{"id":37,"date":"2025-03-27T22:25:45","date_gmt":"2025-03-27T22:25:45","guid":{"rendered":"https:\/\/www.map.org\/jnjethicon\/?page_id=37"},"modified":"2025-12-01T18:43:28","modified_gmt":"2025-12-01T23:43:28","slug":"map-practitioner-agreement","status":"publish","type":"page","link":"https:\/\/www.map.org\/jnjmedtech\/medical-mission-program\/apply-to-order\/map-practitioner-agreement\/","title":{"rendered":"MAP Practitioner Agreement"},"content":{"rendered":"<meta name=\"robots\" content=\"noindex,nofollow\">\n<table class=\"wp-list-table widefat fixed striped table-view-list forms\">\n<tbody id=\"the-list\" data-wp-lists=\"list:form\">\n<tr>\n<td class=\"shortcode column-shortcode\" data-colname=\"Shortcode\"><style id=\"wpforms-css-vars-20\">\n\t\t\t\t#wpforms-20 {\n\t\t\t\t\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-container-save-resume wpforms-render-modern\" id=\"wpforms-20\"><form id=\"wpforms-form-20\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"20\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/jnjmedtech\/wp-json\/wp\/v2\/pages\/37?wpforms_form_id=20\" data-token=\"02834943bc5f4715d19c9b5baa16c928\" data-token-time=\"1775446962\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\">\t\t<div id=\"wpforms-20-field_2-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"2\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-20-field_2\" >trip. procedures upload<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-20-field_2\" class=\"wpforms-field-medium\" name=\"wpforms[fields][2]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-20-field_1-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"1\"><h3 id=\"wpforms-20-field_1\" aria-errormessage=\"wpforms-20-field_1-error\">Practioner Information<\/h3><\/div><div id=\"wpforms-20-field_3-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"3\"><fieldset><legend class=\"wpforms-field-label\">Are you the ordering surgeon? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-20-field_3\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-20-field_3_1\" name=\"wpforms[fields][3]\" value=\"Yes\" aria-errormessage=\"wpforms-20-field_3_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-20-field_3_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-20-field_3_2\" name=\"wpforms[fields][3]\" value=\"No\" aria-errormessage=\"wpforms-20-field_3_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-20-field_3_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-20-field_4-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"4\" style=\"display:none;\"><div id=\"wpforms-20-field_4\" aria-errormessage=\"wpforms-20-field_4-error\">\ud83d\udce7\r\n    Need to send this form to the ordering surgeon?\r\n  \r\n  \r\n    \r\n      Click here to open your email client\r\n    \r\n    and send the form link below to the ordering surgeon.\r\n  \r\n\r\n  \r\n    \r\n    \ud83d\udccb Copy Link\r\n    Copied!\r\n  \r\n\r\n  \r\n    If clicking the link doesn't work, you can copy and paste the form URL above into any email manually.<\/div><\/div><div id=\"wpforms-20-field_5-container\" class=\"wpforms-field wpforms-field-name wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"5\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Ordering surgeon&#039;s name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-20-field_5\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][5][first]\" aria-errormessage=\"wpforms-20-field_5-error\" required><label for=\"wpforms-20-field_5\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-20-field_5-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][5][last]\" aria-errormessage=\"wpforms-20-field_5-last-error\" required><label for=\"wpforms-20-field_5-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-20-field_6-container\" class=\"wpforms-field wpforms-field-phone wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"6\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-20-field_6\">Ordering surgeon&#039;s phone # <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-20-field_6\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][6]\" aria-label=\"Ordering surgeon&#039;s phone #\" aria-errormessage=\"wpforms-20-field_6-error\" required><\/div><div id=\"wpforms-20-field_7-container\" class=\"wpforms-field wpforms-field-email wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"7\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-20-field_7\">Ordering surgeon&#039;s email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-20-field_7\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][7]\" spellcheck=\"false\" aria-errormessage=\"wpforms-20-field_7-error\" required><\/div><div id=\"wpforms-20-field_26-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"26\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-20-field_26\">Medical license # <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-20-field_26\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][26]\" aria-errormessage=\"wpforms-20-field_26-error\" required><\/div><div id=\"wpforms-20-field_13-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"13\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-20-field_13\">Country of active medical license <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-20-field_13\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][13]\" required=\"required\"><option value=\"Afghanistan\"  class=\"choice-254 depth-1\"  >Afghanistan<\/option><option value=\"\u00c5land Islands\"  class=\"choice-5 depth-1\"  >\u00c5land Islands<\/option><option value=\"Albania\"  class=\"choice-6 depth-1\"  >Albania<\/option><option value=\"Algeria\"  class=\"choice-7 depth-1\"  >Algeria<\/option><option value=\"American Samoa\"  class=\"choice-8 depth-1\"  >American Samoa<\/option><option value=\"Andorra\"  class=\"choice-9 depth-1\"  >Andorra<\/option><option value=\"Angola\"  class=\"choice-10 depth-1\"  >Angola<\/option><option value=\"Anguilla\"  class=\"choice-11 depth-1\"  >Anguilla<\/option><option value=\"Antarctica\"  class=\"choice-12 depth-1\"  >Antarctica<\/option><option value=\"Antigua and Barbuda\"  class=\"choice-13 depth-1\"  >Antigua and Barbuda<\/option><option value=\"Argentina\"  class=\"choice-14 depth-1\"  >Argentina<\/option><option value=\"Armenia\"  class=\"choice-15 depth-1\"  >Armenia<\/option><option value=\"Aruba\"  class=\"choice-16 depth-1\"  >Aruba<\/option><option value=\"Australia\"  class=\"choice-2 depth-1\"  >Australia<\/option><option value=\"Austria\"  class=\"choice-18 depth-1\"  >Austria<\/option><option value=\"Azerbaijan\"  class=\"choice-19 depth-1\"  >Azerbaijan<\/option><option value=\"Bahamas\"  class=\"choice-20 depth-1\"  >Bahamas<\/option><option value=\"Bahrain\"  class=\"choice-21 depth-1\"  >Bahrain<\/option><option value=\"Bangladesh\"  class=\"choice-22 depth-1\"  >Bangladesh<\/option><option value=\"Barbados\"  class=\"choice-23 depth-1\"  >Barbados<\/option><option value=\"Belarus\"  class=\"choice-24 depth-1\"  >Belarus<\/option><option value=\"Belgium\"  class=\"choice-25 depth-1\"  >Belgium<\/option><option value=\"Belize\"  class=\"choice-26 depth-1\"  >Belize<\/option><option value=\"Benin\"  class=\"choice-27 depth-1\"  >Benin<\/option><option value=\"Bermuda\"  class=\"choice-28 depth-1\"  >Bermuda<\/option><option value=\"Bhutan\"  class=\"choice-29 depth-1\"  >Bhutan<\/option><option value=\"Bolivia\"  class=\"choice-30 depth-1\"  >Bolivia<\/option><option value=\"Bonaire, Sint Eustatius and Saba\"  class=\"choice-31 depth-1\"  >Bonaire, Sint Eustatius and Saba<\/option><option value=\"Bosnia and Herzegovina\"  class=\"choice-32 depth-1\"  >Bosnia and Herzegovina<\/option><option value=\"Botswana\"  class=\"choice-33 depth-1\"  >Botswana<\/option><option value=\"Bouvet Island\"  class=\"choice-34 depth-1\"  >Bouvet Island<\/option><option value=\"Brazil\"  class=\"choice-35 depth-1\"  >Brazil<\/option><option value=\"British Indian Ocean Territory\"  class=\"choice-36 depth-1\"  >British Indian Ocean Territory<\/option><option value=\"British Virgin Islands\"  class=\"choice-37 depth-1\"  >British Virgin Islands<\/option><option value=\"Brunei\"  class=\"choice-38 depth-1\"  >Brunei<\/option><option value=\"Bulgaria\"  class=\"choice-39 depth-1\"  >Bulgaria<\/option><option value=\"Burkina Faso\"  class=\"choice-40 depth-1\"  >Burkina Faso<\/option><option value=\"Burundi\"  class=\"choice-41 depth-1\"  >Burundi<\/option><option value=\"Cabo Verde\"  class=\"choice-42 depth-1\"  >Cabo Verde<\/option><option value=\"Cambodia\"  class=\"choice-43 depth-1\"  >Cambodia<\/option><option value=\"Cameroon\"  class=\"choice-44 depth-1\"  >Cameroon<\/option><option value=\"Canada\"  class=\"choice-45 depth-1\"  >Canada<\/option><option value=\"Caribbean Netherlands\"  class=\"choice-46 depth-1\"  >Caribbean Netherlands<\/option><option value=\"Cayman Islands\"  class=\"choice-47 depth-1\"  >Cayman Islands<\/option><option value=\"Central African Republic\"  class=\"choice-48 depth-1\"  >Central African Republic<\/option><option value=\"Chad\"  class=\"choice-49 depth-1\"  >Chad<\/option><option value=\"Chile\"  class=\"choice-50 depth-1\"  >Chile<\/option><option value=\"China\"  class=\"choice-51 depth-1\"  >China<\/option><option value=\"Christmas Island\"  class=\"choice-52 depth-1\"  >Christmas Island<\/option><option value=\"Cocos (Keeling) Islands\"  class=\"choice-53 depth-1\"  >Cocos (Keeling) Islands<\/option><option value=\"Colombia\"  class=\"choice-54 depth-1\"  >Colombia<\/option><option value=\"Comoros\"  class=\"choice-55 depth-1\"  >Comoros<\/option><option value=\"Congo (Brazzaville)\"  class=\"choice-56 depth-1\"  >Congo (Brazzaville)<\/option><option value=\"Congo (Kinshasa)\"  class=\"choice-57 depth-1\"  >Congo (Kinshasa)<\/option><option value=\"Cook Islands\"  class=\"choice-58 depth-1\"  >Cook Islands<\/option><option value=\"Costa Rica\"  class=\"choice-59 depth-1\"  >Costa Rica<\/option><option value=\"Croatia\"  class=\"choice-60 depth-1\"  >Croatia<\/option><option value=\"Cuba\"  class=\"choice-61 depth-1\"  >Cuba<\/option><option value=\"Cura\u00e7ao\"  class=\"choice-62 depth-1\"  >Cura\u00e7ao<\/option><option value=\"Cyprus\"  class=\"choice-63 depth-1\"  >Cyprus<\/option><option value=\"Czechia\"  class=\"choice-64 depth-1\"  >Czechia<\/option><option value=\"Denmark\"  class=\"choice-65 depth-1\"  >Denmark<\/option><option value=\"Djibouti\"  class=\"choice-66 depth-1\"  >Djibouti<\/option><option value=\"Dominica\"  class=\"choice-67 depth-1\"  >Dominica<\/option><option value=\"Dominican Republic\"  class=\"choice-68 depth-1\"  >Dominican Republic<\/option><option value=\"Ecuador\"  class=\"choice-69 depth-1\"  >Ecuador<\/option><option value=\"Egypt\"  class=\"choice-70 depth-1\"  >Egypt<\/option><option value=\"El Salvador\"  class=\"choice-71 depth-1\"  >El Salvador<\/option><option value=\"Equatorial Guinea\"  class=\"choice-72 depth-1\"  >Equatorial Guinea<\/option><option value=\"Eritrea\"  class=\"choice-73 depth-1\"  >Eritrea<\/option><option value=\"Estonia\"  class=\"choice-74 depth-1\"  >Estonia<\/option><option value=\"Eswatini\"  class=\"choice-75 depth-1\"  >Eswatini<\/option><option value=\"Ethiopia\"  class=\"choice-76 depth-1\"  >Ethiopia<\/option><option value=\"Falkland Islands\"  class=\"choice-77 depth-1\"  >Falkland Islands<\/option><option value=\"Faroe Islands\"  class=\"choice-78 depth-1\"  >Faroe Islands<\/option><option value=\"Fiji\"  class=\"choice-79 depth-1\"  >Fiji<\/option><option value=\"Finland\"  class=\"choice-80 depth-1\"  >Finland<\/option><option value=\"France\"  class=\"choice-81 depth-1\"  >France<\/option><option value=\"French Guiana\"  class=\"choice-82 depth-1\"  >French Guiana<\/option><option value=\"French Polynesia\"  class=\"choice-83 depth-1\"  >French Polynesia<\/option><option value=\"French Southern Territories\"  class=\"choice-84 depth-1\"  >French Southern Territories<\/option><option value=\"Gabon\"  class=\"choice-85 depth-1\"  >Gabon<\/option><option value=\"Gambia\"  class=\"choice-86 depth-1\"  >Gambia<\/option><option value=\"Georgia\"  class=\"choice-87 depth-1\"  >Georgia<\/option><option value=\"Germany\"  class=\"choice-88 depth-1\"  >Germany<\/option><option value=\"Ghana\"  class=\"choice-89 depth-1\"  >Ghana<\/option><option value=\"Gibraltar\"  class=\"choice-90 depth-1\"  >Gibraltar<\/option><option value=\"Greece\"  class=\"choice-91 depth-1\"  >Greece<\/option><option value=\"Greenland\"  class=\"choice-92 depth-1\"  >Greenland<\/option><option value=\"Grenada\"  class=\"choice-93 depth-1\"  >Grenada<\/option><option value=\"Guadeloupe\"  class=\"choice-94 depth-1\"  >Guadeloupe<\/option><option value=\"Guam\"  class=\"choice-95 depth-1\"  >Guam<\/option><option value=\"Guatemala\"  class=\"choice-96 depth-1\"  >Guatemala<\/option><option value=\"Guernsey\"  class=\"choice-97 depth-1\"  >Guernsey<\/option><option value=\"Guinea\"  class=\"choice-98 depth-1\"  >Guinea<\/option><option value=\"Guinea-Bissau\"  class=\"choice-99 depth-1\"  >Guinea-Bissau<\/option><option value=\"Guyana\"  class=\"choice-100 depth-1\"  >Guyana<\/option><option value=\"Haiti\"  class=\"choice-101 depth-1\"  >Haiti<\/option><option value=\"Heard Island and McDonald Islands\"  class=\"choice-102 depth-1\"  >Heard Island and McDonald Islands<\/option><option value=\"Honduras\"  class=\"choice-103 depth-1\"  >Honduras<\/option><option value=\"Hong Kong\"  class=\"choice-104 depth-1\"  >Hong Kong<\/option><option value=\"Hungary\"  class=\"choice-105 depth-1\"  >Hungary<\/option><option value=\"Iceland\"  class=\"choice-106 depth-1\"  >Iceland<\/option><option value=\"India\"  class=\"choice-107 depth-1\"  >India<\/option><option value=\"Indonesia\"  class=\"choice-108 depth-1\"  >Indonesia<\/option><option value=\"Iran\"  class=\"choice-109 depth-1\"  >Iran<\/option><option value=\"Iraq\"  class=\"choice-110 depth-1\"  >Iraq<\/option><option value=\"Ireland\"  class=\"choice-111 depth-1\"  >Ireland<\/option><option value=\"Isle of Man\"  class=\"choice-112 depth-1\"  >Isle of Man<\/option><option value=\"Israel\"  class=\"choice-113 depth-1\"  >Israel<\/option><option value=\"Italy\"  class=\"choice-114 depth-1\"  >Italy<\/option><option value=\"Ivory Coast\"  class=\"choice-115 depth-1\"  >Ivory Coast<\/option><option value=\"Jamaica\"  class=\"choice-116 depth-1\"  >Jamaica<\/option><option value=\"Japan\"  class=\"choice-117 depth-1\"  >Japan<\/option><option value=\"Jersey\"  class=\"choice-118 depth-1\"  >Jersey<\/option><option value=\"Jordan\"  class=\"choice-119 depth-1\"  >Jordan<\/option><option value=\"Kazakhstan\"  class=\"choice-120 depth-1\"  >Kazakhstan<\/option><option value=\"Kenya\"  class=\"choice-3 depth-1\"  >Kenya<\/option><option value=\"Kiribati\"  class=\"choice-122 depth-1\"  >Kiribati<\/option><option value=\"Korea, North\"  class=\"choice-123 depth-1\"  >Korea, North<\/option><option value=\"Korea, South\"  class=\"choice-124 depth-1\"  >Korea, South<\/option><option value=\"Kosovo\"  class=\"choice-125 depth-1\"  >Kosovo<\/option><option value=\"Kuwait\"  class=\"choice-126 depth-1\"  >Kuwait<\/option><option value=\"Kyrgyzstan\"  class=\"choice-127 depth-1\"  >Kyrgyzstan<\/option><option value=\"Laos\"  class=\"choice-128 depth-1\"  >Laos<\/option><option value=\"Latvia\"  class=\"choice-129 depth-1\"  >Latvia<\/option><option value=\"Lebanon\"  class=\"choice-130 depth-1\"  >Lebanon<\/option><option value=\"Lesotho\"  class=\"choice-131 depth-1\"  >Lesotho<\/option><option value=\"Liberia\"  class=\"choice-132 depth-1\"  >Liberia<\/option><option value=\"Libya\"  class=\"choice-133 depth-1\"  >Libya<\/option><option value=\"Liechtenstein\"  class=\"choice-134 depth-1\"  >Liechtenstein<\/option><option value=\"Lithuania\"  class=\"choice-135 depth-1\"  >Lithuania<\/option><option value=\"Luxembourg\"  class=\"choice-136 depth-1\"  >Luxembourg<\/option><option value=\"Macau\"  class=\"choice-137 depth-1\"  >Macau<\/option><option value=\"Madagascar\"  class=\"choice-138 depth-1\"  >Madagascar<\/option><option value=\"Malawi\"  class=\"choice-139 depth-1\"  >Malawi<\/option><option value=\"Malaysia\"  class=\"choice-140 depth-1\"  >Malaysia<\/option><option value=\"Maldives\"  class=\"choice-141 depth-1\"  >Maldives<\/option><option value=\"Mali\"  class=\"choice-142 depth-1\"  >Mali<\/option><option value=\"Malta\"  class=\"choice-143 depth-1\"  >Malta<\/option><option value=\"Marshall Islands\"  class=\"choice-144 depth-1\"  >Marshall Islands<\/option><option value=\"Martinique\"  class=\"choice-145 depth-1\"  >Martinique<\/option><option value=\"Mauritania\"  class=\"choice-146 depth-1\"  >Mauritania<\/option><option value=\"Mauritius\"  class=\"choice-147 depth-1\"  >Mauritius<\/option><option value=\"Mayotte\"  class=\"choice-148 depth-1\"  >Mayotte<\/option><option value=\"Mexico\"  class=\"choice-149 depth-1\"  >Mexico<\/option><option value=\"Micronesia\"  class=\"choice-150 depth-1\"  >Micronesia<\/option><option value=\"Moldova\"  class=\"choice-151 depth-1\"  >Moldova<\/option><option value=\"Monaco\"  class=\"choice-152 depth-1\"  >Monaco<\/option><option value=\"Mongolia\"  class=\"choice-153 depth-1\"  >Mongolia<\/option><option value=\"Montenegro\"  class=\"choice-154 depth-1\"  >Montenegro<\/option><option value=\"Montserrat\"  class=\"choice-155 depth-1\"  >Montserrat<\/option><option value=\"Morocco\"  class=\"choice-156 depth-1\"  >Morocco<\/option><option value=\"Mozambique\"  class=\"choice-157 depth-1\"  >Mozambique<\/option><option value=\"Myanmar\"  class=\"choice-158 depth-1\"  >Myanmar<\/option><option value=\"Namibia\"  class=\"choice-159 depth-1\"  >Namibia<\/option><option value=\"Nauru\"  class=\"choice-160 depth-1\"  >Nauru<\/option><option value=\"Nepal\"  class=\"choice-161 depth-1\"  >Nepal<\/option><option value=\"Netherlands\"  class=\"choice-162 depth-1\"  >Netherlands<\/option><option value=\"New Caledonia\"  class=\"choice-163 depth-1\"  >New Caledonia<\/option><option value=\"New Zealand\"  class=\"choice-164 depth-1\"  >New Zealand<\/option><option value=\"Nicaragua\"  class=\"choice-165 depth-1\"  >Nicaragua<\/option><option value=\"Niger\"  class=\"choice-166 depth-1\"  >Niger<\/option><option value=\"Nigeria\"  class=\"choice-167 depth-1\"  >Nigeria<\/option><option value=\"Niue\"  class=\"choice-168 depth-1\"  >Niue<\/option><option value=\"Norfolk Island\"  class=\"choice-169 depth-1\"  >Norfolk Island<\/option><option value=\"North Macedonia\"  class=\"choice-170 depth-1\"  >North Macedonia<\/option><option value=\"Northern Mariana Islands\"  class=\"choice-171 depth-1\"  >Northern Mariana Islands<\/option><option value=\"Norway\"  class=\"choice-172 depth-1\"  >Norway<\/option><option value=\"Oman\"  class=\"choice-173 depth-1\"  >Oman<\/option><option value=\"Pakistan\"  class=\"choice-174 depth-1\"  >Pakistan<\/option><option value=\"Palau\"  class=\"choice-175 depth-1\"  >Palau<\/option><option value=\"Palestine\"  class=\"choice-176 depth-1\"  >Palestine<\/option><option value=\"Panama\"  class=\"choice-177 depth-1\"  >Panama<\/option><option value=\"Papua New Guinea\"  class=\"choice-178 depth-1\"  >Papua New Guinea<\/option><option value=\"Paraguay\"  class=\"choice-179 depth-1\"  >Paraguay<\/option><option value=\"Peru\"  class=\"choice-180 depth-1\"  >Peru<\/option><option value=\"Philippines\"  class=\"choice-181 depth-1\"  >Philippines<\/option><option value=\"Pitcairn Islands\"  class=\"choice-182 depth-1\"  >Pitcairn Islands<\/option><option value=\"Poland\"  class=\"choice-183 depth-1\"  >Poland<\/option><option value=\"Portugal\"  class=\"choice-184 depth-1\"  >Portugal<\/option><option value=\"Puerto Rico\"  class=\"choice-185 depth-1\"  >Puerto Rico<\/option><option value=\"Qatar\"  class=\"choice-186 depth-1\"  >Qatar<\/option><option value=\"R\u00e9union\"  class=\"choice-187 depth-1\"  >R\u00e9union<\/option><option value=\"Romania\"  class=\"choice-188 depth-1\"  >Romania<\/option><option value=\"Russia\"  class=\"choice-189 depth-1\"  >Russia<\/option><option value=\"Rwanda\"  class=\"choice-190 depth-1\"  >Rwanda<\/option><option value=\"Saint Barth\u00e9lemy\"  class=\"choice-191 depth-1\"  >Saint Barth\u00e9lemy<\/option><option value=\"Saint Helena, Ascension and Tristan da Cunha\"  class=\"choice-192 depth-1\"  >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"Saint Kitts and Nevis\"  class=\"choice-193 depth-1\"  >Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\"  class=\"choice-194 depth-1\"  >Saint Lucia<\/option><option value=\"Saint Martin\"  class=\"choice-195 depth-1\"  >Saint Martin<\/option><option value=\"Saint Pierre and Miquelon\"  class=\"choice-196 depth-1\"  >Saint Pierre and Miquelon<\/option><option value=\"Saint Vincent and the Grenadines\"  class=\"choice-197 depth-1\"  >Saint Vincent and the Grenadines<\/option><option value=\"Samoa\"  class=\"choice-198 depth-1\"  >Samoa<\/option><option value=\"San Marino\"  class=\"choice-199 depth-1\"  >San Marino<\/option><option value=\"S\u00e3o Tom\u00e9 and Pr\u00edncipe\"  class=\"choice-200 depth-1\"  >S\u00e3o Tom\u00e9 and Pr\u00edncipe<\/option><option value=\"Saudi Arabia\"  class=\"choice-201 depth-1\"  >Saudi Arabia<\/option><option value=\"Senegal\"  class=\"choice-202 depth-1\"  >Senegal<\/option><option value=\"Serbia\"  class=\"choice-203 depth-1\"  >Serbia<\/option><option value=\"Seychelles\"  class=\"choice-204 depth-1\"  >Seychelles<\/option><option value=\"Sierra Leone\"  class=\"choice-205 depth-1\"  >Sierra Leone<\/option><option value=\"Singapore\"  class=\"choice-206 depth-1\"  >Singapore<\/option><option value=\"Sint Maarten\"  class=\"choice-207 depth-1\"  >Sint Maarten<\/option><option value=\"Slovakia\"  class=\"choice-208 depth-1\"  >Slovakia<\/option><option value=\"Slovenia\"  class=\"choice-209 depth-1\"  >Slovenia<\/option><option value=\"Solomon Islands\"  class=\"choice-210 depth-1\"  >Solomon Islands<\/option><option value=\"Somalia\"  class=\"choice-211 depth-1\"  >Somalia<\/option><option value=\"South Africa\"  class=\"choice-212 depth-1\"  >South Africa<\/option><option value=\"South Georgia and the South Sandwich Islands\"  class=\"choice-213 depth-1\"  >South Georgia and the South Sandwich Islands<\/option><option value=\"South Sudan\"  class=\"choice-214 depth-1\"  >South Sudan<\/option><option value=\"Spain\"  class=\"choice-215 depth-1\"  >Spain<\/option><option value=\"Sri Lanka\"  class=\"choice-216 depth-1\"  >Sri Lanka<\/option><option value=\"State of Palestine\"  class=\"choice-217 depth-1\"  >State of Palestine<\/option><option value=\"Sudan\"  class=\"choice-218 depth-1\"  >Sudan<\/option><option value=\"Suriname\"  class=\"choice-219 depth-1\"  >Suriname<\/option><option value=\"Svalbard and Jan Mayen\"  class=\"choice-220 depth-1\"  >Svalbard and Jan Mayen<\/option><option value=\"Sweden\"  class=\"choice-221 depth-1\"  >Sweden<\/option><option value=\"Switzerland\"  class=\"choice-222 depth-1\"  >Switzerland<\/option><option value=\"Syria\"  class=\"choice-223 depth-1\"  >Syria<\/option><option value=\"Taiwan\"  class=\"choice-224 depth-1\"  >Taiwan<\/option><option value=\"Tajikistan\"  class=\"choice-225 depth-1\"  >Tajikistan<\/option><option value=\"Tanzania\"  class=\"choice-226 depth-1\"  >Tanzania<\/option><option value=\"Thailand\"  class=\"choice-227 depth-1\"  >Thailand<\/option><option value=\"Timor-Leste\"  class=\"choice-228 depth-1\"  >Timor-Leste<\/option><option value=\"Togo\"  class=\"choice-229 depth-1\"  >Togo<\/option><option value=\"Tokelau\"  class=\"choice-230 depth-1\"  >Tokelau<\/option><option value=\"Tonga\"  class=\"choice-231 depth-1\"  >Tonga<\/option><option value=\"Trinidad and Tobago\"  class=\"choice-232 depth-1\"  >Trinidad and Tobago<\/option><option value=\"Tunisia\"  class=\"choice-233 depth-1\"  >Tunisia<\/option><option value=\"Turkey\"  class=\"choice-234 depth-1\"  >Turkey<\/option><option value=\"Turkmenistan\"  class=\"choice-235 depth-1\"  >Turkmenistan<\/option><option value=\"Tuvalu\"  class=\"choice-236 depth-1\"  >Tuvalu<\/option><option value=\"Uganda\"  class=\"choice-237 depth-1\"  >Uganda<\/option><option value=\"Ukraine\"  class=\"choice-238 depth-1\"  >Ukraine<\/option><option value=\"United Arab Emirates\"  class=\"choice-239 depth-1\"  >United Arab Emirates<\/option><option value=\"United Kingdom\"  class=\"choice-240 depth-1\"  >United Kingdom<\/option><option value=\"United States\"  class=\"choice-1 depth-1\"  >United States<\/option><option value=\"Uruguay\"  class=\"choice-242 depth-1\"  >Uruguay<\/option><option value=\"Uzbekistan\"  class=\"choice-243 depth-1\"  >Uzbekistan<\/option><option value=\"Vanuatu\"  class=\"choice-244 depth-1\"  >Vanuatu<\/option><option value=\"Vatican City\"  class=\"choice-245 depth-1\"  >Vatican City<\/option><option value=\"Venezuela\"  class=\"choice-246 depth-1\"  >Venezuela<\/option><option value=\"Vietnam\"  class=\"choice-247 depth-1\"  >Vietnam<\/option><option value=\"Virgin Islands (U.S.)\"  class=\"choice-248 depth-1\"  >Virgin Islands (U.S.)<\/option><option value=\"Wallis and Futuna\"  class=\"choice-249 depth-1\"  >Wallis and Futuna<\/option><option value=\"Western Sahara\"  class=\"choice-250 depth-1\"  >Western Sahara<\/option><option value=\"Yemen\"  class=\"choice-251 depth-1\"  >Yemen<\/option><option value=\"Zambia\"  class=\"choice-252 depth-1\"  >Zambia<\/option><option value=\"Zimbabwe\"  class=\"choice-253 depth-1\"  >Zimbabwe<\/option><\/select><\/div><div id=\"wpforms-20-field_23-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-id=\"23\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-20-field_23\">If licensed in the USA, which state? (USA only) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-20-field_23\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][23]\" required=\"required\"><option value=\"Alabama\"  class=\"choice-1 depth-1\"  >Alabama<\/option><option value=\"Alaska\"  class=\"choice-2 depth-1\"  >Alaska<\/option><option value=\"Arizona\"  class=\"choice-3 depth-1\"  >Arizona<\/option><option value=\"Arkansas\"  class=\"choice-4 depth-1\"  >Arkansas<\/option><option value=\"California\"  class=\"choice-50 depth-1\"  >California<\/option><option value=\"Colorado\"  class=\"choice-49 depth-1\"  >Colorado<\/option><option value=\"Connecticut\"  class=\"choice-48 depth-1\"  >Connecticut<\/option><option value=\"Delaware\"  class=\"choice-47 depth-1\"  >Delaware<\/option><option value=\"Florida\"  class=\"choice-46 depth-1\"  >Florida<\/option><option value=\"Georgia\"  class=\"choice-45 depth-1\"  >Georgia<\/option><option value=\"Hawaii\"  class=\"choice-44 depth-1\"  >Hawaii<\/option><option value=\"Idaho\"  class=\"choice-43 depth-1\"  >Idaho<\/option><option value=\"Illinois\"  class=\"choice-42 depth-1\"  >Illinois<\/option><option value=\"Indiana\"  class=\"choice-41 depth-1\"  >Indiana<\/option><option value=\"Iowa\"  class=\"choice-40 depth-1\"  >Iowa<\/option><option value=\"Kansas\"  class=\"choice-39 depth-1\"  >Kansas<\/option><option value=\"Kentucky\"  class=\"choice-38 depth-1\"  >Kentucky<\/option><option value=\"Louisiana\"  class=\"choice-37 depth-1\"  >Louisiana<\/option><option value=\"Maine\"  class=\"choice-36 depth-1\"  >Maine<\/option><option value=\"Maryland\"  class=\"choice-35 depth-1\"  >Maryland<\/option><option value=\"Massachusetts\"  class=\"choice-34 depth-1\"  >Massachusetts<\/option><option value=\"Michigan\"  class=\"choice-33 depth-1\"  >Michigan<\/option><option value=\"Minnesota\"  class=\"choice-32 depth-1\"  >Minnesota<\/option><option value=\"Mississippi\"  class=\"choice-31 depth-1\"  >Mississippi<\/option><option value=\"Missouri\"  class=\"choice-30 depth-1\"  >Missouri<\/option><option value=\"Montana\"  class=\"choice-29 depth-1\"  >Montana<\/option><option value=\"Nebraska\"  class=\"choice-28 depth-1\"  >Nebraska<\/option><option value=\"Nevada\"  class=\"choice-27 depth-1\"  >Nevada<\/option><option value=\"New Hampshire\"  class=\"choice-26 depth-1\"  >New Hampshire<\/option><option value=\"New Jersey\"  class=\"choice-25 depth-1\"  >New Jersey<\/option><option value=\"New Mexico\"  class=\"choice-24 depth-1\"  >New Mexico<\/option><option value=\"New York\"  class=\"choice-23 depth-1\"  >New York<\/option><option value=\"North Carolina\"  class=\"choice-22 depth-1\"  >North Carolina<\/option><option value=\"North Dakota\"  class=\"choice-21 depth-1\"  >North Dakota<\/option><option value=\"Ohio\"  class=\"choice-20 depth-1\"  >Ohio<\/option><option value=\"Oklahoma\"  class=\"choice-19 depth-1\"  >Oklahoma<\/option><option value=\"Oregon\"  class=\"choice-18 depth-1\"  >Oregon<\/option><option value=\"Pennsylvania\"  class=\"choice-17 depth-1\"  >Pennsylvania<\/option><option value=\"Rhode Island\"  class=\"choice-16 depth-1\"  >Rhode Island<\/option><option value=\"South Carolina\"  class=\"choice-15 depth-1\"  >South Carolina<\/option><option value=\"South Dakota\"  class=\"choice-14 depth-1\"  >South Dakota<\/option><option value=\"Tennessee\"  class=\"choice-13 depth-1\"  >Tennessee<\/option><option value=\"Texas\"  class=\"choice-12 depth-1\"  >Texas<\/option><option value=\"Utah\"  class=\"choice-11 depth-1\"  >Utah<\/option><option value=\"Vermont\"  class=\"choice-10 depth-1\"  >Vermont<\/option><option value=\"Virginia\"  class=\"choice-9 depth-1\"  >Virginia<\/option><option value=\"Washington\"  class=\"choice-8 depth-1\"  >Washington<\/option><option value=\"Washington DC\"  class=\"choice-7 depth-1\"  >Washington DC<\/option><option value=\"West Virginia\"  class=\"choice-6 depth-1\"  >West Virginia<\/option><option value=\"Wisconsin\"  class=\"choice-5 depth-1\"  >Wisconsin<\/option><option value=\"Wyoming\"  class=\"choice-51 depth-1\"  >Wyoming<\/option><\/select><\/div><div id=\"wpforms-20-field_10-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"10\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-20-field_10\">DEA number (USA only)<\/label><input type=\"text\" id=\"wpforms-20-field_10\" class=\"wpforms-field-medium\" name=\"wpforms[fields][10]\" aria-errormessage=\"wpforms-20-field_10-error\" ><\/div><div id=\"wpforms-20-field_12-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"12\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-20-field_12\">License expiration date <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-20-field_12\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][12][date]\" aria-errormessage=\"wpforms-20-field_12-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-20-field_14-container\" class=\"wpforms-field wpforms-field-file-upload wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"14\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-20-field_14\">If licensed outside the USA, please upload a copy of your active medical license here <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div\n\t\tclass=\"wpforms-uploader wpforms-field-required\"\n\t\tdata-field-id=\"14\"\n\t\tdata-form-id=\"20\"\n\t\tdata-input-name=\"wpforms_20_14\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,png,gif,webp,mov,qt,avif,avi,mpeg,mpg,mpe,3gp,3gpp,3g2,3gp2,mid,midi,pdf,doc,docx,docm,pot,pps,ppt,pptx,pptm,odt,ppsx,ppsm,xla,xls,xlt,xlw,xlsx,xlsm,xlsb,key,mp3,m4a,m4b,ogg,oga,flac,wav,x-wav,mp4,m4v,webm,ogv,csv,svg,jpg,jpeg,xls,ppt\"\n\t\tdata-max-size=\"4294967296\"\n\t\tdata-max-file-number=\"1\"\n\t\tdata-post-max-size=\"4294967296\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg  viewBox=\"0 0 640 640\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M352 173.3L352 384C352 401.7 337.7 416 320 416C302.3 416 288 401.7 288 384L288 173.3L246.6 214.7C234.1 227.2 213.8 227.2 201.3 214.7C188.8 202.2 188.8 181.9 201.3 169.4L297.3 73.4C309.8 60.9 330.1 60.9 342.6 73.4L438.6 169.4C451.1 181.9 451.1 202.2 438.6 214.7C426.1 227.2 405.8 227.2 393.3 214.7L352 173.3zM320 464C364.2 464 400 428.2 400 384L480 384C515.3 384 544 412.7 544 448L544 480C544 515.3 515.3 544 480 544L160 544C124.7 544 96 515.3 96 480L96 448C96 412.7 124.7 384 160 384L240 384C240 428.2 275.8 464 320 464zM464 488C477.3 488 488 477.3 488 464C488 450.7 477.3 440 464 440C450.7 440 440 450.7 440 464C440 477.3 450.7 488 464 488z\"\/>\n\t\t<\/svg>\n\n\t\t<span class=\"modern-title\">\n\t\t\t\t\t\t\tDrag &amp; Drop Files, \t\t\t\t<span>Choose Files to Upload<\/span>\n\t\t\t\t\t<\/span>\n\n\t\t\t<\/div>\n<\/div>\n\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-20-field_14\"\n\t\tname=\"wpforms_20_14\" required\t\tvalue=\"\">\n<div id=\"wpforms-20-field_14-description\" class=\"wpforms-field-description\">File types allowed:.doc, .xls, .ppt, .pdf, .png, .gif, .jpg Maximum file size 25mb.<\/div><\/div><div id=\"wpforms-20-field_18-container\" class=\"wpforms-field wpforms-field-file-upload wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"18\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-20-field_18\">If licensed outside the USA, please upload an official letter of privileges from a local hospital certifying you have full clearance to perform surgical procedures using JNJ products you are requesting. As an alternative, you may upload an official letter from the licensing medical board of your country certifying your credentials to perform surgical procedures using JNJ products. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div\n\t\tclass=\"wpforms-uploader wpforms-field-required\"\n\t\tdata-field-id=\"18\"\n\t\tdata-form-id=\"20\"\n\t\tdata-input-name=\"wpforms_20_18\"\n\t\tdata-extensions=\"doc,docx,pdf\"\n\t\tdata-max-size=\"26214400\"\n\t\tdata-max-file-number=\"3\"\n\t\tdata-post-max-size=\"4294967296\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg  viewBox=\"0 0 640 640\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M352 173.3L352 384C352 401.7 337.7 416 320 416C302.3 416 288 401.7 288 384L288 173.3L246.6 214.7C234.1 227.2 213.8 227.2 201.3 214.7C188.8 202.2 188.8 181.9 201.3 169.4L297.3 73.4C309.8 60.9 330.1 60.9 342.6 73.4L438.6 169.4C451.1 181.9 451.1 202.2 438.6 214.7C426.1 227.2 405.8 227.2 393.3 214.7L352 173.3zM320 464C364.2 464 400 428.2 400 384L480 384C515.3 384 544 412.7 544 448L544 480C544 515.3 515.3 544 480 544L160 544C124.7 544 96 515.3 96 480L96 448C96 412.7 124.7 384 160 384L240 384C240 428.2 275.8 464 320 464zM464 488C477.3 488 488 477.3 488 464C488 450.7 477.3 440 464 440C450.7 440 440 450.7 440 464C440 477.3 450.7 488 464 488z\"\/>\n\t\t<\/svg>\n\n\t\t<span class=\"modern-title\">\n\t\t\t\t\t\t\tDrag &amp; Drop Files, \t\t\t\t<span>Choose Files to Upload<\/span>\n\t\t\t\t\t<\/span>\n\n\t\t\t\t\t<span class=\"modern-hint\">You can upload up to 3 files.<\/span>\n\t\t\t<\/div>\n<\/div>\n\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-20-field_18\"\n\t\tname=\"wpforms_20_18\" required\t\tvalue=\"\">\n<div id=\"wpforms-20-field_18-description\" class=\"wpforms-field-description\">File types allowed: .doc, .docx, .pdf. Maximum file size 25mb.<\/div><\/div><div id=\"wpforms-20-field_19-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"19\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-20-field_19\">Please provide any additional information regarding your credentials not already listed on this application.<\/label><textarea id=\"wpforms-20-field_19\" class=\"wpforms-field-medium\" name=\"wpforms[fields][19]\" aria-errormessage=\"wpforms-20-field_19-error\" ><\/textarea><\/div><div id=\"wpforms-20-field_20-container\" class=\"wpforms-field wpforms-field-divider wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"20\" style=\"display:none;\"><h3 id=\"wpforms-20-field_20\" aria-errormessage=\"wpforms-20-field_20-error\">Post-Mission Reporting Agreement<\/h3><\/div><div id=\"wpforms-20-field_25-container\" class=\"wpforms-field wpforms-field-signature wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"25\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-20-field_25\">Signature <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-20-field_25\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][25]\" autocomplete=\"off\" inputmode=\"none\" aria-errormessage=\"wpforms-20-field_25-error\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-20-field_25-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Clear Signature\" tabindex=\"0\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"1em\" height=\"1em\" preserveAspectRatio=\"xMidYMid meet\" viewBox=\"0 0 1536 1536\">\n\t\t\t\t\t<path fill=\"var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )\" d=\"M1149 994q0-26-19-45L949 768l181-181q19-19 19-45q0-27-19-46l-90-90q-19-19-46-19q-26 0-45 19L768 587L587 406q-19-19-45-19q-27 0-46 19l-90 90q-19 19-19 46q0 26 19 45l181 181l-181 181q-19 19-19 45q0 27 19 46l90 90q19 19 46 19q26 0 45-19l181-181l181 181q19 19 45 19q27 0 46-19l90-90q19-19 19-46zm387-226q0 209-103 385.5T1153.5 1433T768 1536t-385.5-103T103 1153.5T0 768t103-385.5T382.5 103T768 0t385.5 103T1433 382.5T1536 768z\"\/>\n\t\t\t\t<\/svg>\n\t\t\t\t<div class=\"wpforms-signature-clear-caption\">Clear Signature<\/div>\n\t\t\t<\/div><\/div><\/div><div id=\"wpforms-20-field_22-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"22\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">I agree to document the product description, brand name, product code (REF or SKU), lot number, expiration date, and quantity of any product left in-country at the conclusion of my trip. I understand MAP will require this information in the post-mission reporting process <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-20-field_22\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-20-field_22_1\" name=\"wpforms[fields][22][]\" value=\"Yes\" aria-errormessage=\"wpforms-20-field_22_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-20-field_22_1\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-20-field_24-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"24\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-20-field_24\">Today&#039;s Date <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-20-field_24\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][24][date]\" aria-errormessage=\"wpforms-20-field_24-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-20-field_2-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-20-field_2-container input { visibility: hidden; } #wpforms-conversational-form-page #wpforms-20-field_2-container label { counter-increment: none; }' ) );\n\t\t\t\t\tdocument.head.appendChild( style );\n\t\t\t\t\tdocument.currentScript?.remove();\n\t\t\t\t} )();\n\t\t\t<\/script><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"20\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/www.map.org\/jnjmedtech\/wp-json\/wp\/v2\/pages\/37\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-20\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.map.org\/jnjmedtech\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><a href=\"#\" class=\"wpforms-save-resume-button\"><span>Save and Resume Later<\/span><\/a><\/div><\/form><\/div>  <!-- .wpforms-container -->\n<div class=\"wpforms-save-resume-confirmation\" id=\"wpforms-save-resume-confirmation-20\" style=\"display: none\">\n\n\t\n\t<div class=\"message\">\n\t\t<p>Your form entry has been saved and a unique link has been created which you can access to resume this form.<\/p>\n<p>Enter your email address to receive the link via email. Alternatively, you can copy and save the link below.<\/p>\n<p>Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.<\/p>\n\t<\/div>\n\n\t<div class=\"wpforms-save-resume-actions\">\n\t\t\t\t\t<div class=\"wpforms-field\">\n\t\t\t\t<label class=\"wpforms-field-label wpforms-save-resume-label\">\n\t\t\t\t\tCopy Link\t\t\t\t<\/label>\n\t\t\t\t<div class=\"wpforms-save-resume-shortcode-container\">\n\t\t\t\t\t<input type=\"text\" class=\"wpforms-save-resume-shortcode\" value=\"\" disabled \/>\n\t\t\t\t\t<span class=\"wpforms-save-resume-shortcode-copy\" title=\"Copy resume link to clipboard\">\n\t\t\t\t\t\t\t<span class=\"copy-icon\"><\/span>\n\t\t\t\t\t\t<\/span>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\n\t\t\t\t\t<form class=\"wpforms-validate wpforms-form wpforms-save-resume-email-notification\" method=\"post\" action=\"\/jnjmedtech\/wp-json\/wp\/v2\/pages\/37\" data-token=\"0319504cef5ce68194a1715efa33e60f\">\n\t\t\t\t<div class=\"wpforms-field wpforms-field-email\">\n\t\t\t\t\t<label class=\"wpforms-field-label wpforms-save-resume-label\">\n\t\t\t\t\t\tEmail\t\t\t\t\t\t<span class=\"wpforms-required-label\">*<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t\t\t<input type=\"email\" name=\"wpforms[save_resume_email]\" required>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"wpforms-submit-container\">\n\t\t\t\t\t<input type=\"hidden\" id=\"_wpnonce\" name=\"_wpnonce\" value=\"0524e8e4de\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/jnjmedtech\/wp-json\/wp\/v2\/pages\/37\" \/>\t\t\t\t\t<input type=\"hidden\" name=\"wpforms[form_id]\" value=\"20\">\n\t\t\t\t\t<input type=\"hidden\" name=\"wpforms[entry_id]\" class=\"wpforms-save-resume-entry-id\" value=\"\">\n\t\t\t\t\t<button type=\"submit\" name=\"wpforms[save-resume]\" class=\"wpforms-submit\" value=\"wpforms-submit\" disabled>\n\t\t\t\t\t\tSend Link\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/form>\n\t\t\t<\/div>\n<\/div>\n<\/td>\n<td class=\"created 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