<div > <label for="fe66343">Salutation </label> <select class="w-select" id="fe66343" name="salutation" style="width:100%;" data-value="~~eloqua..type--emailfield..syntax--AUT_GM_Salutation1~~" required> <option value="">Please select... </option> <option value="Miss">Miss </option> <option value="Mr.">Mr. </option> <option value="Mrs.">Mrs. </option> <option value="Ms.">Ms. </option> <option value="Dr.">Dr. </option> <option value="Prof.">Prof. </option> </select> </div> <div > <label for="fe65332">First Name </label> <input type="text" class="w-input" name="firstName" id="fe65332" value="" style="width:100%;" required> </div> <div > <label for="fe65333">Last Name </label> <input type="text" class="w-input" name="lastName" id="fe65333" value="" style="width:100%;" required> </div> <div > <label for="fe65331">Email Address </label> <input type="text" class="w-input" name="emailAddress" id="fe65331" value="" style="width:100%;" type="email" title="Please enter a valid email address." pattern="^[a-zA-Z0-9._%+-]+@[a-zA-Z0-9.-]+\.[a-zA-Z]{2,4}$" required> </div> <div > <label for="fe65334">Mobile Phone (optional) </label> <input type="text" class="w-input" name="mobilePhone" id="fe65334" value="" style="width:100%;"> </div> <div > <label for="fe65356">Business Phone </label> <input type="text" class="w-input" name="busPhone" id="fe65356" value="" style="width:100%;" required> </div> <div> <label class="w-label" for="fe65341">Country </label> <!-- Country list is added with some javascript on the footer --> <select class="w-select" id="fe65341" name="country" style="width:100%;" data-value="~~eloqua..type--emailfield..syntax--Country~~" required> <option value="">Please select... </option> </select> </div> <div > <label for="fe65335">Institution/Organisation </label> <input type="text" class="w-input" name="organisation" id="fe65335" value="" style="width:100%;" required> </div> <div> <label class="w-label" for="fe65338">Job Role </label> <select class="w-select" id="fe65338" name="jobRole1" style="width:100%;" data-value="~~eloqua..type--emailfield..syntax--Job_Role1~~" required> <option value="">Please select… </option> <option value="(DG APAC) President/ Rector/ Chancellor">President/Rector/Chancellor </option> <option value="(DG APAC) Vice President/ Vice-Rector/ Vice Chancellor">Vice President/Vice-Rector/Vice Chancellor </option> <option value="(DG APAC) Dean/ Department Chair/ Programme Head/ Department Head">Dean/Programme Head/Department Head </option> <option value="(DG APAC) Director/Manager">Director/Manager </option> <option value="(DG APAC) Faculty">Faculty </option> <option value="(DG APAC) Head of Research">Head of Research </option> <option value="(DG APAC) Instructor/ Lecturer">Instructor/Lecturer </option> <option value="(DG APAC) Librarian">Librarian </option> <option value="(DG APAC) Library Director">Library Director </option> <option value="(DG APAC) Professor">Professor </option> <option value="(DG APAC) Provost">Provost </option> <option value="(DG APAC) Researcher">Researcher </option> <option value="(DG APAC) Postgraduate Student">Postgraduate Student </option> <option value="(DG APAC) Undergraduate Student">Undergraduate Student </option> </select> </div> <h4>Let’s Stay in Touch… </h4> <div> <label class="w-form-label"> <input type="checkbox" name="consent" id="fe65345"> <span class="privacy"></span> </label> </div>