{"id":2941,"date":"2026-09-10T20:48:58","date_gmt":"2026-09-10T20:48:58","guid":{"rendered":"https:\/\/ebmedco.ca\/open-an-account\/"},"modified":"2026-09-24T19:57:04","modified_gmt":"2026-09-24T19:57:04","slug":"ouvrir-un-compte","status":"publish","type":"page","link":"https:\/\/ebmedco.ca\/fr\/ouvrir-un-compte\/","title":{"rendered":"Ouvrir un compte"},"content":{"rendered":"<div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_3_container\" data-token=\"42189e339ca4de4444869c6565b3449b\">\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_js_validate  frm_ajax_submit  frm_pro_form \" id=\"form_new-account-form\" data-token=\"42189e339ca4de4444869c6565b3449b\">\n<div class=\"frm_form_fields  frm_page_num_1\">\n<fieldset>\n<legend class=\"frm_screen_reader\">Formulaire d&rsquo;ouverture de compte<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"3\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_3\" id=\"frm_hide_fields_3\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"new-account-form\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_3\" name=\"frm_submit_entry_3\" value=\"88a6cc106d\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/fr\/wp-json\/wp\/v2\/pages\/2941\" \/>\t\t<input  type=\"hidden\" name=\"item_meta[17]\" id=\"field_form_language\" value=\"fr\"  data-frmval=\"fr\"   \/>\n\t\t<div id=\"frm_field_18_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top\">Votre organisation<\/h3>\r\n<div id=\"frm_desc_field_sec_organization\" class=\"frm_description frm_section_spacing\">C&rsquo;est le nom qui figurera sur vos soumissions et vos factures.<\/div>\r\n\r\n<div id=\"frm_field_19_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full vertical_radio\">\r\n\t<div  id=\"field_org_type_label\" class=\"frm_primary_label\">Quel type d&rsquo;organisation repr\u00e9sentez-vous?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_org_type_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_19-18-0\">\t\t\t<label  for=\"field_org_type-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[19]\" id=\"field_org_type-0\" value=\"Hospital\"\n\t\t data-sectionid=\"18\"  data-reqmsg=\"Quel type d&#039;organisation repr\u00e9sentez-vous? ne peut pas \u00eatre vide.\" data-invmsg=\"Quel type d&#039;organisation repr\u00e9sentez-vous? n&#039;est pas valide\" aria-describedby=\"frm_desc_field_org_type\"   \/> H\u00f4pital<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_19-18-1\">\t\t\t<label  for=\"field_org_type-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[19]\" id=\"field_org_type-1\" value=\"Ambulatory surgery centre\"\n\t\t data-sectionid=\"18\"  data-reqmsg=\"Quel type d&#039;organisation repr\u00e9sentez-vous? ne peut pas \u00eatre vide.\" data-invmsg=\"Quel type d&#039;organisation repr\u00e9sentez-vous? n&#039;est pas valide\" aria-describedby=\"frm_desc_field_org_type\"   \/> Centre de chirurgie ambulatoire<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_19-18-2\">\t\t\t<label  for=\"field_org_type-2\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[19]\" id=\"field_org_type-2\" value=\"Physician practice or clinic\"\n\t\t data-sectionid=\"18\"  data-reqmsg=\"Quel type d&#039;organisation repr\u00e9sentez-vous? ne peut pas \u00eatre vide.\" data-invmsg=\"Quel type d&#039;organisation repr\u00e9sentez-vous? n&#039;est pas valide\" aria-describedby=\"frm_desc_field_org_type\"   \/> Cabinet m\u00e9dical ou clinique<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_19-18-3\">\t\t\t<label  for=\"field_org_type-3\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[19]\" id=\"field_org_type-3\" value=\"University or research institution\"\n\t\t data-sectionid=\"18\"  data-reqmsg=\"Quel type d&#039;organisation repr\u00e9sentez-vous? ne peut pas \u00eatre vide.\" data-invmsg=\"Quel type d&#039;organisation repr\u00e9sentez-vous? n&#039;est pas valide\" aria-describedby=\"frm_desc_field_org_type\"   \/> \u00c9tablissement universitaire ou de recherche<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_19-18-4\">\t\t\t<label  for=\"field_org_type-4\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[19]\" id=\"field_org_type-4\" value=\"Government or public health authority\"\n\t\t data-sectionid=\"18\"  data-reqmsg=\"Quel type d&#039;organisation repr\u00e9sentez-vous? ne peut pas \u00eatre vide.\" data-invmsg=\"Quel type d&#039;organisation repr\u00e9sentez-vous? n&#039;est pas valide\" aria-describedby=\"frm_desc_field_org_type\"   \/> Organisme gouvernemental ou autorit\u00e9 de sant\u00e9 publique<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_19-18-5\">\t\t\t<label  for=\"field_org_type-5\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[19]\" id=\"field_org_type-5\" value=\"Distributor or dealer\"\n\t\t data-sectionid=\"18\"  data-reqmsg=\"Quel type d&#039;organisation repr\u00e9sentez-vous? ne peut pas \u00eatre vide.\" data-invmsg=\"Quel type d&#039;organisation repr\u00e9sentez-vous? n&#039;est pas valide\" aria-describedby=\"frm_desc_field_org_type\"   \/> Distributeur ou revendeur<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_19-18-6\">\t\t\t<label  for=\"field_org_type-6\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[19]\" id=\"field_org_type-6\" value=\"Instrument repair or reprocessing company\"\n\t\t data-sectionid=\"18\"  data-reqmsg=\"Quel type d&#039;organisation repr\u00e9sentez-vous? ne peut pas \u00eatre vide.\" data-invmsg=\"Quel type d&#039;organisation repr\u00e9sentez-vous? n&#039;est pas valide\" aria-describedby=\"frm_desc_field_org_type\"   \/> Entreprise de r\u00e9paration ou de retraitement d&rsquo;instruments<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_19-18-7\">\t\t\t<label  for=\"field_org_type-7\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[19]\" id=\"field_org_type-7\" value=\"Other\"\n\t\t data-sectionid=\"18\"  data-reqmsg=\"Quel type d&#039;organisation repr\u00e9sentez-vous? ne peut pas \u00eatre vide.\" data-invmsg=\"Quel type d&#039;organisation repr\u00e9sentez-vous? n&#039;est pas valide\" aria-describedby=\"frm_desc_field_org_type\"   \/> Autre<\/label><\/div>\n<\/div>\r\n\t<div class=\"frm_description\" id=\"frm_desc_field_org_type\">Cela adapte le reste du formulaire \u00e0 votre situation.<\/div>\r\n\t\r\n<\/div>\n<div id=\"frm_field_20_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n\t<label for=\"field_legal_name\" id=\"field_legal_name_label\" class=\"frm_primary_label\">D\u00e9nomination sociale\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_legal_name\" name=\"item_meta[20]\" value=\"\"  data-sectionid=\"18\"  maxlength=\"120\" data-reqmsg=\"D\u00e9nomination sociale ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"D\u00e9nomination sociale n&#039;est pas valide\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_21_container\" class=\"frm_form_field form-field  frm_top_container frm_full\">\r\n\t<label for=\"field_health_authority\" id=\"field_health_authority_label\" class=\"frm_primary_label\">Autorit\u00e9 sanitaire, r\u00e9gion ou r\u00e9seau\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_health_authority\" name=\"item_meta[21]\" value=\"\"  data-sectionid=\"18\"  maxlength=\"120\" data-invmsg=\"Autorit\u00e9 sanitaire, r\u00e9gion ou r\u00e9seau n&#039;est pas valide\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_health_authority\" \/>\r\n\t<div class=\"frm_description\" id=\"frm_desc_field_health_authority\">Par exemple Alberta Health Services, Vitalit\u00e9, Shared Health.<\/div>\r\n\t\r\n<\/div>\n<div id=\"frm_field_22_container\" class=\"frm_form_field form-field  frm_top_container frm_full\">\r\n\t<label for=\"field_website\" id=\"field_website_label\" class=\"frm_primary_label\">Site Web\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"url\" id=\"field_website\" name=\"item_meta[22]\" value=\"\"  data-sectionid=\"18\"  data-invmsg=\"Site Web n&#039;est pas valide\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_23_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n\t<label for=\"field_main_phone\" id=\"field_main_phone_label\" class=\"frm_primary_label\">T\u00e9l\u00e9phone principal\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"tel\" id=\"field_main_phone\" name=\"item_meta[23]\" value=\"\"  data-sectionid=\"18\"  data-reqmsg=\"T\u00e9l\u00e9phone principal ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"T\u00e9l\u00e9phone principal n&#039;est pas valide\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_24_container\" class=\"frm_form_field form-field  frm_top_container frm_full vertical_radio\">\r\n\t<div  id=\"field_gpo_affiliation_label\" class=\"frm_primary_label\">Groupe d&rsquo;achats\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_gpo_affiliation_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_24-18-0\">\t\t\t<label  for=\"field_gpo_affiliation-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[24][]\" id=\"field_gpo_affiliation-0\" value=\"HealthPRO\"  data-sectionid=\"18\"  data-invmsg=\"Groupe d&#039;achats n&#039;est pas valide\" aria-describedby=\"frm_desc_field_gpo_affiliation\"   \/> HealthPRO<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_24-18-1\">\t\t\t<label  for=\"field_gpo_affiliation-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[24][]\" id=\"field_gpo_affiliation-1\" value=\"Mohawk Medbuy\"  data-sectionid=\"18\"  data-invmsg=\"Groupe d&#039;achats n&#039;est pas valide\" aria-describedby=\"frm_desc_field_gpo_affiliation\"   \/> Mohawk Medbuy<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_24-18-2\">\t\t\t<label  for=\"field_gpo_affiliation-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[24][]\" id=\"field_gpo_affiliation-2\" value=\"Plexxus\"  data-sectionid=\"18\"  data-invmsg=\"Groupe d&#039;achats n&#039;est pas valide\" aria-describedby=\"frm_desc_field_gpo_affiliation\"   \/> Plexxus<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_24-18-3\">\t\t\t<label  for=\"field_gpo_affiliation-3\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[24][]\" id=\"field_gpo_affiliation-3\" value=\"3sHealth\"  data-sectionid=\"18\"  data-invmsg=\"Groupe d&#039;achats n&#039;est pas valide\" aria-describedby=\"frm_desc_field_gpo_affiliation\"   \/> 3sHealth<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_24-18-4\">\t\t\t<label  for=\"field_gpo_affiliation-4\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[24][]\" id=\"field_gpo_affiliation-4\" value=\"CAG (Quebec)\"  data-sectionid=\"18\"  data-invmsg=\"Groupe d&#039;achats n&#039;est pas valide\" aria-describedby=\"frm_desc_field_gpo_affiliation\"   \/> CAG (Quebec)<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_24-18-5\">\t\t\t<label  for=\"field_gpo_affiliation-5\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[24][]\" id=\"field_gpo_affiliation-5\" value=\"Another GPO\"  data-sectionid=\"18\"  data-invmsg=\"Groupe d&#039;achats n&#039;est pas valide\" aria-describedby=\"frm_desc_field_gpo_affiliation\"   \/> Un autre groupe d&rsquo;achats<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_24-18-6\">\t\t\t<label  for=\"field_gpo_affiliation-6\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[24][]\" id=\"field_gpo_affiliation-6\" value=\"None, we buy direct\"  data-sectionid=\"18\"  data-invmsg=\"Groupe d&#039;achats n&#039;est pas valide\" aria-describedby=\"frm_desc_field_gpo_affiliation\"   \/> Aucun, nous achetons directement<\/label><\/div>\n<\/div>\r\n\t<div class=\"frm_description\" id=\"frm_desc_field_gpo_affiliation\">Cochez tous les groupes par lesquels vous achetez. Plusieurs centres ont plus d&rsquo;une entente.<\/div>\r\n\t\r\n<\/div>\n<div id=\"frm_field_25_container\" class=\"frm_form_field form-field  frm_top_container frm_full\">\r\n\t<label for=\"field_gpo_numbers\" id=\"field_gpo_numbers_label\" class=\"frm_primary_label\">Num\u00e9ros d&rsquo;adh\u00e9sion aux groupes d&rsquo;achats\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<textarea name=\"item_meta[25]\" id=\"field_gpo_numbers\" rows=\"5\"  data-sectionid=\"18\"  data-invmsg=\"Num\u00e9ros d&#039;adh\u00e9sion aux groupes d&#039;achats n&#039;est pas valide\" aria-invalid=\"false\" aria-describedby=\"frm_desc_field_gpo_numbers\"  ><\/textarea>\r\n\t<div class=\"frm_description\" id=\"frm_desc_field_gpo_numbers\">Un par ligne, avec le nom du groupe.<\/div>\r\n\t\r\n<\/div>\n<div id=\"frm_field_26_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n\t<label for=\"field_dist_territory\" id=\"field_dist_territory_label\" class=\"frm_primary_label\">Territoire ou provinces que vous desservez\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_dist_territory\" name=\"item_meta[26]\" value=\"\"  data-sectionid=\"18\"  maxlength=\"180\" data-reqmsg=\"Territoire ou provinces que vous desservez ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"Territoire ou provinces que vous desservez n&#039;est pas valide\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_27_container\" class=\"frm_form_field form-field  frm_top_container frm_full\">\r\n\t<label for=\"field_dist_years\" id=\"field_dist_years_label\" class=\"frm_primary_label\">Ann\u00e9es d&rsquo;exp\u00e9rience en distribution\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_dist_years\" name=\"item_meta[27]\" value=\"\"  data-sectionid=\"18\"  data-invmsg=\"Ann\u00e9es d&#039;exp\u00e9rience en distribution n&#039;est pas valide\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_28_container\" class=\"frm_form_field form-field  frm_top_container frm_full\">\r\n\t<label for=\"field_dist_lines\" id=\"field_dist_lines_label\" class=\"frm_primary_label\">Gammes que vous distribuez actuellement\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_dist_lines\" name=\"item_meta[28]\" value=\"\"  data-sectionid=\"18\"  maxlength=\"200\" data-invmsg=\"Gammes que vous distribuez actuellement n&#039;est pas valide\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_dist_lines\" \/>\r\n\t<div class=\"frm_description\" id=\"frm_desc_field_dist_lines\">Cela nous aide \u00e0 comprendre notre place parmi les produits que vous vendez d\u00e9j\u00e0.<\/div>\r\n\t\r\n<\/div>\n<div id=\"frm_field_29_container\" class=\"frm_form_field form-field  frm_top_container frm_full\">\r\n\t<label for=\"field_mdel_number\" id=\"field_mdel_number_label\" class=\"frm_primary_label\">Votre num\u00e9ro de LEIM de Sant\u00e9 Canada\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_mdel_number\" name=\"item_meta[29]\" value=\"\"  data-sectionid=\"18\"  data-invmsg=\"Votre num\u00e9ro de LEIM de Sant\u00e9 Canada n&#039;est pas valide\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_mdel_number\" \/>\r\n\t<div class=\"frm_description\" id=\"frm_desc_field_mdel_number\">Obligatoire si vous importez ou distribuez des instruments m\u00e9dicaux au Canada.<\/div>\r\n\t\r\n<\/div>\n<div id=\"frm_field_30_container\" class=\"frm_form_field form-field  frm_top_container frm_full vertical_radio\">\r\n\t<div  id=\"field_dist_blind_ship_label\" class=\"frm_primary_label\">Livraison directe\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_dist_blind_ship_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_30-18-0\">\t\t\t<label  for=\"field_dist_blind_ship-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[30][]\" id=\"field_dist_blind_ship-0\" value=\"We will need drop shipping to our customers under neutral packaging\"  data-sectionid=\"18\"  data-invmsg=\"Livraison directe n&#039;est pas valide\"   \/> Nous aurons besoin de la livraison directe \u00e0 nos clients sous emballage neutre<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<\/div>\n<input type=\"hidden\" name=\"frm_page_order_3\" id=\"frm_page_order_3\" value=\"32\" \/><input type=\"hidden\" name=\"item_meta[33]\" id=\"field_sec_shipping\" value=\"\" \/>\n\t\t\t\t\t<input  type=\"hidden\" name=\"item_meta[34]\" id=\"field_end_sec_shipping\" value=\"\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[35]\" id=\"field_break_2\" value=\"\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[36]\" id=\"field_sec_billing\" value=\"\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[37]\" id=\"field_billing_same-0\" value=\"\"  data-sectionid=\"36\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[38]\" id=\"field_bill_street\" value=\"\"  data-sectionid=\"36\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[39]\" id=\"field_bill_street2\" value=\"\"  data-sectionid=\"36\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[40]\" id=\"field_bill_city\" value=\"\"  data-sectionid=\"36\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[41]\" id=\"field_bill_province\" value=\"\"  data-sectionid=\"36\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[42]\" id=\"field_bill_postal\" value=\"\"  data-sectionid=\"36\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[43]\" id=\"field_end_sec_billing\" value=\"\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[44]\" id=\"field_break_3\" value=\"\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[45]\" id=\"field_sec_contacts\" value=\"\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[46]\" id=\"field_purch_name\" value=\"\"  data-sectionid=\"45\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[47]\" id=\"field_purch_title\" value=\"\"  data-sectionid=\"45\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[48]\" id=\"field_purch_phone\" value=\"\"  data-sectionid=\"45\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[49]\" id=\"field_purch_email\" value=\"\"  data-sectionid=\"45\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[50]\" id=\"field_ap_same-0\" value=\"\"  data-sectionid=\"45\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[51]\" id=\"field_ap_name\" value=\"\"  data-sectionid=\"45\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[52]\" 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name=\"item_meta[87]\" id=\"field_tax_exempt-0\" value=\"\"  data-sectionid=\"76\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[88]\" id=\"field_tax_exempt_cert\" value=\"\"  data-sectionid=\"76\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[89]\" id=\"field_docs_needed-0\" value=\"\"  data-sectionid=\"76\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[90]\" id=\"field_docs_other\" value=\"\"  data-sectionid=\"76\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[91]\" id=\"field_end_sec_payment\" value=\"\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[92]\" id=\"field_break_6\" value=\"\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[93]\" id=\"field_sec_confirm\" value=\"\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[94]\" id=\"field_heard_about\" value=\"\"  data-sectionid=\"93\"     \/>\n\t\t\t\t<input  type=\"hidden\" name=\"item_meta[95]\" id=\"field_referred_by\" value=\"\"  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