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<form action="http://local.b2bzend.com/gtxwebservices/customer-wallet/b2c-wallet-recharge/" name="frm1" method="post" id="paymentsubmitCash" autocomplete="off" class="ng-pristine ng-valid">
<input type="text" name="Firstname" placeholder="Firstname" value="MD" autocomplete="off" fdprocessedid="i3xpr6">
<input type="text" name="email" placeholder="email" value="sibo.sarso@gmail.com" autocomplete="off" fdprocessedid="9a101l">
<input type="text" name="phone" placeholder="phone" value="8447455883" autocomplete="off" fdprocessedid="x22prh">
<input type="text" name="CustomerSysId" placeholder="CustomerSysId" value="216033" autocomplete="off" fdprocessedid="5k0lzd">
<input type="text" name="amount" placeholder="amount" value="" autocomplete="off" fdprocessedid="if5d3b">
<input type="text" name="Remark" placeholder="Remark" value="" autocomplete="off" fdprocessedid="snbwcq">
<input type="text" name="txnid" placeholder="txnid" value="BFC0AEB8BA8D48E4B90C48F4915E597D" autocomplete="off" fdprocessedid="p98h89">
<input type="text" name="SecurityKey" placeholder="SecurityKey" value="F38C55F4-5771-4EED-AAB2-D1CE094AEB4E" autocomplete="off" fdprocessedid="6js64oh">
<input type="text" name="PaymentMode" placeholder="PaymentMode" value="Online" autocomplete="off" fdprocessedid="r0r4ap">
<input type="text" name="udf5" placeholder="udf5" value="http://b2c.hellogtx.com/customer/wallet-recharge" autocomplete="off" fdprocessedid="kumu9">
<input type="submit" value="Submit" autocomplete="off" fdprocessedid="7exf2">
</form>