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nowrap><span id="dnn_ctr385_dnnTITLE_lblTitle" class="Head">Request a THA MarketIQ© User License</span> </td> <td class="ctr-header-actions"></td> <td class="ctr-header-right"></td> </tr> </table> </td> </tr> <tr> <td class="mt-l"><img src="/web/20131209003243im_/http://tha-hin.com/Portals/_default/Containers/containers/spacer.gif"/></td> <td class="mt-c"></td> <td class="mt-r"><img src="/web/20131209003243im_/http://tha-hin.com/Portals/_default/Containers/containers/spacer.gif"/></td> </tr> <tr> <td class="mb-l"></td> <td id="dnn_ctr385_ContentPane" class="mb-c DNNAlignleft"><div id="dnn_ctr385_ModuleContent" class="Complete Feedback DesignerContent"> <script> function taLimit(taObj, iTotal) { if (taObj.value.length==iTotal) return false; } function taCount(taObj, visCnt, iTotal) { if (taObj.value.length > iTotal) { taObj.value = taObj.value.substring(0,iTotal); } if (visCnt) { visCnt.innerHTML = iTotal - taObj.value.length; } } </script> <span id="dnn_ctr385_CFD_lblMsg"></span> <span id="dnn_ctr385_CFD_lblIntro"><p>To request a THA MarketIQ user account, simply complete the form below and click the "Send" button. All fields all required. When THA HIN staff have established your account on the system, you will receive further instructions via e-mail.</p> <p align="center">** Please note, only employees of THA HIN member hospitals will be allowed access to THA MarketIQ **</p> <p>For questions or support, <a href="/web/20131209003243/http://tha-hin.com/ContactUs.aspx">contact us</a> or call 1-866-2THA-HIN</p> <hr width="100%" size="2"/></span> <span id="dnn_ctr385_CFD_lblError"><b><font color="Red"></font></b></span> <div id="dnn_ctr385_CFD_pnlContent"> <div id="dnn_ctr385_CFD_pnlCtrls"> <p><strong><span>Your Name</span></strong>:<br/> <input name="dnn$ctr385$CFD$tbName-7" type="text" id="dnn_ctr385_CFD_tbName-7" class="NormalTextBox"/>  <img src="/web/20131209003243im_/http://tha-hin.com/DesktopModules/Complete%20Feedback%20Designer/images/Req.gif" border="0"/><br/></p><p><strong><span>Your Email</span></strong>:<br/> <input name="dnn$ctr385$CFD$tbEmail-8" type="text" id="dnn_ctr385_CFD_tbEmail-8" class="NormalTextBox"/>  <img src="/web/20131209003243im_/http://tha-hin.com/DesktopModules/Complete%20Feedback%20Designer/images/Req.gif" border="0"/><br/></p><p><strong><span>Title</span></strong>:<br/> <input name="dnn$ctr385$CFD$cfd10" type="text" id="dnn_ctr385_CFD_cfd10" class="NormalTextBox"/>  <img src="/web/20131209003243im_/http://tha-hin.com/DesktopModules/Complete%20Feedback%20Designer/images/Req.gif" border="0"/><br/></p><p><strong><span>Organization</span></strong>:<br/> <input name="dnn$ctr385$CFD$cfd11" type="text" id="dnn_ctr385_CFD_cfd11" class="NormalTextBox"/>  <img src="/web/20131209003243im_/http://tha-hin.com/DesktopModules/Complete%20Feedback%20Designer/images/Req.gif" border="0"/><br/></p><p><strong><span>Phone Number</span></strong>:<br/> <input name="dnn$ctr385$CFD$cfd12" type="text" id="dnn_ctr385_CFD_cfd12" class="NormalTextBox"/>  <img src="/web/20131209003243im_/http://tha-hin.com/DesktopModules/Complete%20Feedback%20Designer/images/Req.gif" border="0"/><br/></p><p><strong><span>Fax Number</span></strong>:<br/> <input name="dnn$ctr385$CFD$cfd13" type="text" id="dnn_ctr385_CFD_cfd13" class="NormalTextBox"/>  <img src="/web/20131209003243im_/http://tha-hin.com/DesktopModules/Complete%20Feedback%20Designer/images/Req.gif" border="0"/><br/></p> </div> <table cellspacing="0" cellpadding="3" width="200" border="0"> <tr valign="top"> <td align="right"> <a id="dnn_ctr385_CFD_cmdCancel" title="Reset" class="CommandButton" href="javascript:__doPostBack('dnn$ctr385$CFD$cmdCancel','')">Reset</a></td> <td> <a id="dnn_ctr385_CFD_cmdSend" title="Send" class="CommandButton" href="javascript:WebForm_DoPostBackWithOptions(new WebForm_PostBackOptions("dnn$ctr385$CFD$cmdSend", "", true, "", "", false, true))">Send</a></td> <td> </td> </tr> </table> </div> </div></td> <td class="mb-r"></td> </tr> <tr> <td class="mb-l"></td> <td class="mb-c"> <table width="100%" cellpadding="0" cellspacing="0"> <tr> <td class="ctr-color-admin" nowrap></td> </tr> </table> </td> <td class="mb-r"></td> </tr> <tr> <td class="b-l"></td> <td class="b-c"></td> <td class="b-r"></td> </tr> </table> </td> </tr> </table> <table width="100%" cellpadding="0" cellspacing="0"> <tr> </tr> </table> </td> </tr> </table> </td> </tr> <tr> <td id="baseline-row" valign="top"> <table class="site-width-narrow" cellspacing="0" cellpadding="0" align="center"> <tr> </tr> </table> </td> </tr> <tr> <td id="footer-row" valign="top"> <table class="site-width-narrow" cellspacing="0" cellpadding="0" align="center"> <tr> <td class="copyright-td"><span id="dnn_dnnCOPYRIGHT_lblCopyright" class="CopyrightText">© THA/THA Health Information Network<br/>Toll Free: 1-866-2THA-HIN • Fax: 615-401-7475</span> </td> <td class="privacy-td"><a id="dnn_dnnTERMS_hypTerms" class="footer-link" rel="nofollow" href="https://web.archive.org/web/20131209003243/http://tha-hin.com/Terms.aspx">Terms Of Use</a><img src="/web/20131209003243im_/http://tha-hin.com/Portals/_default/Skins/skins/spacer.gif"/><a id="dnn_dnnPRIVACY_hypPrivacy" class="footer-link" rel="nofollow" href="https://web.archive.org/web/20131209003243/http://tha-hin.com/Privacy.aspx">Privacy Statement</a></td> </tr> </table> </td> </tr> <tr><td colspan="2"><img src="/web/20131209003243im_/http://tha-hin.com/Portals/_default/Skins/skins/spacer.gif"/> <a id="dnn_dnnLOGIN_cmdLogin" class="login-link" href="javascript:__doPostBack('dnn$dnnLOGIN$cmdLogin','')">Login</a></td></tr> </table> <script type="text/javascript"> var gaJsHost = (("https:" == document.location.protocol) ? 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