-match="DC" data-professionid="2" data-hidden-jurisdictions="["BS"]">DC - Doctor of Chiropractic</option>
<option value="169" data-match="DNM" data-professionid="2" data-hidden-jurisdictions="["BS","FL"]">DNM - Doctor of Naturopathic Medicine</option>
<option value="48" data-match="DPM" data-professionid="2" data-hidden-jurisdictions="["BS"]">DPM - Doctor of Podiatric Medicine</option>
<option value="92" data-match="TPMD" data-professionid="2" data-hidden-jurisdictions="["BS"]">TPMD - Temporary Physician Permit</option>
</optgroup>
<optgroup label="Physician Assistant" data-professionid="11">
<option value="165" data-match="OPA" data-professionid="11" data-allowed-jurisdictions="["PA","ME","NM","NV","WV"]">OPA - Osteopathic Physician Assistant</option>
<option value="13" data-match="PA" data-professionid="11">PA - Physician Assistant</option>
<option value="100" data-match="TPPA" data-professionid="11">TPPA - Temporary Physician Assistant Permit</option>
<option value="103" data-match="AA" data-professionid="11"
data-allowed-jurisdictions="["FL","MO","WI","CO","DC","IN","SC","NC","AL","VT","OK","OH","GA"]">AA -
Anesthesiologist Assistant</option>
<option value="46" data-match="MP" data-professionid="11" data-allowed-jurisdictions="["FL"]">MP - Medical Physicist</option>
</optgroup>
<optgroup label="Pharmacist" data-professionid="26">
<option value="288" data-match="ADV" data-professionid="26" data-allowed-jurisdictions="["ME"]">ADV - Administration of Drugs and Vaccines Approval</option>
<option value="287" data-match="CA" data-professionid="26" data-allowed-jurisdictions="["ME"]">CA - Contraceptive Administration Approval</option>
<option value="283" data-match="CPA" data-professionid="26" data-allowed-jurisdictions="["ME","NJ"]">CPA - Collaborative Practice Approval</option>
<option value="285" data-match="DTMP" data-professionid="26" data-allowed-jurisdictions="["GA"]">DTMP - Drug Therapy Modification Protocol Approval</option>
<option value="284" data-match="IA" data-professionid="26" data-allowed-jurisdictions="["NJ"]">IA - Immunization Administration Approval</option>
<option value="281" data-match="PIC" data-professionid="26" data-allowed-jurisdictions="["LA","ME","SC"]">PIC - Pharmacist in Charge</option>
<option value="195" data-match="PH" data-professionid="26"
data-hidden-jurisdictions="["WV","CA","GA","ND","OH","OK","OR","PA","RI","MT"]">PH - Pharmacist</option>
<option value="205" data-match="RPH" data-professionid="26"
data-allowed-jurisdictions="["WV","CA","GA","ND","OH","OK","OR","PA","RI","MT"]">RPH - Registered Pharmacist</option>
<option value="286" data-match="APH" data-professionid="26" data-allowed-jurisdictions="["CA"]">APH - Advanced Practice Pharmacist</option>
<option value="274" data-match="CPH" data-professionid="26" data-allowed-jurisdictions="["FL"]">CPH - Consultant Pharmacist</option>
<option value="278" data-match="CPP" data-professionid="26" data-allowed-jurisdictions="["NC","NC","MT"]">CPP - Clinical Pharmacist Practitioner</option>
<option value="275" data-match="NPH" data-professionid="26" data-allowed-jurisdictions="["GA","FL"]">NPH - Nuclear Pharmacist</option>
<option value="279" data-match="TPPH" data-professionid="26">TPPH - Temporary Pharmacist</option>
</optgroup>
<optgroup label="Pharmacy Technician" data-professionid="27">
<option value="196" data-match="CPHT" data-professionid="27"
data-allowed-jurisdictions="["ID","NH","OR","KY","KS","LA","MT","OH","SC","SD"]">CPHT - Certified Pharmacy Technician</option>
<option value="282" data-match="PHA" data-professionid="27" data-allowed-jurisdictions="["WA"]">PHA - Pharmacy Assistant</option>
<option value="229" data-match="RPHT" data-professionid="27" data-allowed-jurisdictions="["FL","ND","NH","NY","OH","WY"]">RPHT - Registered Pharmacy Technician</option>
<option value="277" data-match="PHT" data-professionid="27"
data-hidden-jurisdictions="["FL","KS","LA","MT","ND","NH","NY","SD","WY","OH"]">PHT - Pharmacy Technician</option>
<option value="276" data-match="NPHT" data-professionid="27" data-allowed-jurisdictions="["FL","WV"]">NPHT - Nuclear Pharmacy Technician</option>
<option value="280" data-match="TPPHT" data-professionid="27">TPPHT - Temporary Pharmacy Technician</option>
</optgroup>
<optgroup label="Social Worker" data-professionid="4">
<option value="249" data-match="BSW" data-professionid="4" data-allowed-jurisdictions="["PA"]">BSW - Bachelor Social Worker</option>
<option value="144" data-match="CMSW" data-professionid="4" data-allowed-jurisdictions="["NC","NE","FL"]">CMSW - Certified Master Social Worker</option>
<option value="63" data-match="CSW" data-professionid="4"
data-allowed-jurisdictions="["NC","RI","UT","WY","MS","NJ","GA","KY","LA","SD","US","NE"]">CSW - Certified Social
Worker</option>
<option value="248" data-match="CSW" data-professionid="4" data-allowed-jurisdictions="["??","AK","PA","NH"]">CSW - Clinical Social Worker</option>
<option value="233" data-match="CSWA" data-professionid="4" data-allowed-jurisdictions="["CA","OR"]">CSWA - Clinical Social Work Associate</option>
<option value="84" data-match="CSWI" data-professionid="4" data-allowed-jurisdictions="["FM"]">CSWI - Registered Clinical Social Work Intern</option>
<option value="247" data-match="LCSW" data-professionid="4" data-allowed-jurisdictions="["AR","??","MA","MS","WV"]">LCSW - Licensed Certified Social Worker</option>
<option value="245" data-match="LCSWC" data-professionid="4" data-allowed-jurisdictions="["MD"]">LCSWC - Licensed Certified Social Worker Clinical</option>
<option value="135" data-match="LGSW" data-professionid="4" data-allowed-jurisdictions="["MN","WV","DC"]">LGSW - Licensed Graduate Social Worker</option>
<option value="250" data-match="LISWCP" data-professionid="4" data-allowed-jurisdictions="["SC"]">LISWCP - Licensed Independent Social Worker Clinical Practice</option>
<option value="21" data-match="LSW" data-professionid="4"
data-allowed-jurisdictions="["AR","HI","CO","NV","MN","IN","MA","MS","OH","VA","IL","WV","NJ","KY","ME","ND","OK"]">
LSW - Licensed Social Worker</option>
<option value="258" data-match="LSWI" data-professionid="4" data-allowed-jurisdictions="["ID"]">LSWI - Licensed Social Worker Independent</option>
<option value="138" data-match="MSW" data-professionid="4" data-allowed-jurisdictions="["AK","GA","ME","US"]">MSW - Master Social Worker</option>
<option value="149" data-match="RSW" data-professionid="4" data-allowed-jurisdictions="["OR","VA","LA"]">RSW - Registered Social Worker</option>
<option value="30" data-match="SW" data-professionid="4"
data-allowed-jurisdictions="["UT","VA","WI","PA","SD","AS","GU","MH","FM","MP","XX","PW","PR","VI"]">
SW - Social Worker</option>
<option value="139" data-match="SWA" data-professionid="4" data-allowed-jurisdictions="["WA","VA"]">SWA - Social Work Associate</option>
<option value="257" data-match="SWS" data-professionid="4">SWS - Social Worker Supervisor</option>
<option value="94" data-match="TPSW" data-professionid="4" data-allowed-jurisdictions="["FM"]">TPSW - Temporary Social Worker Permit</option>
<option value="218" data-match="APSW" data-professionid="4" data-allowed-jurisdictions="["WA","WI","WI"]">APSW - Advanced Practice Social Worker</option>
<option value="152" data-match="ASW" data-professionid="4">ASW - Associate Social Worker</option>
<option value="17" data-match="LCSW" data-professionid="4"
data-allowed-jurisdictions="["MO","AZ","HI","CO","IN","MD","MT","ID","NV","DE","NC","NM","NY","OR","TX","UT","VA","WI","WY","CA","IL","NJ","CT","FL","KY","LA","ME","ND","TN","OK","VT"]">
LCSW - Licensed Clinical Social Worker</option>
<option value="66" data-match="LISW" data-professionid="4" data-allowed-jurisdictions="["SC","NV","MN","NM","OH","WI","WV","IA","DC"]">LISW -
Licensed Independent Social Worker</option>
<option value="228" data-match="LAPSW" data-professionid="4" data-allowed-jurisdictions="["TN"]">LAPSW - Licensed Advanced Practitioner Social Worker</option>
<option value="244" data-match="LISWD" data-professionid="4" data-allowed-jurisdictions="["SC"]">LISWD - Licensed Independent Social Worker Dual Practice</option>
<option value="73" data-match="LBSW" data-professionid="4"
data-allowed-jurisdictions="["AL","AZ","HI","SC","MD","AK","KS","MI","MT","ID","DE","IN","NM","TX","VA","IA","MO","US","TN"]">
LBSW - Licensed Bachelor Social Worker</option>
<option value="75" data-match="LICSW" data-professionid="4" data-allowed-jurisdictions="["AL","WA","MN","MA","DC","RI","ND"]">LICSW - Licensed Independent Clinical
Social Worker</option>
<option value="289" data-match="LCSWA" data-professionid="4" data-allowed-jurisdictions="["NC"]">LCSWA - Licensed Clinical Social Worker Associate</option>
<option value="29" data-match="LMSW" data-professionid="4"
data-allowed-jurisdictions="["AL","CT","MI","AR","AZ","NV","SC","MD","KS","ND","MT","ID","MN","DE","MS","NM","NY","OR","TX","IA","LA","US","TN","MO","OK"]">
LMSW - Licensed Master Social Worker</option>
<option value="212" data-match="LMSWI" data-professionid="4" data-allowed-jurisdictions="["ID","CA"]">LMSWI - Licensed Independent Master Social Worker</option>
<option value="232" data-match="LSCSW" data-professionid="4" data-allowed-jurisdictions="["KS"]">LSCSW - Licensed Specialist Clinical Social Worker</option>
<option value="76" data-match="LSWA" data-professionid="4" data-allowed-jurisdictions="["KS","OH","NV","MA","DC","OK"]">LSWA - Licensed Social Worker Associate</option>
</optgroup>
<optgroup label="Counselor/Therapist" data-professionid="16">
<option value="162" data-match="AT" data-professionid="16" data-allowed-jurisdictions="["FM"]">AT - Art Therapist</option>
<option value="234" data-match="CMHC" data-professionid="16" data-allowed-jurisdictions="["NH"]">CMHC - Clinical Mental Health Counselor</option>
<option value="150" data-match="IMHP" data-professionid="16" data-allowed-jurisdictions="["NE"]">IMHP - Independent Mental Health Practitioner</option>
<option value="163" data-match="LMHA" data-professionid="16" data-allowed-jurisdictions="["WA","IN"]">LMHA - Licensed Mental Health Counselor Associate</option>
<option value="128" data-match="LPCI" data-professionid="16" data-allowed-jurisdictions="["FM"]">LPCI - Licensed Professional Counselor Intern</option>
<option value="19" data-match="MFC" data-professionid="16" data-allowed-jurisdictions="["FM"]">MFC - Marriage and Family Counselor</option>
<option value="83" data-match="MFTI" data-professionid="16" data-allowed-jurisdictions="["FM"]">MFTI - Marriage and Family Therapist Intern</option>
<option value="82" data-match="MHCI" data-professionid="16" data-allowed-jurisdictions="["FM"]">MHCI - Mental Health Counselor Intern</option>
<option value="142" data-match="MHP" data-professionid="16" data-allowed-jurisdictions="["NE","VA"]">MHP - Mental Health Practitioner</option>
<option value="159" data-match="MTBC" data-professionid="16" data-allowed-jurisdictions="["FM"]">MTBC - Music Therapist-Board Certified</option>
<option value="130" data-match="NCC" data-professionid="16" data-allowed-jurisdictions="["FM","US"]">NCC - National Certified Counselor</option>
<option value="141" data-match="PAC" data-professionid="16" data-allowed-jurisdictions="["ME"]">PAC - Pastoral Counselor</option>
<option value="160" data-match="PC" data-professionid="16"
data-allowed-jurisdictions="["PA","GU","AS","MH","MP","XX","PW","PR","VI","GA"]">PC - Professional Counselor</option>
<option value="129" data-match="RC" data-professionid="16" data-allowed-jurisdictions="["ME","NJ","MA"]">RC - Registered Counselor</option>
<option value="101" data-match="TPCT" data-professionid="16" data-allowed-jurisdictions="["ME"]">TPCT - Temporary Counselor/Therapist Permit</option>
<option value="64" data-match="AP" data-professionid="16"
data-allowed-jurisdictions="["WV","WY","UT","DC","IN","LA","AL","CO","MA","RI","CA","FL","KY","XX","US"]">
AP - Addiction Professional</option>
<option value="179" data-match="CDP" data-professionid="16" data-allowed-jurisdictions="["FM","AK","WA"]">CDP - Chemical Dependency Professional</option>
<option value="211" data-match="LADC" data-professionid="16" data-allowed-jurisdictions="["FM","MN","CT","ME","NE","NH","NM","NV","OK"]">LADC -
Licensed Alcohol and Drug Counselor</option>
<option value="140" data-match="CPC" data-professionid="16" data-allowed-jurisdictions="["NV","AR","NE","WA"]">CPC - Certified Professional Counselor</option>
<option value="58" data-match="CADC" data-professionid="16"
data-allowed-jurisdictions="["CT","MD","AR","DC","NJ","SD","AZ","IA","IL","ME","MO","MS","RI","TX","VT","WV","CA","FL","GA","ID","NV","PA","XX","MI","OR"]">
CADC - Certified Alcohol/Drug Counselor</option>
<option value="145" data-match="LCADC" data-professionid="16" data-allowed-jurisdictions="["AR","ND","NJ","NC","MD"]">LCADC - Licensed Clinical Alcohol and Drug Counselor</option>
<option value="71" data-match="SAC" data-professionid="16" data-allowed-jurisdictions="["AK","VA","HI","NM","RI","WI","NY","TN"]">SAC - Substance Abuse
Counselor</option>
<option value="143" data-match="AC" data-professionid="16" data-allowed-jurisdictions="["CA","SC","GA","MD","AR","NJ","DE"]">AC - Associate Counselor</option>
<option value="148" data-match="LISAC" data-professionid="16" data-allowed-jurisdictions="["AZ"]">LISAC - Licensed Independent Substance Abuse Counselor</option>
<option value="74" data-match="MFTA" data-professionid="16" data-allowed-jurisdictions="["CA","WA","GA","IN","TX","AL","NM","XX","KY"]">MFTA -
Marriage and Family Therapist Associate</option>
<option value="146" data-match="LMHC" data-professionid="16" data-allowed-jurisdictions="["FL","AR","NY","NM","MA"]">LMHC - Licensed Mental Health Counselor</option>
<option value="178" data-match="LPCA" data-professionid="16" data-allowed-jurisdictions="["AR","AL"]">LPCA - Licensed Professional Counselor Associate</option>
<option value="161" data-match="LSAT" data-professionid="16" data-allowed-jurisdictions="["AZ"]">LSAT - Licensed Substance Abuse Technician</option>
<option value="18" data-match="MFT" data-professionid="16"
data-allowed-jurisdictions="["UT","WA","WI","GA","KY","NV","OK","PA","MI","AK","AR","HI","IA","IN","ME","MO","NE","NH","NJ","RI","AL","IL","CT","DC","VT","XX","US","OH","MS"]">
MFT - Marriage and Family Therapist</option>
<option value="219" data-match="CAC" data-professionid="16" data-allowed-jurisdictions="["IN"]">CAC - Clinical Addiction Counselor</option>
<option value="50" data-match="MHC" data-professionid="16" data-allowed-jurisdictions="["WA","WY","UT","AR","HI","IA","IN","RI","VT"]">MHC -
Mental Health Counselor</option>
<option value="220" data-match="CACA" data-professionid="16" data-allowed-jurisdictions="["IN"]">CACA - Clinical Addiction Counselor Associate</option>
<option value="259" data-match="IMFT" data-professionid="16" data-allowed-jurisdictions="["OH"]">IMFT - Independent Marriage and Family Therapist</option>
<option value="65" data-match="LEP" data-professionid="16" data-allowed-jurisdictions="["CA","SC","MA"]">LEP - Licensed Educational Psychologist</option>
<option value="260" data-match="IMFTS" data-professionid="16" data-allowed-jurisdictions="["OH"]">IMFTS - Independent Marriage and Family Therapist Supervisor</option>
<option value="177" data-match="LCPC" data-professionid="16" data-allowed-jurisdictions="["TN","IL","MT","KS","ID","MD"]">LCPC - Licensed Clinical Professional Counselor
</option>
<option value="20" data-match="LPC" data-professionid="16"
data-allowed-jurisdictions="["MI","SD","WI","WY","GA","ID","KY","MD","WV","OK","OR","SC","OH","AK","AR","AZ","CO","DC","IL","KS","LA","MO","MS","ND","NJ","TX","CT","NM","AL","MN","VA","XX"]">
LPC - Licensed Professional Counselor</option>
<option value="127" data-match="LPCS" data-professionid="16" data-allowed-jurisdictions="["OH","AR","MS","NC","SC"]">LPCS - Licensed Professional Counselor Supervisor</option>
<option value="224" data-match="LAMFT" data-professionid="16" data-allowed-jurisdictions="["MN","AZ","ND","AR"]">LAMFT - Licensed Associate Marriage and Family Therapist</option>
<option value="223" data-match="LAC" data-professionid="16" data-allowed-jurisdictions="["AZ"]">LAC - Licensed Associate Counselor</option>
<option value="225" data-match="LASAC" data-professionid="16" data-allowed-jurisdictions="["AZ"]">LASAC - Licensed Associate Substance Abuse Counselor</option>
<option value="72" data-match="LPCC" data-professionid="16"
data-allowed-jurisdictions="["CA","ID","KY","MD","CO","ME","ND","NM","XX","OH"]">LPCC - Licensed Professional Clinical Counselor
</option>
<option value="222" data-match="LPCCS" data-professionid="16" data-allowed-jurisdictions="["OH"]">LPCCS - Licensed Professional Clinical Counselor Supervisor</option>
<option value="186" data-match="LCDC" data-professionid="16" data-allowed-jurisdictions="["TX","DE","OH"]">LCDC - Licensed Chemical Dependency Counselor</option>
<option value="221" data-match="LCMFT" data-professionid="16" data-allowed-jurisdictions="["KS"]">LCMFT - Licensed Clinical Marriage and Family Therapist</option>
<option value="136" data-match="LMFT" data-professionid="16"
data-allowed-jurisdictions="["WV","LA","MN","WY","CA","DE","FL","ID","MD","NY","TN","OR","SC","TX","AZ","MT","NC","KS","SD","VA","CO","NM","MA","ND","XX"]">
LMFT - Licensed Marriage and Family Therapist</option>
<option value="208" data-match="LCMHC" data-professionid="16" data-allowed-jurisdictions="["NC"]">LCMHC - Licensed Clinical Mental Health Counselor</option>
<option value="213" data-match="LPCMH" data-professionid="16" data-allowed-jurisdictions="["SD","DE"]">LPCMH - Licensed Professional Counselor Mental Health</option>
<option value="210" data-match="LCMHCS" data-professionid="16" data-allowed-jurisdictions="["NC"]">LCMHCS - Licensed Clinical Mental Health Counselor Supervisor</option>
<option value="263" data-match="LCAC" data-professionid="16" data-allowed-jurisdictions="["KS"]">LCAC - Licensed Clinical Addiction Counselor</option>
<option value="264" data-match="LMAC" data-professionid="16" data-allowed-jurisdictions="["KS"]">LMAC - Licensed Master Addiction Counselor</option>
<option value="270" data-match="LMFS" data-professionid="16" data-allowed-jurisdictions="["XX"]">LMFS - Licensed Marriage and Family Therapist Supervisor</option>
<option value="236" data-match="MFTS" data-professionid="16" data-allowed-jurisdictions="["SC"]">MFTS - Marriage and Family Therapy Supervisor</option>
<option value="246" data-match="MHA" data-professionid="16" data-allowed-jurisdictions="["IN"]">MHA - Mental Health Associate</option>
<option value="235" data-match="LACS" data-professionid="16" data-allowed-jurisdictions="["SC"]">LACS - Licensed Addiction Counselor Supervisor</option>
<option value="226" data-match="LAC" data-professionid="16" data-allowed-jurisdictions="["SC","MT","CO","KS"]">LAC - Licensed Addiction Counselor</option>
<option value="271" data-match="LACA" data-professionid="16" data-allowed-jurisdictions="["SC"]">LACA - Licensed Addiction Counselor Associate</option>
<option value="209" data-match="LCMHCA" data-professionid="16" data-allowed-jurisdictions="["NC"]">LCMHCA - Licensed Clinical Mental Health Counselor Associate</option>
<option value="266" data-match="LRC" data-professionid="16" data-allowed-jurisdictions="["NJ"]">LRC - Licensed Rehabilitation Counselor</option>
</optgroup>
<optgroup label="Psychologist" data-professionid="5">
<option value="52" data-match="PHD" data-professionid="5">PHD - Psychologist PhD</option>
<option value="23" data-match="PSYD" data-professionid="5">PSYD - Doctor of Psychology</option>
<option value="89" data-match="PSYM" data-professionid="5">PSYM - Master of Psychology</option>
<option value="217" data-match="MPsy" data-professionid="5" data-allowed-jurisdictions="["LA"]">MPsy - Medical Psychologist</option>
<option value="95" data-match="TPPS" data-professionid="5">TPPS - Temporary Psychologist Permit</option>
<option value="272" data-match="PP" data-professionid="5" data-allowed-jurisdictions="["WY"]">PP - Psychological Practitioner</option>
<option value="273" data-match="SSP" data-professionid="5" data-allowed-jurisdictions="["WY"]">SSP - Specialist in School Psychology</option>
</optgroup>
<optgroup label="Certified Case Manager" data-professionid="7">
<option value="26" data-match="CCM" data-professionid="7">CCM - Certified Case Manager</option>
</optgroup>
<optgroup label="Certified Diabetes Educator" data-professionid="25">
<option value="62" data-match="CDE" data-professionid="25">CDE - Certified Diabetes Educator</option>
</optgroup>
<optgroup label="Nursing Assistant" data-professionid="17">
<option value="4" data-match="CNA" data-professionid="17">CNA - Certified Nurse Assistant</option>
<option value="137" data-match="TPCNA" data-professionid="17">TPCNA - Temporary Certified Nurse Assistant</option>
</optgroup>
<optgroup label="Certified Surgical Assistant" data-professionid="24">
<option value="155" data-match="CSA" data-professionid="24">CSA - Certified Surgical Assistant</option>
</optgroup>
<optgroup label="CST/CSFA" data-professionid="6">
<option value="25" data-match="CSFA" data-professionid="6">CSFA - Certified Surgical First Assistant</option>
<option value="24" data-match="CST" data-professionid="6">CST - Certified Surgical Technician</option>
<option value="96" data-match="TPCST" data-professionid="6">TPCST - Temporary CST Permit</option>
</optgroup>
<optgroup label="Dental Assistant" data-professionid="23">
<option value="36" data-match="CDA" data-professionid="23" data-allowed-jurisdictions="["US"]">CDA - Certified Dental Assistant</option>
<option value="185" data-match="DSA" data-professionid="23" data-allowed-jurisdictions="["CA"]">DSA - Dental Sedation Assistant</option>
<option value="253" data-match="DT" data-professionid="23" data-allowed-jurisdictions="["SC"]">DT - Dental Technician</option>
<option value="252" data-match="LDA" data-professionid="23" data-allowed-jurisdictions="["MN"]">LDA - Licensed Dental Assistant</option>
<option value="184" data-match="OA" data-professionid="23" data-allowed-jurisdictions="["CA"]">OA - Orthodontic Assistant</option>
<option value="15" data-match="RDA" data-professionid="23" data-allowed-jurisdictions="["CA","PA","MA","MI"]">RDA - Registered Dental Assistant</option>
<option value="167" data-match="RDAEF" data-professionid="23" data-allowed-jurisdictions="["CA","PA"]">RDAEF - Registered Dental Assistant Extended Function</option>
<option value="251" data-match="DA" data-professionid="23" data-hidden-jurisdictions="["CA","MA","SC","PA","MI","MN"]">DA - Dental Assistant</option>
</optgroup>
<optgroup label="Dental Hygienist" data-professionid="22">
<option value="14" data-match="RDH" data-professionid="22" data-allowed-jurisdictions="["OK","CA","PA","MI"]">RDH - Registered Dental Hygienist</option>
<option value="168" data-match="RDHEF" data-professionid="22" data-allowed-jurisdictions="["CA"]">RDHEF - Registered Dental Hygienist Extended Function</option>
<option value="154" data-match="DH" data-professionid="22" data-hidden-jurisdictions="["CA","PA","MI","OK"]">DH - Dental Hygienist</option>
<option value="207" data-match="RDHAP" data-professionid="22" data-allowed-jurisdictions="["CA"]">RDHAP - Registered Dental Hygienist Alternative Practice</option>
</optgroup>
<optgroup label="Dentist" data-professionid="3">
<option value="241" data-match="CSED" data-professionid="3" data-allowed-jurisdictions="["CA"]">CSED - Conscious Sedation</option>
<option value="239" data-match="DGA" data-professionid="3" data-allowed-jurisdictions="["CA"]">DGA - Dental General Anesthesia</option>
<option value="35" data-match="DMD" data-professionid="3" data-allowed-jurisdictions="["US"]">DMD - Doctor of Dental Medicine</option>
<option value="240" data-match="MGA" data-professionid="3" data-allowed-jurisdictions="["CA"]">MGA - Medical General Anesthesia</option>
<option value="256" data-match="MSED" data-professionid="3" data-allowed-jurisdictions="["CA"]">MSED - Moderate Sedation</option>
<option value="243" data-match="OMS" data-professionid="3" data-allowed-jurisdictions="["CA"]">OMS - Oral Maxillofacial Surgery</option>
<option value="242" data-match="OSED" data-professionid="3" data-allowed-jurisdictions="["CA"]">OSED - Oral Conscious Sedation</option>
<option value="31" data-match="DDS" data-professionid="3">DDS - Doctor of Dental Surgery</option>
<option value="93" data-match="TPD" data-professionid="3" data-hidden-jurisdictions="["FL","SC","OK"]">TPD - Temporary Dental Permit</option>
</optgroup>
<optgroup label="Nursing Home Administrator" data-professionid="9">
<option value="28" data-match="NHA" data-professionid="9">NHA - Nursing Home Administrator</option>
<option value="98" data-match="TPNHA" data-professionid="9">TPNHA - Temporary Nursing Home Administrator</option>
</optgroup>
<optgroup label="Respiratory Therapist" data-professionid="13">
<option value="33" data-match="RT" data-professionid="13">RT - Respiratory Therapist</option>
</optgroup>
<optgroup label="Research Professional" data-professionid="14">
<option value="38" data-match="CCRA" data-professionid="14">CCRA - Certified Clinical Research Associate</option>
<option value="37" data-match="CCRC" data-professionid="14">CCRC - Certified Clinical Research Coordinator</option>
<option value="39" data-match="CCRI" data-professionid="14">CCRI - Certified Clinical Research Investigator</option>
</optgroup>
<optgroup label="Other/IACET" data-professionid="20">
<option value="34" data-match="OTH" data-professionid="20">OTH - Other IACET qualification</option>
</optgroup>
<optgroup label="Medical Assistant" data-professionid="15">
<option value="41" data-match="CMA" data-professionid="15">CMA - Certified Medical Assistant</option>
<option value="40" data-match="MA" data-professionid="15">MA - Medical Assistant</option>
</optgroup>
</select>
</div>
</div>
</div>
<div class="row-fluid">
<div class="span12">
<div class="control-group">
<label class="hidden" for="license_num">License Number</label>
<div class="controls">
<input type="text" id="license_num" placeholder="License Number" class="input-block-level required" name="license" maxlength="30" tabindex="19" data-field-type="license" data-connected-fields="license" required="required" value=""
disabled="disabled">
</div>
</div>
</div>
</div>
<div class="row-fluid">
<div class="span8">
<!-- Add the .error class to .control-group if the input is invald -->
<div class="control-group phone-wrapper">
<label for="phone" class="hidden"> Phone: <span class="err_ast">*</span>
</label>
<div class="controls prepend_icon">
<!-- <input id="id_phone" placeholder="Phone Number" name="phonenumber" type="tel" tabindex="25" class=""/> -->
<i id="phoneinfo" class="icon-phone-sign"><!-- --></i>
<input type="tel" id="id_phone" placeholder="Phone Number" class="input-block-level" name="phones_phonenumber_d" tabindex="20" data-purpose="dayphone" data-field-type="phones_phonenumber_d" required="required" value="">
<input type="hidden" value="0" name="phones_fax_d">
</div>
<div class="custom-tooltip custom-tooltip-phone">
<i id="phoneinfo" class="custom-tooltip-handler icon-phone-sign" tabindex="21"><!-- --></i>
<div class="custom-tooltip-content hide">
<p>Please enter US phone numbers including area code.</p>
<p>Ex: 916-333-2233</p>
<p>Please enter non-US phone numbers starting with +. Please separate country code and area/city code from local number using spaces or dashes.</p>
<p>Ex: +55 656 2233222.</p>
<span class="custom-tooltip-content-close"></span>
</div>
</div>
</div>
</div>
<div class="span4">
<div class="control-group">
<label class="hidden" for="phone_ext">Ext</label>
<div class="controls">
<input type="text" id="id_ext" placeholder="Ext" class="input-block-level" autocomplete="nofill" name="phones_extension_d" tabindex="22" data-purpose="dayphone-extension" data-field-type="phones_extension_d" value="">
</div>
</div>
</div>
</div>
<div class="row-fluid">
<!-- Email -->
<div class="span12">
<div class="control-group">
<label class="hidden" for="email_address">Email</label>
<div class="controls prepend_icon">
<input type="email" id="email_address" placeholder="Email Address" class="input-block-level nopaste" tabindex="23" name="username" autocomplete="username" data-field-type="username" data-connected-fields="email" required="required"
value="">
<i class="icon-envelope"><!-- --></i>
</div>
</div>
</div>
</div>
<div class="row-fluid">
<!-- Email -->
<div class="span12">
<div class="control-group">
<label class="hidden" for="email_address2">Retype Email</label>
<div class="controls prepend_icon">
<input type="email" id="email_address2" placeholder="Retype Email Address" class="input-block-level nopaste" tabindex="24" name="username2" autocomplete="username" data-field-type="usernameRetype" data-connected-fields="email"
required="required" value="" disabled="disabled">
<i class="icon-envelope"><!-- --></i>
</div>
</div>
</div>
</div>
<div class="row-fluid">
<!-- Password -->
<div class="span12 bump-down">
<div class="control-group">
<label class="hidden" for="password">Select Password</label>
<div class="controls prepend_icon">
<input type="password" id="password" placeholder="Select Password" class="input-block-level" tabindex="25" name="password" autocomplete="new-password" data-field-type="password" required="required" value="">
<i class="icon-lock"><!-- --></i>
</div>
</div>
</div>
</div>
</fieldset>
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Contraceptive Administration ApprovalCPA - Collaborative Practice ApprovalDTMP - Drug Therapy Modification Protocol ApprovalIA - Immunization Administration ApprovalPIC - Pharmacist in ChargePH - PharmacistRPH - Registered PharmacistAPH - Advanced Practice PharmacistCPH - Consultant PharmacistCPP - Clinical Pharmacist PractitionerNPH - Nuclear PharmacistTPPH - Temporary PharmacistCPHT - Certified Pharmacy TechnicianPHA - Pharmacy AssistantRPHT - Registered Pharmacy TechnicianPHT - Pharmacy TechnicianNPHT - Nuclear Pharmacy TechnicianTPPHT - Temporary Pharmacy TechnicianBSW - Bachelor Social WorkerCMSW - Certified Master Social WorkerCSW - Certified Social WorkerCSW - Clinical Social WorkerCSWA - Clinical Social Work AssociateCSWI - Registered Clinical Social Work InternLCSW - Licensed Certified Social WorkerLCSWC - Licensed Certified Social Worker ClinicalLGSW - Licensed Graduate Social WorkerLISWCP - Licensed Independent Social Worker Clinical PracticeLSW - Licensed Social WorkerLSWI - 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Marriage and Family Therapist InternMHCI - Mental Health Counselor InternMHP - Mental Health PractitionerMTBC - Music Therapist-Board CertifiedNCC - National Certified CounselorPAC - Pastoral CounselorPC - Professional CounselorRC - Registered CounselorTPCT - Temporary Counselor/Therapist PermitAP - Addiction ProfessionalCDP - Chemical Dependency ProfessionalLADC - Licensed Alcohol and Drug CounselorCPC - Certified Professional CounselorCADC - Certified Alcohol/Drug CounselorLCADC - Licensed Clinical Alcohol and Drug CounselorSAC - Substance Abuse CounselorAC - Associate CounselorLISAC - Licensed Independent Substance Abuse CounselorMFTA - Marriage and Family Therapist AssociateLMHC - Licensed Mental Health CounselorLPCA - Licensed Professional Counselor AssociateLSAT - Licensed Substance Abuse TechnicianMFT - Marriage and Family TherapistCAC - Clinical Addiction CounselorMHC - Mental Health CounselorCACA - Clinical Addiction Counselor AssociateIMFT - Independent Marriage and Family TherapistLEP - Licensed Educational PsychologistIMFTS - Independent Marriage and Family Therapist SupervisorLCPC - Licensed Clinical Professional CounselorLPC - Licensed Professional CounselorLPCS - Licensed Professional Counselor SupervisorLAMFT - Licensed Associate Marriage and Family TherapistLAC - Licensed Associate CounselorLASAC - Licensed Associate Substance Abuse CounselorLPCC - Licensed Professional Clinical CounselorLPCCS - Licensed Professional Clinical Counselor SupervisorLCDC - Licensed Chemical Dependency CounselorLCMFT - Licensed Clinical Marriage and Family TherapistLMFT - Licensed Marriage and Family TherapistLCMHC - Licensed Clinical Mental Health CounselorLPCMH - Licensed Professional Counselor Mental HealthLCMHCS - Licensed Clinical Mental Health Counselor SupervisorLCAC - Licensed Clinical Addiction CounselorLMAC - Licensed Master Addiction CounselorLMFS - Licensed Marriage and Family Therapist SupervisorMFTS - Marriage and Family Therapy SupervisorMHA - Mental Health AssociateLACS - 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