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Rev 35298 Rev 35549
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                            <option value="2" selected>Female</option>
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                            <option value="2" selected>Female</option>
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                        </select>
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                        </select>
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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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                            <label for="dateOfBirth">Date Of Birth</label> <input
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                            <label for="dateOfBirth">Date Of Birth</label> <input
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                                placeholder="Date Of Birth" id="dateOfBirth" name="dateOfBirth"
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                                placeholder="Date Of Birth" id="dateOfBirth"
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                                type="text" value="" class="form-control">
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                                type="date" value="" class="form-control">
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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>
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                </div>
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                <div class="col-lg-3">
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                <div class="col-lg-3">
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                    <div id="payment-details"
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                    <div id="payment-details"