{"id":1053,"date":"2023-05-19T17:02:04","date_gmt":"2023-05-19T17:02:04","guid":{"rendered":"https:\/\/womenschoiceaward.com\/partners\/?page_id=1053"},"modified":"2024-02-07T22:41:59","modified_gmt":"2024-02-07T22:41:59","slug":"qualification-request","status":"publish","type":"page","link":"https:\/\/womenschoiceaward.com\/partners\/qualification-request\/","title":{"rendered":"Qualification Request"},"content":{"rendered":"<p><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container fusion-parallax-none nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-background-position:center top;--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:50px;--awb-padding-bottom:30px;--awb-background-color:#c48c00;--awb-background-image:url(&quot;https:\/\/womenschoiceaward.com\/partners\/wp-content\/uploads\/2022\/11\/hospitals_AdobeStock_270789669.png&quot;);--awb-background-size:cover;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1248px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_4 1_4 fusion-flex-column fusion-no-small-visibility\" style=\"--awb-bg-size:cover;--awb-width-large:25%;--awb-margin-top-large:0px;--awb-spacing-right-large:7.68%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:7.68%;--awb-width-medium:25%;--awb-order-medium:0;--awb-spacing-right-medium:7.68%;--awb-spacing-left-medium:7.68%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-image-element \" style=\"--awb-caption-title-font-family:var(--h2_typography-font-family);--awb-caption-title-font-weight:var(--h2_typography-font-weight);--awb-caption-title-font-style:var(--h2_typography-font-style);--awb-caption-title-size:var(--h2_typography-font-size);--awb-caption-title-transform:var(--h2_typography-text-transform);--awb-caption-title-line-height:var(--h2_typography-line-height);--awb-caption-title-letter-spacing:var(--h2_typography-letter-spacing);\"><span class=\" fusion-imageframe imageframe-none imageframe-1 hover-type-none\"><img decoding=\"async\" width=\"600\" height=\"579\" alt=\"Best Doctors Seal 2024\" src=\"https:\/\/womenschoiceaward.com\/partners\/wp-content\/uploads\/2024\/02\/WCA_Best_Doctors_Hor_2024-600x579.png\" class=\"img-responsive wp-image-1406\" srcset=\"https:\/\/womenschoiceaward.com\/partners\/wp-content\/uploads\/2024\/02\/WCA_Best_Doctors_Hor_2024-200x193.png 200w, https:\/\/womenschoiceaward.com\/partners\/wp-content\/uploads\/2024\/02\/WCA_Best_Doctors_Hor_2024-400x386.png 400w, https:\/\/womenschoiceaward.com\/partners\/wp-content\/uploads\/2024\/02\/WCA_Best_Doctors_Hor_2024-600x579.png 600w, https:\/\/womenschoiceaward.com\/partners\/wp-content\/uploads\/2024\/02\/WCA_Best_Doctors_Hor_2024-800x772.png 800w, https:\/\/womenschoiceaward.com\/partners\/wp-content\/uploads\/2024\/02\/WCA_Best_Doctors_Hor_2024.png 1000w\" sizes=\"(max-width: 640px) 100vw, 400px\" \/><\/span><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-padding-bottom:30px;--awb-bg-color:rgba(0,0,0,0.29);--awb-bg-color-hover:rgba(0,0,0,0.29);--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:3.84%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:3.84%;--awb-width-medium:50%;--awb-order-medium:0;--awb-spacing-right-medium:3.84%;--awb-spacing-left-medium:3.84%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-1 fusion-animated\" data-animationType=\"rubberBand\" data-animationDuration=\"0.3\" data-animationOffset=\"top-into-view\"><h1 style=\"text-align: center;\"><span style=\"color: #ffffff;\">Best Doctors &amp; Dentists<\/span><\/h1>\n<\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_4 1_4 fusion-flex-column fusion-no-small-visibility\" style=\"--awb-bg-size:cover;--awb-width-large:25%;--awb-margin-top-large:0px;--awb-spacing-right-large:7.68%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:7.68%;--awb-width-medium:25%;--awb-order-medium:0;--awb-spacing-right-medium:7.68%;--awb-spacing-left-medium:7.68%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-image-element \" style=\"--awb-caption-title-font-family:var(--h2_typography-font-family);--awb-caption-title-font-weight:var(--h2_typography-font-weight);--awb-caption-title-font-style:var(--h2_typography-font-style);--awb-caption-title-size:var(--h2_typography-font-size);--awb-caption-title-transform:var(--h2_typography-text-transform);--awb-caption-title-line-height:var(--h2_typography-line-height);--awb-caption-title-letter-spacing:var(--h2_typography-letter-spacing);\"><span class=\" fusion-imageframe imageframe-none imageframe-2 hover-type-none\"><img decoding=\"async\" width=\"800\" height=\"772\" alt=\"Best Dentists\" src=\"https:\/\/womenschoiceaward.com\/partners\/wp-content\/uploads\/2023\/03\/WCA_Best_Dentists_Hor_2023-800x772.png\" class=\"img-responsive wp-image-1024\" srcset=\"https:\/\/womenschoiceaward.com\/partners\/wp-content\/uploads\/2023\/03\/WCA_Best_Dentists_Hor_2023-200x193.png 200w, https:\/\/womenschoiceaward.com\/partners\/wp-content\/uploads\/2023\/03\/WCA_Best_Dentists_Hor_2023-400x386.png 400w, https:\/\/womenschoiceaward.com\/partners\/wp-content\/uploads\/2023\/03\/WCA_Best_Dentists_Hor_2023-600x579.png 600w, https:\/\/womenschoiceaward.com\/partners\/wp-content\/uploads\/2023\/03\/WCA_Best_Dentists_Hor_2023-800x772.png 800w, https:\/\/womenschoiceaward.com\/partners\/wp-content\/uploads\/2023\/03\/WCA_Best_Dentists_Hor_2023.png 1000w\" sizes=\"(max-width: 640px) 100vw, 400px\" \/><\/span><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1248px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-3 fusion_builder_column_3_5 3_5 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:60%;--awb-margin-top-large:0px;--awb-spacing-right-large:3.2%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:3.2%;--awb-width-medium:60%;--awb-order-medium:0;--awb-spacing-right-medium:3.2%;--awb-spacing-left-medium:3.2%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-separator fusion-full-width-sep\" style=\"align-self: center;margin-left: auto;margin-right: auto;margin-top:20px;width:100%;\"><\/div><div class=\"fusion-text fusion-text-2\"><h1>See if you qualify.<\/h1>\n<p>The Women&#8217;s Choice Award is recognizing the BEST DOCTORS \/ DENTISTS in our online listings and in our next national USA TODAY announcement, but we need to confirm your qualification status.<\/p>\n<p>There is NO FEE to apply and all doctors \/ dentists who qualify for the Women&#8217;s Choice Award designation receive a free listing on our pages: <a href=\"https:\/\/womenschoiceaward.com\/Best-Doctors\">Best Doctors<\/a> or <a href=\"https:\/\/womenschoiceaward.com\/Best-Dentists\">Best Dentists<\/a>. Consumers use\u00a0 our listings to search for the best doctors and dentists in their community, so &#8211; DON&#8217;T MISS YOUR FREE OPPORTUNITY TO STAND OUT.<\/p>\n<p>Simply enter in the fields below and you&#8217;ll be notified within 2 &#8211; 5 days. Qualified doctors \/\u00a0dentists will receive information on securing a spotlight in our\u00a0USA TODAY, as well as additional marketing opportunities (ie. plaque, enhanced listing, award licensing, best practices, etc.).<\/p>\n<\/div><div class=\"fusion-separator fusion-full-width-sep\" style=\"align-self: center;margin-left: auto;margin-right: auto;margin-top:20px;width:100%;\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-4 fusion_builder_column_2_5 2_5 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:40%;--awb-margin-top-large:0px;--awb-spacing-right-large:4.8%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:4.8%;--awb-width-medium:40%;--awb-order-medium:0;--awb-spacing-right-medium:4.8%;--awb-spacing-left-medium:4.8%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-separator fusion-full-width-sep\" style=\"align-self: center;margin-left: auto;margin-right: auto;margin-top:20px;width:100%;\"><\/div><div class=\"fusion-image-element \" style=\"--awb-caption-title-font-family:var(--h2_typography-font-family);--awb-caption-title-font-weight:var(--h2_typography-font-weight);--awb-caption-title-font-style:var(--h2_typography-font-style);--awb-caption-title-size:var(--h2_typography-font-size);--awb-caption-title-transform:var(--h2_typography-text-transform);--awb-caption-title-line-height:var(--h2_typography-line-height);--awb-caption-title-letter-spacing:var(--h2_typography-letter-spacing);\"><span class=\" fusion-imageframe imageframe-none imageframe-3 hover-type-none\"><img decoding=\"async\" width=\"400\" height=\"624\" src=\"https:\/\/womenschoiceaward.com\/partners\/wp-content\/uploads\/2023\/07\/001-Daily-News-Cover-Mockup-400x624.jpg\" alt class=\"img-responsive wp-image-1079\" srcset=\"https:\/\/womenschoiceaward.com\/partners\/wp-content\/uploads\/2023\/07\/001-Daily-News-Cover-Mockup-200x312.jpg 200w, https:\/\/womenschoiceaward.com\/partners\/wp-content\/uploads\/2023\/07\/001-Daily-News-Cover-Mockup-400x624.jpg 400w, https:\/\/womenschoiceaward.com\/partners\/wp-content\/uploads\/2023\/07\/001-Daily-News-Cover-Mockup.jpg 600w\" sizes=\"(max-width: 640px) 100vw, 400px\" \/><\/span><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-5 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form fusion-form-builder fusion-form-form-wrapper fusion-form-1054\" style=\"--awb-tooltip-text-color:#ffffff;--awb-tooltip-background-color:#333333;--awb-form-placeholder-color:rgba(71,71,71,0.5);--awb-form-text-color:#474747;\" data-form-id=\"1054\" data-config=\"{&quot;form_id&quot;:&quot;1054&quot;,&quot;form_post_id&quot;:&quot;1054&quot;,&quot;post_id&quot;:1053,&quot;form_type&quot;:&quot;ajax&quot;,&quot;confirmation_type&quot;:&quot;message&quot;,&quot;redirect_url&quot;:&quot;&quot;,&quot;field_labels&quot;:{&quot;doctor_first_name&quot;:&quot;First Name&quot;,&quot;dr_last_name&quot;:&quot;Last Name&quot;,&quot;specialty&quot;:&quot;Specialty&quot;,&quot;practice_name&quot;:&quot;Practice Name&quot;,&quot;email&quot;:&quot;Email&quot;,&quot;street_address&quot;:&quot;Street Address&quot;,&quot;dr_city&quot;:&quot;City&quot;,&quot;state&quot;:&quot;State&quot;,&quot;zip&quot;:&quot;Zip&quot;,&quot;business_number_phone&quot;:&quot;Business Phone&quot;,&quot;dr_personal_email&quot;:&quot;Doctor Personal Email&quot;,&quot;submitting_party_email&quot;:&quot;Submitting Party Email&quot;,&quot;consent&quot;:&quot;Consent&quot;},&quot;field_logics&quot;:{&quot;doctor_first_name&quot;:&quot;&quot;,&quot;dr_last_name&quot;:&quot;&quot;,&quot;specialty&quot;:&quot;&quot;,&quot;practice_name&quot;:&quot;&quot;,&quot;email&quot;:&quot;&quot;,&quot;street_address&quot;:&quot;&quot;,&quot;dr_city&quot;:&quot;&quot;,&quot;state&quot;:&quot;&quot;,&quot;zip&quot;:&quot;&quot;,&quot;business_number_phone&quot;:&quot;&quot;,&quot;dr_personal_email&quot;:&quot;&quot;,&quot;submitting_party_email&quot;:&quot;&quot;,&quot;consent&quot;:&quot;&quot;,&quot;notice_1&quot;:&quot;&quot;},&quot;field_types&quot;:{&quot;doctor_first_name&quot;:&quot;text&quot;,&quot;dr_last_name&quot;:&quot;text&quot;,&quot;specialty&quot;:&quot;text&quot;,&quot;practice_name&quot;:&quot;text&quot;,&quot;email&quot;:&quot;email&quot;,&quot;street_address&quot;:&quot;text&quot;,&quot;dr_city&quot;:&quot;text&quot;,&quot;state&quot;:&quot;select&quot;,&quot;zip&quot;:&quot;text&quot;,&quot;business_number_phone&quot;:&quot;phone_number&quot;,&quot;dr_personal_email&quot;:&quot;email&quot;,&quot;submitting_party_email&quot;:&quot;email&quot;,&quot;consent&quot;:&quot;text&quot;,&quot;notice_1&quot;:&quot;notice&quot;,&quot;submit_1&quot;:&quot;submit&quot;,&quot;recaptcha_1&quot;:&quot;recaptcha&quot;},&quot;nonce_method&quot;:&quot;ajax&quot;}\"><form action=\"https:\/\/womenschoiceaward.com\/partners\/qualification-request\/\" method=\"post\" class=\"fusion-form fusion-form-1054\"><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling fusion-animated\" style=\"--awb-border-sizes-top:3px;--awb-border-sizes-bottom:3px;--awb-border-sizes-left:3px;--awb-border-sizes-right:3px;--awb-border-color:#e8e8e8;--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-background-image:linear-gradient(180deg, #f4f4f4 0%,#f9f9f9 100%);--awb-flex-wrap:wrap;\" data-animationType=\"slideInLeft\" data-animationDuration=\"0.3\" data-animationOffset=\"top-into-view\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:103% !important;max-width:103% !important;margin-left: calc(-3% \/ 2 );margin-right: calc(-3% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-6 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.455%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:1.455%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.455%;--awb-spacing-left-medium:1.455%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.455%;--awb-spacing-left-small:1.455%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-3\"><h4><b>Doctor Information<\/b><\/h4>\n<\/div><div class=\"fusion-separator fusion-full-width-sep\" style=\"align-self: center;margin-left: auto;margin-right: auto;width:100%;\"><div class=\"fusion-separator-border sep-single sep-dashed\" style=\"--awb-height:20px;--awb-amount:20px;border-color:#e2e2e2;border-top-width:1px;\"><\/div><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-7 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:2.91%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:2.91%;--awb-width-medium:50%;--awb-order-medium:0;--awb-spacing-right-medium:2.91%;--awb-spacing-left-medium:2.91%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.455%;--awb-spacing-left-small:1.455%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"1054\"><div class=\"fusion-form-label-wrapper\"><label for=\"doctor_first_name\">First Name <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"doctor_first_name\" id=\"doctor_first_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"1054\"><div class=\"fusion-form-label-wrapper\"><label for=\"dr_last_name\">Last Name <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"dr_last_name\" id=\"dr_last_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"1054\"><div class=\"fusion-form-label-wrapper\"><label for=\"specialty\">Specialty <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"specialty\" id=\"specialty\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"1054\"><div class=\"fusion-form-label-wrapper\"><label for=\"practice_name\">Practice Name <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"practice_name\" id=\"practice_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-text fusion-text-4\"><p>To which email shall we send your qualification status?<\/p>\n<\/div><div class=\"fusion-form-field fusion-form-email-field fusion-form-label-above\" style=\"\" data-form-id=\"1054\"><div class=\"fusion-form-label-wrapper\"><label for=\"email\">Email <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"email\" name=\"email\" id=\"email\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-8 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:2.91%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:2.91%;--awb-width-medium:50%;--awb-order-medium:0;--awb-spacing-right-medium:2.91%;--awb-spacing-left-medium:2.91%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.455%;--awb-spacing-left-small:1.455%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"1054\"><div class=\"fusion-form-label-wrapper\"><label for=\"street_address\">Street Address<\/label><\/div><input type=\"text\" name=\"street_address\" id=\"street_address\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"1054\"><div class=\"fusion-form-label-wrapper\"><label for=\"dr_city\">City <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"dr_city\" id=\"dr_city\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-builder-row fusion-builder-row-inner fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:103% !important;max-width:103% !important;margin-left: calc(-3% \/ 2 );margin-right: calc(-3% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-0 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:2.91%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:2.91%;--awb-width-medium:50%;--awb-order-medium:0;--awb-spacing-right-medium:2.91%;--awb-spacing-left-medium:2.91%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.455%;--awb-spacing-left-small:1.455%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-select-field fusion-form-label-above\" style=\"\" data-form-id=\"1054\"><label for=\"state\">State <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><div class=\"fusion-select-wrapper\"><select tabindex=\"\" id=\"state\" name=\"state\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"><option value=\"Alabama\" >Alabama<\/option><option value=\"Alaska\" >Alaska<\/option><option value=\"Arizona\" >Arizona<\/option><option value=\"Arkansas\" >Arkansas<\/option><option value=\"California\" >California<\/option><option value=\"Colorado\" >Colorado<\/option><option value=\"Connecticut\" >Connecticut<\/option><option value=\"Delaware\" >Delaware<\/option><option value=\"District Of Columbia\" >District Of Columbia<\/option><option value=\"Florida\" >Florida<\/option><option value=\"Georgia\" >Georgia<\/option><option value=\"Hawaii\" >Hawaii<\/option><option value=\"Idaho\" >Idaho<\/option><option value=\"Illinois\" >Illinois<\/option><option value=\"Indiana\" >Indiana<\/option><option value=\"Iowa\" >Iowa<\/option><option value=\"Kansas\" >Kansas<\/option><option value=\"Kentucky\" >Kentucky<\/option><option value=\"Louisiana\" >Louisiana<\/option><option value=\"Maine\" >Maine<\/option><option value=\"Maryland\" >Maryland<\/option><option value=\"Massachusetts\" >Massachusetts<\/option><option value=\"Michigan\" >Michigan<\/option><option value=\"Minnesota\" >Minnesota<\/option><option value=\"Mississippi\" >Mississippi<\/option><option value=\"Missouri\" >Missouri<\/option><option value=\"Montana\" >Montana<\/option><option value=\"Nebraska\" >Nebraska<\/option><option value=\"Nevada\" >Nevada<\/option><option value=\"New Hampshire\" >New Hampshire<\/option><option value=\"New Jersey\" >New Jersey<\/option><option value=\"New Mexico\" >New Mexico<\/option><option value=\"New York\" >New York<\/option><option value=\"North Carolina\" >North Carolina<\/option><option value=\"North Dakota\" >North Dakota<\/option><option value=\"Ohio\" >Ohio<\/option><option value=\"Oklahoma\" >Oklahoma<\/option><option value=\"Oregon\" >Oregon<\/option><option value=\"Pennsylvania\" >Pennsylvania<\/option><option value=\"Rhode Island\" >Rhode Island<\/option><option value=\"South Carolina\" >South Carolina<\/option><option value=\"South Dakota\" >South Dakota<\/option><option value=\"Tennessee\" >Tennessee<\/option><option value=\"Texas\" >Texas<\/option><option value=\"Utah\" >Utah<\/option><option value=\"Vermont\" >Vermont<\/option><option value=\"Virginia\" >Virginia<\/option><option value=\"Washington\" >Washington<\/option><option value=\"West Virginia\" >West Virginia<\/option><option value=\"Wisconsin\" >Wisconsin<\/option><option value=\"Wyoming\" >Wyoming<\/option><option value=\"Armed Forces (AA)\" >Armed Forces (AA)<\/option><option value=\"Armed Forces (AE)\" >Armed Forces (AE)<\/option><option value=\"Armed Forces (AP)\" >Armed Forces (AP)<\/option><\/select><div class=\"select-arrow\"><svg width=\"12\" height=\"8\" viewBox=\"0 0 12 8\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"> <path d=\"M1.5 1.75L6 6.25L10.5 1.75\" stroke=\"#6D6D6D\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\"\/> <\/svg><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-1 fusion_builder_column_inner_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:2.91%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:2.91%;--awb-width-medium:50%;--awb-order-medium:0;--awb-spacing-right-medium:2.91%;--awb-spacing-left-medium:2.91%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.455%;--awb-spacing-left-small:1.455%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"1054\"><div class=\"fusion-form-label-wrapper\"><label for=\"zip\">Zip <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"zip\" id=\"zip\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><\/div><div class=\"fusion-separator fusion-full-width-sep\" style=\"align-self: center;margin-left: auto;margin-right: auto;margin-top:30px;width:100%;\"><\/div><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" style=\"\" data-form-id=\"1054\"><div class=\"fusion-form-label-wrapper\"><label for=\"business_number_phone\">Business Phone<\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"awb-form-icon fa-phone-square-alt fas\"><\/i><input type=\"tel\" name=\"business_number_phone\" id=\"business_number_phone\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><\/div><\/div><div class=\"fusion-form-field fusion-form-email-field fusion-form-label-above\" style=\"\" data-form-id=\"1054\"><div class=\"fusion-form-label-wrapper\"><label for=\"dr_personal_email\">Doctor Personal Email<\/label><\/div><input type=\"email\" name=\"dr_personal_email\" id=\"dr_personal_email\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><\/div><div class=\"fusion-form-field fusion-form-email-field fusion-form-label-above\" style=\"\" data-form-id=\"1054\"><div class=\"fusion-form-label-wrapper\"><label for=\"submitting_party_email\">Submitting Party Email<\/label><\/div><input type=\"email\" name=\"submitting_party_email\" id=\"submitting_party_email\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-9 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.455%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:1.455%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.455%;--awb-spacing-left-medium:1.455%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.455%;--awb-spacing-left-small:1.455%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-5\"><p>I consent that the information provided above is accurate and may be used by WomenCertified Inc. on the Women\u2019s Choice Award website. Email and phone details provided will not made public. Applicants may not use the Women\u2019s Choice Award award logo (seal) without licensing rights. For more information contact Julia at\u00a0 <a href=\"mailto:Jragland@womenschoiceaward.com\">Jragland@womenschoiceaward.com.<\/a><\/p>\n<\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"1054\"><div class=\"fusion-form-label-wrapper\"><label for=\"consent\">Consent <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"consent\" id=\"consent\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Write the name of the applying physician or their representative giving consent*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"form-submission-notices data-notice_1\" id=\"fusion-notices-1\"><div class=\"fusion-alert alert success alert-success fusion-alert-center fusion-form-response fusion-form-response-success awb-alert-native-link-color alert-dismissable awb-alert-close-boxed\" role=\"alert\"><div class=\"fusion-alert-content-wrapper\"><span class=\"alert-icon\"><i class=\"awb-icon-check-circle\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-alert-content\">Thank you for your interest. We will get back to you shortly!<\/span><\/div><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><\/div><div class=\"fusion-alert alert error alert-danger fusion-alert-center fusion-form-response fusion-form-response-error awb-alert-native-link-color alert-dismissable awb-alert-close-boxed\" role=\"alert\"><div class=\"fusion-alert-content-wrapper\"><span class=\"alert-icon\"><i class=\"awb-icon-exclamation-triangle\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-alert-content\">There was an error trying to send your message. Please try again later.<\/span><\/div><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><\/div><\/div><div class=\"fusion-separator fusion-full-width-sep\" style=\"align-self: center;margin-left: auto;margin-right: auto;margin-top:30px;width:100%;\"><\/div><div class=\"fusion-form-field fusion-form-submit-field fusion-form-label-above\" style=\"\" data-form-id=\"1054\"><div ><button type=\"submit\" class=\"fusion-button button-flat fusion-button-default-size button-default fusion-button-default button-1 fusion-button-default-span  form-form-submit button-default\" data-form-number=\"1054\" tabindex=\"\"><span class=\"fusion-button-text\">Submit<\/span><\/button><\/div><\/div><div class=\"fusion-form-field fusion-form-recaptcha-field fusion-form-label-above\" style=\"\" data-form-id=\"1054\">\t\t\t\t<div class=\"form-creator-recaptcha\" >\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"fusion-form-recaptcha-wrapper\">\n\t\t\t\t\t\t<div\n\t\t\t\t\t\t\tid=\"g-recaptcha-id-form-1054\"\n\t\t\t\t\t\t\tclass=\"awb-recaptcha-v2 fusion-form-recaptcha-v2\"\n\t\t\t\t\t\t\tdata-theme=\"light\"\n\t\t\t\t\t\t\tdata-sitekey=\"6LfkDdEUAAAAAIIDg-tYrLcrB9_wPpCBaiF3tCiU\"\n\t\t\t\t\t\t\tdata-tabindex=\"\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div><\/div><\/div><\/div><\/div><\/form><\/div><\/div><\/div><\/div><\/div><\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"open","template":"100-width.php","meta":{"footnotes":""},"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v20.0 - 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