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FrameBuilder.get=qsProxy||[];var initialHeight="LEGACY"==='CARD'?640:539;var i63205346084149=new FrameBuilder("63205346084149",false,initialHeight,"<!DOCTYPE HTML PUBLIC \"-\/\/W3C\/\/DTD HTML 4.01\/\/EN\" \"http:\/\/www.w3.org\/TR\/html4\/strict.dtd\">\n<html lang=\"en-US\"  class=\"supernova \"><head>\n<meta http-equiv=\"Content-Type\" content=\"text\/html; charset=utf-8\" \/>\n<link rel=\"alternate\" type=\"application\/json+oembed\" href=\"https:\/\/www.jotform.com\/oembed\/?format=json&amp;url=https%3A%2F%2Fform.jotform.com%2F63205346084149\" title=\"oEmbed Form\">\n<link rel=\"alternate\" type=\"text\/xml+oembed\" href=\"https:\/\/www.jotform.com\/oembed\/?format=xml&amp;url=https%3A%2F%2Fform.jotform.com%2F63205346084149\" title=\"oEmbed Form\">\n<meta property=\"og:title\" content=\"Shipping Pickup Order\" >\n<meta property=\"og:url\" content=\"https:\/\/form.jotform.com\/63205346084149\" >\n<meta property=\"og:description\" content=\"Please click the link to complete this form.\" >\n<meta name=\"slack-app-id\" content=\"AHNMASS8M\">\n<meta property=\"og:image\" content=\"https:\/\/cdn.jotfor.ms\/assets\/img\/landing\/opengraph.png\" \/>\n<link rel=\"shortcut icon\" href=\"https:\/\/cdn.jotfor.ms\/assets\/img\/favicons\/favicon-2021-light%402x.png\">\n<link rel=\"apple-touch-icon\" href=\"https:\/\/cdn.jotfor.ms\/assets\/img\/favicons\/favicon-2021-light%402x.png\">\n<script>\n          var favicon = document.querySelector('link[rel=\"shortcut icon\"]');\n          window.isDarkMode = (window.matchMedia && window.matchMedia('(prefers-color-scheme: dark)').matches);\n          if(favicon && window.isDarkMode) {\n              favicon.href = favicon.href.replaceAll('favicon-2021-light%402x.png', 'favicon-2021-dark%402x.png');\n          }\n      <\/script><link rel=\"canonical\" href=\"https:\/\/form.jotform.com\/63205346084149\" \/>\n<meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0, maximum-scale=2.0, user-scalable=1\" \/>\n<meta name=\"HandheldFriendly\" content=\"true\" \/>\n<title>Shipping Pickup Order<\/title>\n<link href=\"https:\/\/cdn01.jotfor.ms\/static\/formCss.css?3.3.51776\" rel=\"stylesheet\" type=\"text\/css\" \/>\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/cdn02.jotfor.ms\/stylebuilder\/static\/form-common.css?v=18cfc0e\n\"\/>\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/cdn03.jotfor.ms\/css\/styles\/nova.css?3.3.51776\" \/>\n<style type=\"text\/css\">@media print{*{-webkit-print-color-adjust: exact !important;color-adjust: exact !important;}.form-section{display:inline!important}.form-pagebreak{display:none!important}.form-section-closed{height:auto!important}.page-section{position:initial!important}}<\/style>\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/cdn01.jotfor.ms\/themes\/CSS\/566a91c2977cdfcd478b4567.css?v=3.3.51776\"\/>\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/cdn02.jotfor.ms\/css\/styles\/payment\/payment_feature.css?3.3.51776\" \/>\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/cdn03.jotfor.ms\/stylebuilder\/static\/donationBox.css?v=3.3.51776\">\n<style type=\"text\/css\">\n    .form-label-left{\n        width:150px;\n    }\n    .form-line{\n        padding-top:12px;\n        padding-bottom:12px;\n    }\n    .form-label-right{\n        width:150px;\n    }\n    body, html{\n        margin:0;\n        padding:0;\n        background:false;\n    }\n\n    .form-all{\n        margin:0px auto;\n        padding-top:0px;\n        width:750px;\n        color:#555 !important;\n        font-family:\"Lucida Grande\", \"Lucida Sans Unicode\", \"Lucida Sans\", Verdana, sans-serif;\n        font-size:14px;\n    }\n    .form-radio-item label, .form-checkbox-item label, .form-grading-label, .form-header{\n        color: #555;\n    }\n\n<\/style>\n\n<style type=\"text\/css\" id=\"form-designer-style\">\n    \/* Injected CSS Code *\/\n\/*PREFERENCES STYLE*\/\n    .form-label.form-label-auto {\n      \n    display: inline-block;\n    float: left;\n    text-align: left;\n  \n    }\n  \n    .form-line {\n      margin-top: 12px;\n      margin-bottom: 12px;\n    }\n  \n    .form-all {\n      width: 750px;\n    }\n  \n    .form-label-left,\n    .form-label-right {\n      width: 150px\n    }\n  \n    .form-all {\n      font-family: Lucida Grande, sans-serif;\n    }\n    .form-all .qq-upload-button,\n    .form-all .form-submit-button,\n    .form-all .form-submit-reset,\n    .form-all .form-submit-print {\n      font-family: Lucida Grande, sans-serif;\n    }\n    .form-all .form-pagebreak-back-container,\n    .form-all .form-pagebreak-next-container {\n      font-family: Lucida Grande, sans-serif;\n    }\n    .form-header-group {\n      font-family: Lucida Grande, sans-serif;\n    }\n    .form-label {\n      font-family: Lucida Grande, sans-serif;\n    }\n  \n    .form-all {\n      font-size: 14px\n    }\n    .form-all .qq-upload-button,\n    .form-all .qq-upload-button,\n    .form-all .form-submit-button,\n    .form-all .form-submit-reset,\n    .form-all .form-submit-print {\n      font-size: 14px\n    }\n    .form-all .form-pagebreak-back-container,\n    .form-all .form-pagebreak-next-container {\n      font-size: 14px\n    }\n  \n    .supernova .form-all, .form-all {\n      background-color: ;\n      border: 1px solid transparent;\n    }\n  \n    .form-all {\n      color: #555;\n    }\n    .form-header-group .form-header {\n      color: #555;\n    }\n    .form-header-group .form-subHeader {\n      color: #555;\n    }\n    .form-label-top,\n    .form-label-left,\n    .form-label-right,\n    .form-html,\n    .form-checkbox-item label,\n    .form-radio-item label {\n      color: #555;\n    }\n  \n    .supernova {\n      background-color: #f5f5f5;\n    }\n    .supernova body {\n      background: transparent;\n    }\n  \n    .form-textbox,\n    .form-textarea,\n    .form-radio-other-input,\n    .form-checkbox-other-input,\n    .form-captcha input,\n    .form-spinner input {\n      background-color: #fff;\n    }\n  \n    .supernova {\n      background-image: none;\n    }\n    #stage {\n      background-image: none;\n    }\n  \n    .form-all {\n      background-image: none;\n    }\n  \/*PREFERENCES STYLE*\/\/*__INSPECT_SEPERATOR__*\/\n    \/* Injected CSS Code *\/\n<\/style>\n\n<script src=\"https:\/\/cdn01.jotfor.ms\/static\/prototype.forms.js?v=3.3.51776\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn02.jotfor.ms\/static\/jotform.forms.js?v=3.3.51776\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn03.jotfor.ms\/js\/paypal.js?v=3.3.51776\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn01.jotfor.ms\/js\/payments\/paymentUtils.js?v=3.3.51776\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn02.jotfor.ms\/js\/payments\/validategateways.js?v=3.3.51776\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn01.jotfor.ms\/s\/umd\/9443516321b\/for-widgets-server.js?v=3.3.51776\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn01.jotfor.ms\/s\/umd\/9443516321b\/for-form-branding-footer.js?v=3.3.51776\" type=\"text\/javascript\" defer><\/script>\n<script type=\"text\/javascript\">\tJotForm.newDefaultTheme = false;\n\tJotForm.extendsNewTheme = false;\n\tJotForm.singleProduct = false;\n\tJotForm.newPaymentUIForNewCreatedForms = false;\n\tJotForm.texts = {\"confirmEmail\":\"E-mail does not match\",\"pleaseWait\":\"Please wait...\",\"validateEmail\":\"You need to validate this e-mail\",\"confirmClearForm\":\"Are you sure you want to clear the form\",\"lessThan\":\"Your score should be less than or equal to\",\"incompleteFields\":\"There are incomplete required fields. 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Please enter the address manually.\",\"geoTimeoutTitle\":\"Timeout\",\"geoTimeoutDesc\":\"Please check your internet connection and try again.\",\"selectedTime\":\"Selected Time\",\"formerSelectedTime\":\"Former Time\",\"cancelAppointment\":\"Cancel Appointment\",\"cancelSelection\":\"Cancel Selection\",\"noSlotsAvailable\":\"No slots available\",\"slotUnavailable\":\"{time} on {date} has been selected is unavailable. Please select another slot.\",\"multipleError\":\"There are {count} errors on this page. Please correct them before moving on.\",\"oneError\":\"There is {count} error on this page. Please correct it before moving on.\",\"doneMessage\":\"Well done! 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Multiple submissions are disabled for this form.\",\"reviewBackText\":\"Back to Form\",\"seeAllText\":\"See All\",\"progressMiddleText\":\"of\",\"fieldError\":\"field has an error.\",\"error\":\"Error\"};\n\n var jsTime = setInterval(function(){try{\n   JotForm.jsForm = true;\n\tJotForm.replaceTagTest = true;\n\tJotForm.clearFieldOnHide=\"disable\";\n\tJotForm.submitError=\"jumpToFirstError\";\n\twindow.addEventListener('DOMContentLoaded',function(){window.brandingFooter.init({\"formID\":63205346084149,\"campaign\":\"powered_by_jotform_le\",\"isCardForm\":false,\"isLegacyForm\":true})});\n\tJotForm.init(function(){\n\t\/*INIT-START*\/\n\n JotForm.calendarMonths = [\"January\",\"February\",\"March\",\"April\",\"May\",\"June\",\"July\",\"August\",\"September\",\"October\",\"November\",\"December\"];\n if (!JotForm.calenderViewMonths) JotForm.calenderViewMonths = {};  JotForm.calenderViewMonths[3] = 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{\"days\":{\"monday\":true,\"tuesday\":true,\"wednesday\":true,\"thursday\":true,\"friday\":true,\"saturday\":true,\"sunday\":true},\"future\":true,\"past\":true,\"custom\":false,\"ranges\":false,\"start\":\"\",\"end\":\"\",\"countSelectedDaysOnly\":false}); }, 0); });\n } \n JotForm.onTranslationsFetch(function() { JotForm.setCalendar(\"3\", false, {\"days\":{\"monday\":true,\"tuesday\":true,\"wednesday\":true,\"thursday\":true,\"friday\":true,\"saturday\":true,\"sunday\":true},\"future\":true,\"past\":true,\"custom\":false,\"ranges\":false,\"start\":\"\",\"end\":\"\",\"countSelectedDaysOnly\":false}); });\nif (window.JotForm && JotForm.accessible) $('input_4').setAttribute('tabindex',0);\nif (window.JotForm && JotForm.accessible) $('input_5').setAttribute('tabindex',0);\nif (window.JotForm && JotForm.accessible) $('input_6').setAttribute('tabindex',0);\nif (window.JotForm && JotForm.accessible) $('input_8').setAttribute('tabindex',0);\nif (window.JotForm && JotForm.accessible) $('input_9').setAttribute('tabindex',0);\nif (window.JotForm && JotForm.accessible) $('input_10').setAttribute('tabindex',0);\nif (window.JotForm && JotForm.accessible) $('input_12').setAttribute('tabindex',0);\n      productID = {};\n      paymentType = \"product\";\n      JotForm.setCurrencyFormat('USD',true, 'point');\n      JotForm.totalCounter({});\n      $$('.form-product-custom_quantity').each(function(el, i){el.observe('blur', function(){isNaN(this.value) || this.value < 1 ? this.value = '0' : this.value = parseInt(this.value)})});\n      $$('.form-product-custom_quantity').each(function(el, i){el.observe('focus', function(){this.value == 0 ? this.value = '' : this.value})});\n      JotForm.handleProductLightbox();\n\t\/*INIT-END*\/\n\t});\n\n   clearInterval(jsTime);\n }catch(e){}}, 1000);\n\n   setTimeout(function() {\nJotForm.paymentExtrasOnTheFly([null,{\"name\":\"heading\",\"qid\":\"1\",\"text\":\"Shipping Pickup 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name=\"buildDate\" value=\"1708962187054\" \/>\n  <div role=\"main\" class=\"form-all\">\n    <ul class=\"form-section page-section\">\n      <li id=\"cid_1\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group  header-default\">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_1\" class=\"form-header\" data-component=\"header\">Shipping Pickup Order<\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_datetime\" id=\"id_3\"><label class=\"form-label form-label-left form-label-auto\" id=\"label_3\" for=\"month_3\" aria-hidden=\"false\"> Date <\/label>\n        <div id=\"cid_3\" class=\"form-input\">\n          <div data-wrapper-react=\"true\" class=\"extended notLiteMode\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"tel\" class=\"form-textbox validate[limitDate]\" id=\"month_3\" name=\"q3_date[month]\" size=\"2\" 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data-maxlength=\"4\" data-age=\"\" maxLength=\"4\" value=\"\" autoComplete=\"off\" aria-labelledby=\"label_3 sublabel_3_year\" \/><label class=\"form-sub-label\" for=\"year_3\" id=\"sublabel_3_year\" style=\"min-height:13px\">Year<\/label><\/span><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><img class=\"showAutoCalendar newDefaultTheme-dateIcon icon-seperatedMode\" alt=\"Pick a Date\" id=\"input_3_pick\" src=\"https:\/\/cdn.jotfor.ms\/images\/calendar.png\" data-component=\"datetime\" aria-hidden=\"true\" data-allow-time=\"No\" data-version=\"v1\" \/><label class=\"form-sub-label\" for=\"input_3_pick\" style=\"border:0;clip:rect(0 0 0 0);height:1px;margin:-1px;overflow:hidden;padding:0;position:absolute;width:1px;white-space:nowrap\" aria-hidden=\"true\" tabindex=\"-1\">Date Picker Icon<\/label><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_4\"><label class=\"form-label form-label-left form-label-auto\" id=\"label_4\" for=\"input_4\" aria-hidden=\"false\"> When Ready <\/label>\n        <div id=\"cid_4\" class=\"form-input\"> <input type=\"text\" id=\"input_4\" name=\"q4_whenReady4\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" size=\"20\" placeholder=\" \" data-component=\"textbox\" aria-labelledby=\"label_4\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_5\"><label class=\"form-label form-label-left form-label-auto\" id=\"label_5\" for=\"input_5\" aria-hidden=\"false\"> Company <\/label>\n        <div id=\"cid_5\" class=\"form-input\"> <input type=\"text\" id=\"input_5\" name=\"q5_company\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" size=\"20\" placeholder=\" \" data-component=\"textbox\" aria-labelledby=\"label_5\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_address\" id=\"id_7\"><label class=\"form-label form-label-left form-label-auto\" id=\"label_7\" for=\"input_7_addr_line1\" aria-hidden=\"false\"> Address <\/label>\n        <div id=\"cid_7\" class=\"form-input\">\n          <div summary=\"\" class=\"form-address-table jsTest-addressField\">\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\"><span class=\"form-address-line form-address-street-line jsTest-address-lineField\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_7_addr_line1\" name=\"q7_address[addr_line1]\" class=\"form-textbox form-address-line\" data-defaultvalue=\"\" autoComplete=\"section-input_7 address-line1\" data-component=\"address_line_1\" aria-labelledby=\"label_7 sublabel_7_addr_line1\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_7_addr_line1\" id=\"sublabel_7_addr_line1\" style=\"min-height:13px\">Street Address<\/label><\/span><\/span><\/div>\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\"><span class=\"form-address-line form-address-street-line jsTest-address-lineField\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_7_addr_line2\" name=\"q7_address[addr_line2]\" class=\"form-textbox form-address-line\" data-defaultvalue=\"\" autoComplete=\"section-input_7 address-line2\" data-component=\"address_line_2\" aria-labelledby=\"label_7 sublabel_7_addr_line2\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_7_addr_line2\" id=\"sublabel_7_addr_line2\" style=\"min-height:13px\">Street Address Line 2<\/label><\/span><\/span><\/div>\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\"><span class=\"form-address-line form-address-city-line jsTest-address-lineField \"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_7_city\" name=\"q7_address[city]\" class=\"form-textbox form-address-city\" data-defaultvalue=\"\" autoComplete=\"section-input_7 address-level2\" data-component=\"city\" aria-labelledby=\"label_7 sublabel_7_city\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_7_city\" id=\"sublabel_7_city\" style=\"min-height:13px\">City<\/label><\/span><\/span><span class=\"form-address-line form-address-state-line jsTest-address-lineField \"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_7_state\" name=\"q7_address[state]\" class=\"form-textbox form-address-state\" data-defaultvalue=\"\" autoComplete=\"section-input_7 address-level1\" data-component=\"state\" aria-labelledby=\"label_7 sublabel_7_state\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_7_state\" id=\"sublabel_7_state\" style=\"min-height:13px\">State \/ Province<\/label><\/span><\/span><\/div>\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\"><span class=\"form-address-line form-address-zip-line jsTest-address-lineField \"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_7_postal\" name=\"q7_address[postal]\" class=\"form-textbox form-address-postal\" data-defaultvalue=\"\" autoComplete=\"section-input_7 postal-code\" data-component=\"zip\" aria-labelledby=\"label_7 sublabel_7_postal\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_7_postal\" id=\"sublabel_7_postal\" style=\"min-height:13px\">Postal \/ Zip Code<\/label><\/span><\/span><span class=\"form-address-line form-address-country-line jsTest-address-lineField \"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><select class=\"form-dropdown form-address-country\" name=\"q7_address[country]\" id=\"input_7_country\" data-component=\"country\" required=\"\" aria-labelledby=\"label_7 sublabel_7_country\" autoComplete=\"section-input_7 country\">\n                    <option value=\"\">Please Select<\/option>\n                    <option value=\"United States\">United States<\/option>\n                    <option value=\"Afghanistan\">Afghanistan<\/option>\n                    <option value=\"Albania\">Albania<\/option>\n                    <option value=\"Algeria\">Algeria<\/option>\n                    <option value=\"American Samoa\">American Samoa<\/option>\n                    <option value=\"Andorra\">Andorra<\/option>\n                    <option value=\"Angola\">Angola<\/option>\n                    <option value=\"Anguilla\">Anguilla<\/option>\n                    <option value=\"Antigua and Barbuda\">Antigua and Barbuda<\/option>\n                    <option value=\"Argentina\">Argentina<\/option>\n                    <option value=\"Armenia\">Armenia<\/option>\n                    <option value=\"Aruba\">Aruba<\/option>\n                    <option value=\"Australia\">Australia<\/option>\n                    <option value=\"Austria\">Austria<\/option>\n                    <option value=\"Azerbaijan\">Azerbaijan<\/option>\n                    <option value=\"The Bahamas\">The Bahamas<\/option>\n                    <option value=\"Bahrain\">Bahrain<\/option>\n                    <option value=\"Bangladesh\">Bangladesh<\/option>\n                    <option value=\"Barbados\">Barbados<\/option>\n                    <option value=\"Belarus\">Belarus<\/option>\n                    <option value=\"Belgium\">Belgium<\/option>\n                    <option value=\"Belize\">Belize<\/option>\n                    <option value=\"Benin\">Benin<\/option>\n                    <option value=\"Bermuda\">Bermuda<\/option>\n                    <option value=\"Bhutan\">Bhutan<\/option>\n                    <option value=\"Bolivia\">Bolivia<\/option>\n                    <option value=\"Bosnia and Herzegovina\">Bosnia and Herzegovina<\/option>\n                    <option value=\"Botswana\">Botswana<\/option>\n                    <option value=\"Brazil\">Brazil<\/option>\n                    <option value=\"Brunei\">Brunei<\/option>\n                    <option value=\"Bulgaria\">Bulgaria<\/option>\n                    <option value=\"Burkina Faso\">Burkina Faso<\/option>\n                    <option value=\"Burundi\">Burundi<\/option>\n                    <option value=\"Cambodia\">Cambodia<\/option>\n                    <option value=\"Cameroon\">Cameroon<\/option>\n                    <option value=\"Canada\">Canada<\/option>\n                    <option value=\"Cape Verde\">Cape Verde<\/option>\n                    <option value=\"Cayman Islands\">Cayman Islands<\/option>\n                    <option value=\"Central African Republic\">Central African Republic<\/option>\n                    <option value=\"Chad\">Chad<\/option>\n                    <option value=\"Chile\">Chile<\/option>\n                    <option value=\"China\">China<\/option>\n                    <option value=\"Christmas Island\">Christmas Island<\/option>\n                    <option value=\"Cocos (Keeling) Islands\">Cocos (Keeling) Islands<\/option>\n                    <option value=\"Colombia\">Colombia<\/option>\n                    <option value=\"Comoros\">Comoros<\/option>\n                    <option value=\"Congo\">Congo<\/option>\n                    <option value=\"Cook Islands\">Cook Islands<\/option>\n                    <option value=\"Costa Rica\">Costa Rica<\/option>\n                    <option value=\"Cote d&#x27;Ivoire\">Cote d&#x27;Ivoire<\/option>\n                    <option value=\"Croatia\">Croatia<\/option>\n                    <option value=\"Cuba\">Cuba<\/option>\n                    <option value=\"Cura\u00e7ao\">Cura\u00e7ao<\/option>\n                    <option value=\"Cyprus\">Cyprus<\/option>\n                    <option value=\"Czech Republic\">Czech Republic<\/option>\n                    <option value=\"Democratic Republic of the Congo\">Democratic Republic of the Congo<\/option>\n                    <option value=\"Denmark\">Denmark<\/option>\n                    <option value=\"Djibouti\">Djibouti<\/option>\n                    <option value=\"Dominica\">Dominica<\/option>\n                    <option value=\"Dominican Republic\">Dominican Republic<\/option>\n                    <option value=\"Ecuador\">Ecuador<\/option>\n                    <option value=\"Egypt\">Egypt<\/option>\n                    <option value=\"El Salvador\">El Salvador<\/option>\n                    <option value=\"Equatorial Guinea\">Equatorial Guinea<\/option>\n                    <option value=\"Eritrea\">Eritrea<\/option>\n                    <option value=\"Estonia\">Estonia<\/option>\n                    <option value=\"Ethiopia\">Ethiopia<\/option>\n                    <option value=\"Falkland Islands\">Falkland Islands<\/option>\n                    <option value=\"Faroe Islands\">Faroe Islands<\/option>\n                    <option value=\"Fiji\">Fiji<\/option>\n                    <option value=\"Finland\">Finland<\/option>\n                    <option value=\"France\">France<\/option>\n                    <option value=\"French Polynesia\">French Polynesia<\/option>\n                    <option value=\"Gabon\">Gabon<\/option>\n                    <option value=\"The Gambia\">The Gambia<\/option>\n                    <option value=\"Georgia\">Georgia<\/option>\n                    <option value=\"Germany\">Germany<\/option>\n                    <option value=\"Ghana\">Ghana<\/option>\n                    <option value=\"Gibraltar\">Gibraltar<\/option>\n                    <option value=\"Greece\">Greece<\/option>\n                    <option value=\"Greenland\">Greenland<\/option>\n                    <option value=\"Grenada\">Grenada<\/option>\n                    <option value=\"Guadeloupe\">Guadeloupe<\/option>\n                    <option value=\"Guam\">Guam<\/option>\n                    <option value=\"Guatemala\">Guatemala<\/option>\n                    <option value=\"Guernsey\">Guernsey<\/option>\n                    <option value=\"Guinea\">Guinea<\/option>\n                    <option value=\"Guinea-Bissau\">Guinea-Bissau<\/option>\n                    <option value=\"Guyana\">Guyana<\/option>\n                    <option value=\"Haiti\">Haiti<\/option>\n                    <option value=\"Honduras\">Honduras<\/option>\n                    <option value=\"Hong Kong\">Hong Kong<\/option>\n                    <option value=\"Hungary\">Hungary<\/option>\n                    <option value=\"Iceland\">Iceland<\/option>\n                    <option value=\"India\">India<\/option>\n                    <option value=\"Indonesia\">Indonesia<\/option>\n                    <option value=\"Iran\">Iran<\/option>\n                    <option value=\"Iraq\">Iraq<\/option>\n                    <option value=\"Ireland\">Ireland<\/option>\n                    <option value=\"Israel\">Israel<\/option>\n                    <option value=\"Italy\">Italy<\/option>\n                    <option value=\"Jamaica\">Jamaica<\/option>\n                    <option value=\"Japan\">Japan<\/option>\n                    <option value=\"Jersey\">Jersey<\/option>\n                    <option value=\"Jordan\">Jordan<\/option>\n                    <option value=\"Kazakhstan\">Kazakhstan<\/option>\n                    <option value=\"Kenya\">Kenya<\/option>\n                    <option value=\"Kiribati\">Kiribati<\/option>\n                    <option value=\"North Korea\">North Korea<\/option>\n                    <option value=\"South Korea\">South Korea<\/option>\n                    <option value=\"Kosovo\">Kosovo<\/option>\n                    <option value=\"Kuwait\">Kuwait<\/option>\n                    <option value=\"Kyrgyzstan\">Kyrgyzstan<\/option>\n                    <option value=\"Laos\">Laos<\/option>\n                    <option value=\"Latvia\">Latvia<\/option>\n                    <option value=\"Lebanon\">Lebanon<\/option>\n                    <option value=\"Lesotho\">Lesotho<\/option>\n                    <option value=\"Liberia\">Liberia<\/option>\n                    <option value=\"Libya\">Libya<\/option>\n                    <option value=\"Liechtenstein\">Liechtenstein<\/option>\n                    <option value=\"Lithuania\">Lithuania<\/option>\n                    <option value=\"Luxembourg\">Luxembourg<\/option>\n                    <option value=\"Macau\">Macau<\/option>\n                    <option value=\"Macedonia\">Macedonia<\/option>\n                    <option value=\"Madagascar\">Madagascar<\/option>\n                    <option value=\"Malawi\">Malawi<\/option>\n                    <option value=\"Malaysia\">Malaysia<\/option>\n                    <option value=\"Maldives\">Maldives<\/option>\n                    <option value=\"Mali\">Mali<\/option>\n                    <option value=\"Malta\">Malta<\/option>\n                    <option value=\"Marshall Islands\">Marshall Islands<\/option>\n                    <option value=\"Martinique\">Martinique<\/option>\n                    <option value=\"Mauritania\">Mauritania<\/option>\n                    <option value=\"Mauritius\">Mauritius<\/option>\n                    <option value=\"Mayotte\">Mayotte<\/option>\n                    <option value=\"Mexico\">Mexico<\/option>\n                    <option value=\"Micronesia\">Micronesia<\/option>\n                    <option value=\"Moldova\">Moldova<\/option>\n                    <option value=\"Monaco\">Monaco<\/option>\n                    <option value=\"Mongolia\">Mongolia<\/option>\n                    <option value=\"Montenegro\">Montenegro<\/option>\n                    <option value=\"Montserrat\">Montserrat<\/option>\n                    <option value=\"Morocco\">Morocco<\/option>\n                    <option value=\"Mozambique\">Mozambique<\/option>\n                    <option value=\"Myanmar\">Myanmar<\/option>\n                    <option value=\"Nagorno-Karabakh\">Nagorno-Karabakh<\/option>\n                    <option value=\"Namibia\">Namibia<\/option>\n                    <option value=\"Nauru\">Nauru<\/option>\n                    <option value=\"Nepal\">Nepal<\/option>\n                    <option value=\"Netherlands\">Netherlands<\/option>\n                    <option value=\"Netherlands Antilles\">Netherlands Antilles<\/option>\n                    <option value=\"New Caledonia\">New Caledonia<\/option>\n                    <option value=\"New Zealand\">New Zealand<\/option>\n                    <option value=\"Nicaragua\">Nicaragua<\/option>\n                    <option value=\"Niger\">Niger<\/option>\n                    <option value=\"Nigeria\">Nigeria<\/option>\n                    <option value=\"Niue\">Niue<\/option>\n                    <option value=\"Norfolk Island\">Norfolk Island<\/option>\n                    <option value=\"Turkish Republic of Northern Cyprus\">Turkish Republic of Northern Cyprus<\/option>\n                    <option value=\"Northern Mariana\">Northern Mariana<\/option>\n                    <option value=\"Norway\">Norway<\/option>\n                    <option value=\"Oman\">Oman<\/option>\n                    <option value=\"Pakistan\">Pakistan<\/option>\n                    <option value=\"Palau\">Palau<\/option>\n                    <option value=\"Palestine\">Palestine<\/option>\n                    <option value=\"Panama\">Panama<\/option>\n                    <option value=\"Papua New Guinea\">Papua New Guinea<\/option>\n                    <option value=\"Paraguay\">Paraguay<\/option>\n                    <option value=\"Peru\">Peru<\/option>\n                    <option value=\"Philippines\">Philippines<\/option>\n                    <option value=\"Pitcairn Islands\">Pitcairn Islands<\/option>\n                    <option value=\"Poland\">Poland<\/option>\n                    <option value=\"Portugal\">Portugal<\/option>\n                    <option value=\"Puerto Rico\">Puerto Rico<\/option>\n                    <option value=\"Qatar\">Qatar<\/option>\n                    <option value=\"Republic of the Congo\">Republic of the Congo<\/option>\n                    <option value=\"Romania\">Romania<\/option>\n                    <option value=\"Russia\">Russia<\/option>\n                    <option value=\"Rwanda\">Rwanda<\/option>\n                    <option value=\"Saint Barthelemy\">Saint Barthelemy<\/option>\n                    <option value=\"Saint Helena\">Saint Helena<\/option>\n                    <option value=\"Saint Kitts and Nevis\">Saint Kitts and Nevis<\/option>\n                    <option value=\"Saint Lucia\">Saint Lucia<\/option>\n                    <option value=\"Saint Martin\">Saint Martin<\/option>\n                    <option value=\"Saint Pierre and Miquelon\">Saint Pierre and Miquelon<\/option>\n                    <option value=\"Saint Vincent and the Grenadines\">Saint Vincent and the Grenadines<\/option>\n                    <option value=\"Samoa\">Samoa<\/option>\n                    <option value=\"San Marino\">San Marino<\/option>\n                    <option value=\"Sao Tome and Principe\">Sao Tome and Principe<\/option>\n                    <option value=\"Saudi Arabia\">Saudi Arabia<\/option>\n                    <option value=\"Senegal\">Senegal<\/option>\n                    <option value=\"Serbia\">Serbia<\/option>\n                    <option value=\"Seychelles\">Seychelles<\/option>\n                    <option value=\"Sierra Leone\">Sierra Leone<\/option>\n                    <option value=\"Singapore\">Singapore<\/option>\n                    <option value=\"Slovakia\">Slovakia<\/option>\n                    <option value=\"Slovenia\">Slovenia<\/option>\n                    <option value=\"Solomon Islands\">Solomon Islands<\/option>\n                    <option value=\"Somalia\">Somalia<\/option>\n                    <option value=\"Somaliland\">Somaliland<\/option>\n                    <option value=\"South Africa\">South Africa<\/option>\n                    <option value=\"South Ossetia\">South Ossetia<\/option>\n                    <option value=\"South Sudan\">South Sudan<\/option>\n                    <option value=\"Spain\">Spain<\/option>\n                    <option value=\"Sri Lanka\">Sri Lanka<\/option>\n                    <option value=\"Sudan\">Sudan<\/option>\n                    <option value=\"Suriname\">Suriname<\/option>\n                    <option value=\"Svalbard\">Svalbard<\/option>\n                    <option value=\"eSwatini\">eSwatini<\/option>\n                    <option value=\"Sweden\">Sweden<\/option>\n                    <option value=\"Switzerland\">Switzerland<\/option>\n                    <option value=\"Syria\">Syria<\/option>\n                    <option value=\"Taiwan\">Taiwan<\/option>\n                    <option value=\"Tajikistan\">Tajikistan<\/option>\n                    <option value=\"Tanzania\">Tanzania<\/option>\n                    <option value=\"Thailand\">Thailand<\/option>\n                    <option value=\"Timor-Leste\">Timor-Leste<\/option>\n                    <option value=\"Togo\">Togo<\/option>\n                    <option value=\"Tokelau\">Tokelau<\/option>\n                    <option value=\"Tonga\">Tonga<\/option>\n                    <option value=\"Transnistria Pridnestrovie\">Transnistria Pridnestrovie<\/option>\n                    <option value=\"Trinidad and Tobago\">Trinidad and Tobago<\/option>\n                    <option value=\"Tristan da Cunha\">Tristan da Cunha<\/option>\n                    <option value=\"Tunisia\">Tunisia<\/option>\n                    <option value=\"Turkey\">Turkey<\/option>\n                    <option value=\"Turkmenistan\">Turkmenistan<\/option>\n                    <option value=\"Turks and Caicos Islands\">Turks and Caicos Islands<\/option>\n                    <option value=\"Tuvalu\">Tuvalu<\/option>\n                    <option value=\"Uganda\">Uganda<\/option>\n                    <option value=\"Ukraine\">Ukraine<\/option>\n                    <option value=\"United Arab Emirates\">United Arab Emirates<\/option>\n                    <option value=\"United Kingdom\">United Kingdom<\/option>\n                    <option value=\"Uruguay\">Uruguay<\/option>\n                    <option value=\"Uzbekistan\">Uzbekistan<\/option>\n                    <option value=\"Vanuatu\">Vanuatu<\/option>\n                    <option value=\"Vatican City\">Vatican City<\/option>\n                    <option value=\"Venezuela\">Venezuela<\/option>\n                    <option value=\"Vietnam\">Vietnam<\/option>\n                    <option value=\"British Virgin Islands\">British Virgin Islands<\/option>\n                    <option value=\"Isle of Man\">Isle of Man<\/option>\n                    <option value=\"US Virgin Islands\">US Virgin Islands<\/option>\n                    <option value=\"Wallis and Futuna\">Wallis and Futuna<\/option>\n                    <option value=\"Western Sahara\">Western Sahara<\/option>\n                    <option value=\"Yemen\">Yemen<\/option>\n                    <option value=\"Zambia\">Zambia<\/option>\n                    <option value=\"Zimbabwe\">Zimbabwe<\/option>\n                    <option value=\"other\">Other<\/option>\n                  <\/select><label class=\"form-sub-label\" for=\"input_7_country\" id=\"sublabel_7_country\" style=\"min-height:13px\">Country<\/label><\/span><\/span><\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_6\"><label class=\"form-label form-label-left form-label-auto\" id=\"label_6\" for=\"input_6\" aria-hidden=\"false\"> Quantity <\/label>\n        <div id=\"cid_6\" class=\"form-input\"> <input type=\"text\" id=\"input_6\" name=\"q6_quantity\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" size=\"20\" placeholder=\" \" data-component=\"textbox\" aria-labelledby=\"label_6\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_widget\" id=\"id_14\"><label class=\"form-label form-label-left form-label-auto\" id=\"label_14\" for=\"input_14\" aria-hidden=\"true\"> <\/label>\n        <div id=\"cid_14\" class=\"\"> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_8\"><label class=\"form-label form-label-left form-label-auto\" id=\"label_8\" for=\"input_8\" aria-hidden=\"false\"> Description <\/label>\n        <div id=\"cid_8\" class=\"form-input\"> <input type=\"text\" id=\"input_8\" name=\"q8_description\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" size=\"20\" placeholder=\" \" data-component=\"textbox\" aria-labelledby=\"label_8\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_9\"><label class=\"form-label form-label-left form-label-auto\" id=\"label_9\" for=\"input_9\" aria-hidden=\"false\"> Authorization <\/label>\n        <div id=\"cid_9\" class=\"form-input\"> <input type=\"text\" id=\"input_9\" name=\"q9_authorization\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" size=\"20\" placeholder=\" \" data-component=\"textbox\" aria-labelledby=\"label_9\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_10\"><label class=\"form-label form-label-left form-label-auto\" id=\"label_10\" for=\"input_10\" aria-hidden=\"false\"> Deliver To: <\/label>\n        <div id=\"cid_10\" class=\"form-input\"> <input type=\"text\" id=\"input_10\" name=\"q10_deliverTo10\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" size=\"20\" placeholder=\" \" data-component=\"textbox\" aria-labelledby=\"label_10\" value=\"\" \/> <\/div>\n      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