<p>Business name</p>
<input type="text" name="business_name">
<p>Dba</p>
<input type="text" name="dba">
<p>Tax id</p>
<input type="text" name="tax_id">
<p>License</p>
<input type="text" name="license">
<p>Dea</p>
<input type="text" name="dea">
<p>Medicaire</p>
<input type="text" name="medicaire">
<p>Clia</p>
<input type="text" name="clia">
<p>Contact name</p>
<input type="text" name="contact_name">
<p>Contact email</p>
<input type="text" name="contact_email">
<p>Contact number</p>
<input type="text" name="contact_number">
<p>Address </p>
<input type="text" name="address_1">
<p>Address </p>
<input type="text" name="address_2">
<p>City</p>
<input type="text" name="city">
<p>County</p>
<input type="text" name="county">
<p>Contact email </p>
<input type="text" name="contact_email_2">
<p>Contact number </p>
<input type="text" name="contact_number_2">
<p>Fax</p>
<input type="text" name="fax">
<p>State</p>
<input type="text" name="state">
<p>Zip</p>
<input type="text" name="zip4">
<p>Mail to address</p>
<input type="text" name="mail_to_address">
<p>Mail to email</p>
<input type="text" name="mail_to_email">
<p>Mail to phone</p>
<input type="text" name="mail_to_phone">
<p>Pay to address</p>
<input type="text" name="pay_to_address">
<p>Pay to email</p>
<input type="text" name="pay_to_email">
<p>Pay to city</p>
<input type="text" name="pay_to_city">
<p>Pay to phone</p>
<input type="text" name="pay_to_phone">
<p>Pay to fax</p>
<input type="text" name="pay_to_fax">
<p>Pay to county</p>
<input type="text" name="pay_to_county">
<p>Home phone</p>
<input type="text" name="home_phone">
<p>Home address</p>
<input type="text" name="home_address">
<p>Home city</p>
<input type="text" name="home_city">
<p>Home county</p>
<input type="text" name="home_county">
<p>Home fax</p>
<input type="text" name="home_fax">
<p>Home state zip</p>
<input type="text" name="home_state_zip">
<p>Npi</p>
<input type="text" name="npi">
<p>Taxonomy</p>
<input type="text" name="taxonomy">
<p>Zip </p>
<input type="text" name="zip_">
<p>Primary specialty</p>
<input type="text" name="primary_specialty">
<p>Primary taxonomy</p>
<input type="text" name="primary_taxonomy">
<p>Secondary specialty</p>
<input type="text" name="secondary_specialty">
<p>Secondary taxonomy</p>
<input type="text" name="secondary_taxonomy">
<p>Third specialty</p>
<input type="text" name="third_specialty">
<p>Third taxonomy</p>
<input type="text" name="third_taxonomy">
<p>Fourth specialty</p>
<input type="text" name="fourth_specialty">
<p>Fourth taxonomy</p>
<input type="text" name="fourth_taxonomy">
<p>Business license </p>
<input type="text" name="business_license_3">
<p>Type of pharmacy </p>
<input type="text" name="type_of_pharmacy_3">
<p>Business name </p>
<input type="text" name="business_name_3">
<p>Pharmacist license </p>
<input type="text" name="pharmacist_license_3">
<p>Pharmacist name </p>
<input type="text" name="pharmacist_name_3">
<p>Bank state zip </p>
<input type="text" name="bank_state_zip_3">
<p>Bank branch </p>
<input type="text" name="bank_branch_3">
<p>Aba routing number </p>
<input type="text" name="aba_routing_number_3">
<p>Name on bank account </p>
<input type="text" name="name_on_bank_account_3">
<p>Name  </p>
<input type="text" name="name_3_3">
<p>Name  </p>
<input type="text" name="name_1_3">
<p>System vendor name </p>
<input type="text" name="system_vendor_name_3">
<p>Grouping preference number </p>
<input type="text" name="grouping_preference_number_3">
<p>Phone number </p>
<input type="text" name="phone_number_3">
<p>City </p>
<input type="text" name="city_3">
<p>Bank name </p>
<input type="text" name="bank_name_3">
<p>Bank account number </p>
<input type="text" name="bank_account_number_3">
<p>Name  </p>
<input type="text" name="name_4_3">
<p>Name  </p>
<input type="text" name="name_2_3">
<p>Zip  </p>
<input type="text" name="zip_4_4">
<p>City  </p>
<input type="text" name="city_4_4">
<p>Licensenumber   </p>
<input type="text" name="licensenumber_4_4_4">
<p>Owner </p>
<input type="text" name="owner_4">
<p>Ssn  </p>
<input type="text" name="ssn_4_4">
<p>Ownername  </p>
<input type="text" name="ownername_4_4">
<p>Address </p>
<input type="text" name="address_4">
<p>Dateofbirth </p>
<input type="text" name="dateofbirth_4">
<p>Zip </p>
<input type="text" name="zip_4">
<p>City </p>
<input type="text" name="city_4">
<p>Phone  </p>
<input type="text" name="phone_4_4">
<p>Licensenumber  </p>
<input type="text" name="licensenumber_4_4">
<p>Ownerpercentpharmacist </p>
<input type="text" name="ownerpercentpharmacist_4">
<p>Ownerssnpharmacist </p>
<input type="text" name="ownerssnpharmacist_4">
<p>Ownernamepharmacist </p>
<input type="text" name="ownernamepharmacist_4">
<p>Dateofbirthpharmacist </p>
<input type="text" name="dateofbirthpharmacist_4">
<p>Addresspharmacist </p>
<input type="text" name="addresspharmacist_4">
<p>Ownername </p>
<input type="text" name="ownername_4">
<p>Ssn </p>
<input type="text" name="ssn_4">
<p>Ownerpercent </p>
<input type="text" name="ownerpercent_4">
<p>Licensenumber </p>
<input type="text" name="licensenumber_4">
<p>Phone </p>
<input type="text" name="phone_4">
<p>Dateofbirth  </p>
<input type="text" name="dateofbirth_4_4">
<p>Address  </p>
<input type="text" name="address_4_4">
<p>City </p>
<input type="text" name="city_5">
<p>Zip </p>
<input type="text" name="zip_5">
<p>Owner </p>
<input type="text" name="owner_5">
<p>Ssn </p>
<input type="text" name="ssn_5">
<p>Owner  </p>
<input type="text" name="owner_5_5">
<p>License </p>
<input type="text" name="license_5">
<p>Phone </p>
<input type="text" name="phone_5">
<p>City  </p>
<input type="text" name="city_5_5">
<p>Date </p>
<input type="text" name="date_5">
<p>Address </p>
<input type="text" name="address_5">
<p>Owner name </p>
<input type="text" name="owner_name_7">
<p>Date of submission </p>
<input type="text" name="date_of_submission_7">
<p>Atn </p>
<input type="text" name="atn_7">
<p>Home email</p>
<input type="text" name="home_email">
<p>State zip</p>
<input type="text" name="state_zip">
<p>Pay to state zip</p>
<input type="text" name="pay_to_state_zip">
<p>Practice type</p>
<input type="text" name="practice_type">
<p>Base pdf</p>
<input type="text" name="base_pdf">