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Rev 23882 Rev 24203
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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 = "Mobile Number*" class="mobileNumber" addressId="" name="mobileNumber" type="text" value="" class="form-control phone input-sm">
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                                <input placeholder = "Mobile Number*" class="mobileNumber" addressId="" name="mobileNumber" 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-3 form-group">
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                            <div class="col-lg-3 form-group">
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                                <input placeholder="Address Line 1" class="line1" name="line1" type="text" size="50" value="" class="form-control input-sm">
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                                <input placeholder="Address Line 1" class="line1" name="line1" type="text" size="50" v
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                                alue="" class="form-control input-sm">
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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-3 form-group">
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                            <div class="col-lg-3 form-group">
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                                <input placeholder="Address Line 2" class="line2" name="line2" type="text" value="" class="form-control input-sm">
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                                <input placeholder="Address Line 2" class="line2" name="line2" type="text" value="" class="form-control input-sm">
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	                <button type="button" class="btn btn-default" data-dismiss="modal">Close</button>
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	                <button type="button" class="btn btn-default" data-dismiss="modal">Close</button>
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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>
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	</div>
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</div>
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</div>

          

          

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