<p>Country:<br />
[select menu-773 "Afghanistan" "Albania" "Algeria" "Andorra" "Angola" "Antigua & Barbuda" "Argentina" "Armenia" "Australia" "Austria" "Azerbaijan" "Bahamas" "Bahrain" "Bangladesh" "Barbados" "Belarus" "Belgium" "Belize" "Benin" "Bhutan" "Bolivia" "Bosnia & Herzegovina" "Botswana" "Brazil" "Brunei" "Bulgaria" "Burkina Faso" "Burundi" "Cambodia" "Cameroon" "Canada" "Cape Verde" "Central African Republic" "Chad" "Chile" "China" "Colombia" "Comoros" "Congo" "Congo Democratic Republic" "Costa Rica" "Cote d'Ivoire" "Croatia" "Cuba" "Cyprus" "Czech Republic" "Denmark" "Djibouti" "Dominica" "Dominican Republic" "Ecuador" "East Timor" "Egypt" "El Salvador" "Equatorial Guinea" "Eritrea" "Estonia" "Ethiopia" "Fiji" "Finland" "France" "Gabon" "Gambia" "Georgia" "Germany" "Ghana" "Greece" "Grenada" "Guatemala" "Guinea" "Guinea-Bissau" "Guyana" "Haiti" "Honduras" "Hungary" "Iceland" "India" "Indonesia" "Iran" "Iraq" "Ireland" "Israel" "Italy" "Jamaica" "Japan" "Jordan" "Kazakhstan" "Kenya" "Kiribati" "Korea North" "Korea South" "Kosovo" "Kuwait" "Kyrgyzstan" "Laos" "Latvia" "Lebanon" "Lesotho" "Liberia" "Libya" "Liechtenstein" "Lithuania" "Luxembourg" "Macedonia" "Madagascar" "Malawi" "Malaysia" "Maldives" "Mali" "Malta" "Marshall Islands" "Mauritania" "Mauritius" "Mexico" "Micronesia" "Moldova" "Monaco" "Mongolia" "Montenegro" "Morocco" "Mozambique" "Myanmar (Burma)" "Namibia" "Nauru" "Nepal" "The Netherlands" "New Zealand" "Nicaragua" "Niger" "Nigeria" "Norway" "Oman" "Pakistan" "Palau" "Palestinian State*" "Panama" "Papua New Guinea" "Paraguay" "Peru" "The Philippines" "Poland" "Portugal" "Qatar" "Romania" "Russia" "Rwanda" "St. Kitts & Nevis" "St. Lucia" "St. Vincent & The Grenadines" "Samoa" "San Marino" "Sao Tome & Principe" "Saudi Arabia" "Senegal" "Serbia" "Seychelles" "Sierra Leone" "Singapore" "Slovakia" "Slovenia" "Solomon Islands" "Somalia" "South Africa" "South Sudan" "Spain" "Sri Lanka" "Sudan" "Suriname" "Swaziland" "Sweden" "Switzerland" "Syria" "Taiwan" "Tajikistan" "Tanzania" "Thailand" "Togo" "Tonga" "Trinidad & Tobago" "Tunisia" "Turkey" "Turkmenistan" "Tuvalu" "Uganda" "Ukraine" "United Arab Emirates" "United Kingdom" "United States of America" "Uruguay" "Uzbekistan" "Vanuatu" "Vatican City (Holy See)" "Venezuela" "Vietnam" "Yemen" "Zambia" "Zimbabwe"]</p>

<p>Country Code:<br />
[select menu-774 "AL" "AK" "AS" "AZ" "AR" "CA" "CO" "CT" "DE" "DC" "FM" "FL" "GA" "GU" "HI" "ID" "IL" "IN" "IA" "KS" "KY" "LA" "ME" "MH" "MD" "MA" "MI" "MN" "MS" "MO" "MT" "NE" "NV" "NH" "NJ" "NM" "NY" "NC" "ND" "MP" "OH" "OK" "OR" "PW" "PA" "PR" "RI" "SC" "SD" "TN" "TX" "UT" "VT" "VI" "VA" "WA" "WV" "WI" "WY"]</p>

<p>State:<br />
[select menu-946 "Alabama" "Alaska" "American Samoa" "Arizona" "Arkansas" "California" "Colorado" "Connecticut" "Delaware" "District of Columbia" "Florida" "Georgia" "Guam" "Hawaii" "Idaho" "Illinois" "Indiana" "Iowa" "Kansas" "Kentucky" "Louisiana" "Maine" "Maryland" "Massachusetts" "Michigan" "Minnesota" "Mississippi" "Missouri" "Montana" "Nebraska" "Nevada" "New Hampshire" "New Jersey" "New Mexico" "New York" "North Carolina" "North Dakota" "Northern Marianas Islands" "Ohio" "Oklahoma" "Oregon" "Pennsylvania" "Puerto Rico" "Rhode Island" "South Carolina" "South Dakota" "Tennessee" "Texas" "Utah" "Vermont" "Virginia" "Virgin Islands" "Washington" "West Virginia" "Wisconsin" "Wyoming"]</p>