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Rev 22860 Rev 23181
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}
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}
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</style>
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</style>
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<script type="text/javascript">
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<script type="text/javascript">
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	var cartItemIndex = 0;
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	var cartItemIndex = 0;
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	$(function() {
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    	$('input[name="dateOfBirth"]').daterangepicker({
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    		"singleDatePicker": true,
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    		"showDropdowns": true,
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    		"startDate": "01/01/2000",
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    		"autoUpdateInput": false,
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    		locale: {
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    			cancelLabel: 'Clear',
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    			format: 'DD/MM/YYYY'
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  			}
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	    });
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	    $('input[name="dateOfBirth"]').on('apply.daterangepicker', function(ev, picker) {
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      		$(this).val(picker.startDate.format('DD/MM/YYYY'));
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  		});
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  		$('input[name="dateOfBirth"]').on('cancel.daterangepicker', function(ev, picker) {
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      		$(this).val('');
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  		});
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	});
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</script>
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</script>
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<section class="wrapper">
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<section class="wrapper">
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<div class="row">
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<div class="row">
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		<div class="col-lg-12">
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		<div class="col-lg-12">
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	  		<table class="table">
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	  		<table class="table">
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	    		<tr>
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	    		<tr>
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	    			<td><h4 class="grnProductInfo modelHeaderCustom table-align-center">Description</h4></td>
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	    			<td><h4 class="grnProductInfo modelHeaderCustom table-align-center">Description</h4></td>
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	    			<td><h4 class="grnProductInfo modelHeaderCustom table-align-center">Quantity</h4></dt>
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	    			<td><h4 class="grnProductInfo modelHeaderCustom table-align-center">Quantity</h4></dt>
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	    			<td><h4 class="grnProductInfo modelHeaderCustom">Serial Number</h4></td>
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	    			<td><h4 class="grnProductInfo modelHeaderCustom">Serial Number</h4></td>
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	    			<td><h4 class="grnProductInfo modelHeaderCustom">Insurance Amount</h4></td>
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	    			<td><h4 class="grnProductInfo modelHeaderCustom">Damage Protection</h4></td>
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	    			<td><h4 class="grnProductInfo modelHeaderCustom table-align-center">Unit Price</h4></td>
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	    			<td><h4 class="grnProductInfo modelHeaderCustom table-align-center">Unit Price</h4></td>
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	    			<td><h4 class="grnProductInfo modelHeaderCustom table-align-center">Discount</h4></td>
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	    			<td><h4 class="grnProductInfo modelHeaderCustom table-align-center">Discount</h4></td>
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	    			<td><h4 class="grnProductInfo modelHeaderCustom table-align-center">Total Price</h4></td>
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	    			<td><h4 class="grnProductInfo modelHeaderCustom table-align-center">Total Price</h4></td>
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	    		</tr>
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	    		</tr>
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			</div>
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			</div>
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			<div class="col-lg-3 form-group">
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			<div class="col-lg-3 form-group">
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				<input placeholder = "Phone Number*" id="phone" addressId="" name="phone" type="text" value="" class="form-control phone input-sm">
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				<input placeholder = "Phone Number*" id="phone" addressId="" name="phone" type="text" value="" class="form-control phone input-sm">
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			</div>
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			</div>
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			<div class="col-lg-2 form-group">
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			<div class="col-lg-2 form-group">
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				<input placeholder = "Date Of Birth*" id="dateOfBirth" name="dateOfBirth" type="date" value="" class="form-control input-sm">
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				<input placeholder = "Date Of Birth*" id="dateOfBirth" name="dateOfBirth" type="text" value="" class="">
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			</div>
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			</div>
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		</div>
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		</div>
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		<div class = "row">
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		<div class = "row">
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			<div class="col-lg-4 form-group">
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			<div class="col-lg-4 form-group">