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<option value="Mr">Mr</option> <option value="Mrs">Mrs</option> <option value="Miss">Miss</option> <option value="Ms">Ms</option> </select> </p> <p> <label for="first_name">First Name:</label> <input type="text" name="first_name" class="form-text" value=""/> <span class="required">*</span> </p> <p> <label for="last_name">Last Name:</label> <input type="text" maxlength="75" name="last_name" class="form-text" value=""/> <span class="required">*</span> </p><p> <label for="city">City/Town:</label> <input type="text" maxlength="75" name="city" class="form-text" value=""/> <span class="required">*</span> <input type="hidden" name="street1" class="form-text" value="Incomplete Address"> </p> <p> <label for="state">County/State/Province (if applicable): </label> <select name="state_form_select"> <option value="">Please select...</option> <optgroup label="United Kingdom"> <option value="209:Aberdeenshire">Aberdeenshire</option> <option value="209:Angus">Angus</option> <option 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<optgroup label="Australia"> <option value="227:AAT">Australian Antarctic Territory</option> <option value="227:ACT">Australian Capital Territory</option> <option value="227:NSW">New South Wales</option> <option value="227:NT">Northern Territory</option> <option value="227:QLD">Queensland</option> <option value="227:SA">South Australia</option> <option value="227:TAS">Tasmania</option> <option value="227:VIC">Victoria</option> <option value="227:WA">Western Australia</option> </optgroup> </select> </p> <p> <label for="postal_code">Post/Zip code</label> <input type="text" maxlength="75" name="postal_code" class="form-text" value=""/> <span class="required">*</span> </p> <p> <label for="edit-prefix">Country:</label> <select name="country"> <option value="226">Afghanistan</option> <option value="239">Aland Islands</option> <option value="3">Albania</option> <option value="4">Algeria</option> <option value="240">American Samoa</option> <option value="5">Andorra</option> <option 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<option value="248">British Indian Ocean Territory</option> <option value="202">British Virgin Island</option> <option value="28">Brunei Darussalam</option> <option value="29">Bulgaria</option> <option value="21">Burkina Faso</option> <option value="23">Burundi</option> <option value="249">Cambodia</option> <option value="31">Cameroon</option> <option value="32">Canada</option> <option value="46">Cape Verde</option> <option value="49">Cayman Islands</option> <option value="33">Central African Rep</option> <option value="36">Chad</option> <option value="37">Chile</option> <option value="38">China</option> <option value="250">Christmas Island</option> <option value="251">Cocos (Keeling) Islands</option> <option value="43">Colombia</option> <option value="40">Comoros</option> <option value="44">Congo</option> <option value="252">Congo, Democratic epublic of</option> <option value="39">Cook Islands</option> <option value="45">Costa Rica</option> <option value="232">Croatia</option> <option 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value="255">Gambia</option> <option value="236">Georgia</option> <option value="74">Germany</option> <option value="75">Ghana</option> <option value="76">Gibraltar</option> <option value="79">Greece</option> <option value="80">Greenland</option> <option value="73">Grenada</option> <option value="81">Guadaloupe</option> <option value="256">Guam</option> <option value="78">Guatemala</option> <option value="257">Guernsey</option> <option value="83">Guinea</option> <option value="82">Guinea-Bissau</option> <option value="84">Guyana</option> <option value="85">Haiti</option> <option value="258">Heard and McDonald Islands</option> <option value="88">Honduras</option> <option value="86">Hong Kong</option> <option value="89">Hungary</option> <option value="90">Iceland</option> <option value="92">India</option> <option value="91">Indonesia</option> <option value="95">Iran</option> <option value="96">Iraq</option> <option value="94">Ireland</option> <option value="97">Isle Of Man</option> <option value="98">Israel</option> <option value="99">Italy</option> <option value="100">Ivory Coast</option> <option value="101">Jamaica</option> <option value="102">Japan</option> <option value="259">Jersey</option> <option value="103">Jordan</option> <option value="289">Kazakhstan</option> <option value="106">Kenya</option> <option value="108">Kiribati</option> <option value="260">Krygyzstan</option> <option value="109">Kuwait</option> <option value="110">Laos</option> <option value="111">Latvia</option> <option value="112">Lebanon</option> <option value="113">Lesotho</option> <option value="114">Liberia</option> <option value="118">Libya</option> <option value="115">Liechtenstein</option> <option value="116">Lithuania</option> <option value="117">Luxembourg</option> <option value="119">Macao</option> <option value="261">Macedonia</option> <option value="120">Madagascar</option> <option value="127">Malawi</option> <option value="121">Malaysia</option> <option 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value="147">Nigeria</option> <option value="144">Niue</option> <option value="268">Norfolk Island</option> <option value="269">Northern Mariana Islands</option> <option value="146">Norway</option> <option value="151">Oman</option> <option value="153">Pakistan</option> <option value="270">Palau</option> <option value="235">Palestine</option> <option value="154">Panama</option> <option value="155">Papua New Guinea</option> <option value="156">Paraguay</option> <option value="157">Peru</option> <option value="158">Philippines</option> <option value="159">Pitcairn</option> <option value="160">Poland</option> <option value="161">Portugal</option> <option value="271">Puerto Rico</option> <option value="162">Qatar</option> <option value="177">Republic of Korea</option> <option value="124">Republic of Maldives</option> <option value="163">Reunion Islands</option> <option value="164">Romania</option> <option value="233">Russia</option> <option value="166">Rwanda</option> <option value="272">Saint Barthelemy</option> <option value="273">Saint Helena, Ascension, TdC</option> <option value="176">Saint Kitts and Nevis</option> <option value="185">Saint Lucia</option> <option value="186">Saint Martin</option> <option value="274">Saint Pierre and Miquelon</option> <option value="187">Saint Vincent & the Grenadines</option> <option value="178">San Marino</option> <option value="168">Sao Tome & Principe</option> <option value="169">Saudi Arabia</option> <option value="172">Senegal</option> <option value="237">Serbia</option> <option value="173">Seychelles</option> <option value="174">Sierra Leone</option> <option value="175">Singapore</option> <option value="275">Sint Maarten (Dutch Part)</option> <option value="234">Slovakia</option> <option value="228">Slovenia</option> <option value="181">Solomon Islands</option> <option value="182">Somalia</option> <option value="180">South Africa</option> <option value="276">South Georgia and Sandwich Is</option> <option value="277">South Sudan</option> <option value="183">Spain</option> <option value="184">Sri Lanka</option> <option value="188">Sudan</option> <option value="189">Suriname</option> <option value="278">Svalbard and Jan Mayen</option> <option value="190">Swaziland</option> <option value="191">Sweden</option> <option value="192">Switzerland</option> <option value="193">Syria</option> <option value="195">Taiwan</option> <option value="279">Tajikistan</option> <option value="196">Tanzania</option> <option value="197">Thailand</option> <option value="199">Timor-Leste</option> <option value="200">Togo</option> <option value="280">Tokelau</option> <option value="201">Tonga</option> <option value="203">Trinidad & Tobago</option> <option value="204">Tunisia</option> <option value="205">Turkey</option> <option value="281">Turkmenistan</option> <option value="282">Turks and Caicos Islands</option> <option value="206">Tuvalu</option> <option value="208">Uganda</option> <option value="283">Ukraine</option> <option value="207">United Arab Emirates</option> <option selected value="209">United Kingdom</option> <option value="211">Uruguay</option> <option value="284">US Minor Outlying Islands</option> <option value="1">USA</option> <option value="285">Uzbekistan</option> <option value="215">Vanuatu</option> <option value="214">Vatican City</option> <option value="216">Venezuela</option> <option value="217">Vietnam</option> <option value="286">Virgin Islands, US</option> <option value="287">Wallis and Futuna</option> <option value="288">Western Sahara</option> <option value="179">Western Samoa</option> <option value="220">Yemen Arab Republic</option> <option value="224">Zambia</option> <option value="225">Zimbabwe</option> </select> </p> <p> <label for="email">Email Address:</label> <input type="email" name="email" class="form-text" value=""/> <span class="required">*</span> </p> <p> <label>Confirm Email :</label> <input type="email" name="confirmEmail" 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