<div class="ecp-component ecp_EditBillingAddress">
  <h2>{message:EditBillingAddress/Title}</h2>
  <form class="ecp-form">
    <div class="ecp-form-fieldset-scrunched">
      <input type="text" name="first_name" placeholder="{message:EditBillingAddress/FirstNameInput}" aria-label="{message:EditBillingAddress/FirstNameInputLabel}" autocomplete="billing given-name" required>
      <input type="text" name="last_name" placeholder="{message:EditBillingAddress/LastNameInput}" aria-label="{message:EditBillingAddress/LastNameInputLabel}" autocomplete="billing family-name" required>
      <input type="text" name="company_name" placeholder="{message:EditBillingAddress/CompanyNameInput}" aria-label="{message:EditBillingAddress/CompanyNameInputLabel}" autocomplete="billing organization">
      <input type="text" name="address_line_1" placeholder="{message:EditBillingAddress/AddressLine1Input}" aria-label="{message:EditBillingAddress/AddressLine1InputLabel}" autocomplete="billing address-line1" required>
      <input type="text" name="address_line_2" placeholder="{message:EditBillingAddress/AddressLine2Input}" aria-label="{message:EditBillingAddress/AddressLine2InputLabel}" autocomplete="billing address-line2">
      <input type="text" name="city" placeholder="{message:EditBillingAddress/CityInput}" aria-label="{message:EditBillingAddress/CityInputLabel}" autocomplete="billing address-level2" required>
      <select name="state_code" aria-label="{message:EditBillingAddress/StateCodeLabel}" autocomplete="billing address-level1" required>
        <!-- | Address__StateOption template | -->
      </select>
      <input type="text" name="region" placeholder="{message:EditBillingAddress/RegionInput}" aria-label="{message:EditBillingAddress/RegionInputLabel}" autocomplete="billing address-level1">
      <input type="text" name="postal_code" placeholder="{message:EditBillingAddress/PostalCodeInput}" aria-label="{message:EditBillingAddress/PostalCodeInputLabel}" autocomplete="billing postal-code" required>
      <input type="text" name="zip_extension" placeholder="{message:EditBillingAddress/ZipExtensionInput}" maxlength="4" aria-label="{message:EditBillingAddress/ZipExtensionInputLabel}" autocomplete="xyzpdq">
      <select name="country_code" data-ecp-action="change-country">
        <!-- | Address__CountryOption template | -->
      </select>
    </div>
    <p class="ecp-summary">{message:EditBillingAddress/PhoneAndBirthDateInfo}</p>
    <div class="ecp-form-fieldset-scrunched">
      <input type="text" name="birth_date" placeholder="{message:EditBillingAddress/BirthDateInput}" aria-label="{message:EditBillingAddress/BirthDateInputLabel}" autocomplete="bday" required>
      <input type="text" name="phone" placeholder="{message:EditBillingAddress/PhoneInput}" aria-label="{message:EditBillingAddress/PhoneInputLabel}" autocomplete="mobile tel" required>
    </div>
    <div class="ecp-grid">
      <div class="ecp-grid-row ecp-clearfix">
        <span class="ecp-grid-col-6">
          <button class="ecp-secondary" data-ecp-action="cancel" aria-label="{message:EditBillingAddress/CancelButtonLabel}">{message:EditBillingAddress/CancelButton}</button>
        </span>
        <span class="ecp-grid-col-6">
          <button data-ecp-action="save" aria-label="{message:EditBillingAddress/SaveButtonLabel}">{message:EditBillingAddress/SaveButton}</button>
        </span>
      </div>
    </div>
  </form>
</div>