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Line 28... |
| 28 |
<input type="text" id="name" name="name"/>
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28 |
<input type="text" id="name" name="name"/>
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| 29 |
<label>Address Line 1<span>*</span></label>
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29 |
<label>Address Line 1<span>*</span></label>
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| 30 |
<input type="text" id="line1" name="line1"/>
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<input type="text" id="line1" name="line1"/>
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| 31 |
<label>Address Line 2</label>
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<label>Address Line 2</label>
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| 32 |
<input type="text" id="line2" name="line2"/>
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<input type="text" id="line2" name="line2"/>
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| 33 |
<!-- <label>State<span>*</span></label>
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<label>State<span>*</span></label>
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| 34 |
<select id="state" name="state">
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34 |
<select id="state" name="state">
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| - |
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<option value="">Select State</option>
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| - |
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<option value="Andaman & Nicobar Island">Andaman & Nicobar Island</option>
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| - |
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<option value="Andhra Pradesh">Andhra Pradesh</option>
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| - |
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<option value="Arunachal Pradesh">Arunachal Pradesh</option>
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| - |
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39 |
<option value="Assam">Assam</option>
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| 35 |
<option>haryana</option>
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<option value="Bihar">Bihar</option>
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| - |
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<option value="Chandigarh">Chandigarh</option>
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| - |
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<option value="Chattisgarh">Chattisgarh</option>
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| - |
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43 |
<option value="Dadra & Nagar Haveli">Dadra & Nagar Haveli</option>
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| - |
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44 |
<option value="Daman & Diu">Daman & Diu</option>
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| 36 |
<option>Delhi</option>
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45 |
<option value="Delhi">Delhi</option>
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| 37 |
<option>Goa</option>
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46 |
<option value="Goa">Goa</option>
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| 38 |
<option>Gujrat</option>
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<option value="Gujarat">Gujrat</option>
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| - |
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<option value="Haryana">Haryana</option>
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| - |
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<option value="Himachal Pradesh">Himachal Pradesh</option>
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| - |
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<option value="Jammu & Kashmir">Jammu & Kashmir</option>
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| - |
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<option value="Jharkhand">Jharkhand</option>
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| - |
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52 |
<option value="Karnataka">Karnataka</option>
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| - |
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53 |
<option value="Kerala">Kerala</option>
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| - |
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<option value="Lakshadweep">Lakshadweep</option>
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| - |
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<option value="Madhya Pradesh">Madhya Pradesh</option>
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| - |
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<option value="Maharashtra">Maharashtra</option>
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| - |
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<option value="Manipur">Manipur</option>
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| - |
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<option value="Meghalaya">Meghalaya</option>
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| - |
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<option value="Mizoram">Mizoram</option>
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| - |
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<option value="Nagaland">Nagaland</option>
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| - |
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61 |
<option value="Orissa">Orissa</option>
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| - |
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62 |
<option value="Pondicherry">Pondicherry</option>
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| - |
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<option value="Punjab">Punjab</option>
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| - |
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<option value="Rajasthan">Rajasthan</option>
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| - |
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65 |
<option value="Sikkim">Sikkim</option>
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| - |
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66 |
<option value="Tamil Nadu">Tamil Nadu</option>
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| - |
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67 |
<option value="Tripura">Tripura</option>
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| - |
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68 |
<option value="Uttar Pradesh">Uttar Pradesh</option>
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| - |
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<option value="Uttarakhand">Uttarakhand</option>
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| - |
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<option value="West Bengal">West Bengal</option>
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| 39 |
</select> -->
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71 |
</select>
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| 40 |
<label>City<span>*</span></label>
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72 |
<label>City<span>*</span></label>
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| 41 |
<input type="text" id="city" name="city"/>
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73 |
<input type="text" id="city" name="city"/>
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| 42 |
<label>Pincode<span>*</span></label>
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74 |
<label>Pincode<span>*</span></label>
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| 43 |
<input type="number" id="pin" name="pin"/>
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75 |
<input type="number" id="pin" name="pin"/>
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| 44 |
<label>Phone<span>*</span></label>
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76 |
<label>Phone<span>*</span></label>
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