csjoseph.org
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Submitted URL: https://t.e2ma.net/click/f6kxdu/bb2aakrc/fervige
Effective URL: https://csjoseph.org/giving-tuesday/
Submission: On November 30 via api from US — Scanned from DE
Effective URL: https://csjoseph.org/giving-tuesday/
Submission: On November 30 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
<form id="mongo-form">
<div id="bboxdonation_BBEmbeddedForm" class="BBFormContainer" data-bbox-part-id="0dba16ce-4a3f-406f-9657-04cc9ebfb1a8">
<div id="bboxdonation_divForm">
<div id="divClientError" class="BBFormErrorBlock" style="display: none"></div>
<div class="BBFormSection BBDFormSectionGiftInfo">
<fieldset>
<legend>
<div class="BBFormSectionHeading">
<label id="bboxdonation_gift_lblHeadingDonation" class="BBFormFieldLabelEdit">Donation</label>
</div>
</legend>
<div id="bboxdonation_gift_fldAmountWithLevels" class="BBFormFieldContainer BBFormFieldContainerGivingLevels BBFormErrorNoMargin" data-style="Narrow_Buttons">
<span id="bboxdonation_gift_lblGivingLevels" class="BBFormFieldLabelGivingLevel BBFormFieldLabel BBFormFieldLabelEdit" style="display:none;">Gift amount:</span>
<div id="bboxdonation_gift_rdlstGivingLevels" class="BBFormRadioList">
<div class="BBFormRadioItem BBFormRadioGivingLevelItem" tabindex="0">
<div class="BBFormRadioButtonContainer"><input value="250" name="bboxdonation$gift$GivingLevel" type="radio" id="bboxdonation_gift_rdGivingLevel1" class="BBFormRadioButton BBFormRadioGivingLevel"><label
for="bboxdonation_gift_rdGivingLevel1" class="BBFormRadioLabel BBFormRadioLabelGivingLevel BBFormRadioLabelGivingLevelNotSelected"><span class="BBFormRadioAmount">$250</span></label></div>
</div>
<div class="BBFormRadioItem BBFormRadioGivingLevelItem" tabindex="0">
<div class="BBFormRadioButtonContainer"><input value="100" name="bboxdonation$gift$GivingLevel" type="radio" id="bboxdonation_gift_rdGivingLevel2" class="BBFormRadioButton BBFormRadioGivingLevel"><label
for="bboxdonation_gift_rdGivingLevel2" class="BBFormRadioLabel BBFormRadioLabelGivingLevel BBFormRadioLabelGivingLevelNotSelected"><span class="BBFormRadioAmount">$100</span></label></div>
</div>
<div class="BBFormRadioItem BBFormRadioGivingLevelItem" tabindex="0">
<div class="BBFormRadioButtonContainer"><input value="50" name="bboxdonation$gift$GivingLevel" type="radio" id="bboxdonation_gift_rdGivingLevel3" checked="checked"
class="BBFormRadioButton BBFormRadioGivingLevel BBFormRadioGivingLevelSelected"><label for="bboxdonation_gift_rdGivingLevel3" class="BBFormRadioLabel BBFormRadioLabelGivingLevel BBFormRadioLabelGivingLevelSelected"><span
class="BBFormRadioAmount">$50</span></label></div>
</div>
<div class="BBFormRadioItem BBFormRadioGivingLevelItem" tabindex="0">
<div class="BBFormRadioButtonContainer"><input value="35" name="bboxdonation$gift$GivingLevel" type="radio" id="bboxdonation_gift_rdGivingLevel4" class="BBFormRadioButton BBFormRadioGivingLevel"><label
for="bboxdonation_gift_rdGivingLevel4" class="BBFormRadioLabel BBFormRadioLabelGivingLevel BBFormRadioLabelGivingLevelNotSelected"><span class="BBFormRadioAmount">$35</span></label></div>
</div>
<div class="BBFormRadioItem BBFormRadioGivingLevelItem" tabindex="0">
<div class="BBFormRadioButtonContainer"><input value="rdGivingLevel5" name="bboxdonation$gift$GivingLevel" type="radio" id="bboxdonation_gift_rdGivingLevel5" data-min-payment="10" title="Other gift amount"
class="BBFormRadioButton BBFormRadioGivingLevel BBFormRadioGivingLevelOther"><label for="bboxdonation_gift_rdGivingLevel5" title="Other gift amount" aria-labelledby="bboxdonation_gift_rdGivingLevel5"
class="BBFormRadioLabel BBFormRadioLabelGivingLevel BBFormRadioLabelGivingLevelNotSelected BBFormRadioLabelGivingLevelOther"><span class="BBFormRadioDescriptionOther">Other</span><input
name="bboxdonation$gift$txtOtherAmountButtons" type="text" id="bboxdonation_gift_txtOtherAmountButtons" class="BBFormTextbox BBFormGiftOtherAmount BBFormCurrency" placeholder="$" data-culture="en-US"
aria-labelledby="bboxdonation_gift_rdGivingLevel5" title="Other gift amount"></label></div>
</div>
</div>
<div class="BBClearFix">
</div>
</div>
<div id="bboxdonation_gift_fldPledgeAmountWhenNoLevels" class="BBFormFieldContainer BBFormNoLevels BBFormPledgeFields" style="display: none;">
<label for="bboxdonation_gift_txtAmountPledge" id="bboxdonation_gift_lblAmountPledge" class="BBFormFieldLabel BBFormFieldLabelAmount BBFormFieldLabelEdit">Amount:</label>
<input name="bboxdonation$gift$txtAmountPledge" type="text" id="bboxdonation_gift_txtAmountPledge" class="BBFormTextbox BBFormCurrency" required="required" placeholder="$" data-culture="en-US" data-min-payment="10.0000">
</div>
</fieldset>
</div>
<input name="bboxdonation$gift$hdnGivingLevelButtonsEnabled" type="hidden" id="bboxdonation_gift_hdnGivingLevelButtonsEnabled" class="hdnGivingLevelButtonsEnabled" value="true">
<input name="bboxdonation$gift$hdnPledgeDuration" type="hidden" id="bboxdonation_gift_hdnPledgeDuration" class="hdnPledgeDuration">
<input name="bboxdonation$gift$hdnPledgePayment" type="hidden" id="bboxdonation_gift_hdnPledgePayment" class="hdnPledgePayment">
<input name="bboxdonation$gift$hdnGiftButtonsStyle" type="hidden" id="bboxdonation_gift_hdnGiftButtonsStyle" class="hdnGiftButtonsStyle">
<div id="bboxdonation_designation_divSection" class="BBFormSection BBDFormSectionDesignationInfo" style="display:none;">
<fieldset>
<legend>
<div class="BBFormSectionHeading">
<label id="bboxdonation_designation_lblHeadingDesignation" class="BBFormFieldLabelEdit">Designation</label>
</div>
</legend>
<div class="BBFormFieldContainer">
<label for="bboxdonation_designation_ddDesignations" id="bboxdonation_designation_lblDesignation" class="BBFormFieldLabel BBFormFieldLabelEdit">Designation:</label>
<select name="bboxdonation$designation$ddDesignations" id="bboxdonation_designation_ddDesignations" class="BBFormSelectList">
<option value="3077">General (where needed most) </option>
</select>
<label for="bboxdonation_designation_txtOtherDesignation" id="bboxdonation_designation_lblOtherDesignation" style="display: none;">other Designation:</label>
<input name="bboxdonation$designation$txtOtherDesignation" type="text" id="bboxdonation_designation_txtOtherDesignation" class="BBFormTextbox BBFormOtherDesignation" placeholder="other designation (optional)" style="display: none;">
</div>
<div class="BBFormFieldContainer BBFormOtherDesignationContatiner" style="display: none;">
</div>
</fieldset>
</div>
<div class="BBFormSection BBDFormSectionTributeInfo BBFormAddressBlock">
<fieldset>
<legend>
<div class="BBFormSectionHeading">
<label id="bboxdonation_tribute_lblHeadingTribute" class="BBFormFieldLabelEdit">Tribute</label>
</div>
</legend>
<div id="bboxdonation_tribute_divTributeGeneral">
<div class="BBFormFieldContainer">
<input name="bboxdonation$tribute$chkTributeGift" type="checkbox" id="bboxdonation_tribute_chkTributeGift">
<label for="bboxdonation_tribute_chkTributeGift" id="bboxdonation_tribute_lblTributeGift" class="BBFormFieldLabel BBFormCheckbox BBFormCheckboxLabel BBFormFieldLabelEdit">This gift is in honor, memory, or support of someone</label>
</div>
<div id="divGeneralTributeInfo" style="display: none;">
<div class="BBFormFieldContainer BBFormFieldTributeInfo">
<span id="bboxdonation_tribute_lblGeneralTributeInfo" class="BBFormFieldLabel BBFormFieldLabelEdit">This gift is</span>
<select name="bboxdonation$tribute$ddTributeTypes" id="bboxdonation_tribute_ddTributeTypes" class="BBFormSelectList">
<option value="132">in honor of</option>
<option value="131">in memory of</option>
</select>
</div>
<div class="BBFormFieldContainer BBFormFieldTributeInfo">
<label for="bboxdonation_tribute_txtTributeRecordName" id="bboxdonation_tribute_lblTributeRecordName" class="BBFormFieldLabel BBAccessibilityOnly">Tribute honoree name:</label>
<input name="bboxdonation$tribute$txtTributeRecordName" type="text" id="bboxdonation_tribute_txtTributeRecordName" class="BBFormTextbox" required="required" placeholder="full name" maxlength="150">
</div>
</div>
</div>
<div id="divTributeAcknowledge" class="BBFormTributeAcknowledgeContainer" style="display: none;">
<div class="BBFormFieldContainer">
<input name="bboxdonation$tribute$hdnAllowTributeNotification" type="hidden" id="bboxdonation_tribute_hdnAllowTributeNotification" value="1">
<input name="bboxdonation$tribute$chkTributeAcknowledgee" type="checkbox" id="bboxdonation_tribute_chkTributeAcknowledgee">
<label for="bboxdonation_tribute_chkTributeAcknowledgee" id="bboxdonation_tribute_lblTributeAcknowledgee" class="BBFormFieldLabel BBFormCheckbox BBFormCheckboxLabel BBFormFieldLabelEdit">Please notify the following person of my
gift</label>
</div>
<div id="divTributeAcknowledgeeInfo" class="BBFormTributeAcknowledgeeContainer" style="display: none;">
<div class="BBFormIndivFields">
<div class="BBFormFieldContainer BBFormFieldContainerRequired BBTwoFields">
<label for="bboxdonation_tribute_txtFirstName" id="bboxdonation_tribute_lblName" class="BBFormFieldLabel BBFormFieldLabelEdit ">Name:</label>
<div aria-describedby="bboxdonation_tribute_txtFirstName">
<span id="bboxdonation_tribute_lblFirstName" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly ">First name:</span>
</div>
<input name="bboxdonation$tribute$txtFirstName" type="text" id="bboxdonation_tribute_txtFirstName" class="BBFormTextbox" required="required" maxlength="50" placeholder="first name">
<label for="bboxdonation_tribute_txtLastName" id="bboxdonation_tribute_lblLastName" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">Last name:</label>
<input name="bboxdonation$tribute$txtLastName" type="text" id="bboxdonation_tribute_txtLastName" class="BBFormTextbox" required="required" maxlength="100" placeholder="last name">
</div>
</div>
<div class="BBFormFieldTributeAcknowledgee BBFormAddressBlock">
<div class="BBFormAddress">
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="bboxdonation_tribute_tributeAddress_ddCountry" id="bboxdonation_tribute_tributeAddress_lblCountry" class="BBFormFieldLabel BBFormFieldLabelEdit">Country:</label>
<select name="bboxdonation$tribute$tributeAddress$ddCountry" id="bboxdonation_tribute_tributeAddress_ddCountry" class="BBFormSelectList BBFormCountryDropDown" required="required">
<option selected="selected" value="United States" data-country-format="1" data-short-text="US">United States</option>
<option value="Australia" data-country-format="1" data-short-text="AU">Australia</option>
<option value="Barbados" data-country-format="1" data-short-text="BB">Barbados</option>
<option value="Canada" data-country-format="3" data-short-text="CA">Canada</option>
<option value="Dominican Republic" data-country-format="1" data-short-text="DO">Dominican Republic</option>
<option value="Egypt" data-country-format="1" data-short-text="EG">Egypt</option>
<option value="El Salvador" data-country-format="1" data-short-text="SV">El Salvador</option>
<option value="France" data-country-format="1" data-short-text="FR">France</option>
<option value="Germany" data-country-format="1" data-short-text="DE">Germany</option>
<option value="Honduras" data-country-format="1" data-short-text="HN">Honduras</option>
<option value="India" data-country-format="1" data-short-text="IN">India</option>
<option value="Indonesia" data-country-format="1" data-short-text="ID">Indonesia</option>
<option value="Ireland" data-country-format="1" data-short-text="IE">Ireland</option>
<option value="Italy" data-country-format="1" data-short-text="IT">Italy</option>
<option value="Japan" data-country-format="3" data-short-text="JP">Japan</option>
<option value="Mexico" data-country-format="1" data-short-text="MX">Mexico</option>
<option value="Nicaragua" data-country-format="3" data-short-text="NI">Nicaragua</option>
<option value="Nigeria" data-country-format="1" data-short-text="NG">Nigeria</option>
<option value="Peru" data-country-format="2" data-short-text="PE">Peru</option>
<option value="Philippines" data-country-format="5" data-short-text="PH">Philippines</option>
</select>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="bboxdonation_tribute_tributeAddress_txtAddress" id="bboxdonation_tribute_tributeAddress_lblAddress" class="BBFormFieldLabel BBFormFieldLabelEdit">Address:</label>
<textarea name="bboxdonation$tribute$tributeAddress$txtAddress" id="bboxdonation_tribute_tributeAddress_txtAddress" class="BBFormTextArea" rows="2" cols="30" required="required" data-country-field="address"
maxlength="150"></textarea>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="1">
<label for="bboxdonation_tribute_tributeAddress_txtCity" id="bboxdonation_tribute_tributeAddress_lblCity" class="BBFormFieldLabel BBFormFieldLabelEdit">City:</label>
<input name="bboxdonation$tribute$tributeAddress$txtCity" type="text" id="bboxdonation_tribute_tributeAddress_txtCity" class="BBFormTextbox" data-country-field="city" data-country-sync="1" required="required" maxlength="50">
</div>
<div class="BBTwoFields BBFieldBillingStateZip">
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="1">
<label for="bboxdonation_tribute_tributeAddress_ddState" id="bboxdonation_tribute_tributeAddress_lblStateZip" class="BBFormFieldLabel BBFormFieldLabelEdit">State & zip:</label>
<div aria-describedby="bboxdonation_tribute_tributeAddress_ddState">
<span id="bboxdonation_tribute_tributeAddress_lblState" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">State:</span>
</div>
<select name="bboxdonation$tribute$tributeAddress$ddState" id="bboxdonation_tribute_tributeAddress_ddState" class="BBFormSelectList GhostText" data-country-sync="1" data-country-field="state" required="required">
<option selected="selected" value="" default="default">state</option>
<option value="NF">NF</option>
<option value="UK">UK</option>
<option value="AA">AA</option>
<option value="AB">AB</option>
<option value="AE">AE</option>
<option value="AK">AK</option>
<option value="AL">AL</option>
<option value="AP">AP</option>
<option value="AR">AR</option>
<option value="AS">AS</option>
<option value="AZ">AZ</option>
<option value="BC">BC</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="CZ">CZ</option>
<option value="DC">DC</option>
<option value="DE">DE</option>
<option value="FL">FL</option>
<option value="FM">FM</option>
<option value="GA">GA</option>
<option value="GU">GU</option>
<option value="HI">HI</option>
<option value="IA">IA</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="MA">MA</option>
<option value="MB">MB</option>
<option value="MD">MD</option>
<option value="ME">ME</option>
<option value="MH">MH</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MO">MO</option>
<option value="MP">MP</option>
<option value="MS">MS</option>
<option value="MT">MT</option>
<option value="NB">NB</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="NE">NE</option>
<option value="NL">NL</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NS">NS</option>
<option value="NT">NT</option>
<option value="NU">NU</option>
<option value="NV">NV</option>
<option value="NY">NY</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="ON">ON</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="PE">PE</option>
<option value="PR">PR</option>
<option value="PW">PW</option>
<option value="QC">QC</option>
<option value="RI">RI</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="SK">SK</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VA">VA</option>
<option value="VI">VI</option>
<option value="VT">VT</option>
<option value="WA">WA</option>
<option value="WI">WI</option>
<option value="WV">WV</option>
<option value="WY">WY</option>
<option value="YT">YT</option>
<option value="QLD">QLD</option>
</select>
<label for="bboxdonation_tribute_tributeAddress_txtZip" id="bboxdonation_tribute_tributeAddress_lblZip" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">Zip:</label>
<input name="bboxdonation$tribute$tributeAddress$txtZip" type="tel" id="bboxdonation_tribute_tributeAddress_txtZip" class="BBFormTextbox" data-country-field="postcode" data-country-sync="1" required="required" maxlength="12"
placeholder="zip">
</div>
</div>
<div class="BBTwoFields BBFieldBillingStateZip">
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="2" style="display: none;">
<label for="bboxdonation_tribute_tributeAddress_txtUKCity" id="bboxdonation_tribute_tributeAddress_lblUKCityCounty" class="BBFormFieldLabel BBFormFieldLabelEdit">City & county:</label>
<div aria-describedby="bboxdonation_tribute_tributeAddress_txtUKCity">
<span id="bboxdonation_tribute_tributeAddress_lblUKCity" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">City:</span>
</div>
<input name="bboxdonation$tribute$tributeAddress$txtUKCity" type="text" id="bboxdonation_tribute_tributeAddress_txtUKCity" class="BBFormTextbox" data-country-field="city" data-country-sync="1" required="required" maxlength="50"
placeholder="city">
<label for="bboxdonation_tribute_tributeAddress_ddUKCounty" id="bboxdonation_tribute_tributeAddress_lblUKCounty" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">County:</label>
<select name="bboxdonation$tribute$tributeAddress$ddUKCounty" id="bboxdonation_tribute_tributeAddress_ddUKCounty" class="BBFormSelectList GhostText" data-country-field="county">
<option selected="selected" value="" default="default">county (optional)</option>
<option value="Accomack">Accomack</option>
<option value="Ada">Ada</option>
<option value="Adams">Adams</option>
<option value="Aiken">Aiken</option>
<option value="Alachua">Alachua</option>
<option value="Alameda">Alameda</option>
<option value="Albany">Albany</option>
<option value="Albemarle">Albemarle</option>
<option value="Alexandria City">Alexandria City</option>
<option value="Allegan">Allegan</option>
<option value="Allegany">Allegany</option>
<option value="Allegheny">Allegheny</option>
<option value="Allen">Allen</option>
<option value="Amelia">Amelia</option>
<option value="Amherst">Amherst</option>
<option value="Anchorage">Anchorage</option>
<option value="Anderson">Anderson</option>
<option value="Andrew">Andrew</option>
<option value="Androscoggin">Androscoggin</option>
<option value="Anne Arundel">Anne Arundel</option>
<option value="Anoka">Anoka</option>
<option value="APONLY">APONLY</option>
<option value="Arapahoe">Arapahoe</option>
<option value="Archuleta">Archuleta</option>
<option value="Arlington">Arlington</option>
<option value="Aroostook">Aroostook</option>
<option value="Ascension">Ascension</option>
<option value="Ashland">Ashland</option>
<option value="Ashtabula">Ashtabula</option>
<option value="Assumption">Assumption</option>
<option value="Atchison">Atchison</option>
<option value="Athens">Athens</option>
<option value="Atlantic">Atlantic</option>
<option value="Auglaize">Auglaize</option>
<option value="Augusta">Augusta</option>
<option value="Australia">Australia</option>
<option value="Autauga">Autauga</option>
<option value="Avery">Avery</option>
<option value="Baldwin">Baldwin</option>
<option value="Baltimore">Baltimore</option>
<option value="Baltimore City">Baltimore City</option>
<option value="Bannock">Bannock</option>
<option value="Barber">Barber</option>
<option value="Barbour">Barbour</option>
<option value="Barnstable">Barnstable</option>
<option value="Barry">Barry</option>
<option value="Bartholomew">Bartholomew</option>
<option value="Barton">Barton</option>
<option value="Bastrop">Bastrop</option>
<option value="Bath">Bath</option>
<option value="Baxter">Baxter</option>
<option value="Bay">Bay</option>
<option value="Bayfield">Bayfield</option>
<option value="Beaufort">Beaufort</option>
<option value="Beaver">Beaver</option>
<option value="Bedford">Bedford</option>
<option value="Belknap">Belknap</option>
<option value="Bell">Bell</option>
<option value="Belmont">Belmont</option>
<option value="Benton">Benton</option>
<option value="Bergen">Bergen</option>
<option value="Berkeley">Berkeley</option>
<option value="Berks">Berks</option>
<option value="Bernalillo">Bernalillo</option>
<option value="Berrien">Berrien</option>
<option value="Bexar">Bexar</option>
<option value="Bibb">Bibb</option>
<option value="Black Hawk">Black Hawk</option>
<option value="Blackford">Blackford</option>
<option value="Blaine">Blaine</option>
<option value="Blair">Blair</option>
<option value="Blount">Blount</option>
<option value="Bonneville">Bonneville</option>
<option value="Boone">Boone</option>
<option value="Boulder">Boulder</option>
<option value="Bourbon">Bourbon</option>
<option value="Bowie">Bowie</option>
<option value="Boyd">Boyd</option>
<option value="Braxton">Braxton</option>
<option value="Brazoria">Brazoria</option>
<option value="Brazos">Brazos</option>
<option value="Brevard">Brevard</option>
<option value="Bristol">Bristol</option>
<option value="Bronx">Bronx</option>
<option value="Brooke">Brooke</option>
<option value="Broome">Broome</option>
<option value="Broomfield">Broomfield</option>
<option value="Broward">Broward</option>
<option value="Brown">Brown</option>
<option value="Brunswick">Brunswick</option>
<option value="Bucks">Bucks</option>
<option value="Buena Vista City">Buena Vista City</option>
<option value="Buffalo">Buffalo</option>
<option value="Bulloch">Bulloch</option>
<option value="Buncombe">Buncombe</option>
<option value="Burlington">Burlington</option>
<option value="Burnet">Burnet</option>
<option value="Butler">Butler</option>
<option value="Butts">Butts</option>
<option value="Cabarrus">Cabarrus</option>
<option value="Cabell">Cabell</option>
<option value="Caddo">Caddo</option>
<option value="Calaveras">Calaveras</option>
<option value="Calcasieu">Calcasieu</option>
<option value="Caldwell">Caldwell</option>
<option value="Calhoun">Calhoun</option>
<option value="Callaway">Callaway</option>
<option value="Calvert">Calvert</option>
<option value="Cambria">Cambria</option>
<option value="Camden">Camden</option>
<option value="Cameron">Cameron</option>
<option value="Campbell">Campbell</option>
<option value="Canada">Canada</option>
<option value="Canadian">Canadian</option>
<option value="Cape May">Cape May</option>
<option value="Caroline">Caroline</option>
<option value="Carroll">Carroll</option>
<option value="Carteret">Carteret</option>
<option value="Carver">Carver</option>
<option value="Cass">Cass</option>
<option value="Catawba">Catawba</option>
<option value="Cecil">Cecil</option>
<option value="Centre">Centre</option>
<option value="Chaffee">Chaffee</option>
<option value="Champaign">Champaign</option>
<option value="Charles">Charles</option>
<option value="Charleston">Charleston</option>
<option value="Charlotte">Charlotte</option>
<option value="Charlottesville City">Charlottesville City</option>
<option value="Chatham">Chatham</option>
<option value="Chautauqua">Chautauqua</option>
<option value="Chaves">Chaves</option>
<option value="Cheboygan">Cheboygan</option>
<option value="Chelan">Chelan</option>
<option value="Chemung">Chemung</option>
<option value="Cherokee">Cherokee</option>
<option value="Chesapeake City">Chesapeake City</option>
<option value="Cheshire">Cheshire</option>
<option value="Chester">Chester</option>
<option value="Chesterfield">Chesterfield</option>
<option value="Chickasaw">Chickasaw</option>
<option value="Chittenden">Chittenden</option>
<option value="Christian">Christian</option>
<option value="Churchill">Churchill</option>
<option value="Citrus">Citrus</option>
<option value="Clackamas">Clackamas</option>
<option value="Clallam">Clallam</option>
<option value="Clarendon">Clarendon</option>
<option value="Clarion">Clarion</option>
<option value="Clark">Clark</option>
<option value="Clay">Clay</option>
<option value="Clearfield">Clearfield</option>
<option value="Cleburne">Cleburne</option>
<option value="Clermont">Clermont</option>
<option value="Cleveland">Cleveland</option>
<option value="Clinton">Clinton</option>
<option value="Cloud">Cloud</option>
<option value="Coahoma">Coahoma</option>
<option value="Cobb">Cobb</option>
<option value="Cochise">Cochise</option>
<option value="Coconino">Coconino</option>
<option value="Coffee">Coffee</option>
<option value="Cole">Cole</option>
<option value="Coles">Coles</option>
<option value="Collier">Collier</option>
<option value="Collin">Collin</option>
<option value="Colonial Heights City">Colonial Heights City</option>
<option value="Columbia">Columbia</option>
<option value="Columbiana">Columbiana</option>
<option value="Comal">Comal</option>
<option value="Comanche">Comanche</option>
<option value="Contra Costa">Contra Costa</option>
<option value="Converse">Converse</option>
<option value="Cook">Cook</option>
<option value="Cooke">Cooke</option>
<option value="Coryell">Coryell</option>
<option value="Coshocton">Coshocton</option>
<option value="Costilla">Costilla</option>
<option value="Coweta">Coweta</option>
<option value="Cowley">Cowley</option>
<option value="Cowlitz">Cowlitz</option>
<option value="Craighead">Craighead</option>
<option value="Craven">Craven</option>
<option value="Crawford">Crawford</option>
<option value="Culpeper">Culpeper</option>
<option value="Cumberland">Cumberland</option>
<option value="Curry">Curry</option>
<option value="Custer">Custer</option>
<option value="Cuyahoga">Cuyahoga</option>
<option value="Dakota">Dakota</option>
<option value="Dallam">Dallam</option>
<option value="Dallas">Dallas</option>
<option value="Dane">Dane</option>
<option value="Dare">Dare</option>
<option value="Darke">Darke</option>
<option value="Darlington">Darlington</option>
<option value="Dauphin">Dauphin</option>
<option value="Davidson">Davidson</option>
<option value="Davis">Davis</option>
<option value="De Kalb">De Kalb</option>
<option value="Decatur">Decatur</option>
<option value="Defiance">Defiance</option>
<option value="Dekalb">Dekalb</option>
<option value="Delaware">Delaware</option>
<option value="Delta">Delta</option>
<option value="Denton">Denton</option>
<option value="Denver">Denver</option>
<option value="Deschutes">Deschutes</option>
<option value="DeSoto">DeSoto</option>
<option value="Dickinson">Dickinson</option>
<option value="Dickson">Dickson</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Doddridge">Doddridge</option>
<option value="Dodge">Dodge</option>
<option value="Dona Ana">Dona Ana</option>
<option value="Door">Door</option>
<option value="Dorchester">Dorchester</option>
<option value="Douglas">Douglas</option>
<option value="Du Page">Du Page</option>
<option value="Dubois">Dubois</option>
<option value="Dubuque">Dubuque</option>
<option value="DuPage">DuPage</option>
<option value="Durham">Durham</option>
<option value="Dutchess">Dutchess</option>
<option value="Duval">Duval</option>
<option value="Eagle">Eagle</option>
<option value="East Baton Rouge">East Baton Rouge</option>
<option value="Eaton">Eaton</option>
<option value="Eau Claire">Eau Claire</option>
<option value="Ector">Ector</option>
<option value="Edgar">Edgar</option>
<option value="Edwards">Edwards</option>
<option value="El Dorado">El Dorado</option>
<option value="El Paso">El Paso</option>
<option value="Elk">Elk</option>
<option value="Elkhart">Elkhart</option>
<option value="Ellis">Ellis</option>
<option value="Ellsworth">Ellsworth</option>
<option value="Elmore">Elmore</option>
<option value="Emporia City">Emporia City</option>
<option value="Erie">Erie</option>
<option value="Escambia">Escambia</option>
<option value="Essex">Essex</option>
<option value="Etowah">Etowah</option>
<option value="Fairfax">Fairfax</option>
<option value="Fairfax City">Fairfax City</option>
<option value="Fairfield">Fairfield</option>
<option value="Falls Church City">Falls Church City</option>
<option value="Fauquier">Fauquier</option>
<option value="Fayette">Fayette</option>
<option value="Finney">Finney</option>
<option value="Flagler">Flagler</option>
<option value="Fleming">Fleming</option>
<option value="Floyd">Floyd</option>
<option value="Fluvanna">Fluvanna</option>
<option value="Fond du Lac">Fond du Lac</option>
<option value="Ford">Ford</option>
<option value="Forsyth">Forsyth</option>
<option value="Fort Bend">Fort Bend</option>
<option value="Fountain">Fountain</option>
<option value="Franklin">Franklin</option>
<option value="Frederick">Frederick</option>
<option value="Fredericksburg City">Fredericksburg City</option>
<option value="Fresno">Fresno</option>
<option value="Fulton">Fulton</option>
<option value="Gallia">Gallia</option>
<option value="Galveston">Galveston</option>
<option value="Garfield">Garfield</option>
<option value="Garland">Garland</option>
<option value="Garrard">Garrard</option>
<option value="Garrett">Garrett</option>
<option value="Gasconade">Gasconade</option>
<option value="Gaston">Gaston</option>
<option value="Geary">Geary</option>
<option value="Geauga">Geauga</option>
<option value="Genesee">Genesee</option>
<option value="Georgetown">Georgetown</option>
<option value="Gila">Gila</option>
<option value="Gillespie">Gillespie</option>
<option value="Gilmer">Gilmer</option>
<option value="Gladwin">Gladwin</option>
<option value="Gloucester">Gloucester</option>
<option value="Glynn">Glynn</option>
<option value="Gogebic">Gogebic</option>
<option value="Goochland">Goochland</option>
<option value="Grafton">Grafton</option>
<option value="Grand">Grand</option>
<option value="Grand Forks">Grand Forks</option>
<option value="Grant">Grant</option>
<option value="Gray">Gray</option>
<option value="Grayson">Grayson</option>
<option value="Greeley">Greeley</option>
<option value="Green">Green</option>
<option value="Greenbrier">Greenbrier</option>
<option value="Greene">Greene</option>
<option value="Greenup">Greenup</option>
<option value="Greenville">Greenville</option>
<option value="Greenwood">Greenwood</option>
<option value="Grundy">Grundy</option>
<option value="Guadalupe">Guadalupe</option>
<option value="Guernsey">Guernsey</option>
<option value="Guilford">Guilford</option>
<option value="Gwinnett">Gwinnett</option>
<option value="Hale">Hale</option>
<option value="Hall">Hall</option>
<option value="Hamilton">Hamilton</option>
<option value="Hampden">Hampden</option>
<option value="Hampshire">Hampshire</option>
<option value="Hampton">Hampton</option>
<option value="Hampton City">Hampton City</option>
<option value="Hancock">Hancock</option>
<option value="Hanover">Hanover</option>
<option value="Hanson">Hanson</option>
<option value="Hardin">Hardin</option>
<option value="Hardy">Hardy</option>
<option value="Harford">Harford</option>
<option value="Harney">Harney</option>
<option value="Harper">Harper</option>
<option value="Harris">Harris</option>
<option value="Harrison">Harrison</option>
<option value="Harrisonburg City">Harrisonburg City</option>
<option value="Hartford">Hartford</option>
<option value="Harvey">Harvey</option>
<option value="Haskell">Haskell</option>
<option value="Hays">Hays</option>
<option value="Henderson">Henderson</option>
<option value="Hendricks">Hendricks</option>
<option value="Hendry">Hendry</option>
<option value="Hennepin">Hennepin</option>
<option value="Henrico">Henrico</option>
<option value="Henry">Henry</option>
<option value="Hernando">Hernando</option>
<option value="Hidalgo">Hidalgo</option>
<option value="Highland">Highland</option>
<option value="Highlands">Highlands</option>
<option value="Hillsborough">Hillsborough</option>
<option value="Hillsdale">Hillsdale</option>
<option value="Hinds">Hinds</option>
<option value="Hodgeman">Hodgeman</option>
<option value="Holt">Holt</option>
<option value="Honolulu">Honolulu</option>
<option value="Hood">Hood</option>
<option value="Hopewell City">Hopewell City</option>
<option value="Horry">Horry</option>
<option value="Howard">Howard</option>
<option value="Hudson">Hudson</option>
<option value="Humboldt">Humboldt</option>
<option value="Hunt">Hunt</option>
<option value="Huntingdon">Huntingdon</option>
<option value="Huntington">Huntington</option>
<option value="Huron">Huron</option>
<option value="Independence">Independence</option>
<option value="Indian River">Indian River</option>
<option value="Indiana">Indiana</option>
<option value="Ingham">Ingham</option>
<option value="Inyo">Inyo</option>
<option value="Iowa">Iowa</option>
<option value="Iredell">Iredell</option>
<option value="Iron">Iron</option>
<option value="Iroquois">Iroquois</option>
<option value="Island">Island</option>
<option value="Jackson">Jackson</option>
<option value="James City">James City</option>
<option value="Japan">Japan</option>
<option value="Jasper">Jasper</option>
<option value="Jay">Jay</option>
<option value="Jefferson">Jefferson</option>
<option value="Jefferson Davis">Jefferson Davis</option>
<option value="Jo Daviess">Jo Daviess</option>
<option value="Johnson">Johnson</option>
<option value="Johnston">Johnston</option>
<option value="Juneau">Juneau</option>
<option value="Kalamazoo">Kalamazoo</option>
<option value="Kanawha">Kanawha</option>
<option value="Kandiyohi">Kandiyohi</option>
<option value="Kane">Kane</option>
<option value="Kankakee">Kankakee</option>
<option value="Kay">Kay</option>
<option value="Kearny">Kearny</option>
<option value="Kenai Peninsula">Kenai Peninsula</option>
<option value="Kendall">Kendall</option>
<option value="Kennebec">Kennebec</option>
<option value="Kenosha">Kenosha</option>
<option value="Kent">Kent</option>
<option value="Kenton">Kenton</option>
<option value="Kern">Kern</option>
<option value="Kerr">Kerr</option>
<option value="King">King</option>
<option value="Kingfisher">Kingfisher</option>
<option value="Kingman">Kingman</option>
<option value="Kings">Kings</option>
<option value="Kiowa">Kiowa</option>
<option value="Kitsap">Kitsap</option>
<option value="Knox">Knox</option>
<option value="Kosciusko">Kosciusko</option>
<option value="La Crosse">La Crosse</option>
<option value="La Paz">La Paz</option>
<option value="La Plata">La Plata</option>
<option value="La Porte">La Porte</option>
<option value="La Salle">La Salle</option>
<option value="Labette">Labette</option>
<option value="Lackawanna">Lackawanna</option>
<option value="Lafayette">Lafayette</option>
<option value="Lagrange">Lagrange</option>
<option value="Lake">Lake</option>
<option value="Lancaster">Lancaster</option>
<option value="Lane">Lane</option>
<option value="Lapeer">Lapeer</option>
<option value="Laramie">Laramie</option>
<option value="Larimer">Larimer</option>
<option value="Las Animas">Las Animas</option>
<option value="Lauderdale">Lauderdale</option>
<option value="Laurel">Laurel</option>
<option value="Lawrence">Lawrence</option>
<option value="Lea">Lea</option>
<option value="Leavenworth">Leavenworth</option>
<option value="Lebanon">Lebanon</option>
<option value="Lee">Lee</option>
<option value="Leelanau">Leelanau</option>
<option value="Lehigh">Lehigh</option>
<option value="Lenawee">Lenawee</option>
<option value="Leon">Leon</option>
<option value="Levy">Levy</option>
<option value="Lewis">Lewis</option>
<option value="Lexington">Lexington</option>
<option value="Licking">Licking</option>
<option value="Lincoln">Lincoln</option>
<option value="Linn">Linn</option>
<option value="Litchfield">Litchfield</option>
<option value="Livingston">Livingston</option>
<option value="Logan">Logan</option>
<option value="Lorain">Lorain</option>
<option value="Los Alamos">Los Alamos</option>
<option value="Los Angeles">Los Angeles</option>
<option value="Loudon">Loudon</option>
<option value="Loudoun">Loudoun</option>
<option value="Lowndes">Lowndes</option>
<option value="Lubbock">Lubbock</option>
<option value="Lucas">Lucas</option>
<option value="Luna">Luna</option>
<option value="Luzerne">Luzerne</option>
<option value="LYBUNT">LYBUNT</option>
<option value="Lycoming">Lycoming</option>
<option value="Lynchburg City">Lynchburg City</option>
<option value="Lyon">Lyon</option>
<option value="Macomb">Macomb</option>
<option value="Macon">Macon</option>
<option value="Madison">Madison</option>
<option value="Mahoning">Mahoning</option>
<option value="Manassas City">Manassas City</option>
<option value="Manatee">Manatee</option>
<option value="Marathon">Marathon</option>
<option value="Maricopa">Maricopa</option>
<option value="Marin">Marin</option>
<option value="Marinette">Marinette</option>
<option value="Marion">Marion</option>
<option value="Mariposa">Mariposa</option>
<option value="Marquette">Marquette</option>
<option value="Marshall">Marshall</option>
<option value="Martin">Martin</option>
<option value="Mason">Mason</option>
<option value="Matanuska Susitna">Matanuska Susitna</option>
<option value="Maui">Maui</option>
<option value="Mcdonald">Mcdonald</option>
<option value="McDowell">McDowell</option>
<option value="McHenry">McHenry</option>
<option value="McKinley">McKinley</option>
<option value="McLean">McLean</option>
<option value="McLennan">McLennan</option>
<option value="McMinn">McMinn</option>
<option value="Mcpherson">Mcpherson</option>
<option value="Meade">Meade</option>
<option value="Mecklenburg">Mecklenburg</option>
<option value="Medina">Medina</option>
<option value="Meigs">Meigs</option>
<option value="Menominee">Menominee</option>
<option value="Mercer">Mercer</option>
<option value="Merrimack">Merrimack</option>
<option value="Mesa">Mesa</option>
<option value="Miami">Miami</option>
<option value="Miami-Dade">Miami-Dade</option>
<option value="Middlesex">Middlesex</option>
<option value="Midland">Midland</option>
<option value="Milwaukee">Milwaukee</option>
<option value="Mineral">Mineral</option>
<option value="Mingo">Mingo</option>
<option value="Minnehaha">Minnehaha</option>
<option value="Missoula">Missoula</option>
<option value="Mobile">Mobile</option>
<option value="Mohave">Mohave</option>
<option value="Monmouth">Monmouth</option>
<option value="Monongalia">Monongalia</option>
<option value="Monroe">Monroe</option>
<option value="Monroe County">Monroe County</option>
<option value="Montague">Montague</option>
<option value="Monterey">Monterey</option>
<option value="Montgomery">Montgomery</option>
<option value="Montmorency">Montmorency</option>
<option value="Montour">Montour</option>
<option value="Montrose">Montrose</option>
<option value="Moore">Moore</option>
<option value="Morgan">Morgan</option>
<option value="Morris">Morris</option>
<option value="Morton">Morton</option>
<option value="Mower">Mower</option>
<option value="Multnomah">Multnomah</option>
<option value="Muscogee">Muscogee</option>
<option value="Muskegon">Muskegon</option>
<option value="Muskingum">Muskingum</option>
<option value="Muskogee">Muskogee</option>
<option value="Napa">Napa</option>
<option value="Nassau">Nassau</option>
<option value="Nelson">Nelson</option>
<option value="Neosho">Neosho</option>
<option value="Neshoba">Neshoba</option>
<option value="Ness">Ness</option>
<option value="Nevada">Nevada</option>
<option value="New Castle">New Castle</option>
<option value="New Hanover">New Hanover</option>
<option value="New Haven">New Haven</option>
<option value="New London">New London</option>
<option value="New York">New York</option>
<option value="Newaygo">Newaygo</option>
<option value="Newport">Newport</option>
<option value="Newport News City">Newport News City</option>
<option value="Niagara">Niagara</option>
<option value="Nicholas">Nicholas</option>
<option value="Nicollet">Nicollet</option>
<option value="Noble">Noble</option>
<option value="Nodaway">Nodaway</option>
<option value="Norfolk">Norfolk</option>
<option value="Norfolk City">Norfolk City</option>
<option value="Northampton">Northampton</option>
<option value="Northumberland">Northumberland</option>
<option value="Nowata">Nowata</option>
<option value="Nueces">Nueces</option>
<option value="Oakland">Oakland</option>
<option value="Ocean">Ocean</option>
<option value="Oconee">Oconee</option>
<option value="Oconto">Oconto</option>
<option value="Ogle">Ogle</option>
<option value="Ohio">Ohio</option>
<option value="Okaloosa">Okaloosa</option>
<option value="Okeechobee">Okeechobee</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oldham">Oldham</option>
<option value="Olmsted">Olmsted</option>
<option value="Oneida">Oneida</option>
<option value="Onondaga">Onondaga</option>
<option value="Onslow">Onslow</option>
<option value="Orange">Orange</option>
<option value="Orleans">Orleans</option>
<option value="Osage">Osage</option>
<option value="Osceola">Osceola</option>
<option value="Oswego">Oswego</option>
<option value="Otero">Otero</option>
<option value="Ottawa">Ottawa</option>
<option value="Outagamie">Outagamie</option>
<option value="Owen">Owen</option>
<option value="Ozaukee">Ozaukee</option>
<option value="Page">Page</option>
<option value="Palm Beach">Palm Beach</option>
<option value="Palo Pinto">Palo Pinto</option>
<option value="Park">Park</option>
<option value="Parker">Parker</option>
<option value="Pasco">Pasco</option>
<option value="Passaic">Passaic</option>
<option value="Pawnee">Pawnee</option>
<option value="Payne">Payne</option>
<option value="Pearl River">Pearl River</option>
<option value="Pender">Pender</option>
<option value="Pendleton">Pendleton</option>
<option value="Peoria">Peoria</option>
<option value="Person">Person</option>
<option value="Philadelphia">Philadelphia</option>
<option value="Pickaway">Pickaway</option>
<option value="Pierce">Pierce</option>
<option value="Pike">Pike</option>
<option value="Pima">Pima</option>
<option value="Pinal">Pinal</option>
<option value="Pinellas">Pinellas</option>
<option value="Pitkin">Pitkin</option>
<option value="Pittsburg">Pittsburg</option>
<option value="Placer">Placer</option>
<option value="Platte">Platte</option>
<option value="Pleasants">Pleasants</option>
<option value="Plumas">Plumas</option>
<option value="Plymouth">Plymouth</option>
<option value="Pocahontas">Pocahontas</option>
<option value="Pointe Coupee">Pointe Coupee</option>
<option value="Polk">Polk</option>
<option value="Poquoson City">Poquoson City</option>
<option value="Portage">Portage</option>
<option value="Porter">Porter</option>
<option value="Pottawatomie">Pottawatomie</option>
<option value="Pottawattamie">Pottawattamie</option>
<option value="Potter">Potter</option>
<option value="Pratt">Pratt</option>
<option value="Preble">Preble</option>
<option value="Presque Isle">Presque Isle</option>
<option value="Preston">Preston</option>
<option value="Prince George">Prince George</option>
<option value="Prince Georges">Prince Georges</option>
<option value="Prince William">Prince William</option>
<option value="Providence">Providence</option>
<option value="Prowers">Prowers</option>
<option value="Pueblo">Pueblo</option>
<option value="Pulaski">Pulaski</option>
<option value="Putnam">Putnam</option>
<option value="Queen Annes">Queen Annes</option>
<option value="Queens">Queens</option>
<option value="R98ONLY">R98ONLY</option>
<option value="Racine">Racine</option>
<option value="Raleigh">Raleigh</option>
<option value="Ramsey">Ramsey</option>
<option value="Randolph">Randolph</option>
<option value="Rapides">Rapides</option>
<option value="Rappahannock">Rappahannock</option>
<option value="Reno">Reno</option>
<option value="Rensselaer">Rensselaer</option>
<option value="Republic">Republic</option>
<option value="Rice">Rice</option>
<option value="Richland">Richland</option>
<option value="Richmond">Richmond</option>
<option value="Richmond City">Richmond City</option>
<option value="Riley">Riley</option>
<option value="Rio Grande">Rio Grande</option>
<option value="Ritchie">Ritchie</option>
<option value="Riverside">Riverside</option>
<option value="Roane">Roane</option>
<option value="Roanoke">Roanoke</option>
<option value="Roanoke City">Roanoke City</option>
<option value="Rock">Rock</option>
<option value="Rock Island">Rock Island</option>
<option value="Rockdale">Rockdale</option>
<option value="Rockingham">Rockingham</option>
<option value="Rockland">Rockland</option>
<option value="Rogers">Rogers</option>
<option value="Rooks">Rooks</option>
<option value="Ross">Ross</option>
<option value="Routt">Routt</option>
<option value="Rowan">Rowan</option>
<option value="Runnels">Runnels</option>
<option value="Rush">Rush</option>
<option value="Rutherford">Rutherford</option>
<option value="Rutland">Rutland</option>
<option value="Sabine">Sabine</option>
<option value="Sacramento">Sacramento</option>
<option value="Saginaw">Saginaw</option>
<option value="Saint Charles">Saint Charles</option>
<option value="Saint Clair">Saint Clair</option>
<option value="Saint Johns">Saint Johns</option>
<option value="Saint Joseph">Saint Joseph</option>
<option value="Saint Landry">Saint Landry</option>
<option value="Saint Louis">Saint Louis</option>
<option value="Saint Louis City">Saint Louis City</option>
<option value="Saint Lucie">Saint Lucie</option>
<option value="Saint Marys">Saint Marys</option>
<option value="Saint Tammany">Saint Tammany</option>
<option value="Salem">Salem</option>
<option value="Saline">Saline</option>
<option value="Salt Lake">Salt Lake</option>
<option value="Sampson">Sampson</option>
<option value="San Bernardino">San Bernardino</option>
<option value="San Diego">San Diego</option>
<option value="San Francisco">San Francisco</option>
<option value="San Jacinto">San Jacinto</option>
<option value="San Joaquin">San Joaquin</option>
<option value="San Luis Obispo">San Luis Obispo</option>
<option value="San Mateo">San Mateo</option>
<option value="San Miguel">San Miguel</option>
<option value="Sandoval">Sandoval</option>
<option value="Sandusky">Sandusky</option>
<option value="Sangamon">Sangamon</option>
<option value="Sanilac">Sanilac</option>
<option value="Santa Barbara">Santa Barbara</option>
<option value="Santa Clara">Santa Clara</option>
<option value="Santa Cruz">Santa Cruz</option>
<option value="Santa Fe">Santa Fe</option>
<option value="Santa Rosa">Santa Rosa</option>
<option value="Sarasota">Sarasota</option>
<option value="Saratoga">Saratoga</option>
<option value="Sauk">Sauk</option>
<option value="Schuylkill">Schuylkill</option>
<option value="Scioto">Scioto</option>
<option value="Scotland">Scotland</option>
<option value="Scott">Scott</option>
<option value="Sebastian">Sebastian</option>
<option value="Sedgwick">Sedgwick</option>
<option value="Seminole">Seminole</option>
<option value="Seneca">Seneca</option>
<option value="Sevier">Sevier</option>
<option value="Seward">Seward</option>
<option value="Sharp">Sharp</option>
<option value="Shasta">Shasta</option>
<option value="Shawnee">Shawnee</option>
<option value="Shelby">Shelby</option>
<option value="Shenandoah">Shenandoah</option>
<option value="Sheridan">Sheridan</option>
<option value="Sherman">Sherman</option>
<option value="Shiawassee">Shiawassee</option>
<option value="Simpson">Simpson</option>
<option value="Siskiyou">Siskiyou</option>
<option value="Skagit">Skagit</option>
<option value="Smith">Smith</option>
<option value="Snohomish">Snohomish</option>
<option value="Solano">Solano</option>
<option value="Somerset">Somerset</option>
<option value="Sonnora">Sonnora</option>
<option value="Sonoma">Sonoma</option>
<option value="Southampton">Southampton</option>
<option value="Spartanburg">Spartanburg</option>
<option value="Spokane">Spokane</option>
<option value="Spotsylvania">Spotsylvania</option>
<option value="St John the Baptist">St John the Baptist</option>
<option value="St Joseph">St Joseph</option>
<option value="Stafford">Stafford</option>
<option value="Stanislaus">Stanislaus</option>
<option value="Stark">Stark</option>
<option value="Starke">Starke</option>
<option value="Stephens">Stephens</option>
<option value="Stephenson">Stephenson</option>
<option value="Stevens">Stevens</option>
<option value="Stokes">Stokes</option>
<option value="Stone">Stone</option>
<option value="Story">Story</option>
<option value="Strafford">Strafford</option>
<option value="Suffolk">Suffolk</option>
<option value="Suffolk City">Suffolk City</option>
<option value="Sullivan">Sullivan</option>
<option value="Summers">Summers</option>
<option value="Summit">Summit</option>
<option value="Sumner">Sumner</option>
<option value="Sumter">Sumter</option>
<option value="Surry">Surry</option>
<option value="Susquehanna">Susquehanna</option>
<option value="Sussex">Sussex</option>
<option value="Sutter">Sutter</option>
<option value="Suwannee">Suwannee</option>
<option value="Talbot">Talbot</option>
<option value="Taney">Taney</option>
<option value="Tarrant">Tarrant</option>
<option value="Taylor">Taylor</option>
<option value="Tazewell">Tazewell</option>
<option value="Teller">Teller</option>
<option value="Teton">Teton</option>
<option value="Texas">Texas</option>
<option value="Thurston">Thurston</option>
<option value="Tippecanoe">Tippecanoe</option>
<option value="Tipton">Tipton</option>
<option value="Tolland">Tolland</option>
<option value="Tompkins">Tompkins</option>
<option value="Tooele">Tooele</option>
<option value="Transylvania">Transylvania</option>
<option value="Travis">Travis</option>
<option value="Trujillo Alto">Trujillo Alto</option>
<option value="Trumbull">Trumbull</option>
<option value="Tucker">Tucker</option>
<option value="Tulare">Tulare</option>
<option value="Tulsa">Tulsa</option>
<option value="Tuolumne">Tuolumne</option>
<option value="Tuscarawas">Tuscarawas</option>
<option value="Tyler">Tyler</option>
<option value="Ulster">Ulster</option>
<option value="Union">Union</option>
<option value="UNONLY">UNONLY</option>
<option value="UNONLY2">UNONLY2</option>
<option value="Upshur">Upshur</option>
<option value="USA">USA</option>
<option value="Valencia">Valencia</option>
<option value="Valley">Valley</option>
<option value="Van Buren">Van Buren</option>
<option value="Van Wert">Van Wert</option>
<option value="Vance">Vance</option>
<option value="Vanderburgh">Vanderburgh</option>
<option value="Ventura">Ventura</option>
<option value="Vermilion">Vermilion</option>
<option value="Vernon">Vernon</option>
<option value="Victoria">Victoria</option>
<option value="Vigo">Vigo</option>
<option value="Vilas">Vilas</option>
<option value="Virginia Beach City">Virginia Beach City</option>
<option value="Volusia">Volusia</option>
<option value="Wabash">Wabash</option>
<option value="Wagoner">Wagoner</option>
<option value="Wake">Wake</option>
<option value="Walla Walla">Walla Walla</option>
<option value="Walton">Walton</option>
<option value="Walworth">Walworth</option>
<option value="Ward">Ward</option>
<option value="Warren">Warren</option>
<option value="Warrick">Warrick</option>
<option value="Washington">Washington</option>
<option value="Washoe">Washoe</option>
<option value="Washtenaw">Washtenaw</option>
<option value="Waukesha">Waukesha</option>
<option value="Wayne">Wayne</option>
<option value="Waynesboro City">Waynesboro City</option>
<option value="Weber">Weber</option>
<option value="Webster">Webster</option>
<option value="Weld">Weld</option>
<option value="Wells">Wells</option>
<option value="Westchester">Westchester</option>
<option value="Westmoreland">Westmoreland</option>
<option value="Wetzel">Wetzel</option>
<option value="Whatcom">Whatcom</option>
<option value="Wheeling">Wheeling</option>
<option value="White">White</option>
<option value="Whitley">Whitley</option>
<option value="Wichita">Wichita</option>
<option value="Will">Will</option>
<option value="Williamson">Williamson</option>
<option value="Wilson">Wilson</option>
<option value="Winchester City">Winchester City</option>
<option value="Windham">Windham</option>
<option value="Windsor">Windsor</option>
<option value="Winnebago">Winnebago</option>
<option value="Wirt">Wirt</option>
<option value="Wise">Wise</option>
<option value="Wood">Wood</option>
<option value="Woodford">Woodford</option>
<option value="Woodson">Woodson</option>
<option value="Woodward">Woodward</option>
<option value="Worcester">Worcester</option>
<option value="Wright">Wright</option>
<option value="Wyandotte">Wyandotte</option>
<option value="Wyoming">Wyoming</option>
<option value="Yakima">Yakima</option>
<option value="Yamhill">Yamhill</option>
<option value="Yavapai">Yavapai</option>
<option value="Yellowstone">Yellowstone</option>
<option value="Yolo">Yolo</option>
<option value="York">York</option>
<option value="Yuma">Yuma</option>
</select>
</div>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="2" style="display: none;">
<label for="bboxdonation_tribute_tributeAddress_txtUKPostCode" id="bboxdonation_tribute_tributeAddress_lblUKPostCode" class="BBFormFieldLabel BBFormFieldLabelEdit">Postcode:</label>
<input name="bboxdonation$tribute$tributeAddress$txtUKPostCode" type="text" id="bboxdonation_tribute_tributeAddress_txtUKPostCode" class="BBFormTextbox" data-country-field="postcode" data-country-sync="1" required="required"
maxlength="12">
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="3" style="display: none;">
<label for="bboxdonation_tribute_tributeAddress_txtCACity" id="bboxdonation_tribute_tributeAddress_lblCACity" class="BBFormFieldLabel BBFormFieldLabelEdit">City:</label>
<input name="bboxdonation$tribute$tributeAddress$txtCACity" type="text" id="bboxdonation_tribute_tributeAddress_txtCACity" class="BBFormTextbox" data-country-field="city" data-country-sync="1" required="required" maxlength="50">
</div>
<div class="BBTwoFields BBFieldBillingStateZip">
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="3" style="display: none;">
<label for="bboxdonation_tribute_tributeAddress_ddCAProvince" id="bboxdonation_tribute_tributeAddress_lblCAProvincePostCode" class="BBFormFieldLabel BBFormFieldLabelEdit">Province & postal:</label>
<div aria-describedby="bboxdonation_tribute_tributeAddress_ddCAProvince">
<span id="bboxdonation_tribute_tributeAddress_lblCAProvince" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">Province:</span>
</div>
<select name="bboxdonation$tribute$tributeAddress$ddCAProvince" id="bboxdonation_tribute_tributeAddress_ddCAProvince" class="BBFormSelectList GhostText" data-country-sync="1" data-country-field="state" required="required">
<option selected="selected" value="" default="default">province</option>
<option value="NF">NF</option>
<option value="UK">UK</option>
<option value="AA">AA</option>
<option value="AB">AB</option>
<option value="AE">AE</option>
<option value="AK">AK</option>
<option value="AL">AL</option>
<option value="AP">AP</option>
<option value="AR">AR</option>
<option value="AS">AS</option>
<option value="AZ">AZ</option>
<option value="BC">BC</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="CZ">CZ</option>
<option value="DC">DC</option>
<option value="DE">DE</option>
<option value="FL">FL</option>
<option value="FM">FM</option>
<option value="GA">GA</option>
<option value="GU">GU</option>
<option value="HI">HI</option>
<option value="IA">IA</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="MA">MA</option>
<option value="MB">MB</option>
<option value="MD">MD</option>
<option value="ME">ME</option>
<option value="MH">MH</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MO">MO</option>
<option value="MP">MP</option>
<option value="MS">MS</option>
<option value="MT">MT</option>
<option value="NB">NB</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="NE">NE</option>
<option value="NL">NL</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NS">NS</option>
<option value="NT">NT</option>
<option value="NU">NU</option>
<option value="NV">NV</option>
<option value="NY">NY</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="ON">ON</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="PE">PE</option>
<option value="PR">PR</option>
<option value="PW">PW</option>
<option value="QC">QC</option>
<option value="RI">RI</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="SK">SK</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VA">VA</option>
<option value="VI">VI</option>
<option value="VT">VT</option>
<option value="WA">WA</option>
<option value="WI">WI</option>
<option value="WV">WV</option>
<option value="WY">WY</option>
<option value="YT">YT</option>
<option value="QLD">QLD</option>
</select>
<label for="bboxdonation_tribute_tributeAddress_txtCAPostCode" id="bboxdonation_tribute_tributeAddress_lblCAPostCode" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">Postal:</label>
<input name="bboxdonation$tribute$tributeAddress$txtCAPostCode" type="text" id="bboxdonation_tribute_tributeAddress_txtCAPostCode" class="BBFormTextbox" required="required" data-country-sync="1" data-country-field="postcode"
maxlength="12" placeholder="postal">
</div>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="4" style="display: none;">
<label for="bboxdonation_tribute_tributeAddress_txtAUCity" id="bboxdonation_tribute_tributeAddress_lblAUCity" class="BBFormFieldLabel BBFormFieldLabelEdit">Suburb:</label>
<input name="bboxdonation$tribute$tributeAddress$txtAUCity" type="text" id="bboxdonation_tribute_tributeAddress_txtAUCity" class="BBFormTextbox" data-country-sync="1" data-country-field="city" required="required" maxlength="50">
</div>
<div class="BBTwoFields BBFieldBillingStateZip">
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="4" style="display: none;">
<label for="bboxdonation_tribute_tributeAddress_ddAUState" id="bboxdonation_tribute_tributeAddress_lblAUStatePostCode" class="BBFormFieldLabel BBFormFieldLabelEdit">State & postcode:</label>
<div aria-describedby="bboxdonation_tribute_tributeAddress_ddAUState">
<span id="bboxdonation_tribute_tributeAddress_lblAUState" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">State:</span>
</div>
<select name="bboxdonation$tribute$tributeAddress$ddAUState" id="bboxdonation_tribute_tributeAddress_ddAUState" class="BBFormSelectList GhostText" data-country-sync="1" data-country-field="state" required="required">
<option selected="selected" value="" default="default">state</option>
<option value="NF">NF</option>
<option value="UK">UK</option>
<option value="AA">AA</option>
<option value="AB">AB</option>
<option value="AE">AE</option>
<option value="AK">AK</option>
<option value="AL">AL</option>
<option value="AP">AP</option>
<option value="AR">AR</option>
<option value="AS">AS</option>
<option value="AZ">AZ</option>
<option value="BC">BC</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="CZ">CZ</option>
<option value="DC">DC</option>
<option value="DE">DE</option>
<option value="FL">FL</option>
<option value="FM">FM</option>
<option value="GA">GA</option>
<option value="GU">GU</option>
<option value="HI">HI</option>
<option value="IA">IA</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="MA">MA</option>
<option value="MB">MB</option>
<option value="MD">MD</option>
<option value="ME">ME</option>
<option value="MH">MH</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MO">MO</option>
<option value="MP">MP</option>
<option value="MS">MS</option>
<option value="MT">MT</option>
<option value="NB">NB</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="NE">NE</option>
<option value="NL">NL</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NS">NS</option>
<option value="NT">NT</option>
<option value="NU">NU</option>
<option value="NV">NV</option>
<option value="NY">NY</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="ON">ON</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="PE">PE</option>
<option value="PR">PR</option>
<option value="PW">PW</option>
<option value="QC">QC</option>
<option value="RI">RI</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="SK">SK</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VA">VA</option>
<option value="VI">VI</option>
<option value="VT">VT</option>
<option value="WA">WA</option>
<option value="WI">WI</option>
<option value="WV">WV</option>
<option value="WY">WY</option>
<option value="YT">YT</option>
<option value="QLD">QLD</option>
</select>
<label for="bboxdonation_tribute_tributeAddress_txtAUPostCode" id="bboxdonation_tribute_tributeAddress_lblAUPostCode" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">Postcode:</label>
<input name="bboxdonation$tribute$tributeAddress$txtAUPostCode" type="tel" id="bboxdonation_tribute_tributeAddress_txtAUPostCode" class="BBFormTextbox" required="required" data-country-sync="1" data-country-field="postcode"
maxlength="12" placeholder="postcode">
</div>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="5" style="display: none;">
<label for="bboxdonation_tribute_tributeAddress_ddNZSuburb" id="bboxdonation_tribute_tributeAddress_lblNZSuburb" class="BBFormFieldLabel BBFormFieldLabelEdit">Suburb:</label>
<select name="bboxdonation$tribute$tributeAddress$ddNZSuburb" id="bboxdonation_tribute_tributeAddress_ddNZSuburb" class="BBFormSelectList GhostText" required="required" data-country-field="nzsuburb">
<option selected="selected" value="" default="default">suburb</option>
</select>
</div>
<div class="BBTwoFields BBFieldBillingStateZip">
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="5" style="display: none;">
<label for="bboxdonation_tribute_tributeAddress_ddNZCity" id="bboxdonation_tribute_tributeAddress_lblNZCityPostCode" class="BBFormFieldLabel BBFormFieldLabelEdit">City & post code:</label>
<div aria-describedby="bboxdonation_tribute_tributeAddress_ddNZCity">
<span id="bboxdonation_tribute_tributeAddress_lblNZCity" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">City:</span>
</div>
<select name="bboxdonation$tribute$tributeAddress$ddNZCity" id="bboxdonation_tribute_tributeAddress_ddNZCity" class="BBFormSelectList GhostText" required="required" data-country-field="nzcity">
<option selected="selected" value="" default="default">city</option>
<option value="1126 Metro Manila">1126 Metro Manila</option>
</select>
<label for="bboxdonation_tribute_tributeAddress_txtNZPostCode" id="bboxdonation_tribute_tributeAddress_lblNZPostCode" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">Post code:</label>
<input name="bboxdonation$tribute$tributeAddress$txtNZPostCode" type="tel" id="bboxdonation_tribute_tributeAddress_txtNZPostCode" class="BBFormTextbox" required="required" data-country-sync="1" data-country-field="postcode"
maxlength="12" placeholder="post code">
</div>
</div>
</div>
</div>
</div>
</div>
</fieldset>
</div>
<div class="BBFormSection BBDFormSectionComments">
<fieldset>
<legend></legend>
<div id="bboxdonation_comment_fldComments" class="BBFormFieldContainer">
<label for="bboxdonation_comment_txtComments" id="bboxdonation_comment_lblComments" class="BBFormFieldLabel BBFormFieldLabelEdit">Leave a comment (optional):</label>
<textarea name="bboxdonation$comment$txtComments" id="bboxdonation_comment_txtComments" class="BBFormTextArea" rows="2" cols="30" maxlength="255" placeholder="optional"></textarea>
</div>
</fieldset>
</div>
<div id="bboxdonation_billing_divBillingSection" class="BBFormSection BBDFormSectionBillingInfo BBFormAddressBlock" data-section="Billing">
<fieldset>
<legend>
<div id="bboxdonation_billing_divBillingHeader" class="BBFormSectionHeading">
<label id="bboxdonation_billing_lblHeadingContact" class="BBFormFieldLabelEdit">Billing Address</label>
</div>
</legend>
<div id="fldOrgInfo" class="BBFormOrgFields" style="display: none;">
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="bboxdonation_billing_txtOrgName" id="bboxdonation_billing_lblOrgName" class="BBFormFieldLabel BBFormFieldLabelEdit ">Organization name:</label>
<input name="bboxdonation$billing$txtOrgName" type="text" id="bboxdonation_billing_txtOrgName" class="BBFormTextbox" required="required" data-billing-field="orgname" maxlength="60">
</div>
</div>
<div id="fldIndivInfo" class="BBFormIndivFields">
<div id="divName" class="BBFormFieldContainer BBFormFieldContainerRequired BBTwoFields">
<span id="bboxdonation_billing_lblFullName" class="BBFormFieldLabel BBFormFieldLabelEdit">Name:</span>
<label for="bboxdonation_billing_ddTitle" id="bboxdonation_billing_lblTitle" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">Title:</label>
<label for="bboxdonation_billing_txtFirstName" id="bboxdonation_billing_lblFirstName" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">First name:</label>
<input name="bboxdonation$billing$txtFirstName" type="text" id="bboxdonation_billing_txtFirstName" class="BBFormTextbox" data-billing-field="firstname" maxlength="50" required="required" placeholder="first name">
<label for="bboxdonation_billing_txtLastName" id="bboxdonation_billing_lblLastName" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">Last name:</label>
<input name="bboxdonation$billing$txtLastName" type="text" id="bboxdonation_billing_txtLastName" class="BBFormTextbox" data-billing-field="lastname" maxlength="100" required="required" placeholder="last name">
</div>
</div>
<div id="bboxdonation_billing_divEmail" class="BBFormFieldContainer BBFormFieldContainerRequired BBFormBillingEmail">
<label for="bboxdonation_billing_txtEmail" id="bboxdonation_billing_lblEmail" class="BBFormFieldLabel BBFormFieldLabelEdit">Email:</label>
<input name="bboxdonation$billing$txtEmail" type="email" id="bboxdonation_billing_txtEmail" class="BBFormTextbox" data-billing-field="email" required="required">
</div>
<div id="bboxdonation_billing_divPhone" class="BBFormFieldContainer BBFormBillingPhone BBFormFieldContainerRequired">
<label for="bboxdonation_billing_txtPhone" id="bboxdonation_billing_lblPhone" class="BBFormFieldLabel BBFormFieldLabelEdit">Phone:</label>
<input name="bboxdonation$billing$txtPhone" type="tel" id="bboxdonation_billing_txtPhone" class="BBFormTextbox" data-billing-field="phone" placeholder="optional">
</div>
<div class="BBFormAddress">
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="bboxdonation_billing_billingAddress_ddCountry" id="bboxdonation_billing_billingAddress_lblCountry" class="BBFormFieldLabel BBFormFieldLabelEdit">Country:</label>
<select name="bboxdonation$billing$billingAddress$ddCountry" id="bboxdonation_billing_billingAddress_ddCountry" class="BBFormSelectList BBFormCountryDropDown" required="required">
<option selected="selected" value="United States" data-country-format="1" data-short-text="US">United States</option>
<option value="Australia" data-country-format="1" data-short-text="AU">Australia</option>
<option value="Barbados" data-country-format="1" data-short-text="BB">Barbados</option>
<option value="Canada" data-country-format="3" data-short-text="CA">Canada</option>
<option value="Dominican Republic" data-country-format="1" data-short-text="DO">Dominican Republic</option>
<option value="Egypt" data-country-format="1" data-short-text="EG">Egypt</option>
<option value="El Salvador" data-country-format="1" data-short-text="SV">El Salvador</option>
<option value="France" data-country-format="1" data-short-text="FR">France</option>
<option value="Germany" data-country-format="1" data-short-text="DE">Germany</option>
<option value="Honduras" data-country-format="1" data-short-text="HN">Honduras</option>
<option value="India" data-country-format="1" data-short-text="IN">India</option>
<option value="Indonesia" data-country-format="1" data-short-text="ID">Indonesia</option>
<option value="Ireland" data-country-format="1" data-short-text="IE">Ireland</option>
<option value="Italy" data-country-format="1" data-short-text="IT">Italy</option>
<option value="Japan" data-country-format="3" data-short-text="JP">Japan</option>
<option value="Mexico" data-country-format="1" data-short-text="MX">Mexico</option>
<option value="Nicaragua" data-country-format="3" data-short-text="NI">Nicaragua</option>
<option value="Nigeria" data-country-format="1" data-short-text="NG">Nigeria</option>
<option value="Peru" data-country-format="2" data-short-text="PE">Peru</option>
<option value="Philippines" data-country-format="5" data-short-text="PH">Philippines</option>
</select>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="bboxdonation_billing_billingAddress_txtAddress" id="bboxdonation_billing_billingAddress_lblAddress" class="BBFormFieldLabel BBFormFieldLabelEdit">Address:</label>
<textarea name="bboxdonation$billing$billingAddress$txtAddress" id="bboxdonation_billing_billingAddress_txtAddress" class="BBFormTextArea" rows="2" cols="30" required="required" data-country-field="address" maxlength="150"></textarea>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="1">
<label for="bboxdonation_billing_billingAddress_txtCity" id="bboxdonation_billing_billingAddress_lblCity" class="BBFormFieldLabel BBFormFieldLabelEdit">City:</label>
<input name="bboxdonation$billing$billingAddress$txtCity" type="text" id="bboxdonation_billing_billingAddress_txtCity" class="BBFormTextbox" data-country-field="city" data-country-sync="1" required="required" maxlength="50">
</div>
<div class="BBTwoFields BBFieldBillingStateZip">
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="1">
<label for="bboxdonation_billing_billingAddress_ddState" id="bboxdonation_billing_billingAddress_lblStateZip" class="BBFormFieldLabel BBFormFieldLabelEdit">State & zip:</label>
<div aria-describedby="bboxdonation_billing_billingAddress_ddState">
<span id="bboxdonation_billing_billingAddress_lblState" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">State:</span>
</div>
<select name="bboxdonation$billing$billingAddress$ddState" id="bboxdonation_billing_billingAddress_ddState" class="BBFormSelectList GhostText" data-country-sync="1" data-country-field="state" required="required">
<option selected="selected" value="" default="default">state</option>
<option value="NF">NF</option>
<option value="UK">UK</option>
<option value="AA">AA</option>
<option value="AB">AB</option>
<option value="AE">AE</option>
<option value="AK">AK</option>
<option value="AL">AL</option>
<option value="AP">AP</option>
<option value="AR">AR</option>
<option value="AS">AS</option>
<option value="AZ">AZ</option>
<option value="BC">BC</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="CZ">CZ</option>
<option value="DC">DC</option>
<option value="DE">DE</option>
<option value="FL">FL</option>
<option value="FM">FM</option>
<option value="GA">GA</option>
<option value="GU">GU</option>
<option value="HI">HI</option>
<option value="IA">IA</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="MA">MA</option>
<option value="MB">MB</option>
<option value="MD">MD</option>
<option value="ME">ME</option>
<option value="MH">MH</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MO">MO</option>
<option value="MP">MP</option>
<option value="MS">MS</option>
<option value="MT">MT</option>
<option value="NB">NB</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="NE">NE</option>
<option value="NL">NL</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NS">NS</option>
<option value="NT">NT</option>
<option value="NU">NU</option>
<option value="NV">NV</option>
<option value="NY">NY</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="ON">ON</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="PE">PE</option>
<option value="PR">PR</option>
<option value="PW">PW</option>
<option value="QC">QC</option>
<option value="RI">RI</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="SK">SK</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VA">VA</option>
<option value="VI">VI</option>
<option value="VT">VT</option>
<option value="WA">WA</option>
<option value="WI">WI</option>
<option value="WV">WV</option>
<option value="WY">WY</option>
<option value="YT">YT</option>
<option value="QLD">QLD</option>
</select>
<label for="bboxdonation_billing_billingAddress_txtZip" id="bboxdonation_billing_billingAddress_lblZip" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">Zip:</label>
<input name="bboxdonation$billing$billingAddress$txtZip" type="tel" id="bboxdonation_billing_billingAddress_txtZip" class="BBFormTextbox" data-country-field="postcode" data-country-sync="1" required="required" maxlength="12"
placeholder="zip">
</div>
</div>
<div class="BBTwoFields BBFieldBillingStateZip">
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="2" style="display: none;">
<label for="bboxdonation_billing_billingAddress_txtUKCity" id="bboxdonation_billing_billingAddress_lblUKCityCounty" class="BBFormFieldLabel BBFormFieldLabelEdit">City & county:</label>
<div aria-describedby="bboxdonation_billing_billingAddress_txtUKCity">
<span id="bboxdonation_billing_billingAddress_lblUKCity" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">City:</span>
</div>
<input name="bboxdonation$billing$billingAddress$txtUKCity" type="text" id="bboxdonation_billing_billingAddress_txtUKCity" class="BBFormTextbox" data-country-field="city" data-country-sync="1" required="required" maxlength="50"
placeholder="city">
<label for="bboxdonation_billing_billingAddress_ddUKCounty" id="bboxdonation_billing_billingAddress_lblUKCounty" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">County:</label>
<select name="bboxdonation$billing$billingAddress$ddUKCounty" id="bboxdonation_billing_billingAddress_ddUKCounty" class="BBFormSelectList GhostText" data-country-field="county">
<option selected="selected" value="" default="default">county (optional)</option>
<option value="Accomack">Accomack</option>
<option value="Ada">Ada</option>
<option value="Adams">Adams</option>
<option value="Aiken">Aiken</option>
<option value="Alachua">Alachua</option>
<option value="Alameda">Alameda</option>
<option value="Albany">Albany</option>
<option value="Albemarle">Albemarle</option>
<option value="Alexandria City">Alexandria City</option>
<option value="Allegan">Allegan</option>
<option value="Allegany">Allegany</option>
<option value="Allegheny">Allegheny</option>
<option value="Allen">Allen</option>
<option value="Amelia">Amelia</option>
<option value="Amherst">Amherst</option>
<option value="Anchorage">Anchorage</option>
<option value="Anderson">Anderson</option>
<option value="Andrew">Andrew</option>
<option value="Androscoggin">Androscoggin</option>
<option value="Anne Arundel">Anne Arundel</option>
<option value="Anoka">Anoka</option>
<option value="APONLY">APONLY</option>
<option value="Arapahoe">Arapahoe</option>
<option value="Archuleta">Archuleta</option>
<option value="Arlington">Arlington</option>
<option value="Aroostook">Aroostook</option>
<option value="Ascension">Ascension</option>
<option value="Ashland">Ashland</option>
<option value="Ashtabula">Ashtabula</option>
<option value="Assumption">Assumption</option>
<option value="Atchison">Atchison</option>
<option value="Athens">Athens</option>
<option value="Atlantic">Atlantic</option>
<option value="Auglaize">Auglaize</option>
<option value="Augusta">Augusta</option>
<option value="Australia">Australia</option>
<option value="Autauga">Autauga</option>
<option value="Avery">Avery</option>
<option value="Baldwin">Baldwin</option>
<option value="Baltimore">Baltimore</option>
<option value="Baltimore City">Baltimore City</option>
<option value="Bannock">Bannock</option>
<option value="Barber">Barber</option>
<option value="Barbour">Barbour</option>
<option value="Barnstable">Barnstable</option>
<option value="Barry">Barry</option>
<option value="Bartholomew">Bartholomew</option>
<option value="Barton">Barton</option>
<option value="Bastrop">Bastrop</option>
<option value="Bath">Bath</option>
<option value="Baxter">Baxter</option>
<option value="Bay">Bay</option>
<option value="Bayfield">Bayfield</option>
<option value="Beaufort">Beaufort</option>
<option value="Beaver">Beaver</option>
<option value="Bedford">Bedford</option>
<option value="Belknap">Belknap</option>
<option value="Bell">Bell</option>
<option value="Belmont">Belmont</option>
<option value="Benton">Benton</option>
<option value="Bergen">Bergen</option>
<option value="Berkeley">Berkeley</option>
<option value="Berks">Berks</option>
<option value="Bernalillo">Bernalillo</option>
<option value="Berrien">Berrien</option>
<option value="Bexar">Bexar</option>
<option value="Bibb">Bibb</option>
<option value="Black Hawk">Black Hawk</option>
<option value="Blackford">Blackford</option>
<option value="Blaine">Blaine</option>
<option value="Blair">Blair</option>
<option value="Blount">Blount</option>
<option value="Bonneville">Bonneville</option>
<option value="Boone">Boone</option>
<option value="Boulder">Boulder</option>
<option value="Bourbon">Bourbon</option>
<option value="Bowie">Bowie</option>
<option value="Boyd">Boyd</option>
<option value="Braxton">Braxton</option>
<option value="Brazoria">Brazoria</option>
<option value="Brazos">Brazos</option>
<option value="Brevard">Brevard</option>
<option value="Bristol">Bristol</option>
<option value="Bronx">Bronx</option>
<option value="Brooke">Brooke</option>
<option value="Broome">Broome</option>
<option value="Broomfield">Broomfield</option>
<option value="Broward">Broward</option>
<option value="Brown">Brown</option>
<option value="Brunswick">Brunswick</option>
<option value="Bucks">Bucks</option>
<option value="Buena Vista City">Buena Vista City</option>
<option value="Buffalo">Buffalo</option>
<option value="Bulloch">Bulloch</option>
<option value="Buncombe">Buncombe</option>
<option value="Burlington">Burlington</option>
<option value="Burnet">Burnet</option>
<option value="Butler">Butler</option>
<option value="Butts">Butts</option>
<option value="Cabarrus">Cabarrus</option>
<option value="Cabell">Cabell</option>
<option value="Caddo">Caddo</option>
<option value="Calaveras">Calaveras</option>
<option value="Calcasieu">Calcasieu</option>
<option value="Caldwell">Caldwell</option>
<option value="Calhoun">Calhoun</option>
<option value="Callaway">Callaway</option>
<option value="Calvert">Calvert</option>
<option value="Cambria">Cambria</option>
<option value="Camden">Camden</option>
<option value="Cameron">Cameron</option>
<option value="Campbell">Campbell</option>
<option value="Canada">Canada</option>
<option value="Canadian">Canadian</option>
<option value="Cape May">Cape May</option>
<option value="Caroline">Caroline</option>
<option value="Carroll">Carroll</option>
<option value="Carteret">Carteret</option>
<option value="Carver">Carver</option>
<option value="Cass">Cass</option>
<option value="Catawba">Catawba</option>
<option value="Cecil">Cecil</option>
<option value="Centre">Centre</option>
<option value="Chaffee">Chaffee</option>
<option value="Champaign">Champaign</option>
<option value="Charles">Charles</option>
<option value="Charleston">Charleston</option>
<option value="Charlotte">Charlotte</option>
<option value="Charlottesville City">Charlottesville City</option>
<option value="Chatham">Chatham</option>
<option value="Chautauqua">Chautauqua</option>
<option value="Chaves">Chaves</option>
<option value="Cheboygan">Cheboygan</option>
<option value="Chelan">Chelan</option>
<option value="Chemung">Chemung</option>
<option value="Cherokee">Cherokee</option>
<option value="Chesapeake City">Chesapeake City</option>
<option value="Cheshire">Cheshire</option>
<option value="Chester">Chester</option>
<option value="Chesterfield">Chesterfield</option>
<option value="Chickasaw">Chickasaw</option>
<option value="Chittenden">Chittenden</option>
<option value="Christian">Christian</option>
<option value="Churchill">Churchill</option>
<option value="Citrus">Citrus</option>
<option value="Clackamas">Clackamas</option>
<option value="Clallam">Clallam</option>
<option value="Clarendon">Clarendon</option>
<option value="Clarion">Clarion</option>
<option value="Clark">Clark</option>
<option value="Clay">Clay</option>
<option value="Clearfield">Clearfield</option>
<option value="Cleburne">Cleburne</option>
<option value="Clermont">Clermont</option>
<option value="Cleveland">Cleveland</option>
<option value="Clinton">Clinton</option>
<option value="Cloud">Cloud</option>
<option value="Coahoma">Coahoma</option>
<option value="Cobb">Cobb</option>
<option value="Cochise">Cochise</option>
<option value="Coconino">Coconino</option>
<option value="Coffee">Coffee</option>
<option value="Cole">Cole</option>
<option value="Coles">Coles</option>
<option value="Collier">Collier</option>
<option value="Collin">Collin</option>
<option value="Colonial Heights City">Colonial Heights City</option>
<option value="Columbia">Columbia</option>
<option value="Columbiana">Columbiana</option>
<option value="Comal">Comal</option>
<option value="Comanche">Comanche</option>
<option value="Contra Costa">Contra Costa</option>
<option value="Converse">Converse</option>
<option value="Cook">Cook</option>
<option value="Cooke">Cooke</option>
<option value="Coryell">Coryell</option>
<option value="Coshocton">Coshocton</option>
<option value="Costilla">Costilla</option>
<option value="Coweta">Coweta</option>
<option value="Cowley">Cowley</option>
<option value="Cowlitz">Cowlitz</option>
<option value="Craighead">Craighead</option>
<option value="Craven">Craven</option>
<option value="Crawford">Crawford</option>
<option value="Culpeper">Culpeper</option>
<option value="Cumberland">Cumberland</option>
<option value="Curry">Curry</option>
<option value="Custer">Custer</option>
<option value="Cuyahoga">Cuyahoga</option>
<option value="Dakota">Dakota</option>
<option value="Dallam">Dallam</option>
<option value="Dallas">Dallas</option>
<option value="Dane">Dane</option>
<option value="Dare">Dare</option>
<option value="Darke">Darke</option>
<option value="Darlington">Darlington</option>
<option value="Dauphin">Dauphin</option>
<option value="Davidson">Davidson</option>
<option value="Davis">Davis</option>
<option value="De Kalb">De Kalb</option>
<option value="Decatur">Decatur</option>
<option value="Defiance">Defiance</option>
<option value="Dekalb">Dekalb</option>
<option value="Delaware">Delaware</option>
<option value="Delta">Delta</option>
<option value="Denton">Denton</option>
<option value="Denver">Denver</option>
<option value="Deschutes">Deschutes</option>
<option value="DeSoto">DeSoto</option>
<option value="Dickinson">Dickinson</option>
<option value="Dickson">Dickson</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Doddridge">Doddridge</option>
<option value="Dodge">Dodge</option>
<option value="Dona Ana">Dona Ana</option>
<option value="Door">Door</option>
<option value="Dorchester">Dorchester</option>
<option value="Douglas">Douglas</option>
<option value="Du Page">Du Page</option>
<option value="Dubois">Dubois</option>
<option value="Dubuque">Dubuque</option>
<option value="DuPage">DuPage</option>
<option value="Durham">Durham</option>
<option value="Dutchess">Dutchess</option>
<option value="Duval">Duval</option>
<option value="Eagle">Eagle</option>
<option value="East Baton Rouge">East Baton Rouge</option>
<option value="Eaton">Eaton</option>
<option value="Eau Claire">Eau Claire</option>
<option value="Ector">Ector</option>
<option value="Edgar">Edgar</option>
<option value="Edwards">Edwards</option>
<option value="El Dorado">El Dorado</option>
<option value="El Paso">El Paso</option>
<option value="Elk">Elk</option>
<option value="Elkhart">Elkhart</option>
<option value="Ellis">Ellis</option>
<option value="Ellsworth">Ellsworth</option>
<option value="Elmore">Elmore</option>
<option value="Emporia City">Emporia City</option>
<option value="Erie">Erie</option>
<option value="Escambia">Escambia</option>
<option value="Essex">Essex</option>
<option value="Etowah">Etowah</option>
<option value="Fairfax">Fairfax</option>
<option value="Fairfax City">Fairfax City</option>
<option value="Fairfield">Fairfield</option>
<option value="Falls Church City">Falls Church City</option>
<option value="Fauquier">Fauquier</option>
<option value="Fayette">Fayette</option>
<option value="Finney">Finney</option>
<option value="Flagler">Flagler</option>
<option value="Fleming">Fleming</option>
<option value="Floyd">Floyd</option>
<option value="Fluvanna">Fluvanna</option>
<option value="Fond du Lac">Fond du Lac</option>
<option value="Ford">Ford</option>
<option value="Forsyth">Forsyth</option>
<option value="Fort Bend">Fort Bend</option>
<option value="Fountain">Fountain</option>
<option value="Franklin">Franklin</option>
<option value="Frederick">Frederick</option>
<option value="Fredericksburg City">Fredericksburg City</option>
<option value="Fresno">Fresno</option>
<option value="Fulton">Fulton</option>
<option value="Gallia">Gallia</option>
<option value="Galveston">Galveston</option>
<option value="Garfield">Garfield</option>
<option value="Garland">Garland</option>
<option value="Garrard">Garrard</option>
<option value="Garrett">Garrett</option>
<option value="Gasconade">Gasconade</option>
<option value="Gaston">Gaston</option>
<option value="Geary">Geary</option>
<option value="Geauga">Geauga</option>
<option value="Genesee">Genesee</option>
<option value="Georgetown">Georgetown</option>
<option value="Gila">Gila</option>
<option value="Gillespie">Gillespie</option>
<option value="Gilmer">Gilmer</option>
<option value="Gladwin">Gladwin</option>
<option value="Gloucester">Gloucester</option>
<option value="Glynn">Glynn</option>
<option value="Gogebic">Gogebic</option>
<option value="Goochland">Goochland</option>
<option value="Grafton">Grafton</option>
<option value="Grand">Grand</option>
<option value="Grand Forks">Grand Forks</option>
<option value="Grant">Grant</option>
<option value="Gray">Gray</option>
<option value="Grayson">Grayson</option>
<option value="Greeley">Greeley</option>
<option value="Green">Green</option>
<option value="Greenbrier">Greenbrier</option>
<option value="Greene">Greene</option>
<option value="Greenup">Greenup</option>
<option value="Greenville">Greenville</option>
<option value="Greenwood">Greenwood</option>
<option value="Grundy">Grundy</option>
<option value="Guadalupe">Guadalupe</option>
<option value="Guernsey">Guernsey</option>
<option value="Guilford">Guilford</option>
<option value="Gwinnett">Gwinnett</option>
<option value="Hale">Hale</option>
<option value="Hall">Hall</option>
<option value="Hamilton">Hamilton</option>
<option value="Hampden">Hampden</option>
<option value="Hampshire">Hampshire</option>
<option value="Hampton">Hampton</option>
<option value="Hampton City">Hampton City</option>
<option value="Hancock">Hancock</option>
<option value="Hanover">Hanover</option>
<option value="Hanson">Hanson</option>
<option value="Hardin">Hardin</option>
<option value="Hardy">Hardy</option>
<option value="Harford">Harford</option>
<option value="Harney">Harney</option>
<option value="Harper">Harper</option>
<option value="Harris">Harris</option>
<option value="Harrison">Harrison</option>
<option value="Harrisonburg City">Harrisonburg City</option>
<option value="Hartford">Hartford</option>
<option value="Harvey">Harvey</option>
<option value="Haskell">Haskell</option>
<option value="Hays">Hays</option>
<option value="Henderson">Henderson</option>
<option value="Hendricks">Hendricks</option>
<option value="Hendry">Hendry</option>
<option value="Hennepin">Hennepin</option>
<option value="Henrico">Henrico</option>
<option value="Henry">Henry</option>
<option value="Hernando">Hernando</option>
<option value="Hidalgo">Hidalgo</option>
<option value="Highland">Highland</option>
<option value="Highlands">Highlands</option>
<option value="Hillsborough">Hillsborough</option>
<option value="Hillsdale">Hillsdale</option>
<option value="Hinds">Hinds</option>
<option value="Hodgeman">Hodgeman</option>
<option value="Holt">Holt</option>
<option value="Honolulu">Honolulu</option>
<option value="Hood">Hood</option>
<option value="Hopewell City">Hopewell City</option>
<option value="Horry">Horry</option>
<option value="Howard">Howard</option>
<option value="Hudson">Hudson</option>
<option value="Humboldt">Humboldt</option>
<option value="Hunt">Hunt</option>
<option value="Huntingdon">Huntingdon</option>
<option value="Huntington">Huntington</option>
<option value="Huron">Huron</option>
<option value="Independence">Independence</option>
<option value="Indian River">Indian River</option>
<option value="Indiana">Indiana</option>
<option value="Ingham">Ingham</option>
<option value="Inyo">Inyo</option>
<option value="Iowa">Iowa</option>
<option value="Iredell">Iredell</option>
<option value="Iron">Iron</option>
<option value="Iroquois">Iroquois</option>
<option value="Island">Island</option>
<option value="Jackson">Jackson</option>
<option value="James City">James City</option>
<option value="Japan">Japan</option>
<option value="Jasper">Jasper</option>
<option value="Jay">Jay</option>
<option value="Jefferson">Jefferson</option>
<option value="Jefferson Davis">Jefferson Davis</option>
<option value="Jo Daviess">Jo Daviess</option>
<option value="Johnson">Johnson</option>
<option value="Johnston">Johnston</option>
<option value="Juneau">Juneau</option>
<option value="Kalamazoo">Kalamazoo</option>
<option value="Kanawha">Kanawha</option>
<option value="Kandiyohi">Kandiyohi</option>
<option value="Kane">Kane</option>
<option value="Kankakee">Kankakee</option>
<option value="Kay">Kay</option>
<option value="Kearny">Kearny</option>
<option value="Kenai Peninsula">Kenai Peninsula</option>
<option value="Kendall">Kendall</option>
<option value="Kennebec">Kennebec</option>
<option value="Kenosha">Kenosha</option>
<option value="Kent">Kent</option>
<option value="Kenton">Kenton</option>
<option value="Kern">Kern</option>
<option value="Kerr">Kerr</option>
<option value="King">King</option>
<option value="Kingfisher">Kingfisher</option>
<option value="Kingman">Kingman</option>
<option value="Kings">Kings</option>
<option value="Kiowa">Kiowa</option>
<option value="Kitsap">Kitsap</option>
<option value="Knox">Knox</option>
<option value="Kosciusko">Kosciusko</option>
<option value="La Crosse">La Crosse</option>
<option value="La Paz">La Paz</option>
<option value="La Plata">La Plata</option>
<option value="La Porte">La Porte</option>
<option value="La Salle">La Salle</option>
<option value="Labette">Labette</option>
<option value="Lackawanna">Lackawanna</option>
<option value="Lafayette">Lafayette</option>
<option value="Lagrange">Lagrange</option>
<option value="Lake">Lake</option>
<option value="Lancaster">Lancaster</option>
<option value="Lane">Lane</option>
<option value="Lapeer">Lapeer</option>
<option value="Laramie">Laramie</option>
<option value="Larimer">Larimer</option>
<option value="Las Animas">Las Animas</option>
<option value="Lauderdale">Lauderdale</option>
<option value="Laurel">Laurel</option>
<option value="Lawrence">Lawrence</option>
<option value="Lea">Lea</option>
<option value="Leavenworth">Leavenworth</option>
<option value="Lebanon">Lebanon</option>
<option value="Lee">Lee</option>
<option value="Leelanau">Leelanau</option>
<option value="Lehigh">Lehigh</option>
<option value="Lenawee">Lenawee</option>
<option value="Leon">Leon</option>
<option value="Levy">Levy</option>
<option value="Lewis">Lewis</option>
<option value="Lexington">Lexington</option>
<option value="Licking">Licking</option>
<option value="Lincoln">Lincoln</option>
<option value="Linn">Linn</option>
<option value="Litchfield">Litchfield</option>
<option value="Livingston">Livingston</option>
<option value="Logan">Logan</option>
<option value="Lorain">Lorain</option>
<option value="Los Alamos">Los Alamos</option>
<option value="Los Angeles">Los Angeles</option>
<option value="Loudon">Loudon</option>
<option value="Loudoun">Loudoun</option>
<option value="Lowndes">Lowndes</option>
<option value="Lubbock">Lubbock</option>
<option value="Lucas">Lucas</option>
<option value="Luna">Luna</option>
<option value="Luzerne">Luzerne</option>
<option value="LYBUNT">LYBUNT</option>
<option value="Lycoming">Lycoming</option>
<option value="Lynchburg City">Lynchburg City</option>
<option value="Lyon">Lyon</option>
<option value="Macomb">Macomb</option>
<option value="Macon">Macon</option>
<option value="Madison">Madison</option>
<option value="Mahoning">Mahoning</option>
<option value="Manassas City">Manassas City</option>
<option value="Manatee">Manatee</option>
<option value="Marathon">Marathon</option>
<option value="Maricopa">Maricopa</option>
<option value="Marin">Marin</option>
<option value="Marinette">Marinette</option>
<option value="Marion">Marion</option>
<option value="Mariposa">Mariposa</option>
<option value="Marquette">Marquette</option>
<option value="Marshall">Marshall</option>
<option value="Martin">Martin</option>
<option value="Mason">Mason</option>
<option value="Matanuska Susitna">Matanuska Susitna</option>
<option value="Maui">Maui</option>
<option value="Mcdonald">Mcdonald</option>
<option value="McDowell">McDowell</option>
<option value="McHenry">McHenry</option>
<option value="McKinley">McKinley</option>
<option value="McLean">McLean</option>
<option value="McLennan">McLennan</option>
<option value="McMinn">McMinn</option>
<option value="Mcpherson">Mcpherson</option>
<option value="Meade">Meade</option>
<option value="Mecklenburg">Mecklenburg</option>
<option value="Medina">Medina</option>
<option value="Meigs">Meigs</option>
<option value="Menominee">Menominee</option>
<option value="Mercer">Mercer</option>
<option value="Merrimack">Merrimack</option>
<option value="Mesa">Mesa</option>
<option value="Miami">Miami</option>
<option value="Miami-Dade">Miami-Dade</option>
<option value="Middlesex">Middlesex</option>
<option value="Midland">Midland</option>
<option value="Milwaukee">Milwaukee</option>
<option value="Mineral">Mineral</option>
<option value="Mingo">Mingo</option>
<option value="Minnehaha">Minnehaha</option>
<option value="Missoula">Missoula</option>
<option value="Mobile">Mobile</option>
<option value="Mohave">Mohave</option>
<option value="Monmouth">Monmouth</option>
<option value="Monongalia">Monongalia</option>
<option value="Monroe">Monroe</option>
<option value="Monroe County">Monroe County</option>
<option value="Montague">Montague</option>
<option value="Monterey">Monterey</option>
<option value="Montgomery">Montgomery</option>
<option value="Montmorency">Montmorency</option>
<option value="Montour">Montour</option>
<option value="Montrose">Montrose</option>
<option value="Moore">Moore</option>
<option value="Morgan">Morgan</option>
<option value="Morris">Morris</option>
<option value="Morton">Morton</option>
<option value="Mower">Mower</option>
<option value="Multnomah">Multnomah</option>
<option value="Muscogee">Muscogee</option>
<option value="Muskegon">Muskegon</option>
<option value="Muskingum">Muskingum</option>
<option value="Muskogee">Muskogee</option>
<option value="Napa">Napa</option>
<option value="Nassau">Nassau</option>
<option value="Nelson">Nelson</option>
<option value="Neosho">Neosho</option>
<option value="Neshoba">Neshoba</option>
<option value="Ness">Ness</option>
<option value="Nevada">Nevada</option>
<option value="New Castle">New Castle</option>
<option value="New Hanover">New Hanover</option>
<option value="New Haven">New Haven</option>
<option value="New London">New London</option>
<option value="New York">New York</option>
<option value="Newaygo">Newaygo</option>
<option value="Newport">Newport</option>
<option value="Newport News City">Newport News City</option>
<option value="Niagara">Niagara</option>
<option value="Nicholas">Nicholas</option>
<option value="Nicollet">Nicollet</option>
<option value="Noble">Noble</option>
<option value="Nodaway">Nodaway</option>
<option value="Norfolk">Norfolk</option>
<option value="Norfolk City">Norfolk City</option>
<option value="Northampton">Northampton</option>
<option value="Northumberland">Northumberland</option>
<option value="Nowata">Nowata</option>
<option value="Nueces">Nueces</option>
<option value="Oakland">Oakland</option>
<option value="Ocean">Ocean</option>
<option value="Oconee">Oconee</option>
<option value="Oconto">Oconto</option>
<option value="Ogle">Ogle</option>
<option value="Ohio">Ohio</option>
<option value="Okaloosa">Okaloosa</option>
<option value="Okeechobee">Okeechobee</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oldham">Oldham</option>
<option value="Olmsted">Olmsted</option>
<option value="Oneida">Oneida</option>
<option value="Onondaga">Onondaga</option>
<option value="Onslow">Onslow</option>
<option value="Orange">Orange</option>
<option value="Orleans">Orleans</option>
<option value="Osage">Osage</option>
<option value="Osceola">Osceola</option>
<option value="Oswego">Oswego</option>
<option value="Otero">Otero</option>
<option value="Ottawa">Ottawa</option>
<option value="Outagamie">Outagamie</option>
<option value="Owen">Owen</option>
<option value="Ozaukee">Ozaukee</option>
<option value="Page">Page</option>
<option value="Palm Beach">Palm Beach</option>
<option value="Palo Pinto">Palo Pinto</option>
<option value="Park">Park</option>
<option value="Parker">Parker</option>
<option value="Pasco">Pasco</option>
<option value="Passaic">Passaic</option>
<option value="Pawnee">Pawnee</option>
<option value="Payne">Payne</option>
<option value="Pearl River">Pearl River</option>
<option value="Pender">Pender</option>
<option value="Pendleton">Pendleton</option>
<option value="Peoria">Peoria</option>
<option value="Person">Person</option>
<option value="Philadelphia">Philadelphia</option>
<option value="Pickaway">Pickaway</option>
<option value="Pierce">Pierce</option>
<option value="Pike">Pike</option>
<option value="Pima">Pima</option>
<option value="Pinal">Pinal</option>
<option value="Pinellas">Pinellas</option>
<option value="Pitkin">Pitkin</option>
<option value="Pittsburg">Pittsburg</option>
<option value="Placer">Placer</option>
<option value="Platte">Platte</option>
<option value="Pleasants">Pleasants</option>
<option value="Plumas">Plumas</option>
<option value="Plymouth">Plymouth</option>
<option value="Pocahontas">Pocahontas</option>
<option value="Pointe Coupee">Pointe Coupee</option>
<option value="Polk">Polk</option>
<option value="Poquoson City">Poquoson City</option>
<option value="Portage">Portage</option>
<option value="Porter">Porter</option>
<option value="Pottawatomie">Pottawatomie</option>
<option value="Pottawattamie">Pottawattamie</option>
<option value="Potter">Potter</option>
<option value="Pratt">Pratt</option>
<option value="Preble">Preble</option>
<option value="Presque Isle">Presque Isle</option>
<option value="Preston">Preston</option>
<option value="Prince George">Prince George</option>
<option value="Prince Georges">Prince Georges</option>
<option value="Prince William">Prince William</option>
<option value="Providence">Providence</option>
<option value="Prowers">Prowers</option>
<option value="Pueblo">Pueblo</option>
<option value="Pulaski">Pulaski</option>
<option value="Putnam">Putnam</option>
<option value="Queen Annes">Queen Annes</option>
<option value="Queens">Queens</option>
<option value="R98ONLY">R98ONLY</option>
<option value="Racine">Racine</option>
<option value="Raleigh">Raleigh</option>
<option value="Ramsey">Ramsey</option>
<option value="Randolph">Randolph</option>
<option value="Rapides">Rapides</option>
<option value="Rappahannock">Rappahannock</option>
<option value="Reno">Reno</option>
<option value="Rensselaer">Rensselaer</option>
<option value="Republic">Republic</option>
<option value="Rice">Rice</option>
<option value="Richland">Richland</option>
<option value="Richmond">Richmond</option>
<option value="Richmond City">Richmond City</option>
<option value="Riley">Riley</option>
<option value="Rio Grande">Rio Grande</option>
<option value="Ritchie">Ritchie</option>
<option value="Riverside">Riverside</option>
<option value="Roane">Roane</option>
<option value="Roanoke">Roanoke</option>
<option value="Roanoke City">Roanoke City</option>
<option value="Rock">Rock</option>
<option value="Rock Island">Rock Island</option>
<option value="Rockdale">Rockdale</option>
<option value="Rockingham">Rockingham</option>
<option value="Rockland">Rockland</option>
<option value="Rogers">Rogers</option>
<option value="Rooks">Rooks</option>
<option value="Ross">Ross</option>
<option value="Routt">Routt</option>
<option value="Rowan">Rowan</option>
<option value="Runnels">Runnels</option>
<option value="Rush">Rush</option>
<option value="Rutherford">Rutherford</option>
<option value="Rutland">Rutland</option>
<option value="Sabine">Sabine</option>
<option value="Sacramento">Sacramento</option>
<option value="Saginaw">Saginaw</option>
<option value="Saint Charles">Saint Charles</option>
<option value="Saint Clair">Saint Clair</option>
<option value="Saint Johns">Saint Johns</option>
<option value="Saint Joseph">Saint Joseph</option>
<option value="Saint Landry">Saint Landry</option>
<option value="Saint Louis">Saint Louis</option>
<option value="Saint Louis City">Saint Louis City</option>
<option value="Saint Lucie">Saint Lucie</option>
<option value="Saint Marys">Saint Marys</option>
<option value="Saint Tammany">Saint Tammany</option>
<option value="Salem">Salem</option>
<option value="Saline">Saline</option>
<option value="Salt Lake">Salt Lake</option>
<option value="Sampson">Sampson</option>
<option value="San Bernardino">San Bernardino</option>
<option value="San Diego">San Diego</option>
<option value="San Francisco">San Francisco</option>
<option value="San Jacinto">San Jacinto</option>
<option value="San Joaquin">San Joaquin</option>
<option value="San Luis Obispo">San Luis Obispo</option>
<option value="San Mateo">San Mateo</option>
<option value="San Miguel">San Miguel</option>
<option value="Sandoval">Sandoval</option>
<option value="Sandusky">Sandusky</option>
<option value="Sangamon">Sangamon</option>
<option value="Sanilac">Sanilac</option>
<option value="Santa Barbara">Santa Barbara</option>
<option value="Santa Clara">Santa Clara</option>
<option value="Santa Cruz">Santa Cruz</option>
<option value="Santa Fe">Santa Fe</option>
<option value="Santa Rosa">Santa Rosa</option>
<option value="Sarasota">Sarasota</option>
<option value="Saratoga">Saratoga</option>
<option value="Sauk">Sauk</option>
<option value="Schuylkill">Schuylkill</option>
<option value="Scioto">Scioto</option>
<option value="Scotland">Scotland</option>
<option value="Scott">Scott</option>
<option value="Sebastian">Sebastian</option>
<option value="Sedgwick">Sedgwick</option>
<option value="Seminole">Seminole</option>
<option value="Seneca">Seneca</option>
<option value="Sevier">Sevier</option>
<option value="Seward">Seward</option>
<option value="Sharp">Sharp</option>
<option value="Shasta">Shasta</option>
<option value="Shawnee">Shawnee</option>
<option value="Shelby">Shelby</option>
<option value="Shenandoah">Shenandoah</option>
<option value="Sheridan">Sheridan</option>
<option value="Sherman">Sherman</option>
<option value="Shiawassee">Shiawassee</option>
<option value="Simpson">Simpson</option>
<option value="Siskiyou">Siskiyou</option>
<option value="Skagit">Skagit</option>
<option value="Smith">Smith</option>
<option value="Snohomish">Snohomish</option>
<option value="Solano">Solano</option>
<option value="Somerset">Somerset</option>
<option value="Sonnora">Sonnora</option>
<option value="Sonoma">Sonoma</option>
<option value="Southampton">Southampton</option>
<option value="Spartanburg">Spartanburg</option>
<option value="Spokane">Spokane</option>
<option value="Spotsylvania">Spotsylvania</option>
<option value="St John the Baptist">St John the Baptist</option>
<option value="St Joseph">St Joseph</option>
<option value="Stafford">Stafford</option>
<option value="Stanislaus">Stanislaus</option>
<option value="Stark">Stark</option>
<option value="Starke">Starke</option>
<option value="Stephens">Stephens</option>
<option value="Stephenson">Stephenson</option>
<option value="Stevens">Stevens</option>
<option value="Stokes">Stokes</option>
<option value="Stone">Stone</option>
<option value="Story">Story</option>
<option value="Strafford">Strafford</option>
<option value="Suffolk">Suffolk</option>
<option value="Suffolk City">Suffolk City</option>
<option value="Sullivan">Sullivan</option>
<option value="Summers">Summers</option>
<option value="Summit">Summit</option>
<option value="Sumner">Sumner</option>
<option value="Sumter">Sumter</option>
<option value="Surry">Surry</option>
<option value="Susquehanna">Susquehanna</option>
<option value="Sussex">Sussex</option>
<option value="Sutter">Sutter</option>
<option value="Suwannee">Suwannee</option>
<option value="Talbot">Talbot</option>
<option value="Taney">Taney</option>
<option value="Tarrant">Tarrant</option>
<option value="Taylor">Taylor</option>
<option value="Tazewell">Tazewell</option>
<option value="Teller">Teller</option>
<option value="Teton">Teton</option>
<option value="Texas">Texas</option>
<option value="Thurston">Thurston</option>
<option value="Tippecanoe">Tippecanoe</option>
<option value="Tipton">Tipton</option>
<option value="Tolland">Tolland</option>
<option value="Tompkins">Tompkins</option>
<option value="Tooele">Tooele</option>
<option value="Transylvania">Transylvania</option>
<option value="Travis">Travis</option>
<option value="Trujillo Alto">Trujillo Alto</option>
<option value="Trumbull">Trumbull</option>
<option value="Tucker">Tucker</option>
<option value="Tulare">Tulare</option>
<option value="Tulsa">Tulsa</option>
<option value="Tuolumne">Tuolumne</option>
<option value="Tuscarawas">Tuscarawas</option>
<option value="Tyler">Tyler</option>
<option value="Ulster">Ulster</option>
<option value="Union">Union</option>
<option value="UNONLY">UNONLY</option>
<option value="UNONLY2">UNONLY2</option>
<option value="Upshur">Upshur</option>
<option value="USA">USA</option>
<option value="Valencia">Valencia</option>
<option value="Valley">Valley</option>
<option value="Van Buren">Van Buren</option>
<option value="Van Wert">Van Wert</option>
<option value="Vance">Vance</option>
<option value="Vanderburgh">Vanderburgh</option>
<option value="Ventura">Ventura</option>
<option value="Vermilion">Vermilion</option>
<option value="Vernon">Vernon</option>
<option value="Victoria">Victoria</option>
<option value="Vigo">Vigo</option>
<option value="Vilas">Vilas</option>
<option value="Virginia Beach City">Virginia Beach City</option>
<option value="Volusia">Volusia</option>
<option value="Wabash">Wabash</option>
<option value="Wagoner">Wagoner</option>
<option value="Wake">Wake</option>
<option value="Walla Walla">Walla Walla</option>
<option value="Walton">Walton</option>
<option value="Walworth">Walworth</option>
<option value="Ward">Ward</option>
<option value="Warren">Warren</option>
<option value="Warrick">Warrick</option>
<option value="Washington">Washington</option>
<option value="Washoe">Washoe</option>
<option value="Washtenaw">Washtenaw</option>
<option value="Waukesha">Waukesha</option>
<option value="Wayne">Wayne</option>
<option value="Waynesboro City">Waynesboro City</option>
<option value="Weber">Weber</option>
<option value="Webster">Webster</option>
<option value="Weld">Weld</option>
<option value="Wells">Wells</option>
<option value="Westchester">Westchester</option>
<option value="Westmoreland">Westmoreland</option>
<option value="Wetzel">Wetzel</option>
<option value="Whatcom">Whatcom</option>
<option value="Wheeling">Wheeling</option>
<option value="White">White</option>
<option value="Whitley">Whitley</option>
<option value="Wichita">Wichita</option>
<option value="Will">Will</option>
<option value="Williamson">Williamson</option>
<option value="Wilson">Wilson</option>
<option value="Winchester City">Winchester City</option>
<option value="Windham">Windham</option>
<option value="Windsor">Windsor</option>
<option value="Winnebago">Winnebago</option>
<option value="Wirt">Wirt</option>
<option value="Wise">Wise</option>
<option value="Wood">Wood</option>
<option value="Woodford">Woodford</option>
<option value="Woodson">Woodson</option>
<option value="Woodward">Woodward</option>
<option value="Worcester">Worcester</option>
<option value="Wright">Wright</option>
<option value="Wyandotte">Wyandotte</option>
<option value="Wyoming">Wyoming</option>
<option value="Yakima">Yakima</option>
<option value="Yamhill">Yamhill</option>
<option value="Yavapai">Yavapai</option>
<option value="Yellowstone">Yellowstone</option>
<option value="Yolo">Yolo</option>
<option value="York">York</option>
<option value="Yuma">Yuma</option>
</select>
</div>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="2" style="display: none;">
<label for="bboxdonation_billing_billingAddress_txtUKPostCode" id="bboxdonation_billing_billingAddress_lblUKPostCode" class="BBFormFieldLabel BBFormFieldLabelEdit">Postcode:</label>
<input name="bboxdonation$billing$billingAddress$txtUKPostCode" type="text" id="bboxdonation_billing_billingAddress_txtUKPostCode" class="BBFormTextbox" data-country-field="postcode" data-country-sync="1" required="required"
maxlength="12">
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="3" style="display: none;">
<label for="bboxdonation_billing_billingAddress_txtCACity" id="bboxdonation_billing_billingAddress_lblCACity" class="BBFormFieldLabel BBFormFieldLabelEdit">City:</label>
<input name="bboxdonation$billing$billingAddress$txtCACity" type="text" id="bboxdonation_billing_billingAddress_txtCACity" class="BBFormTextbox" data-country-field="city" data-country-sync="1" required="required" maxlength="50">
</div>
<div class="BBTwoFields BBFieldBillingStateZip">
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="3" style="display: none;">
<label for="bboxdonation_billing_billingAddress_ddCAProvince" id="bboxdonation_billing_billingAddress_lblCAProvincePostCode" class="BBFormFieldLabel BBFormFieldLabelEdit">Province & postal:</label>
<div aria-describedby="bboxdonation_billing_billingAddress_ddCAProvince">
<span id="bboxdonation_billing_billingAddress_lblCAProvince" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">Province:</span>
</div>
<select name="bboxdonation$billing$billingAddress$ddCAProvince" id="bboxdonation_billing_billingAddress_ddCAProvince" class="BBFormSelectList GhostText" data-country-sync="1" data-country-field="state" required="required">
<option selected="selected" value="" default="default">province</option>
<option value="NF">NF</option>
<option value="UK">UK</option>
<option value="AA">AA</option>
<option value="AB">AB</option>
<option value="AE">AE</option>
<option value="AK">AK</option>
<option value="AL">AL</option>
<option value="AP">AP</option>
<option value="AR">AR</option>
<option value="AS">AS</option>
<option value="AZ">AZ</option>
<option value="BC">BC</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="CZ">CZ</option>
<option value="DC">DC</option>
<option value="DE">DE</option>
<option value="FL">FL</option>
<option value="FM">FM</option>
<option value="GA">GA</option>
<option value="GU">GU</option>
<option value="HI">HI</option>
<option value="IA">IA</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="MA">MA</option>
<option value="MB">MB</option>
<option value="MD">MD</option>
<option value="ME">ME</option>
<option value="MH">MH</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MO">MO</option>
<option value="MP">MP</option>
<option value="MS">MS</option>
<option value="MT">MT</option>
<option value="NB">NB</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="NE">NE</option>
<option value="NL">NL</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NS">NS</option>
<option value="NT">NT</option>
<option value="NU">NU</option>
<option value="NV">NV</option>
<option value="NY">NY</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="ON">ON</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="PE">PE</option>
<option value="PR">PR</option>
<option value="PW">PW</option>
<option value="QC">QC</option>
<option value="RI">RI</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="SK">SK</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VA">VA</option>
<option value="VI">VI</option>
<option value="VT">VT</option>
<option value="WA">WA</option>
<option value="WI">WI</option>
<option value="WV">WV</option>
<option value="WY">WY</option>
<option value="YT">YT</option>
<option value="QLD">QLD</option>
</select>
<label for="bboxdonation_billing_billingAddress_txtCAPostCode" id="bboxdonation_billing_billingAddress_lblCAPostCode" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">Postal:</label>
<input name="bboxdonation$billing$billingAddress$txtCAPostCode" type="text" id="bboxdonation_billing_billingAddress_txtCAPostCode" class="BBFormTextbox" required="required" data-country-sync="1" data-country-field="postcode"
maxlength="12" placeholder="postal">
</div>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="4" style="display: none;">
<label for="bboxdonation_billing_billingAddress_txtAUCity" id="bboxdonation_billing_billingAddress_lblAUCity" class="BBFormFieldLabel BBFormFieldLabelEdit">Suburb:</label>
<input name="bboxdonation$billing$billingAddress$txtAUCity" type="text" id="bboxdonation_billing_billingAddress_txtAUCity" class="BBFormTextbox" data-country-sync="1" data-country-field="city" required="required" maxlength="50">
</div>
<div class="BBTwoFields BBFieldBillingStateZip">
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="4" style="display: none;">
<label for="bboxdonation_billing_billingAddress_ddAUState" id="bboxdonation_billing_billingAddress_lblAUStatePostCode" class="BBFormFieldLabel BBFormFieldLabelEdit">State & postcode:</label>
<div aria-describedby="bboxdonation_billing_billingAddress_ddAUState">
<span id="bboxdonation_billing_billingAddress_lblAUState" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">State:</span>
</div>
<select name="bboxdonation$billing$billingAddress$ddAUState" id="bboxdonation_billing_billingAddress_ddAUState" class="BBFormSelectList GhostText" data-country-sync="1" data-country-field="state" required="required">
<option selected="selected" value="" default="default">state</option>
<option value="NF">NF</option>
<option value="UK">UK</option>
<option value="AA">AA</option>
<option value="AB">AB</option>
<option value="AE">AE</option>
<option value="AK">AK</option>
<option value="AL">AL</option>
<option value="AP">AP</option>
<option value="AR">AR</option>
<option value="AS">AS</option>
<option value="AZ">AZ</option>
<option value="BC">BC</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="CZ">CZ</option>
<option value="DC">DC</option>
<option value="DE">DE</option>
<option value="FL">FL</option>
<option value="FM">FM</option>
<option value="GA">GA</option>
<option value="GU">GU</option>
<option value="HI">HI</option>
<option value="IA">IA</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="MA">MA</option>
<option value="MB">MB</option>
<option value="MD">MD</option>
<option value="ME">ME</option>
<option value="MH">MH</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MO">MO</option>
<option value="MP">MP</option>
<option value="MS">MS</option>
<option value="MT">MT</option>
<option value="NB">NB</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="NE">NE</option>
<option value="NL">NL</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NS">NS</option>
<option value="NT">NT</option>
<option value="NU">NU</option>
<option value="NV">NV</option>
<option value="NY">NY</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="ON">ON</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="PE">PE</option>
<option value="PR">PR</option>
<option value="PW">PW</option>
<option value="QC">QC</option>
<option value="RI">RI</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="SK">SK</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VA">VA</option>
<option value="VI">VI</option>
<option value="VT">VT</option>
<option value="WA">WA</option>
<option value="WI">WI</option>
<option value="WV">WV</option>
<option value="WY">WY</option>
<option value="YT">YT</option>
<option value="QLD">QLD</option>
</select>
<label for="bboxdonation_billing_billingAddress_txtAUPostCode" id="bboxdonation_billing_billingAddress_lblAUPostCode" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">Postcode:</label>
<input name="bboxdonation$billing$billingAddress$txtAUPostCode" type="tel" id="bboxdonation_billing_billingAddress_txtAUPostCode" class="BBFormTextbox" required="required" data-country-sync="1" data-country-field="postcode"
maxlength="12" placeholder="postcode">
</div>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="5" style="display: none;">
<label for="bboxdonation_billing_billingAddress_ddNZSuburb" id="bboxdonation_billing_billingAddress_lblNZSuburb" class="BBFormFieldLabel BBFormFieldLabelEdit">Suburb:</label>
<select name="bboxdonation$billing$billingAddress$ddNZSuburb" id="bboxdonation_billing_billingAddress_ddNZSuburb" class="BBFormSelectList GhostText" required="required" data-country-field="nzsuburb">
<option selected="selected" value="" default="default">suburb</option>
</select>
</div>
<div class="BBTwoFields BBFieldBillingStateZip">
<div class="BBFormFieldContainer BBFormFieldContainerRequired" data-country-format-for="5" style="display: none;">
<label for="bboxdonation_billing_billingAddress_ddNZCity" id="bboxdonation_billing_billingAddress_lblNZCityPostCode" class="BBFormFieldLabel BBFormFieldLabelEdit">City & post code:</label>
<div aria-describedby="bboxdonation_billing_billingAddress_ddNZCity">
<span id="bboxdonation_billing_billingAddress_lblNZCity" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">City:</span>
</div>
<select name="bboxdonation$billing$billingAddress$ddNZCity" id="bboxdonation_billing_billingAddress_ddNZCity" class="BBFormSelectList GhostText" required="required" data-country-field="nzcity">
<option selected="selected" value="" default="default">city</option>
<option value="1126 Metro Manila">1126 Metro Manila</option>
</select>
<label for="bboxdonation_billing_billingAddress_txtNZPostCode" id="bboxdonation_billing_billingAddress_lblNZPostCode" class="BBFormFieldLabel BBFormFieldLabelEdit BBAccessibilityOnly">Post code:</label>
<input name="bboxdonation$billing$billingAddress$txtNZPostCode" type="tel" id="bboxdonation_billing_billingAddress_txtNZPostCode" class="BBFormTextbox" required="required" data-country-sync="1" data-country-field="postcode"
maxlength="12" placeholder="post code">
</div>
</div>
</div>
<div id="bboxdonation_billing_fldAnonymous" class="BBFormFieldContainer">
<input name="bboxdonation$billing$chkAnonymous" type="checkbox" id="bboxdonation_billing_chkAnonymous">
<label for="bboxdonation_billing_chkAnonymous" id="bboxdonation_billing_lblAnonymous" class="BBFormFieldLabel BBFormCheckbox BBFormCheckboxLabel BBFormFieldLabelEdit">I would like this gift to remain anonymous</label>
</div>
</fieldset>
</div>
<div class="BBFormSection BBDFormSectionPaymentInfo">
<fieldset>
<legend>
<div id="bboxdonation_payment_divHeadingPayment" class="BBFormSectionHeading">
<label id="bboxdonation_payment_lblHeadingPayment" class="BBFormFieldLabelEdit">Payment details</label>
</div>
</legend>
<div id="bboxdonation_payment_PaymentChoices" class="BBFormPaymentChoice">
<div class="BBFormFieldContainer">
<span id="bboxdonation_payment_lblPaymentMethod" class="BBFormFieldLabel BBFormFieldLabelEdit">Payment method:</span>
<div class="BBFormFieldContainerPaymentMethods">
<div id="bboxdonation_payment_divPaymentChoiceCreditCard" class="BBFormFieldContainer BBFormPaymentRadioOptions">
<input value="0" name="bboxdonation$payment$BBFormPaymentChoice" type="radio" id="bboxdonation_payment_BBFormPaymentChoiceCredit" data-pmtchoice="1" checked="checked">
<label for="bboxdonation_payment_BBFormPaymentChoiceCredit" id="bboxdonation_payment_lblChoiceCredit" class="BBFormFieldLabelEdit BBFormRadioPaymentSelected">Credit card</label>
</div>
<div id="bboxdonation_payment_divPaymentChoiceDirectDebit" class="BBFormFieldContainer BBFormPaymentRadioOptions">
<input value="2" name="bboxdonation$payment$BBFormPaymentChoice" type="radio" id="bboxdonation_payment_BBFormPaymentChoiceDirectDebit" data-pmtchoice="1">
<label for="bboxdonation_payment_BBFormPaymentChoiceDirectDebit" id="bboxdonation_payment_lblChoiceDirectDebit" class="BBFormFieldLabelEdit BBFormRadioPaymentNotSelected">Direct Debit</label>
</div>
</div>
</div>
</div>
<div id="bboxdonation_payment_BBFormCCDetails" class="BBFormCreditCardDetails">
<div id="bboxdonation_payment_divProcessedByBlackbaud" class="BBFormFieldContainer ">
<a id="bboxsecure" class="BBLinkSecureInfo hasTooltip" href="#bbsecure" rel="https://bbox.blackbaudhosting.com/webforms/components/custom.ashx?handler=blackbaud.appfx.mongo.parts.getcontenthandler&c=secure&callback=?" title="Learn more about how your credit card information will be protected by Blackbaud" tabindex="0" style="text-decoration: none; border-bottom: 1px dashed;">Payment Processed by Blackbaud</a>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="bboxdonation_payment_txtCardholder" id="bboxdonation_payment_lblCardHoldersName" class="BBFormFieldLabel BBFormFieldLabelEdit ">Cardholder name:</label>
<input name="bboxdonation$payment$txtCardholder" type="text" id="bboxdonation_payment_txtCardholder" class="BBFormTextbox" maxlength="60" required="required">
</div>
<div id="DCCreditNumber" class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="bboxdonation_payment_txtCardNumber" id="bboxdonation_payment_lblCCNumber" class="BBFormFieldLabel BBFormFieldLabelEdit ">Card number:</label>
<input name="bboxdonation$payment$txtCardNumber" type="tel" id="bboxdonation_payment_txtCardNumber" class="BBFormTextbox BBCardNumber" autocomplete="off" maxlength="20" required="required">
</div>
<div id="DCCreditType" class="BBFormFieldContainer BBFormFieldContainerRequired BBCCreditType">
<label for="bboxdonation_payment_cboCardType" id="bboxdonation_payment_lblCCType" class="BBFormFieldLabel BBFormFieldLabelEdit" style="visibility: hidden;">Card type:</label>
<div class="BBFormFieldContainer BBFormFieldContainerRequired BBCCreditType">
<select name="bboxdonation$payment$cboCardType" id="bboxdonation_payment_cboCardType" class="BBFormSelectList" required="required" style="display: none;">
<option value="<Please Select>"><Please Select></option>
<option value="5963a708-fc7f-48af-952f-16d574c4b833">Visa</option>
<option value="c4a56513-9fdb-44c5-9b19-e617f2596107">American Express</option>
<option value="12c6cbd6-4b35-4e2d-9222-f9acb37181c7">Diners Club</option>
<option value="bf0ed898-ab0c-4374-9cef-1e66b09e816d">Discover</option>
<option value="0c016b00-2180-4b80-affb-05f0854033d0">JCB</option>
<option value="2319d342-d766-49b8-a72e-d384faee4562">Maestro</option>
<option value="b34832f7-8a95-47fa-9c43-bc8682562ea5">MasterCard</option>
</select>
<div id="bboxdonation_payment_divCardTypes">
<div class="BBCardImageContainer">
<img id="bboxdonation_payment_lvwCardTypes_imgCardImage_0" class="BBCardImage" data-card-type="visa" alt="visa" data-card-type-id="5963a708-fc7f-48af-952f-16d574c4b833"
src="https://bbox.blackbaudhosting.com/webforms/images/cards/visa_normal.png">
<img id="bboxdonation_payment_lvwCardTypes_imgCardImage_1" class="BBCardImage" data-card-type="amex" alt="amex" data-card-type-id="c4a56513-9fdb-44c5-9b19-e617f2596107"
src="https://bbox.blackbaudhosting.com/webforms/images/cards/amex_normal.png">
<img id="bboxdonation_payment_lvwCardTypes_imgCardImage_2" class="BBCardImage" data-card-type="diners" alt="diners" data-card-type-id="12c6cbd6-4b35-4e2d-9222-f9acb37181c7"
src="https://bbox.blackbaudhosting.com/webforms/images/cards/diners_normal.png">
<img id="bboxdonation_payment_lvwCardTypes_imgCardImage_3" class="BBCardImage" data-card-type="discover" alt="discover" data-card-type-id="bf0ed898-ab0c-4374-9cef-1e66b09e816d"
src="https://bbox.blackbaudhosting.com/webforms/images/cards/discover_normal.png">
<img id="bboxdonation_payment_lvwCardTypes_imgCardImage_4" class="BBCardImage" data-card-type="jcb" alt="jcb" data-card-type-id="0c016b00-2180-4b80-affb-05f0854033d0"
src="https://bbox.blackbaudhosting.com/webforms/images/cards/jcb_normal.png">
<img id="bboxdonation_payment_lvwCardTypes_imgCardImage_5" class="BBCardImage" data-card-type="maestro" alt="maestro" data-card-type-id="2319d342-d766-49b8-a72e-d384faee4562"
src="https://bbox.blackbaudhosting.com/webforms/images/cards/maestro_normal.png">
<img id="bboxdonation_payment_lvwCardTypes_imgCardImage_6" class="BBCardImage" data-card-type="mastercard" alt="mastercard" data-card-type-id="b34832f7-8a95-47fa-9c43-bc8682562ea5"
src="https://bbox.blackbaudhosting.com/webforms/images/cards/mastercard_normal.png">
</div>
</div>
</div>
</div>
<div class="BBExpirationCSC">
<div id="DC_ValidOther" class="BBFormFieldContainer BBFormFieldContainerRequired BBFieldExpiration">
<label for="bboxdonation_payment_cboMonth" id="bboxdonation_payment_lblExpiryLbl" class="BBFormFieldLabel BBFormFieldLabelEdit">Expiration:</label>
<div aria-describedby="bboxdonation_payment_cboMonth">
<span id="bboxdonation_payment_lblMonth" class="BBFormFieldLabel BBAccessibilityOnly">Month:</span>
</div>
<select name="bboxdonation$payment$cboMonth" id="bboxdonation_payment_cboMonth" class="BBFormSelectList GhostText" required="required">
<option value="" default="default">month</option>
<option value="1">01</option>
<option value="2">02</option>
<option value="3">03</option>
<option value="4">04</option>
<option value="5">05</option>
<option value="6">06</option>
<option value="7">07</option>
<option value="8">08</option>
<option value="9">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select>
<label for="bboxdonation_payment_cboYear" id="bboxdonation_payment_lblYear" class="BBFormFieldLabel BBAccessibilityOnly">Year:</label>
<select name="bboxdonation$payment$cboYear" id="bboxdonation_payment_cboYear" class="BBFormSelectList GhostText" required="required">
<option value="" default="default">year</option>
<option value="2023">2023</option>
<option value="2024">2024</option>
<option value="2025">2025</option>
<option value="2026">2026</option>
<option value="2027">2027</option>
<option value="2028">2028</option>
<option value="2029">2029</option>
<option value="2030">2030</option>
<option value="2031">2031</option>
<option value="2032">2032</option>
<option value="2033">2033</option>
<option value="2034">2034</option>
<option value="2035">2035</option>
<option value="2036">2036</option>
<option value="2037">2037</option>
</select>
</div>
<div id="DCCreditSecurityCode" class="BBFormFieldContainer BBFormFieldContainerRequired BBFieldSecurityCode">
<label for="bboxdonation_payment_txtCSC" id="bboxdonation_payment_lblSecCode" class="BBFormFieldLabel BBFormFieldLabelEdit">CSC:</label>
<input name="bboxdonation$payment$txtCSC" type="password" id="bboxdonation_payment_txtCSC" inputmode="numeric" autocomplete="off" class="BBFormTextbox DonationCaptureTextboxNarrow" maxlength="4" style="width: 60px;"
required="required">
<a id="cscWhatsThis" href="#csc" rel="https://bbox.blackbaudhosting.com/webforms/components/custom.ashx?handler=blackbaud.appfx.mongo.parts.getcontenthandler&c=csc&callback=?" title="What are Card Security Codes?" tabindex="-1" style="text-decoration: none;" class="hasTooltip">
<img style="display: inline; border: 0;" alt="Help" src="https://bbox.blackbaudhosting.com/webforms/images/bboxhelp.png"></a>
</div>
</div>
</div>
<div id="bboxdonation_payment_BBFormDDDetails" class="BBFormDirectDebitDetails" style="display: none;">
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="bboxdonation_payment_txtBankName" id="bboxdonation_payment_lblBankName" class="BBFormFieldLabel BBFormFieldLabelEdit ">Bank name:</label>
<input name="bboxdonation$payment$txtBankName" type="text" id="bboxdonation_payment_txtBankName" class="BBFormTextbox" maxlength="60" required="required">
</div>
<div id="BBFormDDRoutingData">
<div id="bboxdonation_payment_BBFormDDRoutingNumber">
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="bboxdonation_payment_txtRoutingNumber" id="bboxdonation_payment_lblRoutingNumber" class="BBFormFieldLabel BBFormFieldLabelEdit ">Routing number:</label>
<input name="bboxdonation$payment$txtRoutingNumber" type="tel" id="bboxdonation_payment_txtRoutingNumber" class="BBFormTextbox" maxlength="9" required="required">
<a id="routingUSWhatsThis" href="#routing" rel="https://bbox.blackbaudhosting.com/webforms/components/custom.ashx?handler=blackbaud.appfx.mongo.parts.getcontenthandler&c=routingus&callback=?" title="What are Routing Numbers?" tabindex="-1" style="text-decoration: none;" class="hasTooltip">
<img style="display: inline; border: 0;" alt="Help" src="https://bbox.blackbaudhosting.com/webforms/images/bboxhelp.png"></a>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="bboxdonation_payment_ddAccountType" id="bboxdonation_payment_lblAccountType" class="BBFormFieldLabel BBFormFieldLabelEdit ">Account type:</label>
<select name="bboxdonation$payment$ddAccountType" id="bboxdonation_payment_ddAccountType" class="BBFormSelectList" required="required">
<option selected="selected" value="Checking">Checking</option>
<option value="Savings">Savings</option>
<option value="Other">Other</option>
</select>
</div>
</div>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="bboxdonation_payment_txtAccountNumber" id="bboxdonation_payment_lblAccount" class="BBFormFieldLabel BBFormFieldLabelEdit ">Account number:</label>
<span id="bboxdonation_payment_spanAccountNumber">
<input name="bboxdonation$payment$txtAccountNumber" type="tel" id="bboxdonation_payment_txtAccountNumber" class="BBFormTextbox BBFormAccountNumber" maxlength="20" required="required">
</span>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="bboxdonation_payment_txtAccountHolder" id="bboxdonation_payment_lblAccountHolder" class="BBFormFieldLabel BBFormFieldLabelEdit ">Account holder:</label>
<input name="bboxdonation$payment$txtAccountHolder" type="text" id="bboxdonation_payment_txtAccountHolder" class="BBFormTextbox" maxlength="60" required="required">
</div>
<!-- hidden field for tracking direct debit account lookups -->
<input name="bboxdonation$payment$hdnDirectDebitLookupCount" type="hidden" id="hdnDirectDebitLookupCount" value="0">
<input name="bboxdonation$payment$hdnDirectDebitShouldLookup" type="hidden" id="hdnDirectDebitShouldLookup" value="0">
</div>
<div id="bboxdonation_payment_BBFormConfirmationBoxWrapper" class="BBFormConfirmationBoxWrapper" style="display: none;">
<div id="bboxdonation_payment_BBFormDDConfirmationBox" class="BBFormDDConfirmationBox">
<div class="BBFormBoxHeader">Is the information you entered to set up the Direct Debit Instruction correct?</div>
<div class="BBFormBoxContent">
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="DDAccountHolder" id="lblDDAccountHolder" class="BBFormFieldLabel"> Account holder: </label>
<span id="bboxdonation_payment_DDAccountHolder" class="BBFormFieldValueLabel"></span>
<br>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="DDSortCode" id="lblDDSortCode" class="BBFormFieldLabel"> Sort Code: </label>
<span id="bboxdonation_payment_DDSortCode" class="BBFormFieldValueLabel"></span>
<br>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="DDAccountNumber" id="lblDDAccountNumber" class="BBFormFieldLabel"> Account number: </label>
<span id="bboxdonation_payment_DDAccountNumber" class="BBFormFieldValueLabel"></span>
<br>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="DDDebitAmount" id="lblDDDebitAmount" class="BBFormFieldLabel"> Amount to be debited: </label>
<span id="bboxdonation_payment_DDDebitAmount" class="BBFormFieldValueLabel"></span>
<br>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="DDFrequency" id="lblDDFrequency" class="BBFormFieldLabel"> Collection frequency: </label>
<span id="bboxdonation_payment_DDFrequency" class="BBFormFieldValueLabel"></span>
<br>
</div>
<div class="BBFormFieldContainer BBFormFieldContainerRequired">
<label for="DDDateOfFirstGift" id="lblDDDateOfFirstGift" class="BBFormFieldLabel"> Date of first gift: </label>
<span id="bboxdonation_payment_DDDateOfFirstGift" class="BBFormFieldValueLabel"></span>
<br>
</div>
</div>
<div class="BBFormFieldContainer BBFormBoxActionButtons">
<input name="bboxdonation$payment$btnDonateNow" type="button" id="bboxdonation_payment_btnDonateNow" class="BBFormSubmitbutton BBFormSubmitbuttonEdit" value="Yes, donate now">
<input name="bboxdonation$payment$btnBackToForm" type="button" id="bboxdonation_payment_btnBackToForm" class="BBFormSubmitbutton BBFormBackbutton" value="Back to form">
</div>
</div>
</div>
</fieldset>
</div>
<input name="bboxdonation$payment$hdnMerchantAccountId" type="hidden" id="bboxdonation_payment_hdnMerchantAccountId" class="hdnMerchantAccountId" value="3f19a6af-fb1d-418f-8b71-71ac990e7b72">
<div id="reCAPTCHASection" class="BBFormSection">
<div class="BBFormFieldContainer">
<div id="bbox_reCAPTCHA">
<div class="grecaptcha-badge" data-style="bottomright"
style="width: 256px; height: 60px; display: block; transition: right 0.3s ease 0s; position: fixed; bottom: 14px; right: -186px; box-shadow: gray 0px 0px 5px; border-radius: 2px; overflow: hidden;">
<div class="grecaptcha-logo"><iframe title="reCAPTCHA" width="256" height="60" role="presentation" name="a-2pvxkvz1zzpu" frameborder="0" scrolling="no"
sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox allow-storage-access-by-user-activation"
src="https://www.google.com/recaptcha/api2/anchor?ar=1&k=6LdkFJMUAAAAAB1v49N1aaMoEPH85Qvfib4VqlNH&co=aHR0cHM6Ly9jc2pvc2VwaC5vcmc6NDQz&hl=de&v=-QbJqHfGOUB8nuVRLvzFLVed&size=invisible&cb=vvotoo6gn74y"></iframe>
</div>
<div class="grecaptcha-error"></div><textarea id="g-recaptcha-response-100000" name="g-recaptcha-response" class="g-recaptcha-response"
style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
</div><iframe style="display: none;"></iframe>
</div>
</div>
</div>
<div class="BBFormSection BBFormButtonRow">
<div class="BBFormFieldContainer">
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