<form id="edit-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Address_city')}:</label>
        <div class="col-xs-12 col-sm-8">
            <div class='control-relative'>
                <input id="c-address_city" data-rule="required" class="form-control form-control" data-toggle="city-picker" name="row[address_city]" value="{$row.address_city}" type="text">
            </div>
            <input type="hidden" id="province" name="row[province]" value="{$row.province}" >
            <input type="hidden" id="city" name="row[city]" value="{$row.city}" >
            <input type="hidden" id="district" name="row[district]" value="{$row.district}" >
        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-primary btn-embossed disabled">{:__('OK')}</button>
        </div>
    </div>
</form>