STEP 2 – NOW WE NEED A LITTLE INFORMATION FROM YOU Please fill out the form below, include as much information as you can. Don’t worry, we will not give your information to ANYONE for ANY REASON! Real Geeks Site Details Now it's time to start customizing your new Real Geeks website! Please use the form below to let us know the content, cities, agents, Social Media etc... that you want your new site configured with. Step 1 of 5 20% Choose your Real Geeks Buildout Package - 50% Upfront the Remaining Balance Due When the Site is Ready to Go Live*Basic Package $500Basic Package with Area Page Content $625Premium Package $750Premium Package with Area Page Content $1,125Platinum Package $1,000Platinum Package with Area Page Content $2,000Custom CSS Website PackagesYesNoAre you interested in seeing some of the Custom CSS websites we have built recently and Custom CSS "Add-Ons" we offer?Why do I see 6 options above and yet you only have 3 packages you ask? Each package also has the option of having me hire a Content Writer to research each area and give me 4-5 SEO friendly, non-duplicate content describing the Area. Really helps rank the page on Google. It's $25 per page so I have the Basic Package, then Basic with Content, Premium Package then Premium with Content, Platinum Package and Platinum with Content. We are currently scheduled out about a week so you can expect your site to be done in about 10 business days. I understand Area Page Content can take up to 4-6 weeks after the site is launched to receive.*I UnderstandI Do Not AgreeIt takes about 4-6 weeks for me to get the content back and I can't order it until the site goes live. Many (if not most) times the Area's change during the build process and I would end up ordering content, and the client having to pay for content, that is not used nor needed. The Content Writer I use does a very good job, but that has it's downside too, I only use her and her alone and give her literally 100's of pages a month. Let me know if that still works for you, the content is more for Google than for the visitor and going live beforehand won't affect the SEO value of the content as Google is continually indexing the site. If it doesn't and you want to try another avenue I would recommend using www.textbroker.com or www.scripted.com. Your Name First Last Your Email Address Your Cell Phone NumberAgency/Broker NameEmail Address you would like used for the site Main Business Phone NumberBusiness Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Office MLS ID#We will use this to filter and display your "Featured Properties" and "Recently Sold Listings"Agent MLS ID#We will use this to filter and display your "Featured Properties" and "Recently Sold Listings"Can you please provide me with a couple of MLS #'s for Active listings your office has?Would you like the Featured Listings page to display listings based on your Agent ID or Office ID?Agent MLS IDOffice MLS IDI don't want a Featured Listings PageCan you please provide me with a couple of MLS #'s for Active listing you have under your Agent MLS ID?DRE License #Your Real Estate License Number, some states require it in the Footer for compliance. Do you already have a real estate website?NoYesCurrent Website URLDo you already have a real estate website?Current website usernameCurrent website passwordDomain Name For New Real Geeks SiteWhat domain name do you want to use for your new Real Geeks site? Might be the same as the last question if you are replacing your current site. Do you use this Domain Name for your email addresses?NoYesi.e. todd@mydomain.comDo you know what provider you use for your email?Google AppsOffice 365 (Microsoft Exchange)GoDaddyOtherDo you know who the provider is?If so please let us know so we can make sure we keep your email flowing when we set the site live!Real Geeks Domain Name RegistrarGoDaddy, Hostgator, Cheap Domains etc...Domain Name Registrar Account UsernameDomain Name Registrar PasswordDo you currently use Dropbox?NoYesWhat email address do you use with Dropbox? The next 2 items are from the Welcome Email Real Geeks sent youReal Geeks Site Admin Email Address*This is the email address you used to sign up for your Real Geeks account.Real Geeks Site Admin Password*Please choose the "Save and Continue Later" link below, copy the URL it gives you and add your email address in the field provided! Then click that same link to be taken back to the form and continue filling it out. That way if anything happens you can always go back and finish the form from where you left off. Did you follow the "Save and Continue" instructions above?*NoYesOur site does not require registration, if you don't follow the instructions given above and something happens to your brokswer or internet connection you may lose all the data you have entered into the form! First we need the highest resolution copy you have of your logoAccepted file types: jpg, jpeg, png, pdf.An image 400px wide by 86px high works best!Main Banner ImageAccepted file types: jpg, jpeg, png, pdf.This image needs to be at least 2100px wide by 1100px high.If you don't have an image you would like to use as your Main Banner Image (large image across the top of most pages on the site) then please look at www.shutterstock.com, find an image you would like us to use and enter the Image ID # below.Main Banner Image Shutterstock.com Stock Photo ID #1st "Round" Image Shutterstock.com Stock Photo ID #2nd "Round" Image Shutterstock.com Stock Photo ID #Do you want the "Welcome to Our Website" video added to the site?*YesNoShow me the video first! (then choose Yes or No above) Do you want the "Home Buying Process" video added to the site?*YesNoShow me the video first! (then choose Yes or No above) Do you want the "Selling Your Home" video added to the site?*YesNoShow me the video first! (then choose Yes or No above) Now I need you to please sign up for a FREE Wistia account at https://wistia.com/account/signup, then enter the Username and Password you choose below. I will use this account to host the videos I will be embedding into your site.Wistia.com UsernameThe email address you used to sign up on Wistia.com withWistia.com PasswordDo you have a Facebook Page?NoYesFacebook Page URLDo you have an Instagram account?NoYesDo you have a Google + Page?NoYesInstagram Profile URLGoogle + Page URLDo you have a YouTube Channel?NoYes YouTube Channel URLDo you have a Twitter account?NoYesTwitter IDDo you have a Zillow profile?NoYesI do not want to displayZillow Account UsernameZillow Account PasswordWe can use this to add the "Zillow Review Widget" to your About or Agent Detail pages. Do you have a Lender you are working with and would like displayed on the site?NoYesLending Company NameLenders LogoIf you don't have one we can usually find it for you. Loan Officers NameLoan Officers HeadhsotLoan Officers NMLS #Loan Officers Contact Phone #Loan Officers Fax #Loan Officers Email Address Loan Officers Online Loan Application Link Lender's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country How do you want your Area Pages labeled? Hold Ctrl on Windows or Command on a Mac to choose all that apply.HomesCondosThis is for the Title Tag, H1 Tag and Latest Listings on your site. Is your market only "Homes for Sale", or do you want it shown as "Homes and Condos for Sale"?Do you want a Minimum Price Point to be displayed in the Search Box on each page?*No$50,000$100,000$100,000$150,000$200,000Main Target Market Description*How would you generally describe your Main Target Market? This would be for the Homepage, the Buying and Selling pages etc... for example, a site in Phoenix might be "Your Valley of the Sun Real Estate Source", a site in Seattle could be either "Your Seattle Real Estate Source" or "Your NW Washington Real Estate Source". 1st Area you would like added as an Area and Market Report page5 Area Pages / Market Reports are included in the Basic Package, 15 included in the Premium Package and 40 in the Platinum Package. 1st City, Sub Division or Community Description1 or 2 paragrphs describing the Area. 2nd Area you would like added as an Area and Market Report page5 Area Pages / Market Reports are included in the Basic Package, 15 included in the Premium Package and 30 in the Platinum Package. 2nd City, Sub Division or Community Description3rd Area you would like added as an Area and Market Report page5 Area Pages / Market Reports are included in the Basic Package, 15 included in the Premium Package and 30 in the Platinum Package. 3rd City, Sub Division or Community Description4th Area you would like added as an Area and Market Report page5 Area Pages / Market Reports are included in the Basic Package, 15 included in the Premium Package and 40 in the Platinum Package. 4th City, Sub Division or Community Description5th Area you would like added as an Area and Market Report page5 Area Pages / Market Reports are included in the Basic Package, 15 included in the Premium Package and 40 in the Platinum Package. 5th City, Sub Division or Community Description6th Area you would like added as an Area and Market Report page5 Area Pages / Market Reports are included in the Basic Package, 15 included in the Premium Package and 30 in the Platinum Package. 6th City, Sub Division or Community Description7th Area you would like added as an Area and Market Report page5 Area Pages / Market Reports are included in the Basic Package, 15 included in the Premium Package and 30 in the Platinum Package. 7th City, Sub Division or Community Description8th Area you would like added as an Area and Market Report page5 Area Pages / Market Reports are included in the Basic Package, 15 included in the Premium Package and 30 in the Platinum Package. 8th Area you would like added as an Area and Market Report page9th Area you would like added as an Area and Market Report page5 Area Pages / Market Reports are included in the Basic Package, 15 included in the Premium Package and 40 in the Platinum Package. 9th City, Sub Division or Community Description10th Area you would like added as an Area and Market Report page5 Area Pages are included in the Basic Package, 15 Area Pages are included in the Premium Package and 30 Area Pages are included in the Platinum Package. 10th City, Sub Division or Community Description11th Area you would like added as an Area and Market Report page5 Area Pages / Market Reports are included in the Basic Package, 15 included in the Premium Package and 30 in the Platinum Package. 11th City, Sub Division or Community Description12th Area you would like added as an Area and Market Report page5 Area Pages are included in the Basic Package, 15 Area Pages are included in the Premium Package and 30 Area Pages are included in the Platinum Package. 12th City, Sub Division or Community Description13th Area you would like added as an Area and Market Report page5 Area Pages are included in the Basic Package, 15 Area Pages are included in the Premium Package and 30 Area Pages are included in the Platinum Package. 13th City, Sub Division or Community Description14th Area you would like added as an Area and Market Report page5 Area Pages are included in the Basic Package, 15 Area Pages are included in the Premium Package and 40 Area Pages are included in the Platinum Package. 14th City, Sub Division or Community Description15th Area you would like added as an Area and Market Report page5 Area Pages / Market Reports are included in the Basic Package, 15 included in the Premium Package and 40 in the Platinum Package. 15th City, Sub Division or Community Description16th Area you would like added as an Area and Market Report page5 Area Pages are included in the Basic Package, 15 Area Pages are included in the Premium Package and 40 Area Pages are included in the Platinum Package.16th City, Sub Division or Community Description17th Area you would like added as an Area and Market Report page5 Area Pages are included in the Basic Package, 15 Area Pages are included in the Premium Package and 40 Area Pages are included in the Platinum Package.17th City, Sub Division or Community Description18th Area you would like added as an Area and Market Report page5 Area Pages are included in the Basic Package, 15 Area Pages are included in the Premium Package and 40 Area Pages are included in the Platinum Package. 18th City, Sub Division or Community Description19th Area you would like added as an Area and Market Report page5 Area Pages are included in the Basic Package, 15 Area Pages are included in the Premium Package and 40 Area Pages are included in the Platinum Package.19th City, Sub Division or Community Description20th Area you would like added as an Area and Market Report page5 Area Pages are included in the Basic Package, 15 Area Pages are included in the Premium Package and 40 Area Pages are included in the Platinum Package. 20th City, Sub Division or Community Description21st Area you would like added as an Area and Market Report page5 Area Pages / Market Reports are included in the Basic Package, 15 included in the Premium Package and 40 in the Platinum Package. 21st City, Sub Division or Community Description22nd Area you would like added as an Area and Market Report page5 Area Pages are included in the Basic Package, 15 Area Pages are included in the Premium Package and 40 Area Pages are included in the Platinum Package. 22nd City, Sub Division or Community Description23rd Area you would like added as an Area and Market Report page5 Area Pages are included in the Basic Package, 15 Area Pages are included in the Premium Package and 40 Area Pages are included in the Platinum Package. 23rd City, Sub Division or Community Description24th Area you would like added as an Area and Market Report page5 Area Pages are included in the Basic Package, 15 Area Pages are included in the Premium Package and 30 Area Pages are included in the Platinum Package. 24th City, Sub Division or Community Description25th Area you would like added as an Area and Market Report page5 Area Pages are included in the Basic Package, 15 Area Pages are included in the Premium Package and 40 Area Pages are included in the Platinum Package. 25th City, Sub Division or Community Description26th Area you would like added as an Area and Market Report page5 Area Pages are included in the Basic Package, 15 Area Pages are included in the Premium Package and 40 Area Pages are included in the Platinum Package. 26th City, Sub Division or Community Description27th Area you would like added as an Area and Market Report page5 Area Pages are included in the Basic Package, 15 Area Pages are included in the Premium Package and 40 Area Pages are included in the Platinum Package. 27th City, Sub Division or Community Description28th Area you would like added as an Area and Market Report page5 Area Pages are included in the Basic Package, 15 Area Pages are included in the Premium Package and 40 Area Pages are included in the Platinum Package. 28th City, Sub Division or Community Description29th Area you would like added as an Area and Market Report page5 Area Pages are included in the Basic Package, 15 Area Pages are included in the Premium Package and 40 Area Pages are included in the Platinum Package. 29th City, Sub Division or Community Description30th Area you would like added as an Area and Market Report page5 Area Pages / Market Reports are included in the Basic Package, 15 included in the Premium Package and 40 in the Platinum Package. 30th City, Sub Division or Community Description1 or 2 paragraphs describing the Area. This is more for Google than for the end user, having a little content on the page can help the page rank higher. If you don't want to write the content yourself I would recommend using www.textbroker.com or www.scripted.com.31st Area you would like added as an Area and Market Report page5 Area Pages / Market Reports are included in the Basic Package, 15 included in the Premium Package and 40 in the Platinum Package. 31st City, Sub Division or Community Description1 or 2 paragraphs describing the Area. This is more for Google than for the end user, having a little content on the page can help the page rank higher. If you don't want to write the content yourself I would recommend using www.textbroker.com or www.scripted.com.32nd Area you would like added as an Area and Market Report page5 Area Pages / Market Reports are included in the Basic Package, 15 included in the Premium Package and 40 in the Platinum Package. 32nd City, Sub Division or Community Description1 or 2 paragraphs describing the Area. This is more for Google than for the end user, having a little content on the page can help the page rank higher. If you don't want to write the content yourself I would recommend using www.textbroker.com or www.scripted.com.33rd Area you would like added as an Area and Market Report page5 Area Pages / Market Reports are included in the Basic Package, 15 included in the Premium Package and 40 in the Platinum Package. 33rd City, Sub Division or Community Description1 or 2 paragraphs describing the Area. This is more for Google than for the end user, having a little content on the page can help the page rank higher. If you don't want to write the content yourself I would recommend using www.textbroker.com or www.scripted.com.34th Area you would like added as an Area and Market Report page5 Area Pages / Market Reports are included in the Basic Package, 15 included in the Premium Package and 40 in the Platinum Package. 34th City, Sub Division or Community Description1 or 2 paragraphs describing the Area. This is more for Google than for the end user, having a little content on the page can help the page rank higher. If you don't want to write the content yourself I would recommend using www.textbroker.com or www.scripted.com.35th Area you would like added as an Area and Market Report page5 Area Pages / Market Reports are included in the Basic Package, 15 included in the Premium Package and 40 in the Platinum Package. 35th City, Sub Division or Community Description1 or 2 paragraphs describing the Area. This is more for Google than for the end user, having a little content on the page can help the page rank higher. If you don't want to write the content yourself I would recommend using www.textbroker.com or www.scripted.com.36th Area you would like added as an Area and Market Report page5 Area Pages / Market Reports are included in the Basic Package, 15 included in the Premium Package and 40 in the Platinum Package. 36th City, Sub Division or Community Description1 or 2 paragraphs describing the Area. This is more for Google than for the end user, having a little content on the page can help the page rank higher. If you don't want to write the content yourself I would recommend using www.textbroker.com or www.scripted.com.37th Area you would like added as an Area and Market Report page5 Area Pages / Market Reports are included in the Basic Package, 15 included in the Premium Package and 40 in the Platinum Package. 37th City, Sub Division or Community Description1 or 2 paragraphs describing the Area. This is more for Google than for the end user, having a little content on the page can help the page rank higher. If you don't want to write the content yourself I would recommend using www.textbroker.com or www.scripted.com.38th Area you would like added as an Area and Market Report page5 Area Pages / Market Reports are included in the Basic Package, 15 included in the Premium Package and 40 in the Platinum Package. 38th City, Sub Division or Community Description1 or 2 paragraphs describing the Area. This is more for Google than for the end user, having a little content on the page can help the page rank higher. If you don't want to write the content yourself I would recommend using www.textbroker.com or www.scripted.com.39th Area you would like added as an Area and Market Report page5 Area Pages / Market Reports are included in the Basic Package, 15 included in the Premium Package and 40 in the Platinum Package. 39th City, Sub Division or Community Description1 or 2 paragraphs describing the Area. This is more for Google than for the end user, having a little content on the page can help the page rank higher. If you don't want to write the content yourself I would recommend using www.textbroker.com or www.scripted.com.40th Area you would like added as an Area and Market Report page5 Area Pages / Market Reports are included in the Basic Package, 15 included in the Premium Package and 40 in the Platinum Package. 40th City, Sub Division or Community Description1 or 2 paragraphs describing the Area. This is more for Google than for the end user, having a little content on the page can help the page rank higher. If you don't want to write the content yourself I would recommend using www.textbroker.com or www.scripted.com.Did you want to add the Real Geeks Home Valuation Tool?*NoYes - I am aware Real Geeks will add $50 to my monthly bill"What's My Home Worth?" Page Background Image Shutterstock.com Stock Photo ID #1st Custom Home Valuation page CityCustom "What's My Home Worth?" page to target a certain city i.e. "What's My Phoenix Home Worth?"2nd Custom Home Valuation page CityCustom "What's My Home Worth?" page to target a certain city i.e. "What's My Phoenix Home Worth?"3rd Custom Home Valuation page CityCustom "What's My Home Worth?" page to target a certain city i.e. "What's My Phoenix Home Worth?"4th Custom Home Valuation page CityCustom "What's My Home Worth?" page to target a certain city i.e. "What's My Phoenix Home Worth?"5th Custom Home Valuation page CityCustom "What's My Home Worth?" page to target a certain city i.e. "What's My Phoenix Home Worth?" Content for the Home PageContent for the About Us/Meet the Team PageTeam PictureDo you have any Client Testimonials you would like to display? If so please copy and paste them here.Content for the Buying PageContent for the Selling PageWould you like "Recently Sold" page?Yes - Use my Office MLS IDYes - Use my Agent MLS IDNo(Some MLS's don't have SOLD Data yet) Do you want a Foreclosures page?YesNoPlease give me a few MLS #'s of Foreclosure Homes in your Area1st Agent or Team Member Name First Last 1st Agent or Team Member TitleReal Estate AgentREALTOR®BrokerLenderTransaction CoordinatorOther1st Agent Email 1st Agent Cell Phone1st Agent Head ShotAn image 300px wide by 400px high works best!1st Agent Bio2nd Agent or Team Member Name First Last 2nd Agent or Team Member TitleReal Estate AgentREALTOR®BrokerLenderTransaction CoordinatorOther2nd Agent Email 2nd Agent Cell Phone2nd Agent Head ShotAn image 300px wide by 400px high works best!2nd Agent Bio3rd Agent or Team Member Name First Last 3rd Agent or Team Member TitleReal Estate AgentREALTOR®BrokerLenderTransaction CoordinatorOther3rd Agent Email 3rd Agent Cell Phone3rd Agent HeadshotAn image 300px wide by 400px high works best!3rd Agent Bio4th Agent or Team Member Name First Last 4th Agent or Team Member TitleReal Estate AgentREALTOR®BrokerLenderTransaction CoordinatorOther4th Agent Email 4th Agent Cell Phone4th Agent HeadshotAn image 300px wide by 400px high works best!4th Agent Bio5th Agent or Team Member Name First Last 5th Agent or Team Member TitleReal Estate AgentREALTOR®BrokerLenderTransaction CoordinatorOther5th Agent Email 5th Agent Cell Phone5th Agent HeadshotAn image 300px wide by 400px high works best!5th Agent BioLead Follow-Up Add Ons*NoYesWould you like to see how we can help you follow-up with your Leads faster and more efficiently?Would you like more information on Slybroadcast / Real Geeks integration?NoYesSlybroadcast is a 3rd party add-on that will automatically send a voicemail to potential clients who sign up on your site within 5 min of them registering! Real Geeks recommends calling people who signup on your site within the first 10 min of them registering but we all know this is not always possible, life get’s in the way. Maybe you’re out showing homes, on a Listing Appointment or just on the beach and don’t feel like being interrupted on your day off! Using Slybroadcast we can set it up so potential clients receive a pre-recorded voicemail from you automatically after signing up on your site!Slybroadcast Phone #Enter your cell phone # and you will automatically get a Voicemail from me using Slybroadcast! Aiva works your leads while you sleep! Leads slipping away? Aiva engages, qualifies, and nurtures leads for real estate agents. Anything else you would like to add?You being happy with our services and your new Real Geeks website is very important to us. Please take a moment to read and download the Standard Services Agreement below. If you have any questions about what's included in our Basic, Premium or Platinum packages please let us know. I agree with the RG Sitebuilder Services Contract above*YesNoI understand it can around 2 weeks to get my site finished.*YesNoIt doesn't take us that long to build the site but we are normally booked out pretty far in advance. We hope to get your site done sooner but would rather "under promise and over deliver"!I understand Area Page Content can take up to 4-6 weeks after the site is launched to receive.*I UnderstandI Do Not AgreeIt takes about 4-6 weeks for me to get the content back and I can't order it until the site goes live. Many (if not most) times the Area's change during the build process and I would end up ordering content, and the client having to pay for content, that is not used nor needed. The Content Writer I use does a very good job, but that has it's downside too, I only use her and her alone and give her literally 100's of pages a month. Let me know if that still works for you, the content is more for Google than for the visitor and going live beforehand won't affect the SEO value of the content as Google is continually indexing the site. If it doesn't and you want to try another avenue I would recommend using www.textbroker.com or www.scripted.com. There will be a 15% Late Fee charged to Invoices not paid within 15 days of client receiving them.*I UnderstandI Don't AgreeIs it ok if we keep in touch with you in the future?*YesNoOnce you submit the form you cannot make changes to it.*I Do Not AgreeI UnderstandChanges to your order can only be made by sending them to support@rgsitebuilder.com Billing First Name*Billing Last Name*Billing Email Address* Billing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name This iframe contains the logic required to handle Ajax powered Gravity Forms.
