{"id":5933,"date":"2021-01-20T02:15:02","date_gmt":"2021-01-20T02:15:02","guid":{"rendered":"http:\/\/cfpcstate.iseo.biz\/?page_id=5933"},"modified":"2021-03-16T17:52:38","modified_gmt":"2021-03-16T17:52:38","slug":"standard-or-retired-commercial-fishing-license-renewal","status":"publish","type":"page","link":"https:\/\/commercialfishingpermits.us\/state\/north-carolina\/standard-or-retired-commercial-fishing-license-renewal\/","title":{"rendered":"Standard or Retired Commercial Fishing License Renewal"},"content":{"rendered":"<p><span id=\"docs-internal-guid-6245e55f-7fff-322e-6c42-3509cab4e260\"><span style=\"font-size: 11pt; font-family: Arial; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\"><p class=\"mt-25\">Standard Commercial Fishing License (SCFL) or Retired Standard Commercial Fishing License (RSCFL) Renewal or Replacement Application.<\/p><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_314' style='display:none'>\n                        <div class='gform_heading'>\n                            <p class='gform_description'>A brief description of the form or Application to be filled out here.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_314'  action='\/state\/wp-json\/wp\/v2\/pages\/5933' data-formid='314' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_314' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_314_1\" class=\"gfield gfield--type-text vessel-name gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_1'>Vessel Name<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_1' id='input_314_1' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_39\" class=\"gfield gfield--type-checkbox gfield--type-choice vessel-use gf_right_half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Vessel Use \/ Endorsement<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_314_39'><li class='checkbox gchoice gchoice_314_39_1'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_39.1' type='checkbox'  value='Pleasure'  id='choice_314_39_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_314_39_1' id='label_314_39_1' class='gform-field-label gform-field-label--type-inline'>Pleasure<\/label>\n\t\t\t\t\t\t\t<\/li><li class='checkbox gchoice gchoice_314_39_2'>\n\t\t\t\t\t\t\t\t<input style='margin-left:1px;' class='gfield-choice-input' name='input_39.2' type='checkbox'  value='Commercial'  id='choice_314_39_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_314_39_2' id='label_314_39_2' class='gform-field-label gform-field-label--type-inline'>Commercial<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_314_9\" class=\"gfield gfield--type-text gf_left_half official-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_9'>Official Number<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_9' id='input_314_9' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_17\" class=\"gfield gfield--type-text gf_right_half official-number-confirm field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_17'>Confirm Official Number<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_17' id='input_314_17' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_41\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_314_42\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Choose transfer type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_314_42'>\n\t\t\t<li class='radio gchoice gchoice_314_42_0'>\n\t\t\t\t<input style='margin-left:1px;' name='input_42' type='radio' value='SCFL - no age restrictions is assignable'  id='choice_314_42_0'    \/>\n\t\t\t\t<label for='choice_314_42_0' id='label_314_42_0' class='gform-field-label gform-field-label--type-inline'>SCFL - no age restrictions is assignable<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_314_42_1'>\n\t\t\t\t<input style='margin-left:1px;' name='input_42' type='radio' value='RSCFL - 65 years or older, not assignable, not in business name'  id='choice_314_42_1'    \/>\n\t\t\t\t<label for='choice_314_42_1' id='label_314_42_1' class='gform-field-label gform-field-label--type-inline'>RSCFL - 65 years or older, not assignable, not in business name<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_314_119\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Check one<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_314_119'>\n\t\t\t<li class='radio gchoice gchoice_314_119_0'>\n\t\t\t\t<input style='margin-left:1px;' name='input_119' type='radio' value='Renew'  id='choice_314_119_0'    \/>\n\t\t\t\t<label for='choice_314_119_0' id='label_314_119_0' class='gform-field-label gform-field-label--type-inline'>Renew<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_314_119_1'>\n\t\t\t\t<input style='margin-left:1px;' name='input_119' type='radio' value='Replace'  id='choice_314_119_1'    \/>\n\t\t\t\t<label for='choice_314_119_1' id='label_314_119_1' class='gform-field-label gform-field-label--type-inline'>Replace<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_314_48\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_48'>SCFL\/RSCFL Number<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_48' id='input_314_48' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_51\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Shellfish Endorsements?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_314_51'>\n\t\t\t<li class='radio gchoice gchoice_314_51_0'>\n\t\t\t\t<input style='margin-left:1px;' name='input_51' type='radio' value='Yes'  id='choice_314_51_0'    \/>\n\t\t\t\t<label for='choice_314_51_0' id='label_314_51_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_314_51_1'>\n\t\t\t\t<input style='margin-left:1px;' name='input_51' type='radio' value='No'  id='choice_314_51_1'    \/>\n\t\t\t\t<label for='choice_314_51_1' id='label_314_51_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_314_52\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >NC Residency?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_314_52'>\n\t\t\t<li class='radio gchoice gchoice_314_52_0'>\n\t\t\t\t<input style='margin-left:1px;' name='input_52' type='radio' value='Non-resident - less than 60 days'  id='choice_314_52_0'    \/>\n\t\t\t\t<label for='choice_314_52_0' id='label_314_52_0' class='gform-field-label gform-field-label--type-inline'>Non-resident - less than 60 days<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_314_52_1'>\n\t\t\t\t<input style='margin-left:1px;' name='input_52' type='radio' value='60 days - 6 months'  id='choice_314_52_1'    \/>\n\t\t\t\t<label for='choice_314_52_1' id='label_314_52_1' class='gform-field-label gform-field-label--type-inline'>60 days - 6 months<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_314_52_2'>\n\t\t\t\t<input style='margin-left:1px;' name='input_52' type='radio' value='Over 6 months'  id='choice_314_52_2'    \/>\n\t\t\t\t<label for='choice_314_52_2' id='label_314_52_2' class='gform-field-label gform-field-label--type-inline'>Over 6 months<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_314_141\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_141'>State of License<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select class='form-control' name='input_141' id='input_314_141' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Choose State<\/option><option value='Alabama' >Alabama<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Mississippi' >Mississippi<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New York' >New York<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='Texas' >Texas<\/option><option value='Virginia' >Virginia<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_314_53\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Choose one<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_314_53'>\n\t\t\t<li class='radio gchoice gchoice_314_53_0'>\n\t\t\t\t<input style='margin-left:1px;' name='input_53' type='radio' value='Individual'  id='choice_314_53_0'    \/>\n\t\t\t\t<label for='choice_314_53_0' id='label_314_53_0' class='gform-field-label gform-field-label--type-inline'>Individual<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_314_53_1'>\n\t\t\t\t<input style='margin-left:1px;' name='input_53' type='radio' value='Business Agent'  id='choice_314_53_1'    \/>\n\t\t\t\t<label for='choice_314_53_1' id='label_314_53_1' class='gform-field-label gform-field-label--type-inline'>Business Agent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_314_54\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Individual or Business Agent Participant Information<\/h2><\/li><li id=\"field_314_55\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_55'>Participant ID<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_55' id='input_314_55' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_56\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name has_suffix gf_name_has_4 ginput_container_name gform-grid-row' id='input_314_56'>\n                            \n                            <span id='input_314_56_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input class='form-control' type='text' name='input_56.3' id='input_314_56_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_314_56_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_314_56_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input class='form-control' type='text' name='input_56.4' id='input_314_56_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_314_56_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_314_56_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input class='form-control' type='text' name='input_56.6' id='input_314_56_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_314_56_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_314_56_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input class='form-control' type='text' name='input_56.8' id='input_314_56_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_314_56_8' class='gform-field-label gform-field-label--type-sub '>Suffix<\/label>\n                                                <\/span>\n                        <\/div><\/li><li id=\"field_314_57\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Check one<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_314_57'>\n\t\t\t<li class='radio gchoice gchoice_314_57_0'>\n\t\t\t\t<input style='margin-left:1px;' name='input_57' type='radio' value='Drivers License No.'  id='choice_314_57_0'    \/>\n\t\t\t\t<label for='choice_314_57_0' id='label_314_57_0' class='gform-field-label gform-field-label--type-inline'>Drivers License No.<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_314_57_1'>\n\t\t\t\t<input style='margin-left:1px;' name='input_57' type='radio' value='State I.D. No.'  id='choice_314_57_1'    \/>\n\t\t\t\t<label for='choice_314_57_1' id='label_314_57_1' class='gform-field-label gform-field-label--type-inline'>State I.D. No.<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_314_57_2'>\n\t\t\t\t<input style='margin-left:1px;' name='input_57' type='radio' value='Military I.D. No.'  id='choice_314_57_2'    \/>\n\t\t\t\t<label for='choice_314_57_2' id='label_314_57_2' class='gform-field-label gform-field-label--type-inline'>Military I.D. No.<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_314_57_3'>\n\t\t\t\t<input style='margin-left:1px;' name='input_57' type='radio' value='Resident Alien I.D. NO.'  id='choice_314_57_3'    \/>\n\t\t\t\t<label for='choice_314_57_3' id='label_314_57_3' class='gform-field-label gform-field-label--type-inline'>Resident Alien I.D. NO.<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_314_57_4'>\n\t\t\t\t<input style='margin-left:1px;' name='input_57' type='radio' value='Passport No.'  id='choice_314_57_4'    \/>\n\t\t\t\t<label for='choice_314_57_4' id='label_314_57_4' class='gform-field-label gform-field-label--type-inline'>Passport No.<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_314_60\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_60'>Number<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_60' id='input_314_60' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_120\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_120'>Expiration Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_120' id='input_314_120' type='text' value='' class='datepicker form-control gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_314_120_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_314_120_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_314_120' class='gform_hidden' value='https:\/\/commercialfishingpermits.us\/state\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_314_121\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_121'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_121' id='input_314_121' type='text' value='' class='datepicker form-control gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_314_121_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_314_121_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_314_121' class='gform_hidden' value='https:\/\/commercialfishingpermits.us\/state\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_314_61\" class=\"gfield gfield--type-text gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_61'>Primary Residence (State)<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_61' id='input_314_61' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_62\" class=\"gfield gfield--type-email gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_62'>Email Address<\/label><div class='ginput_container ginput_container_email'>\n                            <input class='form-control' name='input_62' id='input_314_62' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_314_63\" class=\"gfield gfield--type-text gf_left_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_63'>Race<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_63' id='input_314_63' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_65\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Gender<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_314_65'>\n\t\t\t<li class='radio gchoice gchoice_314_65_0'>\n\t\t\t\t<input style='margin-left:1px;' name='input_65' type='radio' value='Male'  id='choice_314_65_0'    \/>\n\t\t\t\t<label for='choice_314_65_0' id='label_314_65_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_314_65_1'>\n\t\t\t\t<input style='margin-left:1px;' name='input_65' type='radio' value='Female'  id='choice_314_65_1'    \/>\n\t\t\t\t<label for='choice_314_65_1' id='label_314_65_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_314_66\" class=\"gfield gfield--type-text gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_66'>Height<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_66' id='input_314_66' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_67\" class=\"gfield gfield--type-text gf_left_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_67'>Weight<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_67' id='input_314_67' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_68\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_68'>Eye Color<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_68' id='input_314_68' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_69\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_69'>Hair Color<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_69' id='input_314_69' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_70\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Physical Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_314_70' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_314_70_1_container' >\n                                        <input class='form-control' type='text' name='input_70.1' id='input_314_70_1' value=''    aria-required='false'    \/>\n                                        <label for='input_314_70_1' id='input_314_70_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_314_70_2_container' >\n                                        <input class='form-control' type='text' name='input_70.2' id='input_314_70_2' value=''     aria-required='false'   \/>\n                                        <label for='input_314_70_2' id='input_314_70_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_314_70_3_container' >\n                                    <input class='form-control' type='text' name='input_70.3' id='input_314_70_3' value=''    aria-required='false'    \/>\n                                    <label for='input_314_70_3' id='input_314_70_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_314_70_4_container' >\n                                        <input class='form-control' type='text' name='input_70.4' id='input_314_70_4' value=''      aria-required='false'    \/>\n                                        <label for='input_314_70_4' id='input_314_70_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_314_70_5_container' >\n                                    <input class='form-control' type='text' name='input_70.5' id='input_314_70_5' value=''    aria-required='false'    \/>\n                                    <label for='input_314_70_5' id='input_314_70_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_314_70_6_container' >\n                                        <select class='form-control' class='form-control' name='input_70.6' id='input_314_70_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_314_70_6' id='input_314_70_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_314_122\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_122'>County<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_122' id='input_314_122' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_72\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Mailing Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_314_72' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_314_72_1_container' >\n                                        <input class='form-control' type='text' name='input_72.1' id='input_314_72_1' value=''    aria-required='false'    \/>\n                                        <label for='input_314_72_1' id='input_314_72_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_314_72_2_container' >\n                                        <input class='form-control' type='text' name='input_72.2' id='input_314_72_2' value=''     aria-required='false'   \/>\n                                        <label for='input_314_72_2' id='input_314_72_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_314_72_3_container' >\n                                    <input class='form-control' type='text' name='input_72.3' id='input_314_72_3' value=''    aria-required='false'    \/>\n                                    <label for='input_314_72_3' id='input_314_72_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_314_72_4_container' >\n                                        <input class='form-control' type='text' name='input_72.4' id='input_314_72_4' value=''      aria-required='false'    \/>\n                                        <label for='input_314_72_4' id='input_314_72_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_314_72_5_container' >\n                                    <input class='form-control' type='text' name='input_72.5' id='input_314_72_5' value=''    aria-required='false'    \/>\n                                    <label for='input_314_72_5' id='input_314_72_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_314_72_6_container' >\n                                        <select class='form-control' class='form-control' name='input_72.6' id='input_314_72_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_314_72_6' id='input_314_72_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_314_123\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_123'>County<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_123' id='input_314_123' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_73\" class=\"gfield gfield--type-phone gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_73'>Home Phone<\/label><div class='ginput_container ginput_container_phone'><input class='form-control' name='input_73' id='input_314_73' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_74\" class=\"gfield gfield--type-phone gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_74'>Business Phone<\/label><div class='ginput_container ginput_container_phone'><input class='form-control' name='input_74' id='input_314_74' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_75\" class=\"gfield gfield--type-phone gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_75'>Fax Phone<\/label><div class='ginput_container ginput_container_phone'><input class='form-control' name='input_75' id='input_314_75' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_76\" class=\"gfield gfield--type-phone gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_76'>Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input class='form-control' name='input_76' id='input_314_76' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_58\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Business Participant Information<\/h2><\/li><li id=\"field_314_77\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Type of Business Entity<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_314_77'>\n\t\t\t<li class='radio gchoice gchoice_314_77_0'>\n\t\t\t\t<input style='margin-left:1px;' name='input_77' type='radio' value='Coorporation'  id='choice_314_77_0'    \/>\n\t\t\t\t<label for='choice_314_77_0' id='label_314_77_0' class='gform-field-label gform-field-label--type-inline'>Coorporation<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_314_77_1'>\n\t\t\t\t<input style='margin-left:1px;' name='input_77' type='radio' value='Partnership'  id='choice_314_77_1'    \/>\n\t\t\t\t<label for='choice_314_77_1' id='label_314_77_1' class='gform-field-label gform-field-label--type-inline'>Partnership<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_314_77_2'>\n\t\t\t\t<input style='margin-left:1px;' name='input_77' type='radio' value='Sole Proprietorship'  id='choice_314_77_2'    \/>\n\t\t\t\t<label for='choice_314_77_2' id='label_314_77_2' class='gform-field-label gform-field-label--type-inline'>Sole Proprietorship<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_314_77_3'>\n\t\t\t\t<input style='margin-left:1px;' name='input_77' type='radio' value='LLC'  id='choice_314_77_3'    \/>\n\t\t\t\t<label for='choice_314_77_3' id='label_314_77_3' class='gform-field-label gform-field-label--type-inline'>LLC<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_314_78\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_78'>Participant ID<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_78' id='input_314_78' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_79\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_79'>Business Name<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_79' id='input_314_79' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_80\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_80'>State of Incorporation<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_80' id='input_314_80' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_81\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_81'>Charter State<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_81' id='input_314_81' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_82\" class=\"gfield gfield--type-phone gf_left_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_82'>Business Phone<\/label><div class='ginput_container ginput_container_phone'><input class='form-control' name='input_82' id='input_314_82' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_83\" class=\"gfield gfield--type-phone gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_83'>Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input class='form-control' name='input_83' id='input_314_83' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_124\" class=\"gfield gfield--type-phone gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_124'>Home Phone<\/label><div class='ginput_container ginput_container_phone'><input class='form-control' name='input_124' id='input_314_124' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_84\" class=\"gfield gfield--type-phone gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_84'>Fax<\/label><div class='ginput_container ginput_container_phone'><input class='form-control' name='input_84' id='input_314_84' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_85\" class=\"gfield gfield--type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_85'>Email Address<\/label><div class='ginput_container ginput_container_email'>\n                            <input class='form-control' name='input_85' id='input_314_85' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_314_86\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Business Owner Name 1<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_314_86'>\n                            \n                            <span id='input_314_86_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input class='form-control' type='text' name='input_86.3' id='input_314_86_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_314_86_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_314_86_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input class='form-control' type='text' name='input_86.4' id='input_314_86_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_314_86_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_314_86_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input class='form-control' type='text' name='input_86.6' id='input_314_86_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_314_86_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_314_87\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Business Owner Name 2<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_314_87'>\n                            \n                            <span id='input_314_87_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input class='form-control' type='text' name='input_87.3' id='input_314_87_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_314_87_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_314_87_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input class='form-control' type='text' name='input_87.4' id='input_314_87_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_314_87_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_314_87_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input class='form-control' type='text' name='input_87.6' id='input_314_87_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_314_87_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_314_88\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Business Owner Name 3<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_314_88'>\n                            \n                            <span id='input_314_88_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input class='form-control' type='text' name='input_88.3' id='input_314_88_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_314_88_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_314_88_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input class='form-control' type='text' name='input_88.4' id='input_314_88_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_314_88_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_314_88_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input class='form-control' type='text' name='input_88.6' id='input_314_88_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_314_88_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_314_90\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Physical Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_314_90' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_314_90_1_container' >\n                                        <input class='form-control' type='text' name='input_90.1' id='input_314_90_1' value=''    aria-required='false'    \/>\n                                        <label for='input_314_90_1' id='input_314_90_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_314_90_2_container' >\n                                        <input class='form-control' type='text' name='input_90.2' id='input_314_90_2' value=''     aria-required='false'   \/>\n                                        <label for='input_314_90_2' id='input_314_90_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_314_90_3_container' >\n                                    <input class='form-control' type='text' name='input_90.3' id='input_314_90_3' value=''    aria-required='false'    \/>\n                                    <label for='input_314_90_3' id='input_314_90_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_314_90_4_container' >\n                                        <input class='form-control' type='text' name='input_90.4' id='input_314_90_4' value=''      aria-required='false'    \/>\n                                        <label for='input_314_90_4' id='input_314_90_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_314_90_5_container' >\n                                    <input class='form-control' type='text' name='input_90.5' id='input_314_90_5' value=''    aria-required='false'    \/>\n                                    <label for='input_314_90_5' id='input_314_90_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_314_90_6_container' >\n                                        <select class='form-control' class='form-control' name='input_90.6' id='input_314_90_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_314_90_6' id='input_314_90_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_314_132\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_132'>County<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_132' id='input_314_132' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_92\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Mailing Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_314_92' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_314_92_1_container' >\n                                        <input class='form-control' type='text' name='input_92.1' id='input_314_92_1' value=''    aria-required='false'    \/>\n                                        <label for='input_314_92_1' id='input_314_92_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_314_92_2_container' >\n                                        <input class='form-control' type='text' name='input_92.2' id='input_314_92_2' value=''     aria-required='false'   \/>\n                                        <label for='input_314_92_2' id='input_314_92_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_314_92_3_container' >\n                                    <input class='form-control' type='text' name='input_92.3' id='input_314_92_3' value=''    aria-required='false'    \/>\n                                    <label for='input_314_92_3' id='input_314_92_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_314_92_4_container' >\n                                        <input class='form-control' type='text' name='input_92.4' id='input_314_92_4' value=''      aria-required='false'    \/>\n                                        <label for='input_314_92_4' id='input_314_92_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_314_92_5_container' >\n                                    <input class='form-control' type='text' name='input_92.5' id='input_314_92_5' value=''    aria-required='false'    \/>\n                                    <label for='input_314_92_5' id='input_314_92_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_314_92_6_container' >\n                                        <select class='form-control' class='form-control' name='input_92.6' id='input_314_92_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_314_92_6' id='input_314_92_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_314_133\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_133'>County<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_133' id='input_314_133' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_59\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Single Vessel Corporations<\/h2><\/li><li id=\"field_314_93\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_93'>Participant ID<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_93' id='input_314_93' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_94\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name has_suffix gf_name_has_4 ginput_container_name gform-grid-row' id='input_314_94'>\n                            \n                            <span id='input_314_94_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input class='form-control' type='text' name='input_94.3' id='input_314_94_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_314_94_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_314_94_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input class='form-control' type='text' name='input_94.4' id='input_314_94_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_314_94_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_314_94_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input class='form-control' type='text' name='input_94.6' id='input_314_94_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_314_94_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_314_94_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input class='form-control' type='text' name='input_94.8' id='input_314_94_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_314_94_8' class='gform-field-label gform-field-label--type-sub '>Suffix<\/label>\n                                                <\/span>\n                        <\/div><\/li><li id=\"field_314_95\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Choose one<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_314_95'>\n\t\t\t<li class='radio gchoice gchoice_314_95_0'>\n\t\t\t\t<input style='margin-left:1px;' name='input_95' type='radio' value='Driver&#039;s License No.'  id='choice_314_95_0'    \/>\n\t\t\t\t<label for='choice_314_95_0' id='label_314_95_0' class='gform-field-label gform-field-label--type-inline'>Driver's License No.<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_314_95_1'>\n\t\t\t\t<input style='margin-left:1px;' name='input_95' type='radio' value='State I.D. No.'  id='choice_314_95_1'    \/>\n\t\t\t\t<label for='choice_314_95_1' id='label_314_95_1' class='gform-field-label gform-field-label--type-inline'>State I.D. No.<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_314_95_2'>\n\t\t\t\t<input style='margin-left:1px;' name='input_95' type='radio' value='Military I.D. No.'  id='choice_314_95_2'    \/>\n\t\t\t\t<label for='choice_314_95_2' id='label_314_95_2' class='gform-field-label gform-field-label--type-inline'>Military I.D. No.<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_314_95_3'>\n\t\t\t\t<input style='margin-left:1px;' name='input_95' type='radio' value='Resident Alien I.D. No.'  id='choice_314_95_3'    \/>\n\t\t\t\t<label for='choice_314_95_3' id='label_314_95_3' class='gform-field-label gform-field-label--type-inline'>Resident Alien I.D. No.<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_314_95_4'>\n\t\t\t\t<input style='margin-left:1px;' name='input_95' type='radio' value='Passport No.'  id='choice_314_95_4'    \/>\n\t\t\t\t<label for='choice_314_95_4' id='label_314_95_4' class='gform-field-label gform-field-label--type-inline'>Passport No.<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_314_129\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_129'>Identification Number<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_129' id='input_314_129' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_96\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_96'>Expiration Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_96' id='input_314_96' type='text' value='' class='datepicker form-control gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_314_96_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_314_96_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_314_96' class='gform_hidden' value='https:\/\/commercialfishingpermits.us\/state\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_314_97\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_97'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_97' id='input_314_97' type='text' value='' class='datepicker form-control gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_314_97_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_314_97_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_314_97' class='gform_hidden' value='https:\/\/commercialfishingpermits.us\/state\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_314_98\" class=\"gfield gfield--type-text gf_left_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_98'>Race<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_98' id='input_314_98' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_125\" class=\"gfield gfield--type-text gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_125'>Primary Residence<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_125' id='input_314_125' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_126\" class=\"gfield gfield--type-email gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_126'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input class='form-control' name='input_126' id='input_314_126' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_314_99\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Gender<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_314_99'>\n\t\t\t<li class='radio gchoice gchoice_314_99_0'>\n\t\t\t\t<input style='margin-left:1px;' name='input_99' type='radio' value='Male'  id='choice_314_99_0'    \/>\n\t\t\t\t<label for='choice_314_99_0' id='label_314_99_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_314_99_1'>\n\t\t\t\t<input style='margin-left:1px;' name='input_99' type='radio' value='Female'  id='choice_314_99_1'    \/>\n\t\t\t\t<label for='choice_314_99_1' id='label_314_99_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_314_100\" class=\"gfield gfield--type-text gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_100'>Height<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_100' id='input_314_100' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_101\" class=\"gfield gfield--type-text gf_left_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_101'>Weight<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_101' id='input_314_101' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_102\" class=\"gfield gfield--type-text gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_102'>Eye Color<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_102' id='input_314_102' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_103\" class=\"gfield gfield--type-text gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_103'>Hair Color<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_103' id='input_314_103' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_104\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Physical Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_314_104' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_314_104_1_container' >\n                                        <input class='form-control' type='text' name='input_104.1' id='input_314_104_1' value=''    aria-required='false'    \/>\n                                        <label for='input_314_104_1' id='input_314_104_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_314_104_2_container' >\n                                        <input class='form-control' type='text' name='input_104.2' id='input_314_104_2' value=''     aria-required='false'   \/>\n                                        <label for='input_314_104_2' id='input_314_104_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_314_104_3_container' >\n                                    <input class='form-control' type='text' name='input_104.3' id='input_314_104_3' value=''    aria-required='false'    \/>\n                                    <label for='input_314_104_3' id='input_314_104_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_314_104_4_container' >\n                                        <input class='form-control' type='text' name='input_104.4' id='input_314_104_4' value=''      aria-required='false'    \/>\n                                        <label for='input_314_104_4' id='input_314_104_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_314_104_5_container' >\n                                    <input class='form-control' type='text' name='input_104.5' id='input_314_104_5' value=''    aria-required='false'    \/>\n                                    <label for='input_314_104_5' id='input_314_104_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_314_104_6_container' >\n                                        <select class='form-control' class='form-control' name='input_104.6' id='input_314_104_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_314_104_6' id='input_314_104_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_314_130\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_130'>County<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_130' id='input_314_130' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_106\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Mailing Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_314_106' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_314_106_1_container' >\n                                        <input class='form-control' type='text' name='input_106.1' id='input_314_106_1' value=''    aria-required='false'    \/>\n                                        <label for='input_314_106_1' id='input_314_106_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_314_106_2_container' >\n                                        <input class='form-control' type='text' name='input_106.2' id='input_314_106_2' value=''     aria-required='false'   \/>\n                                        <label for='input_314_106_2' id='input_314_106_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_314_106_3_container' >\n                                    <input class='form-control' type='text' name='input_106.3' id='input_314_106_3' value=''    aria-required='false'    \/>\n                                    <label for='input_314_106_3' id='input_314_106_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_314_106_4_container' >\n                                        <input class='form-control' type='text' name='input_106.4' id='input_314_106_4' value=''      aria-required='false'    \/>\n                                        <label for='input_314_106_4' id='input_314_106_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_314_106_5_container' >\n                                    <input class='form-control' type='text' name='input_106.5' id='input_314_106_5' value=''    aria-required='false'    \/>\n                                    <label for='input_314_106_5' id='input_314_106_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_314_106_6_container' >\n                                        <select class='form-control' class='form-control' name='input_106.6' id='input_314_106_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_314_106_6' id='input_314_106_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_314_131\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_131'>County<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_131' id='input_314_131' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_107\" class=\"gfield gfield--type-phone gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_107'>Home Phone<\/label><div class='ginput_container ginput_container_phone'><input class='form-control' name='input_107' id='input_314_107' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_108\" class=\"gfield gfield--type-phone gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_108'>Business Phone<\/label><div class='ginput_container ginput_container_phone'><input class='form-control' name='input_108' id='input_314_108' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_109\" class=\"gfield gfield--type-phone gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_109'>Fax<\/label><div class='ginput_container ginput_container_phone'><input class='form-control' name='input_109' id='input_314_109' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_110\" class=\"gfield gfield--type-phone gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_110'>Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input class='form-control' name='input_110' id='input_314_110' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_112\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_314_127\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name of Responsible Party that completed Economic Survey<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_314_127'>\n                            \n                            <span id='input_314_127_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input class='form-control' type='text' name='input_127.3' id='input_314_127_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_314_127_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_314_127_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input class='form-control' type='text' name='input_127.4' id='input_314_127_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_314_127_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_314_127_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input class='form-control' type='text' name='input_127.6' id='input_314_127_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_314_127_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_314_111\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >At least 50% of the income is derived from commercial fishing?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_314_111'>\n\t\t\t<li class='radio gchoice gchoice_314_111_0'>\n\t\t\t\t<input style='margin-left:1px;' name='input_111' type='radio' value='Yes'  id='choice_314_111_0'    \/>\n\t\t\t\t<label for='choice_314_111_0' id='label_314_111_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_314_111_1'>\n\t\t\t\t<input style='margin-left:1px;' name='input_111' type='radio' value='No'  id='choice_314_111_1'    \/>\n\t\t\t\t<label for='choice_314_111_1' id='label_314_111_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_314_113\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Certification Statement<\/h2><\/li><li id=\"field_314_128\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_128'>I (enter name) All the information provided on this application and any supporting documentation provided is true, accurate, and complete. And further, for renewals, any changes in information or supporting documents have been provided at the time of renewal<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_128' id='input_314_128' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_115\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_115'>I am a resident of the State of:<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_115' id='input_314_115' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_117\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >If claiming resident status in North Carolina, I certify further that (check one):<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_314_117'>\n\t\t\t<li class='radio gchoice gchoice_314_117_0'>\n\t\t\t\t<input style='margin-left:1px;' name='input_117' type='radio' value='I have been a legal resident for more than six months, or'  id='choice_314_117_0'    \/>\n\t\t\t\t<label for='choice_314_117_0' id='label_314_117_0' class='gform-field-label gform-field-label--type-inline'>I have been a legal resident for more than six months, or<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_314_117_1'>\n\t\t\t\t<input style='margin-left:1px;' name='input_117' type='radio' value='If domiciled in North Carolina between 60 days and six months, I have completed and submitted with this application a notarized Certificate of Eligibility for North Carolina Residency.'  id='choice_314_117_1'    \/>\n\t\t\t\t<label for='choice_314_117_1' id='label_314_117_1' class='gform-field-label gform-field-label--type-inline'>If domiciled in North Carolina between 60 days and six months, I have completed and submitted with this application a notarized Certificate of Eligibility for North Carolina Residency.<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_314_116\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_116'>Your Initials<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_116' id='input_314_116' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_118\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >If accepting a Standard or Retired Standard Commercial Fishing License as a North Carolina Resident, I also certify that:<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_314_118'>\n\t\t\t<li class='radio gchoice gchoice_314_118_0'>\n\t\t\t\t<input style='margin-left:1px;' name='input_118' type='radio' value='I filed a North Carolina State Income Tax Return for the previous calendar or tax year.'  id='choice_314_118_0'    \/>\n\t\t\t\t<label for='choice_314_118_0' id='label_314_118_0' class='gform-field-label gform-field-label--type-inline'>I filed a North Carolina State Income Tax Return for the previous calendar or tax year.<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='radio gchoice gchoice_314_118_1'>\n\t\t\t\t<input style='margin-left:1px;' name='input_118' type='radio' value='I was not required to file a North Carolina State Income Tax Return for the previous calendar or tax year.'  id='choice_314_118_1'    \/>\n\t\t\t\t<label for='choice_314_118_1' id='label_314_118_1' class='gform-field-label gform-field-label--type-inline'>I was not required to file a North Carolina State Income Tax Return for the previous calendar or tax year.<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_314_10\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Contact Information<\/h2><\/li><li id=\"field_314_11\" class=\"gfield gfield--type-name contact-info-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_314_11'>\n                            \n                            <span id='input_314_11_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input class='form-control' type='text' name='input_11.3' id='input_314_11_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_314_11_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_314_11_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input class='form-control' type='text' name='input_11.6' id='input_314_11_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_314_11_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_314_12\" class=\"gfield gfield--type-email contact-info-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Email<\/label><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_314_12_container'>\n                                <span id='input_314_12_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='form-control' class='' type='email' name='input_12' id='input_314_12' value=''     aria-invalid=\"false\"  \/>\n                                    <label for='input_314_12' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_314_12_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='form-control' class='' type='email' name='input_12_2' id='input_314_12_2' value=''     aria-invalid=\"false\"  \/>\n                                    <label for='input_314_12_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/li><li id=\"field_314_13\" class=\"gfield gfield--type-phone contact-info-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_13'>Phone<\/label><div class='ginput_container ginput_container_phone'><input class='form-control' name='input_13' id='input_314_13' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_137\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_314_14\" class=\"gfield gfield--type-product gfield--input-type-singleproduct base-product gfield_price gfield_price_314_14 gfield_product_314_14 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_314_14_1'>SCFL Resident Application Fee<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_14.1' value='SCFL Resident Application Fee' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_314_14' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_14.2' id='ginput_base_price_314_14' value='$800.00' aria-label='SCFL Resident Application Fee Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_14.3' value='1' class='ginput_quantity_314_14 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_314_160\" class=\"gfield gfield--type-product gfield--input-type-singleproduct gfield--width-full base-product gfield_price gfield_price_314_160 gfield_product_314_160 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_314_160_1'>SCFL Resident Application Fee<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_160.1' value='SCFL Resident Application Fee' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_314_160' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_160.2' id='ginput_base_price_314_160' value='$75.00' aria-label='SCFL Resident Application Fee Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_160.3' value='1' class='ginput_quantity_314_160 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_314_139\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_314_140\" class=\"gfield gfield--type-product gfield--input-type-singleproduct base-product gfield_price gfield_price_314_140 gfield_product_314_140 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_314_140_1'>Alabama SCFL Non Resident Application Fee<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_140.1' value='Alabama SCFL Non Resident Application Fee' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_314_140' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_140.2' id='ginput_base_price_314_140' value='$1,100.00' aria-label='Alabama SCFL Non Resident Application Fee Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_140.3' value='1' class='ginput_quantity_314_140 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_314_143\" class=\"gfield gfield--type-product gfield--input-type-singleproduct base-product gfield_price gfield_price_314_143 gfield_product_314_143 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_314_143_1'>Connecticut SCFL Non Resident Application Fee<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_143.1' value='Connecticut SCFL Non Resident Application Fee' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_314_143' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_143.2' id='ginput_base_price_314_143' value='$2,905.00' aria-label='Connecticut SCFL Non Resident Application Fee Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_143.3' value='1' class='ginput_quantity_314_143 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_314_144\" class=\"gfield gfield--type-product gfield--input-type-singleproduct base-product gfield_price gfield_price_314_144 gfield_product_314_144 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_314_144_1'>Delaware SCFL Non Resident Application Fee<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_144.1' value='Delaware SCFL Non Resident Application Fee' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_314_144' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_144.2' id='ginput_base_price_314_144' value='$2,760.00' aria-label='Delaware SCFL Non Resident Application Fee Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_144.3' value='1' class='ginput_quantity_314_144 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_314_145\" class=\"gfield gfield--type-product gfield--input-type-singleproduct base-product gfield_price gfield_price_314_145 gfield_product_314_145 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_314_145_1'>Florida SCFL Non Resident Application Fee<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_145.1' value='Florida SCFL Non Resident Application Fee' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_314_145' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_145.2' id='ginput_base_price_314_145' value='$2,475.00' aria-label='Florida SCFL Non Resident Application Fee Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_145.3' value='1' class='ginput_quantity_314_145 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_314_146\" class=\"gfield gfield--type-product gfield--input-type-singleproduct base-product gfield_price gfield_price_314_146 gfield_product_314_146 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_314_146_1'>Georgia SCFL Non Resident Application Fee<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_146.1' value='Georgia SCFL Non Resident Application Fee' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_314_146' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_146.2' id='ginput_base_price_314_146' value='$1,425.00' aria-label='Georgia SCFL Non Resident Application Fee Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_146.3' value='1' class='ginput_quantity_314_146 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_314_147\" class=\"gfield gfield--type-product gfield--input-type-singleproduct base-product gfield_price gfield_price_314_147 gfield_product_314_147 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_314_147_1'>Louisiana SCFL Non Resident Application Fee<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_147.1' value='Louisiana SCFL Non Resident Application Fee' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_314_147' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_147.2' id='ginput_base_price_314_147' value='$4,960.00' aria-label='Louisiana SCFL Non Resident Application Fee Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_147.3' value='1' class='ginput_quantity_314_147 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_314_148\" class=\"gfield gfield--type-product gfield--input-type-singleproduct base-product gfield_price gfield_price_314_148 gfield_product_314_148 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_314_148_1'>Maine SCFL Non Resident Application Fee<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_148.1' value='Maine SCFL Non Resident Application Fee' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_314_148' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_148.2' id='ginput_base_price_314_148' value='$1,881.00' aria-label='Maine SCFL Non Resident Application Fee Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_148.3' value='1' class='ginput_quantity_314_148 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_314_149\" class=\"gfield gfield--type-product gfield--input-type-singleproduct base-product gfield_price gfield_price_314_149 gfield_product_314_149 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_314_149_1'>Maryland SCFL Non Resident Application Fee<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_149.1' value='Maryland SCFL Non Resident Application Fee' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_314_149' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_149.2' id='ginput_base_price_314_149' value='$1,360.00' aria-label='Maryland SCFL Non Resident Application Fee Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_149.3' value='1' class='ginput_quantity_314_149 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_314_150\" class=\"gfield gfield--type-product gfield--input-type-singleproduct base-product gfield_price gfield_price_314_150 gfield_product_314_150 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_314_150_1'>Massachusetts SCFL Non Resident Application Fee<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_150.1' value='Massachusetts SCFL Non Resident Application Fee' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_314_150' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_150.2' id='ginput_base_price_314_150' value='$1,710.00' aria-label='Massachusetts SCFL Non Resident Application Fee Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_150.3' value='1' class='ginput_quantity_314_150 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_314_151\" class=\"gfield gfield--type-product gfield--input-type-singleproduct base-product gfield_price gfield_price_314_151 gfield_product_314_151 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_314_151_1'>Mississippi SCFL Non Resident Application Fee<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_151.1' value='Mississippi SCFL Non Resident Application Fee' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_314_151' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_151.2' id='ginput_base_price_314_151' value='$1,510.00' aria-label='Mississippi SCFL Non Resident Application Fee Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_151.3' value='1' class='ginput_quantity_314_151 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_314_152\" class=\"gfield gfield--type-product gfield--input-type-singleproduct base-product gfield_price gfield_price_314_152 gfield_product_314_152 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_314_152_1'>New Hampshire SCFL Non Resident Application Fee<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_152.1' value='New Hampshire SCFL Non Resident Application Fee' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_314_152' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_152.2' id='ginput_base_price_314_152' value='$2,100.00' aria-label='New Hampshire SCFL Non Resident Application Fee Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_152.3' value='1' class='ginput_quantity_314_152 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_314_153\" class=\"gfield gfield--type-product gfield--input-type-singleproduct base-product gfield_price gfield_price_314_153 gfield_product_314_153 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_314_153_1'>New Jersey SCFL Non Resident Application Fee<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_153.1' value='New Jersey SCFL Non Resident Application Fee' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_314_153' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_153.2' id='ginput_base_price_314_153' value='$1,452.00' aria-label='New Jersey SCFL Non Resident Application Fee Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_153.3' value='1' class='ginput_quantity_314_153 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_314_154\" class=\"gfield gfield--type-product gfield--input-type-singleproduct base-product gfield_price gfield_price_314_154 gfield_product_314_154 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_314_154_1'>New York SCFL Non Resident Application Fee<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_154.1' value='New York SCFL Non Resident Application Fee' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_314_154' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_154.2' id='ginput_base_price_314_154' value='$1,850.00' aria-label='New York SCFL Non Resident Application Fee Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_154.3' value='1' class='ginput_quantity_314_154 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_314_155\" class=\"gfield gfield--type-product gfield--input-type-singleproduct base-product gfield_price gfield_price_314_155 gfield_product_314_155 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_314_155_1'>Rhode Island SCFL Non Resident Application Fee<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_155.1' value='Rhode Island SCFL Non Resident Application Fee' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_314_155' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_155.2' id='ginput_base_price_314_155' value='$1,025.00' aria-label='Rhode Island SCFL Non Resident Application Fee Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_155.3' value='1' class='ginput_quantity_314_155 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_314_156\" class=\"gfield gfield--type-product gfield--input-type-singleproduct base-product gfield_price gfield_price_314_156 gfield_product_314_156 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_314_156_1'>South Carolina SCFL Non Resident Application Fee<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_156.1' value='South Carolina SCFL Non Resident Application Fee' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_314_156' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_156.2' id='ginput_base_price_314_156' value='$1,425.00' aria-label='South Carolina SCFL Non Resident Application Fee Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_156.3' value='1' class='ginput_quantity_314_156 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_314_157\" class=\"gfield gfield--type-product gfield--input-type-singleproduct base-product gfield_price gfield_price_314_157 gfield_product_314_157 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_314_157_1'>Texas SCFL Non Resident Application Fee<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_157.1' value='Texas SCFL Non Resident Application Fee' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_314_157' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_157.2' id='ginput_base_price_314_157' value='$4,775.00' aria-label='Texas SCFL Non Resident Application Fee Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_157.3' value='1' class='ginput_quantity_314_157 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_314_158\" class=\"gfield gfield--type-product gfield--input-type-singleproduct base-product gfield_price gfield_price_314_158 gfield_product_314_158 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_314_158_1'>Virginia SCFL Non Resident Application Fee<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_158.1' value='Virginia SCFL Non Resident Application Fee' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_314_158' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_158.2' id='ginput_base_price_314_158' value='$1,748.00' aria-label='Virginia SCFL Non Resident Application Fee Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_158.3' value='1' class='ginput_quantity_314_158 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_314_142\" class=\"gfield gfield--type-product gfield--input-type-singleproduct base-product gfield_price gfield_price_314_142 gfield_product_314_142 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_314_142_1'>State SCFL Non Resident Application Fee<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_142.1' value='State SCFL Non Resident Application Fee' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_314_142' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_142.2' id='ginput_base_price_314_142' value='$900.00' aria-label='State SCFL Non Resident Application Fee Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_142.3' value='1' class='ginput_quantity_314_142 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_314_16\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_314_138\" class=\"gfield gfield--type-product gfield--input-type-singleproduct base-product gfield_price gfield_price_314_138 gfield_product_314_138 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_314_138_1'>RSCFL Resident Application Fee<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_138.1' value='RSCFL Resident Application Fee' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_314_138' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_138.2' id='ginput_base_price_314_138' value='$400.00' aria-label='RSCFL Resident Application Fee Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_138.3' value='1' class='ginput_quantity_314_138 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_314_159\" class=\"gfield gfield--type-product gfield--input-type-singleproduct gfield--width-full base-product gfield_price gfield_price_314_159 gfield_product_314_159 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_314_159_1'>RSCFL Resident Application Fee<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_159.1' value='RSCFL Resident Application Fee' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_314_159' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_159.2' id='ginput_base_price_314_159' value='$75.00' aria-label='RSCFL Resident Application Fee Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_159.3' value='1' class='ginput_quantity_314_159 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_314_135\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_314_136\" class=\"gfield gfield--type-product gfield--input-type-singleproduct base-product gfield_price gfield_price_314_136 gfield_product_314_136 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_314_136_1'>RSCFL Non Resident Application Fee<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_136.1' value='RSCFL Non Resident Application Fee' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_314_136' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_136.2' id='ginput_base_price_314_136' value='$460.00' aria-label='RSCFL Non Resident Application Fee Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_136.3' value='1' class='ginput_quantity_314_136 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_314_134\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_314_36\" class=\"gfield gfield--type-option gfield--type-choice gfield--input-type-radio advanced-renewal gfield_price gfield_price_314_14 gfield_option_314_14 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >RENEWAL ADVANCED PAYMENT OPTION<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_314_36'>\n\t\t\t<li class='gchoice gchoice_314_36_0'>\n\t\t\t\t<input name='input_36' type='radio' value='No Additional Years|0'  id='choice_314_36_0'    \/>\n\t\t\t\t<label for='choice_314_36_0' id='label_314_36_0' class='gform-field-label gform-field-label--type-inline'>No Additional Years<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_314_36_1'>\n\t\t\t\t<input name='input_36' type='radio' value='2 year renewal|75'  id='choice_314_36_1'    \/>\n\t\t\t\t<label for='choice_314_36_1' id='label_314_36_1' class='gform-field-label gform-field-label--type-inline'>2 year renewal<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_314_36_2'>\n\t\t\t\t<input name='input_36' type='radio' value='3 year renewal|150'  id='choice_314_36_2'    \/>\n\t\t\t\t<label for='choice_314_36_2' id='label_314_36_2' class='gform-field-label gform-field-label--type-inline'>3 year renewal<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_314_36_3'>\n\t\t\t\t<input name='input_36' type='radio' value='4 year renewal|225'  id='choice_314_36_3'    \/>\n\t\t\t\t<label for='choice_314_36_3' id='label_314_36_3' class='gform-field-label gform-field-label--type-inline'>4 year renewal<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_314_36_4'>\n\t\t\t\t<input name='input_36' type='radio' value='5 year renewal|300'  id='choice_314_36_4'    \/>\n\t\t\t\t<label for='choice_314_36_4' id='label_314_36_4' class='gform-field-label gform-field-label--type-inline'>5 year renewal<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_314_18\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_314_19\" class=\"gfield gfield--type-total pricing-total gfield_price gfield_price_314_ gfield_total gfield_total_314_ field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  aria-atomic=\"true\" aria-live=\"polite\" ><label class='gfield_label gform-field-label' for='input_314_19'>Total<\/label><div class='ginput_container ginput_container_total'>\n\t\t\t\t\t\t\t<span class='ginput_total ginput_total_314'>$0.00<\/span>\n\t\t\t\t\t\t\t<input type='hidden' name='input_19' id='input_314_19' class='gform_hidden'\/>\n\t\t\t\t\t\t<\/div><\/li><li id=\"field_314_21\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_314_22\" class=\"gfield gfield--type-consent gfield--type-choice consent-agree field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Consent<\/label><div class='ginput_container ginput_container_consent'><input name='input_22.1' id='input_314_22_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_314_22\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_314_22_1' >I agree<\/label><input type='hidden' name='input_22.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_22.3' value='1604' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_314_22' tabindex='0'>I CERTIFY THAT THE RECITATIONS CONCERNING THE VESSEL: NAME, TONNAGE, DIMENSIONS, PROPULSION, OWNERSHIP, HAILING PORT, RESTRICTIONS, ENTITLEMENTS, REMARKS AND ENDORSEMENTS CONTAINED IN THE CERTIFICATE OF DOCUMENTATION REMAIN ABSOLUTELY THE SAME.<\/div><\/li><li id=\"field_314_20\" class=\"gfield gfield--type-text typed-name-for-signature field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_20'>NAME:<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_20' id='input_314_20' type='text' value='' class='medium'  aria-describedby=\"gfield_description_314_20\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_314_20'>Type your full name to sign this secure webform<\/div><\/li><li id=\"field_314_27\" class=\"gfield gfield--type-signature signature field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_27'>Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_314_27_Container' class='gfield_signature_container ginput_container' style='height:180px; width:500px; ' ><input type='hidden' class='gform_hidden' name='input_314_27_valid' id='input_314_27_valid' \/><canvas id='input_314_27' width='500' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/commercialfishingpermits.us\/state\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_314_27_toolbar' style='margin:5px 0;position:relative;height:20px;width:500px;max-width:100%;'><img id = 'input_314_27_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_314_27_data' name='input_314_27_data' value=''><\/div><\/li><li id=\"field_314_23\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_23'>CAPACITY OF PERSON SIGNING (E.G., OWNER, AGENT, TRUSTEE, GENERAL PARTNER, CORPORATE OFFICER, MEMBER)<\/label><div class='ginput_container ginput_container_text'><input class='form-control' name='input_23' id='input_314_23' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_314_24\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon signed-date field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_314_24'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_24' id='input_314_24' type='text' value='04\/16\/2026' class='datepicker form-control gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_314_24_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_314_24_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_314_24' class='gform_hidden' value='https:\/\/commercialfishingpermits.us\/state\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_314_25\" class=\"gfield gfield--type-consent gfield--type-choice consent_authorization field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Authorization<\/label><div class='ginput_container ginput_container_consent'><input name='input_25.1' id='input_314_25_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_314_25\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_314_25_1' >I agree<\/label><input type='hidden' name='input_25.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_25.3' value='1604' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_314_25' tabindex='0'>I agree to pay the above total amount according to the card issuer agreement and hereby authorize the charge for the total amount above for the processing of selected permits. I understand that my application will be processed in the order in which it is received by Commercial Fishing Permits Center, a private fee-for-service documentation company, not owned or operated by any governmental agency. I understand that application and processing fees are non-refundable as per Commercial Fishing Permits Center's no refund policy. I understand that submitting another application for a license or permit will supersede the current\/pending application for that license or permit. I understand that Commercial Fishing Permits Center does not issue or sell any licenses or permits.<\/div><\/li><li id=\"field_314_26\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_314_164\" class=\"gfield gfield--type-stripe_creditcard field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--type-stripe_creditcard-card\"  ><label class='gfield_label gfield_label_before_complex gform-field-label' for='input_314_164_1'>Credit Card<\/label><div class='ginput_complex ginput_container ginput_container_creditcard ginput_stripe_creditcard gform-grid-row' id='input_314_164'><div class='ginput_full gform-grid-col' id='input_314_164_1_container' data-payment-element='false'><div id='input_314_164_1' class='gform-theme-field-control StripeElement--card'><\/div><label for='input_314_164_1' id='input_314_164_1_label' class='gform-field-label gform-field-label--type-sub'>Card Details<\/label><\/div><!-- .ginput_full --><div class='ginput_full gform-grid-col' id='input_314_164_5_container'>\r\n\t\t\t\t\t<input type='text' name='input_164.5' id='input_314_164_5' value=''>\r\n\t\t\t\t\t<label for='input_314_164_5' id='input_314_164_5_label' class='gform-field-label gform-field-label--type-sub'>Cardholder Name<\/label>\r\n\t\t\t\t<\/div><\/div><!-- .ginput_container -->\r\n\t\t\t<style type=\"text\/css\">\r\n\t\t\t\t:root {\r\n  \t\t\t\t\t--link-login-string: \"Link login\"\r\n\t\t\t\t}\r\n\t\t\t<\/style><\/li><li id=\"field_314_29\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_314_33\" class=\"gfield gfield--type-consent gfield--type-choice payment_not_working field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Having Trouble with your card?<\/label><div class='ginput_container ginput_container_consent'><input name='input_33.1' id='input_314_33_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_314_33\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_314_33_1' >My card information is not working<\/label><input type='hidden' name='input_33.2' value='My card information is not working' class='gform_hidden' \/><input type='hidden' name='input_33.3' value='1604' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_314_33' tabindex='0'>Check this box to move forward without your Credit Card.<\/div><\/li><li id=\"field_314_40\" class=\"gfield gfield--type-address billing-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >BILLING ADDRESS<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_314_40' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_314_40_1_container' >\n                                        <input class='form-control' type='text' name='input_40.1' id='input_314_40_1' value=''    aria-required='false'    \/>\n                                        <label for='input_314_40_1' id='input_314_40_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_314_40_2_container' >\n                                        <input class='form-control' type='text' name='input_40.2' id='input_314_40_2' value=''     aria-required='false'   \/>\n                                        <label for='input_314_40_2' id='input_314_40_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_314_40_3_container' >\n                                    <input class='form-control' type='text' name='input_40.3' id='input_314_40_3' value=''    aria-required='false'    \/>\n                                    <label for='input_314_40_3' id='input_314_40_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_314_40_4_container' >\n                                        <input class='form-control' type='text' name='input_40.4' id='input_314_40_4' value=''      aria-required='false'    \/>\n                                        <label for='input_314_40_4' id='input_314_40_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_314_40_5_container' >\n                                    <input class='form-control' type='text' name='input_40.5' id='input_314_40_5' value=''    aria-required='false'    \/>\n                                    <label for='input_314_40_5' id='input_314_40_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_314_40_6_container' >\n                                        <select class='form-control' class='form-control' name='input_40.6' id='input_314_40_6'   aria-required='false'    ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' selected='selected'>United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_314_40_6' id='input_314_40_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_314_30\" class=\"gfield gfield--type-section gsection 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