<div class="alert alert-warning" id="form-container">
<h2 class="block-title">For More Information</h2>
<form action="/" method="POST" id="request_form">
<input keyname="" name="captcha_settings" type="hidden" value="{"/>
<input name="orgid" type="hidden" value="00D390000005Z6D"/>
<!--Form Info -->
<label class="hidden" for="name">Name</label><br/>
<input class="form-control" id="name" maxlength="80" name="name" placeholder="Name *" required="required" size="20" type="text"/>
<label class="hidden" for="phone">Phone</label><br/>
<input class="form-control" id="phone" maxlength="40" name="phone" placeholder="Phone *" required="required" size="20" type="text"/>
<label class="hidden" for="email">Email</label><br/>
<input class="form-control" id="email" maxlength="80" name="email" placeholder="Email *" required="required" size="20" type="email"/>
<br />
<!--SMS Opt In-->
<div class="form-check">
<label class="form-check-label">
<input class="form-check-input" id="smsCheck" type="checkbox" value=""/>
<small>I would like to receive occasional support and advising for the selected program via text message to the phone number provided. Message and data rates may apply. Reply HELP for help or STOP to cancel.</small>
</label>
</div>
<!--CE/DE Record type, edit value if necessary-->
<input id="recordType" name="recordType" type="hidden" value="0120z000000UPbc"/>
<!-- Interest Area--><input id="00N0z000003GGtk" name="00N0z000003GGtk" type="hidden" value="CE0005"/>
<!-- Event Tag --> <input id="00N0z000003O0Xj" name="00N0z000003O0Xj" type="hidden" value="MCS" />
<!-- Campaign --> <input data-defaultvalue="hZql-RFI%20-%20Medical%20Coding%20Certificate" id="00N0z000003GGtU" name="00N0z000003GGtU" type="hidden" value="hZql-RFI%20-%20Medical%20Coding%20Certificate" />
<!--Description edit value-->
<input id="description" name="description" type="hidden" value="RFI Form completed for Medical Coding Specialist Certificate"/>
<!--Case Type, edit value if necessary-->
<input id="type" name="type" type="hidden" value="Recruitment"/>
<!--Thank you/return url edit value-->
<input id="retURL" name="retURL" type="hidden" value="https://professional.charlotte.edu/programs/thank-you" />
<label class="hidden" for="submitBtn">Submit</label>
<div id="submitContainer">
<button class="button button-small button-green noFloat" id="submitBtn" name="submit" type="submit">
<span id="submitText">Submit</span>
</button>
</div>
</br>
<div id="ErrorAlert" class="alert-danger alert" role="alert" style="display:none">
<!--Edit text to edit the error alert.-->
There was an error submitting your request. If this issue persists, please contact our registration center at <a href="mailto:ceregistration@uncc.edu">ceregistration@uncc.edu</a> or <a href="tel:704-687-8900">704-687-8900</a>.
</div>
<div id="recaptchaText">
<!-- Do not edit this text, it is required to be present-->
<p><small>This site is protected by reCAPTCHA and the Google <a href="https://policies.google.com/privacy">Privacy Policy</a> and <a href="https://policies.google.com/terms">Terms of Service</a> apply.</small> </p>
</div>
</form>
</div>
