chrome/browser/resources/options/autofill_edit_address_overlay.html

<div id="autofill-edit-address-overlay" class="page" hidden>
  <div class="close-button"></div>
  <h1 id="autofill-address-title"></h1>
  <div class="content-area">
    <div>
      <div id="autofill-name-labels">
        <span i18n-content="autofillFirstNameLabel"></span>
        <span i18n-content="autofillMiddleNameLabel"></span>
        <span i18n-content="autofillLastNameLabel"></span>
      </div>
    </div>
    <div>
      <list id="full-name-list"></list>
    </div>

    <label class="settings-row">
      <div i18n-content="autofillCompanyNameLabel"></div>
      <input id="company-name" type="text">
    </label>

    <label class="settings-row">
      <div i18n-content="autofillAddrLine1Label"></div>
      <input id="addr-line-1" type="text">
    </label>

    <label class="settings-row">
      <div i18n-content="autofillAddrLine2Label"></div>
      <input id="addr-line-2" type="text">
    </label>

    <div class="input-group settings-row">
      <label>
        <div i18n-content="autofillCityLabel"></div>
        <input id="city" type="text">
      </label>

      <label>
        <div id="state-label"></div>
        <input id="state" type="text">
      </label>

      <label>
        <div id="postal-code-label"></div>
        <input id="postal-code" type="text">
      </label>
    </div>

    <div class="settings-row">
      <div i18n-content="autofillCountryLabel"></div>
      <select id="country"></select>
    </div>

    <div class="input-group settings-row">
      <div>
        <div i18n-content="autofillPhoneLabel"></div>
        <list id="phone-list"
            i18n-values="placeholder:autofillAddPhonePlaceholder"></list>
      </div>

      <div>
        <div i18n-content="autofillEmailLabel"></div>
        <list id="email-list"
            i18n-values="placeholder:autofillAddEmailPlaceholder"></list>
      </div>
    </div>

  </div>

  <div class="action-area button-strip">
    <button id="autofill-edit-address-cancel-button" type="reset"
        i18n-content="cancel"></button>
    <button id="autofill-edit-address-apply-button" type="submit"
        class="default-button" i18n-content="ok" disabled></button>
  </div>
</div>