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Cannot Access My Account
Need Certificate For Completed Course
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Housing Question
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Staff Offboarding
Staff Onboarding
<div class="control-group ticket_section"> <label class=" control-label cf_current_email_1227156-label " for="helpdesk_ticket_cf_current_email_1227156">Tell us what email you are trying to use</label> <div class="controls "> <input class=" text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_current_email_1227156]" id="helpdesk_ticket_custom_field_cf_current_email_1227156" /> </div> </div> <div class="control-group ticket_section"> <label class=" control-label cf_old_email_1227156-label " for="helpdesk_ticket_cf_old_email_1227156">Tell us if there is another email(s) that you may have used</label> <div class="controls "> <input class=" text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_old_email_1227156]" id="helpdesk_ticket_custom_field_cf_old_email_1227156" /> </div> </div> <div class="control-group ticket_section"> <label class=" control-label cf_old_course_1227156-label " for="helpdesk_ticket_cf_old_course_1227156">Tell us the name(s) of courses you may have taken with AHEC</label> <div class="controls "> <input class=" text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_old_course_1227156]" id="helpdesk_ticket_custom_field_cf_old_course_1227156" /> </div> </div>
<div class="control-group ticket_section"> <label class=" required control-label cf_ahec_1227156-label " for="helpdesk_ticket_cf_ahec_1227156">AHEC</label> <div class="controls "> <select class=" required dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_ahec_1227156]" id="helpdesk_ticket_custom_field_cf_ahec_1227156"><option value="">...</option> <option data-id="47000350195" value="Area L">Area L</option> <option data-id="47000350196" value="Charlotte">Charlotte</option> <option data-id="47000350197" value="Eastern">Eastern</option> <option data-id="47000350198" value="Greensboro">Greensboro</option> <option data-id="47000350199" value="Mountain">Mountain</option> <option data-id="47000350200" value="Northwest">Northwest</option> <option data-id="47000350201" value="South East">South East</option> <option data-id="47000350202" value="Southern Regional">Southern Regional</option> <option data-id="47000350203" value="Wake">Wake</option></select> </div> </div>
<div class="control-group ticket_section"> <label class=" required control-label cf_name_of_staff_to_be_separated_1227156-label " for="helpdesk_ticket_cf_name_of_staff_to_be_separated_1227156">Name of Staff to Be Separated</label> <div class="controls "> <input class=" required text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_name_of_staff_to_be_separated_1227156]" id="helpdesk_ticket_custom_field_cf_name_of_staff_to_be_separated_1227156" /> </div> </div> <div class="control-group ticket_section"> <label class=" required control-label cf_date_to_cut_access_1227156-label " for="helpdesk_ticket_cf_date_to_cut_access_1227156">Date to Cut Access</label> <div class="controls support-date-field "> <input type="text" name="helpdesk_ticket[custom_field][cf_date_to_cut_access_1227156]" id="helpdesk_ticket_custom_field_cf_date_to_cut_access_1227156" class=" required date section_field datepicker_popover" readonly="readonly" data-show-image="true" data-date-format="d M, yy" placeholder="" /> </div> </div> <div class="control-group ticket_section"> <div class="controls"> <label class="checkbox "> <input name="helpdesk_ticket[custom_field][cf_ps_coach_1227156]" type="hidden" value="0" /><input class=" checkbox section_field" id="helpdesk_ticket_custom_field_cf_ps_coach_1227156_47001750739" type="checkbox" value="1" name="helpdesk_ticket[custom_field][cf_ps_coach_1227156]" /> Check if this person is a practice support coach </label> </div> </div> <div class="control-group ticket_section"> <div class="controls"> <label class="checkbox "> <input name="helpdesk_ticket[custom_field][cf_health_careers_1227156]" type="hidden" value="0" /><input class=" checkbox section_field" id="helpdesk_ticket_custom_field_cf_health_careers_1227156_47001750739" type="checkbox" value="1" name="helpdesk_ticket[custom_field][cf_health_careers_1227156]" /> Check if this person works in Health Careers systems </label> </div> </div> <div class="control-group ticket_section"> <label class=" control-label cf_other_notes_1227156-label " for="helpdesk_ticket_cf_other_notes_1227156">Any special notes about this separation</label> <div class="controls "> <textarea class=" paragraph section_field span12" rows="6" placeholder="" name="helpdesk_ticket[custom_field][cf_other_notes_1227156]" id="helpdesk_ticket_custom_field_cf_other_notes_1227156"> </textarea> </div> </div>
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