<label for="last_name">Confirm Email Address <span style="color: red;">*</span></label>
<input type="text" name="con_email_address" id="con_email_address" class="send_data"/>
<label for="phone_number">Contact Number <span style="color: red;">*</span></label>
<input type="text" name="contactno" id="contactno" class="send_data"/>
<label for="address_line1">Address Line 1 <span style="color: red;">*</span></label>
<input type="text" name="address1" id="address1" class="send_data"/>
</div>
<div class="input-right">
<label for="address_line2">Address Line 2</label>
<input type="text" name="address2" id="address2" class="send_data"/>
<label for="country">Country <span style="color: red;">*</span></label>
<div class="select-wrapper" style="width: 94%;">
<select name="country" id="country" class="send_data" style="width: 100%; background-position: 97% center;">
<option value="">Select the Country</option>
<?php
$country_count = $country->getAllCountry();
for ($i = 0; $i < count($country_count); $i++) {
$country->extractor($country_count, $i); ?>
<option value="<?php echo($country->countryId()); ?>"><?php echo($country->countryName()); ?></option>
<?php } ?>
</select>
</div>
<label for="city">City <span style="color: red;">*</span></label>
<input type="text" name="city" id="city" class="send_data"/>
<label for="state_county">State/ Province</label>
<input type="text" name="state" id="state" class="send_data"/>
<label for="zip_postcode">Postal/ Zip</label>
<input type="text" name="zipcode" id="zipcode" class="send_data" style="margin-bottom: 25px;"/>
</div>
<label for="special_requirements" style="display:block; ">Special Requirments</label>
<textarea name="message" id="message" rows="10" class="send_data"></textarea>