<div class="wpforms-container wpforms-container-full" id="wpforms-5071"><form id="wpforms-form-5071" class="wpforms-validate wpforms-form wpforms-ajax-form" data-formid="5071" method="post" enctype="multipart/form-data" action="/tag/manufacturer-rep/" data-token="642cd720def10f6c7ee1805941c909b7"><noscript class="wpforms-error-noscript">Please enable JavaScript in your browser to complete this form.</noscript><div class="wpforms-field-container"><div id="wpforms-5071-field_0-container" class="wpforms-field wpforms-field-name" data-field-id="0"><label class="wpforms-field-label" for="wpforms-5071-field_0">Name <span class="wpforms-required-label">*</span></label><div class="wpforms-field-row wpforms-field-medium"><div class="wpforms-field-row-block wpforms-first wpforms-one-half"><input type="text" id="wpforms-5071-field_0" class="wpforms-field-name-first wpforms-field-required" name="wpforms[fields][0][first]" required><label for="wpforms-5071-field_0" class="wpforms-field-sublabel after ">First</label></div><div class="wpforms-field-row-block wpforms-one-half"><input type="text" id="wpforms-5071-field_0-last" class="wpforms-field-name-last wpforms-field-required" name="wpforms[fields][0][last]" required><label for="wpforms-5071-field_0-last" class="wpforms-field-sublabel after ">Last</label></div></div></div><div id="wpforms-5071-field_3-container" class="wpforms-field wpforms-field-phone" data-field-id="3"><label class="wpforms-field-label" for="wpforms-5071-field_3">Phone Number <span class="wpforms-required-label">*</span></label><input type="tel" id="wpforms-5071-field_3" class="wpforms-field-medium wpforms-field-required wpforms-smart-phone-field" data-rule-smart-phone-field="true" name="wpforms[fields][3]" required></div><div id="wpforms-5071-field_1-container" class="wpforms-field wpforms-field-email" data-field-id="1"><label class="wpforms-field-label" for="wpforms-5071-field_1">Work Email <span class="wpforms-required-label">*</span></label><input type="email" id="wpforms-5071-field_1" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][1]" required></div><div id="wpforms-5071-field_5-container" class="wpforms-field wpforms-field-select wpforms-field-select-style-classic" data-field-id="5"><label class="wpforms-field-label" for="wpforms-5071-field_5">Business Type <span class="wpforms-required-label">*</span></label><select id="wpforms-5071-field_5" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][5]" required="required"><option value="" class="placeholder" disabled selected='selected'>Please Select</option><option value="Manufacturers&#039; Representative" >Manufacturers&#039; Representative</option><option value="Manufacturer" >Manufacturer</option></select></div><div id="wpforms-5071-field_4-container" class="wpforms-field wpforms-field-text" data-field-id="4"><label class="wpforms-field-label" for="wpforms-5071-field_4">Company Name <span class="wpforms-required-label">*</span></label><input type="text" id="wpforms-5071-field_4" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][4]" placeholder="Enter your company name" required></div><div id="wpforms-5071-field_6-container" class="wpforms-field wpforms-field-number" data-field-id="6"><label class="wpforms-field-label" for="wpforms-5071-field_6">Size of Sales Team</label><input type="number" pattern="\d*" id="wpforms-5071-field_6" class="wpforms-field-medium" name="wpforms[fields][6]" placeholder="How many people are on your sales team?" ></div><div id="wpforms-5071-field_7-container" class="wpforms-field wpforms-field-select wpforms-field-select-style-classic" data-field-id="7"><label class="wpforms-field-label" for="wpforms-5071-field_7">What is your priority?</label><select id="wpforms-5071-field_7" class="wpforms-field-medium" name="wpforms[fields][7]"><option value="" class="placeholder" disabled selected='selected'>Please Select</option><option value="High (Have someone call me ASAP)" >High (Have someone call me ASAP)</option><option value="Medium" >Medium</option><option value="Low" >Low</option></select></div><div id="wpforms-5071-field_8-container" class="wpforms-field wpforms-field-checkbox" data-field-id="8"><label class="wpforms-field-label" for="wpforms-5071-field_8">Checkboxes</label><ul id="wpforms-5071-field_8"><li class="choice-4 depth-1"><input type="checkbox" id="wpforms-5071-field_8_4" name="wpforms[fields][8][]" value="Call Me" ><label class="wpforms-field-label-inline" for="wpforms-5071-field_8_4">Call Me</label></li><li class="choice-1 depth-1"><input type="checkbox" id="wpforms-5071-field_8_1" name="wpforms[fields][8][]" value="Schedule Demonstration" ><label class="wpforms-field-label-inline" for="wpforms-5071-field_8_1">Schedule Demonstration</label></li><li class="choice-2 depth-1"><input type="checkbox" id="wpforms-5071-field_8_2" name="wpforms[fields][8][]" value="Send Information" ><label class="wpforms-field-label-inline" for="wpforms-5071-field_8_2">Send Information</label></li><li class="choice-3 depth-1"><input type="checkbox" id="wpforms-5071-field_8_3" name="wpforms[fields][8][]" value="Pricing" ><label class="wpforms-field-label-inline" for="wpforms-5071-field_8_3">Pricing</label></li></ul></div><div id="wpforms-5071-field_2-container" class="wpforms-field wpforms-field-textarea" data-field-id="2"><label class="wpforms-field-label" for="wpforms-5071-field_2">Comments (let us know if you have any specific requests)</label><textarea id="wpforms-5071-field_2" class="wpforms-field-medium" name="wpforms[fields][2]" ></textarea></div><div id="wpforms-5071-field_9-container" class="wpforms-field wpforms-field-hidden" data-field-id="9"><input type="hidden" id="wpforms-5071-field_9" name="wpforms[fields][9]"></div><div id="wpforms-5071-field_10-container" class="wpforms-field wpforms-field-hidden" data-field-id="10"><input type="hidden" id="wpforms-5071-field_10" name="wpforms[fields][10]" value="3.223.3.251"></div><div id="wpforms-5071-field_11-container" class="wpforms-field wpforms-field-hidden" data-field-id="11"><input type="hidden" id="wpforms-5071-field_11" name="wpforms[fields][11]" value="o9vtTAkBz5VremhZ"></div></div><div class="wpforms-submit-container"><input type="hidden" name="wpforms[id]" value="5071"><input type="hidden" name="wpforms[author]" value="9"><button type="submit" name="wpforms[submit]" id="wpforms-submit-5071" class="wpforms-submit om-trigger-conversion" data-alt-text="Sending..." data-submit-text="Submit" aria-live="assertive" value="wpforms-submit">Submit</button><img src="https://empoweringsystems.com/wp-content/plugins/wpforms/assets/images/submit-spin.svg" class="wpforms-submit-spinner" style="display: none;" width="26" height="26" alt="Loading"></div></form></div> <!-- .wpforms-container -->