{"id":356,"date":"2016-01-27T17:28:33","date_gmt":"2016-01-27T17:28:33","guid":{"rendered":"http:\/\/onpoint.project-sites.com\/uspolymer\/?page_id=356"},"modified":"2016-01-28T19:16:11","modified_gmt":"2016-01-28T19:16:11","slug":"credit-application","status":"publish","type":"page","link":"https:\/\/sentient.project-sites.com\/polymer\/credit-application\/","title":{"rendered":"Credit Application"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_2' ><div id='gf_2' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_2' id='gform_2'  action='\/polymer\/wp-json\/wp\/v2\/pages\/356#gf_2' data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_2_29\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>We submit herewith the following information to be used as a basis for extension of credit.<\/p><\/li><li id=\"field_2_1\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_1'>Trade or Corporate Name<\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_2_1' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_2\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_2'>Initial Order ($)<\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_2_2' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_3\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_3'>Street Address<\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_2_3' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_4\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_4'>Monthly Requirement ($)<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_2_4' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_5\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_5'>City, States, and ZIP Code<\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_2_5' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_6\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_6'>Date Business Began<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_2_6' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_7\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_7'>Telephone #<\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_2_7' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_8\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_8'>Sales\/Use Tax Exempt #<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_2_8' type='text' value='' class='medium'  aria-describedby=\"gfield_description_2_8\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_2_8'>(Provincial Sales Tax Exemption in Canada)<\/div><\/li><li id=\"field_2_24\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>I. Type<\/h2><\/li><li id=\"field_2_9\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Type<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_9'><li class='gchoice gchoice_2_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.1' type='checkbox'  value='Proprietorship'  id='choice_2_9_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_1' id='label_2_9_1' class='gform-field-label gform-field-label--type-inline'>Proprietorship<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_9_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.2' type='checkbox'  value='Partnership'  id='choice_2_9_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_2' id='label_2_9_2' class='gform-field-label gform-field-label--type-inline'>Partnership<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_9_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.3' type='checkbox'  value='Corporation'  id='choice_2_9_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_3' id='label_2_9_3' class='gform-field-label gform-field-label--type-inline'>Corporation<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_10\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Ownership<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_10'><li class='gchoice gchoice_2_10_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.1' type='checkbox'  value='Public'  id='choice_2_10_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_10_1' id='label_2_10_1' class='gform-field-label gform-field-label--type-inline'>Public<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_10_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.2' type='checkbox'  value='Private'  id='choice_2_10_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_10_2' id='label_2_10_2' class='gform-field-label gform-field-label--type-inline'>Private<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_11\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Note: Notify us in writing of any change in ownership, structure, or organization within 30 days.<\/p><\/li><li id=\"field_2_25\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>II. Owner, Partners or Officers (Name and Title)<\/h2><\/li><li id=\"field_2_12\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_12'>(Name and Title)<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_2_12' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_26\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>III. Parent Company, Divisions or Subsidiaries if applicable<\/h2><\/li><li id=\"field_2_27\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_27'>(Name, address, relationship)<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_2_27' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_22\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>IV. Banking Reference<\/h2><\/li><li id=\"field_2_28\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_28'>(Name, complete address, telephone number &amp; account numbers)<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_2_28' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_23\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>V. Trade Reference<\/h2><\/li><li id=\"field_2_13\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_13'>1.) (Name, complete address, telephone number &amp; fax number)<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_2_13' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_14\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_14'>2.) (Name, complete address, telephone number &amp; fax number)<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_2_14' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_15\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_15'>3.) (Name, complete address, telephone number &amp; fax number)<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_2_15' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_17\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>VI. Financial Statement<\/h2>\n<p>Please attach a copy of your latest Financial Statement, signed by owner, partner, or officer of the business.<\/p><\/li><li id=\"field_2_16\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_16'>Fiscal Year End<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_2_16' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_18\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_18'>Sales last fiscal year ($)<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_2_18' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_19\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_19'>Current Net Worth ($)<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_2_19' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_20\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_20'>Dun &amp; Bradstreet Duns Number<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_2_20' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_21\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>VII. Other Information<\/h2><\/li><li id=\"field_2_30\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >You agree to pay within an invoice&#039;s stated payment terms.<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_30'>\n\t\t\t<li class='gchoice gchoice_2_30_0'>\n\t\t\t\t<input name='input_30' type='radio' value='Yes'  id='choice_2_30_0'    \/>\n\t\t\t\t<label for='choice_2_30_0' id='label_2_30_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_30_1'>\n\t\t\t\t<input name='input_30' type='radio' value='No'  id='choice_2_30_1'    \/>\n\t\t\t\t<label for='choice_2_30_1' id='label_2_30_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_31\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you a co-maker, endorser or guarantor on any obligations?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_31'>\n\t\t\t<li class='gchoice gchoice_2_31_0'>\n\t\t\t\t<input name='input_31' type='radio' value='Yes'  id='choice_2_31_0'    \/>\n\t\t\t\t<label for='choice_2_31_0' id='label_2_31_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_31_1'>\n\t\t\t\t<input name='input_31' type='radio' value='No'  id='choice_2_31_1'    \/>\n\t\t\t\t<label for='choice_2_31_1' id='label_2_31_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_32\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are there judgments or lawsuits pending against you?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_32'>\n\t\t\t<li class='gchoice gchoice_2_32_0'>\n\t\t\t\t<input name='input_32' type='radio' value='Yes'  id='choice_2_32_0'    \/>\n\t\t\t\t<label for='choice_2_32_0' id='label_2_32_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_32_1'>\n\t\t\t\t<input name='input_32' type='radio' value='No'  id='choice_2_32_1'    \/>\n\t\t\t\t<label for='choice_2_32_1' id='label_2_32_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_33\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you filed for bankruptcy in the last seven years?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_33'>\n\t\t\t<li class='gchoice gchoice_2_33_0'>\n\t\t\t\t<input name='input_33' type='radio' value='Yes'  id='choice_2_33_0'    \/>\n\t\t\t\t<label for='choice_2_33_0' id='label_2_33_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_33_1'>\n\t\t\t\t<input name='input_33' type='radio' value='No'  id='choice_2_33_1'    \/>\n\t\t\t\t<label for='choice_2_33_1' id='label_2_33_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_34\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you capable of making electronic fund payments?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_34'>\n\t\t\t<li class='gchoice gchoice_2_34_0'>\n\t\t\t\t<input name='input_34' type='radio' value='Yes'  id='choice_2_34_0'    \/>\n\t\t\t\t<label for='choice_2_34_0' id='label_2_34_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_34_1'>\n\t\t\t\t<input name='input_34' type='radio' value='No'  id='choice_2_34_1'    \/>\n\t\t\t\t<label for='choice_2_34_1' id='label_2_34_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_35\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>The undersigned certifies that the information set forth herein is correct and complete in all respects and authorizes release of credit information requested form bank and trade references provided.<\/p>\n\n<p>In the event that U.S. Polymers, Inc, agrees to sell product to the undersigned, the undersigned promises to pay all sums due to U.S. Polymers, Inc, for the product within agreed credit terms from date of invoice. Further, the undersigned agrees to pay the maximum interest rate allowed on all balances that have not been paid within such terms. Additionally, the undersigned agrees to promptly pay any and all costs of collection, including attorney's fees and\/or collection agent fees, incurred in the collection of any outstanding balances owing, Jurisdiction of the Massachusetts courts will apply to any dispute between Buyer and Seller and to the interpretation and enforcement of this Contract. This Contract and not be changed except such change is submitted in writing and accepted by signature of an authorized agent or office of U.S. Polymers, Inc.<\/p><\/li><li id=\"field_2_37\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_37'>Signature (by authorized agent)<\/label><div class='gfield_description' id='gfield_description_2_37'>By my eSignature below, I verify that I understand the culpability of an electronic signature as the legally binding equivalent of my physical (handwritten) signature.\u00a0I\u00a0confirm all information completed in this electronic form and authenticated by my signature to be accurate and truthful and agree to all credit terms hereto outlined by U.S. Polymers for the extension of credit.\u00a0<\/div><div class='ginput_container ginput_container_text'><input name='input_37' 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