Customer Name :

{err-first_name}

{fld-panno class="form-control textfield_reg" placeholder="PAN No"}

{err-panno}

{fld-email_a class="form-control textfield_reg" placeholder="Email"}

{err-email_a}

{fld-mobile_a class="form-control textfield_reg" placeholder="Mobile"}

{err-mobile_a}

{fld-date_of_birth class="form-control textfield_reg" placeholder="Date of Birth (DD/MM/YYYY)"}

{err-date_of_birth}

{fld-passw class="form-control textfield_reg" placeholder="Password"}

{err-passw}