CINXE.COM

<meta http-equiv="refresh" content="0;URL='https://healthcareconference.yuktan.com/'" /> <!DOCTYPE html> <html lang="en"> <head>  <meta charset="utf-8">  <meta http-equiv="X-UA-Compatible" content="IE=edge"> <meta name="viewport" content="width=device-width, initial-scale=1.0, user-scalable=0">  <title>Registration</title> <meta name="keywords" content=""/> <meta name="description" content=""/>  <link rel="shortcut icon" href="images/fav.png" type="image/x-icon"> <link rel="icon" href="images/fav.png" type="image/x-icon">   <link rel="stylesheet" href="css/bootstrap.min.css">  <link rel="stylesheet" href="css/style.css">  <link rel="stylesheet" href="css/responsive.css">  <link rel="stylesheet" href="css/font-awesome.min.css">  <link rel="stylesheet" href="css/animate.css">  <link rel="stylesheet" href="css/colorbox.css">     <script async src="https://www.googletagmanager.com/gtag/js?id=UA-135184418-4"></script> <script> window.dataLayer = window.dataLayer || []; function 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<span class="icon-bar"></span> <span class="icon-bar"></span> </button> <nav class="collapse navbar-collapse navbar-responsive-collapse pull-right"> <ul class="nav navbar-nav"> <li class="dropdown"> <a href="#" class="dropdown-toggle" data-toggle="dropdown">About <i class="fa fa-angle-down"></i></a> <ul class="dropdown-menu menu-center" role="menu"> <li><a href="about.php">ABOUT HEALTHCARE LEAGUE</a></li> <li><a href="important-dates.php">IMPORTANT DATES</a></li> <li><a href="visa.php">VISA</a></li>  </ul> </li> <li class="dropdown"> <a href="#" class="dropdown-toggle" data-toggle="dropdown">OUR EXPERTS <i class="fa fa-angle-down"></i></a> <ul class="dropdown-menu menu-center" role="menu"> <li><a href="organizing-committee.php">COMMITTEE</a></li> <li><a href="featured-speakers.php">FEATURED SPEAKERS</a></li> </ul> </li> <li class="dropdown"> <a href="#" class="dropdown-toggle" data-toggle="dropdown">ABSTRACT <i class="fa fa-angle-down"></i></a> <ul class="dropdown-menu menu-center" role="menu"> <li><a href="abstract-submission.php">ABSTRACT SUBMISSION</a></li> </ul> </li> <li class="dropdown"> <a href="#" class="dropdown-toggle" data-toggle="dropdown">PROGRAM <i class="fa fa-angle-down"></i></a> <ul class="dropdown-menu menu-center" role="menu"> <li><a href="#">PROGRAM</a></li>  <li><a href="review-process.php">REVIEW PROCESS</a></li> <li><a href="speaker-guidelines.php">SPEAKER GUIDELINES</a></li> <li><a href="poster-guidelines.php">POSTER GUIDELINES</a></li> </ul> </li> <li class="dropdown"> <a href="#" class="dropdown-toggle" data-toggle="dropdown">EVENT VENUE <i class="fa fa-angle-down"></i></a> <ul class="dropdown-menu menu-center" role="menu"> <li><a href="hotel-information.php">HOTEL INFORMATION</a></li> <li><a href="cityattraction.php">CITY ATTRACTION</a></li> </ul> </li> <li class="dropdown"> <a href="#" class="dropdown-toggle" data-toggle="dropdown">SPONSORS<i class="fa fa-angle-down"></i></a> <ul class="dropdown-menu menu-center" role="menu"> <li><a href="exhibition-opportunities.php">EXHIBITION OPPORTUNITY</a></li> <li><a href="become_a_sponsor.php">BECOME A SPONSOR</a></li> </ul> </li>  <li class="header-ticket"> <a class="ticket-btn btn-primary" href="registration_form.php"><i class="fa fa-ticket"></i> REGISTER</a> </li> </ul> </nav> </div> </div> <style> .rowdates{background: #77ab01;margin-bottom: 0.5%;border-radius: 5px; font-size:13px;} .dates a:link, .dates a:active, .dates a:visited{color:#fff;} .dates a:hover{color:#acc7e1;} </style>  </div> </header> <style> .extra-nights-box{background:#19546b; color:#fff; padding:10px; width:320px; margin:10px 0px 25px;} .summery-invisible{padding:10px 20px 5px;} hr.style-one { border: 0; height: 1px; background: #333; background-image: linear-gradient(to right, #ccc, #333, #ccc); } h4 { font-size: 17px;} ul{margin:1% 3%;} .panel-body label{width:100% !important;} </style> <link rel="stylesheet" href="https://cdnjs.cloudflare.com/ajax/libs/font-awesome/4.7.0/css/font-awesome.min.css"> <script src="https://code.jquery.com/jquery-1.12.4.js" type="text/javascript"></script> <script src="js/regsupport.js"></script> <div id="page-banner-area" class="page-banner-area" style="background-image:url(images/banner/banner1.jpg)">  <div class="page-banner-title"> <div class="text-center"> <h2>Online Registration</h2> </div> </div> </div>  <section class="banner-bottom-w3ls" id="speakers"> <div class="container"> <div class="inner-sec-w3ls"> <h3 class="tittle-w3 text-center"><span class="sub-tittle">Online</span> Registration</h3> <div class="col-md-12 agileits_services_grid" data-aos="fade-right"><br /> <div class="col-md-4"> </div> <div class="col-md-4" style="margin-bottom:25px;"><img src="images/logo-stripe.png" alt="Stripe" style="text-align:center; width:100%;" /></div> </div> <p class="text"> <form class="form-horizontal" name="form1" id="form1" method="post"> <div class="form-group"> <label class="control-label col-sm-2" for="title">Title:</label> <div class="col-sm-10"> <div class="input-group"> <span class="input-group-addon"><i class="fa fa-asterisk"></i></span> <select class="form-control" name="title" style="width:auto;"> <option value="Dr.">Dr.</option> <option value="Mr.">Mr.</option> <option value="Mrs.">Mrs.</option> <option value="Ms.">Ms.</option> </select> </div> </div> </div> <div class="form-group"> <label class="control-label col-sm-2" for="name">Name:</label> <div class="col-sm-10"> <div class="input-group"> <span class="input-group-addon"><i class="fa fa-user"></i></span> <input type="text" class="form-control" id="Name" placeholder="Enter your name" name="name" required="required"> </div> </div> </div> <div class="form-group"> <label class="control-label col-sm-2" for="email">Email:</label> <div class="col-sm-10"> <div class="input-group"> <span class="input-group-addon"><i class="fa fa-envelope"></i></span> <input type="email" class="form-control" id="email" placeholder="Enter your email" name="email" required="required"> </div> </div> </div> <div class="form-group"> <label class="control-label col-sm-2" for="organization">Organization:</label> <div class="col-sm-10"> <div class="input-group"> <span class="input-group-addon"><i class="fa fa-briefcase"></i></span> <input type="text" class="form-control" id="organization" placeholder="Organization/Institution" name="organization" required="required"> </div> </div> </div> <div class="form-group"> <label class="control-label col-sm-2" for="phone">Telephone:</label> <div class="col-sm-10"> <div class="input-group"> <span class="input-group-addon"><i class="fa fa-phone-square"></i></span> <input type="tel" class="form-control" id="Telephone" placeholder="Enter your phone number" name="phone" required="required"> </div> </div> </div> <div class="form-group"> <label class="control-label col-sm-2" for="city">City:</label> <div class="col-sm-10"><div class="input-group"> <span class="input-group-addon"><i class="fa fa-home"></i></span> <input type="text" class="form-control" id="City" placeholder="Enter your city name" name="city" required="required"> </div> </div> </div> <div class="form-group"> <label class="control-label col-sm-2" for="country">Country:</label> <div class="col-sm-10"> <div class="input-group"> <span class="input-group-addon"><i class="fa fa-map-marker"></i></span> <select class="form-control" name="country" data-country="US" style="width:auto;"> <option value="Select Any" selected="selected">Select country</option> <option value="United States" >United States</option> <option value="United Kingdom">United Kingdom</option> <option value="Afghanistan">Afghanistan</option> <option value="Albania">Albania</option> <option value="Algeria">Algeria</option> <option value="American Samoa">American Samoa</option> <option value="Andorra">Andorra</option> <option value="Angola">Angola</option> <option value="Anguilla">Anguilla</option> <option value="Antarctica">Antarctica</option> <option value="Antigua and Barbuda">Antigua and Barbuda</option> <option value="Argentina">Argentina</option> <option value="Armenia">Armenia</option> <option value="Aruba">Aruba</option> <option value="Australia">Australia</option> <option value="Austria">Austria</option> <option value="Azerbaijan">Azerbaijan</option> <option value="Bahamas">Bahamas</option> <option value="Bahrain">Bahrain</option> <option value="Bangladesh">Bangladesh</option> <option value="Barbados">Barbados</option> <option value="Belarus">Belarus</option> <option value="Belgium">Belgium</option> <option value="Belize">Belize</option> <option value="Benin">Benin</option> <option value="Bermuda">Bermuda</option> <option value="Bhutan">Bhutan</option> <option value="Bolivia">Bolivia</option> <option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option> <option value="Botswana">Botswana</option> <option value="Bouvet Island">Bouvet Island</option> <option value="Brazil">Brazil</option> <option value="British Indian Ocean Territory">British Indian Ocean Territory</option> <option value="Brunei Darussalam">Brunei Darussalam</option> <option value="Bulgaria">Bulgaria</option> <option value="Burkina Faso">Burkina Faso</option> <option value="Burundi">Burundi</option> <option value="Cambodia">Cambodia</option> <option value="Cameroon">Cameroon</option> <option value="Canada">Canada</option> <option value="Canadian Nunavut Territory">Canadian Nunavut Territory</option> <option value="Cape Verde">Cape Verde</option> <option value="Cayman Islands">Cayman Islands</option> <option value="Central African Republic">Central African Republic</option> <option value="Chad">Chad</option> <option value="Chile">Chile</option> <option value="China">China</option> <option value="Christmas Island">Christmas Island</option> <option value="Cocos (Keeling Islands)">Cocos (Keeling Islands)</option> <option value="Colombia">Colombia</option> <option value="Comoros">Comoros</option> <option value="Congo">Congo</option> <option value="Cook Islands">Cook Islands</option> <option value="Costa Rica">Costa Rica</option> <option value="Cote D'Ivoire (Ivory Coast)">Cote D'Ivoire (Ivory Coast)</option> <option value="Croatia (Hrvatska)">Croatia (Hrvatska)</option> <option value="Cuba">Cuba</option> <option value="Cyprus">Cyprus</option> <option value="Czech Republic">Czech Republic</option> <option value="Denmark">Denmark</option> <option value="Djibouti">Djibouti</option> <option value="Dominica">Dominica</option> <option value="Dominican Republic">Dominican Republic</option> <option value="East Timor">East Timor</option> <option value="Ecuador">Ecuador</option> <option value="Egypt">Egypt</option> <option value="El Salvador">El Salvador</option> <option value="Equatorial Guinea">Equatorial Guinea</option> <option value="Eritrea">Eritrea</option> <option value="Estonia">Estonia</option> <option value="Ethiopia">Ethiopia</option> <option value="Falkland Islands (Malvinas)">Falkland Islands (Malvinas)</option> <option value="Faroe Islands">Faroe Islands</option> <option value="Fiji">Fiji</option> <option value="Finland">Finland</option> <option value="France">France</option> <option value="France, Metropolitan">France, Metropolitan</option> <option value="French Guiana">French Guiana</option> <option value="French Polynesia">French Polynesia</option> <option value="French Southern Territories">French Southern Territories</option> <option value="Gabon">Gabon</option> <option value="Gambia">Gambia</option> <option value="Georgia">Georgia</option> <option value="Germany">Germany</option> <option value="Ghana">Ghana</option> <option value="Gibraltar">Gibraltar</option> <option value="Greece">Greece</option> <option value="Greenland">Greenland</option> <option value="Grenada">Grenada</option> <option value="Guadeloupe">Guadeloupe</option> <option value="Guam">Guam</option> <option value="Guatemala">Guatemala</option> <option value="Guinea">Guinea</option> <option value="Guinea-Bissau">Guinea-Bissau</option> <option value="Guyana">Guyana</option> <option value="Haiti">Haiti</option> <option value="Heard and McDonald Islands">Heard and McDonald Islands</option> <option value="Honduras">Honduras</option> <option value="Hong Kong">Hong Kong</option> <option value="Hungary">Hungary</option> <option value="Iceland">Iceland</option> <option value="India">India</option> <option value="Indonesia">Indonesia</option> <option value="Iran">Iran</option> <option value="Iraq">Iraq</option> <option value="Ireland">Ireland</option> <option value="Israel">Israel</option> <option value="Italy">Italy</option> <option value="Jamaica">Jamaica</option> <option value="Japan">Japan</option> <option value="Jordan">Jordan</option> <option value="Kazakhstan">Kazakhstan</option> <option value="Kenya">Kenya</option> <option value="Kiribati">Kiribati</option> <option value="Korea (North)">Korea (North)</option> <option value="Korea (South)">Korea (South)</option> <option value="Kuwait">Kuwait</option> <option value="Kyrgyzstan">Kyrgyzstan</option> <option value="Laos">Laos</option> <option value="Latvia">Latvia</option> <option value="Lebanon">Lebanon</option> <option value="Lesotho">Lesotho</option> <option value="Liberia">Liberia</option> <option value="Libya">Libya</option> <option value="Liechtenstein">Liechtenstein</option> <option value="Lithuania">Lithuania</option> <option value="Luxembourg">Luxembourg</option> <option value="Macau">Macau</option> <option value="Macedonia">Macedonia</option> <option value="Madagascar">Madagascar</option> <option value="Malawi">Malawi</option> <option value="Malaysia">Malaysia</option> <option value="Maldives">Maldives</option> <option value="Mali">Mali</option> <option value="Malta<">Malta</option> <option value="Marshall Islands">Marshall Islands</option> <option value="Martinique">Martinique</option> <option value="Mauritania">Mauritania</option> <option value="Mauritius">Mauritius</option> <option value="Mayotte">Mayotte</option> <option value="Mexico">Mexico</option> <option value="Micronesia">Micronesia</option> <option value="Moldova">Moldova</option> <option value="Monaco">Monaco</option> <option value="Mongolia">Mongolia</option> <option value="Montserrat">Montserrat</option> <option value="Morocco">Morocco</option> <option value="Mozambique">Mozambique</option> <option value="Myanmar">Myanmar</option> <option value="Namibia">Namibia</option> <option value="Nauru">Nauru</option> <option value="Nepal">Nepal</option> <option value="Netherlands">Netherlands</option> <option value="Netherlands Antilles">Netherlands Antilles</option> <option value="New Caledonia">New Caledonia</option> <option value="New Zealand">New Zealand</option> <option value="Nicaragua">Nicaragua</option> <option value="Niger">Niger</option> <option value="Nigeria">Nigeria</option> <option value="Niue">Niue</option> <option value="Norfolk Island">Norfolk Island</option> <option value="Northern Mariana Islands">Northern Mariana Islands</option> <option value="Norway">Norway</option> <option value="Oman">Oman</option> <option value="Pakistan">Pakistan</option> <option value="Palau">Palau</option> <option value="Panama">Panama</option> <option value="Papua New Guinea">Papua New Guinea</option> <option value="Paraguay">Paraguay</option> <option value="Peru">Peru</option> <option value="Philippines">Philippines</option> <option value="Pitcairn">Pitcairn</option> <option value="Poland">Poland</option> <option value="Portugal">Portugal</option> <option value="Qatar">Qatar</option> <option value="Reunion">Reunion</option> <option value="Romania">Romania</option> <option value="Russian Federation">Russian Federation</option> <option value="Rwanda">Rwanda</option> <option value="S. Georgia and S. Sandwich Isls.">S. Georgia and S. Sandwich Isls.</option> <option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option> <option value="Saint Lucia">Saint Lucia</option> <option value="Saint Vincent and The Grenadines">Saint Vincent and The Grenadines</option> <option value="Samoa">Samoa</option> <option value="San Marino">San Marino</option> <option value="Sao Tome and Principe">Sao Tome and Principe</option> <option value="Saudi Arabia">Saudi Arabia</option> <option value="Senegal">Senegal</option> <option value="Seychelles">Seychelles</option> <option value="Sierra Leone">Sierra Leone</option> <option value="Singapore">Singapore</option> <option value="Slovak Republic">Slovak Republic</option> <option value="Slovenia">Slovenia</option> <option value="Solomon Islands">Solomon Islands</option> <option value="Somalia">Somalia</option> <option value="South Africa">South Africa</option> <option value="Spain">Spain</option> <option value="Sri Lanka">Sri Lanka</option> <option value="St. Helena">St. Helena</option> <option value="St. Pierre and Miquelon">St. Pierre and Miquelon</option> <option value="Sudan">Sudan</option> <option value="Suriname">Suriname</option> <option value="Svalbard and Jan Mayen Islands">Svalbard and Jan Mayen Islands</option> <option value="Swaziland">Swaziland</option> <option value="Sweden">Sweden</option> <option value="Switzerland">Switzerland</option> <option value="Syria">Syria</option> <option value="Taiwan">Taiwan</option> <option value="Tajikistan">Tajikistan</option> <option value="Tanzania">Tanzania</option> <option value="Thailand">Thailand</option> <option value="Togo">Togo</option> <option value="Tokelau">Tokelau</option> <option value="Tonga">Tonga</option> <option value="Trinidad and Tobago">Trinidad and Tobago</option> <option value="Tunisia">Tunisia</option> <option value="Turkey">Turkey</option> <option value="Turkmenistan">Turkmenistan</option> <option value="Turks and Caicos Islands">Turks and Caicos Islands</option> <option value="Tuvalu">Tuvalu</option> <option value="US Minor Outlying Islands">US Minor Outlying Islands</option> <option value="Uganda">Uganda</option> <option value="Ukraine">Ukraine</option> <option value="United Arab Emirates">United Arab Emirates</option> <option value="United Kingdom">United Kingdom</option> <option value="United States">United States</option> <option value="Uruguay">Uruguay</option> <option value="Uzbekistan">Uzbekistan</option> <option value="Vanuatu">Vanuatu</option> <option value="Vatican City State (Holy See)">Vatican City State (Holy See)</option> <option value="Venezuela">Venezuela</option> <option value="Viet Nam">Viet Nam</option> <option value="Virgin Islands (British)">Virgin Islands (British)</option> <option value="Wallis and Futuna Islands">Wallis and Futuna Islands</option> <option value="Western Sahara">Western Sahara</option> <option value="Yemen">Yemen</option> <option value="Yugoslavia">Yugoslavia</option> <option value="Zaire">Zaire</option> <option value="Zambia">Zambia</option> <option value="Zimbabwe">Zimbabwe</option> </select> </div> </div> </div> <div class="form-group"> <label class="control-label col-sm-2" for="interest">Interested In:</label> <div class="col-sm-10"> <div class="input-group"> <span class="input-group-addon"><i class="fa fa-list"></i></span> <select class="form-control" name="interest" style="width:auto;"> <option value="Poster Presentation"> Poster Presentation </option> <option value="Oral Presentation"> Oral Presentation </option> <option value="Conducting Workshop"> Conducting Workshop </option> <option value="Conducting Symposium"> Conducting Symposium </option> <option value="Others"> Others </option> </select> </div> </div> </div> <div class="form-group"> <label class="control-label col-sm-2" for="address">Billing Address:</label> <div class="col-sm-10"> <div class="input-group"> <span class="input-group-addon"><i class="fa fa-globe"></i></span> <textarea class="form-control" name="address" rows="5" required="required" /></textarea> </div> </div> </div> <div class="form-group"> <label class="control-label col-sm-2" for="participants">Participants:</label> <div class="col-sm-10"> <div class="input-group"> <span class="input-group-addon"><i class="fa fa-plus"></i></span> <select class="form-control" name="participants" id="participants_id" style="width:auto;"> <option value="1">1</option> <option value="2">2</option> <option value="3">3</option> <option value="4">4</option> <option value="5">5</option> <option value="6">6</option> <option value="7">7</option> <option value="8">8</option> <option value="9">9</option> <option value="10">10</option> </select> </div> </div> </div>  <style> .nonBold{font-weight:normal;} .priceBox{border:1px solid #ebccd1; padding:5px 10px; float: right; color:#a94442; background:#fff;} </style> <div class="form-group"> <div class="col-sm-3" style="opacity:0.4;"> <div class="panel panel-primary"> <div class="panel-heading"><h4 class="text-center"><s>Extend Early Bird Registration<br /><small style="color:#fff;"> November 15, 2019 </small></s></h4> <input type="checkbox" class="form-control" name="earlybird" id="check_earlybird" disabled /></div> <div class="panel-body"> <div class="form-group"> <label class="control-label col-sm-12" style="text-align:left;"><input type="radio" name="r1" value="1300" onClick="return get_radio_value()" data-value="Group"> <span class="nonBold">Group of 3</span>   <span class="priceBox">€1300</span></label> </div> <div class="form-group"> <label class="control-label col-sm-12" style="text-align:left;"><input type="radio" name="r1" value="499" onClick="return get_radio_value()" data-value="Academic"> <span class="nonBold">Academic</span>   <span class="priceBox">€499</span></label> </div> <div class="form-group"> <label class="control-label col-sm-12" style="text-align:left;"><input type="radio" name="r1" value="599" onClick="return get_radio_value()" data-value="Business"> <span class="nonBold">Business</span>   <span class="priceBox">€599</span></label> </div> <div class="form-group"> <label class="control-label col-sm-12" style="text-align:left;"><input type="radio" name="r1" value="449" onClick="return get_radio_value()" data-value="Delegate"> <span class="nonBold">Delegate</span>  <span class="priceBox">€449</span></label> </div> <div class="form-group"> <label class="control-label col-sm-12" style="text-align:left;"><input type="radio" name="r1" value="249" onClick="return get_radio_value()" data-value="Student"> <span class="nonBold">Student</span>   <span class="priceBox">€249</span></label> </div> </div> </div> </div> <div class="col-sm-3" style="opacity:0.4;"> <div class="panel panel-primary"> <div class="panel-heading"><h4 class="text-center"><s>Mid Term Registration<br /><small style="color:#fff;"> December 31, 2019 </small></s></h4> <input type="checkbox" class="form-control" name="speaker" onClick="return check_speaker()" disabled /></div> <div class="panel-body"> <div class="form-group"> <label class="control-label col-sm-12" style="text-align:left;"><input type="radio" name="r2" value="1500" onClick="return get_radio_value()" data-value="Group"> <span class="nonBold">Group of 3</span>   <span class="priceBox">€1500</span></label> </div> <div class="form-group"> <label class="control-label col-sm-12" style="text-align:left;"><input type="radio" name="r2" value="599" onClick="return get_radio_value()" data-value="Academic"> <span class="nonBold">Academic</span>   <span class="priceBox">€599</span></label> </div> <div class="form-group"> <label class="control-label col-sm-12" style="text-align:left;"><input type="radio" name="r2" value="699" onClick="return get_radio_value()" data-value="Business"> <span class="nonBold">Business</span>   <span class="priceBox">€699</span></label> </div> <div class="form-group"> <label class="control-label col-sm-12" style="text-align:left;"><input type="radio" name="r2" value="549" onClick="return get_radio_value()" data-value="Delegate"> <span class="nonBold">Delegate</span>   <span class="priceBox">€549</span></label> </div> <div class="form-group"> <label class="control-label col-sm-12" style="text-align:left;"><input type="radio" name="r2" value="249" onClick="return get_radio_value()" data-value="Student"> <span class="nonBold">Student</span>   <span class="priceBox">€249</span></label> </div> </div> </div> </div> <div class="col-sm-3" style="opacity:0.4;"> <div class="panel panel-primary"> <div class="panel-heading"><s><h4 class="text-center">Late Registration<br /><small style="color:#fff;"> January 31, 2020</small></h4></s> <input type="checkbox" class="form-control" name="poster" onClick="return check_poster()" disabled /></div> <div class="panel-body"> <div class="form-group"> <label class="control-label col-sm-12" style="text-align:left;"><input type="radio" name="r3" value="1700" onClick="return get_radio_value()" data-value="Group"> <span class="nonBold">Group of 3</span>   <span class="priceBox">€1700</span></label> </div> <div class="form-group"> <label class="control-label col-sm-12" style="text-align:left;"><input type="radio" name="r3" value="699" onClick="return get_radio_value()" data-value="Academic"> <span class="nonBold">Academic</span>   <span class="priceBox">€699</span></label> </div> <div class="form-group"> <label class="control-label col-sm-12" style="text-align:left;"><input type="radio" name="r3" value="799" onClick="return get_radio_value()" data-value="Business"> <span class="nonBold">Business</span>   <span class="priceBox">€799</span></label> </div> <div class="form-group"> <label class="control-label col-sm-12" style="text-align:left;"><input type="radio" name="r3" value="649" onClick="return get_radio_value()" data-value="Delegate"> <span class="nonBold">Delegate</span>   <span class="priceBox">€649</span></label> </div> <div class="form-group"> <label class="control-label col-sm-12" style="text-align:left;"><input type="radio" name="r3" value="249" onClick="return get_radio_value()" data-value="Student"> <span class="nonBold">Student</span>   <span class="priceBox">€249</span></label> </div> </div> </div> </div> <div class="col-sm-3"> <div class="panel panel-primary"> <div class="panel-heading"><h4 class="text-center">Final Registration<br /><small style="color:#fff;">Before February 20, 2020 </small></h4> <input type="checkbox" class="form-control" name="onspot" onClick="return check_onspot()" /></div> <div class="panel-body"> <div class="form-group"> <label class="control-label col-sm-12" style="text-align:left;"><input type="radio" name="r4" value="2000" onClick="return get_radio_value()" data-value="Group"> <span class="nonBold">Group of 3</span>   <span class="priceBox">€2000</span></label> </div> <div class="form-group"> <label class="control-label col-sm-12" style="text-align:left;"><input type="radio" name="r4" value="999" onClick="return get_radio_value()" data-value="Academic"> <span class="nonBold">Academic</span>   <span class="priceBox">€999</span></label> </div> <div class="form-group"> <label class="control-label col-sm-12" style="text-align:left;"><input type="radio" name="r4" value="1099" onClick="return get_radio_value()" data-value="Business"> <span class="nonBold">Business</span>   <span class="priceBox">€1099</span></label> </div> <div class="form-group"> <label class="control-label col-sm-12" style="text-align:left;"><input type="radio" name="r4" value="949" onClick="return get_radio_value()" data-value="Delegate"> <span class="nonBold">Delegate</span>   <span class="priceBox">€949</span></label> </div> <div class="form-group"> <label class="control-label col-sm-12" style="text-align:left;"><input type="radio" name="r4" value="249" onClick="return get_radio_value()" data-value="Student"> <span class="nonBold">Student</span>   <span class="priceBox">€249</span></label> </div> </div> </div> </div> <div class="col-sm-4" style="display:none;"> <div class="panel panel-danger"> <div class="panel-heading"><h4 class="text-center" style="padding:10px 0;">Accommodation<br /><small>Per Night </small></h4></div> <div class="panel-body"> <div class="form-group"> <div class="input-group"> <label class="control-label col-sm-10" style="text-align:left;"><input type="radio" name="r5" value="120">€120 Single Occupancy</label> <span class="input-group-addon"><i class="fa fa-bed"></i></span> <div class="col-sm-2">   </div> </div> </div> </div> </div> </div> <div class="col-sm-4" style="display:none;"> <div class="panel panel-danger"> <div class="panel-heading"><h4 class="text-center" style="padding:10px 0;">Accommodation<br /><small>Per Night </small></h4></div> <div class="panel-body"> <div class="form-group"> <div class="input-group"> <label class="control-label col-sm-12" style="text-align:left;"><input type="radio" name="r5" value="140">€140 Double Occupancy</label> <span class="input-group-addon"><i class="fa fa-bed"></i></span>   <span class="input-group-addon"><i class="fa fa-bed"></i></span> <div class="col-sm-2">   </div> </div> </div> </div> </div> </div> <div class="col-sm-4"> <div class="panel panel-danger"> <div class="panel-heading"><h4 class="text-center" style="padding:10px 0;">Single Day Participation<br /><input type="checkbox" class="form-control" name="single-day-participation" /></h4></div> <div class="panel-body"> <div> <div> <label class="control-label col-sm-12" style="text-align:left;"><input type="radio" name="r6" value="150" data-value="Single Day Participation"> <span class="nonBold">Single Day Participation</span>   <span class="priceBox">€150</span></label> </div> </div> </div> </div> </div> <div class="col-sm-12" style="padding:2%; text-align:justify; background:#eee; border:1px solid #ccc; border-radius:3px;"> <strong>ALERT :</strong> Healthcare League 2020 has learned that a variety of travel companies are contacting our attendees and exhibitors to assist with hotel reservations in the Lisbon area for the International Conference on Healthcare Technologies and Public Health. These companies ARE NOT affiliated with Healthcare League in any capacity. If you are contacted by travel booking agencies, we strongly urge you not to utilize their services. Please only book hotel accommodations through this web page or contact <a href="mailto:arnab.das@healthcareleague.com">arnab.das@healthcareleague.com</a> </div> <div class="col-sm-4">   </div> </div> <div id="ead_checkbox" class="extra-nights-box" style="display:none;"><input type="checkbox" name="extraaccommodation" id="extra_accommodation" style="margin-top:-2px; margin-left:1px; vertical-align: middle;" /><span style="margin-left:2px;">Need Extra Nights Accommodation</span></div> <div class="accommodation_extrabox" id="acd_extrabox" style="display:none;"> <div class="form-group"> <label class="control-label col-sm-2" for="title">Extra Nights:</label> <div class="col-sm-10"> <div class="input-group"> <span class="input-group-addon"><i class="fa fa-calendar"></i></span> <select class="form-control" name="numberofdays" id="numberof_days" onChange="days_accomodation();" style="width:auto;"> <option value="" selected="selected">Select Nights</option> <option value="1">1</option> <option value="2">2</option> <option value="3">3</option> <option value="4">4</option> <option value="5">5</option> <option value="6">6</option> <option value="7">7</option> </select> </div> </div> </div> <div class="form-group"> <label class="control-label col-sm-2" for="Check-in">Check-in Date:</label> <div class="col-sm-10"> <div class="input-group"> <span class="input-group-addon"><i class="fa fa-calendar"></i></span> <select class="form-control" name="dateofaccommodation" id="dateof_accommodation" style="width:auto;"> <option value="" selected="selected">Select Date</option> <option value="02/22/2020" class="datesecond">02-22-20</option> <option value="02/23/2020">02-23-20</option> <option value="02/24/2020">02-24-20</option> </select> </div> </div> </div> <div class="form-group"> <label class="control-label col-sm-2" for="Checkout-date">Check-out Date:</label> <div class="col-sm-10"> <div class="input-group"> <span class="input-group-addon"><i class="fa fa-calendar"></i></span> <input type="text" class="form-control" placeholder="Enter your name" name="checkoutdate" data="" id="checkoutdate" readonly> </div> </div> </div> </div> <div id="afterdiscount" style="display:none;"></div> <div id="afterdiscount_accm" style="display:none;"></div> <input type="hidden" name="discount_accom" id="discount_accom" /> <input type="hidden" name="discount_registrationprice" id="discount_registrationprice" /> <input type="hidden" name="discount_price" id="discount_price" /> <input type="hidden" name="apply_discountcode" id="apply_discountcode" /> <input type="hidden" name="selectcategory_type" id="selectcategory_type" /> <input type="hidden" name="showcheckin_date" id="showcheckin_date" /> <input type="hidden" name="showcheckout_date" id="showcheckout_date" /> <div id="discountpercentage" style="display:none;"></div> <div id="discounttype_category" style="display:none;"></div> <div> <div id="discount_checkbox" class="extra-nights-box"><input type="checkbox" name="discountregistration" id="discountregistration" style="margin-top:-2px; margin-left:1px; vertical-align: middle;" /><span style="margin-left:2px;">Have a promo code?</span></div> <div id="display_discountinput" style="display:none;"> <div class="panel-body"> <div class="form-group"> <div class="col-sm-8 text-center"> <div class="input-group"> <span class="input-group-addon"><i class="fa fa-barcode"></i></span> <input type="text" name="discount_code" id="discount_code" value="" class="form-control" placeholder="Enter Discount Code" /> </div> </div> <div class="col-sm-4 text-center"> <input type="submit" value="Apply" class="discountcheck control-label" style="width:125px; background:#900; color:#fff; text-align: center; padding: 10px; border: 0px; margin: -5px;" /> </div> </div> </div> </div> <div class="form-group"> <label class="control-label col-sm-3" for="participants">Accompanying (€ 300 for each person):</label> <div class="col-sm-8"> <div class="input-group"> <span class="input-group-addon"><i class="fa fa-plus"></i></span> <select class="form-control" name="accompanying_name" id="accompanying" style="width:auto;"> <option value="0">0</option> <option value="1">1</option> <option value="2">2</option> <option value="3">3</option> <option value="4">4</option> <option value="5">5</option> <option value="6">6</option> <option value="7">7</option> <option value="8">8</option> <option value="9">9</option> <option value="10">10</option> </select> </div> </div> </div> <span id="jsonpResult"></span> </div> <div class="panel panel-danger"> <h1 class="text-center text-uppercase text"><strong>Summary</strong></h1> <div class="row"> <div class="col-md-6"> <p class="summery-invisible" style="text-align:left; margin-bottom: 0px;">Registration Price:<strong style="float:right;">€ <span id="showregistration_price"></span></strong> <span class="disocuntsec" style="text-align:left; display:none;"><small>Discount Amount:</small><strong style="float:right;">€ <span id="registrationdiscount"></span></strong></span></p><div class="clearfix"></div> <p class="summery-invisible" style="text-align:left; margin-bottom: 0px;">Accommodation:<strong style="float:right;">€ <span id="showaccommodation_price"></span></strong> <span class="disocuntsec" style="text-align:left; display:none;"><small>Discount Amount:</small><strong style="float:right;">€ <span id="accommodationdiscount"></span></strong></span></p><div class="clearfix"></div> <p class="summery-invisible disocuntsec" style="text-align:left; display:none;"><strong>Total Discounts:</strong><strong style="float:right;">€ <span id="showdiscount_price"></span></strong><div class="clearfix"></div> </p> </div> <div class="col-md-6"> <p class="summery-invisible" style="text-align:left;">Participants:<strong style="float:right;"> <span id="shownumberof_participants"></span></strong><div class="clearfix"></div></p> <p class="summery-invisible" style="text-align:left;">Total No. Nights:<strong style="float:right;"> <span id="showselected_numberofdays"></span></strong><div class="clearfix"></div></p> </div> <div class="col-md-6"> <p class="summery-invisible" style="text-align:left;"><strong>Check-in Date:</strong><strong style="float:right;"> <span id="showcheckin"></span></strong><div class="clearfix"></div> <span class="summery-invisible" style="text-align:left; width: 50%; padding-right: 0; color:#777;"><strong>Check-out Date:</strong></span><strong style="float:right;"> <span id="showcheckout" style="padding-right: 17px; float: right; color:#777;"></span></strong><div class="clearfix"></div> <span class="summery-invisible disocuntsec" style="display:none; float:left; color:#777;"><strong>Discounts Code:</strong></span><strong style="float:right;"> <span id="showdiscountcode" style="padding-right: 17px; color:#777; float: right; margin-top: 13%;"></span></strong><div class="clearfix"></div> </p> </div> <div class="col-md-6"> </div> <div class="clearfix"></div> <style> hr.style-one {border: 0; border-bottom: 1px dashed #333; background: #fff; width:90%; margin:0px auto; padding:0px;} </style> <hr class="style-one"> <div class="col-md-4"> </div> <div class="col-md-4 text-center"> <div class="summery-invisible"><h3><strong>Total Price:</strong><strong style="float:right;">€ <span id="showtotalprice"></span></strong></h3></div> </div> <div class="col-md-4"> </div> </div> <br /> </div> <div class="well well-lg"> <h4 class="text-center">By clicking "pay", you agree to the <a href="https://yuktan.com/privacy-policy.php" target="_blank" title="Privacy Policy" style="color:#000;">privacy policy</a>, <span id="terms">terms & conditions</span> and <span id="cpolicy">cancellation policy</span></h4> <p class="text-center">Selected Price €: <small>Inclusive of all taxes.</small></p> <div class="input-group col-md-3" style="margin:0 auto;"> <span class="input-group-addon"><i class="fa fa-eur"></i></span> <div id="displayprice" class="form-control"></div> <input class="form-control" type="hidden" readonly name="price" id="price" value="2000" placeholder="2000" required style="width:80%;" /> <input type="hidden" id="participants_regtotal" name="participants_regtotal" value="2000"> <input type="hidden" name="registration_price" id="registration_price" value="2000"> <input type="hidden" name="accompanying_priceonly" id="accompanying_priceonly"> <input type="hidden" name="accommodation_total" id="accommodation_total"> </div> <br>  <div class="row"> <div class="col-md-4"></div> <div class="col-md-2"> <div class="input-group" style="display: flex; margin-bottom: 1%;"> <button type="submit" class="btn btn-primary btn-lg" style="width:100% !important;" name="register">Pay</button> </div> </div> <div class="col-md-2"> <div class="input-group" style="display: flex; margin-bottom: 1%;"> <button type="reset" class="btn btn-secondary btn-lg" style="width:100% !important; background:#900; color:#fff;">Reset</button> </div> </div> </div> </div> </form> <div class="clearfix"></div> <div class="row"> <div class="col-md-12" style="padding-top:20px;"> <div style="background:#eee; padding:10px; margin:5px 0; border:1px solid #ddd;"> <p style="padding:5px 0; margin:5px 0; font-size:16px;" class="text-uppercase"><strong>Registration includes ↓</strong></p> <ul> <li>Welcome coffee</li> <li>Access to main conference sessions, exhibits, poster sessions and round table discussions</li> <li>Conference material</li> <li>Lunch, tea / coffee breaks during the conference days</li> <li>WiFi in meeting rooms</li> </ul> </div> <div id="cancellation"></div> <div id="tconditions"></div> <div style="background:#eee; padding:10px; margin:5px 0; border:1px solid #ddd;"> <p style="padding:5px 0; margin:5px 0; font-size:16px;" class="text-uppercase"><strong>Registration Cancellation policy ↓</strong></p> <p> <ul> <li>Cancellation policy is strictly followed and all cancellations must be made in writing.</li> <li>Cancellation before 90 days of the conference start date will receive a full refund, less a €100 towards administrative fee.</li> <li>Cancellation between 89 and 45 days prior to the conference start date will receive 50 % refund.</li> <li>Cancellations received below 45 days of the conference start date are non-refundable.</li> <li>Refunds will be made within 28 days of receipt of cancellation notification.</li> </ul> </p> </div> <div style="background:#fff; padding:10px; margin:5px 0; border:1px solid #ddd;"> <p style="padding:5px 0; margin:5px 0; font-size:16px;" class="text-uppercase"><strong>Terms and conditions ↓</strong></p> <ul> <li>Organizer reserves the right to make last minute changes without prior notice, should the need arise.</li> <li>The organisers reserve the right to cancel the conference in case of any unpredictable event. In that case, payments made towards registration and/or lodging will be refunded. Organizer will have no further liability to the client. Refunds will be made within 28 days of receipt of cancellation notification.</li> <li>Registrations remain valid if the conference has to be postponed.</li> <li>The organizers will not accept any liability for personal injuries or for loss or damage to property belonging to the delegates, either during, or as a result of the conference.</li> </ul> </div> </div> </div> </p> </div> </div> </section> <style> .form-control { box-shadow: none; padding: 6px 12px; height: 34px; background: none; color: #333 !important; font-size: 12px; border-radius: 0; border: 0; border-radius: 0; color: #fff; border: 1px solid #dedede; border-bottom: 1px solid rgba(0, 0, 0, 0.15); } .form-control:focus { box-shadow: none; border-bottom: 1px solid #ff0763; } .form-control::-moz-placeholder { color: #999; opacity: 1; } .form-control:-ms-input-placeholder { color: #999; } .form-control::-webkit-input-placeholder { color: #999; } </style> <section id="ts-intro" class="ts-intro" style="padding-bottom: 30px;"> <div class="container"> <div class="row"> <div class="col-sm-4"> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title text-center"><strong>Contact us</strong></h3> </div> <div class="panel-body"> <div class="row">  <div class="col-xs-12"><strong><u>Organising Partner</u></strong></div> <div class="col-xs-12"><p style="line-height:16px;"><strong>GED Biomedical Innovations AB</strong><br> Per Albin Hanssons vag 41<br> Malmo- 20512, Sweden<br> Phone: +46 40 666 53 35<br></p> </div> <div class="col-xs-12"><strong><u>Administrative Office</u></strong></div> <div class="col-xs-12"><p style="line-height:16px;"><strong>Yuktan Technologies Pvt Ltd</strong><br> 1 Raffles Place, #44-01A<br> One Raffles Place, Singapore 048616<br> Phone: +65 9189 1271<br></p>  </div> </div> </div> </div> </div> <div class="col-sm-8"> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title text-center"><strong>Leave us message</strong></h3> </div> <div class="panel-body"> <div class="row"> <form class="form-horizontal" action="#" method="post" id="contactForm"> <div class="col-sm-6"> <div class="form-group"> <div class="col-sm-12"> <input type="text" class="form-control" placeholder="Enter full name" id="name" name="name"> </div> </div> <div class="form-group"> <div class="col-sm-12"> <select class="form-control" id="country" name="country" data-country="US"> <option value="Select Any" selected="selected">Select country</option> <option value="United States" >United States</option> <option value="United Kingdom" >United Kingdom</option> <option value="Afghanistan" >Afghanistan</option> <option value="Albania" >Albania</option> <option value="Algeria" >Algeria</option> <option value="American Samoa" >American Samoa</option> <option value="Andorra" >Andorra</option> <option value="Angola" >Angola</option> <option value="Anguilla" >Anguilla</option> <option value="Antarctica" >Antarctica</option> <option value="Antigua and Barbuda" >Antigua and Barbuda</option> <option value="Argentina" >Argentina</option> <option value="Armenia" >Armenia</option> <option value="Aruba" >Aruba</option> <option value="Australia" >Australia</option> <option value="Austria" >Austria</option> <option value="Azerbaijan" >Azerbaijan</option> <option value="Bahamas" >Bahamas</option> <option value="Bahrain" >Bahrain</option> <option value="Bangladesh" >Bangladesh</option> <option value="Barbados" >Barbados</option> <option value="Belarus" >Belarus</option> <option value="Belgium" >Belgium</option> <option value="Belize" >Belize</option> <option value="Benin" >Benin</option> <option value="Bermuda" >Bermuda</option> <option value="Bhutan" >Bhutan</option> <option value="Bolivia" >Bolivia</option> <option value="Bosnia and Herzegovina" >Bosnia and Herzegovina</option> <option value="Botswana" >Botswana</option> <option value="Bouvet Island" >Bouvet Island</option> <option value="Brazil" >Brazil</option> <option value="British Indian Ocean Territory" >British Indian Ocean Territory</option> <option value="Brunei Darussalam" >Brunei Darussalam</option> <option value="Bulgaria" >Bulgaria</option> <option value="Burkina Faso" >Burkina Faso</option> <option value="Burundi" >Burundi</option> <option value="Cambodia" >Cambodia</option> <option value="Cameroon" >Cameroon</option> <option value="Canada" >Canada</option> <option value="Canadian Nunavut Territory" >Canadian Nunavut Territory</option> <option value="Cape Verde" >Cape Verde</option> <option value="Cayman Islands" >Cayman Islands</option> <option value="Central African Republic" >Central African Republic</option> <option value="Chad" >Chad</option> <option value="Chile" >Chile</option> <option value="China" >China</option> <option value="Christmas Island" >Christmas Island</option> <option value="Cocos (Keeling Islands)" >Cocos (Keeling Islands)</option> <option value="Colombia" >Colombia</option> <option value="Comoros" >Comoros</option> <option value="Congo" >Congo</option> <option value="Cook Islands" >Cook Islands</option> <option value="Costa Rica" >Costa Rica</option> <option value="Cote D'Ivoire (Ivory Coast)" >Cote D'Ivoire (Ivory Coast)</option> <option value="Croatia (Hrvatska)" >Croatia (Hrvatska)</option> <option value="Cuba" >Cuba</option> <option value="Cyprus" >Cyprus</option> <option value="Czech Republic" >Czech Republic</option> <option value="Denmark" >Denmark</option> <option value="Djibouti" >Djibouti</option> <option value="Dominica" >Dominica</option> <option value="Dominican Republic" >Dominican Republic</option> <option value="East Timor" >East Timor</option> <option value="Ecuador" >Ecuador</option> <option value="Egypt" >Egypt</option> <option value="El Salvador" >El Salvador</option> <option value="Equatorial Guinea" >Equatorial Guinea</option> <option value="Eritrea" >Eritrea</option> <option value="Estonia" >Estonia</option> <option value="Ethiopia" >Ethiopia</option> <option value="Falkland Islands (Malvinas)" >Falkland Islands (Malvinas)</option> <option value="Faroe Islands" >Faroe Islands</option> <option value="Fiji" >Fiji</option> <option value="Finland" >Finland</option> <option value="France" >France</option> <option value="France, Metropolitan" >France, Metropolitan</option> <option value="French Guiana" >French Guiana</option> <option value="French Polynesia" >French Polynesia</option> <option value="French Southern Territories" >French Southern Territories</option> <option value="Gabon" >Gabon</option> <option value="Gambia" >Gambia</option> <option value="Georgia" >Georgia</option> <option value="Germany" >Germany</option> <option value="Ghana" >Ghana</option> <option value="Gibraltar" >Gibraltar</option> <option value="Greece" >Greece</option> <option value="Greenland" >Greenland</option> <option value="Grenada" >Grenada</option> <option value="Guadeloupe" >Guadeloupe</option> <option value="Guam" >Guam</option> <option value="Guatemala" >Guatemala</option> <option value="Guinea" >Guinea</option> <option value="Guinea-Bissau" >Guinea-Bissau</option> <option value="Guyana" >Guyana</option> <option value="Haiti" >Haiti</option> <option value="Heard and McDonald Islands" >Heard and McDonald Islands</option> <option value="Honduras" >Honduras</option> <option value="Hong Kong" >Hong Kong</option> <option value="Hungary" >Hungary</option> <option value="Iceland" >Iceland</option> <option value="India" >India</option> <option value="Indonesia" >Indonesia</option> <option value="Iran" >Iran</option> <option value="Iraq" >Iraq</option> <option value="Ireland" >Ireland</option> <option value="Israel" >Israel</option> <option value="Italy" >Italy</option> <option value="Jamaica" >Jamaica</option> <option value="Japan" >Japan</option> <option value="Jordan" >Jordan</option> <option value="Kazakhstan" >Kazakhstan</option> <option value="Kenya" >Kenya</option> <option value="Kiribati" >Kiribati</option> <option value="Korea (North)" >Korea (North)</option> <option value="Korea (South)" >Korea (South)</option> <option value="Kuwait" >Kuwait</option> <option value="Kyrgyzstan" >Kyrgyzstan</option> <option value="Laos" >Laos</option> <option value="Latvia" >Latvia</option> <option value="Lebanon" >Lebanon</option> <option value="Lesotho" >Lesotho</option> <option value="Liberia" >Liberia</option> <option value="Libya" >Libya</option> <option value="Liechtenstein" >Liechtenstein</option> <option value="Lithuania" >Lithuania</option> <option value="Luxembourg" >Luxembourg</option> <option value="Macau" >Macau</option> <option value="Macedonia" >Macedonia</option> <option value="Madagascar" >Madagascar</option> <option value="Malawi" >Malawi</option> <option value="Malaysia" >Malaysia</option> <option value="Maldives" >Maldives</option> <option value="Mali" >Mali</option> <option value="Malta<" >Malta</option> <option value="Marshall Islands" >Marshall Islands</option> <option value="Martinique" >Martinique</option> <option value="Mauritania" >Mauritania</option> <option value="Mauritius" >Mauritius</option> <option value="Mayotte" >Mayotte</option> <option value="Mexico" >Mexico</option> <option value="Micronesia" >Micronesia</option> <option value="Moldova" >Moldova</option> <option value="Monaco" >Monaco</option> <option value="Mongolia" >Mongolia</option> <option value="Montserrat" >Montserrat</option> <option value="Morocco" >Morocco</option> <option value="Mozambique" >Mozambique</option> <option value="Myanmar" >Myanmar</option> <option value="Namibia" >Namibia</option> <option value="Nauru" >Nauru</option> <option value="Nepal" >Nepal</option> <option value="Netherlands" >Netherlands</option> <option value="Netherlands Antilles" >Netherlands Antilles</option> <option value="New Caledonia" >New Caledonia</option> <option value="New Zealand" >New Zealand</option> <option value="Nicaragua" >Nicaragua</option> <option value="Niger" >Niger</option> <option value="Nigeria" >Nigeria</option> <option value="Niue" >Niue</option> <option value="Norfolk Island" >Norfolk Island</option> <option value="Northern Mariana Islands" >Northern Mariana Islands</option> <option value="Norway" >Norway</option> <option value="Oman" >Oman</option> <option value="Pakistan" >Pakistan</option> <option value="Palau" >Palau</option> <option value="Panama" >Panama</option> <option value="Papua New Guinea" >Papua New Guinea</option> <option value="Paraguay" >Paraguay</option> <option value="Peru" >Peru</option> <option value="Philippines" >Philippines</option> <option value="Pitcairn" >Pitcairn</option> <option value="Poland" >Poland</option> <option value="Portugal" >Portugal</option> <option value="Qatar" >Qatar</option> <option value="Reunion" >Reunion</option> <option value="Romania" >Romania</option> <option value="Russian Federation" >Russian Federation</option> <option value="Rwanda" >Rwanda</option> <option value="S. Georgia and S. Sandwich Isls." >S. Georgia and S. Sandwich Isls.</option> <option value="Saint Kitts and Nevis" >Saint Kitts and Nevis</option> <option value="Saint Lucia" >Saint Lucia</option> <option value="Saint Vincent and The Grenadines" >Saint Vincent and The Grenadines</option> <option value="Samoa" >Samoa</option> <option value="San Marino" >San Marino</option> <option value="Sao Tome and Principe" >Sao Tome and Principe</option> <option value="Saudi Arabia" >Saudi Arabia</option> <option value="Senegal" >Senegal</option> <option value="Seychelles" >Seychelles</option> <option value="Sierra Leone" >Sierra Leone</option> <option value="Singapore" >Singapore</option> <option value="Slovak Republic" >Slovak Republic</option> <option value="Slovenia" >Slovenia</option> <option value="Solomon Islands" >Solomon Islands</option> <option value="Somalia" >Somalia</option> <option value="South Africa" >South Africa</option> <option value="Spain" >Spain</option> <option value="Sri Lanka" >Sri Lanka</option> <option value="St. Helena" >St. Helena</option> <option value="St. Pierre and Miquelon" >St. Pierre and Miquelon</option> <option value="Sudan" >Sudan</option> <option value="Suriname" >Suriname</option> <option value="Svalbard and Jan Mayen Islands" >Svalbard and Jan Mayen Islands</option> <option value="Swaziland" >Swaziland</option> <option value="Sweden" >Sweden</option> <option value="Switzerland" >Switzerland</option> <option value="Syria" >Syria</option> <option value="Taiwan" >Taiwan</option> <option value="Tajikistan" >Tajikistan</option> <option value="Tanzania" >Tanzania</option> <option value="Thailand" >Thailand</option> <option value="Togo" >Togo</option> <option value="Tokelau" >Tokelau</option> <option value="Tonga" >Tonga</option> <option value="Trinidad and Tobago" >Trinidad and Tobago</option> <option value="Tunisia" >Tunisia</option> <option value="Turkey" >Turkey</option> <option value="Turkmenistan" >Turkmenistan</option> <option value="Turks and Caicos Islands" >Turks and Caicos Islands</option> <option value="Tuvalu" >Tuvalu</option> <option value="US Minor Outlying Islands" >US Minor Outlying Islands</option> <option value="Uganda" >Uganda</option> <option value="Ukraine" >Ukraine</option> <option value="United Arab Emirates" >United Arab Emirates</option> <option value="United Kingdom">United Kingdom</option> <option value="United States">United States</option> <option value="Uruguay" >Uruguay</option> <option value="Uzbekistan" >Uzbekistan</option> <option value="Vanuatu" >Vanuatu</option> <option value="Vatican City State (Holy See)" >Vatican City State (Holy See)</option> <option value="Venezuela" >Venezuela</option> <option value="Viet Nam" >Viet Nam</option> <option value="Virgin Islands (British)" >Virgin Islands (British)</option> <option value="Wallis and Futuna Islands" >Wallis and Futuna Islands</option> <option value="Western Sahara" >Western Sahara</option> <option value="Yemen" >Yemen</option> <option value="Yugoslavia" >Yugoslavia</option> <option value="Zaire" >Zaire</option> <option value="Zambia" >Zambia</option> <option value="Zimbabwe" >Zimbabwe</option> </select> </div> </div> <div class="form-group"> <div class="col-sm-12"> <input type="phone" class="form-control" placeholder="Enter phone number" id="phone" name="phone"> </div> </div> <div class="form-group"> <div class="col-sm-12"> <input type="email" class="form-control" placeholder="Enter email" name="email" id="email"> </div> </div> </div>  <div class="col-sm-6"> <textarea class="form-control" placeholder="Enter your message" id="message" name="message" style="height: 150px;margin: 10px 0;"></textarea> <input type="submit" value="Submit" class="btn btn-default"> </div> </form> <div id="msgSubmit" class="h3 text-center hidden">Submitted Successfully! 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