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Submission: On November 05 via manual from US — Scanned from DE
Submission: On November 05 via manual from US — Scanned from DE
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POST ./referral.aspx?brokerid=743&brokerunid=e4dc6a19&t=0&tpid=
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5GK1OwsFP/ch1Fc4TKHgxsYDRDAYQvJE1u/X+9yAoEp7xJPKWEL0izsVj0DSNUGZCFzXBvi/hAdWGZ3vAXTAWnvl1XHexGCiaSon8FnpMTReIIh+4jCzLdKHy1kztsezdZ3u7W6y6TaXzr6A80OWfRiDytlNurBp/IUj9yuC4tCnBxdOwsCX1ynEawlJz3Ulhsdn5h3eE8+2lujBJd0c+FI47+sN9RCn7B06kgtde2P8uD6VNyx9aavQpGR5VFH+vYr4MxuTRnH5qHG7Wu+wGsUr65wN3KZRgnowKEROZTHqkDF33URAha1yegfdQxaEMyRF5oHQy5zl3Ru+Yn99B3jMs6tvTcYYt/UFyyTOUjOEOSl7/uTJbWru11iv7NOPKldvK/qzs2URZ79pudw734Lw1nAbWz8sTmvvxjM5xPV7ZCPVmBIdjcbXYBhClwMX30KCtKh5KsddU72cOvcbLY1dAHt140aY0yefH5rf7qpApMJZ26QC5u8R3vYbtUyRcQl4bad8C0fVE2hrmxuRQHxMGJ4fuzkMF3he5UfTHbizjLIqnCxveMP/mrHChsapHpPnAifY5PNtfP9OZM9bFl7kAY9KPngnbnS6X7S/3gncDA++y+nRIxpYh5crdX+OYmhc3m15SBtn+JEp/nFltk6NrXTI6o05dzTGHmlRqqmy9IvjxAM7r76zY9QDaGDQcs2swtbys3VhcaK59pw77gDZ91EPIZLwisAkyxiALoGB9VzO65Cta+XTIl3cqVmROKw8CVgfMdU2I37lX8odI0FAN+nOvjbnOGCh4Tzh/FZzleCQ1mPNWpUN+Q0QygSWyxpD567W1/DRYCV5aT7umJoVdHKq9TQNz/xqO4m3nNvHbX23O0zFH54TeFfQiyQHxDairJLhiB34Cfib7S5nXjzWv1ZLK4OUFax5v1m4G35nrtQwR2LatMGhQwDd352BEpL48eatDA2neZyGRF5r9YErktUovwu6fmLJbfSymF5zAoc7JthQ5GiOPNEgD4Z8hLK2Yyz6HNbpTPLu4UgKIcbThK4D0uL6uRHGC6/DAr95Y0jjQvYnR1V54Qkr1gtegGEyN/fEAaO4GoYzZKDjlnn5CwPH4ell81xxNQb66DJeH4rB0Rlc3i1pjAbSvcYx0LMhji3D3RAhwSaW16jMQauP0kPXByKlq4cn7M3TXzJJ6deEmuxnqGVbwfu045GHOp8yCiYrJsbeGwaAHezLX9cllEjxQNW2UiNM3r6C0e1BUobThvUcBKMx7F93K+9mGtNppGYkI0Byi73fB+PnMDG6fl5suta9q3ilyoHH9MthaJNkciO14RaTDQkQg0dxLQLVWtlR4Oqtb8A0FT6GK7S3QxnsQfx034d+VkwL1pzVQFYa+v4iICHfU+mavA5koyUc13vpf3yTOHQnlTRM41yHt/q1UYyyB8EXqHQodEmTQ8eAqx6Gzi65eTuxdPwQY1QsL5zS5WbcFWcIyEgJ/nihBjHR+fysqCS9PD2lZOyiwkeM4Bkw0b6VKK96L6zwCBJnLYvHseJ+ixvCCOJYAgxEZATnmBo0SDniJuKKAPUcV/VyWwptbvnsC000qRTPxLYy+PaLWc2tOwxnSlH3EoKyEbJ2rK/ejt3MNE3UO6I7cDYJHuo1Ebtn0tR27m6K3udHB77BtVrTXTbSlin4e+xR9T8ssFAg0VP7eDCNJCUdvUKWkaY5fvEqWx9kYG8wI8BAH91kzeCCJB2hoasD/qjZPmEHHxVPM65OvkSachiioh4kd+c5hi1I2cohTLegc6mkJg9q8Qm6UCacI8Coxd7KCnqv3b+zyOdIUNfZYgjyGRIYY8rzd6Rv5RwMpc8SsPEMXMzTFrwfKMhyEhUcM7cLrSYyCn5E3n5TGqQStu4GVWmqWQLE7bBX8pQRkdknPx/6/Qf306cI07XP3ewraXJzyc2yVjmRquwUUAb9junEnLYQqkXVKPxh2d+4L8ev/DBLh+XTh35j+7uTyKVMCU09PyDF4AOAW1JX9xs6sl+rgepMlfmLnxx/oq6p/3iCXtZA4uqRTUjDpPrdNHxsTnlb3eXwDNlZNN9QNVVWQTiLWn/GRaIPH4mrxGYNj+TFW254KnuCpxedDsQIKrPuzPisQ57zyeEA3oP0RgTgy6RRtrPAQb41z65IrhonkZ7rEc2Zm3glHq2ixiSfxy/yajpGjRiCi92WCoQXqOAtnsCLWLENmRjCqiR0vKUAOxc9NZKtQE5PsScNVjooVBqkOH8DdbmE2LZBvK/xBzmNd8wzeQ1bB/vtX99TRGOEU9Mb83iRai/38GhZ3pMRXVYK0nVyI28K0JFAC/qX9Ylakg8IZ8FOmRwGPGq1ehTwm4yvsjpssQQUJ90gfsUynREmOxF0+d0UFQ+sVOqYOdJjqv1k2krbFOfGuSml+brkcyZjEHJK4i+apSJ7QiUW0OtqAmm6bGzxwbUCcX8A26wXpNe9R2b1JrPeyNlW3H0jbPeb+NxWlEdrWr7gkgwnn6brbuOjkwe1vlw2AYvyioY5qq7qnHP71h1Rw79jFXS6SDR3rn9kOHsE2fqzgxRcYNds+9eDm0Fd0Q473ljX4fhdooowk0WGnEusEhd1NOb3IyfJs0uq4TkFhDhbVFXsJZw5jJSaOACUT3qt0yRS4tw2c1gOZ+8JyQBTQTCUYng5yiHpj8idVPuKtFOH1rXKUDo9jcM8bLfzGirvUMyeYjjQZb5uyuQkkfSQVP6VhSeQ3uQphMTHW8Xiwpdu9+e8LYYyGakKMi6v4DFPlcfpNVDF0iZ889hmhTaaHvJkuZbCUewawBCrt9snxSYH0e8Vg4Uq4/yQvZfEg1FtHGOLPPsY+QO04I6QKkeiQNLryqkfP9iUGj7+0KDcArDJ4TLrdgqCDtvb1MGvn4AmmxY9RxLmDPWKhNTPWp/MbhxYpDlMDyj6IPUfhiDcnrOA+Co5Id7Xadr+Am817s6XVj9vEEmquVvlFzBeZN5ItpdK2h2mV72l3uN/CUrHfrDwir8JSpsqgHiTVNscWLtu67cVKaZjogmxmn7xsYmZzr83Yd07RNxrfNnzsQrlUnBKng4bWc3lq/TAccI4hsVNoTc3NFA1Ei7XhkbFHBFV0CLHGcgaL8Cco2URHn0DyeItbduMfcCU9E+cQG2hbJq4DBDVqxL8rg4hjphhmkOVzzSz/es+0qon5vXKppgTtYon1wimEbGq6R6pNKlYs5ib+SH6FANZWRL4DYOZj9wWERJ5jVHvRjrIk6MTLbb8GnxSny3Yn1R+gxGNzDEuVxBXkFMYCEv3ai2mC0CnTe6nJg/oNaSQuoWg8cP9x8FZ1cnHiyZWVj67iLi8f97P1CP4tHol77fBO5RQiSJR3076r4raxiklJLNK6b89eepfhc2mfUt+b64U12Y1ONqKwKAFAGQKbC1rgFy2QtOz2vAswyD9RLjHj/YyjPqFsUz6kPkK1a+YJLn3f52u4Y/jCWQih61ylv3tQqwZPpdBzTSRFtr3M4e8EPVylYs7AnI3jMFPDrIpYBGVQycy2LZsCDsxfvUmcpKajB44w5lysUleCmfaa7UYnTS39eYPMnOYoeNqMX+1LZlR2l5wODZWJKyMPiC929ucmf2sE5c5n+Vmrp3jpvehg0Tp8l0nDKyRiemM0LDNQV6G4jUsdn6b8PJzTrtcy0E0xTtvvvZ/c8xPqgLgv8lhvdGlt3utGHIuJlRhtSuLKRL8rjVySwWTBHrCA3S4v1DQ68uyN6L+bTmM4p+Ah2r0QEmiTpoNgc6CiT1+qR+uabrM6U8zbqBoaeeLz6d/gnr/MiFWJyQxsBwiu6+mRkS3woHb0D9wvoWmKAaCdfbv+b22jCNmWKaVA3wg+hnW/UCFULOIaoKO4Db4gk2efMzTpbiwfAMo0qsTT/F1VzCsKfCsxOw71JOWPmMMyhaKJuTfo3xP80ng+l6XSTZGEJbHfNWY+qx6GaWu/W+SHmSAAz+Cn7EQ/jMd5ectu/NeYwgNiDHB0tN1sIbmMbrGuoOFgKJiA97ShmOqozENU7TZN0Sr+FPjuKWQDB1Rpe+NHiZKR0PQq7DatbrZFaOKpZpIqpBH1ELUcAjwgyijHuDCLDHE0UvN1ccqw+gnEokPxJoypkFXV3/U47H22XurM9GDWqyEIw9JuOKeUtLZju7eP2POHywgpI5td0rFYMzXOcWSLDIW+Jl0qoYce+GB3xPMfcCfZ2DWkrsBJtB0KYcaU1VdRvorBx7HAf7mWFu0OfhVwZArp85PWm7G1dAtlOj2FdkKPvXKlCpmXswnqCAsSgY1DvuuNJIoLQ/twR39Ml4W0vniJEd2ON8GCbbJ+Cs/oiUPcwFQOlqfaWFVRQzsChwPfPPujGMuUInjbZR/xnKmRdkGT2g/ObauePoGvPBtP0C2m2e+m0PytQNt5/Hb36v2ZyfL2ErKaef8STrA7he0IF0Qz18ulWhFL7onp+tH6JzUZ74Ez7YgdbQ3LIVLIFbEIwV0dZWcn8r10KP++OOwqS4lD8ZLU9LDgsTTLbjxZKvZaTeTH24TfZMApVRW53hvnjLHccAKcB1j0+wz5B/aNqLl/6C5wzzvl8IVQyNUH09dGfaeE7B5ABy9hL1Ki3BAAe2FxqhtPxmQbFUrxEAexI4ns9Ico11sYjR5Na/fl5EAl7jTwlkcwRst03p0VEcLc8sfTIaWWRSmGFB65SSkYwx90obSdQOdxtTDExeSaGmAv57IylC2wVebuxGRGUHE7AW2ishFIO1wqkBxnW21SDVkefAVU4Ywbj3uOSdwBusmStW7OIxXXowtVcSu6EsdXL2Ydr2kTU0OZSFVVILqGUsMR/ZkeCMb2euj/qX5N+o59R7gOXDJ9mDjXliDf0ZD+GP/nYCBDDEVRGXTWzyfJYx0DJDkN/IBQJOpHRjl48Re4+z84l6lDrYUVuMFSBPh5G8OFcRAEbad0UaB6WWLewJH/MQXljqBZN8K5ldB7k6wpz69QegYCHntDnuE4rwU5LqN8ZWZ39oXwVH4FDGXFw5zilCsiC96j7wI2vEIucLyEKaEi/XR0Cnn63miE/hTHpRBhsMsVf8VpT0QyyYq5MfLfaxrEouFueXaECRzH82iFZDHd+2gS2tM5P1xqARwsKQgdCjuHTzO1qNwhx2q4qTC17Egp6p1XyYDInqeXDg57dJp0geEAsYwqBxsKIsh97o+JgYGg4QXYPTHhlSknxDjlVyQl5tCVrKe89t3XkP8lQ2uTICIQKvnio2zmiHN1bfUf05GquKaO8LFImxYFgo0H3UKqWvKc/vMZyjFQDp1VRY+bIfUM59umPVqkx96oLRyei+PNL2v5Vjn1/JMHatL5kFy8A8cmgVaNn0neZjeqDAi6ggDLMgPU242S6c3jlHUSEYCDZbMdEVPf2d95xm2sOHXYZkYMaYDRVh2hpMMDSQYeiD05P+hHMz6qfaeGLRs/AFJd0Ic7Qq893QVlbibOccsJk25K0vR75adiXI93arsxnINTksNGuVoXmLEZ/ClXKvFPhZGIrIa3Hh3AO/b6o6g31sZRscOW0Lm+zQ+B2hYFDIE5iMWTAbn5kroM5L4VEOdUus+UCUZVk0SjinJ5tcaJhxJWthDC6jfcJP1EM/wMYjV2AVk7mtkoFSqAtZ8cnxe0SRRHx7RwscAdoK9FjlYwt+JXzPQGbOe8XKMPLYGZwv60cBmFTCzTPeJXg9T63Ro4XFlpGjQ7821bMdFpZaue+cJuTbufvYI9EeAiZsV7cklA7TpJLH455lKIf4QAmipbhObci67+cFygfANZpisn+RxA+J3D+2E204Jgj/Rn3VlWcHoSj5WduYa1qQn/yNvoFmSyn+P96ACcx2JqJZ07IRZV12rlPAhoie8Rj5NdXWN4mJSM/z1q5YRuD5BNSQx8nhwXe1zp/nnDj4CQm4qQXfJV7FnbHli3kavXl/xbFY/BsLpofUxCSrnxM6g53KkMqFYPQ01iJc+Ohc1gW3tCvbV2WG/TAHOjGtrJIrug1cyh7HEvcTFKqI8LmfsOpdY9m8wl3VlHRDzdqdAJYObrijvVOQepZk5j5q8GQNp83pMgxyNWFyF1LWDWTFhLeP18cVOB2ppSU+cB2DpcMWTiE90S3+L1HCJ0JnlKBxA/C1/HPssTnp/QXuHJxYRJQ8p3EKgkVi+fCemR1AK4q8TSKNa8fZUoGTJ2DazjN0Gzp641HQvilWCv8ZshEVob0pYvf4vbatSUFe1T0N6MmFL1o4u90JMi0Aj1kVKXa7yaBAdmSDQTl9S4tehC/PeKp1x07/7KKIPNRnBv3fHEm/1AdCNCVabtSOFFOG7Vxi1oEIYaxncGxJ6frYu9RFMg18UICMmZ4CDIao62sMjnMCr0qGtKau6uCVLQ3pYFIzDpKVieZn4ywfrsrXHswNFa2siuWe3+KYqljx6A3hYO+2Hf+2QL+OQTFQNEgtYTQ9J+gmhGLnuJXpsiD5ppu4KLw0fQYitIAncNuh+1FTcHDFwFVyMv5DYVcpgaFuPxt4fS931pNKsZ975efGVlcna3wnyv+2tv7CyAm/HlYQ1K9bjfJuBPwULadpxFJXjqO2GkN9heKeZ4oEWcH3ppFRA4qTfiv6JOyll67tIhEc0SpwKDdM1F94VkKtV7c4TIwxJZYVJIHYKRDXVvxbyb6TqXcUCi5hk0on7ck1buugsQpXAhxsbCZnIA1TURRN0L0gm5x5nUhloPlTi2dDrQk54eOpRx8IoC8icdHHf4ktLhBVCfIBnxwSI2vnXwLoORgboqoPEkatwFi6JuZhtZeu9wOluQa8x5PeQJfPZsWP0iJCKD8UOb7XrJc+F2X6zHF5SWmQOAkBCqgkAsECELEsi+k4TOUG8oJkbv1YtOQPivJn5od22xEFzdrcRSrgULHLxznHhl5OHjwFt10OP4xixSAYWZheVVMdlWdYnIu9cXXKOwGo1JJUKM+E7I2ysCT0vaU+Klu+YgHWt82Jt0gbIReAabZRdYQd8vXwAA0tdwmXsNrFpEsCE9Bag4x68obUkPtVmFa50KO7dByQO+acNhBHborldwhnAvb4FwKL8jKVpVjlhb12veLkvbPvw7MXafnA7TNBcTz07UvZ15hFuj8+izTlDEShuFFcgNj5ViACNKa8KctqV4y/GHTK6kgoBX5lUb2C0RRE9X+wr86VkYavL3B5zD9nIQZVhket3mxlzwmU9sQUFy3ZXDeLwlR70FCL5pfFjM7vTsEFW970+qq5u5k3fS0IzXvpKhGZQLJGlNexro4d7dgFV5nDX3t0pYK2EAquF2YL4ghsWHWi6mdedXKBHdDizOA89Q6Y8gWnIpT0HpBjE2ut4pED9Tkg2PMIex7Hr+w82M/tVrBPM03LZlegf6kHHqdaR/8GgPg+VbRkkQWec2gXv4Rlbh2USFVJLqnhaKnuUpTtUgBPdjIwhmAo8UAmUqAV9mLgqesRuZLdk2yY/NCrOML/AA0ONlNdWwLdL+wloAn11KZr4R1MObHvmF+oi3awNbBRDDfw6b8+dU9yt4YT9kZZ2aoW2KhVjaVYwHygbW4vNB9edLXntCcJQuZimXZX0QRVNhtgw1PjRs9Db5ocuEoURDTdVDWzYwLedl8HfMlHjEtYA8lAWCHMYZIvpR8ZaDKe6LcYhp8YST7XnvsLLAZyeUBgtVyS9pWDFJSqpBoxleiunm2j/unfBrX11hE3MStagG9o86X215xXU1DY5J/kG1KHJ2xTAfTPPgTgsgHMgDtTf8P/n70y/bRNBwTcsm8PZvqqGSg4CLnYNPgbm+Uuuf4LMaPMMeVtiaVgdniLlbgXIg3kBlQCkXzMu9W49f6GRlr1bcsRIW7Lyy8YqiUypEqLBK/iSrOu58Uncg6W7riP6rnFI3QpUTTFwf+VUA5vxf89ycrYTnpY32QFPdNhFwCPYc0tGrB7eIbhHPjbeRUUZYoB7f1twLo3cSV9eFGuh0LTEK5Z3qQIAVmLO8tc/7HoqVLi8U9RrK8MHtRtwcq7Mj1O3mJqq1VTjhJNK94teADP/TXJIX3QFOrezkeuROVp4DxbVV4flXqLtw2ubZPfa33FhXwimojhE1DKkCQnqXsXua7kE8svoiWu7QWmpPzaIt2W37o/vayMRSNgm8V0xdKJKkwZ+ihfl62WFixev109Toj/P+zitE5xIAFx4dz8CSfEtdsJCxF+eDS+fBx4sgsYfxSOUTBANf3J6lOImbk3ZWHcxHNCDrYCQyP5ceZR5QxJqqogyLMxfoDG5V3hkLP8CB0VMwFxE7aZGZ+TCK1Lj41J/bfS6PSTJxmSXPtPrXktOLe+5Egl8qKd+FB147zWUjG4wcpkUYDI9ls7gpd9ESNh/S2YJp/W4Uj+orGC66/nHCB5k8DtFb+04Gndv33JtmJXqoTlf0evgq/FnWfXN9URaAPXbAFJAOmy4MT5AtwiQTcgYd3pHhVetG+AoDPxwod3OazRG/Y1AISHQO1PhIhNc+FkE7AXWlV7Tr5SnyMpRU4DlXZM+BA5FFZivv6tWNapKx7hVkXdgCEeK+O6sneNrdGXw3nPAMo+vkn80aIh0NcWvxQGCJ5CbSjffsQuD01G09kHOXJwNF6rs6mLmwRY0xSZL0uxdYYytlLXIyE8CmTo4WTm43SRtEAoKho5hqJbWsXqOsO6o/AFubmIpfof86JpdDGTqLFjn4dYMFfKbmg12AA1WwN7km6B8yJPFDG3a8VUpCdosx63oPQU108mjWFtfz8wAOxuXvFOilUZ9Fqyro2skhjAnFS2/+GLjdkK/dcnYJAsbzobJlZ7AXUcncHelGgKwn9+crkEKVuvyMZjhHAMdc3PHDj1XTlRsc+qa4D1fSV1e6c9WBzGV36WM0ow+pcE8LHhWryXpwqZayv1O5yVqBe2Z/++sPDJSflMj0vLiC05w0CB6C/Hab7xmzrI8jl2f8niAdxZWuTWWMyCVE3UESn5zBBfZtrzTusIUjLx7xGA3KNbRsaGakErxRyx71/9JIDFusKf+FOb7G+nH/NFVAKa2t9NUkPdilMERHjclqVh+BcZu16YZm/tkmvb+YXU/fRzlwjT9v2x5OuXHRiCx9se0gWMeEWvq7VLZD4hqm8tu6bdMtOzdudbM+eJzO1OddPmARhrM6sZ/iAnI1Vya32hIXEweYXXthGsNpO+nOKYsLamMP8O9Q+QwHsGNcbVsuAJAYXTQhXVfjOtgXs5ofpiNagVOl9DBBpPqDfyvfGx837ra15Bns4GbVk6J5nSZFo/wFgD2kjaAd6bBZViuXqK/1TjtQG0AujaG2a2eRuBtrVF8jh9PnKBNdEZ5JZUykp+RVFEkFqm7k1TaT3Kl9FzP8jKNGaTrzE5onKOyc4+WTWAz6ZhZz50KRBWoG+iIxbVBy4QcPqoMZefDy9cSgVz2gGwqndp8ySjMTQLThxBziXHDmyp1AeYhKZDD6Pp2Jxoa8EQtmulRypHq1Y2WnKQHmxk+4cXAbr2mJqSVXnUyRWAE8UueOIJF+bVYZYeRNlODHEwFQHQOtvqxQGtqMTL8pY7JzXEKJloipC3w0bTykb9wicCVta/klPMAlht55MjJ/MG7Zqnymmwdbtwo0wQKOabEYBK7rwjTVtyscZxx2LdQ+56qCpRlH5hLUT2Im79e1JdTHbD65DihrC44rhM3TT23HPg9iMB6SsN13STnUewfdF5BLwT6hCX89DN/0aaiN4gATjn2CDue0aI07eFT/ZrWYGG2h1QWBWposs0IyG0LW+S3OD5I6PvGhusopcMTzhR5bRLRaeK2OGjD4C1LpjwIRvKzvO8l77Hke/bo1RaXwGvXLtJLWS8oyDrrrVrPJaYIRziDNkqFeQlUqgqQmf6qR9SoyH+RMgDJjx+UTCfxIbOIkpT7QseB1qTsTyUlnlwfSBfvQWdZk8PV9lXl4a+QL+uVJo3W+iLmUzatj/tEgL+P0ZjxVHhb4R4h5jwvCIWLByhCbACgW6fE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</section>
<div class="er_bluespace"> </div>
<div class="body-content er_contentBody container">
<div class="er_loader d-none"></div>
<div class="er_content">
<div class="er_titlebar">ERA Summit- Submit OGR / AGR to Relocation</div>
<div class="er_imgrow row text-right">
<div class="col-sm-12 er_imgdiv">
<img src="/brokerimages/logo.ashx?brokerid=743&brokerimageguid=8e01e97e-25b2-4baa-882c-df278b1f8aef" id="ContentBodyPlaceHolder_BrokerLogo" class="er_blogo">
</div>
</div>
<ul class="nav nav-tabs er_tabstuff">
<li class="nav-item" style="display: none;">
<a class="nav-link active er_taby er_referralTab" href="#1" data-toggle="tab">Submit a Referral</a>
</li>
<li class="nav-item" role="presentation" style="display: none;">
<a class="nav-link er_taby er_customerTab" href="#2" data-toggle="tab">Register an Incoming Customer</a>
</li>
</ul>
<div class="tab-content er_tabstuff" style="background: #ffffff">
<div class="tab-pane active" id="1">
<div class="er_tabsection">
<div class="er_htmlTopDiv">
<span id="ContentBodyPlaceHolder_HTMLTextAtTop">Please use this form to submit an Outgoing Listing or Buyer referral, or to place an existing customer into an Anywhere Rewards Program (AGR or Agent Generated Referral). Please provide as
much information about your customer as possible. Once your OGR has been submitted and placed, you'll be notified of the receiving brokerage and agent. If you have questions, please contact Lisa Scherlacher at 505-203-3386 or
lisascherlacher@eraabq.com. Thank you.</span>
</div>
<div id="ThisReferralRow" class="form-group row">
<label class="col-sm-2 col-form-label"><span class="req">*</span>This is:</label>
<div class="col-sm-8">
<select id="OutgoingType" class="form-control" required="required">
<option value="">Choose...</option>
<option value="1" rel="0|0|1">Outbound Broker-to-Broker</option>
<option value="2" rel="1|0|1">Anywhere Military Rewards AGR (enroll in program)</option>
<option value="3" rel="1|0|1">NFCU AGR</option>
<option value="99" rel="0|0|1">Other (please specify in comments)</option>
<option value="66" rel="0|0|1">AARP Real Estate Benefits from Anywhere</option>
</select>
</div>
</div>
<div id="MemberNumberRow" class="trAGR form-group row" style="display: none;">
<label class="col-sm-2 col-form-label">Member Number:</label>
<div class="col-sm-8">
<input id="MemberNumber" type="text" class="form-control">
</div>
</div>
<div class="form-group row">
<label class="col-sm-2 col-form-label"><span class="req">*</span>Customer Name:</label>
<div class="col-sm-4">
<input id="FirstName1" type="text" class="form-control" maxlength="50" placeholder="Primary First Name" required="required">
</div>
<div class="col-sm-4">
<input type="text" id="LastName1" class="form-control" maxlength="50" placeholder="Primary Last Name" required="">
</div>
</div>
<div class="form-group row">
<label class="col-sm-2 col-form-label"></label>
<div class="col-sm-4">
<input type="text" id="FirstName2" class="form-control" placeholder="Secondary First Name">
</div>
<div class="col-sm-4">
<input type="text" id="LastName2" class="form-control" placeholder="Secondary Last Name">
</div>
</div>
<div id="ContentBodyPlaceHolder_MaritalStatusRow" class="form-group row">
<label class="col-sm-2 col-form-label">Marital Status:</label>
<div class="col-sm-8">
<select id="MaritalStatus" class="form-control">
<option value="0">-- Please Choose --</option>
<option value="12">Common Law Spouse</option>
<option value="4">Divorced</option>
<option value="3">Divorcing</option>
<option value="13">Domestic Partner</option>
<option value="6">Engaged</option>
<option value="7">Legally Separated</option>
<option value="2">Married</option>
<option value="8">Never Married</option>
<option value="14">Other</option>
<option value="11">Partner</option>
<option value="9">Separated</option>
<option value="1">Single</option>
<option value="5">Widowed</option>
<option value="10">Unmarried Couple</option>
</select>
</div>
</div>
<div id="RelationToCustomerRow" class="form-group row">
<label class="col-sm-2 col-form-label">Your Relation to Customer:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$YourRelation" type="text" id="YourRelation" size="50" maxlength="50" class="form-control">
</div>
</div>
<div id="ContentBodyPlaceHolder_HasCustomerHadContactRow" class="form-group row">
<label class="col-sm-2 col-form-label">Has customer had prior contact with an agent?:</label>
<div class="col-sm-8">
<select id="HasCustomerHadContact" class="form-control">
<option value="">-- Please Choose --</option>
<option value="0">No</option>
<option value="1">Yes</option>
</select>
</div>
</div>
<div id="ContentBodyPlaceHolder_ContactWithWhomRow" class="form-group row">
<label class="col-sm-2 col-form-label">If yes, provide company name, agent name, email and phone #:</label>
<div class="col-sm-8">
<textarea id="ContactWithWhom" maxlength="250" class="form-control er_autoGrowTextArea" oninput="auto_grow(this)"></textarea>
</div>
</div>
<div id="ContentBodyPlaceHolder_OgrMailingSection">
<div class="form-group row">
<label class="col-sm-2 col-form-label"><span class="mailRequired req">*</span>Mailing Address Country:</label>
<div class="col-sm-8">
<select id="Country" class="input-medium form-control er_countrydd" required="required">
<option value="233">United States</option>
<option value="39">Canada</option>
<option value="1">Afghanistan</option>
<option value="2">Aland Islands</option>
<option value="3">Albania</option>
<option value="4">Algeria</option>
<option value="5">American Samoa</option>
<option value="6">Andorra</option>
<option value="7">Angola</option>
<option value="8">Anguilla</option>
<option value="9">Antarctica</option>
<option value="10">Antigua and Barbuda</option>
<option value="11">Argentina</option>
<option value="12">Armenia</option>
<option value="13">Aruba</option>
<option value="14">Australia</option>
<option value="15">Austria</option>
<option value="16">Azerbaijan</option>
<option value="18">Bahrain</option>
<option value="19">Bangladesh</option>
<option value="20">Barbados</option>
<option value="21">Belarus</option>
<option value="22">Belgium</option>
<option value="23">Belize</option>
<option value="24">Benin</option>
<option value="25">Bermuda</option>
<option value="26">Bhutan</option>
<option value="27">Bolivia</option>
<option value="155">Bonaire, Sint Eustatius and Saba</option>
<option value="28">Bosnia and Herzegovina</option>
<option value="29">Botswana</option>
<option value="30">Bouvet Island</option>
<option value="31">Brazil</option>
<option value="32">British Indian Ocean Territory</option>
<option value="33">Brunei</option>
<option value="34">Bulgaria</option>
<option value="35">Burkina Faso</option>
<option value="36">Burundi</option>
<option value="37">Cambodia</option>
<option value="38">Cameroon</option>
<option value="40">Cape Verde</option>
<option value="41">Cayman Islands</option>
<option value="42">Central African Republic</option>
<option value="43">Chad</option>
<option value="44">Chile</option>
<option value="45">China</option>
<option value="46">Christmas Island</option>
<option value="47">Cocos (Keeling) Islands</option>
<option value="48">Colombia</option>
<option value="49">Comoros</option>
<option value="50">Congo</option>
<option value="52">Cook Islands</option>
<option value="53">Costa Rica</option>
<option value="54">Cote D'Ivoire (Ivory Coast)</option>
<option value="55">Croatia</option>
<option value="56">Cuba</option>
<option value="249">Curaçao</option>
<option value="57">Cyprus</option>
<option value="58">Czech Republic</option>
<option value="51">Democratic Republic of the Congo</option>
<option value="59">Denmark</option>
<option value="60">Djibouti</option>
<option value="61">Dominica</option>
<option value="62">Dominican Republic</option>
<option value="64">Ecuador</option>
<option value="65">Egypt</option>
<option value="66">El Salvador</option>
<option value="67">Equatorial Guinea</option>
<option value="68">Eritrea</option>
<option value="69">Estonia</option>
<option value="212">Eswatini</option>
<option value="70">Ethiopia</option>
<option value="71">Falkland Islands</option>
<option value="72">Faroe Islands</option>
<option value="73">Fiji Islands</option>
<option value="74">Finland</option>
<option value="75">France</option>
<option value="76">French Guiana</option>
<option value="77">French Polynesia</option>
<option value="78">French Southern Territories</option>
<option value="79">Gabon</option>
<option value="80">Gambia The</option>
<option value="81">Georgia</option>
<option value="82">Germany</option>
<option value="83">Ghana</option>
<option value="84">Gibraltar</option>
<option value="85">Greece</option>
<option value="86">Greenland</option>
<option value="87">Grenada</option>
<option value="88">Guadeloupe</option>
<option value="89">Guam</option>
<option value="90">Guatemala</option>
<option value="91">Guernsey and Alderney</option>
<option value="92">Guinea</option>
<option value="93">Guinea-Bissau</option>
<option value="94">Guyana</option>
<option value="95">Haiti</option>
<option value="96">Heard Island and McDonald Islands</option>
<option value="97">Honduras</option>
<option value="98">Hong Kong S.A.R.</option>
<option value="99">Hungary</option>
<option value="100">Iceland</option>
<option value="101">India</option>
<option value="102">Indonesia</option>
<option value="103">Iran</option>
<option value="104">Iraq</option>
<option value="105">Ireland</option>
<option value="106">Israel</option>
<option value="107">Italy</option>
<option value="108">Jamaica</option>
<option value="109">Japan</option>
<option value="110">Jersey</option>
<option value="111">Jordan</option>
<option value="112">Kazakhstan</option>
<option value="113">Kenya</option>
<option value="114">Kiribati</option>
<option value="248">Kosovo</option>
<option value="117">Kuwait</option>
<option value="118">Kyrgyzstan</option>
<option value="119">Laos</option>
<option value="120">Latvia</option>
<option value="121">Lebanon</option>
<option value="122">Lesotho</option>
<option value="123">Liberia</option>
<option value="124">Libya</option>
<option value="125">Liechtenstein</option>
<option value="126">Lithuania</option>
<option value="127">Luxembourg</option>
<option value="128">Macau S.A.R.</option>
<option value="130">Madagascar</option>
<option value="131">Malawi</option>
<option value="132">Malaysia</option>
<option value="133">Maldives</option>
<option value="134">Mali</option>
<option value="135">Malta</option>
<option value="136">Man (Isle of)</option>
<option value="137">Marshall Islands</option>
<option value="138">Martinique</option>
<option value="139">Mauritania</option>
<option value="140">Mauritius</option>
<option value="141">Mayotte</option>
<option value="142">Mexico</option>
<option value="143">Micronesia</option>
<option value="144">Moldova</option>
<option value="145">Monaco</option>
<option value="146">Mongolia</option>
<option value="147">Montenegro</option>
<option value="148">Montserrat</option>
<option value="149">Morocco</option>
<option value="150">Mozambique</option>
<option value="151">Myanmar</option>
<option value="152">Namibia</option>
<option value="153">Nauru</option>
<option value="154">Nepal</option>
<option value="156">Netherlands</option>
<option value="157">New Caledonia</option>
<option value="158">New Zealand</option>
<option value="159">Nicaragua</option>
<option value="160">Niger</option>
<option value="161">Nigeria</option>
<option value="162">Niue</option>
<option value="163">Norfolk Island</option>
<option value="115">North Korea</option>
<option value="129">North Macedonia</option>
<option value="164">Northern Mariana Islands</option>
<option value="165">Norway</option>
<option value="166">Oman</option>
<option value="167">Pakistan</option>
<option value="168">Palau</option>
<option value="169">Palestinian Territory Occupied</option>
<option value="170">Panama</option>
<option value="171">Papua New Guinea</option>
<option value="172">Paraguay</option>
<option value="173">Peru</option>
<option value="174">Philippines</option>
<option value="175">Pitcairn Island</option>
<option value="176">Poland</option>
<option value="177">Portugal</option>
<option value="178">Puerto Rico</option>
<option value="179">Qatar</option>
<option value="180">Reunion</option>
<option value="181">Romania</option>
<option value="182">Russia</option>
<option value="183">Rwanda</option>
<option value="184">Saint Helena</option>
<option value="185">Saint Kitts and Nevis</option>
<option value="186">Saint Lucia</option>
<option value="187">Saint Pierre and Miquelon</option>
<option value="188">Saint Vincent and the Grenadines</option>
<option value="189">Saint-Barthelemy</option>
<option value="190">Saint-Martin (French part)</option>
<option value="191">Samoa</option>
<option value="192">San Marino</option>
<option value="193">Sao Tome and Principe</option>
<option value="194">Saudi Arabia</option>
<option value="195">Senegal</option>
<option value="196">Serbia</option>
<option value="197">Seychelles</option>
<option value="198">Sierra Leone</option>
<option value="199">Singapore</option>
<option value="250">Sint Maarten (Dutch part)</option>
<option value="200">Slovakia</option>
<option value="201">Slovenia</option>
<option value="202">Solomon Islands</option>
<option value="203">Somalia</option>
<option value="204">South Africa</option>
<option value="205">South Georgia</option>
<option value="116">South Korea</option>
<option value="206">South Sudan</option>
<option value="207">Spain</option>
<option value="208">Sri Lanka</option>
<option value="209">Sudan</option>
<option value="210">Suriname</option>
<option value="211">Svalbard and Jan Mayen Islands</option>
<option value="213">Sweden</option>
<option value="214">Switzerland</option>
<option value="215">Syria</option>
<option value="216">Taiwan</option>
<option value="217">Tajikistan</option>
<option value="218">Tanzania</option>
<option value="219">Thailand</option>
<option value="17">The Bahamas</option>
<option value="63">Timor-Leste</option>
<option value="220">Togo</option>
<option value="221">Tokelau</option>
<option value="222">Tonga</option>
<option value="223">Trinidad and Tobago</option>
<option value="224">Tunisia</option>
<option value="225">Turkey</option>
<option value="226">Turkmenistan</option>
<option value="227">Turks and Caicos Islands</option>
<option value="228">Tuvalu</option>
<option value="229">Uganda</option>
<option value="230">Ukraine</option>
<option value="231">United Arab Emirates</option>
<option value="232">United Kingdom</option>
<option value="234">United States Minor Outlying Islands</option>
<option value="235">Uruguay</option>
<option value="236">Uzbekistan</option>
<option value="237">Vanuatu</option>
<option value="238">Vatican City State (Holy See)</option>
<option value="239">Venezuela</option>
<option value="240">Vietnam</option>
<option value="241">Virgin Islands (British)</option>
<option value="242">Virgin Islands (US)</option>
<option value="243">Wallis and Futuna Islands</option>
<option value="244">Western Sahara</option>
<option value="245">Yemen</option>
<option value="246">Zambia</option>
<option value="247">Zimbabwe</option>
</select>
</div>
</div>
<div class="form-group row">
<label class="col-sm-2 col-form-label"><span class="mailRequired req">*</span>Customer's Mailing Address:</label>
<div class="col-sm-8">
<input type="text" id="MailAddress" maxlength="100" class="form-control" required="required">
</div>
</div>
<div class="form-group row">
<label class="col-sm-2 col-form-label"><span class="mailRequired req">*</span>Mailing Address City:</label>
<div class="col-sm-8">
<input type="text" id="MailCityStZip" maxlength="100" class="form-control" required="required">
</div>
</div>
<div class="form-group row">
<label class="col-sm-2 col-form-label"><span class="mailRequired mailStateRequired req">*</span>Mailing Address State / Province:</label>
<div class="col-sm-8">
<select id="MailStateSelected" class="input-medium form-control" clientidmode="static" required="required">
<option value="">-- Please Choose --</option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AS">American Samoa</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="UM-81">Baker Island</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="GU">Guam</option>
<option value="HI">Hawaii</option>
<option value="UM-84">Howland Island</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="UM-86">Jarvis Island</option>
<option value="UM-67">Johnston Atoll</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="UM-89">Kingman Reef</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="UM-71">Midway Atoll</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="UM-76">Navassa Island</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="MP">Northern Mariana Islands</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="UM-95">Palmyra Atoll</option>
<option value="PA">Pennsylvania</option>
<option value="PR">Puerto Rico</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="VI">United States Virgin Islands</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="UM-79">Wake Island</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select>
</div>
</div>
<div class="form-group row">
<label class="col-sm-2 col-form-label"><span class="mailRequired zipRequired req">*</span>Mailing Address Zip / Postal Code:</label>
<div class="col-sm-8">
<input type="text" id="MailZip" maxlength="10" class="form-control" required="required">
</div>
</div>
</div>
<div class="form-group row">
<label class="col-sm-8 col-form-label er_bold er_underline"><span class="req">*</span>Phone Numbers:</label>
</div>
<div id="CellRow" class="form-group row">
<label class="col-sm-2 col-form-label">Cell (primary):</label>
<div class="col-sm-4">
<input type="text" id="HisCell" class="bfh-phone form-control er_ref_phone" data-country="HisC">
</div>
<label class="col-sm-2 col-form-label">Cell Country:</label>
<div class="col-sm-4">
<select id="HisC" class="input-medium bfh-countries form-control" data-country="US">
<option value=""></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="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</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="VG">British Virgin Islands</option>
<option value="BN">Brunei</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="CI">Côte d'Ivoire</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="CV">Cape Verde</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="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="CD">Democratic Republic of the Congo</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="TP">East Timor</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="ET">Ethiopia</option>
<option value="FO">Faeroe Islands</option>
<option value="FK">Falkland Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="MK">Former Yugoslav Republic of Macedonia</option>
<option value="FR">France</option>
<option value="FX">France, Metropolitan</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="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="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard and Mc Donald 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</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Laos</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">Macau</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</option>
<option value="MD">Moldova</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="AN">Netherlands Antilles</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="KP">North Korea</option>
<option value="MP">Northern Marianas</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</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 Islands</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico</option>
<option value="QA">Qatar</option>
<option value="RE">Reunion</option>
<option value="RO">Romania</option>
<option value="RU">Russia</option>
<option value="RW">Rwanda</option>
<option value="ST">São Tomé and Príncipe</option>
<option value="SH">Saint Helena</option>
<option value="PM">St. Pierre and Miquelon</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</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="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="KR">South Korea</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 Islands</option>
<option value="SZ">Swaziland</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syria</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania</option>
<option value="TH">Thailand</option>
<option value="BS">The Bahamas</option>
<option value="GM">The Gambia</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="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks and Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="VI">US Virgin Islands</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom</option>
<option value="US">United States</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VA">Vatican City</option>
<option value="VE">Venezuela</option>
<option value="VN">Vietnam</option>
<option value="WF">Wallis and Futuna Islands</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select>
</div>
</div>
<div id="Cell2Row" class="form-group row">
<label class="col-sm-2 col-form-label">Cell (secondary):</label>
<div class="col-sm-4">
<input type="text" id="HerCell" class="bfh-phone form-control er_ref_phone" data-country="HerC2">
</div>
<label class="col-sm-2 col-form-label">Cell (secondary) Country:</label>
<div class="col-sm-4">
<select id="HerC2" class="input-medium bfh-countries form-control" data-country="US">
<option value=""></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="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</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="VG">British Virgin Islands</option>
<option value="BN">Brunei</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="CI">Côte d'Ivoire</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="CV">Cape Verde</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="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="CD">Democratic Republic of the Congo</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="TP">East Timor</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="ET">Ethiopia</option>
<option value="FO">Faeroe Islands</option>
<option value="FK">Falkland Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="MK">Former Yugoslav Republic of Macedonia</option>
<option value="FR">France</option>
<option value="FX">France, Metropolitan</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="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="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard and Mc Donald 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</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Laos</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">Macau</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</option>
<option value="MD">Moldova</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="AN">Netherlands Antilles</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="KP">North Korea</option>
<option value="MP">Northern Marianas</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</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 Islands</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico</option>
<option value="QA">Qatar</option>
<option value="RE">Reunion</option>
<option value="RO">Romania</option>
<option value="RU">Russia</option>
<option value="RW">Rwanda</option>
<option value="ST">São Tomé and Príncipe</option>
<option value="SH">Saint Helena</option>
<option value="PM">St. Pierre and Miquelon</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</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="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="KR">South Korea</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 Islands</option>
<option value="SZ">Swaziland</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syria</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania</option>
<option value="TH">Thailand</option>
<option value="BS">The Bahamas</option>
<option value="GM">The Gambia</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="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks and Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="VI">US Virgin Islands</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom</option>
<option value="US">United States</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VA">Vatican City</option>
<option value="VE">Venezuela</option>
<option value="VN">Vietnam</option>
<option value="WF">Wallis and Futuna Islands</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select>
</div>
</div>
<div id="HomeRow" class="form-group row">
<label class="col-sm-2 col-form-label">Home Phone:</label>
<div class="col-sm-4">
<input type="text" id="HomePhone" maxlength="20" class="bfh-phone form-control er_ref_phone" data-country="HomeC">
</div>
<label class="col-sm-2 col-form-label">Home Phone Country:</label>
<div class="col-sm-4">
<select id="HomeC" class="input-medium bfh-countries form-control" data-country="US">
<option value=""></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="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</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="VG">British Virgin Islands</option>
<option value="BN">Brunei</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="CI">Côte d'Ivoire</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="CV">Cape Verde</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="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="CD">Democratic Republic of the Congo</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="TP">East Timor</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="ET">Ethiopia</option>
<option value="FO">Faeroe Islands</option>
<option value="FK">Falkland Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="MK">Former Yugoslav Republic of Macedonia</option>
<option value="FR">France</option>
<option value="FX">France, Metropolitan</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="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="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard and Mc Donald 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</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Laos</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">Macau</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</option>
<option value="MD">Moldova</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="AN">Netherlands Antilles</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="KP">North Korea</option>
<option value="MP">Northern Marianas</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</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 Islands</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico</option>
<option value="QA">Qatar</option>
<option value="RE">Reunion</option>
<option value="RO">Romania</option>
<option value="RU">Russia</option>
<option value="RW">Rwanda</option>
<option value="ST">São Tomé and Príncipe</option>
<option value="SH">Saint Helena</option>
<option value="PM">St. Pierre and Miquelon</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</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="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="KR">South Korea</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 Islands</option>
<option value="SZ">Swaziland</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syria</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania</option>
<option value="TH">Thailand</option>
<option value="BS">The Bahamas</option>
<option value="GM">The Gambia</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="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks and Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="VI">US Virgin Islands</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom</option>
<option value="US">United States</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VA">Vatican City</option>
<option value="VE">Venezuela</option>
<option value="VN">Vietnam</option>
<option value="WF">Wallis and Futuna Islands</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select>
</div>
</div>
<div id="WorkRow" class="form-group row">
<label class="col-sm-2 col-form-label">Primary Work Phone:</label>
<div class="col-sm-4">
<input type="text" id="WorkPhone" maxlength="20" class="bfh-phone form-control er_ref_phone" data-country="WorkC">
</div>
<label class="col-sm-2 col-form-label">Work Phone Country:</label>
<div class="col-sm-4">
<select id="WorkC" class="input-medium bfh-countries form-control" data-country="US">
<option value=""></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="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</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="VG">British Virgin Islands</option>
<option value="BN">Brunei</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="CI">Côte d'Ivoire</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="CV">Cape Verde</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="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="CD">Democratic Republic of the Congo</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="TP">East Timor</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="ET">Ethiopia</option>
<option value="FO">Faeroe Islands</option>
<option value="FK">Falkland Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="MK">Former Yugoslav Republic of Macedonia</option>
<option value="FR">France</option>
<option value="FX">France, Metropolitan</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="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="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard and Mc Donald 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</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Laos</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">Macau</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</option>
<option value="MD">Moldova</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="AN">Netherlands Antilles</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="KP">North Korea</option>
<option value="MP">Northern Marianas</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</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 Islands</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico</option>
<option value="QA">Qatar</option>
<option value="RE">Reunion</option>
<option value="RO">Romania</option>
<option value="RU">Russia</option>
<option value="RW">Rwanda</option>
<option value="ST">São Tomé and Príncipe</option>
<option value="SH">Saint Helena</option>
<option value="PM">St. Pierre and Miquelon</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</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="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="KR">South Korea</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 Islands</option>
<option value="SZ">Swaziland</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syria</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania</option>
<option value="TH">Thailand</option>
<option value="BS">The Bahamas</option>
<option value="GM">The Gambia</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="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks and Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="VI">US Virgin Islands</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom</option>
<option value="US">United States</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VA">Vatican City</option>
<option value="VE">Venezuela</option>
<option value="VN">Vietnam</option>
<option value="WF">Wallis and Futuna Islands</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select>
</div>
</div>
<div id="Work2Row" class="form-group row">
<label class="col-sm-2 col-form-label">Secondary Work Phone:</label>
<div class="col-sm-4">
<input type="text" id="HerWorkPhone" maxlength="20" class="bfh-phone form-control er_ref_phone" data-country="HerC">
</div>
<label class="col-sm-2 col-form-label">Secondary Work Phone Country:</label>
<div class="col-sm-4">
<select id="HerC" class="input-medium bfh-countries form-control" data-country="US">
<option value=""></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="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</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="VG">British Virgin Islands</option>
<option value="BN">Brunei</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="CI">Côte d'Ivoire</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="CV">Cape Verde</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="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="CD">Democratic Republic of the Congo</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="TP">East Timor</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="ET">Ethiopia</option>
<option value="FO">Faeroe Islands</option>
<option value="FK">Falkland Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="MK">Former Yugoslav Republic of Macedonia</option>
<option value="FR">France</option>
<option value="FX">France, Metropolitan</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="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="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard and Mc Donald 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</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Laos</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">Macau</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</option>
<option value="MD">Moldova</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="AN">Netherlands Antilles</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="KP">North Korea</option>
<option value="MP">Northern Marianas</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</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 Islands</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico</option>
<option value="QA">Qatar</option>
<option value="RE">Reunion</option>
<option value="RO">Romania</option>
<option value="RU">Russia</option>
<option value="RW">Rwanda</option>
<option value="ST">São Tomé and Príncipe</option>
<option value="SH">Saint Helena</option>
<option value="PM">St. Pierre and Miquelon</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</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="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="KR">South Korea</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 Islands</option>
<option value="SZ">Swaziland</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syria</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania</option>
<option value="TH">Thailand</option>
<option value="BS">The Bahamas</option>
<option value="GM">The Gambia</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="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks and Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="VI">US Virgin Islands</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom</option>
<option value="US">United States</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VA">Vatican City</option>
<option value="VE">Venezuela</option>
<option value="VN">Vietnam</option>
<option value="WF">Wallis and Futuna Islands</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select>
</div>
</div>
<div class="form-group row">
<label class="col-sm-2 col-form-label"><span class="emailRequired req">*</span>Primary Email:</label>
<div class="col-sm-8">
<input type="Email" id="Email" size="55" maxlength="200" class="form-control" required="required">
</div>
</div>
<div id="ContentBodyPlaceHolder_SecondaryEmailRow" class="form-group row">
<label class="col-sm-2 col-form-label">Secondary Email:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$Email2" type="Email" id="Email2" size="55" maxlength="200" class="form-control">
</div>
</div>
<div id="ContentBodyPlaceHolder_BestTimeRow" class="form-group row">
<label class="col-sm-2 col-form-label">Best time to call:</label>
<div class="col-sm-8">
<input type="text" id="BestToCall" maxlength="20" class="form-control">
</div>
</div>
<div id="ContentBodyPlaceHolder_KidsRow" class="form-group row">
<label class="col-sm-2 col-form-label">Kids? Please describe:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$Kids" type="text" id="ContentBodyPlaceHolder_Kids" maxlength="50" class="form-control">
</div>
</div>
<div id="ContentBodyPlaceHolder_ConfidentialReferralRow" class="form-group row">
<label class="col-sm-2 col-form-label">Confidential Referral?:</label>
<div class="col-sm-8">
<select id="Confidential" class="form-control">
<option value="">-- Please Choose --</option>
<option value="0">No</option>
<option value="1">Yes</option>
</select>
</div>
</div>
<div id="ContentBodyPlaceHolder_AskPermissionRow" class="form-group row">
<label class="col-sm-2 col-form-label">Did you ask customer permission?:</label>
<div class="col-sm-8">
<select id="AskedPermission" class="form-control">
<option value="">-- Please Choose --</option>
<option value="0">No</option>
<option value="1">Yes</option>
</select>
</div>
</div>
<div class="form-group row">
<label class="col-sm-2 col-form-label"><span class="req">*</span>Type of Referral:</label>
<div class="col-sm-8">
<select id="TypeOfReferral" class="form-control" required="required">
<option value="">-- Please Choose --</option>
<option value="1">Listing Referral</option>
<option value="2">Buying Referral</option>
</select>
</div>
</div>
<div id="ContentBodyPlaceHolder_PropertyAddressRow" class="form-group row er_referral" style="display: none;">
<label class="col-sm-2 col-form-label">Property Address:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$PropertyAddress" type="text" id="PropertyAddress" maxlength="75" class="form-control">
</div>
</div>
<div id="ContentBodyPlaceHolder_PropertyCityRow" class="form-group row er_referral" style="display: none;">
<label class="col-sm-2 col-form-label">Property City:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$PropertyCityStZip" type="text" id="PropertyCityStZip" size="50" maxlength="75" class="form-control">
</div>
</div>
<div id="ContentBodyPlaceHolder_PropertyStateRow" class="form-group row er_referral" style="display: none;">
<label class="col-sm-2 col-form-label">Property State / Province:</label>
<div class="col-sm-8">
<select id="PropertyState" class="form-control">
<option value="">-- Please Choose --</option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AS">American Samoa</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="UM-81">Baker Island</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="GU">Guam</option>
<option value="HI">Hawaii</option>
<option value="UM-84">Howland Island</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="UM-86">Jarvis Island</option>
<option value="UM-67">Johnston Atoll</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="UM-89">Kingman Reef</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="UM-71">Midway Atoll</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="UM-76">Navassa Island</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="MP">Northern Mariana Islands</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="UM-95">Palmyra Atoll</option>
<option value="PA">Pennsylvania</option>
<option value="PR">Puerto Rico</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="VI">United States Virgin Islands</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="UM-79">Wake Island</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select>
</div>
</div>
<div id="ContentBodyPlaceHolder_PropertyZipRow" class="form-group row er_referral" style="display: none;">
<label class="col-sm-2 col-form-label">Property Zip / Postal Code:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$PropertyZip" type="text" id="PropertyZip" maxlength="10" class="form-control">
</div>
</div>
<div id="ContentBodyPlaceHolder_CurrentlyListRow">
<div class="form-group row er_referral" style="display: none;">
<label class="col-sm-2 col-form-label">Currently Listed?:</label>
<div class="col-sm-8">
<select id="CurrentlyListed" class="form-control">
<option value="">-- Please Choose --</option>
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</div>
</div>
<div id="ContentBodyPlaceHolder_CurrentPriceRow" class="form-group row er_referral" style="display: none;">
<label class="col-sm-2 col-form-label"><span id="CurrentPriceAsterik" class="req hide">*</span>If yes, Listing Price:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$CurrentPrice" type="text" id="ContentBodyPlaceHolder_CurrentPrice" maxlength="15" class="form-control">
</div>
</div>
</div>
<div id="ContentBodyPlaceHolder_EstimatedSalesPriceRow" class="form-group row er_referral" style="display: none;">
<label class="col-sm-2 col-form-label">Estimated Sale Price:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$EstimatedSalePrice" type="text" id="EstimatedSalePrice" maxlength="15" class="form-control">
</div>
</div>
<div id="ContentBodyPlaceHolder_MustSellByRow" class="form-group row er_referral" style="display: none;">
<label class="col-sm-2 col-form-label">Must Sell By:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$MustSellBy" type="date" id="MustSellBy" class="form-control er_mydate">
</div>
</div>
<div id="ContentBodyPlaceHolder_TypeOfHomeRow" class="form-group row er_referral" style="display: none;">
<label class="col-sm-2 col-form-label">Type Of Home:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$TypeOfHome" type="text" id="TypeOfHome" class="form-control">
</div>
</div>
<div id="ContentBodyPlaceHolder_StyleRow" class="form-group row er_referral" style="display: none;">
<label class="col-sm-2 col-form-label">Style:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$Style" type="text" id="Style" maxlength="25" class="form-control">
</div>
</div>
<div id="ContentBodyPlaceHolder_SquerFeetRow" class="form-group row er_referral" style="display: none;">
<label class="col-sm-2 col-form-label">Sq Ft:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$SqFt" type="number" id="SqFt" class="form-control">
</div>
</div>
<div id="ContentBodyPlaceHolder_BedroomsRow" class="form-group row er_referral" style="display: none;">
<label class="col-sm-2 col-form-label">Bedrooms:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$ListBeds" type="text" id="ListBeds" class="form-control" maxlength="5">
</div>
</div>
<div id="ContentBodyPlaceHolder_BathroomsRow" class="form-group row er_referral" style="display: none;">
<label class="col-sm-2 col-form-label">Bathrooms:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$ListBaths" type="text" id="ListBaths" class="form-control" maxlength="5">
</div>
</div>
<div id="ContentBodyPlaceHolder_LotSizeRow" class="form-group row er_referral" style="display: none;">
<label class="col-sm-2 col-form-label">Lot Size:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$LotSize" type="number" id="LotSize" class="form-control">
</div>
</div>
<div id="ContentBodyPlaceHolder_SpecialFeaturesRow" class="form-group row er_referral" style="display: none;">
<label class="col-sm-2 col-form-label">Special Features/Improvements:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$SpecialFeatures" type="text" id="SpecialFeatures" maxlength="50" class="form-control">
</div>
</div>
<div id="ContentBodyPlaceHolder_SpecialNeedsRow" class="form-group row er_referral" style="display: none;">
<label class="col-sm-2 col-form-label">Special Needs:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$ListSpecialNeeds" type="text" id="ListSpecialNeeds" maxlength="50" class="form-control">
</div>
</div>
<div id="ContentBodyPlaceHolder_PrimaryDestinationRow" class="form-group row er_buying" style="display: none;">
<label class="col-sm-2 col-form-label">Primary Destination (City, State):</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$PrimaryDestination" type="text" id="PrimaryDestination" maxlength="50" class="form-control">
</div>
</div>
<div id="ContentBodyPlaceHolder_AlertnateDestinationRow" class="form-group row er_buying" style="display: none;">
<label class="col-sm-2 col-form-label">Alternate Destination:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$AltDestination" type="text" id="AltDestination" maxlength="50" class="form-control">
</div>
</div>
<div id="ContentBodyPlaceHolder_PriceRangeRow" class="form-group row er_buying" style="display: none;">
<label class="col-sm-2 col-form-label"><span id="priceRangeAsterik" class="req">*</span>Price Range:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$PriceRange" type="text" id="PriceRange" class="form-control" required="">
</div>
</div>
<div id="ContentBodyPlaceHolder_FamiliarAreaRow" class="form-group row er_buying" style="display: none;">
<label class="col-sm-2 col-form-label">Familiar w/Area?:</label>
<div class="col-sm-8">
<select id="FamiliarWArea" class="form-control">
<option value="Yes">Yes</option>
<option value="No">No</option>
</select>
</div>
</div>
<div id="ContentBodyPlaceHolder_RelocationReasonRow" class="form-group row er_buying" style="display: none;">
<label class="col-sm-2 col-form-label">Reason for Relocation:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$ReloReason" type="text" id="ReloReason" maxlength="25" class="form-control">
</div>
</div>
<div id="ContentBodyPlaceHolder_InHomeDateRow" class="form-group row er_buying" style="display: none;">
<label class="col-sm-2 col-form-label">In-home Date:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$InHomeDate" type="date" id="InHomeDate" class="form-control er_mydate">
</div>
</div>
<div id="ContentBodyPlaceHolder_TripDateRow" class="form-group row er_buying" style="display: none;">
<label class="col-sm-2 col-form-label"><span class="req er_tripdDateReq hide">*</span>Trip Date:</label>
<div class="col-sm-8">
<input class="form-control er_mydate" type="date" id="TripDate">
</div>
</div>
<div id="ContentBodyPlaceHolder_EmployerRow" class="form-group row er_buying" style="display: none;">
<label class="col-sm-2 col-form-label">Employer:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$Employer" type="text" id="Employer" maxlength="50" class="form-control">
</div>
</div>
<div id="ContentBodyPlaceHolder_StartDateRow" class="form-group row er_buying" style="display: none;">
<label class="col-sm-2 col-form-label">Start Date:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$StartDate" type="date" id="StartDate" class="form-control er_mydate">
</div>
</div>
<div id="ContentBodyPlaceHolder_SecondaryEmployerRow" class="form-group row er_buying" style="display: none;">
<label class="col-sm-2 col-form-label">Secondary Employer:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$SecEmployer" type="text" id="SecEmployer" maxlength="50" class="form-control">
</div>
</div>
<div id="ContentBodyPlaceHolder_PrequalifiedRow">
<div class="form-group row er_buying" style="display: none;">
<label class="col-sm-2 col-form-label">Pre-qualified?:</label>
<div class="col-sm-8">
<select id="Prequalified" class="form-control">
<option value=""></option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select>
</div>
</div>
<div id="PreQualAmountRow" class="form-group row er_buying" style="display: none;">
<label class="col-sm-2 col-form-label"><span id="PreQualAmountAsterik" class="req hide">*</span>If yes, Amount:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$PreQualAmount" type="text" id="PreQualAmount" class="form-control">
</div>
</div>
</div>
<div id="ContentBodyPlaceHolder_FirstTimeBuyerRow" class="form-group row er_buying" style="display: none;">
<label class="col-sm-2 col-form-label">First Time Buyer?:</label>
<div class="col-sm-8">
<select id="FirstTimeBuyer" class="form-control">
<option value=""></option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="form-group row er_buying" style="display: none;">
<label class="col-sm-8 col-form-label er_headlabel">HOUSING REQUIREMENTS</label>
</div>
<div id="ContentBodyPlaceHolder_StyleTypeRow" class="form-group row er_buying" style="display: none;">
<label class="col-sm-2 col-form-label"> Style/Type Desired:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$StyleDesired" type="text" id="StyleDesired" class="form-control">
</div>
</div>
<div id="ContentBodyPlaceHolder_BuyerBedsRow" class="form-group row er_buying" style="display: none;">
<label class="col-sm-2 col-form-label"> Bedrooms:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$BuyBeds" type="text" id="BuyBeds" class="form-control" maxlength="5">
</div>
</div>
<div id="ContentBodyPlaceHolder_BuyerBathsRow" class="form-group row er_buying" style="display: none;">
<label class="col-sm-2 col-form-label">Bathrooms:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$BuyBaths" type="text" id="BuyBaths" class="form-control" maxlength="5">
</div>
</div>
<div class="form-group row er_buying" style="display: none;">
<label class="col-sm-2 col-form-label">Special Needs:</label>
<div class="col-sm-8">
<input type="text" id="BuySpecialNeeds" class="form-control">
</div>
</div>
<div class="form-group row">
<label class="col-sm-2 col-form-label">Additional Comments:</label>
<div class="col-sm-8">
<textarea id="AddlComments" rows="5" cols="500" class="form-control"></textarea>
</div>
</div>
<div class="form-group row er_agentRow">
<label class="col-sm-2 col-form-label"><span class="req">*</span>Your Name:</label>
<div class="col-sm-6 input-group er_agentNameArea">
<select id="CustomerAgenteNum" class="form-control" required="required" tabindex="2025">
<option value="">Choose...</option>
<option value="New">** I'M NOT IN THE DROPDOWN LIST. Let me enter my information manually.</option>
<option value="912">???, ???</option>
<option value="941">Account, Test</option>
<option value="726">Baca, Maria</option>
<option value="626">Baker, Christi</option>
<option value="936">Bennett, Valerie</option>
<option value="151">C de Baca, Ann</option>
<option value="545">Carrico, Connie</option>
<option value="153">Casaus, Johanna</option>
<option value="725">Chan, Helen</option>
<option value="156">Cobb, Larry</option>
<option value="161">Ebbens, Margaret</option>
<option value="685">Erhard, Danielle</option>
<option value="162">Finnegan, Patricia</option>
<option value="877">Finnegan, Tybi</option>
<option value="911">Foley, Elizabeth</option>
<option value="889">Garcia, Andrew</option>
<option value="419">Garcia, Jessica</option>
<option value="707">Garner, Laura</option>
<option value="163">Gilbert, Bridget</option>
<option value="781">Goodhart, Spring</option>
<option value="724">Griego, Jonnice</option>
<option value="937">Hendrickson, Tonia</option>
<option value="890">Herreid, Kristen</option>
<option value="940">Hillson, Bethany</option>
<option value="232">Johnson, Dianne</option>
<option value="933">Khalsa, Deva</option>
<option value="246">Kniffin, CRP, JoLynn</option>
<option value="908">Kovalovsky, Karin</option>
<option value="542">Kutkuhn, Karma</option>
<option value="779">Leisher, Laurel</option>
<option value="883">Leydig, Sue</option>
<option value="932">Martinez-McNeil, Monica</option>
<option value="238">Montemorano, Anna</option>
<option value="657">Nafus, Dianna</option>
<option value="181">Neal, Amy</option>
<option value="901">Nuanes, Victoria</option>
<option value="938">Nunez, Taylor</option>
<option value="900">Padilla, Toby</option>
<option value="934">Parsons, Sharla</option>
<option value="241">Porter, Mary</option>
<option value="914">Relocation, West</option>
<option value="939">Rohl, Holly</option>
<option value="426">Rohl, Michelle</option>
<option value="913">Romero, Haelee</option>
<option value="926">Salazar, AnnMarie</option>
<option value="920">Sanchez, Sasha</option>
<option value="222">Scherlacher, Lisa</option>
<option value="187">Scott, Dale</option>
<option value="886">South, Keri</option>
<option value="759">Sweeney, Christina</option>
<option value="915">Team, Armijo</option>
<option value="636">Team, Homesteps</option>
</select>
<input name="ctl00$ContentBodyPlaceHolder$ReferralNameSelected" type="text" id="ReferralNameSelected" class="form-control searchModalSection hide er_no_click" placeholder="Please select your name (icon on the right)" required=""
style="display: none;">
<span class="input-group-text searchModalSection hide" style="display: none;">
<a class="er_referralNameSearch" href="#searchModal" data-toggle="modal" data-target="#searchModal"><i class="fas fa-search" aria-hidden="true"></i></a>
<a onclick="removeAgent(1)" class="er_removeSearchagent1 hide er_pointer"><i class="fas fa-times" aria-hidden="true"></i></a>
</span>
</div>
<div class="col-sm-3 er_manualAgent hide">
<input type="text" id="RefFName" placeholder="First Name" class="form-control" required="">
</div>
<div class="col-sm-3 er_manualAgent hide">
<input type="text" id="RefLName" placeholder="Last Name" class="form-control" required="">
</div>
<div class="col-sm-3 er_manualAgent hide">
<input type="email" id="RefEmaill" placeholder="Email" class="form-control" required="">
</div>
</div>
<div style="padding: 0 25px 0 25px;">
<span id="ContentBodyPlaceHolder_B2BCustomDisclosure"></span>
</div>
<div class="form-group row">
<div class="col-sm-8 er_btnsection">
<input type="button" class="btn btn-primary btn-lg er_btnSubmit" onclick="SubmitReferral()" value="Submit">
</div>
</div>
</div>
</div>
<div class="tab-pane" id="2">
<div class="er_tabsection">
<div>
<span id="ContentBodyPlaceHolder_lblCustomerRegInstructions">
<p></p>
<p><strong>Note:</strong> Please use this form to let us know if you're working with a customer that could come through as a Relo Referral so we can make sure we assign it to you. It is very important that you enter as much
information as you can, to ensure we can find your customer. Misspelled names, mailing address, or email addresses increase the likelihood we would not be able to find your customer. In addition, for example, if you supply an email
address, but not a phone number, and we receive the referral without an email address, but with a phone number, we may not be able to match the customer.</p>
</span>
</div>
<div class="form-group row">
<label class="col-sm-8 col-form-label er_bold er_underline">Customer Name:</label>
</div>
<div class="form-group row">
<label class="col-sm-2 col-form-label"><span class="req">*</span>First Name:</label>
<div class="col-sm-8">
<input type="text" id="FirstName" class="form-control" required="">
</div>
</div>
<div class="form-group row">
<label class="col-sm-2 col-form-label"><span class="req">*</span>Last Name:</label>
<div class="col-sm-8">
<input type="text" id="LastName" class="form-control" required="">
</div>
</div>
<div class="form-group row">
<label class="col-sm-2 col-form-label">Secondary First Name:</label>
<div class="col-sm-8">
<input type="text" id="SpouseFirstName" class="form-control">
</div>
</div>
<div class="form-group row">
<label class="col-sm-2 col-form-label">Secondary Last Name:</label>
<div class="col-sm-8">
<input type="text" id="SpouseLastName" class="form-control">
</div>
</div>
<div class="form-group row">
<label class="col-sm-2 col-form-label"><span class="req er_employerRequired hide">*</span>Employer:</label>
<div class="col-sm-8">
<input type="text" id="CustomerEmployer" class="form-control">
</div>
</div>
<div id="ContentBodyPlaceHolder_CustomerMemberNumberRow" class="form-group row">
<label class="col-sm-2 col-form-label">Member Number:</label>
<div class="col-sm-8">
<input type="text" id="CustomerMemberNumber" class="form-control">
</div>
</div>
<div class="form-group row">
<label class="col-sm-2 col-form-label">Service Type:</label>
<div class="col-sm-8">
<select id="CustomerServiceType" class="form-control">
<option value="">-- Please Choose --</option>
<option value="Buyer">Buyer</option>
<option value="Seller">Seller</option>
<option value="Buyer & Seller">Buyer & Seller</option>
<option value="Renter">Renter</option>
</select>
</div>
</div> <div id="ContentBodyPlaceHolder_MailingSection">
<div id="ContentBodyPlaceHolder_MailingInfoHeaderDiv" class="form-group row">
<label class="col-sm-8 col-form-label er_bold er_underline">Mailing Info:</label>
</div>
<div class="form-group row">
<label class="col-sm-2 col-form-label">Country:</label>
<div class="col-sm-8">
<select id="MailCountry" class="form-control">
<option value="233">United States</option>
<option value="39">Canada</option>
<option value="1">Afghanistan</option>
<option value="2">Aland Islands</option>
<option value="3">Albania</option>
<option value="4">Algeria</option>
<option value="5">American Samoa</option>
<option value="6">Andorra</option>
<option value="7">Angola</option>
<option value="8">Anguilla</option>
<option value="9">Antarctica</option>
<option value="10">Antigua and Barbuda</option>
<option value="11">Argentina</option>
<option value="12">Armenia</option>
<option value="13">Aruba</option>
<option value="14">Australia</option>
<option value="15">Austria</option>
<option value="16">Azerbaijan</option>
<option value="18">Bahrain</option>
<option value="19">Bangladesh</option>
<option value="20">Barbados</option>
<option value="21">Belarus</option>
<option value="22">Belgium</option>
<option value="23">Belize</option>
<option value="24">Benin</option>
<option value="25">Bermuda</option>
<option value="26">Bhutan</option>
<option value="27">Bolivia</option>
<option value="155">Bonaire, Sint Eustatius and Saba</option>
<option value="28">Bosnia and Herzegovina</option>
<option value="29">Botswana</option>
<option value="30">Bouvet Island</option>
<option value="31">Brazil</option>
<option value="32">British Indian Ocean Territory</option>
<option value="33">Brunei</option>
<option value="34">Bulgaria</option>
<option value="35">Burkina Faso</option>
<option value="36">Burundi</option>
<option value="37">Cambodia</option>
<option value="38">Cameroon</option>
<option value="40">Cape Verde</option>
<option value="41">Cayman Islands</option>
<option value="42">Central African Republic</option>
<option value="43">Chad</option>
<option value="44">Chile</option>
<option value="45">China</option>
<option value="46">Christmas Island</option>
<option value="47">Cocos (Keeling) Islands</option>
<option value="48">Colombia</option>
<option value="49">Comoros</option>
<option value="50">Congo</option>
<option value="52">Cook Islands</option>
<option value="53">Costa Rica</option>
<option value="54">Cote D'Ivoire (Ivory Coast)</option>
<option value="55">Croatia</option>
<option value="56">Cuba</option>
<option value="249">Curaçao</option>
<option value="57">Cyprus</option>
<option value="58">Czech Republic</option>
<option value="51">Democratic Republic of the Congo</option>
<option value="59">Denmark</option>
<option value="60">Djibouti</option>
<option value="61">Dominica</option>
<option value="62">Dominican Republic</option>
<option value="64">Ecuador</option>
<option value="65">Egypt</option>
<option value="66">El Salvador</option>
<option value="67">Equatorial Guinea</option>
<option value="68">Eritrea</option>
<option value="69">Estonia</option>
<option value="212">Eswatini</option>
<option value="70">Ethiopia</option>
<option value="71">Falkland Islands</option>
<option value="72">Faroe Islands</option>
<option value="73">Fiji Islands</option>
<option value="74">Finland</option>
<option value="75">France</option>
<option value="76">French Guiana</option>
<option value="77">French Polynesia</option>
<option value="78">French Southern Territories</option>
<option value="79">Gabon</option>
<option value="80">Gambia The</option>
<option value="81">Georgia</option>
<option value="82">Germany</option>
<option value="83">Ghana</option>
<option value="84">Gibraltar</option>
<option value="85">Greece</option>
<option value="86">Greenland</option>
<option value="87">Grenada</option>
<option value="88">Guadeloupe</option>
<option value="89">Guam</option>
<option value="90">Guatemala</option>
<option value="91">Guernsey and Alderney</option>
<option value="92">Guinea</option>
<option value="93">Guinea-Bissau</option>
<option value="94">Guyana</option>
<option value="95">Haiti</option>
<option value="96">Heard Island and McDonald Islands</option>
<option value="97">Honduras</option>
<option value="98">Hong Kong S.A.R.</option>
<option value="99">Hungary</option>
<option value="100">Iceland</option>
<option value="101">India</option>
<option value="102">Indonesia</option>
<option value="103">Iran</option>
<option value="104">Iraq</option>
<option value="105">Ireland</option>
<option value="106">Israel</option>
<option value="107">Italy</option>
<option value="108">Jamaica</option>
<option value="109">Japan</option>
<option value="110">Jersey</option>
<option value="111">Jordan</option>
<option value="112">Kazakhstan</option>
<option value="113">Kenya</option>
<option value="114">Kiribati</option>
<option value="248">Kosovo</option>
<option value="117">Kuwait</option>
<option value="118">Kyrgyzstan</option>
<option value="119">Laos</option>
<option value="120">Latvia</option>
<option value="121">Lebanon</option>
<option value="122">Lesotho</option>
<option value="123">Liberia</option>
<option value="124">Libya</option>
<option value="125">Liechtenstein</option>
<option value="126">Lithuania</option>
<option value="127">Luxembourg</option>
<option value="128">Macau S.A.R.</option>
<option value="130">Madagascar</option>
<option value="131">Malawi</option>
<option value="132">Malaysia</option>
<option value="133">Maldives</option>
<option value="134">Mali</option>
<option value="135">Malta</option>
<option value="136">Man (Isle of)</option>
<option value="137">Marshall Islands</option>
<option value="138">Martinique</option>
<option value="139">Mauritania</option>
<option value="140">Mauritius</option>
<option value="141">Mayotte</option>
<option value="142">Mexico</option>
<option value="143">Micronesia</option>
<option value="144">Moldova</option>
<option value="145">Monaco</option>
<option value="146">Mongolia</option>
<option value="147">Montenegro</option>
<option value="148">Montserrat</option>
<option value="149">Morocco</option>
<option value="150">Mozambique</option>
<option value="151">Myanmar</option>
<option value="152">Namibia</option>
<option value="153">Nauru</option>
<option value="154">Nepal</option>
<option value="156">Netherlands</option>
<option value="157">New Caledonia</option>
<option value="158">New Zealand</option>
<option value="159">Nicaragua</option>
<option value="160">Niger</option>
<option value="161">Nigeria</option>
<option value="162">Niue</option>
<option value="163">Norfolk Island</option>
<option value="115">North Korea</option>
<option value="129">North Macedonia</option>
<option value="164">Northern Mariana Islands</option>
<option value="165">Norway</option>
<option value="166">Oman</option>
<option value="167">Pakistan</option>
<option value="168">Palau</option>
<option value="169">Palestinian Territory Occupied</option>
<option value="170">Panama</option>
<option value="171">Papua New Guinea</option>
<option value="172">Paraguay</option>
<option value="173">Peru</option>
<option value="174">Philippines</option>
<option value="175">Pitcairn Island</option>
<option value="176">Poland</option>
<option value="177">Portugal</option>
<option value="178">Puerto Rico</option>
<option value="179">Qatar</option>
<option value="180">Reunion</option>
<option value="181">Romania</option>
<option value="182">Russia</option>
<option value="183">Rwanda</option>
<option value="184">Saint Helena</option>
<option value="185">Saint Kitts and Nevis</option>
<option value="186">Saint Lucia</option>
<option value="187">Saint Pierre and Miquelon</option>
<option value="188">Saint Vincent and the Grenadines</option>
<option value="189">Saint-Barthelemy</option>
<option value="190">Saint-Martin (French part)</option>
<option value="191">Samoa</option>
<option value="192">San Marino</option>
<option value="193">Sao Tome and Principe</option>
<option value="194">Saudi Arabia</option>
<option value="195">Senegal</option>
<option value="196">Serbia</option>
<option value="197">Seychelles</option>
<option value="198">Sierra Leone</option>
<option value="199">Singapore</option>
<option value="250">Sint Maarten (Dutch part)</option>
<option value="200">Slovakia</option>
<option value="201">Slovenia</option>
<option value="202">Solomon Islands</option>
<option value="203">Somalia</option>
<option value="204">South Africa</option>
<option value="205">South Georgia</option>
<option value="116">South Korea</option>
<option value="206">South Sudan</option>
<option value="207">Spain</option>
<option value="208">Sri Lanka</option>
<option value="209">Sudan</option>
<option value="210">Suriname</option>
<option value="211">Svalbard and Jan Mayen Islands</option>
<option value="213">Sweden</option>
<option value="214">Switzerland</option>
<option value="215">Syria</option>
<option value="216">Taiwan</option>
<option value="217">Tajikistan</option>
<option value="218">Tanzania</option>
<option value="219">Thailand</option>
<option value="17">The Bahamas</option>
<option value="63">Timor-Leste</option>
<option value="220">Togo</option>
<option value="221">Tokelau</option>
<option value="222">Tonga</option>
<option value="223">Trinidad and Tobago</option>
<option value="224">Tunisia</option>
<option value="225">Turkey</option>
<option value="226">Turkmenistan</option>
<option value="227">Turks and Caicos Islands</option>
<option value="228">Tuvalu</option>
<option value="229">Uganda</option>
<option value="230">Ukraine</option>
<option value="231">United Arab Emirates</option>
<option value="232">United Kingdom</option>
<option value="234">United States Minor Outlying Islands</option>
<option value="235">Uruguay</option>
<option value="236">Uzbekistan</option>
<option value="237">Vanuatu</option>
<option value="238">Vatican City State (Holy See)</option>
<option value="239">Venezuela</option>
<option value="240">Vietnam</option>
<option value="241">Virgin Islands (British)</option>
<option value="242">Virgin Islands (US)</option>
<option value="243">Wallis and Futuna Islands</option>
<option value="244">Western Sahara</option>
<option value="245">Yemen</option>
<option value="246">Zambia</option>
<option value="247">Zimbabwe</option>
</select>
</div>
</div>
<div class="form-group row">
<label class="col-sm-2 col-form-label"><span class="req hide" id="addressAsterik">*</span>Address:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$CustomerMailAddress" type="text" id="CustomerMailAddress" class="form-control">
</div>
</div>
<div class="form-group row">
<label class="col-sm-2 col-form-label"><span id="CityAsterik" class="req hide">*</span>City:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$MailCity" type="text" id="MailCity" class="form-control">
</div>
</div>
<div class="form-group row">
<label class="col-sm-2 col-form-label"><span id="StateAsterik" class="req hide">*</span>State:</label>
<div class="col-sm-8">
<select id="MailState" class="input-medium bfh-states form-control">
<option value="">-- Please Choose --</option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AS">American Samoa</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="UM-81">Baker Island</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="GU">Guam</option>
<option value="HI">Hawaii</option>
<option value="UM-84">Howland Island</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="UM-86">Jarvis Island</option>
<option value="UM-67">Johnston Atoll</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="UM-89">Kingman Reef</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="UM-71">Midway Atoll</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="UM-76">Navassa Island</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="MP">Northern Mariana Islands</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="UM-95">Palmyra Atoll</option>
<option value="PA">Pennsylvania</option>
<option value="PR">Puerto Rico</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="VI">United States Virgin Islands</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="UM-79">Wake Island</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select>
</div>
</div>
<div class="form-group row">
<label class="col-sm-2 col-form-label"><span class="req hide" id="zipAsterik" clientidmode="static">*</span>Zip:</label>
<div class="col-sm-8">
<input name="ctl00$ContentBodyPlaceHolder$CustomerMailZip" type="text" id="CustomerMailZip" maxlength="10" class="form-control">
</div>
</div>
</div> <div class="form-group row">
<label class="col-sm-8 col-form-label er_bold er_underline"><span class="req">*</span>Phone Numbers:</label>
</div>
<div id="ContentBodyPlaceHolder_PrimaryCellRow" class="form-group row">
<label class="col-sm-2 col-form-label">Primary Cell #:</label>
<div class="col-sm-4">
<input type="text" id="CustomerCellPhone" maxlength="20" class="bfh-phone form-control er_cust_phone" data-country="CustomerCellC">
</div>
<label class="col-sm-2 col-form-label">Primary Cell Country:</label>
<div class="col-sm-4">
<select id="CustomerCellC" class="input-medium bfh-countries form-control" data-country="US">
<option value=""></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="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</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="VG">British Virgin Islands</option>
<option value="BN">Brunei</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="CI">Côte d'Ivoire</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="CV">Cape Verde</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="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="CD">Democratic Republic of the Congo</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="TP">East Timor</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="ET">Ethiopia</option>
<option value="FO">Faeroe Islands</option>
<option value="FK">Falkland Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="MK">Former Yugoslav Republic of Macedonia</option>
<option value="FR">France</option>
<option value="FX">France, Metropolitan</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="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="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard and Mc Donald 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</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Laos</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">Macau</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</option>
<option value="MD">Moldova</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="AN">Netherlands Antilles</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="KP">North Korea</option>
<option value="MP">Northern Marianas</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</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 Islands</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico</option>
<option value="QA">Qatar</option>
<option value="RE">Reunion</option>
<option value="RO">Romania</option>
<option value="RU">Russia</option>
<option value="RW">Rwanda</option>
<option value="ST">São Tomé and Príncipe</option>
<option value="SH">Saint Helena</option>
<option value="PM">St. Pierre and Miquelon</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</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="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="KR">South Korea</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 Islands</option>
<option value="SZ">Swaziland</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syria</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania</option>
<option value="TH">Thailand</option>
<option value="BS">The Bahamas</option>
<option value="GM">The Gambia</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="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks and Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="VI">US Virgin Islands</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom</option>
<option value="US">United States</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VA">Vatican City</option>
<option value="VE">Venezuela</option>
<option value="VN">Vietnam</option>
<option value="WF">Wallis and Futuna Islands</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select>
</div>
</div>
<div id="ContentBodyPlaceHolder_HomePhoneRow" class="form-group row">
<label class="col-sm-2 col-form-label">Home Phone:</label>
<div class="col-sm-4">
<input type="text" id="CustomerHomePhone" maxlength="20" class="bfh-phone form-control er_cust_phone" data-country="CustomerHomeC">
</div>
<label class="col-sm-2 col-form-label">Home Phone Country:</label>
<div class="col-sm-4">
<select id="CustomerHomeC" class="input-medium bfh-countries form-control" data-country="US">
<option value=""></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="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</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="VG">British Virgin Islands</option>
<option value="BN">Brunei</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="CI">Côte d'Ivoire</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="CV">Cape Verde</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="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="CD">Democratic Republic of the Congo</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="TP">East Timor</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="ET">Ethiopia</option>
<option value="FO">Faeroe Islands</option>
<option value="FK">Falkland Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="MK">Former Yugoslav Republic of Macedonia</option>
<option value="FR">France</option>
<option value="FX">France, Metropolitan</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="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="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard and Mc Donald 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</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Laos</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">Macau</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</option>
<option value="MD">Moldova</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="AN">Netherlands Antilles</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="KP">North Korea</option>
<option value="MP">Northern Marianas</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</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 Islands</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico</option>
<option value="QA">Qatar</option>
<option value="RE">Reunion</option>
<option value="RO">Romania</option>
<option value="RU">Russia</option>
<option value="RW">Rwanda</option>
<option value="ST">São Tomé and Príncipe</option>
<option value="SH">Saint Helena</option>
<option value="PM">St. Pierre and Miquelon</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</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="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="KR">South Korea</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 Islands</option>
<option value="SZ">Swaziland</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syria</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania</option>
<option value="TH">Thailand</option>
<option value="BS">The Bahamas</option>
<option value="GM">The Gambia</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="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks and Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="VI">US Virgin Islands</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom</option>
<option value="US">United States</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VA">Vatican City</option>
<option value="VE">Venezuela</option>
<option value="VN">Vietnam</option>
<option value="WF">Wallis and Futuna Islands</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select>
</div>
</div>
<div id="ContentBodyPlaceHolder_OtherPhoneRow" class="form-group row">
<label class="col-sm-2 col-form-label">Other Phone:</label>
<div class="col-sm-4">
<input type="text" id="CustomerOtherPhone" maxlength="20" class="bfh-phone form-control er_cust_phone" data-country="CustomerOtherC">
</div>
<label class="col-sm-2 col-form-label">Other Phone Country:</label>
<div class="col-sm-4">
<select id="CustomerOtherC" class="input-medium bfh-countries form-control" data-country="US">
<option value=""></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="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</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="VG">British Virgin Islands</option>
<option value="BN">Brunei</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="CI">Côte d'Ivoire</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="CV">Cape Verde</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="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="CD">Democratic Republic of the Congo</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="TP">East Timor</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="ET">Ethiopia</option>
<option value="FO">Faeroe Islands</option>
<option value="FK">Falkland Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="MK">Former Yugoslav Republic of Macedonia</option>
<option value="FR">France</option>
<option value="FX">France, Metropolitan</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="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="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard and Mc Donald 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</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Laos</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">Macau</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</option>
<option value="MD">Moldova</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="AN">Netherlands Antilles</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="KP">North Korea</option>
<option value="MP">Northern Marianas</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</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 Islands</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico</option>
<option value="QA">Qatar</option>
<option value="RE">Reunion</option>
<option value="RO">Romania</option>
<option value="RU">Russia</option>
<option value="RW">Rwanda</option>
<option value="ST">São Tomé and Príncipe</option>
<option value="SH">Saint Helena</option>
<option value="PM">St. Pierre and Miquelon</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</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="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="KR">South Korea</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 Islands</option>
<option value="SZ">Swaziland</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syria</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania</option>
<option value="TH">Thailand</option>
<option value="BS">The Bahamas</option>
<option value="GM">The Gambia</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="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks and Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="VI">US Virgin Islands</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom</option>
<option value="US">United States</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VA">Vatican City</option>
<option value="VE">Venezuela</option>
<option value="VN">Vietnam</option>
<option value="WF">Wallis and Futuna Islands</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select>
</div>
</div>
<div id="ContentBodyPlaceHolder_SecondaryCellRow" class="form-group row">
<label class="col-sm-2 col-form-label">Secondary Cell #:</label>
<div class="col-sm-4">
<input type="text" id="CustomerCell2Phone" maxlength="20" class="bfh-phone form-control er_cust_phone" data-country="CustomerCell2C">
</div>
<label class="col-sm-2 col-form-label">Secondary Cell Country:</label>
<div class="col-sm-4">
<select id="CustomerCell2C" class="input-medium bfh-countries form-control" data-country="US">
<option value=""></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="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</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="VG">British Virgin Islands</option>
<option value="BN">Brunei</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="CI">Côte d'Ivoire</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="CV">Cape Verde</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="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="CD">Democratic Republic of the Congo</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="TP">East Timor</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="ET">Ethiopia</option>
<option value="FO">Faeroe Islands</option>
<option value="FK">Falkland Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="MK">Former Yugoslav Republic of Macedonia</option>
<option value="FR">France</option>
<option value="FX">France, Metropolitan</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="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="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard and Mc Donald 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</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Laos</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">Macau</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</option>
<option value="MD">Moldova</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="AN">Netherlands Antilles</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="KP">North Korea</option>
<option value="MP">Northern Marianas</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</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 Islands</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico</option>
<option value="QA">Qatar</option>
<option value="RE">Reunion</option>
<option value="RO">Romania</option>
<option value="RU">Russia</option>
<option value="RW">Rwanda</option>
<option value="ST">São Tomé and Príncipe</option>
<option value="SH">Saint Helena</option>
<option value="PM">St. Pierre and Miquelon</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</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="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="KR">South Korea</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 Islands</option>
<option value="SZ">Swaziland</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syria</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania</option>
<option value="TH">Thailand</option>
<option value="BS">The Bahamas</option>
<option value="GM">The Gambia</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="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks and Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="VI">US Virgin Islands</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom</option>
<option value="US">United States</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VA">Vatican City</option>
<option value="VE">Venezuela</option>
<option value="VN">Vietnam</option>
<option value="WF">Wallis and Futuna Islands</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select>
</div>
</div>
<div id="ContentBodyPlaceHolder_PrimaryWorkRow" class="form-group row">
<label class="col-sm-2 col-form-label">Primary Work #:</label>
<div class="col-sm-4">
<input type="text" id="CustomerWorkPhone" maxlength="20" class="bfh-phone form-control er_cust_phone" data-country="CustomerWorkC">
</div>
<label class="col-sm-2 col-form-label">Primary Work Country:</label>
<div class="col-sm-4">
<select id="CustomerWorkC" class="input-medium bfh-countries form-control" data-country="US">
<option value=""></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="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</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="VG">British Virgin Islands</option>
<option value="BN">Brunei</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="CI">Côte d'Ivoire</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="CV">Cape Verde</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="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="CD">Democratic Republic of the Congo</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="TP">East Timor</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="ET">Ethiopia</option>
<option value="FO">Faeroe Islands</option>
<option value="FK">Falkland Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="MK">Former Yugoslav Republic of Macedonia</option>
<option value="FR">France</option>
<option value="FX">France, Metropolitan</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="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="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard and Mc Donald 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</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Laos</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">Macau</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</option>
<option value="MD">Moldova</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="AN">Netherlands Antilles</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="KP">North Korea</option>
<option value="MP">Northern Marianas</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</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 Islands</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico</option>
<option value="QA">Qatar</option>
<option value="RE">Reunion</option>
<option value="RO">Romania</option>
<option value="RU">Russia</option>
<option value="RW">Rwanda</option>
<option value="ST">São Tomé and Príncipe</option>
<option value="SH">Saint Helena</option>
<option value="PM">St. Pierre and Miquelon</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</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="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="KR">South Korea</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 Islands</option>
<option value="SZ">Swaziland</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syria</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania</option>
<option value="TH">Thailand</option>
<option value="BS">The Bahamas</option>
<option value="GM">The Gambia</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="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks and Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="VI">US Virgin Islands</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom</option>
<option value="US">United States</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VA">Vatican City</option>
<option value="VE">Venezuela</option>
<option value="VN">Vietnam</option>
<option value="WF">Wallis and Futuna Islands</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select>
</div>
</div>
<div id="ContentBodyPlaceHolder_SecondaryWorkRow" class="form-group row">
<label class="col-sm-2 col-form-label">Secondary Work #:</label>
<div class="col-sm-4">
<input type="text" id="CustomerWork2Phone" maxlength="20" class="bfh-phone form-control" data-country="CustomerWork2C">
</div>
<label class="col-sm-2 col-form-label">Secondary Work Country:</label>
<div class="col-sm-4">
<select id="CustomerWork2C" class="input-medium bfh-countries form-control" data-country="US">
<option value=""></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="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</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="VG">British Virgin Islands</option>
<option value="BN">Brunei</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="CI">Côte d'Ivoire</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="CV">Cape Verde</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="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="CD">Democratic Republic of the Congo</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="TP">East Timor</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="ET">Ethiopia</option>
<option value="FO">Faeroe Islands</option>
<option value="FK">Falkland Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="MK">Former Yugoslav Republic of Macedonia</option>
<option value="FR">France</option>
<option value="FX">France, Metropolitan</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="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="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard and Mc Donald 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</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Laos</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">Macau</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</option>
<option value="MD">Moldova</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="AN">Netherlands Antilles</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="KP">North Korea</option>
<option value="MP">Northern Marianas</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</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 Islands</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico</option>
<option value="QA">Qatar</option>
<option value="RE">Reunion</option>
<option value="RO">Romania</option>
<option value="RU">Russia</option>
<option value="RW">Rwanda</option>
<option value="ST">São Tomé and Príncipe</option>
<option value="SH">Saint Helena</option>
<option value="PM">St. Pierre and Miquelon</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</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="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="KR">South Korea</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 Islands</option>
<option value="SZ">Swaziland</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syria</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania</option>
<option value="TH">Thailand</option>
<option value="BS">The Bahamas</option>
<option value="GM">The Gambia</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="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks and Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="VI">US Virgin Islands</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom</option>
<option value="US">United States</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VA">Vatican City</option>
<option value="VE">Venezuela</option>
<option value="VN">Vietnam</option>
<option value="WF">Wallis and Futuna Islands</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select>
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<label class="col-sm-8 col-form-label er_bold er_underline">Email:</label>
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<div class="form-group row">
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<div class="col-sm-8">
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<div class="form-group row">
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<label class="col-sm-2 col-form-label"><span class="req">*</span>Your Name:</label>
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<option value="">Choose...</option>
<option value="912">???, ???</option>
<option value="941">Account, Test</option>
<option value="726">Baca, Maria</option>
<option value="626">Baker, Christi</option>
<option value="936">Bennett, Valerie</option>
<option value="151">C de Baca, Ann</option>
<option value="545">Carrico, Connie</option>
<option value="153">Casaus, Johanna</option>
<option value="725">Chan, Helen</option>
<option value="156">Cobb, Larry</option>
<option value="161">Ebbens, Margaret</option>
<option value="685">Erhard, Danielle</option>
<option value="162">Finnegan, Patricia</option>
<option value="877">Finnegan, Tybi</option>
<option value="911">Foley, Elizabeth</option>
<option value="889">Garcia, Andrew</option>
<option value="419">Garcia, Jessica</option>
<option value="707">Garner, Laura</option>
<option value="163">Gilbert, Bridget</option>
<option value="781">Goodhart, Spring</option>
<option value="724">Griego, Jonnice</option>
<option value="937">Hendrickson, Tonia</option>
<option value="890">Herreid, Kristen</option>
<option value="940">Hillson, Bethany</option>
<option value="232">Johnson, Dianne</option>
<option value="933">Khalsa, Deva</option>
<option value="246">Kniffin, CRP, JoLynn</option>
<option value="908">Kovalovsky, Karin</option>
<option value="542">Kutkuhn, Karma</option>
<option value="779">Leisher, Laurel</option>
<option value="883">Leydig, Sue</option>
<option value="932">Martinez-McNeil, Monica</option>
<option value="238">Montemorano, Anna</option>
<option value="657">Nafus, Dianna</option>
<option value="181">Neal, Amy</option>
<option value="901">Nuanes, Victoria</option>
<option value="938">Nunez, Taylor</option>
<option value="900">Padilla, Toby</option>
<option value="934">Parsons, Sharla</option>
<option value="241">Porter, Mary</option>
<option value="914">Relocation, West</option>
<option value="939">Rohl, Holly</option>
<option value="426">Rohl, Michelle</option>
<option value="913">Romero, Haelee</option>
<option value="926">Salazar, AnnMarie</option>
<option value="920">Sanchez, Sasha</option>
<option value="222">Scherlacher, Lisa</option>
<option value="187">Scott, Dale</option>
<option value="886">South, Keri</option>
<option value="759">Sweeney, Christina</option>
<option value="915">Team, Armijo</option>
<option value="636">Team, Homesteps</option>
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<a class="er_searchagent2" href="#searchModal" data-toggle="modal" data-target="#searchModal"><i class="fas fa-search" aria-hidden="true"></i></a>
<a onclick="removeAgent(2)" class="er_removeSearchagent2 hide er_pointer"><i class="fas fa-times" aria-hidden="true"></i></a>
</span>
</div>
<div class="col-sm-3 er_manualAgent hide">
<input type="text" id="CusFName" placeholder="First Name" class="form-control" required="">
</div>
<div class="col-sm-3 er_manualAgent hide">
<input type="text" id="CusLName" placeholder="Last Name" class="form-control" required="">
</div>
<div class="col-sm-3 er_manualAgent hide">
<input type="email" id="CusEmaill" placeholder="Email" class="form-control" required="">
</div>
</div>
<div class="form-group row">
<label class="col-sm-2 col-form-label"></label>
<div class="col-sm-4">
<label class="form-check-label" for="chkEmailCustomer">
<input type="checkbox" id="chkEmailCustomer" class="form-check-input" checked="checked"> Email a Confirmation to Me</label>
</div>
</div>
<div class="form-group row">
<label class="col-sm-2 col-form-label">Comments:</label>
<div class="col-sm-8">
<textarea name="ctl00$ContentBodyPlaceHolder$CustomerComments" id="CustomerComments" rows="5" cols="500" class="form-control"></textarea>
</div>
</div>
<div style="padding: 0 25px 0 25px;">
<span id="ContentBodyPlaceHolder_CustomerClosingStatement"></span>
</div> <div class="form-group row">
<div class="col-sm-8 er_btnsection">
<input type="button" class="btn btn-primary btn-lg er_btnSubmit" onclick="SubmitNewCustomer()" value="Submit">
</div>
</div>
</div>
</div>
<div class="modal fade" id="searchModal" tabindex="-1" role="dialog">
<div class="modal-dialog modal-dialog-centered" role="document">
<div class="modal-content">
<div class="modal-header">
<h5 class="modal-title">Search Agents</h5>
<button type="button" class="close" data-dismiss="modal" aria-label="Close">
<span aria-hidden="true">×</span>
</button>
</div>
<input type="hidden" id="SearchType">
<div class="modal-body"></div>
</div>
</div>
</div>
</div>
<div id="StatusMessageDiv" class="hide">
<h3 class="er_statusMessage"></h3>
</div>
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<input type="hidden" id="TheB2BLinkRequirePriorContact" value="0">
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<input type="hidden" id="TheBrokerUn" value="e4dc6a19">
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<input type="hidden" id="TheCustomerRegistrationRequireEmployer" value="0">
<input type="hidden" id="AllowSubmit" value="1">
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<input type="hidden" id="AgentName2">
<input type="hidden" id="AgenteNum2Customer">
<input type="hidden" id="AgentName2Customer">
<input type="hidden" id="TheB2BCustomQuestionYesRequired">
<input type="hidden" id="TheB2BCustomQuestionYesRequired2">
<input type="hidden" id="TheB2BCustomQuestionYesRequired3">
<input type="hidden" id="TheB2BCustomQuestionYesRequired4">
<input type="hidden" id="TheB2BLinkAgents1UseDropdown2UseModal" value="1">
<input type="hidden" id="TheB2BCustomAnswerYesRequired">
<input type="hidden" id="TheB2BCustomQuestionEitherRequired">
<input type="hidden" id="TheB2BCustomDisclosureStatement">
<input type="hidden" id="TheB2BCustomAnswerYesRequired2">
<input type="hidden" id="TheB2BCustomQuestionEitherRequired2">
<input type="hidden" id="TheB2BCustomAnswerYesRequired3">
<input type="hidden" id="TheB2BCustomQuestionEitherRequired3">
<input type="hidden" id="TheB2BCustomAnswerYesRequired4">
<input type="hidden" id="TheB2BCustomQuestionEitherRequired4">
<input type="hidden" id="CustomerRegistrationCustomText1RequiredIfCustomFlag1YesHidden" value="False">
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<input type="hidden" id="CustomerReg_RequireAddressIfSellerOrBuyerSellerHidden" value="False">
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<input type="hidden" id="DisableCustomerRegistrationsHidden" value="0">
<input type="hidden" id="OGRSubmitHideTabsHidden" value="1">
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<input type="hidden" id="OGRSubmitRequireTripDateBuyerHidden" value="0">
<input type="hidden" id="OGRSubmitRequireStyleTypeDesiredBuyerHidden" value="0">
<input type="hidden" id="OGRSubmitRequireBedroomsBuyerHidden" value="0">
<input type="hidden" id="OGRSubmitRequireBathroomsBuyerHidden" value="0">
<input type="hidden" id="OGRSubmit_OnLoadAlertText">
<input type="hidden" id="OGRSubmit_OnLoadAlertTitle">
<input type="hidden" id="CustomerTitle" value="ERA Summit- Register a Customer with Relocation">
<input type="hidden" id="ReferralTitle" value="ERA Summit- Submit OGR / AGR to Relocation">
<input type="hidden" id="TheOffices" value="ABQ - Relocation, NM**Albuquerque-0001, NM**ERASUMMIT - Corporate, **Relo Prop Mgmt, ">
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<input type="hidden" id="OGRSubmitHideAskCustomerPermission" value="0">
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<input type="hidden" id="OGRSubmitHideKids" value="0">
<input type="hidden" id="OGRSubmitRequireKids" value="0">
<input type="hidden" id="CustomerReg_RequireAddessIfBuyerHidden" value="False">
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<input type="hidden" id="ZipRenterRequired" value="False">
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<input type="hidden" id="HardCodedAgenteNum">
<input type="hidden" id="RemoveCustomerRegistrationTab">
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<input type="hidden" id="RequestAgentManuallyEntered">
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<input type="hidden" id="OrgPath" value="/2.0.0.0/b2breferral5/referral.aspx">
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<span id="ContentBodyPlaceHolder_CustomJavascriptOutgoingReferral"></span>
</div>
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</form>Text Content
ERA Summit- Submit OGR / AGR to Relocation * Submit a Referral * Register an Incoming Customer Please use this form to submit an Outgoing Listing or Buyer referral, or to place an existing customer into an Anywhere Rewards Program (AGR or Agent Generated Referral). Please provide as much information about your customer as possible. Once your OGR has been submitted and placed, you'll be notified of the receiving brokerage and agent. If you have questions, please contact Lisa Scherlacher at 505-203-3386 or lisascherlacher@eraabq.com. Thank you. *This is: Choose... Outbound Broker-to-Broker Anywhere Military Rewards AGR (enroll in program) NFCU AGR Other (please specify in comments) AARP Real Estate Benefits from Anywhere Member Number: *Customer Name: Marital Status: -- Please Choose -- Common Law Spouse Divorced Divorcing Domestic Partner Engaged Legally Separated Married Never Married Other Partner Separated Single Widowed Unmarried Couple Your Relation to Customer: Has customer had prior contact with an agent?: -- Please Choose -- No Yes If yes, provide company name, agent name, email and phone #: *Mailing Address Country: United States Canada Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire (Ivory Coast) Croatia Cuba Curaçao Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Islands Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia The Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey and Alderney Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong S.A.R. Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau S.A.R. Madagascar Malawi Malaysia Maldives Mali Malta Man (Isle of) Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea North Macedonia Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Island Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Saint-Barthelemy Saint-Martin (French part) Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Islands Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Vietnam Virgin Islands (British) Virgin Islands (US) Wallis and Futuna Islands Western Sahara Yemen Zambia Zimbabwe *Customer's Mailing Address: *Mailing Address City: *Mailing Address State / Province: -- Please Choose --AlabamaAlaskaAmerican SamoaArizonaArkansasBaker IslandCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiHowland IslandIdahoIllinoisIndianaIowaJarvis IslandJohnston AtollKansasKentuckyKingman ReefLouisianaMaineMarylandMassachusettsMichiganMidway AtollMinnesotaMississippiMissouriMontanaNavassa IslandNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalmyra AtollPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUnited States Minor Outlying IslandsUnited States Virgin IslandsUtahVermontVirginiaWake IslandWashingtonWest VirginiaWisconsinWyoming *Mailing Address Zip / Postal Code: *Phone Numbers: Cell (primary): Cell Country: AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaeroe IslandsFalkland IslandsFijiFinlandFormer Yugoslav Republic of MacedoniaFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and Mc Donald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern MarianasNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSão Tomé and PríncipeSaint HelenaSt. Pierre and MiquelonSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandThe BahamasThe GambiaTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis and Futuna IslandsWestern SaharaYemenZambiaZimbabwe Cell (secondary): Cell (secondary) Country: AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaeroe IslandsFalkland IslandsFijiFinlandFormer Yugoslav Republic of MacedoniaFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and Mc Donald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern MarianasNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSão Tomé and PríncipeSaint HelenaSt. Pierre and MiquelonSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandThe BahamasThe GambiaTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis and Futuna IslandsWestern SaharaYemenZambiaZimbabwe Home Phone: Home Phone Country: AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaeroe IslandsFalkland IslandsFijiFinlandFormer Yugoslav Republic of MacedoniaFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and Mc Donald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern MarianasNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSão Tomé and PríncipeSaint HelenaSt. Pierre and MiquelonSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandThe BahamasThe GambiaTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis and Futuna IslandsWestern SaharaYemenZambiaZimbabwe Primary Work Phone: Work Phone Country: AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaeroe IslandsFalkland IslandsFijiFinlandFormer Yugoslav Republic of MacedoniaFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and Mc Donald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern MarianasNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSão Tomé and PríncipeSaint HelenaSt. Pierre and MiquelonSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandThe BahamasThe GambiaTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis and Futuna IslandsWestern SaharaYemenZambiaZimbabwe Secondary Work Phone: Secondary Work Phone Country: AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaeroe IslandsFalkland IslandsFijiFinlandFormer Yugoslav Republic of MacedoniaFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and Mc Donald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern MarianasNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSão Tomé and PríncipeSaint HelenaSt. Pierre and MiquelonSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandThe BahamasThe GambiaTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis and Futuna IslandsWestern SaharaYemenZambiaZimbabwe *Primary Email: Secondary Email: Best time to call: Kids? Please describe: Confidential Referral?: -- Please Choose -- No Yes Did you ask customer permission?: -- Please Choose -- No Yes *Type of Referral: -- Please Choose -- Listing Referral Buying Referral Property Address: Property City: Property State / Province: -- Please Choose --AlabamaAlaskaAmerican SamoaArizonaArkansasBaker IslandCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiHowland IslandIdahoIllinoisIndianaIowaJarvis IslandJohnston AtollKansasKentuckyKingman ReefLouisianaMaineMarylandMassachusettsMichiganMidway AtollMinnesotaMississippiMissouriMontanaNavassa IslandNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalmyra AtollPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUnited States Minor Outlying IslandsUnited States Virgin IslandsUtahVermontVirginiaWake IslandWashingtonWest VirginiaWisconsinWyoming Property Zip / Postal Code: Currently Listed?: -- Please Choose -- No Yes *If yes, Listing Price: Estimated Sale Price: Must Sell By: Type Of Home: Style: Sq Ft: Bedrooms: Bathrooms: Lot Size: Special Features/Improvements: Special Needs: Primary Destination (City, State): Alternate Destination: *Price Range: Familiar w/Area?: Yes No Reason for Relocation: In-home Date: *Trip Date: Employer: Start Date: Secondary Employer: Pre-qualified?: Yes No *If yes, Amount: First Time Buyer?: Yes No HOUSING REQUIREMENTS Style/Type Desired: Bedrooms: Bathrooms: Special Needs: Additional Comments: *Your Name: Choose... ** I'M NOT IN THE DROPDOWN LIST. Let me enter my information manually. ???, ??? Account, Test Baca, Maria Baker, Christi Bennett, Valerie C de Baca, Ann Carrico, Connie Casaus, Johanna Chan, Helen Cobb, Larry Ebbens, Margaret Erhard, Danielle Finnegan, Patricia Finnegan, Tybi Foley, Elizabeth Garcia, Andrew Garcia, Jessica Garner, Laura Gilbert, Bridget Goodhart, Spring Griego, Jonnice Hendrickson, Tonia Herreid, Kristen Hillson, Bethany Johnson, Dianne Khalsa, Deva Kniffin, CRP, JoLynn Kovalovsky, Karin Kutkuhn, Karma Leisher, Laurel Leydig, Sue Martinez-McNeil, Monica Montemorano, Anna Nafus, Dianna Neal, Amy Nuanes, Victoria Nunez, Taylor Padilla, Toby Parsons, Sharla Porter, Mary Relocation, West Rohl, Holly Rohl, Michelle Romero, Haelee Salazar, AnnMarie Sanchez, Sasha Scherlacher, Lisa Scott, Dale South, Keri Sweeney, Christina Team, Armijo Team, Homesteps Note: Please use this form to let us know if you're working with a customer that could come through as a Relo Referral so we can make sure we assign it to you. It is very important that you enter as much information as you can, to ensure we can find your customer. Misspelled names, mailing address, or email addresses increase the likelihood we would not be able to find your customer. In addition, for example, if you supply an email address, but not a phone number, and we receive the referral without an email address, but with a phone number, we may not be able to match the customer. Customer Name: *First Name: *Last Name: Secondary First Name: Secondary Last Name: *Employer: Member Number: Service Type: -- Please Choose -- Buyer Seller Buyer & Seller Renter Mailing Info: Country: United States Canada Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire (Ivory Coast) Croatia Cuba Curaçao Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Islands Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia The Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey and Alderney Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong S.A.R. Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau S.A.R. Madagascar Malawi Malaysia Maldives Mali Malta Man (Isle of) Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea North Macedonia Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Island Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Saint-Barthelemy Saint-Martin (French part) Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Islands Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Vietnam Virgin Islands (British) Virgin Islands (US) Wallis and Futuna Islands Western Sahara Yemen Zambia Zimbabwe *Address: *City: *State: -- Please Choose --AlabamaAlaskaAmerican SamoaArizonaArkansasBaker IslandCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiHowland IslandIdahoIllinoisIndianaIowaJarvis IslandJohnston AtollKansasKentuckyKingman ReefLouisianaMaineMarylandMassachusettsMichiganMidway AtollMinnesotaMississippiMissouriMontanaNavassa IslandNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalmyra AtollPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUnited States Minor Outlying IslandsUnited States Virgin IslandsUtahVermontVirginiaWake IslandWashingtonWest VirginiaWisconsinWyoming *Zip: *Phone Numbers: Primary Cell #: Primary Cell Country: AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaeroe IslandsFalkland IslandsFijiFinlandFormer Yugoslav Republic of MacedoniaFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and Mc Donald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern MarianasNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSão Tomé and PríncipeSaint HelenaSt. Pierre and MiquelonSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandThe BahamasThe GambiaTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis and Futuna IslandsWestern SaharaYemenZambiaZimbabwe Home Phone: Home Phone Country: AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaeroe IslandsFalkland IslandsFijiFinlandFormer Yugoslav Republic of MacedoniaFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and Mc Donald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern MarianasNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSão Tomé and PríncipeSaint HelenaSt. Pierre and MiquelonSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandThe BahamasThe GambiaTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis and Futuna IslandsWestern SaharaYemenZambiaZimbabwe Other Phone: Other Phone Country: AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaeroe IslandsFalkland IslandsFijiFinlandFormer Yugoslav Republic of MacedoniaFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and Mc Donald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern MarianasNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSão Tomé and PríncipeSaint HelenaSt. Pierre and MiquelonSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandThe BahamasThe GambiaTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis and Futuna IslandsWestern SaharaYemenZambiaZimbabwe Secondary Cell #: Secondary Cell Country: AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaeroe IslandsFalkland IslandsFijiFinlandFormer Yugoslav Republic of MacedoniaFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and Mc Donald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern MarianasNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSão Tomé and PríncipeSaint HelenaSt. Pierre and MiquelonSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandThe BahamasThe GambiaTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis and Futuna IslandsWestern SaharaYemenZambiaZimbabwe Primary Work #: Primary Work Country: AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaeroe IslandsFalkland IslandsFijiFinlandFormer Yugoslav Republic of MacedoniaFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and Mc Donald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern MarianasNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSão Tomé and PríncipeSaint HelenaSt. Pierre and MiquelonSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandThe BahamasThe GambiaTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis and Futuna IslandsWestern SaharaYemenZambiaZimbabwe Secondary Work #: Secondary Work Country: AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaeroe IslandsFalkland IslandsFijiFinlandFormer Yugoslav Republic of MacedoniaFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and Mc Donald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern MarianasNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSão Tomé and PríncipeSaint HelenaSt. Pierre and MiquelonSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandThe BahamasThe GambiaTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited 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