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+Enter Info for [% uri.host %]
+
+<form action="[% c.uri_for() %]" method="POST">
+<input type="hidden" name="url" value="[% uri | html %]">
+<input type="hidden" name="hostinfo" value="1">
+
+[% location.name %] / [% location.continent %]<br>
+
+Country:
+<select name="country">
+<option value="">--</option>
+[% FOREACH country = c.model('Mirrors').country_list %]
+<option value="[% country.code %]" [% "selected=select" IF country.code == location.code %]>[% country.name | html %]</option>
+[% END %]
+</select>
+
+City: <input type="text" name="city">
+<input type="submit">
+</form>