<form class="list">

  <input id="c1_id" type="hidden" value="">

  <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="c1_name" value="" type="text" placeholder="Name">

        </div>

      </div>

    </li>

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

      <div class="item-inner">

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

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

          <input id="c1_initial" type="text" placeholder="Initial">

        </div>

      </div>

    </li>

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

      <div class="item-inner">

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

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

          <input id="c1_nib" type="text" placeholder="NIB">

        </div>

      </div>

    </li>

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

      <div class="item-inner">

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

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

          <input id="c1_npwp" type="text" placeholder="NPWP">

        </div>

      </div>

    </li>

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

      <div class="item-inner">

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

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

          <input id="c1_address" type="text" placeholder="Address">

        </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">City</div>

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

                <input id="c1_city" type="text" placeholder="City">

              </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">PostCode</div>

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

                <input id="c1_postcode" type="text" placeholder="PostCode">

              </div>

            </div>

          </div>

        </div>

      </div>

    </li>

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

  </ul>

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

  <div class="container">

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

  </div>

</form>

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