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704 lines (692 loc) · 40.5 KB
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<html>
<body>
<h3>Sample Form</h3>
<table border="0" width="100%">
<tr>
<td>
<h3>Input</h3>
<textarea id="textin" cols="80" rows="10"></textarea>
<h3>Console</h3>
<textarea id="keycodes" cols="80" rows="20" wrap="soft"></textarea>
</td>
<td valign="top">
<h3>Scanned Data</h3>
<p>
<input id="firstname" type="text" name="firstname" size="15" placeholder="First Name" />
<input id="middlename" type="text" name="middlename" size="15" placeholder="Middle Name" />
<input id="lastname" type="text" name="lastname" size="20" placeholder="Last Name" />
</p>
<p>
<label>Address</label><br/>
<input id="address1" type="text" name="address1" size="30" placeholder="Address Line 1" /><br/>
<input id="address2" type="text" name="address2" size="30" placeholder="Address Line 2" /><br/>
<input id="city" type="text" name="city" size="20" placeholder="City" />,
<input id="state" type="text" name="state" size="8" placeholder="State" />
<input id="zip" type="text" name="zip" size="12" placeholder="Postal Code" />
</p>
<p>
<label>DOB</label><br/>
<input id="dob" type="text" name="dob" size="15" placeholder="MMDDCCYY" />
</p>
</td>
</tr>
</table>
<div class="questions"><span><div><div id="questions_header" class="modal_header"> <a href="#" id="answers_form_skip" class="modal_close">Skip</a> <h2>Questions</h2> <a href="#" id="submit_answers" class="modal_continue">Continue</a> <!-- class="disabled" --> </div> <div id="questions_body"> <form class="question_form" id="answers_form" action="#" method="post"> <ul> <li class="question_header"> <div class="question_header_event"> <strong>OTAKON 2018</strong> @ Walter E. Washington Convention Ctr in Washington, DC </div> <div class="question_header_date"> ( Aug 10 @ 9:00 AM - Aug 12 @ 4:00 PM ) </div> </li> <li style="padding: 15px;"> Full Weekend Membership for OTAKON 2018
Fri. Aug 10, 2018 at 9:00am - Sun. Aug 12, 2018 at 4:00pm EDT </li> <li class="required"> <div class="question"> <label for="ticket_name_110719124">Name On Ticket</label> </div> <div class="answer"> <span class="required_mark"></span>
<input type="text" id="ticket_name_110719124" name="ticket_name[110719124]" value=""> </div>
</li>
<li>
<div class="question">
<label for="answer_Ticket_110719124_455610" id="Ticket_110719124_455610__label">Membership ID Number (if returning Member)</label>
</div>
<div class="answer"> <span class="required_mark"></span>
<input type="text" id="answer_Ticket_110719124_455610" name="answer[Ticket][110719124][455610]" value=""> </div>
</li>
<li class="required">
<div class="question">
<label for="answer_Ticket_110719124_455612" id="Ticket_110719124_455612__label">MEMBER ADDRESS (Should match your Photo ID)</label>
</div>
<div class="answer"> <span class="required_mark"></span>
<fieldset role="group" aria-labelledby="Ticket_110719124_455612__label">
<select name="answer[Ticket][110719124][455612][country]" id="aqw_country_Ticket_110719124_455612" autocomplete="country" autocorrect="off" type="text" value="">
<option value="AF">Afghanistan</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AS">American Samoa (US)</option>
<option value="AD">Andorra</option>
<option value="AO">Angola</option>
<option value="AI">Anguilla (UK)</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 (UK)</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="BR">Brazil</option>
<option value="VG">British Virgin Islands (UK)</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">Cape Verde</option>
<option value="KY">Cayman Islands (UK)</option>
<option value="CF">Central African Republic</option>
<option value="TD">Chad</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CX">Christmas Island (AU)</option>
<option value="CC">Cocos (Keeling) Islands (AU)</option>
<option value="CO">Colombia</option>
<option value="KM">Comoros</option>
<option value="CD">Congo, Democratic Republic of the</option>
<option value="CG">Congo, Republic of the</option>
<option value="CK">Cook Islands (NZ)</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="CI">Côte D'Ivoire</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="GQ">Equatorial Guinea</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="ET">Ethiopia</option>
<option value="FK">Falkland Islands (UK)</option>
<option value="FO">Faroe Islands (DK)</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="GF">French Guiana (FR)</option>
<option value="PF">French Polynesia (FR)</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 (UK)</option>
<option value="GR">Greece</option>
<option value="GL">Greenland (DK)</option>
<option value="GD">Grenada</option>
<option value="GP">Guadeloupe (FR)</option>
<option value="GU">Guam (US)</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="VA">Holy See (Vatican City)</option>
<option value="HN">Honduras</option>
<option value="HK">Hong Kong (CN)</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</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 (North)</option>
<option value="KR">Korea, Republic of (South)</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Laos</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">Macau (CN)</option>
<option value="MK">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 (FR)</option>
<option value="MR">Mauritania</option>
<option value="MU">Mauritius</option>
<option value="YT">Mayotte (FR)</option>
<option value="MX">Mexico</option>
<option value="FM">Micronesia, Federated States of</option>
<option value="MD">Moldova Republic of</option>
<option value="MC">Monaco</option>
<option value="MN">Mongolia</option>
<option value="ME">Montenegro</option>
<option value="MS">Montserrat (UK)</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 (NL)</option>
<option value="NC">New Caledonia (FR)</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 (AU)</option>
<option value="MP">Northern Mariana Islands (US)</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PK">Pakistan</option>
<option value="PW">Palau</option>
<option value="PS">Palestinian Territories</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 Islands (UK)</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico (US)</option>
<option value="QA">Qatar</option>
<option value="RE">Reunion (FR)</option>
<option value="RO">Romania</option>
<option value="RU">Russia</option>
<option value="RW">Rwanda</option>
<option value="SH">Saint Helena (UK)</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="PM">Saint Pierre & Miquelon (FR)</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 & South Sandwich Islands (UK)</option>
<option value="SS">South Sudan</option>
<option value="ES">Spain</option>
<option value="LK">Sri Lanka</option>
<option value="SD">Sudan</option>
<option value="SR">Suriname</option>
<option value="SZ">Swaziland</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syria</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania</option>
<option value="TH">Thailand</option>
<option value="TL">Timor-Leste</option>
<option value="TG">Togo</option>
<option value="TK">Tokelau</option>
<option value="TO">Tonga</option>
<option value="TT">Trinidad and Tobago</option>
<option value="TN">Tunisia</option>
<option value="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks and Caicos Islands (UK)</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="US">United States</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="VI">Virgin Islands (US)</option>
<option value="WF">Wallis and Futuna (FR)</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select>
<input name="answer[Ticket][110719124][455612][full_name]" id="aqw_full_name_Ticket_110719124_455612" autocomplete="shipping name" autocorrect="off" type="text" value="" placeholder="Full Name">
<input name="answer[Ticket][110719124][455612][address]" id="aqw_address_Ticket_110719124_455612" autocomplete="address-line1" autocorrect="off" type="text" value="" placeholder="Address">
<input name="answer[Ticket][110719124][455612][address2]" id="aqw_address2_Ticket_110719124_455612" autocomplete="address-line2" autocorrect="off" type="text" value="" placeholder="Street Address 2">
<input name="answer[Ticket][110719124][455612][city]" id="aqw_city_Ticket_110719124_455612" autocomplete="address-level2" autocorrect="off" type="text" value="" placeholder="City">
<input name="answer[Ticket][110719124][455612][state]" id="aqw_state_Ticket_110719124_455612" autocomplete="address-level1" autocorrect="off" type="text" value="" placeholder="State">
<input name="answer[Ticket][110719124][455612][zip]" id="aqw_zip_Ticket_110719124_455612" autocomplete="postal-code" autocorrect="off" type="text" value="" placeholder="Zip Code">
<input name="answer[Ticket][110719124][455612][phone]" id="aqw_phone_Ticket_110719124_455612" autocomplete="phone" autocorrect="off" type="tel" value="" placeholder="Mobile Number"> </fieldset>
</div>
</li>
<li class="required">
<div class="question">
<label for="answer_Ticket_110719124_455613" id="Ticket_110719124_455613__label">Member E-Mail</label>
</div>
<div class="answer"> <span class="required_mark"></span>
<input type="text" id="answer_Ticket_110719124_455613" name="answer[Ticket][110719124][455613]" value=""> </div>
</li>
<li class="required">
<div class="question">
<label for="answer_Ticket_110719124_456129" id="Ticket_110719124_456129__label">Gender</label>
</div>
<div class="answer"> <span class="required_mark"></span>
<select id="answer_Ticket_110719124_456129" name="answer[Ticket][110719124][456129]" class="js-question-option-select">
<option value="">---</option>
<option value="Male">Male</option>
<option value="Female">Female</option>
<option value="Other / Non-Binary">Other / Non-Binary</option>
<option value="I Would Rather Not Say">I Would Rather Not Say</option>
</select>
</div>
</li>
<li class="required">
<div class="question">
<label for="answer_Ticket_110719124_456132" id="Ticket_110719124_456132__label">Date of Birth (MM/DD/YYYY)</label>
</div>
<div class="answer"> <span class="required_mark"></span>
<input type="text" id="answer_Ticket_110719124_456132" name="answer[Ticket][110719124][456132]" value=""> </div>
</li>
<li class="required">
<div class="question">
<label for="answer_Ticket_110719124_456134" id="Ticket_110719124_456134__label">Emergency Contact Name</label>
</div>
<div class="answer"> <span class="required_mark"></span>
<input type="text" id="answer_Ticket_110719124_456134" name="answer[Ticket][110719124][456134]" value=""> </div>
</li>
<li class="required">
<div class="question">
<label for="answer_Ticket_110719124_456133" id="Ticket_110719124_456133__label">Emergency Contact Phone Number</label>
</div>
<div class="answer"> <span class="required_mark"></span>
<input type="text" id="answer_Ticket_110719124_456133" name="answer[Ticket][110719124][456133]" value=""> </div>
</li>
<li class="required">
<div class="question">
<label for="answer_Ticket_110719124_456135" id="Ticket_110719124_456135__label">Otakon Subscription Preference</label>
</div>
<div class="answer"> <span class="required_mark"></span>
<select id="answer_Ticket_110719124_456135" name="answer[Ticket][110719124][456135]" class="js-question-option-select">
<option value="">---</option>
<option value="Yes, I want to receive updates about Otakon">Yes, I want to receive updates about Otakon</option>
<option value="No, do not send me updates.">No, do not send me updates.</option>
</select>
</div>
</li>
<li style="padding: 15px;"> Full Weekend Membership for OTAKON 2018 Fri. Aug 10, 2018 at 9:00am - Sun. Aug 12, 2018 at 4:00pm EDT </li>
<li class="required">
<div class="question">
<label for="ticket_name_110719125">Name On Ticket</label>
</div>
<div class="answer"> <span class="required_mark"></span>
<input type="text" id="ticket_name_110719125" name="ticket_name[110719125]" value=""> </div>
</li>
<li>
<div class="question">
<label for="answer_Ticket_110719125_455610" id="Ticket_110719125_455610__label">Membership ID Number (if returning Member)</label>
</div>
<div class="answer"> <span class="required_mark"></span>
<input type="text" id="answer_Ticket_110719125_455610" name="answer[Ticket][110719125][455610]" value=""> </div>
</li>
<li class="required">
<div class="question">
<label for="answer_Ticket_110719125_455612" id="Ticket_110719125_455612__label">MEMBER ADDRESS (Should match your Photo ID)</label>
</div>
<div class="answer"> <span class="required_mark"></span>
<fieldset role="group" aria-labelledby="Ticket_110719125_455612__label">
<select name="answer[Ticket][110719125][455612][country]" id="aqw_country_Ticket_110719125_455612" autocomplete="country" autocorrect="off" type="text" value="">
<option value="AF">Afghanistan</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AS">American Samoa (US)</option>
<option value="AD">Andorra</option>
<option value="AO">Angola</option>
<option value="AI">Anguilla (UK)</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 (UK)</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="BR">Brazil</option>
<option value="VG">British Virgin Islands (UK)</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">Cape Verde</option>
<option value="KY">Cayman Islands (UK)</option>
<option value="CF">Central African Republic</option>
<option value="TD">Chad</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CX">Christmas Island (AU)</option>
<option value="CC">Cocos (Keeling) Islands (AU)</option>
<option value="CO">Colombia</option>
<option value="KM">Comoros</option>
<option value="CD">Congo, Democratic Republic of the</option>
<option value="CG">Congo, Republic of the</option>
<option value="CK">Cook Islands (NZ)</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="CI">Côte D'Ivoire</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="GQ">Equatorial Guinea</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="ET">Ethiopia</option>
<option value="FK">Falkland Islands (UK)</option>
<option value="FO">Faroe Islands (DK)</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="GF">French Guiana (FR)</option>
<option value="PF">French Polynesia (FR)</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 (UK)</option>
<option value="GR">Greece</option>
<option value="GL">Greenland (DK)</option>
<option value="GD">Grenada</option>
<option value="GP">Guadeloupe (FR)</option>
<option value="GU">Guam (US)</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="VA">Holy See (Vatican City)</option>
<option value="HN">Honduras</option>
<option value="HK">Hong Kong (CN)</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</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 (North)</option>
<option value="KR">Korea, Republic of (South)</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Laos</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">Macau (CN)</option>
<option value="MK">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 (FR)</option>
<option value="MR">Mauritania</option>
<option value="MU">Mauritius</option>
<option value="YT">Mayotte (FR)</option>
<option value="MX">Mexico</option>
<option value="FM">Micronesia, Federated States of</option>
<option value="MD">Moldova Republic of</option>
<option value="MC">Monaco</option>
<option value="MN">Mongolia</option>
<option value="ME">Montenegro</option>
<option value="MS">Montserrat (UK)</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 (NL)</option>
<option value="NC">New Caledonia (FR)</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 (AU)</option>
<option value="MP">Northern Mariana Islands (US)</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PK">Pakistan</option>
<option value="PW">Palau</option>
<option value="PS">Palestinian Territories</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 Islands (UK)</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico (US)</option>
<option value="QA">Qatar</option>
<option value="RE">Reunion (FR)</option>
<option value="RO">Romania</option>
<option value="RU">Russia</option>
<option value="RW">Rwanda</option>
<option value="SH">Saint Helena (UK)</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="PM">Saint Pierre & Miquelon (FR)</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 & South Sandwich Islands (UK)</option>
<option value="SS">South Sudan</option>
<option value="ES">Spain</option>
<option value="LK">Sri Lanka</option>
<option value="SD">Sudan</option>
<option value="SR">Suriname</option>
<option value="SZ">Swaziland</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syria</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania</option>
<option value="TH">Thailand</option>
<option value="TL">Timor-Leste</option>
<option value="TG">Togo</option>
<option value="TK">Tokelau</option>
<option value="TO">Tonga</option>
<option value="TT">Trinidad and Tobago</option>
<option value="TN">Tunisia</option>
<option value="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks and Caicos Islands (UK)</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="US">United States</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="VI">Virgin Islands (US)</option>
<option value="WF">Wallis and Futuna (FR)</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select>
<input name="answer[Ticket][110719125][455612][full_name]" id="aqw_full_name_Ticket_110719125_455612" autocomplete="shipping name" autocorrect="off" type="text" value="" placeholder="Full Name">
<input name="answer[Ticket][110719125][455612][address]" id="aqw_address_Ticket_110719125_455612" autocomplete="address-line1" autocorrect="off" type="text" value="" placeholder="Address">
<input name="answer[Ticket][110719125][455612][address2]" id="aqw_address2_Ticket_110719125_455612" autocomplete="address-line2" autocorrect="off" type="text" value="" placeholder="Street Address 2">
<input name="answer[Ticket][110719125][455612][city]" id="aqw_city_Ticket_110719125_455612" autocomplete="address-level2" autocorrect="off" type="text" value="" placeholder="City">
<input name="answer[Ticket][110719125][455612][state]" id="aqw_state_Ticket_110719125_455612" autocomplete="address-level1" autocorrect="off" type="text" value="" placeholder="State">
<input name="answer[Ticket][110719125][455612][zip]" id="aqw_zip_Ticket_110719125_455612" autocomplete="postal-code" autocorrect="off" type="text" value="" placeholder="Zip Code">
<input name="answer[Ticket][110719125][455612][phone]" id="aqw_phone_Ticket_110719125_455612" autocomplete="phone" autocorrect="off" type="tel" value="" placeholder="Mobile Number"> </fieldset>
</div>
</li>
<li class="required">
<div class="question">
<label for="answer_Ticket_110719125_455613" id="Ticket_110719125_455613__label">Member E-Mail</label>
</div>
<div class="answer"> <span class="required_mark"></span>
<input type="text" id="answer_Ticket_110719125_455613" name="answer[Ticket][110719125][455613]" value=""> </div>
</li>
<li class="required">
<div class="question">
<label for="answer_Ticket_110719125_456129" id="Ticket_110719125_456129__label">Gender</label>
</div>
<div class="answer"> <span class="required_mark"></span>
<select id="answer_Ticket_110719125_456129" name="answer[Ticket][110719125][456129]" class="js-question-option-select">
<option value="">---</option>
<option value="Male">Male</option>
<option value="Female">Female</option>
<option value="Other / Non-Binary">Other / Non-Binary</option>
<option value="I Would Rather Not Say">I Would Rather Not Say</option>
</select>
</div>
</li>
<li class="required">
<div class="question">
<label for="answer_Ticket_110719125_456132" id="Ticket_110719125_456132__label">Date of Birth (MM/DD/YYYY)</label>
</div>
<div class="answer"> <span class="required_mark"></span>
<input type="text" id="answer_Ticket_110719125_456132" name="answer[Ticket][110719125][456132]" value=""> </div>
</li>
<li class="required">
<div class="question">
<label for="answer_Ticket_110719125_456134" id="Ticket_110719125_456134__label">Emergency Contact Name</label>
</div>
<div class="answer"> <span class="required_mark"></span>
<input type="text" id="answer_Ticket_110719125_456134" name="answer[Ticket][110719125][456134]" value=""> </div>
</li>
<li class="required">
<div class="question">
<label for="answer_Ticket_110719125_456133" id="Ticket_110719125_456133__label">Emergency Contact Phone Number</label>
</div>
<div class="answer"> <span class="required_mark"></span>
<input type="text" id="answer_Ticket_110719125_456133" name="answer[Ticket][110719125][456133]" value=""> </div>
</li>
<li class="required">
<div class="question">
<label for="answer_Ticket_110719125_456135" id="Ticket_110719125_456135__label">Otakon Subscription Preference</label>
</div>
<div class="answer"> <span class="required_mark"></span>
<select id="answer_Ticket_110719125_456135" name="answer[Ticket][110719125][456135]" class="js-question-option-select">
<option value="">---</option>
<option value="Yes, I want to receive updates about Otakon">Yes, I want to receive updates about Otakon</option>
<option value="No, do not send me updates.">No, do not send me updates.</option>
</select>
</div>
</li>
</ul>
<ul>
<li> Order Questions </li>
<li class="required">
<div class="question">
<label for="answer_Reservation_40601854_456137" id="Reservation_40601854_456137__label">Otakon 2018 Registration Terms and Conditions</label>
</div>
<div class="answer"> <span class="required_mark"></span>
<select id="answer_Reservation_40601854_456137" name="answer[Reservation][40601854][456137]" class="js-question-option-select">
<option value="">---</option>
<option value="I have read and agree to the terms and conditions of Otakon 2018 Registration">I have read and agree to the terms and conditions of Otakon 2018 Registration</option>
</select>
</div>
</li>
</ul>
</form>
</div>
</div>
<div id="modal_close" style="display: none;"></div>
</span>
</div>
</body>
</html>