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class="header-navigation-link primary-link About Us" href="/pages/about-us" > About Us </a> <a class="icon icon-angle-down header-navigation-list-arrow" data-dropdown-toggle tabindex="0" aria-controls="drawer-navigation-menu-1" aria-haspopup="true" aria-expanded="false" > <span class="show-for-sr"> Toggle Dropdown </span> </a><ul class="header-navigation-list secondary-list clearfix About Us" id="drawer-navigation-menu-1" data-is-dropdown > <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link About Us" href="/pages/about-us"> About Us </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Science" href="/pages/science"> Science </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Press" href="/pages/presses"> Press </a> </li> </ul> </li> <li class="header-navigation-list-item primary-list-item has-dropdown"> <a class="header-navigation-link primary-link Products" href="#" > Products </a> <a class="icon icon-angle-down header-navigation-list-arrow" data-dropdown-toggle tabindex="0" aria-controls="drawer-navigation-menu-2" aria-haspopup="true" aria-expanded="false" > <span class="show-for-sr"> Toggle Dropdown </span> </a><ul class="header-navigation-list secondary-list clearfix Products" id="drawer-navigation-menu-2" data-is-dropdown > <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Perfectio" href="/products/perfectio-by-zero-gravity"> Perfectio </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Perfectio+" href="/products/perfectio-plus-by-zero-gravity"> Perfectio+ </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Perfectio+ Special Edition" href="/products/perefctio-plus-special-edition"> Perfectio+ Special Edition </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Perfectio X" href="/products/perfectio-x?view=default"> Perfectio X </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Perfectio X Special Edition" href="https://www.zerogravityskin.com/products/perfectio-x-special-edition?view=default"> Perfectio X Special Edition </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Perfectio X Swarovski Edition" href="/products/perfectio-x-swarovski-edition"> Perfectio X Swarovski Edition </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Juvenis" href="/products/juvenis"> Juvenis </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a 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secondary-link Golden Blue Pro Luxury Kit" href="/products/golden-blue-pro-luxury-kit"> Golden Blue Pro Luxury Kit </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Recreo Hair" href="https://zero-gravity-skin.myshopify.com/products/recreo"> Recreo Hair </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Glorifico" href="/products/glorifico"> Glorifico </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Glorifico Plus" href="/products/glorifico-plus"> Glorifico Plus </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Oxycura" href="/products/oxycura"> Oxycura </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Accessories" href="/collections/accessories"> Accessories </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Perfectio X G2" href="/products/perfectio-x-g2"> Perfectio X G2 </a> </li> </ul> </li> <li class="header-navigation-list-item primary-list-item "> <a class="header-navigation-link primary-link Testimonials" href="/pages/testimonials" > Testimonials </a> </li> <li class="header-navigation-list-item primary-list-item has-dropdown"> <a class="header-navigation-link primary-link Doctors Say" href="/pages/dermatologist-view" > Doctors Say </a> <a class="icon icon-angle-down header-navigation-list-arrow" data-dropdown-toggle tabindex="0" aria-controls="drawer-navigation-menu-4" aria-haspopup="true" aria-expanded="false" > <span class="show-for-sr"> Toggle Dropdown </span> </a><ul class="header-navigation-list secondary-list clearfix Doctors Say" id="drawer-navigation-menu-4" data-is-dropdown > <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Dermatologist View" href="/pages/dermatologist-view"> Dermatologist View </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Osteopathic View" href="/pages/osteopathic-view"> Osteopathic View </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Naturopathic View" href="/pages/naturopathic-view"> Naturopathic View </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Orthopedic View" href="/pages/orthopaedic-view"> Orthopedic View </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Chiropractic View" href="/pages/chiropractic-view"> Chiropractic View </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Aesthetic View" href="/pages/aesthetic-view"> Aesthetic View </a> </li> <li class="header-navigation-list-item secondary-list-item has-dropdown"> <a class="header-navigation-link secondary-link Acupuncturist View" href="/pages/acupuncturist-view"> Acupuncturist View </a> <a class="icon icon-angle-down header-navigation-list-arrow" data-dropdown-toggle tabindex="0" aria-controls="drawer-navigation-menu-4-menu-7" aria-haspopup="true" aria-expanded="false" > <span class="show-for-sr"> Toggle Dropdown </span> </a><ul class="header-navigation-list tertiary-list clearfix" id="drawer-navigation-menu-4-menu-7" data-is-dropdown > <li class="header-navigation-list-item tertiary-list-item"> <a class="header-navigation-link tertiary-link" href="/pages/acupuncturist-view"> Acupuncturist View - Dr. Kailee Carlson </a> </li> <li class="header-navigation-list-item tertiary-list-item"> <a class="header-navigation-link tertiary-link" href="/pages/acupuncturist-view-2"> Acupuncturist View - Dr. Abbey Jo Shulkin </a> </li> </ul> </li> </ul> </li> <li class="header-navigation-list-item primary-list-item has-dropdown"> <a class="header-navigation-link primary-link Results" href="/pages/results" > Results </a> <a class="icon icon-angle-down header-navigation-list-arrow" data-dropdown-toggle tabindex="0" aria-controls="drawer-navigation-menu-5" aria-haspopup="true" aria-expanded="false" > <span class="show-for-sr"> Toggle Dropdown </span> </a><ul class="header-navigation-list secondary-list clearfix Results" id="drawer-navigation-menu-5" data-is-dropdown > <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Perfectio Results" href="/pages/perfectio-results"> Perfectio Results </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Blue Sapphire LED Results" href="/pages/sapphire-results"> Blue Sapphire LED Results </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Perfectio X Results" href="/pages/perfectio-x-result"> Perfectio X Results </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Relaxatio Results" href="/pages/relaxatio-results"> Relaxatio Results </a> </li> </ul> </li> <li class="header-navigation-list-item primary-list-item "> <a class="header-navigation-link primary-link Our Faces" href="/pages/our-faces" > Our Faces </a> </li> <li class="header-navigation-list-item primary-list-item "> <a class="header-navigation-link primary-link FAQ" href="/pages/faq" > FAQ </a> </li> <li class="header-navigation-list-item primary-list-item has-dropdown"> <a class="header-navigation-link primary-link Support" href="#" > Support </a> <a class="icon icon-angle-down header-navigation-list-arrow" data-dropdown-toggle tabindex="0" 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class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Product Registration" href="/pages/product-registration"> Product Registration </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Limited Lifetime Warranty" href="/pages/limited-lifetime-warranty"> Limited Lifetime Warranty </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Warranty Claim" href="/pages/warranty-claim"> Warranty Claim </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Terms & Conditions" href="/pages/terms-conditions"> Terms & Conditions </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Contact Us" href="/pages/contact-me"> Contact Us </a> </li> </ul> </li> <li class="header-navigation-list-item primary-list-item has-dropdown"> <a class="header-navigation-link primary-link Distributor" href="#" > Distributor </a> <a class="icon icon-angle-down header-navigation-list-arrow" data-dropdown-toggle tabindex="0" aria-controls="drawer-navigation-menu-10" aria-haspopup="true" aria-expanded="false" > <span class="show-for-sr"> Toggle Dropdown </span> </a><ul class="header-navigation-list secondary-list clearfix Distributor" id="drawer-navigation-menu-10" data-is-dropdown > <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Become a Distributor" href="/pages/distributors"> Become a Distributor </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Training program" href="/pages/full-training-video"> Training program </a> </li> <li class="header-navigation-list-item secondary-list-item"> <a class="header-navigation-link secondary-link Order Form" href="/pages/order-form"> Order Form </a> </li> </ul> </li> <li class="header-navigation-list-item primary-list-item "> <a class="header-navigation-link primary-link Medical Spa" href="/pages/medical-spa" > Medical Spa </a> </li> <li class="header-navigation-list-item primary-list-item "> <a class="header-navigation-link primary-link NFT" href="/pages/nft" > NFT </a> </li> </ul> </nav> <div class="coin-container"></div> </div> </div> </div> <main class="main-content"> <div class="module-wrapper"> <div class="module module-breadcrumbs"> <!-- <a class="module-breadcrumbs-link" href="/">Home</a> <span class="module-breadcrumbs-divider">/</span> <a class="module-breadcrumbs-link" href="/collections/all">Products</a> <span class="module-breadcrumbs-divider">/</span> <span></span> --> </div> </div> <div class="main_reg_form new_reg_form"> <div class="module-wrapper"> <div class="module module-default-page"> <div class="module-header page-header"> <div class="module-title page-title"> <h1>Product Registration</h1> </div> </div> <div class="module-body page_bodys rte"> <p>Please register your purchase within 7 days in order to activate your warranty</p> <ul> <li>Limited lifetime warranty for Perfectio Plus, Perfectio X, Sapphire, Sapphire X, Relaxatio, Glorifico Plus and Grandio</li> <li>5 years warranty for Oxycura</li> <li>3 years warranty for Glorifico</li> <li>2 years warranty for Perfectio and Recreo</li> <li>1 year warranty for Juvenis</li> </ul> <ul></ul> <p>You may review the full terms of your warranty inside the user manual. After successful registration, you will receive a confirmation email. This is your proof of warranty. Please print and save for your records.</p> </div> </div> <div class="full_banner"> <div id="shopify-section-registration_product" class="shopify-section"><script src="//zerogravityskin.com/cdn/shopifycloud/shopify/assets/themes_support/shopify_common-33bb9d312118840468a53f36b59c62c1e8f2b7d1a0a77250db9e300441827470.js" type="text/javascript"></script> <div class="main-footer"> <div class="form-layout"> <form id="product_sub" method="post" action="javascript:void(0);"> <div> <div class="before-form text-center"> <div class="form-fields-required ">Fields marked with an <span class="required">*</span> are required.</div> </div> <div class="form-content col-row"> <div class="col-two"> <label>First Name <span class="required">*</span> </label> <input type="text" value="" name="f_name" id="first_name"> </div> <div class="col-two"> <label>Last Name <span class="required">*</span> </label> <input type="text" value="" name="l_name" id="last_name"> </div> <div class="col-full"> <label>Address 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Aires&quot;],[&quot;Catamarca&quot;,&quot;Catamarca&quot;],[&quot;Chaco&quot;,&quot;Chaco&quot;],[&quot;Chubut&quot;,&quot;Chubut&quot;],[&quot;Ciudad Autónoma de Buenos Aires&quot;,&quot;Ciudad Autónoma de Buenos Aires&quot;],[&quot;Córdoba&quot;,&quot;Córdoba&quot;],[&quot;Corrientes&quot;,&quot;Corrientes&quot;],[&quot;Entre Ríos&quot;,&quot;Entre Ríos&quot;],[&quot;Formosa&quot;,&quot;Formosa&quot;],[&quot;Jujuy&quot;,&quot;Jujuy&quot;],[&quot;La Pampa&quot;,&quot;La Pampa&quot;],[&quot;La Rioja&quot;,&quot;La Rioja&quot;],[&quot;Mendoza&quot;,&quot;Mendoza&quot;],[&quot;Misiones&quot;,&quot;Misiones&quot;],[&quot;Neuquén&quot;,&quot;Neuquén&quot;],[&quot;Río Negro&quot;,&quot;Río Negro&quot;],[&quot;Salta&quot;,&quot;Salta&quot;],[&quot;San Juan&quot;,&quot;San Juan&quot;],[&quot;San Luis&quot;,&quot;San Luis&quot;],[&quot;Santa Cruz&quot;,&quot;Santa Cruz&quot;],[&quot;Santa Fe&quot;,&quot;Santa Fe&quot;],[&quot;Santiago Del Estero&quot;,&quot;Santiago Del Estero&quot;],[&quot;Tierra Del Fuego&quot;,&quot;Tierra Del Fuego&quot;],[&quot;Tucumán&quot;,&quot;Tucumán&quot;]]">Argentina</option> <option value="Armenia" data-provinces="[]">Armenia</option> <option value="Aruba" data-provinces="[]">Aruba</option> <option value="Australia" data-provinces="[[&quot;Australian Capital Territory&quot;,&quot;Australian Capital Territory&quot;],[&quot;New South Wales&quot;,&quot;New South Wales&quot;],[&quot;Northern Territory&quot;,&quot;Northern Territory&quot;],[&quot;Queensland&quot;,&quot;Queensland&quot;],[&quot;South Australia&quot;,&quot;South Australia&quot;],[&quot;Tasmania&quot;,&quot;Tasmania&quot;],[&quot;Victoria&quot;,&quot;Victoria&quot;],[&quot;Western Australia&quot;,&quot;Western Australia&quot;]]">Australia</option> <option value="Austria" data-provinces="[]">Austria</option> <option value="Azerbaijan" data-provinces="[]">Azerbaijan</option> <option value="Bahamas" data-provinces="[]">Bahamas</option> <option value="Bahrain" data-provinces="[]">Bahrain</option> <option value="Bangladesh" data-provinces="[]">Bangladesh</option> <option value="Barbados" data-provinces="[]">Barbados</option> <option value="Belarus" data-provinces="[]">Belarus</option> <option value="Belgium" data-provinces="[]">Belgium</option> <option value="Belize" data-provinces="[]">Belize</option> <option value="Benin" data-provinces="[]">Benin</option> <option value="Bermuda" data-provinces="[]">Bermuda</option> <option value="Bhutan" data-provinces="[]">Bhutan</option> <option value="Bolivia" data-provinces="[]">Bolivia</option> <option value="Bosnia And Herzegovina" data-provinces="[]">Bosnia &amp; Herzegovina</option> <option value="Botswana" data-provinces="[]">Botswana</option> <option value="Bouvet Island" data-provinces="[]">Bouvet Island</option> <option value="Brazil" data-provinces="[[&quot;Acre&quot;,&quot;Acre&quot;],[&quot;Alagoas&quot;,&quot;Alagoas&quot;],[&quot;Amapá&quot;,&quot;Amapá&quot;],[&quot;Amazonas&quot;,&quot;Amazonas&quot;],[&quot;Bahia&quot;,&quot;Bahia&quot;],[&quot;Ceará&quot;,&quot;Ceará&quot;],[&quot;Distrito Federal&quot;,&quot;Distrito Federal&quot;],[&quot;Espírito Santo&quot;,&quot;Espírito Santo&quot;],[&quot;Goiás&quot;,&quot;Goiás&quot;],[&quot;Maranhão&quot;,&quot;Maranhão&quot;],[&quot;Mato Grosso&quot;,&quot;Mato Grosso&quot;],[&quot;Mato Grosso do Sul&quot;,&quot;Mato Grosso do Sul&quot;],[&quot;Minas Gerais&quot;,&quot;Minas Gerais&quot;],[&quot;Pará&quot;,&quot;Pará&quot;],[&quot;Paraíba&quot;,&quot;Paraíba&quot;],[&quot;Paraná&quot;,&quot;Paraná&quot;],[&quot;Pernambuco&quot;,&quot;Pernambuco&quot;],[&quot;Piauí&quot;,&quot;Piauí&quot;],[&quot;Rio Grande do Norte&quot;,&quot;Rio Grande do Norte&quot;],[&quot;Rio Grande do Sul&quot;,&quot;Rio Grande do Sul&quot;],[&quot;Rio de Janeiro&quot;,&quot;Rio de Janeiro&quot;],[&quot;Rondônia&quot;,&quot;Rondônia&quot;],[&quot;Roraima&quot;,&quot;Roraima&quot;],[&quot;Santa Catarina&quot;,&quot;Santa Catarina&quot;],[&quot;São Paulo&quot;,&quot;São Paulo&quot;],[&quot;Sergipe&quot;,&quot;Sergipe&quot;],[&quot;Tocantins&quot;,&quot;Tocantins&quot;]]">Brazil</option> <option value="British Indian Ocean Territory" data-provinces="[]">British Indian Ocean Territory</option> <option value="Virgin Islands, British" data-provinces="[]">British Virgin Islands</option> <option value="Brunei" data-provinces="[]">Brunei</option> <option value="Bulgaria" data-provinces="[]">Bulgaria</option> <option value="Burkina Faso" data-provinces="[]">Burkina Faso</option> <option value="Burundi" data-provinces="[]">Burundi</option> <option value="Cambodia" data-provinces="[]">Cambodia</option> <option value="Republic of Cameroon" data-provinces="[]">Cameroon</option> <option value="Canada" data-provinces="[[&quot;Alberta&quot;,&quot;Alberta&quot;],[&quot;British Columbia&quot;,&quot;British Columbia&quot;],[&quot;Manitoba&quot;,&quot;Manitoba&quot;],[&quot;New Brunswick&quot;,&quot;New Brunswick&quot;],[&quot;Newfoundland&quot;,&quot;Newfoundland and Labrador&quot;],[&quot;Northwest Territories&quot;,&quot;Northwest Territories&quot;],[&quot;Nova Scotia&quot;,&quot;Nova Scotia&quot;],[&quot;Nunavut&quot;,&quot;Nunavut&quot;],[&quot;Ontario&quot;,&quot;Ontario&quot;],[&quot;Prince Edward Island&quot;,&quot;Prince Edward Island&quot;],[&quot;Quebec&quot;,&quot;Quebec&quot;],[&quot;Saskatchewan&quot;,&quot;Saskatchewan&quot;],[&quot;Yukon&quot;,&quot;Yukon&quot;]]">Canada</option> <option value="Cape Verde" data-provinces="[]">Cape Verde</option> <option value="Bonaire, Sint Eustatius and Saba" data-provinces="[]">Caribbean Netherlands</option> <option value="Cayman Islands" data-provinces="[]">Cayman Islands</option> <option value="Central African Republic" data-provinces="[]">Central African Republic</option> <option value="Chad" data-provinces="[]">Chad</option> <option value="Chile" data-provinces="[]">Chile</option> <option value="China" data-provinces="[[&quot;Anhui&quot;,&quot;Anhui&quot;],[&quot;Beijing&quot;,&quot;Beijing&quot;],[&quot;Chongqing&quot;,&quot;Chongqing&quot;],[&quot;Fujian&quot;,&quot;Fujian&quot;],[&quot;Gansu&quot;,&quot;Gansu&quot;],[&quot;Guangdong&quot;,&quot;Guangdong&quot;],[&quot;Guangxi&quot;,&quot;Guangxi&quot;],[&quot;Guizhou&quot;,&quot;Guizhou&quot;],[&quot;Hainan&quot;,&quot;Hainan&quot;],[&quot;Hebei&quot;,&quot;Hebei&quot;],[&quot;Heilongjiang&quot;,&quot;Heilongjiang&quot;],[&quot;Henan&quot;,&quot;Henan&quot;],[&quot;Hubei&quot;,&quot;Hubei&quot;],[&quot;Hunan&quot;,&quot;Hunan&quot;],[&quot;Inner Mongolia&quot;,&quot;Inner Mongolia&quot;],[&quot;Jiangsu&quot;,&quot;Jiangsu&quot;],[&quot;Jiangxi&quot;,&quot;Jiangxi&quot;],[&quot;Jilin&quot;,&quot;Jilin&quot;],[&quot;Liaoning&quot;,&quot;Liaoning&quot;],[&quot;Ningxia&quot;,&quot;Ningxia&quot;],[&quot;Qinghai&quot;,&quot;Qinghai&quot;],[&quot;Shaanxi&quot;,&quot;Shaanxi&quot;],[&quot;Shandong&quot;,&quot;Shandong&quot;],[&quot;Shanghai&quot;,&quot;Shanghai&quot;],[&quot;Shanxi&quot;,&quot;Shanxi&quot;],[&quot;Sichuan&quot;,&quot;Sichuan&quot;],[&quot;Tianjin&quot;,&quot;Tianjin&quot;],[&quot;Xinjiang&quot;,&quot;Xinjiang&quot;],[&quot;Xizang&quot;,&quot;Xizang&quot;],[&quot;Yunnan&quot;,&quot;Yunnan&quot;],[&quot;Zhejiang&quot;,&quot;Zhejiang&quot;]]">China</option> <option value="Christmas Island" data-provinces="[]">Christmas Island</option> <option value="Cocos (Keeling) Islands" data-provinces="[]">Cocos (Keeling) Islands</option> <option value="Colombia" data-provinces="[[&quot;Bogotá, D.C.&quot;,&quot;Bogotá, D.C.&quot;],[&quot;Amazonas&quot;,&quot;Amazonas&quot;],[&quot;Antioquia&quot;,&quot;Antioquia&quot;],[&quot;Arauca&quot;,&quot;Arauca&quot;],[&quot;Atlántico&quot;,&quot;Atlántico&quot;],[&quot;Bolívar&quot;,&quot;Bolívar&quot;],[&quot;Boyacá&quot;,&quot;Boyacá&quot;],[&quot;Caldas&quot;,&quot;Caldas&quot;],[&quot;Caquetá&quot;,&quot;Caquetá&quot;],[&quot;Casanare&quot;,&quot;Casanare&quot;],[&quot;Cauca&quot;,&quot;Cauca&quot;],[&quot;Cesar&quot;,&quot;Cesar&quot;],[&quot;Chocó&quot;,&quot;Chocó&quot;],[&quot;Córdoba&quot;,&quot;Córdoba&quot;],[&quot;Cundinamarca&quot;,&quot;Cundinamarca&quot;],[&quot;Guainía&quot;,&quot;Guainía&quot;],[&quot;Guaviare&quot;,&quot;Guaviare&quot;],[&quot;Huila&quot;,&quot;Huila&quot;],[&quot;La Guajira&quot;,&quot;La Guajira&quot;],[&quot;Magdalena&quot;,&quot;Magdalena&quot;],[&quot;Meta&quot;,&quot;Meta&quot;],[&quot;Nariño&quot;,&quot;Nariño&quot;],[&quot;Norte de Santander&quot;,&quot;Norte de Santander&quot;],[&quot;Putumayo&quot;,&quot;Putumayo&quot;],[&quot;Quindío&quot;,&quot;Quindío&quot;],[&quot;Risaralda&quot;,&quot;Risaralda&quot;],[&quot;San Andrés, Providencia y Santa Catalina&quot;,&quot;San Andrés, Providencia y Santa Catalina&quot;],[&quot;Santander&quot;,&quot;Santander&quot;],[&quot;Sucre&quot;,&quot;Sucre&quot;],[&quot;Tolima&quot;,&quot;Tolima&quot;],[&quot;Valle del Cauca&quot;,&quot;Valle del Cauca&quot;],[&quot;Vaupés&quot;,&quot;Vaupés&quot;],[&quot;Vichada&quot;,&quot;Vichada&quot;]]">Colombia</option> <option value="Comoros" data-provinces="[]">Comoros</option> <option value="Congo" data-provinces="[]">Congo - Brazzaville</option> <option value="Congo, The Democratic Republic Of The" data-provinces="[]">Congo - Kinshasa</option> <option value="Cook Islands" data-provinces="[]">Cook Islands</option> <option value="Costa Rica" data-provinces="[]">Costa Rica</option> <option value="Croatia" data-provinces="[]">Croatia</option> <option value="Cuba" data-provinces="[]">Cuba</option> <option value="Curaçao" data-provinces="[]">Curaçao</option> <option value="Cyprus" data-provinces="[]">Cyprus</option> <option value="Czech Republic" data-provinces="[]">Czech Republic</option> <option value="Côte d'Ivoire" data-provinces="[]">Côte d’Ivoire</option> <option value="Denmark" data-provinces="[]">Denmark</option> <option value="Djibouti" data-provinces="[]">Djibouti</option> <option value="Dominica" data-provinces="[]">Dominica</option> <option value="Dominican Republic" data-provinces="[]">Dominican Republic</option> <option value="Ecuador" data-provinces="[]">Ecuador</option> <option value="Egypt" data-provinces="[[&quot;6th of October&quot;,&quot;6th of October&quot;],[&quot;Al Sharqia&quot;,&quot;Al Sharqia&quot;],[&quot;Alexandria&quot;,&quot;Alexandria&quot;],[&quot;Aswan&quot;,&quot;Aswan&quot;],[&quot;Asyut&quot;,&quot;Asyut&quot;],[&quot;Beheira&quot;,&quot;Beheira&quot;],[&quot;Beni Suef&quot;,&quot;Beni Suef&quot;],[&quot;Cairo&quot;,&quot;Cairo&quot;],[&quot;Dakahlia&quot;,&quot;Dakahlia&quot;],[&quot;Damietta&quot;,&quot;Damietta&quot;],[&quot;Faiyum&quot;,&quot;Faiyum&quot;],[&quot;Gharbia&quot;,&quot;Gharbia&quot;],[&quot;Giza&quot;,&quot;Giza&quot;],[&quot;Helwan&quot;,&quot;Helwan&quot;],[&quot;Ismailia&quot;,&quot;Ismailia&quot;],[&quot;Kafr el-Sheikh&quot;,&quot;Kafr el-Sheikh&quot;],[&quot;Luxor&quot;,&quot;Luxor&quot;],[&quot;Matrouh&quot;,&quot;Matrouh&quot;],[&quot;Minya&quot;,&quot;Minya&quot;],[&quot;Monufia&quot;,&quot;Monufia&quot;],[&quot;New Valley&quot;,&quot;New Valley&quot;],[&quot;North Sinai&quot;,&quot;North Sinai&quot;],[&quot;Port Said&quot;,&quot;Port Said&quot;],[&quot;Qalyubia&quot;,&quot;Qalyubia&quot;],[&quot;Qena&quot;,&quot;Qena&quot;],[&quot;Red Sea&quot;,&quot;Red Sea&quot;],[&quot;Sohag&quot;,&quot;Sohag&quot;],[&quot;South Sinai&quot;,&quot;South Sinai&quot;],[&quot;Suez&quot;,&quot;Suez&quot;]]">Egypt</option> <option value="El Salvador" data-provinces="[]">El Salvador</option> <option value="Equatorial Guinea" data-provinces="[]">Equatorial Guinea</option> <option value="Eritrea" data-provinces="[]">Eritrea</option> <option value="Estonia" data-provinces="[]">Estonia</option> <option value="Ethiopia" data-provinces="[]">Ethiopia</option> <option value="Falkland Islands (Malvinas)" data-provinces="[]">Falkland Islands</option> <option value="Faroe Islands" data-provinces="[]">Faroe Islands</option> <option value="Fiji" data-provinces="[]">Fiji</option> <option value="Finland" data-provinces="[]">Finland</option> <option value="France" data-provinces="[]">France</option> <option value="French Guiana" data-provinces="[]">French Guiana</option> <option value="French Polynesia" data-provinces="[]">French Polynesia</option> <option value="French Southern Territories" data-provinces="[]">French Southern Territories</option> <option value="Gabon" data-provinces="[]">Gabon</option> <option value="Gambia" data-provinces="[]">Gambia</option> <option value="Georgia" data-provinces="[]">Georgia</option> <option value="Germany" data-provinces="[]">Germany</option> <option value="Ghana" data-provinces="[]">Ghana</option> <option value="Gibraltar" data-provinces="[]">Gibraltar</option> <option value="Greece" data-provinces="[]">Greece</option> <option value="Greenland" data-provinces="[]">Greenland</option> <option value="Grenada" data-provinces="[]">Grenada</option> <option value="Guadeloupe" data-provinces="[]">Guadeloupe</option> <option value="Guatemala" data-provinces="[[&quot;Alta Verapaz&quot;,&quot;Alta Verapaz&quot;],[&quot;Baja Verapaz&quot;,&quot;Baja Verapaz&quot;],[&quot;Chimaltenango&quot;,&quot;Chimaltenango&quot;],[&quot;Chiquimula&quot;,&quot;Chiquimula&quot;],[&quot;El Progreso&quot;,&quot;El Progreso&quot;],[&quot;Escuintla&quot;,&quot;Escuintla&quot;],[&quot;Guatemala&quot;,&quot;Guatemala&quot;],[&quot;Huehuetenango&quot;,&quot;Huehuetenango&quot;],[&quot;Izabal&quot;,&quot;Izabal&quot;],[&quot;Jalapa&quot;,&quot;Jalapa&quot;],[&quot;Jutiapa&quot;,&quot;Jutiapa&quot;],[&quot;Petén&quot;,&quot;Petén&quot;],[&quot;Quetzaltenango&quot;,&quot;Quetzaltenango&quot;],[&quot;Quiché&quot;,&quot;Quiché&quot;],[&quot;Retalhuleu&quot;,&quot;Retalhuleu&quot;],[&quot;Sacatepéquez&quot;,&quot;Sacatepéquez&quot;],[&quot;San Marcos&quot;,&quot;San Marcos&quot;],[&quot;Santa Rosa&quot;,&quot;Santa Rosa&quot;],[&quot;Sololá&quot;,&quot;Sololá&quot;],[&quot;Suchitepéquez&quot;,&quot;Suchitepéquez&quot;],[&quot;Totonicapán&quot;,&quot;Totonicapán&quot;],[&quot;Zacapa&quot;,&quot;Zacapa&quot;]]">Guatemala</option> <option value="Guernsey" data-provinces="[]">Guernsey</option> <option value="Guinea" data-provinces="[]">Guinea</option> <option value="Guinea Bissau" data-provinces="[]">Guinea-Bissau</option> <option value="Guyana" data-provinces="[]">Guyana</option> <option value="Haiti" data-provinces="[]">Haiti</option> <option value="Heard Island And Mcdonald Islands" data-provinces="[]">Heard &amp; McDonald Islands</option> <option value="Honduras" data-provinces="[]">Honduras</option> <option value="Hong Kong" data-provinces="[[&quot;Hong Kong Island&quot;,&quot;Hong Kong Island&quot;],[&quot;Kowloon&quot;,&quot;Kowloon&quot;],[&quot;New Territories&quot;,&quot;New Territories&quot;]]">Hong Kong SAR China</option> <option value="Hungary" data-provinces="[]">Hungary</option> <option value="Iceland" data-provinces="[]">Iceland</option> <option value="India" data-provinces="[[&quot;Andaman and Nicobar&quot;,&quot;Andaman and Nicobar&quot;],[&quot;Andhra Pradesh&quot;,&quot;Andhra Pradesh&quot;],[&quot;Arunachal Pradesh&quot;,&quot;Arunachal Pradesh&quot;],[&quot;Assam&quot;,&quot;Assam&quot;],[&quot;Bihar&quot;,&quot;Bihar&quot;],[&quot;Chandigarh&quot;,&quot;Chandigarh&quot;],[&quot;Chattisgarh&quot;,&quot;Chattisgarh&quot;],[&quot;Dadra and Nagar Haveli&quot;,&quot;Dadra and Nagar Haveli&quot;],[&quot;Daman and Diu&quot;,&quot;Daman and Diu&quot;],[&quot;Delhi&quot;,&quot;Delhi&quot;],[&quot;Goa&quot;,&quot;Goa&quot;],[&quot;Gujarat&quot;,&quot;Gujarat&quot;],[&quot;Haryana&quot;,&quot;Haryana&quot;],[&quot;Himachal Pradesh&quot;,&quot;Himachal Pradesh&quot;],[&quot;Jammu and Kashmir&quot;,&quot;Jammu and Kashmir&quot;],[&quot;Jharkhand&quot;,&quot;Jharkhand&quot;],[&quot;Karnataka&quot;,&quot;Karnataka&quot;],[&quot;Kerala&quot;,&quot;Kerala&quot;],[&quot;Lakshadweep&quot;,&quot;Lakshadweep&quot;],[&quot;Madhya Pradesh&quot;,&quot;Madhya Pradesh&quot;],[&quot;Maharashtra&quot;,&quot;Maharashtra&quot;],[&quot;Manipur&quot;,&quot;Manipur&quot;],[&quot;Meghalaya&quot;,&quot;Meghalaya&quot;],[&quot;Mizoram&quot;,&quot;Mizoram&quot;],[&quot;Nagaland&quot;,&quot;Nagaland&quot;],[&quot;Orissa&quot;,&quot;Orissa&quot;],[&quot;Puducherry&quot;,&quot;Puducherry&quot;],[&quot;Punjab&quot;,&quot;Punjab&quot;],[&quot;Rajasthan&quot;,&quot;Rajasthan&quot;],[&quot;Sikkim&quot;,&quot;Sikkim&quot;],[&quot;Tamil Nadu&quot;,&quot;Tamil Nadu&quot;],[&quot;Telangana&quot;,&quot;Telangana&quot;],[&quot;Tripura&quot;,&quot;Tripura&quot;],[&quot;Uttar Pradesh&quot;,&quot;Uttar Pradesh&quot;],[&quot;Uttarakhand&quot;,&quot;Uttarakhand&quot;],[&quot;West Bengal&quot;,&quot;West Bengal&quot;]]">India</option> <option value="Indonesia" data-provinces="[[&quot;Aceh&quot;,&quot;Aceh&quot;],[&quot;Bali&quot;,&quot;Bali&quot;],[&quot;Bangka Belitung&quot;,&quot;Bangka Belitung&quot;],[&quot;Banten&quot;,&quot;Banten&quot;],[&quot;Bengkulu&quot;,&quot;Bengkulu&quot;],[&quot;Gorontalo&quot;,&quot;Gorontalo&quot;],[&quot;Jakarta&quot;,&quot;Jakarta&quot;],[&quot;Jambi&quot;,&quot;Jambi&quot;],[&quot;Jawa Barat&quot;,&quot;Jawa Barat&quot;],[&quot;Jawa Tengah&quot;,&quot;Jawa Tengah&quot;],[&quot;Jawa Timur&quot;,&quot;Jawa Timur&quot;],[&quot;Kalimantan Barat&quot;,&quot;Kalimantan Barat&quot;],[&quot;Kalimantan Selatan&quot;,&quot;Kalimantan Selatan&quot;],[&quot;Kalimantan Tengah&quot;,&quot;Kalimantan Tengah&quot;],[&quot;Kalimantan Timur&quot;,&quot;Kalimantan Timur&quot;],[&quot;Kalimantan Utara&quot;,&quot;Kalimantan Utara&quot;],[&quot;Kepulauan Riau&quot;,&quot;Kepulauan Riau&quot;],[&quot;Lampung&quot;,&quot;Lampung&quot;],[&quot;Maluku&quot;,&quot;Maluku&quot;],[&quot;Maluku Utara&quot;,&quot;Maluku Utara&quot;],[&quot;Nusa Tenggara Barat&quot;,&quot;Nusa Tenggara Barat&quot;],[&quot;Nusa Tenggara Timur&quot;,&quot;Nusa Tenggara Timur&quot;],[&quot;Papua&quot;,&quot;Papua&quot;],[&quot;Papua Barat&quot;,&quot;Papua Barat&quot;],[&quot;Riau&quot;,&quot;Riau&quot;],[&quot;Sulawesi Barat&quot;,&quot;Sulawesi Barat&quot;],[&quot;Sulawesi Selatan&quot;,&quot;Sulawesi Selatan&quot;],[&quot;Sulawesi Tengah&quot;,&quot;Sulawesi Tengah&quot;],[&quot;Sulawesi Tenggara&quot;,&quot;Sulawesi Tenggara&quot;],[&quot;Sulawesi Utara&quot;,&quot;Sulawesi Utara&quot;],[&quot;Sumatra Barat&quot;,&quot;Sumatra Barat&quot;],[&quot;Sumatra Selatan&quot;,&quot;Sumatra Selatan&quot;],[&quot;Sumatra Utara&quot;,&quot;Sumatra Utara&quot;],[&quot;Yogyakarta&quot;,&quot;Yogyakarta&quot;]]">Indonesia</option> <option value="Iran, Islamic Republic Of" data-provinces="[]">Iran</option> <option value="Iraq" data-provinces="[]">Iraq</option> <option value="Ireland" data-provinces="[[&quot;Carlow&quot;,&quot;Carlow&quot;],[&quot;Cavan&quot;,&quot;Cavan&quot;],[&quot;Clare&quot;,&quot;Clare&quot;],[&quot;Cork&quot;,&quot;Cork&quot;],[&quot;Donegal&quot;,&quot;Donegal&quot;],[&quot;Dublin&quot;,&quot;Dublin&quot;],[&quot;Galway&quot;,&quot;Galway&quot;],[&quot;Kerry&quot;,&quot;Kerry&quot;],[&quot;Kildare&quot;,&quot;Kildare&quot;],[&quot;Kilkenny&quot;,&quot;Kilkenny&quot;],[&quot;Laois&quot;,&quot;Laois&quot;],[&quot;Leitrim&quot;,&quot;Leitrim&quot;],[&quot;Limerick&quot;,&quot;Limerick&quot;],[&quot;Longford&quot;,&quot;Longford&quot;],[&quot;Louth&quot;,&quot;Louth&quot;],[&quot;Mayo&quot;,&quot;Mayo&quot;],[&quot;Meath&quot;,&quot;Meath&quot;],[&quot;Monaghan&quot;,&quot;Monaghan&quot;],[&quot;Offaly&quot;,&quot;Offaly&quot;],[&quot;Roscommon&quot;,&quot;Roscommon&quot;],[&quot;Sligo&quot;,&quot;Sligo&quot;],[&quot;Tipperary&quot;,&quot;Tipperary&quot;],[&quot;Waterford&quot;,&quot;Waterford&quot;],[&quot;Westmeath&quot;,&quot;Westmeath&quot;],[&quot;Wexford&quot;,&quot;Wexford&quot;],[&quot;Wicklow&quot;,&quot;Wicklow&quot;]]">Ireland</option> <option value="Isle Of Man" data-provinces="[]">Isle of Man</option> <option value="Israel" data-provinces="[]">Israel</option> <option value="Italy" data-provinces="[[&quot;Agrigento&quot;,&quot;Agrigento&quot;],[&quot;Alessandria&quot;,&quot;Alessandria&quot;],[&quot;Ancona&quot;,&quot;Ancona&quot;],[&quot;Aosta&quot;,&quot;Aosta&quot;],[&quot;Arezzo&quot;,&quot;Arezzo&quot;],[&quot;Ascoli Piceno&quot;,&quot;Ascoli Piceno&quot;],[&quot;Asti&quot;,&quot;Asti&quot;],[&quot;Avellino&quot;,&quot;Avellino&quot;],[&quot;Bari&quot;,&quot;Bari&quot;],[&quot;Barletta-Andria-Trani&quot;,&quot;Barletta-Andria-Trani&quot;],[&quot;Belluno&quot;,&quot;Belluno&quot;],[&quot;Benevento&quot;,&quot;Benevento&quot;],[&quot;Bergamo&quot;,&quot;Bergamo&quot;],[&quot;Biella&quot;,&quot;Biella&quot;],[&quot;Bologna&quot;,&quot;Bologna&quot;],[&quot;Bolzano&quot;,&quot;Bolzano&quot;],[&quot;Brescia&quot;,&quot;Brescia&quot;],[&quot;Brindisi&quot;,&quot;Brindisi&quot;],[&quot;Cagliari&quot;,&quot;Cagliari&quot;],[&quot;Caltanissetta&quot;,&quot;Caltanissetta&quot;],[&quot;Campobasso&quot;,&quot;Campobasso&quot;],[&quot;Carbonia-Iglesias&quot;,&quot;Carbonia-Iglesias&quot;],[&quot;Caserta&quot;,&quot;Caserta&quot;],[&quot;Catania&quot;,&quot;Catania&quot;],[&quot;Catanzaro&quot;,&quot;Catanzaro&quot;],[&quot;Chieti&quot;,&quot;Chieti&quot;],[&quot;Como&quot;,&quot;Como&quot;],[&quot;Cosenza&quot;,&quot;Cosenza&quot;],[&quot;Cremona&quot;,&quot;Cremona&quot;],[&quot;Crotone&quot;,&quot;Crotone&quot;],[&quot;Cuneo&quot;,&quot;Cuneo&quot;],[&quot;Enna&quot;,&quot;Enna&quot;],[&quot;Fermo&quot;,&quot;Fermo&quot;],[&quot;Ferrara&quot;,&quot;Ferrara&quot;],[&quot;Firenze&quot;,&quot;Firenze&quot;],[&quot;Foggia&quot;,&quot;Foggia&quot;],[&quot;Forlì-Cesena&quot;,&quot;Forlì-Cesena&quot;],[&quot;Frosinone&quot;,&quot;Frosinone&quot;],[&quot;Genova&quot;,&quot;Genova&quot;],[&quot;Gorizia&quot;,&quot;Gorizia&quot;],[&quot;Grosseto&quot;,&quot;Grosseto&quot;],[&quot;Imperia&quot;,&quot;Imperia&quot;],[&quot;Isernia&quot;,&quot;Isernia&quot;],[&quot;L'Aquila&quot;,&quot;L'Aquila&quot;],[&quot;La Spezia&quot;,&quot;La Spezia&quot;],[&quot;Latina&quot;,&quot;Latina&quot;],[&quot;Lecce&quot;,&quot;Lecce&quot;],[&quot;Lecco&quot;,&quot;Lecco&quot;],[&quot;Livorno&quot;,&quot;Livorno&quot;],[&quot;Lodi&quot;,&quot;Lodi&quot;],[&quot;Lucca&quot;,&quot;Lucca&quot;],[&quot;Macerata&quot;,&quot;Macerata&quot;],[&quot;Mantova&quot;,&quot;Mantova&quot;],[&quot;Massa-Carrara&quot;,&quot;Massa-Carrara&quot;],[&quot;Matera&quot;,&quot;Matera&quot;],[&quot;Medio Campidano&quot;,&quot;Medio Campidano&quot;],[&quot;Messina&quot;,&quot;Messina&quot;],[&quot;Milano&quot;,&quot;Milano&quot;],[&quot;Modena&quot;,&quot;Modena&quot;],[&quot;Monza e Brianza&quot;,&quot;Monza e Brianza&quot;],[&quot;Napoli&quot;,&quot;Napoli&quot;],[&quot;Novara&quot;,&quot;Novara&quot;],[&quot;Nuoro&quot;,&quot;Nuoro&quot;],[&quot;Ogliastra&quot;,&quot;Ogliastra&quot;],[&quot;Olbia-Tempio&quot;,&quot;Olbia-Tempio&quot;],[&quot;Oristano&quot;,&quot;Oristano&quot;],[&quot;Padova&quot;,&quot;Padova&quot;],[&quot;Palermo&quot;,&quot;Palermo&quot;],[&quot;Parma&quot;,&quot;Parma&quot;],[&quot;Pavia&quot;,&quot;Pavia&quot;],[&quot;Perugia&quot;,&quot;Perugia&quot;],[&quot;Pesaro e Urbino&quot;,&quot;Pesaro e Urbino&quot;],[&quot;Pescara&quot;,&quot;Pescara&quot;],[&quot;Piacenza&quot;,&quot;Piacenza&quot;],[&quot;Pisa&quot;,&quot;Pisa&quot;],[&quot;Pistoia&quot;,&quot;Pistoia&quot;],[&quot;Pordenone&quot;,&quot;Pordenone&quot;],[&quot;Potenza&quot;,&quot;Potenza&quot;],[&quot;Prato&quot;,&quot;Prato&quot;],[&quot;Ragusa&quot;,&quot;Ragusa&quot;],[&quot;Ravenna&quot;,&quot;Ravenna&quot;],[&quot;Reggio Calabria&quot;,&quot;Reggio Calabria&quot;],[&quot;Reggio Emilia&quot;,&quot;Reggio Emilia&quot;],[&quot;Rieti&quot;,&quot;Rieti&quot;],[&quot;Rimini&quot;,&quot;Rimini&quot;],[&quot;Roma&quot;,&quot;Roma&quot;],[&quot;Rovigo&quot;,&quot;Rovigo&quot;],[&quot;Salerno&quot;,&quot;Salerno&quot;],[&quot;Sassari&quot;,&quot;Sassari&quot;],[&quot;Savona&quot;,&quot;Savona&quot;],[&quot;Siena&quot;,&quot;Siena&quot;],[&quot;Siracusa&quot;,&quot;Siracusa&quot;],[&quot;Sondrio&quot;,&quot;Sondrio&quot;],[&quot;Taranto&quot;,&quot;Taranto&quot;],[&quot;Teramo&quot;,&quot;Teramo&quot;],[&quot;Terni&quot;,&quot;Terni&quot;],[&quot;Torino&quot;,&quot;Torino&quot;],[&quot;Trapani&quot;,&quot;Trapani&quot;],[&quot;Trento&quot;,&quot;Trento&quot;],[&quot;Treviso&quot;,&quot;Treviso&quot;],[&quot;Trieste&quot;,&quot;Trieste&quot;],[&quot;Udine&quot;,&quot;Udine&quot;],[&quot;Varese&quot;,&quot;Varese&quot;],[&quot;Venezia&quot;,&quot;Venezia&quot;],[&quot;Verbano-Cusio-Ossola&quot;,&quot;Verbano-Cusio-Ossola&quot;],[&quot;Vercelli&quot;,&quot;Vercelli&quot;],[&quot;Verona&quot;,&quot;Verona&quot;],[&quot;Vibo Valentia&quot;,&quot;Vibo Valentia&quot;],[&quot;Vicenza&quot;,&quot;Vicenza&quot;],[&quot;Viterbo&quot;,&quot;Viterbo&quot;]]">Italy</option> <option value="Jamaica" data-provinces="[]">Jamaica</option> <option value="Japan" data-provinces="[[&quot;Hokkaidō&quot;,&quot;Hokkaidō&quot;],[&quot;Aomori&quot;,&quot;Aomori&quot;],[&quot;Iwate&quot;,&quot;Iwate&quot;],[&quot;Miyagi&quot;,&quot;Miyagi&quot;],[&quot;Akita&quot;,&quot;Akita&quot;],[&quot;Yamagata&quot;,&quot;Yamagata&quot;],[&quot;Fukushima&quot;,&quot;Fukushima&quot;],[&quot;Ibaraki&quot;,&quot;Ibaraki&quot;],[&quot;Tochigi&quot;,&quot;Tochigi&quot;],[&quot;Gunma&quot;,&quot;Gunma&quot;],[&quot;Saitama&quot;,&quot;Saitama&quot;],[&quot;Chiba&quot;,&quot;Chiba&quot;],[&quot;Tōkyō&quot;,&quot;Tōkyō&quot;],[&quot;Kanagawa&quot;,&quot;Kanagawa&quot;],[&quot;Niigata&quot;,&quot;Niigata&quot;],[&quot;Toyama&quot;,&quot;Toyama&quot;],[&quot;Ishikawa&quot;,&quot;Ishikawa&quot;],[&quot;Fukui&quot;,&quot;Fukui&quot;],[&quot;Yamanashi&quot;,&quot;Yamanashi&quot;],[&quot;Nagano&quot;,&quot;Nagano&quot;],[&quot;Gifu&quot;,&quot;Gifu&quot;],[&quot;Shizuoka&quot;,&quot;Shizuoka&quot;],[&quot;Aichi&quot;,&quot;Aichi&quot;],[&quot;Mie&quot;,&quot;Mie&quot;],[&quot;Shiga&quot;,&quot;Shiga&quot;],[&quot;Kyōto&quot;,&quot;Kyōto&quot;],[&quot;Ōsaka&quot;,&quot;Ōsaka&quot;],[&quot;Hyōgo&quot;,&quot;Hyōgo&quot;],[&quot;Nara&quot;,&quot;Nara&quot;],[&quot;Wakayama&quot;,&quot;Wakayama&quot;],[&quot;Tottori&quot;,&quot;Tottori&quot;],[&quot;Shimane&quot;,&quot;Shimane&quot;],[&quot;Okayama&quot;,&quot;Okayama&quot;],[&quot;Hiroshima&quot;,&quot;Hiroshima&quot;],[&quot;Yamaguchi&quot;,&quot;Yamaguchi&quot;],[&quot;Tokushima&quot;,&quot;Tokushima&quot;],[&quot;Kagawa&quot;,&quot;Kagawa&quot;],[&quot;Ehime&quot;,&quot;Ehime&quot;],[&quot;Kōchi&quot;,&quot;Kōchi&quot;],[&quot;Fukuoka&quot;,&quot;Fukuoka&quot;],[&quot;Saga&quot;,&quot;Saga&quot;],[&quot;Nagasaki&quot;,&quot;Nagasaki&quot;],[&quot;Kumamoto&quot;,&quot;Kumamoto&quot;],[&quot;Ōita&quot;,&quot;Ōita&quot;],[&quot;Miyazaki&quot;,&quot;Miyazaki&quot;],[&quot;Kagoshima&quot;,&quot;Kagoshima&quot;],[&quot;Okinawa&quot;,&quot;Okinawa&quot;]]">Japan</option> <option value="Jersey" data-provinces="[]">Jersey</option> <option value="Jordan" data-provinces="[]">Jordan</option> <option value="Kazakhstan" data-provinces="[]">Kazakhstan</option> <option value="Kenya" data-provinces="[]">Kenya</option> <option value="Kiribati" data-provinces="[]">Kiribati</option> <option value="Kosovo" data-provinces="[]">Kosovo</option> <option value="Kuwait" data-provinces="[]">Kuwait</option> <option value="Kyrgyzstan" data-provinces="[]">Kyrgyzstan</option> <option value="Lao People's Democratic Republic" data-provinces="[]">Laos</option> <option value="Latvia" data-provinces="[]">Latvia</option> <option value="Lebanon" data-provinces="[]">Lebanon</option> <option value="Lesotho" data-provinces="[]">Lesotho</option> <option value="Liberia" data-provinces="[]">Liberia</option> <option value="Libyan Arab Jamahiriya" data-provinces="[]">Libya</option> <option value="Liechtenstein" data-provinces="[]">Liechtenstein</option> <option value="Lithuania" data-provinces="[]">Lithuania</option> <option value="Luxembourg" data-provinces="[]">Luxembourg</option> <option value="Macao" data-provinces="[]">Macau SAR China</option> <option value="Macedonia, Republic Of" data-provinces="[]">Macedonia</option> <option value="Madagascar" data-provinces="[]">Madagascar</option> <option value="Malawi" data-provinces="[]">Malawi</option> <option value="Malaysia" data-provinces="[[&quot;Johor&quot;,&quot;Johor&quot;],[&quot;Kedah&quot;,&quot;Kedah&quot;],[&quot;Kelantan&quot;,&quot;Kelantan&quot;],[&quot;Kuala Lumpur&quot;,&quot;Kuala Lumpur&quot;],[&quot;Labuan&quot;,&quot;Labuan&quot;],[&quot;Melaka&quot;,&quot;Melaka&quot;],[&quot;Negeri Sembilan&quot;,&quot;Negeri Sembilan&quot;],[&quot;Pahang&quot;,&quot;Pahang&quot;],[&quot;Perak&quot;,&quot;Perak&quot;],[&quot;Perlis&quot;,&quot;Perlis&quot;],[&quot;Pulau Pinang&quot;,&quot;Pulau Pinang&quot;],[&quot;Putrajaya&quot;,&quot;Putrajaya&quot;],[&quot;Sabah&quot;,&quot;Sabah&quot;],[&quot;Sarawak&quot;,&quot;Sarawak&quot;],[&quot;Selangor&quot;,&quot;Selangor&quot;],[&quot;Terengganu&quot;,&quot;Terengganu&quot;]]">Malaysia</option> <option value="Maldives" data-provinces="[]">Maldives</option> <option value="Mali" data-provinces="[]">Mali</option> <option value="Malta" data-provinces="[]">Malta</option> <option value="Martinique" data-provinces="[]">Martinique</option> <option value="Mauritania" data-provinces="[]">Mauritania</option> <option value="Mauritius" data-provinces="[]">Mauritius</option> <option value="Mayotte" data-provinces="[]">Mayotte</option> <option value="Mexico" data-provinces="[[&quot;Aguascalientes&quot;,&quot;Aguascalientes&quot;],[&quot;Baja California&quot;,&quot;Baja California&quot;],[&quot;Baja California Sur&quot;,&quot;Baja California Sur&quot;],[&quot;Campeche&quot;,&quot;Campeche&quot;],[&quot;Chiapas&quot;,&quot;Chiapas&quot;],[&quot;Chihuahua&quot;,&quot;Chihuahua&quot;],[&quot;Ciudad de México&quot;,&quot;Ciudad de México&quot;],[&quot;Coahuila&quot;,&quot;Coahuila&quot;],[&quot;Colima&quot;,&quot;Colima&quot;],[&quot;Durango&quot;,&quot;Durango&quot;],[&quot;Guanajuato&quot;,&quot;Guanajuato&quot;],[&quot;Guerrero&quot;,&quot;Guerrero&quot;],[&quot;Hidalgo&quot;,&quot;Hidalgo&quot;],[&quot;Jalisco&quot;,&quot;Jalisco&quot;],[&quot;México&quot;,&quot;México&quot;],[&quot;Michoacán&quot;,&quot;Michoacán&quot;],[&quot;Morelos&quot;,&quot;Morelos&quot;],[&quot;Nayarit&quot;,&quot;Nayarit&quot;],[&quot;Nuevo León&quot;,&quot;Nuevo León&quot;],[&quot;Oaxaca&quot;,&quot;Oaxaca&quot;],[&quot;Puebla&quot;,&quot;Puebla&quot;],[&quot;Querétaro&quot;,&quot;Querétaro&quot;],[&quot;Quintana Roo&quot;,&quot;Quintana Roo&quot;],[&quot;San Luis Potosí&quot;,&quot;San Luis Potosí&quot;],[&quot;Sinaloa&quot;,&quot;Sinaloa&quot;],[&quot;Sonora&quot;,&quot;Sonora&quot;],[&quot;Tabasco&quot;,&quot;Tabasco&quot;],[&quot;Tamaulipas&quot;,&quot;Tamaulipas&quot;],[&quot;Tlaxcala&quot;,&quot;Tlaxcala&quot;],[&quot;Veracruz&quot;,&quot;Veracruz&quot;],[&quot;Yucatán&quot;,&quot;Yucatán&quot;],[&quot;Zacatecas&quot;,&quot;Zacatecas&quot;]]">Mexico</option> <option value="Moldova, Republic of" data-provinces="[]">Moldova</option> <option value="Monaco" data-provinces="[]">Monaco</option> <option value="Mongolia" data-provinces="[]">Mongolia</option> <option value="Montenegro" data-provinces="[]">Montenegro</option> <option value="Montserrat" data-provinces="[]">Montserrat</option> <option value="Morocco" data-provinces="[]">Morocco</option> <option value="Mozambique" data-provinces="[]">Mozambique</option> <option value="Myanmar" data-provinces="[]">Myanmar (Burma)</option> <option value="Namibia" data-provinces="[]">Namibia</option> <option value="Nauru" data-provinces="[]">Nauru</option> <option value="Nepal" data-provinces="[]">Nepal</option> <option value="Netherlands" data-provinces="[]">Netherlands</option> <option value="Netherlands Antilles" data-provinces="[]">Netherlands Antilles</option> <option value="New Caledonia" data-provinces="[]">New Caledonia</option> <option value="New Zealand" data-provinces="[[&quot;Auckland&quot;,&quot;Auckland&quot;],[&quot;Bay of Plenty&quot;,&quot;Bay of Plenty&quot;],[&quot;Canterbury&quot;,&quot;Canterbury&quot;],[&quot;Gisborne&quot;,&quot;Gisborne&quot;],[&quot;Hawke's Bay&quot;,&quot;Hawke's Bay&quot;],[&quot;Manawatu-Wanganui&quot;,&quot;Manawatu-Wanganui&quot;],[&quot;Marlborough&quot;,&quot;Marlborough&quot;],[&quot;Nelson&quot;,&quot;Nelson&quot;],[&quot;Northland&quot;,&quot;Northland&quot;],[&quot;Otago&quot;,&quot;Otago&quot;],[&quot;Southland&quot;,&quot;Southland&quot;],[&quot;Taranaki&quot;,&quot;Taranaki&quot;],[&quot;Tasman&quot;,&quot;Tasman&quot;],[&quot;Waikato&quot;,&quot;Waikato&quot;],[&quot;Wellington&quot;,&quot;Wellington&quot;],[&quot;West Coast&quot;,&quot;West Coast&quot;]]">New Zealand</option> <option value="Nicaragua" data-provinces="[]">Nicaragua</option> <option value="Niger" data-provinces="[]">Niger</option> <option value="Nigeria" data-provinces="[[&quot;Abia&quot;,&quot;Abia&quot;],[&quot;Abuja Federal Capital Territory&quot;,&quot;Abuja Federal Capital Territory&quot;],[&quot;Adamawa&quot;,&quot;Adamawa&quot;],[&quot;Akwa Ibom&quot;,&quot;Akwa Ibom&quot;],[&quot;Anambra&quot;,&quot;Anambra&quot;],[&quot;Bauchi&quot;,&quot;Bauchi&quot;],[&quot;Bayelsa&quot;,&quot;Bayelsa&quot;],[&quot;Benue&quot;,&quot;Benue&quot;],[&quot;Borno&quot;,&quot;Borno&quot;],[&quot;Cross River&quot;,&quot;Cross River&quot;],[&quot;Delta&quot;,&quot;Delta&quot;],[&quot;Ebonyi&quot;,&quot;Ebonyi&quot;],[&quot;Edo&quot;,&quot;Edo&quot;],[&quot;Ekiti&quot;,&quot;Ekiti&quot;],[&quot;Enugu&quot;,&quot;Enugu&quot;],[&quot;Gombe&quot;,&quot;Gombe&quot;],[&quot;Imo&quot;,&quot;Imo&quot;],[&quot;Jigawa&quot;,&quot;Jigawa&quot;],[&quot;Kaduna&quot;,&quot;Kaduna&quot;],[&quot;Kano&quot;,&quot;Kano&quot;],[&quot;Katsina&quot;,&quot;Katsina&quot;],[&quot;Kebbi&quot;,&quot;Kebbi&quot;],[&quot;Kogi&quot;,&quot;Kogi&quot;],[&quot;Kwara&quot;,&quot;Kwara&quot;],[&quot;Lagos&quot;,&quot;Lagos&quot;],[&quot;Nasarawa&quot;,&quot;Nasarawa&quot;],[&quot;Niger&quot;,&quot;Niger&quot;],[&quot;Ogun&quot;,&quot;Ogun&quot;],[&quot;Ondo&quot;,&quot;Ondo&quot;],[&quot;Osun&quot;,&quot;Osun&quot;],[&quot;Oyo&quot;,&quot;Oyo&quot;],[&quot;Plateau&quot;,&quot;Plateau&quot;],[&quot;Rivers&quot;,&quot;Rivers&quot;],[&quot;Sokoto&quot;,&quot;Sokoto&quot;],[&quot;Taraba&quot;,&quot;Taraba&quot;],[&quot;Yobe&quot;,&quot;Yobe&quot;],[&quot;Zamfara&quot;,&quot;Zamfara&quot;]]">Nigeria</option> <option value="Niue" data-provinces="[]">Niue</option> <option value="Norfolk Island" data-provinces="[]">Norfolk Island</option> <option value="Korea, Democratic People's Republic Of" data-provinces="[]">North Korea</option> <option value="Norway" data-provinces="[]">Norway</option> <option value="Oman" data-provinces="[]">Oman</option> <option value="Pakistan" data-provinces="[]">Pakistan</option> <option value="Palestinian Territory, Occupied" data-provinces="[]">Palestinian Territories</option> <option value="Panama" data-provinces="[[&quot;Bocas del Toro&quot;,&quot;Bocas del Toro&quot;],[&quot;Chiriquí&quot;,&quot;Chiriquí&quot;],[&quot;Coclé&quot;,&quot;Coclé&quot;],[&quot;Colón&quot;,&quot;Colón&quot;],[&quot;Darién&quot;,&quot;Darién&quot;],[&quot;Emberá&quot;,&quot;Emberá&quot;],[&quot;Herrera&quot;,&quot;Herrera&quot;],[&quot;Kuna Yala&quot;,&quot;Kuna Yala&quot;],[&quot;Los Santos&quot;,&quot;Los Santos&quot;],[&quot;Ngöbe-Buglé&quot;,&quot;Ngöbe-Buglé&quot;],[&quot;Panamá&quot;,&quot;Panamá&quot;],[&quot;Panamá Oeste&quot;,&quot;Panamá Oeste&quot;],[&quot;Veraguas&quot;,&quot;Veraguas&quot;]]">Panama</option> <option value="Papua New Guinea" data-provinces="[]">Papua New Guinea</option> <option value="Paraguay" data-provinces="[]">Paraguay</option> <option value="Peru" data-provinces="[[&quot;Amazonas&quot;,&quot;Amazonas&quot;],[&quot;Áncash&quot;,&quot;Áncash&quot;],[&quot;Apurímac&quot;,&quot;Apurímac&quot;],[&quot;Arequipa&quot;,&quot;Arequipa&quot;],[&quot;Ayacucho&quot;,&quot;Ayacucho&quot;],[&quot;Cajamarca&quot;,&quot;Cajamarca&quot;],[&quot;Callao&quot;,&quot;Callao&quot;],[&quot;Cuzco&quot;,&quot;Cuzco&quot;],[&quot;Huancavelica&quot;,&quot;Huancavelica&quot;],[&quot;Huánuco&quot;,&quot;Huánuco&quot;],[&quot;Ica&quot;,&quot;Ica&quot;],[&quot;Junín&quot;,&quot;Junín&quot;],[&quot;La Libertad&quot;,&quot;La Libertad&quot;],[&quot;Lambayeque&quot;,&quot;Lambayeque&quot;],[&quot;Lima (departamento)&quot;,&quot;Lima (departamento)&quot;],[&quot;Lima (provincia)&quot;,&quot;Lima (provincia)&quot;],[&quot;Loreto&quot;,&quot;Loreto&quot;],[&quot;Madre de Dios&quot;,&quot;Madre de Dios&quot;],[&quot;Moquegua&quot;,&quot;Moquegua&quot;],[&quot;Pasco&quot;,&quot;Pasco&quot;],[&quot;Piura&quot;,&quot;Piura&quot;],[&quot;Puno&quot;,&quot;Puno&quot;],[&quot;San Martín&quot;,&quot;San Martín&quot;],[&quot;Tacna&quot;,&quot;Tacna&quot;],[&quot;Tumbes&quot;,&quot;Tumbes&quot;],[&quot;Ucayali&quot;,&quot;Ucayali&quot;]]">Peru</option> <option value="Philippines" data-provinces="[]">Philippines</option> <option value="Pitcairn" data-provinces="[]">Pitcairn Islands</option> <option value="Poland" data-provinces="[]">Poland</option> <option value="Portugal" data-provinces="[[&quot;Açores&quot;,&quot;Açores&quot;],[&quot;Aveiro&quot;,&quot;Aveiro&quot;],[&quot;Beja&quot;,&quot;Beja&quot;],[&quot;Braga&quot;,&quot;Braga&quot;],[&quot;Bragança&quot;,&quot;Bragança&quot;],[&quot;Castelo Branco&quot;,&quot;Castelo Branco&quot;],[&quot;Coimbra&quot;,&quot;Coimbra&quot;],[&quot;Évora&quot;,&quot;Évora&quot;],[&quot;Faro&quot;,&quot;Faro&quot;],[&quot;Guarda&quot;,&quot;Guarda&quot;],[&quot;Leiria&quot;,&quot;Leiria&quot;],[&quot;Lisboa&quot;,&quot;Lisboa&quot;],[&quot;Madeira&quot;,&quot;Madeira&quot;],[&quot;Portalegre&quot;,&quot;Portalegre&quot;],[&quot;Porto&quot;,&quot;Porto&quot;],[&quot;Santarém&quot;,&quot;Santarém&quot;],[&quot;Setúbal&quot;,&quot;Setúbal&quot;],[&quot;Viana do Castelo&quot;,&quot;Viana do Castelo&quot;],[&quot;Vila Real&quot;,&quot;Vila Real&quot;],[&quot;Viseu&quot;,&quot;Viseu&quot;]]">Portugal</option> <option value="Qatar" data-provinces="[]">Qatar</option> <option value="Reunion" data-provinces="[]">Réunion</option> <option value="Romania" data-provinces="[[&quot;Alba&quot;,&quot;Alba&quot;],[&quot;Arad&quot;,&quot;Arad&quot;],[&quot;Argeș&quot;,&quot;Argeș&quot;],[&quot;Bacău&quot;,&quot;Bacău&quot;],[&quot;Bihor&quot;,&quot;Bihor&quot;],[&quot;Bistrița-Năsăud&quot;,&quot;Bistrița-Năsăud&quot;],[&quot;Botoșani&quot;,&quot;Botoșani&quot;],[&quot;Brăila&quot;,&quot;Brăila&quot;],[&quot;Brașov&quot;,&quot;Brașov&quot;],[&quot;București&quot;,&quot;București&quot;],[&quot;Buzău&quot;,&quot;Buzău&quot;],[&quot;Caraș-Severin&quot;,&quot;Caraș-Severin&quot;],[&quot;Cluj&quot;,&quot;Cluj&quot;],[&quot;Constanța&quot;,&quot;Constanța&quot;],[&quot;Covasna&quot;,&quot;Covasna&quot;],[&quot;Călărași&quot;,&quot;Călărași&quot;],[&quot;Dolj&quot;,&quot;Dolj&quot;],[&quot;Dâmbovița&quot;,&quot;Dâmbovița&quot;],[&quot;Galați&quot;,&quot;Galați&quot;],[&quot;Giurgiu&quot;,&quot;Giurgiu&quot;],[&quot;Gorj&quot;,&quot;Gorj&quot;],[&quot;Harghita&quot;,&quot;Harghita&quot;],[&quot;Hunedoara&quot;,&quot;Hunedoara&quot;],[&quot;Ialomița&quot;,&quot;Ialomița&quot;],[&quot;Iași&quot;,&quot;Iași&quot;],[&quot;Ilfov&quot;,&quot;Ilfov&quot;],[&quot;Maramureș&quot;,&quot;Maramureș&quot;],[&quot;Mehedinți&quot;,&quot;Mehedinți&quot;],[&quot;Mureș&quot;,&quot;Mureș&quot;],[&quot;Neamț&quot;,&quot;Neamț&quot;],[&quot;Olt&quot;,&quot;Olt&quot;],[&quot;Prahova&quot;,&quot;Prahova&quot;],[&quot;Sălaj&quot;,&quot;Sălaj&quot;],[&quot;Satu Mare&quot;,&quot;Satu Mare&quot;],[&quot;Sibiu&quot;,&quot;Sibiu&quot;],[&quot;Suceava&quot;,&quot;Suceava&quot;],[&quot;Teleorman&quot;,&quot;Teleorman&quot;],[&quot;Timiș&quot;,&quot;Timiș&quot;],[&quot;Tulcea&quot;,&quot;Tulcea&quot;],[&quot;Vâlcea&quot;,&quot;Vâlcea&quot;],[&quot;Vaslui&quot;,&quot;Vaslui&quot;],[&quot;Vrancea&quot;,&quot;Vrancea&quot;]]">Romania</option> <option value="Russia" data-provinces="[[&quot;Altai Krai&quot;,&quot;Altai Krai&quot;],[&quot;Altai Republic&quot;,&quot;Altai Republic&quot;],[&quot;Amur Oblast&quot;,&quot;Amur Oblast&quot;],[&quot;Arkhangelsk Oblast&quot;,&quot;Arkhangelsk Oblast&quot;],[&quot;Astrakhan Oblast&quot;,&quot;Astrakhan Oblast&quot;],[&quot;Belgorod Oblast&quot;,&quot;Belgorod Oblast&quot;],[&quot;Bryansk Oblast&quot;,&quot;Bryansk Oblast&quot;],[&quot;Chechen Republic&quot;,&quot;Chechen Republic&quot;],[&quot;Chelyabinsk Oblast&quot;,&quot;Chelyabinsk Oblast&quot;],[&quot;Chukotka Autonomous Okrug&quot;,&quot;Chukotka Autonomous Okrug&quot;],[&quot;Chuvash Republic&quot;,&quot;Chuvash Republic&quot;],[&quot;Irkutsk Oblast&quot;,&quot;Irkutsk Oblast&quot;],[&quot;Ivanovo Oblast&quot;,&quot;Ivanovo Oblast&quot;],[&quot;Jewish Autonomous Oblast&quot;,&quot;Jewish Autonomous Oblast&quot;],[&quot;Kabardino-Balkarian Republic&quot;,&quot;Kabardino-Balkarian Republic&quot;],[&quot;Kaliningrad Oblast&quot;,&quot;Kaliningrad Oblast&quot;],[&quot;Kaluga Oblast&quot;,&quot;Kaluga Oblast&quot;],[&quot;Kamchatka Krai&quot;,&quot;Kamchatka Krai&quot;],[&quot;Karachay–Cherkess Republic&quot;,&quot;Karachay–Cherkess Republic&quot;],[&quot;Kemerovo Oblast&quot;,&quot;Kemerovo Oblast&quot;],[&quot;Khabarovsk Krai&quot;,&quot;Khabarovsk Krai&quot;],[&quot;Khanty-Mansi Autonomous Okrug&quot;,&quot;Khanty-Mansi Autonomous Okrug&quot;],[&quot;Kirov Oblast&quot;,&quot;Kirov Oblast&quot;],[&quot;Komi Republic&quot;,&quot;Komi Republic&quot;],[&quot;Kostroma Oblast&quot;,&quot;Kostroma Oblast&quot;],[&quot;Krasnodar Krai&quot;,&quot;Krasnodar Krai&quot;],[&quot;Krasnoyarsk Krai&quot;,&quot;Krasnoyarsk Krai&quot;],[&quot;Kurgan Oblast&quot;,&quot;Kurgan Oblast&quot;],[&quot;Kursk Oblast&quot;,&quot;Kursk Oblast&quot;],[&quot;Leningrad Oblast&quot;,&quot;Leningrad Oblast&quot;],[&quot;Lipetsk Oblast&quot;,&quot;Lipetsk Oblast&quot;],[&quot;Magadan Oblast&quot;,&quot;Magadan Oblast&quot;],[&quot;Mari El Republic&quot;,&quot;Mari El Republic&quot;],[&quot;Moscow&quot;,&quot;Moscow&quot;],[&quot;Moscow Oblast&quot;,&quot;Moscow Oblast&quot;],[&quot;Murmansk Oblast&quot;,&quot;Murmansk Oblast&quot;],[&quot;Nizhny Novgorod Oblast&quot;,&quot;Nizhny Novgorod Oblast&quot;],[&quot;Novgorod Oblast&quot;,&quot;Novgorod Oblast&quot;],[&quot;Novosibirsk Oblast&quot;,&quot;Novosibirsk Oblast&quot;],[&quot;Omsk Oblast&quot;,&quot;Omsk Oblast&quot;],[&quot;Orenburg Oblast&quot;,&quot;Orenburg Oblast&quot;],[&quot;Oryol Oblast&quot;,&quot;Oryol Oblast&quot;],[&quot;Penza Oblast&quot;,&quot;Penza Oblast&quot;],[&quot;Perm Krai&quot;,&quot;Perm Krai&quot;],[&quot;Primorsky Krai&quot;,&quot;Primorsky Krai&quot;],[&quot;Pskov Oblast&quot;,&quot;Pskov Oblast&quot;],[&quot;Republic of Adygeya&quot;,&quot;Republic of Adygeya&quot;],[&quot;Republic of Bashkortostan&quot;,&quot;Republic of Bashkortostan&quot;],[&quot;Republic of Buryatia&quot;,&quot;Republic of Buryatia&quot;],[&quot;Republic of Dagestan&quot;,&quot;Republic of Dagestan&quot;],[&quot;Republic of Ingushetia&quot;,&quot;Republic of Ingushetia&quot;],[&quot;Republic of Kalmykia&quot;,&quot;Republic of Kalmykia&quot;],[&quot;Republic of Karelia&quot;,&quot;Republic of Karelia&quot;],[&quot;Republic of Khakassia&quot;,&quot;Republic of Khakassia&quot;],[&quot;Republic of Mordovia&quot;,&quot;Republic of Mordovia&quot;],[&quot;Republic of North Ossetia–Alania&quot;,&quot;Republic of North Ossetia–Alania&quot;],[&quot;Republic of Tatarstan&quot;,&quot;Republic of Tatarstan&quot;],[&quot;Rostov Oblast&quot;,&quot;Rostov Oblast&quot;],[&quot;Ryazan Oblast&quot;,&quot;Ryazan Oblast&quot;],[&quot;Saint Petersburg&quot;,&quot;Saint Petersburg&quot;],[&quot;Sakha Republic (Yakutia)&quot;,&quot;Sakha Republic (Yakutia)&quot;],[&quot;Sakhalin Oblast&quot;,&quot;Sakhalin Oblast&quot;],[&quot;Samara Oblast&quot;,&quot;Samara Oblast&quot;],[&quot;Saratov Oblast&quot;,&quot;Saratov Oblast&quot;],[&quot;Smolensk Oblast&quot;,&quot;Smolensk Oblast&quot;],[&quot;Stavropol Krai&quot;,&quot;Stavropol Krai&quot;],[&quot;Sverdlovsk Oblast&quot;,&quot;Sverdlovsk Oblast&quot;],[&quot;Tambov Oblast&quot;,&quot;Tambov Oblast&quot;],[&quot;Tomsk Oblast&quot;,&quot;Tomsk Oblast&quot;],[&quot;Tula Oblast&quot;,&quot;Tula Oblast&quot;],[&quot;Tver Oblast&quot;,&quot;Tver Oblast&quot;],[&quot;Tyumen Oblast&quot;,&quot;Tyumen Oblast&quot;],[&quot;Tyva Republic&quot;,&quot;Tyva Republic&quot;],[&quot;Udmurtia&quot;,&quot;Udmurtia&quot;],[&quot;Ulyanovsk Oblast&quot;,&quot;Ulyanovsk Oblast&quot;],[&quot;Vladimir Oblast&quot;,&quot;Vladimir Oblast&quot;],[&quot;Volgograd Oblast&quot;,&quot;Volgograd Oblast&quot;],[&quot;Vologda Oblast&quot;,&quot;Vologda Oblast&quot;],[&quot;Voronezh Oblast&quot;,&quot;Voronezh Oblast&quot;],[&quot;Yamalo-Nenets Autonomous Okrug&quot;,&quot;Yamalo-Nenets Autonomous Okrug&quot;],[&quot;Yaroslavl Oblast&quot;,&quot;Yaroslavl Oblast&quot;],[&quot;Zabaykalsky Krai&quot;,&quot;Zabaykalsky Krai&quot;]]">Russia</option> <option value="Rwanda" data-provinces="[]">Rwanda</option> <option value="Samoa" data-provinces="[]">Samoa</option> <option value="San Marino" data-provinces="[]">San Marino</option> <option value="Sao Tome And Principe" data-provinces="[]">São Tomé &amp; Príncipe</option> <option value="Saudi Arabia" data-provinces="[]">Saudi Arabia</option> <option value="Senegal" data-provinces="[]">Senegal</option> <option value="Serbia" data-provinces="[]">Serbia</option> <option value="Seychelles" data-provinces="[]">Seychelles</option> <option value="Sierra Leone" data-provinces="[]">Sierra Leone</option> <option value="Singapore" data-provinces="[]">Singapore</option> <option value="Sint Maarten" data-provinces="[]">Sint Maarten</option> <option value="Slovakia" data-provinces="[]">Slovakia</option> <option value="Slovenia" data-provinces="[]">Slovenia</option> <option value="Solomon Islands" data-provinces="[]">Solomon Islands</option> <option value="Somalia" data-provinces="[]">Somalia</option> <option value="South Africa" data-provinces="[[&quot;Eastern Cape&quot;,&quot;Eastern Cape&quot;],[&quot;Free State&quot;,&quot;Free State&quot;],[&quot;Gauteng&quot;,&quot;Gauteng&quot;],[&quot;KwaZulu-Natal&quot;,&quot;KwaZulu-Natal&quot;],[&quot;Limpopo&quot;,&quot;Limpopo&quot;],[&quot;Mpumalanga&quot;,&quot;Mpumalanga&quot;],[&quot;North West&quot;,&quot;North West&quot;],[&quot;Northern Cape&quot;,&quot;Northern Cape&quot;],[&quot;Western Cape&quot;,&quot;Western Cape&quot;]]">South Africa</option> <option value="South Georgia And The South Sandwich Islands" data-provinces="[]">South Georgia &amp; South Sandwich Islands</option> <option value="South Korea" data-provinces="[[&quot;Busan&quot;,&quot;Busan&quot;],[&quot;Chungbuk&quot;,&quot;Chungbuk&quot;],[&quot;Chungnam&quot;,&quot;Chungnam&quot;],[&quot;Daegu&quot;,&quot;Daegu&quot;],[&quot;Daejeon&quot;,&quot;Daejeon&quot;],[&quot;Gangwon&quot;,&quot;Gangwon&quot;],[&quot;Gwangju&quot;,&quot;Gwangju&quot;],[&quot;Gyeongbuk&quot;,&quot;Gyeongbuk&quot;],[&quot;Gyeonggi&quot;,&quot;Gyeonggi&quot;],[&quot;Gyeongnam&quot;,&quot;Gyeongnam&quot;],[&quot;Incheon&quot;,&quot;Incheon&quot;],[&quot;Jeju&quot;,&quot;Jeju&quot;],[&quot;Jeonbuk&quot;,&quot;Jeonbuk&quot;],[&quot;Jeonnam&quot;,&quot;Jeonnam&quot;],[&quot;Sejong&quot;,&quot;Sejong&quot;],[&quot;Seoul&quot;,&quot;Seoul&quot;],[&quot;Ulsan&quot;,&quot;Ulsan&quot;]]">South Korea</option> <option value="South Sudan" data-provinces="[]">South Sudan</option> <option value="Spain" data-provinces="[[&quot;A Coruña&quot;,&quot;A Coruña&quot;],[&quot;Álava&quot;,&quot;Álava&quot;],[&quot;Albacete&quot;,&quot;Albacete&quot;],[&quot;Alicante&quot;,&quot;Alicante&quot;],[&quot;Almería&quot;,&quot;Almería&quot;],[&quot;Asturias&quot;,&quot;Asturias&quot;],[&quot;Ávila&quot;,&quot;Ávila&quot;],[&quot;Badajoz&quot;,&quot;Badajoz&quot;],[&quot;Balears&quot;,&quot;Balears&quot;],[&quot;Barcelona&quot;,&quot;Barcelona&quot;],[&quot;Burgos&quot;,&quot;Burgos&quot;],[&quot;Cáceres&quot;,&quot;Cáceres&quot;],[&quot;Cádiz&quot;,&quot;Cádiz&quot;],[&quot;Cantabria&quot;,&quot;Cantabria&quot;],[&quot;Castellón&quot;,&quot;Castellón&quot;],[&quot;Ceuta&quot;,&quot;Ceuta&quot;],[&quot;Ciudad Real&quot;,&quot;Ciudad Real&quot;],[&quot;Córdoba&quot;,&quot;Córdoba&quot;],[&quot;Cuenca&quot;,&quot;Cuenca&quot;],[&quot;Girona&quot;,&quot;Girona&quot;],[&quot;Granada&quot;,&quot;Granada&quot;],[&quot;Guadalajara&quot;,&quot;Guadalajara&quot;],[&quot;Guipúzcoa&quot;,&quot;Guipúzcoa&quot;],[&quot;Huelva&quot;,&quot;Huelva&quot;],[&quot;Huesca&quot;,&quot;Huesca&quot;],[&quot;Jaén&quot;,&quot;Jaén&quot;],[&quot;La Rioja&quot;,&quot;La Rioja&quot;],[&quot;Las Palmas&quot;,&quot;Las Palmas&quot;],[&quot;León&quot;,&quot;León&quot;],[&quot;Lleida&quot;,&quot;Lleida&quot;],[&quot;Lugo&quot;,&quot;Lugo&quot;],[&quot;Madrid&quot;,&quot;Madrid&quot;],[&quot;Málaga&quot;,&quot;Málaga&quot;],[&quot;Melilla&quot;,&quot;Melilla&quot;],[&quot;Murcia&quot;,&quot;Murcia&quot;],[&quot;Navarra&quot;,&quot;Navarra&quot;],[&quot;Ourense&quot;,&quot;Ourense&quot;],[&quot;Palencia&quot;,&quot;Palencia&quot;],[&quot;Pontevedra&quot;,&quot;Pontevedra&quot;],[&quot;Salamanca&quot;,&quot;Salamanca&quot;],[&quot;Santa Cruz de Tenerife&quot;,&quot;Santa Cruz de Tenerife&quot;],[&quot;Segovia&quot;,&quot;Segovia&quot;],[&quot;Sevilla&quot;,&quot;Sevilla&quot;],[&quot;Soria&quot;,&quot;Soria&quot;],[&quot;Tarragona&quot;,&quot;Tarragona&quot;],[&quot;Teruel&quot;,&quot;Teruel&quot;],[&quot;Toledo&quot;,&quot;Toledo&quot;],[&quot;Valencia&quot;,&quot;Valencia&quot;],[&quot;Valladolid&quot;,&quot;Valladolid&quot;],[&quot;Vizcaya&quot;,&quot;Vizcaya&quot;],[&quot;Zamora&quot;,&quot;Zamora&quot;],[&quot;Zaragoza&quot;,&quot;Zaragoza&quot;]]">Spain</option> <option value="Sri Lanka" data-provinces="[]">Sri Lanka</option> <option value="Saint Barthélemy" data-provinces="[]">St. Barthélemy</option> <option value="Saint Helena" data-provinces="[]">St. Helena</option> <option value="Saint Kitts And Nevis" data-provinces="[]">St. Kitts &amp; Nevis</option> <option value="Saint Lucia" data-provinces="[]">St. Lucia</option> <option value="Saint Martin" data-provinces="[]">St. Martin</option> <option value="Saint Pierre And Miquelon" data-provinces="[]">St. Pierre &amp; Miquelon</option> <option value="St. Vincent" data-provinces="[]">St. Vincent &amp; Grenadines</option> <option value="Sudan" data-provinces="[]">Sudan</option> <option value="Suriname" data-provinces="[]">Suriname</option> <option value="Svalbard And Jan Mayen" data-provinces="[]">Svalbard &amp; Jan Mayen</option> <option value="Swaziland" data-provinces="[]">Swaziland</option> <option value="Sweden" data-provinces="[]">Sweden</option> <option value="Switzerland" data-provinces="[]">Switzerland</option> <option value="Syria" data-provinces="[]">Syria</option> <option value="Taiwan" data-provinces="[]">Taiwan</option> <option value="Tajikistan" data-provinces="[]">Tajikistan</option> <option value="Tanzania, United Republic Of" data-provinces="[]">Tanzania</option> <option value="Thailand" data-provinces="[[&quot;Amnat Charoen&quot;,&quot;Amnat Charoen&quot;],[&quot;Ang Thong&quot;,&quot;Ang Thong&quot;],[&quot;Bangkok&quot;,&quot;Bangkok&quot;],[&quot;Bueng Kan&quot;,&quot;Bueng Kan&quot;],[&quot;Buriram&quot;,&quot;Buriram&quot;],[&quot;Chachoengsao&quot;,&quot;Chachoengsao&quot;],[&quot;Chai Nat&quot;,&quot;Chai Nat&quot;],[&quot;Chaiyaphum&quot;,&quot;Chaiyaphum&quot;],[&quot;Chanthaburi&quot;,&quot;Chanthaburi&quot;],[&quot;Chiang Mai&quot;,&quot;Chiang Mai&quot;],[&quot;Chiang Rai&quot;,&quot;Chiang Rai&quot;],[&quot;Chon Buri&quot;,&quot;Chon Buri&quot;],[&quot;Chumphon&quot;,&quot;Chumphon&quot;],[&quot;Kalasin&quot;,&quot;Kalasin&quot;],[&quot;Kamphaeng Phet&quot;,&quot;Kamphaeng Phet&quot;],[&quot;Kanchanaburi&quot;,&quot;Kanchanaburi&quot;],[&quot;Khon Kaen&quot;,&quot;Khon Kaen&quot;],[&quot;Krabi&quot;,&quot;Krabi&quot;],[&quot;Lampang&quot;,&quot;Lampang&quot;],[&quot;Lamphun&quot;,&quot;Lamphun&quot;],[&quot;Loei&quot;,&quot;Loei&quot;],[&quot;Lopburi&quot;,&quot;Lopburi&quot;],[&quot;Mae Hong Son&quot;,&quot;Mae Hong Son&quot;],[&quot;Maha Sarakham&quot;,&quot;Maha Sarakham&quot;],[&quot;Mukdahan&quot;,&quot;Mukdahan&quot;],[&quot;Nakhon Nayok&quot;,&quot;Nakhon Nayok&quot;],[&quot;Nakhon Pathom&quot;,&quot;Nakhon Pathom&quot;],[&quot;Nakhon Phanom&quot;,&quot;Nakhon Phanom&quot;],[&quot;Nakhon Ratchasima&quot;,&quot;Nakhon Ratchasima&quot;],[&quot;Nakhon Sawan&quot;,&quot;Nakhon Sawan&quot;],[&quot;Nakhon Si Thammarat&quot;,&quot;Nakhon Si Thammarat&quot;],[&quot;Nan&quot;,&quot;Nan&quot;],[&quot;Narathiwat&quot;,&quot;Narathiwat&quot;],[&quot;Nong Bua Lam Phu&quot;,&quot;Nong Bua Lam Phu&quot;],[&quot;Nong Khai&quot;,&quot;Nong Khai&quot;],[&quot;Nonthaburi&quot;,&quot;Nonthaburi&quot;],[&quot;Pathum Thani&quot;,&quot;Pathum Thani&quot;],[&quot;Pattani&quot;,&quot;Pattani&quot;],[&quot;Pattaya&quot;,&quot;Pattaya&quot;],[&quot;Phangnga&quot;,&quot;Phangnga&quot;],[&quot;Phatthalung&quot;,&quot;Phatthalung&quot;],[&quot;Phayao&quot;,&quot;Phayao&quot;],[&quot;Phetchabun&quot;,&quot;Phetchabun&quot;],[&quot;Phetchaburi&quot;,&quot;Phetchaburi&quot;],[&quot;Phichit&quot;,&quot;Phichit&quot;],[&quot;Phitsanulok&quot;,&quot;Phitsanulok&quot;],[&quot;Phra Nakhon Si Ayutthaya&quot;,&quot;Phra Nakhon Si Ayutthaya&quot;],[&quot;Phrae&quot;,&quot;Phrae&quot;],[&quot;Phuket&quot;,&quot;Phuket&quot;],[&quot;Prachin Buri&quot;,&quot;Prachin Buri&quot;],[&quot;Prachuap Khiri Khan&quot;,&quot;Prachuap Khiri Khan&quot;],[&quot;Ranong&quot;,&quot;Ranong&quot;],[&quot;Ratchaburi&quot;,&quot;Ratchaburi&quot;],[&quot;Rayong&quot;,&quot;Rayong&quot;],[&quot;Roi Et&quot;,&quot;Roi Et&quot;],[&quot;Sa Kaeo&quot;,&quot;Sa Kaeo&quot;],[&quot;Sakon Nakhon&quot;,&quot;Sakon Nakhon&quot;],[&quot;Samut Prakan&quot;,&quot;Samut Prakan&quot;],[&quot;Samut Sakhon&quot;,&quot;Samut Sakhon&quot;],[&quot;Samut Songkhram&quot;,&quot;Samut Songkhram&quot;],[&quot;Saraburi&quot;,&quot;Saraburi&quot;],[&quot;Satun&quot;,&quot;Satun&quot;],[&quot;Sing Buri&quot;,&quot;Sing Buri&quot;],[&quot;Sisaket&quot;,&quot;Sisaket&quot;],[&quot;Songkhla&quot;,&quot;Songkhla&quot;],[&quot;Sukhothai&quot;,&quot;Sukhothai&quot;],[&quot;Suphan Buri&quot;,&quot;Suphan Buri&quot;],[&quot;Surat Thani&quot;,&quot;Surat Thani&quot;],[&quot;Surin&quot;,&quot;Surin&quot;],[&quot;Tak&quot;,&quot;Tak&quot;],[&quot;Trang&quot;,&quot;Trang&quot;],[&quot;Trat&quot;,&quot;Trat&quot;],[&quot;Ubon Ratchathani&quot;,&quot;Ubon Ratchathani&quot;],[&quot;Udon Thani&quot;,&quot;Udon Thani&quot;],[&quot;Uthai Thani&quot;,&quot;Uthai Thani&quot;],[&quot;Uttaradit&quot;,&quot;Uttaradit&quot;],[&quot;Yala&quot;,&quot;Yala&quot;],[&quot;Yasothon&quot;,&quot;Yasothon&quot;]]">Thailand</option> <option value="Timor Leste" data-provinces="[]">Timor-Leste</option> <option value="Togo" data-provinces="[]">Togo</option> <option value="Tokelau" data-provinces="[]">Tokelau</option> <option value="Tonga" data-provinces="[]">Tonga</option> <option value="Trinidad and Tobago" data-provinces="[]">Trinidad &amp; Tobago</option> <option value="Tunisia" data-provinces="[]">Tunisia</option> <option value="Turkey" data-provinces="[]">Turkey</option> <option value="Turkmenistan" data-provinces="[]">Turkmenistan</option> <option value="Turks and Caicos Islands" data-provinces="[]">Turks &amp; Caicos Islands</option> <option value="Tuvalu" data-provinces="[]">Tuvalu</option> <option value="United States Minor Outlying Islands" data-provinces="[]">U.S. Outlying Islands</option> <option value="Uganda" data-provinces="[]">Uganda</option> <option value="Ukraine" data-provinces="[]">Ukraine</option> <option value="United Arab Emirates" data-provinces="[[&quot;Abu Dhabi&quot;,&quot;Abu Dhabi&quot;],[&quot;Ajman&quot;,&quot;Ajman&quot;],[&quot;Dubai&quot;,&quot;Dubai&quot;],[&quot;Fujairah&quot;,&quot;Fujairah&quot;],[&quot;Ras al-Khaimah&quot;,&quot;Ras al-Khaimah&quot;],[&quot;Sharjah&quot;,&quot;Sharjah&quot;],[&quot;Umm al-Quwain&quot;,&quot;Umm al-Quwain&quot;]]">United Arab Emirates</option> <option value="United Kingdom" data-provinces="[]">United Kingdom</option> <option selected value="United States" data-provinces="[[&quot;Alabama&quot;,&quot;Alabama&quot;],[&quot;Alaska&quot;,&quot;Alaska&quot;],[&quot;American Samoa&quot;,&quot;American Samoa&quot;],[&quot;Arizona&quot;,&quot;Arizona&quot;],[&quot;Arkansas&quot;,&quot;Arkansas&quot;],[&quot;California&quot;,&quot;California&quot;],[&quot;Colorado&quot;,&quot;Colorado&quot;],[&quot;Connecticut&quot;,&quot;Connecticut&quot;],[&quot;Delaware&quot;,&quot;Delaware&quot;],[&quot;District of Columbia&quot;,&quot;District of Columbia&quot;],[&quot;Federated States of Micronesia&quot;,&quot;Federated States of Micronesia&quot;],[&quot;Florida&quot;,&quot;Florida&quot;],[&quot;Georgia&quot;,&quot;Georgia&quot;],[&quot;Guam&quot;,&quot;Guam&quot;],[&quot;Hawaii&quot;,&quot;Hawaii&quot;],[&quot;Idaho&quot;,&quot;Idaho&quot;],[&quot;Illinois&quot;,&quot;Illinois&quot;],[&quot;Indiana&quot;,&quot;Indiana&quot;],[&quot;Iowa&quot;,&quot;Iowa&quot;],[&quot;Kansas&quot;,&quot;Kansas&quot;],[&quot;Kentucky&quot;,&quot;Kentucky&quot;],[&quot;Louisiana&quot;,&quot;Louisiana&quot;],[&quot;Maine&quot;,&quot;Maine&quot;],[&quot;Marshall Islands&quot;,&quot;Marshall Islands&quot;],[&quot;Maryland&quot;,&quot;Maryland&quot;],[&quot;Massachusetts&quot;,&quot;Massachusetts&quot;],[&quot;Michigan&quot;,&quot;Michigan&quot;],[&quot;Minnesota&quot;,&quot;Minnesota&quot;],[&quot;Mississippi&quot;,&quot;Mississippi&quot;],[&quot;Missouri&quot;,&quot;Missouri&quot;],[&quot;Montana&quot;,&quot;Montana&quot;],[&quot;Nebraska&quot;,&quot;Nebraska&quot;],[&quot;Nevada&quot;,&quot;Nevada&quot;],[&quot;New Hampshire&quot;,&quot;New Hampshire&quot;],[&quot;New Jersey&quot;,&quot;New Jersey&quot;],[&quot;New Mexico&quot;,&quot;New Mexico&quot;],[&quot;New York&quot;,&quot;New York&quot;],[&quot;North Carolina&quot;,&quot;North Carolina&quot;],[&quot;North Dakota&quot;,&quot;North Dakota&quot;],[&quot;Northern Mariana Islands&quot;,&quot;Northern Mariana Islands&quot;],[&quot;Ohio&quot;,&quot;Ohio&quot;],[&quot;Oklahoma&quot;,&quot;Oklahoma&quot;],[&quot;Oregon&quot;,&quot;Oregon&quot;],[&quot;Palau&quot;,&quot;Palau&quot;],[&quot;Pennsylvania&quot;,&quot;Pennsylvania&quot;],[&quot;Puerto Rico&quot;,&quot;Puerto Rico&quot;],[&quot;Rhode Island&quot;,&quot;Rhode Island&quot;],[&quot;South Carolina&quot;,&quot;South Carolina&quot;],[&quot;South Dakota&quot;,&quot;South Dakota&quot;],[&quot;Tennessee&quot;,&quot;Tennessee&quot;],[&quot;Texas&quot;,&quot;Texas&quot;],[&quot;Utah&quot;,&quot;Utah&quot;],[&quot;Vermont&quot;,&quot;Vermont&quot;],[&quot;Virgin Islands&quot;,&quot;Virgin Islands&quot;],[&quot;Virginia&quot;,&quot;Virginia&quot;],[&quot;Washington&quot;,&quot;Washington&quot;],[&quot;West Virginia&quot;,&quot;West Virginia&quot;],[&quot;Wisconsin&quot;,&quot;Wisconsin&quot;],[&quot;Wyoming&quot;,&quot;Wyoming&quot;],[&quot;Armed Forces Americas&quot;,&quot;Armed Forces Americas&quot;],[&quot;Armed Forces Europe&quot;,&quot;Armed Forces Europe&quot;],[&quot;Armed Forces Pacific&quot;,&quot;Armed Forces Pacific&quot;]]">United States</option> <option value="Uruguay" data-provinces="[]">Uruguay</option> <option value="Uzbekistan" data-provinces="[]">Uzbekistan</option> <option value="Vanuatu" data-provinces="[]">Vanuatu</option> <option value="Holy See (Vatican City State)" data-provinces="[]">Vatican City</option> <option value="Venezuela" data-provinces="[]">Venezuela</option> <option value="Vietnam" data-provinces="[]">Vietnam</option> <option value="Wallis And Futuna" data-provinces="[]">Wallis &amp; Futuna</option> <option value="Western Sahara" data-provinces="[]">Western Sahara</option> <option value="Yemen" data-provinces="[]">Yemen</option> <option value="Zambia" data-provinces="[]">Zambia</option> <option value="Zimbabwe" data-provinces="[]">Zimbabwe</option> </select> </div> <div class="col-two select_box" id="address_province_container_new"> <label for="state">State </label> <select id="state" name="state"></select> </div> <div class="col-two"> <label>City <span class="required">*</span> </label> <input type="text" value="" name="city" id="city"> </div> <div class="col-two"> <label>ZIP/ POST CODE <span class="required">*</span> </label> <input type="text" value="" name="zip_post" id="zip"> </div> <div class="col-two"> <label>Email <span class="required"> *</span> </label> <input type="email" value="" name="email" id="email" class="zg-emails-rgform"> </div> <div class="col-two"> <label>Another Email (Preferred Gmail)</label> <input type="email" value="" name="email2" id="email2" class="zg-emails-rgform"> </div> <div class="col-full"> <label>Phone <span class="required"> *</span> </label> <input type="text" value="" name="phone" id="phone"> </div> </div> <div class="choose_product"> <div class="choose_product_title text-center"> <p><b>Which device/s do you own</b></p> </div> <div class="form-content col-row productQtys"> <div class="col-two"> <input type="checkbox" value="1" name="perfection_silver_850" id="sku1"> <label for="sku1">Perfectio (SKU 850)</label> <div class="qty_box"> <label>Quantity</label><input type="number" value="0" min="0" name="qty_850" id="qty1"> </div> <div class="choose_product_img"> <img src="//zerogravityskin.com/cdn/shop/files/sku1.png?v=2671292819784688377" alt="choose_product_img"> </div> </div> <div class="col-two"> <input type="checkbox" value="1" name="oerfection_plus_gold_900" id="sku2"> <label for="sku2">Perfectio Plus (SKU 900)</label> <div class="qty_box"> <label>Quantity</label><input type="number" value="0" min="0" name="qty_900" id="qty2"> </div> <div class="choose_product_img"> <img src="//zerogravityskin.com/cdn/shop/files/sku2.png?v=2667616739668050465" alt="choose_product_img"> </div> </div> <div class="col-two"> <input type="checkbox" value="1" name="sapphire_blue_415" id="sku3"> <label for="sku3">Blue Sapphire LED (SKU 415)</label> <div class="qty_box"> <label>Quantity</label><input type="number" value="0" min="0" name="qty_415" id="qty3"> </div> <div class="choose_product_img"> <img src="https://cdn.shopify.com/s/files/1/0027/9871/4946/files/Blue_led_Product_Registration_Card.jpg?v=1718880664" alt="choose_product_img"> </div> </div> <div class="col-two" style="display:none!important;"> <input type="checkbox" value="1" name="grandio_300" id="sku4"> <label for="sku4">Grandio (SKU 300)</label> <div class="qty_box"> <label>Quantity</label><input type="number" value="0" min="0" name="qty_300" id="qty4"> </div> <div class="choose_product_img"> <img src="//zerogravityskin.com/cdn/shop/files/grandio2.png?v=5166271321000216945" alt="choose_product_img"> </div> </div> <div class="col-two"> <input type="checkbox" value="1" name="recreo_juvenis_200" id="sku5"> <label for="sku5">Recreo (SKU 200)</label> <div class="qty_box"> <label>Quantity</label><input type="number" value="0" min="0" name="qty_200" id="qty5"> </div> <div class="choose_product_img"> <img src="//zerogravityskin.com/cdn/shop/files/Recreo.png?v=8821281492413212655" alt="Recreo_img"> </div> </div> <div class="col-two"> <input type="checkbox" value="1" name="luvenis_juvenis_700" id="sku6"> <label for="sku6">Juvenis (SKU 700) </label> <div class="qty_box"> <label>Quantity</label><input type="number" value="0" min="0" name="qty_700" id="qty6"> </div> <div class="choose_product_img"> <img src="//zerogravityskin.com/cdn/shop/files/Juvenis_Registration_Card_New.jpg?v=6814955143565587945" alt="Juvenis_img"> </div> </div> <div class="col-two"> <input type="checkbox" value="1" name="Perfectio_X" id="sku7"> <label for="sku7">Perfectio X (SKU X) </label> <div class="qty_box"> <label>Quantity</label><input type="number" value="0" min="0" name="qty_perfectio_X" id="qty7"> </div> <div class="choose_product_img"> <img src="//zerogravityskin.com/cdn/shop/files/X_Warranty.png?v=17049210216969531864" alt="Perfectio X"> </div> </div> <div class="col-two"> <input type="checkbox" value="1" name="Sapphire_X" id="sku8"> <label for="sku8">Sapphire X (SKU X) </label> <div class="qty_box"> <label>Quantity</label><input type="number" value="0" min="0" name="qty_sapphire_X" id="qty8"> </div> <div class="choose_product_img"> <img src="//zerogravityskin.com/cdn/shop/files/SapphireX_Warranty.png?v=12318986070093917330" alt="Sapphire X"> </div> </div> <div class="col-two"> <input type="checkbox" value="1" name="Relaxatio" id="sku9"> <label for="sku9">Relaxatio</label> <div class="qty_box"> <label>Quantity</label><input type="number" value="0" min="0" name="qty_relaxatio" id="qty9"> </div> <div class="choose_product_img"> <img src="//zerogravityskin.com/cdn/shop/files/RelaxatioX_Warranty.png?v=6340990994539309428" alt="Relaxatio"> </div> </div> <div class="col-two"> <input type="checkbox" value="1" name="gl22_sku" id="GL22"> <label for="GL22">Glorifico</label> <div class="qty_box"> <label>Quantity</label><input type="number" value="0" min="0" name="gl22_sku_qty" /> </div> <div class="choose_product_img"> <img src="https://cdn.shopify.com/s/files/1/0027/9871/4946/files/14506.1_Glorifico_Product_Registration_Card_21.2.20242.jpg?v=1708509744' | file_url }}" alt="Glorifico"> </div> </div> <div class="col-two"> <input type="checkbox" value="1" name="gl22plus_sku" id="GL22+"> <label for="GL22+">Glorifico Plus</label> <div class="qty_box"> <label>Quantity</label><input type="number" value="0" min="0" name="gl22plus_sku_qty" /> </div> <div class="choose_product_img"> <img src="https://cdn.shopify.com/s/files/1/0027/9871/4946/files/14506.1_Glorifico_Product_Registration_Card_21.2.2024.jpg?v=1708509744" alt="Glorifico Plus"> </div> </div> <div class="col-two"> <input type="checkbox" value="1" name="g2px_sku" id="G2-PX"> <label for="G2-PX">Perfectio X G2</label> <div class="qty_box"> <label>Quantity</label><input type="number" value="0" min="0" name="g2px_sku_qty" /> </div> <div class="choose_product_img"> <img src="//zerogravityskin.com/cdn/shop/files/Perfectio_X_G2_Regustration_Card.jpg?v=11074693372472992340" alt="Glorifico Plus"> </div> </div> <div class="col-two"> <input type="checkbox" value="1" name="oxycura_sku" id="Oxycura"> <label for="Oxycura">Oxycura</label> <div class="qty_box"> <label>Quantity</label><input type="number" value="0" min="0" name="oxycura_sku_qty" /> </div> <div class="choose_product_img"> <img src="https://cdn.shopify.com/s/files/1/0027/9871/4946/files/OXYCURA_Product_Registration_Card_21.2.2024.jpg?v=1708509744" alt="Oxycura"> </div> </div> </div> </div> <div class="form-content col-row"> <div class="col-two"> <span class="china" onclick="add_row(1);">Enter multiple serial numbers</span> <label for="serial_number">SERIAL NUMBER<span class="required"> *</span> </label> <input type="text" value="" name="serial_number" id="serial_number" placeholder="As appear at the bottom of the box" /> <input type="hidden" id="as1" class="serials" placeholder="As appear at the bottom of the box" /> </div> <div class="col-two" id="asn1"> <label for="invoice_number">INVOICE NUMBER<span class="required"> *</span> </label> <input type="text" value="" name="invoice_number" id="invoice_number" placeholder="As appear on the original receipt" /> </div> <div class="col-two"> <label>DATE OF PURCHASE<span class="required"> *</span> </label> <input type="text" value="" name="date_purchase" id="date" placeholder="Month/ Day/ Year" required /> </div> <div class="col-two placeOfPurchase "> <label>PLACE OF PURCHASE <span class="required"> *</span> </label> <input type="text" value="" name="place_purchase" id="purchase" placeholder="Name of business as appears on original receipt"> </div> <div class="col-two"> <label for="business_address">BUSINESS ADDRESS</label> <input type="text" value="" name="business_address" id="business_address" placeholder="Business address" /> </div> <!-- <div class="col-two"> <label>RECEIPT NUMBER<span class="required"> *</span></label> <input type="text" value="" name="receipt_no" id="re_number"> </div> --> <div class="col-two"> <label>ANSWER THIS QUESTION TO PROVE YOU’RE NOT ROBOT <span class="required"> *</span> </label> <input type="text" value="" name="" id="question" placeholder="How much is 1+2?"> </div> <div class="col-full receive_box"> <input type="checkbox" value="1" name="promo_and_educa" id="receive" checked="checked"> <label for="receive">I would like to receive promotional and educational newsletters from Zero Gravity</label> </div> <div class="col-full submit_btn"> <input type="hidden" name="form_event_source" value="zerogravity" /> <button type="submit" value="submit">Submit</button> <p style="font-family:'Roboto', 'Lato', sans-serif;font-weight:400;padding-top:30px;font-size:15px;">IF YOU RECEIVED THE MESSAGE, "THERE WAS A SERVER ERROR," PLEASE OPEN THIS PAGE IN AN INCOGNITO WINDOW AND TRY AGAIN.</p> </div> </div> <div class="error"></div> </div> <p>* USA ONLINE PURCHASE - Unless the products are purchased from our website, there are no other authorized online sellers. Please be advised that without a receipt from the physical store you purchased the device, our customer service will not honor your warranty. Even if a warranty confirmation is sent to you after registering your product, Zero Gravity will not honor the warranty when you need to activate it in case of device malfunction in the future.</p> </form> </div> </div> <style> .choose_product_img img { max-width: 425px; } span.selected-text { display: none; } .select_box select { position: static; opacity: 1; border: none; height: calc(100% - 2px); padding: 10px; outline: none !important; } </style> <script type="text/javascript" charset="utf-8"> // initialize observers on address selectors new Shopify.CountryProvinceSelector('country', 'state', {hideElement: 'address_province_container_new'}); // new Shopify.CountryProvinceSelector('address_country_new', 'address_province_new', {hideElement: 'address_province_container_new'}); $(document).ready(function(){ $('input[type="checkbox"]').on('click', function(){ if($(this).is(':checked')) { $(this).closest('div').find('input[type="number"]').val(1); } else { $(this).closest('div').find('input[type="number"]').val(0); } }); }); </script></div> </div> <div class="newletter"> <div id="shopify-section-newletter" class="shopify-section"><div class="newletter_form_container"> <div class="newletter_form"> <div class="same_form"> <a href="#"><img src="//zerogravityskin.com/cdn/shop/files/new_latter_form.png?v=1613746252" alt="newletter_form_img"></a> </div><div class="same_form"> <form action="" class="new_form" id="newletter_form"> <input type="email" placeholder="Enter your e-mail" id="email"><button type="submit" value="subscribe">subscribe</button> </form> </div> </div> </div> </div> </div> </div> </main> <div id="shopify-section-general-newsletter" class="shopify-section"> </div> <div id="shopify-section-general-social-feeds" class="shopify-section"> </div> <div id="shopify-section-general-footer" class="shopify-section"><div class="footer-wrapper style-default "> <footer class="main-footer"> <div class="footer-row footer-columns clearfix"> <div class="footer-column footer-content"> <h4 class="footer-title footer-content-title"> About Us </h4> <div class="footer-content-text"> <p>ZERO GRAVITY was founded with one principle in mind; to develop and deliver safe and effective anti-aging facial products to consumers across the globe. Zero Gravity is proud to be a prolific leader in the aesthetic devices market.</p> </div> <div class="footer-social-media"> <a href="https://twitter.com/zerogravityskin" target="_blank"><img src="//zerogravityskin.com/cdn/shop/files/icon_twitter.png?v=12949525966584914608"></a> <a href="https://www.facebook.com/ZeroGravitySkin/" target="_blank"><img src="//zerogravityskin.com/cdn/shop/files/icon_facebook.png?v=3195864730559980028"></a> <a href="https://www.instagram.com/zerogravityskin/" target="_blank"><img src="//zerogravityskin.com/cdn/shop/files/icon_instagram.png?v=14782499994775887943"></a> </div> </div> <div class="footer-column footer-menu"> <h4 class="footer-title footer-menu-title">Zero Gravity</h4> <ul class="footer-menu-list"> <li class="footer-menu-list-item"> <a class="footer-menu-list-item-anchor" href="/">Home</a> </li> <li class="footer-menu-list-item"> <a class="footer-menu-list-item-anchor" href="/pages/about-us">About Us</a> </li> <li class="footer-menu-list-item"> <a class="footer-menu-list-item-anchor" href="/pages/testimonials">Customers Say</a> </li> <li class="footer-menu-list-item"> <a class="footer-menu-list-item-anchor" href="/pages/presses">Press</a> </li> <li class="footer-menu-list-item"> <a class="footer-menu-list-item-anchor" href="/pages/contact-me">Contact us</a> </li> </ul> </div> <div class="footer-column footer-menu"> <h4 class="footer-title footer-menu-title">Customer Service</h4> <ul class="footer-menu-list"> <li class="footer-menu-list-item"> <a class="footer-menu-list-item-anchor" href="/pages/product-registration">Product Registration</a> </li> <li class="footer-menu-list-item"> <a class="footer-menu-list-item-anchor" href="/pages/warranty-claim">Warranty Claim</a> </li> <li class="footer-menu-list-item"> <a class="footer-menu-list-item-anchor" href="/pages/limited-lifetime-warranty">Limited Lifetime Warranty</a> </li> <li class="footer-menu-list-item"> <a class="footer-menu-list-item-anchor" href="/pages/distributors">Distributors</a> </li> <li class="footer-menu-list-item"> <a class="footer-menu-list-item-anchor" href="/pages/authorized-retailer-policy">Authorized Retailer policy</a> </li> </ul> </div> <div class="footer-column footer-menu"> <h4 class="footer-title footer-menu-title">Our Products</h4> <ul class="footer-menu-list"> <li class="footer-menu-list-item"> <a class="footer-menu-list-item-anchor" href="/products/perfectio-by-zero-gravity">Perfectio by Zero Gravity </a> </li> <li class="footer-menu-list-item"> <a class="footer-menu-list-item-anchor" href="/products/perefctio-plus-special-edition">Perfectio Plus by Zero Gravity</a> </li> <li class="footer-menu-list-item"> <a class="footer-menu-list-item-anchor" href="/products/perefctio-plus-special-edition">Perfectio Plus Special Edition</a> </li> <li class="footer-menu-list-item"> <a class="footer-menu-list-item-anchor" href="/products/sapphire-zero-gravity">Sapphire</a> </li> <li class="footer-menu-list-item"> <a class="footer-menu-list-item-anchor" href="/products/silver-blue-pro-luxury-kit">Silver Blue Treat Set</a> </li> <li class="footer-menu-list-item"> <a class="footer-menu-list-item-anchor" href="/products/golden-blue-pro-luxury-kit">Golden Blue Treat Set</a> </li> </ul> </div> <div class="footer-column footer-menu"> <h4 class="footer-title footer-menu-title">Download Our App Today!</h4> <ul class="footer-menu-list"> <li class="footer-menu-list-item"> <a class="footer-menu-list-item-anchor" href="https://play.google.com/store/apps/details?id=com.ommimports.zerogravity">Google Play</a> </li> <li class="footer-menu-list-item"> <a class="footer-menu-list-item-anchor" href="https://apps.apple.com/il/app/perfectio/id1176970194">App Store</a> </li> </ul> </div> </div> <div role="contentinfo" class="footer-row footer-information"> <p class="footer-copyright"> &copy; 2024. 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