<div class="product-registration-wrap">
	<div class="uk-grid product-registration-left">
		<h6 class="header-6 no-space color-main">Personal Information</h6>
		<div class="row">
			<div class="col-md-6">
				<div class="uk-width-1-1 top10 contact-form-wrap">
					<p class="bottom0 input-title">First name<span class="input-required-sign">*</span></p>
					[text* first-name class:uk-input placeholder "First Name"]
				</div>
			</div>
			<div class="col-md-6">
				<div class="uk-width-1-1 top10 contact-form-wrap">
					<p class="bottom0 input-title">Last name<span class="input-required-sign">*</span></p>
					[text* last-name class:uk-input placeholder "Last Name"]
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-md-6">
				<div class="uk-width-1-1 uk-margin-top contact-form-wrap">
					<p class="bottom0 input-title">Contact No.<span class="input-required-sign">*</span></p>
					[text* your-number class:uk-input placeholder "Contact No."]
				</div>
			</div>
			<div class="col-md-6">
				<div class="uk-width-1-1 uk-margin-top contact-form-wrap">
					<p class="bottom0 input-title">Email<span class="input-required-sign">*</span></p>
					[email* your-email class:uk-input placeholder "Email"]
				</div>
			</div>
		</div>
		<div class="uk-width-1-1 uk-margin-top contact-form-wrap">
			<p class="bottom0 input-title">Address<span class="input-required-sign">*</span></p>
			[text* your-address class:uk-input placeholder "Address"]
		</div>
	</div>
	<div class="uk-grid product-registration-right">
		<h6 class="header-6 no-space uk-margin-top color-main">Product Information</h6>
		<div class="row">
			<div class="col-md-6">
				<div class="uk-width-1-1 top10 contact-form-wrap">
					<p class="bottom0 input-title">Model name<span class="input-required-sign">*</span></p>
					[text model-name class:uk-input placeholder "Model Name"]
				</div>
			</div>
			<div class="col-md-6">
				<div class="uk-width-1-1 top10 contact-form-wrap">
					<p class="bottom0 input-title">Purchased from<span class="input-required-sign">*</span></p>
					[text purchased-from class:uk-input placeholder "Purchased from"]
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-md-6">
				<div class="uk-width-1-1 uk-margin-top contact-form-wrap">
					<p class="bottom0 input-title">Purchase date<span class="input-required-sign">*</span></p>
					[date* purchase-date class:uk-input]
				</div>
			</div>
			<div class="col-md-6">
				<div class="uk-width-1-1 uk-margin-top contact-form-wrap">
					<p class="bottom0 input-title">Do you want us to send you product announcements and special offers?<span class="input-required-sign">*</span></p>
					[radio send-announcements-and-offers use_label_element default:1 "Yes" "No"]
				</div>
			</div>
		</div>
		<div class="uk-width-1-1 uk-margin-top">
			[submit class:uk-button class:uk-button-primary "SUBMIT"]
		</div>
		

	</div>
</div>