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Application2.aspx
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Application2.aspx
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<%@ Page Language="C#" AutoEventWireup="true" CodeFile="Application2.aspx.cs" Inherits="Application2" %>
<%@ Register TagPrefix="MaskedInput" Namespace="MaskedInput" Assembly="MaskedInput" %>
<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml" >
<head runat="server">
<title>ePMS | electronic Policy Manager Solution</title>
<link rel="stylesheet" href="css/jquery-ui-1.7.2.custom.css" type="text/css"/>
</head>
<script type="text/javascript" src="js/jquery-1.3.2.min.js"></script>
<script type="text/javascript" src="js/jquery-ui-1.7.2.custom.min.js"></script>
<script type="text/javascript">
$(function()
{
$('#<%= txtBoardCertifiedDesc7.ClientID %>').datepicker({
changeMonth: true,
changeYear: true});
$('#<%= txtBoardCertifiedDesc8.ClientID %>').datepicker({
changeMonth: true,
changeYear: true});
$('#<%= txtBoardCertifiedDesc9.ClientID %>').datepicker({
changeMonth: true,
changeYear: true});
$('#<%= txtEleExpDate.ClientID %>').datepicker({
changeMonth: true,
changeYear: true});
$('#<%= txtWrittenWhen.ClientID %>').datepicker({
changeMonth: true,
changeYear: true});
$('#<%= txtOralWhen.ClientID %>').datepicker({
changeMonth: true,
changeYear: true});
$('#<%= txtBoardDate.ClientID %>').datepicker({
changeMonth: true,
changeYear: true});
});
function ShowDateTimePicker()
{
$('#<%= txtBoardCertifiedDesc7.ClientID %>').datepicker('show');
}
function ShowDateTimePicker2()
{
$('#<%= txtBoardCertifiedDesc8.ClientID %>').datepicker('show');
}
function ShowDateTimePicker3()
{
$('#<%= txtBoardCertifiedDesc9.ClientID %>').datepicker('show');
}
function ShowDateTimePicker4()
{
$('#<%= txtEleExpDate.ClientID %>').datepicker('show');
}
function ShowDateTimePicker5()
{
$('#<%= txtWrittenWhen.ClientID %>').datepicker('show');
}
function ShowDateTimePicker6()
{
$('#<%= txtOralWhen.ClientID %>').datepicker('show');
}
function ShowDateTimePicker7()
{
$('#<%= txtBoardDate.ClientID %>').datepicker('show');
}
</script>
<body background="Images2/SQUARE.GIF" bottommargin="0" leftmargin="0" rightmargin="0" topmargin="19">
<form id="form1" runat="server">
<div>
<table id="Table8" align="center" bgcolor="white" border="0" cellpadding="0" cellspacing="0"
datapagesize="25" style="z-index: 139; left: 4px; width: 921px; position: static;
top: 4px; height: 1px" width="921">
<tr>
<td colspan="3" style="width: 764px; height: 1px">
<p>
<asp:PlaceHolder ID="Placeholder1" runat="server"></asp:PlaceHolder>
</p>
</td>
</tr>
<tr>
<td align="right" colspan="1" rowspan="5" style="font-size: 10pt; width: 5px; position: static;
height: 396px" valign="top">
<p align="center">
<asp:PlaceHolder ID="phTopBanner1" runat="server"></asp:PlaceHolder>
</p>
</td>
<td align="center" style="font-size: 0pt; width: 86px; height: 396px">
<p align="center">
<table id="Table9" bgcolor="white" border="0" cellpadding="0" cellspacing="0" style="width: 819px;
height: 64px" width="819">
<tr>
<td align="center" style="font-size: 0pt; width: 815px; height: 3px">
</td>
<td align="right" colspan="3" style="font-size: 0pt; height: 3px">
</td>
</tr>
<tr>
<td align="left" style="font-size: 0pt; width: 815px; height: 7px">
<table id="Table10" border="0" cellpadding="0" cellspacing="0" style="width: 808px;
height: 12px" width="808">
<tr>
<td align="left">
<asp:Label ID="Label21" runat="server" CssClass="headForm1 " Font-Bold="True" Font-Names="Tahoma"
Font-Size="11pt" ForeColor="Black" Height="16px" Width="92px">Application:</asp:Label>
<asp:Label ID="lblTaskControlID" runat="server" CssClass="HeadField" Font-Names="Tahoma"
Font-Size="9pt" Width="124px"></asp:Label></td>
<td>
</td>
<td align="right">
<asp:Button ID="btnPrevTop" runat="server" BackColor="#400000" BorderColor="#400000"
BorderWidth="0px" Font-Names="Tahoma" ForeColor="White" Height="23px"
Text="< Prev" Width="54px" OnClick="btnPrevTop_Click" TabIndex="1" />
<asp:Button ID="btnNextTop" runat="server" BackColor="#400000" BorderColor="#400000"
BorderWidth="0px" Font-Names="Tahoma" ForeColor="White" Height="23px"
Text="Next >" Width="54px" OnClick="btnNextTop_Click" TabIndex="2" />
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td style="font-size: 0pt; width: 815px" valign="top">
<table id="Table11" bgcolor="indigo" border="0" bordercolor="#4b0082" bordercolordark="#4b0082"
bordercolorlight="#4b0082" cellpadding="0" cellspacing="0" height="1" style="width: 808px"
width="808">
<tr>
<td>
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td align="right" colspan="1" style="font-size: 5pt; width: 815px; height: 17px" valign="top">
</td>
</tr>
<tr>
<td style="font-size: 0pt; width: 815px; height: 19px">
<table id="Table3" border="0" cellpadding="1" cellspacing="1" style="width: 814px;
height: 76px" width="814">
<tr>
<td align="left" style="font-size: 1pt; height: 258px" valign="top">
<table id="Table4" border="0" cellpadding="0" cellspacing="0" style="width: 808px;
height: 1px">
<tr>
<td colspan="2" style="width: 300px">
<asp:Label ID="lblTypeAddress1" runat="server" CssClass="headform3" Font-Bold="True"
Font-Names="Tahoma" Font-Size="9pt" Width="268px">IV.SPECIAL /BOARD CERTIFICATION</asp:Label></td>
<td style="width: 92px">
</td>
<td style="width: 321px">
</td>
</tr>
<tr>
<td align="left" bordercolor="silver" colspan="1" style="width: 125px">
<asp:Label ID="Label18" runat="server" CssClass="headfield1" EnableViewState="False"
Font-Names="Tahoma" Font-Size="9pt" Height="18px" Width="112px">Primary Specialty</asp:Label></td>
<td align="left" bordercolor="silver" style="width: 214px">
<asp:TextBox ID="txtPriSpecialty" runat="server" Font-Names="Tahoma" Font-Size="9pt"
Height="12px" MaxLength="75" Width="288px" TabIndex="3"></asp:TextBox></td>
<td align="left" bordercolor="silver" style="width: 92px">
<asp:Label ID="Label19" runat="server" CssClass="headfield1" EnableViewState="False"
Font-Names="Tahoma" Font-Size="9pt" Height="18px" Width="87px">% of Practice</asp:Label></td>
<td align="left" bordercolor="silver" style="width: 321px">
<asp:TextBox ID="txtPriPractice" runat="server" Font-Names="Tahoma" Font-Size="9pt"
Height="12px" MaxLength="50" Width="120px" TabIndex="4"></asp:TextBox></td>
</tr>
<tr>
<td align="left" bordercolor="silver" colspan="1" style="width: 125px">
<asp:Label ID="Label1" runat="server" CssClass="headfield1" EnableViewState="False"
Font-Names="Tahoma" Font-Size="9pt" Height="18px" Width="112px">Secondary Specialty</asp:Label></td>
<td align="left" bordercolor="silver" style="width: 214px">
<asp:TextBox ID="txtSecSpecialty" runat="server" Font-Names="Tahoma" Font-Size="9pt"
Height="12px" MaxLength="75" Width="288px" TabIndex="5"></asp:TextBox> </td>
<td align="left" bordercolor="silver" style="width: 92px">
<asp:Label ID="Label2" runat="server" CssClass="headfield1" EnableViewState="False"
Font-Names="Tahoma" Font-Size="9pt" Height="18px" Width="87px">% of Practice</asp:Label></td>
<td align="left" bordercolor="silver" style="width: 321px">
<asp:TextBox ID="txtSecPractice" runat="server" Font-Names="Tahoma" Font-Size="9pt"
Height="12px" MaxLength="50" Width="120px" TabIndex="6"></asp:TextBox></td>
</tr>
<tr>
<td align="left" bordercolor="silver" colspan="2" style="width: 440px">
<asp:Label ID="Label3" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="424px">10. Do you limit your practice to either the Primary or Secondary specialty?</asp:Label></td>
<td align="left" bordercolor="silver" style="width: 92px">
<asp:RadioButtonList ID="rdoMcaPracticeLimit" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="7">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList></td>
<td align="left" bordercolor="silver" style="width: 321px">
</td>
</tr>
<tr>
<td align="left" bordercolor="silver" colspan="2" style="width: 158px">
<asp:Label ID="Label4" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="128px">Please explain.</asp:Label></td>
<td align="left" bordercolor="silver" style="width: 92px">
</td>
<td align="left" bordercolor="silver" style="width: 321px">
</td>
</tr>
<tr>
<td align="left" bordercolor="silver" colspan="4" style="width: 158px">
<asp:TextBox ID="txtPracticeLimitDesc" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="24px"
MaxLength="75" Width="664px" TextMode="MultiLine" TabIndex="8"></asp:TextBox></td>
</tr>
<tr>
<td align="left" background="Images2/Barra3.jpg" bordercolor="silver" colspan="4"
style="width: 158px; height: 3px">
</td>
</tr>
<tr>
<td align="left" bordercolor="silver" colspan="2" style="width: 325px">
<asp:Label ID="Label5" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="308px">11. Are you Board Certfied in one or more areas?</asp:Label></td>
<td align="left" bordercolor="silver" colspan="1" style="width: 92px">
<asp:RadioButtonList ID="rdoMcaBoardCertified" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="9">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList></td>
<td align="left" bordercolor="silver" colspan="1" style="width: 158px">
</td>
</tr>
</table>
<table id="Table7" border="0" cellpadding="0" cellspacing="0" style="width: 808px;
height: 8px">
<tr>
<td align="left" colspan="5" style="width: 760px;
height: 3px">
<br />
</td>
</tr>
<tr>
<td align="center" bordercolor="silver" colspan="1" style="width: 281px">
<asp:Label ID="Label31" runat="server" CssClass="headfield1" EnableViewState="False"
Font-Names="Tahoma" Font-Size="9pt" Height="18px" Width="144px">Name of Board</asp:Label></td>
<td align="center" bordercolor="silver" style="width: 206px">
<asp:Label ID="Label32" runat="server" CssClass="headfield1" EnableViewState="False"
Font-Names="Tahoma" Font-Size="9pt" Height="18px" Width="144px">Year Originally Certified</asp:Label></td>
<td align="center" bordercolor="silver" style="width: 222px">
<asp:Label ID="Label33" runat="server" CssClass="headfield1" EnableViewState="False"
Font-Names="Tahoma" Font-Size="9pt" Height="18px" Width="120px">Certification Expires</asp:Label></td>
<td align="center" bordercolor="silver" style="width: 321px">
<asp:Label ID="Label34" runat="server" CssClass="headfield1" EnableViewState="False"
Font-Names="Tahoma" Font-Size="9pt" Height="18px" Width="164px">Recertification Year</asp:Label></td>
</tr>
<tr>
<td align="center" bordercolor="silver" colspan="1" style="width: 281px">
<asp:TextBox ID="txtBoardCertifiedDesc1" runat="server" Font-Names="Tahoma" Font-Size="9pt"
Height="12px" Width="228px" TabIndex="10"></asp:TextBox></td>
<td align="center" bordercolor="silver" style="width: 206px">
<asp:TextBox ID="txtBoardCertifiedDesc4" runat="server" Font-Names="Tahoma" Font-Size="9pt"
Height="12px" Width="120px" TabIndex="11"></asp:TextBox></td>
<td align="center" bordercolor="silver" style="width: 222px">
<asp:TextBox ID="txtBoardCertifiedDesc7" runat="server" onclick="ShowDateTimePicker();" Font-Names="Tahoma" Font-Size="9pt"
Height="12px" Width="92px" TabIndex="12"></asp:TextBox> </td>
<td align="center" bordercolor="silver" style="width: 321px">
<asp:TextBox ID="txtBoardCertifiedDesc10" runat="server" Font-Names="Tahoma" Font-Size="9pt"
Height="12px" Width="108px" TabIndex="13"></asp:TextBox></td>
</tr>
<tr>
<td align="center" bordercolor="silver" colspan="1" style="width: 281px; height: 22px">
<asp:TextBox ID="txtBoardCertifiedDesc2" runat="server" Font-Names="Tahoma" Font-Size="9pt"
Height="12px" Width="228px" TabIndex="14"></asp:TextBox></td>
<td align="center" bordercolor="silver" style="width: 206px; height: 22px">
<asp:TextBox ID="txtBoardCertifiedDesc5" runat="server" Font-Names="Tahoma" Font-Size="9pt"
Height="12px" Width="120px" TabIndex="15"></asp:TextBox></td>
<td align="center" bordercolor="silver" style="width: 222px; height: 22px">
<asp:TextBox ID="txtBoardCertifiedDesc8" runat="server" onclick="ShowDateTimePicker2();" Font-Names="Tahoma" Font-Size="9pt" Height="12px"
Width="92px" TabIndex="16"></asp:TextBox></td>
<td align="center" bordercolor="silver" style="width: 321px; height: 22px">
<asp:TextBox ID="txtBoardCertifiedDesc11" runat="server" Font-Names="Tahoma" Font-Size="9pt"
Height="12px" Width="108px" TabIndex="17"></asp:TextBox></td>
</tr>
<tr>
<td align="center" bordercolor="silver" colspan="1" style="width: 281px; height: 20px;">
<asp:TextBox ID="txtBoardCertifiedDesc3" runat="server" Font-Names="Tahoma" Font-Size="9pt"
Height="12px" Width="228px" TabIndex="18"></asp:TextBox></td>
<td align="center" bordercolor="silver" style="width: 206px; height: 20px;">
<asp:TextBox ID="txtBoardCertifiedDesc6" runat="server" Font-Names="Tahoma" Font-Size="9pt"
Height="12px" Width="120px" TabIndex="19"></asp:TextBox></td>
<td align="center" bordercolor="silver" style="width: 222px; height: 20px;">
<asp:TextBox ID="txtBoardCertifiedDesc9" runat="server" onclick="ShowDateTimePicker3();" Font-Names="Tahoma" Font-Size="9pt" Height="12px"
Width="92px" TabIndex="20"></asp:TextBox></td>
<td align="center" bordercolor="silver" style="width: 321px; height: 20px;">
<asp:TextBox ID="txtBoardCertifiedDesc12" runat="server" Font-Names="Tahoma" Font-Size="9pt"
Height="12px" Width="108px" TabIndex="21"></asp:TextBox></td>
</tr>
</table>
<table id="Table5" border="0" cellpadding="0" cellspacing="0" style="width: 808px;
height: 1px">
<tr>
<td align="left" colspan="2" style="width: 606px;
height: 3px" background="Images2/Barra3.jpg">
</td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 375px; height: 11px">
<asp:Label ID="Label16" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="372px">12. If not Board Certified, what is the expiration date of eligibility?</asp:Label>
</td>
<td align="left" colspan="1" style="width: 429px; height: 11px">
<asp:TextBox ID="txtEleExpDate" runat="server" onclick="ShowDateTimePicker4();" Font-Names="Tahoma" Font-Size="9pt" Height="12px"
Width="92px" TabIndex="22"></asp:TextBox></td>
</tr>
<tr>
<td align="left" colspan="2" style="width: 375px; height: 3px">
<asp:Label ID="Label6" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="100px">If expired, Why?</asp:Label>
<asp:TextBox ID="txtExpiredWhy" runat="server" Font-Names="Tahoma" Font-Size="9pt"
Height="12px" Width="612px" TabIndex="23"></asp:TextBox></td>
</tr>
<tr>
<td align="center" background="Images2/Barra3.jpg" colspan="2" style="width: 121px; height: 3px;">
</td>
</tr>
</table>
<table id="Table1" border="0" cellpadding="0" cellspacing="0" style="width: 808px;
height: 1px">
<tr>
<td align="left" colspan="2" style="width: 606px;
height: 3px">
</td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 500px; height: 11px">
<asp:Label ID="Label7" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="432px">13. If not current certified, are you scheduled to take the board examination?</asp:Label>
</td>
<td align="left" colspan="1" style="width: 429px; height: 11px">
<asp:RadioButtonList ID="rdoMcaBoardExam" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="24">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList></td>
</tr>
<tr>
<td align="left" colspan="2" style="width: 375px; height: 4px">
<asp:Label ID="Label8" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="100px">If expired, Why?</asp:Label>
<asp:TextBox ID="txtBoardExamDesc" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px"
Width="612px" TabIndex="25"></asp:TextBox></td>
</tr>
<tr>
<td align="center" background="Images2/Barra3.jpg" colspan="2" style="width: 121px; height: 3px;">
</td>
</tr>
</table>
<table id="Table6" border="0" cellpadding="0" cellspacing="0" style="width: 808px;
height: 1px">
<tr>
<td align="left" colspan="3" style="width: 606px;
height: 3px">
</td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 500px; height: 11px">
<asp:Label ID="Label14" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="276px">14. If elegible, have you taken the written exam?</asp:Label>
</td>
<td align="left" colspan="1" style="width: 200px; height: 11px">
<asp:RadioButtonList ID="rdoMcaWrittenExam" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="26">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList></td>
<td align="left" colspan="1" style="width: 295px; height: 11px">
<asp:Label ID="Label17" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="44px">When?</asp:Label>
<asp:TextBox ID="txtWrittenWhen" runat="server" onclick="ShowDateTimePicker5();" Font-Names="Tahoma" Font-Size="9pt" Height="12px"
Width="75px" TabIndex="27"></asp:TextBox></td>
<td align="left" colspan="1" style="width: 429px; height: 11px">
<asp:Label ID="Label20" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="44px">Results</asp:Label>
<asp:TextBox ID="txtWrittenResult" runat="server"
Font-Names="Tahoma" Font-Size="9pt" Height="12px"
Width="72px" TabIndex="28"></asp:TextBox></td>
</tr>
<tr>
<td align="left" style="width: 500px; height: 5px">
<asp:Label ID="Label15" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="236px">If elegible, have you taken the oral exam?</asp:Label>
</td>
<td align="left" style="width: 200px; height: 5px">
<asp:RadioButtonList ID="rdoMcaOralExam" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="29">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList></td>
<td align="left" style="width: 295px; height: 5px">
<asp:Label ID="Label23" runat="server" CssClass="headform3"
Font-Bold="False" Font-Names="Tahoma" Font-Size="9pt" Width="44px">When?</asp:Label>
<asp:TextBox
ID="txtOralWhen" runat="server" onclick="ShowDateTimePicker6();" Font-Names="Tahoma" Font-Size="9pt" Height="12px"
Width="75px" TabIndex="30"></asp:TextBox></td>
<td align="left" style="width: 375px; height: 5px">
<asp:Label ID="Label24" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="44px">Results</asp:Label>
<asp:TextBox ID="txtOralResult" runat="server"
Font-Names="Tahoma" Font-Size="9pt" Height="12px"
Width="72px" TabIndex="31"></asp:TextBox></td>
</tr>
<tr>
<td align="center" background="Images2/Barra3.jpg" colspan="4" style="width: 121px; height: 4px;">
</td>
</tr>
</table>
<table id="Table15" border="0" cellpadding="0" cellspacing="0" style="width: 808px;
height: 1px">
<tr>
<td align="left" colspan="2" style="width: 606px;
height: 3px">
</td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 603px; height: 11px">
<asp:Label ID="Label28" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="264px">15. Have you ever failed to pass a Board Exam?</asp:Label>
</td>
<td align="left" colspan="1" style="width: 362px; height: 11px">
<asp:RadioButtonList ID="rdoMcaFailedBoardExam" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="32">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList></td>
<td align="left" colspan="1" style="width: 429px; height: 11px">
</td>
</tr>
<tr>
<td align="left" colspan="2" style="width: 631px; height: 4px">
<asp:Label ID="Label42" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="236px">Name of Specialty Board Failed:</asp:Label>
<asp:TextBox ID="txtBoardFailedSpecialty" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px"
Width="268px" TabIndex="33"></asp:TextBox></td>
<td align="left" style="width: 375px; height: 4px">
<asp:Label ID="Label43" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="36px">Date:</asp:Label>
<asp:TextBox ID="txtBoardDate" runat="server" onclick="ShowDateTimePicker7();" Font-Names="Tahoma" Font-Size="9pt" Height="12px"
Width="116px" TabIndex="34"></asp:TextBox></td>
</tr>
<tr>
<td align="center" background="Images2/Barra3.jpg" colspan="3" style="width: 121px; height: 4px;">
</td>
</tr>
</table>
<table id="Table2" border="0" cellpadding="0" cellspacing="0" style="width: 804px;
height: 1px">
<tr>
<td colspan="4" style="width: 320px">
<asp:Label ID="Label9" runat="server" CssClass="headform3" Font-Bold="True" Font-Names="Tahoma"
Font-Size="9pt" Width="112px">V. MILITARY</asp:Label></td>
</tr>
<tr>
<td align="left" colspan="4" style="width: 572px; height: 14px">
<asp:Label ID="Label10" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="280px">16. Are you current active in Military Servies?</asp:Label></td>
<td align="left" colspan="1" style="width: 572px; height: 14px">
<asp:RadioButtonList ID="rdoMcaMilitary" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="35">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList></td>
</tr>
<tr>
<td align="left" colspan="5" style="width: 572px; height: 4px">
</td>
</tr>
<tr>
<td align="left" colspan="4" style="width: 572px; height: 13px">
<asp:Label ID="Label37" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="56px"> Branch</asp:Label>
<asp:TextBox ID="txtMilitaryDesc" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px"
Width="164px" TabIndex="36"></asp:TextBox></td>
</tr>
<tr>
<td align="left" background="Images2/Barra3.jpg" colspan="5" style="width: 572px;
height: 3px">
</td>
</tr>
<tr>
<td align="left" colspan="4" style="width: 572px; height: 14px">
<asp:Label ID="Label44" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="212px">17. Are you in the Military Reserves?</asp:Label></td>
<td align="left" colspan="1" style="width: 572px; height: 14px">
<asp:RadioButtonList ID="rdoMcaMilitaryReserve" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="37">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList></td>
</tr>
<tr>
<td align="left" background="Images2/Barra3.jpg" colspan="6" style="width: 572px;
height: 3px">
</td>
</tr>
<tr>
<td align="left" colspan="4" style="width: 572px; height: 14px">
<asp:Label ID="Label45" runat="server" CssClass="headform3" Font-Bold="True" Font-Names="Tahoma"
Font-Size="9pt" Width="200px">VI.LICENSES AND AFFILIATIONS</asp:Label></td>
</tr>
<tr>
<td align="left" colspan="4" style="width: 572px; height: 14px">
<asp:Label ID="Label46" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="388px">18. Specify state or countries where you are or have been licensed:</asp:Label></td>
</tr>
<tr>
<td align="center" bordercolor="silver" colspan="1" style="width: 200px">
<asp:Label ID="Label25" runat="server" CssClass="headfield1" EnableViewState="False"
Font-Names="Tahoma" Font-Size="9pt" Height="18px" Width="164px">State/Country</asp:Label></td>
<td align="center" bordercolor="silver" style="width: 194px">
<asp:Label ID="Label13" runat="server" CssClass="headfield1" EnableViewState="False"
Font-Names="Tahoma" Font-Size="9pt" Height="18px" Width="144px">Year</asp:Label></td>
<td align="center" bordercolor="silver" style="width: 154px">
<asp:Label ID="Label22" runat="server" CssClass="headfield1" EnableViewState="False"
Font-Names="Tahoma" Font-Size="9pt" Height="18px" Width="87px">License #</asp:Label></td>
<td align="center" bordercolor="silver" style="width: 154px">
<asp:Label ID="Label26" runat="server" CssClass="headfield1" EnableViewState="False"
Font-Names="Tahoma" Font-Size="9pt" Height="18px" Width="87px">Status</asp:Label></td>
</tr>
<tr>
<td align="left" bordercolor="silver" colspan="1" style="width: 200px; height: 20px">
<asp:TextBox ID="txtLicState1" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px"
Width="120px" TabIndex="38"></asp:TextBox></td>
<td align="center" bordercolor="silver" style="width: 194px; height: 20px">
<asp:TextBox ID="txtLicYear1" runat="server" Font-Names="Tahoma" Font-Size="9pt"
Height="12px" Width="120px" TabIndex="39"></asp:TextBox></td>
<td align="center" bordercolor="silver" style="width: 154px; height: 20px">
<asp:TextBox ID="txtLicNumber1" runat="server" Font-Names="Tahoma" Font-Size="9pt"
Height="12px" Width="120px" TabIndex="40"></asp:TextBox></td>
<td align="center" bordercolor="silver" style="width: 154px; height: 20px">
<asp:TextBox ID="txtLicStatus1" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px"
Width="120px" TabIndex="41"></asp:TextBox></td>
</tr>
<tr>
<td align="left" bordercolor="silver" colspan="1" style="width: 200px">
<asp:TextBox ID="txtLicState2" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px"
Width="120px" TabIndex="42"></asp:TextBox></td>
<td align="center" bordercolor="silver" style="width: 194px">
<asp:TextBox ID="txtLicYear2" runat="server" Font-Names="Tahoma" Font-Size="9pt"
Height="12px" Width="120px" TabIndex="43"></asp:TextBox></td>
<td align="center" bordercolor="silver" style="width: 154px">
<asp:TextBox ID="txtLicNumber2" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px"
Width="120px" TabIndex="44"></asp:TextBox></td>
<td align="center" bordercolor="silver" style="width: 154px">
<asp:TextBox ID="txtLicStatus2" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px"
Width="120px" TabIndex="45"></asp:TextBox></td>
</tr>
<tr>
<td align="left" bordercolor="silver" colspan="1" style="width: 200px; height: 20px">
<asp:TextBox ID="txtLicState3" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px"
Width="120px" TabIndex="46"></asp:TextBox></td>
<td align="center" bordercolor="silver" style="width: 194px; height: 20px">
<asp:TextBox ID="txtLicYear3" runat="server" Font-Names="Tahoma" Font-Size="9pt"
Height="12px" Width="120px" TabIndex="47"></asp:TextBox></td>
<td align="center" bordercolor="silver" style="width: 154px; height: 20px">
<asp:TextBox ID="txtLicNumber3" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px"
Width="120px" TabIndex="48"></asp:TextBox></td>
<td align="center" bordercolor="silver" style="width: 154px; height: 20px">
<asp:TextBox ID="txtLicStatus3" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px"
Width="120px" TabIndex="49"></asp:TextBox></td>
</tr>
</table><table id="Table17" border="0" cellpadding="0" cellspacing="0" style="width: 808px;
height: 1px">
<tr>
<td align="left" colspan="2" style="width: 606px; height: 3px" background="Images2/Barra3.jpg">
</td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 606px; height: 4px">
<asp:Label ID="Label30" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="564px">19. If any of your licenses have been made inactive, suspended, restricted or revoked, please explain.</asp:Label>
</td>
<td align="left" colspan="1" style="width: 429px; height: 4px"></td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 606px; height: 30px">
<asp:TextBox ID="txtLicInactive" runat="server" Font-Names="Tahoma" Font-Size="9pt"
Height="28px" TextMode="MultiLine" Width="572px" TabIndex="50"></asp:TextBox></td>
<td align="left" colspan="1" style="width: 429px; height: 30px">
</td>
</tr>
<tr>
<td align="center" background="Images2/Barra3.jpg" colspan="2" style="width: 121px;
height: 3px">
</td>
</tr>
</table>
</td>
</tr>
</table>
<table id="Table12" border="0" cellpadding="0" cellspacing="0" style="width: 808px;
height: 1px">
<tr>
<td align="left" colspan="2" style="width: 606px;
height: 3px">
</td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 606px; height: 11px">
<asp:Label ID="Label11" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="536px">20. Are you a member of any national (NOT specialty) medical societies?</asp:Label>
</td>
<td align="left" colspan="1" style="width: 429px; height: 11px">
<asp:RadioButtonList ID="rdoMcaMedSocieties" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="51">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList></td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 606px; height: 6px">
<asp:Label ID="Label38" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="52px">If so, list:</asp:Label><asp:TextBox ID="txtMedSocietiesDesc"
runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" Width="468px" TabIndex="52"></asp:TextBox></td>
<td align="left" colspan="1" style="width: 429px; height: 6px">
</td>
</tr>
<tr>
<td align="center" background="Images2/Barra3.jpg" colspan="2" style="width: 121px;">
</td>
</tr>
</table>
<table id="Table16" border="0" cellpadding="0" cellspacing="0" style="width: 808px;
height: 1px">
<tr>
<td align="left" background="Images2/Barra3.jpg" colspan="2" style="width: 606px;
height: 3px">
</td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 606px; height: 4px">
<asp:Label ID="Label12" runat="server" CssClass="headform3" Font-Bold="False"
Font-Names="Tahoma" Font-Size="9pt" Width="536px">21. Are you a member of any national specialty societies?</asp:Label>
</td>
<td align="left" colspan="1" style="width: 429px; height: 4px">
<asp:RadioButtonList ID="rdoMcaNationalSocieties" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="53">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList></td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 606px; height: 3px">
<asp:Label ID="Label27" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="52px">If so, list:</asp:Label><asp:TextBox ID="txtNationalSocietiesDesc"
runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" Width="468px" TabIndex="54"></asp:TextBox></td>
<td align="left" colspan="1" style="width: 429px; height: 3px">
</td>
</tr>
<tr>
<td align="center" background="Images2/Barra3.jpg" colspan="2" style="width: 121px;
height: 3px">
</td>
</tr>
</table>
<table id="Table13" border="0" cellpadding="0" cellspacing="0" style="width: 808px;
height: 1px">
<tr>
<td align="left" colspan="2" style="width: 606px; height: 3px">
<table id="Table18" border="0" cellpadding="0" cellspacing="0" style="width: 808px;
height: 1px">
<tr>
<td align="left" colspan="2" style="width: 606px; height: 3px">
</td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 606px; height: 34px">
<asp:Label ID="Label35" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="612px">22. Are you a member of any state medical society?</asp:Label>
</td>
<td align="left" colspan="1" style="width: 429px; height: 34px">
<asp:RadioButtonList ID="rdoMcaStateMedSocieties" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="55">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList></td>
</tr>
<tr>
<td align="center" background="Images2/Barra3.jpg" colspan="2" style="width: 121px;
height: 3px">
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 606px; height: 34px">
<asp:Label ID="Label39" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="612px">23. Are you a member of your local medical society?</asp:Label>
</td>
<td align="left" colspan="1" style="width: 429px; height: 34px">
<asp:RadioButtonList ID="rdoMcaLocalMedSocieties" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="56">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList></td>
</tr>
<tr>
<td align="center" background="Images2/Barra3.jpg" colspan="2" style="width: 121px;
height: 3px">
</td>
</tr>
</table>
<table id="Table14" border="0" cellpadding="0" cellspacing="0" style="width: 808px;
height: 1px">
<tr>
<td align="left" colspan="2" style="width: 606px; height: 3px">
</td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 606px; height: 7px">
</td>
<td align="right" colspan="1" style="width: 429px; height: 7px"><asp:Button ID="btnPrevBottom" runat="server" BackColor="#400000" BorderColor="#400000"
BorderWidth="0px" Font-Names="Tahoma" ForeColor="White" Height="23px"
Text="< Prev" Width="54px" OnClick="btnPrevBottom_Click" TabIndex="57" />
<asp:Button ID="btnNextBottom" runat="server" BackColor="#400000" BorderColor="#400000"
BorderWidth="0px" Font-Names="Tahoma" ForeColor="White" Height="23px"
Text="Next >" Width="54px" OnClick="btnNextBottom_Click" TabIndex="58" />
</td>
</tr>
<tr>
<td align="center" background="Images2/Barra3.jpg" colspan="2" style="width: 121px;
height: 3px">
</td>
</tr>
</table>
</td>
</tr>
</table>
</p>
<p>
</p>
<p>
</p>
<p>
</p>
<p>
</p>
<p>
</p>
<p>
</p>
</td>
</tr>
</table>
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<MaskedInput:MaskedTextHeader ID="MaskedTextHeader1" runat="server"></MaskedInput:MaskedTextHeader><asp:Literal
ID="litPopUp" runat="server" Visible="False"></asp:Literal>
<input id="ConfirmDialogBoxPopUp" runat="server" name="ConfirmDialogBoxPopUp" size="1"
style="z-index: 102; left: 440px; width: 35px; position: absolute; top: 1156px;
height: 22px" type="hidden" value="false" />
</form>
</body>
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