health: register

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	<script>
	eLang.ErrorPW = "Passwords";
	eLang.ErrorFirst= "First Name";
	eLang.ErrorLast= "Last Name";
	eLang.ErrorAddress= "Address";
	eLang.ErrorCity= "City";
	eLang.ErrorZip= "Zip";
	eLang.ErrorPAddress= "Payment Address";
	eLang.ErrorPCity= "Payment City";
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	<div id="form_body">
	<div class="form_top"></div><!-- end form_top -->
	<div class="form_body">
	<br />
	<h1>Complete your Registration:</h1>
	<br />
	<div id="form_registration">
	<form method="post" id="formSubmit" action="submit.php">
	<table width="450" height="100%" border="0" align="center">
	<tr>
	<td height="25"width="130" class="form_input" style="color:#00CC33">Referred By: </td>
	<td height="25"colspan="4">
	<input name="registerRefer" type="hidden" id="registerRefer" value="anil" />anil@peoplestring.com </td>
	</tr>
	<tr>
	<td height="25"width="130" class="form_input">Username:</td>
	<td height="25"colspan="4"><span id="registerName">12345dodo</span></td>
	</tr>
	<tr>
	<td height="25"width="130" class="form_input" nowrap="nowrap">Password:</td>
	<td height="25"colspan="4"><input name="registerPassword" type="password" id="registerPassword" /></td>
	</tr>
	<tr>
	<td height="25"width="130" class="form_input" nowrap="nowrap">Confirm Password:</td>
	<td height="25"colspan="4"><input name="registerConfirm" type="password" id="registerConfirm" /></td>
	</tr>

	<tr>
	<td height="25"width="130" class="form_input" nowrap="nowrap">Email Address:</td>
	<td height="25"colspan="4"><input name="registerEmail" type="text" id="registerEmail" value="" />
	(used for account verification)</td>
	</tr>
	<tr>
	<td height="25"width="130" class="form_input">Confirm Email:</td>
	<td height="25"colspan="4"><input name="registerEmail2" type="text" id="registerEmail2" value="" /></td>
	</tr>
	<tr>
	<td height="25"width="130" class="form_input">Organization:</td>
	<td height="25"colspan="4"><input name="registerOrg" type="text" id="registerOrg" value="" />
	(Optional)</td>
	</tr>
	<tr>
	<td height="25"width="130" class="form_input">Prefix:</td>
	<td height="25"colspan="4">
	<select name="registerPrefix" id="registerPrefix">
	<option></option>
	<option >Mr</option>
	<option >Ms</option>
	<option >Mrs</option>
	</select>
	</td>
	</tr>
	<tr>
	<td height="25"width="130" class="form_input">First Name:</td>
	<td height="25"colspan="4"><input name="registerFirst" type="text" id="registerFirst" value="" /></td>
	</tr>
	<tr>
	<td height="25"width="130" class="form_input">Middle Initial:</td>
	<td height="25"colspan="4"><input name="registerMiddle" type="text" id="registerMiddle" value="" /></td>
	</tr>
	<tr>
	<td height="25"width="130" class="form_input">Last Name:</td>
	<td height="25"width="188"><input name="registerLast" type="text" id="registerLast" value="" /></td>
	<td height="25"width="51" class="form_input">Suffix:</td>
	<td width="213" height="25"colspan="2">
	<select name="registerSuffix" id="registerSuffix">
	<option></option>
	<option >Sr</option>
	<option >Jr</option>
	<option >I</option>
	<option >II</option>
	<option >III</option>
	</select>
	</td>
	</tr>


	<tr>
	<td height="25"width="130" class="form_input">Address:</td>
	<td height="25"colspan="4"><input name="registerAddress" type="text" id="registerAddress" value="" size="50"/></td>
	</tr>
	<tr>
	<td height="25"width="130"></td>
	<td height="25"colspan="4"><input name="registerAddress2" type="text" id="registerAddress2" value="" size="50"/></td>
	</tr>
	<tr>
	<td height="25"width="130" class="form_input">City:</td>
	<td height="25"width="188"><input name="registerCity" type="text" id="registerCity" value="" /></td>
	<td height="25"width="51" class="form_input">State:</td>
	<td height="25"colspan="2">
	<div id="state_1_1">
	<select name="registerState" id="registerState">

	<option value="AL">Alabama</option>

	<option value="AK">Alaska</option>

	<option value="AS">American Samoa</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">District of Columbia</option>

	<option value="FM">Federated States of Micronesia</option>

	<option value="FL">Florida</option>

	<option value="GA">Georgia</option>

	<option value="GU">Guam</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="MH">Marshall Islands</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">New York</option>

	<option value="NC">North Carolina</option>

	<option value="ND">North Dakota</option>

	<option value="MP">Northern Mariana Islands</option>

	<option value="OH">Ohio</option>

	<option value="OK">Oklahoma</option>

	<option value="OR">Oregon</option>

	<option value="PW">Palau</option>

	<option value="PA">Pennsylvania</option>

	<option value="PR">Puerto Rico</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="VI">Virgin Islands</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>
	</select>
	</div>
	<div id="state_1_2" style="display:none">
	<input type="text" name="registerState2" id="registerState2" />
	</div>
	</td>
	</tr>
	<tr>
	<td height="25"width="130" class="form_input">Zip:</td>
	<td height="25"colspan="4"><input name="registerZip" type="text" id="registerZip" value="" /></td>
	</tr>
	<tr>
	<td height="25"width="130" class="form_input">Country:</td>
	<td height="25"colspan="4">
	<select name="registerCountry" id="registerCountry" onchange="registerCountrySelect(this,0);">

	<option value="USA">United States</option>

	<option value="CAN">Canada</option>

	<option value="ALA">Åland Islands</option>

	<option value="AFG">Afghanistan</option>

	<option value="ALB">Albania</option>

	<option value="DZA">Algeria</option>

	<option value="ASM">American Samoa</option>

	<option value="AND">Andorra</option>

	<option value="AGO">Angola</option>

	<option value="AIA">Anguilla</option>

	<option value="ATA">Antarctica</option>

	<option value="ATG">Antigua and Barbuda</option>

	<option value="ARG">Argentina</option>

	<option value="ARM">Armenia</option>

	<option value="ABW">Aruba</option>

	<option value="AUS">Australia</option>

	<option value="AUT">Austria</option>

	<option value="AZE">Azerbaijan</option>

	<option value="BHS">Bahamas</option>

	<option value="BHR">Bahrain</option>

	<option value="BGD">Bangladesh</option>

	<option value="BRB">Barbados</option>

	<option value="BLR">Belarus</option>

	<option value="BEL">Belgium</option>

	<option value="BLZ">Belize</option>

	<option value="BEN">Benin</option>

	<option value="BMU">Bermuda</option>

	<option value="BTN">Bhutan</option>

	<option value="BOL">Bolivia</option>

	<option value="BIH">Bosnia and Herzegovina</option>

	<option value="BWA">Botswana</option>

	<option value="BVT">Bouvet Island</option>

	<option value="BRA">Brazil</option>

	<option value="IOT">British Indian Ocean Territory</option>

	<option value="BRN">Brunei Darussalam</option>

	<option value="BGR">Bulgaria</option>

	<option value="BFA">Burkina Faso</option>

	<option value="BDI">Burundi</option>

	<option value="CIV">Côte d'Ivoire</option>

	<option value="KHM">Cambodia</option>

	<option value="CMR">Cameroon</option>

	<option value="CPV">Cape Verde</option>

	<option value="CYM">Cayman Islands</option>

	<option value="CAF">Central African Republic</option>

	<option value="TCD">Chad</option>

	<option value="CHL">Chile</option>

	<option value="CHN">China</option>

	<option value="CXR">Christmas Island</option>

	<option value="CCK">Cocos (Keeling) Islands</option>

	<option value="COL">Colombia</option>

	<option value="COM">Comoros</option>

	<option value="COG">Congo</option>

	<option value="COD">Congo, the Democratic Republic of the</option>

	<option value="COK">Cook Islands</option>

	<option value="CRI">Costa Rica</option>

	<option value="HRV">Croatia</option>

	<option value="CUB">Cuba</option>

	<option value="CYP">Cyprus</option>

	<option value="CZE">Czech Republic</option>

	<option value="DNK">Denmark</option>

	<option value="DJI">Djibouti</option>

	<option value="DMA">Dominica</option>

	<option value="DOM">Dominican Republic</option>

	<option value="ECU">Ecuador</option>

	<option value="EGY">Egypt</option>

	<option value="SLV">El Salvador</option>

	<option value="GNQ">Equatorial Guinea</option>

	<option value="ERI">Eritrea</option>

	<option value="EST">Estonia</option>

	<option value="ETH">Ethiopia</option>

	<option value="FLK">Falkland Islands (Malvinas)</option>

	<option value="FRO">Faroe Islands</option>

	<option value="FJI">Fiji</option>

	<option value="FIN">Finland</option>

	<option value="FRA">France</option>

	<option value="GUF">French Guiana</option>

	<option value="PYF">French Polynesia</option>

	<option value="ATF">French Southern Territories</option>

	<option value="GAB">Gabon</option>

	<option value="GMB">Gambia</option>

	<option value="GEO">Georgia</option>

	<option value="DEU">Germany</option>

	<option value="GHA">Ghana</option>

	<option value="GIB">Gibraltar</option>

	<option value="GRC">Greece</option>

	<option value="GRL">Greenland</option>

	<option value="GRD">Grenada</option>

	<option value="GLP">Guadeloupe</option>

	<option value="GUM">Guam</option>

	<option value="GTM">Guatemala</option>

	<option value="GGY">Guernsey</option>

	<option value="GIN">Guinea</option>

	<option value="GNB">Guinea-Bissau</option>

	<option value="GUY">Guyana</option>

	<option value="HTI">Haiti</option>

	<option value="HMD">Heard Island and McDonald Islands</option>

	<option value="VAT">Holy See (Vatican City State)</option>

	<option value="HND">Honduras</option>

	<option value="HKG">Hong Kong</option>

	<option value="HUN">Hungary</option>

	<option value="ISL">Iceland</option>

	<option value="IND">India</option>

	<option value="IDN">Indonesia</option>

	<option value="IRN">Iran, Islamic Republic of</option>

	<option value="IRQ">Iraq</option>

	<option value="IRL">Ireland</option>

	<option value="IMN">Isle of Man</option>

	<option value="ISR">Israel</option>

	<option value="ITA">Italy</option>

	<option value="JAM">Jamaica</option>

	<option value="JPN">Japan</option>

	<option value="JEY">Jersey</option>

	<option value="JOR">Jordan</option>

	<option value="KAZ">Kazakhstan</option>

	<option value="KEN">Kenya</option>

	<option value="KIR">Kiribati</option>

	<option value="PRK">Korea, Democratic People's Republic of</option>

	<option value="KOR">Korea, Republic of</option>

	<option value="KWT">Kuwait</option>

	<option value="KGZ">Kyrgyzstan</option>

	<option value="LAO">Lao People's Democratic Republic</option>

	<option value="LVA">Latvia</option>

	<option value="LBN">Lebanon</option>

	<option value="LSO">Lesotho</option>

	<option value="LBR">Liberia</option>

	<option value="LBY">Libyan Arab Jamahiriya</option>

	<option value="LIE">Liechtenstein</option>

	<option value="LTU">Lithuania</option>

	<option value="LUX">Luxembourg</option>

	<option value="MAC">Macao</option>

	<option value="MKD">Macedonia, the former Yugoslav Republic of</option>

	<option value="MDG">Madagascar</option>

	<option value="MWI">Malawi</option>

	<option value="MYS">Malaysia</option>

	<option value="MDV">Maldives</option>

	<option value="MLI">Mali</option>

	<option value="MLT">Malta</option>

	<option value="MHL">Marshall Islands</option>

	<option value="MTQ">Martinique</option>

	<option value="MRT">Mauritania</option>

	<option value="MUS">Mauritius</option>

	<option value="MYT">Mayotte</option>

	<option value="MEX">Mexico</option>

	<option value="FSM">Micronesia, Federated States of</option>

	<option value="MDA">Moldova, Republic of</option>

	<option value="MCO">Monaco</option>

	<option value="MNG">Mongolia</option>

	<option value="MNE">Montenegro</option>

	<option value="MSR">Montserrat</option>

	<option value="MAR">Morocco</option>

	<option value="MOZ">Mozambique</option>

	<option value="MMR">Myanmar</option>

	<option value="NAM">Namibia</option>

	<option value="NRU">Nauru</option>

	<option value="NPL">Nepal</option>

	<option value="NLD">Netherlands</option>

	<option value="ANT">Netherlands Antilles</option>

	<option value="NCL">New Caledonia</option>

	<option value="NZL">New Zealand</option>

	<option value="NIC">Nicaragua</option>

	<option value="NER">Niger</option>

	<option value="NGA">Nigeria</option>

	<option value="NIU">Niue</option>

	<option value="NFK">Norfolk Island</option>

	<option value="MNP">Northern Mariana Islands</option>

	<option value="NOR">Norway</option>

	<option value="OMN">Oman</option>

	<option value="PAK">Pakistan</option>

	<option value="PLW">Palau</option>

	<option value="PSE">Palestinian Territory, Occupied</option>

	<option value="PAN">Panama</option>

	<option value="PNG">Papua New Guinea</option>

	<option value="PRY">Paraguay</option>

	<option value="PER">Peru</option>

	<option value="PHL">Philippines</option>

	<option value="PCN">Pitcairn</option>

	<option value="POL">Poland</option>

	<option value="PRT">Portugal</option>

	<option value="PRI">Puerto Rico</option>

	<option value="QAT">Qatar</option>

	<option value="REU">Réunion</option>

	<option value="ROU">Romania</option>

	<option value="RUS">Russian Federation</option>

	<option value="RWA">Rwanda</option>

	<option value="BLM">Saint Barthélemy</option>

	<option value="SHN">Saint Helena</option>

	<option value="KNA">Saint Kitts and Nevis</option>

	<option value="LCA">Saint Lucia</option>

	<option value="MAF">Saint Martin (French part)</option>

	<option value="SPM">Saint Pierre and Miquelon</option>

	<option value="VCT">Saint Vincent and the Grenadines</option>

	<option value="WSM">Samoa</option>

	<option value="SMR">San Marino</option>

	<option value="STP">Sao Tome and Principe</option>

	<option value="SAU">Saudi Arabia</option>

	<option value="SEN">Senegal</option>

	<option value="SRB">Serbia</option>

	<option value="SYC">Seychelles</option>

	<option value="SLE">Sierra Leone</option>

	<option value="SGP">Singapore</option>

	<option value="SVK">Slovakia</option>

	<option value="SVN">Slovenia</option>

	<option value="SLB">Solomon Islands</option>

	<option value="SOM">Somalia</option>

	<option value="ZAF">South Africa</option>

	<option value="SGS">South Georgia and the South Sandwich Islands</option>

	<option value="ESP">Spain</option>

	<option value="LKA">Sri Lanka</option>

	<option value="SDN">Sudan</option>

	<option value="SUR">Suriname</option>

	<option value="SJM">Svalbard and Jan Mayen</option>

	<option value="SWZ">Swaziland</option>

	<option value="SWE">Sweden</option>

	<option value="CHE">Switzerland</option>

	<option value="SYR">Syrian Arab Republic</option>

	<option value="TWN">Taiwan, Province of China</option>

	<option value="TJK">Tajikistan</option>

	<option value="TZA">Tanzania, United Republic of</option>

	<option value="THA">Thailand</option>

	<option value="TLS">Timor-Leste</option>

	<option value="TGO">Togo</option>

	<option value="TKL">Tokelau</option>

	<option value="TON">Tonga</option>

	<option value="TTO">Trinidad and Tobago</option>

	<option value="TUN">Tunisia</option>

	<option value="TUR">Turkey</option>

	<option value="TKM">Turkmenistan</option>

	<option value="TCA">Turks and Caicos Islands</option>

	<option value="TUV">Tuvalu</option>

	<option value="UGA">Uganda</option>

	<option value="UKR">Ukraine</option>

	<option value="ARE">United Arab Emirates</option>

	<option value="GBR">United Kingdom</option>

	<option value="UMI">United States Minor Outlying Islands</option>

	<option value="URY">Uruguay</option>

	<option value="UZB">Uzbekistan</option>

	<option value="VUT">Vanuatu</option>

	<option value="VEN">Venezuela</option>

	<option value="VNM">Viet Nam</option>

	<option value="VGB">Virgin Islands, British</option>

	<option value="VIR">Virgin Islands, U.S.</option>

	<option value="WLF">Wallis and Futuna</option>

	<option value="ESH">Western Sahara</option>

	<option value="YEM">Yemen</option>

	<option value="ZMB">Zambia</option>

	<option value="ZWE">Zimbabwe</option>
	</select>
	</td>
	</tr>

	<tr>
	<td height="40"colspan="5" class="form_bold">Address to receive payments from PeopleString:</td>
	</tr>
	<tr>
	<td height="25"colspan="5"><input name="billingSame" type="checkbox" id="billingSame" onclick="showHideBilling();" />
	Check if same as above</td>
	</tr>
	<tr id="billingSame1">
	<td height="40"colspan="5" class="form_bold">New Payment Address:</td>
	</tr>
	<tr id="billingSame2">
	<td height="25"width="130" class="form_input">Address:</td>
	<td height="25"colspan="4"><input name="registerOtherAddress" type="text" id="registerOtherAddress" size="50" value="" /></td>
	</tr>
	<tr id="billingSame3">
	<td height="25"width="130"></td>
	<td height="25"colspan="4"><input name="registerOtherAddress2" type="text" id="registerOtherAddress2" size="50" value="" /></td>
	</tr>
	<tr id="billingSame4">
	<td height="25"width="130" class="form_input">City:</td>
	<td height="25"width="188"><input name="registerOtherCity" type="text" id="registerOtherCity" value="" /></td>
	<td height="25"width="51" class="form_input">State:</td>
	<td height="25"colspan="2">
	<div id="state_2_1">
	<select name="registerOtherState" id="registerOtherState">

	<option value="AL">Alabama</option>

	<option value="AK">Alaska</option>

	<option value="AS">American Samoa</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">District of Columbia</option>

	<option value="FM">Federated States of Micronesia</option>

	<option value="FL">Florida</option>

	<option value="GA">Georgia</option>

	<option value="GU">Guam</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="MH">Marshall Islands</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">New York</option>

	<option value="NC">North Carolina</option>

	<option value="ND">North Dakota</option>

	<option value="MP">Northern Mariana Islands</option>

	<option value="OH">Ohio</option>

	<option value="OK">Oklahoma</option>

	<option value="OR">Oregon</option>

	<option value="PW">Palau</option>

	<option value="PA">Pennsylvania</option>

	<option value="PR">Puerto Rico</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="VI">Virgin Islands</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>
	</select>
	</div>
	<div id="state_2_2" style="display:none">
	<input name="registerOtherState2" id="registerOtherState2" type="text" />
	</div>
	</td>
	</tr>
	<tr id="billingSame5">
	<td height="25"width="130" class="form_input">Zip:</td>
	<td height="25"colspan="4"><input name="registerOtherZip" type="text" id="registerOtherZip" value="" /></td>
	</tr>
	<tr id="billingSame6">
	<td height="25"width="130" class="form_input">Country:</td>
	<td height="25"colspan="4">
	<select name="registerOtherCountry" id="registerOtherCountry" onchange="registerCountrySelect(this,1);">

	<option value="USA">United States</option>

	<option value="CAN">Canada</option>

	<option value="ALA">Åland Islands</option>

	<option value="AFG">Afghanistan</option>

	<option value="ALB">Albania</option>

	<option value="DZA">Algeria</option>

	<option value="ASM">American Samoa</option>

	<option value="AND">Andorra</option>

	<option value="AGO">Angola</option>

	<option value="AIA">Anguilla</option>

	<option value="ATA">Antarctica</option>

	<option value="ATG">Antigua and Barbuda</option>

	<option value="ARG">Argentina</option>

	<option value="ARM">Armenia</option>

	<option value="ABW">Aruba</option>

	<option value="AUS">Australia</option>

	<option value="AUT">Austria</option>

	<option value="AZE">Azerbaijan</option>

	<option value="BHS">Bahamas</option>

	<option value="BHR">Bahrain</option>

	<option value="BGD">Bangladesh</option>

	<option value="BRB">Barbados</option>

	<option value="BLR">Belarus</option>

	<option value="BEL">Belgium</option>

	<option value="BLZ">Belize</option>

	<option value="BEN">Benin</option>

	<option value="BMU">Bermuda</option>

	<option value="BTN">Bhutan</option>

	<option value="BOL">Bolivia</option>

	<option value="BIH">Bosnia and Herzegovina</option>

	<option value="BWA">Botswana</option>

	<option value="BVT">Bouvet Island</option>

	<option value="BRA">Brazil</option>

	<option value="IOT">British Indian Ocean Territory</option>

	<option value="BRN">Brunei Darussalam</option>

	<option value="BGR">Bulgaria</option>

	<option value="BFA">Burkina Faso</option>

	<option value="BDI">Burundi</option>

	<option value="CIV">Côte d'Ivoire</option>

	<option value="KHM">Cambodia</option>

	<option value="CMR">Cameroon</option>

	<option value="CPV">Cape Verde</option>

	<option value="CYM">Cayman Islands</option>

	<option value="CAF">Central African Republic</option>

	<option value="TCD">Chad</option>

	<option value="CHL">Chile</option>

	<option value="CHN">China</option>

	<option value="CXR">Christmas Island</option>

	<option value="CCK">Cocos (Keeling) Islands</option>

	<option value="COL">Colombia</option>

	<option value="COM">Comoros</option>

	<option value="COG">Congo</option>

	<option value="COD">Congo, the Democratic Republic of the</option>

	<option value="COK">Cook Islands</option>

	<option value="CRI">Costa Rica</option>

	<option value="HRV">Croatia</option>

	<option value="CUB">Cuba</option>

	<option value="CYP">Cyprus</option>

	<option value="CZE">Czech Republic</option>

	<option value="DNK">Denmark</option>

	<option value="DJI">Djibouti</option>

	<option value="DMA">Dominica</option>

	<option value="DOM">Dominican Republic</option>

	<option value="ECU">Ecuador</option>

	<option value="EGY">Egypt</option>

	<option value="SLV">El Salvador</option>

	<option value="GNQ">Equatorial Guinea</option>

	<option value="ERI">Eritrea</option>

	<option value="EST">Estonia</option>

	<option value="ETH">Ethiopia</option>

	<option value="FLK">Falkland Islands (Malvinas)</option>

	<option value="FRO">Faroe Islands</option>

	<option value="FJI">Fiji</option>

	<option value="FIN">Finland</option>

	<option value="FRA">France</option>

	<option value="GUF">French Guiana</option>

	<option value="PYF">French Polynesia</option>

	<option value="ATF">French Southern Territories</option>

	<option value="GAB">Gabon</option>

	<option value="GMB">Gambia</option>

	<option value="GEO">Georgia</option>

	<option value="DEU">Germany</option>

	<option value="GHA">Ghana</option>

	<option value="GIB">Gibraltar</option>

	<option value="GRC">Greece</option>

	<option value="GRL">Greenland</option>

	<option value="GRD">Grenada</option>

	<option value="GLP">Guadeloupe</option>

	<option value="GUM">Guam</option>

	<option value="GTM">Guatemala</option>

	<option value="GGY">Guernsey</option>

	<option value="GIN">Guinea</option>

	<option value="GNB">Guinea-Bissau</option>

	<option value="GUY">Guyana</option>

	<option value="HTI">Haiti</option>

	<option value="HMD">Heard Island and McDonald Islands</option>

	<option value="VAT">Holy See (Vatican City State)</option>

	<option value="HND">Honduras</option>

	<option value="HKG">Hong Kong</option>

	<option value="HUN">Hungary</option>

	<option value="ISL">Iceland</option>

	<option value="IND">India</option>

	<option value="IDN">Indonesia</option>

	<option value="IRN">Iran, Islamic Republic of</option>

	<option value="IRQ">Iraq</option>

	<option value="IRL">Ireland</option>

	<option value="IMN">Isle of Man</option>

	<option value="ISR">Israel</option>

	<option value="ITA">Italy</option>

	<option value="JAM">Jamaica</option>

	<option value="JPN">Japan</option>

	<option value="JEY">Jersey</option>

	<option value="JOR">Jordan</option>

	<option value="KAZ">Kazakhstan</option>

	<option value="KEN">Kenya</option>

	<option value="KIR">Kiribati</option>

	<option value="PRK">Korea, Democratic People's Republic of</option>

	<option value="KOR">Korea, Republic of</option>

	<option value="KWT">Kuwait</option>

	<option value="KGZ">Kyrgyzstan</option>

	<option value="LAO">Lao People's Democratic Republic</option>

	<option value="LVA">Latvia</option>

	<option value="LBN">Lebanon</option>

	<option value="LSO">Lesotho</option>

	<option value="LBR">Liberia</option>

	<option value="LBY">Libyan Arab Jamahiriya</option>

	<option value="LIE">Liechtenstein</option>

	<option value="LTU">Lithuania</option>

	<option value="LUX">Luxembourg</option>

	<option value="MAC">Macao</option>

	<option value="MKD">Macedonia, the former Yugoslav Republic of</option>

	<option value="MDG">Madagascar</option>

	<option value="MWI">Malawi</option>

	<option value="MYS">Malaysia</option>

	<option value="MDV">Maldives</option>

	<option value="MLI">Mali</option>

	<option value="MLT">Malta</option>

	<option value="MHL">Marshall Islands</option>

	<option value="MTQ">Martinique</option>

	<option value="MRT">Mauritania</option>

	<option value="MUS">Mauritius</option>

	<option value="MYT">Mayotte</option>

	<option value="MEX">Mexico</option>

	<option value="FSM">Micronesia, Federated States of</option>

	<option value="MDA">Moldova, Republic of</option>

	<option value="MCO">Monaco</option>

	<option value="MNG">Mongolia</option>

	<option value="MNE">Montenegro</option>

	<option value="MSR">Montserrat</option>

	<option value="MAR">Morocco</option>

	<option value="MOZ">Mozambique</option>

	<option value="MMR">Myanmar</option>

	<option value="NAM">Namibia</option>

	<option value="NRU">Nauru</option>

	<option value="NPL">Nepal</option>

	<option value="NLD">Netherlands</option>

	<option value="ANT">Netherlands Antilles</option>

	<option value="NCL">New Caledonia</option>

	<option value="NZL">New Zealand</option>

	<option value="NIC">Nicaragua</option>

	<option value="NER">Niger</option>

	<option value="NGA">Nigeria</option>

	<option value="NIU">Niue</option>

	<option value="NFK">Norfolk Island</option>

	<option value="MNP">Northern Mariana Islands</option>

	<option value="NOR">Norway</option>

	<option value="OMN">Oman</option>

	<option value="PAK">Pakistan</option>

	<option value="PLW">Palau</option>

	<option value="PSE">Palestinian Territory, Occupied</option>

	<option value="PAN">Panama</option>

	<option value="PNG">Papua New Guinea</option>

	<option value="PRY">Paraguay</option>

	<option value="PER">Peru</option>

	<option value="PHL">Philippines</option>

	<option value="PCN">Pitcairn</option>

	<option value="POL">Poland</option>

	<option value="PRT">Portugal</option>

	<option value="PRI">Puerto Rico</option>

	<option value="QAT">Qatar</option>

	<option value="REU">Réunion</option>

	<option value="ROU">Romania</option>

	<option value="RUS">Russian Federation</option>

	<option value="RWA">Rwanda</option>

	<option value="BLM">Saint Barthélemy</option>

	<option value="SHN">Saint Helena</option>

	<option value="KNA">Saint Kitts and Nevis</option>

	<option value="LCA">Saint Lucia</option>

	<option value="MAF">Saint Martin (French part)</option>

	<option value="SPM">Saint Pierre and Miquelon</option>

	<option value="VCT">Saint Vincent and the Grenadines</option>

	<option value="WSM">Samoa</option>

	<option value="SMR">San Marino</option>

	<option value="STP">Sao Tome and Principe</option>

	<option value="SAU">Saudi Arabia</option>

	<option value="SEN">Senegal</option>

	<option value="SRB">Serbia</option>

	<option value="SYC">Seychelles</option>

	<option value="SLE">Sierra Leone</option>

	<option value="SGP">Singapore</option>

	<option value="SVK">Slovakia</option>

	<option value="SVN">Slovenia</option>

	<option value="SLB">Solomon Islands</option>

	<option value="SOM">Somalia</option>

	<option value="ZAF">South Africa</option>

	<option value="SGS">South Georgia and the South Sandwich Islands</option>

	<option value="ESP">Spain</option>

	<option value="LKA">Sri Lanka</option>

	<option value="SDN">Sudan</option>

	<option value="SUR">Suriname</option>

	<option value="SJM">Svalbard and Jan Mayen</option>

	<option value="SWZ">Swaziland</option>

	<option value="SWE">Sweden</option>

	<option value="CHE">Switzerland</option>

	<option value="SYR">Syrian Arab Republic</option>

	<option value="TWN">Taiwan, Province of China</option>

	<option value="TJK">Tajikistan</option>

	<option value="TZA">Tanzania, United Republic of</option>

	<option value="THA">Thailand</option>

	<option value="TLS">Timor-Leste</option>

	<option value="TGO">Togo</option>

	<option value="TKL">Tokelau</option>

	<option value="TON">Tonga</option>

	<option value="TTO">Trinidad and Tobago</option>

	<option value="TUN">Tunisia</option>

	<option value="TUR">Turkey</option>

	<option value="TKM">Turkmenistan</option>

	<option value="TCA">Turks and Caicos Islands</option>

	<option value="TUV">Tuvalu</option>

	<option value="UGA">Uganda</option>

	<option value="UKR">Ukraine</option>

	<option value="ARE">United Arab Emirates</option>

	<option value="GBR">United Kingdom</option>

	<option value="UMI">United States Minor Outlying Islands</option>

	<option value="URY">Uruguay</option>

	<option value="UZB">Uzbekistan</option>

	<option value="VUT">Vanuatu</option>

	<option value="VEN">Venezuela</option>

	<option value="VNM">Viet Nam</option>

	<option value="VGB">Virgin Islands, British</option>

	<option value="VIR">Virgin Islands, U.S.</option>

	<option value="WLF">Wallis and Futuna</option>

	<option value="ESH">Western Sahara</option>

	<option value="YEM">Yemen</option>

	<option value="ZMB">Zambia</option>

	<option value="ZWE">Zimbabwe</option>
	</select> </td>
	</tr>
	<tr>
	<td height="40"colspan="5" class="form_bold">Additional info:</td>
	</tr>
	<tr>
	<td height="25"width="130" class="form_input">Telephone:</td>
	<td height="25"colspan="4"><input name="registerTelephone" type="text" id="registerTelephone" value="" />
	(confidential)</td>
	</tr>
	<tr>
	<td height="25"width="130" class="form_input">Mobile:</td>
	<td height="25"colspan="4"><input name="registerMobile" type="text" id="registerMobile" value="" />
	(optional & confidential)</td>
	</tr>
	<tr>
	<td height="25"width="130" class="form_input">Sex:</td>
	<td height="25"colspan="4">
	<select name="registerSex" id="registerSex">
	<option>Select one...</option>
	<option >Male</option>
	<option >Female</option>
	</select>
	</td>
	</tr>
	<tr>
	<td height="25"width="130" class="form_input">Age:</td>
	<td height="25"colspan="4"><input name="registerAge" type="text" id="registerAge" size="5" value="" /></td>
	</tr>
	<tr>
	<td height="25"width="130" class="form_input">Secret Question:</td>
	<td height="25"colspan="4">
	<select name="registerQuestion" id="registerQuestion">
	<option>Select one...</option>
	<option>What is the first & last name of your first boyfriend or girlfriend?</option><option>Which phone number do you remember most from your childhood?</option><option>What was your favorite place to visit as a child?</option><option>Who is your favorite actor, musician, or artist?</option><option>What is the name of your favorite pet?</option><option>In what city were you born?</option><option>What high school did you attend?</option><option>What is your favorite movie?</option><option>What is your mother's maiden name?</option><option>What street did you grow up on?</option><option>What was the make of your first car?</option><option>When is your anniversary?</option><option>What is your favorite color?</option><option>Who is your childhood superhero?</option> </select>
	</td>
	</tr>
	<tr>
	<td height="25"width="130" class="form_input">Secret Answer:</td>
	<td height="25"colspan="4"><input name="registerAnswer" type="text" id="registerAnswer" /></td>
	</tr>

	<tr>
	<td height="25"colspan="5"><input name="registerTOS" type="checkbox" id="registerTOS"/>
	I have read the <a href='/terms.php' target='_blank'>Terms of Service</a> and <a href='/privacy.php' target='_blank'>Privacy Policy</a> and agree to the terms.</td>
	</tr>
	<tr>
	<td width="130" height="25" class="form_input" valign="top">Confirmation code:</td>
	<td height="25"colspan="5"><script type="text/javascript" src="http://api.recaptcha.net/challenge?k=6Lev9gQAAAAAAO-4S2Dwzbq1IkTW2_pZa1YnR7cS"></script>

	<noscript>
	<iframe src="http://api.recaptcha.net/noscript?k=6Lev9gQAAAAAAO-4S2Dwzbq1IkTW2_pZa1YnR7cS" height="300" width="500" frameborder="0"></iframe><br/>
	<textarea name="recaptcha_challenge_field" rows="3" cols="40"></textarea>
	<input type="hidden" name="recaptcha_response_field" value="manual_challenge"/>
	</noscript></td>
	</tr>
	<tr>
	<td height="50"colspan="5" style="font-weight:bold; color:#12649b;"><input type="button" value="Continue" onclick="allowRegisterSubmit();" />
	<input type="button" value="Cancel" onclick="registerCancel();" /></td>
	</tr>
	</table>
	</form>
	</div>
	<br />
	</div><!-- end form_body -->
	<div class="form_bottom"></div><!-- form bottom -->
	</div><!-- end form_body -->

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	<div style="visibility:hidden">
	<form id="hiddenForm" target="_blank">
	<input type="hidden" name="user" id="hiddenUserForm" value="" />
	<input type="hidden" name="pass" id="hiddenPassForm" value="" />
	<input type="hidden" name="option" id="hiddenOptionForm" value="" />
	</form>
	</div>

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health

Saturday, August 21, 2010

register

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