{"id":907,"date":"2020-04-15T19:42:00","date_gmt":"2020-04-15T19:42:00","guid":{"rendered":"https:\/\/nma1.org\/141\/?page_id=907"},"modified":"2020-04-15T19:45:47","modified_gmt":"2020-04-15T19:45:47","slug":"withdrawal","status":"publish","type":"page","link":"https:\/\/nma1.org\/141\/withdrawal\/","title":{"rendered":"Withdrawal Form"},"content":{"rendered":"\n<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-906\"><form id=\"wpforms-form-906\" class=\"wpforms-validate wpforms-form\" data-formid=\"906\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/141\/wp-json\/wp\/v2\/pages\/907\" data-token=\"f328f561f27ea35ae2ed9a4cd88bf653\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-906-field_12-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-906-field_12\">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-906-field_12\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][12][first]\" required><label for=\"wpforms-906-field_12\" class=\"wpforms-field-sublabel after \">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-906-field_12-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][12][last]\" required><label for=\"wpforms-906-field_12-last\" class=\"wpforms-field-sublabel after \">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-906-field_23-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-906-field_23\">Employee ID <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-906-field_23\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][23]\" required><\/div><div id=\"wpforms-906-field_27-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-906-field_27\">Employee Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-906-field_27\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][27]\" required><\/div><div id=\"wpforms-906-field_24-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-906-field_24\">Job Title <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-906-field_24\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][24]\" required><\/div><div id=\"wpforms-906-field_25-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-906-field_25\">Address<\/label><input type=\"text\" id=\"wpforms-906-field_25\" class=\"wpforms-field-medium\" name=\"wpforms[fields][25]\" ><\/div><div id=\"wpforms-906-field_16-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-906-field_16\">Home Phone Number<\/label><input type=\"number\" pattern=\"\\d*\" id=\"wpforms-906-field_16\" class=\"wpforms-field-medium\" name=\"wpforms[fields][16]\" ><\/div><div id=\"wpforms-906-field_5-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-906-field_5\">Organization <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-906-field_5\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-906-field_5_1\" name=\"wpforms[fields][5]\" value=\"BCBSM\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-906-field_5_1\">BCBSM<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-906-field_5_3\" name=\"wpforms[fields][5]\" value=\"BCN\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-906-field_5_3\">BCN<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-906-field_5_2\" name=\"wpforms[fields][5]\" value=\"Emerging Markets\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-906-field_5_2\">Emerging Markets<\/label><\/li><\/ul><\/div><div id=\"wpforms-906-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-906-field_9\">Department\/Division <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-906-field_9\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][9]\" required><\/div><div id=\"wpforms-906-field_18-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-906-field_18\">Cancel Payroll Authorization <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-906-field_18\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-906-field_18_1\" name=\"wpforms[fields][18][]\" value=\"Payroll deduction is cancelled\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-906-field_18_1\">Payroll deduction is cancelled<\/label><\/li><\/ul><div class=\"wpforms-field-description\">I hereby authorize the BCBSM payroll department to cancel the deduction of $4.10 each month from my monthly salary for BCBSM Leadership Development Association dues. I understand this cancellation will be effective for the following month's dues.<\/div><\/div><div id=\"wpforms-906-field_26-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-906-field_26\">Share your experience<\/label><textarea id=\"wpforms-906-field_26\" class=\"wpforms-field-medium\" name=\"wpforms[fields][26]\" ><\/textarea><\/div><\/div><div class=\"wpforms-field wpforms-field-hp\"><label for=\"wpforms-906-field-hp\" class=\"wpforms-field-label\">Name<\/label><input type=\"text\" name=\"wpforms[hp]\" id=\"wpforms-906-field-hp\" class=\"wpforms-field-medium\"><\/div><div class=\"wpforms-submit-container\"><input type=\"hidden\" name=\"wpforms[id]\" value=\"906\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"2\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-906\" class=\"wpforms-submit\" data-alt-text=\"Sending... you&#039;re almost done\" data-submit-text=\"SUBMIT NOW\" aria-live=\"assertive\" value=\"wpforms-submit\">SUBMIT NOW<\/button><\/div><\/form><\/div>  <!-- .wpforms-container -->\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"_links":{"self":[{"href":"https:\/\/nma1.org\/141\/wp-json\/wp\/v2\/pages\/907"}],"collection":[{"href":"https:\/\/nma1.org\/141\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/nma1.org\/141\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/nma1.org\/141\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/nma1.org\/141\/wp-json\/wp\/v2\/comments?post=907"}],"version-history":[{"count":2,"href":"https:\/\/nma1.org\/141\/wp-json\/wp\/v2\/pages\/907\/revisions"}],"predecessor-version":[{"id":912,"href":"https:\/\/nma1.org\/141\/wp-json\/wp\/v2\/pages\/907\/revisions\/912"}],"wp:attachment":[{"href":"https:\/\/nma1.org\/141\/wp-json\/wp\/v2\/media?parent=907"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}