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<div class="form-header">
    <h2>Let’s Connect</h2>
    <p>Please fill out the form below and our team will contact you shortly to discuss your restaurant’s needs.</p>
</div>
<div class="contact-wrapper">
    
    
    

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        <input type=hidden name="retURL" value="https://microsrestaurantsystems.com/thank-you">

        
        
        
                                  
         
        

        <label for="first_name">First Name</label><input id="first_name" maxlength="40" name="first_name" size="20"
            type="text" />

        <label for="last_name">Last Name</label><input id="last_name" maxlength="80" name="last_name" size="20"
            type="text" />

        <label for="email">Email</label><input id="email" maxlength="80" name="email" size="20" type="text" />

        <label for="company">Company</label><input id="company" maxlength="40" name="company" size="20"
            type="text" />

        <label for="country_code">Country</label>
        <select id="country_code" name="country_code">
            <option value="">-- Select Country --</option>
            <option value="US">United States</option>
            <option value="CA">Canada</option>
            <option value="MX">Mexico</option>
            <option value="PR">Puerto Rico</option>
            <option value="CR">Costa Rica</option>
            <option value="PH">Philippines</option>
            <option value="DO">Dominican Republic</option>
            <option value="VI">Virgin Islands</option>
            <option value="GB">United Kingdom</option>
            <option value="IE">Ireland</option>
        </select>
        

        <label for="state_code">State/Province</label>
        <select id="state_code" name="state_code">
            <option value="">-- Select State/Province --</option>
        </select>
        
<label for="city">City</label><input id="city" maxlength="40" name="city" size="20" type="text" />
        <label for="title">Title</label><input id="title" maxlength="40" name="title" size="20" type="text" />

        <label for="phone">Phone</label><input id="phone" maxlength="40" name="phone" size="20" type="text" />

        <label for="lead_source" class="dnone">Lead Source</label><select id="lead_source" name="lead_source"
            class="dnone">
            <option value="Website Contact Form">Website Contact Form</option>
        </select>

        <label for="description">Description</label><textarea name="description"></textarea>
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    <script>
        const statesByCountry = {
            US: [
                { code: "AL", name: "Alabama" },
                { code: "AK", name: "Alaska" },
                { code: "AZ", name: "Arizona" },
                { code: "AR", name: "Arkansas" },
                { code: "CA", name: "California" },
                { code: "CO", name: "Colorado" },
                { code: "CT", name: "Connecticut" },
                { code: "DE", name: "Delaware" },
                { code: "FL", name: "Florida" },
                { code: "GA", name: "Georgia" },
                { code: "HI", name: "Hawaii" },
                { code: "ID", name: "Idaho" },
                { code: "IL", name: "Illinois" },
                { code: "IN", name: "Indiana" },
                { code: "IA", name: "Iowa" },
                { code: "KS", name: "Kansas" },
                { code: "KY", name: "Kentucky" },
                { code: "LA", name: "Louisiana" },
                { code: "ME", name: "Maine" },
                { code: "MD", name: "Maryland" },
                { code: "MA", name: "Massachusetts" },
                { code: "MI", name: "Michigan" },
                { code: "MN", name: "Minnesota" },
                { code: "MS", name: "Mississippi" },
                { code: "MO", name: "Missouri" },
                { code: "MT", name: "Montana" },
                { code: "NE", name: "Nebraska" },
                { code: "NV", name: "Nevada" },
                { code: "NH", name: "New Hampshire" },
                { code: "NJ", name: "New Jersey" },
                { code: "NM", name: "New Mexico" },
                { code: "NY", name: "New York" },
                { code: "NC", name: "North Carolina" },
                { code: "ND", name: "North Dakota" },
                { code: "OH", name: "Ohio" },
                { code: "OK", name: "Oklahoma" },
                { code: "OR", name: "Oregon" },
                { code: "PA", name: "Pennsylvania" },
                { code: "RI", name: "Rhode Island" },
                { code: "SC", name: "South Carolina" },
                { code: "SD", name: "South Dakota" },
                { code: "TN", name: "Tennessee" },
                { code: "TX", name: "Texas" },
                { code: "UT", name: "Utah" },
                { code: "VT", name: "Vermont" },
                { code: "VA", name: "Virginia" },
                { code: "WA", name: "Washington" },
                { code: "WV", name: "West Virginia" },
                { code: "WI", name: "Wisconsin" },
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                { code: "BC", name: "British Columbia" },
                { code: "MB", name: "Manitoba" },
                { code: "NB", name: "New Brunswick" },
                { code: "NL", name: "Newfoundland and Labrador" },
                { code: "NS", name: "Nova Scotia" },
                { code: "ON", name: "Ontario" },
                { code: "PE", name: "Prince Edward Island" },
                { code: "QC", name: "Quebec" },
                { code: "SK", name: "Saskatchewan" },
                { code: "NT", name: "Northwest Territories" },
                { code: "NU", name: "Nunavut" },
                { code: "YT", name: "Yukon" }
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            MX: [
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                { code: "BC", name: "Baja California" },
                { code: "BS", name: "Baja California Sur" },
                { code: "CM", name: "Campeche" },
                { code: "CS", name: "Chiapas" },
                { code: "CH", name: "Chihuahua" },
                { code: "CO", name: "Coahuila" },
                { code: "CL", name: "Colima" },
                { code: "DG", name: "Durango" },
                { code: "GT", name: "Guanajuato" },
                { code: "GR", name: "Guerrero" },
                { code: "HG", name: "Hidalgo" },
                { code: "JA", name: "Jalisco" },
                { code: "MX", name: "México" },
                { code: "MI", name: "Michoacán" },
                { code: "MO", name: "Morelos" },
                { code: "NA", name: "Nayarit" },
                { code: "NL", name: "Nuevo León" },
                { code: "OA", name: "Oaxaca" },
                { code: "PU", name: "Puebla" },
                { code: "QT", name: "Querétaro" },
                { code: "QR", name: "Quintana Roo" },
                { code: "SL", name: "San Luis Potosí" },
                { code: "SI", name: "Sinaloa" },
                { code: "SO", name: "Sonora" },
                { code: "TB", name: "Tabasco" },
                { code: "TM", name: "Tamaulipas" },
                { code: "TL", name: "Tlaxcala" },
                { code: "VE", name: "Veracruz" },
                { code: "YU", name: "Yucatán" },
                { code: "ZA", name: "Zacatecas" }
            ],
            PR: [
                { code: "PR", name: "Puerto Rico" }
            ],
            CR: [
                { code: "A", name: "Alajuela" },
                { code: "C", name: "Cartago" },
                { code: "G", name: "Guanacaste" },
                { code: "H", name: "Heredia" },
                { code: "L", name: "Limón" },
                { code: "P", name: "Puntarenas" },
                { code: "SJ", name: "San José" }
            ],
            PH: [
                { code: "ABR", name: "Abra" },
                { code: "AGN", name: "Agusan del Norte" },
                { code: "AGS", name: "Agusan del Sur" },
                { code: "AKL", name: "Aklan" },
                { code: "ALB", name: "Albay" },
                { code: "ANT", name: "Antique" },
                { code: "APA", name: "Apayao" },
                { code: "AUR", name: "Aurora" },
                { code: "BAS", name: "Basilan" },
                { code: "BAN", name: "Bataan" },
                { code: "BTN", name: "Batanes" },
                { code: "BTG", name: "Batangas" },
                { code: "BEN", name: "Benguet" },
                { code: "BIL", name: "Biliran" },
                { code: "BOH", name: "Bohol" },
                { code: "BUK", name: "Bukidnon" },
                { code: "BUL", name: "Bulacan" },
                { code: "CAG", name: "Cagayan" },
                { code: "CAM", name: "Camiguin" },
                { code: "CAN", name: "Camarines Norte" },
                { code: "CAS", name: "Camarines Sur" },
                { code: "CAP", name: "Capiz" },
                { code: "CAT", name: "Catanduanes" },
                { code: "CAV", name: "Cavite" },
                { code: "CEB", name: "Cebu" },
                { code: "COM", name: "Compostela Valley (Davao de Oro)" },
                { code: "DAV", name: "Davao del Norte" },
                { code: "DAS", name: "Davao del Sur" },
                { code: "DAO", name: "Davao Oriental" },
                { code: "DVO", name: "Davao Occidental" },
                { code: "DIN", name: "Dinagat Islands" },
                { code: "EAS", name: "Eastern Samar" },
                { code: "GUI", name: "Guimaras" },
                { code: "IFU", name: "Ifugao" },
                { code: "ILN", name: "Ilocos Norte" },
                { code: "ILS", name: "Ilocos Sur" },
                { code: "ILI", name: "Iloilo" },
                { code: "ISA", name: "Isabela" },
                { code: "KAL", name: "Kalinga" },
                { code: "LAG", name: "Laguna" },
                { code: "LAN", name: "Lanao del Norte" },
                { code: "LAS", name: "Lanao del Sur" },
                { code: "LEY", name: "Leyte" },
                { code: "LUN", name: "La Union" },
                { code: "MAD", name: "Marinduque" },
                { code: "MAS", name: "Masbate" },
                { code: "MDC", name: "Mindoro Occidental" },
                { code: "MDR", name: "Mindoro Oriental" },
                { code: "MGN", name: "Maguindanao del Norte" },
                { code: "MGS", name: "Maguindanao del Sur" },
                { code: "MOU", name: "Mountain Province" },
                { code: "MSC", name: "Misamis Occidental" },
                { code: "MSR", name: "Misamis Oriental" },
                { code: "NCO", name: "Cotabato (North Cotabato)" },
                { code: "NSA", name: "Northern Samar" },
                { code: "NEC", name: "Negros Occidental" },
                { code: "NER", name: "Negros Oriental" },
                { code: "NUE", name: "Nueva Ecija" },
                { code: "NUV", name: "Nueva Vizcaya" },
                { code: "PLW", name: "Palawan" },
                { code: "PAM", name: "Pampanga" },
                { code: "PAN", name: "Pangasinan" },
                { code: "QUE", name: "Quezon" },
                { code: "QUI", name: "Quirino" },
                { code: "RIZ", name: "Rizal" },
                { code: "ROM", name: "Romblon" },
                { code: "SAR", name: "Sarangani" },
                { code: "SCO", name: "South Cotabato" },
                { code: "SIG", name: "Siquijor" },
                { code: "SLE", name: "Southern Leyte" },
                { code: "SLU", name: "Sulu" },
                { code: "SOR", name: "Sorsogon" },
                { code: "SUK", name: "Sultan Kudarat" },
                { code: "SUN", name: "Surigao del Norte" },
                { code: "SUR", name: "Surigao del Sur" },
                { code: "TAR", name: "Tarlac" },
                { code: "TAW", name: "Tawi-Tawi" },
                { code: "WSA", name: "Samar (Western Samar)" },
                { code: "ZAN", name: "Zamboanga del Norte" },
                { code: "ZAS", name: "Zamboanga del Sur" },
                { code: "ZMB", name: "Zambales" },
                { code: "ZSI", name: "Zamboanga Sibuguey (Zamboanga Sibugay)" }
            ],
            DO: [
                { code: "01", name: "Distrito Nacional" },
                { code: "02", name: "Azua" },
                { code: "03", name: "Baoruco" },
                { code: "04", name: "Barahona" },
                { code: "05", name: "Dajabón" },
                { code: "06", name: "Duarte" },
                { code: "07", name: "Elías Piña" },
                { code: "08", name: "El Seibo" },
                { code: "09", name: "Espaillat" },
                { code: "10", name: "Independencia" },
                { code: "11", name: "La Altagracia" },
                { code: "12", name: "La Romana" },
                { code: "13", name: "La Vega" },
                { code: "14", name: "María Trinidad Sánchez" },
                { code: "15", name: "Monte Cristi" },
                { code: "16", name: "Pedernales" },
                { code: "17", name: "Peravia" },
                { code: "18", name: "Puerto Plata" },
                { code: "19", name: "Salcedo" },
                { code: "20", name: "Samaná" },
                { code: "21", name: "San Cristóbal" },
                { code: "22", name: "San Juan" },
                { code: "23", name: "San Pedro de Macorís" },
                { code: "24", name: "Sánchez Ramírez" },
                { code: "25", name: "Santiago" },
                { code: "26", name: "Santiago Rodríguez" },
                { code: "27", name: "Valverde" },
                { code: "28", name: "Monseñor Nouel" },
                { code: "29", name: "Monte Plata" },
                { code: "30", name: "Hato Mayor" }
            ],
            VI: [
                { code: "VI", name: "Virgin Islands (U.S.)" }
            ],
            GB: [
                { code: "ENG", name: "England" },
                { code: "NIR", name: "Northern Ireland" },
                { code: "SCT", name: "Scotland" },
                { code: "WLS", name: "Wales" }
            ],
            IE: [
                // Ireland counties per ISO-3166-2:
                { code: "CW", name: "Carlow" },
                { code: "CN", name: "Cavan" },
                { code: "CE", name: "Clare" },
                { code: "C", name: "Cork" },
                { code: "DL", name: "Donegal" },
                { code: "D", name: "Dublin" },
                { code: "G", name: "Galway" },
                { code: "KY", name: "Kerry" },
                { code: "KE", name: "Kildare" },
                { code: "KK", name: "Kilkenny" },
                { code: "LD", name: "Longford" },
                { code: "LH", name: "Louth" },
                { code: "LK", name: "Limerick" },
                { code: "LM", name: "Leitrim" },
                { code: "LS", name: "Laois" },
                { code: "ME", name: "Meath" },
                { code: "MN", name: "Monaghan" },
                { code: "MO", name: "Mayo" },
                { code: "OY", name: "Offaly" },
                { code: "RN", name: "Roscommon" },
                { code: "SO", name: "Sligo" },
                { code: "TA", name: "Tipperary" },
                { code: "WD", name: "Waterford" },
                { code: "WH", name: "Westmeath" },
                { code: "WW", name: "Wicklow" },
                { code: "WX", name: "Wexford" }
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            const stateDropdown = document.getElementById("state_code");

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            if (statesByCountry[country]) {
                statesByCountry[country].forEach(state => {
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                    opt.value = state.code; // short code for CRM
                    opt.textContent = state.name; // display name
                    stateDropdown.appendChild(opt);
                });
            }
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    <style>
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            max-width: 700px;
            margin: 0 auto;
            padding: 40px 20px;
            font-family: sans-serif;
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        .dnone {
            display: none !important;
        }

        form label,
        form input,
        form select,
        form textarea {
            width: 100%;
            box-sizing: border-box;
            margin-bottom: 10px;
        }

        input[type="submit"] {
            background-color: #007bff;
            color: white;
            border: none;
            padding: 12px 24px;
            font-weight: bold;
            border-radius: 6px;
            cursor: pointer;
            font-size: 16px;
            transition: background-color 0.3s;
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        input[type="submit"]:hover {
            background-color: #0056b3;
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</div>