<div class="modal-header">
    <button type="button" class="close" data-dismiss="modal" aria-hidden="true">&times;</button>
    <h3>{$_L['Edit Contact Address']}</h3>
</div>
<div class="modal-body">

   
<form class="form-horizontal" id="modal_edit_address_rform">
         <div class="alert alert-danger" id="modal_edit_address_emsg">
              <span id="modal_edit_address_emsgbody"></span>
        </div>
            <div class="row" style="margin-top:20px">

                <div class=" col-md-6 col-sm-12 col-xs-12">
                    <label class="control-label" for="account">{$_L['Name']}<small class="red">*</small> </label>
                    <input  value="{$d['account']}" type="text" id="account" name="account" class="form-control " readonly="" placeholder="{$_L['Full Name or Business Name']}" maxlength="100">
                </div>

                <div class="pj col-md-6 col-sm-12 col-xs-12">
                    <label class="control-label">{$_L['Name Fantasy']}</label>
                    <input value="{$d['company']}" type="text" id="company" name="company" class="form-control disabled" readonly="" maxlength="100">
                </div>
            </div>
            

            <div class='row' id="div_zip">
                <div class="col-xs-12 div_form">  <h2> {$_L['Address']}</h2> </div>
                       
                <div class="col-md-3 col-sm-12 col-xs-12">
                   <label class="control-label" for="zip">{$_L['ZIP Postal Code']} </label>
                        <input value="{$address['zip']}" type="text" id="modal_edit_address_zip" name="zip" class="cep form-control">
                </div>


                <div class="col-md-4 col-sm-12 col-xs-12">
                   <label class="control-label" for="state">{$_L['State Region']}</label>
                   <select name="state" id="modal_edit_address_state" class="form-control modal_edit_address_select" style="width:100%">
                       <option value="">{$_L['Select State']}</option>
                            {foreach $state as $s}
                                <option value="{$s['id']}" {if $address['state_id']==$s['id'] } selected{/if}>{$s['state_name']}</option>
                            {/foreach}
                   </select>
                </div>                 

                <div class="col-md-5 col-sm-12 col-xs-12">
                   <label class=" control-label" id="label_cidade" for="city">{$_L['City']}</label>
                   <select name="city" id="modal_edit_address_city" class="form-control modal_edit_address_select" style="width:100%">
                   </select>
                </div>   


                <div class="col-md-12 col-sm-12 col-xs-12">
                    <label class="control-label" for="address">{$_L['Address']}</label>
                   <input value="{$address['address']}" type="text" id="modal_edit_address_address" name="address" class="form-control" maxlength="100"/>
                </div>
                <div class="col-md-4 col-sm-12 col-xs-12">
                    <label class="control-label">{$_L['Neighborhood']}</label>
                    <input value="{$address['neighborhood']}" type="text" id="modal_edit_address_neighborhood" name="neighborhood" class="form-control" maxlength="100"/>
                </div>

                <div class="col-md-2 col-sm-12 col-xs-12">
                    <label class="control-label">{$_L['Number']}</label>
                    <input value="{$address['number']}"  type="text" id="modal_edit_address_number" name="number" class="form-control" maxlength="100"/>
                </div> 

                <div class="col-md-6 col-sm-12 col-xs-12">
                    <label class="control-label" >{$_L['Complement']}</label>
                    <input value="{$address['complement']}"  type="text" id="modal_edit_address_complement" name="complement" class="form-control" maxlength="100"/>
                </div> 

                <div class="col-md-12 checkbox _hide-from-view">
                    <label>
                            <input name="billing_address" value="Y" id="modal_edit_address_billing_address" type="checkbox" {if $d['billing_address']=='Y'}checked{/if}>
                            <p>{$_L['Has billing address different from main address']}</p>
                    </label>
                </div>
            </div>
            <div class='row' id="modal_edit_address_not_equal_billing_address">
                <div class="col-xs-12 div_form">  <h2> {$_L['Different billing address']}</h2> </div>
             
                <div class="col-md-3 col-sm-12 col-xs-12">
                    <label class="control-label" for="zip">{$_L['ZIP Postal Code']} </label>
                    <input value="{$address_c['zip']}" type="text" id="modal_edit_address_zip_c" name="zip_c" class="cep form-control">
                </div>

                <div class="col-md-4 col-sm-12 col-xs-12">
                   <label class="control-label" for="state">{$_L['State Region']}</label>
                   <select name="state_c" id="modal_edit_address_state_c" class="form-control modal_edit_address_select" style="width:100%">
                       <option value="">{$_L['Select State']}</option>
                            {foreach $state as $e}
                                <option value="{$e['id']}" {if $address_c['state_id']==$e['id']} selected{/if}>{$e['state_name']}</option>
                            {/foreach}
                   </select>
                </div>                 

                <div class="col-md-5 col-sm-12 col-xs-12">
                   <label class=" control-label" id="label_cidade" for="city">{$_L['City']}</label>
                   <select name="city_c" id="modal_edit_address_city_c" class="form-control modal_edit_address_select" style="width:100%">

                   </select>
                </div>   

                <div class="col-md-12 col-sm-12 col-xs-12">
                    <label class="control-label" for="address">{$_L['Address']}</label>
                   <input value="{$address_c['address']}" type="text" id="modal_edit_address_address_c" name="address_c" class="form-control" maxlength="100"/>
                </div>
                <div class="col-md-4 col-sm-12 col-xs-12">
                    <label class="control-label" >{$_L['Neighborhood']}</label>
                    <input value="{$address_c['neighborhood']}" type="text" id="modal_edit_address_neighborhood_c" name="neighborhood_c" class="form-control" maxlength="100"/>
                </div>

                <div class="col-md-2 col-sm-12 col-xs-12">
                    <label class="control-label" for="numero">{$_L['Number']}</label>
                    <input value="{$address_c['number']}" type="text" id="modal_edit_address_number_c" name="number_c" class="form-control" maxlength="100"/>
                </div> 

                <div class="col-md-6 col-sm-12 col-xs-12">
                    <label class="control-label" for="complemento">{$_L['Complement']}</label>
                    <input value="{$address_c['complement']}" type="text" id="modal_edit_address_complement_c" name="complement_c" class="form-control" maxlength="100"/>
                </div> 
            </div>
 
    <input type="hidden" name="fcid" id="fcid" value="{$d['id']}"> 
</form>


</div>
                
<div class="modal-footer">
    <button type="button" data-dismiss="modal" class="btn btn-danger">{$_L['Cancel']}</button>
    <button class="btn btn-primary modal_edit_address_contact_submit" type="submit" id="modal_edit_address_contact_submit"><i class="fa fa-check"></i> {$_L['Edit Contact Address']}</button>
</div>

<input type="hidden" id="select_city_id" value="{$address['city_id']}">
<input type="hidden" id="select_city_id_c" value="{$address_c['city_id']}">
<input type="hidden" id="select_state" value="{$_L['Select State']}">
<input type="hidden" id="select_city" value="{$_L['Select City']}">