src/chrome/test/data/autofill/heuristics/input/16_crbug_87517.html

   1 <!-- https://www.givedirect.org/give/givefrm.asp?CID=1721 -->
   2 <table align="center" id="btable" width="810">
   3   <tr>
   4     <td valign="top" align="center" id="btable">
   5       <h1>
   6         MATHCOUNTS Foundation
   7       </h1>
   8       <h2>
   9         Online Donation Form
  10       </h2>
  11     </td>
  12   </tr>
  13   <tr>
  14     <td></td>
  15   </tr>
  16   <tr>
  17     <td>
  18       <form name="donation" method="post" id="donation">
  19         <!--begin the form-->
  20         <input type="hidden" name="IsSubmitted" value="Yes"> <input type="hidden" name="BaseURL" value=""> <span>
  21         <textarea name="f1" id="f1" value="" rows="2" cols="3">
  22 </textarea></span>
  23         <table border="0">
  24           <tr>
  25             <td width="310">
  26               <table>
  27                 <tr>
  28                   <td width="20">
  29                     <img src="#">
  30                   </td>
  31                   <td valign="middle" width="330">
  32                     <div>
  33                       Contact Information
  34                     </div>
  35                   </td>
  36                 </tr>
  37               </table>
  38               <div>
  39                 <div>
  40                   Name <span>*</span><br>
  41                   <input name="dnrfirst" value="" type="text" size="15" maxlength="50" tabindex="1">&nbsp;<input name="dnrlast" value="" type="text" size="15" maxlength="50" tabindex="2"><br>
  42                   Company<br>
  43                   <input name="company" value="" type="text" size="36" maxlength="100" tabindex="3"><br>
  44                   Address 1 <span>*</span><br>
  45                   <input name="dadd1" id="dadd1" value="" type="text" size="36" maxlength="155" tabindex="4" autocomplete="off"><br>
  46                   Address 2<br>
  47                   <input name="dadd2" id="dadd2" type="text" value="" size="36" maxlength="155" tabindex="5"><br>
  48                   City / State / Zip <span>*</span><br>
  49                   <input name="dcity" id="dcity" value="" type="text" size="12" maxlength="60" tabindex="6"> &nbsp; <select name="dstate" id="dstate" tabindex="6">
  50                     <option id="USA-AL" value="AL">
  51                       AL
  52                     </option>
  53                     <option id="USA-AK" value="AK">
  54                       AK
  55                     </option>
  56                     <option id="USA-AZ" value="AZ">
  57                       AZ
  58                     </option>
  59                     <option id="USA-AR" value="AR">
  60                       AR
  61                     </option>
  62                     <option id="USA-CA" value="CA">
  63                       CA
  64                     </option>
  65                     <option id="USA-CO" value="CO">
  66                       CO
  67                     </option>
  68                     <option id="USA-CT" value="CT">
  69                       CT
  70                     </option>
  71                     <option id="USA-DE" value="DE">
  72                       DE
  73                     </option>
  74                     <option id="USA-DC" value="DC">
  75                       DC
  76                     </option>
  77                     <option id="USA-FL" value="FL">
  78                       FL
  79                     </option>
  80                     <option id="USA-GA" value="GA">
  81                       GA
  82                     </option>
  83                     <option id="USA-GU" value="GU">
  84                       GU
  85                     </option>
  86                     <option id="USA-HI" value="HI">
  87                       HI
  88                     </option>
  89                     <option id="USA-ID" value="ID">
  90                       ID
  91                     </option>
  92                     <option id="USA-IL" value="IL">
  93                       IL
  94                     </option>
  95                     <option id="USA-IN" value="IN">
  96                       IN
  97                     </option>
  98                     <option id="USA-IA" value="IA">
  99                       IA
 100                     </option>
 101                     <option id="USA-KS" value="KS">
 102                       KS
 103                     </option>
 104                     <option id="USA-KY" value="KY">
 105                       KY
 106                     </option>
 107                     <option id="USA-LA" value="LA">
 108                       LA
 109                     </option>
 110                     <option id="USA-ME" value="ME">
 111                       ME
 112                     </option>
 113                     <option id="USA-MD" value="MD">
 114                       MD
 115                     </option>
 116                     <option id="USA-MA" value="MA">
 117                       MA
 118                     </option>
 119                     <option id="USA-MI" value="MI">
 120                       MI
 121                     </option>
 122                     <option id="USA-MN" value="MN">
 123                       MN
 124                     </option>
 125                     <option id="USA-MS" value="MS">
 126                       MS
 127                     </option>
 128                     <option id="USA-MO" value="MO">
 129                       MO
 130                     </option>
 131                     <option id="USA-MT" value="MT">
 132                       MT
 133                     </option>
 134                     <option id="USA-NE" value="NE">
 135                       NE
 136                     </option>
 137                     <option id="USA-NV" value="NV">
 138                       NV
 139                     </option>
 140                     <option id="USA-NH" value="NH">
 141                       NH
 142                     </option>
 143                     <option id="USA-NJ" value="NJ">
 144                       NJ
 145                     </option>
 146                     <option id="USA-NM" value="NM">
 147                       NM
 148                     </option>
 149                     <option id="USA-NY" value="NY">
 150                       NY
 151                     </option>
 152                     <option id="USA-NC" value="NC">
 153                       NC
 154                     </option>
 155                     <option id="USA-ND" value="ND">
 156                       ND
 157                     </option>
 158                     <option id="USA-OH" value="OH">
 159                       OH
 160                     </option>
 161                     <option id="USA-OK" value="OK">
 162                       OK
 163                     </option>
 164                     <option id="USA-OR" value="OR">
 165                       OR
 166                     </option>
 167                     <option id="USA-PA" value="PA">
 168                       PA
 169                     </option>
 170                     <option id="USA-PR" value="PR">
 171                       PR
 172                     </option>
 173                     <option id="USA-RI" value="RI">
 174                       RI
 175                     </option>
 176                     <option id="USA-SC" value="SC">
 177                       SC
 178                     </option>
 179                     <option id="USA-SD" value="SD">
 180                       SD
 181                     </option>
 182                     <option id="USA-TN" value="TN">
 183                       TN
 184                     </option>
 185                     <option id="USA-TX" value="TX">
 186                       TX
 187                     </option>
 188                     <option id="USA-UT" value="UT">
 189                       UT
 190                     </option>
 191                     <option id="USA-VT" value="VT">
 192                       VT
 193                     </option>
 194                     <option id="USA-VA" value="VA">
 195                       VA
 196                     </option>
 197                     <option id="USA-VI" value="VI">
 198                       VI
 199                     </option>
 200                     <option id="USA-WA" value="WA">
 201                       WA
 202                     </option>
 203                     <option id="USA-WV" value="WV">
 204                       WV
 205                     </option>
 206                     <option id="USA-WI" value="WI">
 207                       WI
 208                     </option>
 209                     <option id="USA-WY" value="WY">
 210                       WY
 211                     </option>
 212                     <option>
 213                       ----
 214                     </option>
 215                     <option id="CAN-AB" value="AB">
 216                       AB
 217                     </option>
 218                     <option id="CAN-BC" value="BC">
 219                       BC
 220                     </option>
 221                     <option id="CAN-MB" value="MB">
 222                       MB
 223                     </option>
 224                     <option id="CAN-NB" value="NB">
 225                       NB
 226                     </option>
 227                     <option id="CAN-NL" value="NL">
 228                       NL
 229                     </option>
 230                     <option id="CAN-NT" value="NT">
 231                       NT
 232                     </option>
 233                     <option id="CAN-NS" value="NS">
 234                       NS
 235                     </option>
 236                     <option id="CAN-NU" value="NU">
 237                       NU
 238                     </option>
 239                     <option id="CAN-PE" value="PE">
 240                       PE
 241                     </option>
 242                     <option id="CAN-SK" value="SK">
 243                       SK
 244                     </option>
 245                     <option id="CAN-ON" value="ON">
 246                       ON
 247                     </option>
 248                     <option id="CAN-QC" value="QC">
 249                       QC
 250                     </option>
 251                     <option id="CAN-YT" value="YT">
 252                       YT
 253                     </option>
 254                     <option>
 255                       ----
 256                     </option>
 257                     <option id="OS-AA" value="AA">
 258                       AA
 259                     </option>
 260                     <option id="OS-AE" value="AE">
 261                       AE
 262                     </option>
 263                     <option id="OS-AP" value="AP">
 264                       AP
 265                     </option>
 266                   </select> &nbsp; <input name="dzip" id="dzip" value="" type="text" size="8" maxlength="10" tabindex="7"><br>
 267                   Country<br>
 268                   <select name="CC_COUNTRY">
 269                     <option value="Albania">
 270                       Albania
 271                     </option>
 272                     <option value="Algeria">
 273                       Algeria
 274                     </option>
 275                     <option value="American Samoa">
 276                       American Samoa
 277                     </option>
 278                     <option value="Andorra">
 279                       Andorra
 280                     </option>
 281                     <option value="Anguilla">
 282                       Anguilla
 283                     </option>
 284                     <option value="Antigua">
 285                       Antigua
 286                     </option>
 287                     <option value="Argentina">
 288                       Argentina
 289                     </option>
 290                     <option value="Aruba">
 291                       Aruba
 292                     </option>
 293                     <option value="Australia">
 294                       Australia
 295                     </option>
 296                     <option value="Austria">
 297                       Austria
 298                     </option>
 299                     <option value="Azores">
 300                       Azores
 301                     </option>
 302                     <option value="Bahamas">
 303                       Bahamas
 304                     </option>
 305                     <option value="Bahrain">
 306                       Bahrain
 307                     </option>
 308                     <option value="Bangladesh">
 309                       Bangladesh
 310                     </option>
 311                     <option value="Barbados">
 312                       Barbados
 313                     </option>
 314                     <option value="Belgium">
 315                       Belgium
 316                     </option>
 317                     <option value="Belize">
 318                       Belize
 319                     </option>
 320                     <option value="Belarus">
 321                       Belarus
 322                     </option>
 323                     <option value="Benin">
 324                       Benin
 325                     </option>
 326                     <option value="Bermuda">
 327                       Bermuda
 328                     </option>
 329                     <option value="Bolivia">
 330                       Bolivia
 331                     </option>
 332                     <option value="Bonaire">
 333                       Bonaire
 334                     </option>
 335                     <option value="Botswana">
 336                       Botswana
 337                     </option>
 338                     <option value="Brazil">
 339                       Brazil
 340                     </option>
 341                     <option value="Brunei">
 342                       Brunei
 343                     </option>
 344                     <option value="Bulgaria">
 345                       Bulgaria
 346                     </option>
 347                     <option value="Burkina Faso">
 348                       Burkina Faso
 349                     </option>
 350                     <option value="Burundi">
 351                       Burundi
 352                     </option>
 353                     <option value="Cambodia">
 354                       Cambodia
 355                     </option>
 356                     <option value="Cameroon">
 357                       Cameroon
 358                     </option>
 359                     <option value="Canada">
 360                       Canada
 361                     </option>
 362                     <option value="Canary Islands">
 363                       Canary Islands
 364                     </option>
 365                     <option value="Cape Verde Islands">
 366                       Cape Verde Islands
 367                     </option>
 368                     <option value="Cayman Islands">
 369                       Cayman Islands
 370                     </option>
 371                     <option value="Channel Islands">
 372                       Channel Islands
 373                     </option>
 374                     <option value="Chile">
 375                       Chile
 376                     </option>
 377                     <option value="China">
 378                       China
 379                     </option>
 380                     <option value="Colombia">
 381                       Colombia
 382                     </option>
 383                     <option value="Congo">
 384                       Congo
 385                     </option>
 386                     <option value="Cook Islands">
 387                       Cook Islands
 388                     </option>
 389                     <option value="Costa Rica">
 390                       Costa Rica
 391                     </option>
 392                     <option value="Croatia">
 393                       Croatia
 394                     </option>
 395                     <option value="Curacao">
 396                       Curacao
 397                     </option>
 398                     <option value="Cyprus">
 399                       Cyprus
 400                     </option>
 401                     <option value="Czech Republic">
 402                       Czech Republic
 403                     </option>
 404                     <option value="Denmark">
 405                       Denmark
 406                     </option>
 407                     <option value="Djibouti">
 408                       Djibouti
 409                     </option>
 410                     <option value="Dominica">
 411                       Dominica
 412                     </option>
 413                     <option value="Dominican Republic">
 414                       Dominican Republic
 415                     </option>
 416                     <option value="Ecuador">
 417                       Ecuador
 418                     </option>
 419                     <option value="Egypt">
 420                       Egypt
 421                     </option>
 422                     <option value="El Salvador">
 423                       El Salvador
 424                     </option>
 425                     <option value="England">
 426                       England
 427                     </option>
 428                     <option value="Equitorial Guinea">
 429                       Equitorial Guinea
 430                     </option>
 431                     <option value="Eritrea">
 432                       Eritrea
 433                     </option>
 434                     <option value="Estonia">
 435                       Estonia
 436                     </option>
 437                     <option value="Ethiopia">
 438                       Ethiopia
 439                     </option>
 440                     <option value="Faeroe Islands">
 441                       Faeroe Islands
 442                     </option>
 443                     <option value="Fiji">
 444                       Fiji
 445                     </option>
 446                     <option value="Finland">
 447                       Finland
 448                     </option>
 449                     <option value="France">
 450                       France
 451                     </option>
 452                     <option value="French Guiana">
 453                       French Guiana
 454                     </option>
 455                     <option value="French Polynesia">
 456                       French Polynesia
 457                     </option>
 458                     <option value="Gabon">
 459                       Gabon
 460                     </option>
 461                     <option value="Gambia">
 462                       Gambia
 463                     </option>
 464                     <option value="Georgia">
 465                       Georgia
 466                     </option>
 467                     <option value="Germany">
 468                       Germany
 469                     </option>
 470                     <option value="Ghana">
 471                       Ghana
 472                     </option>
 473                     <option value="Gibraltar">
 474                       Gibraltar
 475                     </option>
 476                     <option value="Greece">
 477                       Greece
 478                     </option>
 479                     <option value="Greenland">
 480                       Greenland
 481                     </option>
 482                     <option value="Grenada">
 483                       Grenada
 484                     </option>
 485                     <option value="Guadeloupe">
 486                       Guadeloupe
 487                     </option>
 488                     <option value="Guam">
 489                       Guam
 490                     </option>
 491                     <option value="Guatemala">
 492                       Guatemala
 493                     </option>
 494                     <option value="Guinea">
 495                       Guinea
 496                     </option>
 497                     <option value="Guinea-Bissau">
 498                       Guinea-Bissau
 499                     </option>
 500                     <option value="Guyana">
 501                       Guyana
 502                     </option>
 503                     <option value="Haiti">
 504                       Haiti
 505                     </option>
 506                     <option value="Holland">
 507                       Holland
 508                     </option>
 509                     <option value="Honduras">
 510                       Honduras
 511                     </option>
 512                     <option value="Hong Kong">
 513                       Hong Kong
 514                     </option>
 515                     <option value="Hungary">
 516                       Hungary
 517                     </option>
 518                     <option value="Iceland">
 519                       Iceland
 520                     </option>
 521                     <option value="India">
 522                       India
 523                     </option>
 524                     <option value="Indonesia">
 525                       Indonesia
 526                     </option>
 527                     <option value="Ireland">
 528                       Ireland
 529                     </option>
 530                     <option value="Israel">
 531                       Israel
 532                     </option>
 533                     <option value="Italy">
 534                       Italy
 535                     </option>
 536                     <option value="Ivory Coast">
 537                       Ivory Coast
 538                     </option>
 539                     <option value="Jamaica">
 540                       Jamaica
 541                     </option>
 542                     <option value="Japan">
 543                       Japan
 544                     </option>
 545                     <option value="Jordan">
 546                       Jordan
 547                     </option>
 548                     <option value="Kazakhstan">
 549                       Kazakhstan
 550                     </option>
 551                     <option value="Kenya">
 552                       Kenya
 553                     </option>
 554                     <option value="Kiribati">
 555                       Kiribati
 556                     </option>
 557                     <option value="Kosrae">
 558                       Kosrae
 559                     </option>
 560                     <option value="Kuwait">
 561                       Kuwait
 562                     </option>
 563                     <option value="Kyrgyzstan">
 564                       Kyrgyzstan
 565                     </option>
 566                     <option value="Laos">
 567                       Laos
 568                     </option>
 569                     <option value="Latvia">
 570                       Latvia
 571                     </option>
 572                     <option value="Lebanon">
 573                       Lebanon
 574                     </option>
 575                     <option value="Lesotho">
 576                       Lesotho
 577                     </option>
 578                     <option value="Liberia">
 579                       Liberia
 580                     </option>
 581                     <option value="Liechtenstein">
 582                       Liechtenstein
 583                     </option>
 584                     <option value="Lithuania">
 585                       Lithuania
 586                     </option>
 587                     <option value="Luxembourg">
 588                       Luxembourg
 589                     </option>
 590                     <option value="Macau">
 591                       Macau
 592                     </option>
 593                     <option value="Macedonia">
 594                       Macedonia
 595                     </option>
 596                     <option value="Madagascar">
 597                       Madagascar
 598                     </option>
 599                     <option value="Madeira">
 600                       Madeira
 601                     </option>
 602                     <option value="Malawi">
 603                       Malawi
 604                     </option>
 605                     <option value="Malaysia">
 606                       Malaysia
 607                     </option>
 608                     <option value="Maldives">
 609                       Maldives
 610                     </option>
 611                     <option value="Mali">
 612                       Mali
 613                     </option>
 614                     <option value="Malta">
 615                       Malta
 616                     </option>
 617                     <option value="Marshall Islands">
 618                       Marshall Islands
 619                     </option>
 620                     <option value="Martinique">
 621                       Martinique
 622                     </option>
 623                     <option value="Mauritania">
 624                       Mauritania
 625                     </option>
 626                     <option value="Mauritius">
 627                       Mauritius
 628                     </option>
 629                     <option value="Mexico">
 630                       Mexico
 631                     </option>
 632                     <option value="Moldova">
 633                       Moldova
 634                     </option>
 635                     <option value="Monaco">
 636                       Monaco
 637                     </option>
 638                     <option value="Montserrat">
 639                       Montserrat
 640                     </option>
 641                     <option value="Morocco">
 642                       Morocco
 643                     </option>
 644                     <option value="Mozambique">
 645                       Mozambique
 646                     </option>
 647                     <option value="Myanmar">
 648                       Myanmar
 649                     </option>
 650                     <option value="Namibia">
 651                       Namibia
 652                     </option>
 653                     <option value="Nepal">
 654                       Nepal
 655                     </option>
 656                     <option value="Netherlands">
 657                       Netherlands
 658                     </option>
 659                     <option value="New Caledonia">
 660                       New Caledonia
 661                     </option>
 662                     <option value="New Zealand">
 663                       New Zealand
 664                     </option>
 665                     <option value="Nicaragua">
 666                       Nicaragua
 667                     </option>
 668                     <option value="Niger">
 669                       Niger
 670                     </option>
 671                     <option value="Nigeria">
 672                       Nigeria
 673                     </option>
 674                     <option value="Norfolk Island">
 675                       Norfolk Island
 676                     </option>
 677                     <option value="Northern Ireland">
 678                       Northern Ireland
 679                     </option>
 680                     <option value="Norway">
 681                       Norway
 682                     </option>
 683                     <option value="Oman">
 684                       Oman
 685                     </option>
 686                     <option value="Pakistan">
 687                       Pakistan
 688                     </option>
 689                     <option value="Palau">
 690                       Palau
 691                     </option>
 692                     <option value="Panama">
 693                       Panama
 694                     </option>
 695                     <option value="Papua New Guinea">
 696                       Papua New Guinea
 697                     </option>
 698                     <option value="Paraguay">
 699                       Paraguay
 700                     </option>
 701                     <option value="Peru">
 702                       Peru
 703                     </option>
 704                     <option value="Philippines">
 705                       Philippines
 706                     </option>
 707                     <option value="Poland">
 708                       Poland
 709                     </option>
 710                     <option value="Ponape">
 711                       Ponape
 712                     </option>
 713                     <option value="Portugal">
 714                       Portugal
 715                     </option>
 716                     <option value="Puerto Rico">
 717                       Puerto Rico
 718                     </option>
 719                     <option value="Qatar">
 720                       Qatar
 721                     </option>
 722                     <option value="Reunion">
 723                       Reunion
 724                     </option>
 725                     <option value="Romania">
 726                       Romania
 727                     </option>
 728                     <option value="Rota">
 729                       Rota
 730                     </option>
 731                     <option value="Russia">
 732                       Russia
 733                     </option>
 734                     <option value="Rwanda">
 735                       Rwanda
 736                     </option>
 737                     <option value="Saba">
 738                       Saba
 739                     </option>
 740                     <option value="Saipan">
 741                       Saipan
 742                     </option>
 743                     <option value="Saudi Arabia">
 744                       Saudi Arabia
 745                     </option>
 746                     <option value="Scotland">
 747                       Scotland
 748                     </option>
 749                     <option value="Senegal">
 750                       Senegal
 751                     </option>
 752                     <option value="Seychelles">
 753                       Seychelles
 754                     </option>
 755                     <option value="Sierra Leone">
 756                       Sierra Leone
 757                     </option>
 758                     <option value="Singapore">
 759                       Singapore
 760                     </option>
 761                     <option value="Slovakia">
 762                       Slovakia
 763                     </option>
 764                     <option value="Slovenia">
 765                       Slovenia
 766                     </option>
 767                     <option value="Solomon Islands">
 768                       Solomon Islands
 769                     </option>
 770                     <option value="South Africa">
 771                       South Africa
 772                     </option>
 773                     <option value="South Korea">
 774                       South Korea
 775                     </option>
 776                     <option value="Spain">
 777                       Spain
 778                     </option>
 779                     <option value="Sri Lanka">
 780                       Sri Lanka
 781                     </option>
 782                     <option value="St. Barthelemy">
 783                       St. Barthelemy
 784                     </option>
 785                     <option value="St. Christopher">
 786                       St. Christopher
 787                     </option>
 788                     <option value="St. Croix">
 789                       St. Croix
 790                     </option>
 791                     <option value="St. Eustatius">
 792                       St. Eustatius
 793                     </option>
 794                     <option value="St. John">
 795                       St. John
 796                     </option>
 797                     <option value="St. Lucia">
 798                       St. Lucia
 799                     </option>
 800                     <option value="St. Maarten">
 801                       St. Maarten
 802                     </option>
 803                     <option value="St. Martin">
 804                       St. Martin
 805                     </option>
 806                     <option value="St. Thomas">
 807                       St. Thomas
 808                     </option>
 809                     <option value="Sudan">
 810                       Sudan
 811                     </option>
 812                     <option value="Suriname">
 813                       Suriname
 814                     </option>
 815                     <option value="Swaziland">
 816                       Swaziland
 817                     </option>
 818                     <option value="Sweden">
 819                       Sweden
 820                     </option>
 821                     <option value="Switzerland">
 822                       Switzerland
 823                     </option>
 824                     <option value="Syria">
 825                       Syria
 826                     </option>
 827                     <option value="Tahiti">
 828                       Tahiti
 829                     </option>
 830                     <option value="Taiwan">
 831                       Taiwan
 832                     </option>
 833                     <option value="Tajikistan">
 834                       Tajikistan
 835                     </option>
 836                     <option value="Tanzania">
 837                       Tanzania
 838                     </option>
 839                     <option value="Thailand">
 840                       Thailand
 841                     </option>
 842                     <option value="Tinian">
 843                       Tinian
 844                     </option>
 845                     <option value="Togo">
 846                       Togo
 847                     </option>
 848                     <option value="Tonga">
 849                       Tonga
 850                     </option>
 851                     <option value="Tortola">
 852                       Tortola
 853                     </option>
 854                     <option value="Trinidad and Tobago">
 855                       Trinidad and Tobago
 856                     </option>
 857                     <option value="Truk">
 858                       Truk
 859                     </option>
 860                     <option value="Tunisia">
 861                       Tunisia
 862                     </option>
 863                     <option value="Turkey">
 864                       Turkey
 865                     </option>
 866                     <option value="Tuvalu">
 867                       Tuvalu
 868                     </option>
 869                     <option value="Uganda">
 870                       Uganda
 871                     </option>
 872                     <option value="Ukraine">
 873                       Ukraine
 874                     </option>
 875                     <option value="Union Island">
 876                       Union Island
 877                     </option>
 878                     <option value="United Arab Emirates">
 879                       United Arab Emirates
 880                     </option>
 881                     <option value="United Kingdom">
 882                       United Kingdom
 883                     </option>
 884                     <option value="United States" selected>
 885                       United States
 886                     </option>
 887                     <option value="Uruguay">
 888                       Uruguay
 889                     </option>
 890                     <option value="US Virgin Islands">
 891                       US Virgin Islands
 892                     </option>
 893                     <option value="Uzbekistan">
 894                       Uzbekistan
 895                     </option>
 896                     <option value="Vanuatu">
 897                       Vanuatu
 898                     </option>
 899                     <option value="Venezuela">
 900                       Venezuela
 901                     </option>
 902                     <option value="Vietnam">
 903                       Vietnam
 904                     </option>
 905                     <option value="Virgin Gorda">
 906                       Virgin Gorda
 907                     </option>
 908                     <option value="Wake Island">
 909                       Wake Island
 910                     </option>
 911                     <option value="Wales">
 912                       Wales
 913                     </option>
 914                     <option value="Western Samoa">
 915                       Western Samoa
 916                     </option>
 917                     <option value="Yap">
 918                       Yap
 919                     </option>
 920                     <option value="Yemen">
 921                       Yemen
 922                     </option>
 923                     <option value="Zaire">
 924                       Zaire
 925                     </option>
 926                     <option value="Zambia">
 927                       Zambia
 928                     </option>
 929                     <option value="Zimbabwe">
 930                       Zimbabwe
 931                     </option>
 932                   </select><br>
 933                   Telephone<br>
 934                   <input name="dphone" value="" type="text" size="36" maxlength="20" tabindex="8"><br>
 935                   Email <span>*</span><br>
 936                   <input name="demail" value="" type="text" size="36" maxlength="155" tabindex="9"><br>
 937                   <br>
 938                 </div>
 939               </div>
 940             </td>
 941             <td>
 942               <div>
 943                 <table border="0">
 944                   <tr>
 945                     <td>
 946                       <img src="#" alt="Number 2">
 947                     </td>
 948                     <td valign="middle" width="350">
 949                       <div>
 950                         &nbsp;Donation Information
 951                       </div>
 952                     </td>
 953                   </tr>
 954                 </table>
 955                 <div>
 956                   <b>Gift amount in USD <span>($10 minimum)</span><br>
 957                   $<input name="amt" id="amt" type="text" value="" size="5" maxlength="25" tabindex="10">.00</b>
 958                   <p>
 959                     <input type="checkbox" name="tributeSelect" tabindex="11" value="on"> My donation is In Honor or In Memory of someone special
 960                   </p>
 961                   <p>
 962                     <!--<b>Donation Preference</b><br>-->
 963                      <input name="DonationType" type="radio" value="OneTime" checked tabindex="12">This is a one time donation<br>
 964                     <input name="DonationType" type="radio" value="Recurs" tabindex="13">I would like to make this a recurring donation deducted <select name="ccrecurring" tabindex="14">
 965                       <option value="Monthly">
 966                         Monthly
 967                       </option>
 968                       <option value="Quarterly">
 969                         Quarterly
 970                       </option>
 971                       <option value="Annually">
 972                         Annually
 973                       </option>
 974                     </select>
 975                   </p>
 976                   <p>
 977                     <b>Comments</b><br>
 978                     <span>( You may enter up to 500 characters. )&nbsp;&nbsp;&nbsp;<input value="500" name="remLen" size="3" maxlength="3" readonly="readonly"> characters left</span><br>
 979                     <textarea name="Comments" rows="3" cols="45" wrap="physical" onkeydown="textCounter(this.form.Comments,this.form.remLen,500);" onkeyup="textCounter(this.form.Comments,this.form.remLen,500);" tabindex="17">
 980 </textarea>
 981                   </p>
 982                 </div>
 983               </div>
 984             </td>
 985           </tr>
 986           <tr>
 987             <td colspan="2">
 988               <div id="div_tribute" style='display: none;'><br>
 989               <table border="0">
 990                 <tr>
 991                   <td width="20">
 992                     <img src="#">
 993                   </td>
 994                   <td valign="middle" width="330">
 995                     <div>
 996                       Tribute Information:
 997                     </div>
 998                   </td>
 999                 </tr>
1000               </table>
1001               <div>
1002                 <table>
1003                   <tr>
1004                     <td>
1005                       <table>
1006                         <tr>
1007                           <td></td>
1008                           <td>
1009                             <input type="radio" name="tribute" value="IHO" tabindex="18">In Honor Of &nbsp;&nbsp;&nbsp; <input type="radio" name="tribute" value="IMO" tabindex="19">In Memory Of
1010                           </td>
1011                         </tr>
1012                         <tr>
1013                           <td>
1014                             Name:
1015                           </td>
1016                           <td>
1017                             <input type="text" name="Tribute_Name" maxlength="100" size="35" value="" tabindex="20">
1018                           </td>
1019                         </tr>
1020                         <tr>
1021                           <td>
1022                             Occasion:
1023                           </td>
1024                           <td>
1025                             <input type="text" name="Tribute_occasion" maxlength="100" size="35" value="" tabindex="21">
1026                           </td>
1027                         </tr>
1028                         <tr>
1029                           <td colspan="2" align="left">
1030                             <input type="checkbox" name="Tribute_Disclosure" value="on" tabindex="22">I wish to remain anonymous<br>
1031                             <input type="checkbox" name="Tribute_Notification" value="on" tabindex="23">Please send a notification of my gift to the following address:
1032                           </td>
1033                         </tr>
1034                       </table>
1035                     </td>
1036                     <td>
1037                       <div id="div_notify" style='display: none;'>
1038                       <div>
1039                         <table>
1040                           <tr>
1041                             <td colspan="2" align="right">
1042                               <input type="radio" name="Tribute_IncludeAmount" tabindex="24" value="1">Include the amount &nbsp;&nbsp; <input type="radio" name="Tribute_IncludeAmount" checked tabindex="25" value="0">Do not include the amount
1043                             </td>
1044                           </tr>
1045                           <tr>
1046                             <td>
1047                               Name:
1048                             </td>
1049                             <td>
1050                               <input type="text" name="Tribute_NotifyName" maxlength="100" size="40" value="" tabindex="26">
1051                             </td>
1052                           </tr>
1053                           <tr>
1054                             <td>
1055                               Email:
1056                             </td>
1057                             <td>
1058                               <input type="text" name="Tribute_Email" maxlength="50" size="40" value="" tabindex="27">
1059                             </td>
1060                           </tr>
1061                           <tr>
1062                             <td>
1063                               Street:
1064                             </td>
1065                             <td>
1066                               <input type="text" name="Tribute_NotifyAddr" maxlength="200" size="40" value="" tabindex="28">
1067                             </td>
1068                           </tr>
1069                           <tr>
1070                             <td>
1071                               City / St. / Zip:
1072                             </td>
1073                             <td>
1074                               <input type="text" name="Tribute_NotifyCity" maxlength="60" size="15" value="" tabindex="29"> &nbsp; <input type="text" name="Tribute_NotifyState" maxlength="10" size="2" value="" tabindex="30"> &nbsp; <input type="text" name="Tribute_NotifyZip" maxlength="10" size="10" value="" tabindex="31">
1075                             </td>
1076                           </tr>
1077                         </table>
1078                       </div>
1079                     </td>
1080                   </tr>
1081                 </table>
1082               </div><!-- End Hide Notify Div -->
1083               <!-- End TributeBox Div --><!-- End Hide Tribute Div -->
1084             </td>
1085           </tr>
1086           <tr>
1087             <td colspan="2">
1088               <!-- ///PAYMENT BOX -->
1089               <br>
1090               <table border="0">
1091                 <tr>
1092                   <td width="20">
1093                     <div id="div_payment">
1094                       <img src='images/icons/red4.png'>
1095                     </div>
1096                     <div id="div_paymentmain">
1097                       <img src='images/icons/red3.png'>
1098                     </div>
1099                   </td>
1100                   <td valign="middle" width="330">
1101                     <div>
1102                       Payment Information:
1103                     </div>
1104                   </td>
1105                 </tr>
1106               </table>
1107               <div>
1108                 <table>
1109                   <tr>
1110                     <td width="10"></td>
1111                     <td>
1112                       <p>
1113                         <b>Credit Card Information</b><br>
1114                         <img src="#"><br>
1115                         <br>
1116                         Credit Card Type <span>*</span><br>
1117                         <select name="cctype" tabindex="32">
1118                           <option value="Visa">
1119                             Visa
1120                           </option>
1121                           <option value="MasterCard">
1122                             MasterCard
1123                           </option>
1124                           <option value="AmericanExpress">
1125                             American Express
1126                           </option>
1127                         </select><br>
1128                         Credit Card Number <span>*</span><br>
1129                         <input name="ccard" type="text" value="" size="25" maxlength="25" tabindex="32" autocomplete="off"><br>
1130                         CSC Number <span>* <a href="#">What Is This?</a></span><br>
1131                         <input tabindex="33" name="csc" type="text" value="" size="25" maxlength="4" autocomplete="off"><br>
1132                         Expiration Date <span>*</span><br>
1133                         Month <select name="ExpMon" tabindex="34">
1134                           <option value="1">
1135                             1
1136                           </option>
1137                           <option value="2">
1138                             2
1139                           </option>
1140                           <option value="3">
1141                             3
1142                           </option>
1143                           <option value="4">
1144                             4
1145                           </option>
1146                           <option value="5">
1147                             5
1148                           </option>
1149                           <option value="6">
1150                             6
1151                           </option>
1152                           <option value="7">
1153                             7
1154                           </option>
1155                           <option value="8">
1156                             8
1157                           </option>
1158                           <option value="9">
1159                             9
1160                           </option>
1161                           <option value="10">
1162                             10
1163                           </option>
1164                           <option value="11">
1165                             11
1166                           </option>
1167                           <option value="12">
1168                             12
1169                           </option>
1170                         </select> Year <select name="ExpYear" size="1" tabindex="35">
1171                           <option value="11">
1172                             2011
1173                           </option>
1174                           <option value="12">
1175                             2012
1176                           </option>
1177                           <option value="13">
1178                             2013
1179                           </option>
1180                           <option value="14">
1181                             2014
1182                           </option>
1183                           <option value="15">
1184                             2015
1185                           </option>
1186                           <option value="16">
1187                             2016
1188                           </option>
1189                           <option value="17">
1190                             2017
1191                           </option>
1192                           <option value="18">
1193                             2018
1194                           </option>
1195                           <option value="19">
1196                             2019
1197                           </option>
1198                         </select><br>
1199                       </p>
1200                     </td>
1201                     <td width="150"></td>
1202                     <td>
1203                       <p>
1204                         <b>Billing Address</b> - <input type="checkbox" name="SameAddress" value="checkbox" tabindex="36">Same As Contact Address<br>
1205                         <br>
1206                         Address 1 <span>*</span><br>
1207                         <input name="CC_Addr" id="CC_Addr" value="" type="text" size="36" maxlength="155" tabindex="37"><br>
1208                         Address 2<br>
1209                         <input name="CC_Addr2" id="CC_Addr2" type="text" value="" size="36" maxlength="155" tabindex="38"><br>
1210                         City / State / Zip <span>*</span><br>
1211                         <input name="CC_City" id="CC_City" value="" type="text" size="12" maxlength="60" tabindex="39"> &nbsp; <input name="CC_State" id="CC_State" value="" type="text" size="2" maxlength="10" tabindex="40"> &nbsp; <input name="CC_Zip" id="CC_Zip" value="" type="text" size="10" maxlength="10" tabindex="41">
1212                       </p>
1213                       <p>
1214                         <b>Thank you for your support!</b>
1215                       </p>
1216                       <p>
1217                         <input type="image" src="#" name="Action" value="Submit" tabindex="42">
1218                       </p>
1219                     </td>
1220                   </tr>
1221                 </table>
1222               </div><!-- End Payment Box div  -->
1223             </td>
1224           </tr>
1225         </table>
1226       </form>
1227     </td>
1228   </tr>
1229 </table>