{"status":"success","response":"<div id=\"custom_forms\">\n\n<div class=\"report_row\" id=\"custom_field_row_9\"><h4>Info entered into Description textbox above=PUBLIC <br>Info entered into fields below=PRIVATE <\/h4><input type=\"text\" name=\"custom_field[9]\" value=\"\" id=\"custom_field_9\" class=\"text custom_text\" \/><\/div><div class=\"report_row\" id=\"custom_field_row_1\"><h4>Midwife Name<span class='required'> *<\/span> <\/h4><input type=\"text\" name=\"custom_field[1]\" value=\"\" id=\"custom_field_1\" class=\"text custom_text\" \/><\/div><div class=\"report_row\" id=\"custom_field_row_10\"><h4>Credential(s) (Indicate whether you are certified by either NARM or the AMCB - i.e. CPM, CNM, or CM)<span class='required'> *<\/span> <\/h4><input type=\"text\" name=\"custom_field[10]\" value=\"\" id=\"custom_field_10\" class=\"text custom_text\" \/><\/div><div class=\"report_row\" id=\"custom_field_row_2\"><h4>Primary Phone No.<span class='required'> *<\/span> <\/h4><input type=\"text\" name=\"custom_field[2]\" value=\"\" id=\"custom_field_2\" class=\"text custom_text\" \/><\/div><div class=\"report_row\" id=\"custom_field_row_3\"><h4>Secondary Phone <\/h4><input type=\"text\" name=\"custom_field[3]\" value=\"\" id=\"custom_field_3\" class=\"text custom_text\" \/><\/div><div class=\"report_row\" id=\"custom_field_row_4\"><h4>E-mail Address<span class='required'> *<\/span> <\/h4><input type=\"text\" name=\"custom_field[4]\" value=\"\" id=\"custom_field_4\" class=\"text custom_text\" \/><\/div><div class=\"report_row\" id=\"custom_field_row_5\"><h4>State Midwife is in<span class='required'> *<\/span> <\/h4><input type=\"text\" name=\"custom_field[5]\" value=\"\" id=\"custom_field_5\" class=\"text custom_text\" \/><\/div><div class=\"report_row\" id=\"custom_field_row_6\"><h4>Cities\/Counties Midwife can reach <\/h4><input type=\"text\" name=\"custom_field[6]\" value=\"\" id=\"custom_field_6\" class=\"text custom_text\" \/><\/div><div class=\"report_row\" id=\"custom_field_row_11\"><h4>Licensure (Is Midwife licensed? Provide the license credential (i.e. LM, LDEM, RM, CNM, ARNP, etc.)<span class='required'> *<\/span> <\/h4><input type=\"text\" name=\"custom_field[11]\" value=\"\" id=\"custom_field_11\" class=\"text custom_text\" \/><\/div><div class=\"report_row\" id=\"custom_field_row_8\"><h4>Midwife Website <\/h4><input type=\"text\" name=\"custom_field[8]\" value=\"\" id=\"custom_field_8\" class=\"text custom_text\" \/><\/div><\/div>"}