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value="CH">Switzerland</option> <option value="CI">Cote D'ivoire</option> <option value="CK">Cook Islands</option> <option value="CL">Chile</option> <option value="CM">Cameroon</option> <option value="CN">People's Republic of China</option> <option value="CO">Colombia</option> <option value="CR">Costa Rica</option> <option value="CU">Cuba</option> <option value="CV">Cape Verde Islands</option> <option value="CY">Cyprus</option> <option value="CZ">Czech Republic</option> <option value="DE">Germany</option> <option value="DJ">Republic of Djibouti</option> <option value="DK">Denmark</option> <option value="DM">Dominica</option> <option value="DO">Dominican Republic</option> <option value="DZ">Algeria</option> <option value="EC">Ecuador</option> <option value="EE">Estonia</option> <option value="EG">Egypt</option> <option value="EI">East Timor</option> <option value="EN">England</option> <option value="ER">Eritrea</option> <option value="ES">Spain</option> <option value="ET">Ethiopia</option> <option value="FI">Finland</option> <option value="FJ">Fiji</option> <option value="FK">Falkland Islands</option> <option value="FM">Micronesia, Federated States of</option> <option value="FO">Faroe Islands</option> <option value="FR">France</option> <option value="GA">Gabon</option> <option value="GB">British Citizenship</option> <option value="GD">Grenada</option> <option value="GE">Georgia</option> <option value="GF">French Guiana</option> <option value="GH">Ghana</option> <option value="GI">Gibraltar</option> <option value="GL">Greenland</option> <option value="GM">The Gambia</option> <option value="GN">Guinea</option> <option value="GP">Guadeloupe</option> <option value="GQ">Equatorial Guinea</option> <option value="GR">Greece</option> <option value="GT">Guatemala</option> <option value="GW">Guinea-Bissau</option> <option value="GY">Guyana</option> <option value="HK">Hong Kong</option> <option value="HN">Honduras</option> <option value="HR">Croatia </option> <option value="HT">Haiti</option> <option value="HU">Hungary</option> <option value="ID">Indonesia</option> <option value="IE">Ireland</option> <option value="IL">Israel</option> <option value="IM">Isle of Man</option> <option value="IN">India</option> <option value="IQ">Iraq</option> <option value="IR">Iran </option> <option value="IS">Iceland</option> <option value="IT">Italy</option> <option value="JM">Jamaica</option> <option value="JO">Jordan</option> <option value="JP">Japan</option> <option value="KE">Kenya</option> <option value="KG">Kyrgyzstan</option> <option value="KH">Cambodia</option> <option value="KI">Kiribati</option> <option value="KM">Comoro Islands</option> <option value="KN">Saint Kitts and Nevis</option> <option value="KP">Democratic People's Republic of Korea</option> <option value="KR">Republic of Korea</option> <option value="KS">Kosovo</option> <option value="KW">Kuwait</option> <option value="KY">Cayman Islands</option> <option value="KZ">Republic of Kazakhstan</option> <option value="LA">Laos</option> <option value="LB">Lebanon</option> <option value="LC">Saint Lucia</option> <option value="LI">Liechtenstein</option> <option value="LK">Sri Lanka</option> <option value="LR">Liberia</option> <option value="LS">Lesotho</option> <option value="LT">Lithuania</option> <option value="LU">Luxembourg</option> <option value="LV">Latvia</option> <option value="LY">Libya</option> <option value="MA">Morocco</option> <option value="MC">Monaco</option> <option value="MD">Republic of Moldova</option> <option value="ME">Republic of Montenegro</option> <option value="MG">Madagascar</option> <option value="MI">Marshall Islands</option> <option value="MK">Macedonia</option> <option value="ML">Mali</option> <option value="MM">Myanmar</option> <option value="MN">Mongolia</option> <option value="MO">Macau</option> <option value="MQ">Martinique</option> <option value="MR">Mauritania</option> <option value="MS">Montserrat </option> <option value="MT">Malta</option> <option value="MU">Mauritius</option> <option value="MV">Maldives</option> <option value="MW">Malawi</option> <option value="MX">Mexico</option> <option value="MY">Malaysia</option> <option value="MZ">Mozambique</option> <option value="NA">Namibia</option> <option value="NC">New Caledonia</option> <option value="ND">Northern Ireland</option> <option value="NE">Niger</option> <option value="NG">Nigeria</option> <option value="NI">Nicaragua</option> <option value="NL">The Netherlands</option> <option value="NO">Norway</option> <option value="NP">Nepal</option> <option value="NR">Nauru</option> <option value="NU">Niue</option> <option value="NZ">New Zealand</option> <option value="OD">Republic of South Sudan</option> <option value="OM">Oman</option> <option value="PA">Panama</option> <option value="PE">Peru</option> <option value="PF">French Polynesia</option> <option value="PG">Papua New Guinea</option> <option value="PH">Philippines</option> <option value="PK">Pakistan</option> <option value="PL">Poland</option> <option value="PN">Pitcairn Island</option> <option value="PR">Palestinian National Authority</option> <option value="PT">Portugal</option> <option value="PU">Palau</option> <option value="PY">Paraguay</option> <option value="QA">Qatar</option> <option value="RE">Reunion</option> <option value="RO">Romania</option> <option value="RS">Republic of Serbia</option> <option value="RU">Russia</option> <option value="RW">Rwanda</option> <option value="SA">Saudi Arabia</option> <option value="SB">Solomon Islands</option> <option value="SC">Seychelles</option> <option value="SD">Republic of Sudan</option> <option value="SE">Sweden</option> <option value="SF">Scotland</option> <option value="SG">Singapore</option> <option value="SI">Slovenia</option> <option value="SK">Slovakia</option> <option value="SL">Sierra Leone</option> <option value="SM">San Marino</option> <option value="SN">Senegal</option> <option value="SO">Somalia</option> <option value="SR">Surinam</option> <option value="ST">Sao Tome And Principe</option> <option value="SV">El Salvador</option> <option value="SX">Sint Maarten</option> <option value="SY">Syria</option> <option value="SZ">Swaziland</option> <option value="TC">Turks and Caicos Islands</option> <option value="TD">Chad</option> <option value="TG">Togo</option> <option value="TH">Thailand</option> <option value="TJ">Republic of Tajikistan</option> <option value="TM">Turkmenistan</option> <option value="TN">Tunisia</option> <option value="TO">Tonga</option> <option value="TR">Turkey</option> <option value="TT">Trinidad and Tobago</option> <option value="TV">Tuvalu</option> <option value="TW">Taiwan</option> <option value="TZ">Tanzania</option> <option value="UA">Ukraine</option> <option value="UG">Uganda</option> <option value="US">USA</option> <option value="UY">Uruguay</option> <option value="UZ">Republic of Uzbekistan</option> <option value="VA">Holy See (Vatican City State)</option> <option value="VC">Saint Vincent and The Grenadines</option> <option value="VE">Venezuela</option> <option value="VG">British Virgin Islands</option> <option value="VN">Vietnam</option> <option value="VU">Vanuatu</option> <option value="WA">Wales</option> <option value="WS">Independent State of Samoa</option> <option value="YE">Republic of Yemen</option> <option value="ZA">South Africa</option> <option value="ZM">Zambia</option> <option value="ZR">Zaire</option> <option value="ZW">Zimbabwe</option> <option value="ZZ">Foreign Phone Only</option> </select> </div> </div> </div> <div class="row"> <div class="col-xs-24 col-md-14"> <div class="form-group"> <label for="street1" class="sr-only">Street Line 1 *</label> <input autocomplete="address-line1" type="text" id="street1" name="street1" maxlength="100" class='form-control' placeholder="Street" required='required' data-errormessage-value-missing="Street is Required" value="" /> </div> </div> </div> <div class="row"> <div class="col-xs-24 col-md-14"> <div class="form-group"> <label for="street2" class="sr-only">Apartment or P.O.Box</label> <input autocomplete="address-line2" type="text" id="street2" name="street2" maxlength="100" class='form-control' placeholder="Apt/PO Box" value="" /> </div> </div> </div> <div class="row"> <div class="col-xs-24 col-md-6 form-group"> <label for="city" class="sr-only">City</label> <input autocomplete="address-level2" type="text" id="city" name="city" maxlength="100" class='form-control' placeholder="City" required='required' data-errormessage-value-missing="City is Required" value="" /> </div> <div class="col-xs-24 col-md-3 form-group"> <label for="state" class="sr-only">State or Province</label> <input autocomplete="address-level1" type='text' id="state" name="state" class='form-control js-state' maxlength='2' required='required' data-errormessage-value-missing="State or Province is Required" value="" /> </div> <div class="col-xs-24 col-md-5 form-group"> <label for="city" class="sr-only">ZIP or Postal Code</label> <input autocomplete="postal-code" type="text" id="zipCode" maxlength="20" name="zipCode" class='form-control' placeholder="ZIP/Postal Code" data-errormessage-value-missing="ZIP/Postal Code is Required" value="" /> </div> <div class="col-xs-24 col-md-12"> </div> </div> <div class="row"> <div class="col-xs-24 col-md-14"> <div class="form-group"> <label for="phoneNumber">Phone Number *</label> <input autocomplete="tel" type="tel" id="phoneNumber" name="phoneNumber" required maxlength="50" class='form-control' data-errormessage-value-missing="Phone Number is Required" value="" /> </div> </div> </div> <div class="row"> <div class="col-xs-24 col-md-14"> <div class="form-group"> <label for="degree">Degree *</label> <input type="text" id="degree" name="degree" required maxlength="100" class='form-control' data-errormessage-value-missing="Degree is Required" value="" /> </div> </div> </div> <div class="row"> <div class="col-xs-24 col-md-14"> <div class="form-group"> <label for="classYear">Class Year *</label> <select id="classYear" name="classYear" required class='form-control' data-errormessage-value-missing="Class Year is Required"> <option value="">Please Select…</option> <option value="2029">2029</option> <option value="2028">2028</option> <option value="2027">2027</option> <option value="2026">2026</option> <option value="2025">2025</option> <option value="2024">2024</option> <option value="2023">2023</option> <option value="2022">2022</option> <option value="2021">2021</option> <option value="2020">2020</option> <option value="2019">2019</option> <option value="2018">2018</option> <option value="2017">2017</option> <option value="2016">2016</option> <option value="2015">2015</option> <option value="2014">2014</option> <option value="2013">2013</option> <option value="2012">2012</option> <option value="2011">2011</option> <option value="2010">2010</option> <option value="2009">2009</option> <option value="2008">2008</option> <option value="2007">2007</option> <option value="2006">2006</option> <option value="2005">2005</option> <option value="2004">2004</option> <option value="2003">2003</option> <option value="2002">2002</option> <option value="2001">2001</option> <option value="2000">2000</option> <option value="1999">1999</option> <option value="1998">1998</option> <option value="1997">1997</option> <option value="1996">1996</option> <option value="1995">1995</option> <option value="1994">1994</option> <option value="1993">1993</option> <option value="1992">1992</option> <option value="1991">1991</option> <option value="1990">1990</option> <option value="1989">1989</option> <option value="1988">1988</option> <option value="1987">1987</option> <option value="1986">1986</option> <option value="1985">1985</option> <option value="1984">1984</option> <option value="1983">1983</option> <option value="1982">1982</option> <option value="1981">1981</option> <option value="1980">1980</option> <option value="1979">1979</option> <option value="1978">1978</option> <option value="1977">1977</option> <option value="1976">1976</option> <option value="1975">1975</option> <option value="1974">1974</option> <option value="1973">1973</option> <option value="1972">1972</option> <option value="1971">1971</option> <option value="1970">1970</option> <option value="1969">1969</option> <option value="1968">1968</option> <option value="1967">1967</option> <option value="1966">1966</option> <option value="1965">1965</option> <option value="1964">1964</option> <option value="1963">1963</option> <option value="1962">1962</option> <option value="1961">1961</option> <option value="1960">1960</option> <option value="1959">1959</option> <option value="1958">1958</option> <option value="1957">1957</option> <option value="1956">1956</option> <option value="1955">1955</option> <option value="1954">1954</option> <option value="1953">1953</option> <option value="1952">1952</option> <option value="1951">1951</option> <option value="1950">1950</option> <option value="1949">1949</option> <option value="1948">1948</option> <option value="1947">1947</option> <option value="1946">1946</option> <option value="1945">1945</option> <option value="1944">1944</option> <option value="1943">1943</option> <option value="1942">1942</option> <option value="1941">1941</option> <option value="1940">1940</option> <option value="1939">1939</option> <option value="1938">1938</option> <option value="1937">1937</option> <option value="1936">1936</option> <option value="1935">1935</option> <option value="1934">1934</option> <option value="1933">1933</option> <option value="1932">1932</option> <option value="1931">1931</option> <option value="1930">1930</option> <option value="1929">1929</option> <option value="1928">1928</option> <option value="1927">1927</option> <option value="1926">1926</option> <option value="1925">1925</option> </select> </div> </div> </div> <div class="row"> <div class="col-xs-24 col-md-14"> <div class="form-group"> <label for="school">School *</label> <select id="school" name="school" required class='form-control' data-errormessage-value-missing="Harvard School is Required"> <option value="">Please Select…</option> <option value="ART">American Repertory Theatre</option> <option value="FAS">Faculty of Arts and Sciences</option> <option value="GSD">Graduate School of Design</option> <option value="GSE">Graduate School of Education</option> <option value="HBS">Harvard Business School</option> <option value="COL">Harvard College</option> <option value="HDS">Harvard Divinity School</option> <option value="EXT">Harvard Extension School </option> <option value="GSA">Harvard Griffin Graduate School of Arts and Sciences</option> <option value="KSG">Harvard Kennedy School</option> <option value="HLS">Harvard Law School</option> <option value="HMS">Harvard Medical School</option> <option value="SDM">Harvard School of Dental Medicine</option> <option value="SPH">Harvard T.H. Chan School of Public Health</option> <option value="DAS">Harvard's Paulson School of Engineering and Applied Sciences</option> <option value="NIE">Nieman Foundation</option> <option value="RAD">Radcliffe College</option> <option value="RDI">Radcliffe Institute</option> <option value="UFI">University Interfaculty Initiatives</option> </select> </div> </div> </div> <div class="row"> <div class="col-xs-24 col-md-14"> <div class="form-group"> <label for="birthday">Date of Birth *</label><br /> <input autocomplete="bday" id="birthday" required type="date" data-date-split-input="true" name="birthday" value="" /> </div> </div> </div> <div class="row"> <div class="col-xs-24 col-md-24"> <div class="form-group"> <label for="comments" >Please Describe Your Request *</label><br /> <textarea required placeholder="Enter your request here…" rows="6" style="width: 100%" data-errormessage-value-missing="Comments are Required" id="comments" name="comments"></textarea> </div> </div> </div> <div class="row"> <div class="col-xs-24 col-md-14"> <div class="form-group"> <label for="harvardAlumniId">Harvard Alumni ID (found at the bottom of HAA emails)</label> <input type="text" id="harvardAlumniId" name="harvardAlumniId" class='form-control' size='10' maxlength='10' pattern="[0-9]{10}" data-errormessage-pattern-mismatch="Please enter your 10-digit Harvard Alumni ID." value="" /> </div> </div> </div> <div class="row"> <div class="col-xs-24 col-md-14"> <div class="form-group"> <label for="huid">HUID (8-digit number from your Harvard ID card)</label> <input type="text" id="huid" name="huid" class='form-control' size='8' maxlength='8' pattern="[0-9]{8}" data-errormessage-pattern-mismatch="Please enter your 8-digit HUID." value="" /> </div> </div> </div> <input type="submit" value="Submit" id="submit-button" class="g-recaptcha" data-callback='onSubmit' data-action='submit' data-sitekey="6LdnXHkpAAAAAO5d83wVfCjdcUsKWTU-Rf93nNKQ"/> </form> </div> </div> </div> </div> </div> </main> 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