<!-- [et_pb_line_break_holder] --><!DOCTYPE html><!-- [et_pb_line_break_holder] --><html><!-- [et_pb_line_break_holder] --><head><!-- [et_pb_line_break_holder] --> <meta charset="utf-8"><!-- [et_pb_line_break_holder] --> <meta http-equiv="X-UA-Compatible" content="IE=edge"><!-- [et_pb_line_break_holder] --> <meta name="viewport" content="width=device-width, initial-scale=1"><!-- [et_pb_line_break_holder] --> <title> Single Registration<!-- [et_pb_line_break_holder] -->AMIC 25th Annual Conference</title><!-- [et_pb_line_break_holder] --> <link href="/API/Giftit-Account/addons/shared_addons/themes/gifit_account/css/bootstrap/bootstrap.min.css" rel="stylesheet" type="text/css" /><!-- [et_pb_line_break_holder] --> <link rel="stylesheet" href="/css/font-awesome.min.css"><!-- [et_pb_line_break_holder] --> <link href="/gava_css/custom/amicmanila/2017/override.css" rel="stylesheet"><!-- [et_pb_line_break_holder] --> <link href="/gava_css/custom/amicmanila/2017/main.css?1501651187" 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href="http://amicmanila2017.net">Home</a></li><!-- [et_pb_line_break_holder] --> <li class="separator"><span>|</span></li><!-- [et_pb_line_break_holder] --> <li><!-- [et_pb_line_break_holder] --> <a href="#" class="dropdown dropdown-submenu">Information</a><!-- [et_pb_line_break_holder] --> <ul class="dropdown-menu"><!-- [et_pb_line_break_holder] --> <li><a href="http://amicmanila2017.net/message-from-the-chairman"><b>Message from the BOD Chairman</b></a></li><!-- [et_pb_line_break_holder] --> <li><a href="http://amicmanila2017.net/board-members"><b>AMIC Board Members</b></a></li><!-- [et_pb_line_break_holder] --> <li><a href="http://amicmanila2017.net/organizing-team"><b>Organizing Team</b></a></li><!-- [et_pb_line_break_holder] --> <li><a href="http://amicmanila2017.net/about-amic"><b>About AMIC</b></a></li><!-- [et_pb_line_break_holder] --> <li><a href="http://amicmanila2017.net/25th-annual-conference"><b>25th Annual Conference</b></a></li><!-- [et_pb_line_break_holder] --> <li><a href="http://amicmanila2017.net/nomination"><b>Nomination for 2017 AMIC Asia Communication Award</b></a></li><!-- [et_pb_line_break_holder] --> <li><a href="http://amicmanila2017.net/about-manila"><b>About Manila, Philippines</b></a></li><!-- [et_pb_line_break_holder] --> <li><a href="http://amicmanila2017.net/about-the-venue"><b>The Venue</b></a></li><!-- [et_pb_line_break_holder] --> </ul><!-- [et_pb_line_break_holder] --> </li><!-- [et_pb_line_break_holder] --> <li class="separator"><span>|</span></li><!-- [et_pb_line_break_holder] --> <li><!-- [et_pb_line_break_holder] --> <a href="#" class="dropdown dropdown-submenu">Program</a><!-- [et_pb_line_break_holder] --> <ul class="dropdown-menu"><!-- [et_pb_line_break_holder] --> <li><a href="http://amicmanila2017.net/conference-program"><b>Conference Program</b></a></li><!-- [et_pb_line_break_holder] --> <li><a href="http://amicmanila2017.net/invited-speakers"><b>Invited Speakers</b></a></li><!-- [et_pb_line_break_holder] --> <li><a href="http://amicmanila2017.net/call-for-papers"><b>Call for Papers</b></a></li><!-- [et_pb_line_break_holder] --> </ul><!-- [et_pb_line_break_holder] --> </li><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <li class="separator"><span>|</span></li><!-- [et_pb_line_break_holder] --> <li><!-- [et_pb_line_break_holder] --> <a href="#" class="dropdown dropdown-submenu">Registration and Accomodation</a><!-- [et_pb_line_break_holder] --> <ul class="dropdown-menu"><!-- [et_pb_line_break_holder] --> <li><a href="http://amicmanila2017.net/registration-categories-and-fees"><b>Registration Categories and Fees</b></a></li><!-- [et_pb_line_break_holder] --> <li><a href="https://www.gavagives.com/event/registration/amicmanila2017/"><b>Registration</b></a></li><!-- [et_pb_line_break_holder] --> <li><a href="http://amicmanila2017.net/hotel-accomodation"><b>Hotel Accomodation</b></a></li><!-- [et_pb_line_break_holder] --> <li><a href="http://amicmanila2017.net/transfers"><b>Transfers</b></a></li><!-- [et_pb_line_break_holder] --> </ul><!-- [et_pb_line_break_holder] --> </li><!-- [et_pb_line_break_holder] --> <li class="separator"><span>|</span></li><!-- [et_pb_line_break_holder] --> <li><a href="http://amicmanila2017.net/visa">Visa</a></li><!-- [et_pb_line_break_holder] --> <li class="separator"><span>|</span></li><!-- [et_pb_line_break_holder] --> <li><!-- [et_pb_line_break_holder] --> <a class="dropdown dropdown-submenu" href="#">Sponsors and Trade Expo</a><!-- [et_pb_line_break_holder] --> <ul class="dropdown-menu"><!-- [et_pb_line_break_holder] --> <li><!-- [et_pb_line_break_holder] --> <a href="http://amicmanila2017.net/mediapartners"><b>Sponsors</b></a><!-- [et_pb_line_break_holder] --> </li><!-- [et_pb_line_break_holder] --> <li><!-- [et_pb_line_break_holder] --> <a href="http://amicmanila2017.net/sponsorship"><b>Sponsorship Proposal</b></a><!-- [et_pb_line_break_holder] --> </li><!-- [et_pb_line_break_holder] --> </ul><!-- [et_pb_line_break_holder] --> </li><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <li class="separator"><span>|</span></li><!-- [et_pb_line_break_holder] --> <li><a href="http://amicmanila2017.net/contactus">Contact Us</a></li><!-- [et_pb_line_break_holder] --> </ul><!-- [et_pb_line_break_holder] --> </div><!-- /.navbar-collapse --><!-- [et_pb_line_break_holder] --> </div><!-- /.container-fluid --><!-- [et_pb_line_break_holder] --> </nav><!-- [et_pb_line_break_holder] --> <div class="content"><!-- [et_pb_line_break_holder] --> <div class="bg-white padding page-content"><!-- [et_pb_line_break_holder] --> <h3 class="text-center">Registration</h3><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <hr /><!-- [et_pb_line_break_holder] --> <form method="POST" action="" accept-charset="UTF-8" id="formregistration" novalidate="novalidate"><!-- [et_pb_line_break_holder] --> <input name="_token" type="hidden" value=""><!-- [et_pb_line_break_holder] --> <div class="row"><!-- [et_pb_line_break_holder] --> <div class="col-md-12"><!-- [et_pb_line_break_holder] --> <p><!-- [et_pb_line_break_holder] --> Please complete the form below then click "Submit" button.<br /><!-- [et_pb_line_break_holder] --> <span class="text-danger">* - required fields</span><!-- [et_pb_line_break_holder] --> </p><!-- [et_pb_line_break_holder] --> <h4 class="text-center"><!-- [et_pb_line_break_holder] --> Delegate Information<!-- [et_pb_line_break_holder] --> <hr /><!-- [et_pb_line_break_holder] --> </h4><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="col-md-6"><!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <label for="firstname" class="control-label">First name</label> <span class="text-danger">*</span><!-- [et_pb_line_break_holder] --> <input class="form-control" required="required" name="firstname" type="text" id="firstname"><!-- [et_pb_line_break_holder] --> </div> <!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="col-md-6"><!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <label for="lastname" class="control-label">Last name</label> <span class="text-danger">*</span><!-- [et_pb_line_break_holder] --> <input class="form-control" name="lastname" type="text" id="lastname"><!-- [et_pb_line_break_holder] --> </div> <!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="col-md-4"><!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <label for="organization" class="control-label">Company/Organization/School</label> <span class="text-danger">*</span><!-- [et_pb_line_break_holder] --> <input class="form-control" name="organization" type="text" id="organization"><!-- [et_pb_line_break_holder] --> </div> <!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="col-md-4"><!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <label for="nationality" class="control-label">Nationality</label> <span class="text-danger">*</span><!-- [et_pb_line_break_holder] --> <input class="form-control" name="nationality" type="text" id="nationality"><!-- [et_pb_line_break_holder] --> </div> <!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="col-md-4"><!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <label for="profession" class="control-label">Profession</label> <span class="text-danger">*</span><!-- [et_pb_line_break_holder] --> <input class="form-control" name="profession" type="text" id="profession"><!-- [et_pb_line_break_holder] --> </div> <!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="col-md-4"><!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <label for="gender" class="control-label">Gender</label> <span class="text-danger">*</span><!-- [et_pb_line_break_holder] --> <select name="gender" id="gender" class="form-control"><!-- [et_pb_line_break_holder] --> <option value="">Select gender</option><!-- [et_pb_line_break_holder] --> <option value="male" >Male</option><!-- [et_pb_line_break_holder] --> <option value="female" >Female</option><!-- [et_pb_line_break_holder] --> </select><!-- [et_pb_line_break_holder] --> </div> <!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="col-md-4"><!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <label for="phone" class="control-label">Phone</label> <span class="text-danger">*</span><!-- [et_pb_line_break_holder] --> <input class="form-control" name="phone" type="text" id="phone"><!-- [et_pb_line_break_holder] --> </div> <!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="col-md-4"><!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <label for="email" class="control-label">Email</label> <span class="text-danger">*</span><!-- [et_pb_line_break_holder] --> <input class="form-control" name="email" type="text" id="email"><!-- [et_pb_line_break_holder] --> </div> <!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="col-md-12"><!-- [et_pb_line_break_holder] --> <h4 class="text-center"><!-- [et_pb_line_break_holder] --> Mailing Address<!-- [et_pb_line_break_holder] --> <hr /><!-- [et_pb_line_break_holder] --> </h4><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="col-md-12"><!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <label for="address1" class="control-label">Address</label> <span class="text-danger">*</span><!-- [et_pb_line_break_holder] --> <input class="form-control" name="address1" type="text" id="address1"><!-- [et_pb_line_break_holder] --> </div> <!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="col-md-6"><!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <label for="city" class="control-label">City</label> <span class="text-danger">*</span><!-- [et_pb_line_break_holder] --> <input class="form-control" name="city" type="text" id="city"><!-- [et_pb_line_break_holder] --> </div> <!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="col-md-6"><!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <label for="province" class="control-label">State/Province</label> <span class="text-danger">*</span><!-- [et_pb_line_break_holder] --> <input class="form-control" name="province" type="text" id="province"><!-- [et_pb_line_break_holder] --> </div> <!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="col-md-6"><!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <label for="country" class="control-label">Country</label> <span class="text-danger">*</span><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <select class="form-control" name="country" id="country"><!-- [et_pb_line_break_holder] --> <option value="">Select Country</option><!-- [et_pb_line_break_holder] --> <option value="AF" >Afghanistan</option><!-- [et_pb_line_break_holder] --> <option value="AX" >Åland Islands</option><!-- [et_pb_line_break_holder] --> <option value="AL" >Albania</option><!-- [et_pb_line_break_holder] --> <option value="DZ" >Algeria</option><!-- [et_pb_line_break_holder] --> <option value="AS" >American Samoa</option><!-- [et_pb_line_break_holder] --> <option value="AD" >Andorra</option><!-- [et_pb_line_break_holder] --> <option value="AO" >Angola</option><!-- [et_pb_line_break_holder] --> <option value="AI" >Anguilla</option><!-- [et_pb_line_break_holder] --> <option value="AQ" >Antarctica</option><!-- [et_pb_line_break_holder] --> <option value="AG" >Antigua and Barbuda</option><!-- [et_pb_line_break_holder] --> <option value="AR" >Argentina</option><!-- [et_pb_line_break_holder] --> <option value="AM" >Armenia</option><!-- [et_pb_line_break_holder] --> <option value="AW" >Aruba</option><!-- [et_pb_line_break_holder] --> <option value="AU" >Australia</option><!-- [et_pb_line_break_holder] --> <option value="AT" >Austria</option><!-- [et_pb_line_break_holder] --> <option value="AZ" >Azerbaijan</option><!-- [et_pb_line_break_holder] --> <option value="BS" >Bahamas</option><!-- [et_pb_line_break_holder] --> <option value="BH" >Bahrain</option><!-- [et_pb_line_break_holder] --> <option value="BD" >Bangladesh</option><!-- [et_pb_line_break_holder] --> <option value="BB" >Barbados</option><!-- [et_pb_line_break_holder] --> <option value="BY" >Belarus</option><!-- [et_pb_line_break_holder] --> <option value="BE" >Belgium</option><!-- [et_pb_line_break_holder] --> <option value="BZ" >Belize</option><!-- [et_pb_line_break_holder] --> <option value="BJ" >Benin</option><!-- [et_pb_line_break_holder] --> <option value="BM" >Bermuda</option><!-- [et_pb_line_break_holder] --> <option value="BT" >Bhutan</option><!-- [et_pb_line_break_holder] --> <option value="BO" >Bolivia</option><!-- [et_pb_line_break_holder] --> <option value="BA" >Bosnia and Herzegovina</option><!-- [et_pb_line_break_holder] --> <option value="BW" >Botswana</option><!-- [et_pb_line_break_holder] --> <option value="BV" >Bouvet Island</option><!-- [et_pb_line_break_holder] --> <option value="BR" >Brazil</option><!-- [et_pb_line_break_holder] --> <option value="IO" >British Indian Ocean Territory</option><!-- [et_pb_line_break_holder] --> <option value="BN" >Brunei Darussalam</option><!-- [et_pb_line_break_holder] --> <option value="BG" >Bulgaria</option><!-- [et_pb_line_break_holder] --> <option value="BF" >Burkina Faso</option><!-- [et_pb_line_break_holder] --> <option value="BI" >Burundi</option><!-- [et_pb_line_break_holder] --> <option value="KH" >Cambodia</option><!-- [et_pb_line_break_holder] --> <option value="CM" >Cameroon</option><!-- [et_pb_line_break_holder] --> <option value="CA" >Canada</option><!-- [et_pb_line_break_holder] --> <option value="CV" >Cape Verde</option><!-- [et_pb_line_break_holder] --> <option value="KY" >Cayman Islands</option><!-- [et_pb_line_break_holder] --> <option value="CF" >Central African Republic</option><!-- [et_pb_line_break_holder] --> <option value="TD" >Chad</option><!-- [et_pb_line_break_holder] --> <option value="CL" >Chile</option><!-- [et_pb_line_break_holder] --> <option value="CN" >China</option><!-- [et_pb_line_break_holder] --> <option value="CX" >Christmas Island</option><!-- [et_pb_line_break_holder] --> <option value="CC" >Cocos (Keeling) Islands</option><!-- [et_pb_line_break_holder] --> <option value="CO" >Colombia</option><!-- [et_pb_line_break_holder] --> <option value="KM" >Comoros</option><!-- [et_pb_line_break_holder] --> <option value="CG" >Congo</option><!-- [et_pb_line_break_holder] --> <option value="CD" >Congo, The Democratic Republic of The</option><!-- [et_pb_line_break_holder] --> <option value="CK" >Cook Islands</option><!-- [et_pb_line_break_holder] --> <option value="CR" >Costa Rica</option><!-- [et_pb_line_break_holder] --> <option value="CI" >Cote D'ivoire</option><!-- [et_pb_line_break_holder] --> <option value="HR" >Croatia</option><!-- [et_pb_line_break_holder] --> <option value="CU" >Cuba</option><!-- [et_pb_line_break_holder] --> <option value="CY" >Cyprus</option><!-- [et_pb_line_break_holder] --> <option value="CZ" >Czech Republic</option><!-- [et_pb_line_break_holder] --> <option value="DK" >Denmark</option><!-- [et_pb_line_break_holder] --> <option value="DJ" >Djibouti</option><!-- [et_pb_line_break_holder] --> <option value="DM" >Dominica</option><!-- [et_pb_line_break_holder] --> <option value="DO" >Dominican Republic</option><!-- [et_pb_line_break_holder] --> <option value="EC" >Ecuador</option><!-- [et_pb_line_break_holder] --> <option value="EG" >Egypt</option><!-- [et_pb_line_break_holder] --> <option value="SV" >El Salvador</option><!-- [et_pb_line_break_holder] --> <option value="GQ" >Equatorial Guinea</option><!-- [et_pb_line_break_holder] --> <option value="ER" >Eritrea</option><!-- [et_pb_line_break_holder] --> <option value="EE" >Estonia</option><!-- [et_pb_line_break_holder] --> <option value="ET" >Ethiopia</option><!-- [et_pb_line_break_holder] --> <option value="FK" >Falkland Islands (Malvinas)</option><!-- [et_pb_line_break_holder] --> <option value="FO" >Faroe Islands</option><!-- [et_pb_line_break_holder] --> <option value="FJ" >Fiji</option><!-- [et_pb_line_break_holder] --> <option value="FI" >Finland</option><!-- [et_pb_line_break_holder] --> <option value="FR" >France</option><!-- [et_pb_line_break_holder] --> <option value="GF" >French Guiana</option><!-- [et_pb_line_break_holder] --> <option value="PF" >French Polynesia</option><!-- [et_pb_line_break_holder] --> <option value="TF" >French Southern Territories</option><!-- [et_pb_line_break_holder] --> <option value="GA" >Gabon</option><!-- [et_pb_line_break_holder] --> <option value="GM" >Gambia</option><!-- [et_pb_line_break_holder] --> <option value="GE" >Georgia</option><!-- [et_pb_line_break_holder] --> <option value="DE" >Germany</option><!-- [et_pb_line_break_holder] --> <option value="GH" >Ghana</option><!-- [et_pb_line_break_holder] --> <option value="GI" >Gibraltar</option><!-- [et_pb_line_break_holder] --> <option value="GR" >Greece</option><!-- [et_pb_line_break_holder] --> <option value="GL" >Greenland</option><!-- [et_pb_line_break_holder] --> <option value="GD" >Grenada</option><!-- [et_pb_line_break_holder] --> <option value="GP" >Guadeloupe</option><!-- [et_pb_line_break_holder] --> <option value="GU" >Guam</option><!-- [et_pb_line_break_holder] --> <option value="GT" >Guatemala</option><!-- [et_pb_line_break_holder] --> <option value="GG" >Guernsey</option><!-- [et_pb_line_break_holder] --> <option value="GN" >Guinea</option><!-- [et_pb_line_break_holder] --> <option value="GW" >Guinea-bissau</option><!-- [et_pb_line_break_holder] --> <option value="GY" >Guyana</option><!-- [et_pb_line_break_holder] --> <option value="HT" >Haiti</option><!-- [et_pb_line_break_holder] --> <option value="HM" >Heard Island and Mcdonald Islands</option><!-- [et_pb_line_break_holder] --> <option value="VA" >Holy See (Vatican City State)</option><!-- [et_pb_line_break_holder] --> <option value="HN" >Honduras</option><!-- [et_pb_line_break_holder] --> <option value="HK" >Hong Kong</option><!-- [et_pb_line_break_holder] --> <option value="HU" >Hungary</option><!-- [et_pb_line_break_holder] --> <option value="IS" >Iceland</option><!-- [et_pb_line_break_holder] --> <option value="IN" >India</option><!-- [et_pb_line_break_holder] --> <option value="ID" >Indonesia</option><!-- [et_pb_line_break_holder] --> <option value="IR" >Iran, Islamic Republic of</option><!-- [et_pb_line_break_holder] --> <option value="IQ" >Iraq</option><!-- [et_pb_line_break_holder] --> <option value="IE" >Ireland</option><!-- [et_pb_line_break_holder] --> <option value="IM" >Isle of Man</option><!-- [et_pb_line_break_holder] --> <option value="IL" >Israel</option><!-- [et_pb_line_break_holder] --> <option value="IT" >Italy</option><!-- [et_pb_line_break_holder] --> <option value="JM" >Jamaica</option><!-- [et_pb_line_break_holder] --> <option value="JP" >Japan</option><!-- [et_pb_line_break_holder] --> <option value="JE" >Jersey</option><!-- [et_pb_line_break_holder] --> <option value="JO" >Jordan</option><!-- [et_pb_line_break_holder] --> <option value="KZ" >Kazakhstan</option><!-- [et_pb_line_break_holder] --> <option value="KE" >Kenya</option><!-- [et_pb_line_break_holder] --> <option value="KI" >Kiribati</option><!-- [et_pb_line_break_holder] --> <option value="KP" >Korea, Democratic People's Republic of</option><!-- [et_pb_line_break_holder] --> <option value="KR" >Korea, Republic of</option><!-- [et_pb_line_break_holder] --> <option value="KW" >Kuwait</option><!-- [et_pb_line_break_holder] --> <option value="KG" >Kyrgyzstan</option><!-- [et_pb_line_break_holder] --> <option value="LA" >Lao People's Democratic Republic</option><!-- [et_pb_line_break_holder] --> <option value="LV" >Latvia</option><!-- [et_pb_line_break_holder] --> <option value="LB" >Lebanon</option><!-- [et_pb_line_break_holder] --> <option value="LS" >Lesotho</option><!-- [et_pb_line_break_holder] --> <option value="LR" >Liberia</option><!-- [et_pb_line_break_holder] --> <option value="LY" >Libyan Arab Jamahiriya</option><!-- [et_pb_line_break_holder] --> <option value="LI" >Liechtenstein</option><!-- [et_pb_line_break_holder] --> <option value="LT" >Lithuania</option><!-- [et_pb_line_break_holder] --> <option value="LU" >Luxembourg</option><!-- [et_pb_line_break_holder] --> <option value="MO" >Macao</option><!-- [et_pb_line_break_holder] --> <option value="MK" >Macedonia, The Former Yugoslav Republic of</option><!-- [et_pb_line_break_holder] --> <option value="MG" >Madagascar</option><!-- [et_pb_line_break_holder] --> <option value="MW" >Malawi</option><!-- [et_pb_line_break_holder] --> <option value="MY" >Malaysia</option><!-- [et_pb_line_break_holder] --> <option value="MV" >Maldives</option><!-- [et_pb_line_break_holder] --> <option value="ML" >Mali</option><!-- [et_pb_line_break_holder] --> <option value="MT" >Malta</option><!-- [et_pb_line_break_holder] --> <option value="MH" >Marshall Islands</option><!-- [et_pb_line_break_holder] --> <option value="MQ" >Martinique</option><!-- [et_pb_line_break_holder] --> <option value="MR" >Mauritania</option><!-- [et_pb_line_break_holder] --> <option value="MU" >Mauritius</option><!-- [et_pb_line_break_holder] --> <option value="YT" >Mayotte</option><!-- [et_pb_line_break_holder] --> <option value="MX" >Mexico</option><!-- [et_pb_line_break_holder] --> <option value="FM" >Micronesia, Federated States of</option><!-- [et_pb_line_break_holder] --> <option value="MD" >Moldova, Republic of</option><!-- [et_pb_line_break_holder] --> <option value="MC" >Monaco</option><!-- [et_pb_line_break_holder] --> <option value="MN" >Mongolia</option><!-- [et_pb_line_break_holder] --> <option value="ME" >Montenegro</option><!-- [et_pb_line_break_holder] --> <option value="MS" >Montserrat</option><!-- [et_pb_line_break_holder] --> <option value="MA" >Morocco</option><!-- [et_pb_line_break_holder] --> <option value="MZ" >Mozambique</option><!-- [et_pb_line_break_holder] --> <option value="MM" >Myanmar</option><!-- [et_pb_line_break_holder] --> <option value="NA" >Namibia</option><!-- [et_pb_line_break_holder] --> <option value="NR" >Nauru</option><!-- [et_pb_line_break_holder] --> <option value="NP" >Nepal</option><!-- [et_pb_line_break_holder] --> <option value="NL" >Netherlands</option><!-- [et_pb_line_break_holder] --> <option value="AN" >Netherlands Antilles</option><!-- [et_pb_line_break_holder] --> <option value="NC" >New Caledonia</option><!-- [et_pb_line_break_holder] --> <option value="NZ" >New Zealand</option><!-- [et_pb_line_break_holder] --> <option value="NI" >Nicaragua</option><!-- [et_pb_line_break_holder] --> <option value="NE" >Niger</option><!-- [et_pb_line_break_holder] --> <option value="NG" >Nigeria</option><!-- [et_pb_line_break_holder] --> <option value="NU" >Niue</option><!-- [et_pb_line_break_holder] --> <option value="NF" >Norfolk Island</option><!-- [et_pb_line_break_holder] --> <option value="MP" >Northern Mariana Islands</option><!-- [et_pb_line_break_holder] --> <option value="NO" >Norway</option><!-- [et_pb_line_break_holder] --> <option value="OM" >Oman</option><!-- [et_pb_line_break_holder] --> <option value="PK" >Pakistan</option><!-- [et_pb_line_break_holder] --> <option value="PW" >Palau</option><!-- [et_pb_line_break_holder] --> <option value="PS" >Palestinian Territory, Occupied</option><!-- [et_pb_line_break_holder] --> <option value="PA" >Panama</option><!-- [et_pb_line_break_holder] --> <option value="PG" >Papua New Guinea</option><!-- [et_pb_line_break_holder] --> <option value="PY" >Paraguay</option><!-- [et_pb_line_break_holder] --> <option value="PE" >Peru</option><!-- [et_pb_line_break_holder] --> <option value="PH" >Philippines</option><!-- [et_pb_line_break_holder] --> <option value="PN" >Pitcairn</option><!-- [et_pb_line_break_holder] --> <option value="PL" >Poland</option><!-- [et_pb_line_break_holder] --> <option value="PT" >Portugal</option><!-- [et_pb_line_break_holder] --> <option value="PR" >Puerto Rico</option><!-- [et_pb_line_break_holder] --> <option value="QA" >Qatar</option><!-- [et_pb_line_break_holder] --> <option value="RE" >Reunion</option><!-- [et_pb_line_break_holder] --> <option value="RO" >Romania</option><!-- [et_pb_line_break_holder] --> <option value="RU" >Russian Federation</option><!-- [et_pb_line_break_holder] --> <option value="RW" >Rwanda</option><!-- [et_pb_line_break_holder] --> <option value="SH" >Saint Helena</option><!-- [et_pb_line_break_holder] --> <option value="KN" >Saint Kitts and Nevis</option><!-- [et_pb_line_break_holder] --> <option value="LC" >Saint Lucia</option><!-- [et_pb_line_break_holder] --> <option value="PM" >Saint Pierre and Miquelon</option><!-- [et_pb_line_break_holder] --> <option value="VC" >Saint Vincent and The Grenadines</option><!-- [et_pb_line_break_holder] --> <option value="WS" >Samoa</option><!-- [et_pb_line_break_holder] --> <option value="SM" >San Marino</option><!-- [et_pb_line_break_holder] --> <option value="ST" >Sao Tome and Principe</option><!-- [et_pb_line_break_holder] --> <option value="SA" >Saudi Arabia</option><!-- [et_pb_line_break_holder] --> <option value="SN" >Senegal</option><!-- [et_pb_line_break_holder] --> <option value="RS" >Serbia</option><!-- [et_pb_line_break_holder] --> <option value="SC" >Seychelles</option><!-- [et_pb_line_break_holder] --> <option value="SL" >Sierra Leone</option><!-- [et_pb_line_break_holder] --> <option value="SG" >Singapore</option><!-- [et_pb_line_break_holder] --> <option value="SK" >Slovakia</option><!-- [et_pb_line_break_holder] --> <option value="SI" >Slovenia</option><!-- [et_pb_line_break_holder] --> <option value="SB" >Solomon Islands</option><!-- [et_pb_line_break_holder] --> <option value="SO" >Somalia</option><!-- [et_pb_line_break_holder] --> <option value="ZA" >South Africa</option><!-- [et_pb_line_break_holder] --> <option value="GS" >South Georgia and The South Sandwich Islands</option><!-- [et_pb_line_break_holder] --> <option value="ES" >Spain</option><!-- [et_pb_line_break_holder] --> <option value="LK" >Sri Lanka</option><!-- [et_pb_line_break_holder] --> <option value="SD" >Sudan</option><!-- [et_pb_line_break_holder] --> <option value="SR" >Suriname</option><!-- [et_pb_line_break_holder] --> <option value="SJ" >Svalbard and Jan Mayen</option><!-- [et_pb_line_break_holder] --> <option value="SZ" >Swaziland</option><!-- [et_pb_line_break_holder] --> <option value="SE" >Sweden</option><!-- [et_pb_line_break_holder] --> <option value="CH" >Switzerland</option><!-- [et_pb_line_break_holder] --> <option value="SY" >Syrian Arab Republic</option><!-- [et_pb_line_break_holder] --> <option value="TW" >Taiwan, Province of China</option><!-- [et_pb_line_break_holder] --> <option value="TJ" >Tajikistan</option><!-- [et_pb_line_break_holder] --> <option value="TZ" >Tanzania, United Republic of</option><!-- [et_pb_line_break_holder] --> <option value="TH" >Thailand</option><!-- [et_pb_line_break_holder] --> <option value="TL" >Timor-leste</option><!-- [et_pb_line_break_holder] --> <option value="TG" >Togo</option><!-- [et_pb_line_break_holder] --> <option value="TK" >Tokelau</option><!-- [et_pb_line_break_holder] --> <option value="TO" >Tonga</option><!-- [et_pb_line_break_holder] --> <option value="TT" >Trinidad and Tobago</option><!-- [et_pb_line_break_holder] --> <option value="TN" >Tunisia</option><!-- [et_pb_line_break_holder] --> <option value="TR" >Turkey</option><!-- [et_pb_line_break_holder] --> <option value="TM" >Turkmenistan</option><!-- [et_pb_line_break_holder] --> <option value="TC" >Turks and Caicos Islands</option><!-- [et_pb_line_break_holder] --> <option value="TV" >Tuvalu</option><!-- [et_pb_line_break_holder] --> <option value="UG" >Uganda</option><!-- [et_pb_line_break_holder] --> <option value="UA" >Ukraine</option><!-- [et_pb_line_break_holder] --> <option value="AE" >United Arab Emirates</option><!-- [et_pb_line_break_holder] --> <option value="GB" >United Kingdom</option><!-- [et_pb_line_break_holder] --> <option value="US" >United States</option><!-- [et_pb_line_break_holder] --> <option value="UM" >United States Minor Outlying Islands</option><!-- [et_pb_line_break_holder] --> <option value="UY" >Uruguay</option><!-- [et_pb_line_break_holder] --> <option value="UZ" >Uzbekistan</option><!-- [et_pb_line_break_holder] --> <option value="VU" >Vanuatu</option><!-- [et_pb_line_break_holder] --> <option value="VE" >Venezuela</option><!-- [et_pb_line_break_holder] --> <option value="VN" >Viet Nam</option><!-- [et_pb_line_break_holder] --> <option value="VG" >Virgin Islands, British</option><!-- [et_pb_line_break_holder] --> <option value="VI" >Virgin Islands, U.S.</option><!-- [et_pb_line_break_holder] --> <option value="WF" >Wallis and Futuna</option><!-- [et_pb_line_break_holder] --> <option value="EH" >Western Sahara</option><!-- [et_pb_line_break_holder] --> <option value="YE" >Yemen</option><!-- [et_pb_line_break_holder] --> <option value="ZM" >Zambia</option><!-- [et_pb_line_break_holder] --> <option value="ZW" >Zimbabwe</option><!-- [et_pb_line_break_holder] --> </select><!-- [et_pb_line_break_holder] --> </div> <!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="col-md-6"><!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <label for="zipcode" class="control-label">Zipcode</label><!-- [et_pb_line_break_holder] --> <input class="form-control" name="zipcode" type="text" id="zipcode"><!-- [et_pb_line_break_holder] --> </div> <!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <div class="col-md-12"><!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <input type="checkbox" name="social_night" id="social_night" value="1" style="float:left; margin-right:10px;" /><!-- [et_pb_line_break_holder] --> <label for="social_night" class="control-label" style="font-weight:400; width: 90%; padding-left:5px;"><b>AMIC GOT TALENT</b> Videoke Night on 26 September, 6:30PM - 9:00PM, at Novotel Hotel. Invitation is open to all full-paying foreign and local delegates, but hard confirmation of attendance is a must. <b>Only 100 slots are available</b>. Please tick the box if you are confirming. You will be notified if you made or missed the cut.</label><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <input type="checkbox" name="meal_preference" id="meal_preference" value="1" /><!-- [et_pb_line_break_holder] --> <label for="meal_preference" class="control-label" style="font-weight:400; width: 90%; padding-left:5px;"><b>Halal food</b> Please tick the box if this is your meal preference.</label><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <div class="col-md-12"><!-- [et_pb_line_break_holder] --> <div id="f_container" style="display:none;"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <label for="city_tour" class="control-label">Are you joining the Conference organized city tour? </label><!-- [et_pb_line_break_holder] --> <select id="f_city_tour" name="f_city_tour"><!-- [et_pb_line_break_holder] --> <option value="">Select</option><!-- [et_pb_line_break_holder] --> <option value="1" >Yes</option><!-- [et_pb_line_break_holder] --> <option value="0" selected=selected>No</option><!-- [et_pb_line_break_holder] --> </select><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="table-responsive"><!-- [et_pb_line_break_holder] --> <table class="table table-bordered"><!-- [et_pb_line_break_holder] --> <thead><!-- [et_pb_line_break_holder] --> <tr class="active"><!-- [et_pb_line_break_holder] --> <th></th><!-- [et_pb_line_break_holder] --> <th style="vertical-align: top;">FOREIGN DELEGATES <br /><br /><!-- [et_pb_line_break_holder] --> Inclusion:<br /><!-- [et_pb_line_break_holder] --> <ul><!-- [et_pb_line_break_holder] --> <li>Conference Kit</li><!-- [et_pb_line_break_holder] --> <li>Conference Meals</li><!-- [et_pb_line_break_holder] --> <li>Conference Organized City Tour with Lunch</li><!-- [et_pb_line_break_holder] --> </ul><!-- [et_pb_line_break_holder] --> </th><!-- [et_pb_line_break_holder] --> <th style="vertical-align: top; text-align: center;">EARLY BIRD UNTIL <br>AUGUST 15-31, 2017</th><!-- [et_pb_line_break_holder] --> <!--<th style="vertical-align: top; text-align: center;">REGULAR REGISTRATION AUGUST 16 - 31, 2017</th>--><!-- [et_pb_line_break_holder] --> <th style="vertical-align: top; text-align: center;"><!-- [et_pb_line_break_holder] --> REGULAR REGISTRATION <br>SEPTEMBER 1 - 28, 2017<br>PENALTY FEE:<br />USD 50.00<!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> </th><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> </thead><!-- [et_pb_line_break_holder] --> <tbody><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td><input type="radio" name="reg_category" id="f_amic_member" value="f_amic_member" checked=checked/></td><!-- [et_pb_line_break_holder] --> <td>AMIC Member</td><!-- [et_pb_line_break_holder] --> <td>USD 250.00</td><!-- [et_pb_line_break_holder] --> <!--<td>USD 350.00</td>--><!-- [et_pb_line_break_holder] --> <td>USD 400.00</td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td><input type="radio" name="reg_category" id="f_non_amic_member" value="f_non_amic_member" /></td><!-- [et_pb_line_break_holder] --> <td>Non-AMIC Member</td><!-- [et_pb_line_break_holder] --> <td>USD 400.00</td><!-- [et_pb_line_break_holder] --> <!--<td>USD 500.00</td>--><!-- [et_pb_line_break_holder] --> <td>USD 550.00</td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td><input type="radio" name="reg_category" id="f_student" value="f_student" /></td><!-- [et_pb_line_break_holder] --> <td>Foreign Student</td><!-- [et_pb_line_break_holder] --> <td>USD 250.00</td><!-- [et_pb_line_break_holder] --> <!--<td>USD 250.00</td>--><!-- [et_pb_line_break_holder] --> <td>USD 300.00</td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td colspan="5"><small><i>Deadline of Full Payment of Conference Fee is on August 31, 2017. Late payment penalty of USD 50.00 applies.</i></small></td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> </tbody><!-- [et_pb_line_break_holder] --> </table><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div id="l_container" style="display:none;"><!-- [et_pb_line_break_holder] --> <div class="table-responsive"><!-- [et_pb_line_break_holder] --> <table class="table table-bordered"><!-- [et_pb_line_break_holder] --> <thead><!-- [et_pb_line_break_holder] --> <tr class="active"><!-- [et_pb_line_break_holder] --> <th></th><!-- [et_pb_line_break_holder] --> <th style="vertical-align: top;">LOCAL DELEGATES<br /><br /><!-- [et_pb_line_break_holder] --> Inclusions:<!-- [et_pb_line_break_holder] --> <ul><!-- [et_pb_line_break_holder] --> <li>Conference Kit</li><!-- [et_pb_line_break_holder] --> <li>Meals Per Day (Except where indicated)</li><!-- [et_pb_line_break_holder] --> </ul><!-- [et_pb_line_break_holder] --> </th><!-- [et_pb_line_break_holder] --> <th style="vertical-align: top; text-align: center;">LOCAL RATE PER DAY UNTIL AUGUST 31, 2017</th><!-- [et_pb_line_break_holder] --> <th style="vertical-align: top; text-align: center;"><!-- [et_pb_line_break_holder] --> LOCAL RATE PER DAY SEPTEMBER 1 - 28, 2017<br /><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> </th><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> </thead><!-- [et_pb_line_break_holder] --> <tbody><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td><input type="radio" name="reg_category" id="l_amic_member" value="l_amic_member" /></td><!-- [et_pb_line_break_holder] --> <td>AMIC Member</td><!-- [et_pb_line_break_holder] --> <td>PHP 3,000.00</td><!-- [et_pb_line_break_holder] --> <td>PHP 4,000.00</td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td><input type="radio" name="reg_category" id="l_non_amic_member" value="l_non_amic_member" /></td><!-- [et_pb_line_break_holder] --> <td>Non-AMIC Member (Inclusive of 1 Year AMIC Membership Fee)</td><!-- [et_pb_line_break_holder] --> <td>PHP 5,000.00</td><!-- [et_pb_line_break_holder] --> <td>PHP 6,000.00</td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td><input type="radio" name="reg_category" id="grad_student_meal" value="grad_student_meal" /></td><!-- [et_pb_line_break_holder] --> <td>Graduate Student(Inclusive of Meals, Except Gala Dinner)</td><!-- [et_pb_line_break_holder] --> <td>PHP 1,500.00</td><!-- [et_pb_line_break_holder] --> <td>PHP 2,500.00</td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td><input type="radio" name="reg_category" id="grad_student_nomeal" value="grad_student_nomeal" /></td><!-- [et_pb_line_break_holder] --> <td>Graduate Student(No Meals Included)</td><!-- [et_pb_line_break_holder] --> <td>PHP 1,000.00</td><!-- [et_pb_line_break_holder] --> <td>PHP 2,000.00</td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td><input type="radio" name="reg_category" id="ugrad_student_meal" value="ugrad_student_meal" /></td><!-- [et_pb_line_break_holder] --> <td>Undergraduate Student(Inclusive of Meals, Except Gala Dinner)</td><!-- [et_pb_line_break_holder] --> <td>PHP 800.00</td><!-- [et_pb_line_break_holder] --> <td>PHP 1,000.00</td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td><input type="radio" name="reg_category" id="ugrad_student_nomeal" value="ugrad_student_nomeal" /></td><!-- [et_pb_line_break_holder] --> <td>Undergraduate Student(No Meals Included)</td><!-- [et_pb_line_break_holder] --> <td>PHP 500.00</td><!-- [et_pb_line_break_holder] --> <td>PHP 500.00</td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td colspan="4" class="active"> </td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> <!--tr><!-- [et_pb_line_break_holder] --> <td colspan="4"><!-- [et_pb_line_break_holder] --> <strong class="text-danger">Note:</strong> Conference Organized City Tour is not included in the Local Delegates Package. However, delegates who are interested in the said tour may directly contact the travel agency through this <a href="http://www.sharptravelservice.com/contact-us" target="_blank">link</a>.<!-- [et_pb_line_break_holder] --> </td><!-- [et_pb_line_break_holder] --> </tr--><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td><input type="checkbox" name="l_city_tour" id="l_city_tour" value="l_city_tour" /></td><!-- [et_pb_line_break_holder] --> <td>Conference Organized City Tour (Inclusive of Round Trip Transfers and Lunch)</td><!-- [et_pb_line_break_holder] --> <td>PHP 1,000.00</td><!-- [et_pb_line_break_holder] --> <td>PHP 1,500.00</td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td colspan="4"><!--<small><i>Deadline of Full Payment of Conference Fee is on August 31, 2017. Late payment penalty of PHP 1,000.00 applies.</i></small>--></td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> </tbody><!-- [et_pb_line_break_holder] --> </table><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="form-group"><!-- [et_pb_line_break_holder] --> <label for="conference_day" class="control-label">On what day are you going to attend? </label><!-- [et_pb_line_break_holder] --> <select id="l_conference_day" name="l_conference_day"><!-- [et_pb_line_break_holder] --> <option value="">Select</option><!-- [et_pb_line_break_holder] --> <option value="0" >1st day</option><!-- [et_pb_line_break_holder] --> <option value="1" >2nd day</option><!-- [et_pb_line_break_holder] --> <option value="2" >1st and 2nd day</option><!-- [et_pb_line_break_holder] --> </select><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="col-md-12 paymentOption" style="display:none"><!-- [et_pb_line_break_holder] --> <table class="table table-bordered"><!-- [et_pb_line_break_holder] --> <thead><!-- [et_pb_line_break_holder] --> <tr class="active"><!-- [et_pb_line_break_holder] --> <th colspan="2"><!-- [et_pb_line_break_holder] --> Select your payment option<!-- [et_pb_line_break_holder] --> </th><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> </thead><!-- [et_pb_line_break_holder] --> <tbody><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td style="width:25%;" style="overflow-x:hidden;"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <input name="SelectedMethod" class="SelectedMethod" type="hidden" maxlength="50" readonly="readonly" style="position: absolute; top: -10000000px; "><!-- [et_pb_line_break_holder] --> <input name="TotalPayment" class="TotalPayment" type="hidden" maxlength="50" readonly="readonly" style="position: absolute; top: -10000000px;"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <div class="fund-campaign" style="text-align:center;width:99%; overflow-x:hidden;"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <div class="opt-row"><!-- [et_pb_line_break_holder] --> <div class="opt-col-full"><!-- [et_pb_line_break_holder] --> <div class="btn btn-border-only literadius wide gift-donation-amount gift-donation-amount-asiapay PaymentMethod" data-method="Credit Card"><!-- [et_pb_line_break_holder] --> <img src="/gava_images/Creditcard.jpg"><!-- [et_pb_line_break_holder] --> <div class="font500">Credit Card</div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- <div class="opt-row"><!-- [et_pb_line_break_holder] --> <div class="opt-col-full"><!-- [et_pb_line_break_holder] --> <div class="btn btn-sm btn-border-only wide literadius gift-donation-amount1 gift-donation-amount-asiapay-bancnet1 PaymentMethod" onclick="alert('Payment under maintenance.'); return false;" style="opacity:.3; cursor:none; box-shadow:none !important;" data-dismiss="modal" data-method="BancNet"><!-- [et_pb_line_break_holder] --> <img src="/gava_images/Bancnet.jpg"><!-- [et_pb_line_break_holder] --> <div class="font500">BancNet</div><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <div class="opt-row"><!-- [et_pb_line_break_holder] --> <div class="opt-col-full"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <div class="btn btn-border-only wide literadius gift-donation-amount1 gift-donation-amount-paypal1 PaymentMethod1" data-dismiss="modal" data-method="PayPal" onclick="alert('Payment under maintenance.'); return false;" style="opacity:.3; cursor:none; box-shadow:none !important;"><!-- [et_pb_line_break_holder] --> <img src="/gava_images/Paypal.jpg"><!-- [et_pb_line_break_holder] --> <span class="font500">Paypal</span></div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div> --><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <div class="opt-row"><!-- [et_pb_line_break_holder] --> <div class="opt-col-full"><!-- [et_pb_line_break_holder] --> <div class="btn btn-sm btn-border-only wide literadius gift-donation-amount gift-donation-amount-dragonpay PaymentMethod" data-dismiss="modal" data-method="Internet Banking"><!-- [et_pb_line_break_holder] --> <img src="/gava_images/InternetBanking.jpg"><!-- [et_pb_line_break_holder] --> <div class="font500">Internet Banking</div><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="opt-row"><!-- [et_pb_line_break_holder] --> <div class="opt-col-full"><!-- [et_pb_line_break_holder] --> <div class="btn btn-sm btn-border-only wide literadius gift-donation-amount gift-donation-amount-asiapay-GCash PaymentMethod" data-dismiss="modal" data-method="GCash"><!-- [et_pb_line_break_holder] --> <img src="/gava_images/GCash.jpg"><!-- [et_pb_line_break_holder] --> <div class="font500">GCash</div><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <div class="opt-row"><!-- [et_pb_line_break_holder] --> <div class="opt-col-full"><!-- [et_pb_line_break_holder] --> <div class="btn btn-sm btn-border-only wide literadius gift-donation-amount gift-donation-amount-asiapay-SmartMoney PaymentMethod" data-dismiss="modal" data-method="Smartmoney"><!-- [et_pb_line_break_holder] --> <img src="/gava_images/Smartmoney.jpg"><!-- [et_pb_line_break_holder] --> <div class="font500">Smart Money</div><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <div class="opt-row"><!-- [et_pb_line_break_holder] --> <div class="opt-col-full"><!-- [et_pb_line_break_holder] --> <div class="btn btn-sm btn-border-only wide literadius gift-donation-amount gift-donation-amount-dragonpay-pc PaymentMethod" data-dismiss="modal" id="dragonpayPayment-pcX" data-method="Payment Center"><!-- [et_pb_line_break_holder] --> <img src="/gava_images/PaymentCenter.jpg"><!-- [et_pb_line_break_holder] --> <div class="font500">Payment Center</div><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="opt-row"><!-- [et_pb_line_break_holder] --> <div class="opt-col-full"><!-- [et_pb_line_break_holder] --> <div class="btn btn-sm btn-border-only wide literadius gift-donation-amount gift-donation-amount-coinpay PaymentMethod" data-dismiss="modal" data-method="7 Eleven"><!-- [et_pb_line_break_holder] --> <img src="/gava_images/7Eleven.jpg"><!-- [et_pb_line_break_holder] --> <div class="font500"><!-- [et_pb_line_break_holder] --> <span>7-ELEVEN</span><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <div class="opt-row"><!-- [et_pb_line_break_holder] --> <div class="opt-col-full"><!-- [et_pb_line_break_holder] --> <div class="btn btn-sm btn-border-only wide literadius gift-donation-amount gift-donation-amount-offline-payment PaymentMethod" data-dismiss="modal" id="offline-payment" data-method="Bank Deposit"><!-- [et_pb_line_break_holder] --> <img src="/gava_images/BankDeposit.jpg"><!-- [et_pb_line_break_holder] --> <div class="font500">Bank Deposit</div><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <!-- </div> --><!-- [et_pb_line_break_holder] --> <div class="PaymentInfo" style="text-align:left;"></div><!-- [et_pb_line_break_holder] --> <div class="smalltext">brought to you by <a href="https:www.gavagives.com">gavagives.com</a></div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> </td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> </tbody><!-- [et_pb_line_break_holder] --> </table><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="col-md-6" style="overflow-x: hidden;"><!-- [et_pb_line_break_holder] --> <div class="g-recaptcha" data-callback="recaptchaCallback" data-sitekey="6Lc32CgTAAAAAK8epgaDeLfc9vZDHg0Oj_SMUuSx"></div><br /><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="col-md-6"><!-- [et_pb_line_break_holder] --> <button class="btn btn-primary" id="btnsubmit">Submit</button><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </form><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <!-- holder--><!-- [et_pb_line_break_holder] --> <div class="holder"><!-- [et_pb_line_break_holder] --> <!-- asiapay--><!-- [et_pb_line_break_holder] --> <div class="gift-fund-modal gift-fund-gateways" id="gift-donation-amount-asiapay" style="display:none; position:absolute; top:-1000000000px; opacity:0;"><!-- [et_pb_line_break_holder] --> <div class="box box-solid giftit-sign-card small"> <!-- [et_pb_line_break_holder] --> <div class="box-body"><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <div class="fund-amount-wrapper"><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <form name="payFormCcard" id="asiapayForm" method="post" action="https://www.pesopay.com/b2c2/eng/payment/payForm.jsp" style="display:none; position:absolute; top:-1000000000px; opacity:0;"><!-- [et_pb_line_break_holder] --> <input type="hidden" name="merchantId" value=""><!-- [et_pb_line_break_holder] --> <input type="number" class="form-control input-text-lite amount-asiapay" name="amount" ><!-- [et_pb_line_break_holder] --> <input type="hidden" name="orderRef" value=""><!-- [et_pb_line_break_holder] --> <input type="hidden" name="currCode" value="608" ><!-- [et_pb_line_break_holder] --> <input type="hidden" name="mpsMode" value="NIL" ><!-- [et_pb_line_break_holder] --> <input type="hidden" name="successUrl" value="https://www.gavagives.com/app/giftit_account/webshared/campaignpaymvr4/thankyou"><!-- [et_pb_line_break_holder] --> <input type="hidden" name="failUrl" value="https://www.gavagives.com/app/giftit_account/webshared/campaignpaymvr4/failed"><!-- [et_pb_line_break_holder] --> <input type="hidden" name="cancelUrl" value="https://www.gavagives.com/app/giftit_account/webshared/campaignpaymvr4/failed"><!-- [et_pb_line_break_holder] --> <input type="hidden" name="payType" value="N"><!-- [et_pb_line_break_holder] --> <input type="hidden" name="lang" value="E"><!-- [et_pb_line_break_holder] --> <input type="hidden" name="payMethod" class="asiaPayMethod" value="CC"><!-- [et_pb_line_break_holder] --> <input type="hidden" name="secureHash" value=""><!-- [et_pb_line_break_holder] --> <input type="hidden" name="remark" value=""><!-- [et_pb_line_break_holder] --> </form><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> <!-- [et_pb_line_break_holder] --> <form name="payFormCcard" id="dragonpayForm" method="post" action="https://gw.dragonpay.ph/Pay.aspx" style="display:none; position:absolute; top:-1000000000px; opacity:0;"><!-- [et_pb_line_break_holder] --> <input type="text" name="merchantid" value="GAVA"><!-- [et_pb_line_break_holder] --> <div class="error-report"></div><!-- [et_pb_line_break_holder] --> <input type="number" class="form-control input-text-lite c" id="dragonpay-amount" name="amount" placeholder="In Php" ><!-- [et_pb_line_break_holder] --> <input type="text" name="txnid" value=""><!-- [et_pb_line_break_holder] --> <input type="text" name="ccy" value="PHP"><!-- [et_pb_line_break_holder] --> <input type="text" name="description" value=""><!-- [et_pb_line_break_holder] --> <input type="text" name="email" value=""><!-- [et_pb_line_break_holder] --> <input type="text" name="mode" value="1"><!-- [et_pb_line_break_holder] --> 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