Application.getConciergeUrl = function(required struct contextStruct) {
          var contextJSON = serializeJSON(contextStruct);
          var encrypted = URLEncodedFormat(Encrypt(contextJSON, Application.secretKey, "AES/CBC/PKCS5Padding", "Base64"));
          return "/Process_Auto.cfm?context=" & encrypted;
      };


<!-- Page: form_temp_info.cfm -->

 

<header>
  <nav class="navbar navbar-expand-md navbar-dark fixed-top bg-dark">
    <div class="container">
      <a class="navbar-brand d-flex align-items-center gap-2" href="/">
        <img src="/images/logos/UBS-Logo.png" alt="The UBSI Group" style="height:40px;" loading="lazy">
        <span class="fw-bold">The UBSI Group</span>
      </a>
      <button class="navbar-toggler" type="button" data-bs-toggle="collapse" data-bs-target="#ubsiMainNav" aria-controls="#ubsiMainNav" aria-expanded="false" aria-label="Toggle navigation">
        <span class="navbar-toggler-icon"></span>
      </button>
      
      <div class="collapse navbar-collapse" id="ubsiMainNav">
        <ul class="navbar-nav me-auto mb-2 mb-md-0">
          <li class="nav-item"><a class="nav-link" href="/">Home</a></li>
          <li class="nav-item"><a class="nav-link" href="/Process_Auto.cfm?isFinance=1&noFlags=1">Mortgage Finance</a></li>
          <li class="nav-item"><a class="nav-link" href="/Process_Auto.cfm?isRealEstate=1&noFlags=1">Real Estate</a></li>
          <li class="nav-item"><a class="nav-link" href="/Process_Auto.cfm?isInsurance=1&noFlags=1">Insurance</a></li>
          <li class="nav-item"><a class="nav-link" href="/Process_Auto.cfm?isProduct=1&noFlags=1">Consumer Products</a></li>
        </ul>
        <a class="btn btn-outline-light" href="/contact/">Contact</a>
      </div>

    </div>
  </nav>
</header>

<div class="container my-5 checkout-container">
  <div class="row g-5">
    <div class="col-md-5 col-lg-4 order-md-last">
      <div class="checkout-summary">
        <h4 class="d-flex justify-content-between align-items-center mb-3">
          <span class="text-primary">Concierge summary</span>
          <span class="badge bg-primary rounded-pill">Concierge Request</span>
        </h4>
        <ul class="list-group mb-3">
          		
        </ul>
        <p class="small text-muted">*Savings vary by partner, transaction size, and state regulations. The concierge team will confirm eligibility.</p>
      </div>
    </div>
    <div class="col-md-7 col-lg-8">
      <h3 class="mb-3">Tell us about yourself</h3>
      <form action="form_temp_info.cfm" method="post" class="needs-validation" novalidate>
        <input type="hidden" name="csrfToken" value="A29F8D5F-5056-BF34-3F865DE8BC73A98F">
        

        <div class="row g-3">
          <div class="col-sm-6">
            <label class="form-label" for="firstName">First name</label>
            <input class="form-control" id="firstName" name="firstName" type="text" value="" required>
            <div class="invalid-feedback">Valid first name is required.</div>
          </div>
          <div class="col-sm-6">
            <label class="form-label" for="lastName">Last name</label>
            <input class="form-control" id="lastName" name="lastName" type="text" value="" required>
            <div class="invalid-feedback">Valid last name is required.</div>
          </div>
          <div class="col-12">
            <label class="form-label" for="email">Email</label>
            <input class="form-control" id="email" name="email" type="email" value="" required>
            <div class="invalid-feedback">Please enter a valid email.</div>
          </div>
          <div class="col-12">
            <label class="form-label" for="addr1">Address</label>
            <input class="form-control" id="addr1" name="addr1" type="text" value="">
          </div>
          <div class="col-md-6">
            <label class="form-label" for="city">City</label>
            <input class="form-control" id="city" name="City" type="text" value="">
          </div>
          <div class="col-md-3">
            <label class="form-label" for="state">State</label>
            <input class="form-control" id="state" name="State" type="text" value="">
          </div>
          <div class="col-md-3">
            <label class="form-label" for="zip">Zip</label>
            <input class="form-control" id="zip" name="Zip" type="text" value="" pattern="^\d{5}(-\d{4})?$" required>
            <div class="invalid-feedback">Zip code required.</div>
          </div>
        </div>

        <hr class="my-4">

        <div class="row g-3">
          <div class="col-md-6">
            <label class="form-label" for="dayPhone">Day phone</label>
            <input class="form-control" id="dayPhone" name="BPhone" type="tel" value="">
          </div>
          <div class="col-md-6">
            <label class="form-label" for="eveningPhone">Evening phone</label>
            <input class="form-control" id="eveningPhone" name="homePhone" type="tel" value="">
          </div>
          <div class="col-md-6">
            <label class="form-label" for="mobilePhone">Mobile phone</label>
            <input class="form-control" id="mobilePhone" name="CellPhone" type="tel" value="">
          </div>
          <div class="col-md-6">
            <label class="form-label" for="fax">Fax</label>
            <input class="form-control" id="fax" name="Fax" type="text" value="">
          </div>
        </div>

        <hr class="my-4">

        <h4 class="mb-3">Concierge preferences</h4>
        <div class="row g-3">
          <div class="col-md-6">
            <label class="form-label" for="contactTime">Best contact time</label>
            <select class="form-select" id="contactTime" name="ContactTime">
              
                <option value="Morning" >Morning</option>
  
                <option value="Afternoon" >Afternoon</option>
  
                <option value="Evening" >Evening</option>
  
                <option value="Anytime" >Anytime</option>
  
            </select>
          </div>
          <div class="col-md-6">
            <label class="form-label" for="referralSource">How did you hear about us?</label>
            <select class="form-select" id="referralSource" name="referredBy">
              <option value="">Select an option</option>
              
                <option value="Organization" >Organization</option>
	
                <option value="Searching&#x20;Web" >Searching Web</option>
	
                <option value="Internet" >Internet</option>
	
                <option value="TV" >TV</option>
	
                <option value="Newspaper" >Newspaper</option>
	
                <option value="Referral&#x20;From&#x20;Friend" >Referral From Friend</option>
	
                <option value="E-mail" >E-mail</option>
	
                <option value="Mailing" >Mailing</option>
	
</select>
          </div>
          <div class="col-12">
            <div class="form-check">
              <input class="form-check-input" id="referredFlag" name="referredFlag" type="checkbox" value="1" >
              <label class="form-check-label" for="referredFlag">I was referred by my organization</label>
            </div>
          </div>
          <div class="col-12">
            <label class="form-label" for="NameOfOrg">Organization name</label>
            <input class="form-control" id="NameOfOrg" name="NameOfOrg" type="text" value="">
          </div>
        </div>

        <hr class="my-4">

        <div class="mb-3">
          <label class="form-label" for="message">How can we help?</label>
          <textarea class="form-control" id="message" name="message" rows="4"></textarea>
        </div>

        <div class="form-check mb-3">
          <input class="form-check-input" id="OptIn" name="OptIn" type="checkbox" value="1" >
          <label class="form-check-label" for="OptIn">Send me future UBSI Group savings insights</label>
        </div>

        

        <hr class="my-4">

        <button class="w-100 btn btn-advisor btn-lg" type="submit" name="submit" value="1">Submit request</button>
      </form>
    </div>
  </div>
</div>



  </main>
  <!-- Footer modeled after Bootstrap example structure -->
  <footer class="ubsi-footer py-5">
    <div class="container">
      <div class="row g-4">
        <div class="col-12 col-md-3 mb-4">
          <h5 class="text-uppercase">The UBSI Group</h5>
          <p class="mb-2">Concierge mortgage, real estate, insurance, and consumer savings for members nationwide.</p>
          <p class="mb-0">Call <a href="tel:18006102277">800-610-2277</a> or email <a href="mailto:info@ubsi.com">info@ubsi.com</a></p>
        </div>
        <div class="col-6 col-md-3">
          <h6 class="text-uppercase">Services</h6>
          <ul class="nav flex-column">
            
            <li class="nav-item mb-2"><a class="nav-link p-0" href="&#x2f;Process_Auto.cfm&#x3f;context&#x3d;utslE8RMoi9gcuJUrsITQ4ZjX&#x25;2BPexWsRKTX0SPViTHk&#x25;3D">Mortgage Concierge</a></li>
            <li class="nav-item mb-2"><a class="nav-link p-0" href="&#x2f;Process_Auto.cfm&#x3f;context&#x3d;Rly3X6wXm7NMonbJjYa&#x25;2Be&#x25;2Fxf&#x25;2Fr3BR&#x25;2Fe4OnSC5Fml0f64DxhRvUX66wZvXgahTxcH">Real Estate Rebates</a></li>
            <li class="nav-item mb-2"><a class="nav-link p-0" href="&#x2f;Process_Auto.cfm&#x3f;context&#x3d;2cyLRqEdb0rWDD3WSW74qX4TSxdotL&#x25;2B5k0QSyVLDb3jwp56JiDisKDFaJRWH0m1c">Insurance Bundles</a></li>
            <li class="nav-item mb-2"><a class="nav-link p-0" href="&#x2f;Process_Auto.cfm&#x3f;context&#x3d;LjhOI5IM&#x25;2BWZ3Q4UrZiI4b22e6uSTRj9v3OAhLXlnhd4&#x25;3D">Consumer Buying</a></li>
            
          </ul>
        </div>
        <div class="col-6 col-md-3">
          <h6 class="text-uppercase">Company</h6>
          <ul class="nav flex-column">
            <li class="nav-item mb-2"><a class="nav-link p-0" href="/about-united-buying-service/">About</a></li>
            <li class="nav-item mb-2"><a class="nav-link p-0" href="/organizations/">Organizations</a></li>
            <li class="nav-item mb-2"><a class="nav-link p-0" href="/employment/">Careers</a></li>
            <li class="nav-item mb-2"><a class="nav-link p-0" href="/contact/">Contact</a></li>
          </ul>
        </div>


        <div class="col-12 col-md-3">
          <h6 class="text-uppercase">Stay informed</h6>
          <p>Get savings updates delivered to your inbox.</p>
          
          <form class="newsletter-form" method="post" action="https://oi.vresp.com?fid=a9224b2731" target="vr_optin_popup" onsubmit="window.open( 'http://www.verticalresponse.com', 'vr_optin_popup', 'scrollbars=yes,width=600,height=450' ); return true;" >
            <div class="mb-3">
              <label class="visually-hidden" for="newsletterEmail">Email</label>
              <input class="form-control" id="newsletterEmail" name="email_address" type="email" placeholder="Email address" required>
            </div>
            
            <button class="btn btn-ubsi-accent mt-3" type="submit">Subscribe</button>
            
            <div class="mt-2">
              <small>Email & Social Media Marketing by <a title="Email & Social Media Marketing by VerticalResponse" href="http://www.verticalresponse.com" rel="nofollow">VerticalResponse</a></small>
            </div>
          </form>
        </div>
		
		
		
    </div>
    <div class="d-flex flex-column flex-sm-row justify-content-between pt-4 mt-4 border-top border-light-subtle">
      <p class="mb-0">&copy; 2026 The UBSI Group. All rights reserved.</p>
      <p class="mb-0">Trusted savings for homes, autos, and beyond.</p>
    </div>
  </footer>
  <!-- Load Bootstrap bundle and project script -->
  <script src="https://cdn.jsdelivr.net/npm/bootstrap@5.3.3/dist/js/bootstrap.bundle.min.js" integrity="sha384-YvpcrYf0tY3lHB60NNkmXc5s9fDV0gP9e+O2C6J5kPxXykpKepE+0YraUokhM1Q5" crossorigin="anonymous"></script> <!-- Bootstrap JS bundle -->
  <script src="/assets/js/site.js" defer></script> <!-- UBSI custom JS -->

</body>
</html>