<form action="https://www.united.com/ual/en/us/flight-search/book-a-flight/billinginfo/default/rev" data-randomhash="https://www.united.com/ual/en/us/flight-search/book-a-flight/billinginfo/generatehash/rev" id="billingInfoForm" method="post" novalidate="novalidate"><input data-val="true" data-val-required="The HasUnitedFundOption field is required." id="HasUnitedFundOption" name="HasUnitedFundOption" type="hidden" value="False"><input data-val="true" data-val-number="The field PosAddressLines must be a number." data-val-required="The PosAddressLines field is required." id="PosAddressLines" name="PosAddressLines" type="hidden" value="3"><input data-val="true" data-val-required="The IsPosAddressZipBeforeCity field is required." id="IsPosAddressZipBeforeCity" name="IsPosAddressZipBeforeCity" type="hidden" value="False"><input data-val="true" data-val-required="The IsPosStateVisible field is required." id="IsPosStateVisible" name="IsPosStateVisible" type="hidden" value="True"><input data-val="true" data-val-required="The IsPosZipVisible field is required." id="IsPosZipVisible" name="IsPosZipVisible" type="hidden" value="True"><input data-val="true" data-val-required="The IsRefundable field is required." id="IsRefundable" name="IsRefundable" type="hidden" value="False"> <div class="panel panel-travel-info" style="display: none">
<div id="divCard0" style="display:">
<div class="form-row">
<div class="form-group card-type"><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="CreditCardViewModels[0].CardTypeCode" data-valmsg-replace="true"></span><div class="selector fixedWidth" id="uniform-CreditCardViewModels_0__CardTypeCode"><span aria-hidden="true" style="-webkit-user-select: none;"></span><label class="ifl" for="CreditCardViewModels_0__CardTypeCode" style="opacity: 1;">Select card type<em aria-hidden="true" class="rqrd">*</em></label><select aria-label="Select card type" aria-required="true" data-val="true" data-val-required="Please select a Card type.<!--EC:V2-->" id="CreditCardViewModels_0__CardTypeCode" name="CreditCardViewModels[0].CardTypeCode" class="preproc"><option selected="selected" value=""></option>
<option value="VI">MileagePlus Visa</option>
<option value="VI">Visa</option>
<option value="JC">JCB</option>
<option value="MC">MasterCard</option>
<option value="AX">American Express</option>
<option value="DS">Discover Network</option>
<option value="DC">Diners Club</option>
<option value="TP">UATP</option>
</select></div></div>
</div>
<div class="form-row">
<div class="form-group card-number"><label class="ifl" for="CreditCardViewModels_0__CardNumber">Card number<em aria-hidden="true" class="rqrd">*</em></label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="CreditCardViewModels[0].CardNumber" data-valmsg-replace="true"></span><input aria-required="true" data-privacy="no-capture" data-val="true" data-val-length="The field Card number must be a string with a maximum length of 20." data-val-length-max="20" data-val-regex="Please provide a valid debit or credit card number.<!--EC:CC98-->" data-val-regex-pattern="[13456]{1}[0-9 ]{1,}" data-val-required="Please provide a valid debit or credit card number.<!--EC:CC98-->" id="CreditCardViewModels_0__CardNumber" maxlength="20" name="CreditCardViewModels[0].CardNumber" type="text" value=""></div>
<input type="text" class="hidden"><input type="password" class="hidden">
<input id="CreditCardViewModels_0__EncryptedCardNumber" name="CreditCardViewModels[0].EncryptedCardNumber" type="hidden" value="">
<input id="CreditCardViewModels_0__CardNumberLast4Digits" name="CreditCardViewModels[0].CardNumberLast4Digits" type="hidden" value="">
<input id="CreditCardViewModels_0__CardNumberToken" name="CreditCardViewModels[0].CardNumberToken" type="hidden" value="">
<input id="CreditCardViewModels_0__ErrorType" name="CreditCardViewModels[0].ErrorType" type="hidden" value="">
<input id="CreditCardViewModels_0__ErrorNumber" name="CreditCardViewModels[0].ErrorNumber" type="hidden" value="">
</div>
<div class="form-row">
<div class="form-group date-month"><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="CreditCardViewModels[0].ExpMonth" data-valmsg-replace="true"></span><div class="selector fixedWidth" id="uniform-CreditCardViewModels_0__ExpMonth"><span aria-hidden="true" style="-webkit-user-select: none;"></span><label class="ifl" for="CreditCardViewModels_0__ExpMonth">Expiration month<em aria-hidden="true" class="rqrd">*</em></label><select aria-label="Expiration month" aria-required="true" data-val="true" data-val-number="The field Expiration month must be a number." data-val-required="Please select an Expiration month.<!--EC:V13-->" id="CreditCardViewModels_0__ExpMonth" name="CreditCardViewModels[0].ExpMonth" class="preproc"><option selected="selected" value=""></option>
<option value="1">01 - January</option>
<option value="2">02 - February</option>
<option value="3">03 - March</option>
<option value="4">04 - April</option>
<option value="5">05 - May</option>
<option value="6">06 - June</option>
<option value="7">07 - July</option>
<option value="8">08 - August</option>
<option value="9">09 - September</option>
<option value="10">10 - October</option>
<option value="11">11 - November</option>
<option value="12">12 - December</option>
</select></div></div>
<div class="form-group card-exp-year"><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="CreditCardViewModels[0].ExpYear" data-valmsg-replace="true"></span><div class="selector fixedWidth" id="uniform-CreditCardViewModels_0__ExpYear"><span aria-hidden="true" style="-webkit-user-select: none;"></span><label class="ifl" for="CreditCardViewModels_0__ExpYear">Year<em aria-hidden="true" class="rqrd">*</em></label><select aria-label="Year" aria-required="true" data-val="true" data-val-number="The field Expiration year must be a number." data-val-required="Please select an Expiration year.<!--EC:V13-->" id="CreditCardViewModels_0__ExpYear" name="CreditCardViewModels[0].ExpYear" class="preproc"><option selected="selected" value=""></option>
<option value="2016">2016</option>
<option value="2017">2017</option>
<option value="2018">2018</option>
<option value="2019">2019</option>
<option value="2020">2020</option>
<option value="2021">2021</option>
<option value="2022">2022</option>
<option value="2023">2023</option>
<option value="2024">2024</option>
<option value="2025">2025</option>
<option value="2026">2026</option>
</select></div></div>
<div id="divCreditCardSecurityCode0" class="form-groupset">
<div class="form-group card-security-code"><label class="ifl" for="CreditCardViewModels_0__SecurityCode">Security code<em aria-hidden="true" class="rqrd">*</em></label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="CreditCardViewModels[0].SecurityCode" data-valmsg-replace="true"></span><input aria-required="true" data-privacy="no-capture" data-val="true" data-val-length="The field Security code must be a string with a maximum length of 4." data-val-length-max="4" data-val-regex="Please enter a valid Security code.<!--EC:V15-->" data-val-regex-pattern="[abcdefghijklmnopqrstuvwxyzABCDEFGHIJKLMNOPQRSTUVWXYZ0123456789 ,///-]{3,}" data-val-required="Please enter a Security code.<!--EC:V1-->" id="CreditCardViewModels_0__SecurityCode" maxlength="4" name="CreditCardViewModels[0].SecurityCode" type="password" value=""></div>
<button type="button" class="icon-tooltip-large-clear-bg tool-tip-security-code" data-toggle="tooltip" data-tooltip-style="default" tabindex="0" data-hasqtip="3" oldtitle="What's a security code?" title=""><span class="visuallyhidden">About credit card security code</span></button>
<div class="tip-security-code">
<div class="tip-security-code-default">
<h6>Security code</h6>
<p>The card security code consists of the last three digits of the number on the back of your Visa, MasterCard or Discover Card, or the four digits above the main number on your American Express card.</p>
</div>
<div class="tip-security-code-visa" style="display: none;">
<h6>Visa - CVV2</h6>
<p>The card security code consists of the last three digits of the number on the back of your Visa.</p>
<img src="https://www.united.com/web/format/img/card/CVV2_Visa.GIF" alt="Visa security code">
</div>
<div class="tip-security-code-mc" style="display: none;">
<h6>MasterCard - CVC2</h6>
<p>The card security code consists of the last three digits of the number on the back of your MasterCard.</p>
<img src="https://www.united.com/web/format/img/card/CVC2_MC.GIF" alt="MasterCard security code">
</div>
<div class="tip-security-code-amex" style="display: none;">
<h6>American Express – CID</h6>
<p>The card security code consists of the four digits above the main number on your American Express card.</p>
<img src="https://www.united.com/web/format/img/card/CID_Amex.GIF" alt="American Express security code">
</div>
<div class="tip-security-code-discover" style="display: none;">
<h6>Discover – CID</h6>
<p>The card security code consists of the last three digits of the number on the back of your Discover Card.</p>
<img src="https://www.united.com/web/format/img/card/CID_Discover.GIF" alt="Discover security code">
</div>
</div>
</div>
</div>
<div class="form-row">
<div class="form-group card-holder-name"><label class="ifl" for="CreditCardViewModels_0__CardHolderName">Full name as it appears on your card<em aria-hidden="true" class="rqrd">*</em></label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="CreditCardViewModels[0].CardHolderName" data-valmsg-replace="true"></span><input aria-required="true" data-val="true" data-val-length="The field Full name as it appears on your card must be a string with a maximum length of 35." data-val-length-max="35" data-val-regex="Please enter a valid Full name as it appears on your card.<!--EC:V15-->" data-val-regex-pattern="[A-Za-z]{1,}[A-Za-z '-.]{1,}" data-val-required="Please enter a Full name as it appears on your card.<!--EC:V1-->" id="CreditCardViewModels_0__CardHolderName" maxlength="35" name="CreditCardViewModels[0].CardHolderName" type="text" value=""></div>
</div>
<div class="form-row">
<div class="form-group address-line"><label class="ifl" for="CreditCardViewModels_0__AddressLine1">Billing address line 1<em aria-hidden="true" class="rqrd">*</em></label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="CreditCardViewModels[0].AddressLine1" data-valmsg-replace="true"></span><input aria-required="true" data-val="true" data-val-length="The field Billing address line 1 must be a string with a maximum length of 30." data-val-length-max="30" data-val-regex="Please enter a valid Billing address line 1.<!--EC:V15-->" data-val-regex-pattern="[A-Za-z0-9]{1}[A-Za-z0-9 '\-,\./#]{1,}" data-val-required="Please enter a Billing address line 1.<!--EC:V1-->" id="CreditCardViewModels_0__AddressLine1" maxlength="30" name="CreditCardViewModels[0].AddressLine1" type="text" value=""></div>
</div>
<div class="form-row">
<div class="form-group address-line"><label class="ifl" for="CreditCardViewModels_0__AddressLine2">Billing address line 2 (Optional)</label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="CreditCardViewModels[0].AddressLine2" data-valmsg-replace="true"></span><input data-val="true" data-val-length="The field Billing address line 2 (Optional) must be a string with a maximum length of 30." data-val-length-max="30" data-val-regex="Please enter a valid Billing address line 2 (Optional).<!--EC:V15-->" data-val-regex-pattern="[A-Za-z0-9]{1}[A-Za-z0-9 '\-,\./#]{1,}" id="CreditCardViewModels_0__AddressLine2" maxlength="30" name="CreditCardViewModels[0].AddressLine2" type="text" value=""></div>
</div>
<div class="form-row">
<div class="form-group address-line"><label class="ifl" for="CreditCardViewModels_0__AddressLine3">Billing address line 3 (Optional)</label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="CreditCardViewModels[0].AddressLine3" data-valmsg-replace="true"></span><input data-val="true" data-val-length="The field Billing address line 3 (Optional) must be a string with a maximum length of 30." data-val-length-max="30" data-val-regex="Please enter a valid Billing address line 3 (Optional).<!--EC:V15-->" data-val-regex-pattern="[A-Za-z0-9]{1}[A-Za-z0-9 '\-,\./#]{1,}" id="CreditCardViewModels_0__AddressLine3" maxlength="30" name="CreditCardViewModels[0].AddressLine3" type="text" value=""></div>
</div>
<div class="form-row">
<div class="form-group address-city"><label class="ifl" for="CreditCardViewModels_0__City">City/town/department<em aria-hidden="true" class="rqrd">*</em></label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="CreditCardViewModels[0].City" data-valmsg-replace="true"></span><input aria-required="true" data-val="true" data-val-length="The field City/town/department must be a string with a maximum length of 30." data-val-length-max="30" data-val-regex="Please enter a valid City/town/department.<!--EC:V15-->" data-val-regex-pattern="[A-Za-z., \-]{2,}" data-val-required="Please enter a City/town/department.<!--EC:V1-->" id="CreditCardViewModels_0__City" maxlength="30" name="CreditCardViewModels[0].City" type="text" value=""></div>
<div class="form-group address-state"><label class="ifl" for="CreditCardViewModels_0__StateCode">State/province/region/county<em aria-hidden="true" class="rqrd">*</em></label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="CreditCardViewModels[0].StateCode" data-valmsg-replace="true"></span><input aria-required="true" data-val="true" data-val-regex="Please enter a valid State/province/region/county.<!--EC:V15-->" data-val-regex-pattern="[A-Za-z., ]{2,}" data-val-required="Please enter a State/province/region/county.<!--EC:V1-->" id="CreditCardViewModels_0__StateCode" name="CreditCardViewModels[0].StateCode" type="text" value=""></div> <div class="form-group address-post-code"><label class="ifl" for="CreditCardViewModels_0__PostalCode">ZIP/Postal code<em aria-hidden="true" class="rqrd">*</em></label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="CreditCardViewModels[0].PostalCode" data-valmsg-replace="true"></span><input aria-required="true" data-val="true" data-val-length="The field ZIP/Postal code must be a string with a maximum length of 10." data-val-length-max="10" data-val-regex="Please enter a valid ZIP/Postal code.<!--EC:V15-->" data-val-regex-pattern="[abcdefghijklmnopqrstuvwxyzABCDEFGHIJKLMNOPQRSTUVWXYZ0123456789 ,///-]{1,}" data-val-required="Please enter a ZIP/Postal code.<!--EC:V1-->" id="CreditCardViewModels_0__PostalCode" maxlength="10" name="CreditCardViewModels[0].PostalCode" type="text" value=""></div> </div>
<div class="form-row">
<div class="form-group address-country">
<div class="form-group"><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="CreditCardViewModels[0].CountryCode" data-valmsg-replace="true"></span><div class="selector fixedWidth" id="uniform-CreditCardViewModels_0__CountryCode"><span aria-hidden="true" style="-webkit-user-select: none;">United States</span><label class="ifl visuallyhidden" for="CreditCardViewModels_0__CountryCode">Country<em aria-hidden="true" class="rqrd">*</em></label><select aria-label="Country" aria-required="true" data-val="true" data-val-required="The Country field is required." id="CreditCardViewModels_0__CountryCode" name="CreditCardViewModels[0].CountryCode" class="preproc"><option selected="selected" value="US">United States</option>
<option value="CA">Canada</option>
<option value="GB">United Kingdom</option>
<option value="AG">Antigua and Barbuda</option>
<option value="AR">Argentina</option>
<option value="AW">Aruba</option>
<option value="AU">Australia</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BB">Barbados</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BM">Bermuda</option>
<option value="BR">Brazil</option>
<option value="CA">Canada</option>
<option value="KY">Cayman Islands</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CO">Colombia</option>
<option value="CR">Costa Rica</option>
<option value="DK">Denmark</option>
<option value="DO">Dominican Republic</option>
<option value="EC">Ecuador</option>
<option value="SV">El Salvador</option>
<option value="FR">France</option>
<option value="DE">Germany</option>
<option value="GR">Greece</option>
<option value="GU">Guam</option>
<option value="GT">Guatemala</option>
<option value="HN">Honduras</option>
<option value="HK">Hong Kong</option>
<option value="IN">India</option>
<option value="ID">Indonesia</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="KR">Korea, South</option>
<option value="KW">Kuwait</option>
<option value="MH">Marshall Islands</option>
<option value="MX">Mexico</option>
<option value="FM">Micronesia</option>
<option value="NL">Netherlands</option>
<option value="AN">Netherlands Antilles</option>
<option value="NZ">New Zealand</option>
<option value="NI">Nicaragua</option>
<option value="MP">Northern Mariana Islands</option>
<option value="NO">Norway</option>
<option value="PW">Palau</option>
<option value="PA">Panama</option>
<option value="PE">Peru</option>
<option value="PH">Philippines</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico</option>
<option value="QA">Qatar</option>
<option value="RU">Russia</option>
<option value="SG">Singapore</option>
<option value="ES">Spain & Canary Islands</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="TW">Taiwan</option>
<option value="TH">Thailand</option>
<option value="TT">Trinidad and Tobago</option>
<option value="TR">Turkey</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom</option>
<option selected="selected" value="US">United States</option>
<option value="VN">Vietnam</option>
</select></div></div>
</div>
</div>
<p>Your bank may apply a credit card conversion fee.</p>
</div>
</fieldset>
</div>
<div class="panel-body-section" id="divOtherFop" style="display">
<div id="fop-other-alert">
<div class="payment-notice"><i class="icon-information-small-gray"></i> Alipay is not eligible forms of payment based on your current selections.</div>
</div>
<div id="fop-other" class="label-payment-type" style="">
<div class="form-group">
<span aria-hidden="true" class="field-validation-valid" data-valmsg-for="FOPOption" data-valmsg-replace="true"></span><div class="radio" id="uniform-FOPOption_OtherFop"><span><input aria-required="true" class="type-radio rotherform preproc" id="FOPOption_OtherFop" name="FOPOption" tabindex="0" type="radio" value="OtherFop"></span></div><label class="radio" for="FOPOption_OtherFop">Other forms of payment</label>
</div>
<div id="fop-other-images" class="form-group container-payment-type-images fop-other">
<ul><li><i class="icon-payment-type-visa-checkout-small" title="Visa Checkout"><span class="visuallyhidden">Visa Checkout</span></i></li><li><i class="icon-payment-type-check-small" title="TeleCheck Online Checks"><span class="visuallyhidden">TeleCheck Online Checks</span></i></li><li><i class="icon-payment-type-cash-small" title="Western Union Cash"><span class="visuallyhidden">Western Union Cash</span></i></li><li><i class="icon-payment-type-paypal-small" title="PayPal"><span class="visuallyhidden">PayPal</span></i></li><li><i class="icon-payment-type-bill-me-later-small" title="PayPal Credit"><span class="visuallyhidden">PayPal Credit</span></i></li></ul>
</div>
</div>
<div id="other-fop-section" style="">
<div class="form-row section-other-fop" id="other_fop_list" style="display: none;">
<label for="OtherFOPType" class="visuallyhidden">Form of payment</label>
<div class="selector fixedWidth" id="uniform-OtherFOPType"><span aria-hidden="true" style="-webkit-user-select: none;">Not Selected</span><select class="ddlotherfop preproc" data-cartid="83029498-98C8-4043-AA9B-106E1F89C4BF" data-fopurl="https://www.united.com/ual/en/us/flight-search/book-a-flight/billinginfo/getotherfops/rev" id="OtherFOPType" name="OtherFOPType"><option hideoptions="" value="">Not Selected</option><option hideoptions="" value="VCO">Visa Checkout</option><option hideoptions="PAS, AAC" value="CASH">Cash</option><option hideoptions="PAS, AAC" value="CHECK">Online check</option><option hideoptions="" value="PP">PayPal</option><option hideoptions="" value="BML">PayPal Credit</option></select></div>
<a href="https://www.united.com/web/en-US/content/booking/flight/whatIsBML.aspx" target="_blank" class="info-link" id="BML-info-link">What is PayPal Credit?</a>
<a href="https://www.united.com/web/en-US/content/booking/flight/whatispaypal.aspx" target="_blank" class="info-link" id="PayPal-info-link">What is PayPal?</a>
</div>
<div class="section-PayPal-type" style="display: none;">
<p>You will be directed to PayPal's website to enroll or to sign in to your account. You will then be redirected to united.com to complete this purchase.</p>
<input type="hidden" id="paypalUrl">
<button class="btn" id="btnPayPalCheckOut" value="PayPal">Check out with PayPal</button>
</div>
<div class="section-Alipay-type" style="display: none;">
<input type="hidden" id="alipayUrl">
<fieldset>
<legend class="visuallyhidden">Billing information <small class="required" aria-required="true">(*Required)</small></legend>
<h4 class="legend">Billing information <small class="required" aria-required="true">(*Required)</small></h4>
<p>Please enter the purchaser's name and billing address below. Selecting "Purchase" will direct you to Alipay's website to enroll or to sign in to your account. You'll then be redirected to united.com for your purchase confirmation.</p>
<div class="form-row">
<div class="form-group card-holder-name"><label class="ifl" for="AlipayCardHolderName">Full name as it appears on your card<em aria-hidden="true" class="rqrd">*</em></label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="AlipayCardHolderName" data-valmsg-replace="true"></span><input aria-required="true" data-val="true" data-val-length="The field Full name as it appears on your card must be a string with a maximum length of 35." data-val-length-max="35" data-val-regex="Please enter a valid Full name as it appears on your card.<!--EC:V15-->" data-val-regex-pattern="[A-Za-z]{1,}[A-Za-z '-.]{1,}" data-val-required="Please enter a Full name as it appears on your card.<!--EC:V1-->" id="AlipayCardHolderName" maxlength="35" name="AlipayCardHolderName" type="text" value=""></div>
</div>
<div class="form-row">
<div class="form-group address-line"><label class="ifl" for="AlipayBillingAddressLine1">Billing address line 1<em aria-hidden="true" class="rqrd">*</em></label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="AlipayBillingAddressLine1" data-valmsg-replace="true"></span><input aria-required="true" data-val="true" data-val-length="The field Billing address line 1 must be a string with a maximum length of 30." data-val-length-max="30" data-val-regex="Please enter a valid Billing address line 1.<!--EC:V15-->" data-val-regex-pattern="[A-Za-z0-9]{1}[A-Za-z0-9 '\-,\./#]{1,}" data-val-required="Please enter a Billing address line 1.<!--EC:V1-->" id="AlipayBillingAddressLine1" maxlength="30" name="AlipayBillingAddressLine1" type="text" value=""></div>
</div>
<div class="form-row">
<div class="form-group address-line"><label class="ifl" for="AlipayBillingAddressLine2">Billing address line 2 (Optional)</label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="AlipayBillingAddressLine2" data-valmsg-replace="true"></span><input data-val="true" data-val-length="The field Billing address line 2 (Optional) must be a string with a maximum length of 30." data-val-length-max="30" data-val-regex="Please enter a valid Billing address line 2 (Optional).<!--EC:V15-->" data-val-regex-pattern="[A-Za-z0-9]{1}[A-Za-z0-9 '\-,\./#]{1,}" id="AlipayBillingAddressLine2" maxlength="30" name="AlipayBillingAddressLine2" type="text" value=""></div>
</div>
<div class="form-row">
<div class="form-group address-line"><label class="ifl" for="AlipayBillingAddressLine3">Billing address line 3 (Optional)</label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="AlipayBillingAddressLine3" data-valmsg-replace="true"></span><input data-val="true" data-val-length="The field Billing address line 3 (Optional) must be a string with a maximum length of 30." data-val-length-max="30" data-val-regex="Please enter a valid Billing address line 3 (Optional).<!--EC:V15-->" data-val-regex-pattern="[A-Za-z0-9]{1}[A-Za-z0-9 '\-,\./#]{1,}" id="AlipayBillingAddressLine3" maxlength="30" name="AlipayBillingAddressLine3" type="text" value=""></div>
</div>
<div class="form-row">
<div class="form-group address-city"><label class="ifl" for="AlipayCity">City/town/department<em aria-hidden="true" class="rqrd">*</em></label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="AlipayCity" data-valmsg-replace="true"></span><input aria-required="true" data-val="true" data-val-length="The field City/town/department must be a string with a maximum length of 30." data-val-length-max="30" data-val-regex="Please enter a valid City/town/department.<!--EC:V15-->" data-val-regex-pattern="[A-Za-z., \-]{2,}" data-val-required="Please enter a City/town/department.<!--EC:V1-->" id="AlipayCity" maxlength="30" name="AlipayCity" type="text" value=""></div>
<div class="form-group paypal-address-post-code"><label class="ifl" for="AlipayZipCode">ZIP/Postal code<em aria-hidden="true" class="rqrd">*</em></label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="AlipayZipCode" data-valmsg-replace="true"></span><input aria-required="true" data-val="true" data-val-length="The field ZIP/Postal code must be a string with a maximum length of 10." data-val-length-max="10" data-val-regex="Please enter a valid ZIP/Postal code.<!--EC:V15-->" data-val-regex-pattern="[abcdefghijklmnopqrstuvwxyzABCDEFGHIJKLMNOPQRSTUVWXYZ0123456789 ,///-]{1,}" data-val-required="Please enter a ZIP/Postal code.<!--EC:V1-->" id="AlipayZipCode" maxlength="10" name="AlipayZipCode" type="text" value=""></div>
</div>
<div class="form-row">
<div class="selector fixedWidth" id="uniform-AlipayCountryCode"><span aria-hidden="true" style="-webkit-user-select: none;">United States</span><select class="phone-country-list preproc" id="AlipayCountryCode" name="AlipayCountryCode"><option selected="selected" value="US">United States</option>
<option value="CA">Canada</option>
<option value="GB">United Kingdom</option>
<option value="AG">Antigua and Barbuda</option>
<option value="AR">Argentina</option>
<option value="AW">Aruba</option>
<option value="AU">Australia</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BB">Barbados</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BM">Bermuda</option>
<option value="BR">Brazil</option>
<option value="CA">Canada</option>
<option value="KY">Cayman Islands</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CO">Colombia</option>
<option value="CR">Costa Rica</option>
<option value="DK">Denmark</option>
<option value="DO">Dominican Republic</option>
<option value="EC">Ecuador</option>
<option value="SV">El Salvador</option>
<option value="FR">France</option>
<option value="DE">Germany</option>
<option value="GR">Greece</option>
<option value="GU">Guam</option>
<option value="GT">Guatemala</option>
<option value="HN">Honduras</option>
<option value="HK">Hong Kong</option>
<option value="IN">India</option>
<option value="ID">Indonesia</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="KR">Korea, South</option>
<option value="KW">Kuwait</option>
<option value="MH">Marshall Islands</option>
<option value="MX">Mexico</option>
<option value="FM">Micronesia</option>
<option value="NL">Netherlands</option>
<option value="AN">Netherlands Antilles</option>
<option value="NZ">New Zealand</option>
<option value="NI">Nicaragua</option>
<option value="MP">Northern Mariana Islands</option>
<option value="NO">Norway</option>
<option value="PW">Palau</option>
<option value="PA">Panama</option>
<option value="PE">Peru</option>
<option value="PH">Philippines</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico</option>
<option value="QA">Qatar</option>
<option value="RU">Russia</option>
<option value="SG">Singapore</option>
<option value="ES">Spain & Canary Islands</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="TW">Taiwan</option>
<option value="TH">Thailand</option>
<option value="TT">Trinidad and Tobago</option>
<option value="TR">Turkey</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom</option>
<option selected="selected" value="US">United States</option>
<option value="VN">Vietnam</option>
</select></div>
</div>
</fieldset>
</div>
<div class="section-VisaCheckout-type" style="display: none;">
<input id="WalletVCOEnvironment" name="WalletVCOEnvironment" type="hidden" value="prod">
<input data-val="true" data-val-required="Please enter a WalletId.<!--EC:V1-->" id="WalletId" name="WalletId" type="hidden" value="">
<input id="WalletCardType" name="WalletCardType" type="hidden" value="">
<input id="WalletCreditCardTypeList" name="WalletCreditCardTypeList" type="hidden" value="["VISA","JCB","MASTERCARD","AMEX","DISCOVER","DINERS","UATP"]">
<input id="WalletBillingAddress" name="WalletBillingAddress" type="hidden" value="">
<input id="WalletBillingCity" name="WalletBillingCity" type="hidden" value="">
<input id="WalletBillingZipCode" name="WalletBillingZipCode" type="hidden" value="">
<input id="WalletBillingCountryCode" name="WalletBillingCountryCode" type="hidden" value="">
<input type="hidden" name="vcoTotalCartAmount" id="vcoTotalCartAmount">
<input type="hidden" name="vcoCurrencyCode" id="vcoCurrencyCode">
<p>To use Visa Checkout, click the button below. You will be prompted to log in or create an account.</p>
<button class="btn-visa" id="btnVisaCheckOut" value="Visa Checkout">
<img class="btn-img-visa" alt="Use Visa Checkout" src="https://sandbox.secure.checkout.visa.com/wallet-services-web/xo/button.png">
</button>
</div>
<div id="spinner-visaCheckout" class="spinner-container-visa-checkout-form" style="display: none"> </div>
<div id="form-payPal" class="form-PayPal" style="display: none">
<div class="PayPal-selected-info">
<i class="icon-payment-type-paypal"></i>
<p><span id="paypalName"></span>, you have selected PayPal as your payment method. PayPal account: <span id="paypalEmail"></span></p>
</div>
<fieldset>
<legend class="visuallyhidden">Billing information <small class="rqrd" aria-hidden="true">(*Required)</small></legend>
<h4 class="legend">Billing information <small class="rqrd" aria-hidden="true">(*Required)</small></h4>
<p>Please enter the billing information associated with the specified PayPal account.</p>
<div class="form-row">
<div class="form-group paypal-address-line"><label class="ifl" for="PayPalBillingAddress">Billing address<em aria-hidden="true" class="rqrd">*</em></label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="PayPalBillingAddress" data-valmsg-replace="true"></span><input aria-required="true" data-val="true" data-val-length="The field Billing address must be a string with a maximum length of 30." data-val-length-max="30" data-val-regex="Please enter a valid Billing address.<!--EC:V15-->" data-val-regex-pattern="[A-Za-z0-9]{1}[A-Za-z0-9 '\-,\./#]{1,}" data-val-required="Please enter a Billing address.<!--EC:V1-->" id="PayPalBillingAddress" maxlength="30" name="PayPalBillingAddress" type="text" value=""></div>
</div>
<div class="form-row">
<div class="form-group address-city"><label class="ifl" for="PayPalCity">City/town/department<em aria-hidden="true" class="rqrd">*</em></label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="PayPalCity" data-valmsg-replace="true"></span><input aria-required="true" data-val="true" data-val-length="The field City/town/department must be a string with a maximum length of 30." data-val-length-max="30" data-val-regex="Please enter a valid City/town/department.<!--EC:V15-->" data-val-regex-pattern="[A-Za-z., \-]{2,}" data-val-required="Please enter a City/town/department.<!--EC:V1-->" id="PayPalCity" maxlength="30" name="PayPalCity" type="text" value=""></div>
<div class="form-group address-state"><label class="ifl" for="PayPalState">State/province/region/county<em aria-hidden="true" class="rqrd">*</em></label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="PayPalState" data-valmsg-replace="true"></span><input aria-required="true" data-val="true" data-val-required="Please enter a State/province/region/county.<!--EC:V1-->" id="PayPalState" name="PayPalState" type="text" value=""></div>
<div class="form-group paypal-address-post-code"><label class="ifl" for="PayPalZipCode">ZIP/Postal code<em aria-hidden="true" class="rqrd">*</em></label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="PayPalZipCode" data-valmsg-replace="true"></span><input aria-required="true" data-val="true" data-val-length="The field ZIP/Postal code must be a string with a maximum length of 10." data-val-length-max="10" data-val-regex="Please enter a valid ZIP/Postal code.<!--EC:V15-->" data-val-regex-pattern="[abcdefghijklmnopqrstuvwxyzABCDEFGHIJKLMNOPQRSTUVWXYZ0123456789 ,///-]{1,}" data-val-required="Please enter a ZIP/Postal code.<!--EC:V1-->" id="PayPalZipCode" maxlength="10" name="PayPalZipCode" type="text" value=""></div>
</div>
<div class="form-row">
<div class="selector fixedWidth" id="uniform-PayPalCountryCode"><span aria-hidden="true" style="-webkit-user-select: none;">United States</span><select class="address-country preproc" id="PayPalCountryCode" name="PayPalCountryCode"><option value="US">United States</option>
<option value="CA">Canada</option>
<option value="GB">United Kingdom</option>
<option value="AG">Antigua and Barbuda</option>
<option value="AR">Argentina</option>
<option value="AW">Aruba</option>
<option value="AU">Australia</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BB">Barbados</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BM">Bermuda</option>
<option value="BR">Brazil</option>
<option value="CA">Canada</option>
<option value="KY">Cayman Islands</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CO">Colombia</option>
<option value="CR">Costa Rica</option>
<option value="DK">Denmark</option>
<option value="DO">Dominican Republic</option>
<option value="EC">Ecuador</option>
<option value="SV">El Salvador</option>
<option value="FR">France</option>
<option value="DE">Germany</option>
<option value="GR">Greece</option>
<option value="GU">Guam</option>
<option value="GT">Guatemala</option>
<option value="HN">Honduras</option>
<option value="HK">Hong Kong</option>
<option value="IN">India</option>
<option value="ID">Indonesia</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="KR">Korea, South</option>
<option value="KW">Kuwait</option>
<option value="MH">Marshall Islands</option>
<option value="MX">Mexico</option>
<option value="FM">Micronesia</option>
<option value="NL">Netherlands</option>
<option value="AN">Netherlands Antilles</option>
<option value="NZ">New Zealand</option>
<option value="NI">Nicaragua</option>
<option value="MP">Northern Mariana Islands</option>
<option value="NO">Norway</option>
<option value="PW">Palau</option>
<option value="PA">Panama</option>
<option value="PE">Peru</option>
<option value="PH">Philippines</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico</option>
<option value="QA">Qatar</option>
<option value="RU">Russia</option>
<option value="SG">Singapore</option>
<option value="ES">Spain & Canary Islands</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="TW">Taiwan</option>
<option value="TH">Thailand</option>
<option value="TT">Trinidad and Tobago</option>
<option value="TR">Turkey</option>
<option value="AE">United Arab Emirates</option>
<option value="GB">United Kingdom</option>
<option value="US">United States</option>
<option value="VN">Vietnam</option>
</select></div>
</div>
</fieldset>
</div>
<div id="form-visaCheckout" class="form-visaCheckout" style="display: none">
<div class="visa-checkout-selected-info">
<p>You have selected the following payment method:</p>
</div>
<div>
<div id="vcoCardToExpireMsg" class="info-msg"></div>
<div id="vcoCardBrandImage"></div>
<div id="spinner-visaCheckout-data" class="spinner-container-visa-checkout-data" style="display: none"> </div>
<div class="visa-checkout-data">
<div id="cardNumber"></div>
<div><a id="editVisaCheckoutPayment" href="javascript:void(0);">Edit Visa Checkout payment</a> | <a id="selectDiffPaymentMethod" href="javascript:void(0);">Select a different payment method</a></div>
<div id="customerEmail"></div>
<div class="form-row" style="margin-top: 12px; display: none">
<div id="divWalletCCSecurityCode" class="form-groupset" style="display: none; visibility: hidden">
<div class="form-group card-security-code"><label class="ifl" for="WalletCCSecurityCode">Security code</label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="WalletCCSecurityCode" data-valmsg-replace="true"></span><input data-privacy="no-capture" id="WalletCCSecurityCode" maxlength="4" name="WalletCCSecurityCode" type="password" value=""></div>
<button type="button" class="icon-tooltip-large-clear-bg tool-tip-security-code" data-toggle="tooltip" data-tooltip-style="default" tabindex="0" data-hasqtip="4" oldtitle="What's a security code?" title=""><span class="visuallyhidden">About credit card security code</span></button>
<div class="tip-security-code">
<div class="tip-security-code-default">
<h6>Security code</h6>
<p>The card security code consists of the last three digits of the number on the back of your Visa, MasterCard or Discover Card, or the four digits above the main number on your American Express card.</p>
</div>
<div class="tip-security-code-visa" style="display: none;">
<h6>Visa - CVV2</h6>
<p>The card security code consists of the last three digits of the number on the back of your Visa.</p>
<img src="https://www.united.com/web/format/img/card/CVV2_Visa.GIF" alt="Visa security code">
</div>
<div class="tip-security-code-mc" style="display: none;">
<h6>MasterCard - CVC2</h6>
<p>The card security code consists of the last three digits of the number on the back of your MasterCard.</p>
<img src="https://www.united.com/web/format/img/card/CVC2_MC.GIF" alt="MasterCard security code">
</div>
<div class="tip-security-code-amex" style="display: none;">
<h6>American Express – CID</h6>
<p>The card security code consists of the four digits above the main number on your American Express card.</p>
<img src="https://www.united.com/web/format/img/card/CID_Amex.GIF" alt="American Express security code">
</div>
<div class="tip-security-code-discover" style="display: none;">
<h6>Discover – CID</h6>
<p>The card security code consists of the last three digits of the number on the back of your Discover Card.</p>
<img src="https://www.united.com/web/format/img/card/CID_Discover.GIF" alt="Discover security code">
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div id="divcashoptions">
<fieldset class="section-cash-type form-group" style="display: none;">
<p>If you plan to pay with cash, your reservation will be held until midnight CT on Wed, Mar 02, 2016 and must be purchased by that time or the reservation will be released for another customer to purchase.</p>
<legend>Select where you will complete your cash purchase <small class="rqrd" aria-hidden="true">(*Required)</small></legend>
<h4 class="legend">Select where you will complete your cash purchase <small class="rqrd" aria-hidden="true">(*Required)</small></h4>
<div class="form-group group-type-radio group-type-radio-cash">
<div class="form-row"><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="CashType" data-valmsg-replace="true"></span><div class="radio" id="uniform-CashType_WU"><span><input aria-required="true" class="type-radio rcashtype preproc" data-number="1" data-val="true" data-val-required="Please make a selection.<!--EC:V152-->" id="CashType_WU" name="CashType" tabindex="0" type="radio" value="WU"></span></div><label class="radio" for="CashType_WU">Western Union ($11.95 service charge per transaction)</label></div>
<div class="form-row"><div class="radio" id="uniform-CashType_ATO"><span><input aria-required="true" class="type-radio rcashtype preproc" data-number="2" id="CashType_ATO" name="CashType" tabindex="0" type="radio" value="ATO"></span></div><label class="radio" for="CashType_ATO">Airport Ticket Office (service charge per transaction may apply)</label></div>
<div class="form-row"><div class="radio" id="uniform-CashType_CTO"><span><input aria-required="true" class="type-radio rcashtype preproc" data-number="3" id="CashType_CTO" name="CashType" tabindex="0" type="radio" value="CTO"></span></div><label class="radio" for="CashType_CTO">United Ticket Office (service charge per transaction may apply)</label></div>
</div>
</fieldset>
</div>
<div id="BMLInfo" class="booking-content" style="display: none;">
<p>PayPal Credit is a fast and secure way to pay online without using a credit card. After your ticket is confirmed, you will receive a billing statement. <a href="https://www.united.com/web/en-US/content/booking/flight/whatIsBML.aspx" target="_blank">Learn more about PayPal Credit</a></p>
<div class="form-row">
<span aria-hidden="true" class="field-validation-valid" data-valmsg-for="BmlModel.IfForSixMonthsNoPayment" data-valmsg-replace="true"></span><div class="checker" id="uniform-BmlModel_IfForSixMonthsNoPayment"><span><input class="type-checkbox type-checkbox preproc" data-val="true" data-val-required="The IfForSixMonthsNoPayment field is required." id="BmlModel_IfForSixMonthsNoPayment" name="BmlModel.IfForSixMonthsNoPayment" type="checkbox" value="true"></span></div><input name="BmlModel.IfForSixMonthsNoPayment" type="hidden" value="false"><label class="checkbox" for="BmlModel_IfForSixMonthsNoPayment">Yes, I would like to make no payments for six months on orders greater than $250.</label>
</div>
<fieldset id="PayPal CreditInfo">
<legend class="visuallyhidden">Apply for PayPal Credit <small class="rqrd" aria-hidden="true">(*Required)</small></legend>
<h4 class="legend" aria-hidden="true">Apply for PayPal Credit <small class="rqrd" aria-hidden="true">(*Required)</small></h4>
<p>The information entered below will be sent to PayPal Credit.</p>
<div>
<div class="form-row">
<div class="form-group"><label class="ifl" for="BmlModel_FirstName">First name<em aria-hidden="true" class="rqrd">*</em></label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="BmlModel.FirstName" data-valmsg-replace="true"></span><input aria-required="true" data-val="true" data-val-regex="Please enter a valid First name.<!--EC:V15-->" data-val-regex-pattern="[A-Za-z]{1,}[A-Za-z -]{0,}" data-val-required="Please enter a First name.<!--EC:V1-->" id="BmlModel_FirstName" name="BmlModel.FirstName" type="text" value=""></div>
<div class="form-group"><label class="ifl" for="BmlModel_LastName">Last name<em aria-hidden="true" class="rqrd">*</em></label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="BmlModel.LastName" data-valmsg-replace="true"></span><input aria-required="true" data-val="true" data-val-regex="Please enter a valid Last name.<!--EC:V15-->" data-val-regex-pattern="[A-Za-z]{2,}[A-Za-z -]{0,}" data-val-required="Please enter a Last name.<!--EC:V1-->" id="BmlModel_LastName" name="BmlModel.LastName" type="text" value=""></div>
</div>
<div id="guestBML">
<div class="form-row">
<div class="form-group bml-address-line"><label class="ifl" for="BmlModel_BMLAddressLine1">Billing address<em aria-hidden="true" class="rqrd">*</em></label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="BmlModel.BMLAddressLine1" data-valmsg-replace="true"></span><input aria-required="true" data-val="true" data-val-required="Please enter a Billing address.<!--EC:V1-->" id="BmlModel_BMLAddressLine1" name="BmlModel.BMLAddressLine1" type="text" value=""></div>
</div>
<div class="form-row">
<div class="form-group address-city"><label class="ifl" for="BmlModel_BMLCity">City<em aria-hidden="true" class="rqrd">*</em></label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="BmlModel.BMLCity" data-valmsg-replace="true"></span><input aria-required="true" data-val="true" data-val-length="The field City must be a string with a maximum length of 30." data-val-length-max="30" data-val-regex="Please enter a valid City.<!--EC:V15-->" data-val-regex-pattern="[A-Za-z., \-]{2,}" data-val-required="Please enter a City.<!--EC:V1-->" id="BmlModel_BMLCity" maxlength="30" name="BmlModel.BMLCity" type="text" value=""></div>
<div class="form-group address-state"><label class="ifl" for="BmlModel_BMLStateCode">State/territory/province<em aria-hidden="true" class="rqrd">*</em></label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="BmlModel.BMLStateCode" data-valmsg-replace="true"></span><input aria-required="true" data-val="true" data-val-required="Please enter a State/territory/province.<!--EC:V1-->" id="BmlModel_BMLStateCode" name="BmlModel.BMLStateCode" type="text" value=""></div>
<div class="form-group bml-address-post-code"><label class="ifl" for="BmlModel_BMLPostalCode">Zip/Postal code<em aria-hidden="true" class="rqrd">*</em></label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="BmlModel.BMLPostalCode" data-valmsg-replace="true"></span><input aria-required="true" data-val="true" data-val-length="The field Zip/Postal code must be a string with a maximum length of 10." data-val-length-max="10" data-val-regex="Please enter a valid Zip/Postal code.<!--EC:V15-->" data-val-regex-pattern="[abcdefghijklmnopqrstuvwxyzABCDEFGHIJKLMNOPQRSTUVWXYZ0123456789 ,///-]{1,}" data-val-required="Please enter a Zip/Postal code.<!--EC:V1-->" id="BmlModel_BMLPostalCode" maxlength="10" name="BmlModel.BMLPostalCode" type="text" value=""></div>
</div>
<h4 id="countryDescription" class="legend"></h4>
<div id="divBMLGuestPhoneInputFields" style="display:">
<div class="form-row">
<div class="form-group">
<div class="group-label">Phone prefix<em class="rqrd" aria-hidden="true">*</em></div>
<label for="BmlModel_BMLPhoneCountryAccessCode" class="visuallyhidden">Phone Country</label>
<div class="selector fixedWidth" id="uniform-BmlModel_BMLPhoneCountryAccessCode"><span aria-hidden="true" style="-webkit-user-select: none;">United States</span><select id="BmlModel_BMLPhoneCountryAccessCode" name="BmlModel.BMLPhoneCountryAccessCode" class="preproc"><option value="US">United States</option>
<option value="CA">Canada</option>
<option value="GB">United Kingdom</option>
<option value="AF">Afghanistan</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AS">American Samoa</option>
<option value="AD">Andorra</option>
<option value="AO">Angola</option>
<option value="AI">Anguilia</option>
<option value="AQ">Antarctica</option>
<option value="AG">Antigua and Barbuda</option>
<option value="AR">Argentina</option>
<option value="AM">Armenia</option>
<option value="AW">Aruba</option>
<option value="AU">Australia</option>
<option value="AT">Austria</option>
<option value="AZ">Azerbaijan</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BD">Bangladesh</option>
<option value="BB">Barbados</option>
<option value="BY">Belarus</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BJ">Benin</option>
<option value="BM">Bermuda</option>
<option value="BT">Bhutan</option>
<option value="BO">Bolivia</option>
<option value="BQ">Bonaire, Sint Eustatius and Saba</option>
<option value="BA">Bosnia and Herzegovina</option>
<option value="BW">Botswana</option>
<option value="BR">Brazil</option>
<option value="IO">British Indian Ocean Territory</option>
<option value="VG">British Virgin Islands</option>
<option value="BN">Brunei</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CV">Cape Verde</option>
<option value="KY">Cayman Islands</option>
<option value="CF">Central African Republic</option>
<option value="TD">Chad</option>
<option value="CL">Chile</option>
<option value="CN">China, People's Republic of</option>
<option value="CX">Christmas Island</option>
<option value="CC">Cocos (Keeling) Islands</option>
<option value="CO">Colombia</option>
<option value="KM">Comoros</option>
<option value="CG">Congo</option>
<option value="CD">Congo, Democratic Republic of the (Zaire)</option>
<option value="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="CI">Cote d'ivoire</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CW">Curaçao</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="DK">Denmark</option>
<option value="DG">Diego Garcia</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="TP">East Timor</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="GQ">Equatorial Guinea</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="ET">Ethiopia</option>
<option value="FK">Falkland Islands</option>
<option value="FO">Faroe Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="GF">French Guiana</option>
<option value="PF">French Polynesia</option>
<option value="GA">Gabon</option>
<option value="GM">Gambia</option>
<option value="GE">Georgia</option>
<option value="DE">Germany</option>
<option value="GH">Ghana</option>
<option value="GI">Gibraltar</option>
<option value="GR">Greece</option>
<option value="GL">Greenland</option>
<option value="GD">Grenada</option>
<option value="GP">Guadeloupe</option>
<option value="GU">Guam</option>
<option value="GT">Guatemala</option>
<option value="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HN">Honduras</option>
<option value="HK">Hong Kong</option>
<option value="HU">Hungary</option>
<option value="IS">Iceland</option>
<option value="IN">India</option>
<option value="ID">Indonesia</option>
<option value="IR">Iran</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KP">Korea, North</option>
<option value="KR">Korea, South</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LA">Laos</option>
<option value="LV">Latvia</option>
<option value="LB">Lebanon</option>
<option value="LS">Lesotho</option>
<option value="LR">Liberia</option>
<option value="LY">Libya</option>
<option value="LI">Liechtenstein</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="MO">Macau</option>
<option value="MK">Macedonia (FYROM)</option>
<option value="MG">Madagascar</option>
<option value="MW">Malawi</option>
<option value="MY">Malaysia</option>
<option value="MV">Maldives</option>
<option value="ML">Mali</option>
<option value="MT">Malta</option>
<option value="MH">Marshall Islands</option>
<option value="MQ">Martinique</option>
<option value="MR">Mauritania</option>
<option value="MU">Mauritius</option>
<option value="YT">Mayotte</option>
<option value="MX">Mexico</option>
<option value="FM">Micronesia</option>
<option value="MD">Moldova</option>
<option value="MC">Monaco</option>
<option value="MN">Mongolia</option>
<option value="ME">Montenegro</option>
<option value="MS">Montserrat</option>
<option value="MA">Morocco</option>
<option value="MZ">Mozambique</option>
<option value="MM">Myanmar (Burma)</option>
<option value="NA">Namibia</option>
<option value="NR">Nauru</option>
<option value="NP">Nepal</option>
<option value="NL">Netherlands</option>
<option value="NC">New Caledonia</option>
<option value="NZ">New Zealand</option>
<option value="NI">Nicaragua</option>
<option value="NE">Niger</option>
<option value="NG">Nigeria</option>
<option value="NU">Niue</option>
<option value="NF">Norfolk Island</option>
<option value="MP">Northern Mariana Islands</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PK">Pakistan</option>
<option value="PW">Palau</option>
<option value="PS">Palestinian Territories</option>
<option value="PA">Panama</option>
<option value="PG">Papua New Guinea</option>
<option value="PY">Paraguay</option>
<option value="PE">Peru</option>
<option value="PH">Philippines</option>
<option value="PN">Pitcairn</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico</option>
<option value="QA">Qatar</option>
<option value="RE">Reunion</option>
<option value="RO">Romania</option>
<option value="RU">Russia</option>
<option value="RW">Rwanda</option>
<option value="GS">South Georgia and the South Sandwich Islands</option>
<option value="BL">Saint Barthélemy</option>
<option value="KN">Saint Kitts and Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="MF">Saint Martin (France)</option>
<option value="VC">Saint Vincent and the Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</option>
<option value="ST">Sao Tome and Principe</option>
<option value="SA">Saudi Arabia</option>
<option value="SN">Senegal</option>
<option value="RS">Serbia</option>
<option value="SC">Seychelles</option>
<option value="SL">Sierra Leone</option>
<option value="SG">Singapore</option>
<option value="SX">Sint Maarten (Netherlands)</option>
<option value="SK">Slovakia</option>
<option value="SI">Slovenia</option>
<option value="SB">Solomon Islands</option>
<option value="SO">Somalia</option>
<option value="ZA">South Africa</option>
<option value="SS">South Sudan</option>
<option value="ES">Spain & Canary Islands</option>
<option value="LK">Sri Lanka</option>
<option value="SH">Saint Helena</option>
<option value="PM">Saint Pierre and Miquelon</option>
<option value="SD">Sudan</option>
<option value="SR">Suriname</option>
<option value="SJ">Svalbard and Jan Mayen Islands</option>
<option value="SZ">Swaziland</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syria</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania</option>
<option value="TH">Thailand</option>
<option value="TG">Togo</option>
<option value="TK">Tokelau</option>
<option value="TO">Tonga</option>
<option value="TT">Trinidad and Tobago</option>
<option value="TN">Tunisia</option>
<option value="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks and Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VA">Vatican City State (Holy See)</option>
<option value="VE">Venezuela</option>
<option value="VN">Vietnam</option>
<option value="VI">U.S. Virgin Islands</option>
<option value="WF">Wallis and Futuna</option>
<option value="YE">Yemen</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select></div>
</div>
</div>
<div class="form-row">
<div class="form-group"><label class="ifl" for="BmlModel_BMLPhoneNumber">Phone number<em aria-hidden="true" class="rqrd">*</em></label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="BmlModel.BMLPhoneNumber" data-valmsg-replace="true"></span><input aria-required="true" data-val="true" data-val-regex="Please enter a valid Phone number.<!--EC:V15-->" data-val-regex-pattern="[0-9 .+\\()/-]{6,}" data-val-required="Please enter a Phone number.<!--EC:V1-->" id="BmlModel_BMLPhoneNumber" name="BmlModel.BMLPhoneNumber" type="text" value=""></div>
<div class="form-group"><label class="ifl" for="BmlModel_BMLPhoneExtension">Extension (Optional)</label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="BmlModel.BMLPhoneExtension" data-valmsg-replace="true"></span><input data-val="true" data-val-regex="Please enter a valid Extension (Optional).<!--EC:V15-->" data-val-regex-pattern="[A-Za-z0-9 ]+" id="BmlModel_BMLPhoneExtension" name="BmlModel.BMLPhoneExtension" type="text" value=""></div>
</div>
<div class="form-row">
<div class="form-group" id="guest-bml-email"><label class="ifl" for="BmlModel_BMLEmail">Email address<em aria-hidden="true" class="rqrd">*</em></label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="BmlModel.BMLEmail" data-valmsg-replace="true"></span><input aria-required="true" data-val="true" data-val-length="The field Email address must be a string with a maximum length of 75." data-val-length-max="75" data-val-regex="Please enter a valid Email address.<!--EC:V15-->" data-val-regex-pattern="^( ?)([\w\.\-_]+)@([\w\-]+)((\.([\w\-]{2,}))?)+$" data-val-required="Please enter a Email address.<!--EC:V1-->" id="BmlModel_BMLEmail" maxlength="75" name="BmlModel.BMLEmail" type="text" value=""></div>
</div>
</div>
<div id="divBMLGuestSelectedPhoneData" class="form-row"></div>
</div>
</div>
<div class="form-row">
For verification purposes , please enter your date of birth and the last four digits of your Social Security Number.
</div>
<div class="form-row">
<div class="form-group bml-birth-month">
<div class="group-label">Date of birth<em class="rqrd" aria-hidden="true">*</em></div>
<span aria-hidden="true" class="field-validation-valid" data-valmsg-for="BmlModel.DobMonth" data-valmsg-replace="true"></span>
<label for="BmlModel_DobMonth" class="visuallyhidden">Date Of Birth Month</label>
<div class="selector fixedWidth" id="uniform-BmlModel_DobMonth"><span aria-hidden="true" style="-webkit-user-select: none;">Month</span><select data-val="true" data-val-required="Please enter a Month.<!--EC:V1-->" id="BmlModel_DobMonth" name="BmlModel.DobMonth" class="preproc"><option value="">Month</option>
<option value="1">01 - January</option>
<option value="2">02 - February</option>
<option value="3">03 - March</option>
<option value="4">04 - April</option>
<option value="5">05 - May</option>
<option value="6">06 - June</option>
<option value="7">07 - July</option>
<option value="8">08 - August</option>
<option value="9">09 - September</option>
<option value="10">10 - October</option>
<option value="11">11 - November</option>
<option value="12">12 - December</option>
</select></div>
</div>
<div class="form-group date-day">
<div class="group-label"> </div>
<div class="form-group"><label class="ifl" for="BmlModel_DobDay">DD<em aria-hidden="true" class="rqrd">*</em></label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="BmlModel.DobDay" data-valmsg-replace="true"></span><input length="2" aria-required="true" data-val="true" data-val-regex="Please enter a valid DD.<!--EC:V15-->" data-val-regex-pattern="(0[1-9]|[12]\d|3[01])" data-val-required="Please enter a DD.<!--EC:V1-->" id="BmlModel_DobDay" name="BmlModel.DobDay" type="text" value=""></div>
</div>
<div class="form-group bml-birth-year">
<div class="group-label"> </div>
<div class="form-group"><label class="ifl" for="BmlModel_DobYear">YYYY<em aria-hidden="true" class="rqrd">*</em></label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="BmlModel.DobYear" data-valmsg-replace="true"></span><input length="4" aria-required="true" data-val="true" data-val-range="Date of Birth year cannot be greater than cuurent year." data-val-range-max="2014" data-val-range-min="1880" data-val-required="Please enter a YYYY.<!--EC:V1-->" id="BmlModel_DobYear" name="BmlModel.DobYear" type="text" value=""></div>
</div>
<div class="form-group ssn-last-four">
<div class="group-label">Social Security Number<em class="rqrd" aria-hidden="true">*</em></div>
<span class="ssn-hash">#### - ### -</span> <div class="form-group"><label class="ifl" for="BmlModel_SocialSN">Last 4 digits<em aria-hidden="true" class="rqrd">*</em></label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="BmlModel.SocialSN" data-valmsg-replace="true"></span><input aria-required="true" data-privacy="no-capture" data-val="true" data-val-regex="Invalid Social Security Number - last 4 digits" data-val-regex-pattern="^\d{4}$" data-val-required="Last 4 digits" id="BmlModel_SocialSN" name="BmlModel.SocialSN" type="text" value=""></div>
</div>
</div>
<p>You must read the E-Sign consent of the Terms and Conditions listed below prior to checking the following box: <a href="https://www.united.com/web/en-US/content/booking/flight/FNGENP36.pdf" target="_blank">See E-Sign printer-friendly version</a></p>
<div class="form-row">
<div class="form-group group-type-checkbox">
<span aria-hidden="true" class="field-validation-valid" data-valmsg-for="BmlModel.IfBMLTermsElectronicAccepted" data-valmsg-replace="true"></span><div class="checker" id="uniform-BmlModel_IfBMLTermsElectronicAccepted"><span><input class="type-checkbox type-checkbox preproc" data-val="true" data-val-mandatory="Please make a selection.<!--EC:V152-->" data-val-required="The IfBMLTermsElectronicAccepted field is required." id="BmlModel_IfBMLTermsElectronicAccepted" name="BmlModel.IfBMLTermsElectronicAccepted" type="checkbox" value="true"></span></div><input name="BmlModel.IfBMLTermsElectronicAccepted" type="hidden" value="false"><label class="checkbox" for="BmlModel_IfBMLTermsElectronicAccepted"></label>
<label for="BmlModel_IfBMLTermsElectronicAccepted">I agree to have the <a href="https://www.united.com/web/en-US/content/booking/flight/bmlTerms.aspx" target="_blank">PayPal Credit terms and conditions</a> presented electronically</label>
<div class="inline-validation-msg"></div>
</div>
</div>
<div class="form-row ">
<div>
<iframe src="https://www.securecheckout.billmelater.com/paycapture-content/fetch?hash=AU631DB5&content=/bmlweb/bmlwebtnc_iframe.html" width="100%" height="100%" class="terms"></iframe>
</div>
</div>
<div class="form-row">
<div class="form-group group-type-checkbox">
<span aria-hidden="true" class="field-validation-valid" data-valmsg-for="BmlModel.IfBMLTermsAccepted" data-valmsg-replace="true"></span><div class="checker" id="uniform-BmlModel_IfBMLTermsAccepted"><span><input class="type-checkbox type-checkbox preproc" data-val="true" data-val-mandatory="Please make a selection.<!--EC:V152-->" data-val-required="The IfBMLTermsAccepted field is required." id="BmlModel_IfBMLTermsAccepted" name="BmlModel.IfBMLTermsAccepted" type="checkbox" value="true"></span></div><input name="BmlModel.IfBMLTermsAccepted" type="hidden" value="false"><label class="checkbox" for="BmlModel_IfBMLTermsAccepted"></label>
<label for="BmlModel_IfBMLTermsAccepted">I agree to the <a href="https://www.united.com/web/en-US/content/booking/flight/bmlTerms.aspx" target="_blank">PayPal Credit terms and conditions</a></label>
<div class="inline-validation-msg"></div>
</div>
</div>
</fieldset>
</div>
<div class="panel-body-section">
<fieldset>
<legend class="visuallyhidden">Purchaser contact information</legend>
<h3 class="legend">Purchaser contact information</h3>
<div id="divEmailAddressList" class="form-row" style="display:none">
<div class="form-group">
<div class="selector fixedWidth" id="uniform-EmailAddressList"><span aria-hidden="true" style="-webkit-user-select: none;"></span><select id="EmailAddressList" name="EmailAddressList" class="saved-emails-list-sync preproc" onchange="UA.Account.EmailList.getSelectedEmailData('#EmailAddressList','','#hdnEmailAddressList','#divEmailAddressList','#divEmailAddressInputFields','#divSelectedEmailAddressData','/ual/en/us/flight-search/book-a-flight/billinginfo/rev/')"></select></div>
<input type="hidden" id="hdnEmailAddressList" value="1st">
</div>
<div class="form-group">
<aside>Your email address will be used to contact you about this reservation only.</aside>
</div>
</div>
<div class="form-row" id="divEmailAddressInputFields" style="display:">
<div class="form-group"><label class="ifl visuallyhidden" for="PurchaserEmailAddress">Email address<em aria-hidden="true" class="rqrd">*</em></label><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="PurchaserEmailAddress" data-valmsg-replace="true"></span><input aria-required="true" data-val="true" data-val-length="Email address must be no more than 75 characters.<!--EC:V142-->" data-val-length-max="75" data-val-regex="Please enter a valid Email address.<!--EC:V15-->" data-val-regex-pattern="^( ?)([\w\.\-_]+)@([\w\-]+)((\.([\w\-]{2,}))?)+$" data-val-required="Please enter a Email address.<!--EC:V1-->" id="PurchaserEmailAddress" maxlength="75" name="PurchaserEmailAddress" type="text" value="[email protected]"></div>
<div class="form-group">
<aside>Your email address will be used to contact you about this reservation only.</aside>
</div>
</div>
<ul id="divSelectedEmailAddressData" class="field-edit-links">
<li><a href="#" class="btn-edit-email">Edit email address</a></li>
<li><a href="#" class="btn-add-email">Add new email address</a></li>
</ul>
<div id="divPhoneList" class="form-row" style="display:none">
<div class="selector fixedWidth" id="uniform-PhoneList"><span aria-hidden="true" style="-webkit-user-select: none;"></span><select id="PhoneList" name="PhoneList" class="saved-phones-list-sync preproc" onchange="UA.Account.PhoneList.getSelectedPhoneData('#PhoneList','','#hdnPhoneList','#divPhoneList','#divPhoneInputFields','#divSelectedPhoneData','/ual/en/us/flight-search/book-a-flight/billinginfo/rev/')"></select></div>
<input type="hidden" id="hdnPhoneList" value="1st">
</div>
<div id="divPhoneInputFields" style="display:">
<div class="form-row">
<div class="form-group"><span aria-hidden="true" class="field-validation-valid" data-valmsg-for="PhoneCountryCode" data-valmsg-replace="true"></span><div class="selector fixedWidth" id="uniform-PhoneCountryCode"><span aria-hidden="true" style="-webkit-user-select: none;">United States</span><label class="ifl visuallyhidden" for="PhoneCountryCode">Country</label><select aria-label="Country" class="phone-country-list preproc" id="PhoneCountryCode" name="PhoneCountryCode"><option value=""></option>
<option selected="selected" value="US">United States</option>
<option value="CA">Canada</option>
<option value="GB">United Kingdom</option>
<option value="AF">Afghanistan</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AS">American Samoa</option>
<option value="AD">Andorra</option>
<option value="AO">Angola</option>
<option value="AI">Anguilia</option>
<option value="AQ">Antarctica</option>
<option value="AG">Antigua and Barbuda</option>
<option value="AR">Argentina</option>
<option value="AM">Armenia</option>
</select></div></div>
</div>
</div>
</fieldset>
</div>
</div>
<input id="CartId" name="CartId" type="hidden" value="83029498-98C8-4043-AA9B-106E1F89C4BF"><input id="PageError" name="PageError" type="hidden" value="False"><input id="TripInsurancePurchased" name="TripInsurancePurchased" type="hidden" value="False"><input id="AdditionalData" name="AdditionalData" type="hidden" value=""></form>
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