{"id":39,"date":"2024-11-08T19:51:18","date_gmt":"2024-11-08T19:51:18","guid":{"rendered":"https:\/\/wasemelaw.com\/boi\/?page_id=39"},"modified":"2024-11-08T19:51:18","modified_gmt":"2024-11-08T19:51:18","slug":"corporate-transparency-boi","status":"publish","type":"page","link":"https:\/\/wasemelaw.com\/boi\/corporate-transparency-boi\/","title":{"rendered":"Corporate Transparency Act &amp; BOI Registration"},"content":{"rendered":"\n<figure class=\"wp-block-image size-full is-resized wp-duotone-111111-f9f9f9-1\"><img loading=\"lazy\" decoding=\"async\" width=\"600\" height=\"73\" src=\"https:\/\/wasemelaw.com\/boi\/wp-content\/uploads\/2024\/11\/images.png\" alt=\"\" class=\"wp-image-45\" style=\"width:641px;height:auto\" srcset=\"https:\/\/wasemelaw.com\/boi\/wp-content\/uploads\/2024\/11\/images.png 600w, https:\/\/wasemelaw.com\/boi\/wp-content\/uploads\/2024\/11\/images-300x37.png 300w\" sizes=\"auto, (max-width: 600px) 100vw, 600px\" \/><\/figure>\n\n\n\n<div class=\"wp-block-group alignfull has-base-background-color has-background is-vertical is-content-justification-center is-layout-flex wp-container-core-group-is-layout-5e8f9c74 wp-block-group-is-layout-flex\" style=\"min-height:100vh;margin-top:0;margin-bottom:0;padding-top:var(--wp--preset--spacing--60);padding-right:var(--wp--preset--spacing--50);padding-bottom:var(--wp--preset--spacing--60);padding-left:var(--wp--preset--spacing--50)\"><div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_2_container\" data-token=\"e1eadbadfc40a41142c0238c4e6a2e0f\">\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_boi-form\" data-token=\"e1eadbadfc40a41142c0238c4e6a2e0f\">\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">BOI Form<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"2\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_2\" id=\"frm_hide_fields_2\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"boi-form\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_2\" name=\"frm_submit_entry_2\" value=\"d427a7ee23\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/boi\/wp-json\/wp\/v2\/pages\/39\" \/><div id=\"frm_field_60_container\" class=\"frm_form_field  frm12 frm_first frm_html_container form-field\">\n<p data-pm-slice=\"1 1 []\"><strong>Effective January 1, 2024, all US and foreign companies that were formed in, or have registered with any of the 50 US states, must comply with new Beneficial Ownership Information (BOI) reporting requirements with the Financial Crimes Enforcement Network (FinCEN), as prescribed by the Corporate Transparency Act (CTA.).<\/strong><\/p>\n<p>______________________________________________________________<\/p>\n<p><strong>OUR FIRM WILL COLLECT THE NECESSARY INFORMATION AND PROCESS YOUR BOI APPLICATION FOR YOU. ONCE THE FILING IS COMPLETED, WE WILL PROVIDE YOU WITH CONFIRMATION AND YOUR <\/strong>FinCEN ID NUMBER.<\/div>\n<div id=\"frm_field_96_container\" class=\"frm_form_field  frm12 frm_first frm_html_container form-field\">\n<h2 style=\"text-align: center;\">Reporting Company Information<\/h2>\n<\/div>\n<div id=\"frm_field_91_container\" class=\"frm_form_field frm_section_heading form-field \">\n<h3 class=\"frm_pos_top frm_section_spacing\"><\/h3>\n\n\n<div id=\"frm_field_14_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_company_name\" id=\"field_company_name_label\" class=\"frm_primary_label\">Company Legal Name\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_company_name\" name=\"item_meta[14]\" value=\"\"  data-sectionid=\"91\"  data-reqmsg=\"Company Legal Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Company Legal Name is invalid\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_15_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_trade_name\" id=\"field_trade_name_label\" class=\"frm_primary_label\">Alternate Name (Trade Name, DBA)\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_trade_name\" name=\"item_meta[15]\" value=\"\"  data-sectionid=\"91\"  data-reqmsg=\"Alternate Name (Trade Name, DBA) cannot be blank.\" aria-required=\"true\" data-invmsg=\"Alternate Name (Trade Name, DBA) is invalid\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_18_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_first\">\r\n\t<label for=\"field_cz4ed\" id=\"field_cz4ed_label\" class=\"frm_primary_label\">Company Phone\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"tel\" id=\"field_cz4ed\" name=\"item_meta[18]\" value=\"\"  data-sectionid=\"91\"  data-reqmsg=\"Company Phone cannot be blank.\" aria-required=\"true\" data-invmsg=\"Company Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_68_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<div  id=\"field_xaby9_label\" class=\"frm_primary_label\">Company Address (Street, City, State, Zip) \r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_xaby9_label\">\n<legend class=\"frm_screen_reader frm_hidden\">\n\tCompany Address (Street, City, State, Zip) <\/legend>\n<div class=\"frm_combo_inputs_container\">\n<div id=\"frm_field_68-line1_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_xaby9_line1\" class=\"frm_screen_reader frm_hidden\">\n\t\tCompany Address (Street, City, State, Zip) \t<\/label>\n\t\t<input type=\"text\" id=\"field_xaby9_line1\" value=\"\" name=\"item_meta[68][line1]\"  placeholder=\"Street Address 1\" data-placeholder=\"Street Address 1\" data-sectionid=\"91\"  data-reqmsg=\"Company Address (Street, City, State, Zip)  cannot be blank.\" aria-required=\"true\" data-invmsg=\"Company Address (Street, City, State, Zip)  is invalid\" aria-invalid=\"false\"   autocomplete=\"address-line1\" \/>\n\t<\/div>\n<div id=\"frm_field_68-line2_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_xaby9_line2\" class=\"frm_screen_reader frm_hidden\">\n\t\tCompany Address (Street, City, State, Zip) \t<\/label>\n\t\t<input type=\"text\" id=\"field_xaby9_line2\" value=\"\" name=\"item_meta[68][line2]\"  placeholder=\"Street Address 2 (Optional)\" data-placeholder=\"Street Address 2 (Optional)\" data-sectionid=\"91\"  data-reqmsg=\"Company Address (Street, City, State, Zip)  cannot be blank.\" aria-required=\"true\" data-invmsg=\"Company Address (Street, City, State, Zip)  is invalid\" class=\"frm_optional\" aria-invalid=\"false\"   autocomplete=\"address-line2\" \/>\n\t<\/div>\n<div id=\"frm_field_68-city_container\" class=\"frm_form_field form-field frm_third frm_first\">\n\t<label for=\"field_xaby9_city\" class=\"frm_screen_reader frm_hidden\">\n\t\tCity\t<\/label>\n\t\t<input type=\"text\" id=\"field_xaby9_city\" value=\"\" name=\"item_meta[68][city]\"  placeholder=\"\" data-placeholder=\"\" data-sectionid=\"91\"  data-reqmsg=\"Company Address (Street, City, State, Zip)  cannot be blank.\" aria-required=\"true\" data-invmsg=\"Company Address (Street, City, State, Zip)  is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level2\" \/>\n\t<div class=\"frm_description\">City<\/div><\/div>\n<div id=\"frm_field_68-state_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_xaby9_state\" class=\"frm_screen_reader frm_hidden\">\n\t\tState\/Province\t<\/label>\n\t\t<input type=\"text\" id=\"field_xaby9_state\" value=\"\" name=\"item_meta[68][state]\"  placeholder=\"\" data-placeholder=\"\" data-sectionid=\"91\"  data-reqmsg=\"Company Address (Street, City, State, Zip)  cannot be blank.\" aria-required=\"true\" data-invmsg=\"Company Address (Street, City, State, Zip)  is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level1\" \/>\n\t<div class=\"frm_description\">State\/Province<\/div><\/div>\n<div id=\"frm_field_68-zip_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_xaby9_zip\" class=\"frm_screen_reader frm_hidden\">\n\t\tZip\/Postal\t<\/label>\n\t\t<input type=\"text\" id=\"field_xaby9_zip\" value=\"\" name=\"item_meta[68][zip]\"  placeholder=\"\" data-placeholder=\"\" data-sectionid=\"91\"  data-reqmsg=\"Company Address (Street, City, State, Zip)  cannot be blank.\" aria-required=\"true\" data-invmsg=\"Company Address (Street, City, State, Zip)  is invalid\" aria-invalid=\"false\"   autocomplete=\"postal-code\" \/>\n\t<div class=\"frm_description\">Zip\/Postal<\/div><\/div>\n<div id=\"frm_field_68-country_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_xaby9_country\" class=\"frm_screen_reader frm_hidden\">\n\t\tCountry\t<\/label>\n\t\t\t<select name=\"item_meta[68][country]\" id=\"field_xaby9_country\"  placeholder=\"\" data-placeholder=\"\" data-sectionid=\"91\"  data-reqmsg=\"Company Address (Street, City, State, Zip)  cannot be blank.\" aria-required=\"true\" data-invmsg=\"Company Address (Street, City, State, Zip)  is invalid\" aria-invalid=\"false\"   autocomplete=\"country-name\">\n\t\t\t<option value=\"\" >\n\t\t\t\t\t\t\t<\/option>\n\t\t\t<option  value=\"Afghanistan\" data-code=\"AF\">Afghanistan<\/option><option  value=\"Aland Islands\" data-code=\"AX\">Aland Islands<\/option><option  value=\"Albania\" data-code=\"AL\">Albania<\/option><option  value=\"Algeria\" data-code=\"DZ\">Algeria<\/option><option  value=\"American Samoa\" data-code=\"AS\">American Samoa<\/option><option  value=\"Andorra\" data-code=\"AD\">Andorra<\/option><option  value=\"Angola\" data-code=\"AO\">Angola<\/option><option  value=\"Anguilla\" data-code=\"AI\">Anguilla<\/option><option  value=\"Antarctica\" data-code=\"AQ\">Antarctica<\/option><option  value=\"Antigua and Barbuda\" data-code=\"AG\">Antigua and Barbuda<\/option><option  value=\"Argentina\" data-code=\"AR\">Argentina<\/option><option  value=\"Armenia\" data-code=\"AM\">Armenia<\/option><option  value=\"Aruba\" data-code=\"AW\">Aruba<\/option><option  value=\"Australia\" data-code=\"AU\">Australia<\/option><option  value=\"Austria\" data-code=\"AT\">Austria<\/option><option  value=\"Azerbaijan\" data-code=\"AZ\">Azerbaijan<\/option><option  value=\"Bahamas\" data-code=\"BS\">Bahamas<\/option><option  value=\"Bahrain\" data-code=\"BH\">Bahrain<\/option><option  value=\"Bangladesh\" data-code=\"BD\">Bangladesh<\/option><option  value=\"Barbados\" data-code=\"BB\">Barbados<\/option><option  value=\"Belarus\" data-code=\"BY\">Belarus<\/option><option  value=\"Belgium\" data-code=\"BE\">Belgium<\/option><option  value=\"Belize\" data-code=\"BZ\">Belize<\/option><option  value=\"Benin\" data-code=\"BJ\">Benin<\/option><option  value=\"Bermuda\" data-code=\"BM\">Bermuda<\/option><option  value=\"Bhutan\" data-code=\"BT\">Bhutan<\/option><option  value=\"Bolivia\" data-code=\"BO\">Bolivia<\/option><option  value=\"Bonaire, Sint Eustatius and Saba\">Bonaire, Sint Eustatius and Saba<\/option><option  value=\"Bosnia and Herzegovina\" data-code=\"BA\">Bosnia and Herzegovina<\/option><option  value=\"Botswana\" data-code=\"BW\">Botswana<\/option><option  value=\"Bouvet Island\" data-code=\"BV\">Bouvet Island<\/option><option  value=\"Brazil\" data-code=\"BR\">Brazil<\/option><option  value=\"British Indian Ocean Territory\" data-code=\"IO\">British Indian Ocean Territory<\/option><option  value=\"Brunei\" data-code=\"BN\">Brunei<\/option><option  value=\"Bulgaria\" data-code=\"BG\">Bulgaria<\/option><option  value=\"Burkina Faso\" data-code=\"BF\">Burkina Faso<\/option><option  value=\"Burundi\" data-code=\"BI\">Burundi<\/option><option  value=\"C&ocirc;te d&#039;Ivoire\">C&ocirc;te d&#039;Ivoire<\/option><option  value=\"Cambodia\" data-code=\"KH\">Cambodia<\/option><option  value=\"Cameroon\" data-code=\"CM\">Cameroon<\/option><option  value=\"Canada\" data-code=\"CA\">Canada<\/option><option  value=\"Cape Verde\" data-code=\"CV\">Cape Verde<\/option><option  value=\"Cayman Islands\" data-code=\"KY\">Cayman Islands<\/option><option  value=\"Central African Republic\" data-code=\"CF\">Central African Republic<\/option><option  value=\"Chad\" data-code=\"TD\">Chad<\/option><option  value=\"Chile\" data-code=\"CL\">Chile<\/option><option  value=\"China\" data-code=\"CN\">China<\/option><option  value=\"Christmas Island\" data-code=\"CX\">Christmas Island<\/option><option  value=\"Cocos (Keeling) Islands\">Cocos (Keeling) Islands<\/option><option  value=\"Colombia\" data-code=\"CO\">Colombia<\/option><option  value=\"Comoros\" data-code=\"KM\">Comoros<\/option><option  value=\"Congo\">Congo<\/option><option  value=\"Cook Islands\" data-code=\"CK\">Cook Islands<\/option><option  value=\"Costa Rica\" data-code=\"CR\">Costa Rica<\/option><option  value=\"Croatia\" data-code=\"HR\">Croatia<\/option><option  value=\"Cuba\" data-code=\"CU\">Cuba<\/option><option  value=\"Curacao\" data-code=\"CW\">Curacao<\/option><option  value=\"Cyprus\" data-code=\"CY\">Cyprus<\/option><option  value=\"Czech Republic\" data-code=\"CZ\">Czech Republic<\/option><option  value=\"Denmark\" data-code=\"DK\">Denmark<\/option><option  value=\"Djibouti\" data-code=\"DJ\">Djibouti<\/option><option  value=\"Dominica\" data-code=\"DM\">Dominica<\/option><option  value=\"Dominican Republic\" data-code=\"DO\">Dominican Republic<\/option><option  value=\"East Timor\" data-code=\"TL\">East Timor<\/option><option  value=\"Ecuador\" data-code=\"EC\">Ecuador<\/option><option  value=\"Egypt\" data-code=\"EG\">Egypt<\/option><option  value=\"El Salvador\" data-code=\"SV\">El Salvador<\/option><option  value=\"Equatorial Guinea\" data-code=\"GQ\">Equatorial Guinea<\/option><option  value=\"Eritrea\" data-code=\"ER\">Eritrea<\/option><option  value=\"Estonia\" data-code=\"EE\">Estonia<\/option><option  value=\"Ethiopia\" data-code=\"ET\">Ethiopia<\/option><option  value=\"Falkland Islands (Malvinas)\">Falkland Islands (Malvinas)<\/option><option  value=\"Faroe Islands\" data-code=\"FO\">Faroe Islands<\/option><option  value=\"Fiji\" data-code=\"FJ\">Fiji<\/option><option  value=\"Finland\" data-code=\"FI\">Finland<\/option><option  value=\"France\" data-code=\"FR\">France<\/option><option  value=\"French Guiana\" data-code=\"GF\">French Guiana<\/option><option  value=\"French Polynesia\" data-code=\"PF\">French Polynesia<\/option><option  value=\"French Southern Territories\" data-code=\"TF\">French Southern Territories<\/option><option  value=\"Gabon\" data-code=\"GA\">Gabon<\/option><option  value=\"Gambia\" data-code=\"GM\">Gambia<\/option><option  value=\"Georgia\" data-code=\"GE\">Georgia<\/option><option  value=\"Germany\" data-code=\"DE\">Germany<\/option><option  value=\"Ghana\" data-code=\"GH\">Ghana<\/option><option  value=\"Gibraltar\" data-code=\"GI\">Gibraltar<\/option><option  value=\"Greece\" data-code=\"GR\">Greece<\/option><option  value=\"Greenland\" data-code=\"GL\">Greenland<\/option><option  value=\"Grenada\" data-code=\"GD\">Grenada<\/option><option  value=\"Guadeloupe\" data-code=\"GP\">Guadeloupe<\/option><option  value=\"Guam\" data-code=\"GU\">Guam<\/option><option  value=\"Guatemala\" data-code=\"GT\">Guatemala<\/option><option  value=\"Guernsey\" data-code=\"GG\">Guernsey<\/option><option  value=\"Guinea\" data-code=\"GN\">Guinea<\/option><option  value=\"Guinea-Bissau\" data-code=\"GW\">Guinea-Bissau<\/option><option  value=\"Guyana\" data-code=\"GY\">Guyana<\/option><option  value=\"Haiti\" data-code=\"HT\">Haiti<\/option><option  value=\"Heard Island and McDonald Islands\" data-code=\"HM\">Heard Island and McDonald Islands<\/option><option  value=\"Holy See\">Holy See<\/option><option  value=\"Honduras\" data-code=\"HN\">Honduras<\/option><option  value=\"Hong Kong\" data-code=\"HK\">Hong Kong<\/option><option  value=\"Hungary\" data-code=\"HU\">Hungary<\/option><option  value=\"Iceland\" data-code=\"IS\">Iceland<\/option><option  value=\"India\" data-code=\"IN\">India<\/option><option  value=\"Indonesia\" data-code=\"ID\">Indonesia<\/option><option  value=\"Iran\" data-code=\"IR\">Iran<\/option><option  value=\"Iraq\" data-code=\"IQ\">Iraq<\/option><option  value=\"Ireland\" data-code=\"IE\">Ireland<\/option><option  value=\"Isle of Man\" data-code=\"IM\">Isle of Man<\/option><option  value=\"Israel\" data-code=\"IL\">Israel<\/option><option  value=\"Italy\" data-code=\"IT\">Italy<\/option><option  value=\"Jamaica\" data-code=\"JM\">Jamaica<\/option><option  value=\"Japan\" data-code=\"JP\">Japan<\/option><option  value=\"Jersey\" data-code=\"JE\">Jersey<\/option><option  value=\"Jordan\" data-code=\"JO\">Jordan<\/option><option  value=\"Kazakhstan\" data-code=\"KZ\">Kazakhstan<\/option><option  value=\"Kenya\" data-code=\"KE\">Kenya<\/option><option  value=\"Kiribati\" data-code=\"KI\">Kiribati<\/option><option  value=\"Kosovo\" data-code=\"XK\">Kosovo<\/option><option  value=\"Kuwait\" data-code=\"KW\">Kuwait<\/option><option  value=\"Kyrgyzstan\" data-code=\"KG\">Kyrgyzstan<\/option><option  value=\"Laos\" data-code=\"LA\">Laos<\/option><option  value=\"Latvia\" data-code=\"LV\">Latvia<\/option><option  value=\"Lebanon\" data-code=\"LB\">Lebanon<\/option><option  value=\"Lesotho\" data-code=\"LS\">Lesotho<\/option><option  value=\"Liberia\" data-code=\"LR\">Liberia<\/option><option  value=\"Libya\" data-code=\"LY\">Libya<\/option><option  value=\"Liechtenstein\" data-code=\"LI\">Liechtenstein<\/option><option  value=\"Lithuania\" data-code=\"LT\">Lithuania<\/option><option  value=\"Luxembourg\" data-code=\"LU\">Luxembourg<\/option><option  value=\"Macao\" data-code=\"MO\">Macao<\/option><option  value=\"Macedonia\" data-code=\"MK\">Macedonia<\/option><option  value=\"Madagascar\" data-code=\"MG\">Madagascar<\/option><option  value=\"Malawi\" data-code=\"MW\">Malawi<\/option><option  value=\"Malaysia\" data-code=\"MY\">Malaysia<\/option><option  value=\"Maldives\" data-code=\"MV\">Maldives<\/option><option  value=\"Mali\" data-code=\"ML\">Mali<\/option><option  value=\"Malta\" data-code=\"MT\">Malta<\/option><option  value=\"Marshall Islands\" data-code=\"MH\">Marshall Islands<\/option><option  value=\"Martinique\" data-code=\"MQ\">Martinique<\/option><option  value=\"Mauritania\" data-code=\"MR\">Mauritania<\/option><option  value=\"Mauritius\" data-code=\"MU\">Mauritius<\/option><option  value=\"Mayotte\" data-code=\"YT\">Mayotte<\/option><option  value=\"Mexico\" data-code=\"MX\">Mexico<\/option><option  value=\"Micronesia\" data-code=\"FM\">Micronesia<\/option><option  value=\"Moldova\" data-code=\"MD\">Moldova<\/option><option  value=\"Monaco\" data-code=\"MC\">Monaco<\/option><option  value=\"Mongolia\" data-code=\"MN\">Mongolia<\/option><option  value=\"Montenegro\" data-code=\"ME\">Montenegro<\/option><option  value=\"Montserrat\" data-code=\"MS\">Montserrat<\/option><option  value=\"Morocco\" data-code=\"MA\">Morocco<\/option><option  value=\"Mozambique\" data-code=\"MZ\">Mozambique<\/option><option  value=\"Myanmar\" data-code=\"MM\">Myanmar<\/option><option  value=\"Namibia\" data-code=\"NA\">Namibia<\/option><option  value=\"Nauru\" data-code=\"NR\">Nauru<\/option><option  value=\"Nepal\" data-code=\"NP\">Nepal<\/option><option  value=\"Netherlands\" data-code=\"NL\">Netherlands<\/option><option  value=\"New Caledonia\" data-code=\"NC\">New Caledonia<\/option><option  value=\"New Zealand\" data-code=\"NZ\">New Zealand<\/option><option  value=\"Nicaragua\" data-code=\"NI\">Nicaragua<\/option><option  value=\"Niger\" data-code=\"NE\">Niger<\/option><option  value=\"Nigeria\" data-code=\"NG\">Nigeria<\/option><option  value=\"Niue\" data-code=\"NU\">Niue<\/option><option  value=\"Norfolk Island\" data-code=\"NF\">Norfolk Island<\/option><option  value=\"North Korea\" data-code=\"KP\">North Korea<\/option><option  value=\"Northern Mariana Islands\" data-code=\"MP\">Northern Mariana Islands<\/option><option  value=\"Norway\" data-code=\"NO\">Norway<\/option><option  value=\"Oman\" data-code=\"OM\">Oman<\/option><option  value=\"Pakistan\" data-code=\"PK\">Pakistan<\/option><option  value=\"Palau\" data-code=\"PW\">Palau<\/option><option  value=\"Palestine\">Palestine<\/option><option  value=\"Panama\" data-code=\"PA\">Panama<\/option><option  value=\"Papua New Guinea\" data-code=\"PG\">Papua New Guinea<\/option><option  value=\"Paraguay\" data-code=\"PY\">Paraguay<\/option><option  value=\"Peru\" data-code=\"PE\">Peru<\/option><option  value=\"Philippines\" data-code=\"PH\">Philippines<\/option><option  value=\"Pitcairn\" data-code=\"PN\">Pitcairn<\/option><option  value=\"Poland\" data-code=\"PL\">Poland<\/option><option  value=\"Portugal\" data-code=\"PT\">Portugal<\/option><option  value=\"Puerto Rico\" data-code=\"PR\">Puerto Rico<\/option><option  value=\"Qatar\" data-code=\"QA\">Qatar<\/option><option  value=\"Reunion\" data-code=\"RE\">Reunion<\/option><option  value=\"Romania\" data-code=\"RO\">Romania<\/option><option  value=\"Russia\" data-code=\"RU\">Russia<\/option><option  value=\"Rwanda\" data-code=\"RW\">Rwanda<\/option><option  value=\"Saint Barthelemy\" data-code=\"BL\">Saint Barthelemy<\/option><option  value=\"Saint Helena, Ascension and Tristan da Cunha\">Saint Helena, Ascension and Tristan da Cunha<\/option><option  value=\"Saint Kitts and Nevis\" data-code=\"KN\">Saint Kitts and Nevis<\/option><option  value=\"Saint Lucia\" data-code=\"LC\">Saint Lucia<\/option><option  value=\"Saint Martin (French part)\">Saint Martin (French part)<\/option><option  value=\"Saint Pierre and Miquelon\" data-code=\"PM\">Saint Pierre and Miquelon<\/option><option  value=\"Saint Vincent and the Grenadines\" data-code=\"VC\">Saint Vincent and the Grenadines<\/option><option  value=\"Samoa\" data-code=\"WS\">Samoa<\/option><option  value=\"San Marino\" data-code=\"SM\">San Marino<\/option><option  value=\"Sao Tome and Principe\" data-code=\"ST\">Sao Tome and Principe<\/option><option  value=\"Saudi Arabia\" data-code=\"SA\">Saudi Arabia<\/option><option  value=\"Senegal\" data-code=\"SN\">Senegal<\/option><option  value=\"Serbia\" data-code=\"RS\">Serbia<\/option><option  value=\"Seychelles\" data-code=\"SC\">Seychelles<\/option><option  value=\"Sierra Leone\" data-code=\"SL\">Sierra Leone<\/option><option  value=\"Singapore\" data-code=\"SG\">Singapore<\/option><option  value=\"Sint Maarten (Dutch part)\">Sint Maarten (Dutch part)<\/option><option  value=\"Slovakia\" data-code=\"SK\">Slovakia<\/option><option  value=\"Slovenia\" data-code=\"SI\">Slovenia<\/option><option  value=\"Solomon Islands\" data-code=\"SB\">Solomon Islands<\/option><option  value=\"Somalia\" data-code=\"SO\">Somalia<\/option><option  value=\"South Africa\" data-code=\"ZA\">South Africa<\/option><option  value=\"South Georgia and the South Sandwich Islands\" data-code=\"GS\">South Georgia and the South Sandwich Islands<\/option><option  value=\"South Korea\" data-code=\"KR\">South Korea<\/option><option  value=\"South Sudan\" data-code=\"SS\">South Sudan<\/option><option  value=\"Spain\" data-code=\"ES\">Spain<\/option><option  value=\"Sri Lanka\" data-code=\"LK\">Sri Lanka<\/option><option  value=\"Sudan\" data-code=\"SD\">Sudan<\/option><option  value=\"Suriname\" data-code=\"SR\">Suriname<\/option><option  value=\"Svalbard and Jan Mayen\" data-code=\"SJ\">Svalbard and Jan Mayen<\/option><option  value=\"Swaziland\" data-code=\"SZ\">Swaziland<\/option><option  value=\"Sweden\" data-code=\"SE\">Sweden<\/option><option  value=\"Switzerland\" data-code=\"CH\">Switzerland<\/option><option  value=\"Syria\" data-code=\"SY\">Syria<\/option><option  value=\"Taiwan\" data-code=\"TW\">Taiwan<\/option><option  value=\"Tajikistan\" data-code=\"TJ\">Tajikistan<\/option><option  value=\"Tanzania\" data-code=\"TZ\">Tanzania<\/option><option  value=\"Thailand\" data-code=\"TH\">Thailand<\/option><option  value=\"Timor-Leste\">Timor-Leste<\/option><option  value=\"Togo\" data-code=\"TG\">Togo<\/option><option  value=\"Tokelau\" data-code=\"TK\">Tokelau<\/option><option  value=\"Tonga\" data-code=\"TO\">Tonga<\/option><option  value=\"Trinidad and Tobago\" data-code=\"TT\">Trinidad and Tobago<\/option><option  value=\"Tunisia\" data-code=\"TN\">Tunisia<\/option><option  value=\"Turkey\" data-code=\"TR\">Turkey<\/option><option  value=\"Turkmenistan\" data-code=\"TM\">Turkmenistan<\/option><option  value=\"Turks and Caicos Islands\" data-code=\"TC\">Turks and Caicos Islands<\/option><option  value=\"Tuvalu\" data-code=\"TV\">Tuvalu<\/option><option  value=\"Uganda\" data-code=\"UG\">Uganda<\/option><option  value=\"Ukraine\" data-code=\"UA\">Ukraine<\/option><option  value=\"United Arab Emirates\" data-code=\"AE\">United Arab Emirates<\/option><option  value=\"United Kingdom\" data-code=\"GB\">United Kingdom<\/option><option  value=\"United States\" data-code=\"US\">United States<\/option><option  value=\"United States Minor Outlying Islands\" data-code=\"UM\">United States Minor Outlying Islands<\/option><option  value=\"Uruguay\" data-code=\"UY\">Uruguay<\/option><option  value=\"Uzbekistan\" data-code=\"UZ\">Uzbekistan<\/option><option  value=\"Vanuatu\" data-code=\"VU\">Vanuatu<\/option><option  value=\"Vatican City\">Vatican City<\/option><option  value=\"Venezuela\" data-code=\"VE\">Venezuela<\/option><option  value=\"Vietnam\" data-code=\"VN\">Vietnam<\/option><option  value=\"Virgin Islands, British\">Virgin Islands, British<\/option><option  value=\"Virgin Islands, U.S.\">Virgin Islands, U.S.<\/option><option  value=\"Wallis and Futuna\" data-code=\"WF\">Wallis and Futuna<\/option><option  value=\"Western Sahara\" data-code=\"EH\">Western Sahara<\/option><option  value=\"Yemen\" data-code=\"YE\">Yemen<\/option><option  value=\"Zambia\" data-code=\"ZM\">Zambia<\/option><option  value=\"Zimbabwe\" data-code=\"ZW\">Zimbabwe<\/option>\t\t<\/select>\n\t<div class=\"frm_description\">Country<\/div><\/div>\n<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_19_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n\t<div  id=\"field_8n0ct_label\" class=\"frm_primary_label\">Tax Identification Type\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_8n0ct_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_19-91-0\">\t\t\t<label  for=\"field_8n0ct-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[19]\" id=\"field_8n0ct-0\" value=\"EIN\"\n\t\t   data-sectionid=\"91\"  data-reqmsg=\"Tax Identification Type cannot be blank.\" data-invmsg=\"Tax Identification Type is invalid\" aria-invalid=\"false\"  \/> EIN<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_19-91-1\">\t\t\t<label  for=\"field_8n0ct-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[19]\" id=\"field_8n0ct-1\" value=\"SSN\/ITIN\"\n\t\t   data-sectionid=\"91\"  data-reqmsg=\"Tax Identification Type cannot be blank.\" data-invmsg=\"Tax Identification Type is invalid\" aria-invalid=\"false\"  \/> SSN\/ITIN<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_19-91-2\">\t\t\t<label  for=\"field_8n0ct-2\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[19]\" id=\"field_8n0ct-2\" value=\"Foreign\"\n\t\t   data-sectionid=\"91\"  data-reqmsg=\"Tax Identification Type cannot be blank.\" data-invmsg=\"Tax Identification Type is invalid\" aria-invalid=\"false\"  \/> Foreign<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_21_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_ak9op\" id=\"field_ak9op_label\" class=\"frm_primary_label\">Company Tax Identification Number \r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_ak9op\" name=\"item_meta[21]\" value=\"\"  data-sectionid=\"91\"  data-reqmsg=\"Company Tax Identification Number  cannot be blank.\" aria-required=\"true\" data-invmsg=\"Company Tax Identification Number  is invalid\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_22_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_cah6c\" id=\"field_cah6c_label\" class=\"frm_primary_label\">Country\/Jurisdiction (if FOREGIN, list tax ID#)\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_cah6c\" name=\"item_meta[22]\" value=\"\"  data-sectionid=\"91\"  data-reqmsg=\"Country\/Jurisdiction (if FOREGIN, list tax ID#) cannot be blank.\" aria-required=\"true\" data-invmsg=\"Country\/Jurisdiction (if FOREGIN, list tax ID#) is invalid\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_23_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_capitalize\">\r\n\t<label for=\"field_i8984\" id=\"field_i8984_label\" class=\"frm_primary_label\">State of Incorporation\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_i8984\" name=\"item_meta[23]\" value=\"\"  data-sectionid=\"91\"  data-reqmsg=\"State of Incorporation cannot be blank.\" aria-required=\"true\" data-invmsg=\"State of Incorporation is invalid\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<\/div>\n<div id=\"frm_field_61_container\" class=\"frm_form_field  frm_html_container form-field\">\n<p data-pm-slice=\"1 1 []\"><strong><em>Please fill in the form completely and accurately for ALL members or beneficial owners who directly own 25% or more of the company&#8217;s equity. Note that the specific criteria for determining Beneficial Owners may vary depending on the company&#8217;s structure and ownership arrangements and could include managing members that are not majority shareholders.<\/em><\/strong><\/p>\n<\/div>\n<div id=\"frm_field_62_container\" class=\"frm_form_field  frm_html_container form-field\">\n<h2 style=\"text-align: center;\" data-pm-slice=\"1 1 []\"><strong>Beneficial Owner Information<\/strong><\/h2>\n<\/div>\n<div id=\"frm_field_95_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\n\t<label for=\"field_u9r85\" id=\"field_u9r85_label\" class=\"frm_primary_label\">Enter total number of Beneficial Owners or Members\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t\t\t<select name=\"item_meta[95]\" id=\"field_u9r85\"  data-reqmsg=\"Enter total number of Beneficial Owners or Members cannot be blank.\" aria-required=\"true\" data-invmsg=\"Enter total number of Beneficial Owners or Members is invalid\" class=\"auto_width\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/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>\t<\/select>\n\t\n\t\n\t\n<\/div>\n<div id=\"frm_field_65_container\" class=\"frm_form_field frm_section_heading form-field  frm12 frm_first\">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Owner\/Member 1<\/h3>\r\n\r\n\r\n<div id=\"frm_field_26_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_capitalize frm12 frm_first\">\r\n\t<label for=\"field_sq92a\" id=\"field_sq92a_label\" class=\"frm_primary_label\">1. Full Name \r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_sq92a\" name=\"item_meta[26]\" value=\"\"  data-sectionid=\"65\"  placeholder=\"(First, MI, Last)\" data-reqmsg=\"1. Full Name  cannot be blank.\" aria-required=\"true\" data-invmsg=\"1. Full Name  is invalid\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_67_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_fqxv7\" id=\"field_fqxv7_label\" class=\"frm_primary_label\">1. Date of Birth\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_fqxv7\" name=\"item_meta[67]\" value=\"\"  data-sectionid=\"65\"  maxlength=\"10\" placeholder=\"(MM\/DD\/YYYY)\" data-reqmsg=\"1. Date of Birth cannot be blank.\" aria-required=\"true\" data-invmsg=\"1. Date of Birth is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_97_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<div  id=\"field_yiwpc_label\" class=\"frm_primary_label\">1. Address\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_yiwpc_label\">\n<legend class=\"frm_screen_reader frm_hidden\">\n\t1. Address<\/legend>\n<div class=\"frm_combo_inputs_container\">\n<div id=\"frm_field_97-line1_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_yiwpc_line1\" class=\"frm_screen_reader frm_hidden\">\n\t\t1. Address\t<\/label>\n\t\t<input type=\"text\" id=\"field_yiwpc_line1\" value=\"\" name=\"item_meta[97][line1]\"  placeholder=\"Street Address 1\" data-placeholder=\"Street Address 1\" data-sectionid=\"65\"  data-reqmsg=\"1. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"1. Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-line1\" \/>\n\t<\/div>\n<div id=\"frm_field_97-line2_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_yiwpc_line2\" class=\"frm_screen_reader frm_hidden\">\n\t\t1. Address\t<\/label>\n\t\t<input type=\"text\" id=\"field_yiwpc_line2\" value=\"\" name=\"item_meta[97][line2]\"  placeholder=\"Street Address 2 (Optional)\" data-placeholder=\"Street Address 2 (Optional)\" data-sectionid=\"65\"  data-reqmsg=\"1. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"1. Address is invalid\" class=\"frm_optional\" aria-invalid=\"false\"   autocomplete=\"address-line2\" \/>\n\t<\/div>\n<div id=\"frm_field_97-city_container\" class=\"frm_form_field form-field frm_third frm_first\">\n\t<label for=\"field_yiwpc_city\" class=\"frm_screen_reader frm_hidden\">\n\t\tCity\t<\/label>\n\t\t<input type=\"text\" id=\"field_yiwpc_city\" value=\"\" name=\"item_meta[97][city]\"  placeholder=\"\" data-placeholder=\"\" data-sectionid=\"65\"  data-reqmsg=\"1. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"1. Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level2\" \/>\n\t<div class=\"frm_description\">City<\/div><\/div>\n<div id=\"frm_field_97-state_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_yiwpc_state\" class=\"frm_screen_reader frm_hidden\">\n\t\tState\/Province\t<\/label>\n\t\t<input type=\"text\" id=\"field_yiwpc_state\" value=\"\" name=\"item_meta[97][state]\"  placeholder=\"\" data-placeholder=\"\" data-sectionid=\"65\"  data-reqmsg=\"1. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"1. Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level1\" \/>\n\t<div class=\"frm_description\">State\/Province<\/div><\/div>\n<div id=\"frm_field_97-zip_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_yiwpc_zip\" class=\"frm_screen_reader frm_hidden\">\n\t\tZip\/Postal\t<\/label>\n\t\t<input type=\"text\" id=\"field_yiwpc_zip\" value=\"\" name=\"item_meta[97][zip]\"  placeholder=\"\" data-placeholder=\"\" data-sectionid=\"65\"  data-reqmsg=\"1. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"1. Address is invalid\" aria-invalid=\"false\"   autocomplete=\"postal-code\" \/>\n\t<div class=\"frm_description\">Zip\/Postal<\/div><\/div>\n<div id=\"frm_field_97-country_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_yiwpc_country\" class=\"frm_screen_reader frm_hidden\">\n\t\tCountry\t<\/label>\n\t\t\t<select name=\"item_meta[97][country]\" id=\"field_yiwpc_country\"  placeholder=\"\" data-placeholder=\"\" data-sectionid=\"65\"  data-reqmsg=\"1. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"1. Address is invalid\" aria-invalid=\"false\"   autocomplete=\"country-name\">\n\t\t\t<option value=\"\" >\n\t\t\t\t\t\t\t<\/option>\n\t\t\t<option  value=\"Afghanistan\" data-code=\"AF\">Afghanistan<\/option><option  value=\"Aland Islands\" data-code=\"AX\">Aland Islands<\/option><option  value=\"Albania\" data-code=\"AL\">Albania<\/option><option  value=\"Algeria\" data-code=\"DZ\">Algeria<\/option><option  value=\"American Samoa\" data-code=\"AS\">American Samoa<\/option><option  value=\"Andorra\" data-code=\"AD\">Andorra<\/option><option  value=\"Angola\" data-code=\"AO\">Angola<\/option><option  value=\"Anguilla\" data-code=\"AI\">Anguilla<\/option><option  value=\"Antarctica\" data-code=\"AQ\">Antarctica<\/option><option  value=\"Antigua and Barbuda\" data-code=\"AG\">Antigua and Barbuda<\/option><option  value=\"Argentina\" data-code=\"AR\">Argentina<\/option><option  value=\"Armenia\" data-code=\"AM\">Armenia<\/option><option  value=\"Aruba\" data-code=\"AW\">Aruba<\/option><option  value=\"Australia\" data-code=\"AU\">Australia<\/option><option  value=\"Austria\" data-code=\"AT\">Austria<\/option><option  value=\"Azerbaijan\" data-code=\"AZ\">Azerbaijan<\/option><option  value=\"Bahamas\" data-code=\"BS\">Bahamas<\/option><option  value=\"Bahrain\" data-code=\"BH\">Bahrain<\/option><option  value=\"Bangladesh\" data-code=\"BD\">Bangladesh<\/option><option  value=\"Barbados\" data-code=\"BB\">Barbados<\/option><option  value=\"Belarus\" data-code=\"BY\">Belarus<\/option><option  value=\"Belgium\" data-code=\"BE\">Belgium<\/option><option  value=\"Belize\" data-code=\"BZ\">Belize<\/option><option  value=\"Benin\" data-code=\"BJ\">Benin<\/option><option  value=\"Bermuda\" data-code=\"BM\">Bermuda<\/option><option  value=\"Bhutan\" data-code=\"BT\">Bhutan<\/option><option  value=\"Bolivia\" data-code=\"BO\">Bolivia<\/option><option  value=\"Bonaire, Sint Eustatius and Saba\">Bonaire, Sint Eustatius and Saba<\/option><option  value=\"Bosnia and Herzegovina\" data-code=\"BA\">Bosnia and Herzegovina<\/option><option  value=\"Botswana\" data-code=\"BW\">Botswana<\/option><option  value=\"Bouvet Island\" data-code=\"BV\">Bouvet Island<\/option><option  value=\"Brazil\" data-code=\"BR\">Brazil<\/option><option  value=\"British Indian Ocean Territory\" data-code=\"IO\">British Indian Ocean Territory<\/option><option  value=\"Brunei\" data-code=\"BN\">Brunei<\/option><option  value=\"Bulgaria\" data-code=\"BG\">Bulgaria<\/option><option  value=\"Burkina Faso\" data-code=\"BF\">Burkina Faso<\/option><option  value=\"Burundi\" data-code=\"BI\">Burundi<\/option><option  value=\"C&ocirc;te d&#039;Ivoire\">C&ocirc;te d&#039;Ivoire<\/option><option  value=\"Cambodia\" data-code=\"KH\">Cambodia<\/option><option  value=\"Cameroon\" data-code=\"CM\">Cameroon<\/option><option  value=\"Canada\" data-code=\"CA\">Canada<\/option><option  value=\"Cape Verde\" data-code=\"CV\">Cape Verde<\/option><option  value=\"Cayman Islands\" data-code=\"KY\">Cayman Islands<\/option><option  value=\"Central African Republic\" data-code=\"CF\">Central African Republic<\/option><option  value=\"Chad\" data-code=\"TD\">Chad<\/option><option  value=\"Chile\" data-code=\"CL\">Chile<\/option><option  value=\"China\" data-code=\"CN\">China<\/option><option  value=\"Christmas Island\" data-code=\"CX\">Christmas Island<\/option><option  value=\"Cocos (Keeling) Islands\">Cocos (Keeling) Islands<\/option><option  value=\"Colombia\" data-code=\"CO\">Colombia<\/option><option  value=\"Comoros\" data-code=\"KM\">Comoros<\/option><option  value=\"Congo\">Congo<\/option><option  value=\"Cook Islands\" data-code=\"CK\">Cook Islands<\/option><option  value=\"Costa Rica\" data-code=\"CR\">Costa Rica<\/option><option  value=\"Croatia\" data-code=\"HR\">Croatia<\/option><option  value=\"Cuba\" data-code=\"CU\">Cuba<\/option><option  value=\"Curacao\" data-code=\"CW\">Curacao<\/option><option  value=\"Cyprus\" data-code=\"CY\">Cyprus<\/option><option  value=\"Czech Republic\" data-code=\"CZ\">Czech Republic<\/option><option  value=\"Denmark\" data-code=\"DK\">Denmark<\/option><option  value=\"Djibouti\" data-code=\"DJ\">Djibouti<\/option><option  value=\"Dominica\" data-code=\"DM\">Dominica<\/option><option  value=\"Dominican Republic\" data-code=\"DO\">Dominican Republic<\/option><option  value=\"East Timor\" data-code=\"TL\">East Timor<\/option><option  value=\"Ecuador\" data-code=\"EC\">Ecuador<\/option><option  value=\"Egypt\" data-code=\"EG\">Egypt<\/option><option  value=\"El Salvador\" data-code=\"SV\">El Salvador<\/option><option  value=\"Equatorial Guinea\" data-code=\"GQ\">Equatorial Guinea<\/option><option  value=\"Eritrea\" data-code=\"ER\">Eritrea<\/option><option  value=\"Estonia\" data-code=\"EE\">Estonia<\/option><option  value=\"Ethiopia\" data-code=\"ET\">Ethiopia<\/option><option  value=\"Falkland Islands (Malvinas)\">Falkland Islands (Malvinas)<\/option><option  value=\"Faroe Islands\" data-code=\"FO\">Faroe Islands<\/option><option  value=\"Fiji\" data-code=\"FJ\">Fiji<\/option><option  value=\"Finland\" data-code=\"FI\">Finland<\/option><option  value=\"France\" data-code=\"FR\">France<\/option><option  value=\"French Guiana\" data-code=\"GF\">French Guiana<\/option><option  value=\"French Polynesia\" data-code=\"PF\">French Polynesia<\/option><option  value=\"French Southern Territories\" data-code=\"TF\">French Southern Territories<\/option><option  value=\"Gabon\" data-code=\"GA\">Gabon<\/option><option  value=\"Gambia\" data-code=\"GM\">Gambia<\/option><option  value=\"Georgia\" data-code=\"GE\">Georgia<\/option><option  value=\"Germany\" data-code=\"DE\">Germany<\/option><option  value=\"Ghana\" data-code=\"GH\">Ghana<\/option><option  value=\"Gibraltar\" data-code=\"GI\">Gibraltar<\/option><option  value=\"Greece\" data-code=\"GR\">Greece<\/option><option  value=\"Greenland\" data-code=\"GL\">Greenland<\/option><option  value=\"Grenada\" data-code=\"GD\">Grenada<\/option><option  value=\"Guadeloupe\" data-code=\"GP\">Guadeloupe<\/option><option  value=\"Guam\" data-code=\"GU\">Guam<\/option><option  value=\"Guatemala\" data-code=\"GT\">Guatemala<\/option><option  value=\"Guernsey\" data-code=\"GG\">Guernsey<\/option><option  value=\"Guinea\" data-code=\"GN\">Guinea<\/option><option  value=\"Guinea-Bissau\" data-code=\"GW\">Guinea-Bissau<\/option><option  value=\"Guyana\" data-code=\"GY\">Guyana<\/option><option  value=\"Haiti\" data-code=\"HT\">Haiti<\/option><option  value=\"Heard Island and McDonald Islands\" data-code=\"HM\">Heard Island and McDonald Islands<\/option><option  value=\"Holy See\">Holy See<\/option><option  value=\"Honduras\" data-code=\"HN\">Honduras<\/option><option  value=\"Hong Kong\" data-code=\"HK\">Hong Kong<\/option><option  value=\"Hungary\" data-code=\"HU\">Hungary<\/option><option  value=\"Iceland\" data-code=\"IS\">Iceland<\/option><option  value=\"India\" data-code=\"IN\">India<\/option><option  value=\"Indonesia\" data-code=\"ID\">Indonesia<\/option><option  value=\"Iran\" data-code=\"IR\">Iran<\/option><option  value=\"Iraq\" data-code=\"IQ\">Iraq<\/option><option  value=\"Ireland\" data-code=\"IE\">Ireland<\/option><option  value=\"Isle of Man\" data-code=\"IM\">Isle of Man<\/option><option  value=\"Israel\" data-code=\"IL\">Israel<\/option><option  value=\"Italy\" data-code=\"IT\">Italy<\/option><option  value=\"Jamaica\" data-code=\"JM\">Jamaica<\/option><option  value=\"Japan\" data-code=\"JP\">Japan<\/option><option  value=\"Jersey\" data-code=\"JE\">Jersey<\/option><option  value=\"Jordan\" data-code=\"JO\">Jordan<\/option><option  value=\"Kazakhstan\" data-code=\"KZ\">Kazakhstan<\/option><option  value=\"Kenya\" data-code=\"KE\">Kenya<\/option><option  value=\"Kiribati\" data-code=\"KI\">Kiribati<\/option><option  value=\"Kosovo\" data-code=\"XK\">Kosovo<\/option><option  value=\"Kuwait\" data-code=\"KW\">Kuwait<\/option><option  value=\"Kyrgyzstan\" data-code=\"KG\">Kyrgyzstan<\/option><option  value=\"Laos\" data-code=\"LA\">Laos<\/option><option  value=\"Latvia\" data-code=\"LV\">Latvia<\/option><option  value=\"Lebanon\" data-code=\"LB\">Lebanon<\/option><option  value=\"Lesotho\" data-code=\"LS\">Lesotho<\/option><option  value=\"Liberia\" data-code=\"LR\">Liberia<\/option><option  value=\"Libya\" data-code=\"LY\">Libya<\/option><option  value=\"Liechtenstein\" data-code=\"LI\">Liechtenstein<\/option><option  value=\"Lithuania\" data-code=\"LT\">Lithuania<\/option><option  value=\"Luxembourg\" data-code=\"LU\">Luxembourg<\/option><option  value=\"Macao\" data-code=\"MO\">Macao<\/option><option  value=\"Macedonia\" data-code=\"MK\">Macedonia<\/option><option  value=\"Madagascar\" data-code=\"MG\">Madagascar<\/option><option  value=\"Malawi\" data-code=\"MW\">Malawi<\/option><option  value=\"Malaysia\" data-code=\"MY\">Malaysia<\/option><option  value=\"Maldives\" data-code=\"MV\">Maldives<\/option><option  value=\"Mali\" data-code=\"ML\">Mali<\/option><option  value=\"Malta\" data-code=\"MT\">Malta<\/option><option  value=\"Marshall Islands\" data-code=\"MH\">Marshall Islands<\/option><option  value=\"Martinique\" data-code=\"MQ\">Martinique<\/option><option  value=\"Mauritania\" data-code=\"MR\">Mauritania<\/option><option  value=\"Mauritius\" data-code=\"MU\">Mauritius<\/option><option  value=\"Mayotte\" data-code=\"YT\">Mayotte<\/option><option  value=\"Mexico\" data-code=\"MX\">Mexico<\/option><option  value=\"Micronesia\" data-code=\"FM\">Micronesia<\/option><option  value=\"Moldova\" data-code=\"MD\">Moldova<\/option><option  value=\"Monaco\" data-code=\"MC\">Monaco<\/option><option  value=\"Mongolia\" data-code=\"MN\">Mongolia<\/option><option  value=\"Montenegro\" data-code=\"ME\">Montenegro<\/option><option  value=\"Montserrat\" data-code=\"MS\">Montserrat<\/option><option  value=\"Morocco\" data-code=\"MA\">Morocco<\/option><option  value=\"Mozambique\" data-code=\"MZ\">Mozambique<\/option><option  value=\"Myanmar\" data-code=\"MM\">Myanmar<\/option><option  value=\"Namibia\" data-code=\"NA\">Namibia<\/option><option  value=\"Nauru\" data-code=\"NR\">Nauru<\/option><option  value=\"Nepal\" data-code=\"NP\">Nepal<\/option><option  value=\"Netherlands\" data-code=\"NL\">Netherlands<\/option><option  value=\"New Caledonia\" data-code=\"NC\">New Caledonia<\/option><option  value=\"New Zealand\" data-code=\"NZ\">New Zealand<\/option><option  value=\"Nicaragua\" data-code=\"NI\">Nicaragua<\/option><option  value=\"Niger\" data-code=\"NE\">Niger<\/option><option  value=\"Nigeria\" data-code=\"NG\">Nigeria<\/option><option  value=\"Niue\" data-code=\"NU\">Niue<\/option><option  value=\"Norfolk Island\" data-code=\"NF\">Norfolk Island<\/option><option  value=\"North Korea\" data-code=\"KP\">North Korea<\/option><option  value=\"Northern Mariana Islands\" data-code=\"MP\">Northern Mariana Islands<\/option><option  value=\"Norway\" data-code=\"NO\">Norway<\/option><option  value=\"Oman\" data-code=\"OM\">Oman<\/option><option  value=\"Pakistan\" data-code=\"PK\">Pakistan<\/option><option  value=\"Palau\" data-code=\"PW\">Palau<\/option><option  value=\"Palestine\">Palestine<\/option><option  value=\"Panama\" data-code=\"PA\">Panama<\/option><option  value=\"Papua New Guinea\" data-code=\"PG\">Papua New Guinea<\/option><option  value=\"Paraguay\" data-code=\"PY\">Paraguay<\/option><option  value=\"Peru\" data-code=\"PE\">Peru<\/option><option  value=\"Philippines\" data-code=\"PH\">Philippines<\/option><option  value=\"Pitcairn\" data-code=\"PN\">Pitcairn<\/option><option  value=\"Poland\" data-code=\"PL\">Poland<\/option><option  value=\"Portugal\" data-code=\"PT\">Portugal<\/option><option  value=\"Puerto Rico\" data-code=\"PR\">Puerto Rico<\/option><option  value=\"Qatar\" data-code=\"QA\">Qatar<\/option><option  value=\"Reunion\" data-code=\"RE\">Reunion<\/option><option  value=\"Romania\" data-code=\"RO\">Romania<\/option><option  value=\"Russia\" data-code=\"RU\">Russia<\/option><option  value=\"Rwanda\" data-code=\"RW\">Rwanda<\/option><option  value=\"Saint Barthelemy\" data-code=\"BL\">Saint Barthelemy<\/option><option  value=\"Saint Helena, Ascension and Tristan da Cunha\">Saint Helena, Ascension and Tristan da Cunha<\/option><option  value=\"Saint Kitts and Nevis\" data-code=\"KN\">Saint Kitts and Nevis<\/option><option  value=\"Saint Lucia\" data-code=\"LC\">Saint Lucia<\/option><option  value=\"Saint Martin (French part)\">Saint Martin (French part)<\/option><option  value=\"Saint Pierre and Miquelon\" data-code=\"PM\">Saint Pierre and Miquelon<\/option><option  value=\"Saint Vincent and the Grenadines\" data-code=\"VC\">Saint Vincent and the Grenadines<\/option><option  value=\"Samoa\" data-code=\"WS\">Samoa<\/option><option  value=\"San Marino\" data-code=\"SM\">San Marino<\/option><option  value=\"Sao Tome and Principe\" data-code=\"ST\">Sao Tome and Principe<\/option><option  value=\"Saudi Arabia\" data-code=\"SA\">Saudi Arabia<\/option><option  value=\"Senegal\" data-code=\"SN\">Senegal<\/option><option  value=\"Serbia\" data-code=\"RS\">Serbia<\/option><option  value=\"Seychelles\" data-code=\"SC\">Seychelles<\/option><option  value=\"Sierra Leone\" data-code=\"SL\">Sierra Leone<\/option><option  value=\"Singapore\" data-code=\"SG\">Singapore<\/option><option  value=\"Sint Maarten (Dutch part)\">Sint Maarten (Dutch part)<\/option><option  value=\"Slovakia\" data-code=\"SK\">Slovakia<\/option><option  value=\"Slovenia\" data-code=\"SI\">Slovenia<\/option><option  value=\"Solomon Islands\" data-code=\"SB\">Solomon Islands<\/option><option  value=\"Somalia\" data-code=\"SO\">Somalia<\/option><option  value=\"South Africa\" data-code=\"ZA\">South Africa<\/option><option  value=\"South Georgia and the South Sandwich Islands\" data-code=\"GS\">South Georgia and the South Sandwich Islands<\/option><option  value=\"South Korea\" data-code=\"KR\">South Korea<\/option><option  value=\"South Sudan\" data-code=\"SS\">South Sudan<\/option><option  value=\"Spain\" data-code=\"ES\">Spain<\/option><option  value=\"Sri Lanka\" data-code=\"LK\">Sri Lanka<\/option><option  value=\"Sudan\" data-code=\"SD\">Sudan<\/option><option  value=\"Suriname\" data-code=\"SR\">Suriname<\/option><option  value=\"Svalbard and Jan Mayen\" data-code=\"SJ\">Svalbard and Jan Mayen<\/option><option  value=\"Swaziland\" data-code=\"SZ\">Swaziland<\/option><option  value=\"Sweden\" data-code=\"SE\">Sweden<\/option><option  value=\"Switzerland\" data-code=\"CH\">Switzerland<\/option><option  value=\"Syria\" data-code=\"SY\">Syria<\/option><option  value=\"Taiwan\" data-code=\"TW\">Taiwan<\/option><option  value=\"Tajikistan\" data-code=\"TJ\">Tajikistan<\/option><option  value=\"Tanzania\" data-code=\"TZ\">Tanzania<\/option><option  value=\"Thailand\" data-code=\"TH\">Thailand<\/option><option  value=\"Timor-Leste\">Timor-Leste<\/option><option  value=\"Togo\" data-code=\"TG\">Togo<\/option><option  value=\"Tokelau\" data-code=\"TK\">Tokelau<\/option><option  value=\"Tonga\" data-code=\"TO\">Tonga<\/option><option  value=\"Trinidad and Tobago\" data-code=\"TT\">Trinidad and Tobago<\/option><option  value=\"Tunisia\" data-code=\"TN\">Tunisia<\/option><option  value=\"Turkey\" data-code=\"TR\">Turkey<\/option><option  value=\"Turkmenistan\" data-code=\"TM\">Turkmenistan<\/option><option  value=\"Turks and Caicos Islands\" data-code=\"TC\">Turks and Caicos Islands<\/option><option  value=\"Tuvalu\" data-code=\"TV\">Tuvalu<\/option><option  value=\"Uganda\" data-code=\"UG\">Uganda<\/option><option  value=\"Ukraine\" data-code=\"UA\">Ukraine<\/option><option  value=\"United Arab Emirates\" data-code=\"AE\">United Arab Emirates<\/option><option  value=\"United Kingdom\" data-code=\"GB\">United Kingdom<\/option><option  value=\"United States\" data-code=\"US\">United States<\/option><option  value=\"United States Minor Outlying Islands\" data-code=\"UM\">United States Minor Outlying Islands<\/option><option  value=\"Uruguay\" data-code=\"UY\">Uruguay<\/option><option  value=\"Uzbekistan\" data-code=\"UZ\">Uzbekistan<\/option><option  value=\"Vanuatu\" data-code=\"VU\">Vanuatu<\/option><option  value=\"Vatican City\">Vatican City<\/option><option  value=\"Venezuela\" data-code=\"VE\">Venezuela<\/option><option  value=\"Vietnam\" data-code=\"VN\">Vietnam<\/option><option  value=\"Virgin Islands, British\">Virgin Islands, British<\/option><option  value=\"Virgin Islands, U.S.\">Virgin Islands, U.S.<\/option><option  value=\"Wallis and Futuna\" data-code=\"WF\">Wallis and Futuna<\/option><option  value=\"Western Sahara\" data-code=\"EH\">Western Sahara<\/option><option  value=\"Yemen\" data-code=\"YE\">Yemen<\/option><option  value=\"Zambia\" data-code=\"ZM\">Zambia<\/option><option  value=\"Zimbabwe\" data-code=\"ZW\">Zimbabwe<\/option>\t\t<\/select>\n\t<div class=\"frm_description\">Country<\/div><\/div>\n<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<\/div>\n<div id=\"frm_field_69_container\" class=\"frm_form_field frm_section_heading form-field  frm12 frm_first\">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Owner\/Member 2<\/h3>\r\n\r\n\r\n<div id=\"frm_field_70_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_capitalize frm12 frm_first\">\r\n\t<label for=\"field_v9jwu\" id=\"field_v9jwu_label\" class=\"frm_primary_label\">2. Full Name \r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_v9jwu\" name=\"item_meta[70]\" value=\"\"  data-sectionid=\"69\"  placeholder=\"(First, MI, Last)\" data-reqmsg=\"2. Full Name  cannot be blank.\" aria-required=\"true\" data-invmsg=\"2. Full Name  is invalid\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_71_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_b9mh2\" id=\"field_b9mh2_label\" class=\"frm_primary_label\">2. Date of Birth\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_b9mh2\" name=\"item_meta[71]\" value=\"\"  data-sectionid=\"69\"  maxlength=\"10\" placeholder=\"(MM\/DD\/YYYY)\" data-reqmsg=\"2. Date of Birth cannot be blank.\" aria-required=\"true\" data-invmsg=\"2. Date of Birth is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_72_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<div  id=\"field_z13r9_label\" class=\"frm_primary_label\">2. Address\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_z13r9_label\">\n<legend class=\"frm_screen_reader frm_hidden\">\n\t2. Address<\/legend>\n<div class=\"frm_combo_inputs_container\">\n<div id=\"frm_field_72-line1_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_z13r9_line1\" class=\"frm_screen_reader frm_hidden\">\n\t\t2. Address\t<\/label>\n\t\t<input type=\"text\" id=\"field_z13r9_line1\" value=\"\" name=\"item_meta[72][line1]\"  placeholder=\"Street Address 1\" data-placeholder=\"Street Address 1\" data-sectionid=\"69\"  data-reqmsg=\"2. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"2. Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-line1\" \/>\n\t<\/div>\n<div id=\"frm_field_72-line2_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_z13r9_line2\" class=\"frm_screen_reader frm_hidden\">\n\t\t2. Address\t<\/label>\n\t\t<input type=\"text\" id=\"field_z13r9_line2\" value=\"\" name=\"item_meta[72][line2]\"  placeholder=\"Street Address 2 (Optional)\" data-placeholder=\"Street Address 2 (Optional)\" data-sectionid=\"69\"  data-reqmsg=\"2. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"2. Address is invalid\" class=\"frm_optional\" aria-invalid=\"false\"   autocomplete=\"address-line2\" \/>\n\t<\/div>\n<div id=\"frm_field_72-city_container\" class=\"frm_form_field form-field frm_third frm_first\">\n\t<label for=\"field_z13r9_city\" class=\"frm_screen_reader frm_hidden\">\n\t\tCity\t<\/label>\n\t\t<input type=\"text\" id=\"field_z13r9_city\" value=\"\" name=\"item_meta[72][city]\"  placeholder=\"\" data-placeholder=\"\" data-sectionid=\"69\"  data-reqmsg=\"2. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"2. Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level2\" \/>\n\t<div class=\"frm_description\">City<\/div><\/div>\n<div id=\"frm_field_72-state_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_z13r9_state\" class=\"frm_screen_reader frm_hidden\">\n\t\tState\/Province\t<\/label>\n\t\t<input type=\"text\" id=\"field_z13r9_state\" value=\"\" name=\"item_meta[72][state]\"  placeholder=\"\" data-placeholder=\"\" data-sectionid=\"69\"  data-reqmsg=\"2. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"2. Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level1\" \/>\n\t<div class=\"frm_description\">State\/Province<\/div><\/div>\n<div id=\"frm_field_72-zip_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_z13r9_zip\" class=\"frm_screen_reader frm_hidden\">\n\t\tZip\/Postal\t<\/label>\n\t\t<input type=\"text\" id=\"field_z13r9_zip\" value=\"\" name=\"item_meta[72][zip]\"  placeholder=\"\" data-placeholder=\"\" data-sectionid=\"69\"  data-reqmsg=\"2. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"2. Address is invalid\" aria-invalid=\"false\"   autocomplete=\"postal-code\" \/>\n\t<div class=\"frm_description\">Zip\/Postal<\/div><\/div>\n<div id=\"frm_field_72-country_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_z13r9_country\" class=\"frm_screen_reader frm_hidden\">\n\t\tCountry\t<\/label>\n\t\t\t<select name=\"item_meta[72][country]\" id=\"field_z13r9_country\"  placeholder=\"\" data-placeholder=\"\" data-sectionid=\"69\"  data-reqmsg=\"2. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"2. Address is invalid\" aria-invalid=\"false\"   autocomplete=\"country-name\">\n\t\t\t<option value=\"\" >\n\t\t\t\t\t\t\t<\/option>\n\t\t\t<option  value=\"Afghanistan\" data-code=\"AF\">Afghanistan<\/option><option  value=\"Aland Islands\" data-code=\"AX\">Aland Islands<\/option><option  value=\"Albania\" data-code=\"AL\">Albania<\/option><option  value=\"Algeria\" data-code=\"DZ\">Algeria<\/option><option  value=\"American Samoa\" data-code=\"AS\">American Samoa<\/option><option  value=\"Andorra\" data-code=\"AD\">Andorra<\/option><option  value=\"Angola\" data-code=\"AO\">Angola<\/option><option  value=\"Anguilla\" data-code=\"AI\">Anguilla<\/option><option  value=\"Antarctica\" data-code=\"AQ\">Antarctica<\/option><option  value=\"Antigua and Barbuda\" data-code=\"AG\">Antigua and Barbuda<\/option><option  value=\"Argentina\" data-code=\"AR\">Argentina<\/option><option  value=\"Armenia\" data-code=\"AM\">Armenia<\/option><option  value=\"Aruba\" data-code=\"AW\">Aruba<\/option><option  value=\"Australia\" data-code=\"AU\">Australia<\/option><option  value=\"Austria\" data-code=\"AT\">Austria<\/option><option  value=\"Azerbaijan\" data-code=\"AZ\">Azerbaijan<\/option><option  value=\"Bahamas\" data-code=\"BS\">Bahamas<\/option><option  value=\"Bahrain\" data-code=\"BH\">Bahrain<\/option><option  value=\"Bangladesh\" data-code=\"BD\">Bangladesh<\/option><option  value=\"Barbados\" data-code=\"BB\">Barbados<\/option><option  value=\"Belarus\" data-code=\"BY\">Belarus<\/option><option  value=\"Belgium\" data-code=\"BE\">Belgium<\/option><option  value=\"Belize\" data-code=\"BZ\">Belize<\/option><option  value=\"Benin\" data-code=\"BJ\">Benin<\/option><option  value=\"Bermuda\" data-code=\"BM\">Bermuda<\/option><option  value=\"Bhutan\" data-code=\"BT\">Bhutan<\/option><option  value=\"Bolivia\" data-code=\"BO\">Bolivia<\/option><option  value=\"Bonaire, Sint Eustatius and Saba\">Bonaire, Sint Eustatius and Saba<\/option><option  value=\"Bosnia and Herzegovina\" data-code=\"BA\">Bosnia and Herzegovina<\/option><option  value=\"Botswana\" data-code=\"BW\">Botswana<\/option><option  value=\"Bouvet Island\" data-code=\"BV\">Bouvet Island<\/option><option  value=\"Brazil\" data-code=\"BR\">Brazil<\/option><option  value=\"British Indian Ocean Territory\" data-code=\"IO\">British Indian Ocean Territory<\/option><option  value=\"Brunei\" data-code=\"BN\">Brunei<\/option><option  value=\"Bulgaria\" data-code=\"BG\">Bulgaria<\/option><option  value=\"Burkina Faso\" data-code=\"BF\">Burkina Faso<\/option><option  value=\"Burundi\" data-code=\"BI\">Burundi<\/option><option  value=\"C&ocirc;te d&#039;Ivoire\">C&ocirc;te d&#039;Ivoire<\/option><option  value=\"Cambodia\" data-code=\"KH\">Cambodia<\/option><option  value=\"Cameroon\" data-code=\"CM\">Cameroon<\/option><option  value=\"Canada\" data-code=\"CA\">Canada<\/option><option  value=\"Cape Verde\" data-code=\"CV\">Cape Verde<\/option><option  value=\"Cayman Islands\" data-code=\"KY\">Cayman Islands<\/option><option  value=\"Central African Republic\" data-code=\"CF\">Central African Republic<\/option><option  value=\"Chad\" data-code=\"TD\">Chad<\/option><option  value=\"Chile\" data-code=\"CL\">Chile<\/option><option  value=\"China\" data-code=\"CN\">China<\/option><option  value=\"Christmas Island\" data-code=\"CX\">Christmas Island<\/option><option  value=\"Cocos (Keeling) Islands\">Cocos (Keeling) Islands<\/option><option  value=\"Colombia\" data-code=\"CO\">Colombia<\/option><option  value=\"Comoros\" data-code=\"KM\">Comoros<\/option><option  value=\"Congo\">Congo<\/option><option  value=\"Cook Islands\" data-code=\"CK\">Cook Islands<\/option><option  value=\"Costa Rica\" data-code=\"CR\">Costa Rica<\/option><option  value=\"Croatia\" data-code=\"HR\">Croatia<\/option><option  value=\"Cuba\" data-code=\"CU\">Cuba<\/option><option  value=\"Curacao\" data-code=\"CW\">Curacao<\/option><option  value=\"Cyprus\" data-code=\"CY\">Cyprus<\/option><option  value=\"Czech Republic\" data-code=\"CZ\">Czech Republic<\/option><option  value=\"Denmark\" data-code=\"DK\">Denmark<\/option><option  value=\"Djibouti\" data-code=\"DJ\">Djibouti<\/option><option  value=\"Dominica\" data-code=\"DM\">Dominica<\/option><option  value=\"Dominican Republic\" data-code=\"DO\">Dominican Republic<\/option><option  value=\"East Timor\" data-code=\"TL\">East Timor<\/option><option  value=\"Ecuador\" data-code=\"EC\">Ecuador<\/option><option  value=\"Egypt\" data-code=\"EG\">Egypt<\/option><option  value=\"El Salvador\" data-code=\"SV\">El Salvador<\/option><option  value=\"Equatorial Guinea\" data-code=\"GQ\">Equatorial Guinea<\/option><option  value=\"Eritrea\" data-code=\"ER\">Eritrea<\/option><option  value=\"Estonia\" data-code=\"EE\">Estonia<\/option><option  value=\"Ethiopia\" data-code=\"ET\">Ethiopia<\/option><option  value=\"Falkland Islands (Malvinas)\">Falkland Islands (Malvinas)<\/option><option  value=\"Faroe Islands\" data-code=\"FO\">Faroe Islands<\/option><option  value=\"Fiji\" data-code=\"FJ\">Fiji<\/option><option  value=\"Finland\" data-code=\"FI\">Finland<\/option><option  value=\"France\" data-code=\"FR\">France<\/option><option  value=\"French Guiana\" data-code=\"GF\">French Guiana<\/option><option  value=\"French Polynesia\" data-code=\"PF\">French Polynesia<\/option><option  value=\"French Southern Territories\" data-code=\"TF\">French Southern Territories<\/option><option  value=\"Gabon\" data-code=\"GA\">Gabon<\/option><option  value=\"Gambia\" data-code=\"GM\">Gambia<\/option><option  value=\"Georgia\" data-code=\"GE\">Georgia<\/option><option  value=\"Germany\" data-code=\"DE\">Germany<\/option><option  value=\"Ghana\" data-code=\"GH\">Ghana<\/option><option  value=\"Gibraltar\" data-code=\"GI\">Gibraltar<\/option><option  value=\"Greece\" data-code=\"GR\">Greece<\/option><option  value=\"Greenland\" data-code=\"GL\">Greenland<\/option><option  value=\"Grenada\" data-code=\"GD\">Grenada<\/option><option  value=\"Guadeloupe\" data-code=\"GP\">Guadeloupe<\/option><option  value=\"Guam\" data-code=\"GU\">Guam<\/option><option  value=\"Guatemala\" data-code=\"GT\">Guatemala<\/option><option  value=\"Guernsey\" data-code=\"GG\">Guernsey<\/option><option  value=\"Guinea\" data-code=\"GN\">Guinea<\/option><option  value=\"Guinea-Bissau\" data-code=\"GW\">Guinea-Bissau<\/option><option  value=\"Guyana\" data-code=\"GY\">Guyana<\/option><option  value=\"Haiti\" data-code=\"HT\">Haiti<\/option><option  value=\"Heard Island and McDonald Islands\" data-code=\"HM\">Heard Island and McDonald Islands<\/option><option  value=\"Holy See\">Holy See<\/option><option  value=\"Honduras\" data-code=\"HN\">Honduras<\/option><option  value=\"Hong Kong\" data-code=\"HK\">Hong Kong<\/option><option  value=\"Hungary\" data-code=\"HU\">Hungary<\/option><option  value=\"Iceland\" data-code=\"IS\">Iceland<\/option><option  value=\"India\" data-code=\"IN\">India<\/option><option  value=\"Indonesia\" data-code=\"ID\">Indonesia<\/option><option  value=\"Iran\" data-code=\"IR\">Iran<\/option><option  value=\"Iraq\" data-code=\"IQ\">Iraq<\/option><option  value=\"Ireland\" data-code=\"IE\">Ireland<\/option><option  value=\"Isle of Man\" data-code=\"IM\">Isle of Man<\/option><option  value=\"Israel\" data-code=\"IL\">Israel<\/option><option  value=\"Italy\" data-code=\"IT\">Italy<\/option><option  value=\"Jamaica\" data-code=\"JM\">Jamaica<\/option><option  value=\"Japan\" data-code=\"JP\">Japan<\/option><option  value=\"Jersey\" data-code=\"JE\">Jersey<\/option><option  value=\"Jordan\" data-code=\"JO\">Jordan<\/option><option  value=\"Kazakhstan\" data-code=\"KZ\">Kazakhstan<\/option><option  value=\"Kenya\" data-code=\"KE\">Kenya<\/option><option  value=\"Kiribati\" data-code=\"KI\">Kiribati<\/option><option  value=\"Kosovo\" data-code=\"XK\">Kosovo<\/option><option  value=\"Kuwait\" data-code=\"KW\">Kuwait<\/option><option  value=\"Kyrgyzstan\" data-code=\"KG\">Kyrgyzstan<\/option><option  value=\"Laos\" data-code=\"LA\">Laos<\/option><option  value=\"Latvia\" data-code=\"LV\">Latvia<\/option><option  value=\"Lebanon\" data-code=\"LB\">Lebanon<\/option><option  value=\"Lesotho\" data-code=\"LS\">Lesotho<\/option><option  value=\"Liberia\" data-code=\"LR\">Liberia<\/option><option  value=\"Libya\" data-code=\"LY\">Libya<\/option><option  value=\"Liechtenstein\" data-code=\"LI\">Liechtenstein<\/option><option  value=\"Lithuania\" data-code=\"LT\">Lithuania<\/option><option  value=\"Luxembourg\" data-code=\"LU\">Luxembourg<\/option><option  value=\"Macao\" data-code=\"MO\">Macao<\/option><option  value=\"Macedonia\" data-code=\"MK\">Macedonia<\/option><option  value=\"Madagascar\" data-code=\"MG\">Madagascar<\/option><option  value=\"Malawi\" data-code=\"MW\">Malawi<\/option><option  value=\"Malaysia\" data-code=\"MY\">Malaysia<\/option><option  value=\"Maldives\" data-code=\"MV\">Maldives<\/option><option  value=\"Mali\" data-code=\"ML\">Mali<\/option><option  value=\"Malta\" data-code=\"MT\">Malta<\/option><option  value=\"Marshall Islands\" data-code=\"MH\">Marshall Islands<\/option><option  value=\"Martinique\" data-code=\"MQ\">Martinique<\/option><option  value=\"Mauritania\" data-code=\"MR\">Mauritania<\/option><option  value=\"Mauritius\" data-code=\"MU\">Mauritius<\/option><option  value=\"Mayotte\" data-code=\"YT\">Mayotte<\/option><option  value=\"Mexico\" data-code=\"MX\">Mexico<\/option><option  value=\"Micronesia\" data-code=\"FM\">Micronesia<\/option><option  value=\"Moldova\" data-code=\"MD\">Moldova<\/option><option  value=\"Monaco\" data-code=\"MC\">Monaco<\/option><option  value=\"Mongolia\" data-code=\"MN\">Mongolia<\/option><option  value=\"Montenegro\" data-code=\"ME\">Montenegro<\/option><option  value=\"Montserrat\" data-code=\"MS\">Montserrat<\/option><option  value=\"Morocco\" data-code=\"MA\">Morocco<\/option><option  value=\"Mozambique\" data-code=\"MZ\">Mozambique<\/option><option  value=\"Myanmar\" data-code=\"MM\">Myanmar<\/option><option  value=\"Namibia\" data-code=\"NA\">Namibia<\/option><option  value=\"Nauru\" data-code=\"NR\">Nauru<\/option><option  value=\"Nepal\" data-code=\"NP\">Nepal<\/option><option  value=\"Netherlands\" data-code=\"NL\">Netherlands<\/option><option  value=\"New Caledonia\" data-code=\"NC\">New Caledonia<\/option><option  value=\"New Zealand\" data-code=\"NZ\">New Zealand<\/option><option  value=\"Nicaragua\" data-code=\"NI\">Nicaragua<\/option><option  value=\"Niger\" data-code=\"NE\">Niger<\/option><option  value=\"Nigeria\" data-code=\"NG\">Nigeria<\/option><option  value=\"Niue\" data-code=\"NU\">Niue<\/option><option  value=\"Norfolk Island\" data-code=\"NF\">Norfolk Island<\/option><option  value=\"North Korea\" data-code=\"KP\">North Korea<\/option><option  value=\"Northern Mariana Islands\" data-code=\"MP\">Northern Mariana Islands<\/option><option  value=\"Norway\" data-code=\"NO\">Norway<\/option><option  value=\"Oman\" data-code=\"OM\">Oman<\/option><option  value=\"Pakistan\" data-code=\"PK\">Pakistan<\/option><option  value=\"Palau\" data-code=\"PW\">Palau<\/option><option  value=\"Palestine\">Palestine<\/option><option  value=\"Panama\" data-code=\"PA\">Panama<\/option><option  value=\"Papua New Guinea\" data-code=\"PG\">Papua New Guinea<\/option><option  value=\"Paraguay\" data-code=\"PY\">Paraguay<\/option><option  value=\"Peru\" data-code=\"PE\">Peru<\/option><option  value=\"Philippines\" data-code=\"PH\">Philippines<\/option><option  value=\"Pitcairn\" data-code=\"PN\">Pitcairn<\/option><option  value=\"Poland\" data-code=\"PL\">Poland<\/option><option  value=\"Portugal\" data-code=\"PT\">Portugal<\/option><option  value=\"Puerto Rico\" data-code=\"PR\">Puerto Rico<\/option><option  value=\"Qatar\" data-code=\"QA\">Qatar<\/option><option  value=\"Reunion\" data-code=\"RE\">Reunion<\/option><option  value=\"Romania\" data-code=\"RO\">Romania<\/option><option  value=\"Russia\" data-code=\"RU\">Russia<\/option><option  value=\"Rwanda\" data-code=\"RW\">Rwanda<\/option><option  value=\"Saint Barthelemy\" data-code=\"BL\">Saint Barthelemy<\/option><option  value=\"Saint Helena, Ascension and Tristan da Cunha\">Saint Helena, Ascension and Tristan da Cunha<\/option><option  value=\"Saint Kitts and Nevis\" data-code=\"KN\">Saint Kitts and Nevis<\/option><option  value=\"Saint Lucia\" data-code=\"LC\">Saint Lucia<\/option><option  value=\"Saint Martin (French part)\">Saint Martin (French part)<\/option><option  value=\"Saint Pierre and Miquelon\" data-code=\"PM\">Saint Pierre and Miquelon<\/option><option  value=\"Saint Vincent and the Grenadines\" data-code=\"VC\">Saint Vincent and the Grenadines<\/option><option  value=\"Samoa\" data-code=\"WS\">Samoa<\/option><option  value=\"San Marino\" data-code=\"SM\">San Marino<\/option><option  value=\"Sao Tome and Principe\" data-code=\"ST\">Sao Tome and Principe<\/option><option  value=\"Saudi Arabia\" data-code=\"SA\">Saudi Arabia<\/option><option  value=\"Senegal\" data-code=\"SN\">Senegal<\/option><option  value=\"Serbia\" data-code=\"RS\">Serbia<\/option><option  value=\"Seychelles\" data-code=\"SC\">Seychelles<\/option><option  value=\"Sierra Leone\" data-code=\"SL\">Sierra Leone<\/option><option  value=\"Singapore\" data-code=\"SG\">Singapore<\/option><option  value=\"Sint Maarten (Dutch part)\">Sint Maarten (Dutch part)<\/option><option  value=\"Slovakia\" data-code=\"SK\">Slovakia<\/option><option  value=\"Slovenia\" data-code=\"SI\">Slovenia<\/option><option  value=\"Solomon Islands\" data-code=\"SB\">Solomon Islands<\/option><option  value=\"Somalia\" data-code=\"SO\">Somalia<\/option><option  value=\"South Africa\" data-code=\"ZA\">South Africa<\/option><option  value=\"South Georgia and the South Sandwich Islands\" data-code=\"GS\">South Georgia and the South Sandwich Islands<\/option><option  value=\"South Korea\" data-code=\"KR\">South Korea<\/option><option  value=\"South Sudan\" data-code=\"SS\">South Sudan<\/option><option  value=\"Spain\" data-code=\"ES\">Spain<\/option><option  value=\"Sri Lanka\" data-code=\"LK\">Sri Lanka<\/option><option  value=\"Sudan\" data-code=\"SD\">Sudan<\/option><option  value=\"Suriname\" data-code=\"SR\">Suriname<\/option><option  value=\"Svalbard and Jan Mayen\" data-code=\"SJ\">Svalbard and Jan Mayen<\/option><option  value=\"Swaziland\" data-code=\"SZ\">Swaziland<\/option><option  value=\"Sweden\" data-code=\"SE\">Sweden<\/option><option  value=\"Switzerland\" data-code=\"CH\">Switzerland<\/option><option  value=\"Syria\" data-code=\"SY\">Syria<\/option><option  value=\"Taiwan\" data-code=\"TW\">Taiwan<\/option><option  value=\"Tajikistan\" data-code=\"TJ\">Tajikistan<\/option><option  value=\"Tanzania\" data-code=\"TZ\">Tanzania<\/option><option  value=\"Thailand\" data-code=\"TH\">Thailand<\/option><option  value=\"Timor-Leste\">Timor-Leste<\/option><option  value=\"Togo\" data-code=\"TG\">Togo<\/option><option  value=\"Tokelau\" data-code=\"TK\">Tokelau<\/option><option  value=\"Tonga\" data-code=\"TO\">Tonga<\/option><option  value=\"Trinidad and Tobago\" data-code=\"TT\">Trinidad and Tobago<\/option><option  value=\"Tunisia\" data-code=\"TN\">Tunisia<\/option><option  value=\"Turkey\" data-code=\"TR\">Turkey<\/option><option  value=\"Turkmenistan\" data-code=\"TM\">Turkmenistan<\/option><option  value=\"Turks and Caicos Islands\" data-code=\"TC\">Turks and Caicos Islands<\/option><option  value=\"Tuvalu\" data-code=\"TV\">Tuvalu<\/option><option  value=\"Uganda\" data-code=\"UG\">Uganda<\/option><option  value=\"Ukraine\" data-code=\"UA\">Ukraine<\/option><option  value=\"United Arab Emirates\" data-code=\"AE\">United Arab Emirates<\/option><option  value=\"United Kingdom\" data-code=\"GB\">United Kingdom<\/option><option  value=\"United States\" data-code=\"US\">United States<\/option><option  value=\"United States Minor Outlying Islands\" data-code=\"UM\">United States Minor Outlying Islands<\/option><option  value=\"Uruguay\" data-code=\"UY\">Uruguay<\/option><option  value=\"Uzbekistan\" data-code=\"UZ\">Uzbekistan<\/option><option  value=\"Vanuatu\" data-code=\"VU\">Vanuatu<\/option><option  value=\"Vatican City\">Vatican City<\/option><option  value=\"Venezuela\" data-code=\"VE\">Venezuela<\/option><option  value=\"Vietnam\" data-code=\"VN\">Vietnam<\/option><option  value=\"Virgin Islands, British\">Virgin Islands, British<\/option><option  value=\"Virgin Islands, U.S.\">Virgin Islands, U.S.<\/option><option  value=\"Wallis and Futuna\" data-code=\"WF\">Wallis and Futuna<\/option><option  value=\"Western Sahara\" data-code=\"EH\">Western Sahara<\/option><option  value=\"Yemen\" data-code=\"YE\">Yemen<\/option><option  value=\"Zambia\" data-code=\"ZM\">Zambia<\/option><option  value=\"Zimbabwe\" data-code=\"ZW\">Zimbabwe<\/option>\t\t<\/select>\n\t<div class=\"frm_description\">Country<\/div><\/div>\n<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<\/div>\n<div id=\"frm_field_75_container\" class=\"frm_form_field frm_section_heading form-field  frm12 frm_first\">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Owner\/Member 3<\/h3>\r\n\r\n\r\n<div id=\"frm_field_76_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_capitalize frm12 frm_first\">\r\n\t<label for=\"field_zoc1k\" id=\"field_zoc1k_label\" class=\"frm_primary_label\">3. Full Name \r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_zoc1k\" name=\"item_meta[76]\" value=\"\"  data-sectionid=\"75\"  placeholder=\"(First, MI, Last)\" data-reqmsg=\"3. Full Name  cannot be blank.\" aria-required=\"true\" data-invmsg=\"3. Full Name  is invalid\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_78_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_zd3t3\" id=\"field_zd3t3_label\" class=\"frm_primary_label\">3. Date of Birth\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_zd3t3\" name=\"item_meta[78]\" value=\"\"  data-sectionid=\"75\"  maxlength=\"10\" placeholder=\"(MM\/DD\/YYYY)\" data-reqmsg=\"3. Date of Birth cannot be blank.\" aria-required=\"true\" data-invmsg=\"3. Date of Birth is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_80_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<div  id=\"field_ucq8y_label\" class=\"frm_primary_label\">3. Address\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_ucq8y_label\">\n<legend class=\"frm_screen_reader frm_hidden\">\n\t3. Address<\/legend>\n<div class=\"frm_combo_inputs_container\">\n<div id=\"frm_field_80-line1_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_ucq8y_line1\" class=\"frm_screen_reader frm_hidden\">\n\t\t3. Address\t<\/label>\n\t\t<input type=\"text\" id=\"field_ucq8y_line1\" value=\"\" name=\"item_meta[80][line1]\"  placeholder=\"Street Address 1\" data-placeholder=\"Street Address 1\" data-sectionid=\"75\"  data-reqmsg=\"3. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"3. Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-line1\" \/>\n\t<\/div>\n<div id=\"frm_field_80-line2_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_ucq8y_line2\" class=\"frm_screen_reader frm_hidden\">\n\t\t3. Address\t<\/label>\n\t\t<input type=\"text\" id=\"field_ucq8y_line2\" value=\"\" name=\"item_meta[80][line2]\"  placeholder=\"Street Address 2 (Optional)\" data-placeholder=\"Street Address 2 (Optional)\" data-sectionid=\"75\"  data-reqmsg=\"3. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"3. Address is invalid\" class=\"frm_optional\" aria-invalid=\"false\"   autocomplete=\"address-line2\" \/>\n\t<\/div>\n<div id=\"frm_field_80-city_container\" class=\"frm_form_field form-field frm_third frm_first\">\n\t<label for=\"field_ucq8y_city\" class=\"frm_screen_reader frm_hidden\">\n\t\tCity\t<\/label>\n\t\t<input type=\"text\" id=\"field_ucq8y_city\" value=\"\" name=\"item_meta[80][city]\"  placeholder=\"\" data-placeholder=\"\" data-sectionid=\"75\"  data-reqmsg=\"3. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"3. Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level2\" \/>\n\t<div class=\"frm_description\">City<\/div><\/div>\n<div id=\"frm_field_80-state_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_ucq8y_state\" class=\"frm_screen_reader frm_hidden\">\n\t\tState\/Province\t<\/label>\n\t\t<input type=\"text\" id=\"field_ucq8y_state\" value=\"\" name=\"item_meta[80][state]\"  placeholder=\"\" data-placeholder=\"\" data-sectionid=\"75\"  data-reqmsg=\"3. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"3. Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level1\" \/>\n\t<div class=\"frm_description\">State\/Province<\/div><\/div>\n<div id=\"frm_field_80-zip_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_ucq8y_zip\" class=\"frm_screen_reader frm_hidden\">\n\t\tZip\/Postal\t<\/label>\n\t\t<input type=\"text\" id=\"field_ucq8y_zip\" value=\"\" name=\"item_meta[80][zip]\"  placeholder=\"\" data-placeholder=\"\" data-sectionid=\"75\"  data-reqmsg=\"3. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"3. Address is invalid\" aria-invalid=\"false\"   autocomplete=\"postal-code\" \/>\n\t<div class=\"frm_description\">Zip\/Postal<\/div><\/div>\n<div id=\"frm_field_80-country_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_ucq8y_country\" class=\"frm_screen_reader frm_hidden\">\n\t\tCountry\t<\/label>\n\t\t\t<select name=\"item_meta[80][country]\" id=\"field_ucq8y_country\"  placeholder=\"\" data-placeholder=\"\" data-sectionid=\"75\"  data-reqmsg=\"3. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"3. Address is invalid\" aria-invalid=\"false\"   autocomplete=\"country-name\">\n\t\t\t<option value=\"\" >\n\t\t\t\t\t\t\t<\/option>\n\t\t\t<option  value=\"Afghanistan\" data-code=\"AF\">Afghanistan<\/option><option  value=\"Aland Islands\" data-code=\"AX\">Aland Islands<\/option><option  value=\"Albania\" data-code=\"AL\">Albania<\/option><option  value=\"Algeria\" data-code=\"DZ\">Algeria<\/option><option  value=\"American Samoa\" data-code=\"AS\">American Samoa<\/option><option  value=\"Andorra\" data-code=\"AD\">Andorra<\/option><option  value=\"Angola\" data-code=\"AO\">Angola<\/option><option  value=\"Anguilla\" data-code=\"AI\">Anguilla<\/option><option  value=\"Antarctica\" data-code=\"AQ\">Antarctica<\/option><option  value=\"Antigua and Barbuda\" data-code=\"AG\">Antigua and Barbuda<\/option><option  value=\"Argentina\" data-code=\"AR\">Argentina<\/option><option  value=\"Armenia\" data-code=\"AM\">Armenia<\/option><option  value=\"Aruba\" data-code=\"AW\">Aruba<\/option><option  value=\"Australia\" data-code=\"AU\">Australia<\/option><option  value=\"Austria\" data-code=\"AT\">Austria<\/option><option  value=\"Azerbaijan\" data-code=\"AZ\">Azerbaijan<\/option><option  value=\"Bahamas\" data-code=\"BS\">Bahamas<\/option><option  value=\"Bahrain\" data-code=\"BH\">Bahrain<\/option><option  value=\"Bangladesh\" data-code=\"BD\">Bangladesh<\/option><option  value=\"Barbados\" data-code=\"BB\">Barbados<\/option><option  value=\"Belarus\" data-code=\"BY\">Belarus<\/option><option  value=\"Belgium\" data-code=\"BE\">Belgium<\/option><option  value=\"Belize\" data-code=\"BZ\">Belize<\/option><option  value=\"Benin\" data-code=\"BJ\">Benin<\/option><option  value=\"Bermuda\" data-code=\"BM\">Bermuda<\/option><option  value=\"Bhutan\" data-code=\"BT\">Bhutan<\/option><option  value=\"Bolivia\" data-code=\"BO\">Bolivia<\/option><option  value=\"Bonaire, Sint Eustatius and Saba\">Bonaire, Sint Eustatius and Saba<\/option><option  value=\"Bosnia and Herzegovina\" data-code=\"BA\">Bosnia and Herzegovina<\/option><option  value=\"Botswana\" data-code=\"BW\">Botswana<\/option><option  value=\"Bouvet Island\" data-code=\"BV\">Bouvet Island<\/option><option  value=\"Brazil\" data-code=\"BR\">Brazil<\/option><option  value=\"British Indian Ocean Territory\" data-code=\"IO\">British Indian Ocean Territory<\/option><option  value=\"Brunei\" data-code=\"BN\">Brunei<\/option><option  value=\"Bulgaria\" data-code=\"BG\">Bulgaria<\/option><option  value=\"Burkina Faso\" data-code=\"BF\">Burkina Faso<\/option><option  value=\"Burundi\" data-code=\"BI\">Burundi<\/option><option  value=\"C&ocirc;te d&#039;Ivoire\">C&ocirc;te d&#039;Ivoire<\/option><option  value=\"Cambodia\" data-code=\"KH\">Cambodia<\/option><option  value=\"Cameroon\" data-code=\"CM\">Cameroon<\/option><option  value=\"Canada\" data-code=\"CA\">Canada<\/option><option  value=\"Cape Verde\" data-code=\"CV\">Cape Verde<\/option><option  value=\"Cayman Islands\" data-code=\"KY\">Cayman Islands<\/option><option  value=\"Central African Republic\" data-code=\"CF\">Central African Republic<\/option><option  value=\"Chad\" data-code=\"TD\">Chad<\/option><option  value=\"Chile\" data-code=\"CL\">Chile<\/option><option  value=\"China\" data-code=\"CN\">China<\/option><option  value=\"Christmas Island\" data-code=\"CX\">Christmas Island<\/option><option  value=\"Cocos (Keeling) Islands\">Cocos (Keeling) Islands<\/option><option  value=\"Colombia\" data-code=\"CO\">Colombia<\/option><option  value=\"Comoros\" data-code=\"KM\">Comoros<\/option><option  value=\"Congo\">Congo<\/option><option  value=\"Cook Islands\" data-code=\"CK\">Cook Islands<\/option><option  value=\"Costa Rica\" data-code=\"CR\">Costa Rica<\/option><option  value=\"Croatia\" data-code=\"HR\">Croatia<\/option><option  value=\"Cuba\" data-code=\"CU\">Cuba<\/option><option  value=\"Curacao\" data-code=\"CW\">Curacao<\/option><option  value=\"Cyprus\" data-code=\"CY\">Cyprus<\/option><option  value=\"Czech Republic\" data-code=\"CZ\">Czech Republic<\/option><option  value=\"Denmark\" data-code=\"DK\">Denmark<\/option><option  value=\"Djibouti\" data-code=\"DJ\">Djibouti<\/option><option  value=\"Dominica\" data-code=\"DM\">Dominica<\/option><option  value=\"Dominican Republic\" data-code=\"DO\">Dominican Republic<\/option><option  value=\"East Timor\" data-code=\"TL\">East Timor<\/option><option  value=\"Ecuador\" data-code=\"EC\">Ecuador<\/option><option  value=\"Egypt\" data-code=\"EG\">Egypt<\/option><option  value=\"El Salvador\" data-code=\"SV\">El Salvador<\/option><option  value=\"Equatorial Guinea\" data-code=\"GQ\">Equatorial Guinea<\/option><option  value=\"Eritrea\" data-code=\"ER\">Eritrea<\/option><option  value=\"Estonia\" data-code=\"EE\">Estonia<\/option><option  value=\"Ethiopia\" data-code=\"ET\">Ethiopia<\/option><option  value=\"Falkland Islands (Malvinas)\">Falkland Islands (Malvinas)<\/option><option  value=\"Faroe Islands\" data-code=\"FO\">Faroe Islands<\/option><option  value=\"Fiji\" data-code=\"FJ\">Fiji<\/option><option  value=\"Finland\" data-code=\"FI\">Finland<\/option><option  value=\"France\" data-code=\"FR\">France<\/option><option  value=\"French Guiana\" data-code=\"GF\">French Guiana<\/option><option  value=\"French Polynesia\" data-code=\"PF\">French Polynesia<\/option><option  value=\"French Southern Territories\" data-code=\"TF\">French Southern Territories<\/option><option  value=\"Gabon\" data-code=\"GA\">Gabon<\/option><option  value=\"Gambia\" data-code=\"GM\">Gambia<\/option><option  value=\"Georgia\" data-code=\"GE\">Georgia<\/option><option  value=\"Germany\" data-code=\"DE\">Germany<\/option><option  value=\"Ghana\" data-code=\"GH\">Ghana<\/option><option  value=\"Gibraltar\" data-code=\"GI\">Gibraltar<\/option><option  value=\"Greece\" data-code=\"GR\">Greece<\/option><option  value=\"Greenland\" data-code=\"GL\">Greenland<\/option><option  value=\"Grenada\" data-code=\"GD\">Grenada<\/option><option  value=\"Guadeloupe\" data-code=\"GP\">Guadeloupe<\/option><option  value=\"Guam\" data-code=\"GU\">Guam<\/option><option  value=\"Guatemala\" data-code=\"GT\">Guatemala<\/option><option  value=\"Guernsey\" data-code=\"GG\">Guernsey<\/option><option  value=\"Guinea\" data-code=\"GN\">Guinea<\/option><option  value=\"Guinea-Bissau\" data-code=\"GW\">Guinea-Bissau<\/option><option  value=\"Guyana\" data-code=\"GY\">Guyana<\/option><option  value=\"Haiti\" data-code=\"HT\">Haiti<\/option><option  value=\"Heard Island and McDonald Islands\" data-code=\"HM\">Heard Island and McDonald Islands<\/option><option  value=\"Holy See\">Holy See<\/option><option  value=\"Honduras\" data-code=\"HN\">Honduras<\/option><option  value=\"Hong Kong\" data-code=\"HK\">Hong Kong<\/option><option  value=\"Hungary\" data-code=\"HU\">Hungary<\/option><option  value=\"Iceland\" data-code=\"IS\">Iceland<\/option><option  value=\"India\" data-code=\"IN\">India<\/option><option  value=\"Indonesia\" data-code=\"ID\">Indonesia<\/option><option  value=\"Iran\" data-code=\"IR\">Iran<\/option><option  value=\"Iraq\" data-code=\"IQ\">Iraq<\/option><option  value=\"Ireland\" data-code=\"IE\">Ireland<\/option><option  value=\"Isle of Man\" data-code=\"IM\">Isle of Man<\/option><option  value=\"Israel\" data-code=\"IL\">Israel<\/option><option  value=\"Italy\" data-code=\"IT\">Italy<\/option><option  value=\"Jamaica\" data-code=\"JM\">Jamaica<\/option><option  value=\"Japan\" data-code=\"JP\">Japan<\/option><option  value=\"Jersey\" data-code=\"JE\">Jersey<\/option><option  value=\"Jordan\" data-code=\"JO\">Jordan<\/option><option  value=\"Kazakhstan\" data-code=\"KZ\">Kazakhstan<\/option><option  value=\"Kenya\" data-code=\"KE\">Kenya<\/option><option  value=\"Kiribati\" data-code=\"KI\">Kiribati<\/option><option  value=\"Kosovo\" data-code=\"XK\">Kosovo<\/option><option  value=\"Kuwait\" data-code=\"KW\">Kuwait<\/option><option  value=\"Kyrgyzstan\" data-code=\"KG\">Kyrgyzstan<\/option><option  value=\"Laos\" data-code=\"LA\">Laos<\/option><option  value=\"Latvia\" data-code=\"LV\">Latvia<\/option><option  value=\"Lebanon\" data-code=\"LB\">Lebanon<\/option><option  value=\"Lesotho\" data-code=\"LS\">Lesotho<\/option><option  value=\"Liberia\" data-code=\"LR\">Liberia<\/option><option  value=\"Libya\" data-code=\"LY\">Libya<\/option><option  value=\"Liechtenstein\" data-code=\"LI\">Liechtenstein<\/option><option  value=\"Lithuania\" data-code=\"LT\">Lithuania<\/option><option  value=\"Luxembourg\" data-code=\"LU\">Luxembourg<\/option><option  value=\"Macao\" data-code=\"MO\">Macao<\/option><option  value=\"Macedonia\" data-code=\"MK\">Macedonia<\/option><option  value=\"Madagascar\" data-code=\"MG\">Madagascar<\/option><option  value=\"Malawi\" data-code=\"MW\">Malawi<\/option><option  value=\"Malaysia\" data-code=\"MY\">Malaysia<\/option><option  value=\"Maldives\" data-code=\"MV\">Maldives<\/option><option  value=\"Mali\" data-code=\"ML\">Mali<\/option><option  value=\"Malta\" data-code=\"MT\">Malta<\/option><option  value=\"Marshall Islands\" data-code=\"MH\">Marshall Islands<\/option><option  value=\"Martinique\" data-code=\"MQ\">Martinique<\/option><option  value=\"Mauritania\" data-code=\"MR\">Mauritania<\/option><option  value=\"Mauritius\" data-code=\"MU\">Mauritius<\/option><option  value=\"Mayotte\" data-code=\"YT\">Mayotte<\/option><option  value=\"Mexico\" data-code=\"MX\">Mexico<\/option><option  value=\"Micronesia\" data-code=\"FM\">Micronesia<\/option><option  value=\"Moldova\" data-code=\"MD\">Moldova<\/option><option  value=\"Monaco\" data-code=\"MC\">Monaco<\/option><option  value=\"Mongolia\" data-code=\"MN\">Mongolia<\/option><option  value=\"Montenegro\" data-code=\"ME\">Montenegro<\/option><option  value=\"Montserrat\" data-code=\"MS\">Montserrat<\/option><option  value=\"Morocco\" data-code=\"MA\">Morocco<\/option><option  value=\"Mozambique\" data-code=\"MZ\">Mozambique<\/option><option  value=\"Myanmar\" data-code=\"MM\">Myanmar<\/option><option  value=\"Namibia\" data-code=\"NA\">Namibia<\/option><option  value=\"Nauru\" data-code=\"NR\">Nauru<\/option><option  value=\"Nepal\" data-code=\"NP\">Nepal<\/option><option  value=\"Netherlands\" data-code=\"NL\">Netherlands<\/option><option  value=\"New Caledonia\" data-code=\"NC\">New Caledonia<\/option><option  value=\"New Zealand\" data-code=\"NZ\">New Zealand<\/option><option  value=\"Nicaragua\" data-code=\"NI\">Nicaragua<\/option><option  value=\"Niger\" data-code=\"NE\">Niger<\/option><option  value=\"Nigeria\" data-code=\"NG\">Nigeria<\/option><option  value=\"Niue\" data-code=\"NU\">Niue<\/option><option  value=\"Norfolk Island\" data-code=\"NF\">Norfolk Island<\/option><option  value=\"North Korea\" data-code=\"KP\">North Korea<\/option><option  value=\"Northern Mariana Islands\" data-code=\"MP\">Northern Mariana Islands<\/option><option  value=\"Norway\" data-code=\"NO\">Norway<\/option><option  value=\"Oman\" data-code=\"OM\">Oman<\/option><option  value=\"Pakistan\" data-code=\"PK\">Pakistan<\/option><option  value=\"Palau\" data-code=\"PW\">Palau<\/option><option  value=\"Palestine\">Palestine<\/option><option  value=\"Panama\" data-code=\"PA\">Panama<\/option><option  value=\"Papua New Guinea\" data-code=\"PG\">Papua New Guinea<\/option><option  value=\"Paraguay\" data-code=\"PY\">Paraguay<\/option><option  value=\"Peru\" data-code=\"PE\">Peru<\/option><option  value=\"Philippines\" data-code=\"PH\">Philippines<\/option><option  value=\"Pitcairn\" data-code=\"PN\">Pitcairn<\/option><option  value=\"Poland\" data-code=\"PL\">Poland<\/option><option  value=\"Portugal\" data-code=\"PT\">Portugal<\/option><option  value=\"Puerto Rico\" data-code=\"PR\">Puerto Rico<\/option><option  value=\"Qatar\" data-code=\"QA\">Qatar<\/option><option  value=\"Reunion\" data-code=\"RE\">Reunion<\/option><option  value=\"Romania\" data-code=\"RO\">Romania<\/option><option  value=\"Russia\" data-code=\"RU\">Russia<\/option><option  value=\"Rwanda\" data-code=\"RW\">Rwanda<\/option><option  value=\"Saint Barthelemy\" data-code=\"BL\">Saint Barthelemy<\/option><option  value=\"Saint Helena, Ascension and Tristan da Cunha\">Saint Helena, Ascension and Tristan da Cunha<\/option><option  value=\"Saint Kitts and Nevis\" data-code=\"KN\">Saint Kitts and Nevis<\/option><option  value=\"Saint Lucia\" data-code=\"LC\">Saint Lucia<\/option><option  value=\"Saint Martin (French part)\">Saint Martin (French part)<\/option><option  value=\"Saint Pierre and Miquelon\" data-code=\"PM\">Saint Pierre and Miquelon<\/option><option  value=\"Saint Vincent and the Grenadines\" data-code=\"VC\">Saint Vincent and the Grenadines<\/option><option  value=\"Samoa\" data-code=\"WS\">Samoa<\/option><option  value=\"San Marino\" data-code=\"SM\">San Marino<\/option><option  value=\"Sao Tome and Principe\" data-code=\"ST\">Sao Tome and Principe<\/option><option  value=\"Saudi Arabia\" data-code=\"SA\">Saudi Arabia<\/option><option  value=\"Senegal\" data-code=\"SN\">Senegal<\/option><option  value=\"Serbia\" data-code=\"RS\">Serbia<\/option><option  value=\"Seychelles\" data-code=\"SC\">Seychelles<\/option><option  value=\"Sierra Leone\" data-code=\"SL\">Sierra Leone<\/option><option  value=\"Singapore\" data-code=\"SG\">Singapore<\/option><option  value=\"Sint Maarten (Dutch part)\">Sint Maarten (Dutch part)<\/option><option  value=\"Slovakia\" data-code=\"SK\">Slovakia<\/option><option  value=\"Slovenia\" data-code=\"SI\">Slovenia<\/option><option  value=\"Solomon Islands\" data-code=\"SB\">Solomon Islands<\/option><option  value=\"Somalia\" data-code=\"SO\">Somalia<\/option><option  value=\"South Africa\" data-code=\"ZA\">South Africa<\/option><option  value=\"South Georgia and the South Sandwich Islands\" data-code=\"GS\">South Georgia and the South Sandwich Islands<\/option><option  value=\"South Korea\" data-code=\"KR\">South Korea<\/option><option  value=\"South Sudan\" data-code=\"SS\">South Sudan<\/option><option  value=\"Spain\" data-code=\"ES\">Spain<\/option><option  value=\"Sri Lanka\" data-code=\"LK\">Sri Lanka<\/option><option  value=\"Sudan\" data-code=\"SD\">Sudan<\/option><option  value=\"Suriname\" data-code=\"SR\">Suriname<\/option><option  value=\"Svalbard and Jan Mayen\" data-code=\"SJ\">Svalbard and Jan Mayen<\/option><option  value=\"Swaziland\" data-code=\"SZ\">Swaziland<\/option><option  value=\"Sweden\" data-code=\"SE\">Sweden<\/option><option  value=\"Switzerland\" data-code=\"CH\">Switzerland<\/option><option  value=\"Syria\" data-code=\"SY\">Syria<\/option><option  value=\"Taiwan\" data-code=\"TW\">Taiwan<\/option><option  value=\"Tajikistan\" data-code=\"TJ\">Tajikistan<\/option><option  value=\"Tanzania\" data-code=\"TZ\">Tanzania<\/option><option  value=\"Thailand\" data-code=\"TH\">Thailand<\/option><option  value=\"Timor-Leste\">Timor-Leste<\/option><option  value=\"Togo\" data-code=\"TG\">Togo<\/option><option  value=\"Tokelau\" data-code=\"TK\">Tokelau<\/option><option  value=\"Tonga\" data-code=\"TO\">Tonga<\/option><option  value=\"Trinidad and Tobago\" data-code=\"TT\">Trinidad and Tobago<\/option><option  value=\"Tunisia\" data-code=\"TN\">Tunisia<\/option><option  value=\"Turkey\" data-code=\"TR\">Turkey<\/option><option  value=\"Turkmenistan\" data-code=\"TM\">Turkmenistan<\/option><option  value=\"Turks and Caicos Islands\" data-code=\"TC\">Turks and Caicos Islands<\/option><option  value=\"Tuvalu\" data-code=\"TV\">Tuvalu<\/option><option  value=\"Uganda\" data-code=\"UG\">Uganda<\/option><option  value=\"Ukraine\" data-code=\"UA\">Ukraine<\/option><option  value=\"United Arab Emirates\" data-code=\"AE\">United Arab Emirates<\/option><option  value=\"United Kingdom\" data-code=\"GB\">United Kingdom<\/option><option  value=\"United States\" data-code=\"US\">United States<\/option><option  value=\"United States Minor Outlying Islands\" data-code=\"UM\">United States Minor Outlying Islands<\/option><option  value=\"Uruguay\" data-code=\"UY\">Uruguay<\/option><option  value=\"Uzbekistan\" data-code=\"UZ\">Uzbekistan<\/option><option  value=\"Vanuatu\" data-code=\"VU\">Vanuatu<\/option><option  value=\"Vatican City\">Vatican City<\/option><option  value=\"Venezuela\" data-code=\"VE\">Venezuela<\/option><option  value=\"Vietnam\" data-code=\"VN\">Vietnam<\/option><option  value=\"Virgin Islands, British\">Virgin Islands, British<\/option><option  value=\"Virgin Islands, U.S.\">Virgin Islands, U.S.<\/option><option  value=\"Wallis and Futuna\" data-code=\"WF\">Wallis and Futuna<\/option><option  value=\"Western Sahara\" data-code=\"EH\">Western Sahara<\/option><option  value=\"Yemen\" data-code=\"YE\">Yemen<\/option><option  value=\"Zambia\" data-code=\"ZM\">Zambia<\/option><option  value=\"Zimbabwe\" data-code=\"ZW\">Zimbabwe<\/option>\t\t<\/select>\n\t<div class=\"frm_description\">Country<\/div><\/div>\n<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<\/div>\n<div id=\"frm_field_74_container\" class=\"frm_form_field frm_section_heading form-field  frm12 frm_first\">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Owner\/Member 4<\/h3>\r\n\r\n\r\n<div id=\"frm_field_77_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_capitalize frm12 frm_first\">\r\n\t<label for=\"field_nploh\" id=\"field_nploh_label\" class=\"frm_primary_label\">4. Full Name \r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_nploh\" name=\"item_meta[77]\" value=\"\"  data-sectionid=\"74\"  placeholder=\"(First, MI, Last)\" data-reqmsg=\"4. Full Name  cannot be blank.\" aria-required=\"true\" data-invmsg=\"4. Full Name  is invalid\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_79_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_jnvz8\" id=\"field_jnvz8_label\" class=\"frm_primary_label\">4. Date of Birth\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_jnvz8\" name=\"item_meta[79]\" value=\"\"  data-sectionid=\"74\"  maxlength=\"10\" placeholder=\"(MM\/DD\/YYYY)\" data-reqmsg=\"4. Date of Birth cannot be blank.\" aria-required=\"true\" data-invmsg=\"4. Date of Birth is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_81_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<div  id=\"field_szc5v_label\" class=\"frm_primary_label\">4. Address\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_szc5v_label\">\n<legend class=\"frm_screen_reader frm_hidden\">\n\t4. Address<\/legend>\n<div class=\"frm_combo_inputs_container\">\n<div id=\"frm_field_81-line1_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_szc5v_line1\" class=\"frm_screen_reader frm_hidden\">\n\t\t4. Address\t<\/label>\n\t\t<input type=\"text\" id=\"field_szc5v_line1\" value=\"\" name=\"item_meta[81][line1]\"  placeholder=\"Street Address 1\" data-placeholder=\"Street Address 1\" data-sectionid=\"74\"  data-reqmsg=\"4. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"4. Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-line1\" \/>\n\t<\/div>\n<div id=\"frm_field_81-line2_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_szc5v_line2\" class=\"frm_screen_reader frm_hidden\">\n\t\t4. Address\t<\/label>\n\t\t<input type=\"text\" id=\"field_szc5v_line2\" value=\"\" name=\"item_meta[81][line2]\"  placeholder=\"Street Address 2 (Optional)\" data-placeholder=\"Street Address 2 (Optional)\" data-sectionid=\"74\"  data-reqmsg=\"4. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"4. Address is invalid\" class=\"frm_optional\" aria-invalid=\"false\"   autocomplete=\"address-line2\" \/>\n\t<\/div>\n<div id=\"frm_field_81-city_container\" class=\"frm_form_field form-field frm_third frm_first\">\n\t<label for=\"field_szc5v_city\" class=\"frm_screen_reader frm_hidden\">\n\t\tCity\t<\/label>\n\t\t<input type=\"text\" id=\"field_szc5v_city\" value=\"\" name=\"item_meta[81][city]\"  placeholder=\"\" data-placeholder=\"\" data-sectionid=\"74\"  data-reqmsg=\"4. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"4. Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level2\" \/>\n\t<div class=\"frm_description\">City<\/div><\/div>\n<div id=\"frm_field_81-state_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_szc5v_state\" class=\"frm_screen_reader frm_hidden\">\n\t\tState\/Province\t<\/label>\n\t\t<input type=\"text\" id=\"field_szc5v_state\" value=\"\" name=\"item_meta[81][state]\"  placeholder=\"\" data-placeholder=\"\" data-sectionid=\"74\"  data-reqmsg=\"4. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"4. Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level1\" \/>\n\t<div class=\"frm_description\">State\/Province<\/div><\/div>\n<div id=\"frm_field_81-zip_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_szc5v_zip\" class=\"frm_screen_reader frm_hidden\">\n\t\tZip\/Postal\t<\/label>\n\t\t<input type=\"text\" id=\"field_szc5v_zip\" value=\"\" name=\"item_meta[81][zip]\"  placeholder=\"\" data-placeholder=\"\" data-sectionid=\"74\"  data-reqmsg=\"4. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"4. Address is invalid\" aria-invalid=\"false\"   autocomplete=\"postal-code\" \/>\n\t<div class=\"frm_description\">Zip\/Postal<\/div><\/div>\n<div id=\"frm_field_81-country_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_szc5v_country\" class=\"frm_screen_reader frm_hidden\">\n\t\tCountry\t<\/label>\n\t\t\t<select name=\"item_meta[81][country]\" id=\"field_szc5v_country\"  placeholder=\"\" data-placeholder=\"\" data-sectionid=\"74\"  data-reqmsg=\"4. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"4. Address is invalid\" aria-invalid=\"false\"   autocomplete=\"country-name\">\n\t\t\t<option value=\"\" >\n\t\t\t\t\t\t\t<\/option>\n\t\t\t<option  value=\"Afghanistan\" data-code=\"AF\">Afghanistan<\/option><option  value=\"Aland Islands\" data-code=\"AX\">Aland Islands<\/option><option  value=\"Albania\" data-code=\"AL\">Albania<\/option><option  value=\"Algeria\" data-code=\"DZ\">Algeria<\/option><option  value=\"American Samoa\" data-code=\"AS\">American Samoa<\/option><option  value=\"Andorra\" data-code=\"AD\">Andorra<\/option><option  value=\"Angola\" data-code=\"AO\">Angola<\/option><option  value=\"Anguilla\" data-code=\"AI\">Anguilla<\/option><option  value=\"Antarctica\" data-code=\"AQ\">Antarctica<\/option><option  value=\"Antigua and Barbuda\" data-code=\"AG\">Antigua and Barbuda<\/option><option  value=\"Argentina\" data-code=\"AR\">Argentina<\/option><option  value=\"Armenia\" data-code=\"AM\">Armenia<\/option><option  value=\"Aruba\" data-code=\"AW\">Aruba<\/option><option  value=\"Australia\" data-code=\"AU\">Australia<\/option><option  value=\"Austria\" data-code=\"AT\">Austria<\/option><option  value=\"Azerbaijan\" data-code=\"AZ\">Azerbaijan<\/option><option  value=\"Bahamas\" data-code=\"BS\">Bahamas<\/option><option  value=\"Bahrain\" data-code=\"BH\">Bahrain<\/option><option  value=\"Bangladesh\" data-code=\"BD\">Bangladesh<\/option><option  value=\"Barbados\" data-code=\"BB\">Barbados<\/option><option  value=\"Belarus\" data-code=\"BY\">Belarus<\/option><option  value=\"Belgium\" data-code=\"BE\">Belgium<\/option><option  value=\"Belize\" data-code=\"BZ\">Belize<\/option><option  value=\"Benin\" data-code=\"BJ\">Benin<\/option><option  value=\"Bermuda\" data-code=\"BM\">Bermuda<\/option><option  value=\"Bhutan\" data-code=\"BT\">Bhutan<\/option><option  value=\"Bolivia\" data-code=\"BO\">Bolivia<\/option><option  value=\"Bonaire, Sint Eustatius and Saba\">Bonaire, Sint Eustatius and Saba<\/option><option  value=\"Bosnia and Herzegovina\" data-code=\"BA\">Bosnia and Herzegovina<\/option><option  value=\"Botswana\" data-code=\"BW\">Botswana<\/option><option  value=\"Bouvet Island\" data-code=\"BV\">Bouvet Island<\/option><option  value=\"Brazil\" data-code=\"BR\">Brazil<\/option><option  value=\"British Indian Ocean Territory\" data-code=\"IO\">British Indian Ocean Territory<\/option><option  value=\"Brunei\" data-code=\"BN\">Brunei<\/option><option  value=\"Bulgaria\" data-code=\"BG\">Bulgaria<\/option><option  value=\"Burkina Faso\" data-code=\"BF\">Burkina Faso<\/option><option  value=\"Burundi\" data-code=\"BI\">Burundi<\/option><option  value=\"C&ocirc;te d&#039;Ivoire\">C&ocirc;te d&#039;Ivoire<\/option><option  value=\"Cambodia\" data-code=\"KH\">Cambodia<\/option><option  value=\"Cameroon\" data-code=\"CM\">Cameroon<\/option><option  value=\"Canada\" data-code=\"CA\">Canada<\/option><option  value=\"Cape Verde\" data-code=\"CV\">Cape Verde<\/option><option  value=\"Cayman Islands\" data-code=\"KY\">Cayman Islands<\/option><option  value=\"Central African Republic\" data-code=\"CF\">Central African Republic<\/option><option  value=\"Chad\" data-code=\"TD\">Chad<\/option><option  value=\"Chile\" data-code=\"CL\">Chile<\/option><option  value=\"China\" data-code=\"CN\">China<\/option><option  value=\"Christmas Island\" data-code=\"CX\">Christmas Island<\/option><option  value=\"Cocos (Keeling) Islands\">Cocos (Keeling) Islands<\/option><option  value=\"Colombia\" data-code=\"CO\">Colombia<\/option><option  value=\"Comoros\" data-code=\"KM\">Comoros<\/option><option  value=\"Congo\">Congo<\/option><option  value=\"Cook Islands\" data-code=\"CK\">Cook Islands<\/option><option  value=\"Costa Rica\" data-code=\"CR\">Costa Rica<\/option><option  value=\"Croatia\" data-code=\"HR\">Croatia<\/option><option  value=\"Cuba\" data-code=\"CU\">Cuba<\/option><option  value=\"Curacao\" data-code=\"CW\">Curacao<\/option><option  value=\"Cyprus\" data-code=\"CY\">Cyprus<\/option><option  value=\"Czech Republic\" data-code=\"CZ\">Czech Republic<\/option><option  value=\"Denmark\" data-code=\"DK\">Denmark<\/option><option  value=\"Djibouti\" data-code=\"DJ\">Djibouti<\/option><option  value=\"Dominica\" data-code=\"DM\">Dominica<\/option><option  value=\"Dominican Republic\" data-code=\"DO\">Dominican Republic<\/option><option  value=\"East Timor\" data-code=\"TL\">East Timor<\/option><option  value=\"Ecuador\" data-code=\"EC\">Ecuador<\/option><option  value=\"Egypt\" data-code=\"EG\">Egypt<\/option><option  value=\"El Salvador\" data-code=\"SV\">El Salvador<\/option><option  value=\"Equatorial Guinea\" data-code=\"GQ\">Equatorial Guinea<\/option><option  value=\"Eritrea\" data-code=\"ER\">Eritrea<\/option><option  value=\"Estonia\" data-code=\"EE\">Estonia<\/option><option  value=\"Ethiopia\" data-code=\"ET\">Ethiopia<\/option><option  value=\"Falkland Islands (Malvinas)\">Falkland Islands (Malvinas)<\/option><option  value=\"Faroe Islands\" data-code=\"FO\">Faroe Islands<\/option><option  value=\"Fiji\" data-code=\"FJ\">Fiji<\/option><option  value=\"Finland\" data-code=\"FI\">Finland<\/option><option  value=\"France\" data-code=\"FR\">France<\/option><option  value=\"French Guiana\" data-code=\"GF\">French Guiana<\/option><option  value=\"French Polynesia\" data-code=\"PF\">French Polynesia<\/option><option  value=\"French Southern Territories\" data-code=\"TF\">French Southern Territories<\/option><option  value=\"Gabon\" data-code=\"GA\">Gabon<\/option><option  value=\"Gambia\" data-code=\"GM\">Gambia<\/option><option  value=\"Georgia\" data-code=\"GE\">Georgia<\/option><option  value=\"Germany\" data-code=\"DE\">Germany<\/option><option  value=\"Ghana\" data-code=\"GH\">Ghana<\/option><option  value=\"Gibraltar\" data-code=\"GI\">Gibraltar<\/option><option  value=\"Greece\" data-code=\"GR\">Greece<\/option><option  value=\"Greenland\" data-code=\"GL\">Greenland<\/option><option  value=\"Grenada\" data-code=\"GD\">Grenada<\/option><option  value=\"Guadeloupe\" data-code=\"GP\">Guadeloupe<\/option><option  value=\"Guam\" data-code=\"GU\">Guam<\/option><option  value=\"Guatemala\" data-code=\"GT\">Guatemala<\/option><option  value=\"Guernsey\" data-code=\"GG\">Guernsey<\/option><option  value=\"Guinea\" data-code=\"GN\">Guinea<\/option><option  value=\"Guinea-Bissau\" data-code=\"GW\">Guinea-Bissau<\/option><option  value=\"Guyana\" data-code=\"GY\">Guyana<\/option><option  value=\"Haiti\" data-code=\"HT\">Haiti<\/option><option  value=\"Heard Island and McDonald Islands\" data-code=\"HM\">Heard Island and McDonald Islands<\/option><option  value=\"Holy See\">Holy See<\/option><option  value=\"Honduras\" data-code=\"HN\">Honduras<\/option><option  value=\"Hong Kong\" data-code=\"HK\">Hong Kong<\/option><option  value=\"Hungary\" data-code=\"HU\">Hungary<\/option><option  value=\"Iceland\" data-code=\"IS\">Iceland<\/option><option  value=\"India\" data-code=\"IN\">India<\/option><option  value=\"Indonesia\" data-code=\"ID\">Indonesia<\/option><option  value=\"Iran\" data-code=\"IR\">Iran<\/option><option  value=\"Iraq\" data-code=\"IQ\">Iraq<\/option><option  value=\"Ireland\" data-code=\"IE\">Ireland<\/option><option  value=\"Isle of Man\" data-code=\"IM\">Isle of Man<\/option><option  value=\"Israel\" data-code=\"IL\">Israel<\/option><option  value=\"Italy\" data-code=\"IT\">Italy<\/option><option  value=\"Jamaica\" data-code=\"JM\">Jamaica<\/option><option  value=\"Japan\" data-code=\"JP\">Japan<\/option><option  value=\"Jersey\" data-code=\"JE\">Jersey<\/option><option  value=\"Jordan\" data-code=\"JO\">Jordan<\/option><option  value=\"Kazakhstan\" data-code=\"KZ\">Kazakhstan<\/option><option  value=\"Kenya\" data-code=\"KE\">Kenya<\/option><option  value=\"Kiribati\" data-code=\"KI\">Kiribati<\/option><option  value=\"Kosovo\" data-code=\"XK\">Kosovo<\/option><option  value=\"Kuwait\" data-code=\"KW\">Kuwait<\/option><option  value=\"Kyrgyzstan\" data-code=\"KG\">Kyrgyzstan<\/option><option  value=\"Laos\" data-code=\"LA\">Laos<\/option><option  value=\"Latvia\" data-code=\"LV\">Latvia<\/option><option  value=\"Lebanon\" data-code=\"LB\">Lebanon<\/option><option  value=\"Lesotho\" data-code=\"LS\">Lesotho<\/option><option  value=\"Liberia\" data-code=\"LR\">Liberia<\/option><option  value=\"Libya\" data-code=\"LY\">Libya<\/option><option  value=\"Liechtenstein\" data-code=\"LI\">Liechtenstein<\/option><option  value=\"Lithuania\" data-code=\"LT\">Lithuania<\/option><option  value=\"Luxembourg\" data-code=\"LU\">Luxembourg<\/option><option  value=\"Macao\" data-code=\"MO\">Macao<\/option><option  value=\"Macedonia\" data-code=\"MK\">Macedonia<\/option><option  value=\"Madagascar\" data-code=\"MG\">Madagascar<\/option><option  value=\"Malawi\" data-code=\"MW\">Malawi<\/option><option  value=\"Malaysia\" data-code=\"MY\">Malaysia<\/option><option  value=\"Maldives\" data-code=\"MV\">Maldives<\/option><option  value=\"Mali\" data-code=\"ML\">Mali<\/option><option  value=\"Malta\" data-code=\"MT\">Malta<\/option><option  value=\"Marshall Islands\" data-code=\"MH\">Marshall Islands<\/option><option  value=\"Martinique\" data-code=\"MQ\">Martinique<\/option><option  value=\"Mauritania\" data-code=\"MR\">Mauritania<\/option><option  value=\"Mauritius\" data-code=\"MU\">Mauritius<\/option><option  value=\"Mayotte\" data-code=\"YT\">Mayotte<\/option><option  value=\"Mexico\" data-code=\"MX\">Mexico<\/option><option  value=\"Micronesia\" data-code=\"FM\">Micronesia<\/option><option  value=\"Moldova\" data-code=\"MD\">Moldova<\/option><option  value=\"Monaco\" data-code=\"MC\">Monaco<\/option><option  value=\"Mongolia\" data-code=\"MN\">Mongolia<\/option><option  value=\"Montenegro\" data-code=\"ME\">Montenegro<\/option><option  value=\"Montserrat\" data-code=\"MS\">Montserrat<\/option><option  value=\"Morocco\" data-code=\"MA\">Morocco<\/option><option  value=\"Mozambique\" data-code=\"MZ\">Mozambique<\/option><option  value=\"Myanmar\" data-code=\"MM\">Myanmar<\/option><option  value=\"Namibia\" data-code=\"NA\">Namibia<\/option><option  value=\"Nauru\" data-code=\"NR\">Nauru<\/option><option  value=\"Nepal\" data-code=\"NP\">Nepal<\/option><option  value=\"Netherlands\" data-code=\"NL\">Netherlands<\/option><option  value=\"New Caledonia\" data-code=\"NC\">New Caledonia<\/option><option  value=\"New Zealand\" data-code=\"NZ\">New Zealand<\/option><option  value=\"Nicaragua\" data-code=\"NI\">Nicaragua<\/option><option  value=\"Niger\" data-code=\"NE\">Niger<\/option><option  value=\"Nigeria\" data-code=\"NG\">Nigeria<\/option><option  value=\"Niue\" data-code=\"NU\">Niue<\/option><option  value=\"Norfolk Island\" data-code=\"NF\">Norfolk Island<\/option><option  value=\"North Korea\" data-code=\"KP\">North Korea<\/option><option  value=\"Northern Mariana Islands\" data-code=\"MP\">Northern Mariana Islands<\/option><option  value=\"Norway\" data-code=\"NO\">Norway<\/option><option  value=\"Oman\" data-code=\"OM\">Oman<\/option><option  value=\"Pakistan\" data-code=\"PK\">Pakistan<\/option><option  value=\"Palau\" data-code=\"PW\">Palau<\/option><option  value=\"Palestine\">Palestine<\/option><option  value=\"Panama\" data-code=\"PA\">Panama<\/option><option  value=\"Papua New Guinea\" data-code=\"PG\">Papua New Guinea<\/option><option  value=\"Paraguay\" data-code=\"PY\">Paraguay<\/option><option  value=\"Peru\" data-code=\"PE\">Peru<\/option><option  value=\"Philippines\" data-code=\"PH\">Philippines<\/option><option  value=\"Pitcairn\" data-code=\"PN\">Pitcairn<\/option><option  value=\"Poland\" data-code=\"PL\">Poland<\/option><option  value=\"Portugal\" data-code=\"PT\">Portugal<\/option><option  value=\"Puerto Rico\" data-code=\"PR\">Puerto Rico<\/option><option  value=\"Qatar\" data-code=\"QA\">Qatar<\/option><option  value=\"Reunion\" data-code=\"RE\">Reunion<\/option><option  value=\"Romania\" data-code=\"RO\">Romania<\/option><option  value=\"Russia\" data-code=\"RU\">Russia<\/option><option  value=\"Rwanda\" data-code=\"RW\">Rwanda<\/option><option  value=\"Saint Barthelemy\" data-code=\"BL\">Saint Barthelemy<\/option><option  value=\"Saint Helena, Ascension and Tristan da Cunha\">Saint Helena, Ascension and Tristan da Cunha<\/option><option  value=\"Saint Kitts and Nevis\" data-code=\"KN\">Saint Kitts and Nevis<\/option><option  value=\"Saint Lucia\" data-code=\"LC\">Saint Lucia<\/option><option  value=\"Saint Martin (French part)\">Saint Martin (French part)<\/option><option  value=\"Saint Pierre and Miquelon\" data-code=\"PM\">Saint Pierre and Miquelon<\/option><option  value=\"Saint Vincent and the Grenadines\" data-code=\"VC\">Saint Vincent and the Grenadines<\/option><option  value=\"Samoa\" data-code=\"WS\">Samoa<\/option><option  value=\"San Marino\" data-code=\"SM\">San Marino<\/option><option  value=\"Sao Tome and Principe\" data-code=\"ST\">Sao Tome and Principe<\/option><option  value=\"Saudi Arabia\" data-code=\"SA\">Saudi Arabia<\/option><option  value=\"Senegal\" data-code=\"SN\">Senegal<\/option><option  value=\"Serbia\" data-code=\"RS\">Serbia<\/option><option  value=\"Seychelles\" data-code=\"SC\">Seychelles<\/option><option  value=\"Sierra Leone\" data-code=\"SL\">Sierra Leone<\/option><option  value=\"Singapore\" data-code=\"SG\">Singapore<\/option><option  value=\"Sint Maarten (Dutch part)\">Sint Maarten (Dutch part)<\/option><option  value=\"Slovakia\" data-code=\"SK\">Slovakia<\/option><option  value=\"Slovenia\" data-code=\"SI\">Slovenia<\/option><option  value=\"Solomon Islands\" data-code=\"SB\">Solomon Islands<\/option><option  value=\"Somalia\" data-code=\"SO\">Somalia<\/option><option  value=\"South Africa\" data-code=\"ZA\">South Africa<\/option><option  value=\"South Georgia and the South Sandwich Islands\" data-code=\"GS\">South Georgia and the South Sandwich Islands<\/option><option  value=\"South Korea\" data-code=\"KR\">South Korea<\/option><option  value=\"South Sudan\" data-code=\"SS\">South Sudan<\/option><option  value=\"Spain\" data-code=\"ES\">Spain<\/option><option  value=\"Sri Lanka\" data-code=\"LK\">Sri Lanka<\/option><option  value=\"Sudan\" data-code=\"SD\">Sudan<\/option><option  value=\"Suriname\" data-code=\"SR\">Suriname<\/option><option  value=\"Svalbard and Jan Mayen\" data-code=\"SJ\">Svalbard and Jan Mayen<\/option><option  value=\"Swaziland\" data-code=\"SZ\">Swaziland<\/option><option  value=\"Sweden\" data-code=\"SE\">Sweden<\/option><option  value=\"Switzerland\" data-code=\"CH\">Switzerland<\/option><option  value=\"Syria\" data-code=\"SY\">Syria<\/option><option  value=\"Taiwan\" data-code=\"TW\">Taiwan<\/option><option  value=\"Tajikistan\" data-code=\"TJ\">Tajikistan<\/option><option  value=\"Tanzania\" data-code=\"TZ\">Tanzania<\/option><option  value=\"Thailand\" data-code=\"TH\">Thailand<\/option><option  value=\"Timor-Leste\">Timor-Leste<\/option><option  value=\"Togo\" data-code=\"TG\">Togo<\/option><option  value=\"Tokelau\" data-code=\"TK\">Tokelau<\/option><option  value=\"Tonga\" data-code=\"TO\">Tonga<\/option><option  value=\"Trinidad and Tobago\" data-code=\"TT\">Trinidad and Tobago<\/option><option  value=\"Tunisia\" data-code=\"TN\">Tunisia<\/option><option  value=\"Turkey\" data-code=\"TR\">Turkey<\/option><option  value=\"Turkmenistan\" data-code=\"TM\">Turkmenistan<\/option><option  value=\"Turks and Caicos Islands\" data-code=\"TC\">Turks and Caicos Islands<\/option><option  value=\"Tuvalu\" data-code=\"TV\">Tuvalu<\/option><option  value=\"Uganda\" data-code=\"UG\">Uganda<\/option><option  value=\"Ukraine\" data-code=\"UA\">Ukraine<\/option><option  value=\"United Arab Emirates\" data-code=\"AE\">United Arab Emirates<\/option><option  value=\"United Kingdom\" data-code=\"GB\">United Kingdom<\/option><option  value=\"United States\" data-code=\"US\">United States<\/option><option  value=\"United States Minor Outlying Islands\" data-code=\"UM\">United States Minor Outlying Islands<\/option><option  value=\"Uruguay\" data-code=\"UY\">Uruguay<\/option><option  value=\"Uzbekistan\" data-code=\"UZ\">Uzbekistan<\/option><option  value=\"Vanuatu\" data-code=\"VU\">Vanuatu<\/option><option  value=\"Vatican City\">Vatican City<\/option><option  value=\"Venezuela\" data-code=\"VE\">Venezuela<\/option><option  value=\"Vietnam\" data-code=\"VN\">Vietnam<\/option><option  value=\"Virgin Islands, British\">Virgin Islands, British<\/option><option  value=\"Virgin Islands, U.S.\">Virgin Islands, U.S.<\/option><option  value=\"Wallis and Futuna\" data-code=\"WF\">Wallis and Futuna<\/option><option  value=\"Western Sahara\" data-code=\"EH\">Western Sahara<\/option><option  value=\"Yemen\" data-code=\"YE\">Yemen<\/option><option  value=\"Zambia\" data-code=\"ZM\">Zambia<\/option><option  value=\"Zimbabwe\" data-code=\"ZW\">Zimbabwe<\/option>\t\t<\/select>\n\t<div class=\"frm_description\">Country<\/div><\/div>\n<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<\/div>\n<div id=\"frm_field_84_container\" class=\"frm_form_field frm_section_heading form-field  frm12 frm_first\">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Owner\/Member 5<\/h3>\r\n\r\n\r\n<div id=\"frm_field_85_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_capitalize frm12 frm_first\">\r\n\t<label for=\"field_jchq\" id=\"field_jchq_label\" class=\"frm_primary_label\">5. Full Name \r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_jchq\" name=\"item_meta[85]\" value=\"\"  data-sectionid=\"84\"  placeholder=\"(First, MI, Last)\" data-reqmsg=\"5. Full Name  cannot be blank.\" aria-required=\"true\" data-invmsg=\"5. Full Name  is invalid\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_86_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_1xibl\" id=\"field_1xibl_label\" class=\"frm_primary_label\">5. Date of Birth\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_1xibl\" name=\"item_meta[86]\" value=\"\"  data-sectionid=\"84\"  maxlength=\"10\" placeholder=\"(MM\/DD\/YYYY)\" data-reqmsg=\"5. Date of Birth cannot be blank.\" aria-required=\"true\" data-invmsg=\"5. Date of Birth is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_87_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<div  id=\"field_6gg04_label\" class=\"frm_primary_label\">5. Address\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_6gg04_label\">\n<legend class=\"frm_screen_reader frm_hidden\">\n\t5. Address<\/legend>\n<div class=\"frm_combo_inputs_container\">\n<div id=\"frm_field_87-line1_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_6gg04_line1\" class=\"frm_screen_reader frm_hidden\">\n\t\t5. Address\t<\/label>\n\t\t<input type=\"text\" id=\"field_6gg04_line1\" value=\"\" name=\"item_meta[87][line1]\"  placeholder=\"Street Address 1\" data-placeholder=\"Street Address 1\" data-sectionid=\"84\"  data-reqmsg=\"5. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"5. Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-line1\" \/>\n\t<\/div>\n<div id=\"frm_field_87-line2_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_6gg04_line2\" class=\"frm_screen_reader frm_hidden\">\n\t\t5. Address\t<\/label>\n\t\t<input type=\"text\" id=\"field_6gg04_line2\" value=\"\" name=\"item_meta[87][line2]\"  placeholder=\"Street Address 2 (Optional)\" data-placeholder=\"Street Address 2 (Optional)\" data-sectionid=\"84\"  data-reqmsg=\"5. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"5. Address is invalid\" class=\"frm_optional\" aria-invalid=\"false\"   autocomplete=\"address-line2\" \/>\n\t<\/div>\n<div id=\"frm_field_87-city_container\" class=\"frm_form_field form-field frm_third frm_first\">\n\t<label for=\"field_6gg04_city\" class=\"frm_screen_reader frm_hidden\">\n\t\tCity\t<\/label>\n\t\t<input type=\"text\" id=\"field_6gg04_city\" value=\"\" name=\"item_meta[87][city]\"  placeholder=\"\" data-placeholder=\"\" data-sectionid=\"84\"  data-reqmsg=\"5. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"5. Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level2\" \/>\n\t<div class=\"frm_description\">City<\/div><\/div>\n<div id=\"frm_field_87-state_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_6gg04_state\" class=\"frm_screen_reader frm_hidden\">\n\t\tState\/Province\t<\/label>\n\t\t<input type=\"text\" id=\"field_6gg04_state\" value=\"\" name=\"item_meta[87][state]\"  placeholder=\"\" data-placeholder=\"\" data-sectionid=\"84\"  data-reqmsg=\"5. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"5. Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level1\" \/>\n\t<div class=\"frm_description\">State\/Province<\/div><\/div>\n<div id=\"frm_field_87-zip_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_6gg04_zip\" class=\"frm_screen_reader frm_hidden\">\n\t\tZip\/Postal\t<\/label>\n\t\t<input type=\"text\" id=\"field_6gg04_zip\" value=\"\" name=\"item_meta[87][zip]\"  placeholder=\"\" data-placeholder=\"\" data-sectionid=\"84\"  data-reqmsg=\"5. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"5. Address is invalid\" aria-invalid=\"false\"   autocomplete=\"postal-code\" \/>\n\t<div class=\"frm_description\">Zip\/Postal<\/div><\/div>\n<div id=\"frm_field_87-country_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_6gg04_country\" class=\"frm_screen_reader frm_hidden\">\n\t\tCountry\t<\/label>\n\t\t\t<select name=\"item_meta[87][country]\" id=\"field_6gg04_country\"  placeholder=\"\" data-placeholder=\"\" data-sectionid=\"84\"  data-reqmsg=\"5. Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"5. Address is invalid\" aria-invalid=\"false\"   autocomplete=\"country-name\">\n\t\t\t<option value=\"\" >\n\t\t\t\t\t\t\t<\/option>\n\t\t\t<option  value=\"Afghanistan\" data-code=\"AF\">Afghanistan<\/option><option  value=\"Aland Islands\" data-code=\"AX\">Aland Islands<\/option><option  value=\"Albania\" data-code=\"AL\">Albania<\/option><option  value=\"Algeria\" data-code=\"DZ\">Algeria<\/option><option  value=\"American Samoa\" data-code=\"AS\">American Samoa<\/option><option  value=\"Andorra\" data-code=\"AD\">Andorra<\/option><option  value=\"Angola\" data-code=\"AO\">Angola<\/option><option  value=\"Anguilla\" data-code=\"AI\">Anguilla<\/option><option  value=\"Antarctica\" data-code=\"AQ\">Antarctica<\/option><option  value=\"Antigua and Barbuda\" data-code=\"AG\">Antigua and Barbuda<\/option><option  value=\"Argentina\" data-code=\"AR\">Argentina<\/option><option  value=\"Armenia\" data-code=\"AM\">Armenia<\/option><option  value=\"Aruba\" data-code=\"AW\">Aruba<\/option><option  value=\"Australia\" data-code=\"AU\">Australia<\/option><option  value=\"Austria\" data-code=\"AT\">Austria<\/option><option  value=\"Azerbaijan\" data-code=\"AZ\">Azerbaijan<\/option><option  value=\"Bahamas\" data-code=\"BS\">Bahamas<\/option><option  value=\"Bahrain\" data-code=\"BH\">Bahrain<\/option><option  value=\"Bangladesh\" data-code=\"BD\">Bangladesh<\/option><option  value=\"Barbados\" data-code=\"BB\">Barbados<\/option><option  value=\"Belarus\" data-code=\"BY\">Belarus<\/option><option  value=\"Belgium\" data-code=\"BE\">Belgium<\/option><option  value=\"Belize\" data-code=\"BZ\">Belize<\/option><option  value=\"Benin\" data-code=\"BJ\">Benin<\/option><option  value=\"Bermuda\" data-code=\"BM\">Bermuda<\/option><option  value=\"Bhutan\" data-code=\"BT\">Bhutan<\/option><option  value=\"Bolivia\" data-code=\"BO\">Bolivia<\/option><option  value=\"Bonaire, Sint Eustatius and Saba\">Bonaire, Sint Eustatius and Saba<\/option><option  value=\"Bosnia and Herzegovina\" data-code=\"BA\">Bosnia and Herzegovina<\/option><option  value=\"Botswana\" data-code=\"BW\">Botswana<\/option><option  value=\"Bouvet Island\" data-code=\"BV\">Bouvet Island<\/option><option  value=\"Brazil\" data-code=\"BR\">Brazil<\/option><option  value=\"British Indian Ocean Territory\" data-code=\"IO\">British Indian Ocean Territory<\/option><option  value=\"Brunei\" data-code=\"BN\">Brunei<\/option><option  value=\"Bulgaria\" data-code=\"BG\">Bulgaria<\/option><option  value=\"Burkina Faso\" data-code=\"BF\">Burkina Faso<\/option><option  value=\"Burundi\" data-code=\"BI\">Burundi<\/option><option  value=\"C&ocirc;te d&#039;Ivoire\">C&ocirc;te d&#039;Ivoire<\/option><option  value=\"Cambodia\" data-code=\"KH\">Cambodia<\/option><option  value=\"Cameroon\" data-code=\"CM\">Cameroon<\/option><option  value=\"Canada\" data-code=\"CA\">Canada<\/option><option  value=\"Cape Verde\" data-code=\"CV\">Cape Verde<\/option><option  value=\"Cayman Islands\" data-code=\"KY\">Cayman Islands<\/option><option  value=\"Central African Republic\" data-code=\"CF\">Central African Republic<\/option><option  value=\"Chad\" data-code=\"TD\">Chad<\/option><option  value=\"Chile\" data-code=\"CL\">Chile<\/option><option  value=\"China\" data-code=\"CN\">China<\/option><option  value=\"Christmas Island\" data-code=\"CX\">Christmas Island<\/option><option  value=\"Cocos (Keeling) Islands\">Cocos (Keeling) Islands<\/option><option  value=\"Colombia\" data-code=\"CO\">Colombia<\/option><option  value=\"Comoros\" data-code=\"KM\">Comoros<\/option><option  value=\"Congo\">Congo<\/option><option  value=\"Cook Islands\" data-code=\"CK\">Cook Islands<\/option><option  value=\"Costa Rica\" data-code=\"CR\">Costa Rica<\/option><option  value=\"Croatia\" data-code=\"HR\">Croatia<\/option><option  value=\"Cuba\" data-code=\"CU\">Cuba<\/option><option  value=\"Curacao\" data-code=\"CW\">Curacao<\/option><option  value=\"Cyprus\" data-code=\"CY\">Cyprus<\/option><option  value=\"Czech Republic\" data-code=\"CZ\">Czech Republic<\/option><option  value=\"Denmark\" data-code=\"DK\">Denmark<\/option><option  value=\"Djibouti\" data-code=\"DJ\">Djibouti<\/option><option  value=\"Dominica\" data-code=\"DM\">Dominica<\/option><option  value=\"Dominican Republic\" data-code=\"DO\">Dominican Republic<\/option><option  value=\"East Timor\" data-code=\"TL\">East Timor<\/option><option  value=\"Ecuador\" data-code=\"EC\">Ecuador<\/option><option  value=\"Egypt\" data-code=\"EG\">Egypt<\/option><option  value=\"El Salvador\" data-code=\"SV\">El Salvador<\/option><option  value=\"Equatorial Guinea\" data-code=\"GQ\">Equatorial Guinea<\/option><option  value=\"Eritrea\" data-code=\"ER\">Eritrea<\/option><option  value=\"Estonia\" data-code=\"EE\">Estonia<\/option><option  value=\"Ethiopia\" data-code=\"ET\">Ethiopia<\/option><option  value=\"Falkland Islands (Malvinas)\">Falkland Islands (Malvinas)<\/option><option  value=\"Faroe Islands\" data-code=\"FO\">Faroe Islands<\/option><option  value=\"Fiji\" data-code=\"FJ\">Fiji<\/option><option  value=\"Finland\" data-code=\"FI\">Finland<\/option><option  value=\"France\" data-code=\"FR\">France<\/option><option  value=\"French Guiana\" data-code=\"GF\">French Guiana<\/option><option  value=\"French Polynesia\" data-code=\"PF\">French Polynesia<\/option><option  value=\"French Southern Territories\" data-code=\"TF\">French Southern Territories<\/option><option  value=\"Gabon\" data-code=\"GA\">Gabon<\/option><option  value=\"Gambia\" data-code=\"GM\">Gambia<\/option><option  value=\"Georgia\" data-code=\"GE\">Georgia<\/option><option  value=\"Germany\" data-code=\"DE\">Germany<\/option><option  value=\"Ghana\" data-code=\"GH\">Ghana<\/option><option  value=\"Gibraltar\" data-code=\"GI\">Gibraltar<\/option><option  value=\"Greece\" data-code=\"GR\">Greece<\/option><option  value=\"Greenland\" data-code=\"GL\">Greenland<\/option><option  value=\"Grenada\" data-code=\"GD\">Grenada<\/option><option  value=\"Guadeloupe\" data-code=\"GP\">Guadeloupe<\/option><option  value=\"Guam\" data-code=\"GU\">Guam<\/option><option  value=\"Guatemala\" data-code=\"GT\">Guatemala<\/option><option  value=\"Guernsey\" data-code=\"GG\">Guernsey<\/option><option  value=\"Guinea\" data-code=\"GN\">Guinea<\/option><option  value=\"Guinea-Bissau\" data-code=\"GW\">Guinea-Bissau<\/option><option  value=\"Guyana\" data-code=\"GY\">Guyana<\/option><option  value=\"Haiti\" data-code=\"HT\">Haiti<\/option><option  value=\"Heard Island and McDonald Islands\" data-code=\"HM\">Heard Island and McDonald Islands<\/option><option  value=\"Holy See\">Holy See<\/option><option  value=\"Honduras\" data-code=\"HN\">Honduras<\/option><option  value=\"Hong Kong\" data-code=\"HK\">Hong Kong<\/option><option  value=\"Hungary\" data-code=\"HU\">Hungary<\/option><option  value=\"Iceland\" data-code=\"IS\">Iceland<\/option><option  value=\"India\" data-code=\"IN\">India<\/option><option  value=\"Indonesia\" data-code=\"ID\">Indonesia<\/option><option  value=\"Iran\" data-code=\"IR\">Iran<\/option><option  value=\"Iraq\" data-code=\"IQ\">Iraq<\/option><option  value=\"Ireland\" data-code=\"IE\">Ireland<\/option><option  value=\"Isle of Man\" data-code=\"IM\">Isle of Man<\/option><option  value=\"Israel\" data-code=\"IL\">Israel<\/option><option  value=\"Italy\" data-code=\"IT\">Italy<\/option><option  value=\"Jamaica\" data-code=\"JM\">Jamaica<\/option><option  value=\"Japan\" data-code=\"JP\">Japan<\/option><option  value=\"Jersey\" data-code=\"JE\">Jersey<\/option><option  value=\"Jordan\" data-code=\"JO\">Jordan<\/option><option  value=\"Kazakhstan\" data-code=\"KZ\">Kazakhstan<\/option><option  value=\"Kenya\" data-code=\"KE\">Kenya<\/option><option  value=\"Kiribati\" data-code=\"KI\">Kiribati<\/option><option  value=\"Kosovo\" data-code=\"XK\">Kosovo<\/option><option  value=\"Kuwait\" data-code=\"KW\">Kuwait<\/option><option  value=\"Kyrgyzstan\" data-code=\"KG\">Kyrgyzstan<\/option><option  value=\"Laos\" data-code=\"LA\">Laos<\/option><option  value=\"Latvia\" data-code=\"LV\">Latvia<\/option><option  value=\"Lebanon\" data-code=\"LB\">Lebanon<\/option><option  value=\"Lesotho\" data-code=\"LS\">Lesotho<\/option><option  value=\"Liberia\" data-code=\"LR\">Liberia<\/option><option  value=\"Libya\" data-code=\"LY\">Libya<\/option><option  value=\"Liechtenstein\" data-code=\"LI\">Liechtenstein<\/option><option  value=\"Lithuania\" data-code=\"LT\">Lithuania<\/option><option  value=\"Luxembourg\" data-code=\"LU\">Luxembourg<\/option><option  value=\"Macao\" data-code=\"MO\">Macao<\/option><option  value=\"Macedonia\" data-code=\"MK\">Macedonia<\/option><option  value=\"Madagascar\" data-code=\"MG\">Madagascar<\/option><option  value=\"Malawi\" data-code=\"MW\">Malawi<\/option><option  value=\"Malaysia\" data-code=\"MY\">Malaysia<\/option><option  value=\"Maldives\" data-code=\"MV\">Maldives<\/option><option  value=\"Mali\" data-code=\"ML\">Mali<\/option><option  value=\"Malta\" data-code=\"MT\">Malta<\/option><option  value=\"Marshall Islands\" data-code=\"MH\">Marshall Islands<\/option><option  value=\"Martinique\" data-code=\"MQ\">Martinique<\/option><option  value=\"Mauritania\" data-code=\"MR\">Mauritania<\/option><option  value=\"Mauritius\" data-code=\"MU\">Mauritius<\/option><option  value=\"Mayotte\" data-code=\"YT\">Mayotte<\/option><option  value=\"Mexico\" data-code=\"MX\">Mexico<\/option><option  value=\"Micronesia\" data-code=\"FM\">Micronesia<\/option><option  value=\"Moldova\" data-code=\"MD\">Moldova<\/option><option  value=\"Monaco\" data-code=\"MC\">Monaco<\/option><option  value=\"Mongolia\" data-code=\"MN\">Mongolia<\/option><option  value=\"Montenegro\" data-code=\"ME\">Montenegro<\/option><option  value=\"Montserrat\" data-code=\"MS\">Montserrat<\/option><option  value=\"Morocco\" data-code=\"MA\">Morocco<\/option><option  value=\"Mozambique\" data-code=\"MZ\">Mozambique<\/option><option  value=\"Myanmar\" data-code=\"MM\">Myanmar<\/option><option  value=\"Namibia\" data-code=\"NA\">Namibia<\/option><option  value=\"Nauru\" data-code=\"NR\">Nauru<\/option><option  value=\"Nepal\" data-code=\"NP\">Nepal<\/option><option  value=\"Netherlands\" data-code=\"NL\">Netherlands<\/option><option  value=\"New Caledonia\" data-code=\"NC\">New Caledonia<\/option><option  value=\"New Zealand\" data-code=\"NZ\">New Zealand<\/option><option  value=\"Nicaragua\" data-code=\"NI\">Nicaragua<\/option><option  value=\"Niger\" data-code=\"NE\">Niger<\/option><option  value=\"Nigeria\" data-code=\"NG\">Nigeria<\/option><option  value=\"Niue\" data-code=\"NU\">Niue<\/option><option  value=\"Norfolk Island\" data-code=\"NF\">Norfolk Island<\/option><option  value=\"North Korea\" data-code=\"KP\">North Korea<\/option><option  value=\"Northern Mariana Islands\" data-code=\"MP\">Northern Mariana Islands<\/option><option  value=\"Norway\" data-code=\"NO\">Norway<\/option><option  value=\"Oman\" data-code=\"OM\">Oman<\/option><option  value=\"Pakistan\" data-code=\"PK\">Pakistan<\/option><option  value=\"Palau\" data-code=\"PW\">Palau<\/option><option  value=\"Palestine\">Palestine<\/option><option  value=\"Panama\" data-code=\"PA\">Panama<\/option><option  value=\"Papua New Guinea\" data-code=\"PG\">Papua New Guinea<\/option><option  value=\"Paraguay\" data-code=\"PY\">Paraguay<\/option><option  value=\"Peru\" data-code=\"PE\">Peru<\/option><option  value=\"Philippines\" data-code=\"PH\">Philippines<\/option><option  value=\"Pitcairn\" data-code=\"PN\">Pitcairn<\/option><option  value=\"Poland\" data-code=\"PL\">Poland<\/option><option  value=\"Portugal\" data-code=\"PT\">Portugal<\/option><option  value=\"Puerto Rico\" data-code=\"PR\">Puerto Rico<\/option><option  value=\"Qatar\" data-code=\"QA\">Qatar<\/option><option  value=\"Reunion\" data-code=\"RE\">Reunion<\/option><option  value=\"Romania\" data-code=\"RO\">Romania<\/option><option  value=\"Russia\" data-code=\"RU\">Russia<\/option><option  value=\"Rwanda\" data-code=\"RW\">Rwanda<\/option><option  value=\"Saint Barthelemy\" data-code=\"BL\">Saint Barthelemy<\/option><option  value=\"Saint Helena, Ascension and Tristan da Cunha\">Saint Helena, Ascension and Tristan da Cunha<\/option><option  value=\"Saint Kitts and Nevis\" data-code=\"KN\">Saint Kitts and Nevis<\/option><option  value=\"Saint Lucia\" data-code=\"LC\">Saint Lucia<\/option><option  value=\"Saint Martin (French part)\">Saint Martin (French part)<\/option><option  value=\"Saint Pierre and Miquelon\" data-code=\"PM\">Saint Pierre and Miquelon<\/option><option  value=\"Saint Vincent and the Grenadines\" data-code=\"VC\">Saint Vincent and the Grenadines<\/option><option  value=\"Samoa\" data-code=\"WS\">Samoa<\/option><option  value=\"San Marino\" data-code=\"SM\">San Marino<\/option><option  value=\"Sao Tome and Principe\" data-code=\"ST\">Sao Tome and Principe<\/option><option  value=\"Saudi Arabia\" data-code=\"SA\">Saudi Arabia<\/option><option  value=\"Senegal\" data-code=\"SN\">Senegal<\/option><option  value=\"Serbia\" data-code=\"RS\">Serbia<\/option><option  value=\"Seychelles\" data-code=\"SC\">Seychelles<\/option><option  value=\"Sierra Leone\" data-code=\"SL\">Sierra Leone<\/option><option  value=\"Singapore\" data-code=\"SG\">Singapore<\/option><option  value=\"Sint Maarten (Dutch part)\">Sint Maarten (Dutch part)<\/option><option  value=\"Slovakia\" data-code=\"SK\">Slovakia<\/option><option  value=\"Slovenia\" data-code=\"SI\">Slovenia<\/option><option  value=\"Solomon Islands\" data-code=\"SB\">Solomon Islands<\/option><option  value=\"Somalia\" data-code=\"SO\">Somalia<\/option><option  value=\"South Africa\" data-code=\"ZA\">South Africa<\/option><option  value=\"South Georgia and the South Sandwich Islands\" data-code=\"GS\">South Georgia and the South Sandwich Islands<\/option><option  value=\"South Korea\" data-code=\"KR\">South Korea<\/option><option  value=\"South Sudan\" data-code=\"SS\">South Sudan<\/option><option  value=\"Spain\" data-code=\"ES\">Spain<\/option><option  value=\"Sri Lanka\" data-code=\"LK\">Sri Lanka<\/option><option  value=\"Sudan\" data-code=\"SD\">Sudan<\/option><option  value=\"Suriname\" data-code=\"SR\">Suriname<\/option><option  value=\"Svalbard and Jan Mayen\" data-code=\"SJ\">Svalbard and Jan Mayen<\/option><option  value=\"Swaziland\" data-code=\"SZ\">Swaziland<\/option><option  value=\"Sweden\" data-code=\"SE\">Sweden<\/option><option  value=\"Switzerland\" data-code=\"CH\">Switzerland<\/option><option  value=\"Syria\" data-code=\"SY\">Syria<\/option><option  value=\"Taiwan\" data-code=\"TW\">Taiwan<\/option><option  value=\"Tajikistan\" data-code=\"TJ\">Tajikistan<\/option><option  value=\"Tanzania\" data-code=\"TZ\">Tanzania<\/option><option  value=\"Thailand\" data-code=\"TH\">Thailand<\/option><option  value=\"Timor-Leste\">Timor-Leste<\/option><option  value=\"Togo\" data-code=\"TG\">Togo<\/option><option  value=\"Tokelau\" data-code=\"TK\">Tokelau<\/option><option  value=\"Tonga\" data-code=\"TO\">Tonga<\/option><option  value=\"Trinidad and Tobago\" data-code=\"TT\">Trinidad and Tobago<\/option><option  value=\"Tunisia\" data-code=\"TN\">Tunisia<\/option><option  value=\"Turkey\" data-code=\"TR\">Turkey<\/option><option  value=\"Turkmenistan\" data-code=\"TM\">Turkmenistan<\/option><option  value=\"Turks and Caicos Islands\" data-code=\"TC\">Turks and Caicos Islands<\/option><option  value=\"Tuvalu\" data-code=\"TV\">Tuvalu<\/option><option  value=\"Uganda\" data-code=\"UG\">Uganda<\/option><option  value=\"Ukraine\" data-code=\"UA\">Ukraine<\/option><option  value=\"United Arab Emirates\" data-code=\"AE\">United Arab Emirates<\/option><option  value=\"United Kingdom\" data-code=\"GB\">United Kingdom<\/option><option  value=\"United States\" data-code=\"US\">United States<\/option><option  value=\"United States Minor Outlying Islands\" data-code=\"UM\">United States Minor Outlying Islands<\/option><option  value=\"Uruguay\" data-code=\"UY\">Uruguay<\/option><option  value=\"Uzbekistan\" data-code=\"UZ\">Uzbekistan<\/option><option  value=\"Vanuatu\" data-code=\"VU\">Vanuatu<\/option><option  value=\"Vatican City\">Vatican City<\/option><option  value=\"Venezuela\" data-code=\"VE\">Venezuela<\/option><option  value=\"Vietnam\" data-code=\"VN\">Vietnam<\/option><option  value=\"Virgin Islands, British\">Virgin Islands, British<\/option><option  value=\"Virgin Islands, U.S.\">Virgin Islands, U.S.<\/option><option  value=\"Wallis and Futuna\" data-code=\"WF\">Wallis and Futuna<\/option><option  value=\"Western Sahara\" data-code=\"EH\">Western Sahara<\/option><option  value=\"Yemen\" data-code=\"YE\">Yemen<\/option><option  value=\"Zambia\" data-code=\"ZM\">Zambia<\/option><option  value=\"Zimbabwe\" data-code=\"ZW\">Zimbabwe<\/option>\t\t<\/select>\n\t<div class=\"frm_description\">Country<\/div><\/div>\n<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<\/div>\n<div id=\"frm_field_89_container\" class=\"frm_form_field  frm_html_container form-field\">\n<h3 data-pm-slice=\"1 1 []\">Please upload a copy of a driver&#8217;s license or passport of ALL owners or members.<\/h3>\n<\/div>\n<div id=\"frm_field_56_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_wt67d\" id=\"field_wt67d_label\" class=\"frm_primary_label\">Upload Identification Image \r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"hidden\"  data-reqmsg=\"Upload Identification Image  cannot be blank.\" data-invmsg=\"Upload Identification Image  is invalid\" aria-invalid=\"false\"   name=\"item_meta[56][]\"  data-reqmsg=\"Upload Identification Image  cannot be blank.\"  value=\"\" data-frmfile=\"56\" \/>\n\n<div class=\"frm_dropzone frm_multi_upload frm_clearfix\" id=\"file56_dropzone\" role=\"group\" >\n\t<div class=\"fallback\">\n\t\t<input type=\"file\" name=\"file56[]\" id=\"field_wt67d\"\n\t\t\t data-frmfile=\"56\" multiple=\"multiple\"  data-reqmsg=\"Upload Identification Image  cannot be blank.\" data-invmsg=\"Upload Identification Image  is invalid\" aria-invalid=\"false\"  \t\t\t\/>\n\t\t\t\t<div class=\"frm_clearfix \"><\/div>\n\t<\/div>\n\t<div class=\"dz-message needsclick\">\n\t\t\t\t<svg  viewBox=\"0 0 18 18\" class=\"frmsvg frm-svg-icon\">\n\t<path viewBox=\"0 0 18 18\" fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M8.2 4v8a.8.8 0 001.5 0V4l2.1 2.2A.7.7 0 1013 5L9.5 1.7a.7.7 0 00-1.1 0L5.1 5.2a.8.8 0 001 1l2.1-2zm7.6 4.3c.4 0 .7.3.7.7v6.8c0 .4-.3.7-.8.7H2.3a.8.8 0 01-.8-.8V9A.8.8 0 013 9v6h12V9c0-.4.3-.8.8-.8z\"><\/path>\n<\/svg>\t\t<span class=\"frm_upload_text\"><button type=\"button\" aria-label=\"Upload Identification Image . Drop a file here or click to upload. Maximum file size: 2.1MB\">Drop a file here or click to upload<\/button><\/span>\n\t\t<span class=\"frm_compact_text\"><button type=\"button\" aria-label=\"Upload Identification Image . Choose File. Maximum file size: 2.1MB\">Choose File<\/button><\/span>\n\t\t<div class=\"frm_small_text\">\n\t\t\t<p>Maximum file size: 2.1MB<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_39_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n\t<div  id=\"field_b7zlc_label\" class=\"frm_primary_label\">Terms &#038; Conditions\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_b7zlc_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_39-0\">\t\t\t<label  for=\"field_b7zlc-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[39][]\" id=\"field_b7zlc-0\" value=\"I acknowledge that Waseme Associates is receiving the information on this form for the BOI. I understand that Waseme Associates is not liable for fees or penalties associated with any negligence regarding information that I omit or misinformation that I provide, in submitting BOI before the deadline of January 1, 2025.\"  data-reqmsg=\"Terms &amp; Conditions cannot be blank.\" data-invmsg=\"Terms &amp; Conditions is invalid\" aria-invalid=\"false\"   aria-required=\"true\"  \/> I acknowledge that Waseme Associates is receiving the information on this form for the BOI. I understand that Waseme Associates is not liable for fees or penalties associated with any negligence regarding information that I omit or misinformation that I provide, in submitting BOI before the deadline of January 1, 2025.<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_40_container\" class=\"frm_form_field form-field  frm_none_container\">\r\n\t<label for=\"g-recaptcha-response\" id=\"field_r6ojf_label\" class=\"frm_primary_label\">Captcha\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<div  id=\"field_r6ojf\" class=\"frm-g-recaptcha\" data-sitekey=\"6Lc0K3kqAAAAAEwGxoM2pFx-fVZjK5f17GiSD726\" data-size=\"invisible\" data-theme=\"light\"><\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_59_container\" class=\"frm_form_field  frm_html_container form-field\">\n<h3 data-pm-slice=\"1 1 []\"><strong>Contact Us<\/strong><\/h3>\n<p data-pm-slice=\"1 1 []\">If you have any questions you may contact us by phone (212) 507-9618.<\/p>\n<\/div>\n<div id=\"frm_field_98_container\" class=\"frm_form_field form-field  frm_top_container\">\n\t<label for=\"field_ymky8\" id=\"field_ymky8_label\" class=\"frm_primary_label\">Phone\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t<input type=\"tel\" id=\"field_ymky8\" name=\"item_meta[98]\" value=\"\"  data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_9_container\" class=\"frm_form_field form-field \">\r\n\t<div class=\"frm_submit frm_flex\">\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"  >Submit<\/button>\r\n\r\n\r\n\r\n<\/div>\r\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t\t<div class=\"frm__672bc06d213c6\">\n\t\t\t\t<label for=\"frm_email_2\" >\n\t\t\t\t\tIf you are human, leave this field blank.\t\t\t\t<\/label>\n\t\t\t\t<input  id=\"frm_email_2\" type=\"text\" class=\"frm_verify\" name=\"frm__672bc06d213c6\" value=\"\" autocomplete=\"off\"  \/>\n\t\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"nV1B\/7eaI0DfSSlI2z6WhfKy4H15zpx2eWRpXuvKrZM=\" \/><\/div>\n<\/fieldset>\n<\/div>\n<\/form>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_siteseo_robots_primary_cat":"","pagelayer_contact_templates":[],"_pagelayer_content":"","footnotes":""},"class_list":["post-39","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/wasemelaw.com\/boi\/wp-json\/wp\/v2\/pages\/39","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/wasemelaw.com\/boi\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/wasemelaw.com\/boi\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/wasemelaw.com\/boi\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/wasemelaw.com\/boi\/wp-json\/wp\/v2\/comments?post=39"}],"version-history":[{"count":3,"href":"https:\/\/wasemelaw.com\/boi\/wp-json\/wp\/v2\/pages\/39\/revisions"}],"predecessor-version":[{"id":46,"href":"https:\/\/wasemelaw.com\/boi\/wp-json\/wp\/v2\/pages\/39\/revisions\/46"}],"wp:attachment":[{"href":"https:\/\/wasemelaw.com\/boi\/wp-json\/wp\/v2\/media?parent=39"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}