- "First Name" is a required field.
- "Last Name" is a required field.
- "Email" is a required field.
- "Professional Credential" is a required field.
- "Office Postal Address" is a required field.
- "City" is a required field.
- "State" is a required field.
- "Postal" is a required field.
- "Office Phone" is a required field.
- " I agree to the terms and conditions." is a required field.