Form city and state autofill html

Form HTML

<form id="bronto" class="span12 cat-request" action="http://app.bronto.com/public/webform/process/" method="post" target="_parent">
  <div id="row_3781" class="section">
    <div style="clear: both;">&nbsp;</div>
  </div>
  <div style="clear: both;">&nbsp;</div>
  <div class="info_block first">
    <div class="block">
      <input id="field_63353" class="text field" type="text" name="11341[63353]" value="" size="47" autocomplete="off" required="">
      <label for="field_63353">First Name</label>
    </div>
  </div>
  <div class="info_block last">
    <div class="block">
      <input id="field_63354" class="text field" type="text" name="11346[63354]" value="" size="47" autocomplete="off" required="">
      <label for="field_63354">Last Name</label>
    </div>
  </div>
  <div class="info_block add-1">
    <div class="block">
      <input id="field_65180" class="text field" type="text" name="11342[65180]" value="" size="110" autocomplete="off" required="">
      <label for="field_65180">Address 1 (Primary Mailing Address)</label>
    </div>
  </div>
  <div class="info_block add-2">
    <div class="block">
      <input id="field_65181" class="text field" type="text" name="11343[65181]" value="" size="110" autocomplete="off">
      <label for="field_65181">Address 2 (Suite and Apt numbers)</label>
    </div>
  </div>
  <div class="info_block country">
    <div class="block">
      <select id="field_65183" class="select defaulted" name="11348[65183]">
        <option value="ua">Ukraine</option>
        <option value="ae">United Arab Emirates</option>
        <option value="gb">United Kingdom</option>
        <option selected="selected" value="us">United States</option>
        <option value="um">United States Minor Outlying Islands</option>
        <option value="uy">Uruguay</option>
        <option value="uz">Uzbekistan</option>
      </select>
      <label for="field_65183">Country</label>
    </div>
  </div>
  <div class="info_block zip">
    <div class="block">
      <input id="field_65185" class="text field zip-code" type="text" name="11345[65185]" value="" size="47" maxlength="10" autocomplete="off" required="">
      <label for="field_65185">Zip Code or Postal Code</label>
      <div class="field_error" style="margin-top: 10px; display: none;">
        <div class="alert alert-danger">Whoa There! We couldn't find that zip code.</div>
      </div>
    </div>
  </div>
  <div class="info_block city" style="display: block;">
    <div class="block">
      <input id="field_65182" class="text field" type="text" name="11344[65182]" value="" size="47" autocomplete="off" required="">
      <label for="field_65182">City</label>
    </div>
  </div>
  <div class="info_block state" style="display: block;">
    <div class="block">
      <input id="field_65186" class="text field" type="text" name="11347[65186]" value="" size="47" autocomplete="off" required="">
      <label for="field_65186">State/Province</label>
    </div>
  </div>
  <div class="info_block email">
    <div class="block">
      <input id="cust-email" class="text field fb-email" type="text" name="11349" value="" size="47" autocomplete="off" required="">
      <label for="cust-email">Email Address</label>
    </div>
  </div>
  <div style="clear: both;">&nbsp;</div>
  <div id="row_4155" class="section">
    <div id="column_5359" class="content-container" style="text-align: left;">
      <div class="field_block">
        <div class="field">
          <div align="center"><span>
            <input class="btn btn-primary btn-xlarge" type="submit" value="Submit Catalog Request">
            </span></div>
        </div>
      </div>
      <div align="center">
        <input type="hidden" name="11375[202413]" value="true">
      </div>
    </div>
    <div style="clear: both;">&nbsp;</div>
  </div>
</form>