{"id":117,"date":"2025-03-28T05:21:27","date_gmt":"2025-03-28T05:21:27","guid":{"rendered":"https:\/\/www.map.org\/jnjethicon\/?page_id=117"},"modified":"2025-12-01T18:43:08","modified_gmt":"2025-12-01T23:43:08","slug":"eligibility-form","status":"publish","type":"page","link":"https:\/\/www.map.org\/jnjmedtech\/medical-mission-program\/apply-to-order\/eligibility-form\/","title":{"rendered":"Eligibility Form"},"content":{"rendered":"<meta name=\"robots\" content=\"noindex,nofollow\">\n\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-28f84493 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<div class=\"wp-block-stackable-columns stk-block-columns stk-block stk-30b4658\" data-block-id=\"30b4658\"><div class=\"stk-row stk-inner-blocks stk-block-content stk-content-align stk-30b4658-column\">\n<div class=\"wp-block-stackable-column stk-block-column stk-column stk-block stk-a2ef67b\" data-v=\"4\" data-block-id=\"a2ef67b\"><style>.stk-a2ef67b {margin-left:35px !important;}<\/style><div class=\"stk-column-wrapper stk-block-column__content stk-container stk-a2ef67b-container stk--no-background stk--no-padding\"><div class=\"stk-block-content stk-inner-blocks stk-a2ef67b-inner-blocks\"><style id=\"wpforms-css-vars-81\">\n\t\t\t\t#wpforms-81 {\n\t\t\t\t\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-container-save-resume wpforms-render-modern\" id=\"wpforms-81\"><form id=\"wpforms-form-81\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"81\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/jnjmedtech\/wp-json\/wp\/v2\/pages\/117\" data-token=\"fd8edcb1ee1451d777e8987cfcd2f56c\" data-token-time=\"1775447216\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-81-field_1-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"1\"><h3 id=\"wpforms-81-field_1\" aria-errormessage=\"wpforms-81-field_1-error\">Trip Details<\/h3><\/div><div id=\"wpforms-81-field_27-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_27\">Mission start date <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-81-field_27\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"1\" data-disable-todays-date=\"1\" data-input=\"true\" name=\"wpforms[fields][27][date]\" aria-errormessage=\"wpforms-81-field_27-error\" aria-describedby=\"wpforms-81-field_27-description\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><div id=\"wpforms-81-field_27-description\" class=\"wpforms-field-description\">Please choose the date the mission begins.<\/div><\/div><div id=\"wpforms-81-field_28-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_28\">Mission end date <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-81-field_28\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"1\" data-disable-todays-date=\"1\" data-input=\"true\" name=\"wpforms[fields][28][date]\" aria-errormessage=\"wpforms-81-field_28-error\" aria-describedby=\"wpforms-81-field_28-description\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><div id=\"wpforms-81-field_28-description\" class=\"wpforms-field-description\">Please choose an end date that falls after the Mission start date.<\/div><\/div><div id=\"wpforms-81-field_13-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_13\">Destination Country <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-81-field_13\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][13]\" required=\"required\"><option value=\"Afghanistan\"  class=\"choice-254 depth-1\"  >Afghanistan<\/option><option value=\"Albania\"  class=\"choice-6 depth-1\"  >Albania<\/option><option value=\"Algeria\"  class=\"choice-7 depth-1\"  >Algeria<\/option><option value=\"American Samoa\"  class=\"choice-8 depth-1\"  >American Samoa<\/option><option value=\"Andorra\"  class=\"choice-9 depth-1\"  >Andorra<\/option><option value=\"Angola\"  class=\"choice-10 depth-1\"  >Angola<\/option><option value=\"Anguilla\"  class=\"choice-11 depth-1\"  >Anguilla<\/option><option value=\"Antarctica\"  class=\"choice-12 depth-1\"  >Antarctica<\/option><option value=\"Antigua and Barbuda\"  class=\"choice-13 depth-1\"  >Antigua and Barbuda<\/option><option value=\"Argentina\"  class=\"choice-14 depth-1\"  >Argentina<\/option><option value=\"Armenia\"  class=\"choice-15 depth-1\"  >Armenia<\/option><option value=\"Aruba\"  class=\"choice-16 depth-1\"  >Aruba<\/option><option value=\"Australia\"  class=\"choice-2 depth-1\"  >Australia<\/option><option value=\"Austria\"  class=\"choice-18 depth-1\"  >Austria<\/option><option value=\"Azerbaijan\"  class=\"choice-19 depth-1\"  >Azerbaijan<\/option><option value=\"Bahamas\"  class=\"choice-20 depth-1\"  >Bahamas<\/option><option value=\"Bahrain\"  class=\"choice-21 depth-1\"  >Bahrain<\/option><option value=\"Bangladesh\"  class=\"choice-22 depth-1\"  >Bangladesh<\/option><option value=\"Barbados\"  class=\"choice-23 depth-1\"  >Barbados<\/option><option value=\"Belarus\"  class=\"choice-24 depth-1\"  >Belarus<\/option><option value=\"Belgium\"  class=\"choice-25 depth-1\"  >Belgium<\/option><option value=\"Belize\"  class=\"choice-26 depth-1\"  >Belize<\/option><option value=\"Benin\"  class=\"choice-27 depth-1\"  >Benin<\/option><option value=\"Bermuda\"  class=\"choice-28 depth-1\"  >Bermuda<\/option><option value=\"Bhutan\"  class=\"choice-29 depth-1\"  >Bhutan<\/option><option value=\"Bolivia\"  class=\"choice-30 depth-1\"  >Bolivia<\/option><option value=\"Bonaire, Sint Eustatius and Saba\"  class=\"choice-31 depth-1\"  >Bonaire, Sint Eustatius and Saba<\/option><option value=\"Bosnia and Herzegovina\"  class=\"choice-32 depth-1\"  >Bosnia and Herzegovina<\/option><option value=\"Botswana\"  class=\"choice-33 depth-1\"  >Botswana<\/option><option value=\"Bouvet Island\"  class=\"choice-34 depth-1\"  >Bouvet Island<\/option><option value=\"Brazil\"  class=\"choice-35 depth-1\"  >Brazil<\/option><option value=\"British Indian Ocean Territory\"  class=\"choice-36 depth-1\"  >British Indian Ocean Territory<\/option><option value=\"British Virgin Islands\"  class=\"choice-37 depth-1\"  >British Virgin Islands<\/option><option value=\"Brunei\"  class=\"choice-38 depth-1\"  >Brunei<\/option><option value=\"Bulgaria\"  class=\"choice-39 depth-1\"  >Bulgaria<\/option><option value=\"Burkina Faso\"  class=\"choice-40 depth-1\"  >Burkina Faso<\/option><option value=\"Burundi\"  class=\"choice-41 depth-1\"  >Burundi<\/option><option value=\"Cabo Verde\"  class=\"choice-42 depth-1\"  >Cabo Verde<\/option><option value=\"Cambodia\"  class=\"choice-43 depth-1\"  >Cambodia<\/option><option value=\"Cameroon\"  class=\"choice-44 depth-1\"  >Cameroon<\/option><option value=\"Canada\"  class=\"choice-45 depth-1\"  >Canada<\/option><option value=\"Caribbean Netherlands\"  class=\"choice-46 depth-1\"  >Caribbean Netherlands<\/option><option value=\"Cayman Islands\"  class=\"choice-47 depth-1\"  >Cayman Islands<\/option><option value=\"Central African Republic\"  class=\"choice-48 depth-1\"  >Central African Republic<\/option><option value=\"Chad\"  class=\"choice-49 depth-1\"  >Chad<\/option><option value=\"Chile\"  class=\"choice-50 depth-1\"  >Chile<\/option><option value=\"China\"  class=\"choice-51 depth-1\"  >China<\/option><option value=\"Christmas Island\"  class=\"choice-52 depth-1\"  >Christmas Island<\/option><option value=\"Cocos (Keeling) Islands\"  class=\"choice-53 depth-1\"  >Cocos (Keeling) Islands<\/option><option value=\"Colombia\"  class=\"choice-54 depth-1\"  >Colombia<\/option><option value=\"Comoros\"  class=\"choice-55 depth-1\"  >Comoros<\/option><option value=\"Congo (Brazzaville)\"  class=\"choice-56 depth-1\"  >Congo (Brazzaville)<\/option><option value=\"Congo (Kinshasa)\"  class=\"choice-57 depth-1\"  >Congo (Kinshasa)<\/option><option value=\"Cook Islands\"  class=\"choice-58 depth-1\"  >Cook Islands<\/option><option value=\"Costa Rica\"  class=\"choice-59 depth-1\"  >Costa Rica<\/option><option value=\"Croatia\"  class=\"choice-60 depth-1\"  >Croatia<\/option><option value=\"Cuba\"  class=\"choice-61 depth-1\"  >Cuba<\/option><option value=\"Cura\u00e7ao\"  class=\"choice-62 depth-1\"  >Cura\u00e7ao<\/option><option value=\"Cyprus\"  class=\"choice-63 depth-1\"  >Cyprus<\/option><option value=\"Czechia\"  class=\"choice-64 depth-1\"  >Czechia<\/option><option value=\"Denmark\"  class=\"choice-65 depth-1\"  >Denmark<\/option><option value=\"Djibouti\"  class=\"choice-66 depth-1\"  >Djibouti<\/option><option value=\"Dominica\"  class=\"choice-67 depth-1\"  >Dominica<\/option><option value=\"Dominican Republic\"  class=\"choice-68 depth-1\"  >Dominican Republic<\/option><option value=\"Ecuador\"  class=\"choice-69 depth-1\"  >Ecuador<\/option><option value=\"Egypt\"  class=\"choice-70 depth-1\"  >Egypt<\/option><option value=\"El Salvador\"  class=\"choice-71 depth-1\"  >El Salvador<\/option><option value=\"Equatorial Guinea\"  class=\"choice-72 depth-1\"  >Equatorial Guinea<\/option><option value=\"Eritrea\"  class=\"choice-73 depth-1\"  >Eritrea<\/option><option value=\"Estonia\"  class=\"choice-74 depth-1\"  >Estonia<\/option><option value=\"Eswatini\"  class=\"choice-75 depth-1\"  >Eswatini<\/option><option value=\"Ethiopia\"  class=\"choice-76 depth-1\"  >Ethiopia<\/option><option value=\"Falkland Islands\"  class=\"choice-77 depth-1\"  >Falkland Islands<\/option><option value=\"Faroe Islands\"  class=\"choice-78 depth-1\"  >Faroe Islands<\/option><option value=\"Fiji\"  class=\"choice-79 depth-1\"  >Fiji<\/option><option value=\"Finland\"  class=\"choice-80 depth-1\"  >Finland<\/option><option value=\"France\"  class=\"choice-81 depth-1\"  >France<\/option><option value=\"French Guiana\"  class=\"choice-82 depth-1\"  >French Guiana<\/option><option value=\"French Polynesia\"  class=\"choice-83 depth-1\"  >French Polynesia<\/option><option value=\"French Southern Territories\"  class=\"choice-84 depth-1\"  >French Southern Territories<\/option><option value=\"Gabon\"  class=\"choice-85 depth-1\"  >Gabon<\/option><option value=\"Gambia\"  class=\"choice-86 depth-1\"  >Gambia<\/option><option value=\"Georgia\"  class=\"choice-87 depth-1\"  >Georgia<\/option><option value=\"Germany\"  class=\"choice-88 depth-1\"  >Germany<\/option><option value=\"Ghana\"  class=\"choice-89 depth-1\"  >Ghana<\/option><option value=\"Gibraltar\"  class=\"choice-90 depth-1\"  >Gibraltar<\/option><option value=\"Greece\"  class=\"choice-91 depth-1\"  >Greece<\/option><option value=\"Greenland\"  class=\"choice-92 depth-1\"  >Greenland<\/option><option value=\"Grenada\"  class=\"choice-93 depth-1\"  >Grenada<\/option><option value=\"Guadeloupe\"  class=\"choice-94 depth-1\"  >Guadeloupe<\/option><option value=\"Guam\"  class=\"choice-95 depth-1\"  >Guam<\/option><option value=\"Guatemala\"  class=\"choice-96 depth-1\"  >Guatemala<\/option><option value=\"Guernsey\"  class=\"choice-97 depth-1\"  >Guernsey<\/option><option value=\"Guinea\"  class=\"choice-98 depth-1\"  >Guinea<\/option><option value=\"Guinea-Bissau\"  class=\"choice-99 depth-1\"  >Guinea-Bissau<\/option><option value=\"Guyana\"  class=\"choice-100 depth-1\"  >Guyana<\/option><option value=\"Haiti\"  class=\"choice-101 depth-1\"  >Haiti<\/option><option value=\"Heard Island and McDonald Islands\"  class=\"choice-102 depth-1\"  >Heard Island and McDonald Islands<\/option><option value=\"Honduras\"  class=\"choice-103 depth-1\"  >Honduras<\/option><option value=\"Hong Kong\"  class=\"choice-104 depth-1\"  >Hong Kong<\/option><option value=\"Hungary\"  class=\"choice-105 depth-1\"  >Hungary<\/option><option value=\"Iceland\"  class=\"choice-106 depth-1\"  >Iceland<\/option><option value=\"India\"  class=\"choice-107 depth-1\"  >India<\/option><option value=\"Indonesia\"  class=\"choice-108 depth-1\"  >Indonesia<\/option><option value=\"Iran\"  class=\"choice-109 depth-1\"  >Iran<\/option><option value=\"Iraq\"  class=\"choice-110 depth-1\"  >Iraq<\/option><option value=\"Ireland\"  class=\"choice-111 depth-1\"  >Ireland<\/option><option value=\"Isle of Man\"  class=\"choice-112 depth-1\"  >Isle of Man<\/option><option value=\"Israel\"  class=\"choice-113 depth-1\"  >Israel<\/option><option value=\"Italy\"  class=\"choice-114 depth-1\"  >Italy<\/option><option value=\"Ivory Coast\"  class=\"choice-115 depth-1\"  >Ivory Coast<\/option><option value=\"Jamaica\"  class=\"choice-116 depth-1\"  >Jamaica<\/option><option value=\"Japan\"  class=\"choice-117 depth-1\"  >Japan<\/option><option value=\"Jersey\"  class=\"choice-118 depth-1\"  >Jersey<\/option><option value=\"Jordan\"  class=\"choice-119 depth-1\"  >Jordan<\/option><option value=\"Kazakhstan\"  class=\"choice-120 depth-1\"  >Kazakhstan<\/option><option value=\"Kenya\"  class=\"choice-3 depth-1\"  >Kenya<\/option><option value=\"Kiribati\"  class=\"choice-122 depth-1\"  >Kiribati<\/option><option value=\"Korea, North\"  class=\"choice-123 depth-1\"  >Korea, North<\/option><option value=\"Korea, South\"  class=\"choice-124 depth-1\"  >Korea, South<\/option><option value=\"Kosovo\"  class=\"choice-125 depth-1\"  >Kosovo<\/option><option value=\"Kuwait\"  class=\"choice-126 depth-1\"  >Kuwait<\/option><option value=\"Kyrgyzstan\"  class=\"choice-127 depth-1\"  >Kyrgyzstan<\/option><option value=\"Laos\"  class=\"choice-128 depth-1\"  >Laos<\/option><option value=\"Latvia\"  class=\"choice-129 depth-1\"  >Latvia<\/option><option value=\"Lebanon\"  class=\"choice-130 depth-1\"  >Lebanon<\/option><option value=\"Lesotho\"  class=\"choice-131 depth-1\"  >Lesotho<\/option><option value=\"Liberia\"  class=\"choice-132 depth-1\"  >Liberia<\/option><option value=\"Libya\"  class=\"choice-133 depth-1\"  >Libya<\/option><option value=\"Liechtenstein\"  class=\"choice-134 depth-1\"  >Liechtenstein<\/option><option value=\"Lithuania\"  class=\"choice-135 depth-1\"  >Lithuania<\/option><option value=\"Luxembourg\"  class=\"choice-136 depth-1\"  >Luxembourg<\/option><option value=\"Macau\"  class=\"choice-137 depth-1\"  >Macau<\/option><option value=\"Madagascar\"  class=\"choice-138 depth-1\"  >Madagascar<\/option><option value=\"Malawi\"  class=\"choice-139 depth-1\"  >Malawi<\/option><option value=\"Malaysia\"  class=\"choice-140 depth-1\"  >Malaysia<\/option><option value=\"Maldives\"  class=\"choice-141 depth-1\"  >Maldives<\/option><option value=\"Mali\"  class=\"choice-142 depth-1\"  >Mali<\/option><option value=\"Malta\"  class=\"choice-143 depth-1\"  >Malta<\/option><option value=\"Marshall Islands\"  class=\"choice-144 depth-1\"  >Marshall Islands<\/option><option value=\"Martinique\"  class=\"choice-145 depth-1\"  >Martinique<\/option><option value=\"Mauritania\"  class=\"choice-146 depth-1\"  >Mauritania<\/option><option value=\"Mauritius\"  class=\"choice-147 depth-1\"  >Mauritius<\/option><option value=\"Mayotte\"  class=\"choice-148 depth-1\"  >Mayotte<\/option><option value=\"Mexico\"  class=\"choice-149 depth-1\"  >Mexico<\/option><option value=\"Micronesia\"  class=\"choice-150 depth-1\"  >Micronesia<\/option><option value=\"Moldova\"  class=\"choice-151 depth-1\"  >Moldova<\/option><option value=\"Monaco\"  class=\"choice-152 depth-1\"  >Monaco<\/option><option value=\"Mongolia\"  class=\"choice-153 depth-1\"  >Mongolia<\/option><option value=\"Montenegro\"  class=\"choice-154 depth-1\"  >Montenegro<\/option><option value=\"Montserrat\"  class=\"choice-155 depth-1\"  >Montserrat<\/option><option value=\"Morocco\"  class=\"choice-156 depth-1\"  >Morocco<\/option><option value=\"Mozambique\"  class=\"choice-157 depth-1\"  >Mozambique<\/option><option value=\"Myanmar\"  class=\"choice-158 depth-1\"  >Myanmar<\/option><option value=\"Namibia\"  class=\"choice-159 depth-1\"  >Namibia<\/option><option value=\"Nauru\"  class=\"choice-160 depth-1\"  >Nauru<\/option><option value=\"Nepal\"  class=\"choice-161 depth-1\"  >Nepal<\/option><option value=\"Netherlands\"  class=\"choice-162 depth-1\"  >Netherlands<\/option><option value=\"New Caledonia\"  class=\"choice-163 depth-1\"  >New Caledonia<\/option><option value=\"New Zealand\"  class=\"choice-164 depth-1\"  >New Zealand<\/option><option value=\"Nicaragua\"  class=\"choice-165 depth-1\"  >Nicaragua<\/option><option value=\"Niger\"  class=\"choice-166 depth-1\"  >Niger<\/option><option value=\"Nigeria\"  class=\"choice-167 depth-1\"  >Nigeria<\/option><option value=\"Niue\"  class=\"choice-168 depth-1\"  >Niue<\/option><option value=\"Norfolk Island\"  class=\"choice-169 depth-1\"  >Norfolk Island<\/option><option value=\"North Macedonia\"  class=\"choice-170 depth-1\"  >North Macedonia<\/option><option value=\"Northern Mariana Islands\"  class=\"choice-171 depth-1\"  >Northern Mariana Islands<\/option><option value=\"Norway\"  class=\"choice-172 depth-1\"  >Norway<\/option><option value=\"Oman\"  class=\"choice-173 depth-1\"  >Oman<\/option><option value=\"Pakistan\"  class=\"choice-174 depth-1\"  >Pakistan<\/option><option value=\"Palau\"  class=\"choice-175 depth-1\"  >Palau<\/option><option value=\"Palestine\"  class=\"choice-176 depth-1\"  >Palestine<\/option><option value=\"Panama\"  class=\"choice-177 depth-1\"  >Panama<\/option><option value=\"Papua New Guinea\"  class=\"choice-178 depth-1\"  >Papua New Guinea<\/option><option value=\"Paraguay\"  class=\"choice-179 depth-1\"  >Paraguay<\/option><option value=\"Peru\"  class=\"choice-180 depth-1\"  >Peru<\/option><option value=\"Philippines\"  class=\"choice-181 depth-1\"  >Philippines<\/option><option value=\"Pitcairn Islands\"  class=\"choice-182 depth-1\"  >Pitcairn Islands<\/option><option value=\"Poland\"  class=\"choice-183 depth-1\"  >Poland<\/option><option value=\"Portugal\"  class=\"choice-184 depth-1\"  >Portugal<\/option><option value=\"Puerto Rico\"  class=\"choice-185 depth-1\"  >Puerto Rico<\/option><option value=\"Qatar\"  class=\"choice-186 depth-1\"  >Qatar<\/option><option value=\"R\u00e9union\"  class=\"choice-187 depth-1\"  >R\u00e9union<\/option><option value=\"Romania\"  class=\"choice-188 depth-1\"  >Romania<\/option><option value=\"Russia\"  class=\"choice-189 depth-1\"  >Russia<\/option><option value=\"Rwanda\"  class=\"choice-190 depth-1\"  >Rwanda<\/option><option value=\"Saint Barth\u00e9lemy\"  class=\"choice-191 depth-1\"  >Saint Barth\u00e9lemy<\/option><option value=\"Saint Helena, Ascension and Tristan da Cunha\"  class=\"choice-192 depth-1\"  >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"Saint Kitts and Nevis\"  class=\"choice-193 depth-1\"  >Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\"  class=\"choice-194 depth-1\"  >Saint Lucia<\/option><option value=\"Saint Martin\"  class=\"choice-195 depth-1\"  >Saint Martin<\/option><option value=\"Saint Pierre and Miquelon\"  class=\"choice-196 depth-1\"  >Saint Pierre and Miquelon<\/option><option value=\"Saint Vincent and the Grenadines\"  class=\"choice-197 depth-1\"  >Saint Vincent and the Grenadines<\/option><option value=\"Samoa\"  class=\"choice-198 depth-1\"  >Samoa<\/option><option value=\"San Marino\"  class=\"choice-199 depth-1\"  >San Marino<\/option><option value=\"S\u00e3o Tom\u00e9 and Pr\u00edncipe\"  class=\"choice-200 depth-1\"  >S\u00e3o Tom\u00e9 and Pr\u00edncipe<\/option><option value=\"Saudi Arabia\"  class=\"choice-201 depth-1\"  >Saudi Arabia<\/option><option value=\"Senegal\"  class=\"choice-202 depth-1\"  >Senegal<\/option><option value=\"Serbia\"  class=\"choice-203 depth-1\"  >Serbia<\/option><option value=\"Seychelles\"  class=\"choice-204 depth-1\"  >Seychelles<\/option><option value=\"Sierra Leone\"  class=\"choice-205 depth-1\"  >Sierra Leone<\/option><option value=\"Singapore\"  class=\"choice-206 depth-1\"  >Singapore<\/option><option value=\"Sint Maarten\"  class=\"choice-207 depth-1\"  >Sint Maarten<\/option><option value=\"Slovakia\"  class=\"choice-208 depth-1\"  >Slovakia<\/option><option value=\"Slovenia\"  class=\"choice-209 depth-1\"  >Slovenia<\/option><option value=\"Solomon Islands\"  class=\"choice-210 depth-1\"  >Solomon Islands<\/option><option value=\"Somalia\"  class=\"choice-211 depth-1\"  >Somalia<\/option><option value=\"South Africa\"  class=\"choice-212 depth-1\"  >South Africa<\/option><option value=\"South Georgia and the South Sandwich Islands\"  class=\"choice-213 depth-1\"  >South Georgia and the South Sandwich Islands<\/option><option value=\"South Sudan\"  class=\"choice-214 depth-1\"  >South Sudan<\/option><option value=\"Spain\"  class=\"choice-215 depth-1\"  >Spain<\/option><option value=\"Sri Lanka\"  class=\"choice-216 depth-1\"  >Sri Lanka<\/option><option value=\"State of Palestine\"  class=\"choice-217 depth-1\"  >State of Palestine<\/option><option value=\"Sudan\"  class=\"choice-218 depth-1\"  >Sudan<\/option><option value=\"Suriname\"  class=\"choice-219 depth-1\"  >Suriname<\/option><option value=\"Svalbard and Jan Mayen\"  class=\"choice-220 depth-1\"  >Svalbard and Jan Mayen<\/option><option value=\"Sweden\"  class=\"choice-221 depth-1\"  >Sweden<\/option><option value=\"Switzerland\"  class=\"choice-222 depth-1\"  >Switzerland<\/option><option value=\"Syria\"  class=\"choice-223 depth-1\"  >Syria<\/option><option value=\"Taiwan\"  class=\"choice-224 depth-1\"  >Taiwan<\/option><option value=\"Tajikistan\"  class=\"choice-225 depth-1\"  >Tajikistan<\/option><option value=\"Tanzania\"  class=\"choice-226 depth-1\"  >Tanzania<\/option><option value=\"Thailand\"  class=\"choice-227 depth-1\"  >Thailand<\/option><option value=\"Timor-Leste\"  class=\"choice-228 depth-1\"  >Timor-Leste<\/option><option value=\"Togo\"  class=\"choice-229 depth-1\"  >Togo<\/option><option value=\"Tokelau\"  class=\"choice-230 depth-1\"  >Tokelau<\/option><option value=\"Tonga\"  class=\"choice-231 depth-1\"  >Tonga<\/option><option value=\"Trinidad and Tobago\"  class=\"choice-232 depth-1\"  >Trinidad and Tobago<\/option><option value=\"Tunisia\"  class=\"choice-233 depth-1\"  >Tunisia<\/option><option value=\"Turkey\"  class=\"choice-234 depth-1\"  >Turkey<\/option><option value=\"Turkmenistan\"  class=\"choice-235 depth-1\"  >Turkmenistan<\/option><option value=\"Tuvalu\"  class=\"choice-236 depth-1\"  >Tuvalu<\/option><option value=\"Uganda\"  class=\"choice-237 depth-1\"  >Uganda<\/option><option value=\"Ukraine\"  class=\"choice-238 depth-1\"  >Ukraine<\/option><option value=\"United Arab Emirates\"  class=\"choice-239 depth-1\"  >United Arab Emirates<\/option><option value=\"United Kingdom\"  class=\"choice-240 depth-1\"  >United Kingdom<\/option><option value=\"United States\"  class=\"choice-1 depth-1\"  >United States<\/option><option value=\"Uruguay\"  class=\"choice-242 depth-1\"  >Uruguay<\/option><option value=\"Uzbekistan\"  class=\"choice-243 depth-1\"  >Uzbekistan<\/option><option value=\"Vanuatu\"  class=\"choice-244 depth-1\"  >Vanuatu<\/option><option value=\"Vatican City\"  class=\"choice-245 depth-1\"  >Vatican City<\/option><option value=\"Venezuela\"  class=\"choice-246 depth-1\"  >Venezuela<\/option><option value=\"Vietnam\"  class=\"choice-247 depth-1\"  >Vietnam<\/option><option value=\"Virgin Islands (U.S.)\"  class=\"choice-248 depth-1\"  >Virgin Islands (U.S.)<\/option><option value=\"Wallis and Futuna\"  class=\"choice-249 depth-1\"  >Wallis and Futuna<\/option><option value=\"Western Sahara\"  class=\"choice-250 depth-1\"  >Western Sahara<\/option><option value=\"Yemen\"  class=\"choice-251 depth-1\"  >Yemen<\/option><option value=\"Zambia\"  class=\"choice-252 depth-1\"  >Zambia<\/option><option value=\"Zimbabwe\"  class=\"choice-253 depth-1\"  >Zimbabwe<\/option><\/select><\/div><div id=\"wpforms-81-field_34-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_34\">Destination City\/Region <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-81-field_34\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][34]\" aria-errormessage=\"wpforms-81-field_34-error\" required><\/div><div id=\"wpforms-81-field_36-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"36\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_36\">Requested delivery date* <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-81-field_36\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][36][date]\" aria-errormessage=\"wpforms-81-field_36-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-81-field_151-container\" class=\"wpforms-field wpforms-field-payment-checkbox\" data-field-id=\"151\"><fieldset><legend class=\"wpforms-field-label\">MAP covers the cost of standard UPS Ground shipping within the USA. However, expedited or international shipping will incur additional freight charges. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-81-field_151\" class=\"wpforms-field-required\"><li class=\"choice-1\"><input type=\"checkbox\" id=\"wpforms-81-field_151_1\" class=\"wpforms-payment-price\" data-amount=\"10.00\" name=\"wpforms[fields][151][]\" value=\"1\" aria-errormessage=\"wpforms-81-field_151_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_151_1\">I understand that if my order is placed less than six weeks before the requested delivery date, and expedited shipping is required to meet the deadline, I will be responsible for the additional freight costs.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-81-field_37-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"37\"><h3 id=\"wpforms-81-field_37\" aria-errormessage=\"wpforms-81-field_37-error\" aria-describedby=\"wpforms-81-field_37-description\">Account Details- Applicant Information<\/h3><div id=\"wpforms-81-field_37-description\" class=\"wpforms-field-description\">Please create a username and password below to make your Applicant account. Upon completion of this form, please check your email inbox for successful creation of the account. This is the account that will be used for logging in and ordering product.<\/div><\/div><div id=\"wpforms-81-field_140-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"140\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_140\">Username <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-81-field_140\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][140]\" aria-errormessage=\"wpforms-81-field_140-error\" aria-describedby=\"wpforms-81-field_140-description\" required><div id=\"wpforms-81-field_140-description\" class=\"wpforms-field-description\">Please use only a combination of letters and numbers (no special characters).<\/div><\/div><div id=\"wpforms-81-field_139-container\" class=\"wpforms-field wpforms-field-password\" data-field-id=\"139\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_139\">Password <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"password\" id=\"wpforms-81-field_139\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][139]\" spellcheck=\"false\" aria-errormessage=\"wpforms-81-field_139-error\" required><\/div><div id=\"wpforms-81-field_141-container\" class=\"wpforms-field wpforms-field-name applicant-name\" data-field-id=\"141\"><fieldset><legend class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-81-field_141\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][141][first]\" aria-errormessage=\"wpforms-81-field_141-error\" required><label for=\"wpforms-81-field_141\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-fifth\"><input type=\"text\" id=\"wpforms-81-field_141-middle\" class=\"wpforms-field-name-middle\" name=\"wpforms[fields][141][middle]\" aria-errormessage=\"wpforms-81-field_141-middle-error\" ><label for=\"wpforms-81-field_141-middle\" class=\"wpforms-field-sublabel after\">Middle<\/label><\/div><div class=\"wpforms-field-row-block wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-81-field_141-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][141][last]\" aria-errormessage=\"wpforms-81-field_141-last-error\" required><label for=\"wpforms-81-field_141-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-81-field_5-container\" class=\"wpforms-field wpforms-field-name applicant-prefix\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_5\">Prefix<\/label><input type=\"text\" id=\"wpforms-81-field_5\" class=\"wpforms-field-medium\" name=\"wpforms[fields][5]\" aria-errormessage=\"wpforms-81-field_5-error\" ><\/div><div id=\"wpforms-81-field_39-container\" class=\"wpforms-field wpforms-field-address applicant-address\" data-field-id=\"39\"><fieldset><legend class=\"wpforms-field-label\">Address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-81-field_39\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][39][address1]\" aria-errormessage=\"wpforms-81-field_39-error\" aria-describedby=\"wpforms-81-field_39-description\" required><label for=\"wpforms-81-field_39\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-81-field_39-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][39][address2]\" aria-errormessage=\"wpforms-81-field_39-address2-error\" aria-describedby=\"wpforms-81-field_39-description\" ><label for=\"wpforms-81-field_39-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-81-field_39-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][39][city]\" aria-errormessage=\"wpforms-81-field_39-city-error\" aria-describedby=\"wpforms-81-field_39-description\" required><label for=\"wpforms-81-field_39-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-81-field_39-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][39][state]\" aria-errormessage=\"wpforms-81-field_39-state-error\" aria-describedby=\"wpforms-81-field_39-description\" required><label for=\"wpforms-81-field_39-state\" class=\"wpforms-field-sublabel after\">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-81-field_39-postal\" class=\"wpforms-field-address-postal wpforms-field-required\" name=\"wpforms[fields][39][postal]\" aria-errormessage=\"wpforms-81-field_39-postal-error\" aria-describedby=\"wpforms-81-field_39-description\" required><label for=\"wpforms-81-field_39-postal\" class=\"wpforms-field-sublabel after\">Postal Code<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-81-field_39-country\" class=\"wpforms-field-address-country wpforms-field-required\" name=\"wpforms[fields][39][country]\" aria-errormessage=\"wpforms-81-field_39-country-error\" aria-describedby=\"wpforms-81-field_39-description\" required><option class=\"placeholder\" value=\"\" selected disabled>--- Select country ---<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia (Plurinational State of)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Democratic Republic of the)<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"SZ\" >Eswatini (Kingdom of)<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran (Islamic Republic of)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republic of)<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea (Democratic People&#039;s Republic of)<\/option><option value=\"KR\" >Korea (Republic of)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia (Federated States of)<\/option><option value=\"MD\" >Moldova (Republic of)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MK\" >North Macedonia (Republic of)<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (State of)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Republic of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (United Republic of)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"TR\" >T\u00fcrkiye<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"US\" >United States of America<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican City State<\/option><option value=\"VE\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (U.S.)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AX\" >\u00c5land Islands<\/option><\/select><label for=\"wpforms-81-field_39-country\" class=\"wpforms-field-sublabel after\">Country<\/label><\/div><\/div><div id=\"wpforms-81-field_39-description\" class=\"wpforms-field-description\">Please enter 0000 if you have no zip code<\/div><\/fieldset><\/div><div id=\"wpforms-81-field_40-container\" class=\"wpforms-field wpforms-field-phone applicant-phone\" data-field-id=\"40\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_40\">Phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-81-field_40\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][40]\" aria-label=\"Phone\" aria-errormessage=\"wpforms-81-field_40-error\" required><\/div><div id=\"wpforms-81-field_41-container\" class=\"wpforms-field wpforms-field-phone applicant-phone2\" data-field-id=\"41\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_41\">Secondary Phone \/ WhatsApp<\/label><input type=\"tel\" id=\"wpforms-81-field_41\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][41]\" aria-label=\"Secondary Phone \/ WhatsApp\" aria-errormessage=\"wpforms-81-field_41-error\" aria-describedby=\"wpforms-81-field_41-description\" ><div id=\"wpforms-81-field_41-description\" class=\"wpforms-field-description\">Optional<\/div><\/div><div id=\"wpforms-81-field_42-container\" class=\"wpforms-field wpforms-field-email applicant-email\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_42\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-81-field_42\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][42]\" spellcheck=\"false\" aria-errormessage=\"wpforms-81-field_42-error\" required><\/div><div id=\"wpforms-81-field_43-container\" class=\"wpforms-field wpforms-field-email applicant-email2\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_43\">Secondary email<\/label><input type=\"email\" id=\"wpforms-81-field_43\" class=\"wpforms-field-medium\" name=\"wpforms[fields][43]\" spellcheck=\"false\" aria-errormessage=\"wpforms-81-field_43-error\" aria-describedby=\"wpforms-81-field_43-description\" ><div id=\"wpforms-81-field_43-description\" class=\"wpforms-field-description\">Optional<\/div><\/div><div id=\"wpforms-81-field_44-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"44\"><h3 id=\"wpforms-81-field_44\" aria-errormessage=\"wpforms-81-field_44-error\" aria-describedby=\"wpforms-81-field_44-description\">Account Details - Organization Information (Optional)<\/h3><div id=\"wpforms-81-field_44-description\" class=\"wpforms-field-description\">Please indicate if different than above.<\/div><\/div><div id=\"wpforms-81-field_45-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"45\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_45\">Organization name<\/label><input type=\"text\" id=\"wpforms-81-field_45\" class=\"wpforms-field-medium\" name=\"wpforms[fields][45]\" aria-errormessage=\"wpforms-81-field_45-error\" ><\/div><div id=\"wpforms-81-field_176-container\" class=\"wpforms-field wpforms-field-checkbox copy-to-organization wpforms-conditional-trigger\" data-field-id=\"176\"><fieldset><legend class=\"wpforms-field-label\">Is Organization contact info the same as Applicant information?<\/legend><ul id=\"wpforms-81-field_176\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-81-field_176_1\" name=\"wpforms[fields][176][]\" value=\"Yes\" aria-errormessage=\"wpforms-81-field_176_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_176_1\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-81-field_175-container\" class=\"wpforms-field wpforms-field-name organization-name wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"175\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Organization Contact Name<\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-81-field_175\" class=\"wpforms-field-name-first\" name=\"wpforms[fields][175][first]\" aria-errormessage=\"wpforms-81-field_175-error\" ><label for=\"wpforms-81-field_175\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-fifth\"><input type=\"text\" id=\"wpforms-81-field_175-middle\" class=\"wpforms-field-name-middle\" name=\"wpforms[fields][175][middle]\" aria-errormessage=\"wpforms-81-field_175-middle-error\" ><label for=\"wpforms-81-field_175-middle\" class=\"wpforms-field-sublabel after\">Middle<\/label><\/div><div class=\"wpforms-field-row-block wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-81-field_175-last\" class=\"wpforms-field-name-last\" name=\"wpforms[fields][175][last]\" aria-errormessage=\"wpforms-81-field_175-last-error\" ><label for=\"wpforms-81-field_175-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-81-field_51-container\" class=\"wpforms-field wpforms-field-text organization-prefix wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"51\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_51\">Prefix<\/label><input type=\"text\" id=\"wpforms-81-field_51\" class=\"wpforms-field-medium\" name=\"wpforms[fields][51]\" aria-errormessage=\"wpforms-81-field_51-error\" ><\/div><div id=\"wpforms-81-field_52-container\" class=\"wpforms-field wpforms-field-address organization-address wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"52\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Organization Address<\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-81-field_52\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][52][address1]\" aria-errormessage=\"wpforms-81-field_52-error\" aria-describedby=\"wpforms-81-field_52-description\" ><label for=\"wpforms-81-field_52\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-81-field_52-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][52][address2]\" aria-errormessage=\"wpforms-81-field_52-address2-error\" aria-describedby=\"wpforms-81-field_52-description\" ><label for=\"wpforms-81-field_52-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-81-field_52-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][52][city]\" aria-errormessage=\"wpforms-81-field_52-city-error\" aria-describedby=\"wpforms-81-field_52-description\" ><label for=\"wpforms-81-field_52-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-81-field_52-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][52][state]\" aria-errormessage=\"wpforms-81-field_52-state-error\" aria-describedby=\"wpforms-81-field_52-description\" ><label for=\"wpforms-81-field_52-state\" class=\"wpforms-field-sublabel after\">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-81-field_52-postal\" class=\"wpforms-field-address-postal\" name=\"wpforms[fields][52][postal]\" aria-errormessage=\"wpforms-81-field_52-postal-error\" aria-describedby=\"wpforms-81-field_52-description\" ><label for=\"wpforms-81-field_52-postal\" class=\"wpforms-field-sublabel after\">Postal Code<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-81-field_52-country\" class=\"wpforms-field-address-country\" name=\"wpforms[fields][52][country]\" aria-errormessage=\"wpforms-81-field_52-country-error\" aria-describedby=\"wpforms-81-field_52-description\" ><option class=\"placeholder\" value=\"\" selected disabled>--- Select country ---<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia (Plurinational State of)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Democratic Republic of the)<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"SZ\" >Eswatini (Kingdom of)<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran (Islamic Republic of)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republic of)<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea (Democratic People&#039;s Republic of)<\/option><option value=\"KR\" >Korea (Republic of)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia (Federated States of)<\/option><option value=\"MD\" >Moldova (Republic of)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MK\" >North Macedonia (Republic of)<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (State of)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Republic of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (United Republic of)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"TR\" >T\u00fcrkiye<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"US\" >United States of America<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican City State<\/option><option value=\"VE\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (U.S.)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AX\" >\u00c5land Islands<\/option><\/select><label for=\"wpforms-81-field_52-country\" class=\"wpforms-field-sublabel after\">Country<\/label><\/div><\/div><div id=\"wpforms-81-field_52-description\" class=\"wpforms-field-description\">(Please enter 0000 if you have no code)<\/div><\/fieldset><\/div><div id=\"wpforms-81-field_54-container\" class=\"wpforms-field wpforms-field-phone organization-phone wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"54\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_54\">Organization Contact Phone<\/label><input type=\"tel\" id=\"wpforms-81-field_54\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][54]\" aria-label=\"Organization Contact Phone\" aria-errormessage=\"wpforms-81-field_54-error\" ><\/div><div id=\"wpforms-81-field_55-container\" class=\"wpforms-field wpforms-field-phone organization-phone2 wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"55\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_55\">Secondary Phone \/ WhatsApp<\/label><input type=\"tel\" id=\"wpforms-81-field_55\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][55]\" aria-label=\"Secondary Phone \/ WhatsApp\" aria-errormessage=\"wpforms-81-field_55-error\" ><\/div><div id=\"wpforms-81-field_56-container\" class=\"wpforms-field wpforms-field-email organization-email wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"56\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_56\">Organization Contact Email<\/label><input type=\"email\" id=\"wpforms-81-field_56\" class=\"wpforms-field-medium\" name=\"wpforms[fields][56]\" spellcheck=\"false\" aria-errormessage=\"wpforms-81-field_56-error\" ><\/div><div id=\"wpforms-81-field_57-container\" class=\"wpforms-field wpforms-field-email organization-email2 wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"57\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_57\">Secondary Email<\/label><input type=\"email\" id=\"wpforms-81-field_57\" class=\"wpforms-field-medium\" name=\"wpforms[fields][57]\" spellcheck=\"false\" aria-errormessage=\"wpforms-81-field_57-error\" ><\/div><div id=\"wpforms-81-field_59-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"59\"><h3 id=\"wpforms-81-field_59\" aria-errormessage=\"wpforms-81-field_59-error\">Account Details - Ordering Surgeon Information<\/h3><\/div>\t\t<div id=\"wpforms-81-field_2-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"2\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-81-field_2\" >MAP alter, without<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-81-field_2\" class=\"wpforms-field-medium\" name=\"wpforms[fields][2]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-81-field_60-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"60\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_60\">MAP account number<\/label><input type=\"text\" id=\"wpforms-81-field_60\" class=\"wpforms-field-medium\" name=\"wpforms[fields][60]\" aria-errormessage=\"wpforms-81-field_60-error\" aria-describedby=\"wpforms-81-field_60-description\" ><div id=\"wpforms-81-field_60-description\" class=\"wpforms-field-description\">(for returning partners)<\/div><\/div><div id=\"wpforms-81-field_61-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"61\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_61\">MAP account name<\/label><input type=\"text\" id=\"wpforms-81-field_61\" class=\"wpforms-field-medium\" name=\"wpforms[fields][61]\" aria-errormessage=\"wpforms-81-field_61-error\" aria-describedby=\"wpforms-81-field_61-description\" ><div id=\"wpforms-81-field_61-description\" class=\"wpforms-field-description\">(normally the surgeon's name)<\/div><\/div><div id=\"wpforms-81-field_62-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"62\"><fieldset><legend class=\"wpforms-field-label\">Are you the ordering surgeon? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-81-field_62\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-81-field_62_1\" name=\"wpforms[fields][62]\" value=\"Yes\" aria-errormessage=\"wpforms-81-field_62_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_62_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-81-field_62_2\" name=\"wpforms[fields][62]\" value=\"No\" aria-errormessage=\"wpforms-81-field_62_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_62_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-81-field_177-container\" class=\"wpforms-field wpforms-field-checkbox copy-to-surgeon wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-id=\"177\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Is Ordering Surgeon contact info the same as Applicant information?<\/legend><ul id=\"wpforms-81-field_177\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-81-field_177_1\" name=\"wpforms[fields][177][]\" value=\"Yes\" aria-errormessage=\"wpforms-81-field_177_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_177_1\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-81-field_63-container\" class=\"wpforms-field wpforms-field-name surgeon-name wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"63\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Ordering surgeon&#039;s name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-81-field_63\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][63][first]\" aria-errormessage=\"wpforms-81-field_63-error\" required><label for=\"wpforms-81-field_63\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-fifth\"><input type=\"text\" id=\"wpforms-81-field_63-middle\" class=\"wpforms-field-name-middle\" name=\"wpforms[fields][63][middle]\" aria-errormessage=\"wpforms-81-field_63-middle-error\" ><label for=\"wpforms-81-field_63-middle\" class=\"wpforms-field-sublabel after\">Middle<\/label><\/div><div class=\"wpforms-field-row-block wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-81-field_63-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][63][last]\" aria-errormessage=\"wpforms-81-field_63-last-error\" required><label for=\"wpforms-81-field_63-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-81-field_178-container\" class=\"wpforms-field wpforms-field-text surgeon-prefix wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"178\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_178\">Prefix<\/label><input type=\"text\" id=\"wpforms-81-field_178\" class=\"wpforms-field-medium\" name=\"wpforms[fields][178]\" aria-errormessage=\"wpforms-81-field_178-error\" ><\/div><div id=\"wpforms-81-field_183-container\" class=\"wpforms-field wpforms-field-address surgeon-address wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"183\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Ordering surgeon&#039;s address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-81-field_183\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][183][address1]\" aria-errormessage=\"wpforms-81-field_183-error\" required><label for=\"wpforms-81-field_183\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-81-field_183-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][183][address2]\" aria-errormessage=\"wpforms-81-field_183-address2-error\" ><label for=\"wpforms-81-field_183-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-81-field_183-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][183][city]\" aria-errormessage=\"wpforms-81-field_183-city-error\" required><label for=\"wpforms-81-field_183-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-81-field_183-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][183][state]\" aria-errormessage=\"wpforms-81-field_183-state-error\" required><label for=\"wpforms-81-field_183-state\" class=\"wpforms-field-sublabel after\">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-81-field_183-postal\" class=\"wpforms-field-address-postal wpforms-field-required\" name=\"wpforms[fields][183][postal]\" aria-errormessage=\"wpforms-81-field_183-postal-error\" required><label for=\"wpforms-81-field_183-postal\" class=\"wpforms-field-sublabel after\">Postal Code<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-81-field_183-country\" class=\"wpforms-field-address-country wpforms-field-required\" name=\"wpforms[fields][183][country]\" aria-errormessage=\"wpforms-81-field_183-country-error\" required><option class=\"placeholder\" value=\"\" selected disabled>--- Select country ---<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia (Plurinational State of)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Democratic Republic of the)<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"SZ\" >Eswatini (Kingdom of)<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran (Islamic Republic of)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republic of)<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea (Democratic People&#039;s Republic of)<\/option><option value=\"KR\" >Korea (Republic of)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia (Federated States of)<\/option><option value=\"MD\" >Moldova (Republic of)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MK\" >North Macedonia (Republic of)<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (State of)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Republic of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (United Republic of)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"TR\" >T\u00fcrkiye<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"US\" >United States of America<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican City State<\/option><option value=\"VE\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (U.S.)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AX\" >\u00c5land Islands<\/option><\/select><label for=\"wpforms-81-field_183-country\" class=\"wpforms-field-sublabel after\">Country<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-81-field_64-container\" class=\"wpforms-field wpforms-field-phone surgeon-phone wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"64\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_64\">Ordering surgeon&#039;s phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-81-field_64\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][64]\" aria-label=\"Ordering surgeon&#039;s phone\" aria-errormessage=\"wpforms-81-field_64-error\" required><\/div><div id=\"wpforms-81-field_179-container\" class=\"wpforms-field wpforms-field-phone surgeon-phone2 wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"179\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_179\">Ordering surgeon&#039;s secondary Phone\/WhatsApp<\/label><input type=\"tel\" id=\"wpforms-81-field_179\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][179]\" aria-label=\"Ordering surgeon&#039;s secondary Phone\/WhatsApp\" aria-errormessage=\"wpforms-81-field_179-error\" ><\/div><div id=\"wpforms-81-field_65-container\" class=\"wpforms-field wpforms-field-email surgeon-email wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"65\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_65\">Ordering surgeon&#039;s email address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-81-field_65\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][65]\" spellcheck=\"false\" aria-errormessage=\"wpforms-81-field_65-error\" required><\/div><div id=\"wpforms-81-field_180-container\" class=\"wpforms-field wpforms-field-email surgeon-email2 wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"180\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_180\">Ordering surgeon&#039;s secondary email address<\/label><input type=\"email\" id=\"wpforms-81-field_180\" class=\"wpforms-field-medium\" name=\"wpforms[fields][180]\" spellcheck=\"false\" aria-errormessage=\"wpforms-81-field_180-error\" ><\/div><div id=\"wpforms-81-field_190-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"190\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_190\">Name of the ordering medical professional for this mission: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-81-field_190\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][190]\" aria-errormessage=\"wpforms-81-field_190-error\" required><\/div><div id=\"wpforms-81-field_191-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"191\"><fieldset><legend class=\"wpforms-field-label\">I certify the ordering medical professional will be present during the distribution and use of all MAP products on this mission <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-81-field_191\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-81-field_191_1\" name=\"wpforms[fields][191][]\" value=\"I agree\" aria-errormessage=\"wpforms-81-field_191_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_191_1\">I agree<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-81-field_184-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"184\"><h3 id=\"wpforms-81-field_184\" aria-errormessage=\"wpforms-81-field_184-error\">Account Details - Shipping Information<\/h3><\/div><div id=\"wpforms-81-field_185-container\" class=\"wpforms-field wpforms-field-checkbox copy-to-shipping wpforms-conditional-trigger\" data-field-id=\"185\"><fieldset><legend class=\"wpforms-field-label\">Is Shipping contact info the same as Applicant information?<\/legend><ul id=\"wpforms-81-field_185\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-81-field_185_1\" name=\"wpforms[fields][185][]\" value=\"Yes\" aria-errormessage=\"wpforms-81-field_185_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_185_1\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-81-field_66-container\" class=\"wpforms-field wpforms-field-name shipping-name wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"66\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Optional contact person responsible for receiving the shipment and\/or clearing local customs<\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-81-field_66\" class=\"wpforms-field-name-first\" name=\"wpforms[fields][66][first]\" aria-errormessage=\"wpforms-81-field_66-error\" ><label for=\"wpforms-81-field_66\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-fifth\"><input type=\"text\" id=\"wpforms-81-field_66-middle\" class=\"wpforms-field-name-middle\" name=\"wpforms[fields][66][middle]\" aria-errormessage=\"wpforms-81-field_66-middle-error\" ><label for=\"wpforms-81-field_66-middle\" class=\"wpforms-field-sublabel after\">Middle<\/label><\/div><div class=\"wpforms-field-row-block wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-81-field_66-last\" class=\"wpforms-field-name-last\" name=\"wpforms[fields][66][last]\" aria-errormessage=\"wpforms-81-field_66-last-error\" ><label for=\"wpforms-81-field_66-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-81-field_182-container\" class=\"wpforms-field wpforms-field-text shipping-prefix wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"182\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_182\">Prefix<\/label><input type=\"text\" id=\"wpforms-81-field_182\" class=\"wpforms-field-medium\" name=\"wpforms[fields][182]\" aria-errormessage=\"wpforms-81-field_182-error\" ><\/div><div id=\"wpforms-81-field_70-container\" class=\"wpforms-field wpforms-field-address shipping-address wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"70\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Complete delivery address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-81-field_70\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][70][address1]\" aria-errormessage=\"wpforms-81-field_70-error\" aria-describedby=\"wpforms-81-field_70-description\" required><label for=\"wpforms-81-field_70\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-81-field_70-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][70][address2]\" aria-errormessage=\"wpforms-81-field_70-address2-error\" aria-describedby=\"wpforms-81-field_70-description\" ><label for=\"wpforms-81-field_70-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-81-field_70-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][70][city]\" aria-errormessage=\"wpforms-81-field_70-city-error\" aria-describedby=\"wpforms-81-field_70-description\" required><label for=\"wpforms-81-field_70-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-81-field_70-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][70][state]\" aria-errormessage=\"wpforms-81-field_70-state-error\" aria-describedby=\"wpforms-81-field_70-description\" required><label for=\"wpforms-81-field_70-state\" class=\"wpforms-field-sublabel after\">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-81-field_70-postal\" class=\"wpforms-field-address-postal wpforms-field-required\" name=\"wpforms[fields][70][postal]\" aria-errormessage=\"wpforms-81-field_70-postal-error\" aria-describedby=\"wpforms-81-field_70-description\" required><label for=\"wpforms-81-field_70-postal\" class=\"wpforms-field-sublabel after\">Postal Code<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-81-field_70-country\" class=\"wpforms-field-address-country wpforms-field-required\" name=\"wpforms[fields][70][country]\" aria-errormessage=\"wpforms-81-field_70-country-error\" aria-describedby=\"wpforms-81-field_70-description\" required><option class=\"placeholder\" value=\"\" selected disabled>--- Select country ---<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia (Plurinational State of)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Democratic Republic of the)<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"SZ\" >Eswatini (Kingdom of)<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran (Islamic Republic of)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republic of)<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea (Democratic People&#039;s Republic of)<\/option><option value=\"KR\" >Korea (Republic of)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia (Federated States of)<\/option><option value=\"MD\" >Moldova (Republic of)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MK\" >North Macedonia (Republic of)<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (State of)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Republic of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (United Republic of)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"TR\" >T\u00fcrkiye<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"US\" >United States of America<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican City State<\/option><option value=\"VE\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (U.S.)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AX\" >\u00c5land Islands<\/option><\/select><label for=\"wpforms-81-field_70-country\" class=\"wpforms-field-sublabel after\">Country<\/label><\/div><\/div><div id=\"wpforms-81-field_70-description\" class=\"wpforms-field-description\">(Please enter 0000 if you have no zip code)<\/div><\/fieldset><\/div><div id=\"wpforms-81-field_67-container\" class=\"wpforms-field wpforms-field-phone shipping-phone wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"67\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_67\">Shipping contact phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-81-field_67\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][67]\" aria-label=\"Shipping contact phone\" aria-errormessage=\"wpforms-81-field_67-error\" required><\/div><div id=\"wpforms-81-field_68-container\" class=\"wpforms-field wpforms-field-phone shipping-phone2 wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"68\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_68\">Shipping contact secondary Phone\/WhatsApp<\/label><input type=\"tel\" id=\"wpforms-81-field_68\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][68]\" aria-label=\"Shipping contact secondary Phone\/WhatsApp\" aria-errormessage=\"wpforms-81-field_68-error\" ><\/div><div id=\"wpforms-81-field_69-container\" class=\"wpforms-field wpforms-field-email shipping-email wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"69\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_69\">Shipping contact email address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-81-field_69\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][69]\" spellcheck=\"false\" aria-errormessage=\"wpforms-81-field_69-error\" required><\/div><div id=\"wpforms-81-field_181-container\" class=\"wpforms-field wpforms-field-email shipping-email2 wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"181\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_181\">Shipping contact secondary email address<\/label><input type=\"email\" id=\"wpforms-81-field_181\" class=\"wpforms-field-medium\" name=\"wpforms[fields][181]\" spellcheck=\"false\" aria-errormessage=\"wpforms-81-field_181-error\" ><\/div><div id=\"wpforms-81-field_71-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"71\"><fieldset><legend class=\"wpforms-field-label\">Residential or Business address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-81-field_71\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-81-field_71_1\" name=\"wpforms[fields][71]\" value=\"Residential\" aria-errormessage=\"wpforms-81-field_71_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_71_1\">Residential<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-81-field_71_2\" name=\"wpforms[fields][71]\" value=\"Business\" aria-errormessage=\"wpforms-81-field_71_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_71_2\">Business<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-81-field_131-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"131\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_131\">Special instructions, operating hours, etc<\/label><input type=\"text\" id=\"wpforms-81-field_131\" class=\"wpforms-field-medium\" name=\"wpforms[fields][131]\" aria-errormessage=\"wpforms-81-field_131-error\" ><\/div><div id=\"wpforms-81-field_72-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"72\"><h3 id=\"wpforms-81-field_72\" aria-errormessage=\"wpforms-81-field_72-error\">Project Information<\/h3><\/div><div id=\"wpforms-81-field_75-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"75\"><fieldset><legend class=\"wpforms-field-label\">For Surgeons: The normal limit is 1 order per year per surgeon to max 30 boxes of Ethicon sutures. Requests for more product will be considered on a case-by-case basis. Please contact MAP International at orders@map.org or 1-912-280-6627. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-81-field_75\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-81-field_75_1\" name=\"wpforms[fields][75][]\" value=\"I understand and agree.\" aria-errormessage=\"wpforms-81-field_75_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_75_1\">I understand and agree.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-81-field_76-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"76\"><fieldset><legend class=\"wpforms-field-label\">I agree to document the product description, brand name, product code (REF or SKU), lot number, expiration date, and quantity of any product left in-country at the conclusion of my trip. I understand MAP will require this information in the post-mission reporting process. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-81-field_76\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-81-field_76_1\" name=\"wpforms[fields][76][]\" value=\"I understand and agree.\" aria-errormessage=\"wpforms-81-field_76_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_76_1\">I understand and agree.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-81-field_142-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"142\"><fieldset><legend class=\"wpforms-field-label\">Upon receipt of MAP products, I assume full responsibility for the storage and security of the products.  I agree to immediately report any lost or stolen goods to MAP International. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-81-field_142\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-81-field_142_1\" name=\"wpforms[fields][142][]\" value=\"I understand and agree.\" aria-errormessage=\"wpforms-81-field_142_1-error\" aria-describedby=\"wpforms-81-field_142-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_142_1\">I understand and agree.<\/label><\/li><\/ul><div id=\"wpforms-81-field_142-description\" class=\"wpforms-field-description\">9.5.2.1 Prior to shipment the Donor should ensure the Distributing Partner has a secure facility to store the product with available space to receive the shipment.  (Guidelines provided by the Partnership for Quality Medical Donations)<\/div><\/fieldset><\/div><div id=\"wpforms-81-field_143-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"143\"><fieldset><legend class=\"wpforms-field-label\">I agree to notify MAP within 24 hours of receipt if prescription drugs donated by MAP show evidence of deviation from proper storage conditions during transport. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-81-field_143\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-81-field_143_1\" name=\"wpforms[fields][143][]\" value=\"I understand and agree.\" aria-errormessage=\"wpforms-81-field_143_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_143_1\">I understand and agree.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-81-field_77-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"77\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_77\">How many patients will be served during your mission? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-81-field_77\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][77]\" aria-errormessage=\"wpforms-81-field_77-error\" required><\/div><div id=\"wpforms-81-field_152-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"152\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_152\">Total number of facilities where procedures will be performed<\/label><select id=\"wpforms-81-field_152\" class=\"wpforms-field-medium\" name=\"wpforms[fields][152]\"><option value=\"1\"  class=\"choice-1 depth-1\"  >1<\/option><option value=\"2\"  class=\"choice-2 depth-1\"  >2<\/option><option value=\"3\"  class=\"choice-3 depth-1\"  >3<\/option><\/select><\/div><div id=\"wpforms-81-field_79-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"79\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_79\">Primary hospital\/clinic name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-81-field_79\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][79]\" aria-errormessage=\"wpforms-81-field_79-error\" required><\/div><div id=\"wpforms-81-field_80-container\" class=\"wpforms-field wpforms-field-name wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"80\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Primary hospital\/clinic contact person name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-81-field_80\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][80][first]\" aria-errormessage=\"wpforms-81-field_80-error\" required><label for=\"wpforms-81-field_80\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-81-field_80-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][80][last]\" aria-errormessage=\"wpforms-81-field_80-last-error\" required><label for=\"wpforms-81-field_80-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-81-field_81-container\" class=\"wpforms-field wpforms-field-email wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"81\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_81\">Primary hospital\/clinic contact person email address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-81-field_81\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][81]\" spellcheck=\"false\" aria-errormessage=\"wpforms-81-field_81-error\" required><\/div><div id=\"wpforms-81-field_82-container\" class=\"wpforms-field wpforms-field-phone wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"82\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_82\">Primary hospital\/clinic contact person phone number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-81-field_82\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][82]\" aria-label=\"Primary hospital\/clinic contact person phone number\" aria-errormessage=\"wpforms-81-field_82-error\" required><\/div><div id=\"wpforms-81-field_148-container\" class=\"wpforms-field wpforms-field-address wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"148\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Primary hospital\/clinic address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-81-field_148\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][148][address1]\" aria-errormessage=\"wpforms-81-field_148-error\" required><label for=\"wpforms-81-field_148\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-81-field_148-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][148][address2]\" aria-errormessage=\"wpforms-81-field_148-address2-error\" ><label for=\"wpforms-81-field_148-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-81-field_148-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][148][city]\" aria-errormessage=\"wpforms-81-field_148-city-error\" required><label for=\"wpforms-81-field_148-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-81-field_148-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][148][state]\" aria-errormessage=\"wpforms-81-field_148-state-error\" required><label for=\"wpforms-81-field_148-state\" class=\"wpforms-field-sublabel after\">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-81-field_148-postal\" class=\"wpforms-field-address-postal wpforms-field-required\" name=\"wpforms[fields][148][postal]\" aria-errormessage=\"wpforms-81-field_148-postal-error\" required><label for=\"wpforms-81-field_148-postal\" class=\"wpforms-field-sublabel after\">Postal Code<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-81-field_148-country\" class=\"wpforms-field-address-country wpforms-field-required\" name=\"wpforms[fields][148][country]\" aria-errormessage=\"wpforms-81-field_148-country-error\" required><option class=\"placeholder\" value=\"\" selected disabled>--- Select country ---<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia (Plurinational State of)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Democratic Republic of the)<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"SZ\" >Eswatini (Kingdom of)<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran (Islamic Republic of)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republic of)<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea (Democratic People&#039;s Republic of)<\/option><option value=\"KR\" >Korea (Republic of)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia (Federated States of)<\/option><option value=\"MD\" >Moldova (Republic of)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MK\" >North Macedonia (Republic of)<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (State of)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Republic of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (United Republic of)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"TR\" >T\u00fcrkiye<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"US\" >United States of America<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican City State<\/option><option value=\"VE\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (U.S.)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AX\" >\u00c5land Islands<\/option><\/select><label for=\"wpforms-81-field_148-country\" class=\"wpforms-field-sublabel after\">Country<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-81-field_84-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"84\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_84\">Second hospital\/clinic name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-81-field_84\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][84]\" aria-errormessage=\"wpforms-81-field_84-error\" required><\/div><div id=\"wpforms-81-field_85-container\" class=\"wpforms-field wpforms-field-name wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"85\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Second hospital\/clinic contact person name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-81-field_85\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][85][first]\" aria-errormessage=\"wpforms-81-field_85-error\" required><label for=\"wpforms-81-field_85\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-81-field_85-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][85][last]\" aria-errormessage=\"wpforms-81-field_85-last-error\" required><label for=\"wpforms-81-field_85-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-81-field_86-container\" class=\"wpforms-field wpforms-field-email wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"86\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_86\">Second hospital\/clinic contact person email address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-81-field_86\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][86]\" spellcheck=\"false\" aria-errormessage=\"wpforms-81-field_86-error\" required><\/div><div id=\"wpforms-81-field_87-container\" class=\"wpforms-field wpforms-field-phone wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"87\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_87\">Second hospital\/clinic contact person phone number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-81-field_87\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][87]\" aria-label=\"Second hospital\/clinic contact person phone number\" aria-errormessage=\"wpforms-81-field_87-error\" required><\/div><div id=\"wpforms-81-field_149-container\" class=\"wpforms-field wpforms-field-address wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"149\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Second hospital\/clinic address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-81-field_149\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][149][address1]\" aria-errormessage=\"wpforms-81-field_149-error\" required><label for=\"wpforms-81-field_149\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-81-field_149-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][149][address2]\" aria-errormessage=\"wpforms-81-field_149-address2-error\" ><label for=\"wpforms-81-field_149-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-81-field_149-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][149][city]\" aria-errormessage=\"wpforms-81-field_149-city-error\" required><label for=\"wpforms-81-field_149-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-81-field_149-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][149][state]\" aria-errormessage=\"wpforms-81-field_149-state-error\" required><label for=\"wpforms-81-field_149-state\" class=\"wpforms-field-sublabel after\">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-81-field_149-postal\" class=\"wpforms-field-address-postal wpforms-field-required\" name=\"wpforms[fields][149][postal]\" aria-errormessage=\"wpforms-81-field_149-postal-error\" required><label for=\"wpforms-81-field_149-postal\" class=\"wpforms-field-sublabel after\">Postal Code<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-81-field_149-country\" class=\"wpforms-field-address-country wpforms-field-required\" name=\"wpforms[fields][149][country]\" aria-errormessage=\"wpforms-81-field_149-country-error\" required><option class=\"placeholder\" value=\"\" selected disabled>--- Select country ---<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia (Plurinational State of)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Democratic Republic of the)<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"SZ\" >Eswatini (Kingdom of)<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran (Islamic Republic of)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republic of)<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea (Democratic People&#039;s Republic of)<\/option><option value=\"KR\" >Korea (Republic of)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia (Federated States of)<\/option><option value=\"MD\" >Moldova (Republic of)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MK\" >North Macedonia (Republic of)<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (State of)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Republic of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (United Republic of)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"TR\" >T\u00fcrkiye<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"US\" >United States of America<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican City State<\/option><option value=\"VE\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (U.S.)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AX\" >\u00c5land Islands<\/option><\/select><label for=\"wpforms-81-field_149-country\" class=\"wpforms-field-sublabel after\">Country<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-81-field_88-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"88\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_88\">Third hospital\/clinic name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-81-field_88\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][88]\" aria-errormessage=\"wpforms-81-field_88-error\" required><\/div><div id=\"wpforms-81-field_89-container\" class=\"wpforms-field wpforms-field-name wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"89\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Third hospital\/clinic contact person name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-81-field_89\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][89][first]\" aria-errormessage=\"wpforms-81-field_89-error\" required><label for=\"wpforms-81-field_89\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-81-field_89-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][89][last]\" aria-errormessage=\"wpforms-81-field_89-last-error\" required><label for=\"wpforms-81-field_89-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-81-field_91-container\" class=\"wpforms-field wpforms-field-email wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"91\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_91\">Third hospital\/clinic contact person email address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-81-field_91\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][91]\" spellcheck=\"false\" aria-errormessage=\"wpforms-81-field_91-error\" required><\/div><div id=\"wpforms-81-field_90-container\" class=\"wpforms-field wpforms-field-phone wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"90\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_90\">Third hospital\/clinic contact person phone number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-81-field_90\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][90]\" aria-label=\"Third hospital\/clinic contact person phone number\" aria-errormessage=\"wpforms-81-field_90-error\" required><\/div><div id=\"wpforms-81-field_150-container\" class=\"wpforms-field wpforms-field-address wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"150\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Third hospital\/clinic address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-81-field_150\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][150][address1]\" aria-errormessage=\"wpforms-81-field_150-error\" required><label for=\"wpforms-81-field_150\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-81-field_150-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][150][address2]\" aria-errormessage=\"wpforms-81-field_150-address2-error\" ><label for=\"wpforms-81-field_150-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-81-field_150-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][150][city]\" aria-errormessage=\"wpforms-81-field_150-city-error\" required><label for=\"wpforms-81-field_150-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-81-field_150-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][150][state]\" aria-errormessage=\"wpforms-81-field_150-state-error\" required><label for=\"wpforms-81-field_150-state\" class=\"wpforms-field-sublabel after\">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-81-field_150-postal\" class=\"wpforms-field-address-postal wpforms-field-required\" name=\"wpforms[fields][150][postal]\" aria-errormessage=\"wpforms-81-field_150-postal-error\" required><label for=\"wpforms-81-field_150-postal\" class=\"wpforms-field-sublabel after\">Postal Code<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-81-field_150-country\" class=\"wpforms-field-address-country wpforms-field-required\" name=\"wpforms[fields][150][country]\" aria-errormessage=\"wpforms-81-field_150-country-error\" required><option class=\"placeholder\" value=\"\" selected disabled>--- Select country ---<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia (Plurinational State of)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Democratic Republic of the)<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"SZ\" >Eswatini (Kingdom of)<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran (Islamic Republic of)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republic of)<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea (Democratic People&#039;s Republic of)<\/option><option value=\"KR\" >Korea (Republic of)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia (Federated States of)<\/option><option value=\"MD\" >Moldova (Republic of)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MK\" >North Macedonia (Republic of)<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (State of)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Republic of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (United Republic of)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"TR\" >T\u00fcrkiye<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"US\" >United States of America<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican City State<\/option><option value=\"VE\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (U.S.)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AX\" >\u00c5land Islands<\/option><\/select><label for=\"wpforms-81-field_150-country\" class=\"wpforms-field-sublabel after\">Country<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-81-field_95-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"95\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_95\">Please list all surgeons and medical professionals on this trip. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-81-field_95\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][95]\" aria-errormessage=\"wpforms-81-field_95-error\" required><\/textarea><\/div><div id=\"wpforms-81-field_97-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"97\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_97\">Please list the name, phone and email of all additional in-country partners and organizations not already listed on this application.<\/label><textarea id=\"wpforms-81-field_97\" class=\"wpforms-field-medium\" name=\"wpforms[fields][97]\" aria-errormessage=\"wpforms-81-field_97-error\" ><\/textarea><\/div><div id=\"wpforms-81-field_98-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"98\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_98\">Describe the specific conditions you will be treating with Ethicon products <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-81-field_98\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][98]\" aria-errormessage=\"wpforms-81-field_98-error\" required><\/textarea><\/div><div id=\"wpforms-81-field_99-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"99\"><fieldset><legend class=\"wpforms-field-label\">Disclaimer: Before products are released to you, MAP may contact your in-country contacts as part of our normal vetting process. Please inform your in-country contacts that their information has been provided as part of this application. If they do not promptly respond to an official inquiry from MAP, your application for products may be delayed or denied. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-81-field_99\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-81-field_99_1\" name=\"wpforms[fields][99]\" value=\"I have read and agree.\" aria-errormessage=\"wpforms-81-field_99_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_99_1\">I have read and agree.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-81-field_101-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-id=\"101\"><fieldset><legend class=\"wpforms-field-label\">How will donated medicine and supplies be transported to your destination? Choose one: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-81-field_101\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-81-field_101_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][101][]\" value=\"Direct ship to the facility.\" aria-errormessage=\"wpforms-81-field_101_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_101_1\">Direct ship to the facility.<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-81-field_101_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][101][]\" value=\"Hand carry as baggage.\" aria-errormessage=\"wpforms-81-field_101_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_101_2\">Hand carry as baggage.<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-81-field_101_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][101][]\" value=\"Shipped to a third party for transport.\" aria-errormessage=\"wpforms-81-field_101_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_101_3\">Shipped to a third party for transport.<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-81-field_101_4\" data-rule-check-limit=\"true\" name=\"wpforms[fields][101][]\" value=\"Other\" aria-errormessage=\"wpforms-81-field_101_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_101_4\">Other<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-81-field_94-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"94\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_94\">Please specify<\/label><input type=\"text\" id=\"wpforms-81-field_94\" class=\"wpforms-field-medium\" name=\"wpforms[fields][94]\" aria-errormessage=\"wpforms-81-field_94-error\" ><\/div><div id=\"wpforms-81-field_102-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"102\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_102\">Where will the supplies be stored at the mission site? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-81-field_102\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][102]\" aria-errormessage=\"wpforms-81-field_102-error\" required><\/div><div id=\"wpforms-81-field_192-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"192\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_192\">Where will unused product left in-country be stored? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-81-field_192\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][192]\" aria-errormessage=\"wpforms-81-field_192-error\" required><\/div><div id=\"wpforms-81-field_104-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"104\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_104\">No products can be brought back into the USA after your trip.  Who will take responsibility for unused product left in-country? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-81-field_104\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][104]\" aria-errormessage=\"wpforms-81-field_104-error\" required><\/div><div id=\"wpforms-81-field_172-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"172\"><div id=\"wpforms-81-field_172\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-81-field_172-error\"><p>Terms &amp; Conditions<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-81-field_171-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"171\"><h3 id=\"wpforms-81-field_171\" aria-errormessage=\"wpforms-81-field_171-error\" aria-describedby=\"wpforms-81-field_171-description\">MAP Eligibility Requirements and Guidelines<\/h3><div id=\"wpforms-81-field_171-description\" class=\"wpforms-field-description\">Note: You must scroll and read to the very end of the terms to enable the Yes button.<\/div><\/div><div id=\"wpforms-81-field_155-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"155\"><div id=\"wpforms-81-field_155\" aria-errormessage=\"wpforms-81-field_155-error\">Eligibility Requirements\r\n\r\nMAP International seeks to partner with those who see a world where all people have access to life-changing medicine and health supplies. MAP serves all people, regardless of religion, gender, race, nationality, or ethnic background. MAP's focus includes:\r\n\r\n  \r\n    In disease, Health\r\n    In disaster, Help\r\n    In despair, Hope\r\n  \r\n\r\n  Applicants must be participating in non-profit charitable work.\r\n\r\n  MAP complies with U.S. export controls and screens all applicants against government-published lists prior to releasing any shipment.\r\n\r\n  Applicants must secure sufficient funding to cover MAP service fees, shipping costs and any charges related to customs clearance.\r\n\r\n  The applicant must provide the following materials:\r\n  \r\n    Fully completed eligibility forms. Medical professionals practicing medicine outside the USA will be required to provide additional proof of licensure.\r\n    Proof of charitable, non-profit status (if applicable)\r\n  \r\n\r\n  Additional information, if needed, will be requested to complete the Eligibility screening process.\r\n\r\n  Eligibility to receive donated medicines and supplies will be determined based on the completed eligibility forms. Continued eligibility will be dependent upon reports received and adherence to the stated guidelines.\r\n\r\n  MAP policy does not allow for transport of medicines or medical products to any U.S.-embargoed country, or one\u2019s subject to economic sanctions, e.g. Cuba, Syria, Iran, North Korea and Sudan, without the ordering partner providing proof of having obtained the required licensing from the appropriate departments of the U.S. government.\r\n\r\n  Guidelines\r\n\r\n  \r\n    Limited Stock: Since MAP\u2019s inventory is primarily dependent on donations from the U.S. pharmaceutical industry, the types and quantities of available medicines and medical supplies will vary.\r\n\r\n    Product Use: In compliance with the Food, Drug and Cosmetic Act, as amended, and Internal Revenue Service regulations, all donated products must be used exclusively for the treatment of the ill, needy and infants and may NOT be sold or exchanged for property or services or re-exported. All prescription medicines must be prescribed on-site by a qualified medical professional only. Adequate records must be maintained to document the handling and distribution of all medicines.\r\n\r\n      All recipients assume full responsibility that all medicines and medical supplies donated for programs outside the United States will be used only for those programs stated at the time of request. No product may be left behind in the U.S. or brought back to the U.S. at the end of the mission. Recipients must notify MAP International prior to any changes to the original plan and request.\r\n\r\n      All recipients will be required to submit a detailed plan for the storage and distribution of any unused medicines with a full report of the disposition to be completed upon return.\r\n\r\n      All dated medicines and products shipped by MAP must be dispensed prior to their expiration date.\r\n\r\n      In the case where product must be destroyed, notification must be given to MAP. The recipient must handle that product in compliance with the original manufacturer\u2019s recommendations and the recipient country\u2019s regulations. Failure to notify MAP may result in loss of eligibility for future shipments.\r\n\r\n      All MAP partners must immediately report any adverse event potentially related to MAP-supplied medicines, supplies and\/or products by calling MAP International at (912)280-6627 and emailing or faxing the completed Adverse Event Report form to Ae@map.org or (912)265-6170.\r\n    \r\n\r\n    Customs: Clearing Customs is the responsibility of the consignee\/recipient. Documents are carefully prepared to assist in this process (e.g. detailed packing list, gift certificate, invoice). MAP International is not responsible for customs charges, fines or taxes. Should product be confiscated by customs officials and not released for its intended use, MAP must be notified as soon as possible.\r\n\r\n    Security: Donations from pharmaceutical and medical supply companies are dependent upon the product being transported and dispensed in a secure manner upon receipt. Please exercise caution when making arrangements in other countries. Shipments to locations in the U.S. for international transport should be opened only AFTER their arrival to the overseas destination.\r\n\r\n    Service Fee: Service fees are established for all shipments to recover a portion of MAP\u2019s total annual cost to procure, receive, inventory, audit, process, and ship the donated and\/or purchased medicines\/supplies.\r\n\r\n    Reporting: All recipients of MAP-supplied medicines and medical supplies are asked to complete and return the delivery confirmation form and submit distribution and impact reports to MAP, including human-interest stories and photographs. The submitted information including photographs and stories may be used by MAP International, its donors and mission partners to promote MAP International\u2019s mission and work around the globe. Photos will remain the property of MAP International, will be shared with MAP donors, and will not be provided to other agents or sold for profit.<\/div><\/div><div id=\"wpforms-81-field_163-container\" class=\"wpforms-field wpforms-field-payment-checkbox disable-until-scroll\" data-field-id=\"163\"><fieldset><legend class=\"wpforms-field-label\">I have read and agreed to the MAP Eligibility Requirements and Guidelines <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-81-field_163\" class=\"wpforms-field-required\"><li class=\"choice-1\"><input type=\"checkbox\" id=\"wpforms-81-field_163_1\" class=\"wpforms-payment-price\" data-amount=\"0.00\" name=\"wpforms[fields][163][]\" value=\"1\" aria-errormessage=\"wpforms-81-field_163_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_163_1\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-81-field_170-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"170\"><h3 id=\"wpforms-81-field_170\" aria-errormessage=\"wpforms-81-field_170-error\" aria-describedby=\"wpforms-81-field_170-description\">MAP Agreement and Distribution Policy<\/h3><div id=\"wpforms-81-field_170-description\" class=\"wpforms-field-description\">Note: You must scroll and read to the very end of the terms to enable the Yes button.<\/div><\/div><div id=\"wpforms-81-field_164-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"164\"><div id=\"wpforms-81-field_164\" aria-errormessage=\"wpforms-81-field_164-error\">Agreement for Acceptance and Distribution\r\n\r\n  By accepting receipt of this statement, the undersigned agrees with MAP International\u2019s Mission and Vision statement and all conditions of service as explained in the Eligibility and Guidelines, including, but not limited to, the following:\r\n\r\n  \r\n    \r\n      All donated product received from MAP International will be used exclusively in charitable work outside the U.S. and in the designated country only and \r\n      will not be re-exported either to the U.S. or a third country or transferred in exchange for money, other property or services. \r\n      Violation of this condition may result in prosecution to the fullest extent of the law and\/or civil suit.\r\n    \r\n    \r\n      All non-delivery\/non-distribution of product due to damage, customs problems or excess amount will be reported to MAP immediately.\r\n    \r\n    \r\n      All dated medicines and products shipped by MAP must be dispensed prior to their expiration date or destroyed in accordance with the original manufacturer\u2019s recommendations and the recipient country\u2019s regulations.\r\n    \r\n    \r\n      In case of a product recall, all recipients will adhere to MAP\u2019s recall policies and procedures.\r\n    \r\n    \r\n      All MAP partners must immediately report any adverse event potentially related to MAP-supplied medicines, supplies and\/or products. \r\n      Please complete and submit the Adverse Event form you received with your Eligibility documents. \r\n      Please call MAP International at 1-800-225-8550 for assistance when submitting this report.\r\n    \r\n    \r\n      All recipients of MAP-supplied medicines and medical supplies are required to complete and return the delivery confirmation form and submit distribution and impact reports to MAP, including human-interest stories and photographs. \r\n      The submitted information including photographs and stories may be used by MAP International, its donors and mission partners to promote MAP International\u2019s mission and work around the globe. \r\n      Photos will remain the property of MAP International, will be shared with MAP donors and will not be provided to other agents or sold for profit.\r\n    \r\n    \r\n      MAP International reserves the right to review continued partnership eligibility based on compliance with reporting requirements and adherence to the stated guidelines.<\/div><\/div><div id=\"wpforms-81-field_165-container\" class=\"wpforms-field wpforms-field-payment-checkbox disable-until-scroll-2\" data-field-id=\"165\"><fieldset><legend class=\"wpforms-field-label\">I have read and agreed to the MAP Agreement and Distribution Policy <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-81-field_165\" class=\"wpforms-field-required\"><li class=\"choice-1\"><input type=\"checkbox\" id=\"wpforms-81-field_165_1\" class=\"wpforms-payment-price\" data-amount=\"0.00\" name=\"wpforms[fields][165][]\" value=\"1\" aria-errormessage=\"wpforms-81-field_165_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_165_1\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-81-field_169-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"169\"><h3 id=\"wpforms-81-field_169\" aria-errormessage=\"wpforms-81-field_169-error\" aria-describedby=\"wpforms-81-field_169-description\">MAP Acceptance of Responsibility for Export Clearance Requirements<\/h3><div id=\"wpforms-81-field_169-description\" class=\"wpforms-field-description\">Note: You must scroll and read to the very end of the terms to enable the Yes button.<\/div><\/div><div id=\"wpforms-81-field_136-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"136\"><div id=\"wpforms-81-field_136\" aria-errormessage=\"wpforms-81-field_136-error\">Donee hereby accepts responsibility for export clearance and export license determination requirements with respect to all transactions between MAP International and Donee.\r\n\r\n    Donee or its duly authorized agent in the United States shall be deemed the exporter for purposes of all applicable U.S. laws. This acceptance shall remain in effect until cancelled in writing by Donee and written notification of such cancellation is received by MAP International.\r\n\r\n    Without limiting the foregoing acceptance of export compliance responsibility, Donee agrees to comply with all applicable U.S. economic sanctions and export control laws and regulations, including the U.S. Export Administration Regulations and U.S. Treasury Department economic sanctions regulations. Donee covenants that it shall not -- directly or indirectly -- sell, export, reexport, transfer, provide, donate, divert, loan, lease, consign, or otherwise dispose of any items received from MAP International to or via any person, entity, or destination, or for any use prohibited by the laws or regulations of the United States or any other applicable jurisdiction without obtaining any and all prior governmental authorizations required by law.\r\n\r\n    Notwithstanding any other agreement, neither Donee nor MAP International shall take or refrain from taking any action prohibited or penalized under the laws of the United States or any applicable foreign jurisdiction.\r\n\r\n    Donee\u2019s breach of this covenant shall constitute cause for immediate termination of the Agreement between the parties. Donee agrees to indemnify and hold harmless MAP International and its affiliates for Donee\u2019s noncompliance with these controls in connection with the items. This covenant and all remedies provided in relation thereto shall survive termination or cancellation of this acceptance of responsibility.\r\n\r\n    To ensure that MAP International has complete records with respect to such transactions, Donee shall, at MAP International\u2019s request, provide MAP International with copies of any and all export documents, including export licenses or other bases for export authorization and the Shippers Export Declarations or AES records filed, with respect to any transactions in which Donee has received items from MAP International.<\/div><\/div><div id=\"wpforms-81-field_168-container\" class=\"wpforms-field wpforms-field-payment-checkbox disable-until-scroll-3\" data-field-id=\"168\"><fieldset><legend class=\"wpforms-field-label\">I have read and agreed to the MAP Acceptance of Responsibility for Export Clearance Requirements <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-81-field_168\" class=\"wpforms-field-required\"><li class=\"choice-1\"><input type=\"checkbox\" id=\"wpforms-81-field_168_1\" class=\"wpforms-payment-price\" data-amount=\"0.00\" name=\"wpforms[fields][168][]\" value=\"1\" aria-errormessage=\"wpforms-81-field_168_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_168_1\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-81-field_173-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"173\"><h3 id=\"wpforms-81-field_173\" aria-errormessage=\"wpforms-81-field_173-error\">Adverse Events<\/h3><\/div><div id=\"wpforms-81-field_137-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"137\"><div id=\"wpforms-81-field_137\" aria-errormessage=\"wpforms-81-field_137-error\">I acknowledge receipt of the MAP Adverse Event form. I agree to immediately report any Adverse Event that occurs in the use of surgical, medical and health supplies to MAP International by emailing AE@map.org.*<\/div><\/div><div id=\"wpforms-81-field_113-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"113\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">I acknowledge receipt of the MAP Adverse Event form. I agree to take the MAP Adverse Event form with me on my mission trip. I agree to immediately report any Adverse Event that occurs in the use of surgical, medical and health supplies to MAP International by emailing AE@map.org. (required) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-81-field_113\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-81-field_113_1\" name=\"wpforms[fields][113][]\" value=\"I acknowledge and agree\" aria-errormessage=\"wpforms-81-field_113_1-error\" aria-describedby=\"wpforms-81-field_113-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_113_1\">I acknowledge and agree<\/label><\/li><\/ul><div id=\"wpforms-81-field_113-description\" class=\"wpforms-field-description\">Adverse Event (AE) - Any untoward medical occurrence in a patient or a clinical-trial subject administered a medicinal product and which does not necessarily have to have a causal relationship with this treatment. An adverse event can therefore be any unfavorable and unintended sign (for example, an abnormal laboratory finding), symptom, or disease temporally associated with the use of a medicinal product, whether or not considered related to this medicinal product.<\/div><\/fieldset><\/div><div id=\"wpforms-81-field_187-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"187\"><fieldset><legend class=\"wpforms-field-label\">Upon receipt of MAP products, I assume full responsibility for the storage and security of the products. I agree to immediately report any lost or stolen goods to MAP International. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-81-field_187\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-81-field_187_1\" name=\"wpforms[fields][187][]\" value=\"I agree\" aria-errormessage=\"wpforms-81-field_187_1-error\" aria-describedby=\"wpforms-81-field_187-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_187_1\">I agree<\/label><\/li><\/ul><div id=\"wpforms-81-field_187-description\" class=\"wpforms-field-description\">9.5.2.1 Prior to shipment the Donor should ensure the Distributing Partner has a secure facility to store the product with available space to receive the shipment. (Guidelines provided by the Partnership for Quality Medical Donations)<\/div><\/fieldset><\/div><div id=\"wpforms-81-field_189-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"189\"><div id=\"wpforms-81-field_189\" aria-errormessage=\"wpforms-81-field_189-error\">Product Use and Packaging Restrictions<\/div><\/div><div id=\"wpforms-81-field_188-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"188\"><fieldset><legend class=\"wpforms-field-label\">The receiving MAP partner\/NGO agrees that all products donated by MAP International shall be distributed and used only in the original packaging as provided. The receiving partner shall not repackage, rebrand, alter, or modify any donated product in any way, including removing or replacing original labels, packaging, or markings, without prior written consent from MAP International. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-81-field_188\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-81-field_188_1\" name=\"wpforms[fields][188][]\" value=\"I agree\" aria-errormessage=\"wpforms-81-field_188_1-error\" aria-describedby=\"wpforms-81-field_188-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_188_1\">I agree<\/label><\/li><\/ul><div id=\"wpforms-81-field_188-description\" class=\"wpforms-field-description\">9.5.2.1 Prior to shipment the Donor should ensure the Distributing Partner has a secure facility to store the product with available space to receive the shipment. (Guidelines provided by the Partnership for Quality Medical Donations)<\/div><\/fieldset><\/div><div id=\"wpforms-81-field_174-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"174\"><\/div><div id=\"wpforms-81-field_114-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"114\"><fieldset><legend class=\"wpforms-field-label\">Product Use and Packaging Restrictions: The receiving MAP partner\/NGO agrees that all products donated by MAP International shall be distributed and used only in the original packaging as provided. The receiving partner shall not repackage, rebrand, alter, or modify any donated product in any way, including removing or replacing original labels, packaging, or markings, without prior written consent from MAP International. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-81-field_114\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-81-field_114_1\" name=\"wpforms[fields][114]\" value=\"I agree\" aria-errormessage=\"wpforms-81-field_114_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_114_1\">I agree<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-81-field_146-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"146\"><fieldset><legend class=\"wpforms-field-label\">Are you or your organization under any legal or travel restrictions that would prevent you from ordering MAP products? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-81-field_146\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-81-field_146_1\" name=\"wpforms[fields][146]\" value=\"Yes\" aria-errormessage=\"wpforms-81-field_146_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_146_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-81-field_146_2\" name=\"wpforms[fields][146]\" value=\"No\" aria-errormessage=\"wpforms-81-field_146_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_146_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-81-field_138-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"138\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_138\">If yes, please describe. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-81-field_138\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][138]\" aria-errormessage=\"wpforms-81-field_138-error\" required><\/textarea><\/div><div id=\"wpforms-81-field_116-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"116\"><fieldset><legend class=\"wpforms-field-label\">Service fees are established to recover a portion of MAP&#039;s annual cost to procure, receive, inventory, audit, process and ship donated and\/or purchased products. The normal service fee for this product is $65.00 USD. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-81-field_116\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-81-field_116_1\" name=\"wpforms[fields][116][]\" value=\"I understand and agree to pay any necessary service fees related to my order.\" aria-errormessage=\"wpforms-81-field_116_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_116_1\">I understand and agree to pay any necessary service fees related to my order.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-81-field_118-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"118\"><fieldset><legend class=\"wpforms-field-label\">I have a designated team member or in-country partner who has experience clearing medicines through customs to avoid confiscation. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-81-field_118\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-81-field_118_1\" name=\"wpforms[fields][118]\" value=\"Yes\" aria-errormessage=\"wpforms-81-field_118_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_118_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-81-field_118_2\" name=\"wpforms[fields][118]\" value=\"No\" aria-errormessage=\"wpforms-81-field_118_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-81-field_118_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-81-field_25-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_25\">Applicant Signature <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-81-field_25\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][25]\" autocomplete=\"off\" inputmode=\"none\" aria-errormessage=\"wpforms-81-field_25-error\" aria-describedby=\"wpforms-81-field_25-description\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-81-field_25-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Clear Signature\" tabindex=\"0\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"1em\" height=\"1em\" preserveAspectRatio=\"xMidYMid meet\" viewBox=\"0 0 1536 1536\">\n\t\t\t\t\t<path fill=\"var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )\" d=\"M1149 994q0-26-19-45L949 768l181-181q19-19 19-45q0-27-19-46l-90-90q-19-19-46-19q-26 0-45 19L768 587L587 406q-19-19-45-19q-27 0-46 19l-90 90q-19 19-19 46q0 26 19 45l181 181l-181 181q-19 19-19 45q0 27 19 46l90 90q19 19 46 19q26 0 45-19l181-181l181 181q19 19 45 19q27 0 46-19l90-90q19-19 19-46zm387-226q0 209-103 385.5T1153.5 1433T768 1536t-385.5-103T103 1153.5T0 768t103-385.5T382.5 103T768 0t385.5 103T1433 382.5T1536 768z\"\/>\n\t\t\t\t<\/svg>\n\t\t\t\t<div class=\"wpforms-signature-clear-caption\">Clear Signature<\/div>\n\t\t\t<\/div><\/div><div id=\"wpforms-81-field_25-description\" class=\"wpforms-field-description\">Click and draw your signature<\/div><\/div><div id=\"wpforms-81-field_24-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-81-field_24\">Today&#039;s Date <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-81-field_24\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][24][date]\" aria-errormessage=\"wpforms-81-field_24-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-81-field_193-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"193\"><div id=\"wpforms-81-field_193\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-81-field_193-error\"><p>Compliance and Authorization Clause<br \/>\nThe NGO shall comply with all applicable laws and regulations in the territory where it conducts activities with respect to the Contribution. The NGO affirms that it is familiar with the U.S. Foreign Corrupt Practices Act (the \u201cFCPA\u201d), as well as the sanctions managed by the Office of Foreign Assets Control (OFAC) and the Bureau of Industry and Security (BIS), including their prohibitions and purposes, and agrees not to undertake any actions that may violate the FCPA, OFAC sanctions, or BIS regulations.<\/p>\n<p>The NGO may only import or distribute medicines received from MAP International in accordance with applicable national laws, regulations, and health policies. However, the NGO may receive and act upon\u00a0express written permission from the Ministry of Health or other authorized government entities\u00a0to bring in medicines outside of these parameters.<br \/>\nIn all other cases where government authorization is not expressly granted, the NGO shall\u00a0direct such requests, policies, or processes to MAP International\u00a0and obtain\u00a0express written permission from MAP International before undertaking any such action.<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-81-field_2-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-81-field_2-container input { visibility: hidden; } #wpforms-conversational-form-page #wpforms-81-field_2-container label { counter-increment: none; }' ) );\n\t\t\t\t\tdocument.head.appendChild( style );\n\t\t\t\t\tdocument.currentScript?.remove();\n\t\t\t\t} )();\n\t\t\t<\/script><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"81\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/www.map.org\/jnjmedtech\/wp-json\/wp\/v2\/pages\/117\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-81\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.map.org\/jnjmedtech\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><a href=\"#\" class=\"wpforms-save-resume-button\"><span>Save and Resume Later<\/span><\/a><\/div><\/form><\/div>  <!-- .wpforms-container -->\n<div class=\"wpforms-save-resume-confirmation\" id=\"wpforms-save-resume-confirmation-81\" style=\"display: none\">\n\n\t\n\t<div class=\"message\">\n\t\t<p>Your form entry has been saved and a unique link has been created which you can access to resume this form.<\/p>\n<p>Enter your email address to receive the link via email. Alternatively, you can copy and save the link below.<\/p>\n<p>Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.<\/p>\n\t<\/div>\n\n\t<div class=\"wpforms-save-resume-actions\">\n\t\t\t\t\t<div class=\"wpforms-field\">\n\t\t\t\t<label class=\"wpforms-field-label wpforms-save-resume-label\">\n\t\t\t\t\tCopy Link\t\t\t\t<\/label>\n\t\t\t\t<div class=\"wpforms-save-resume-shortcode-container\">\n\t\t\t\t\t<input type=\"text\" class=\"wpforms-save-resume-shortcode\" value=\"\" disabled \/>\n\t\t\t\t\t<span class=\"wpforms-save-resume-shortcode-copy\" title=\"Copy resume link to clipboard\">\n\t\t\t\t\t\t\t<span class=\"copy-icon\"><\/span>\n\t\t\t\t\t\t<\/span>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\n\t\t\t\t\t<form class=\"wpforms-validate wpforms-form wpforms-save-resume-email-notification\" method=\"post\" action=\"\/jnjmedtech\/wp-json\/wp\/v2\/pages\/117\" data-token=\"0319504cef5ce68194a1715efa33e60f\">\n\t\t\t\t<div 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