{"id":557,"date":"2016-03-22T11:47:35","date_gmt":"2016-03-22T15:47:35","guid":{"rendered":"http:\/\/ccamwp.uh.uconn.edu\/?page_id=557"},"modified":"2017-06-29T12:17:07","modified_gmt":"2017-06-29T16:17:07","slug":"ccam-microscopy-user-request","status":"publish","type":"page","link":"https:\/\/health.uconn.edu\/cell-analysis-modeling\/ccam-microscopy-user-request\/","title":{"rendered":"CCAM Microscopy User Request"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_1' >\n                        <div class='gform_heading'>\n                            <p class='gform_description'>Please fill in the information to determine which microscope system would best suite your needs.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/cell-analysis-modeling\/wp-json\/wp\/v2\/pages\/557' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_27\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_27'><span class='gform-field-label__text'>Name<\/span><\/label><div class='ginput_container'><input name='input_27' id='input_1_27' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_1_27'>This field is for validation purposes and should be left unchanged.<\/div><\/li><li id=\"field_1_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_1'>\n                            \n                            <span id='input_1_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_1_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_1_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_2\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_2'><span class='gform-field-label__text'>Business Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_2' id='input_1_2' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_1_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_3'><span class='gform-field-label__text'>Institution<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_1_3' type='text' value='' class='medium'  aria-describedby=\"gfield_description_1_3\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_3'>UCONN users, please note either Farmington or Storrs campus.<\/div><\/li><li id=\"field_1_5\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Position<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_5'>\n\t\t\t<li class='gchoice gchoice_1_5_0'>\n\t\t\t\t<input name='input_5' type='radio' value='Student'  id='choice_1_5_0'    \/>\n\t\t\t\t<label for='choice_1_5_0' id='label_1_5_0' class='gform-field-label gform-field-label--type-inline'>Student<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_5_1'>\n\t\t\t\t<input name='input_5' type='radio' value='Postdoc'  id='choice_1_5_1'    \/>\n\t\t\t\t<label for='choice_1_5_1' id='label_1_5_1' class='gform-field-label gform-field-label--type-inline'>Postdoc<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_5_2'>\n\t\t\t\t<input name='input_5' type='radio' value='Staff'  id='choice_1_5_2'    \/>\n\t\t\t\t<label for='choice_1_5_2' id='label_1_5_2' class='gform-field-label gform-field-label--type-inline'>Staff<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_5_3'>\n\t\t\t\t<input name='input_5' type='radio' value='Faculty'  id='choice_1_5_3'    \/>\n\t\t\t\t<label for='choice_1_5_3' id='label_1_5_3' class='gform-field-label gform-field-label--type-inline'>Faculty<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_4'><span class='gform-field-label__text'>Principal Investigator<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_1_4' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Type of Service Required<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_26'>\n\t\t\t<li class='gchoice gchoice_1_26_0'>\n\t\t\t\t<input name='input_26' type='radio' value='Training'  id='choice_1_26_0'    \/>\n\t\t\t\t<label for='choice_1_26_0' id='label_1_26_0' class='gform-field-label gform-field-label--type-inline'>Training<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_26_1'>\n\t\t\t\t<input name='input_26' type='radio' value='Service Work'  id='choice_1_26_1'    \/>\n\t\t\t\t<label for='choice_1_26_1' id='label_1_26_1' class='gform-field-label gform-field-label--type-inline'>Service Work<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_6\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Specimen<\/h2><\/li><li id=\"field_1_25\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_25'><span class='gform-field-label__text'>Sample Source<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_25'>Please state the origin of your cells and\/or tissue sample. For example primary human thyroid, human melanoma cell line ####, mouse fibrosarcoma cell line ####.<\/div><div class='ginput_container ginput_container_text'><input name='input_25' id='input_1_25' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_25\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_7\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_7'><span class='gform-field-label__text'>Preparation<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_1_7' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Cells - Fixed - Adherent' >Cells - Fixed - Adherent<\/option><option value='Cells - Live - Adherent' >Cells - Live - Adherent<\/option><option value='Cells - Live - Non-Adherent' >Cells - Live - Non-Adherent<\/option><option value='Cells - Fixed - Non-Adherent' >Cells - Fixed - Non-Adherent<\/option><option value='Tissue - Live' >Tissue - Live<\/option><option value='Tissue - Fixed' >Tissue - Fixed<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_1_8\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_8'><span class='gform-field-label__text'>Other - Please Explain<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_8' id='input_1_8' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_9\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Fluorophore<\/h2><\/li><li id=\"field_1_10\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_10'><span class='gform-field-label__text'>Probe 1<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_1_10' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_11\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_11'><span class='gform-field-label__text'>Probe 2<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_1_11' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_12\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_12'><span class='gform-field-label__text'>Probe 3<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_1_12' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_13\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_13'><span class='gform-field-label__text'>Probe 4<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_1_13' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_14\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_14'><span class='gform-field-label__text'>Probe 5<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_1_14' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_15\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Instrument of Choice<\/h2><\/li><li id=\"field_1_16\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you have a preference?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_16'>\n\t\t\t<li class='gchoice gchoice_1_16_0'>\n\t\t\t\t<input name='input_16' type='radio' value='No' checked='checked' id='choice_1_16_0'    \/>\n\t\t\t\t<label for='choice_1_16_0' id='label_1_16_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_16_1'>\n\t\t\t\t<input name='input_16' type='radio' value='Zeiss LSM 880 - 263 Farmington Avenue'  id='choice_1_16_1'    \/>\n\t\t\t\t<label for='choice_1_16_1' id='label_1_16_1' class='gform-field-label gform-field-label--type-inline'>Zeiss LSM 880 - 263 Farmington Avenue<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_16_2'>\n\t\t\t\t<input name='input_16' type='radio' value='Zeiss TIRF\/Widefield - 263 Farmington Avenue'  id='choice_1_16_2'    \/>\n\t\t\t\t<label for='choice_1_16_2' id='label_1_16_2' class='gform-field-label gform-field-label--type-inline'>Zeiss TIRF\/Widefield - 263 Farmington Avenue<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_16_3'>\n\t\t\t\t<input name='input_16' type='radio' value='Zeiss Elyra 7 - 400 Farmington Avenue'  id='choice_1_16_3'    \/>\n\t\t\t\t<label for='choice_1_16_3' id='label_1_16_3' class='gform-field-label gform-field-label--type-inline'>Zeiss Elyra 7 - 400 Farmington Avenue<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_16_4'>\n\t\t\t\t<input name='input_16' type='radio' value='Nikon Crest Spinning Disk Confocal - 400 Farmington Avenue'  id='choice_1_16_4'    \/>\n\t\t\t\t<label for='choice_1_16_4' id='label_1_16_4' class='gform-field-label gform-field-label--type-inline'>Nikon Crest Spinning Disk Confocal - 400 Farmington Avenue<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_16_5'>\n\t\t\t\t<input name='input_16' type='radio' value='Zeiss LSM 780 - 400 Farmington Avenue'  id='choice_1_16_5'    \/>\n\t\t\t\t<label for='choice_1_16_5' id='label_1_16_5' class='gform-field-label gform-field-label--type-inline'>Zeiss LSM 780 - 400 Farmington Avenue<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_16_6'>\n\t\t\t\t<input name='input_16' type='radio' value='Zeiss LightSheet - 400 Farmington Avenue'  id='choice_1_16_6'    \/>\n\t\t\t\t<label for='choice_1_16_6' id='label_1_16_6' class='gform-field-label gform-field-label--type-inline'>Zeiss LightSheet - 400 Farmington Avenue<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_16_7'>\n\t\t\t\t<input name='input_16' type='radio' value='Zeiss AxioVert 200M - 400 Farmington Avenue'  id='choice_1_16_7'    \/>\n\t\t\t\t<label for='choice_1_16_7' id='label_1_16_7' class='gform-field-label gform-field-label--type-inline'>Zeiss AxioVert 200M - 400 Farmington Avenue<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_17\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Environmental Conditions<\/h2><\/li><li id=\"field_1_18\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Conditions Required<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_18'><li class='gchoice gchoice_1_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='None'  id='choice_1_18_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_18_1' id='label_1_18_1' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_18_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.2' type='checkbox'  value='Heating 37C'  id='choice_1_18_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_18_2' id='label_1_18_2' class='gform-field-label gform-field-label--type-inline'>Heating 37C<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_18_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.3' type='checkbox'  value='Carbon Dioxide'  id='choice_1_18_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_18_3' id='label_1_18_3' class='gform-field-label gform-field-label--type-inline'>Carbon Dioxide<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_18_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.4' type='checkbox'  value='Other'  id='choice_1_18_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_18_4' id='label_1_18_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_19\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_19'><span class='gform-field-label__text'>Other - Please Explain<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_19' id='input_1_19' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_20\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Project<\/h2><\/li><li id=\"field_1_21\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_21'><span class='gform-field-label__text'>Summary<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_21' id='input_1_21' class='textarea medium'  aria-describedby=\"gfield_description_1_21\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_1_21'>Please provide a brief description of your imaging needs and\/or other information you would like us to know.<\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_1' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Submit<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_1' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_1' id='gform_theme_1' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_1' id='gform_style_settings_1' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='rQ5\/qjJ2qxdrfhbtGoY7DzciKqmLm4ei0F5VRuZLVNe2bz0im7Clro9aI2lJ5UPdKLOygOUhBqOeVJ3tJMoIOK+vM739FvzMCs9EBPu\/ptk2Zw4=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' value='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' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_1' id='gform_source_page_number_1' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n           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