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|-
 
| Select the '''state name'''.
 
| Select the '''state name'''.
{{{field|state|input type=combobox|values={{StateList|}} }}}
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{{{field|state|input type=combobox|values=
 +
Alabama, Alaska, American Samoa, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Guam, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Northern Marianas Islands, Ohio, Oklahoma, Oregon, Pennsylvania, Puerto Rico, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Virgin Islands, Washington, West Virginia, Wisconsin, Wyoming
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}}}
 
|-
 
|-
 
| Insert the English name of the '''city'''. Don't use shortcuts.
 
| Insert the English name of the '''city'''. Don't use shortcuts.
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