Medical Reputation BU > CloudPages > API Internal Testing Forms > Physician Resources GME Training Verification Request Form API - TEST FORM


      <h2>Physician Resources GME Training Verification Request Form API - Test Form</h2>
      <form action="https://pages.upmc.com/physician-resources-gme-training-verification-request-form-api-internal-testing-form" method="post">
         
         <label>First Name</label>
         <input type="text" name="first_name"><br>
         <label>Last Name</label>
         <input type="text" name="last_name"><br>
         <label>Company/Institution/Board</label>
         <input type="text" name="company"><br>
         <label>Email</label>
         <input type="text" name="email_address"><br>
         <label>Phone Number</label>
         <input type="text" name="phone_number"><br>
         <label>Street Address</label>
         <input type="text" name="street_address_1"><br>
         <label>Street Address 2</label>
         <input type="text" name="street_address_2"><br>
         <label>City</label>
         <input type="text" name="city"><br>
         <label>State</label>
         <input type="text" name="state"><br>
         <label>Zip Code</label>
         <input type="text" name="zip_code"><br><br>

         <label>Trainee First Name</label>
         <input type="text" name="trainee_first_name"><br>
         <label>Trainee Last Name</label>
         <input type="text" name="trainee_last_name"><br>
         <label>Trainee Aliases</label>
         <input type="text" name="trainee_aliases"><br>
         <label>Trainee Date of Birth</label>
         <input type="text" name="trainee_date_of_birth"><br><br>

         <label>Training Program 1</label>
         <input type="text" name="training_program_1"><br>
         <label>TP1 Start Date</label>
         <input type="text" name="training_program_1_start_date"><br>
         <label>TP1 End Date</label>
         <input type="text" name="training_program_1_end_date"><br><br>

         <label>Training Program 2</label>
         <input type="text" name="training_program_2"><br>
         <label>TP2 Start Date</label>
         <input type="text" name="training_program_2_start_date"><br>
         <label>TP2 End Date</label>
         <input type="text" name="training_program_2_end_date"><br><br>

         <label>Training Program 3</label>
         <input type="text" name="training_program_3"><br>
         <label>TP3 Start Date</label>
         <input type="text" name="training_program_3_start_date"><br>
         <label>TP3 End Date</label>
         <input type="text" name="training_program_3_end_date"><br><br>

         <label>Send the invoice and verification letter to me by: (select one)</label><br>
            <select name="training_verification_method" id="training_verification_method" multiple>
                <option value="Email">Email</option>
                <option value="Mail">Mail</option>
            </select><br><br>

        <p><strong>Fill out the below email/mail fields based on your selection above.</strong></p>

         <label>(If Email) Alternative Email Address</label>
         <input type="text" name="alternative_email"><br><br>

         <label>(If Mail) Alternative Street Address</label>
         <input type="text" name="alternative_street_address_1"><br>
         <label>(If Mail) Alternative Street Address 2</label>
         <input type="text" name="alternative_street_address_2"><br>
         <label>(If Mail) Alternative City</label>
         <input type="text" name="alternative_city"><br>
         <label>(If Mail) Alternative State</label>
         <input type="text" name="alternative_state"><br>
         <label>(If Mail) Alternative Zip Code</label>
         <input type="text" name="alternative_zip_code"><br><br>

         <label>Waive My Fee (select reason for waiver)</label>
            <select name="reason_for_waiver" id="reason_for_waiver">
                <option value="" selected="selected">Select One</option>
                <option value="Current resident">Current resident</option>
                <option value="Training completed within the last 3 years">Training completed within the last 3 years</option>
                <option value="Military">Military</option>
                <option value="UPMC hospital or program making request">UPMC hospital or program making request</option>
                <option value="US Department of Veteran Affairs">US Department of Veteran Affairs</option>
            </select><br><br>

         <label>Authority for Release <em>(on the UPMC form, this will be an 'upload' button where the user can attatch a PDF...but ultimately this field will store a URL, so we can simply just paste a long URL into this field for internal testing sake)</em></label>
         <input type="text" name="document_url"><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>