{fld-first_name class="form-control" placeholder="Retailer Name"}

{err-first_name}

{fld-add1 class="form-control" placeholder="Address Line 1"}

{err-add1}

{fld-add2 class="form-control" placeholder="Address Line 2"}

{err-add2}

{fld-add3 class="form-control" placeholder="Address Line 3"}

{fld-city class="form-control" placeholder="City"}

{err-city}

{fld-zip class="form-control" placeholder="PinCode"}

{err-zip}

District :

State :

{fld-email class="form-control" placeholder="Email"}

{err-email}

{fld-phone class="form-control" placeholder="Mobile"}

{err-phone}