{"id":1300256,"date":"2020-11-19T16:27:45","date_gmt":"2020-11-19T21:27:45","guid":{"rendered":"https:\/\/www.halyardhealth.com\/portal-del-cliente\/formulario-de-solicitud-de-acceso-al-portal-del-cliente"},"modified":"2023-03-16T13:20:18","modified_gmt":"2023-03-16T17:20:18","slug":"formulario-de-solicitud-de-acceso-al-portal-del-cliente","status":"publish","type":"page","link":"https:\/\/www.halyardhealth.com\/es\/portal-del-cliente\/formulario-de-solicitud-de-acceso-al-portal-del-cliente","title":{"rendered":"Formulario de solicitud de acceso al Portal del Cliente"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row row_type=\u00bbpage-hero\u00bb hero_size=\u00bbsmall\u00bb css=\u00bb.vc_custom_1595255598032{background-image: url(https:\/\/www.halyardhealth.com\/wp-content\/uploads\/2020\/07\/knowledge-network-hero-bg.png?id=234) !important;}\u00bb][vc_column]<div class=''><h1 class='      ' style='max-width: 100%; display:inline-block;' >Formulario de solicitud de acceso al portal del cliente<\/h1><\/div>[\/vc_column][\/vc_row][vc_row][vc_column][vc_row_inner][vc_column_inner width=\u00bb1\/4&#8243;]<div class=\"links-list post-list\">\n    <div class=\"post-list-item\">\n      <a class=\"full-link\" href=\"https:\/\/www.nahhcustomerportal.com\/ui\/Site%20Admin%20Center\/Home.aspx?ShowAlert=True\" target=\"_blank\"><\/a>\n      <div class=\"py-2\">\n        <div class=\"post-title h3 mb-0\">Place An Order<\/div>\n      <\/div>\n      <div class=\"read-more-link\">\n        <i class=\"fas fa-arrow-right\" aria-hidden=\"true\"><\/i>\n      <\/div>\n    <\/div>\n\n  \n    <div class=\"post-list-item\">\n      <a class=\"full-link\" href=\"https:\/\/www.halyardhealth.com\/customer-portal\/customer-portal-request\/\" target=\"\"><\/a>\n      <div class=\"py-2\">\n        <div class=\"post-title h3 mb-0\">Portal Enrollment<\/div>\n      <\/div>\n      <div class=\"read-more-link\">\n        <i class=\"fas fa-arrow-right\" aria-hidden=\"true\"><\/i>\n      <\/div>\n    <\/div>\n\n  \n    <div class=\"post-list-item\">\n      <a class=\"full-link\" href=\"http:\/\/www.hyhcustomerportal.com\/\" target=\"_blank\"><\/a>\n      <div class=\"py-2\">\n        <div class=\"post-title h3 mb-0\">Portal Sign In<\/div>\n      <\/div>\n      <div class=\"read-more-link\">\n        <i class=\"fas fa-arrow-right\" aria-hidden=\"true\"><\/i>\n      <\/div>\n    <\/div>\n\n  \n    <div class=\"post-list-item\">\n      <a class=\"full-link\" href=\"http:\/\/mktaccess.halyardhealth.com\/num2neuusape\/num2neuusape.asp?selLanguage=en-US\" target=\"_blank\"><\/a>\n      <div class=\"py-2\">\n        <div class=\"post-title h3 mb-0\">Request\/Forgot Password<\/div>\n      <\/div>\n      <div class=\"read-more-link\">\n        <i class=\"fas fa-arrow-right\" aria-hidden=\"true\"><\/i>\n      <\/div>\n    <\/div>\n\n  \n    <div class=\"post-list-item\">\n      <a class=\"full-link\" href=\"http:\/\/compliance.owens-minor.com\/DistributorToolkit.html\" target=\"\"><\/a>\n      <div class=\"py-2\">\n        <div class=\"post-title h3 mb-0\">Distributor Tool Kit<\/div>\n      <\/div>\n      <div class=\"read-more-link\">\n        <i class=\"fas fa-arrow-right\" aria-hidden=\"true\"><\/i>\n      <\/div>\n    <\/div>\n\n  <\/div>[\/vc_column_inner][vc_column_inner width=\u00bb3\/4&#8243;]<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\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\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_33' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Customer Portal Request<\/h2>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_33'  action='\/es\/wp-json\/wp\/v2\/pages\/1300256' data-formid='33' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_33' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_33_1\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_33_29\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Step 1<\/h3><\/div><div id=\"field_33_3\" class=\"gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_33_3'>Are you currently purchasing direct from Halyard?<\/label><div class='ginput_container ginput_container_select'><select name='input_3' id='input_33_3' class='large gfield_select'     aria-invalid=\"false\" ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/div><\/div><div id=\"field_33_30\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><ul>\n<li>If your organization is not a direct customer, then Customer Portal access is not available.<\/li>\n<li> If your organization is interested in purchasing Surgical and Infection Prevention products, please contact your distributor to find out what options are available.<\/li>\n<\/ul><\/div><div id=\"field_33_43\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Step 2<\/h3><\/div><div id=\"field_33_4\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Please complete the following information to create your Customer Portal User ID:<\/div><div id=\"field_33_5\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_33_5'>Customer Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_33_5' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_33_14\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_33_14'>Company Name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_33_14' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_33_15\" class=\"gfield gfield--type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Company Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_33_15' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_33_15_1_container' >\n                                        <input type='text' name='input_15.1' id='input_33_15_1' value=''    aria-required='true'    \/>\n                                        <label for='input_33_15_1' id='input_33_15_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_33_15_2_container' >\n                                        <input type='text' name='input_15.2' id='input_33_15_2' value=''     aria-required='false'   \/>\n                                        <label for='input_33_15_2' id='input_33_15_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_33_15_3_container' >\n                                    <input type='text' name='input_15.3' id='input_33_15_3' value=''    aria-required='true'    \/>\n                                    <label for='input_33_15_3' id='input_33_15_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_33_15_4_container' >\n                                        <input type='text' name='input_15.4' id='input_33_15_4' value=''      aria-required='true'    \/>\n                                        <label for='input_33_15_4' id='input_33_15_4_label' class='gform-field-label gform-field-label--type-sub '>Estado \/ Provincia \/ Regi\u00f3n<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_33_15_5_container' >\n                                    <input type='text' name='input_15.5' id='input_33_15_5' value=''    aria-required='true'    \/>\n                                    <label for='input_33_15_5' id='input_33_15_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ C\u00f3digo Postal<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_33_15_6_container' >\n                                        <select name='input_15.6' id='input_33_15_6'   aria-required='true'    ><option value='' ><\/option><option value='United States' selected='selected'>United States<\/option><option value='Canada' >Canada<\/option><option value='Mexico' >Mexico<\/option><option value='Puerto Rico' >Puerto Rico<\/option><\/select>\n                                        <label for='input_33_15_6' id='input_33_15_6_label' class='gform-field-label gform-field-label--type-sub '>Pa\u00eds<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_33_16\" class=\"gfield gfield--type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_33_16'>Company Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_16' id='input_33_16' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_33_18\" class=\"gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_33_18'>Company Fax Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_18' id='input_33_18' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_33_17\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_33_17'>\n                            \n                            <span id='input_33_17_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_17.3' id='input_33_17_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_33_17_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            \n                            <span id='input_33_17_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_17.6' id='input_33_17_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_33_17_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_33_19\" class=\"gfield gfield--type-email gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Email<\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_33_19_container'>\n                                <span id='input_33_19_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_19' id='input_33_19' value=''     aria-invalid=\"false\"  \/>\n                                    <label for='input_33_19' class='gform-field-label gform-field-label--type-sub '>Introduce un email<\/label>\n                                <\/span>\n                                <span id='input_33_19_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_19_2' id='input_33_19_2' value=''     aria-invalid=\"false\"  \/>\n                                    <label for='input_33_19_2' class='gform-field-label gform-field-label--type-sub '>Confirmar email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_33_25\" class=\"gfield gfield--type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_33_25'>Department<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_25' id='input_33_25' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Accounting\/Finance' >Accounting\/Finance<\/option><option value='Administration' >Administration<\/option><option value='Anesthesiology' >Anesthesiology<\/option><option value='Hospital' >Hospital<\/option><option value='Marketing' >Marketing<\/option><option value='Pharmacy\/Chemist' >Pharmacy\/Chemist<\/option><option value='Procurement' >Procurement<\/option><option value='Purchasing\/Materials Management' >Purchasing\/Materials Management<\/option><option value='Sales' >Sales<\/option><option value='Surgical Service' >Surgical Service<\/option><option value='Warehousing and Distribution' >Warehousing and Distribution<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_33_24\" class=\"gfield gfield--type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_33_24'>Job role<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_24' id='input_33_24' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Assistant' >Assistant<\/option><option value='Auditor' >Auditor<\/option><option value='Buyer' >Buyer<\/option><option value='Coordinator' >Coordinator<\/option><option value='Manager\/Supervisor' >Manager\/Supervisor<\/option><option value='Nurse' >Nurse<\/option><option value='Operations' >Operations<\/option><option value='Physician\/Doctor' >Physician\/Doctor<\/option><option value='Physician Assistant (P.A.)' >Physician Assistant (P.A.)<\/option><option value='Sales Representative' >Sales Representative<\/option><option value='Surgeon' >Surgeon<\/option><option value='Worker' >Worker<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_33_27\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_33_27'>Halyard Rep<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_33_27' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_33_28\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >If you have other locations for your company where you will require Customer Portal access, please list them below. Each location must have a unique customer account number. If you need additional entries, please include them in the Comments box. <\/div><div id=\"field_33_32\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_33_32'>Customer Number<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_33_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_33_33\" class=\"gfield gfield--type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Customer Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_33_33' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_33_33_1_container' >\n                                        <input type='text' name='input_33.1' id='input_33_33_1' value=''    aria-required='false'    \/>\n                                        <label for='input_33_33_1' id='input_33_33_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_33_33_2_container' >\n                                        <input type='text' name='input_33.2' id='input_33_33_2' value=''     aria-required='false'   \/>\n                                        <label for='input_33_33_2' id='input_33_33_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_33_33_3_container' >\n                                    <input type='text' name='input_33.3' id='input_33_33_3' value=''    aria-required='false'    \/>\n                                    <label for='input_33_33_3' id='input_33_33_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_33_33_4_container' >\n                                        <input type='text' name='input_33.4' id='input_33_33_4' value=''      aria-required='false'    \/>\n                                        <label for='input_33_33_4' id='input_33_33_4_label' class='gform-field-label gform-field-label--type-sub '>Estado \/ Provincia \/ Regi\u00f3n<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_33_33_5_container' >\n                                    <input type='text' name='input_33.5' id='input_33_33_5' value=''    aria-required='false'    \/>\n                                    <label for='input_33_33_5' id='input_33_33_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ C\u00f3digo Postal<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_33_33_6_container' >\n                                        <select name='input_33.6' id='input_33_33_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='United States' >United States<\/option><option value='Canada' >Canada<\/option><option value='Mexico' >Mexico<\/option><option value='Puerto Rico' >Puerto Rico<\/option><\/select>\n                                        <label for='input_33_33_6' id='input_33_33_6_label' class='gform-field-label gform-field-label--type-sub '>Pa\u00eds<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_33_36\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_33_36'>Customer Number<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_33_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_33_39\" class=\"gfield gfield--type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Customer Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_33_39' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_33_39_1_container' >\n                                        <input type='text' name='input_39.1' id='input_33_39_1' value=''    aria-required='false'    \/>\n                                        <label for='input_33_39_1' id='input_33_39_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_33_39_2_container' >\n                                        <input type='text' name='input_39.2' id='input_33_39_2' value=''     aria-required='false'   \/>\n                                        <label for='input_33_39_2' id='input_33_39_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_33_39_3_container' >\n                                    <input type='text' name='input_39.3' id='input_33_39_3' value=''    aria-required='false'    \/>\n                                    <label for='input_33_39_3' id='input_33_39_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_33_39_4_container' >\n                                        <input type='text' name='input_39.4' id='input_33_39_4' value=''      aria-required='false'    \/>\n                                        <label for='input_33_39_4' id='input_33_39_4_label' class='gform-field-label gform-field-label--type-sub '>Estado \/ Provincia \/ Regi\u00f3n<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_33_39_5_container' >\n                                    <input type='text' name='input_39.5' id='input_33_39_5' value=''    aria-required='false'    \/>\n                                    <label for='input_33_39_5' id='input_33_39_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ C\u00f3digo Postal<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_33_39_6_container' >\n                                        <select name='input_39.6' id='input_33_39_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='United States' >United States<\/option><option value='Canada' >Canada<\/option><option value='Mexico' >Mexico<\/option><option value='Puerto Rico' >Puerto Rico<\/option><\/select>\n       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gform-field-label gfield_label_before_complex' >Customer Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_33_38' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_33_38_1_container' >\n                                        <input type='text' name='input_38.1' id='input_33_38_1' value=''    aria-required='false'    \/>\n                                        <label for='input_33_38_1' id='input_33_38_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_33_38_2_container' >\n                                        <input type='text' name='input_38.2' id='input_33_38_2' value=''     aria-required='false'   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