chrome/test/data/autofill/heuristics/input/15_crbug_52198.html

   1 <!-- https://idmanager.its.utexas.edu/eid_self_help/ -->
   2 <form id="personalInfo" method="post" action="./">
   3   <fieldset>
   4     <p>
   5       <label for="firstName"><span>*</span>First (Given) Name:</label> <input type="hidden" name="qwicap-page-id" value="D41F428A46D78104" /><input type="hidden" name="qwicap-form-id" value="9EC0EC3CD02FF862" /><input type="text" id="firstName" name="firstName" size="25" />
   6     </p>
   7     <p>
   8       <label for="middleName">Middle Name:</label> <input type="text" id="middleName" name="middleName" size="25" />
   9     </p>
  10     <p>
  11       <label for="lastName"><span>*</span>Last (Family) Name:</label> <input type="text" id="lastName" name="lastName" size="25" />
  12     </p>
  13     <p>
  14       <label for="suffix">Generational Suffix:</label> <select name="suffix" id="suffix">
  15         <option value="">
  16           None
  17         </option>
  18         <option value="Jr">
  19           Jr.
  20         </option>
  21         <option value="Sr">
  22           Sr.
  23         </option>
  24         <option value="I">
  25           I
  26         </option>
  27         <option value="II">
  28           II
  29         </option>
  30         <option value="III">
  31           III
  32         </option>
  33         <option value="IV">
  34           IV
  35         </option>
  36       </select>
  37     </p>
  38     <p id="otherFName0">
  39       <label for="otherFirstName">Other First Names:<br />
  40       <span>(For example, your nickname.)</span></label> <input type="text" id="otherFirstName" name="otherFirstName" size="25" /> <input id="moreFirstNamesAdd" type="submit" value="+" name="moreFirstNames" />
  41     </p>
  42     <p id="otherLName0">
  43       <label for="otherLastName">Other Last Names:<br />
  44       <span>(For example, your maiden name.)</span></label> <input type="text" id="otherLastName" name="otherLastName" size="25" /> <input id="moreLastNamesAdd" type="submit" value="+" name="moreLastNames" />
  45     </p>
  46     <p>
  47       <label><span>*</span>Date of Birth:</label> <label id="month" for="monthOfBirth">Month:</label> <select id="monthOfBirth" name="monthOfBirth">
  48         <option value="-">
  49           --
  50         </option>
  51         <option value="01">
  52           Jan
  53         </option>
  54         <option value="02">
  55           Feb
  56         </option>
  57         <option value="03">
  58           Mar
  59         </option>
  60         <option value="04">
  61           Apr
  62         </option>
  63         <option value="05">
  64           May
  65         </option>
  66         <option value="06">
  67           Jun
  68         </option>
  69         <option value="07">
  70           Jul
  71         </option>
  72         <option value="08">
  73           Aug
  74         </option>
  75         <option value="09">
  76           Sep
  77         </option>
  78         <option value="10">
  79           Oct
  80         </option>
  81         <option value="11">
  82           Nov
  83         </option>
  84         <option value="12">
  85           Dec
  86         </option>
  87       </select> <label for="dayOfBirth" id="day">Day:</label> <select id="dayOfBirth" name="dayOfBirth">
  88         <option value="-">
  89           --
  90         </option>
  91         <option value="1">
  92           1
  93         </option>
  94         <option value="2">
  95           2
  96         </option>
  97         <option value="3">
  98           3
  99         </option>
 100         <option value="4">
 101           4
 102         </option>
 103         <option value="5">
 104           5
 105         </option>
 106         <option value="6">
 107           6
 108         </option>
 109         <option value="7">
 110           7
 111         </option>
 112         <option value="8">
 113           8
 114         </option>
 115         <option value="9">
 116           9
 117         </option>
 118         <option value="10">
 119           10
 120         </option>
 121         <option value="11">
 122           11
 123         </option>
 124         <option value="12">
 125           12
 126         </option>
 127         <option value="13">
 128           13
 129         </option>
 130         <option value="14">
 131           14
 132         </option>
 133         <option value="15">
 134           15
 135         </option>
 136         <option value="16">
 137           16
 138         </option>
 139         <option value="17">
 140           17
 141         </option>
 142         <option value="18">
 143           18
 144         </option>
 145         <option value="19">
 146           19
 147         </option>
 148         <option value="20">
 149           20
 150         </option>
 151         <option value="21">
 152           21
 153         </option>
 154         <option value="22">
 155           22
 156         </option>
 157         <option value="23">
 158           23
 159         </option>
 160         <option value="24">
 161           24
 162         </option>
 163         <option value="25">
 164           25
 165         </option>
 166         <option value="26">
 167           26
 168         </option>
 169         <option value="27">
 170           27
 171         </option>
 172         <option value="28">
 173           28
 174         </option>
 175         <option value="29">
 176           29
 177         </option>
 178         <option value="30">
 179           30
 180         </option>
 181         <option value="31">
 182           31
 183         </option>
 184       </select> <label id="year" for="yearOfBirth">Year:</label> <select id="yearOfBirth" name="yearOfBirth">
 185         <option value="-">
 186           --
 187         </option>
 188         <option value="1997">
 189           1997
 190         </option>
 191         <option value="1996">
 192           1996
 193         </option>
 194         <option value="1995">
 195           1995
 196         </option>
 197         <option value="1994">
 198           1994
 199         </option>
 200         <option value="1993">
 201           1993
 202         </option>
 203         <option value="1992">
 204           1992
 205         </option>
 206         <option value="1991">
 207           1991
 208         </option>
 209         <option value="1990">
 210           1990
 211         </option>
 212         <option value="1989">
 213           1989
 214         </option>
 215         <option value="1988">
 216           1988
 217         </option>
 218         <option value="1987">
 219           1987
 220         </option>
 221         <option value="1986">
 222           1986
 223         </option>
 224         <option value="1985">
 225           1985
 226         </option>
 227         <option value="1984">
 228           1984
 229         </option>
 230         <option value="1983">
 231           1983
 232         </option>
 233         <option value="1982">
 234           1982
 235         </option>
 236         <option value="1981">
 237           1981
 238         </option>
 239         <option value="1980">
 240           1980
 241         </option>
 242         <option value="1979">
 243           1979
 244         </option>
 245         <option value="1978">
 246           1978
 247         </option>
 248         <option value="1977">
 249           1977
 250         </option>
 251         <option value="1976">
 252           1976
 253         </option>
 254         <option value="1975">
 255           1975
 256         </option>
 257         <option value="1974">
 258           1974
 259         </option>
 260         <option value="1973">
 261           1973
 262         </option>
 263         <option value="1972">
 264           1972
 265         </option>
 266         <option value="1971">
 267           1971
 268         </option>
 269         <option value="1970">
 270           1970
 271         </option>
 272         <option value="1969">
 273           1969
 274         </option>
 275         <option value="1968">
 276           1968
 277         </option>
 278         <option value="1967">
 279           1967
 280         </option>
 281         <option value="1966">
 282           1966
 283         </option>
 284         <option value="1965">
 285           1965
 286         </option>
 287         <option value="1964">
 288           1964
 289         </option>
 290         <option value="1963">
 291           1963
 292         </option>
 293         <option value="1962">
 294           1962
 295         </option>
 296         <option value="1961">
 297           1961
 298         </option>
 299         <option value="1960">
 300           1960
 301         </option>
 302         <option value="1959">
 303           1959
 304         </option>
 305         <option value="1958">
 306           1958
 307         </option>
 308         <option value="1957">
 309           1957
 310         </option>
 311         <option value="1956">
 312           1956
 313         </option>
 314         <option value="1955">
 315           1955
 316         </option>
 317         <option value="1954">
 318           1954
 319         </option>
 320         <option value="1953">
 321           1953
 322         </option>
 323         <option value="1952">
 324           1952
 325         </option>
 326         <option value="1951">
 327           1951
 328         </option>
 329         <option value="1950">
 330           1950
 331         </option>
 332         <option value="1949">
 333           1949
 334         </option>
 335         <option value="1948">
 336           1948
 337         </option>
 338         <option value="1947">
 339           1947
 340         </option>
 341         <option value="1946">
 342           1946
 343         </option>
 344         <option value="1945">
 345           1945
 346         </option>
 347         <option value="1944">
 348           1944
 349         </option>
 350         <option value="1943">
 351           1943
 352         </option>
 353         <option value="1942">
 354           1942
 355         </option>
 356         <option value="1941">
 357           1941
 358         </option>
 359         <option value="1940">
 360           1940
 361         </option>
 362         <option value="1939">
 363           1939
 364         </option>
 365         <option value="1938">
 366           1938
 367         </option>
 368         <option value="1937">
 369           1937
 370         </option>
 371         <option value="1936">
 372           1936
 373         </option>
 374         <option value="1935">
 375           1935
 376         </option>
 377         <option value="1934">
 378           1934
 379         </option>
 380         <option value="1933">
 381           1933
 382         </option>
 383         <option value="1932">
 384           1932
 385         </option>
 386         <option value="1931">
 387           1931
 388         </option>
 389         <option value="1930">
 390           1930
 391         </option>
 392         <option value="1929">
 393           1929
 394         </option>
 395         <option value="1928">
 396           1928
 397         </option>
 398         <option value="1927">
 399           1927
 400         </option>
 401         <option value="1926">
 402           1926
 403         </option>
 404         <option value="1925">
 405           1925
 406         </option>
 407         <option value="1924">
 408           1924
 409         </option>
 410         <option value="1923">
 411           1923
 412         </option>
 413         <option value="1922">
 414           1922
 415         </option>
 416         <option value="1921">
 417           1921
 418         </option>
 419         <option value="1920">
 420           1920
 421         </option>
 422         <option value="1919">
 423           1919
 424         </option>
 425         <option value="1918">
 426           1918
 427         </option>
 428         <option value="1917">
 429           1917
 430         </option>
 431         <option value="1916">
 432           1916
 433         </option>
 434         <option value="1915">
 435           1915
 436         </option>
 437         <option value="1914">
 438           1914
 439         </option>
 440         <option value="1913">
 441           1913
 442         </option>
 443         <option value="1912">
 444           1912
 445         </option>
 446       </select>
 447     </p>
 448     <p>
 449       <label for="cityOrTownOfBirth">City or Town of Birth:</label> <input type="text" id="cityOrTownOfBirth" name="cityOrTownOfBirth" size="25" />
 450     </p>
 451     <p>
 452       <label for="stateOrProvinceOfBirth">State or Province of Birth:<br />
 453       <span>(only if born in the US or Canada)</span></label> <select id="stateOrProvinceOfBirth" name="stateOrProvinceOfBirth">
 454         <option value="">
 455           Not Applicable
 456         </option>
 457         <option value="AL">
 458           Alabama
 459         </option>
 460         <option value="AK">
 461           Alaska
 462         </option>
 463         <option value="AB">
 464           Alberta
 465         </option>
 466         <option value="AS">
 467           American Samoa
 468         </option>
 469         <option value="AZ">
 470           Arizona
 471         </option>
 472         <option value="AR">
 473           Arkansas
 474         </option>
 475         <option value="BC">
 476           British Columbia
 477         </option>
 478         <option value="CA">
 479           California
 480         </option>
 481         <option value="CO">
 482           Colorado
 483         </option>
 484         <option value="CT">
 485           Connecticut
 486         </option>
 487         <option value="DE">
 488           Delaware
 489         </option>
 490         <option value="DC">
 491           District of Columbia
 492         </option>
 493         <option value="FL">
 494           Florida
 495         </option>
 496         <option value="GA">
 497           Georgia
 498         </option>
 499         <option value="GU">
 500           Guam
 501         </option>
 502         <option value="HI">
 503           Hawaii
 504         </option>
 505         <option value="ID">
 506           Idaho
 507         </option>
 508         <option value="IL">
 509           Illinois
 510         </option>
 511         <option value="IN">
 512           Indiana
 513         </option>
 514         <option value="IA">
 515           Iowa
 516         </option>
 517         <option value="KS">
 518           Kansas
 519         </option>
 520         <option value="KY">
 521           Kentucky
 522         </option>
 523         <option value="LA">
 524           Louisiana
 525         </option>
 526         <option value="ME">
 527           Maine
 528         </option>
 529         <option value="MB">
 530           Manitoba
 531         </option>
 532         <option value="MD">
 533           Maryland
 534         </option>
 535         <option value="MA">
 536           Massachusetts
 537         </option>
 538         <option value="MI">
 539           Michigan
 540         </option>
 541         <option value="MN">
 542           Minnesota
 543         </option>
 544         <option value="MS">
 545           Mississippi
 546         </option>
 547         <option value="MO">
 548           Missouri
 549         </option>
 550         <option value="MT">
 551           Montana
 552         </option>
 553         <option value="NE">
 554           Nebraska
 555         </option>
 556         <option value="NV">
 557           Nevada
 558         </option>
 559         <option value="NB">
 560           New Brunswick
 561         </option>
 562         <option value="NH">
 563           New Hampshire
 564         </option>
 565         <option value="NJ">
 566           New Jersey
 567         </option>
 568         <option value="NM">
 569           New Mexico
 570         </option>
 571         <option value="NY">
 572           New York
 573         </option>
 574         <option value="NL">
 575           Newfoundland and Labrador
 576         </option>
 577         <option value="NC">
 578           North Carolina
 579         </option>
 580         <option value="ND">
 581           North Dakota
 582         </option>
 583         <option value="MP">
 584           Northern Mariana Islands
 585         </option>
 586         <option value="NT">
 587           Northwest Territories
 588         </option>
 589         <option value="NS">
 590           Nova Scotia
 591         </option>
 592         <option value="NU">
 593           Nunavut
 594         </option>
 595         <option value="OH">
 596           Ohio
 597         </option>
 598         <option value="OK">
 599           Oklahoma
 600         </option>
 601         <option value="ON">
 602           Ontario
 603         </option>
 604         <option value="OR">
 605           Oregon
 606         </option>
 607         <option value="PA">
 608           Pennsylvania
 609         </option>
 610         <option value="PE">
 611           Prince Edward Island
 612         </option>
 613         <option value="PR">
 614           Puerto Rico
 615         </option>
 616         <option value="QC">
 617           Quebec
 618         </option>
 619         <option value="RI">
 620           Rhode Island
 621         </option>
 622         <option value="SK">
 623           Saskatchewan
 624         </option>
 625         <option value="SC">
 626           South Carolina
 627         </option>
 628         <option value="SD">
 629           South Dakota
 630         </option>
 631         <option value="TN">
 632           Tennessee
 633         </option>
 634         <option value="TX">
 635           Texas
 636         </option>
 637         <option value="UM">
 638           U.S. Minor Outlying Islands
 639         </option>
 640         <option value="UT">
 641           Utah
 642         </option>
 643         <option value="VT">
 644           Vermont
 645         </option>
 646         <option value="VI">
 647           U.S. Virgin Islands
 648         </option>
 649         <option value="VA">
 650           Virginia
 651         </option>
 652         <option value="WA">
 653           Washington
 654         </option>
 655         <option value="WV">
 656           West Virginia
 657         </option>
 658         <option value="WI">
 659           Wisconsin
 660         </option>
 661         <option value="WY">
 662           Wyoming
 663         </option>
 664         <option value="YT">
 665           Yukon Territory
 666         </option>
 667       </select>
 668     </p>
 669     <p>
 670       <label for="countryOfBirth">Country of Birth:</label> <select id="countryOfBirth" name="countryOfBirth">
 671         <option value="">
 672           Choose...
 673         </option>
 674         <option value="US">
 675           United States
 676         </option>
 677         <option value="AF">
 678           Afghanistan
 679         </option>
 680         <option value="AX">
 681           Åland Islands
 682         </option>
 683         <option value="AL">
 684           Albania
 685         </option>
 686         <option value="DZ">
 687           Algeria
 688         </option>
 689         <option value="AD">
 690           Andorra
 691         </option>
 692         <option value="AO">
 693           Angola
 694         </option>
 695         <option value="AI">
 696           Anguilla
 697         </option>
 698         <option value="AQ">
 699           Antarctica
 700         </option>
 701         <option value="AG">
 702           Antigua and Barbuda
 703         </option>
 704         <option value="AR">
 705           Argentina
 706         </option>
 707         <option value="AM">
 708           Armenia
 709         </option>
 710         <option value="AW">
 711           Aruba
 712         </option>
 713         <option value="AU">
 714           Australia
 715         </option>
 716         <option value="AT">
 717           Austria
 718         </option>
 719         <option value="AZ">
 720           Azerbaijan
 721         </option>
 722         <option value="BS">
 723           Bahamas
 724         </option>
 725         <option value="BH">
 726           Bahrain
 727         </option>
 728         <option value="BD">
 729           Bangladesh
 730         </option>
 731         <option value="BB">
 732           Barbados
 733         </option>
 734         <option value="BY">
 735           Belarus
 736         </option>
 737         <option value="BE">
 738           Belgium
 739         </option>
 740         <option value="BZ">
 741           Belize
 742         </option>
 743         <option value="BJ">
 744           Benin
 745         </option>
 746         <option value="BM">
 747           Bermuda
 748         </option>
 749         <option value="BT">
 750           Bhutan
 751         </option>
 752         <option value="BO">
 753           Bolivia
 754         </option>
 755         <option value="BA">
 756           Bosnia and Herzogovina
 757         </option>
 758         <option value="BW">
 759           Botswana
 760         </option>
 761         <option value="BV">
 762           Bouvet Island
 763         </option>
 764         <option value="BR">
 765           Brazil
 766         </option>
 767         <option value="BN">
 768           Brunei Darussalam
 769         </option>
 770         <option value="BG">
 771           Bulgaria
 772         </option>
 773         <option value="BF">
 774           Burkina Faso
 775         </option>
 776         <option value="BI">
 777           Burundi
 778         </option>
 779         <option value="KH">
 780           Cambodia
 781         </option>
 782         <option value="CM">
 783           Cameroon
 784         </option>
 785         <option value="CA">
 786           Canada
 787         </option>
 788         <option value="CV">
 789           Cape Verde
 790         </option>
 791         <option value="KY">
 792           Cayman Islands
 793         </option>
 794         <option value="CF">
 795           Central African Republic
 796         </option>
 797         <option value="TD">
 798           Chad
 799         </option>
 800         <option value="CL">
 801           Chile
 802         </option>
 803         <option value="CN">
 804           People's Republic of China
 805         </option>
 806         <option value="CX">
 807           Christmas Island
 808         </option>
 809         <option value="CC">
 810           Cocos (Keeling) Islands
 811         </option>
 812         <option value="CO">
 813           Colombia
 814         </option>
 815         <option value="KM">
 816           Comoros
 817         </option>
 818         <option value="CD">
 819           Democratic Republic of the Congo
 820         </option>
 821         <option value="CG">
 822           Republic of the Congo
 823         </option>
 824         <option value="CK">
 825           Cook Islands
 826         </option>
 827         <option value="CR">
 828           Costa Rica
 829         </option>
 830         <option value="CI">
 831           Côte d'Ivoire
 832         </option>
 833         <option value="HR">
 834           Croatia
 835         </option>
 836         <option value="CU">
 837           Cuba
 838         </option>
 839         <option value="CY">
 840           Cyprus
 841         </option>
 842         <option value="CZ">
 843           Czech Republic
 844         </option>
 845         <option value="DK">
 846           Denmark
 847         </option>
 848         <option value="DJ">
 849           Djibouti
 850         </option>
 851         <option value="DM">
 852           Dominica
 853         </option>
 854         <option value="DO">
 855           Dominican Republic
 856         </option>
 857         <option value="EC">
 858           Ecuador
 859         </option>
 860         <option value="EG">
 861           Egypt
 862         </option>
 863         <option value="SV">
 864           El Salvador
 865         </option>
 866         <option value="GQ">
 867           Equatorial Guinea
 868         </option>
 869         <option value="ER">
 870           Eritrea
 871         </option>
 872         <option value="EE">
 873           Estonia
 874         </option>
 875         <option value="ET">
 876           Ethiopia
 877         </option>
 878         <option value="FK">
 879           Falklands Islands (Malvinas)
 880         </option>
 881         <option value="FO">
 882           Faroe Islands
 883         </option>
 884         <option value="FJ">
 885           Fiji
 886         </option>
 887         <option value="FI">
 888           Finland
 889         </option>
 890         <option value="FR">
 891           France
 892         </option>
 893         <option value="GA">
 894           Gabon
 895         </option>
 896         <option value="GM">
 897           Gambia
 898         </option>
 899         <option value="GE">
 900           Georgia
 901         </option>
 902         <option value="DE">
 903           Germany
 904         </option>
 905         <option value="GH">
 906           Ghana
 907         </option>
 908         <option value="GI">
 909           Gibraltar
 910         </option>
 911         <option value="GR">
 912           Greece
 913         </option>
 914         <option value="GL">
 915           Greenland
 916         </option>
 917         <option value="GD">
 918           Grenada
 919         </option>
 920         <option value="GP">
 921           Guadeloupe
 922         </option>
 923         <option value="GT">
 924           Guatemala
 925         </option>
 926         <option value="GF">
 927           French Guiana
 928         </option>
 929         <option value="GN">
 930           Guinea
 931         </option>
 932         <option value="GW">
 933           Guinea-Bissau
 934         </option>
 935         <option value="GY">
 936           Guyana
 937         </option>
 938         <option value="HT">
 939           Haïti
 940         </option>
 941         <option value="HM">
 942           Heard Island and McDonald Islands
 943         </option>
 944         <option value="HN">
 945           Honduras
 946         </option>
 947         <option value="HK">
 948           Hong Kong
 949         </option>
 950         <option value="HU">
 951           Hungary
 952         </option>
 953         <option value="IS">
 954           Iceland
 955         </option>
 956         <option value="IN">
 957           India
 958         </option>
 959         <option value="IO">
 960           British Indian Ocean Territory
 961         </option>
 962         <option value="ID">
 963           Indonesia
 964         </option>
 965         <option value="IR">
 966           Iran
 967         </option>
 968         <option value="IQ">
 969           Iraq
 970         </option>
 971         <option value="IE">
 972           Ireland
 973         </option>
 974         <option value="IL">
 975           Israel
 976         </option>
 977         <option value="IT">
 978           Italy
 979         </option>
 980         <option value="JM">
 981           Jamaica
 982         </option>
 983         <option value="JP">
 984           Japan
 985         </option>
 986         <option value="JO">
 987           Jordan
 988         </option>
 989         <option value="KZ">
 990           Kazakhstan
 991         </option>
 992         <option value="KE">
 993           Kenya
 994         </option>
 995         <option value="KI">
 996           Kiribati
 997         </option>
 998         <option value="KP">
 999           North Korea
1000         </option>
1001         <option value="KR">
1002           South Korea
1003         </option>
1004         <option value="KW">
1005           Kuwait
1006         </option>
1007         <option value="KG">
1008           Kyrgyzstan
1009         </option>
1010         <option value="LA">
1011           Laos
1012         </option>
1013         <option value="LV">
1014           Latvia
1015         </option>
1016         <option value="LB">
1017           Lebanon
1018         </option>
1019         <option value="LS">
1020           Lesotho
1021         </option>
1022         <option value="LR">
1023           Liberia
1024         </option>
1025         <option value="LY">
1026           Libya
1027         </option>
1028         <option value="LI">
1029           Liechtenstein
1030         </option>
1031         <option value="LT">
1032           Lithuania
1033         </option>
1034         <option value="LU">
1035           Luxembourg
1036         </option>
1037         <option value="MK">
1038           Macedonia
1039         </option>
1040         <option value="MG">
1041           Madagascar
1042         </option>
1043         <option value="MW">
1044           Malawi
1045         </option>
1046         <option value="MY">
1047           Malaysia
1048         </option>
1049         <option value="MV">
1050           Maldives
1051         </option>
1052         <option value="ML">
1053           Mali
1054         </option>
1055         <option value="MT">
1056           Malta
1057         </option>
1058         <option value="MH">
1059           Marshall Islands
1060         </option>
1061         <option value="MQ">
1062           Martinique
1063         </option>
1064         <option value="MR">
1065           Mauritania
1066         </option>
1067         <option value="MU">
1068           Mauritius
1069         </option>
1070         <option value="YT">
1071           Mayotte
1072         </option>
1073         <option value="MX">
1074           Mexico
1075         </option>
1076         <option value="FM">
1077           Federated States of Micronesia
1078         </option>
1079         <option value="MD">
1080           Moldova
1081         </option>
1082         <option value="MC">
1083           Monaco
1084         </option>
1085         <option value="MS">
1086           Montserrat
1087         </option>
1088         <option value="MA">
1089           Morocco
1090         </option>
1091         <option value="MZ">
1092           Mozambique
1093         </option>
1094         <option value="MM">
1095           Myanmar
1096         </option>
1097         <option value="MO">
1098           Macao
1099         </option>
1100         <option value="MN">
1101           Mongolia
1102         </option>
1103         <option value="NA">
1104           Namibia
1105         </option>
1106         <option value="NR">
1107           Nauru
1108         </option>
1109         <option value="NP">
1110           Nepal
1111         </option>
1112         <option value="NL">
1113           Netherlands
1114         </option>
1115         <option value="AN">
1116           Netherlands Antilles
1117         </option>
1118         <option value="NC">
1119           New Caledonia
1120         </option>
1121         <option value="NZ">
1122           New Zealand
1123         </option>
1124         <option value="NI">
1125           Nicaragua
1126         </option>
1127         <option value="NE">
1128           Niger
1129         </option>
1130         <option value="NG">
1131           Nigeria
1132         </option>
1133         <option value="NU">
1134           Niue
1135         </option>
1136         <option value="NF">
1137           Norfolk Island
1138         </option>
1139         <option value="NO">
1140           Norway
1141         </option>
1142         <option value="OM">
1143           Oman
1144         </option>
1145         <option value="PK">
1146           Pakistan
1147         </option>
1148         <option value="PW">
1149           Palau
1150         </option>
1151         <option value="PS">
1152           Palestinian Territory
1153         </option>
1154         <option value="PA">
1155           Panama
1156         </option>
1157         <option value="PG">
1158           Papua New Guinea
1159         </option>
1160         <option value="PY">
1161           Paraguay
1162         </option>
1163         <option value="PE">
1164           Peru
1165         </option>
1166         <option value="PH">
1167           Philippines
1168         </option>
1169         <option value="PN">
1170           Pitcairn
1171         </option>
1172         <option value="PL">
1173           Poland
1174         </option>
1175         <option value="PF">
1176           French Polynesia
1177         </option>
1178         <option value="PT">
1179           Portugal
1180         </option>
1181         <option value="QA">
1182           Qatar
1183         </option>
1184         <option value="RE">
1185           Réunion
1186         </option>
1187         <option value="RO">
1188           Romania
1189         </option>
1190         <option value="RU">
1191           Russia
1192         </option>
1193         <option value="RW">
1194           Rwanda
1195         </option>
1196         <option value="SH">
1197           Saint Helena
1198         </option>
1199         <option value="KN">
1200           Saint Kitts and Nevis
1201         </option>
1202         <option value="LC">
1203           Saint Lucia
1204         </option>
1205         <option value="PM">
1206           Saint Pierre and Miquelon
1207         </option>
1208         <option value="VC">
1209           Saint Vincent and the Grenadines
1210         </option>
1211         <option value="WS">
1212           Samoa
1213         </option>
1214         <option value="SM">
1215           San Marino
1216         </option>
1217         <option value="ST">
1218           Sao Tome and Principe
1219         </option>
1220         <option value="SA">
1221           Saudi Arabia
1222         </option>
1223         <option value="SN">
1224           Senegal
1225         </option>
1226         <option value="CS">
1227           Serbia and Montenegro
1228         </option>
1229         <option value="SC">
1230           Seychelles
1231         </option>
1232         <option value="SL">
1233           Sierra Leone
1234         </option>
1235         <option value="SG">
1236           Singapore
1237         </option>
1238         <option value="SK">
1239           Slovakia
1240         </option>
1241         <option value="SI">
1242           Slovenia
1243         </option>
1244         <option value="SB">
1245           Solomon Islands
1246         </option>
1247         <option value="SO">
1248           Somalia
1249         </option>
1250         <option value="ZA">
1251           South Africa
1252         </option>
1253         <option value="GS">
1254           South Georgia and the South Sandwich Islands
1255         </option>
1256         <option value="TF">
1257           French Southern Territories
1258         </option>
1259         <option value="ES">
1260           Spain
1261         </option>
1262         <option value="LK">
1263           Sri Lanka
1264         </option>
1265         <option value="SD">
1266           Sudan
1267         </option>
1268         <option value="SR">
1269           Suriname
1270         </option>
1271         <option value="SJ">
1272           Svalbard and Jan Mayen
1273         </option>
1274         <option value="SZ">
1275           Swaziland
1276         </option>
1277         <option value="SE">
1278           Sweden
1279         </option>
1280         <option value="CH">
1281           Switzerland
1282         </option>
1283         <option value="SY">
1284           Syria
1285         </option>
1286         <option value="TW">
1287           Taiwan
1288         </option>
1289         <option value="TJ">
1290           Tajikistan
1291         </option>
1292         <option value="TZ">
1293           Tanzania
1294         </option>
1295         <option value="TH">
1296           Thailand
1297         </option>
1298         <option value="TL">
1299           Timor-Leste (East Timor)
1300         </option>
1301         <option value="TG">
1302           Togo
1303         </option>
1304         <option value="TK">
1305           Tokelau
1306         </option>
1307         <option value="TO">
1308           Tonga
1309         </option>
1310         <option value="TT">
1311           Trinidad and Tobago
1312         </option>
1313         <option value="TN">
1314           Tunisia
1315         </option>
1316         <option value="TR">
1317           Turkey
1318         </option>
1319         <option value="TM">
1320           Turkmenistan
1321         </option>
1322         <option value="TC">
1323           Turks and Caicos Islands
1324         </option>
1325         <option value="TV">
1326           Tuvalu
1327         </option>
1328         <option value="UG">
1329           Uganda
1330         </option>
1331         <option value="UA">
1332           Ukraine
1333         </option>
1334         <option value="AE">
1335           United Arab Emirates
1336         </option>
1337         <option value="GB">
1338           United Kingdom
1339         </option>
1340         <option value="UY">
1341           Uruguay
1342         </option>
1343         <option value="UZ">
1344           Uzbekistan
1345         </option>
1346         <option value="VU">
1347           Vanuatu
1348         </option>
1349         <option value="VA">
1350           Vatican
1351         </option>
1352         <option value="VE">
1353           Venezuela
1354         </option>
1355         <option value="VN">
1356           Vietnam
1357         </option>
1358         <option value="VG">
1359           British Virgin Islands
1360         </option>
1361         <option value="WF">
1362           Wallis and Futuna
1363         </option>
1364         <option value="EH">
1365           Western Sahara
1366         </option>
1367         <option value="YE">
1368           Yemen
1369         </option>
1370         <option value="ZM">
1371           Zambia
1372         </option>
1373         <option value="ZW">
1374           Zaïre
1375         </option>
1376       </select>
1377     </p>
1378     <p>
1379       <label for="studentSSNa">U.S. Social Security Number:<br />
1380       <span>(<a href="javascript:newWin('why_enter_ssn.html')">Why do we ask for your SSN?</a>)</span></label> <input type="text" id="studentSSNa" name="studentSSNa" size="3" maxlength="3" /> <span>&nbsp;-&nbsp;</span> <input type="text" id="studentSSNb" name="studentSSNb" size="2" maxlength="2" /> <span>&nbsp;-&nbsp;</span> <input type="text" id="studentSSNc" name="studentSSNc" size="4" maxlength="4" />
1381     </p>
1382     <p>
1383       <label for="idCardNumber">UT Austin ID Card Number:<br /></label> <input type="text" id="idCardNumber" name="idCardNumber" size="25" /> <span>(The 16-digit number on the front of your UT Austin ID card, if you have one).</span>
1384     </p>
1385     <p>
1386       <label for="emailAddress">E-mail Address:</label> <input type="text" id="emailAddress" name="emailAddress" size="25" /> <span>(Use an e-mail account you will have access to several months from now. <a href="javascript:newWin('why_enter_email.html')">Why?</a>)</span>
1387     </p>
1388     <p>
1389       <label for="emailAddressVerify">Verify Your E-mail Address:</label> <input type="text" id="emailAddressVerify" name="emailAddressVerify" size="25" />
1390     </p>
1391   </fieldset>
1392   <p>
1393     <a id="backSubmit" href="?back&amp;qwicap-page-id=D41F428A46D78104" name="backSubmit">Back</a> <a href="?cancel&amp;qwicap-page-id=D41F428A46D78104">Cancel</a> <input type="hidden" name="continue" value="Continue" /> <input type="submit" name="continue" value="Continue" />
1394   </p>
1395 </form>