<form class="form-horizontal">
<fieldset>
<!-- Form Name -->
<legend>Source address</legend>
<!-- Select Basic -->
<div class="form-group">
<label class="col-md-4 control-label" for="Country">Country</label>
<div class="col-md-5">
<select id="Country" name="Country" class="form-control">
<option value="IR">IR Iran</option>
<option value="USA">United States</option>
</select>
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-4 control-label" for="State">State</label>
<div class="col-md-6">
<input id="State" name="State" type="text" placeholder="state" class="form-control input-md" required="">
<span class="help-block">Enter Source state</span>
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-4 control-label" for="city">City/Town</label>
<div class="col-md-6">
<input id="city" name="city" type="text" placeholder="city or town" class="form-control input-md" required="">
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-4 control-label" for="address1">Address Line1</label>
<div class="col-md-8">
<input id="address1" name="address1" type="text" placeholder="" class="form-control input-md">
<span class="help-block">Street address, P.O. box, company name, c/o</span>
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-4 control-label" for="Address2">Address Line2</label>
<div class="col-md-8">
<input id="Address2" name="Address2" type="text" placeholder="" class="form-control input-md">
<span class="help-block">Apartment, suite , unit, building, floor, etc.</span>
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-4 control-label" for="zip">Zip/Postal code</label>
<div class="col-md-4">
<input id="zip" name="zip" type="text" placeholder="zip or postal code" class="form-control input-md" required="">
</div>
</div>
</fieldset>
</form>
