#this is membership from...
<!DOCTYPE html>
<html lang="en">
<head>
<title>Membership Form</title>
<link rel="stylesheet" href="css/bootstrap.min.css">
</head>
<body>
<div class="container">
<center><h2>Membership Form</h2></center>
<form class="form-horizontal">
<div class="form-group">
<label class="control-label col-sm-2" for="email">Full Name:</label>
<div class="col-sm-10">
<div class="form-inline">
<input type="text" class="form-control" name="first_name" placeholder="First Name">
<input type="text" class="form-control" name="last_name" placeholder="Last Name">
</div>
</div>
</div>
<div class="form-group">
<label class="control-label col-sm-2" for="email">Seconadry Name:</label>
<div class="col-sm-10">
<div class="form-inline">
<input type="text" class="form-control" name="second_first_name" placeholder="First Name">
<input type="text" class="form-control" name="second_last_name" placeholder="Last Name">
</div>
</div>
</div>
<div class="form-group">
<label class="control-label col-sm-2" for="email">Gender:</label>
<div class="col-sm-10">
<div class="radio">
<label><input type="radio" name="gender">Male</label>
</div>
<div class="radio">
<label><input type="radio" name="gender">Female</label>
</div>
</div>
</div>
<div class="form-group">
<label class="control-label col-sm-2" for="email">Marital Status:</label>
<div class="col-sm-4">
<input type="text" class="form-control" name="marital_status" placeholder="Merital Status">
</div>
</div>
<div class="form-group">
<label class="control-label col-sm-2" for="email">Name of Spouse:</label>
<div class="col-sm-4">
<input type="text" class="form-control" name="spouse_name" placeholder="Name of Spouse">
</div>
</div>
<div class="form-group">
<label class="control-label col-sm-2" for="email">Name of Father:</label>
<div class="col-sm-4">
<input type="text" class="form-control" name="father_name" placeholder="Name of Father">
</div>
</div>
<div class="form-group">
<label class="control-label col-sm-2" for="email">Place of Birth:</label>
<div class="col-sm-4">
<input type="text" class="form-control" name="birth_place" placeholder="Place of Birth">
</div>
</div>
<div class="form-group">
<label class="control-label col-sm-2" for="email">Photo Identification Type:</label>
<div class="col-sm-4">
<div class="checkbox">
<label><input type="checkbox" value="voter_id_card">Voter ID Card</label>
</div>
<div class="checkbox">
<label><input type="checkbox" value="aadhar_card">Aadhar ID Card</label>
</div>
<div class="checkbox">
<label><input type="checkbox" value="other">Others</label>
</div>
</div>
</div>
<div class="form-group">
<label class="control-label col-sm-2" for="email">Other Photo Identification details:</label>
<div class="col-sm-4">
<input type="text" class="form-control" name="other_photo_details" placeholder="Other Photo Identification details">
</div>
</div>
<div class="form-group">
<label class="control-label col-sm-2" for="email">Voter ID Card Number:</label>
<div class="col-sm-4">
<input type="text" class="form-control" name="voter_id_card_number" placeholder="Voter ID Card Number">
</div>
</div>
<div class="form-group">
<label class="control-label col-sm-2" for="email">Aadhar Card Number:</label>
<div class="col-sm-4">
<input type="text" class="form-control" name="aadhar_card_number" placeholder="Aadhar Card Number">
</div>
</div>
<div class="form-group">
<label class="control-label col-sm-2" for="email">PAN Card Number:</label>
<div class="col-sm-4">
<input type="text" class="form-control" name="pan_card_number" placeholder="PAN Card Number">
</div>
</div>
<div class="form-group">
<label class="control-label col-sm-2" for="email">Present Address:</label>
<div class="col-sm-5">
<input type="text" class="form-control" name="street_address" placeholder="Street Address">
<br />
<div class="form-inline">
<input type="text" class="form-control" name="city" placeholder="City">
<input type="text" class="form-control" name="state_province" placeholder="State / Province">
</div>
<br />
<div class="form-inline">
<input type="text" class="form-control" name="postal" placeholder="Postal / Zip Code">
<select class="form-control" style="width:43%; "id="sel1">
<option> Select Country </option>
<option value="Afghanistan">Afghanistan</option>
<option value="Albania">Albania</option>
<option value="Algeria">Algeria</option>
<option value="American Samoa">American Samoa</option>
<option value="Andorra">Andorra</option>
<option value="Angola">Angola</option>
<option value="Anguilla">Anguilla</option>
<option value="Antartica">Antarctica</option>
<option value="Antigua and Barbuda">Antigua and Barbuda</option>
<option value="Argentina">Argentina</option>
<option value="Armenia">Armenia</option>
<option value="Aruba">Aruba</option>
<option value="Australia">Australia</option>
<option value="Austria">Austria</option>
<option value="Azerbaijan">Azerbaijan</option>
<option value="Bahamas">Bahamas</option>
<option value="Bahrain">Bahrain</option>
<option value="Bangladesh">Bangladesh</option>
<option value="Barbados">Barbados</option>
<option value="Belarus">Belarus</option>
<option value="Belgium">Belgium</option>
<option value="Belize">Belize</option>
<option value="Benin">Benin</option>
<option value="Bermuda">Bermuda</option>
<option value="Bhutan">Bhutan</option>
<option value="Bolivia">Bolivia</option>
<option value="Bosnia and Herzegowina">Bosnia and Herzegowina</option>
<option value="Botswana">Botswana</option>
<option value="Bouvet Island">Bouvet Island</option>
<option value="Brazil">Brazil</option>
<option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
<option value="Brunei Darussalam">Brunei Darussalam</option>
<option value="Bulgaria">Bulgaria</option>
<option value="Burkina Faso">Burkina Faso</option>
<option value="Burundi">Burundi</option>
<option value="Cambodia">Cambodia</option>
<option value="Cameroon">Cameroon</option>
<option value="Canada">Canada</option>
<option value="Cape Verde">Cape Verde</option>
<option value="Cayman Islands">Cayman Islands</option>
<option value="Central African Republic">Central African Republic</option>
<option value="Chad">Chad</option>
<option value="Chile">Chile</option>
<option value="China">China</option>
<option value="Christmas Island">Christmas Island</option>
<option value="Cocos Islands">Cocos (Keeling) Islands</option>
<option value="Colombia">Colombia</option>
<option value="Comoros">Comoros</option>
<option value="Congo">Congo</option>
<option value="Congo">Congo, the Democratic Republic of the</option>
<option value="Cook Islands">Cook Islands</option>
<option value="Costa Rica">Costa Rica</option>
<option value="Cota D'Ivoire">Cote d'Ivoire</option>
<option value="Croatia">Croatia (Hrvatska)</option>
<option value="Cuba">Cuba</option>
<option value="Cyprus">Cyprus</option>
<option value="Czech Republic">Czech Republic</option>
<option value="Denmark">Denmark</option>
<option value="Djibouti">Djibouti</option>
<option value="Dominica">Dominica</option>
<option value="Dominican Republic">Dominican Republic</option>
<option value="East Timor">East Timor</option>
<option value="Ecuador">Ecuador</option>
<option value="Egypt">Egypt</option>
<option value="El Salvador">El Salvador</option>
<option value="Equatorial Guinea">Equatorial Guinea</option>
<option value="Eritrea">Eritrea</option>
<option value="Estonia">Estonia</option>
<option value="Ethiopia">Ethiopia</option>
<option value="Falkland Islands">Falkland Islands (Malvinas)</option>
<option value="Faroe Islands">Faroe Islands</option>
<option value="Fiji">Fiji</option>
<option value="Finland">Finland</option>
<option value="France">France</option>
<option value="France Metropolitan">France, Metropolitan</option>
<option value="French Guiana">French Guiana</option>
<option value="French Polynesia">French Polynesia</option>
<option value="French Southern Territories">French Southern Territories</option>
<option value="Gabon">Gabon</option>
<option value="Gambia">Gambia</option>
<option value="Georgia">Georgia</option>
<option value="Germany">Germany</option>
<option value="Ghana">Ghana</option>
<option value="Gibraltar">Gibraltar</option>
<option value="Greece">Greece</option>
<option value="Greenland">Greenland</option>
<option value="Grenada">Grenada</option>
<option value="Guadeloupe">Guadeloupe</option>
<option value="Guam">Guam</option>
<option value="Guatemala">Guatemala</option>
<option value="Guinea">Guinea</option>
<option value="Guinea-Bissau">Guinea-Bissau</option>
<option value="Guyana">Guyana</option>
<option value="Haiti">Haiti</option>
<option value="Heard and McDonald Islands">Heard and Mc Donald Islands</option>
<option value="Holy See">Holy See (Vatican City State)</option>
<option value="Honduras">Honduras</option>
<option value="Hong Kong">Hong Kong</option>
<option value="Hungary">Hungary</option>
<option value="Iceland">Iceland</option>
<option value="India">India</option>
<option value="Indonesia">Indonesia</option>
<option value="Iran">Iran (Islamic Republic of)</option>
<option value="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Israel">Israel</option>
<option value="Italy">Italy</option>
<option value="Jamaica">Jamaica</option>
<option value="Japan">Japan</option>
<option value="Jordan">Jordan</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kiribati">Kiribati</option>
<option value="Democratic People's Republic of Korea">Korea, Democratic People's Republic of</option>
<option value="Korea">Korea, Republic of</option>
<option value="Kuwait">Kuwait</option>
<option value="Kyrgyzstan">Kyrgyzstan</option>
<option value="Lao">Lao People's Democratic Republic</option>
<option value="Latvia">Latvia</option>
<option value="Lebanon" selected>Lebanon</option>
<option value="Lesotho">Lesotho</option>
<option value="Liberia">Liberia</option>
<option value="Libyan Arab Jamahiriya">Libyan Arab Jamahiriya</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lithuania">Lithuania</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macau">Macau</option>
<option value="Macedonia">Macedonia, The Former Yugoslav Republic of</option>
<option value="Madagascar">Madagascar</option>
<option value="Malawi">Malawi</option>
<option value="Malaysia">Malaysia</option>
<option value="Maldives">Maldives</option>
<option value="Mali">Mali</option>
<option value="Malta">Malta</option>
<option value="Marshall Islands">Marshall Islands</option>
<option value="Martinique">Martinique</option>
<option value="Mauritania">Mauritania</option>
<option value="Mauritius">Mauritius</option>
<option value="Mayotte">Mayotte</option>
<option value="Mexico">Mexico</option>
<option value="Micronesia">Micronesia, Federated States of</option>
<option value="Moldova">Moldova, Republic of</option>
<option value="Monaco">Monaco</option>
<option value="Mongolia">Mongolia</option>
<option value="Montserrat">Montserrat</option>
<option value="Morocco">Morocco</option>
<option value="Mozambique">Mozambique</option>
<option value="Myanmar">Myanmar</option>
<option value="Namibia">Namibia</option>
<option value="Nauru">Nauru</option>
<option value="Nepal">Nepal</option>
<option value="Netherlands">Netherlands</option>
<option value="Netherlands Antilles">Netherlands Antilles</option>
<option value="New Caledonia">New Caledonia</option>
<option value="New Zealand">New Zealand</option>
<option value="Nicaragua">Nicaragua</option>
<option value="Niger">Niger</option>
<option value="Nigeria">Nigeria</option>
<option value="Niue">Niue</option>
<option value="Norfolk Island">Norfolk Island</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Norway">Norway</option>
<option value="Oman">Oman</option>
<option value="Pakistan">Pakistan</option>
<option value="Palau">Palau</option>
<option value="Panama">Panama</option>
<option value="Papua New Guinea">Papua New Guinea</option>
<option value="Paraguay">Paraguay</option>
<option value="Peru">Peru</option>
<option value="Philippines">Philippines</option>
<option value="Pitcairn">Pitcairn</option>
<option value="Poland">Poland</option>
<option value="Portugal">Portugal</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Qatar">Qatar</option>
<option value="Reunion">Reunion</option>
<option value="Romania">Romania</option>
<option value="Russia">Russian Federation</option>
<option value="Rwanda">Rwanda</option>
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
<option value="Saint LUCIA">Saint LUCIA</option>
<option value="Saint Vincent">Saint Vincent and the Grenadines</option>
<option value="Samoa">Samoa</option>
<option value="San Marino">San Marino</option>
<option value="Sao Tome and Principe">Sao Tome and Principe</option>
<option value="Saudi Arabia">Saudi Arabia</option>
<option value="Senegal">Senegal</option>
<option value="Seychelles">Seychelles</option>
<option value="Sierra">Sierra Leone</option>
<option value="Singapore">Singapore</option>
<option value="Slovakia">Slovakia (Slovak Republic)</option>
<option value="Slovenia">Slovenia</option>
<option value="Solomon Islands">Solomon Islands</option>
<option value="Somalia">Somalia</option>
<option value="South Africa">South Africa</option>
<option value="South Georgia">South Georgia and the South Sandwich Islands</option>
<option value="Span">Spain</option>
<option value="SriLanka">Sri Lanka</option>
<option value="St. Helena">St. Helena</option>
<option value="St. Pierre and Miguelon">St. Pierre and Miquelon</option>
<option value="Sudan">Sudan</option>
<option value="Suriname">Suriname</option>
<option value="Svalbard">Svalbard and Jan Mayen Islands</option>
<option value="Swaziland">Swaziland</option>
<option value="Sweden">Sweden</option>
<option value="Switzerland">Switzerland</option>
<option value="Syria">Syrian Arab Republic</option>
<option value="Taiwan">Taiwan, Province of China</option>
<option value="Tajikistan">Tajikistan</option>
<option value="Tanzania">Tanzania, United Republic of</option>
<option value="Thailand">Thailand</option>
<option value="Togo">Togo</option>
<option value="Tokelau">Tokelau</option>
<option value="Tonga">Tonga</option>
<option value="Trinidad and Tobago">Trinidad and Tobago</option>
<option value="Tunisia">Tunisia</option>
<option value="Turkey">Turkey</option>
<option value="Turkmenistan">Turkmenistan</option>
<option value="Turks and Caicos">Turks and Caicos Islands</option>
<option value="Tuvalu">Tuvalu</option>
<option value="Uganda">Uganda</option>
<option value="Ukraine">Ukraine</option>
<option value="United Arab Emirates">United Arab Emirates</option>
<option value="United Kingdom">United Kingdom</option>
<option value="United States">United States</option>
<option value="United States Minor Outlying Islands">United States Minor Outlying Islands</option>
<option value="Uruguay">Uruguay</option>
<option value="Uzbekistan">Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Venezuela">Venezuela</option>
<option value="Vietnam">Viet Nam</option>
<option value="Virgin Islands (British)">Virgin Islands (British)</option>
<option value="Virgin Islands (U.S)">Virgin Islands (U.S.)</option>
<option value="Wallis and Futana Islands">Wallis and Futuna Islands</option>
<option value="Western Sahara">Western Sahara</option>
<option value="Yemen">Yemen</option>
<option value="Yugoslavia">Yugoslavia</option>
<option value="Zambia">Zambia</option>
<option value="Zimbabwe">Zimbabwe</option>
</select>
</div>
</div>
</div>
<div class="form-group">
<label class="control-label col-sm-2" for="email">Landmark of Present Address:</label>
<div class="col-sm-4">
<input type="text" class="form-control" name="landmark_present_add" placeholder="Landmark of Present Address">
</div>
</div>
<div class="form-group">
<label class="control-label col-sm-2" for="email">Office / Business Address:</label>
<div class="col-sm-5">
<input type="text" class="form-control" name="office_business_add" placeholder="Office / Business Address">
<br />
<div class="form-inline">
<input type="text" class="form-control" name="office_city" placeholder="City">
<input type="text" class="form-control" name="office_state_province" placeholder="State / Province">
</div>
<br />
<div class="form-inline">
<input type="text" class="form-control" name="office_postal" placeholder="Postal / Zip Code">
<select class="form-control" style="width:43%; "id="sel1">
<option> Select Country </option>
<option value="Afghanistan">Afghanistan</option>
<option value="Albania">Albania</option>
<option value="Algeria">Algeria</option>
<option value="American Samoa">American Samoa</option>
<option value="Andorra">Andorra</option>
<option value="Angola">Angola</option>
<option value="Anguilla">Anguilla</option>
<option value="Antartica">Antarctica</option>
<option value="Antigua and Barbuda">Antigua and Barbuda</option>
<option value="Argentina">Argentina</option>
<option value="Armenia">Armenia</option>
<option value="Aruba">Aruba</option>
<option value="Australia">Australia</option>
<option value="Austria">Austria</option>
<option value="Azerbaijan">Azerbaijan</option>
<option value="Bahamas">Bahamas</option>
<option value="Bahrain">Bahrain</option>
<option value="Bangladesh">Bangladesh</option>
<option value="Barbados">Barbados</option>
<option value="Belarus">Belarus</option>
<option value="Belgium">Belgium</option>
<option value="Belize">Belize</option>
<option value="Benin">Benin</option>
<option value="Bermuda">Bermuda</option>
<option value="Bhutan">Bhutan</option>
<option value="Bolivia">Bolivia</option>
<option value="Bosnia and Herzegowina">Bosnia and Herzegowina</option>
<option value="Botswana">Botswana</option>
<option value="Bouvet Island">Bouvet Island</option>
<option value="Brazil">Brazil</option>
<option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
<option value="Brunei Darussalam">Brunei Darussalam</option>
<option value="Bulgaria">Bulgaria</option>
<option value="Burkina Faso">Burkina Faso</option>
<option value="Burundi">Burundi</option>
<option value="Cambodia">Cambodia</option>
<option value="Cameroon">Cameroon</option>
<option value="Canada">Canada</option>
<option value="Cape Verde">Cape Verde</option>
<option value="Cayman Islands">Cayman Islands</option>
<option value="Central African Republic">Central African Republic</option>
<option value="Chad">Chad</option>
<option value="Chile">Chile</option>
<option value="China">China</option>
<option value="Christmas Island">Christmas Island</option>
<option value="Cocos Islands">Cocos (Keeling) Islands</option>
<option value="Colombia">Colombia</option>
<option value="Comoros">Comoros</option>
<option value="Congo">Congo</option>
<option value="Congo">Congo, the Democratic Republic of the</option>
<option value="Cook Islands">Cook Islands</option>
<option value="Costa Rica">Costa Rica</option>
<option value="Cota D'Ivoire">Cote d'Ivoire</option>
<option value="Croatia">Croatia (Hrvatska)</option>
<option value="Cuba">Cuba</option>
<option value="Cyprus">Cyprus</option>
<option value="Czech Republic">Czech Republic</option>
<option value="Denmark">Denmark</option>
<option value="Djibouti">Djibouti</option>
<option value="Dominica">Dominica</option>
<option value="Dominican Republic">Dominican Republic</option>
<option value="East Timor">East Timor</option>
<option value="Ecuador">Ecuador</option>
<option value="Egypt">Egypt</option>
<option value="El Salvador">El Salvador</option>
<option value="Equatorial Guinea">Equatorial Guinea</option>
<option value="Eritrea">Eritrea</option>
<option value="Estonia">Estonia</option>
<option value="Ethiopia">Ethiopia</option>
<option value="Falkland Islands">Falkland Islands (Malvinas)</option>
<option value="Faroe Islands">Faroe Islands</option>
<option value="Fiji">Fiji</option>
<option value="Finland">Finland</option>
<option value="France">France</option>
<option value="France Metropolitan">France, Metropolitan</option>
<option value="French Guiana">French Guiana</option>
<option value="French Polynesia">French Polynesia</option>
<option value="French Southern Territories">French Southern Territories</option>
<option value="Gabon">Gabon</option>
<option value="Gambia">Gambia</option>
<option value="Georgia">Georgia</option>
<option value="Germany">Germany</option>
<option value="Ghana">Ghana</option>
<option value="Gibraltar">Gibraltar</option>
<option value="Greece">Greece</option>
<option value="Greenland">Greenland</option>
<option value="Grenada">Grenada</option>
<option value="Guadeloupe">Guadeloupe</option>
<option value="Guam">Guam</option>
<option value="Guatemala">Guatemala</option>
<option value="Guinea">Guinea</option>
<option value="Guinea-Bissau">Guinea-Bissau</option>
<option value="Guyana">Guyana</option>
<option value="Haiti">Haiti</option>
<option value="Heard and McDonald Islands">Heard and Mc Donald Islands</option>
<option value="Holy See">Holy See (Vatican City State)</option>
<option value="Honduras">Honduras</option>
<option value="Hong Kong">Hong Kong</option>
<option value="Hungary">Hungary</option>
<option value="Iceland">Iceland</option>
<option value="India">India</option>
<option value="Indonesia">Indonesia</option>
<option value="Iran">Iran (Islamic Republic of)</option>
<option value="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Israel">Israel</option>
<option value="Italy">Italy</option>
<option value="Jamaica">Jamaica</option>
<option value="Japan">Japan</option>
<option value="Jordan">Jordan</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kiribati">Kiribati</option>
<option value="Democratic People's Republic of Korea">Korea, Democratic People's Republic of</option>
<option value="Korea">Korea, Republic of</option>
<option value="Kuwait">Kuwait</option>
<option value="Kyrgyzstan">Kyrgyzstan</option>
<option value="Lao">Lao People's Democratic Republic</option>
<option value="Latvia">Latvia</option>
<option value="Lebanon" selected>Lebanon</option>
<option value="Lesotho">Lesotho</option>
<option value="Liberia">Liberia</option>
<option value="Libyan Arab Jamahiriya">Libyan Arab Jamahiriya</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lithuania">Lithuania</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macau">Macau</option>
<option value="Macedonia">Macedonia, The Former Yugoslav Republic of</option>
<option value="Madagascar">Madagascar</option>
<option value="Malawi">Malawi</option>
<option value="Malaysia">Malaysia</option>
<option value="Maldives">Maldives</option>
<option value="Mali">Mali</option>
<option value="Malta">Malta</option>
<option value="Marshall Islands">Marshall Islands</option>
<option value="Martinique">Martinique</option>
<option value="Mauritania">Mauritania</option>
<option value="Mauritius">Mauritius</option>
<option value="Mayotte">Mayotte</option>
<option value="Mexico">Mexico</option>
<option value="Micronesia">Micronesia, Federated States of</option>
<option value="Moldova">Moldova, Republic of</option>
<option value="Monaco">Monaco</option>
<option value="Mongolia">Mongolia</option>
<option value="Montserrat">Montserrat</option>
<option value="Morocco">Morocco</option>
<option value="Mozambique">Mozambique</option>
<option value="Myanmar">Myanmar</option>
<option value="Namibia">Namibia</option>
<option value="Nauru">Nauru</option>
<option value="Nepal">Nepal</option>
<option value="Netherlands">Netherlands</option>
<option value="Netherlands Antilles">Netherlands Antilles</option>
<option value="New Caledonia">New Caledonia</option>
<option value="New Zealand">New Zealand</option>
<option value="Nicaragua">Nicaragua</option>
<option value="Niger">Niger</option>
<option value="Nigeria">Nigeria</option>
<option value="Niue">Niue</option>
<option value="Norfolk Island">Norfolk Island</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Norway">Norway</option>
<option value="Oman">Oman</option>
<option value="Pakistan">Pakistan</option>
<option value="Palau">Palau</option>
<option value="Panama">Panama</option>
<option value="Papua New Guinea">Papua New Guinea</option>
<option value="Paraguay">Paraguay</option>
<option value="Peru">Peru</option>
<option value="Philippines">Philippines</option>
<option value="Pitcairn">Pitcairn</option>
<option value="Poland">Poland</option>
<option value="Portugal">Portugal</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Qatar">Qatar</option>
<option value="Reunion">Reunion</option>
<option value="Romania">Romania</option>
<option value="Russia">Russian Federation</option>
<option value="Rwanda">Rwanda</option>
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
<option value="Saint LUCIA">Saint LUCIA</option>
<option value="Saint Vincent">Saint Vincent and the Grenadines</option>
<option value="Samoa">Samoa</option>
<option value="San Marino">San Marino</option>
<option value="Sao Tome and Principe">Sao Tome and Principe</option>
<option value="Saudi Arabia">Saudi Arabia</option>
<option value="Senegal">Senegal</option>
<option value="Seychelles">Seychelles</option>
<option value="Sierra">Sierra Leone</option>
<option value="Singapore">Singapore</option>
<option value="Slovakia">Slovakia (Slovak Republic)</option>
<option value="Slovenia">Slovenia</option>
<option value="Solomon Islands">Solomon Islands</option>
<option value="Somalia">Somalia</option>
<option value="South Africa">South Africa</option>
<option value="South Georgia">South Georgia and the South Sandwich Islands</option>
<option value="Span">Spain</option>
<option value="SriLanka">Sri Lanka</option>
<option value="St. Helena">St. Helena</option>
<option value="St. Pierre and Miguelon">St. Pierre and Miquelon</option>
<option value="Sudan">Sudan</option>
<option value="Suriname">Suriname</option>
<option value="Svalbard">Svalbard and Jan Mayen Islands</option>
<option value="Swaziland">Swaziland</option>
<option value="Sweden">Sweden</option>
<option value="Switzerland">Switzerland</option>
<option value="Syria">Syrian Arab Republic</option>
<option value="Taiwan">Taiwan, Province of China</option>
<option value="Tajikistan">Tajikistan</option>
<option value="Tanzania">Tanzania, United Republic of</option>
<option value="Thailand">Thailand</option>
<option value="Togo">Togo</option>
<option value="Tokelau">Tokelau</option>
<option value="Tonga">Tonga</option>
<option value="Trinidad and Tobago">Trinidad and Tobago</option>
<option value="Tunisia">Tunisia</option>
<option value="Turkey">Turkey</option>
<option value="Turkmenistan">Turkmenistan</option>
<option value="Turks and Caicos">Turks and Caicos Islands</option>
<option value="Tuvalu">Tuvalu</option>
<option value="Uganda">Uganda</option>
<option value="Ukraine">Ukraine</option>
<option value="United Arab Emirates">United Arab Emirates</option>
<option value="United Kingdom">United Kingdom</option>
<option value="United States">United States</option>
<option value="United States Minor Outlying Islands">United States Minor Outlying Islands</option>
<option value="Uruguay">Uruguay</option>
<option value="Uzbekistan">Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Venezuela">Venezuela</option>
<option value="Vietnam">Viet Nam</option>
<option value="Virgin Islands (British)">Virgin Islands (British)</option>
<option value="Virgin Islands (U.S)">Virgin Islands (U.S.)</option>
<option value="Wallis and Futana Islands">Wallis and Futuna Islands</option>
<option value="Western Sahara">Western Sahara</option>
<option value="Yemen">Yemen</option>
<option value="Yugoslavia">Yugoslavia</option>
<option value="Zambia">Zambia</option>
<option value="Zimbabwe">Zimbabwe</option>
</select>
</div>
</div>
</div>
<div class="form-group">
<label class="control-label col-sm-2" for="email">Landmark of Office Address:</label>
<div class="col-sm-4">
<input type="text" class="form-control" name="landmark_office_add" placeholder="Landmark of Office Address">
</div>
</div>
<div class="form-group">
<label class="control-label col-sm-2" for="email">Nationality:</label>
<div class="col-sm-4">
<input type="text" class="form-control" name="nationality" placeholder="Nationality">
</div>
</div>
<div class="form-group">
<label class="control-label col-sm-2" for="email">Mobile Number:</label>
<div class="col-sm-4">
<input type="text" class="form-control" name="mobile" placeholder="Mobile Number">
</div>
</div>
<div class="form-group">
<label class="control-label col-sm-2" for="email">E-mail:</label>
<div class="col-sm-4">
<input type="text" class="form-control" name="email" placeholder="E-mail">
</div>
</div>
<div class="form-group">
<label class="control-label col-sm-2" for="email">Occupation:</label>
<div class="col-sm-4">
<input type="text" class="form-control" name="occupation" placeholder="Occupation">
</div>
</div>
<div class="form-group">
<label class="control-label col-sm-2" for="email">Phone Number (residential):</label>
<div class="col-sm-4">
<input type="text" class="form-control" name="residential_phone" placeholder="Phone Number (residential)">
</div>
</div>
<div class="form-group">
<label class="control-label col-sm-2" for="email">Phone Number (office):</label>
<div class="col-sm-4">
<input type="text" class="form-control" name="office_phone" placeholder="Phone Number (office)">
</div>
</div>
<div class="form-group">
<label class="control-label col-sm-2" for="email">Select:</label>
<div class="col-sm-10">
<div class="radio">
<label><input type="radio" name="jtype">Self Employed</label>
</div>
<div class="radio">
<label><input type="radio" name="jtype">Job</label>
</div>
</div>
</div>
<div class="form-group">
<label class="control-label col-sm-2" for="email">Source of Income:</label>
<div class="col-sm-4">
<input type="text" class="form-control" name="source_of_income" placeholder="Source of Income">
</div>
</div>
<div class="form-group">
<div class="col-sm-offset-2 col-sm-10">
<button type="submit" class="btn btn-default">Submit</button>
</div>
</div>
</form>
</div>
</body>
</html>