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value="WVFLr0Q4A0Nz6MxOymSVVITrmUoim7jbRdYWcQEq"> <div class="row"> <div class="form-group col-md-12 mb-0"> <label class="control-label" for="select21">Journal: *</label> <select class="form-control select2" id="journal_id" name="journal_id" required> <option selected="true" value="" disabled="disabled" hidden>Select Journal:</option> <option value="1" >ACAMC - Anti-Cancer Agents in Medicinal Chemistry</option> <option value="145" >ACCTRA - Applied Clinical Research, Clinical Trials and Regulatory Affairs</option> <option value="201" >ADCTRA - Applied Drug Research, Clinical Trials and Regulatory Affairs</option> <option value="120" >AIA - Anti-Infective Agents</option> <option value="2" >AIAAMC - Anti-Inflammatory & Anti-Allergy Agents in Medicinal Chemistry</option> <option value="3" >AIAMC - Anti-Infective Agents in Medicinal Chemistry</option> <option value="109" >APS - Adolescent Psychiatry</option> <option value="102" >BIOMENG - Recent Patents on Biomedical Engineering (Discontinued)</option> <option value="276" >BIOS - Biosphere: A Scientific Journal</option> <option value="73" >BIOT - Recent Patents on Biotechnology</option> <option value="4" >CAC - Current Analytical Chemistry</option> <option value="5" >CAD - Current Computer-Aided Drug Design</option> <option value="274" >CADMED - Current Advances in Medicine</option> <option value="165" >CAE - Current Alternative Energy</option> <option value="126" >CAG - Current Angiogenesis (Discontinued)</option> <option value="284" >CAGS - Current Agricultural Sciences</option> <option value="225" >CAI - Current Artificial Intelligence</option> <option value="135" >CAIAAD - Clinical Anti-Inflammatory & Anti-Allergy Drugs (Discontinued)</option> <option value="199" >CAM - Current Applied Materials</option> <option value="166" >CAPS - Current Applied Polymer Science</option> <option value="66" >CAR - Current Alzheimer Research</option> <option value="103" >CAS - Current Aging Science</option> <option value="6" >CBC - Current Bioactive Compounds</option> <option value="138" >CBE - Current Biochemical Engineering (Discontinued)</option> <option value="65" >CBIO - Current Bioinformatics</option> <option value="279" >CBIOS - Current Biological Sciences</option> <option value="122" >CBIOT - Current Biotechnology</option> <option value="164" >CBM - Current Biomarkers (Discontinued)</option> <option value="149" >CBNT - Current Bionanotechnology (Discontinued)</option> <option value="139" >CCAND - Clinical Cancer Drugs</option> <option value="123" >CCAT - Current Catalysis</option> <option value="71" >CCB - Current Chemical Biology</option> <option value="184" >CCCHEM - Current Chinese Chemistry</option> <option value="185" >CCCS - Current Chinese Computer Science</option> <option value="7" >CCDT - Current Cancer Drug Targets</option> <option value="140" >CCHG - Current Chromatography</option> <option value="8" >CCHTS - Combinatorial Chemistry & High Throughput Screening</option> <option value="12" >CCP - Current Clinical Pharmacology</option> <option value="16" >CCR - Current Cardiology Reviews</option> <option value="195" >CCS - Current Chinese Science</option> <option value="9" >CCTR - Current Cancer Therapy Reviews</option> <option value="94" >CDAR - Current Drug Abuse Reviews</option> <option value="18" >CDD - Current Drug Delivery</option> <option value="68" >CDDT - Current Drug Discovery Technologies</option> <option value="170" >CDENT - Current Dentistry</option> <option value="15" >CDM - Current Drug Metabolism</option> <option value="10" >CDR - Current Diabetes Reviews</option> <option value="172" >CDRR - Current Drug Research Reviews</option> <option value="11" >CDS - Current Drug Safety</option> <option value="13" >CDT - Current Drug Targets</option> <option value="83" >CDTCHD - Current Drug Targets - Cardiovascular & Hematological Disorders</option> <option value="90" >CDTCNSND - Current Drug Targets - CNS & Neurological Disorders</option> <option value="14" >CDTH - Current Drug Therapy</option> <option value="92" >CDTIA - Current Drug Targets - Inflammation & Allergy</option> <option value="86" >CDTID - Current Drug Targets - Infectious Disorders</option> <option value="87" >CDTIEMD - Current Drug Targets - Immune, Endocrine & Metabolic Disorders</option> <option value="148" >CEE - Current Environmental Engineering</option> <option value="17" >CEI - Current Enzyme Inhibition</option> <option value="218" >CEL - Current E-Learning (Discontinued)</option> <option value="211" >CELT - Current Engineering Letters and Reviews</option> <option value="177" >CEM - Current Environmental Management (Discontinued)</option> <option value="187" >CENG - Current Chinese Engineering Science</option> <option value="204" >CFF - Current Functional Foods</option> <option value="205" >CFS - Current Forensic Science</option> <option value="24" >CG - Current Genomics</option> <option value="141" >CGC - Current Green Chemistry</option> <option value="167" >CGS - Current Graphene Science (Discontinued)</option> <option value="28" >CGT - Current Gene Therapy</option> <option value="20" >CHAMC - Cardiovascular & Hematological Agents in Medicinal Chemistry</option> <option value="281" >CHCR - Current Healthcare Research</option> <option value="22" >CHDDT - Cardiovascular & Hematological Disorders-Drug Targets</option> <option value="97" >CHENG - Recent Patents on Chemical Engineering</option> <option value="67" >CHR - Current HIV Research</option> <option value="21" >CHYR - Current Hypertension Reviews</option> <option value="114" >CIC - Current Inorganic Chemistry (Discontinued)</option> <option value="142" >CIEMD - Clinical Immunology, Endocrine & Metabolic Drugs (Discontinued)</option> <option value="278" >CIET - Current Innovations and Emerging Technologies</option> <option value="37" >CIR - Current Immunology Reviews (Discontinued)</option> <option value="213" >CIS - Current Indian Science</option> <option value="200" >CJAI - The Chinese Journal of Artificial Intelligence</option> <option value="283" >CJLS - Current Journal of Life Sciences</option> <option value="183" >CMAM - Current Mechanics and Advanced Materials</option> <option value="134" >CMB - Current Metabolomics</option> <option value="25" >CMC - Current Medicinal Chemistry</option> <option value="85" >CMCACA - Current Medicinal Chemistry - Anti-Cancer Agents</option> <option value="91" >CMCAIA - Current Medicinal Chemistry - Anti-Infective Agents</option> <option value="80" >CMCAIAA - Current Medicinal Chemistry - Anti-Inflammatory & Anti-Allergy Agents</option> <option value="93" >CMCCHA - Current Medicinal Chemistry - Cardiovascular & Hematological Agents</option> <option value="82" >CMCCNSA - Current Medicinal Chemistry - Central Nervous System Agents</option> <option value="88" >CMCIEMA - Current Medicinal Chemistry - Immunology, Endocrine & Metabolic Agents</option> <option value="132" >CMI - Current Molecular Imaging (Discontinued)</option> <option value="144" >CMIC - Current Microwave Chemistry</option> <option value="282" >CMICRO - Current Journal of Microbiology</option> <option value="33" >CMIR - Current Medical Imaging</option> <option value="273" >CML - Current Machine Learning</option> <option value="23" >CMM - Current Molecular Medicine</option> <option value="98" >CMP - Current Molecular Pharmacology</option> <option value="175" >CMS - Current Materials Science</option> <option value="176" >CMSB - Current Metabolomics and Systems Biology (Discontinued)</option> <option value="26" >CN - Current Neuropharmacology</option> <option value="27" >CNANO - Current Nanoscience</option> <option value="161" >CNANOM - Current Nanomedicine</option> <option value="277" >CNEU - Current Neuroscience</option> <option value="35" >CNF - Current Nutrition & Food Science</option> <option value="160" >CNM - Current Nanomaterials</option> <option value="31" >CNR - Current Neurovascular Research</option> <option value="36" >CNSAMC - Central Nervous System Agents in Medicinal Chemistry</option> <option value="69" >CNSNDDT - CNS & Neurological Disorders - Drug Targets</option> <option value="181" >CNT - Current Nutraceuticals</option> <option value="189" >CNTP - Current Nanotoxicity and Prevention (Discontinued)</option> <option value="19" >COC - Current Organic Chemistry</option> <option value="143" >COCAT - Current Organocatalysis</option> <option value="34" >COS - Current Organic Synthesis</option> <option value="193" >COSCI - Current Cosmetic Science</option> <option value="190" >COVID - Coronaviruses</option> <option value="70" >CP - Current Proteomics</option> <option value="32" >CPA - Current Pharmaceutical Analysis</option> <option value="30" >CPB - Current Pharmaceutical Biotechnology</option> <option value="107" >CPC - Current Physical Chemistry</option> <option value="29" >CPD - Current Pharmaceutical Design</option> <option value="251" >CPEMH - Clinical Practice & Epidemiology in Mental Health</option> <option value="44" >CPG - Current Pharmacogenomics</option> <option value="219" >CPHS - Current Physics</option> <option value="104" >CPPM - Current Pharmacogenomics and Personalized Medicine</option> <option value="42" >CPPS - Current Protein & Peptide Science</option> <option value="53" >CPR - Current Pediatric Reviews</option> <option value="174" >CPRR - Current Psychiatry Research and Reviews</option> <option value="121" >CPSP - Current Psychopharmacology</option> <option value="41" >CPSR - Current Psychiatry Reviews</option> <option value="208" >CRCEP - Current Reviews in Clinical and Experimental Pharmacology</option> <option value="163" >CRM - Current Regenerative Medicine (Discontinued)</option> <option value="47" >CRMR - Current Respiratory Medicine Reviews</option> <option value="95" >CRP - Current Radiopharmaceuticals</option> <option value="52" >CRR - Current Rheumatology Reviews</option> <option value="228" >CSCH - Current Spectroscopy and Chromatography</option> <option value="217" >CSCI - Current Cell Science</option> <option value="60" >CSCR - Current Stem Cell Research & Therapy</option> <option value="222" >CSE - Current Surgical Endoscopy</option> <option value="99" >CSENG - Recent Patents on Computer Science</option> <option value="285" >CSET - Current Science, Engineering and Technology</option> <option value="162" >CSM - Current Smart Materials (Discontinued)</option> <option value="214" >CSS - Current Social Sciences</option> <option value="43" >CST - Current Signal Transduction Therapy</option> <option value="226" >CTC - Current Topics in Chemistry</option> <option value="124" >CTE - Current Tissue Engineering (Discontinued)</option> <option value="227" >CTENG - Current Topics in Engineering</option> <option value="156" >CTM - Current Traditional Medicine</option> <option value="38" >CTMC - Current Topics in Medicinal Chemistry</option> <option value="224" >CUCS - Current Computer Science</option> <option value="40" >CVP - Current Vascular Pharmacology</option> <option value="58" >CWHR - Current Women`s Health Reviews</option> <option value="75" >DDF - Recent Patents on Drug Delivery & Formulation</option> <option value="119" >DDL - Drug Delivery Letters</option> <option value="84" >DDRO - Drug Design Reviews - Online (Discontinued)</option> <option value="129" >DEEENG - Recent Patents on Electrical & Electronic Engineering</option> <option value="221" >DMBL - Drug Metabolism and Bioanalysis Letters</option> <option value="72" >DML - Drug Metabolism Letters</option> <option value="74" >DNAG - Recent Patents on DNA & Gene Sequences</option> <option value="131" >DRPTELC - Recent Patents on Telecommunication</option> <option value="111" >DRPTST - Recent Patents on Space Technology</option> <option value="147" >EDT - Epigenetic Diagnosis & Therapy (Discontinued)</option> <option value="152" >EEENG - Recent Advances in Electrical & Electronic Engineering</option> <option value="100" >EENG - Recent Patents on Electrical Engineering</option> <option value="77" >EMI - Recent Patents on Endocrine, Metabolic & Immune Drug Discovery (Discontinued)</option> <option value="59" >EMIDDT - Endocrine, Metabolic & Immune Disorders - Drug Targets</option> <option value="78" >ENG - Recent Patents on Engineering</option> <option value="194" >FLME - Journal of Fuzzy Logic and Modeling in Engineering</option> <option value="105" >FNA - Recent Patents on Food, Nutrition & Agriculture</option> <option value="275" >GET - Gene Editing Technologies</option> <option value="223" >GLD - Glucolipid Metabolic Disorders</option> <option value="79" >IAD - Recent Patents on Inflammation & Allergy Drug Discovery</option> <option value="39" >IADT - Inflammation & Allergy - Drug Targets (Discontinued)</option> <option value="153" >ICMS - Innovations in Corrosion and Materials Science (Discontinued)</option> <option value="54" >IDDT - Infectious Disorders - Drug Targets</option> <option value="55" >IEMAMC - Immunology, Endocrine & Metabolic Agents in Medicinal Chemistry (Discontinued)</option> <option value="198" >IJGHD - The International Journal of Gastroenterology and Hepatology Diseases</option> <option value="270" >ISCCE - Journal of Intelligent Systems in Current Computer Engineering</option> <option value="229" >JCTV - Journal of Current Toxicology and Venomics</option> <option value="57" >LDDD - Letters in Drug Design & Discovery</option> <option value="212" >LFF - Letters in Functional Foods</option> <option value="48" >LOC - Letters in Organic Chemistry</option> <option value="96" >MATS - Recent Patents on Materials Science</option> <option value="50" >MC - Medicinal Chemistry</option> <option value="81" >MCRO - Medicinal Chemistry Reviews - Online (Discontinued)</option> <option value="250" >MEDJ - Open Medicine Journal</option> <option value="101" >MENG - Recent Patents on Mechanical Engineering</option> <option value="128" >MIRNA - MicroRNA</option> <option value="106" >MNS - Micro and Nanosystems</option> <option value="56" >MRMC - Mini-Reviews in Medicinal Chemistry</option> <option value="45" >MROC - Mini-Reviews in Organic Chemistry</option> <option value="117" >NANOASIA - Nanoscience & Nanotechnology-Asia</option> <option value="76" >NANOTEC - Recent Patents on Nanotechnology</option> <option value="137" >NBE - Neuroscience and Biomedical Engineering (Discontinued)</option> <option value="186" >NEMJ - New Emirates Medical Journal</option> <option value="118" >NPJ - The Natural Products Journal</option> <option value="180" >PHOTOCAT - Journal of Photocatalysis</option> <option value="280" >PMR - Physiological Mini Reviews</option> <option value="116" >PNM - Recent Patents on Nanomedicine</option> <option value="133" >PNT - Pharmaceutical Nanotechnology</option> <option value="51" >PPL - Protein & Peptide Letters</option> <option value="46" >PRA - Recent Patents on Anti-Cancer Drug Discovery</option> <option value="61" >PRC - Recent Patents on Cardiovascular Drug Discovery</option> <option value="49" >PRI - Recent Patents on Anti-Infective Drug Discovery</option> <option value="206" >PROBIOT - Current Probiotics</option> <option value="207" >RAAIDD - Recent Advances in Anti-Infective Drug Discovery</option> <option value="157" >RACDD - Recent Advances in Cardiovascular Drug Discovery (Discontinued)</option> <option value="179" >RACSC - Recent Advances in Computer Science and Communications</option> <option value="202" >RADDF - Recent Advances in Drug Delivery and Formulation</option> <option value="154" >RADNAG - Recent Advances in DNA & Gene Sequences (Discontinued)</option> <option value="210" >RAFNA - Recent Advances in Food, Nutrition & Agriculture</option> <option value="203" >RAIAD - Recent Advances in Inflammation & Allergy Drug Discovery</option> <option value="158" >RICE - Recent Innovations in Chemical Engineering</option> <option value="89" >RPBM - Recent Patents on Biomarkers</option> <option value="125" >RPCAT - Recent Patents on Catalysis (Discontinued)</option> <option value="62" >RPCN - Recent Patents on CNS Drug Discovery (Discontinued)</option> <option value="108" >RPGM - Recent Patents on Regenerative Medicine</option> <option value="113" >RPTCS - Recent Patents on Corrosion Science</option> <option value="150" >RPTELC - Recent Advances in Communications and Networking Technology (Discontinued)</option> <option value="159" >RPTI - Recent Patents and Topics on Imaging (Discontinued)</option> <option value="110" >RPTMI - Recent Patents on Medical Imaging</option> <option value="112" >RPTSP - Recent Patents on Signal Processing (Discontinued)</option> <option value="151" >RPTST - Recent Progress in Space Technology (Discontinued)</option> <option value="63" >RRCT - Reviews on Recent Clinical Trials</option> <option value="115" >SWCC - International Journal of Sensors, Wireless Communications and Control</option> <option value="252" >TOAIDJ - The Open AIDS Journal</option> <option value="243" >TOASJ - The Open Agriculture Journal</option> <option value="246" >TOATJ - The Open Anesthesia Journal</option> <option value="240" >TOBCTJ - The Open Construction & Building Technology Journal</option> <option value="249" >TOBEJ - The Open Biomedical Engineering Journal</option> <option value="248" >TOBIOCJ - The Open Biochemistry Journal</option> <option value="232" >TOBIOIJ - The Open Bioinformatics Journal</option> <option value="265" >TOBIOJ - The Open Biology Journal</option> <option value="245" >TOBIOMJ - The Open Biomarkers Journal</option> <option value="247" >TOBIOTJ - The Open Biotechnology Journal</option> <option value="267" >TOBMSJ - The Open Biomaterials Science Journal</option> <option value="254" >TOCENGJ - The Open Chemical Engineering Journal</option> <option value="233" >TOCIEJ - The Open Civil Engineering Journal</option> <option value="238" >TOCMJ - The Open Cardiovascular Medicine Journal</option> <option value="269" >TOCOVIDJ - The Open COVID Journal</option> <option value="234" >TODENTJ - The Open Dentistry Journal</option> <option value="255" >TODJ - The Open Dermatology Journal</option> <option value="258" >TOECOLJ - Open Environmental Research Journal</option> <option value="262" >TOIDJ - The Open Infectious Diseases Journal</option> <option value="268" >TOMB - The Open Microalgae Biotechnology Journal</option> <option value="260" >TOMCJ - The Open Medicinal Chemistry Journal</option> <option value="236" >TOMICROJ - The Open Microbiology Journal</option> <option value="253" >TONEUJ - The Open Neurology Journal</option> <option value="257" >TONIJ - The Open Neuroimaging Journal</option> <option value="239" >TONURSJ - The Open Nursing Journal</option> <option value="230" >TOOPHTJ - The Open Ophthalmology Journal</option> <option value="261" >TOORTHJ - The Open Orthopaedics Journal</option> <option value="244" >TOPAINJ - The Open Pain Journal</option> <option value="263" >TOPARAJ - The Open Parasitology Journal</option> <option value="235" >TOPHJ - The Open Public Health Journal</option> <option value="231" >TOPSYJ - The Open Psychology Journal</option> <option value="237" >TORJ - The Open Rheumatology Journal</option> <option value="256" >TORMJ - The Open Respiratory Medicine Journal</option> <option value="241" >TOSSJ - The Open Sports Sciences Journal</option> <option value="242" >TOTJ - The Open Transportation Journal</option> <option value="259" >TOUNJ - The Open Urology &amp; Nephrology Journal</option> <option value="146" >TTE - Technology Transfer and Entrepreneurship (Discontinued)</option> <option value="191" >VAT - Venoms and Toxins</option> <option value="64" >VDP - Vascular Disease Prevention (Discontinued)</option> <option value="271" >WCL - Wireless and Communication Letters</option> </select> </div> </div> <div class="row"> <div class="col-md-6"> <h5 class="border-bottom pb-2 mt-5 mb-4">Contact Information</h5> <div class="form-row"> <div class="form-group col-md-12"> <label>First Name:</label> <input type="text" name="first_name" class="form-control" required = 'required' value="" /> </div> <div class="form-group col-md-12"> <label>Last Name: *</label> <input type="text" name="last_name" class="form-control" required = 'required' value="" /> </div> <div class="form-group col-md-12"> <label>E-mail: *</label> <input type="email" name="email" class="form-control" required = 'required' value="" /> </div> </div> </div> <div class="col-md-6"> <h5 class="border-bottom pb-2 mt-5 mb-4">Institution Contact Details</h5> <div class="form-row"> <div class="form-group col-md-12"> <label>Institution Name: *</label> <input type="text" name="institution_name" class="form-control" required = 'required' value="" /> </div> <div class="form-group col-md-12"> <label>Institution Country: *</label> <select class="form-control" id="institution_country" name="institution_country" required = 'required'> <option value="">Country</option> <option value="Afghanistan" > 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="Antarctica" > Antarctica</option> <option value="Antigua and Barbuda" > Antigua and 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="Bosnia and Herzegovina" > Bosnia and Herzegovina</option> <option value="Botswana" > Botswana</option> <option value="Bouvet Island" > Bouvet Island</option> <option value="Brazil" > Brazil</option> <option value="British Indian Ocean Territory" > British Indian Ocean Territory</option> <option value="Brunei Darussalam" > Brunei Darussalam</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="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="Chile" > Chile</option> <option value="China" > China</option> <option value="Christmas Island" > Christmas Island</option> <option value="Cocos (Keeling) Islands" > Cocos (Keeling) Islands</option> <option value="Colombia" > Colombia</option> <option value="Comoros" > Comoros</option> <option value="Congo" > Congo</option> <option value="Congo, the Democratic Republic of the" > Congo, the Democratic Republic of the</option> <option value="Cook Islands" > Cook Islands</option> <option value="Costa Rica" > Costa Rica</option> <option value="Cote D Ivoire" > Cote D Ivoire</option> <option value="Croatia" > Croatia</option> <option value="Cuba" > Cuba</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="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 (Malvinas)" > Falkland Islands (Malvinas)</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 Territories" > French Southern Territories</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="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="Guinea-Bissau" > Guinea-Bissau</option> <option value="Guyana" > Guyana</option> <option value="Haiti" > Haiti</option> <option value="Heard Island and Mcdonald Islands" > Heard Island and Mcdonald Islands</option> <option value="Holy See (Vatican City State)" > Holy See (Vatican City State)</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="India" > India</option> <option value="Indonesia" > Indonesia</option> <option value="Iran" > Iran</option> <option value="Iraq" > Iraq</option> <option value="Ireland" > Ireland</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, Democratic Peoples Republic of" > Korea, Democratic Peoples Republic of</option> <option value="Korea" > Korea</option> <option value="Kuwait" > Kuwait</option> <option value="Kyrgyzstan" > Kyrgyzstan</option> <option value="Lao Peoples Democratic Republic" > Lao Peoples Democratic Republic</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="Macao" > Macao</option> <option value="North Macedonia" > North Macedonia</option> <option value="Madagascar" > Madagascar</option> <option value="Malawi" > Malawi</option> <option value="Malaysia" > Malaysia</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="Micronesia, Federated States of" > Micronesia, Federated States of</option> <option value="Moldova, Republic of" > Moldova, Republic of</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="Namibia" > Namibia</option> <option value="Nauru" > Nauru</option> <option value="Nepal" > Nepal</option> <option value="Netherlands" > Netherlands</option> <option value="Netherlands Antilles" > Netherlands Antilles</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="Northern Mariana Islands" > Northern Mariana Islands</option> <option value="Norway" > Norway</option> <option value="Oman" > Oman</option> <option value="Pakistan" > Pakistan</option> <option value="Palau" > Palau</option> <option value="Palestinian Territory, Occupied" > Palestinian Territory, Occupied</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="Philippines" > Philippines</option> <option value="Pitcairn" > Pitcairn</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="Reunion" > Reunion</option> <option value="Romania" > Romania</option> <option value="Russian Federation" > Russian Federation</option> <option value="Rwanda" > Rwanda</option> <option value="Saint Helena" > Saint Helena</option> <option value="Saint Kitts and Nevis" > Saint Kitts and Nevis</option> <option value="Saint Lucia" > Saint Lucia</option> <option value="Saint Pierre and Miquelon" > Saint Pierre and Miquelon</option> <option value="Saint Vincent and the Grenadines" > Saint Vincent and the Grenadines</option> <option value="Samoa" > Samoa</option> <option value="San Marino" > San Marino</option> <option value="Sao Tome and Principe" > Sao Tome and Principe</option> <option value="Saudi Arabia" > Saudi Arabia</option> <option value="Senegal" > Senegal</option> <option value="Serbia" > Serbia</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="South Georgia and the South Sandwich Islands" > South Georgia and the South Sandwich Islands</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="Svalbard and Jan Mayen" > Svalbard and Jan Mayen</option> <option value="Swaziland" > Swaziland</option> <option value="Sweden" > Sweden</option> <option value="Switzerland" > Switzerland</option> <option value="Syrian Arab Republic" > Syrian Arab Republic</option> <option value="Taiwan" > Taiwan</option> <option value="Tajikistan" > Tajikistan</option> <option value="Tanzania, United Republic of" > Tanzania, United Republic of</option> <option value="Thailand" > Thailand</option> <option value="Timor-Leste" > Timor-Leste</option> <option value="Togo" > Togo</option> <option value="Tokelau" > Tokelau</option> <option value="Tonga" > Tonga</option> <option value="Trinidad and Tobago" > Trinidad and Tobago</option> <option value="Tunisia" > Tunisia</option> <option value="Turkey" > Turkey</option> <option value="Turkmenistan" > Turkmenistan</option> <option value="Turks and Caicos Islands" > Turks and Caicos Islands</option> <option value="Tuvalu" > Tuvalu</option> <option value="Uganda" > Uganda</option> <option value="Ukraine" > Ukraine</option> <option value="United Arab Emirates" > United Arab Emirates</option> <option value="United Kingdom" > United Kingdom</option> <option value="United States" > United States</option> <option value="United States Minor Outlying Islands" > United States Minor Outlying Islands</option> <option value="Uruguay" > Uruguay</option> <option value="Uzbekistan" > Uzbekistan</option> <option value="Vanuatu" > Vanuatu</option> <option value="Venezuela" > Venezuela</option> <option value="Vietnam" > Vietnam</option> <option value="Virgin Islands, British" > Virgin Islands, British</option> <option value="Virgin Islands, U.s." > Virgin Islands, U.s.</option> <option value="Wallis and Futuna" > Wallis and Futuna</option> <option value="Western Sahara" > Western Sahara</option> <option value="Yemen" > Yemen</option> <option value="Zambia" > Zambia</option> <option value="Zimbabwe" > Zimbabwe</option> <option value="Ascension" > Ascension</option> <option value="Trista Da Chuna" > Trista Da Chuna</option> <option value="Montenegro" > Montenegro</option> <option value="Kosovo" > Kosovo</option> <option value="South Korea" > South Korea</option> <option value="West Indies" > West Indies</option> <option value="Scotland" > Scotland</option> </select> </div> <div class="form-group col-md-12"> <label>Comments: *</label> <textarea name="comments" rows="2" class="form-control" required="required"></textarea> </div> </div> </div> <div class="col-md-12"> <div class="d-flex justify-content-center"> <div class="row col-md-3"> <div class="col-auto mx-auto w-100 d-flex "> <div class="captcha m-1"><span><img src="https://www.eurekaselect.com/captcha/default?zIkxoNuI" ></span></div> <button type="button" class="btn btn-danger m-1" class="refresh-captcha" id="refresh-captcha">↻</button> </div> <div class="col-auto mx-auto w-100 d-flex "> <input id="captcha" type="text" 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