<link rel="stylesheet" href="/beta/styles/feedback.min.css" type="text/css" media="screen, projection">

<div class="beta-feedback">
	<h2>Give Us Your Feedback</h2>
			<p>We welcome your feedback and insights on this project.</p>
	
	<form action="/beta/banner/beta-form-process.php" method="post">
		<input name="referer" type="hidden" value="https://www.eia.gov/beta/states/" />
				<input name="betaproduct" type="hidden" value="State Energy Portal" />
				<label>Your Country:</label><br />
		<select id="country" name="country" style="width:300px;" onchange="if (this.value == 'United States') document.getElementById('state_div').style.display = ''; else document.getElementById('state_div').style.display = 'none';">
			<option value="United States" selected="selected">United States</option>
			<option></option>
			<option value="Afghanistan">Afghanistan</option><option value="Albania">Albania</option><option value="Algeria">Algeria</option><option value="American Samoa">American Samoa</option><option value="Angola">Angola</option><option value="Antarctica">Antarctica</option><option value="Antigua and Barbuda">Antigua and Barbuda</option><option value="Argentina">Argentina</option><option value="Armenia">Armenia</option><option value="Aruba">Aruba</option><option value="Australia">Australia</option><option value="Austria">Austria</option><option value="Azerbaijan">Azerbaijan</option><option value="Bahamas, The">Bahamas, The</option><option value="Bahrain">Bahrain</option><option value="Bangladesh">Bangladesh</option><option value="Barbados">Barbados</option><option value="Belarus">Belarus</option><option value="Belgium">Belgium</option><option value="Belize">Belize</option><option value="Benin">Benin</option><option value="Bermuda">Bermuda</option><option value="Bhutan">Bhutan</option><option value="Bolivia">Bolivia</option><option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option><option value="Botswana">Botswana</option><option value="Brazil">Brazil</option><option value="Brunei">Brunei</option><option value="Bulgaria">Bulgaria</option><option value="Burkina Faso">Burkina Faso</option><option value="Burma (Myanmar)">Burma (Myanmar)</option><option value="Burundi">Burundi</option><option value="Cambodia">Cambodia</option><option value="Cameroon">Cameroon</option><option value="Canada">Canada</option><option value="Cape Verde">Cape Verde</option><option value="Cayman Islands">Cayman Islands</option><option value="Central African Republic">Central African Republic</option><option value="Chad">Chad</option><option value="Chile">Chile</option><option value="China">China</option><option value="Colombia">Colombia</option><option value="Comoros">Comoros</option><option value="Congo (Brazzaville)">Congo (Brazzaville)</option><option value="Congo (Kinshasa)">Congo (Kinshasa)</option><option value="Cook Islands">Cook Islands</option><option value="Costa Rica">Costa Rica</option><option value="Cote dIvoire (IvoryCoast)">Cote dIvoire (IvoryCoast)</option><option value="Croatia">Croatia</option><option value="Cuba">Cuba</option><option value="Cyprus">Cyprus</option><option value="Czech Republic">Czech Republic</option><option value="Denmark">Denmark</option><option value="Djibouti">Djibouti</option><option value="Dominica">Dominica</option><option value="Dominican Republic">Dominican Republic</option><option value="Ecuador">Ecuador</option><option value="Egypt">Egypt</option><option value="El Salvador">El Salvador</option><option value="Equatorial Guinea">Equatorial Guinea</option><option value="Eritrea">Eritrea</option><option value="Estonia">Estonia</option><option value="Ethiopia">Ethiopia</option><option value="Falkland Islands (Islas Malvinas)">Falkland Islands (Islas Malvinas)</option><option value="Faroe Islands">Faroe Islands</option><option value="Fiji">Fiji</option><option value="Finland">Finland</option><option value="France">France</option><option value="French Guiana">French Guiana</option><option value="French Polynesia">French Polynesia</option><option value="Gabon">Gabon</option><option value="Gambia, The">Gambia, The</option><option value="Georgia">Georgia</option><option value="Germany">Germany</option><option value="Ghana">Ghana</option><option value="Gibraltar">Gibraltar</option><option value="Greece">Greece</option><option value="Greenland">Greenland</option><option value="Grenada">Grenada</option><option value="Guadeloupe">Guadeloupe</option><option value="Guam">Guam</option><option value="Guatemala">Guatemala</option><option value="Guinea">Guinea</option><option value="Guinea-Bissau">Guinea-Bissau</option><option value="Guyana">Guyana</option><option value="Haiti">Haiti</option><option value="Honduras">Honduras</option><option value="Hong Kong">Hong Kong</option><option value="Hungary">Hungary</option><option value="Iceland">Iceland</option><option value="India">India</option><option value="Indonesia">Indonesia</option><option value="Iran">Iran</option><option value="Iraq">Iraq</option><option value="Ireland">Ireland</option><option value="Israel">Israel</option><option value="Italy">Italy</option><option value="Jamaica">Jamaica</option><option value="Japan">Japan</option><option value="Jordan">Jordan</option><option value="Kazakhstan">Kazakhstan</option><option value="Kenya">Kenya</option><option value="Kiribati">Kiribati</option><option value="Korea, North">Korea, North</option><option value="Korea, South">Korea, South</option><option value="Kuwait">Kuwait</option><option value="Kyrgyzstan">Kyrgyzstan</option><option value="Laos">Laos</option><option value="Latvia">Latvia</option><option value="Lebanon">Lebanon</option><option value="Lesotho">Lesotho</option><option value="Liberia">Liberia</option><option value="Libya">Libya</option><option value="Lithuania">Lithuania</option><option value="Luxembourg">Luxembourg</option><option value="Macau">Macau</option><option value="Macedonia">Macedonia</option><option value="Madagascar">Madagascar</option><option value="Malawi">Malawi</option><option value="Malaysia">Malaysia</option><option value="Maldives">Maldives</option><option value="Mali">Mali</option><option value="Malta">Malta</option><option value="Martinique">Martinique</option><option value="Mauritania">Mauritania</option><option value="Mauritius">Mauritius</option><option value="Mexico">Mexico</option><option value="Moldova">Moldova</option><option value="Mongolia">Mongolia</option><option value="Montenegro">Montenegro</option><option value="Montserrat">Montserrat</option><option value="Morocco">Morocco</option><option value="Mozambique">Mozambique</option><option value="Namibia">Namibia</option><option value="Nauru">Nauru</option><option value="Nepal">Nepal</option><option value="Netherlands">Netherlands</option><option value="Netherlands Antilles">Netherlands Antilles</option><option value="New Caledonia">New Caledonia</option><option value="New Zealand">New Zealand</option><option value="Nicaragua">Nicaragua</option><option value="Niger">Niger</option><option value="Nigeria">Nigeria</option><option value="Niue">Niue</option><option value="Norway">Norway</option><option value="Oman">Oman</option><option value="Pakistan">Pakistan</option><option value="Palestine">Palestine</option><option value="Panama">Panama</option><option value="Papua New Guinea">Papua New Guinea</option><option value="Paraguay">Paraguay</option><option value="Peru">Peru</option><option value="Philippines">Philippines</option><option value="Poland">Poland</option><option value="Portugal">Portugal</option><option value="Puerto Rico">Puerto Rico</option><option value="Qatar">Qatar</option><option value="Reunion">Reunion</option><option value="Romania">Romania</option><option value="Russia">Russia</option><option value="Rwanda">Rwanda</option><option value="Saint Helena">Saint Helena</option><option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option><option value="Saint Lucia">Saint Lucia</option><option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option><option value="Saint Vincent/Grenadines">Saint Vincent/Grenadines</option><option value="Samoa">Samoa</option><option value="Sao Tome and Principe">Sao Tome and Principe</option><option value="Saudi Arabia">Saudi Arabia</option><option value="Senegal">Senegal</option><option value="Serbia">Serbia</option><option value="Seychelles">Seychelles</option><option value="Sierra Leone">Sierra Leone</option><option value="Singapore">Singapore</option><option value="Slovakia">Slovakia</option><option value="Slovenia">Slovenia</option><option value="Solomon Islands">Solomon Islands</option><option value="Somalia">Somalia</option><option value="South Africa">South Africa</option><option value="Spain">Spain</option><option value="Sri Lanka">Sri Lanka</option><option value="Sudan">Sudan</option><option value="Suriname">Suriname</option><option value="Swaziland">Swaziland</option><option value="Sweden">Sweden</option><option value="Switzerland">Switzerland</option><option value="Syria">Syria</option><option value="Taiwan">Taiwan</option><option value="Tajikistan">Tajikistan</option><option value="Tanzania">Tanzania</option><option value="Thailand">Thailand</option><option value="Timor-Leste (East Timor)">Timor-Leste (East Timor)</option><option value="Togo">Togo</option><option value="Tonga">Tonga</option><option value="Trinidad and Tobago">Trinidad and Tobago</option><option value="Tunisia">Tunisia</option><option value="Turkey">Turkey</option><option value="Turkmenistan">Turkmenistan</option><option value="Turks and Caicos Islands">Turks and Caicos Islands</option><option value="U.S. Pacific Islands">U.S. Pacific Islands</option><option value="Uganda">Uganda</option><option value="Ukraine">Ukraine</option><option value="United Arab Emirates">United Arab Emirates</option><option value="United Kingdom">United Kingdom</option><option value="Uruguay">Uruguay</option><option value="Uzbekistan">Uzbekistan</option><option value="Vanuatu">Vanuatu</option><option value="Venezuela">Venezuela</option><option value="Vietnam">Vietnam</option><option value="Virgin Islands,  U.S.">Virgin Islands,  U.S.</option><option value="Virgin Islands, British">Virgin Islands, British</option><option value="Wake Island">Wake Island</option><option value="Western Sahara">Western Sahara</option><option value="Yemen">Yemen</option><option value="Zambia">Zambia</option><option value="Zimbabwe">Zimbabwe</option>		</select>
		<div id="state_div">
			<label>Your State:</label><br />
			<select name="state" style="width:300px;">
				<option></option>
				<option value="Alabama">Alabama</option><option value="Alaska">Alaska</option><option value="Arizona">Arizona</option><option value="Arkansas">Arkansas</option><option value="California">California</option><option value="Colorado">Colorado</option><option value="Connecticut">Connecticut</option><option value="Delaware">Delaware</option><option value="District of Columbia">District of Columbia</option><option value="Florida">Florida</option><option value="Georgia">Georgia</option><option value="Hawaii">Hawaii</option><option value="Idaho">Idaho</option><option value="Illinois">Illinois</option><option value="Indiana">Indiana</option><option value="Iowa">Iowa</option><option value="Kansas">Kansas</option><option value="Kentucky">Kentucky</option><option value="Louisiana">Louisiana</option><option value="Maine">Maine</option><option value="Maryland">Maryland</option><option value="Massachusetts">Massachusetts</option><option value="Michigan">Michigan</option><option value="Minnesota">Minnesota</option><option value="Mississippi">Mississippi</option><option value="Missouri">Missouri</option><option value="Montana">Montana</option><option value="Nebraska">Nebraska</option><option value="Nevada">Nevada</option><option value="New Hampshire">New Hampshire</option><option value="New Jersey">New Jersey</option><option value="New Mexico">New Mexico</option><option value="New York">New York</option><option value="North Carolina">North Carolina</option><option value="North Dakota">North Dakota</option><option value="Ohio">Ohio</option><option value="Oklahoma">Oklahoma</option><option value="Oregon">Oregon</option><option value="Pennsylvania">Pennsylvania</option><option value="Rhode Island">Rhode Island</option><option value="South Carolina">South Carolina</option><option value="South Dakota">South Dakota</option><option value="Tennessee">Tennessee</option><option value="Texas">Texas</option><option value="Utah">Utah</option><option value="Vermont">Vermont</option><option value="Virginia">Virginia</option><option value="Washington">Washington</option><option value="West Virginia">West Virginia</option><option value="Wisconsin">Wisconsin</option><option value="Wyoming">Wyoming</option>			</select>
		</div>
		<label>Your Email: <span>(optional - will not be published)</span></label> <br />
		<!-- <input type="email" name="email" required pattern="[a-z0-9._%+-]+@[a-z0-9.-]+\.[a-z]{2,}$" /><span class="form_hint">Proper format "name@something.com"</span> -->
		<input name="email" type="text" style="width: 300px;" /><br />
		<label>Your Comments: <span>(maximum of 500 character)</span></label><br />
		<textarea name="feedback" cols="40" rows="5" style="width: 300px;" ></textarea>
		<br />
		<input name="submit" type="submit" value="" class="submit_btn" />
	</form>
</div>