		<label>Country:</label>
								<select>
									<option>United States</option>
									<option>Bangladesh</option>
									<option>UK</option>
									<option>India</option>
									<option>Pakistan</option>
									<option>Ucrane</option>
									<option>Canada</option>
									<option>Dubai</option>
								</select>
								
							</li>
							<li class="single_field">
								<label>Region / State:</label>
								<select>
									<option>Select</option>
									<option>Dhaka</option>
				