Medical Reputation BU > My Landing Pages > TESTING > API Conversion Pixel Testing > Panther Symposium and Reception Event Registration - TEST FORM


      <h2>Panther Symposium and Reception Event Registration - Test Form</h2>
      <form action="https://pages.upmc.com/panther-symposium-event-api-internal-testing-form" method="post">
         <label>Email</label>
         <input type="text" name="email_address"><br>
         <label>First Name</label>
         <input type="text" name="first_name"><br>
         <label>Last Name</label>
         <input type="text" name="last_name"><br><br>
         
         <label>Organization</label>
         <textarea type="text" name="organization"></textarea><br> <br>

         <label>Credentials</label>
            <select name="credentials" id="credentials">
                <option value="" selected="selected">Select One</option>
                <option value="MD">MD</option>
                <option value="DO">DO</option>
                <option value="PhD">PhD</option>
                <option value="PharmD">PharmD</option>
                <option value="NP">NP</option>
                <option value="PA">PA</option>
                <option value="RN">RN</option>
                <option value="Other">Other</option>
            </select><br><br>

         <label>Number of Guests</label>
         <input type="text" name="number_of_guests"><br><br>

         <label>Guest Names</label>
         <textarea type="text" name="guest_names"></textarea><br><br>

         <label>Category</label>
         <input type="text" name="category"><br>
         <label>Subcategory</label>
         <input type="text" name="subcategory"><br>
         <input name="submitted" type="hidden" value="true" />
         <input type="submit" value="Submit">
      </form>