<fieldset class="content-group">
    <legend id="location_name" class="text-bold">Add New Location</legend>
    <input type="hidden" id="location_id" name="location_id" value="0">

    <!-- Basic text input -->
    <!-- Basic text input -->
    <div class="form-group">
        <label class="control-label col-lg-3">Branch Name <span class="text-danger">*</span></label>
        <div class="col-lg-9">
            <input type="text" id="loc_name" name="loc_name" class="form-control" required="required" placeholder="Location Name">
        </div>
    </div>
    <!-- /basic text input -->
    <!-- Basic text input -->
    <div class="form-group">
        <label class="control-label col-lg-3">Phone <span class="text-danger">*</span></label>
        <div class="col-lg-9">
            <input type="text" id="phone" name="phone" class="form-control" required="required" placeholder="phone">
        </div>
    </div>
    <!-- /basic text input -->

    <!-- Input with icons -->
    <div class="form-group has-feedback">
        <label class="control-label col-lg-3">Address <span class="text-danger">*</span></label>
        <div class="col-lg-9">
            <input type="text" id="street" name="street" class="form-control" required="required" placeholder="Address">

        </div>
    </div>
    <!-- /input with icons -->

    <!-- Input with icons -->
    <div class="form-group has-feedback">
        <label class="control-label col-lg-3">City <span class="text-danger">*</span></label>
        <div class="col-lg-9">
            <input type="text" id="city" name="city" class="form-control" required="required" placeholder="City">

        </div>
    </div>
    <!-- /input with icons -->

    <!-- Multiple select -->
    <div class="form-group">
        <label class="control-label col-lg-3">State <span class="text-danger">*</span></label>
        <div class="col-lg-9">
           <?=$states_combo?>
        </div>
    </div>
    <!-- /multiple select -->
    <!-- Input group -->
    <div class="form-group">
        <label class="control-label col-lg-3">Zipcode <span class="text-danger">*</span></label>
        <div class="col-lg-9">
            <div class="input-group">
                <input type="text" id="zipcode" name="zipcode" class="form-control" required="required" placeholder="Zipcode">
            </div>
        </div>
    </div>
    <!-- /input group -->   
    <div class="text-right">
        <button type="submit" class="btn btn-primary btn-xs">Submit <i class="icon-arrow-right14 position-right"></i></button>
    </div>
</fieldset>
