{"id":539,"date":"2023-04-20T19:33:07","date_gmt":"2023-04-20T19:33:07","guid":{"rendered":"https:\/\/srmedicalcenter.org\/?page_id=539"},"modified":"2026-02-24T15:59:37","modified_gmt":"2026-02-24T19:59:37","slug":"employment-application","status":"publish","type":"page","link":"https:\/\/srmedicalcenter.org\/?page_id=539","title":{"rendered":"Employment Application"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"539\" class=\"elementor elementor-539\" data-elementor-post-type=\"page\">\n\t\t\t\t<div data-particle_enable=\"false\" data-particle-mobile-disabled=\"false\" class=\"elementor-element elementor-element-239bdf0 e-flex e-con-boxed e-con e-parent\" data-id=\"239bdf0\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-b854eae elementor-widget elementor-widget-heading\" data-id=\"b854eae\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h4 class=\"elementor-heading-title elementor-size-default\">EMPLOYMENT APPLICATION<\/h4>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-4e3ceb0 application-form eael-gravity-form-button-custom elementor-widget elementor-widget-eael-gravity-form\" data-id=\"4e3ceb0\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"eael-gravity-form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t<div class=\"eael-contact-form eael-gravity-form eael-contact-form-align-default\">\n\t\t        <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 InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return 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 gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_1' style='display:none'><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F539#gf_1' data-formid='1' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6Lf3OfcpAAAAAPuNZ0q38RAWF33NZjloUz5OnRtQ' data-tabindex='0'><input id=\"input_d6940e429b33b630150a5335bca4b629\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_d6940e429b33b630150a5335bca4b629\" value=\"\"\/><\/div>\n        <div id='gf_progressbar_wrapper_1' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>11<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_9' style='width:9%;'><span>9%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_1_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_210\" 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_210'>X\/Twitter<\/label><div class='ginput_container'><input name='input_210' id='input_1_210' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_1_210'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_1_1\" 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\"  ><h3 class=\"gsection_title\">Position (s) Applied For<\/h3><\/div><div id=\"field_1_3\" class=\"gfield gfield--type-text gfield--input-type-text 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_3'>Position 1<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_1_3' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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'>Position 2<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_1_4' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_5\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_5'>Position 3<\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_1_5' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_6\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Positions checkboxes<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_6'><div class='gchoice gchoice_1_6_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.1' type='checkbox'  value='RLS'  id='choice_1_6_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_6_1' id='label_1_6_1' class='gform-field-label gform-field-label--type-inline'>RLS<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_6_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.2' type='checkbox'  value='CKCI'  id='choice_1_6_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_6_2' id='label_1_6_2' class='gform-field-label gform-field-label--type-inline'>CKCI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_6_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.3' type='checkbox'  value='MKS'  id='choice_1_6_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_6_3' id='label_1_6_3' class='gform-field-label gform-field-label--type-inline'>MKS<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_7\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\">Position (s) Applied For<\/h3><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_1_196' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_2' class='gform_page' data-js='page-field-id-196' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_8\" 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\"  ><h3 class=\"gsection_title\">How Can We Contact You?<\/h3><\/div><div id=\"field_1_177\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third 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_177'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_177' id='input_1_177' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_178\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter 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_178'>M.I.<\/label><div class='ginput_container ginput_container_text'><input name='input_178' id='input_1_178' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_179\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-five-twelfths 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_179'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_179' id='input_1_179' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_170\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_170'>Mailing Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_170' id='input_1_170' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_171\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_171'>Physical Address<\/label><div class='ginput_container ginput_container_text'><input name='input_171' id='input_1_171' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_172\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third 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_172'>City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_172' id='input_1_172' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_173\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third 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_173'>State<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_173' id='input_1_173' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_176\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third 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_176'>Zip Code<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_176' id='input_1_176' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_13\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third 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'>Home Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_13' id='input_1_13' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_15\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third 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_15'>Business Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_15' id='input_1_15' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_16\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third 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_16'>Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_16' id='input_1_16' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_12\" class=\"gfield gfield--type-email gfield--input-type-email 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_12'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_12' id='input_1_12' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_14\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full 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'>Desired Salary<\/label><div class='ginput_container ginput_container_number'><input name='input_14' id='input_1_14' type='text' step='any' min='0'  value='' class='small'    placeholder='$'  aria-invalid=\"false\" aria-describedby=\"gfield_instruction_1_14\" \/><div class='gfield_description instruction ' id='gfield_instruction_1_14'>Please enter a number greater than or equal to <strong>0<\/strong>.<\/div><\/div><\/div><div id=\"field_1_11\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\">How Can We Contact You?<\/h3><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_197' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_197' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_3' class='gform_page' data-js='page-field-id-197' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div 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\"  ><h3 class=\"gsection_title\">Education \/ Job Related Training &amp; Course Work<\/h3><\/div><div id=\"field_1_42\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >High School, College, University, or Professional School (An Official Transcript may be required) Vocational, Trade, Government, Business Armed Forces, etc.<\/div><div id=\"field_1_43\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third 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_43'>Name of School<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_1_43' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_44\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-five-twelfths 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_44'>Location<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_1_44' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_47\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>Credit Hours Earned<\/strong><\/div><fieldset id=\"field_1_46\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Start Date<\/legend><div id='input_1_46' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_46_1_container'>\n                                            <input type='number' maxlength='2' name='input_46[]' id='input_1_46_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_1_46_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_1_46_2_container'>\n                                            <input type='number' maxlength='2' name='input_46[]' id='input_1_46_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_1_46_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_1_46_3_container'>\n                                            <input type='number' maxlength='4' name='input_46[]' id='input_1_46_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_1_46_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_1_45\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >End Date<\/legend><div id='input_1_45' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_45_1_container'>\n                                            <input type='number' maxlength='2' name='input_45[]' id='input_1_45_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_1_45_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_1_45_2_container'>\n                                            <input type='number' maxlength='2' name='input_45[]' id='input_1_45_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_1_45_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_1_45_3_container'>\n                                            <input type='number' maxlength='4' name='input_45[]' id='input_1_45_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_1_45_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div data-fieldId=\"45\" class=\"spacer gfield\" style=\"grid-column: span 6;\" data-groupId=\"74966659\"><\/div><div id=\"field_1_48\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>Dates of Attendance<\/strong><\/div><div id=\"field_1_50\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter 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_50'>Quarter<\/label><div class='ginput_container ginput_container_number'><input name='input_50' id='input_1_50' type='number' step='any' min='0' max='1000' value='' class='large'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_1_50\" \/><div class='gfield_description instruction ' id='gfield_instruction_1_50'>Please enter a number from <strong>0<\/strong> to <strong>1000<\/strong>.<\/div><\/div><\/div><div id=\"field_1_49\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter 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_49'>Semester<\/label><div class='ginput_container ginput_container_number'><input name='input_49' id='input_1_49' type='number' step='any' min='0' max='1000' value='' class='large'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_1_49\" \/><div class='gfield_description instruction ' id='gfield_instruction_1_49'>Please enter a number from <strong>0<\/strong> to <strong>1000<\/strong>.<\/div><\/div><\/div><div data-fieldId=\"49\" class=\"spacer gfield\" style=\"grid-column: span 6;\" data-groupId=\"f0db3020\"><\/div><div id=\"field_1_51\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_51'>Course of Study<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_1_51' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_52\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_52'>Type of Degree<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_1_52' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_53\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did you graduate?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_53'>\n\t\t\t<div class='gchoice gchoice_1_53_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Yes'  id='choice_1_53_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_53_0' id='label_1_53_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_53_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='No'  id='choice_1_53_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_53_1' id='label_1_53_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_195\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload 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='gform_browse_button_1_195'>Certificate\/Transcript<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_195' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_195&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_195&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_195&quot;,&quot;filelist&quot;:&quot;gform_preview_1_195&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/srmedicalcenter.org\\\/?gf_page=6157c068526976a&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/srmedicalcenter.org\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/srmedicalcenter.org\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;png,pdf,jpg&quot;}],&quot;max_file_size&quot;:&quot;15728640b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:195,&quot;_gform_file_upload_nonce_1_195&quot;:&quot;86144852a1&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_195&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_195' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_1_195' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_1_195\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_195'>Accepted file types: png, pdf, jpg, Max. file size: 15 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_1_195'><\/ul> <div id='gform_preview_1_195' class='ginput_preview_list'><\/div><\/div><\/div><fieldset id=\"field_1_149\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Add More Education 1<\/legend><div class='ginput_container ginput_container_consent'><input name='input_149.1' id='input_1_149_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_149_1' >Add more<\/label><input type='hidden' name='input_149.2' value='Add more' class='gform_hidden' \/><input type='hidden' name='input_149.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_1_126\" class=\"gfield gfield--type-section gfield--input-type-section gsection form-inner-sections field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Education 2<\/h3><\/div><div id=\"field_1_165\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >High School, College, University, or Professional School (An Official Transcript may be required) Vocational, Trade, Government, Business Armed Forces, etc.<\/div><div id=\"field_1_138\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-five-twelfths 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_138'>2. Name of School<\/label><div class='ginput_container ginput_container_text'><input name='input_138' id='input_1_138' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_139\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-five-twelfths 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_139'>2. Location<\/label><div class='ginput_container ginput_container_text'><input name='input_139' id='input_1_139' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_164\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>Credit Hours Earned<\/strong><\/div><fieldset id=\"field_1_140\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >2. Start Date<\/legend><div id='input_1_140' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_140_1_container'>\n                                            <input type='number' maxlength='2' name='input_140[]' id='input_1_140_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_1_140_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_1_140_2_container'>\n                                            <input type='number' maxlength='2' name='input_140[]' id='input_1_140_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_1_140_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_1_140_3_container'>\n                                            <input type='number' maxlength='4' name='input_140[]' id='input_1_140_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_1_140_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_1_141\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >2. End Date<\/legend><div id='input_1_141' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_141_1_container'>\n                                            <input type='number' maxlength='2' name='input_141[]' id='input_1_141_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_1_141_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_1_141_2_container'>\n                                            <input type='number' maxlength='2' name='input_141[]' id='input_1_141_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_1_141_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_1_141_3_container'>\n                                            <input type='number' maxlength='4' name='input_141[]' id='input_1_141_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_1_141_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div data-fieldId=\"141\" class=\"spacer gfield\" style=\"grid-column: span 6;\" data-groupId=\"55e53dbb\"><\/div><div id=\"field_1_166\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>Dates of Attendance<\/strong><\/div><div id=\"field_1_143\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third 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_143'>2. Quarter<\/label><div class='ginput_container ginput_container_number'><input name='input_143' id='input_1_143' type='number' step='any' min='0' max='1000' value='' class='large'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_1_143\" \/><div class='gfield_description instruction ' id='gfield_instruction_1_143'>Please enter a number from <strong>0<\/strong> to <strong>1000<\/strong>.<\/div><\/div><\/div><div id=\"field_1_144\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third 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_144'>2. Semester<\/label><div class='ginput_container ginput_container_number'><input name='input_144' id='input_1_144' type='number' step='any' min='0' max='1000' value='' class='large'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_1_144\" \/><div class='gfield_description instruction ' id='gfield_instruction_1_144'>Please enter a number from <strong>0<\/strong> to <strong>1000<\/strong>.<\/div><\/div><\/div><div id=\"field_1_145\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_145'>2. Course of Study<\/label><div class='ginput_container ginput_container_text'><input name='input_145' id='input_1_145' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_146\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_146'>2. Type of Degree<\/label><div class='ginput_container ginput_container_text'><input name='input_146' id='input_1_146' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_147\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2. Did you graduate?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_147'>\n\t\t\t<div class='gchoice gchoice_1_147_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_147' type='radio' value='Yes'  id='choice_1_147_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_147_0' id='label_1_147_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_147_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_147' type='radio' value='No'  id='choice_1_147_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_147_1' id='label_1_147_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_150\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Add More Education 2<\/legend><div class='ginput_container ginput_container_consent'><input name='input_150.1' id='input_1_150_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_150_1' >Add more<\/label><input type='hidden' name='input_150.2' value='Add more' class='gform_hidden' \/><input type='hidden' name='input_150.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_1_153\" class=\"gfield gfield--type-section gfield--input-type-section gsection form-inner-sections field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Education 3<\/h3><\/div><div id=\"field_1_169\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >High School, College, University, or Professional School (An Official Transcript may be required) Vocational, Trade, Government, Business Armed Forces, etc.<\/div><div id=\"field_1_154\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_154'>3. Name of School<\/label><div class='ginput_container ginput_container_text'><input name='input_154' id='input_1_154' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_155\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_155'>3. Location<\/label><div class='ginput_container ginput_container_text'><input name='input_155' id='input_1_155' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_168\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>Credit Hours Earned<\/strong><\/div><fieldset id=\"field_1_156\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >3. Start Date<\/legend><div id='input_1_156' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_156_1_container'>\n                                            <input type='number' maxlength='2' name='input_156[]' id='input_1_156_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_1_156_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_1_156_2_container'>\n                                            <input type='number' maxlength='2' name='input_156[]' id='input_1_156_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_1_156_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_1_156_3_container'>\n                                            <input type='number' maxlength='4' name='input_156[]' id='input_1_156_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_1_156_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_1_157\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >3. End Date<\/legend><div id='input_1_157' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_157_1_container'>\n                                            <input type='number' maxlength='2' name='input_157[]' id='input_1_157_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_1_157_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_1_157_2_container'>\n                                            <input type='number' maxlength='2' name='input_157[]' id='input_1_157_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_1_157_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_1_157_3_container'>\n                                            <input type='number' maxlength='4' name='input_157[]' id='input_1_157_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_1_157_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div data-fieldId=\"157\" class=\"spacer gfield\" style=\"grid-column: span 6;\" data-groupId=\"eb5353ab\"><\/div><div id=\"field_1_167\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>Dates of Attendance<\/strong><\/div><div id=\"field_1_158\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third 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_158'>3. Quarter<\/label><div class='ginput_container ginput_container_number'><input name='input_158' id='input_1_158' type='number' step='any' min='0' max='1000' value='' class='large'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_1_158\" \/><div class='gfield_description instruction ' id='gfield_instruction_1_158'>Please enter a number from <strong>0<\/strong> to <strong>1000<\/strong>.<\/div><\/div><\/div><div id=\"field_1_159\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third 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_159'>3. Semester<\/label><div class='ginput_container ginput_container_number'><input name='input_159' id='input_1_159' type='number' step='any' min='0' max='1000' value='' class='large'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_1_159\" \/><div class='gfield_description instruction ' id='gfield_instruction_1_159'>Please enter a number from <strong>0<\/strong> to <strong>1000<\/strong>.<\/div><\/div><\/div><div id=\"field_1_160\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_160'>3. Course of Study<\/label><div class='ginput_container ginput_container_text'><input name='input_160' id='input_1_160' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_161\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_161'>3. Type of Degree<\/label><div class='ginput_container ginput_container_text'><input name='input_161' id='input_1_161' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_162\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >3. Did you graduate?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_162'>\n\t\t\t<div class='gchoice gchoice_1_162_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_162' type='radio' value='Yes'  id='choice_1_162_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_162_0' id='label_1_162_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_162_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_162' type='radio' value='No'  id='choice_1_162_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_162_1' id='label_1_162_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_18\" 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\"  ><h3 class=\"gsection_title\">Education \/ Job Related Training &amp; Course Work<\/h3><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_198' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_198' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_4' class='gform_page' data-js='page-field-id-198' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_19\" 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\"  ><h3 class=\"gsection_title\">Licensure, Registration, Certification (Examples: RN, LPN, PES, CPA, etc.)<\/h3><\/div><div id=\"field_1_56\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_56'>License or Certification<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_1_56' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_58\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_58'>License #<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_1_58' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_60\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >License Date<\/legend><div id='input_1_60' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_60_1_container'>\n                                            <input type='number' maxlength='2' name='input_60[]' id='input_1_60_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_1_60_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_1_60_2_container'>\n                                            <input type='number' maxlength='2' name='input_60[]' id='input_1_60_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_1_60_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_1_60_3_container'>\n                                            <input type='number' maxlength='4' name='input_60[]' id='input_1_60_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_1_60_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_1_59\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >License Expiration Date<\/legend><div id='input_1_59' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_59_1_container'>\n                                            <input type='number' maxlength='2' name='input_59[]' id='input_1_59_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_1_59_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_1_59_2_container'>\n                                            <input type='number' maxlength='2' name='input_59[]' id='input_1_59_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_1_59_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_1_59_3_container'>\n                                            <input type='number' maxlength='4' name='input_59[]' id='input_1_59_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_1_59_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div data-fieldId=\"59\" class=\"spacer gfield\" style=\"grid-column: span 6;\" data-groupId=\"277318b9\"><\/div><div id=\"field_1_137\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload 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='gform_browse_button_1_137'>License Certificate<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_137' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_137&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_137&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_137&quot;,&quot;filelist&quot;:&quot;gform_preview_1_137&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/srmedicalcenter.org\\\/?gf_page=6157c068526976a&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/srmedicalcenter.org\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/srmedicalcenter.org\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;png,pdf,jpg&quot;}],&quot;max_file_size&quot;:&quot;15728640b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:137,&quot;_gform_file_upload_nonce_1_137&quot;:&quot;a050aa50d8&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_137&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_137' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_1_137' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_1_137\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_137'>Accepted file types: png, pdf, jpg, Max. file size: 15 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_1_137'><\/ul> <div id='gform_preview_1_137' class='ginput_preview_list'><\/div><\/div><\/div><fieldset id=\"field_1_125\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Add more license 1<\/legend><div class='ginput_container ginput_container_consent'><input name='input_125.1' id='input_1_125_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_125_1' >Add more<\/label><input type='hidden' name='input_125.2' value='Add more' class='gform_hidden' \/><input type='hidden' name='input_125.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_1_151\" class=\"gfield gfield--type-section gfield--input-type-section gsection form-inner-sections field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">License 2<\/h3><\/div><div id=\"field_1_129\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_129'>2. License or Certification<\/label><div class='ginput_container ginput_container_text'><input name='input_129' id='input_1_129' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_130\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_130'>2. License #<\/label><div class='ginput_container ginput_container_text'><input name='input_130' id='input_1_130' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_131\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >2. License Date<\/legend><div id='input_1_131' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_131_1_container'>\n                                            <input type='number' maxlength='2' name='input_131[]' id='input_1_131_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_1_131_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_1_131_2_container'>\n                                            <input type='number' maxlength='2' name='input_131[]' id='input_1_131_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_1_131_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_1_131_3_container'>\n                                            <input type='number' maxlength='4' name='input_131[]' id='input_1_131_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_1_131_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_1_132\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >2. License Expiration Date<\/legend><div id='input_1_132' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_132_1_container'>\n                                            <input type='number' maxlength='2' name='input_132[]' id='input_1_132_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_1_132_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_1_132_2_container'>\n                                            <input type='number' maxlength='2' name='input_132[]' id='input_1_132_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_1_132_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_1_132_3_container'>\n                                            <input type='number' maxlength='4' name='input_132[]' id='input_1_132_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_1_132_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_1_127\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Add more license 2<\/legend><div class='ginput_container ginput_container_consent'><input name='input_127.1' id='input_1_127_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_127_1' >Add more<\/label><input type='hidden' name='input_127.2' value='Add more' class='gform_hidden' \/><input type='hidden' name='input_127.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_1_128\" class=\"gfield gfield--type-section gfield--input-type-section gsection form-inner-sections field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">License 3<\/h3><\/div><div id=\"field_1_133\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_133'>3. License or Certification<\/label><div class='ginput_container ginput_container_text'><input name='input_133' id='input_1_133' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_134\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_134'>3. License #<\/label><div class='ginput_container ginput_container_text'><input name='input_134' id='input_1_134' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_135\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >3. License Date<\/legend><div id='input_1_135' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_135_1_container'>\n                                            <input type='number' maxlength='2' name='input_135[]' id='input_1_135_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_1_135_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_1_135_2_container'>\n                                            <input type='number' maxlength='2' name='input_135[]' id='input_1_135_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_1_135_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_1_135_3_container'>\n                                            <input type='number' maxlength='4' name='input_135[]' id='input_1_135_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_1_135_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_1_136\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >3. License Expiration Date<\/legend><div id='input_1_136' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_136_1_container'>\n                                            <input type='number' maxlength='2' name='input_136[]' id='input_1_136_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_1_136_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_1_136_2_container'>\n                                            <input type='number' maxlength='2' name='input_136[]' id='input_1_136_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_1_136_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_1_136_3_container'>\n                                            <input type='number' maxlength='4' name='input_136[]' id='input_1_136_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_1_136_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_1_57\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\">Licensure, Registration, Certification (Examples: RN, LPN, PES, CPA, etc.)<\/h3><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_199' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_199' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_5' class='gform_page' data-js='page-field-id-199' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_21\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\">Periods of Employment<\/h3><\/div><div id=\"field_1_76\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Describe your work experience in detail, beginning with your current or most recent job. Include military services (include rank) and job related or volunteer work, if applicable. Indicate the number of employees supervised. ALL information in this section must be completed. Resume must be attached.<\/div><div id=\"field_1_77\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload 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='gform_browse_button_1_77'>Resume<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_1_77' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_77&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_77&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_77&quot;,&quot;filelist&quot;:&quot;gform_preview_1_77&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/srmedicalcenter.org\\\/?gf_page=6157c068526976a&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/srmedicalcenter.org\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/srmedicalcenter.org\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;png,pdf,jpg&quot;}],&quot;max_file_size&quot;:&quot;10485760b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:1,&quot;field_id&quot;:77,&quot;_gform_file_upload_nonce_1_77&quot;:&quot;f27e76ad08&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_1_77&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_1_77' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_1_77' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_1_77\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_77'>Accepted file types: png, pdf, jpg, Max. file size: 10 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_1_77'><\/ul> <div id='gform_preview_1_77' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_1_93\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full 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_93'>Name of Present or Last Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_93' id='input_1_93' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_79\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_79'>Address<\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_1_79' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_80\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half 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_80'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_80' id='input_1_80' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_81\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_81'>Your Job Title<\/label><div class='ginput_container ginput_container_text'><input name='input_81' id='input_1_81' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_82\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_82'>Supervisor\u2019s Name<\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_1_82' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_83\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >From<\/legend><div id='input_1_83' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_83_1_container'>\n                                            <input type='number' maxlength='2' name='input_83[]' id='input_1_83_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_1_83_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_1_83_2_container'>\n                                            <input type='number' maxlength='2' name='input_83[]' id='input_1_83_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_1_83_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_1_83_3_container'>\n                                            <input type='number' maxlength='4' name='input_83[]' id='input_1_83_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_1_83_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_1_84\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >To<\/legend><div id='input_1_84' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_84_1_container'>\n                                            <input type='number' maxlength='2' name='input_84[]' id='input_1_84_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_1_84_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_1_84_2_container'>\n                                            <input type='number' maxlength='2' name='input_84[]' id='input_1_84_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_1_84_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_1_84_3_container'>\n                                            <input type='number' maxlength='4' name='input_84[]' id='input_1_84_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_1_84_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_1_85\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter 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_85'>Hours per Week<\/label><div class='ginput_container ginput_container_number'><input name='input_85' id='input_1_85' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_86\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter 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_86'>No. of Employees Supervised<\/label><div class='ginput_container ginput_container_number'><input name='input_86' id='input_1_86' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_206\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full 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_206'>Duties and Responsibilities<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_206' id='input_1_206' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_87\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_87'>Duties and Responsibilities old<\/label><div class='ginput_container ginput_container_textarea'><div id=\"wp-input_1_87-wrap\" class=\"wp-core-ui wp-editor-wrap tmce-active\"><link rel='stylesheet' id='dashicons-css' href='https:\/\/srmedicalcenter.org\/wp-includes\/css\/dashicons.min.css?ver=7.0.2' media='all' \/>\n<link rel='stylesheet' id='editor-buttons-css' href='https:\/\/srmedicalcenter.org\/wp-includes\/css\/editor.min.css?ver=7.0.2' media='all' \/>\n<div id=\"wp-input_1_87-editor-container\" class=\"wp-editor-container\"><textarea class=\"medium wp-editor-area\" style=\"height: 180px\" autocomplete=\"off\" cols=\"40\" name=\"input_87\" id=\"input_1_87\"><\/textarea><\/div>\n<\/div>\n\n<\/div><\/div><fieldset id=\"field_1_88\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >May we contact your previous supervisor for a reference?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_88'>\n\t\t\t<div class='gchoice gchoice_1_88_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='Yes'  id='choice_1_88_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_88_0' id='label_1_88_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_88_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='No'  id='choice_1_88_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_88_1' id='label_1_88_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_89\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter 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_89'>Starting Salary<\/label><div class='ginput_container ginput_container_number'><input name='input_89' id='input_1_89' type='number' step='any'   value='' class='large'    placeholder='$'  aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_90\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter 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_90'>Ending Salary<\/label><div class='ginput_container ginput_container_number'><input name='input_90' id='input_1_90' type='number' step='any'   value='' class='large'    placeholder='$'  aria-invalid=\"false\"  \/><\/div><\/div><div data-fieldId=\"90\" class=\"spacer gfield\" style=\"grid-column: span 6;\" data-groupId=\"2fb14645\"><\/div><div id=\"field_1_91\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full 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_91'>Reason for Leaving<\/label><div class='ginput_container ginput_container_text'><input name='input_91' id='input_1_91' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_92\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Add more Periods 1<\/legend><div class='ginput_container ginput_container_consent'><input name='input_92.1' id='input_1_92_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_92_1' >Add more<\/label><input type='hidden' name='input_92.2' value='Add more' class='gform_hidden' \/><input type='hidden' name='input_92.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_1_109\" class=\"gfield gfield--type-section gfield--input-type-section gsection form-inner-sections field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Period of Employment 2<\/h3><\/div><div id=\"field_1_78\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full 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_78'>2. Name of Present or Last Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_1_78' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_94\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_94'>2. Address<\/label><div class='ginput_container ginput_container_text'><input name='input_94' id='input_1_94' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_97\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half 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_97'>2. Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_97' id='input_1_97' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_95\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_95'>2. Your Job Title<\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_1_95' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_96\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_96'>2. Supervisor\u2019s Name<\/label><div class='ginput_container ginput_container_text'><input name='input_96' id='input_1_96' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_98\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >2. From<\/legend><div id='input_1_98' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_98_1_container'>\n                                            <input type='number' maxlength='2' name='input_98[]' id='input_1_98_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_1_98_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_1_98_2_container'>\n                                            <input type='number' maxlength='2' name='input_98[]' id='input_1_98_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_1_98_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_1_98_3_container'>\n                                            <input type='number' maxlength='4' name='input_98[]' id='input_1_98_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_1_98_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_1_99\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >2. To<\/legend><div id='input_1_99' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_99_1_container'>\n                                            <input type='number' maxlength='2' name='input_99[]' id='input_1_99_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_1_99_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_1_99_2_container'>\n                                            <input type='number' maxlength='2' name='input_99[]' id='input_1_99_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_1_99_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_1_99_3_container'>\n                                            <input type='number' maxlength='4' name='input_99[]' id='input_1_99_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_1_99_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_1_100\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter 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_100'>2. Hours per Week<\/label><div class='ginput_container ginput_container_number'><input name='input_100' id='input_1_100' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_101\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter 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_101'>2. No. of Employees Supervised<\/label><div class='ginput_container ginput_container_number'><input name='input_101' id='input_1_101' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_207\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full 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_207'>2. Duties and Responsibilities<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_207' id='input_1_207' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_102\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_102'>2. Duties and Responsibilities old<\/label><div class='ginput_container ginput_container_textarea'><div id=\"wp-input_1_102-wrap\" class=\"wp-core-ui wp-editor-wrap tmce-active\"><div id=\"wp-input_1_102-editor-container\" class=\"wp-editor-container\"><textarea class=\"medium wp-editor-area\" style=\"height: 180px\" autocomplete=\"off\" cols=\"40\" name=\"input_102\" id=\"input_1_102\"><\/textarea><\/div>\n<\/div>\n\n<\/div><\/div><fieldset id=\"field_1_103\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2. May we contact your previous supervisor for a reference?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_103'>\n\t\t\t<div class='gchoice gchoice_1_103_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='Yes'  id='choice_1_103_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_103_0' id='label_1_103_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_103_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='No'  id='choice_1_103_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_103_1' id='label_1_103_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_104\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half 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_104'>2. Starting Salary<\/label><div class='ginput_container ginput_container_number'><input name='input_104' id='input_1_104' type='number' step='any'   value='' class='large'    placeholder='$'  aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_105\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half 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_105'>2. Ending Salary<\/label><div class='ginput_container ginput_container_number'><input name='input_105' id='input_1_105' type='number' step='any'   value='' class='large'    placeholder='$'  aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_106\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full 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_106'>2. Reason for Leaving<\/label><div class='ginput_container ginput_container_text'><input name='input_106' id='input_1_106' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_107\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Add more Periods 2<\/legend><div class='ginput_container ginput_container_consent'><input name='input_107.1' id='input_1_107_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_107_1' >Add more<\/label><input type='hidden' name='input_107.2' value='Add more' class='gform_hidden' \/><input type='hidden' name='input_107.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_1_108\" class=\"gfield gfield--type-section gfield--input-type-section gsection form-inner-sections field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Period of Employment 3<\/h3><\/div><div id=\"field_1_110\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full 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_110'>3. Name of Present or Last Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_110' id='input_1_110' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_111\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_111'>3. Address<\/label><div class='ginput_container ginput_container_text'><input name='input_111' id='input_1_111' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_112\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half 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_112'>3. Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_112' id='input_1_112' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_113\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_113'>3. Your Job Title<\/label><div class='ginput_container ginput_container_text'><input name='input_113' id='input_1_113' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_114\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_114'>3. Supervisor\u2019s Name<\/label><div class='ginput_container ginput_container_text'><input name='input_114' id='input_1_114' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_115\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >3. From<\/legend><div id='input_1_115' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_115_1_container'>\n                                            <input type='number' maxlength='2' name='input_115[]' id='input_1_115_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_1_115_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_1_115_2_container'>\n                                            <input type='number' maxlength='2' name='input_115[]' id='input_1_115_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_1_115_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_1_115_3_container'>\n                                            <input type='number' maxlength='4' name='input_115[]' id='input_1_115_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_1_115_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_1_116\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >3. To<\/legend><div id='input_1_116' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_116_1_container'>\n                                            <input type='number' maxlength='2' name='input_116[]' id='input_1_116_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_1_116_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_1_116_2_container'>\n                                            <input type='number' maxlength='2' name='input_116[]' id='input_1_116_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_1_116_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_1_116_3_container'>\n                                            <input type='number' maxlength='4' name='input_116[]' id='input_1_116_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_1_116_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_1_117\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter 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_117'>3. Hours per Week<\/label><div class='ginput_container ginput_container_number'><input name='input_117' id='input_1_117' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_118\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter 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_118'>3. No. of Employees Supervised<\/label><div class='ginput_container ginput_container_number'><input name='input_118' id='input_1_118' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_208\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full 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_208'>3. Duties and Responsibilities<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_208' id='input_1_208' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_119\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_119'>3. Duties and Responsibilities old<\/label><div class='ginput_container ginput_container_textarea'><div id=\"wp-input_1_119-wrap\" class=\"wp-core-ui wp-editor-wrap tmce-active\"><div id=\"wp-input_1_119-editor-container\" class=\"wp-editor-container\"><textarea class=\"medium wp-editor-area\" style=\"height: 180px\" autocomplete=\"off\" cols=\"40\" name=\"input_119\" id=\"input_1_119\"><\/textarea><\/div>\n<\/div>\n\n<\/div><\/div><fieldset id=\"field_1_120\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >3. May we contact your previous supervisor for a reference?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_120'>\n\t\t\t<div class='gchoice gchoice_1_120_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_120' type='radio' value='Yes'  id='choice_1_120_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_120_0' id='label_1_120_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_120_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_120' type='radio' value='No'  id='choice_1_120_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_120_1' id='label_1_120_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_121\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half 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_121'>3. Starting Salary<\/label><div class='ginput_container ginput_container_number'><input name='input_121' id='input_1_121' type='number' step='any'   value='' class='large'    placeholder='$'  aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_122\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half 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_122'>3. Ending Salary<\/label><div class='ginput_container ginput_container_number'><input name='input_122' id='input_1_122' type='number' step='any'   value='' class='large'    placeholder='$'  aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_123\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full 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_123'>3. Reason for Leaving<\/label><div class='ginput_container ginput_container_text'><input name='input_123' id='input_1_123' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_124\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Add more Periods 3<\/legend><div class='ginput_container ginput_container_consent'><input name='input_124.1' id='input_1_124_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_124_1' >Add more<\/label><input type='hidden' name='input_124.2' value='Add more' class='gform_hidden' \/><input type='hidden' name='input_124.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_1_22\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\">Periods of Employment<\/h3><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_200' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_200' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_6' class='gform_page' data-js='page-field-id-200' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_23\" 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\"  ><h3 class=\"gsection_title\">Knowledge \/ Skill \/ Abilities<\/h3><\/div><div id=\"field_1_209\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_209'>Knowledge \/ Skill \/ Abilities<\/label><div class='gfield_description' id='gfield_description_1_209'>List the abilities you possess and believe relevant to the position you seek, such as computer skills, bilingual, etc.\n<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_209' id='input_1_209' class='textarea medium'  aria-describedby=\"gfield_description_1_209\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_62\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_62'>Knowledge \/ Skill \/ Abilities old<\/label><div class='gfield_description' id='gfield_description_1_62'>List the abilities you possess and believe relevant to the position you seek, such as computer skills, bilingual, etc.\n<\/div><div class='ginput_container ginput_container_textarea'><div id=\"wp-input_1_62-wrap\" class=\"wp-core-ui wp-editor-wrap tmce-active\"><div id=\"wp-input_1_62-editor-container\" class=\"wp-editor-container\"><textarea class=\"medium wp-editor-area\" style=\"height: 180px\" autocomplete=\"off\" cols=\"40\" name=\"input_62\" id=\"input_1_62\"><\/textarea><\/div>\n<\/div>\n\n<\/div><\/div><div id=\"field_1_25\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\">Knowledge \/ Skill \/ Abilities<\/h3><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_201' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_201' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_7' class='gform_page' data-js='page-field-id-201' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_24\" 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\"  ><h3 class=\"gsection_title\">How did you hear about us?<\/h3><\/div><fieldset id=\"field_1_63\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >How did you hear about us?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_63'><div class='gchoice gchoice_1_63_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.1' type='checkbox'  value='Walk\u2013in'  id='choice_1_63_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_63_1' id='label_1_63_1' class='gform-field-label gform-field-label--type-inline'>Walk\u2013in<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_63_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.2' type='checkbox'  value='Newspaper\/ Magazine'  id='choice_1_63_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_63_2' id='label_1_63_2' class='gform-field-label gform-field-label--type-inline'>News Paper\/ Magazine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_63_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.3' type='checkbox'  value='Friends\/Family'  id='choice_1_63_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_63_3' id='label_1_63_3' class='gform-field-label gform-field-label--type-inline'>Friends\/Family<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_63_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.4' type='checkbox'  value='Online'  id='choice_1_63_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_63_4' id='label_1_63_4' class='gform-field-label gform-field-label--type-inline'>Online<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_63_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.5' type='checkbox'  value='Website'  id='choice_1_63_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_63_5' id='label_1_63_5' class='gform-field-label gform-field-label--type-inline'>Website<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_63_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.6' type='checkbox'  value='Other'  id='choice_1_63_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_63_6' id='label_1_63_6' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_64\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_64'>How did you hear about us? (other)<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_1_64' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_27\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\">How did you hear about us?<\/h3><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_202' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_202' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_8' class='gform_page' data-js='page-field-id-202' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_26\" 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\"  ><h3 class=\"gsection_title\">Background Information<\/h3><\/div><fieldset id=\"field_1_65\" 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\"  ><legend class='gfield_label gform-field-label' >ARE YOU LEGALLY AUTHORIZED TO WORK IN THE U.S.?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_65'>\n\t\t\t<div class='gchoice gchoice_1_65_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='Yes'  id='choice_1_65_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_65_0' id='label_1_65_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_65_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='No'  id='choice_1_65_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_65_1' id='label_1_65_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_66\" 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\"  ><legend class='gfield_label gform-field-label' >WERE YOU EVER DISCHARGED FROM ANY EMPLOYMENT, REJECTED DURING YOUR PROBATIONARY PERIOD, OR HAVE YOU EVER RESIGNED UNDER THE THREAT OF DISCHARGE FROM ANY EMPLOYMENT?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_66'>\n\t\t\t<div class='gchoice gchoice_1_66_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='Yes'  id='choice_1_66_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_66_0' id='label_1_66_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_66_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='No'  id='choice_1_66_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_66_1' id='label_1_66_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_190\" class=\"gfield gfield--type-text gfield--input-type-text 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_190'>Discharged or rejected during your probationary period: Please explain<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_190' id='input_1_190' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_67\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >WERE YOU EVER CONVICTED OF A SEXUAL CRIMINAL OFFENSE AGAINST A MINOR?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_67'>\n\t\t\t<div class='gchoice gchoice_1_67_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='Yes'  id='choice_1_67_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_1_67\"   \/>\n\t\t\t\t\t<label for='choice_1_67_0' id='label_1_67_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_67_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='No'  id='choice_1_67_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_67_1' id='label_1_67_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_1_67'>If, you answered \u201c<strong>YES<\/strong>\u201d in accordance with <strong>Act #6182<\/strong>, in order to attain employment, you must register with the Virgin Islands Department of Justice and provide evidence of registration.<\/div><\/fieldset><fieldset id=\"field_1_68\" 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\"  ><legend class='gfield_label gform-field-label' >HAVE YOU EVER BEEN CHARGED, CONVICTED, PLED NO CONTEST, OR PLED GUILTY TO A CRIME, WHICH IS A FELONY OR A MISDEMEANOR?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_68'>\n\t\t\t<div class='gchoice gchoice_1_68_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Yes'  id='choice_1_68_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_68_0' id='label_1_68_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_68_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='No'  id='choice_1_68_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_68_1' id='label_1_68_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_185\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_185'>What charge?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_185' id='input_1_185' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_186\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_186'>Where were you convicted and what Date?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_186' id='input_1_186' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_69\" 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\"  ><legend class='gfield_label gform-field-label' >HAVE YOU EVER WORKED AT SCHNEIDER REGIONAL MEDICAL CENTER?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_69'>\n\t\t\t<div class='gchoice gchoice_1_69_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Yes'  id='choice_1_69_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_69_0' id='label_1_69_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_69_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='No'  id='choice_1_69_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_69_1' id='label_1_69_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_182\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third 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_182'>Position<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_182' id='input_1_182' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_183\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third 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_183'>Position End Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_183' id='input_1_183' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_183_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_183_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_183' class='gform_hidden' value='https:\/\/srmedicalcenter.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_184\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third 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_184'>Position Start Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_184' id='input_1_184' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_184_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_184_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_184' class='gform_hidden' value='https:\/\/srmedicalcenter.org\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_1_70\" 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\"  ><legend class='gfield_label gform-field-label' >ARE YOU RELATED TO ANYONE WHO WORKS AT SCHNEIDER REGIONAL MEDICAL CENTER?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_70'>\n\t\t\t<div class='gchoice gchoice_1_70_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Yes'  id='choice_1_70_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_70_0' id='label_1_70_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_70_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='No'  id='choice_1_70_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_70_1' id='label_1_70_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_188\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_188'>Employee&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_188' id='input_1_188' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_189\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_189'>Relationship<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_189' id='input_1_189' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_29\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\">Background Information<\/h3><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_203' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_203' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_9' class='gform_page' data-js='page-field-id-203' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_28\" 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\"  ><h3 class=\"gsection_title\">Veterans Preference Information<\/h3><\/div><fieldset id=\"field_1_71\" 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\"  ><legend class='gfield_label gform-field-label' >DO YOU CLAIM VETERAN\u2019S PREFERENCE, IF ELIGIBLE?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_71'>\n\t\t\t<div class='gchoice gchoice_1_71_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='Yes'  id='choice_1_71_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_71_0' id='label_1_71_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_71_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='No'  id='choice_1_71_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_71_1' id='label_1_71_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_191\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Veteran\u2019s preference: Check one<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_191'><div class='gchoice gchoice_1_191_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_191.1' type='checkbox'  value='Veteran'  id='choice_1_191_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_191_1' id='label_1_191_1' class='gform-field-label gform-field-label--type-inline'>Veteran<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_191_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_191.2' type='checkbox'  value='Widow or Widower of a Veteran'  id='choice_1_191_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_191_2' id='label_1_191_2' class='gform-field-label gform-field-label--type-inline'>Widow or Widower of a Veteran<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_191_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_191.3' type='checkbox'  value='Spouse of a disabled veteran'  id='choice_1_191_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_191_3' id='label_1_191_3' class='gform-field-label gform-field-label--type-inline'>Spouse of a disabled veteran<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_72\" 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\"  ><legend class='gfield_label gform-field-label' >DID YOU SERVE IN ACTIVE DUTY FOR THE U.S. MILITARY<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_72'>\n\t\t\t<div class='gchoice gchoice_1_72_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Yes'  id='choice_1_72_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_72_0' id='label_1_72_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_72_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='No'  id='choice_1_72_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_72_1' id='label_1_72_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_192\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >What was your discharge?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_192'>\n\t\t\t<div class='gchoice gchoice_1_192_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_192' type='radio' value='Honorable'  id='choice_1_192_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_192_0' id='label_1_192_0' class='gform-field-label gform-field-label--type-inline'>Honorable<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_192_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_192' type='radio' value='Dishonorable'  id='choice_1_192_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_192_1' id='label_1_192_1' class='gform-field-label gform-field-label--type-inline'>Dishonorable<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_192_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_192' type='radio' value='General'  id='choice_1_192_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_192_2' id='label_1_192_2' class='gform-field-label gform-field-label--type-inline'>General<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_192_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_192' type='radio' value='Other'  id='choice_1_192_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_192_3' id='label_1_192_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_193\" class=\"gfield gfield--type-text gfield--input-type-text 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_193'>What was your discharge? Explain.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_193' id='input_1_193' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_194\" 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\"  ><legend class='gfield_label gform-field-label' >Do you have a service connected disability (rated 10% or more by V.A)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_194'>\n\t\t\t<div class='gchoice gchoice_1_194_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_194' type='radio' value='Yes'  id='choice_1_194_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_194_0' id='label_1_194_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_194_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_194' type='radio' value='No'  id='choice_1_194_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_194_1' id='label_1_194_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_30\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\">Veterans Preference Information<\/h3><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_204' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_204' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_10' class='gform_page' data-js='page-field-id-204' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_10' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_31\" 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\"  ><h3 class=\"gsection_title\">(Optional) EEO Survey<\/h3><\/div><fieldset id=\"field_1_73\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gender<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_73'>\n\t\t\t<div class='gchoice gchoice_1_73_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='Male'  id='choice_1_73_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_73_0' id='label_1_73_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_73_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='Female'  id='choice_1_73_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_73_1' id='label_1_73_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_75\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Ethnicity<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_75'>\n\t\t\t<div class='gchoice gchoice_1_75_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='African American'  id='choice_1_75_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_75_0' id='label_1_75_0' class='gform-field-label gform-field-label--type-inline'>African American<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_75_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Caucasian'  id='choice_1_75_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_75_1' id='label_1_75_1' class='gform-field-label gform-field-label--type-inline'>Caucasian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_75_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Hispanic'  id='choice_1_75_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_75_2' id='label_1_75_2' class='gform-field-label gform-field-label--type-inline'>Hispanic<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_75_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Asian'  id='choice_1_75_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_75_3' id='label_1_75_3' class='gform-field-label gform-field-label--type-inline'>Asian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_75_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='gf_other_choice'  id='choice_1_75_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_75_4' id='label_1_75_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_1_75_other' class='gchoice_other_control' name='input_75_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_33\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\">(Optional) EEO Survey<\/h3><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_205' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_205' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_11' class='gform_page' data-js='page-field-id-205' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_11' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_32\" 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\"  ><h3 class=\"gsection_title\">Disclaimer<\/h3><\/div><div id=\"field_1_41\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >I acknowledge that Schneider Regional Medical Center operates twenty-four (24) hours a day and seven (7) days a week. By signing below I understand that work hours may vary based on the position I am applying for. I am also aware that any\u00a0<strong>omission, falsification, misstatement, or misrepresentation<\/strong>\u00a0above may disqualify me for employment consideration and if I am hired, may be grounds for termination at a later date. I understand that any information I give may be investigated as by law. I consent to the release of information about my ability, employment history, and fitness for employment by employers, schools, law enforcement agencies, and other individuals and organizations, investigators, personnel staff, and other authorized employees of the Virgin Islands Government for employment purposes. I understand and accept the fact that my consent shall remain effective during the tenure of my employment should I be hired. I certify to the best of my knowledge and belief all of the statements contained herein and on any attachment are\u00a0<strong>true, correct, and made in good faith<\/strong>.<\/div><div id=\"field_1_181\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_181'>Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_181' id='input_1_181' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_40\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_1_40' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_40_1_container'>\n                                            <input type='number' maxlength='2' name='input_40[]' id='input_1_40_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_1_40_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_1_40_2_container'>\n                                            <input type='number' maxlength='2' name='input_40[]' id='input_1_40_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_1_40_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_1_40_3_container'>\n                                            <input type='number' maxlength='4' name='input_40[]' id='input_1_40_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_1_40_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_1_34\" 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\"  ><h3 class=\"gsection_title\">Disclaimer<\/h3><\/div><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_1' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='submit' id='gform_submit_button_1' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \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='gravity-theme' \/>\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='Gw3Ctqe8QSkr5i89njkL+Xjc3ODQYF54e80LwdCLBLgyM4r5CFv\/Xbx3fLsa55H8f1nH+kwDd\/ShU5o3seXirubWJTlYZN\/EyVAfy6m7shqKwkE=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' 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