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Submitted URL: http://jaronnyc.org/
Effective URL: https://donate.hakuapp.com/donations/new?fundraiser=28c80838fd213c7f38f1
Submission: On July 27 via api from US — Scanned from DE
Effective URL: https://donate.hakuapp.com/donations/new?fundraiser=28c80838fd213c7f38f1
Submission: On July 27 via api from US — Scanned from DE
Form analysis 2 forms found in the DOM
POST /donations
<form accept-charset="UTF-8" action="/donations" class="donations-form" data-validate="true" id="donation-form" method="post" novalidate="novalidate">
<div style="margin:0;padding:0;display:inline"><input name="utf8" type="hidden" value="✓"><input name="authenticity_token" type="hidden" value="FymEJkZFpv8ZylqBwsWSIr7bWRRuOfxwp2PhCeEsd5M="></div>
<div class="panel-group form-group" id="panel-donation" role="tablist" aria-multiselectable="true">
<div class="panel panel-default donation-panel" data-fundraiser-key="28c80838fd213c7f38f1" data-team-name="Jaron J Martinez" data-amount="" data-donate-behalf="" data-is-donated="false" data-in-memory-of="false">
<div class="panel-heading hidden" role="tab" id="donation-heading">
<div data-toggle="collapse" data-parent="#panel-donation" data-target="#donation-info" aria-expanded="false" aria-controls="donation-info">
<div class="col-xs-12 no-padding">
<span class="col-xs-9 col-sm-12 no-padding truncate-text"> Donation to Jaron J Martinez </span>
</div>
<span class="media-left media-middle no-wrap currency-container">
<span class="currency"></span>
</span>
<div class="media-left media-middle no-wrap" style="width: 24px;">
<i class="indicator halflings chevron-down"></i>
</div>
</div>
</div>
<div id="donation-info" class="panel-collapse in" role="tabpanel" aria-labelledby="donation-heading">
<div class="col-md-12 no-padding donation-number-circle">
<div class="number-circle text-center">1</div>
<h2 class="title-text no-margin no-border">Your donation</h2>
</div>
<div class="col-xs-12 no-padding">
<table class="col-xs-12 fundraiser-change-panel ">
<tbody>
<tr>
<td class="padding-10 text-center">
<img src="https://s3.amazonaws.com/hakuapps/prod/662bad88d17bd4e50e00c1b65f4456278fab6836.jpeg?1682174533" class="img-circle" alt="Jaron Martinez">
</td>
<td class="padding-right-10"> You are donating to <span class="title-text-color"> Jaron J Martinez </span>
</td>
<td>
<a href="#" class="change-event-promoter">Change</a>
</td>
</tr>
</tbody>
</table>
</div>
<div class="panel-body col-xs-12 no-padding donation-form-container no-padding-x ">
<div id="donationOptionsSection" class="hidden">
<div class="row form-group ">
<fieldset>
<legend id="df_dt_l1" class="col-md-12 font-18 no-margin color-666 text-capitalize no-border">Donate To</legend>
<div class="spacer-5"></div>
<ul class="list-unstyled no-margin col-md-12 donation-selection-options" role="radiogroup" aria-labelledby="df_dt_l1">
<li aria-checked="true" role="radio" class="form-group full-width clearfix">
<div class="">
<input id="ben_key" name="ben_key" type="hidden" value="757da8b090e7f1ae2dc3">
<input id="ben_name" name="ben_name" type="hidden" value="Cystic Fibrosis Foundation">
<div class="radio-holder no-margin">
<input type="radio" aria-labelledby="donation_charity_label donation_charity_span" autocomplete="off" name="donation_to" id="donation_charity" value="false" class="regular-radio beneficiary-radio" checked="">
<label id="donation_charity_label" for="donation_charity" class="no-margin">Cystic Fibrosis Foundation</label>
<span id="donation_charity_span" class="regular-radio-text display-inline-xs">Cystic Fibrosis Foundation</span>
</div>
</div>
</li>
<li aria-checked="true" role="radio" class="form-group full-width clearfix bg-eeeeee">
<div class="">
<div class="radio-holder no-margin">
<input type="radio" aria-labelledby="donation_fundraiser_label donation_fundraiser_span" autocomplete="off" name="donation_to" id="donation_fundraiser" value="28c80838fd213c7f38f1" class="regular-radio fundraiser-radio"
checked="">
<label id="donation_fundraiser_label" for="donation_fundraiser" class="no-margin">An individual fundraiser</label>
<span id="donation_fundraiser_span" class="regular-radio-text display-inline-xs">An individual fundraiser</span>
</div>
</div>
<div class="input-container col-xs-12 " style="margin-top: 10px;">
<div class="dropdown-field form-group col-xs-12 no-padding" id="team_search" data-parent-container="" data-url="/events/f6aab8b88460d18a07ed/event_promoter_search?beneficiary_key=757da8b090e7f1ae2dc3"
data-key="28c80838fd213c7f38f1" data-team-key="">
<label for="donation_fundraiser_input_search" class="sr-only">Search for An individual fundraiser</label>
<span class="fundraiser-search-input"><i class="glyphicons search"></i></span>
<input autocomplete="off" class="form-control search-input-box no-error-label input_search visibleRequired selectionRequired " data-selected="28c80838fd213c7f38f1" id="donation_fundraiser_input_search"
name="donation_fundraiser_input_search" placeholder="Search for An individual fundraiser" type="text" value="Jaron J Martinez" aria-label="Search for An individual fundraiser">
<div class="drop_down_symbol">
<b></b>
</div>
<div id="team_container" class="team-element dropdown-submenu-container hide">
<ul class="sub-menu teams-menu" role="listbox" aria-labelledby="donation_fundraiser_label">
</ul>
</div>
</div>
</div>
</li>
</ul>
</fieldset>
<div class="spacer"></div>
<div class="spacer"></div>
</div>
</div>
<div class="row donation-section form-group">
<div class="col-xs-12">
<div id="fundraiser-container" class="col-sm-12 ">
<span class="header text-capitalize">
<span class="name">Jaron</span> needs <span class="amount">$3,808.00</span> to meet the fundraising minimum commitment of <span class="total">$4,000.00</span>
</span>
<span class="body text-capitalize">Help <span class="name">Jaron</span> reach their fundraising goals!</span>
<div class="col-xs-12">
<button class="btn match-donation-btn" name="button" type="btn match-donation-btn text-capitalize" value="3808.0">Donate <span class="amount">$3,808.00</span> to <span class="name">Jaron</span></button>
</div>
</div>
</div>
<fieldset>
<legend class="col-md-12 font-18 no-margin text-capitalize color-666 no-border">Choose or enter a donation amount</legend>
<div class="flex">
<div class="form-group col-md-12 clearfix">
<div class="donation-amounts col-xs-12 no-padding">
<div class="donation-buttons clearfix full-width" data-toggle="buttons">
<a class="btn margin-x-5" role="button" tabindex="0">
<input id="donation_amount_btn_10" name="donation_amount_btn" type="radio" value="10">$10
<label for="donation_amount_btn_10" class="sr-only">
$10
</label>
</a>
<a class="btn margin-x-5" role="button" tabindex="0">
<input id="donation_amount_btn_25" name="donation_amount_btn" type="radio" value="25">$25
<label for="donation_amount_btn_25" class="sr-only">
$25
</label>
</a>
<a class="btn margin-x-5" role="button" tabindex="0">
<input id="donation_amount_btn_50" name="donation_amount_btn" type="radio" value="50">$50
<label for="donation_amount_btn_50" class="sr-only">
$50
</label>
</a>
<a class="btn margin-x-5" role="button" tabindex="0">
<input id="donation_amount_btn_100" name="donation_amount_btn" type="radio" value="100">$100
<label for="donation_amount_btn_100" class="sr-only">
$100
</label>
</a>
</div> <!-- ./ btn grp -->
</div>
<div class="spacer-25 hidden-xs"></div>
<div class="money-display-container col-xs-12 no-padding">
<div class="input-group margin-x-4">
<span class="input-group-addon">$</span>
<label for="donation_amount" class="sr-only">Donation Amount</label>
<input autocomplete="off" class="form-control text-right money-input " data-rule="money" id="donation_amount" maxlength="50" name="donation_amount" required="required" type="number" aria-required="true">
<span class="input-group-addon not-focus cents-display">.00</span>
</div>
</div>
</div> <!-- ./ col 12 -->
</div>
</fieldset>
</div> <!-- ./row donation section -->
<div class="spacer-25"></div>
<div class="form-group row donation-selection-type">
<fieldset>
<div class="row">
<div class="col-md-12">
<div class="col-md-12">
<div class="number-circle text-center">2</div>
<h2 class="title-text no-margin no-border">Make this donation</h2>
<legend id="df_mtd_l" class="no-border font-18 text-capitalize color-666 margin-top-10">How would you like to donate?</legend>
</div>
<ul class="list-unstyled no-margin col-md-12 donation-selection-list" role="radiogroup" aria-labelledby="df_mtd_l">
<li aria-checked="true" role="radio" class="form-group clearfix full-width">
<div class="media-left media-middle no-wrap">
<div class="radio-holder no-margin">
<input type="radio" autocomplete="off" aria-labelledby="my_name_label my_name_span" name="is_donation_hidden" id="is_donation_hidden1" value="false" class="regular-radio" checked="">
<label for="is_donation_hidden1" id="my_name_label" class="no-margin">In my name</label>
<span class="regular-radio-text" id="my_name_span">In my name</span>
</div>
</div>
</li>
<li aria-checked="false" role="radio" class="form-group clearfix full-width">
<div class="media-left media-middle no-wrap">
<div class="radio-holder no-margin">
<input aria-describedby="different_name_span" aria-labelledby="different_name_label different_name_span" class="regular-radio" data-input-target="#text_for_donate_under_different_name" id="is_donation_hidden2"
name="is_donation_hidden" type="radio" value="false">
<label for="is_donation_hidden2" id="different_name_label" class="no-margin">Under a different name</label>
<span class="regular-radio-text tooltip-link" id="different_name_span" role="tooltip" data-container="body" data-placement="top" data-content="Choose this option to donate as an organization, family, couple, etc"
data-original-title="" title="">Under a different name</span>
</div>
</div>
</li>
<li aria-checked="false" role="radio" class="form-group clearfix full-width">
<div class="media-left media-middle no-wrap">
<div class="radio-holder no-margin">
<input aria-labelledby="honor_of_label honor_of_span" class="regular-radio in-memory-of" data-input-target="#text_for_donate_in_memory_of_name" id="is_donation_hidden3" name="is_donation_hidden" type="radio" value="true">
<label for="is_donation_hidden3" id="honor_of_label" class="no-margin">In memory of someone</label>
<span class="regular-radio-text" id="honor_of_span">In memory of someone</span>
</div>
</div>
</li>
<li aria-checked="false" role="radio" class="form-group clearfix full-width">
<div class="media-left media-middle no-wrap">
<div class="radio-holder no-margin tooltip-link" role="tooltip" id="anonymous_tooltip" data-placement="top" data-offset="50"
data-message="Jaron J Martinez will still be able to see that you are the donor, but your name will be anonymous on the public donation pages"
data-content="Jaron J Martinez will still be able to see that you are the donor, but your name will be anonymous on the public donation pages" data-original-title="" title="">
<input type="radio" autocomplete="off" name="is_donation_hidden" aria-labelledby="anonymous_label anonymous_span" id="is_donation_hidden4" value="true" class="regular-radio anonymous" aria-describedby="anonymous_tooltip">
<label for="is_donation_hidden4" id="anonymous_label" class="no-margin">Anonymous</label>
<span class="regular-radio-text" id="anonymous_span">Anonymous</span>
</div>
</div>
</li>
</ul>
<div class="row">
<div class="col-xs-12">
<div id="donation_hidden" class="full-width padding-x-15">
<input aria-label="Under a different name" autocapitalize="off" autocomplete="off" class="form-control name-mask on-behalf-of hidden" data-rule="alpha_numeric_with_some_special_characters"
id="text_for_donate_under_different_name" maxlength="50" name="text_for_donate_under_different_name" placeholder="Under a Different Name" type="text">
<label class="col-md-12 no-padding hidden in-honor-of-label hidden not-required" for="text_for_donate_in_memory_of_name"><span class="accessibility-asterisk u-display-none">* </span><span class="text-holder">Honoree
Name</span></label>
<input aria-label="In memory of someone" autocapitalize="off" autocomplete="off" class="form-control name-mask on-behalf-of hidden" data-rule="alpha_numeric_with_some_special_characters" id="text_for_donate_in_memory_of_name"
maxlength="50" name="text_for_donate_in_memory_of_name" placeholder="In memory of" type="text">
</div>
<div class="col-xs-12 honoree-info-section hidden">
</div>
</div>
</div>
</div>
<div class="col-md-12 clearfix">
<div class="col-xs-12 comments form-group clearfix no-padding ">
<div class="spacer"></div>
<div class="spacer-5"></div>
<div class="form-group clearfix margin-right-15 margin-left-15">
<h3 class="col-md-12 no-padding leave-note-text font-18 text-capitalize no-margin color-666">Leave a note to the fundraiser Jaron J Martinez</h3>
<div class="spacer-5"></div>
<label for="message" class="sr-only">Leave a note to the fundraiser Jaron J Martinez</label>
<textarea autocapitalize="off" autocomplete="off" class="form-control" cols="40" id="message" name="message" placeholder="This will be displayed on the participant's fundraising page" rows="3" style="resize: none;"></textarea>
</div>
</div>
</div>
</div>
</fieldset>
</div>
</div> <!-- /.panel-body -->
<div class="panel-footer text-uppercase hidden">
<a href="" class="removePanel">
<i aria-hidden="true" class="glyphicons bin"></i>Delete this Donation
</a>
</div>
<div class="row form-group">
<div class="form-group multiple-donation-group col-xs-12">
<button class="color-666 text-capitalize visible-xs-inline-block another-donation-btn semi-bold-text" type="button" data-button-type="add_donation"> Add another Donation </button>
<span class="or-span text-capitalize">or</span>
<button class="btn btn-primary btn-continue text-capitalize semi-bold-text" type="button" data-button-type="complete_donation"> Proceed To The Next Step </button>
</div>
</div>
</div> <!-- /.panel-collapse -->
</div> <!-- /.panel -->
</div> <!-- /.donation-info-collapse -->
<div class="panel panel-default donation-panel hidden" id="payment-form">
<div class="col-md-12 no-padding donation-number-circle">
<div class="number-circle text-center">3</div>
<h2 class="title-text no-margin no-border">Payment Information</h2>
</div>
<div>
<fieldset>
<div class="row user-personal-info form-group">
<div class="spacer-5"></div>
<div class="col-md-12 no-padding clearfix">
<div class="form-group col-xs-12 col-md-12">
<label class="col-md-12 no-padding required" for="first_name" required="required" aria-required="true"><span class="accessibility-asterisk ">* </span><span class="text-holder">First Name</span></label>
<input autocapitalize="off" autocomplete="off" class="form-control name-mask" data-id="first_name" data-rule="name" id="first_name" maxlength="50" name="first_name" placeholder="First Name" required="required" type="text"
aria-required="true">
</div> <!-- ./ -->
<div class="form-group col-xs-12 col-md-12">
<label class="col-md-12 no-padding required" for="last_name" required="required" aria-required="true"><span class="accessibility-asterisk ">* </span><span class="text-holder">Last Name</span></label>
<input autocapitalize="off" autocomplete="off" class="form-control name-mask" data-id="last_name" data-rule="name" id="last_name" maxlength="50" name="last_name" placeholder="Last Name" required="required" type="text"
aria-required="true">
</div> <!-- ./ -->
</div>
<div class="form-group col-md-12">
<label class="col-md-12 no-padding required" for="email" required="required" aria-required="true"><span class="accessibility-asterisk ">* </span><span class="text-holder">Email</span></label>
<input autocomplete="off" autocorrect="off" class="form-control email-format col-md-12" data-id="donate_email" data-rule="email" id="email" maxlength="100" name="email" placeholder="Email Address" required="required" type="email"
aria-required="true">
</div>
</div> <!-- ./ row user-personal-info -->
</fieldset>
<fieldset class="address-container">
<legend class="col-md-12 no-padding bold-font font-18 text-capitalize no-margin color-666 no-border">Address</legend>
<div class="form-group col-md-12 clearfix section-container inline-grp address-section grp-no-marginbottom no-padding" data-div-display="address_entry">
<div class="form-group col-md-12 no-padding">
<label class="col-md-12 no-padding not-required" for="country_code"><span class="accessibility-asterisk u-display-none">* </span><span class="text-holder">Country</span></label>
<select class="selectpicker" data-id="country_code" data-live-search="true" id="country_code" name="country_code" style="display: none;">
<option value="US" selected="selected">United States</option>
<option value="AF">Afghanistan</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AS">American Samoa</option>
<option value="AD">Andorra</option>
<option value="AO">Angola</option>
<option value="AI">Anguilla</option>
<option value="AQ">Antarctica</option>
<option value="AG">Antigua and Barbuda</option>
<option value="AR">Argentina</option>
<option value="AM">Armenia</option>
<option value="AW">Aruba</option>
<option value="AU">Australia</option>
<option value="AT">Austria</option>
<option value="AZ">Azerbaijan</option>
<option value="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</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="CA">Canada</option>
<option value="CV">Cabo 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="TW">Taiwan</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">Côte d'Ivoire</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czechia</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="TP">East Timor</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="GQ">Equatorial Guinea</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="ET">Ethiopia</option>
<option value="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="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="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KP">Korea, Democratic People's Republic of</option>
<option value="KR">Korea, Republic of</option>
<option value="KO">Kosovo</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Lao People'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">North Macedonia</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</option>
<option value="MC">Monaco</option>
<option value="MN">Mongolia</option>
<option value="MS">Montserrat</option>
<option value="MA">Morocco</option>
<option value="MZ">Mozambique</option>
<option value="MM">Myanmar</option>
<option value="NA">Namibia</option>
<option value="NR">Nauru</option>
<option value="NP">Nepal</option>
<option value="NL">Netherlands</option>
<option value="AN">Netherlands Antilles</option>
<option value="NC">New Caledonia</option>
<option value="NZ">New Zealand</option>
<option value="NI">Nicaragua</option>
<option value="NE">Niger</option>
<option value="NG">Nigeria</option>
<option value="NU">Niue</option>
<option value="NF">Norfolk Island</option>
<option value="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">Réunion</option>
<option value="RO">Romania</option>
<option value="RU">Russian Federation</option>
<option value="RW">Rwanda</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</option>
<option value="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="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="ES">Spain</option>
<option value="LK">Sri Lanka</option>
<option value="SH">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="PM">Saint Pierre and Miquelon</option>
<option value="SD">Sudan</option>
<option value="SR">Suriname</option>
<option value="SJ">Svalbard and Jan Mayen</option>
<option value="SZ">Eswatini</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syrian Arab Republic</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania</option>
<option value="TH">Thailand</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</option>
<option value="VN">Vietnam</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>
</select>
<div class="btn-group bootstrap-select"><button aria-haspopup="true" type="button" class="btn dropdown-toggle selectpicker btn-default" data-toggle="dropdown" data-id="country_code"><span class="filter-option pull-left">United
States</span> <span class="caret"></span></button>
<div class="dropdown-menu open">
<div class="bootstrap-select-searchbox"><input aria-label="Search" type="text" class="input-block-level form-control"></div>
<ul class="dropdown-menu inner selectpicker" role="menu">
<li rel="0" class="selected"><a tabindex="0" class="" style=""><span class="text">United States</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="1"><a tabindex="0" class="" style=""><span class="text">Afghanistan</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="2"><a tabindex="0" class="" style=""><span class="text">Albania</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="3"><a tabindex="0" class="" style=""><span class="text">Algeria</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="4"><a tabindex="0" class="" style=""><span class="text">American Samoa</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="5"><a tabindex="0" class="" style=""><span class="text">Andorra</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="6"><a tabindex="0" class="" style=""><span class="text">Angola</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="7"><a tabindex="0" class="" style=""><span class="text">Anguilla</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="8"><a tabindex="0" class="" style=""><span class="text">Antarctica</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="9"><a tabindex="0" class="" style=""><span class="text">Antigua and Barbuda</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="10"><a tabindex="0" class="" style=""><span class="text">Argentina</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="11"><a tabindex="0" class="" style=""><span class="text">Armenia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="12"><a tabindex="0" class="" style=""><span class="text">Aruba</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="13"><a tabindex="0" class="" style=""><span class="text">Australia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="14"><a tabindex="0" class="" style=""><span class="text">Austria</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="15"><a tabindex="0" class="" style=""><span class="text">Azerbaijan</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="16"><a tabindex="0" class="" style=""><span class="text">Bahamas</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="17"><a tabindex="0" class="" style=""><span class="text">Bahrain</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="18"><a tabindex="0" class="" style=""><span class="text">Bangladesh</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="19"><a tabindex="0" class="" style=""><span class="text">Barbados</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="20"><a tabindex="0" class="" style=""><span class="text">Belarus</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="21"><a tabindex="0" class="" style=""><span class="text">Belgium</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="22"><a tabindex="0" class="" style=""><span class="text">Belize</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="23"><a tabindex="0" class="" style=""><span class="text">Benin</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="24"><a tabindex="0" class="" style=""><span class="text">Bermuda</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="25"><a tabindex="0" class="" style=""><span class="text">Bhutan</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="26"><a tabindex="0" class="" style=""><span class="text">Bolivia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="27"><a tabindex="0" class="" style=""><span class="text">Bosnia and Herzegovina</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="28"><a tabindex="0" class="" style=""><span class="text">Botswana</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="29"><a tabindex="0" class="" style=""><span class="text">Bouvet Island</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="30"><a tabindex="0" class="" style=""><span class="text">Brazil</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="31"><a tabindex="0" class="" style=""><span class="text">British Indian Ocean Territory</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="32"><a tabindex="0" class="" style=""><span class="text">Brunei Darussalam</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="33"><a tabindex="0" class="" style=""><span class="text">Bulgaria</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="34"><a tabindex="0" class="" style=""><span class="text">Burkina Faso</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="35"><a tabindex="0" class="" style=""><span class="text">Burundi</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="36"><a tabindex="0" class="" style=""><span class="text">Cambodia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="37"><a tabindex="0" class="" style=""><span class="text">Cameroon</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="38"><a tabindex="0" class="" style=""><span class="text">Canada</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="39"><a tabindex="0" class="" style=""><span class="text">Cabo Verde</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="40"><a tabindex="0" class="" style=""><span class="text">Cayman Islands</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="41"><a tabindex="0" class="" style=""><span class="text">Central African Republic</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="42"><a tabindex="0" class="" style=""><span class="text">Chad</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="43"><a tabindex="0" class="" style=""><span class="text">Chile</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="44"><a tabindex="0" class="" style=""><span class="text">China</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="45"><a tabindex="0" class="" style=""><span class="text">Taiwan</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="46"><a tabindex="0" class="" style=""><span class="text">Christmas Island</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="47"><a tabindex="0" class="" style=""><span class="text">Cocos (Keeling) Islands</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="48"><a tabindex="0" class="" style=""><span class="text">Colombia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="49"><a tabindex="0" class="" style=""><span class="text">Comoros</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="50"><a tabindex="0" class="" style=""><span class="text">Congo</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="51"><a tabindex="0" class="" style=""><span class="text">Congo, The Democratic Republic of the</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="52"><a tabindex="0" class="" style=""><span class="text">Cook Islands</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="53"><a tabindex="0" class="" style=""><span class="text">Costa Rica</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="54"><a tabindex="0" class="" style=""><span class="text">Côte d'Ivoire</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="55"><a tabindex="0" class="" style=""><span class="text">Croatia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="56"><a tabindex="0" class="" style=""><span class="text">Cuba</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="57"><a tabindex="0" class="" style=""><span class="text">Cyprus</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="58"><a tabindex="0" class="" style=""><span class="text">Czechia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="59"><a tabindex="0" class="" style=""><span class="text">Denmark</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="60"><a tabindex="0" class="" style=""><span class="text">Djibouti</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="61"><a tabindex="0" class="" style=""><span class="text">Dominica</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="62"><a tabindex="0" class="" style=""><span class="text">Dominican Republic</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="63"><a tabindex="0" class="" style=""><span class="text">East Timor</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="64"><a tabindex="0" class="" style=""><span class="text">Ecuador</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="65"><a tabindex="0" class="" style=""><span class="text">Egypt</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="66"><a tabindex="0" class="" style=""><span class="text">El Salvador</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="67"><a tabindex="0" class="" style=""><span class="text">Equatorial Guinea</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="68"><a tabindex="0" class="" style=""><span class="text">Eritrea</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="69"><a tabindex="0" class="" style=""><span class="text">Estonia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="70"><a tabindex="0" class="" style=""><span class="text">Ethiopia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="71"><a tabindex="0" class="" style=""><span class="text">Falkland Islands (Malvinas)</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="72"><a tabindex="0" class="" style=""><span class="text">Faroe Islands</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="73"><a tabindex="0" class="" style=""><span class="text">Fiji</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="74"><a tabindex="0" class="" style=""><span class="text">Finland</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="75"><a tabindex="0" class="" style=""><span class="text">France</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="76"><a tabindex="0" class="" style=""><span class="text">French Guiana</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="77"><a tabindex="0" class="" style=""><span class="text">French Polynesia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="78"><a tabindex="0" class="" style=""><span class="text">French Southern Territories</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="79"><a tabindex="0" class="" style=""><span class="text">Gabon</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="80"><a tabindex="0" class="" style=""><span class="text">Gambia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="81"><a tabindex="0" class="" style=""><span class="text">Georgia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="82"><a tabindex="0" class="" style=""><span class="text">Germany</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="83"><a tabindex="0" class="" style=""><span class="text">Ghana</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="84"><a tabindex="0" class="" style=""><span class="text">Gibraltar</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="85"><a tabindex="0" class="" style=""><span class="text">Greece</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="86"><a tabindex="0" class="" style=""><span class="text">Greenland</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="87"><a tabindex="0" class="" style=""><span class="text">Grenada</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="88"><a tabindex="0" class="" style=""><span class="text">Guadeloupe</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="89"><a tabindex="0" class="" style=""><span class="text">Guam</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="90"><a tabindex="0" class="" style=""><span class="text">Guatemala</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="91"><a tabindex="0" class="" style=""><span class="text">Guinea</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="92"><a tabindex="0" class="" style=""><span class="text">Guinea-Bissau</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="93"><a tabindex="0" class="" style=""><span class="text">Guyana</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="94"><a tabindex="0" class="" style=""><span class="text">Haiti</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="95"><a tabindex="0" class="" style=""><span class="text">Heard Island and McDonald Islands</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="96"><a tabindex="0" class="" style=""><span class="text">Holy See (Vatican City State)</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="97"><a tabindex="0" class="" style=""><span class="text">Honduras</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="98"><a tabindex="0" class="" style=""><span class="text">Hong Kong</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="99"><a tabindex="0" class="" style=""><span class="text">Hungary</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="100"><a tabindex="0" class="" style=""><span class="text">Iceland</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="101"><a tabindex="0" class="" style=""><span class="text">India</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="102"><a tabindex="0" class="" style=""><span class="text">Indonesia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="103"><a tabindex="0" class="" style=""><span class="text">Iran, Islamic Republic of</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="104"><a tabindex="0" class="" style=""><span class="text">Iraq</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="105"><a tabindex="0" class="" style=""><span class="text">Ireland</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="106"><a tabindex="0" class="" style=""><span class="text">Israel</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="107"><a tabindex="0" class="" style=""><span class="text">Italy</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="108"><a tabindex="0" class="" style=""><span class="text">Jamaica</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="109"><a tabindex="0" class="" style=""><span class="text">Japan</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="110"><a tabindex="0" class="" style=""><span class="text">Jordan</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="111"><a tabindex="0" class="" style=""><span class="text">Kazakhstan</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="112"><a tabindex="0" class="" style=""><span class="text">Kenya</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="113"><a tabindex="0" class="" style=""><span class="text">Kiribati</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="114"><a tabindex="0" class="" style=""><span class="text">Korea, Democratic People's Republic of</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="115"><a tabindex="0" class="" style=""><span class="text">Korea, Republic of</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="116"><a tabindex="0" class="" style=""><span class="text">Kosovo</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="117"><a tabindex="0" class="" style=""><span class="text">Kuwait</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="118"><a tabindex="0" class="" style=""><span class="text">Kyrgyzstan</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="119"><a tabindex="0" class="" style=""><span class="text">Lao People's Democratic Republic</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="120"><a tabindex="0" class="" style=""><span class="text">Latvia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="121"><a tabindex="0" class="" style=""><span class="text">Lebanon</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="122"><a tabindex="0" class="" style=""><span class="text">Lesotho</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="123"><a tabindex="0" class="" style=""><span class="text">Liberia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="124"><a tabindex="0" class="" style=""><span class="text">Libya</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="125"><a tabindex="0" class="" style=""><span class="text">Liechtenstein</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="126"><a tabindex="0" class="" style=""><span class="text">Lithuania</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="127"><a tabindex="0" class="" style=""><span class="text">Luxembourg</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="128"><a tabindex="0" class="" style=""><span class="text">Macao</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="129"><a tabindex="0" class="" style=""><span class="text">North Macedonia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="130"><a tabindex="0" class="" style=""><span class="text">Madagascar</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="131"><a tabindex="0" class="" style=""><span class="text">Malawi</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="132"><a tabindex="0" class="" style=""><span class="text">Malaysia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="133"><a tabindex="0" class="" style=""><span class="text">Maldives</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="134"><a tabindex="0" class="" style=""><span class="text">Mali</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="135"><a tabindex="0" class="" style=""><span class="text">Malta</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="136"><a tabindex="0" class="" style=""><span class="text">Marshall Islands</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="137"><a tabindex="0" class="" style=""><span class="text">Martinique</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="138"><a tabindex="0" class="" style=""><span class="text">Mauritania</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="139"><a tabindex="0" class="" style=""><span class="text">Mauritius</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="140"><a tabindex="0" class="" style=""><span class="text">Mayotte</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="141"><a tabindex="0" class="" style=""><span class="text">Mexico</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="142"><a tabindex="0" class="" style=""><span class="text">Micronesia, Federated States of</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="143"><a tabindex="0" class="" style=""><span class="text">Moldova</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="144"><a tabindex="0" class="" style=""><span class="text">Monaco</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="145"><a tabindex="0" class="" style=""><span class="text">Mongolia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="146"><a tabindex="0" class="" style=""><span class="text">Montserrat</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="147"><a tabindex="0" class="" style=""><span class="text">Morocco</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="148"><a tabindex="0" class="" style=""><span class="text">Mozambique</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="149"><a tabindex="0" class="" style=""><span class="text">Myanmar</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="150"><a tabindex="0" class="" style=""><span class="text">Namibia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="151"><a tabindex="0" class="" style=""><span class="text">Nauru</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="152"><a tabindex="0" class="" style=""><span class="text">Nepal</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="153"><a tabindex="0" class="" style=""><span class="text">Netherlands</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="154"><a tabindex="0" class="" style=""><span class="text">Netherlands Antilles</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="155"><a tabindex="0" class="" style=""><span class="text">New Caledonia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="156"><a tabindex="0" class="" style=""><span class="text">New Zealand</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="157"><a tabindex="0" class="" style=""><span class="text">Nicaragua</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="158"><a tabindex="0" class="" style=""><span class="text">Niger</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="159"><a tabindex="0" class="" style=""><span class="text">Nigeria</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="160"><a tabindex="0" class="" style=""><span class="text">Niue</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="161"><a tabindex="0" class="" style=""><span class="text">Norfolk Island</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="162"><a tabindex="0" class="" style=""><span class="text">Northern Mariana Islands</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="163"><a tabindex="0" class="" style=""><span class="text">Norway</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="164"><a tabindex="0" class="" style=""><span class="text">Oman</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="165"><a tabindex="0" class="" style=""><span class="text">Pakistan</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="166"><a tabindex="0" class="" style=""><span class="text">Palau</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="167"><a tabindex="0" class="" style=""><span class="text">Palestine, State of</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="168"><a tabindex="0" class="" style=""><span class="text">Panama</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="169"><a tabindex="0" class="" style=""><span class="text">Papua New Guinea</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="170"><a tabindex="0" class="" style=""><span class="text">Paraguay</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="171"><a tabindex="0" class="" style=""><span class="text">Peru</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="172"><a tabindex="0" class="" style=""><span class="text">Philippines</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="173"><a tabindex="0" class="" style=""><span class="text">Pitcairn</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="174"><a tabindex="0" class="" style=""><span class="text">Poland</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="175"><a tabindex="0" class="" style=""><span class="text">Portugal</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="176"><a tabindex="0" class="" style=""><span class="text">Puerto Rico</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="177"><a tabindex="0" class="" style=""><span class="text">Qatar</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="178"><a tabindex="0" class="" style=""><span class="text">Réunion</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="179"><a tabindex="0" class="" style=""><span class="text">Romania</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="180"><a tabindex="0" class="" style=""><span class="text">Russian Federation</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="181"><a tabindex="0" class="" style=""><span class="text">Rwanda</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="182"><a tabindex="0" class="" style=""><span class="text">Saint Kitts and Nevis</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="183"><a tabindex="0" class="" style=""><span class="text">Saint Lucia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="184"><a tabindex="0" class="" style=""><span class="text">Saint Vincent and the Grenadines</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="185"><a tabindex="0" class="" style=""><span class="text">Samoa</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="186"><a tabindex="0" class="" style=""><span class="text">San Marino</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="187"><a tabindex="0" class="" style=""><span class="text">Sao Tome and Principe</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="188"><a tabindex="0" class="" style=""><span class="text">Saudi Arabia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="189"><a tabindex="0" class="" style=""><span class="text">Senegal</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="190"><a tabindex="0" class="" style=""><span class="text">Serbia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="191"><a tabindex="0" class="" style=""><span class="text">Seychelles</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="192"><a tabindex="0" class="" style=""><span class="text">Sierra Leone</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="193"><a tabindex="0" class="" style=""><span class="text">Singapore</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="194"><a tabindex="0" class="" style=""><span class="text">Slovakia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="195"><a tabindex="0" class="" style=""><span class="text">Slovenia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="196"><a tabindex="0" class="" style=""><span class="text">Solomon Islands</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="197"><a tabindex="0" class="" style=""><span class="text">Somalia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="198"><a tabindex="0" class="" style=""><span class="text">South Africa</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="199"><a tabindex="0" class="" style=""><span class="text">South Georgia and the South Sandwich Islands</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="200"><a tabindex="0" class="" style=""><span class="text">Spain</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="201"><a tabindex="0" class="" style=""><span class="text">Sri Lanka</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="202"><a tabindex="0" class="" style=""><span class="text">Saint Helena, Ascension and Tristan da Cunha</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="203"><a tabindex="0" class="" style=""><span class="text">Saint Pierre and Miquelon</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="204"><a tabindex="0" class="" style=""><span class="text">Sudan</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="205"><a tabindex="0" class="" style=""><span class="text">Suriname</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="206"><a tabindex="0" class="" style=""><span class="text">Svalbard and Jan Mayen</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="207"><a tabindex="0" class="" style=""><span class="text">Eswatini</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="208"><a tabindex="0" class="" style=""><span class="text">Sweden</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="209"><a tabindex="0" class="" style=""><span class="text">Switzerland</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="210"><a tabindex="0" class="" style=""><span class="text">Syrian Arab Republic</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="211"><a tabindex="0" class="" style=""><span class="text">Tajikistan</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="212"><a tabindex="0" class="" style=""><span class="text">Tanzania</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="213"><a tabindex="0" class="" style=""><span class="text">Thailand</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="214"><a tabindex="0" class="" style=""><span class="text">Togo</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="215"><a tabindex="0" class="" style=""><span class="text">Tokelau</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="216"><a tabindex="0" class="" style=""><span class="text">Tonga</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="217"><a tabindex="0" class="" style=""><span class="text">Trinidad and Tobago</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="218"><a tabindex="0" class="" style=""><span class="text">Tunisia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="219"><a tabindex="0" class="" style=""><span class="text">Turkey</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="220"><a tabindex="0" class="" style=""><span class="text">Turkmenistan</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="221"><a tabindex="0" class="" style=""><span class="text">Turks and Caicos Islands</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="222"><a tabindex="0" class="" style=""><span class="text">Tuvalu</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="223"><a tabindex="0" class="" style=""><span class="text">Uganda</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="224"><a tabindex="0" class="" style=""><span class="text">Ukraine</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="225"><a tabindex="0" class="" style=""><span class="text">United Arab Emirates</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="226"><a tabindex="0" class="" style=""><span class="text">United Kingdom</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="227"><a tabindex="0" class="" style=""><span class="text">United States Minor Outlying Islands</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="228"><a tabindex="0" class="" style=""><span class="text">Uruguay</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="229"><a tabindex="0" class="" style=""><span class="text">Uzbekistan</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="230"><a tabindex="0" class="" style=""><span class="text">Vanuatu</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="231"><a tabindex="0" class="" style=""><span class="text">Venezuela</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="232"><a tabindex="0" class="" style=""><span class="text">Vietnam</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="233"><a tabindex="0" class="" style=""><span class="text">Virgin Islands, British</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="234"><a tabindex="0" class="" style=""><span class="text">Virgin Islands, U.S.</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="235"><a tabindex="0" class="" style=""><span class="text">Wallis and Futuna</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="236"><a tabindex="0" class="" style=""><span class="text">Western Sahara</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="237"><a tabindex="0" class="" style=""><span class="text">Yemen</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="238"><a tabindex="0" class="" style=""><span class="text">Zambia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="239"><a tabindex="0" class="" style=""><span class="text">Zimbabwe</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
</ul>
</div>
</div>
</div>
<div class="form-group col-md-12 no-padding">
<label class="col-md-12 no-padding not-required" for="line1"><span class="accessibility-asterisk u-display-none">* </span><span class="text-holder">Street Address</span></label>
<input autocomplete="off" class="form-control" data-id="line1" id="line1" maxlength="120" name="line1" placeholder="Street Address" type="text">
</div>
<div class="form-group col-md-12 no-padding">
<label class="col-md-12 no-padding not-required" for="line2"><span class="accessibility-asterisk u-display-none">* </span><span class="text-holder">Apt, Suite, Unit</span></label>
<input autocomplete="off" class="form-control" data-id="line2" id="line2" maxlength="100" name="line2" placeholder="Apt, Suite, Unit" type="text">
</div>
<div class="form-group col-xs-12 col-md-6 no-padding-left city-form-control">
<label class="col-md-12 no-padding not-required" for="city"><span class="accessibility-asterisk u-display-none">* </span><span class="text-holder">City</span></label>
<input autocomplete="off" class="form-control" data-id="city" id="city" maxlength="100" name="city" placeholder="City" type="text">
</div>
<div class="form-group col-xs-6 col-md-4 no-padding-left city-form-control ">
<label class="col-md-12 no-padding not-required" for="state_code"><span class="accessibility-asterisk u-display-none">* </span><span class="text-holder">State</span></label>
<select class="selectpicker" data-aria-label="State" data-id="state_code" data-live-search="true" id="state_code" name="state_code" style="display: none;">
<option value="">Please Select</option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">Washington DC</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="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="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" selected="selected">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="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="AA">Armed Forces Americas</option>
<option value="AE">Armed Forces Europe</option>
<option value="AP">Armed Forces Pacific</option>
<option value="APO">Army/Air Force Post Office (APO)</option>
<option value="DPO">Diplomatic Post Office (DPO)</option>
<option value="FPO">Fleet Post Office (FPO)</option>
</select>
<div class="btn-group bootstrap-select"><button aria-haspopup="true" type="button" class="btn dropdown-toggle selectpicker btn-default" data-toggle="dropdown" data-id="state_code"><span class="filter-option pull-left">New
York</span> <span class="caret"></span></button>
<div class="dropdown-menu open">
<div class="bootstrap-select-searchbox"><input aria-label="Search" type="text" class="input-block-level form-control"></div>
<ul class="dropdown-menu inner selectpicker" role="menu">
<li rel="0"><a tabindex="0" class="" style=""><span class="text">Please Select</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="1"><a tabindex="0" class="" style=""><span class="text">Alabama</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="2"><a tabindex="0" class="" style=""><span class="text">Alaska</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="3"><a tabindex="0" class="" style=""><span class="text">Arizona</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="4"><a tabindex="0" class="" style=""><span class="text">Arkansas</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="5"><a tabindex="0" class="" style=""><span class="text">California</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="6"><a tabindex="0" class="" style=""><span class="text">Colorado</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="7"><a tabindex="0" class="" style=""><span class="text">Connecticut</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="8"><a tabindex="0" class="" style=""><span class="text">Delaware</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="9"><a tabindex="0" class="" style=""><span class="text">Washington DC</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="10"><a tabindex="0" class="" style=""><span class="text">Florida</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="11"><a tabindex="0" class="" style=""><span class="text">Georgia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="12"><a tabindex="0" class="" style=""><span class="text">Hawaii</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="13"><a tabindex="0" class="" style=""><span class="text">Idaho</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="14"><a tabindex="0" class="" style=""><span class="text">Illinois</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="15"><a tabindex="0" class="" style=""><span class="text">Indiana</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="16"><a tabindex="0" class="" style=""><span class="text">Iowa</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="17"><a tabindex="0" class="" style=""><span class="text">Kansas</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="18"><a tabindex="0" class="" style=""><span class="text">Kentucky</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="19"><a tabindex="0" class="" style=""><span class="text">Louisiana</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="20"><a tabindex="0" class="" style=""><span class="text">Maine</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="21"><a tabindex="0" class="" style=""><span class="text">Maryland</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="22"><a tabindex="0" class="" style=""><span class="text">Massachusetts</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="23"><a tabindex="0" class="" style=""><span class="text">Michigan</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="24"><a tabindex="0" class="" style=""><span class="text">Minnesota</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="25"><a tabindex="0" class="" style=""><span class="text">Mississippi</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="26"><a tabindex="0" class="" style=""><span class="text">Missouri</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="27"><a tabindex="0" class="" style=""><span class="text">Montana</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="28"><a tabindex="0" class="" style=""><span class="text">Nebraska</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="29"><a tabindex="0" class="" style=""><span class="text">Nevada</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="30"><a tabindex="0" class="" style=""><span class="text">New Hampshire</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="31"><a tabindex="0" class="" style=""><span class="text">New Jersey</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="32"><a tabindex="0" class="" style=""><span class="text">New Mexico</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="33" class="selected"><a tabindex="0" class="" style=""><span class="text">New York</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="34"><a tabindex="0" class="" style=""><span class="text">North Carolina</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="35"><a tabindex="0" class="" style=""><span class="text">North Dakota</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="36"><a tabindex="0" class="" style=""><span class="text">Ohio</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="37"><a tabindex="0" class="" style=""><span class="text">Oklahoma</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="38"><a tabindex="0" class="" style=""><span class="text">Oregon</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="39"><a tabindex="0" class="" style=""><span class="text">Pennsylvania</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="40"><a tabindex="0" class="" style=""><span class="text">Rhode Island</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="41"><a tabindex="0" class="" style=""><span class="text">South Carolina</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="42"><a tabindex="0" class="" style=""><span class="text">South Dakota</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="43"><a tabindex="0" class="" style=""><span class="text">Tennessee</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="44"><a tabindex="0" class="" style=""><span class="text">Texas</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="45"><a tabindex="0" class="" style=""><span class="text">Utah</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="46"><a tabindex="0" class="" style=""><span class="text">Vermont</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="47"><a tabindex="0" class="" style=""><span class="text">Virginia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="48"><a tabindex="0" class="" style=""><span class="text">Washington</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="49"><a tabindex="0" class="" style=""><span class="text">West Virginia</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="50"><a tabindex="0" class="" style=""><span class="text">Wisconsin</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="51"><a tabindex="0" class="" style=""><span class="text">Wyoming</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="52"><a tabindex="0" class="" style=""><span class="text">Armed Forces Americas</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="53"><a tabindex="0" class="" style=""><span class="text">Armed Forces Europe</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="54"><a tabindex="0" class="" style=""><span class="text">Armed Forces Pacific</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="55"><a tabindex="0" class="" style=""><span class="text">Army/Air Force Post Office (APO)</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="56"><a tabindex="0" class="" style=""><span class="text">Diplomatic Post Office (DPO)</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="57"><a tabindex="0" class="" style=""><span class="text">Fleet Post Office (FPO)</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
</ul>
</div>
</div>
</div>
<div class="form-group col-xs-6 col-md-2 no-padding-left zip-form-control">
<label class="col-md-12 no-padding not-required" for="zip"><span class="accessibility-asterisk u-display-none">* </span><span class="text-holder">Zip</span></label>
<input autocomplete="off" class="form-control zip-field validate-zip-mask" data-aria-label="Zip" data-id="zip" data-mask="99999[-9999]" data-mobile-browser="false" data-validation-regex="\d{5}(-?\d{4})?" id="zip" maxlength="100"
name="zip" placeholder="Zip" type="text">
</div>
</div> <!-- ./ form grp -->
</fieldset>
<div class="row credit-card-info form-group">
<label class="visible-xs col-xs-12">Payment</label>
<div class="hidden-xs col-md-12 no-padding clearfix card-labels-container">
<div class="table-display">
<div class="col-sm-6 card-label">
<label for="card-element">Card Info</label>
</div>
<div class="col-sm-6 text-right card-images">
<ul class="credit-cards">
<li class="visa"></li>
<li class="mastercard"></li>
<li class="amex"></li>
<li class="discover"></li>
</ul>
</div>
</div> <!-- ./ table display -->
</div> <!-- ./ card labels container -->
<div class="col-md-12 no-padding clearfix">
<div class="form-group col-xs-12 col-md-12">
<input autocomplete="off" class="form-control visibleRequired" data-mask="name" id="credit_card_name" maxlength="100" name="credit_card_name" placeholder="Name on Card" size="50" type="text" aria-label="Name on Card">
</div> <!-- ./ -->
</div>
<div class="clearfix section-container card-info-container">
<div class="col-xs-12 card-number">
<!-- <label for="card-element" class="hidden-xs col-md-12 no-padding">Credit Card Number</label> -->
<div id="card-element" class="card-block form-control StripeElement StripeElement--empty">
<div class="__PrivateStripeElement" style="margin: 0px !important; padding: 0px !important; border: none !important; display: block !important; background: transparent !important; position: relative !important; opacity: 1 !important;">
<iframe name="__privateStripeFrame9346" frameborder="0" allowtransparency="true" scrolling="no" role="presentation" allow="payment *"
src="https://js.stripe.com/v3/elements-inner-card-fc3d9301492660d5d28db03432a3149e.html#locale=en-US&wait=false&mids[guid]=NA&mids[muid]=NA&mids[sid]=NA&hidePostalCode=true&style[base][iconColor]=%23F99A52&style[base][color]=%23444444&style[base][lineHeight]=48px&style[base][fontSmoothing]=antialiased&style[base][fontWeight]=400&style[base][fontFamily]=%22Helvetica+Neue%22%2C+%22Helvetica%22%2C+sans-serif&style[base][fontSize]=18px&style[base][::placeholder][color]=%23C7C7C7&style[base][::placeholder][fontFamily]=%22Helvetica+Neue%22%2C+%22Helvetica%22%2C+sans-serif&style[invalid][color]=%23aa1503&style[invalid][:focus][color]=%23aa1503&rtl=false&componentName=card&keyMode=live&apiKey=pk_live_A71VIfxePWalIp7CwNmD8sBG&referrer=https%3A%2F%2Fdonate.hakuapp.com%2Fdonations%2Fnew%3Ffundraiser%3D28c80838fd213c7f38f1&controllerId=__privateStripeController9341"
title="Secure card payment input frame"
style="border: none !important; margin: 0px !important; padding: 0px !important; width: 1px !important; min-width: 100% !important; overflow: hidden !important; display: block !important; user-select: none !important; transform: translate(0px) !important; color-scheme: light only !important; height: 48px;"></iframe><input
class="__PrivateStripeElement-input" aria-hidden="true" aria-label=" " autocomplete="false" maxlength="1"
style="border: none !important; display: block !important; position: absolute !important; height: 1px !important; top: -1px !important; left: 0px !important; padding: 0px !important; margin: 0px !important; width: 100% !important; opacity: 0 !important; background: transparent !important; pointer-events: none !important; font-size: 16px !important;">
<div
style="display: block !important; position: absolute !important; top: 50% !important; right: 0px !important; width: 0px !important; margin: 0px !important; padding: 0px !important; border: 0px !important; background: none !important; opacity: 1 !important; overflow: hidden !important; visibility: visible !important;">
<iframe name="cardButton9347" frameborder="0" allowtransparency="true" scrolling="no"
src="https://js.stripe.com/v3/elements-inner-link-button-for-card-1aea1959861066777a64a4ec8798d791.html#locale=en&style[foregroundColor]=%23444444&frameId=__privateStripeFrame9346&publishableKey=pk_live_A71VIfxePWalIp7CwNmD8sBG&stripeJsId=e53fea9f-3c72-4976-9497-9c07fbcf482f&mids[guid]=NA&mids[muid]=NA&mids[sid]=NA"
style="margin: 0px !important; user-select: none !important; transform: translate(0px) !important; color-scheme: light only !important; display: block !important; position: absolute !important; top: 0px !important; right: 0px !important; height: 0px !important; width: var(--stripeElementWidth) !important; padding: 0px !important; border: 0px !important; overflow: hidden !important; opacity: 1 !important; visibility: visible !important;"></iframe>
</div>
</div>
</div>
<div id="card-errors" class="text-red"></div>
</div>
</div> <!-- ./ form grp -->
</div> <!-- ./ row credit-card-info -->
<div class="row submit-donation">
<div class="form-group col-md-12">
<div class="checkbox-container form-group transaction-fee-wrapper">
<div class="checkbox-label">
<span class="checkbox-styled">
<input aria-describedby="df_iwcf_l" aria-label="transaction fee" checked="checked" class="input-checkbox" id="transaction_fee" name="transaction_fee" type="checkbox">
<label class="input-label" for="transaction_fee"></label>
</span>
<span id="df_iwcf_l" class="checkbox-styled-text"> I will cover the <span class="update">0.00</span> processing fee so 100% of my donation goes to the cause. <span class="tooltip-link inline-block" data-placement="top"
data-content="By helping us cover the processing fee, which includes the cost of technology and credit card processing, you ensure that your money goes to the cause and not to administrative expenses." data-original-title=""
title="">
<b>What is this for?</b>
</span>
</span>
<span id="df_iwcf_l_r" class="checkbox-styled-text" style="display: none;"> I will cover the <span class="update">0.00</span>. processing fee on each recurring donation so 100% of my donation goes to the cause. <span
class="tooltip-link inline-block" data-placement="top"
data-content="By helping us cover the processing fee, which includes the cost of technology and credit card processing, you ensure that your money goes to the cause and not to administrative expenses." data-original-title=""
title="">
<b>What is this for?</b>
</span>
</span>
</div>
</div><!-- ./checkbox -->
</div>
<div class="form-group captcha-container hidden" style="text-align: center;">
<input id="captcha_min_amount" name="captcha_min_amount" type="hidden" value="15.0">
<style>
.g-recaptcha {
display: inline-block
}
</style>
<script src="https://www.google.com/recaptcha/api.js" async="" defer=""></script>
<div data-sitekey="6LeNDDghAAAAAAXt923K4e5GW5FnxNrUNPuZpadE" class="g-recaptcha ">
<div style="width: 304px; height: 78px;">
<div><iframe title="reCAPTCHA"
src="https://www.google.com/recaptcha/api2/anchor?ar=1&k=6LeNDDghAAAAAAXt923K4e5GW5FnxNrUNPuZpadE&co=aHR0cHM6Ly9kb25hdGUuaGFrdWFwcC5jb206NDQz&hl=de&v=pCoGBhjs9s8EhFOHJFe8cqis&size=normal&cb=9el1cm6ohx0s"
width="304" height="78" role="presentation" name="a-te99uwbfd9hz" frameborder="0" scrolling="no"
sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox"></iframe></div><textarea id="g-recaptcha-response" name="g-recaptcha-response"
class="g-recaptcha-response" style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
</div>
</div>
<noscript>
<div>
<div style="width: 302px; height: 422px; position: relative;">
<div style="width: 302px; height: 422px; position: absolute;">
<iframe src="https://www.google.com/recaptcha/api/fallback?k=6LeNDDghAAAAAAXt923K4e5GW5FnxNrUNPuZpadE" scrolling="no" name="ReCAPTCHA" style="width: 302px; height: 422px; border-style: none; border: 0;">
</iframe>
</div>
</div>
<div style="width: 300px; height: 60px; border-style: none;
bottom: 12px; left: 25px; margin: 0px; padding: 0px; right: 25px;
background: #f9f9f9; border: 1px solid #c1c1c1; border-radius: 3px;">
<textarea id="g-recaptcha-response" name="g-recaptcha-response" class="g-recaptcha-response" style="width: 250px; height: 40px; border: 1px solid #c1c1c1;
margin: 10px 25px; padding: 0px; resize: none;"> </textarea>
</div>
</div>
</noscript>
<label for="g-recaptcha-response" id="recaptcha-custom-error" class="error" style="display:none; width:100%;">error</label>
</div>
<div class="col-md-12">
<button type="button" id="donate" class="donate-btn btn btn-success btn-block col-md-12" data-click="disableOnSubmit" data-fee=""> Donate <span class="amount"></span>
<span class="transaction-fee-message hide">and pay the <span class="update">0.00</span> transaction fee</span>
</button>
<span class="small-text"> By clicking "Donate", you agree to our
<a onclick="window.open('http://www.hakuapp.com/legal/', '_blank', 'location=yes,height=600,width=800,scrollbars=yes,status=yes');" href="javascript:void(0)"><b>privacy policy</b></a> and
<a onclick="window.open('https://www.hakuapp.com/legal', '_blank', 'location=yes,height=600,width=800,scrollbars=yes,status=yes');" href="javascript:void(0)"><b>terms of use</b></a>
</span>
</div>
</div> <!-- ./ row comments -->
<div class="error-container display-none">
<div class="col-xs-12 payment-alert clearfix">
<div class="alert-icon">
<i aria-hidden="true" class="glyphicons circle_exclamation_mark"></i>
</div>
<div class="alert-text">
</div>
</div> <!-- payment alert -->
</div>
</div>
<input id="is_recurring_update" name="is_recurring_update" type="hidden" value="false">
</div>
<input id="payment_start_date" name="payment_start_date" type="hidden" value="2023-11-05">
<input id="key" name="key" type="hidden" value="f6aab8b88460d18a07ed">
<input id="payment_name" name="payment_name" type="hidden" value="2023 TCS New York City Marathon Fundraising">
<input id="referred_by" name="referred_by" type="hidden">
<input id="referral_source" name="referral_source" type="hidden">
<input id="campaign" name="campaign" type="hidden">
<input id="referring_url" name="referring_url" type="hidden">
<input id="interaction" name="interaction" type="hidden">
<input id="displayed_charge" name="displayed_charge" type="hidden" value="0">
<input id="total_charge_amount" name="total_charge_amount" type="hidden">
<input id="credit_card_code" name="credit_card_code" type="hidden">
<input id="organization_key" name="organization_key" type="hidden" value="e4e15610c685b45f6981">
<input id="event_promoter_key" name="event_promoter_key" type="hidden" value="28c80838fd213c7f38f1">
</form>POST /customer_services/process_feedback
<form accept-charset="UTF-8" action="/customer_services/process_feedback" id="feedback-form" method="post" novalidate="novalidate">
<div style="margin:0;padding:0;display:inline"><input name="utf8" type="hidden" value="✓"><input name="authenticity_token" type="hidden" value="FymEJkZFpv8ZylqBwsWSIr7bWRRuOfxwp2PhCeEsd5M="></div>
<div class="modal-content">
<div class="modal-header">
<button type="button" class="close" data-dismiss="modal" aria-label="Close">
<span aria-hidden="true">×</span></button>
<h2 id="feedback-modal" class="modal-title text-center text-uppercase font-18">What do you need help with?</h2>
</div>
<div class="modal-body">
<div class="form-content col-xs-12">
<div class="form-group display-none">
<fieldset>
<legend class="hidden"></legend>
<ul class="list-unstyled">
<li>
<div class="custom-radio-container block">
<div class="valing">
<input type="radio" class="custom-radio required-input" id="issue1" name="feedback_type" value="trouble">
<label for="issue1" class="custom-label no-margin not-required hide-text-ada"> I'm having trouble donating </label>
</div>
<div class="valing no-padding">
<span class="custom-radio-text"> I'm having trouble donating </span>
</div>
</div>
</li>
<li>
<div class="custom-radio-container block">
<div class="valing">
<input type="radio" class="custom-radio required-input" id="issue2" name="feedback_type" value="question">
<label for="issue2" class="custom-label no-margin not-required hide-text-ada"> I have a question about donating to the event </label>
</div>
<div class="valing no-padding">
<span class="custom-radio-text"> I have a question about donating to the event </span>
</div>
</div>
</li>
</ul>
</fieldset>
</div>
<div class="row">
<div class="form-group col-xs-12 col-md-6">
<label for="feedback-name">Name</label>
<input type="text" class="form-control" id="feedback-name" name="feedback_name" placeholder="Full Name" maxlength="100">
</div>
<div class="form-group col-xs-12 col-md-6">
<label for="feedback-phone">Phone</label>
<input class="form-control phone-format-required" id="feedback-phone" name="feedback_phone" placeholder="ex: (555) 555-5555" type="tel" data-mask="phone">
</div>
</div>
<div class="form-group">
<label for="feedback-email">Email address</label>
<input type="email" class="form-control" id="feedback-email" name="feedback_email" placeholder="ex: jdoe@gmail.com" maxlength="100">
</div>
<div class="form-group">
<label for="feedback-body">* Comments or Questions</label>
<textarea class="form-control" rows="3" id="feedback-body" name="feedback_body" maxlength="500"></textarea>
</div>
<div class="form-group hidden">
<label for="feedback-contact-back">Would you like us to contact you about this?</label>
<input id="feedback-contact-back" type="checkbox" class="ie-checkbox" name="feedback_contact_back" data-text-checked="YES" data-text-unchecked="NO">
</div>
<div class="form-group">
<script src="https://www.google.com/recaptcha/api.js" async="" defer=""></script>
<div data-sitekey="6LeNDDghAAAAAAXt923K4e5GW5FnxNrUNPuZpadE" class="g-recaptcha ">
<div style="width: 304px; height: 78px;">
<div><iframe title="reCAPTCHA"
src="https://www.google.com/recaptcha/api2/anchor?ar=1&k=6LeNDDghAAAAAAXt923K4e5GW5FnxNrUNPuZpadE&co=aHR0cHM6Ly9kb25hdGUuaGFrdWFwcC5jb206NDQz&hl=de&v=pCoGBhjs9s8EhFOHJFe8cqis&size=normal&cb=eetv2vfiaxr0"
width="304" height="78" role="presentation" name="a-bwfn6ifrabc8" frameborder="0" scrolling="no"
sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox"></iframe></div><textarea id="g-recaptcha-response-1" name="g-recaptcha-response"
class="g-recaptcha-response" style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
</div><iframe style="display: none;"></iframe>
</div>
<noscript>
<div>
<div style="width: 302px; height: 422px; position: relative;">
<div style="width: 302px; height: 422px; position: absolute;">
<iframe src="https://www.google.com/recaptcha/api/fallback?k=6LeNDDghAAAAAAXt923K4e5GW5FnxNrUNPuZpadE" scrolling="no" name="ReCAPTCHA" style="width: 302px; height: 422px; border-style: none; border: 0;">
</iframe>
</div>
</div>
<div style="width: 300px; height: 60px; border-style: none;
bottom: 12px; left: 25px; margin: 0px; padding: 0px; right: 25px;
background: #f9f9f9; border: 1px solid #c1c1c1; border-radius: 3px;">
<textarea id="g-recaptcha-response" name="g-recaptcha-response" class="g-recaptcha-response" style="width: 250px; height: 40px; border: 1px solid #c1c1c1;
margin: 10px 25px; padding: 0px; resize: none;"> </textarea>
</div>
</div>
</noscript>
<span id="recaptcha-custom-error" class="error" for="g-recaptcha-response" style="display:none;">error</span>
</div>
</div>
<input id="action_type" name="action_type" type="hidden" value="donating">
<input id="source_name" name="source_name" type="hidden" value="2023 TCS New York City Marathon Fundraising">
<input id="source_url" name="source_url" type="hidden">
</div>
<div class="modal-footer">
<div class="col-xs-12">
<input class="btn btn-primary btn-block" id="feedback-form-submit" name="commit" type="submit" value="Send">
</div>
</div>
</div><!-- /.modal-content -->
</form>Text Content
Need Help? CYSTIC FIBROSIS FOUNDATION IS A PROUD CHARITY PARTNER OF THE 2023 TCS NEW YORK CITY MARATHON FUNDRAISING. PLEASE CONSIDER MAKING A DONATION TO SUPPORT THIS GREAT CAUSE! Your donation will count towards Jaron J Martinez's fundraising efforts benefiting Cystic Fibrosis Foundation. Donation to Jaron J Martinez 1 YOUR DONATION You are donating to Jaron J Martinez Change Donate To * Cystic Fibrosis Foundation Cystic Fibrosis Foundation * An individual fundraiser An individual fundraiser Search for An individual fundraiser Jaron needs $3,808.00 to meet the fundraising minimum commitment of $4,000.00 Help Jaron reach their fundraising goals! 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