<form class="list">

  <input id="a4_id" type="hidden" value="">

  <input id="a4_cat" type="hidden" value="5">

  <input id="a4_inout" type="hidden" value="2">        

  <ul>

    <li class="item-content item-input">

      <div class="item-inner">

        <div class="item-title item-label">Name</div>

        <div class="item-input-wrap">

          <input id="a4_name" value="" disabled type="text" placeholder="Name">

        </div>

      </div>

    </li>

    <li class="item-content item-input">

      <div class="item-inner">

        <div class="item-title item-label">Seller</div>

        <div class="item-input-wrap">

          <input id="a4_from" type="text" placeholder="From/Seller">

        </div>

      </div>

    </li>

    <li class="item-content item-input">

      <div class="item-inner">

        <div class="item-title item-label">Invoice</div>

        <div class="item-input-wrap">

          <input id="a4_invoice" type="text" placeholder="Invoice">

        </div>

      </div>

    </li>

    <li class="item-content item-input">

      <div class="item-inner">

        <div class="item-title item-label">Description</div>

        <div class="item-input-wrap">

          <textarea id="a4_descr" placeholder="Description"></textarea>

        </div>

      </div>

    </li>

    <li class="item-content item-input">

      <div class="row">

        <div class="col-50">

          <div class="item-content item-input item-input-with-value">

            <div class="item-inner">

              <div class="item-title item-label">Qty</div>

              <div class="item-input-wrap">

                <input id="a4_qty" type="text" placeholder="Qty">

              </div>

            </div>

          </div>

        </div>

        <div class="col-50">

          <div class="item-content item-input item-input-with-value">

            <div class="item-inner">

              <div class="item-title item-label">Price/unit</div>

              <div class="item-input-wrap">

                <input id="a4_price" type="text" placeholder="Price">

              </div>

            </div>

          </div>

        </div>

      </div>

    </li>

    <div class="separator-small"></div>

    <li class="item-content item-input">

      <div class="row">

        <div class="col-50">

          <div class="item-content item-input item-input-with-value">

            <div class="item-inner">

              <div class="item-title item-label">Action At</div>

              <div class="item-input-wrap">

                <input id="a4_action_at" type="date" placeholder="Action At">

              </div>

            </div>

          </div>

        </div>

        <div class="col-50">

          <div class="item-content item-input item-input-with-value">

            <div class="item-inner">

              <div class="item-title item-label">Due Days</div>

              <div class="item-input-wrap">

                <input id="a4_due_days" value="0" type="text" placeholder="Due Days">

              </div>

            </div>

          </div>

        </div>

      </div>

    </li>

  </ul>

  <div class="separator-medium"></div>

  <div class="container">

    <button id="product_buy_button" class="btn btn-primary btn-block fw-700">Save</button>

  </div>

</form>

<div class="separator-large"></div>