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Rev 3903 Rev 4136
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					<tr>
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					<tr>
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						<td>&nbsp;</td>
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						<td>&nbsp;</td>
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						<td class="instruction">All Fields are required</td>
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						<td class="instruction">All Fields are required</td>
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                    </tr>
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                    </tr>
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                <tr>
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                <tr>
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					<td class="label" align="right">Name:</td>
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					<td class="label" align="right"><sup>*</sup>Name:</td>
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					<td class="input">
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					<td class="input">
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						<input type="text" id="shipName" name="name" value="$fullname" class="searchbox right" />
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						<input type="text" id="shipName" name="name" value="$fullname" class="searchbox right" />
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					</td>
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					</td>
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				</tr>
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				</tr>
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                <tr>
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                <tr>
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					<td class="label" align="right">Address Line 1:</td>
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					<td class="label" align="right"><sup>*</sup>Address Line 1:</td>
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					<td class="input">
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					<td class="input">
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						<input type="text" id="shipAddress1" name="line1" class="searchbox right" />
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						<input type="text" id="shipAddress1" name="line1" class="searchbox right" />
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					</td>
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					</td>
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				</tr>
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				</tr>
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                <tr>
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                <tr>
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					<td class="input">
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					<td class="input">
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						<input type="text" id="shipAddress2" name="line2" class="searchbox right" />
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						<input type="text" id="shipAddress2" name="line2" class="searchbox right" />
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					</td>
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					</td>
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				</tr>
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				</tr>
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                <tr>
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                <tr>
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					<td class="label" align="right">State</td>
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					<td class="label" align="right"><sup>*</sup>State</td>
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					<td class="input">
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					<td class="input">
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						<select class="select_state" name="state" id="shipState">
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						<select class="select_state" name="state" id="shipState">
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						#include("templates/stateslist.vm")
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						#include("templates/stateslist.vm")
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						</select>
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						</select>
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					</td>
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					</td>
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				</tr>
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				</tr>
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                <tr>
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                <tr>
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					<td class="label" align="right">City:</td>
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					<td class="label" align="right"><sup>*</sup>City:</td>
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					<td class="input">
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					<td class="input">
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						<input type="text" id="shipCity" name="city" class="searchbox"/>
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						<input type="text" id="shipCity" name="city" class="searchbox"/>
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					</td>
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					</td>
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				</tr>
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				</tr>
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                <tr>
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                <tr>
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					<td class="label" align="right">Pin Code:</td>
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					<td class="label" align="right"><sup>*</sup>Pin Code:</td>
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					<td class="input">
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					<td class="input">
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						<input type="text" id="shipPin" name="pincode" value="" class="searchbox textbox-pincode" />
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						<input type="text" id="shipPin" name="pincode" value="" class="searchbox textbox-pincode" />
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					</td>
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					</td>
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				</tr>
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				</tr>
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                <tr>
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                <tr>
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					<td class="label" align="right">Phone:</td>
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					<td class="label" align="right"><sup>*</sup>Phone:</td>
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					<td class="input">
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					<td class="input">
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						<input type="text" id="shipPhone" name="phone" value="" class="searchbox right" />
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						<input type="text" id="shipPhone" name="phone" value="" class="searchbox right" />
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					</td>
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					</td>
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				</tr>
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				</tr>
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                <tr>
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                <tr>