<?php
/*
 * LEAD FORM :: Int
 * This is the lead form template for CA.
 */
?>

<div class="mml_form_body clearfix">
	<div class="mml_col-xs-6 float-label mml_main-col">
		<div class="mml_row clearfix">

			<div class="mml_group mml_col-xs-12 mml_control">
				<div class="mml_col-xs-12 mml_control mml_field_wrap mml_origincountry_wrap">
					<select name="mml_origin_country" required="" class="mml_countryselect">
						<option value="" selected disabled>Select Origin Country</option>
						<option value="AF">Afghanistan</option>
						<option value="AX">Aland Islands</option>
						<option value="AL">Albania</option>
						<option value="DZ">Algeria</option>
						<option value="AS">American Samoa</option>
						<option value="AD">Andorra</option>
						<option value="AO">Angola</option>
						<option value="AI">Anguilla</option>
						<option value="AG">Antigua and Barbuda</option>
						<option value="AR">Argentina</option>
						<option value="AM">Armenia</option>
						<option value="AW">Aruba</option>
						<option value="AU">Australia</option>
						<option value="AT">Austria</option>
						<option value="AZ">Azerbaijan</option>
						<option value="BS">Bahamas</option>
						<option value="BH">Bahrain</option>
						<option value="BD">Bangladesh</option>
						<option value="BB">Barbados</option>
						<option value="BY">Belarus</option>
						<option value="BE">Belgium</option>
						<option value="BZ">Belize</option>
						<option value="BJ">Benin</option>
						<option value="BM">Bermuda</option>
						<option value="BT">Bhutan</option>
						<option value="BO">Bolivia</option>
						<option value="BQ">Bonaire, Saint Eustatius and Saba </option>
						<option value="BA">Bosnia and Herzegovina</option>
						<option value="BW">Botswana</option>
						<option value="BV">Bouvet Island</option>
						<option value="BR">Brazil</option>
						<option value="IO">British Indian Ocean Territory</option>
						<option value="VG">British Virgin Islands</option>
						<option value="BN">Brunei</option>
						<option value="BG">Bulgaria</option>
						<option value="BF">Burkina Faso</option>
						<option value="BI">Burundi</option>
						<option value="KH">Cambodia</option>
						<option value="CM">Cameroon</option>
						<option value="CA">Canada</option>
						<option value="CV">Cape Verde</option>
						<option value="KY">Cayman Islands</option>
						<option value="CF">Central African Republic</option>
						<option value="TD">Chad</option>
						<option value="CL">Chile</option>
						<option value="CN">China</option>
						<option value="CX">Christmas Island</option>
						<option value="CC">Cocos Islands</option>
						<option value="CO">Colombia</option>
						<option value="KM">Comoros</option>
						<option value="CK">Cook Islands</option>
						<option value="CR">Costa Rica</option>
						<option value="HR">Croatia</option>
						<option value="CU">Cuba</option>
						<option value="CW">Curacao</option>
						<option value="CY">Cyprus</option>
						<option value="CZ">Czech Republic</option>
						<option value="CD">Democratic Republic of the Congo</option>
						<option value="DK">Denmark</option>
						<option value="DJ">Djibouti</option>
						<option value="DM">Dominica</option>
						<option value="DO">Dominican Republic</option>
						<option value="TL">East Timor</option>
						<option value="EC">Ecuador</option>
						<option value="EG">Egypt</option>
						<option value="SV">El Salvador</option>
						<option value="GQ">Equatorial Guinea</option>
						<option value="ER">Eritrea</option>
						<option value="EE">Estonia</option>
						<option value="ET">Ethiopia</option>
						<option value="FK">Falkland Islands</option>
						<option value="FO">Faroe Islands</option>
						<option value="FJ">Fiji</option>
						<option value="FI">Finland</option>
						<option value="FR">France</option>
						<option value="GF">French Guiana</option>
						<option value="PF">French Polynesia</option>
						<option value="TF">French Southern Territories</option>
						<option value="GA">Gabon</option>
						<option value="GM">Gambia</option>
						<option value="GE">Georgia</option>
						<option value="DE">Germany</option>
						<option value="GH">Ghana</option>
						<option value="GI">Gibraltar</option>
						<option value="GR">Greece</option>
						<option value="GL">Greenland</option>
						<option value="GD">Grenada</option>
						<option value="GP">Guadeloupe</option>
						<option value="GU">Guam</option>
						<option value="GT">Guatemala</option>
						<option value="GG">Guernsey</option>
						<option value="GN">Guinea</option>
						<option value="GW">Guinea-Bissau</option>
						<option value="GY">Guyana</option>
						<option value="HT">Haiti</option>
						<option value="HM">Heard Island and McDonald Islands</option>
						<option value="HN">Honduras</option>
						<option value="HK">Hong Kong</option>
						<option value="HU">Hungary</option>
						<option value="IS">Iceland</option>
						<option value="IN">India</option>
						<option value="ID">Indonesia</option>
						<option value="IR">Iran</option>
						<option value="IQ">Iraq</option>
						<option value="IE">Ireland</option>
						<option value="IM">Isle of Man</option>
						<option value="IL">Israel</option>
						<option value="IT">Italy</option>
						<option value="CI">Ivory Coast</option>
						<option value="JM">Jamaica</option>
						<option value="JP">Japan</option>
						<option value="JE">Jersey</option>
						<option value="JO">Jordan</option>
						<option value="KZ">Kazakhstan</option>
						<option value="KE">Kenya</option>
						<option value="KI">Kiribati</option>
						<option value="XK">Kosovo</option>
						<option value="KW">Kuwait</option>
						<option value="KG">Kyrgyzstan</option>
						<option value="LA">Laos</option>
						<option value="LV">Latvia</option>
						<option value="LB">Lebanon</option>
						<option value="LS">Lesotho</option>
						<option value="LR">Liberia</option>
						<option value="LY">Libya</option>
						<option value="LI">Liechtenstein</option>
						<option value="LT">Lithuania</option>
						<option value="LU">Luxembourg</option>
						<option value="MO">Macao</option>
						<option value="MK">Macedonia</option>
						<option value="MG">Madagascar</option>
						<option value="MW">Malawi</option>
						<option value="MY">Malaysia</option>
						<option value="MV">Maldives</option>
						<option value="ML">Mali</option>
						<option value="MT">Malta</option>
						<option value="MH">Marshall Islands</option>
						<option value="MQ">Martinique</option>
						<option value="MR">Mauritania</option>
						<option value="MU">Mauritius</option>
						<option value="YT">Mayotte</option>
						<option value="MX">Mexico</option>
						<option value="FM">Micronesia</option>
						<option value="MD">Moldova</option>
						<option value="MC">Monaco</option>
						<option value="MN">Mongolia</option>
						<option value="ME">Montenegro</option>
						<option value="MS">Montserrat</option>
						<option value="MA">Morocco</option>
						<option value="MZ">Mozambique</option>
						<option value="MM">Myanmar</option>
						<option value="NA">Namibia</option>
						<option value="NR">Nauru</option>
						<option value="NP">Nepal</option>
						<option value="NL">Netherlands</option>
						<option value="AN">Netherlands Antilles</option>
						<option value="NC">New Caledonia</option>
						<option value="NZ">New Zealand</option>
						<option value="NI">Nicaragua</option>
						<option value="NE">Niger</option>
						<option value="NG">Nigeria</option>
						<option value="NU">Niue</option>
						<option value="NF">Norfolk Island</option>
						<option value="MP">Northern Mariana Islands</option>
						<option value="NO">Norway</option>
						<option value="OM">Oman</option>
						<option value="PK">Pakistan</option>
						<option value="PW">Palau</option>
						<option value="PS">Palestinian Territory</option>
						<option value="PA">Panama</option>
						<option value="PG">Papua New Guinea</option>
						<option value="PY">Paraguay</option>
						<option value="PE">Peru</option>
						<option value="PH">Philippines</option>
						<option value="PN">Pitcairn</option>
						<option value="PL">Poland</option>
						<option value="PT">Portugal</option>
						<option value="PR">Puerto Rico</option>
						<option value="QA">Qatar</option>
						<option value="CG">Republic of the Congo</option>
						<option value="RE">Reunion</option>
						<option value="RO">Romania</option>
						<option value="RU">Russia</option>
						<option value="RW">Rwanda</option>
						<option value="BL">Saint Barthelemy</option>
						<option value="SH">Saint Helena</option>
						<option value="KN">Saint Kitts and Nevis</option>
						<option value="LC">Saint Lucia</option>
						<option value="MF">Saint Martin</option>
						<option value="PM">Saint Pierre and Miquelon</option>
						<option value="VC">Saint Vincent and the Grenadines</option>
						<option value="WS">Samoa</option>
						<option value="SM">San Marino</option>
						<option value="ST">Sao Tome and Principe</option>
						<option value="SA">Saudi Arabia</option>
						<option value="SN">Senegal</option>
						<option value="RS">Serbia</option>
						<option value="SC">Seychelles</option>
						<option value="SL">Sierra Leone</option>
						<option value="SG">Singapore</option>
						<option value="SX">Sint Maarten</option>
						<option value="SK">Slovakia</option>
						<option value="SI">Slovenia</option>
						<option value="SB">Solomon Islands</option>
						<option value="SO">Somalia</option>
						<option value="ZA">South Africa</option>
						<option value="GS">South Georgia and the South Sandwich Islands</option>
						<option value="KR">South Korea</option>
						<option value="SS">South Sudan</option>
						<option value="ES">Spain</option>
						<option value="LK">Sri Lanka</option>
						<option value="SD">Sudan</option>
						<option value="SR">Suriname</option>
						<option value="SJ">Svalbard and Jan Mayen</option>
						<option value="SZ">Swaziland</option>
						<option value="SE">Sweden</option>
						<option value="CH">Switzerland</option>
						<option value="SY">Syria</option>
						<option value="TW">Taiwan</option>
						<option value="TJ">Tajikistan</option>
						<option value="TZ">Tanzania</option>
						<option value="TH">Thailand</option>
						<option value="TG">Togo</option>
						<option value="TK">Tokelau</option>
						<option value="TO">Tonga</option>
						<option value="TT">Trinidad and Tobago</option>
						<option value="TN">Tunisia</option>
						<option value="TR">Turkey</option>
						<option value="TM">Turkmenistan</option>
						<option value="TC">Turks and Caicos Islands</option>
						<option value="TV">Tuvalu</option>
						<option value="UG">Uganda</option>
						<option value="UA">Ukraine</option>
						<option value="AE">United Arab Emirates</option>
						<option value="GB">United Kingdom</option>
						<option value="US">United States</option>
						<option value="UM">United States Minor Outlying Islands</option>
						<option value="UY">Uruguay</option>
						<option value="VI">U.S. Virgin Islands</option>
						<option value="UZ">Uzbekistan</option>
						<option value="VU">Vanuatu</option>
						<option value="VE">Venezuela</option>
						<option value="VN">Vietnam</option>
						<option value="WF">Wallis and Futuna</option>
						<option value="EH">Western Sahara</option>
						<option value="YE">Yemen</option>
						<option value="ZM">Zambia</option>
						<option value="ZW">Zimbabwe</option>
					</select>
					<label for="mml_origin_country" class="mml_placeholder">Origin Country</label>
					<div class="mml_arrow-down"></div>
				</div>
				<div class="mml_col-xs-6 mml_control mml_field_wrap mml_originstate_wrap mml_int_us" style="display: none;">
					<select name="mml_origin_state_us" class="mml_col-xs-12 mml_stateselect mml_origin_state_us">
						<option value="" selected disabled>Select State</option>
						<option value="AK">AK - Alaska</option>
						<option value="AL">AL - Alabama</option>
						<option value="AR">AR - Arkansas</option>
						<option value="AZ">AZ - Arizona</option>
						<option value="CA">CA - California</option>
						<option value="CO">CO - Colorado</option>
						<option value="CT">CT - Connecticut</option>
						<option value="DC">DC - District of Columbia</option>
						<option value="DE">DE - Delaware</option>
						<option value="FL">FL - Florida</option>
						<option value="GA">GA - Georgia</option>
						<option value="HI">HI - Hawaii</option>
						<option value="ID">ID - Idaho</option>
						<option value="IL">IL - Illinois</option>
						<option value="IN">IN - Indiana</option>
						<option value="IA">IA - Iowa</option>
						<option value="KS">KS - Kansas</option>
						<option value="KY">KY - Kentucky</option>
						<option value="LA">LA - Louisiana</option>
						<option value="MA">MA - Massachusetts</option>
						<option value="MD">MD - Maryland</option>
						<option value="ME">ME - Maine</option>
						<option value="MI">MI - Michigan</option>
						<option value="MN">MN - Minnesota</option>
						<option value="MO">MO - Missouri</option>
						<option value="MS">MS - Mississippi</option>
						<option value="MT">MT - Montana</option>
						<option value="NC">NC - North Carolina</option>
						<option value="ND">ND - North Dakota</option>
						<option value="NE">NE - Nebraska</option>
						<option value="NH">NH - New Hampshire</option>
						<option value="NJ">NJ - New Jersey</option>
						<option value="NM">NM - New Mexico</option>
						<option value="NV">NV - Nevada</option>
						<option value="NY">NY - New York</option>
						<option value="OH">OH - Ohio</option>
						<option value="OK">OK - Oklahoma</option>
						<option value="OR">OR - Oregon</option>
						<option value="PA">PA - Pennsylvania</option>
						<option value="PR">PR - Puerto Rico</option>
						<option value="RI">RI - Rhode Island</option>
						<option value="SC">SC - South Carolina</option>
						<option value="SD">SD - South Dakota</option>
						<option value="TN">TN - Tennessee</option>
						<option value="TX">TX - Texas</option>
						<option value="UT">UT - Utah</option>
						<option value="VT">VT - Vermont</option>
						<option value="VA">VA - Virginia</option>
						<option value="WA">WA - Washington</option>
						<option value="WV">WV - West Virginia</option>
						<option value="WI">WI - Wisconsin</option>
						<option value="WY">WY - Wyoming</option>
					</select>
					<label for="mml_origin_state_us" class="mml_placeholder">Origin State</label>
					<div class="mml_arrow-down"></div>
				</div>
				<div class="mml_col-xs-6 mml_control mml_field_wrap mml_originstate_wrap mml_int_ca" style="display: none;">
					<select name="mml_origin_state_ca" class="mml_col-xs-12 mml_stateselect mml_origin_state_ca">
						<option value="" selected disabled>Select Province</option>
						<option value="AB">AB - Alberta</option>
						<option value="BC">BC - British Columbia</option>
						<option value="MB">MB - Manitoba</option>
						<option value="NB">NB - New Brunswick</option>
						<option value="NL">NL - Newfoundland and Labrador</option>
						<option value="NT">NT - Northwest Territories</option>
						<option value="NS">NS - Nova Scotia</option>
						<option value="NU">NU - Nunavut</option>
						<option value="ON">ON - Ontario</option>
						<option value="PE">PE - Prince Edward Island</option>
						<option value="QC">QC - Quebec</option>
						<option value="SK">SK - Saskatchewan</option>
						<option value="YT">YT - Yukon</option>
					</select>
					<label for="mml_origin_state_ca" class="mml_placeholder">Origin Province</label>
					<div class="mml_arrow-down"></div>
				</div>
				<div class="mml_col-xs-6 mml_control mml_field_wrap mml_originstate_wrap mml_int_au" style="display: none;">
					<select name="mml_origin_state_au" class="mml_col-xs-12 mml_stateselect mml_origin_state_au">
						<option value="" selected disabled>Select state</option>
						<option value="ACT">ACT - Australian Capital Territory</option>
						<option value="NSW">NSW - State of New South Wales</option>
						<option value="NT">NT - Northern Territory</option>
						<option value="QLD">QLD - State of Queensland</option>
						<option value="SA">SA - State of South Australia</option>
						<option value="TAS">TAS - State of Tasmania</option>
						<option value="VIC">VIC - State of Victoria</option>
						<option value="WA">WA - State of Western Australia</option>
					</select>
					<label for="mml_origin_state_au" class="mml_placeholder">Origin State</label>
					<div class="mml_arrow-down"></div>
				</div>
				<div class="mml_col-xs-12 mml_control mml_field_wrap mml_origincity_wrap">
					<input type="text" name="mml_origin_city" placeholder="Origin City" autocomplete="off" class="mml_col-xs-12 mml_cityfield"  value="" required="" autocapitalize="off" />
					<label for="mml_origin_city" class="mml_placeholder">Origin City</label>
				</div>
			</div>
			<div class="mml_col-xs-12 mml_control mml_field_wrap mml_arrow-to mml_middle-arrow">
				<span class="mml_from-city"></span>
			</div>
			<div class="mml_group mml_col-xs-12 mml_control">
				<div class="mml_col-xs-12 mml_control mml_field_wrap mml_destinationcountry_wrap">
					<select name="mml_destination_country" required="" class="mml_countryselect">
						<option value="" disabled="" selected="">Select Delivery Country</option>
						<option value="AF">Afghanistan</option>
						<option value="AX">Aland Islands</option>
						<option value="AL">Albania</option>
						<option value="DZ">Algeria</option>
						<option value="AS">American Samoa</option>
						<option value="AD">Andorra</option>
						<option value="AO">Angola</option>
						<option value="AI">Anguilla</option>
						<option value="AG">Antigua and Barbuda</option>
						<option value="AR">Argentina</option>
						<option value="AM">Armenia</option>
						<option value="AW">Aruba</option>
						<option value="AU">Australia</option>
						<option value="AT">Austria</option>
						<option value="AZ">Azerbaijan</option>
						<option value="BS">Bahamas</option>
						<option value="BH">Bahrain</option>
						<option value="BD">Bangladesh</option>
						<option value="BB">Barbados</option>
						<option value="BY">Belarus</option>
						<option value="BE">Belgium</option>
						<option value="BZ">Belize</option>
						<option value="BJ">Benin</option>
						<option value="BM">Bermuda</option>
						<option value="BT">Bhutan</option>
						<option value="BO">Bolivia</option>
						<option value="BQ">Bonaire, Saint Eustatius and Saba </option>
						<option value="BA">Bosnia and Herzegovina</option>
						<option value="BW">Botswana</option>
						<option value="BV">Bouvet Island</option>
						<option value="BR">Brazil</option>
						<option value="IO">British Indian Ocean Territory</option>
						<option value="VG">British Virgin Islands</option>
						<option value="BN">Brunei</option>
						<option value="BG">Bulgaria</option>
						<option value="BF">Burkina Faso</option>
						<option value="BI">Burundi</option>
						<option value="KH">Cambodia</option>
						<option value="CM">Cameroon</option>
						<option value="CA">Canada</option>
						<option value="CV">Cape Verde</option>
						<option value="KY">Cayman Islands</option>
						<option value="CF">Central African Republic</option>
						<option value="TD">Chad</option>
						<option value="CL">Chile</option>
						<option value="CN">China</option>
						<option value="CX">Christmas Island</option>
						<option value="CC">Cocos Islands</option>
						<option value="CO">Colombia</option>
						<option value="KM">Comoros</option>
						<option value="CK">Cook Islands</option>
						<option value="CR">Costa Rica</option>
						<option value="HR">Croatia</option>
						<option value="CU">Cuba</option>
						<option value="CW">Curacao</option>
						<option value="CY">Cyprus</option>
						<option value="CZ">Czech Republic</option>
						<option value="CD">Democratic Republic of the Congo</option>
						<option value="DK">Denmark</option>
						<option value="DJ">Djibouti</option>
						<option value="DM">Dominica</option>
						<option value="DO">Dominican Republic</option>
						<option value="TL">East Timor</option>
						<option value="EC">Ecuador</option>
						<option value="EG">Egypt</option>
						<option value="SV">El Salvador</option>
						<option value="GQ">Equatorial Guinea</option>
						<option value="ER">Eritrea</option>
						<option value="EE">Estonia</option>
						<option value="ET">Ethiopia</option>
						<option value="FK">Falkland Islands</option>
						<option value="FO">Faroe Islands</option>
						<option value="FJ">Fiji</option>
						<option value="FI">Finland</option>
						<option value="FR">France</option>
						<option value="GF">French Guiana</option>
						<option value="PF">French Polynesia</option>
						<option value="TF">French Southern Territories</option>
						<option value="GA">Gabon</option>
						<option value="GM">Gambia</option>
						<option value="GE">Georgia</option>
						<option value="DE">Germany</option>
						<option value="GH">Ghana</option>
						<option value="GI">Gibraltar</option>
						<option value="GR">Greece</option>
						<option value="GL">Greenland</option>
						<option value="GD">Grenada</option>
						<option value="GP">Guadeloupe</option>
						<option value="GU">Guam</option>
						<option value="GT">Guatemala</option>
						<option value="GG">Guernsey</option>
						<option value="GN">Guinea</option>
						<option value="GW">Guinea-Bissau</option>
						<option value="GY">Guyana</option>
						<option value="HT">Haiti</option>
						<option value="HM">Heard Island and McDonald Islands</option>
						<option value="HN">Honduras</option>
						<option value="HK">Hong Kong</option>
						<option value="HU">Hungary</option>
						<option value="IS">Iceland</option>
						<option value="IN">India</option>
						<option value="ID">Indonesia</option>
						<option value="IR">Iran</option>
						<option value="IQ">Iraq</option>
						<option value="IE">Ireland</option>
						<option value="IM">Isle of Man</option>
						<option value="IL">Israel</option>
						<option value="IT">Italy</option>
						<option value="CI">Ivory Coast</option>
						<option value="JM">Jamaica</option>
						<option value="JP">Japan</option>
						<option value="JE">Jersey</option>
						<option value="JO">Jordan</option>
						<option value="KZ">Kazakhstan</option>
						<option value="KE">Kenya</option>
						<option value="KI">Kiribati</option>
						<option value="XK">Kosovo</option>
						<option value="KW">Kuwait</option>
						<option value="KG">Kyrgyzstan</option>
						<option value="LA">Laos</option>
						<option value="LV">Latvia</option>
						<option value="LB">Lebanon</option>
						<option value="LS">Lesotho</option>
						<option value="LR">Liberia</option>
						<option value="LY">Libya</option>
						<option value="LI">Liechtenstein</option>
						<option value="LT">Lithuania</option>
						<option value="LU">Luxembourg</option>
						<option value="MO">Macao</option>
						<option value="MK">Macedonia</option>
						<option value="MG">Madagascar</option>
						<option value="MW">Malawi</option>
						<option value="MY">Malaysia</option>
						<option value="MV">Maldives</option>
						<option value="ML">Mali</option>
						<option value="MT">Malta</option>
						<option value="MH">Marshall Islands</option>
						<option value="MQ">Martinique</option>
						<option value="MR">Mauritania</option>
						<option value="MU">Mauritius</option>
						<option value="YT">Mayotte</option>
						<option value="MX">Mexico</option>
						<option value="FM">Micronesia</option>
						<option value="MD">Moldova</option>
						<option value="MC">Monaco</option>
						<option value="MN">Mongolia</option>
						<option value="ME">Montenegro</option>
						<option value="MS">Montserrat</option>
						<option value="MA">Morocco</option>
						<option value="MZ">Mozambique</option>
						<option value="MM">Myanmar</option>
						<option value="NA">Namibia</option>
						<option value="NR">Nauru</option>
						<option value="NP">Nepal</option>
						<option value="NL">Netherlands</option>
						<option value="AN">Netherlands Antilles</option>
						<option value="NC">New Caledonia</option>
						<option value="NZ">New Zealand</option>
						<option value="NI">Nicaragua</option>
						<option value="NE">Niger</option>
						<option value="NG">Nigeria</option>
						<option value="NU">Niue</option>
						<option value="NF">Norfolk Island</option>
						<option value="MP">Northern Mariana Islands</option>
						<option value="NO">Norway</option>
						<option value="OM">Oman</option>
						<option value="PK">Pakistan</option>
						<option value="PW">Palau</option>
						<option value="PS">Palestinian Territory</option>
						<option value="PA">Panama</option>
						<option value="PG">Papua New Guinea</option>
						<option value="PY">Paraguay</option>
						<option value="PE">Peru</option>
						<option value="PH">Philippines</option>
						<option value="PN">Pitcairn</option>
						<option value="PL">Poland</option>
						<option value="PT">Portugal</option>
						<option value="PR">Puerto Rico</option>
						<option value="QA">Qatar</option>
						<option value="CG">Republic of the Congo</option>
						<option value="RE">Reunion</option>
						<option value="RO">Romania</option>
						<option value="RU">Russia</option>
						<option value="RW">Rwanda</option>
						<option value="BL">Saint Barthelemy</option>
						<option value="SH">Saint Helena</option>
						<option value="KN">Saint Kitts and Nevis</option>
						<option value="LC">Saint Lucia</option>
						<option value="MF">Saint Martin</option>
						<option value="PM">Saint Pierre and Miquelon</option>
						<option value="VC">Saint Vincent and the Grenadines</option>
						<option value="WS">Samoa</option>
						<option value="SM">San Marino</option>
						<option value="ST">Sao Tome and Principe</option>
						<option value="SA">Saudi Arabia</option>
						<option value="SN">Senegal</option>
						<option value="RS">Serbia</option>
						<option value="SC">Seychelles</option>
						<option value="SL">Sierra Leone</option>
						<option value="SG">Singapore</option>
						<option value="SX">Sint Maarten</option>
						<option value="SK">Slovakia</option>
						<option value="SI">Slovenia</option>
						<option value="SB">Solomon Islands</option>
						<option value="SO">Somalia</option>
						<option value="ZA">South Africa</option>
						<option value="GS">South Georgia and the South Sandwich Islands</option>
						<option value="KR">South Korea</option>
						<option value="SS">South Sudan</option>
						<option value="ES">Spain</option>
						<option value="LK">Sri Lanka</option>
						<option value="SD">Sudan</option>
						<option value="SR">Suriname</option>
						<option value="SJ">Svalbard and Jan Mayen</option>
						<option value="SZ">Swaziland</option>
						<option value="SE">Sweden</option>
						<option value="CH">Switzerland</option>
						<option value="SY">Syria</option>
						<option value="TW">Taiwan</option>
						<option value="TJ">Tajikistan</option>
						<option value="TZ">Tanzania</option>
						<option value="TH">Thailand</option>
						<option value="TG">Togo</option>
						<option value="TK">Tokelau</option>
						<option value="TO">Tonga</option>
						<option value="TT">Trinidad and Tobago</option>
						<option value="TN">Tunisia</option>
						<option value="TR">Turkey</option>
						<option value="TM">Turkmenistan</option>
						<option value="TC">Turks and Caicos Islands</option>
						<option value="TV">Tuvalu</option>
						<option value="UG">Uganda</option>
						<option value="UA">Ukraine</option>
						<option value="AE">United Arab Emirates</option>
						<option value="GB">United Kingdom</option>
						<option value="US">United States</option>
						<option value="UM">United States Minor Outlying Islands</option>
						<option value="UY">Uruguay</option>
						<option value="VI">U.S. Virgin Islands</option>
						<option value="UZ">Uzbekistan</option>
						<option value="VU">Vanuatu</option>
						<option value="VE">Venezuela</option>
						<option value="VN">Vietnam</option>
						<option value="WF">Wallis and Futuna</option>
						<option value="EH">Western Sahara</option>
						<option value="YE">Yemen</option>
						<option value="ZM">Zambia</option>
						<option value="ZW">Zimbabwe</option>
					</select>
					<label for="mml_destination_country" class="mml_placeholder">Delivery Country</label>
					<div class="mml_arrow-down"></div>
				</div>
				<div class="mml_col-xs-6 mml_control mml_field_wrap mml_deliverystate_wrap mml_int_us" style="display: none;">
					<select name="mml_delivery_state_us" class="mml_col-xs-12 mml_stateselect mml_delivery_state_us">
						<option value="" selected disabled>Delivery State</option>
						<option value="AK">AK - Alaska</option>
						<option value="AL">AL - Alabama</option>
						<option value="AR">AR - Arkansas</option>
						<option value="AZ">AZ - Arizona</option>
						<option value="CA">CA - California</option>
						<option value="CO">CO - Colorado</option>
						<option value="CT">CT - Connecticut</option>
						<option value="DC">DC - District of Columbia</option>
						<option value="DE">DE - Delaware</option>
						<option value="FL">FL - Florida</option>
						<option value="GA">GA - Georgia</option>
						<option value="HI">HI - Hawaii</option>
						<option value="ID">ID - Idaho</option>
						<option value="IL">IL - Illinois</option>
						<option value="IN">IN - Indiana</option>
						<option value="IA">IA - Iowa</option>
						<option value="KS">KS - Kansas</option>
						<option value="KY">KY - Kentucky</option>
						<option value="LA">LA - Louisiana</option>
						<option value="MA">MA - Massachusetts</option>
						<option value="MD">MD - Maryland</option>
						<option value="ME">ME - Maine</option>
						<option value="MI">MI - Michigan</option>
						<option value="MN">MN - Minnesota</option>
						<option value="MO">MO - Missouri</option>
						<option value="MS">MS - Mississippi</option>
						<option value="MT">MT - Montana</option>
						<option value="NC">NC - North Carolina</option>
						<option value="ND">ND - North Dakota</option>
						<option value="NE">NE - Nebraska</option>
						<option value="NH">NH - New Hampshire</option>
						<option value="NJ">NJ - New Jersey</option>
						<option value="NM">NM - New Mexico</option>
						<option value="NV">NV - Nevada</option>
						<option value="NY">NY - New York</option>
						<option value="OH">OH - Ohio</option>
						<option value="OK">OK - Oklahoma</option>
						<option value="OR">OR - Oregon</option>
						<option value="PA">PA - Pennsylvania</option>
						<option value="PR">PR - Puerto Rico</option>
						<option value="RI">RI - Rhode Island</option>
						<option value="SC">SC - South Carolina</option>
						<option value="SD">SD - South Dakota</option>
						<option value="TN">TN - Tennessee</option>
						<option value="TX">TX - Texas</option>
						<option value="UT">UT - Utah</option>
						<option value="VT">VT - Vermont</option>
						<option value="VA">VA - Virginia</option>
						<option value="WA">WA - Washington</option>
						<option value="WV">WV - West Virginia</option>
						<option value="WI">WI - Wisconsin</option>
						<option value="WY">WY - Wyoming</option>
					</select>
					<label for="mml_delivery_state_us" class="mml_placeholder">Delivery State</label>
					<div class="mml_arrow-down"></div>
				</div>
				<div class="mml_col-xs-6 mml_control mml_field_wrap mml_deliverystate_wrap mml_int_ca" style="display: none;">
					<select name="mml_delivery_state_ca" class="mml_col-xs-12 mml_stateselect mml_delivery_state_ca">
						<option value="" selected disabled>Delivery Province</option>
						<option value="AB">AB - Alberta</option>
						<option value="BC">BC - British Columbia</option>
						<option value="MB">MB - Manitoba</option>
						<option value="NB">NB - New Brunswick</option>
						<option value="NL">NL - Newfoundland and Labrador</option>
						<option value="NT">NT - Northwest Territories</option>
						<option value="NS">NS - Nova Scotia</option>
						<option value="NU">NU - Nunavut</option>
						<option value="ON">ON - Ontario</option>
						<option value="PE">PE - Prince Edward Island</option>
						<option value="QC">QC - Quebec</option>
						<option value="SK">SK - Saskatchewan</option>
						<option value="YT">YT - Yukon</option>
					</select>
					<label for="mml_delivery_state_ca" class="mml_placeholder">Delivery State</label>
					<div class="mml_arrow-down"></div>
				</div>
				<div class="mml_col-xs-6 mml_control mml_field_wrap mml_deliverystate_wrap mml_int_au" style="display: none;">
					<select name="mml_delivery_state_au" class="mml_col-xs-12 mml_stateselect mml_delivery_state_au">
						<option value="" selected disabled>Select state</option>
						<option value="ACT">ACT - Australian Capital Territory</option>
						<option value="NSW">NSW - State of New South Wales</option>
						<option value="NT">NT - Northern Territory</option>
						<option value="QLD">QLD - State of Queensland</option>
						<option value="SA">SA - State of South Australia</option>
						<option value="TAS">TAS - State of Tasmania</option>
						<option value="VIC">VIC - State of Victoria</option>
						<option value="WA">WA - State of Western Australia</option>
					</select>
					<label for="mml_delivery_state_au" class="mml_placeholder">Delivery State</label>
					<div class="mml_arrow-down"></div>
				</div>
				<div class="mml_col-xs-12 mml_control mml_field_wrap mml_deliverycity_wrap">
					<input type="text" name="mml_destination_city" placeholder="Delivery City" autocomplete="off" class="mml_col-xs-12 mml_destination_city mml_cityfield"  value="" required="" autocapitalize="off" />
					<label for="mml_destination_city" class="mml_placeholder">Delivery City</label>
					<span class="mml_distance"></span>
				</div>
			</div>
		</div>
		<div class="mml_switch_int-wrap mml_col-xs-12" style="display: none;">
			<a class="mml_switch mml_switch_int" data-to="int"></a>
		</div>
	</div>
	<div class="mml_col-xs-6 float-label mml_main-col">
		<div class="mml_row clearfix">
			<div class="mml_col-xs-12 mml_control mml_field_wrap mml_movingdate_wrap">
				<input type="text" name="mml_moving_date" placeholder="Moving Date" autocomplete="off" class="mml_col-xs-12 mml_moving_date mml_date_format_int" max="200" value="" required="" readonly="readonly" />
				<label for="mml_moving_date" class="mml_placeholder datepicker-int">Moving Date</label>
				<span class="mml_days_left_wrap"></span>
			</div>
			<div class="mml_col-xs-12 mml_control mml_field_wrap mml_size_wrap">
				<select name="mml_size" class="mml_col-xs-12 mml_size" required="">
					<option value="" selected disabled>Select Home Size</option>
					<option value="2">Studio</option>
					<option value="3">1 Bedroom Home</option>
					<option value="4">2 Bedroom Home</option>
					<option value="5">3 Bedroom Home</option>
					<option value="6">4 Bedroom Home</option>
					<option value="7">4+ Bedroom Home</option>
					<option value="1">Partial</option>
					<option disabled>----------------</option>
					<option value="7">Office Move</option>
					<option value="7">Commercial Move</option>
				</select>
				<label for="mml_size" class="mml_placeholder">Selected Home Size</label>
				<div class="mml_arrow-down"></div>
			</div>

			<div class="mml_col-xs-12 mml_control mml_field_wrap mml_name_wrap">
				<input type="text" name="mml_customer_name" placeholder="First &amp; Last Name" autocomplete="off" class="mml_col-xs-12" required="" autocapitalize="off" max="200" />
				<label for="mml_customer_name" class="mml_placeholder">First &amp; Last Name</label>
			</div>

			<div class="mml_col-xs-12 mml_control mml_field_wrap mml_phone_wrap">
				<input type="tel" name="mml_customer_phone" placeholder="Your Phone" autocomplete="off" class="mml_col-xs-12" min="6" max="200" required="" />
				<label for="mml_customer_phone" class="mml_placeholder">Your Phone</label>
			</div>

			<div class="mml_col-xs-12 mml_control mml_field_wrap mml_email_wrap">
				<input type="email" name="mml_customer_email" placeholder="Your Email" autocomplete="off" class="mml_col-xs-12" max="200" required="" />
				<label for="mml_customer_email" class="mml_placeholder">Your Email</label>
			</div>
		</div>
		<div class="mml_col-xs-12 mml_termstoagree clearfix">
			<div class="mml_termstoagree-wrap mml_col-xs-12 clearfix">
				<label class="mml_termslabel"><input class="mml_termstoagree" type="checkbox"> Consent for data collection<span class="mml_infoicon"></span></label>
			</div>
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