{"id":741,"date":"2025-07-18T23:54:16","date_gmt":"2025-07-18T14:54:16","guid":{"rendered":"https:\/\/teamoncology.com\/teamoncology-membership-new-registration\/"},"modified":"2025-07-24T17:50:54","modified_gmt":"2025-07-24T08:50:54","slug":"signup","status":"publish","type":"page","link":"https:\/\/teamoncology.com\/en\/signup\/","title":{"rendered":"TeamOncology Membership &#8211; Sign Up"},"content":{"rendered":"\n<h1 class=\"wp-block-heading has-text-align-center is-style-normal\" style=\"font-size:3rem\">TeamOncology Membership &#8211; Sign Up<\/h1>\n\n\n<div class=\"wp-block-pmpro-checkout-page is-layout-flow wp-block-pmpro-checkout-page-is-layout-flow\">\n\t\n<div class=\"pmpro\">\n\n\t\n\t<section id=\"pmpro_level-0\" class=\"pmpro_section pmpro_checkout_gateway-none\">\n\n\t\t<form id=\"pmpro_form\" class=\"pmpro_form\" action=\"\" method=\"post\">\n\n\t\t\t<input type=\"hidden\" id=\"pmpro_level\" name=\"pmpro_level\" value=\"0\" \/>\n\t\t\t<input type=\"hidden\" id=\"checkjavascript\" name=\"checkjavascript\" value=\"1\" \/>\n\t\t\t\n\t\t\t\t\t\t\t<div id=\"pmpro_message\" class=\"pmpro_message\" style=\"display: none;\"><\/div>\n\t\t\t\n\t\t\t\n\t\t\t\t\t\t\t<div id=\"pmpro_pricing_fields\" class=\"pmpro_card\">\n\n\t\t\t\t\t<h2 class=\"pmpro_card_title pmpro_font-large\">Membership Information<\/h2>\n\n\t\t\t\t\t<div class=\"pmpro_card_content\">\n\n\t\t\t\t\t\t<p class=\"pmpro_level_name_text\">\n\t\t\t\t\t\t\tYou have selected the <strong>Invalid Level<\/strong> membership level.\t\t\t\t\t\t<\/p> <!-- end pmpro_level_name_text -->\n\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"pmpro_level_description_text\">\n\t\t\t\t\t\t\t\t\t<p>Invalid Level<\/p>\n\t\t\t\t\t\t\t\t<\/div> <!-- end pmpro_level_description_text -->\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t<div id=\"pmpro_level_cost\">\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"pmpro_level_cost_text\">\n\t\t\t\t\t\t\t\t\t\t<p>The price for membership is <strong>Free<\/strong>. <\/p>\n\t\t\t\t\t\t\t\t\t<\/div> <!-- end pmpro_level_cost_text -->\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div> <!-- end #pmpro_level_cost -->\n\n\t\t\t\t\t\t\n\t\t\t\t\t<\/div> <!-- end pmpro_card_content -->\n\t\t\t\t\t\t\t\t\t<\/div> <!-- end pmpro_pricing_fields -->\n\t\t\t\t\n\t\t\t\n\t\t\t\t\t\t\t<fieldset id=\"pmpro_user_fields\" class=\"pmpro_form_fieldset\">\n\t\t\t\t\t<div class=\"pmpro_card\">\n\t\t\t\t\t\t<div class=\"pmpro_card_content\">\n\t\t\t\t\t\t\t<legend class=\"pmpro_form_legend\">\n\t\t\t\t\t\t\t\t<h2 class=\"pmpro_form_heading pmpro_font-large\">Account Information<\/h2>\n\t\t\t\t\t\t\t<\/legend>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"pmpro_form_fields\">\n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<div class=\"pmpro_form_field pmpro_form_field-text pmpro_form_field-username\">\n\t\t\t\t\t\t\t\t\t\t<label for=\"username\" class=\"pmpro_form_label\">Username<\/label>\n\t\t\t\t\t\t\t\t\t\t<input id=\"username\" name=\"username\" type=\"text\" class=\"pmpro_form_input pmpro_form_input-text\" autocomplete=\"username\" value=\"\" \/>\n\t\t\t\t\t\t\t\t\t<\/div> <!-- end pmpro_form_field-username -->\n\n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<div class=\"pmpro_cols-2\">\n\t\t\t\t\t\t\t\t\t<div class=\"pmpro_form_field pmpro_form_field-password\">\n\t\t\t\t\t\t\t\t\t\t<label for=\"password\" class=\"pmpro_form_label\">\n\t\t\t\t\t\t\t\t\t\t\tPassword\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t<input type=\"password\" name=\"password\" id=\"password\" class=\"pmpro_form_input pmpro_form_input-password\" autocomplete=\"new-password\" spellcheck=\"false\" value=\"\" \/>\n\t\t\t\t\t\t\t\t\t\t<div class=\"pmpro_form_field-password-toggle\">\n\t\t\t\t\t\t\t\t\t\t\t<button type=\"button\" class=\"pmpro_btn pmpro_btn-plain pmpro_btn-password-toggle hide-if-no-js\" data-toggle=\"0\">\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"pmpro_icon pmpro_icon-eye\" aria-hidden=\"true\"><svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"20\" height=\"20\" viewBox=\"0 0 24 24\" fill=\"none\" stroke=\"var(--pmpro--color--accent)\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\" class=\"feather feather-eye\"><path d=\"M1 12s4-8 11-8 11 8 11 8-4 8-11 8-11-8-11-8z\"><\/path><circle cx=\"12\" cy=\"12\" r=\"3\"><\/circle><\/svg><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"pmpro_form_field-password-toggle-state\">Show Password<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div> <!-- end pmpro_form_field-password-toggle -->\n\t\t\t\t\t\t\t\t\t<\/div> <!-- end pmpro_form_field-password -->\n\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"pmpro_form_field pmpro_form_field-password\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"password2\" class=\"pmpro_form_label\">Confirm Password<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"password\" name=\"password2\" id=\"password2\" class=\"pmpro_form_input pmpro_form_input-password\" autocomplete=\"new-password\" spellcheck=\"false\" value=\"\" \/>\n\t\t\t\t\t\t\t\t\t\t\t<\/div> <!-- end pmpro_form_field-password2 -->\n\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<div class=\"pmpro_cols-2\">\n\t\t\t\t\t\t\t\t\t<div class=\"pmpro_form_field pmpro_form_field-email pmpro_form_field-bemail\">\n\t\t\t\t\t\t\t\t\t\t<label for=\"bemail\" class=\"pmpro_form_label\">Email Address<\/label>\n\t\t\t\t\t\t\t\t\t\t<input id=\"bemail\" name=\"bemail\" type=\"email\" class=\"pmpro_form_input pmpro_form_input-email\" value=\"\" \/>\n\t\t\t\t\t\t\t\t\t<\/div> <!-- end pmpro_form_field-bemail -->\n\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"pmpro_form_field pmpro_form_field-email pmpro_form_field-bconfirmemail\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"bconfirmemail\" class=\"pmpro_form_label\">Confirm Email Address<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t<input id=\"bconfirmemail\" name=\"bconfirmemail\" type=\"email\" class=\"pmpro_form_input pmpro_form_input-email\" value=\"\" \/>\n\t\t\t\t\t\t\t\t\t\t\t<\/div> <!-- end pmpro_form_field-bconfirmemail -->\n\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<div class=\"pmpro_hidden\">\n\t\t\t\t\t\t\t\t\t\t<label for=\"fullname\">Full Name<\/label>\n\t\t\t\t\t\t\t\t\t\t<input id=\"fullname\" name=\"fullname\" type=\"text\" value=\"\" autocomplete=\"off\" aria-hidden=\"true\" aria-label=\"Do not fill this field out. Leave this blank.\"\/> <strong>LEAVE THIS BLANK<\/strong>\n\t\t\t\t\t\t\t\t\t<\/div> <!-- end pmpro_hidden -->\n\t\t\t\t\t\t\t\t<\/div>  <!-- end pmpro_form_fields -->\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div> <!-- end pmpro_card_content -->\n\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"pmpro_card_actions\">\n\t\t\t\t\t\t\t\tAlready have an account? <a href=\"https:\/\/teamoncology.com\/en\/login\/?redirect_to=https%3A%2F%2Fteamoncology.com%2Fen%2Fsignup%2F%3Fpmpro_level%3D7\">Log in here<\/a>\n\t\t\t\t\t\t\t<\/div> <!-- end pmpro_card_actions -->\n\t\t\t\t\t\t\t\t\t\t\t<\/div> <!-- end pmpro_card -->\n\t\t\t\t<\/fieldset> <!-- end pmpro_user_fields -->\n\t\t\t\n\t\t\t\n\t\t\t\t\t\t<fieldset id=\"pmpro_form_fieldset-%e4%bc%9a%e5%93%a1%e6%83%85%e5%a0%b1\" class=\"pmpro_form_fieldset\">\n\t\t\t\t<div class=\"pmpro_card\">\n\t\t\t\t\t<div class=\"pmpro_card_content\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<legend class=\"pmpro_form_legend\">\n\t\t\t\t\t\t\t\t<h2 class=\"pmpro_form_heading pmpro_font-large\">\u4f1a\u54e1\u60c5\u5831<\/h2>\n\t\t\t\t\t\t\t<\/legend>\n\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"pmpro_form_fields\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div id=\"family_id_div\" class=\"pmpro_form_field pmpro_form_field-text pmpro_form_field-family_id\">\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"pmpro_form_label\" for=\"family_id\">\n\t\t\t\t\t\t\tJ-TOP Family ID\t\t\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<input type=\"text\" id=\"family_id\" name=\"family_id\" value=\"\" size=\"30\" class=\"pmpro_form_input pmpro_form_input-text pmpro_form_input-family_id\" readonly=\"readonly\"  \/>\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div id=\"name_en_div\" class=\"pmpro_form_field pmpro_form_field-text pmpro_form_field-name_en pmpro_form_field-required\">\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"pmpro_form_label\" for=\"name_en\">\n\t\t\t\t\t\t\t\u6c0f\u540d\u30d5\u30eb\u30cd\u30fc\u30e0(\u82f1\u8a9e\u8868\u8a18)\t\t\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<input type=\"text\" id=\"name_en\" name=\"name_en\" value=\"\" size=\"30\" class=\"pmpro_form_input pmpro_form_input-text pmpro_form_input-name_en pmpro_form_input-required\"  \/>\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<p class=\"pmpro_form_hint\">\u4f8b\uff1aTaro Yamada<\/p>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div id=\"name_jp_div\" class=\"pmpro_form_field pmpro_form_field-text pmpro_form_field-name_jp\">\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"pmpro_form_label\" for=\"name_jp\">\n\t\t\t\t\t\t\t\u6c0f\u540d\u30d5\u30eb\u30cd\u30fc\u30e0(\u65e5\u672c\u8a9e\u3082\u3057\u304f\u306f\u30aa\u30ea\u30b8\u30ca\u30eb\u8a00\u8a9e\u8868\u8a18)\t\t\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<input type=\"text\" id=\"name_jp\" name=\"name_jp\" value=\"\" size=\"30\" class=\"pmpro_form_input pmpro_form_input-text pmpro_form_input-name_jp\"  \/>\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<p class=\"pmpro_form_hint\">\u4f8b\uff1a\u5c71\u7530 \u592a\u90ce<\/p>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div id=\"profession_div\" class=\"pmpro_form_field pmpro_form_field-select pmpro_form_field-profession pmpro_form_field-required\">\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"pmpro_form_label\" for=\"profession\">\n\t\t\t\t\t\t\t\u8077\u7a2e\t\t\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<select id=\"profession\" name=\"profession\" class=\"pmpro_form_input pmpro_form_input-select pmpro_form_input-profession pmpro_form_input-required\" >\n<option value=\"\u533b\u5e2b\" >\u533b\u5e2b<\/option>\n<option value=\"\u770b\u8b77\u5e2b\" >\u770b\u8b77\u5e2b<\/option>\n<option value=\"\u85ac\u5264\u5e2b\" >\u85ac\u5264\u5e2b<\/option>\n<option value=\"\u7406\u5b66\u7642\u6cd5\u58eb\" >\u7406\u5b66\u7642\u6cd5\u58eb<\/option>\n<option value=\"\u4f5c\u696d\u7642\u6cd5\u58eb\" >\u4f5c\u696d\u7642\u6cd5\u58eb<\/option>\n<option value=\"\u8a00\u8a9e\u8074\u899a\u58eb\" >\u8a00\u8a9e\u8074\u899a\u58eb<\/option>\n<option value=\"\u7ba1\u7406\u6804\u990a\u58eb\" >\u7ba1\u7406\u6804\u990a\u58eb<\/option>\n<option value=\"\u533b\u7642\u30bd\u30fc\u30b7\u30e3\u30eb\u30ef\u30fc\u30ab\u30fc\" >\u533b\u7642\u30bd\u30fc\u30b7\u30e3\u30eb\u30ef\u30fc\u30ab\u30fc<\/option>\n<option value=\"\u305d\u306e\u4ed6\u306e\u533b\u7642\u5f93\u4e8b\u8005\" >\u305d\u306e\u4ed6\u306e\u533b\u7642\u5f93\u4e8b\u8005<\/option>\n<option value=\"\u533b\u5b66\u751f\" >\u533b\u5b66\u751f<\/option>\n<option value=\"\u770b\u8b77\u5b66\u751f\" >\u770b\u8b77\u5b66\u751f<\/option>\n<option value=\"\u85ac\u5b66\u751f\" >\u85ac\u5b66\u751f<\/option>\n<option value=\"\u7814\u7a76\u6559\u80b2\u8005\" >\u7814\u7a76\u6559\u80b2\u8005<\/option>\n<option value=\"\u88fd\u85ac\u4f01\u696d\u95a2\u4fc2\u8005\" >\u88fd\u85ac\u4f01\u696d\u95a2\u4fc2\u8005<\/option>\n<option value=\"\u305d\u306e\u4ed6\u306e\u533b\u7642\u95a2\u4fc2\u4f01\u696d\u30fb\u56e3\u4f53\u95a2\u4fc2\u8005\" >\u305d\u306e\u4ed6\u306e\u533b\u7642\u95a2\u4fc2\u4f01\u696d\u30fb\u56e3\u4f53\u95a2\u4fc2\u8005<\/option>\n<option value=\"\u305d\u306e\u4ed6\" >\u305d\u306e\u4ed6<\/option>\n<\/select>\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<p class=\"pmpro_form_hint\">\u8077\u7a2e\u3092\u9078\u629e\u3057\u3066\u304f\u3060\u3055\u3044\u3002<\/p>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div id=\"profession_override_div\" class=\"pmpro_form_field pmpro_form_field-text pmpro_form_field-profession_override\">\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"pmpro_form_label\" for=\"profession_override\">\n\t\t\t\t\t\t\t\u8077\u7a2e(\u624b\u5165\u529b\u7528)\t\t\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<input type=\"text\" id=\"profession_override\" name=\"profession_override\" value=\"\" size=\"30\" class=\"pmpro_form_input pmpro_form_input-text pmpro_form_input-profession_override\"  \/>\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div id=\"department_div\" class=\"pmpro_form_field pmpro_form_field-select2 pmpro_form_field-department\">\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"pmpro_form_label\" for=\"department\">\n\t\t\t\t\t\t\t\u5c02\u9580\u5206\u91ce\t\t\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<select id=\"department\" name=\"department[]\" multiple=\"multiple\" style=\"width: 100%\" placeholder=\"Choose one or more.\" class=\"pmpro_form_input pmpro_form_input-select2 pmpro_form_input-department\" ><option value=\"\u5185\u79d1\" >\u5185\u79d1<\/option><option value=\"\u5916\u79d1\" >\u5916\u79d1<\/option><option value=\"\u5c0f\u5150\u79d1\" >\u5c0f\u5150\u79d1<\/option><option value=\"\u7523\u5a66\u4eba\u79d1\" >\u7523\u5a66\u4eba\u79d1<\/option><option value=\"\u8133\u795e\u7d4c\u5916\u79d1\" >\u8133\u795e\u7d4c\u5916\u79d1<\/option><option value=\"\u547c\u5438\u5668\u79d1\" >\u547c\u5438\u5668\u79d1<\/option><option value=\"\u6d88\u5316\u5668\u79d1\" >\u6d88\u5316\u5668\u79d1<\/option><option value=\"\u5faa\u74b0\u5668\u79d1\" >\u5faa\u74b0\u5668\u79d1<\/option><option value=\"\u6ccc\u5c3f\u5668\u79d1\" >\u6ccc\u5c3f\u5668\u79d1<\/option><option value=\"\u76ae\u819a\u79d1\" >\u76ae\u819a\u79d1<\/option><option value=\"\u6574\u5f62\u5916\u79d1\" >\u6574\u5f62\u5916\u79d1<\/option><option value=\"\u5f62\u6210\u5916\u79d1\" >\u5f62\u6210\u5916\u79d1<\/option><option value=\"\u8840\u6db2\u30fb\u79fb\u690d\" >\u8840\u6db2\u30fb\u79fb\u690d<\/option><option value=\"\u653e\u5c04\u7dda\u79d1\" >\u653e\u5c04\u7dda\u79d1<\/option><option value=\"\u9ebb\u9154\u79d1\" >\u9ebb\u9154\u79d1<\/option><option value=\"\u773c\u79d1\" >\u773c\u79d1<\/option><option value=\"\u8033\u9f3b\u54bd\u5589\u79d1\" >\u8033\u9f3b\u54bd\u5589\u79d1<\/option><option value=\"\u6c17\u7ba1\u98df\u9053\u79d1\" >\u6c17\u7ba1\u98df\u9053\u79d1<\/option><option value=\"\u53e3\u8154\u5916\u79d1\" >\u53e3\u8154\u5916\u79d1<\/option><option value=\"\u6b6f\u79d1\" >\u6b6f\u79d1<\/option><option value=\"\u7cbe\u795e\u79d1\" >\u7cbe\u795e\u79d1<\/option><option value=\"\u795e\u7d4c\u5185\u79d1\" >\u795e\u7d4c\u5185\u79d1<\/option><option value=\"\u305d\u306e\u4ed6\" >\u305d\u306e\u4ed6<\/option><\/select><input type=\"hidden\" name=\"department_checkbox\" value=\"1\" \/><script>jQuery(document).ready(function($){ $(\"#department\").select2( { theme: \"classic\", width: \"resolve\" }); });<\/script>\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<p class=\"pmpro_form_hint\">\u5c02\u9580\u5206\u91ce\u3001\u3082\u3057\u304f\u306f\u95a2\u308f\u308a\u306e\u3042\u308b\u8a3a\u7642\u79d1\u3092\u9078\u629e\u3057\u3066\u304f\u3060\u3055\u3044(\u8907\u6570\u9078\u629e\u53ef)\u3002<\/p>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div id=\"interest_div\" class=\"pmpro_form_field pmpro_form_field-select2 pmpro_form_field-interest\">\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"pmpro_form_label\" for=\"interest\">\n\t\t\t\t\t\t\t\u95a2\u4fc2\u306e\u3042\u308b\uff0f\u95a2\u5fc3\u306e\u3042\u308b\u304c\u3093\u7a2e\t\t\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<select id=\"interest\" name=\"interest[]\" multiple=\"multiple\" style=\"width: 100%\" placeholder=\"Choose one or more.\" class=\"pmpro_form_input pmpro_form_input-select2 pmpro_form_input-interest\" ><option value=\"\u8133\u30fb\u982d\u90e8\" >\u8133\u30fb\u982d\u90e8<\/option><option value=\"\u6d88\u5316\u5668\" >\u6d88\u5316\u5668<\/option><option value=\"\u547c\u5438\u5668\" >\u547c\u5438\u5668<\/option><option value=\"\u81b5\u81d3\u30fb\u809d\u81d3\" >\u81b5\u81d3\u30fb\u809d\u81d3<\/option><option value=\"\u4e73\u817a\u30fb\u4e73\u304c\u3093\" >\u4e73\u817a\u30fb\u4e73\u304c\u3093<\/option><option value=\"\u5a66\u4eba\u79d1\" >\u5a66\u4eba\u79d1<\/option><option value=\"\u6ccc\u5c3f\u5668\" >\u6ccc\u5c3f\u5668<\/option><option value=\"\u8840\u6db2\" >\u8840\u6db2<\/option><option value=\"\u6a2a\u65ad\u7684\u306b\u95a2\u5fc3\u304c\u3042\u308b\" >\u6a2a\u65ad\u7684\u306b\u95a2\u5fc3\u304c\u3042\u308b<\/option><option value=\"\u305d\u306e\u4ed6\" >\u305d\u306e\u4ed6<\/option><\/select><input type=\"hidden\" name=\"interest_checkbox\" value=\"1\" \/><script>jQuery(document).ready(function($){ $(\"#interest\").select2( { theme: \"classic\", width: \"resolve\" }); });<\/script>\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<p class=\"pmpro_form_hint\">\u95a2\u4fc2\u306e\u3042\u308b\u304c\u3093\u7a2e\u3001\u3082\u3057\u304f\u306f\u95a2\u5fc3\u306e\u3042\u308b\u304c\u3093\u7a2e\u3092\u9078\u629e\u3057\u3066\u304f\u3060\u3055\u3044(\u8907\u6570\u9078\u629e\u53ef)\u3002<\/p>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div id=\"affiliation_en_div\" class=\"pmpro_form_field pmpro_form_field-text pmpro_form_field-affiliation_en pmpro_form_field-required\">\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"pmpro_form_label\" for=\"affiliation_en\">\n\t\t\t\t\t\t\t\u6240\u5c5e\u5148\u540d\uff0f\u52e4\u52d9\u5148\u540d(\u82f1\u8a9e\u8868\u8a18)\t\t\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<input type=\"text\" id=\"affiliation_en\" name=\"affiliation_en\" value=\"\" size=\"30\" class=\"pmpro_form_input pmpro_form_input-text pmpro_form_input-affiliation_en pmpro_form_input-required\"  \/>\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<p class=\"pmpro_form_hint\">\u4f8b\uff1aJ-TOP Hospital<\/p>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div id=\"affiliation_jp_div\" class=\"pmpro_form_field pmpro_form_field-text pmpro_form_field-affiliation_jp\">\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"pmpro_form_label\" for=\"affiliation_jp\">\n\t\t\t\t\t\t\t\u6240\u5c5e\u5148\u540d\uff0f\u52e4\u52d9\u5148\u540d(\u65e5\u672c\u8a9e\u3082\u3057\u304f\u306f\u30aa\u30ea\u30b8\u30ca\u30eb\u8a00\u8a9e\u8868\u8a18)\t\t\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<input type=\"text\" id=\"affiliation_jp\" name=\"affiliation_jp\" value=\"\" size=\"30\" class=\"pmpro_form_input pmpro_form_input-text pmpro_form_input-affiliation_jp\"  \/>\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<p class=\"pmpro_form_hint\">\u4f8b\uff1a\u30b8\u30a7\u30a4\u30c8\u30c3\u30d7\u75c5\u9662<\/p>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div id=\"country_div\" class=\"pmpro_form_field pmpro_form_field-select pmpro_form_field-country\">\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"pmpro_form_label\" for=\"country\">\n\t\t\t\t\t\t\t\u5c45\u4f4f\u56fd\t\t\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<select id=\"country\" name=\"country\" class=\"pmpro_form_input pmpro_form_input-select pmpro_form_input-country\" >\n<option value=\"Afghanistan\" >Afghanistan<\/option>\n<option value=\"Albania\" >Albania<\/option>\n<option value=\"Algeria\" >Algeria<\/option>\n<option value=\"Andorra\" >Andorra<\/option>\n<option value=\"Angola\" >Angola<\/option>\n<option value=\"Antigua and Barbuda\" >Antigua and Barbuda<\/option>\n<option value=\"Argentina\" >Argentina<\/option>\n<option value=\"Armenia\" >Armenia<\/option>\n<option value=\"Australia\" >Australia<\/option>\n<option value=\"Austria\" >Austria<\/option>\n<option value=\"Azerbaijan\" >Azerbaijan<\/option>\n<option value=\"Bahamas\" >Bahamas<\/option>\n<option value=\"Bahrain\" >Bahrain<\/option>\n<option value=\"Bangladesh\" >Bangladesh<\/option>\n<option value=\"Barbados\" >Barbados<\/option>\n<option value=\"Belarus\" >Belarus<\/option>\n<option value=\"Belgium\" >Belgium<\/option>\n<option value=\"Belize\" >Belize<\/option>\n<option value=\"Benin\" >Benin<\/option>\n<option value=\"Bhutan\" >Bhutan<\/option>\n<option value=\"Bolivia\" >Bolivia<\/option>\n<option value=\"Bosnia and Herzegovina\" >Bosnia and Herzegovina<\/option>\n<option value=\"Botswana\" >Botswana<\/option>\n<option value=\"Brazil\" >Brazil<\/option>\n<option value=\"Brunei\" >Brunei<\/option>\n<option value=\"Bulgaria\" >Bulgaria<\/option>\n<option value=\"Burkina Faso\" >Burkina Faso<\/option>\n<option value=\"Burundi\" >Burundi<\/option>\n<option value=\"Cabo Verde\" >Cabo Verde<\/option>\n<option value=\"Cambodia\" >Cambodia<\/option>\n<option value=\"Cameroon\" >Cameroon<\/option>\n<option value=\"Canada\" >Canada<\/option>\n<option value=\"Central African Republic\" >Central African Republic<\/option>\n<option value=\"Chad\" >Chad<\/option>\n<option value=\"Chile\" >Chile<\/option>\n<option value=\"China\" >China<\/option>\n<option value=\"Colombia\" >Colombia<\/option>\n<option value=\"Comoros\" >Comoros<\/option>\n<option value=\"Congo (Congo-Brazzaville)\" >Congo (Congo-Brazzaville)<\/option>\n<option value=\"Costa Rica\" >Costa Rica<\/option>\n<option value=\"Cote d&#039;Ivoire\" >Cote d&#039;Ivoire<\/option>\n<option value=\"Croatia\" >Croatia<\/option>\n<option value=\"Cuba\" >Cuba<\/option>\n<option value=\"Cyprus\" >Cyprus<\/option>\n<option value=\"Czechia (Czech Republic)\" >Czechia (Czech Republic)<\/option>\n<option value=\"Democratic Republic of the Congo\" >Democratic Republic of the Congo<\/option>\n<option value=\"Denmark\" >Denmark<\/option>\n<option value=\"Djibouti\" >Djibouti<\/option>\n<option value=\"Dominica\" >Dominica<\/option>\n<option value=\"Dominican Republic\" >Dominican Republic<\/option>\n<option value=\"Ecuador\" >Ecuador<\/option>\n<option value=\"Egypt\" >Egypt<\/option>\n<option value=\"El Salvador\" >El Salvador<\/option>\n<option value=\"Equatorial Guinea\" >Equatorial Guinea<\/option>\n<option value=\"Eritrea\" >Eritrea<\/option>\n<option value=\"Estonia\" >Estonia<\/option>\n<option value=\"Eswatini (formerly Swaziland)\" >Eswatini (formerly Swaziland)<\/option>\n<option value=\"Ethiopia\" >Ethiopia<\/option>\n<option value=\"Fiji\" >Fiji<\/option>\n<option value=\"Finland\" >Finland<\/option>\n<option value=\"France\" >France<\/option>\n<option value=\"Gabon\" >Gabon<\/option>\n<option value=\"Gambia\" >Gambia<\/option>\n<option value=\"Georgia\" >Georgia<\/option>\n<option value=\"Germany\" >Germany<\/option>\n<option value=\"Ghana\" >Ghana<\/option>\n<option value=\"Greece\" >Greece<\/option>\n<option value=\"Grenada\" >Grenada<\/option>\n<option value=\"Guatemala\" >Guatemala<\/option>\n<option value=\"Guinea\" >Guinea<\/option>\n<option value=\"Guinea-Bissau\" >Guinea-Bissau<\/option>\n<option value=\"Guyana\" >Guyana<\/option>\n<option value=\"Haiti\" >Haiti<\/option>\n<option value=\"Holy See (Vatican City)\" >Holy See (Vatican City)<\/option>\n<option value=\"Honduras\" >Honduras<\/option>\n<option value=\"Hungary\" >Hungary<\/option>\n<option value=\"Iceland\" >Iceland<\/option>\n<option value=\"India\" >India<\/option>\n<option value=\"Indonesia\" >Indonesia<\/option>\n<option value=\"Iran\" >Iran<\/option>\n<option value=\"Iraq\" >Iraq<\/option>\n<option value=\"Ireland\" >Ireland<\/option>\n<option value=\"Israel\" >Israel<\/option>\n<option value=\"Italy\" >Italy<\/option>\n<option value=\"Jamaica\" >Jamaica<\/option>\n<option value=\"Japan\" >Japan<\/option>\n<option value=\"Jordan\" >Jordan<\/option>\n<option value=\"Kazakhstan\" >Kazakhstan<\/option>\n<option value=\"Kenya\" >Kenya<\/option>\n<option value=\"Kiribati\" >Kiribati<\/option>\n<option value=\"Kuwait\" >Kuwait<\/option>\n<option value=\"Kyrgyzstan\" >Kyrgyzstan<\/option>\n<option value=\"Laos\" >Laos<\/option>\n<option value=\"Latvia\" >Latvia<\/option>\n<option value=\"Lebanon\" >Lebanon<\/option>\n<option value=\"Lesotho\" >Lesotho<\/option>\n<option value=\"Liberia\" >Liberia<\/option>\n<option value=\"Libya\" >Libya<\/option>\n<option value=\"Liechtenstein\" >Liechtenstein<\/option>\n<option value=\"Lithuania\" >Lithuania<\/option>\n<option value=\"Luxembourg\" >Luxembourg<\/option>\n<option value=\"Madagascar\" >Madagascar<\/option>\n<option value=\"Malawi\" >Malawi<\/option>\n<option value=\"Malaysia\" >Malaysia<\/option>\n<option value=\"Maldives\" >Maldives<\/option>\n<option value=\"Mali\" >Mali<\/option>\n<option value=\"Malta\" >Malta<\/option>\n<option value=\"Marshall Islands\" >Marshall Islands<\/option>\n<option value=\"Mauritania\" >Mauritania<\/option>\n<option value=\"Mauritius\" >Mauritius<\/option>\n<option value=\"Mexico\" >Mexico<\/option>\n<option value=\"Micronesia\" >Micronesia<\/option>\n<option value=\"Moldova\" >Moldova<\/option>\n<option value=\"Monaco\" >Monaco<\/option>\n<option value=\"Mongolia\" >Mongolia<\/option>\n<option value=\"Montenegro\" >Montenegro<\/option>\n<option value=\"Morocco\" >Morocco<\/option>\n<option value=\"Mozambique\" >Mozambique<\/option>\n<option value=\"Myanmar (formerly Burma)\" >Myanmar (formerly Burma)<\/option>\n<option value=\"Namibia\" >Namibia<\/option>\n<option value=\"Nauru\" >Nauru<\/option>\n<option value=\"Nepal\" >Nepal<\/option>\n<option value=\"Netherlands\" >Netherlands<\/option>\n<option value=\"New Zealand\" >New Zealand<\/option>\n<option value=\"Nicaragua\" >Nicaragua<\/option>\n<option value=\"Niger\" >Niger<\/option>\n<option value=\"Nigeria\" >Nigeria<\/option>\n<option value=\"North Korea\" >North Korea<\/option>\n<option value=\"North Macedonia\" >North Macedonia<\/option>\n<option value=\"Norway\" >Norway<\/option>\n<option value=\"Oman\" >Oman<\/option>\n<option value=\"Pakistan\" >Pakistan<\/option>\n<option value=\"Palau\" >Palau<\/option>\n<option value=\"Palestine, State of\" >Palestine, State of<\/option>\n<option value=\"Panama\" >Panama<\/option>\n<option value=\"Papua New Guinea\" >Papua New Guinea<\/option>\n<option value=\"Paraguay\" >Paraguay<\/option>\n<option value=\"Peru\" >Peru<\/option>\n<option value=\"Philippines\" >Philippines<\/option>\n<option value=\"Poland\" >Poland<\/option>\n<option value=\"Portugal\" >Portugal<\/option>\n<option value=\"Qatar\" >Qatar<\/option>\n<option value=\"Romania\" >Romania<\/option>\n<option value=\"Russia\" >Russia<\/option>\n<option value=\"Rwanda\" >Rwanda<\/option>\n<option value=\"Saint Kitts and Nevis\" >Saint Kitts and Nevis<\/option>\n<option value=\"Saint Lucia\" >Saint Lucia<\/option>\n<option value=\"Saint Vincent and the Grenadines\" >Saint Vincent and the Grenadines<\/option>\n<option value=\"Samoa\" >Samoa<\/option>\n<option value=\"San Marino\" >San Marino<\/option>\n<option value=\"Sao Tome and Principe\" >Sao Tome and Principe<\/option>\n<option value=\"Saudi Arabia\" >Saudi Arabia<\/option>\n<option value=\"Senegal\" >Senegal<\/option>\n<option value=\"Serbia\" >Serbia<\/option>\n<option value=\"Seychelles\" >Seychelles<\/option>\n<option value=\"Sierra Leone\" >Sierra Leone<\/option>\n<option value=\"Singapore\" >Singapore<\/option>\n<option value=\"Slovakia\" >Slovakia<\/option>\n<option value=\"Slovenia\" >Slovenia<\/option>\n<option value=\"Solomon Islands\" >Solomon Islands<\/option>\n<option value=\"Somalia\" >Somalia<\/option>\n<option value=\"South Africa\" >South Africa<\/option>\n<option value=\"South Korea\" >South Korea<\/option>\n<option value=\"South Sudan\" >South Sudan<\/option>\n<option value=\"Spain\" >Spain<\/option>\n<option value=\"Sri Lanka\" >Sri Lanka<\/option>\n<option value=\"Sudan\" >Sudan<\/option>\n<option value=\"Suriname\" >Suriname<\/option>\n<option value=\"Sweden\" >Sweden<\/option>\n<option value=\"Switzerland\" >Switzerland<\/option>\n<option value=\"Syria\" >Syria<\/option>\n<option value=\"Taiwan\" >Taiwan<\/option>\n<option value=\"Tajikistan\" >Tajikistan<\/option>\n<option value=\"Tanzania\" >Tanzania<\/option>\n<option value=\"Thailand\" >Thailand<\/option>\n<option value=\"Timor-Leste\" >Timor-Leste<\/option>\n<option value=\"Togo\" >Togo<\/option>\n<option value=\"Tonga\" >Tonga<\/option>\n<option value=\"Trinidad and Tobago\" >Trinidad and Tobago<\/option>\n<option value=\"Tunisia\" >Tunisia<\/option>\n<option value=\"T\u00fcrkiye\" >T\u00fcrkiye<\/option>\n<option value=\"Turkmenistan\" >Turkmenistan<\/option>\n<option value=\"Tuvalu\" >Tuvalu<\/option>\n<option value=\"Uganda\" >Uganda<\/option>\n<option value=\"Ukraine\" >Ukraine<\/option>\n<option value=\"United Arab Emirates\" >United Arab Emirates<\/option>\n<option value=\"United Kingdom\" >United Kingdom<\/option>\n<option value=\"United States of America\" >United States of America<\/option>\n<option value=\"Uruguay\" >Uruguay<\/option>\n<option value=\"Uzbekistan\" >Uzbekistan<\/option>\n<option value=\"Vanuatu\" >Vanuatu<\/option>\n<option value=\"Venezuela\" >Venezuela<\/option>\n<option value=\"Vietnam\" >Vietnam<\/option>\n<option value=\"Yemen\" >Yemen<\/option>\n<option value=\"Zambia\" >Zambia<\/option>\n<option value=\"Zimbabwe\" >Zimbabwe<\/option>\n<\/select>\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t<p class=\"pmpro_form_hint\">\u5c45\u4f4f\u56fd\u3092\u9078\u629e\u3057\u3066\u304f\u3060\u3055\u3044\u3002<\/p>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div id=\"committee_title_div\" class=\"pmpro_form_field pmpro_form_field-text pmpro_form_field-committee_title\">\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"pmpro_form_label\" for=\"committee_title\">\n\t\t\t\t\t\t\t\u59d4\u54e1\u4f1a\u7b49\u3067\u306e\u5f79\u5272\t\t\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<input type=\"text\" id=\"committee_title\" name=\"committee_title\" value=\"\" size=\"30\" class=\"pmpro_form_input pmpro_form_input-text pmpro_form_input-committee_title\"  \/>\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div id=\"mentor_order_div\" class=\"pmpro_form_field pmpro_form_field-text pmpro_form_field-mentor_order\">\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"pmpro_form_label\" for=\"mentor_order\">\n\t\t\t\t\t\t\t\u8868\u793a\u9806(\u30e1\u30f3\u30bf\u30fc\u30da\u30fc\u30b8\u7528)\t\t\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<input type=\"text\" id=\"mentor_order\" name=\"mentor_order\" value=\"\" size=\"30\" class=\"pmpro_form_input pmpro_form_input-text pmpro_form_input-mentor_order\"  \/>\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div id=\"tutor_order_div\" class=\"pmpro_form_field pmpro_form_field-text pmpro_form_field-tutor_order\">\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"pmpro_form_label\" for=\"tutor_order\">\n\t\t\t\t\t\t\t\u8868\u793a\u9806(\u30c1\u30e5\u30fc\u30bf\u30fc\u30da\u30fc\u30b8\u7528)\t\t\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<input type=\"text\" id=\"tutor_order\" name=\"tutor_order\" value=\"\" size=\"30\" class=\"pmpro_form_input pmpro_form_input-text pmpro_form_input-tutor_order\"  \/>\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div id=\"committee_order_div\" class=\"pmpro_form_field pmpro_form_field-text pmpro_form_field-committee_order\">\n\t\t\t\t\t\t\t\t\t\t\t<label class=\"pmpro_form_label\" for=\"committee_order\">\n\t\t\t\t\t\t\t\u8868\u793a\u9806(\u59d4\u54e1\u4f1a\u30da\u30fc\u30b8\u7528)\t\t\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<input type=\"text\" id=\"committee_order\" name=\"committee_order\" value=\"\" size=\"30\" class=\"pmpro_form_input pmpro_form_input-text pmpro_form_input-committee_order\"  \/>\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<\/div> <!-- end pmpro_form_fields -->\n\t\t\t\t\t<\/div> <!-- end pmpro_card_content -->\n\t\t\t\t<\/div> <!-- end pmpro_card -->\n\t\t\t<\/fieldset> <!-- end pmpro_form_fieldset -->\n\t\t\t\n\t\t\t\t\t\t<fieldset id=\"pmpro_billing_address_fields\" class=\"pmpro_form_fieldset\" style=\"display: none;\">\n\t\t\t\t<div class=\"pmpro_card\">\n\t\t\t\t\t<div class=\"pmpro_card_content\">\n\t\t\t\t\t\t<legend class=\"pmpro_form_legend\">\n\t\t\t\t\t\t\t<h2 class=\"pmpro_form_heading pmpro_font-large\">Billing Address<\/h2>\n\t\t\t\t\t\t<\/legend>\n\t\t\t\t\t\t<div class=\"pmpro_form_fields pmpro_cols-2\">\n\t\t\t\t\t\t\t<div class=\"pmpro_form_field pmpro_form_field-text pmpro_form_field-bfirstname\">\n\t\t\t\t\t\t\t\t<label for=\"bfirstname\" class=\"pmpro_form_label\">First Name<\/label>\n\t\t\t\t\t\t\t\t<input id=\"bfirstname\" name=\"bfirstname\" type=\"text\" class=\"pmpro_form_input pmpro_form_input-text\" value=\"\" autocomplete=\"given-name\" \/>\n\t\t\t\t\t\t\t<\/div> <!-- end pmpro_form_field-bfirstname -->\n\t\t\t\t\t\t\t<div class=\"pmpro_form_field pmpro_form_field-text pmpro_form_field-blastname\">\n\t\t\t\t\t\t\t\t<label for=\"blastname\" class=\"pmpro_form_label\">Last Name<\/label>\n\t\t\t\t\t\t\t\t<input id=\"blastname\" name=\"blastname\" type=\"text\" class=\"pmpro_form_input pmpro_form_input-text\" value=\"\" autocomplete=\"family-name\" \/>\n\t\t\t\t\t\t\t<\/div> <!-- end pmpro_form_field-blastname -->\n\t\t\t\t\t\t\t<div class=\"pmpro_form_field pmpro_form_field-text pmpro_form_field-baddress1\">\n\t\t\t\t\t\t\t\t<label for=\"baddress1\" class=\"pmpro_form_label\">Address 1<\/label>\n\t\t\t\t\t\t\t\t<input id=\"baddress1\" name=\"baddress1\" type=\"text\" class=\"pmpro_form_input pmpro_form_input-text\" value=\"\" autocomplete=\"billing street-address\" \/>\n\t\t\t\t\t\t\t<\/div> <!-- end pmpro_form_field-baddress1 -->\n\t\t\t\t\t\t\t<div class=\"pmpro_form_field pmpro_form_field-text pmpro_form_field-baddress2\">\n\t\t\t\t\t\t\t\t<label for=\"baddress2\" class=\"pmpro_form_label\">Address 2<\/label>\n\t\t\t\t\t\t\t\t<input id=\"baddress2\" name=\"baddress2\" type=\"text\" class=\"pmpro_form_input pmpro_form_input-text\" value=\"\" \/>\n\t\t\t\t\t\t\t<\/div> <!-- end pmpro_form_field-baddress2 -->\n\t\t\t\t\t\t\t\t<div class=\"pmpro_form_field pmpro_form_field-text pmpro_form_field-bcity\">\n\t\t\t\t\t\t\t\t\t<label for=\"bcity\" class=\"pmpro_form_label\">City<\/label>\n\t\t\t\t\t\t\t\t\t<input id=\"bcity\" name=\"bcity\" type=\"text\" class=\"pmpro_form_input pmpro_form_input-text\" value=\"\" \/>\n\t\t\t\t\t\t\t\t<\/div> <!-- end pmpro_form_field-bcity -->\n\t\t\t\t\t\t\t\t<div class=\"pmpro_form_field pmpro_form_field-text pmpro_form_field-bstate\">\n\t\t\t\t\t\t\t\t\t<label for=\"bstate\" class=\"pmpro_form_label\">State<\/label>\n\t\t\t\t\t\t\t\t\t<input id=\"bstate\" name=\"bstate\" type=\"text\" class=\"pmpro_form_input pmpro_form_input-text\" value=\"\" \/>\n\t\t\t\t\t\t\t\t<\/div> <!-- end pmpro_form_field-bstate -->\n\t\t\t\t\t\t\t\t<div class=\"pmpro_form_field pmpro_form_field-text pmpro_form_field-bzipcode\">\n\t\t\t\t\t\t\t\t\t<label for=\"bzipcode\" class=\"pmpro_form_label\">Postal Code<\/label>\n\t\t\t\t\t\t\t\t\t<input id=\"bzipcode\" name=\"bzipcode\" type=\"text\" class=\"pmpro_form_input pmpro_form_input-text\" value=\"\" autocomplete=\"billing postal-code\" \/>\n\t\t\t\t\t\t\t\t<\/div> <!-- end pmpro_form_field-bzipcode -->\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"pmpro_form_field pmpro_form_field-select pmpro_form_field-bcountry\">\n\t\t\t\t\t\t\t\t\t\t<label for=\"bcountry\" class=\"pmpro_form_label\">Country<\/label>\n\t\t\t\t\t\t\t\t\t\t<select name=\"bcountry\" id=\"bcountry\" class=\"pmpro_form_input pmpro_form_input-select\" autocomplete=\"billing country\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"AF\" >Afghanistan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"AX\" >Aland Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"AL\" >Albania<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"DZ\" >Algeria<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"AS\" >American Samoa<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"AD\" >Andorra<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"AO\" >Angola<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"AI\" >Anguilla<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"AQ\" >Antarctica<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"AG\" >Antigua and Barbuda<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"AR\" >Argentina<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"AM\" >Armenia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"AW\" >Aruba<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"AU\" >Australia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"AT\" >Austria<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"AZ\" >Azerbaijan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"BS\" >Bahamas<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"BH\" >Bahrain<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"BD\" >Bangladesh<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"BB\" >Barbados<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"BY\" >Belarus<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"BE\" >Belgium<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"BZ\" >Belize<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"BJ\" >Benin<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"BM\" >Bermuda<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"BT\" >Bhutan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"BO\" >Bolivia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"BA\" >Bosnia and Herzegovina<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"BW\" >Botswana<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"BV\" >Bouvet Island<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"BR\" >Brazil<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"IO\" >British Indian Ocean Territory<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"VG\" >British Virgin Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"BN\" >Brunei<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"BG\" >Bulgaria<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"BF\" >Burkina Faso<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"BI\" >Burundi<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"KH\" >Cambodia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"CM\" >Cameroon<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"CA\" >Canada<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"CV\" >Cape Verde<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"KY\" >Cayman Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"CF\" >Central African Republic<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"TD\" >Chad<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"CL\" >Chile<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"CN\" >China<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"CX\" >Christmas Island<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"CC\" >Cocos (Keeling) Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"CO\" >Colombia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"KM\" >Comoros<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"CG\" >Congo (Brazzaville)<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"CD\" >Congo (Kinshasa)<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"CK\" >Cook Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"CR\" >Costa Rica<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"HR\" >Croatia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"CU\" >Cuba<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"CY\" >Cyprus<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"CZ\" >Czech Republic<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"DK\" >Denmark<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"DJ\" >Djibouti<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"DM\" >Dominica<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"DO\" >Dominican Republic<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"EC\" >Ecuador<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"EG\" >Egypt<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"SV\" >El Salvador<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"GQ\" >Equatorial Guinea<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"ER\" >Eritrea<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"EE\" >Estonia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"ET\" >Ethiopia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"FK\" >Falkland Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"FO\" >Faroe Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"FJ\" >Fiji<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"FI\" >Finland<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"FR\" >France<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"GF\" >French Guiana<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"PF\" >French Polynesia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"TF\" >French Southern Territories<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"GA\" >Gabon<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"GM\" >Gambia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"GE\" >Georgia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"DE\" >Germany<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"GH\" >Ghana<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"GI\" >Gibraltar<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"GR\" >Greece<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"GL\" >Greenland<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"GD\" >Grenada<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"GP\" >Guadeloupe<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"GU\" >Guam<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"GT\" >Guatemala<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"GG\" >Guernsey<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"GN\" >Guinea<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"GW\" >Guinea-Bissau<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"GY\" >Guyana<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"HT\" >Haiti<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"HM\" >Heard Island and McDonald Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"HN\" >Honduras<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"HK\" >Hong Kong S.A.R., China<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"HU\" >Hungary<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"IS\" >Iceland<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"IN\" >India<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"ID\" >Indonesia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"IR\" >Iran<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"IQ\" >Iraq<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"IE\" >Ireland<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"IM\" >Isle of Man<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"IL\" >Israel<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"IT\" >Italy<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"CI\" >Ivory Coast<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"JM\" >Jamaica<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"JP\" >Japan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"JE\" >Jersey<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"JO\" >Jordan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"KZ\" >Kazakhstan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"KE\" >Kenya<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"KI\" >Kiribati<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"KW\" >Kuwait<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"KG\" >Kyrgyzstan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"LA\" >Laos<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"LV\" >Latvia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"LB\" >Lebanon<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"LS\" >Lesotho<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"LR\" >Liberia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"LY\" >Libya<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"LI\" >Liechtenstein<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"LT\" >Lithuania<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"LU\" >Luxembourg<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"MO\" >Macao S.A.R., China<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"MK\" >Macedonia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"MG\" >Madagascar<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"MW\" >Malawi<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"MY\" >Malaysia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"MV\" >Maldives<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"ML\" >Mali<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"MT\" >Malta<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"MH\" >Marshall Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"MQ\" >Martinique<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"MR\" >Mauritania<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"MU\" >Mauritius<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"YT\" >Mayotte<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"MX\" >Mexico<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"FM\" >Micronesia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"MD\" >Moldova<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"MC\" >Monaco<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"MN\" >Mongolia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"ME\" >Montenegro<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"MS\" >Montserrat<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"MA\" >Morocco<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"MZ\" >Mozambique<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"MM\" >Myanmar<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"NA\" >Namibia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"NR\" >Nauru<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"NP\" >Nepal<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"NL\" >Netherlands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"AN\" >Netherlands Antilles<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"NC\" >New Caledonia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"NZ\" >New Zealand<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"NI\" >Nicaragua<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"NE\" >Niger<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"NG\" >Nigeria<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"NU\" >Niue<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"NF\" >Norfolk Island<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"KP\" >North Korea<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"MP\" >Northern Mariana Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"NO\" >Norway<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"OM\" >Oman<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"PK\" >Pakistan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"PW\" >Palau<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"PS\" >Palestinian Territory<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"PA\" >Panama<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"PG\" >Papua New Guinea<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"PY\" >Paraguay<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"PE\" >Peru<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"PH\" >Philippines<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"PN\" >Pitcairn<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"PL\" >Poland<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"PT\" >Portugal<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"PR\" >Puerto Rico<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"QA\" >Qatar<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"RE\" >Reunion<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"RO\" >Romania<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"RU\" >Russia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"RW\" >Rwanda<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"BL\" >Saint Barthelemy<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"SH\" >Saint Helena<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"KN\" >Saint Kitts and Nevis<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"LC\" >Saint Lucia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"MF\" >Saint Martin (French part)<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"PM\" >Saint Pierre and Miquelon<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"VC\" >Saint Vincent and the Grenadines<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"WS\" >Samoa<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"SM\" >San Marino<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"ST\" >Sao Tome and Principe<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"SA\" >Saudi Arabia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"SN\" >Senegal<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"RS\" >Serbia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"SC\" >Seychelles<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"SL\" >Sierra Leone<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"SG\" >Singapore<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"SK\" >Slovakia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"SI\" >Slovenia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"SB\" >Solomon Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"SO\" >Somalia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"ZA\" >South Africa<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"KR\" >South Korea<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"ES\" >Spain<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"LK\" >Sri Lanka<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"SD\" >Sudan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"SR\" >Suriname<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"SJ\" >Svalbard and Jan Mayen<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"SZ\" >Swaziland<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"SE\" >Sweden<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"CH\" >Switzerland<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"SY\" >Syria<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"TW\" >Taiwan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"TJ\" >Tajikistan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"TZ\" >Tanzania<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"TH\" >Thailand<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"TL\" >Timor-Leste<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"TG\" >Togo<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"TK\" >Tokelau<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"TO\" >Tonga<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"TT\" >Trinidad and Tobago<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"TN\" >Tunisia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"TR\" >Turkey<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"TM\" >Turkmenistan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"TC\" >Turks and Caicos Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"TV\" >Tuvalu<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"VI\" >U.S. Virgin Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"USAF\" >US Armed Forces<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"UG\" >Uganda<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"UA\" >Ukraine<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"AE\" >United Arab Emirates<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"GB\" >United Kingdom<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"US\" selected=\"selected\">United States<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"UM\" >United States Minor Outlying Islands<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"UY\" >Uruguay<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"UZ\" >Uzbekistan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"VU\" >Vanuatu<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"VA\" >Vatican<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"VE\" >Venezuela<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"VN\" >Vietnam<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"WF\" >Wallis and Futuna<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"EH\" >Western Sahara<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"YE\" >Yemen<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"ZM\" >Zambia<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"ZW\" >Zimbabwe<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t\t\t<\/div> <!-- end pmpro_form_field-bcountry -->\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"pmpro_form_field pmpro_form_field-text pmpro_form_field-bphone\">\n\t\t\t\t\t\t\t\t<label for=\"bphone\" class=\"pmpro_form_label\">Phone<\/label>\n\t\t\t\t\t\t\t\t<input id=\"bphone\" name=\"bphone\" type=\"text\" class=\"pmpro_form_input pmpro_form_input-text\" value=\"\" autocomplete=\"tel\" \/>\n\t\t\t\t\t\t\t<\/div> <!-- end pmpro_form_field-bphone -->\n\t\t\t\t\t\t<\/div> <!-- end pmpro_form_fields -->\n\t\t\t\t\t<\/div> <!-- end pmpro_card_content -->\n\t\t\t\t<\/div> <!-- end pmpro_card -->\n\t\t\t<\/fieldset> <!-- end pmpro_billing_address_fields -->\n\t\t\t\n\t\t\t\n\t\t\t\t\t\t\t\t<fieldset id=\"pmpro_payment_information_fields\" class=\"pmpro_form_fieldset\" style=\"display: none;\">\n\t\t\t\t\t\t<div class=\"pmpro_card\">\n\t\t\t\t\t\t\t<div class=\"pmpro_card_content\">\n\t\t\t\t\t\t\t\t<legend class=\"pmpro_form_legend\">\n\t\t\t\t\t\t\t\t\t<h2 class=\"pmpro_form_heading pmpro_font-large\">Payment Information<\/h2>\n\t\t\t\t\t\t\t\t<\/legend>\n\t\t\t\t\t\t\t\t<div class=\"pmpro_form_fields\">\n\t\t\t\t\t\t\t\t\t<input type=\"hidden\" id=\"CardType\" name=\"CardType\" value=\"\" \/>\n\t\t\t\t\t\t\t\t\t<div class=\"pmpro_form_field pmpro_form_field-text pmpro_payment-account-number\">\n\t\t\t\t\t\t\t\t\t\t<label for=\"AccountNumber\" class=\"pmpro_form_label\">Card Number<\/label>\n\t\t\t\t\t\t\t\t\t\t<input id=\"AccountNumber\" name=\"AccountNumber\" class=\"pmpro_form_input pmpro_form_input-text\" type=\"text\" value=\"\" data-encrypted-name=\"number\" autocomplete=\"off\" \/>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"pmpro_cols-2\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"pmpro_form_field pmpro_form_field-select pmpro_payment-expiration\">\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"ExpirationMonth\" class=\"pmpro_form_label\">Expiration Date<\/label>\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"pmpro_form_fields-inline\">\n\t\t\t\t\t\t\t\t\t\t\t\t<select id=\"ExpirationMonth\" name=\"ExpirationMonth\" class=\"pmpro_form_input pmpro_form_input-select\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"01\" >01<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"02\" >02<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"03\" >03<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"04\" >04<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"05\" >05<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"06\" >06<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"07\" >07<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"08\" >08<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"09\" >09<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"10\" >10<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"11\" >11<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"12\" >12<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t<\/select>\/<select id=\"ExpirationYear\" name=\"ExpirationYear\" class=\"pmpro_form_input pmpro_form_input-select\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2026\" >2026<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2027\" selected=\"selected\">2027<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2028\" >2028<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2029\" >2029<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2030\" >2030<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2031\" >2031<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2032\" >2032<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2033\" >2033<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2034\" >2034<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2035\" >2035<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t\t\t\t\t<\/div> <!-- end pmpro_form_fields-inline -->\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"pmpro_form_field pmpro_form_field-text pmpro_payment-cvv\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"CVV\" class=\"pmpro_form_label\">Security Code (CVC)<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t<input id=\"CVV\" name=\"CVV\" type=\"text\" size=\"4\" value=\"\" class=\"pmpro_form_input pmpro_form_input-text\" \/>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div> <!-- end pmpro_cols-2 -->\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div> <!-- end pmpro_form_fields -->\n\t\t\t\t\t\t\t<\/div> <!-- end pmpro_card_content -->\n\t\t\t\t\t\t<\/div> <!-- end pmpro_card -->\n\t\t\t\t\t<\/fieldset> <!-- end pmpro_payment_information_fields -->\n\t\t\t\t\t\n\t\t\t\t<fieldset id=\"pmpro_tos_fields\" class=\"pmpro_form_fieldset\">\n\t\t<div class=\"pmpro_form_fields\">\n\t\t\t\t\t\t<div class=\"pmpro_form_field pmpro_form_field-checkbox pmpro_form_field-required\">\n\t\t\t\t<label class=\"pmpro_form_label pmpro_clickable\" for=\"tos\">\n\t\t\t\t\t<input type=\"checkbox\" name=\"tos\" value=\"1\" id=\"tos\"  class=\"pmpro_form_input pmpro_form_input-checkbox pmpro_form_input-required\" \/>\n\t\t\t\t\tI agree to the <a href=\"https:\/\/teamoncology.com\/terms\/\" target=\"_blank\">\u30c1\u30fc\u30e0\u30aa\u30f3\u30b3\u30ed\u30b8\u30fc\u4f1a\u54e1 \u5229\u7528\u898f\u7d04<\/a>\t\t\t\t<\/label>\n\t\t\t<\/div> <!-- end pmpro_form_field-tos -->\n\t\t\t\t\t<\/div> <!-- end pmpro_form_fields -->\n\t<\/fieldset> <!-- end pmpro_tos_fields -->\n\t<input type=\"hidden\" id=\"pmpro_checkout_nonce\" name=\"pmpro_checkout_nonce\" value=\"dc986bf1da\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/741\" \/>\n\t\t\t\t\t\t\t<div id=\"pmpro_message_bottom\" class=\"pmpro_message\" style=\"display: none;\"><\/div>\n\t\t\t\n\t\t\t<div class=\"pmpro_form_submit\">\n\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t<span id=\"pmpro_submit_span\">\n\t\t\t\t\t\t\t\t<input type=\"hidden\" name=\"submit-checkout\" value=\"1\" \/>\n\t\t\t\t\t\t\t\t<input type=\"submit\" id=\"pmpro_btn-submit\" class=\"pmpro_btn pmpro_btn-submit-checkout\" value=\"Submit and Confirm\" \/>\n\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div id=\"pmpro_processing_message\" style=\"visibility: hidden;\">\n\t\t\t\t\tProcessing&#8230;\t\t\t\t<\/div>\n\n\t\t\t<\/div> <!-- end pmpro_form_submit -->\n\n\t\t<\/form> <!-- end pmpro_form -->\n\n\t\t\n\t<\/section> <!-- end pmpro_level-ID -->\n\n<\/div> <!-- end pmpro -->\n<\/div>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>TeamOncology Membership &#8211; Sign 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