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Rev 10950 Rev 11119
Line 36... Line 36...
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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>City<span>*</span></label>
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          <input type="text" id="city" name="city"/>
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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="">Select State</option>
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						<option value="Andaman &amp; Nicobar Island">Andaman &amp; Nicobar Island</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="Andhra Pradesh">Andhra Pradesh</option>
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						<option value="Tripura">Tripura</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="Uttar Pradesh">Uttar Pradesh</option>
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						<option value="Uttarakhand">Uttarakhand</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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						<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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					<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>
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					<input type="number" id="phone" name="phone"/>
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					<input type="number" id="phone" name="phone"/>
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