formstack.io
Open in
urlscan Pro
52.167.179.134
Public Scan
URL:
https://formstack.io/ffbDz1IbTzzNdbhm86CBmjre92euLYKuicfh9qYvfX0wOjURHvjKTOUPOVCt1O69161uy4CZ3i9wNniwCP9gUg
Submission: On October 06 via manual from US — Scanned from DE
Submission: On October 06 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST https://sfapi.formstack.io/FormEngine/EngineFrame/UploadFile
<form action="https://sfapi.formstack.io/FormEngine/EngineFrame/UploadFile" enctype="multipart/form-data" id="form1" method="post" target="ffIframe"><input id="userTimeZone" name="userTimeZone" type="hidden" value="0"><input id="txtHtmlId"
name="txtHtmlId" type="hidden" value="rlWXsaq5lRGHlng1s_jLTA"><input id="txtSendSizeChange" name="txtSendSizeChange" type="hidden" value=""><input id="txtObjId" name="txtObjId" type="hidden"
value="dgEGyvTNwqgiEvkdybM2hSGkqrKbZSQ6WZzAsG2Z3Bg"><input id="txtOrgId" name="txtOrgId" type="hidden" value="c58IKteAtKgb2MrI5cKMmYWxZKDuB5g62TPtrDd-CLc"><input id="txtAuthToken" name="txtAuthToken" type="hidden"
value="p9Houyv4WEFWeqzCz1O2_0SxxmoUBQJAiTpqbXtBa0mWYs__XT93LTWixsSPoSVL3JYBrNxlaP3JDzTn2Gr2I0nFNip9cEowtNrtmskUNMH0j4FSMtTBhAZQpQesrn6JAQMhIjQ8qRcm6srG4KnnDFEyN07arDewpltpgArDJHs"><input id="txtRefreshToken" name="txtRefreshToken" type="hidden"
value="JAoZswkhw8ZcznpiHrnsWGYBb3Vz19u2xTLA59zSViqCvR07CO3_x22CHk47d9YQRq2KowtnkY3k36ZUGs0tVK-QLipXz2vQTA-TmH3ITC1yU3Qjk8zcFlM0zwnDrA-l"><input id="txtAccessURI" name="txtAccessURI" type="hidden"
value="XgWospRAWwpEjJUV6xYuL_LIHuXXSD7EMaG1G24VBE6lSfCzfBIcxCWqmKvXohvs"><input id="txtSessionID" name="txtSessionID" type="hidden" value="aoprnWav_96xpHp3sBXeRPBnf8IMIzjUve92QlBuU3-Csv2-fY2SFv1X8Ld5S6ng"><input id="formHtml" name="formHtml"
type="hidden" value=""><input data-val="true" data-val-required="The Boolean field is required." id="multipageEnabled" name="multipageEnabled" type="hidden" value="False"><input data-val="true" data-val-required="The Boolean field is required."
id="breadcrumbEnabled" name="breadcrumbEnabled" type="hidden" value="False"><input data-val="true" data-val-required="The Boolean field is required." id="breadcrumbNumbered" name="breadcrumbNumbered" type="hidden" value="False"><input
id="breadcrumbPrefix" name="breadcrumbPrefix" type="hidden" value=""><input id="submitMessage" name="submitMessage" type="hidden" value="Thank you for agreeing to accept TDS' MasterCard Virtual Card as payment for all future invoices."><input
id="submitUrl" name="submitUrl" type="hidden" value=""><input id="submitBtnText" name="submitBtnText" type="hidden" value="Submit Enrollment Form"><input id="prevBtnText" name="prevBtnText" type="hidden" value="Back"><input id="nextBtnText"
name="nextBtnText" type="hidden" value="Next"><input id="pageValType" name="pageValType" type="hidden" value="form"><input id="txtUserContentId" name="txtUserContentId" type="hidden" value=""><input data-val="true"
data-val-required="The Boolean field is required." id="hasCustomCSS" name="hasCustomCSS" type="hidden" value="True"><input id="isCurrentForm" name="isCurrentForm" type="hidden" value=""><input id="packageTier" name="packageTier" type="hidden"
value=""><input data-val="true" data-val-required="The Boolean field is required." id="isDraft" name="isDraft" type="hidden" value="False"><input data-val="true" data-val-required="The Boolean field is required." id="saveForLaterEnabled"
name="saveForLaterEnabled" type="hidden" value="False"><input id="saveBtnText" name="saveBtnText" type="hidden" value="Save"><input id="discardBtnText" name="discardBtnText" type="hidden" value="Discard"><input id="draftSaved" name="draftSaved"
type="hidden" value=""><input id="draftEmail" name="draftEmail" type="hidden" value=""><input id="paymentType" name="paymentType" type="hidden" value=""><input id="formName" name="formName" type="hidden" value="TDS W8"><input
id="CommunityInstanceURL" name="CommunityInstanceURL" type="hidden" value=""><input id="CommunitySessioID" name="CommunitySessioID" type="hidden" value=""><input id="CommunityUserId" name="CommunityUserId" type="hidden" value=""><input
id="CommunityUserType" name="CommunityUserType" type="hidden" value=""><input id="CommunityViewMode" name="CommunityViewMode" type="hidden" value=""><input id="comPrefillDataset" name="comPrefillDataset" type="hidden" value=""><input
id="prefillDataset" name="prefillDataset" type="hidden" value=""><input id="comPrefillObj" name="comPrefillObj" type="hidden" value=""><input id="hfIsFileServiceOn" name="hfIsFileServiceOn" type="hidden" value="1"><input
id="hfFileServiceEndpoint" name="hfFileServiceEndpoint" type="hidden" value="https://sfapi.formstack.io"><input id="hfFileServiceApiKey" name="hfFileServiceApiKey" type="hidden" value="8fc5982e-6eca-4d73-a3ff-997902b163b0-20212151122"><input
id="reCaptchaV3token" name="reCaptchaV3token" type="hidden" value="">
<div id="dvBannerHTML" runat="server">
<div>
<style>
.ff-form {
background-color: #1c2729;
background-attachment: fixed;
background-repeat: no-repeat;
background-repeat: repeat;
}
#dvFastForms .ff-page-header {
font-family: Arial;
font-weight: bold;
color: #564d4d;
font-size: 100px;
}
#dvFastForms .ff-page-header-row {
border-style: solid;
border-radius: 5px;
border-color: #dfdbdb;
border-width: 100px;
padding: 8px;
}
.ff-logo {
background-color: #ffffff;
background-image: url(https://epayables--visualantidote.visualforce.com/servlet/servlet.ImageServer?id=0152I000008xPwiQAE&oid=00DA0000000JA2rMAG);
width: 789px;
height: 146px;
margin: auto;
padding: 0px;
}
.ff-header {
background-color: #ffffff;
background-image: url(https://na10.salesforce.com/servlet/servlet.ImageServer?id=015F00000067Fi1IAE&oid=00DA0000000JA2rMAG);
background-attachment: fixed;
background-repeat: no-repeat;
padding: 11px;
}
.ff-form-main {
background-color: #fcfcfc;
margin: auto;
max-width: 1000px;
border-style: solid;
border-radius: 5px;
border-color: #f5f2f5;
border-width: 0px;
padding: 50px;
}
#dvFastForms .ff-group-row {
background-color: #ffffff;
border-style: solid;
border-radius: 5px;
border-color: #000509;
border-width: 3px;
max-width: 1000px;
padding: 10px;
margin: 0px;
}
#dvFastForms .ff-section-header {
font-family: Tahoma;
font-weight: bold;
color: #030303;
font-size: 33px;
}
#dvFastForms .ff-footer-group {
background-color: #ffffff;
background-attachment: fixed;
background-repeat: no-repeat;
background-repeat: repeat;
padding: 56px;
}
#dvFastForms .ff-col-2.ff-field-col {
clear: none;
}
#dvFastForms .ff-label,
#dvFastForms .ff-footnote-label {
font-family: Tahoma;
font-weight: bold;
font-size: 14px;
}
#dvFastForms .ff-label {
color: #0a0a0a;
}
#dvFastForms .ff-label-col {
text-align: left;
padding: 10px;
}
#dvFastForms .ff-field-col {
font-family: Tahoma;
font-weight: bold;
font-size: 14px;
text-align: left;
padding: 5px;
}
#dvFastForms .ff-field-col,
#dvFastForms .ff-rating-widget a {
color: #000000;
}
#dvFastForms .ff-type-text,
#dvFastForms .ff-textarea,
#dvFastForms select.ff-select-type,
#dvFastForms .ff-fileupload-drop-area,
#dvFastForms .select2-container {
background-color: #c9c3c3;
}
#dvFastForms .ff-type-text,
#dvFastForms .ff-textarea,
#dvFastForms select.ff-select-type,
#dvFastForms .ff-fileupload-drop-area,
#dvFastForms .select2-container .select2-choice,
#dvFastForms .select2-container .select2-choices {
border-style: solid;
border-radius: 5px;
border-color: #000609;
border-width: 1px;
padding: 5px;
}
#dvFastForms .ff-textarea {
height: 25px;
}
#dvFastForms .ff-item-row .ff-type-text:not(.ff-creditcard),
#dvFastForms .ff-textarea,
#dvFastForms .ff-fileupload-drop-area {
width: 358px;
}
#dvFastForms div.ff-select-to-checkbox-list,
#dvFastForms div.ff-select-to-radiobtn-list {
width: 100%;
}
#dvFastForms .ff-invalid-msg {
font-family: Tahoma;
font-weight: bold;
color: #aea9a9;
font-size: 10px;
}
#dvFastForms .ff-required-mark {
font-family: Tahoma;
font-weight: bold;
color: #ff0000;
font-size: 14px;
}
#dvFastForms .ff-btn-submit {
background-color: #a0a2a3;
font-family: Tahoma;
font-weight: bold;
color: #070000;
font-size: 15px;
border-style: solid;
border-radius: 5px;
border-color: #010000;
border-width: 3px;
padding: 10px;
}
#dvFastForms .ff-btn-submit:hover {
background-color: #004f87;
}
</style>
<div class="ff-form-main">
<div id="ffOverlay"></div>
<div id="ffPage10331" class="ff-page-row page-1" data-pagetitle="Page Title">
<div class="ff-group-row group-0" id="ffSection0">
<div class="ff-item-row">
<div class="ff-col-1 ff-section-col"><label class="ff-section-header" id="sectionLabel0">TDS Enrollment Form</label></div>
</div>
<div class="ff-item-row" style="display: none;">
<div class="ff-col-1 ff-label-col"><label vatt="PICKLIST" for="Lead.Status" class="ff-label" id="lblLeadStatus">Status</label></div>
<div class="ff-col-2 ff-field-col"><select name="Lead.Status" id="Lead.Status" vatt="PICKLIST" class="ff-select-type ff-singlepicklist" data-flexcontrol="" data-requiredmessage="required" data-isupsert="false" data-ishidden="true"
data-vatt="PICKLIST">
<option value=""></option>
<option value="Won">Won</option>
<option value="Lost">Lost</option>
<option value="Supplier Remorse">Supplier Remorse</option>
<option value="Open" selected="selected">Open</option>
<option value="Return">Return</option>
<option value="Won/Converted">Won/Converted</option>
</select></div>
</div>
<div class="ff-item-row" style="display: none;">
<div class="ff-col-1 ff-label-col"><label vatt="PICKLIST" for="Lead.Reason__c" class="ff-label" id="lblLeadReason__c">Reason</label></div>
<div class="ff-col-2 ff-field-col"><select name="Lead.Reason__c" id="Lead.Reason__c" vatt="PICKLIST" class="ff-select-type ff-singlepicklist" data-flexcontrol="" data-requiredmessage="required" data-isupsert="false" data-ishidden="true"
data-vatt="PICKLIST">
<option value=""></option>
<option value="Acquiring Prospect">Acquiring Prospect</option>
<option value="Alt Pmt Method">Alt Pmt Method</option>
<option value="App In Progress">App In Progress</option>
<option value="Auto Enroll">Auto Enroll</option>
<option value="Better Contact Information">Better Contact Information</option>
<option value="BIP Full Acquiring">BIP Full Acquiring</option>
<option value="BIP MID">BIP MID</option>
<option value="BIP No MID">BIP No MID</option>
<option value="Call" selected="selected">Call</option>
<option value="CANCELLED">CANCELLED</option>
<option value="Client Discount">Client Discount</option>
<option value="Contractual Term">Contractual Term</option>
<option value="Customer Acct #">Customer Acct #</option>
<option value="Do Not Call">Do Not Call</option>
<option value="Email">Email</option>
<option value="Enroll Email">Enroll Email</option>
<option value="Enroll Form">Enroll Form</option>
<option value="Full Acquiring">Full Acquiring</option>
<option value="Inactive Client">Inactive Client</option>
<option value="Max Attempts">Max Attempts</option>
<option value="No Discounts Accepted">No Discounts Accepted</option>
<option value="No Longer in Business">No Longer in Business</option>
<option value="Non Acceptor">Non Acceptor</option>
<option value="Not Preferred">Not Preferred</option>
<option value="Not Started">Not Started</option>
<option value="ON HOLD">ON HOLD</option>
<option value="Processing Limit">Processing Limit</option>
<option value="Require Invoice #">Require Invoice #</option>
<option value="Research">Research</option>
<option value="Rework Lead">Rework Lead</option>
<option value="SE ENROLL">SE ENROLL</option>
<option value="SE FULL ACQUIRING">SE FULL ACQUIRING</option>
<option value="SE MID">SE MID</option>
<option value="Supplier Remorse">Supplier Remorse</option>
<option value="Surcharge/Fees">Surcharge/Fees</option>
<option value="Validate with Client">Validate with Client</option>
<option value="Verbal">Verbal</option>
<option value="Voicemail">Voicemail</option>
</select></div>
</div>
<div class="ff-item-row" style="display: none;">
<div class="ff-col-1 ff-label-col"><label vatt="DATE" for="Lead.Enroll_Date__c" class="ff-label" id="lblLeadEnroll_Date__c">Enroll Date</label></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.Enroll_Date__c" placeholder="" aria-placeholder="" name="Lead.Enroll_Date__c" vatt="DATE" class="ff-input-type ff-type-text hasDatepicker"
data-maxlengthmessage="Maximum 10 characters" maxlength="10" data-validatefieldtype="" value="" data-requiredmessage="required" data-isupsert="true" data-ishidden="true" data-vatt="DATE"></div>
</div>
<div class="ff-item-row" style="display: none;">
<div class="ff-col-1 ff-label-col"><label vatt="DATE" for="Lead.Win_Date__c" class="ff-label" id="lblLeadWin_Date__c">Win Date</label></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.Win_Date__c" placeholder="" aria-placeholder="" name="Lead.Win_Date__c" vatt="DATE" class="ff-input-type ff-type-text hasDatepicker"
data-maxlengthmessage="Maximum 10 characters" maxlength="10" data-validatefieldtype="" value="" data-requiredmessage="required" data-isupsert="true" data-ishidden="true" data-vatt="DATE"></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="STRING" for="Lead.Company" class="ff-label" id="lblLeadCompany">Company</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.Company" placeholder="" aria-placeholder="" name="Lead.Company" vatt="STRING" class="ff-input-type ff-type-text" data-maxlengthmessage="Maximum 255 characters"
maxlength="255" data-validatefieldtype="" value="INTERACTIVE COMMUNICATIONS INTL" data-requiredmessage="required" data-isrequired="true" aria-required="true" data-isupsert="true" data-ishidden="false" data-vatt="STRING"></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="STRING" for="Lead.FirstName" class="ff-label" id="lblLeadFirstName">First Name</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.FirstName" placeholder="" aria-placeholder="" name="Lead.FirstName" vatt="STRING" class="ff-input-type ff-type-text" data-maxlengthmessage="Maximum 40 characters"
maxlength="40" data-validatefieldtype="" value="Interactive Communications" data-requiredmessage="required" data-isrequired="true" aria-required="true" data-isupsert="true" data-ishidden="false" data-vatt="STRING"></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="STRING" for="Lead.LastName" class="ff-label" id="lblLeadLastName">Last Name</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.LastName" placeholder="" aria-placeholder="" name="Lead.LastName" vatt="STRING" class="ff-input-type ff-type-text" data-maxlengthmessage="Maximum 80 characters"
maxlength="80" data-validatefieldtype="" value="AR Dept." data-requiredmessage="required" data-isrequired="true" aria-required="true" data-isupsert="true" data-ishidden="false" data-vatt="STRING"></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="EMAIL" for="Lead.Email" class="ff-label" id="lblLeadEmail">Email</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.Email" placeholder="" aria-placeholder="" name="Lead.Email" vatt="EMAIL" class="ff-input-type ff-type-text" data-maxlengthmessage="Maximum 80 characters" maxlength="80"
data-validatefieldtype="" value="icibilling@incomm.com" data-requiredmessage="required" data-isrequired="true" aria-required="true" data-isupsert="true" data-ishidden="false" data-vatt="EMAIL"></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="TEXTAREA" for="Lead.Street" class="ff-label" id="lblLeadStreet">Street</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><textarea id="Lead.Street" placeholder="" aria-placeholder="" name="Lead.Street" vatt="TEXTAREA" class="ff-textarea" data-maxlengthmessage="Maximum 255 characters" maxlength="255"
data-ishtmlformatted="false" value="" data-requiredmessage="required" data-isrequired="true" aria-required="true" data-isupsert="true" data-ishidden="false" data-vatt="TEXTAREA">PO BOX 935359</textarea></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="STRING" for="Lead.City" class="ff-label" id="lblLeadCity">City</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.City" placeholder="" aria-placeholder="" name="Lead.City" vatt="STRING" class="ff-input-type ff-type-text" data-maxlengthmessage="Maximum 40 characters" maxlength="40"
data-validatefieldtype="" value="ATLANTA" data-requiredmessage="required" data-isrequired="true" aria-required="true" data-isupsert="true" data-ishidden="false" data-vatt="STRING"></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="PICKLIST" for="Lead.StateCode" class="ff-label" id="lblLeadStateCode">State/Province Code</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><select name="Lead.StateCode" id="Lead.StateCode" vatt="PICKLIST" class="ff-select-type ff-singlepicklist" data-flexcontrol="" data-requiredmessage="required" data-isrequired="true"
aria-required="true" data-isupsert="false" data-ishidden="false" data-vatt="PICKLIST">
<option value=""></option>
<option value="AK">AK</option>
<option value="AL">AL</option>
<option value="AB">AB</option>
<option value="AR">AR</option>
<option value="ACT">ACT</option>
<option value="AZ">AZ</option>
<option value="BC">BC</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DC">DC</option>
<option value="DE">DE</option>
<option value="FL">FL</option>
<option value="GA" selected="selected">GA</option>
<option value="GU">GU</option>
<option value="HI">HI</option>
<option value="IA">IA</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="MA">MA</option>
<option value="MB">MB</option>
<option value="MD">MD</option>
<option value="ME">ME</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MO">MO</option>
<option value="MS">MS</option>
<option value="MT">MT</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="NE">NE</option>
<option value="NB">NB</option>
<option value="NL">NL</option>
<option value="NSW">NSW</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NT">NT</option>
<option value="NT">NT</option>
<option value="NS">NS</option>
<option value="NU">NU</option>
<option value="NV">NV</option>
<option value="NY">NY</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="ON">ON</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="PR">PR</option>
<option value="PE">PE</option>
<option value="QC">QC</option>
<option value="QLD">QLD</option>
<option value="RI">RI</option>
<option value="SK">SK</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="SA">SA</option>
<option value="TAS">TAS</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VA">VA</option>
<option value="VI">VI</option>
<option value="VIC">VIC</option>
<option value="VT">VT</option>
<option value="WA">WA</option>
<option value="WA">WA</option>
<option value="WI">WI</option>
<option value="WV">WV</option>
<option value="WY">WY</option>
<option value="YT">YT</option>
</select></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="STRING" for="Lead.PostalCode" class="ff-label" id="lblLeadPostalCode">Postal Code</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.PostalCode" placeholder="" aria-placeholder="" name="Lead.PostalCode" vatt="STRING" class="ff-input-type ff-type-text" data-maxlengthmessage="Maximum 20 characters"
maxlength="20" data-validatefieldtype="" value="311935359" data-requiredmessage="required" data-isrequired="true" aria-required="true" data-isupsert="true" data-ishidden="false" data-vatt="STRING"></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="PHONE" for="Lead.Phone" class="ff-label" id="lblLeadPhone">Phone</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.Phone" placeholder="" aria-placeholder="" name="Lead.Phone" vatt="PHONE" class="ff-input-type ff-type-text" data-maxlengthmessage="Maximum 40 characters" maxlength="40"
data-validatefieldtype="" value="(770) 240-6100" data-requiredmessage="required" data-isrequired="true" aria-required="true" data-isupsert="false" data-ishidden="false" data-vatt="PHONE"></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="EMAIL" for="Lead.Payment_Remittance_Email__c" class="ff-label" id="lblLeadPayment_Remittance_Email__c">Payment Remittance Email</label><span class="requiredSpan ff-required-mark">*</span>
</div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.Payment_Remittance_Email__c" placeholder="" aria-placeholder="" name="Lead.Payment_Remittance_Email__c" vatt="EMAIL" class="ff-input-type ff-type-text"
data-maxlengthmessage="Maximum 80 characters" maxlength="80" data-validatefieldtype="" value="" data-requiredmessage="required" data-isrequired="true" aria-required="true" data-isupsert="true" data-ishidden="false"
data-vatt="EMAIL"></div>
</div>
<div class="ff-item-row fw-row">
<div class="ff-col-1 ff-label-col"><label id="GENERALTEXT361" class="ff-label ff-general-text-label" vatt="STRING" data-ishidden="false">Please answer the questions below:</label></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="PICKLIST" for="Lead.Citi_Form_Question_1__c" class="ff-label" id="lblLeadCiti_Form_Question_1__c">Our company accepts virtual credit card payments from all buyers. There are no fees or
other stipulations to this acceptance. </label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col">
<div class="ff-select-to-radiobtn-list custom-flex-control-container">
<ul id="ulLead.Citi_Form_Question_1__c" class="ff-select-to-radiobtn-ul ff-ext-vertical" role="radiogroup" aria-labelledby="lblLeadCiti_Form_Question_1__c">
<li class="ff-radio-li"><span class="ff-ext-radio-css ff-ext-selected" role="radio" aria-checked="true" aria-labelledby="lblLead.Citi_Form_Question_1__c__1" tabindex="0" name="Lead.Citi_Form_Question_1__c"
id="Lead.Citi_Form_Question_1__c__1" data-value="Yes" data-ff-ext-radio-checked="true"></span><label for="Lead.Citi_Form_Question_1__c__1" id="lblLead.Citi_Form_Question_1__c__1">Yes </label></li>
<li class="ff-radio-li"><span class="ff-ext-radio-css" role="radio" aria-checked="false" aria-labelledby="lblLead.Citi_Form_Question_1__c__2" tabindex="0" name="Lead.Citi_Form_Question_1__c" id="Lead.Citi_Form_Question_1__c__2"
data-value="No" data-ff-ext-radio-checked="false"></span><label for="Lead.Citi_Form_Question_1__c__2" id="lblLead.Citi_Form_Question_1__c__2">No </label></li>
</ul>
</div><select name="Lead.Citi_Form_Question_1__c" id="Lead.Citi_Form_Question_1__c" vatt="PICKLIST" class="ff-select-type ff-singlepicklist custom-select-offscreen" data-flexcontrol="picklist-radiobutton-vertical"
data-requiredmessage="required" data-isrequired="true" aria-required="true" data-isupsert="true" data-ishidden="false" data-vatt="PICKLIST">
<option value="">--select an item--</option>
<option value="Yes" selected="selected">Yes </option>
<option value="No">No </option>
</select>
</div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="PICKLIST" for="Lead.Citi_Form_Question_2__c" class="ff-label" id="lblLeadCiti_Form_Question_2__c">Buyers wanting to pay our company by virtual card in the future may be automatically
enrolled.</label><span class="requiredSpan ff-required-mark">*</span></div>
<div class="ff-col-2 ff-field-col">
<div class="ff-select-to-radiobtn-list custom-flex-control-container">
<ul id="ulLead.Citi_Form_Question_2__c" class="ff-select-to-radiobtn-ul ff-ext-vertical" role="radiogroup" aria-labelledby="lblLeadCiti_Form_Question_2__c">
<li class="ff-radio-li"><span class="ff-ext-radio-css" role="radio" aria-checked="false" aria-labelledby="lblLead.Citi_Form_Question_2__c__1" tabindex="0" name="Lead.Citi_Form_Question_2__c" id="Lead.Citi_Form_Question_2__c__1"
data-value="Yes" data-ff-ext-radio-checked="false"></span><label for="Lead.Citi_Form_Question_2__c__1" id="lblLead.Citi_Form_Question_2__c__1">Yes </label></li>
<li class="ff-radio-li"><span class="ff-ext-radio-css" role="radio" aria-checked="false" aria-labelledby="lblLead.Citi_Form_Question_2__c__2" tabindex="0" name="Lead.Citi_Form_Question_2__c" id="Lead.Citi_Form_Question_2__c__2"
data-value="No" data-ff-ext-radio-checked="false"></span><label for="Lead.Citi_Form_Question_2__c__2" id="lblLead.Citi_Form_Question_2__c__2">No </label></li>
</ul>
</div><select name="Lead.Citi_Form_Question_2__c" id="Lead.Citi_Form_Question_2__c" vatt="PICKLIST" class="ff-select-type ff-singlepicklist custom-select-offscreen" data-flexcontrol="picklist-radiobutton-vertical"
data-requiredmessage="required" data-isrequired="true" aria-required="true" data-isupsert="true" data-ishidden="false" data-vatt="PICKLIST">
<option value="" selected="selected">--select an item--</option>
<option value="Yes">Yes </option>
<option value="No">No </option>
</select>
</div>
</div>
<div class="ff-item-row fw-row">
<div class="ff-col-1 ff-label-col"><label id="GENERALTEXT889" class="ff-label ff-general-text-label" vatt="STRING" data-ishidden="false"> * I understand there is an interchange rate that is assessed by my merchant bank. There will be no
additional charges or fees assessed by US bank or TDS.</label></div>
</div>
<div class="ff-item-row fw-row">
<div class="ff-col-1 ff-label-col"><label id="GENERALTEXT793" class="ff-label ff-general-text-label" vatt="STRING" data-ishidden="false">* Contact us at TDS@b2bepayables.com or call us at 844-279-8860. Our fax number is
855-859-6873.</label></div>
</div>
<div class="ff-item-row">
<div class="ff-col-1 ff-label-col"><label vatt="STRING" for="Lead.Supplier_ID__c" class="ff-label" id="lblLeadSupplier_ID__c">Supplier ID</label></div>
<div class="ff-col-2 ff-field-col"><input type="textbox" id="Lead.Supplier_ID__c" placeholder="" aria-placeholder="" name="Lead.Supplier_ID__c" vatt="STRING" class="ff-input-type ff-type-text"
data-maxlengthmessage="Maximum 50 characters" maxlength="50" data-validatefieldtype="" value="220412" data-requiredmessage="required" data-isupsert="false" data-ishidden="false" data-vatt="STRING"></div>
</div>
</div>
</div>
<div class="ff-footer-group">
<div class="ff-item-row ff-footer-row">
<div class="ff-submit-btn">
<div class="footnoteDiv"><span class="requiredSpan ff-footnote ff-required-mark">*</span><label class="ff-footnote-label ff-label">- required</label></div>
<div class="btnDiv"><input type="button" class="sectionHeader ff-btn-submit" id="btnsubmit" value="Submit Enrollment Form"
data-btnmessage="Thank you for agreeing to accept TDS' MasterCard Virtual Card as payment for all future invoices." data-btnurl=""></div>
</div>
</div>
</div>
</div>
<script>
if (!window.jQuery) {
console.log('External jQuery not found. Loading FS4SF jQuery.');
try {
$ = fs;
} catch (error) {
console.log(error)
};
try {
jQuery = fs;
} catch (error) {
console.log(error)
};
}
function FF_OnAfterRender() {
var dt = new Date();
var todaysDate = new Date();
$('#Lead\\.Enroll_Date__c').datepicker("setDate", todaysDate);
$('#Lead\\.Win_Date__c').datepicker("setDate", todaysDate);
$('#Lead\\.Status').val("Won");
$('#Lead\\.Reason__c').val("Enroll Form");
}
</script>
</div>
</div>
<iframe id="ffIframe" name="ffIframe" style="display:none"></iframe>
<div id="dialog">
</div>
<div id="paymentDialog" style="display:none;overflow:hidden;">
<iframe id="paymentDialogIFrame" style="width:100%;height:100%;margin:0px;padding:0px;border:0" scrolling="no"></iframe>
</div>
<div id="ffLookupDialog" style="overflow:hidden">
</div>
<input type="hidden" id="selectedId" value="">
</form>Text Content
TDS Enrollment Form Status WonLostSupplier RemorseOpenReturnWon/Converted Reason Acquiring ProspectAlt Pmt MethodApp In ProgressAuto EnrollBetter Contact InformationBIP Full AcquiringBIP MIDBIP No MIDCallCANCELLEDClient DiscountContractual TermCustomer Acct #Do Not CallEmailEnroll EmailEnroll FormFull AcquiringInactive ClientMax AttemptsNo Discounts AcceptedNo Longer in BusinessNon AcceptorNot PreferredNot StartedON HOLDProcessing LimitRequire Invoice #ResearchRework LeadSE ENROLLSE FULL ACQUIRINGSE MIDSupplier RemorseSurcharge/FeesValidate with ClientVerbalVoicemail Enroll Date Win Date Company* First Name* Last Name* Email* Street* PO BOX 935359 City* State/Province Code* AKALABARACTAZBCCACOCTDCDEFLGAGUHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNCNDNENBNLNSWNHNJNMNTNTNSNUNVNYOHOKONORPAPRPEQCQLDRISKSCSDSATASTNTXUTVAVIVICVTWAWAWIWVWYYT Postal Code* Phone* Payment Remittance Email* Please answer the questions below: Our company accepts virtual credit card payments from all buyers. There are no fees or other stipulations to this acceptance. * * Yes * No --select an item--Yes No Buyers wanting to pay our company by virtual card in the future may be automatically enrolled.* * Yes * No --select an item--Yes No * I understand there is an interchange rate that is assessed by my merchant bank. There will be no additional charges or fees assessed by US bank or TDS. * Contact us at TDS@b2bepayables.com or call us at 844-279-8860. Our fax number is 855-859-6873. Supplier ID *- required PrevNext JanFebMarAprMayJunJulAugSepOctNovDec192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025202620272028202920302031 SuMoTuWeThFrSa 12345678910111213141516171819202122232425262728293031 NowDone