| Title: | |
| Name: | John Doe |
| Phone Number: | 1234567890 |
| Email= Id: | john@example.com |
| Are you an Indian Citizan= ? | Yes |
| Are you residing in India? | Yes |
| Gender? | Male |
| Date of Birth: | 09111950 |
| Home Address: | ABC Street |
| State: | Iowa |
| District: | idaho |
| Pincode: | |
| Payment Mode: | <= /td> |