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Rev 17998 Rev 18040
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						<!-- <label>Phone<span>*</span></label> -->
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						<!-- <label>Phone<span>*</span></label> -->
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						<input type="text" id="phone" value="<?php echo $user_contact;?>" placeholder="Contact number*" name="phone" pattern="\d.{9,9}" required title="Invalid Phone number.."/>
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						<input type="text" id="phone" value="<?php echo $user_contact;?>" placeholder="Contact number*" name="phone" pattern="\d.{9,9}" required title="Invalid Phone number.."/>
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					</div>
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					</div>
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					<div class='col-xs-6' style='padding:0px 0px 0px 5px ;'>
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					<div class='col-xs-6' style='padding:0px 0px 0px 5px ;'>
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						<!-- <label>Pincode<span>*</span></label> -->
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						<input placeholder="Pincode*" required value='<?php echo $pinval;?>' type="text" id="pin" name="pin" pattern="\d.{5,5}" title="Invalid Pin" />
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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" required>
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						<select id="state" name="state" required>
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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="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>Pincode<span>*</span></label> -->
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						<input placeholder="Pincode*" required value='<?php echo $pinval;?>' type="text" id="pin" name="pin" pattern="\d.{5,5}" title="Invalid Pin" />
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					</div>
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					</div>
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				</div>
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				</div>
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			</fieldset>
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			</fieldset>
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