<table border="0" cellpadding="5" cellspacing="0" width="100%">
<tbody><tr>
<td><label>*NAME:</label> (first and last) </td>
<td><div class="frm-position-note"><div class="frm-text-note txt-12">* Indicates a required field</div></div>
<input class="" data-required="" id="BillingFirstLastName" maxlength="80" name="BillingFirstName" type="text" value=""Cote D'Ivoire">Cote D'Ivoire</option><option short="HR" value="">Cancel</a></div>
</td>
</tr>
</tbody></table>