<SELECT NAME="state">
          <OPTION VALUE="none">Select State/Province </OPTION>
          <OPTION VALUE="N/A">Not Applicable</OPTION>
          <OPTION
          VALUE="select">-------------------------</OPTION>
          <OPTION VALUE="AL">Alabama</OPTION>
          <OPTION VALUE="AK">Alaska</OPTION>
          <OPTION VALUE="AZ">Arizona</OPTION>
          <OPTION VALUE="AR">Arkansas</OPTION>
          <OPTION VALUE="CA">California</OPTION>
          <OPTION VALUE="CO">Colorado</OPTION>
          <OPTION VALUE="CT">Connecticut</OPTION>
          <OPTION VALUE="DE">Delaware</OPTION>
          <OPTION VALUE="DC">District of Columbia</OPTION>
          <OPTION VALUE="FL">Florida</OPTION>
          <OPTION VALUE="GA">Georgia</OPTION>
          <OPTION VALUE="HI">Hawaii</OPTION>
          <OPTION VALUE="ID">Idaho</OPTION>
          <OPTION VALUE="IL">Illinois</OPTION>
          <OPTION VALUE="IN">Indiana</OPTION>
          <OPTION VALUE="IA">Iowa</OPTION>
          <OPTION VALUE="KS">Kansas</OPTION>
          <OPTION VALUE="KY">Kentucky</OPTION>
          <OPTION VALUE="LA">Louisiana</OPTION>
          <OPTION VALUE="ME">Maine</OPTION>
          <OPTION VALUE="MD">Maryland</OPTION>
          <OPTION VALUE="MA">Massachusetts</OPTION>
          <OPTION VALUE="MI">Michigan</OPTION>
          <OPTION VALUE="MN">Minnesota</OPTION>
          <OPTION VALUE="MS">Mississippi</OPTION>
          <OPTION VALUE="MO">Missouri</OPTION>
          <OPTION VALUE="MT">Montana</OPTION>
          <OPTION VALUE="NE">Nebraska</OPTION>
          <OPTION VALUE="NV">Nevada</OPTION>
          <OPTION VALUE="NH">New Hampshire</OPTION>
          <OPTION VALUE="NJ">New Jersey</OPTION>
          <OPTION VALUE="NM">New Mexico</OPTION>
          <OPTION VALUE="NY">New York</OPTION>
          <OPTION VALUE="NC">North Carolina</OPTION>
          <OPTION VALUE="ND">North Dakota</OPTION>
          <OPTION VALUE="OH">Ohio</OPTION>
          <OPTION VALUE="OK">Oklahoma</OPTION>
          <OPTION VALUE="OR">Oregon</OPTION>
          <OPTION VALUE="PA">Pennsylvania</OPTION>
          <OPTION VALUE="PR">Puerto Rico</OPTION>
          <OPTION VALUE="RI">Rhode Island</OPTION>
          <OPTION VALUE="SC">South Carolina</OPTION>
          <OPTION VALUE="SD">South Dakota</OPTION>
          <OPTION VALUE="TN">Tennessee</OPTION>
          <OPTION VALUE="TX">Texas</OPTION>
          <OPTION VALUE="UT">Utah</OPTION>
          <OPTION VALUE="VT">Vermont</OPTION>
          <OPTION VALUE="VA">Virginia</OPTION>
          <OPTION VALUE="WA">Washington</OPTION>
          <OPTION VALUE="WV">West Virginia</OPTION>
          <OPTION VALUE="WI">Wisconsin</OPTION>
          <OPTION VALUE="WY">Wyoming</OPTION>
          <OPTION VALUE="99">-------------------------</OPTION>

          <OPTION VALUE="AB">Alberta</OPTION>
          <OPTION VALUE="BC">British Columbia</OPTION>
          <OPTION VALUE="MB">Manitoba</OPTION>
          <OPTION VALUE="NB">New Brunswick</OPTION>
          <OPTION VALUE="NF">Newfoundland</OPTION>
          <OPTION VALUE="NS">Nova Scotia</OPTION>
          <OPTION VALUE="NT">Northwest Territory</OPTION>
          <OPTION VALUE="ON">Ontario</OPTION>
          <OPTION VALUE="PE">Prince Edward Island</OPTION>
          <OPTION VALUE="PQ">Quebec</OPTION>
          <OPTION VALUE="SK">Saskatchewan</OPTION>
          <OPTION VALUE="YT">Yukon</OPTION>
        </SELECT>