{"id":8871,"date":"2018-12-07T19:53:17","date_gmt":"2018-12-07T19:53:17","guid":{"rendered":"https:\/\/radiologyassist.com\/forms\/?page_id=8871"},"modified":"2020-02-05T04:35:20","modified_gmt":"2020-02-05T04:35:20","slug":"card","status":"publish","type":"page","link":"https:\/\/radiologyassist.com\/forms\/card\/","title":{"rendered":"Card Payment"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;margin-bottom: 50px;margin-top: 15px;border-width: 0px 0px 0px 0px;border-color:#eae9e9;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_3 1_3 fusion-one-third fusion-column-first\" style=\"width:33.333333333333%;width:calc(33.333333333333% - ( ( 4% ) * 0.33333333333333 ) );margin-right: 4%;margin-top:80px;margin-bottom:20px;\" id=\"Payment_Summary\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#f2f2f2;padding: 20px 20px 20px 20px;\"><div class=\"fusion-text fusion-text-1\"><h2>Payment Summary<\/h2>\n<\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-separator fusion-clearfix\" style=\"float:left;margin-bottom:15px;width:100%;max-width:85%;\"><div class=\"fusion-separator-border sep-single sep-solid\" style=\"border-color:#e0dede;border-top-width:1px;\"><\/div><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-text fusion-text-2\"><div style=\"float: left; width: 210px;\">Account Subtotal<\/div>\n<div style=\"float: left;\">N\/A<\/div>\n<div style=\"clear: both;\"><\/div>\n<div style=\"float: left; width: 210px;\">Current Payments<\/div>\n<div style=\"float: left;\">N\/A<\/div>\n<div style=\"clear: both;\"><\/div>\n<\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-separator fusion-clearfix\" style=\"float:left;margin-top:15px;margin-bottom:15px;width:100%;max-width:85%;\"><div class=\"fusion-separator-border sep-single sep-solid\" style=\"border-color:#e0dede;border-top-width:1px;\"><\/div><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-text fusion-text-3\"><div style=\"float: left; font-size: 18px; width: 210px;\"><b>Total<\/b><\/div>\n<div style=\"float: left; font-size: 18px;\"><b>N\/A<\/b><\/div>\n<\/div><div class=\"fusion-text fusion-text-4\"><p><script src=\"\/js\/Payment_Hide_Summary.js\" type=\"text\/javascript\"><\/script><\/p>\n<\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_2_3 2_3 fusion-two-third fusion-column-last\" style=\"width:66.666666666667%;width:calc(66.666666666667% - ( ( 4% ) * 0.66666666666667 ) );margin-top:0px;margin-bottom:0px;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-5\">\n                <div class='gf_browser_gecko gform_wrapper' id='gform_wrapper_29' ><div id='gf_29' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_29' id='gform_29'  action='\/forms\/wp-json\/wp\/v2\/pages\/8871#gf_29'><div id='gf_page_steps_29' class='gf_page_steps'><div id='gf_step_29_1' class='gf_step gf_step_active gf_step_first'><span class='gf_step_number'>1<\/span>&nbsp;<span class='gf_step_label'>Payment Amount<\/span><\/div><div id='gf_step_29_2' class='gf_step gf_step_next gf_step_pending'><span class='gf_step_number'>2<\/span>&nbsp;<span class='gf_step_label'>Your Information<\/span><\/div><div id='gf_step_29_3' class='gf_step gf_step_last gf_step_pending'><span class='gf_step_number'>3<\/span>&nbsp;<span class='gf_step_label'>Card Information<\/span><\/div><div class='gf_step_clear'><\/div><\/div>\n                        <div class='gform_body'><div id='gform_page_29_1' class='gform_page' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_29' class='gform_fields top_label form_sublabel_below description_below'><li id='field_29_16'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Payment Amount<\/h2><\/li><li id='field_29_1'  class='gfield gfield_price gfield_price_29_1 gfield_product_29_1 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_29_1' >Payment Amount<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_product_price'>\n\t\t\t\t\t<input name='input_1' id='input_29_1' type='text' value='' class='small ginput_amount'   aria-required=\"true\" aria-invalid=\"false\" \/>\n\t\t\t\t<\/div><div class='gfield_description' id='gfield_description_29_1'>Please enter the payment amount<\/div><\/li><li id='field_29_2'  class='gfield gf_list_inline gfield_price gfield_price_29_2 gfield_product_29_2 gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label'  >Donation Amount<span class='gfield_required'>*<\/span><\/label><div class='gfield_description' id='gfield_description_29_2'>Your donations provide imaging for low income individuals via the<a target=\"_blank\" href=\"https:\/\/radiologyassist.com\/financial-assistance\/get-healthy-grant\/\"> Get Healthy Grant.<\/a><\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_29_2'><li class='gchoice_29_2_0'><input name='input_2' type='radio' value='$0|0'  id='choice_29_2_0'    \/><label for='choice_29_2_0' id='label_29_2_0'>$0<\/label><\/li><li class='gchoice_29_2_1'><input name='input_2' type='radio' value='$2|2' checked='checked' id='choice_29_2_1'    \/><label for='choice_29_2_1' id='label_29_2_1'>$2<\/label><\/li><li class='gchoice_29_2_2'><input name='input_2' type='radio' value='$5|5'  id='choice_29_2_2'    \/><label for='choice_29_2_2' id='label_29_2_2'>$5<\/label><\/li><li class='gchoice_29_2_3'><input name='input_2' type='radio' value='$10|10'  id='choice_29_2_3'    \/><label for='choice_29_2_3' id='label_29_2_3'>$10<\/label><\/li><li class='gchoice_29_2_4'><input name='input_2' type='radio' value='$20|20'  id='choice_29_2_4'    \/><label for='choice_29_2_4' id='label_29_2_4'>$20<\/label><\/li><\/ul><\/div><\/li><li id='field_29_12'  class='gfield gfield_price gfield_price_29_ gfield_total gfield_total_29_ field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_29_12' >Total<\/label><div class='ginput_container ginput_container_total'>\n\t\t\t\t\t\t<span class='ginput_total ginput_total_29' aria-live='polite'>$0.00<\/span>\n\t\t\t\t\t\t<input type='hidden' name='input_12' id='input_29_12' class='gform_hidden'\/>\n\t\t\t\t\t<\/div><\/li><li id='field_29_18'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><br>\nBy clicking \"Continue\" you confirm and acknowledge that you have read, understood and agree to be bound by the <a target=\"_blank\" href=\"https:\/\/radiologyassist.com\/privacy-practices\/\">Notice of Privacy Practices<\/a>, <a  target=\"_blank\" href=\"https:\/\/radiologyassist.com\/terms-of-use\/\">Terms Of Use<\/a> and our <a  target=\"_blank\" href=\"https:\/\/radiologyassist.com\/refund-policy\/\">Refunds Policy<\/a>.<\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                         <input type='button' id='gform_next_button_29_17' class='gform_next_button button' value='Continue'  onclick='jQuery(\"#gform_target_page_number_29\").val(\"2\");  jQuery(\"#gform_29\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_29\").val(\"2\");  jQuery(\"#gform_29\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_29_2' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_29_2' class='gform_fields top_label form_sublabel_below description_below'><li id='field_29_4'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Your Information<\/h2><\/li><li id='field_29_5'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Your Name<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_29_5'>\n                            \n                            <span id='input_29_5_3_container' class='name_first' >\n                                                    <input type='text' name='input_5.3' id='input_29_5_3' value='' aria-label='First name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_29_5_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_29_5_6_container' class='name_last' >\n                                                    <input type='text' name='input_5.6' id='input_29_5_6' value='' aria-label='Last name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_29_5_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id='field_29_14'  class='gfield field_sublabel_below field_description_below gfield_visibility_hidden' ><label class='gfield_label' for='input_29_14' >Patient ID<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_29_14' type='text' value='' class='medium'  aria-describedby=\"gfield_description_29_14\"    aria-invalid=\"false\" \/><\/div><div class='gfield_description' id='gfield_description_29_14'>Please enter if known<\/div><\/li><li id='field_29_19'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_29_19' >Patient Name<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_29_19' type='text' value='' class='medium'  aria-describedby=\"gfield_description_29_19\"    aria-invalid=\"false\" \/><\/div><div class='gfield_description' id='gfield_description_29_19'>(if different than your name)<\/div><\/li><li id='field_29_8'  class='gfield field_sublabel_below field_description_below gfield_visibility_hidden' ><label class='gfield_label' for='input_29_8' >Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_29_8' type='text' value='' class='medium'    aria-invalid=\"false\" aria-describedby=\"gfield_description_29_8\" \/><\/div><div class='gfield_description' id='gfield_description_29_8'>Incase we have a question about this payment.<\/div><\/li><li id='field_29_6'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_29_6' >Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_6' id='input_29_6' type='text' value='' class='medium'     aria-invalid=\"false\" aria-describedby=\"gfield_description_29_6\"\/>\n                        <\/div><div class='gfield_description' id='gfield_description_29_6'>Transaction receipt will be sent to this email address. Please ensure the email address is correct, as RadiologyAssist can not resend transaction receipts at a later time.<\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                        <input type='button' id='gform_previous_button_29_20' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_29\").val(\"1\");  jQuery(\"#gform_29\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_29\").val(\"1\");  jQuery(\"#gform_29\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_29_20' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_29\").val(\"3\");  jQuery(\"#gform_29\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_29\").val(\"3\");  jQuery(\"#gform_29\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_29_3' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_29_3' class='gform_fields top_label form_sublabel_below description_below'><li id='field_29_7'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Payment Information<\/h2><\/li><li id='field_29_10'  class='gfield field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Billing Address<\/label><div class='gfield_description' id='gfield_description_29_10'>Address entered must exactly match the cards statement billing address. Incorrect zipcodes will result in a declined transaction.<\/div>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_29_10' >\n                         <span class='ginput_full address_line_1' id='input_29_10_1_container' >\n                                        <input type='text' name='input_10.1' id='input_29_10_1' value=''    \/>\n                                        <label for='input_29_10_1' id='input_29_10_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2' id='input_29_10_2_container' >\n                                        <input type='text' name='input_10.2' id='input_29_10_2' value=''   \/>\n                                        <label for='input_29_10_2' id='input_29_10_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city' id='input_29_10_3_container' >\n                                    <input type='text' name='input_10.3' id='input_29_10_3' value=''   \/>\n                                    <label for='input_29_10_3' id='input_29_10_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state' id='input_29_10_4_container' >\n                                        <input type='text' name='input_10.4' id='input_29_10_4' value=''      \/>\n                                        <label for='input_29_10_4' id='input_29_10_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip' id='input_29_10_5_container' >\n                                    <input type='text' name='input_10.5' id='input_29_10_5' value=''    \/>\n                                    <label for='input_29_10_5' id='input_29_10_5_label' >ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country' id='input_29_10_6_container' >\n                                        <select name='input_10.6' id='input_29_10_6'   ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darrussalam' >Brunei Darrussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard and McDonald Islands' >Heard and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macau' >Macau<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Korea' >North Korea<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia' >South Georgia<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' selected='selected'>United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' 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