{"id":50,"date":"2018-01-21T01:22:45","date_gmt":"2018-01-21T01:22:45","guid":{"rendered":"http:\/\/www.thewisedc.com\/cms\/2018\/01\/21\/register\/"},"modified":"2024-07-18T03:13:06","modified_gmt":"2024-07-18T10:13:06","slug":"register","status":"publish","type":"page","link":"https:\/\/www.thewisedc.com\/cms\/register\/","title":{"rendered":"Register"},"content":{"rendered":"\n<div class=\"um um-register um-1876\">\n\t<div class=\"um-form\" data-mode=\"register\">\n\t\t<form method=\"post\" action=\"\">\n\t\t\t<div class=\"um-row _um_row_1 \" style=\"margin: 0 0 30px 0;\"><div class=\"um-col-1\"><div  id=\"um_field_1876_user_login\" class=\"um-field um-field-text  um-field-user_login um-field-text um-field-type_text\" data-key=\"user_login\"><div class=\"um-field-label\"><label for=\"user_login-1876\">Username<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid \" type=\"text\" name=\"user_login-1876\" id=\"user_login-1876\" value=\"\" placeholder=\"\" data-validate=\"unique_username\" data-key=\"user_login\"  aria-invalid=\"false\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_1876_user_password\" class=\"um-field um-field-password  um-field-user_password um-field-password um-field-type_password\" data-key=\"user_password\"><div class=\"um-field-label\"><label for=\"user_password-1876\">Password<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input class=\"um-form-field valid \" type=\"password\" name=\"user_password-1876\" id=\"user_password-1876\" value=\"\" placeholder=\"\" data-validate=\"\" data-key=\"user_password\"  aria-invalid=\"false\" \/>\n\n\t\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_1876_confirm_user_password\" class=\"um-field um-field-password  um-field-user_password um-field-password um-field-type_password\" data-key=\"confirm_user_password\"><div class=\"um-field-label\"><label for=\"confirm_user_password-1876\">Confirm Password<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input class=\"um-form-field valid \" type=\"password\" name=\"confirm_user_password-1876\" id=\"confirm_user_password-1876\" value=\"\" placeholder=\"Confirm Password\" data-validate=\"\" data-key=\"confirm_user_password\"  aria-invalid=\"false\" \/><\/div><\/div><div  id=\"um_field_1876_user_email\" class=\"um-field um-field-text  um-field-user_email um-field-text um-field-type_text\" data-key=\"user_email\"><div class=\"um-field-label\"><label for=\"user_email-1876\">E-mail Address<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid \" type=\"text\" name=\"user_email-1876\" id=\"user_email-1876\" value=\"\" placeholder=\"\" data-validate=\"unique_email\" data-key=\"user_email\"  aria-invalid=\"false\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><\/div><\/div><div class=\"um-row _um_row_2 \" style=\"margin: 0 0 30px 0;\"><div class=\"um-col-1\"><div  class=\"um-field um-field-block  um-field-block um-field-type_block\" data-key=\"um_block_1876_8\"><h2>Personal Information -<\/h2>\r\n<h4>You must fill in all of the required information or the system will not be able to generate your certificate. License Information must be completed for each state in which you hold a professional license.<\/h4><\/div><div  id=\"um_field_1876_first_name\" class=\"um-field um-field-text  um-field-first_name um-field-text um-field-type_text\" data-key=\"first_name\"><div class=\"um-field-label\"><label for=\"first_name-1876\">First Name<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid \" type=\"text\" name=\"first_name-1876\" id=\"first_name-1876\" value=\"\" placeholder=\"\" data-validate=\"\" data-key=\"first_name\"  aria-invalid=\"false\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_1876_middle_initial\" class=\"um-field um-field-text  um-field-middle_initial um-field-text um-field-type_text\" data-key=\"middle_initial\"><div class=\"um-field-label\"><label for=\"middle_initial-1876\">Middle Initial<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid \" type=\"text\" name=\"middle_initial-1876\" id=\"middle_initial-1876\" value=\"\" placeholder=\"\" data-validate=\"\" data-key=\"middle_initial\"  aria-invalid=\"false\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_1876_last_name\" class=\"um-field um-field-text  um-field-last_name um-field-text um-field-type_text\" data-key=\"last_name\"><div class=\"um-field-label\"><label for=\"last_name-1876\">Last Name<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid \" type=\"text\" name=\"last_name-1876\" id=\"last_name-1876\" value=\"\" placeholder=\"\" data-validate=\"\" data-key=\"last_name\"  aria-invalid=\"false\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_1876_birth_date\" class=\"um-field um-field-date  um-field-birth_date um-field-date um-field-type_date\" data-key=\"birth_date\"><div class=\"um-field-label\"><div class=\"um-field-label-icon\"><i class=\"um-faicon-calendar\" aria-label=\"Date of Birth\"><\/i><\/div><label for=\"birth_date-1876\">Date of Birth<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input   class=\"um-form-field valid um-datepicker \" type=\"text\" name=\"birth_date-1876\" id=\"birth_date-1876\" value=\"\" placeholder=\"\" data-validate=\"\" data-key=\"birth_date\" data-range=\"years\" data-years=\"115\" data-years_x=\"past\" data-disabled_weekdays=\"\" data-date_min=\"1911,5,27\" data-date_max=\"2026,5,27\" data-format=\"d mmm yyyy\" data-value=\"\"  aria-invalid=\"false\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_1876_ssn_last_digits\" class=\"um-field um-field-text  um-field-ssn_last_digits um-field-text um-field-type_text\" data-key=\"ssn_last_digits\"><div class=\"um-field-label\"><label for=\"ssn_last_digits-1876\">Last 4 digits of SSN<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid \" type=\"text\" name=\"ssn_last_digits-1876\" id=\"ssn_last_digits-1876\" value=\"\" placeholder=\"\" data-validate=\"numeric\" data-key=\"ssn_last_digits\"  aria-invalid=\"false\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_1876_street_address\" class=\"um-field um-field-text  um-field-street_address um-field-text um-field-type_text\" data-key=\"street_address\"><div class=\"um-field-label\"><label for=\"street_address-1876\">Street Address<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid \" type=\"text\" name=\"street_address-1876\" id=\"street_address-1876\" value=\"\" placeholder=\"\" data-validate=\"\" data-key=\"street_address\"  aria-invalid=\"false\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_1876_street_address_2\" class=\"um-field um-field-text  um-field-street_address_2 um-field-text um-field-type_text\" data-key=\"street_address_2\"><div class=\"um-field-label\"><label for=\"street_address_2-1876\">Street Address 2<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid \" type=\"text\" name=\"street_address_2-1876\" id=\"street_address_2-1876\" value=\"\" placeholder=\"\" data-validate=\"\" data-key=\"street_address_2\"  aria-invalid=\"false\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_1876_city\" class=\"um-field um-field-text  um-field-city um-field-text um-field-type_text\" data-key=\"city\"><div class=\"um-field-label\"><label for=\"city-1876\">City\/Town<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid \" type=\"text\" name=\"city-1876\" id=\"city-1876\" value=\"\" placeholder=\"\" data-validate=\"\" data-key=\"city\"  aria-invalid=\"false\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_1876_country\" class=\"um-field um-field-select  um-field-country um-field-select um-field-type_select\" data-key=\"country\"><div class=\"um-field-label\"><label for=\"country-1876\">Country<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area  \"><select data-default=\"\"     name=\"country\" id=\"country\" data-validate=\"\" data-key=\"country\" class=\"um-form-field valid um-s1 \" style=\"width: 100%\" data-placeholder=\"Choose a Country\"  data-um-ajax-source=\"smartsites_get_countries\"   aria-invalid=\"false\" ><option value=\"\"><\/option><option value=\"US\" >United States or Canada<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"AX\" >\u00c5land Islands<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia, Plurinational State of<\/option><option value=\"BQ\" >Bonaire, Sint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CV\" >Cape Verde<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo, the Democratic Republic of the<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"VA\" >Holy See (Vatican City State)<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran, Islamic Republic of<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea, Democratic People&#039;s Republic of<\/option><option value=\"KR\" >Korea, Republic of<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MK\" >Macedonia, the Former Yugoslav Republic of<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia, Federated States of<\/option><option value=\"MD\" >Moldova, Republic of<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine, State of<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SZ\" >Swaziland<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Province of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania, United Republic of<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TR\" >Turkey<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VE\" >Venezuela, Bolivarian Republic of<\/option><option value=\"VN\" >Viet Nam<\/option><option value=\"VG\" >Virgin Islands, British<\/option><option value=\"VI\" >Virgin Islands, U.S.<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AN\" >Netherlands Antilles<\/option><option value=\"FX\" >France, Metropolitan<\/option><option value=\"TP\" >East Timor<\/option><option value=\"YU\" >Yugoslavia<\/option><\/select><\/div><\/div><div  id=\"um_field_1876_state\" class=\"um-field um-field-text  um-is-conditional um-field-state um-field-text um-field-type_text\" data-key=\"state\" data-cond-0-action=\"hide\" data-cond-0-field=\"country\" data-cond-0-operator=\"equals to\" data-cond-0-value=\"US\"><div class=\"um-field-label\"><label for=\"state-1876\">State\/Province\/Territory<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid \" type=\"text\" name=\"state-1876\" id=\"state-1876\" value=\"\" placeholder=\"\" data-validate=\"\" data-key=\"state\"  aria-invalid=\"false\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_1876_state_usa\" class=\"um-field um-field-select  um-is-conditional um-field-state_usa um-field-select um-field-type_select\" data-key=\"state_usa\" data-cond-0-action=\"show\" data-cond-0-field=\"country\" data-cond-0-operator=\"equals to\" data-cond-0-value=\"US\"><div class=\"um-field-label\"><label for=\"state_usa-1876\">State\/Province\/Territory<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area  \"><select data-default=\"\"     name=\"state_usa\" id=\"state_usa\" data-validate=\"\" data-key=\"state_usa\" class=\"um-form-field valid not-required um-s1 \" style=\"width: 100%\" data-placeholder=\"\"  data-um-ajax-source=\"smartsites_get_usa_states\"   aria-invalid=\"false\" ><option value=\"\"><\/option><option value=\"AB\" >Alberta<\/option><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"BC\" >British Columbia<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"DE\" >Delaware<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MB\" >Manitoba<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\" >Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NB\" >Newfoundland and Labrador<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"NS\" >Nova Scotia<\/option><option value=\"NT\" >Northwest Territories<\/option><option value=\"NU\" >Nunavut<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"ON\" >Ontario<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"PE\" >Prince Edward Island<\/option><option value=\"QC\" >Quebec<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SK\" >Saskatchewan<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><option value=\"YT\" >Yukon<\/option><\/select><\/div><\/div><div  id=\"um_field_1876_postal_code\" class=\"um-field um-field-text  um-field-postal_code um-field-text um-field-type_text\" data-key=\"postal_code\"><div class=\"um-field-label\"><label for=\"postal_code-1876\">Zip\/Postal Code<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid \" type=\"text\" name=\"postal_code-1876\" id=\"postal_code-1876\" value=\"\" placeholder=\"\" data-validate=\"alpha_numeric\" data-key=\"postal_code\"  aria-invalid=\"false\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_1876_phone_number\" class=\"um-field um-field-tel  um-field-phone_number um-field-tel um-field-type_tel\" data-key=\"phone_number\"><div class=\"um-field-label\"><div class=\"um-field-label-icon\"><i class=\"um-faicon-phone\" aria-label=\"Phone\"><\/i><\/div><label for=\"phone_number-1876\">Phone<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid \" type=\"tel\" name=\"phone_number-1876\" id=\"phone_number-1876\" value=\"\" placeholder=\"\" data-validate=\"phone_number\" data-key=\"phone_number\"  aria-invalid=\"false\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><\/div><\/div><div class=\"um-row _um_row_3 \" style=\"margin: 0 0 30px 0;\"><div class=\"um-col-1\"><div  class=\"um-field um-field-block  um-field-block um-field-type_block\" data-key=\"um_block_1876_20\"><h2><strong>License Information<\/strong><\/h2><\/div><div  id=\"um_field_1876_license_country_1\" class=\"um-field um-field-select  um-field-license_country_1 um-field-select um-field-type_select\" data-key=\"license_country_1\"><div class=\"um-field-label\"><label for=\"license_country_1-1876\">License Country 1<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area  \"><select data-default=\"\"     name=\"license_country_1\" id=\"license_country_1\" data-validate=\"\" data-key=\"license_country_1\" class=\"um-form-field valid um-s1 \" style=\"width: 100%\" data-placeholder=\"\"  data-um-ajax-source=\"smartsites_get_countries\"   aria-invalid=\"false\" ><option value=\"\"><\/option><option value=\"US\" >United States or Canada<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"AX\" >\u00c5land Islands<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia, Plurinational State of<\/option><option value=\"BQ\" >Bonaire, Sint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CV\" >Cape Verde<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo, the Democratic Republic of the<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"VA\" >Holy See (Vatican City State)<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran, Islamic Republic of<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea, Democratic People&#039;s Republic of<\/option><option value=\"KR\" >Korea, Republic of<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MK\" >Macedonia, the Former Yugoslav Republic of<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia, Federated States of<\/option><option value=\"MD\" >Moldova, Republic of<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine, State of<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SZ\" >Swaziland<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Province of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania, United Republic of<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TR\" >Turkey<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VE\" >Venezuela, Bolivarian Republic of<\/option><option value=\"VN\" >Viet Nam<\/option><option value=\"VG\" >Virgin Islands, British<\/option><option value=\"VI\" >Virgin Islands, U.S.<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AN\" >Netherlands Antilles<\/option><option value=\"FX\" >France, Metropolitan<\/option><option value=\"TP\" >East Timor<\/option><option value=\"YU\" >Yugoslavia<\/option><\/select><\/div><\/div><div  id=\"um_field_1876_license_1_state\" class=\"um-field um-field-text  um-is-conditional um-field-license_1_state um-field-text um-field-type_text\" data-key=\"license_1_state\" data-cond-0-action=\"hide\" data-cond-0-field=\"license_country_1\" data-cond-0-operator=\"equals to\" data-cond-0-value=\"US\"><div class=\"um-field-label\"><label for=\"license_1_state-1876\">State\/Province\/Territory<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid \" type=\"text\" name=\"license_1_state-1876\" id=\"license_1_state-1876\" value=\"\" placeholder=\"\" data-validate=\"\" data-key=\"license_1_state\"  aria-invalid=\"false\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_1876_license_1_state_usa\" class=\"um-field um-field-select  um-is-conditional um-field-license_1_state_usa um-field-select um-field-type_select\" data-key=\"license_1_state_usa\" data-cond-0-action=\"show\" data-cond-0-field=\"license_country_1\" data-cond-0-operator=\"equals to\" data-cond-0-value=\"US\"><div class=\"um-field-label\"><label for=\"license_1_state_usa-1876\">State\/Province\/Territory<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area  \"><select data-default=\"\"     name=\"license_1_state_usa\" id=\"license_1_state_usa\" data-validate=\"\" data-key=\"license_1_state_usa\" class=\"um-form-field valid not-required um-s1 \" style=\"width: 100%\" data-placeholder=\"\"  data-um-ajax-source=\"smartsites_get_usa_states\"   aria-invalid=\"false\" ><option value=\"\"><\/option><option value=\"AB\" >Alberta<\/option><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"BC\" >British Columbia<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"DE\" >Delaware<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MB\" >Manitoba<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\" >Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NB\" >Newfoundland and Labrador<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"NS\" >Nova Scotia<\/option><option value=\"NT\" >Northwest Territories<\/option><option value=\"NU\" >Nunavut<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"ON\" >Ontario<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"PE\" >Prince Edward Island<\/option><option value=\"QC\" >Quebec<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SK\" >Saskatchewan<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><option value=\"YT\" >Yukon<\/option><\/select><\/div><\/div><div  id=\"um_field_1876_license_1\" class=\"um-field um-field-text  um-field-license_1 um-field-text um-field-type_text\" data-key=\"license_1\"><div class=\"um-field-label\"><label for=\"license_1-1876\">License #<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid \" type=\"text\" name=\"license_1-1876\" id=\"license_1-1876\" value=\"\" placeholder=\"\" data-validate=\"\" data-key=\"license_1\"  aria-invalid=\"false\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_1876_pa_license_number\" class=\"um-field um-field-text  um-is-conditional um-field-pa_license_number um-field-text um-field-type_text\" data-key=\"pa_license_number\" data-cond-0-action=\"show\" data-cond-0-field=\"license_1_state_usa\" data-cond-0-operator=\"equals to\" data-cond-0-value=\"PA\"><div class=\"um-field-label\"><label for=\"pa_license_number-1876\">Repeat PA License Number so form will be accepted<\/label><span class=\"um-tip um-tip-w\" title=\"Re-enter PA license number for data to be accepted\"><i class=\"um-icon-help-circled\"><\/i><\/span><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid not-required \" type=\"text\" name=\"pa_license_number-1876\" id=\"pa_license_number-1876\" value=\"DC\" placeholder=\"\" data-validate=\"\" data-key=\"pa_license_number\"  aria-invalid=\"false\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_1876_photo_id\" class=\"um-field um-field-image  um-is-conditional um-field-photo_id um-field-image um-field-type_image\" data-key=\"photo_id\" data-cond-0-action=\"show\" data-cond-0-field=\"license_1_state_usa\" data-cond-0-operator=\"equals to\" data-cond-0-value=\"FL\" data-mode=\"register\" data-upload-label=\"Upload Photo ID\"><input type=\"hidden\" name=\"photo_id-1876\" id=\"photo_id-1876\" value=\"\"  aria-invalid=\"false\" \/><div class=\"um-field-label\"><label for=\"photo_id-1876\">Photo ID Upload as Required by the Florida Board of Chiropractic Medicine for verification.<\/label><span class=\"um-tip um-tip-w\" title=\"This upload field is for Florida DC&#039;s to upload their Photo ID or Driver&#039;s License image.\"><i class=\"um-icon-help-circled\"><\/i><\/span><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\" style=\"text-align: center;\"><div class=\"um-single-image-preview \" data-crop=\"0\" data-key=\"photo_id\"><a href=\"javascript:void(0);\" class=\"cancel\"><i class=\"um-icon-close\"><\/i><\/a><img decoding=\"async\" class=\"fusion-lazyload-ignore\" src=\"\" alt=\"\" \/><div class=\"um-clear\"><\/div><\/div><a href=\"javascript:void(0);\" data-modal=\"um_upload_single\" data-modal-size=\"normal\" data-modal-copy=\"1\" class=\"um-button um-btn-auto-width\">Upload Photo ID<\/a><\/div><div class=\"um-modal-hidden-content\"><div class=\"um-modal-header\"> Photo ID Upload as Required by the Florida Board of Chiropractic Medicine for verification.<\/div><div class=\"um-modal-body\"><div class=\"um-single-image-preview \"  data-crop=\"0\" data-ratio=\"1\" data-min_width=\"\" data-min_height=\"\" data-coord=\"\"><a href=\"javascript:void(0);\" class=\"cancel\"><i class=\"um-icon-close\"><\/i><\/a><img decoding=\"async\" class=\"fusion-lazyload-ignore\" src=\"\" alt=\"\" \/><div class=\"um-clear\"><\/div><\/div><div class=\"um-clear\"><\/div><div class=\"um-single-image-upload\" data-user_id=\"\" data-nonce=\"52339c7a36\" data-timestamp=\"1779867649\"  data-set_id=\"1876\" data-set_mode=\"register\" data-type=\"image\" data-key=\"photo_id\" data-max_size=\"999999999\" data-max_size_error=\"This image is too large!\" data-min_size_error=\"This image is too small!\" data-extension_error=\"Sorry this is not a valid image.\"  data-allowed_types=\"png,jpeg,jpg,gif\" data-upload_text=\"Drag &amp; Drop Photo\" data-max_files_error=\"You can only upload one image\" data-upload_help_text=\"Click on the Upload button to choose a file from your computer\">Upload Photo ID<\/div><div class=\"um-modal-footer\">\n\t\t\t\t\t\t\t\t\t<div class=\"um-modal-right\">\n\t\t\t\t\t\t\t\t\t\t<a href=\"javascript:void(0);\" class=\"um-modal-btn um-finish-upload image disabled\" data-key=\"photo_id\" data-change=\"Change photo\" data-processing=\"Processing...\">Apply<\/a>\n\t\t\t\t\t\t\t\t\t\t<a href=\"javascript:void(0);\" class=\"um-modal-btn alt\" data-action=\"um_remove_modal\"> Cancel<\/a>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"um-clear\"><\/div>\n\t\t\t\t\t\t\t\t<\/div><\/div><\/div><\/div><div  class=\"um-field um-field-divider  um-field-divider um-field-type_divider\" data-key=\"um_divider_1876_27\" style=\"border-bottom:4px solid #eeeeee;\"><\/div><div  id=\"um_field_1876_license_country_2\" class=\"um-field um-field-select  um-field-license_country_2 um-field-select um-field-type_select\" data-key=\"license_country_2\"><div class=\"um-field-label\"><label for=\"license_country_2-1876\">License Country 2<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area  \"><select data-default=\"\"     name=\"license_country_2\" id=\"license_country_2\" data-validate=\"\" data-key=\"license_country_2\" class=\"um-form-field valid um-s1 \" style=\"width: 100%\" data-placeholder=\"\"  data-um-ajax-source=\"smartsites_get_countries\"   aria-invalid=\"false\" ><option value=\"\"><\/option><option value=\"US\" >United States or Canada<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"AX\" >\u00c5land Islands<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia, Plurinational State of<\/option><option value=\"BQ\" >Bonaire, Sint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CV\" >Cape Verde<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo, the Democratic Republic of the<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"VA\" >Holy See (Vatican City State)<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran, Islamic Republic of<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea, Democratic People&#039;s Republic of<\/option><option value=\"KR\" >Korea, Republic of<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MK\" >Macedonia, the Former Yugoslav Republic of<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia, Federated States of<\/option><option value=\"MD\" >Moldova, Republic of<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine, State of<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SZ\" >Swaziland<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Province of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania, United Republic of<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TR\" >Turkey<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VE\" >Venezuela, Bolivarian Republic of<\/option><option value=\"VN\" >Viet Nam<\/option><option value=\"VG\" >Virgin Islands, British<\/option><option value=\"VI\" >Virgin Islands, U.S.<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AN\" >Netherlands Antilles<\/option><option value=\"FX\" >France, Metropolitan<\/option><option value=\"TP\" >East Timor<\/option><option value=\"YU\" >Yugoslavia<\/option><\/select><\/div><\/div><div  id=\"um_field_1876_license_2_state\" class=\"um-field um-field-text  um-is-conditional um-field-license_2_state um-field-text um-field-type_text\" data-key=\"license_2_state\" data-cond-0-action=\"hide\" data-cond-0-field=\"license_country_2\" data-cond-0-operator=\"equals to\" data-cond-0-value=\"US\"><div class=\"um-field-label\"><label for=\"license_2_state-1876\">State\/Province\/Territory<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid \" type=\"text\" name=\"license_2_state-1876\" id=\"license_2_state-1876\" value=\"\" placeholder=\"\" data-validate=\"\" data-key=\"license_2_state\"  aria-invalid=\"false\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  id=\"um_field_1876_license_2_state_usa\" class=\"um-field um-field-select  um-is-conditional um-field-license_2_state_usa um-field-select um-field-type_select\" data-key=\"license_2_state_usa\" data-cond-0-action=\"show\" data-cond-0-field=\"license_country_2\" data-cond-0-operator=\"equals to\" data-cond-0-value=\"US\"><div class=\"um-field-label\"><label for=\"license_2_state_usa-1876\">State\/Province\/Territory<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area  \"><select data-default=\"\"     name=\"license_2_state_usa\" id=\"license_2_state_usa\" data-validate=\"\" data-key=\"license_2_state_usa\" class=\"um-form-field valid um-s1 \" style=\"width: 100%\" data-placeholder=\"\"  data-um-ajax-source=\"smartsites_get_usa_states\"   aria-invalid=\"false\" ><option value=\"\"><\/option><option value=\"AB\" >Alberta<\/option><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"BC\" >British Columbia<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"DE\" >Delaware<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MB\" >Manitoba<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\" >Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NB\" >Newfoundland and Labrador<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"NS\" >Nova Scotia<\/option><option value=\"NT\" >Northwest Territories<\/option><option value=\"NU\" >Nunavut<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"ON\" >Ontario<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"PE\" >Prince Edward Island<\/option><option value=\"QC\" >Quebec<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SK\" >Saskatchewan<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><option value=\"YT\" >Yukon<\/option><\/select><\/div><\/div><div  id=\"um_field_1876_license_2\" class=\"um-field um-field-text  um-field-license_2 um-field-text um-field-type_text\" data-key=\"license_2\"><div class=\"um-field-label\"><label for=\"license_2-1876\">License #<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area\"><input  autocomplete=\"off\" class=\"um-form-field valid \" type=\"text\" name=\"license_2-1876\" id=\"license_2-1876\" value=\"\" placeholder=\"\" data-validate=\"\" data-key=\"license_2\"  aria-invalid=\"false\" \/>\n\n\t\t\t\t\t\t<\/div><\/div><div  class=\"um-field um-field-divider  um-field-divider um-field-type_divider\" data-key=\"um_divider_1876_27_28\" style=\"border-bottom:4px solid #eeeeee;\"><\/div><div  id=\"um_field_1876_license_country_3\" class=\"um-field um-field-select  um-field-license_country_3 um-field-select um-field-type_select\" data-key=\"license_country_3\"><div class=\"um-field-label\"><label for=\"license_country_3-1876\">License Country 3<\/label><div class=\"um-clear\"><\/div><\/div><div class=\"um-field-area  \"><select data-default=\"\"     name=\"license_country_3\" id=\"license_country_3\" data-validate=\"\" data-key=\"license_country_3\" class=\"um-form-field valid um-s1 \" style=\"width: 100%\" data-placeholder=\"\"  data-um-ajax-source=\"smartsites_get_countries\"   aria-invalid=\"false\" ><option value=\"\"><\/option><option value=\"US\" >United States or Canada<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"AX\" >\u00c5land Islands<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia, Plurinational State of<\/option><option value=\"BQ\" >Bonaire, Sint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CV\" >Cape Verde<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo, the Democratic Republic of the<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"VA\" >Holy See (Vatican City State)<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran, Islamic Republic of<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea, Democratic People&#039;s Republic of<\/option><option value=\"KR\" >Korea, Republic of<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MK\" >Macedonia, the Former Yugoslav Republic of<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia, Federated States of<\/option><option value=\"MD\" >Moldova, Republic of<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine, State of<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SZ\" >Swaziland<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Province of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania, United Republic of<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TR\" >Turkey<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VE\" >Venezuela, Bolivarian Republic of<\/option><option value=\"VN\" >Viet Nam<\/option><option value=\"VG\" >Virgin Islands, British<\/option><option value=\"VI\" >Virgin Islands, U.S.<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AN\" >Netherlands Antilles<\/option><option value=\"FX\" >France, Metropolitan<\/option><option value=\"TP\" >East Timor<\/option><option value=\"YU\" >Yugoslavia<\/option><\/select><\/div><\/div><div  id=\"um_field_1876_license_3_state\" class=\"um-field um-field-text  um-is-conditional um-field-license_3_state um-field-text um-field-type_text\" data-key=\"license_3_state\" data-cond-0-action=\"hide\" data-cond-0-field=\"license_country_3\" data-cond-0-operator=\"equals to\" data-cond-0-value=\"US\"><div class=\"um-field-label\"><label 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data-validate=\"\" data-key=\"license_3_state_usa\" class=\"um-form-field valid um-s1 \" style=\"width: 100%\" data-placeholder=\"\"  data-um-ajax-source=\"smartsites_get_usa_states\"   aria-invalid=\"false\" ><option value=\"\"><\/option><option value=\"AB\" >Alberta<\/option><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"BC\" >British Columbia<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"DE\" >Delaware<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" 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