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Rev 10582 Rev 10702
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					<input type="text" id="name" name="name"/>
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					<input type="text" id="name" name="name"/>
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					<label>Address Line 1<span>*</span></label>
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					<label>Address Line 1<span>*</span></label>
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					<input type="text" id="line1" name="line1"/>
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					<input type="text" id="line1" name="line1"/>
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					<label>Address Line 2</label>
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					<label>Address Line 2</label>
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					<input type="text" id="line2" name="line2"/>
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					<input type="text" id="line2" name="line2"/>
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					<!-- <label>State<span>*</span></label>
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					<label>State<span>*</span></label>
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					<select id="state" name="state">
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					<select id="state" name="state">
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						<option value="">Select State</option>
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						<option value="Andaman &amp; Nicobar Island">Andaman &amp; Nicobar Island</option>
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						<option value="Andhra Pradesh">Andhra Pradesh</option>
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						<option value="Arunachal Pradesh">Arunachal Pradesh</option>
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						<option value="Assam">Assam</option>
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						<option>haryana</option>
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						<option value="Bihar">Bihar</option>
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						<option value="Chandigarh">Chandigarh</option>
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						<option value="Chattisgarh">Chattisgarh</option>
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						<option value="Dadra &amp; Nagar Haveli">Dadra &amp; Nagar Haveli</option>
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						<option value="Daman &amp; Diu">Daman &amp; Diu</option>
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						<option>Delhi</option>
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						<option value="Delhi">Delhi</option>
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						<option>Goa</option>
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						<option value="Goa">Goa</option>
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						<option>Gujrat</option>
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						<option value="Gujarat">Gujrat</option>
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						<option value="Haryana">Haryana</option>
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						<option value="Himachal Pradesh">Himachal Pradesh</option>
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						<option value="Jammu &amp; Kashmir">Jammu &amp; Kashmir</option>
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						<option value="Jharkhand">Jharkhand</option>
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						<option value="Karnataka">Karnataka</option>
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						<option value="Kerala">Kerala</option>
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						<option value="Lakshadweep">Lakshadweep</option>
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						<option value="Madhya Pradesh">Madhya Pradesh</option>
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						<option value="Maharashtra">Maharashtra</option>
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						<option value="Manipur">Manipur</option>
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						<option value="Meghalaya">Meghalaya</option>
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						<option value="Mizoram">Mizoram</option>
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						<option value="Nagaland">Nagaland</option>
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						<option value="Orissa">Orissa</option>
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						<option value="Pondicherry">Pondicherry</option>
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						<option value="Punjab">Punjab</option>
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						<option value="Rajasthan">Rajasthan</option>
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						<option value="Sikkim">Sikkim</option>
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						<option value="Tamil Nadu">Tamil Nadu</option>
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						<option value="Tripura">Tripura</option>
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						<option value="Uttar Pradesh">Uttar Pradesh</option>
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						<option value="Uttarakhand">Uttarakhand</option>
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						<option value="West Bengal">West Bengal</option>
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					</select> -->
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					</select>
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					<label>City<span>*</span></label>
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					<label>City<span>*</span></label>
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					<input type="text" id="city" name="city"/>
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					<input type="text" id="city" name="city"/>
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					<label>Pincode<span>*</span></label>
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					<label>Pincode<span>*</span></label>
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					<input type="number" id="pin" name="pin"/>
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					<input type="number" id="pin" name="pin"/>
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					<label>Phone<span>*</span></label>
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					<label>Phone<span>*</span></label>