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class="col-md-6 col-xs-12" style="margin-top: 25px;"> <input type="text" name="org" class="form-control" placeholder="Organization Name *" required=""> </div> <div class="col-md-6 col-xs-12" style="margin-top: 25px;"> <select class="form-control" name="mode" required=""> <option value="">Mode of Participation*</option> <option value="In-person">In-person</option> <option value="Online">Online</option> </select> </div> <div class="col-md-6 col-xs-12" style="margin-top: 25px;"> <input type="text" name="social" class="form-control" placeholder="Social Profile (if any)" > </div> <div class="col-md-6 col-xs-12" style="margin-top: 25px;"> <select class="form-control" name="session" required=""> <option value="">Please Select session</option> <option value="Clinical Cardiology">Clinical Cardiology</option> <option value="Heart Diseases & Failure">Heart Diseases & Failure</option> <option value="Cardiovascular Diseases">Cardiovascular Diseases</option> <option value="Cardiac Nursing">Cardiac Nursing</option> <option value="Heart Transplantation">Heart Transplantation</option> <option value="Cardiac Stroke">Cardiac Stroke</option> <option value="Cardiac physiology">Cardiac physiology"</option> <option value="Cardiac Pharmacology">Cardiac Pharmacology</option> <option value="Pediatric Cardiology">Pediatric Cardiology</option> <option value="Myocarditis">Myocarditis</option> <option value="Heart Rhythm and Arrhythmias">Heart Rhythm and Arrhythmias</option> <option value="Neuro-cardiology">Neuro-cardiology</option> <option value="Cardiology - Future Medicine">Cardiology - Future Medicine</option> <option value="Others">Others</option> </select> </div> <div class="col-md-6 col-xs-12" style="margin-top: 25px;"> <input type="text" name="phone" class="form-control" placeholder="Your Phone*" required=""> </div> <div class="col-md-6 col-xs-12" style="margin-top: 25px;"> <select id="country" name="country" class="form-control" required=""> <option value="">Country*</option> <option value="select country">select country</option> <option value="Afganistan">Afghanistan</option> <option value="Albania">Albania</option> <option value="Algeria">Algeria</option> <option value="American Samoa">American Samoa</option> <option value="Andorra">Andorra</option> <option value="Angola">Angola</option> <option value="Anguilla">Anguilla</option> <option value="Antigua & Barbuda">Antigua & Barbuda</option> <option value="Argentina">Argentina</option> <option value="Armenia">Armenia</option> <option value="Aruba">Aruba</option> <option value="Australia">Australia</option> <option value="Austria">Austria</option> <option value="Azerbaijan">Azerbaijan</option> <option value="Bahamas">Bahamas</option> <option value="Bahrain">Bahrain</option> <option value="Bangladesh">Bangladesh</option> <option value="Barbados">Barbados</option> <option value="Belarus">Belarus</option> <option value="Belgium">Belgium</option> <option value="Belize">Belize</option> <option value="Benin">Benin</option> <option value="Bermuda">Bermuda</option> <option value="Bhutan">Bhutan</option> <option value="Bolivia">Bolivia</option> <option value="Bonaire">Bonaire</option> <option value="Bosnia & Herzegovina">Bosnia & Herzegovina</option> <option value="Botswana">Botswana</option> <option value="Brazil">Brazil</option> <option value="British Indian Ocean Ter">British Indian Ocean Ter</option> <option value="Brunei">Brunei</option> <option value="Bulgaria">Bulgaria</option> <option value="Burkina Faso">Burkina Faso</option> <option value="Burundi">Burundi</option> <option value="Cambodia">Cambodia</option> <option value="Cameroon">Cameroon</option> <option value="Canada">Canada</option> <option value="Canary Islands">Canary Islands</option> <option value="Cape Verde">Cape Verde</option> <option value="Cayman Islands">Cayman Islands</option> <option value="Central African Republic">Central African Republic</option> <option value="Chad">Chad</option> <option value="Channel Islands">Channel Islands</option> <option value="Chile">Chile</option> <option value="China">China</option> <option value="Christmas Island">Christmas Island</option> <option value="Cocos Island">Cocos Island</option> <option value="Colombia">Colombia</option> <option value="Comoros">Comoros</option> <option value="Congo">Congo</option> <option value="Cook Islands">Cook Islands</option> <option value="Costa Rica">Costa Rica</option> <option value="Cote DIvoire">Cote DIvoire</option> <option value="Croatia">Croatia</option> <option value="Cuba">Cuba</option> <option value="Curaco">Curacao</option> <option value="Cyprus">Cyprus</option> <option value="Czech Republic">Czech Republic</option> <option value="Denmark">Denmark</option> <option value="Djibouti">Djibouti</option> <option value="Dominica">Dominica</option> <option value="Dominican Republic">Dominican Republic</option> <option value="East Timor">East Timor</option> <option value="Ecuador">Ecuador</option> <option value="Egypt">Egypt</option> <option value="El Salvador">El Salvador</option> <option value="Equatorial Guinea">Equatorial Guinea</option> <option value="Eritrea">Eritrea</option> <option value="Estonia">Estonia</option> <option value="Ethiopia">Ethiopia</option> <option value="Falkland Islands">Falkland Islands</option> <option value="Faroe Islands">Faroe Islands</option> <option value="Fiji">Fiji</option> <option value="Finland">Finland</option> <option value="France">France</option> <option value="French Guiana">French Guiana</option> <option value="French Polynesia">French Polynesia</option> <option value="French Southern Ter">French Southern Ter</option> <option value="Gabon">Gabon</option> <option value="Gambia">Gambia</option> <option value="Georgia">Georgia</option> <option value="Germany">Germany</option> <option value="Ghana">Ghana</option> <option value="Gibraltar">Gibraltar</option> <option value="Great Britain">Great Britain</option> <option value="Greece">Greece</option> <option value="Greenland">Greenland</option> <option value="Grenada">Grenada</option> <option value="Guadeloupe">Guadeloupe</option> <option value="Guam">Guam</option> <option value="Guatemala">Guatemala</option> <option value="Guinea">Guinea</option> <option value="Guyana">Guyana</option> <option value="Haiti">Haiti</option> <option value="Hawaii">Hawaii</option> <option value="Honduras">Honduras</option> <option value="Hong Kong">Hong Kong</option> <option value="Hungary">Hungary</option> <option value="Iceland">Iceland</option> <option value="Indonesia">Indonesia</option> <option value="India">India</option> <option value="Iran">Iran</option> <option value="Iraq">Iraq</option> <option value="Ireland">Ireland</option> <option value="Isle of Man">Isle of Man</option> <option value="Israel">Israel</option> <option value="Italy">Italy</option> <option value="Jamaica">Jamaica</option> <option value="Japan">Japan</option> <option value="Jordan">Jordan</option> <option value="Kazakhstan">Kazakhstan</option> <option value="Kenya">Kenya</option> <option value="Kiribati">Kiribati</option> <option value="Korea North">Korea North</option> <option value="Korea Sout">Korea South</option> <option value="Kuwait">Kuwait</option> <option value="Kyrgyzstan">Kyrgyzstan</option> <option value="Laos">Laos</option> <option value="Latvia">Latvia</option> <option value="Lebanon">Lebanon</option> <option value="Lesotho">Lesotho</option> <option value="Liberia">Liberia</option> <option value="Libya">Libya</option> <option value="Liechtenstein">Liechtenstein</option> <option value="Lithuania">Lithuania</option> <option value="Luxembourg">Luxembourg</option> <option value="Macau">Macau</option> <option value="Macedonia">Macedonia</option> <option value="Madagascar">Madagascar</option> <option value="Malaysia">Malaysia</option> <option value="Malawi">Malawi</option> <option value="Maldives">Maldives</option> <option value="Mali">Mali</option> <option value="Malta">Malta</option> <option value="Marshall Islands">Marshall Islands</option> <option value="Martinique">Martinique</option> <option value="Mauritania">Mauritania</option> <option value="Mauritius">Mauritius</option> <option value="Mayotte">Mayotte</option> <option value="Mexico">Mexico</option> <option value="Midway Islands">Midway Islands</option> <option value="Moldova">Moldova</option> <option value="Monaco">Monaco</option> <option value="Mongolia">Mongolia</option> <option value="Montserrat">Montserrat</option> <option value="Morocco">Morocco</option> <option value="Mozambique">Mozambique</option> <option value="Myanmar">Myanmar</option> <option value="Nambia">Nambia</option> <option value="Nauru">Nauru</option> <option value="Nepal">Nepal</option> <option value="Netherland Antilles">Netherland Antilles</option> <option value="Netherlands">Netherlands (Holland, Europe)</option> <option value="Nevis">Nevis</option> <option value="New Caledonia">New Caledonia</option> <option value="New Zealand">New Zealand</option> <option value="Nicaragua">Nicaragua</option> <option value="Niger">Niger</option> <option value="Nigeria">Nigeria</option> <option value="Niue">Niue</option> <option value="Norfolk Island">Norfolk Island</option> <option value="Norway">Norway</option> <option value="Oman">Oman</option> <option value="Pakistan">Pakistan</option> <option value="Palau Island">Palau Island</option> <option value="Palestine">Palestine</option> <option value="Panama">Panama</option> <option value="Papua New Guinea">Papua New Guinea</option> <option value="Paraguay">Paraguay</option> <option value="Peru">Peru</option> <option value="Phillipines">Philippines</option> <option value="Pitcairn Island">Pitcairn Island</option> <option value="Poland">Poland</option> <option value="Portugal">Portugal</option> <option value="Puerto Rico">Puerto Rico</option> <option value="Qatar">Qatar</option> <option value="Republic of Montenegro">Republic of Montenegro</option> <option value="Republic of Serbia">Republic of Serbia</option> <option value="Reunion">Reunion</option> <option value="Romania">Romania</option> <option value="Russia">Russia</option> <option value="Rwanda">Rwanda</option> <option value="St Barthelemy">St Barthelemy</option> <option value="St Eustatius">St Eustatius</option> <option value="St Helena">St Helena</option> <option value="St Kitts-Nevis">St Kitts-Nevis</option> <option value="St Lucia">St Lucia</option> <option value="St Maarten">St Maarten</option> <option value="St Pierre & Miquelon">St Pierre & Miquelon</option> <option value="St Vincent & Grenadines">St Vincent & Grenadines</option> <option value="Saipan">Saipan</option> <option value="Samoa">Samoa</option> <option value="Samoa American">Samoa American</option> <option value="San Marino">San Marino</option> <option value="Sao Tome & Principe">Sao Tome & Principe</option> <option value="Saudi Arabia">Saudi Arabia</option> <option value="Senegal">Senegal</option> <option value="Seychelles">Seychelles</option> <option value="Sierra Leone">Sierra Leone</option> <option value="Singapore">Singapore</option> <option value="Slovakia">Slovakia</option> <option value="Slovenia">Slovenia</option> <option value="Solomon Islands">Solomon Islands</option> <option value="Somalia">Somalia</option> <option value="South Africa">South Africa</option> <option value="Spain">Spain</option> <option value="Sri Lanka">Sri Lanka</option> <option value="Sudan">Sudan</option> <option value="Suriname">Suriname</option> <option value="Swaziland">Swaziland</option> <option value="Sweden">Sweden</option> <option value="Switzerland">Switzerland</option> <option value="Syria">Syria</option> <option value="Tahiti">Tahiti</option> <option value="Taiwan">Taiwan</option> <option value="Tajikistan">Tajikistan</option> <option value="Tanzania">Tanzania</option> <option value="Thailand">Thailand</option> <option value="Togo">Togo</option> <option value="Tokelau">Tokelau</option> <option value="Tonga">Tonga</option> <option value="Trinidad & Tobago">Trinidad & Tobago</option> <option value="Tunisia">Tunisia</option> <option value="Turkey">Turkey</option> <option value="Turkmenistan">Turkmenistan</option> <option value="Turks & Caicos Is">Turks & Caicos Is</option> <option value="Tuvalu">Tuvalu</option> <option value="Uganda">Uganda</option> <option value="United Kingdom">United Kingdom</option> <option value="Ukraine">Ukraine</option> <option value="United Arab Erimates">United Arab Emirates</option> <option value="United States of America">United States of America</option> <option value="Uraguay">Uruguay</option> <option value="Uzbekistan">Uzbekistan</option> <option value="Vanuatu">Vanuatu</option> <option value="Vatican City State">Vatican City State</option> <option value="Venezuela">Venezuela</option> <option value="Vietnam">Vietnam</option> <option value="Virgin Islands (Brit)">Virgin Islands (Brit)</option> <option value="Virgin Islands (USA)">Virgin Islands 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