Bootstrap Address Details Modal Form


	  <div class="row">
    <div class="col-md-4 col-md-offset-4">
      <form class="form-horizontal" role="form">
        <fieldset>

          <!-- Form Name -->
          <legend>Address Details</legend>

          <!-- Text input-->
          <div class="form-group">
            <label class="col-sm-2 control-label" for="textinput">Line 1</label>
            <div class="col-sm-10">
              <input type="text" placeholder="Address Line 1" class="form-control">
            </div>
          </div>

          <!-- Text input-->
          <div class="form-group">
            <label class="col-sm-2 control-label" for="textinput">Line 2</label>
            <div class="col-sm-10">
              <input type="text" placeholder="Address Line 2" class="form-control">
            </div>
          </div>

          <!-- Text input-->
          <div class="form-group">
            <label class="col-sm-2 control-label" for="textinput">City</label>
            <div class="col-sm-10">
              <input type="text" placeholder="City" class="form-control">
            </div>
          </div>

          <!-- Text input-->
          <div class="form-group">
            <label class="col-sm-2 control-label" for="textinput">State</label>
            <div class="col-sm-4">
              <input type="text" placeholder="State" class="form-control">
            </div>

            <label class="col-sm-2 control-label" for="textinput">Postcode</label>
            <div class="col-sm-4">
              <input type="text" placeholder="Post Code" class="form-control">
            </div>
          </div>



          <!-- Text input-->
          <div class="form-group">
            <label class="col-sm-2 control-label" for="textinput">Country</label>
            <div class="col-sm-10">
              <input type="text" placeholder="Country" class="form-control">
            </div>
          </div>

          <div class="form-group">
            <div class="col-sm-offset-2 col-sm-10">
              <div class="pull-right">
                <button type="submit" class="btn btn-default">Cancel</button>
                <button type="submit" class="btn btn-primary">Save</button>
              </div>
            </div>
          </div>

        </fieldset>
      </form>
    </div><!-- /.col-lg-12 -->
</div><!-- /.row -->
	<script type="text/javascript">
	
	</script>