47">Virginia</option>
			<option value="48">Washington</option>
			<option value="49">West Virginia</option>
			<option value="50">Wisconsin</option>
			<option value="51">Wyoming</option>
			<option value="55">Puerto Rico</option>
			<option value="99">[Unknown State]</option>
		</select>
                <input id="services" maxlength="25" name="services" type="text" value="" style="display:none;">
                <input id="period" maxlength="25" name="period" type="text" value="" style="display:none;">
	