| Line 154... |
Line 154... |
| 154 |
</div>
|
154 |
</div>
|
| 155 |
<div class="col-lg-3 form-group">
|
155 |
<div class="col-lg-3 form-group">
|
| 156 |
<input placeholder="Email*" id="email" name="email" type="text" value="" class="form-control input-sm">
|
156 |
<input placeholder="Email*" id="email" name="email" type="text" value="" class="form-control input-sm">
|
| 157 |
</div>
|
157 |
</div>
|
| 158 |
<div class="col-lg-3 form-group">
|
158 |
<div class="col-lg-3 form-group">
|
| 159 |
<input placeholder = "Phone Number*" id="phone" name="phone" type="text" value="" class="form-control phone input-sm">
|
159 |
<input placeholder = "Phone Number*" id="phone" addressId="" name="phone" type="text" value="" class="form-control phone input-sm">
|
| 160 |
</div>
|
160 |
</div>
|
| 161 |
<div class="col-lg-2 form-group">
|
161 |
<div class="col-lg-2 form-group">
|
| 162 |
<input placeholder = "Date Of Birth*" id="dateOfBirth" name="dateOfBirth" type="date" value="" class="form-control input-sm">
|
162 |
<input placeholder = "Date Of Birth*" id="dateOfBirth" name="dateOfBirth" type="date" value="" class="form-control input-sm">
|
| 163 |
</div>
|
163 |
</div>
|
| 164 |
|
164 |
|
| Line 183... |
Line 183... |
| 183 |
</div>
|
183 |
</div>
|
| 184 |
<div class="col-lg-3 form-group">
|
184 |
<div class="col-lg-3 form-group">
|
| 185 |
<input placeholder="City" id="city" name="city" type="text" value="" class="form-control input-sm">
|
185 |
<input placeholder="City" id="city" name="city" type="text" value="" class="form-control input-sm">
|
| 186 |
</div>
|
186 |
</div>
|
| 187 |
<div class="col-lg-4 form-group">
|
187 |
<div class="col-lg-4 form-group">
|
| 188 |
<select class="form-control input-sm" name = "state" placeholder="State">
|
188 |
<select class="form-control input-sm" id = "state" name = "state" placeholder="State">
|
| 189 |
<option value="Andaman & Nicobar Islands">Andaman and Nicobar Islands</option>
|
189 |
<option value="Andaman & Nicobar Islands">Andaman and Nicobar Islands</option>
|
| 190 |
<option value="Andhra Pradesh">Andhra Pradesh</option>
|
190 |
<option value="Andhra Pradesh">Andhra Pradesh</option>
|
| 191 |
<option value="Arunachal Pradesh">Arunachal Pradesh</option>
|
191 |
<option value="Arunachal Pradesh">Arunachal Pradesh</option>
|
| 192 |
<option value="Assam">Assam</option>
|
192 |
<option value="Assam">Assam</option>
|
| 193 |
<option value="Bihar">Bihar</option>
|
193 |
<option value="Bihar">Bihar</option>
|