gistfile1.html

<form id="create-order-form" method="post" name="create_order_form" novalidate=""
      data-extend="CreateOrderForm"
      data-subscribe='on-fields-change : validate'
      data-coform-validator-type='server-side'>

    <div class="h-mb-20">
        <select id="dd_payment_option"
                name="dd_payment_option"
                data-extend="SimpleDropdown "
                data-subscribe=' on-error@create-order-form "dd_payment_option" : show-error
                               ; click : SimpleDropdown/open'
                class="b-drop-down b-drop-down_color_light-bottom b-drop-down_width_218">
            <option selected=selected> --Выберите способ оплаты-- </option>    
            <option value="185510"> Безналичный расчет </option>
            <option value="185511"> Наложенный платеж фирмой "НОВАЯ ПОЧТА"</option>
            <option value="185515"> На платежную карту Приватбанка </option>
            <option value="185525"> Наложенный платеж фирмой "Автолюкс"</option>
        </select>
    </div>

    <div class="h-mb-20">
        <select id="dd_delivery_option"
                name="dd_delivery_option"
                data-extend="SimpleDropdown "
                data-subscribe=' on-error@create-order-form "dd_delivery_option" : show-error
                               ; click : SimpleDropdown/open'                
                class="b-drop-down b-drop-down_color_light-bottom b-drop-down_width_218">
            <option selected=selected> --Выберите способ доставки-- </option>    
            <option value="227756"> Доставка почтой </option>
            <option value="227757"> Транспортная компания </option>
            <option value="468210"> НОВА ПОШТА </option>
        </select>
    </div>

    <div id="address_zip_code_line" class="b-input b-order-prepare__zip-code h-hidden">
        <input id="address_zip_code" name="address_zip_code" 
               data-extend="SimpleDropdown "
               data-subscribe=' on-error@create-order-form "address_zip_code" : show-error
                              ; click : SimpleDropdown/open'
               class="b-input__field" 
               type="text" placeholder="Индекс" value="" tabindex="3" disabled="disabled">
    </div>
    
    <div id="dd_country_option" class="h-layout-hidden">
        <input id="address_region"name="address_region"
               data-extend="RegionSelector"
               data-subscribe=' on-error@create-order-form "address_region" : show-error
                              ; click : RegionSelector/open'               
               class="b-drop-down b-drop-down_color_light-bottom b-drop-down_width_218"
               type="text" value="194012000" tabindex="4" />
    </div>
    
    <div class="h-layout-clear"></div>

    <div class="h-mv-20">
        <div id="address_city_line" class="b-input" style="display: none;">
            <input id="address_city" name="address_city" 
                   data-subscribe='on-error@create-order-form "address_city" : show-error'
                   class="b-input__field" 
                   placeholder="Город" type="text" value="" tabindex="5" />
        </div>
    </div>
    
    <div class="h-mv-20">
        <div id="address_street_line" class="b-input" style="">
            <input id="address_street" name="address_street" 
                   data-subscribe='on-error@create-order-form "address_street" : show-error'
                   class="b-input__field" 
                   type="text" placeholder="Адрес" value="fgh" tabindex="6" />
        </div>
    </div>
    
    <div class="h-mv-20">
        <div id="from_last_name_line" class="b-input h-hidden">
            <input id="from_last_name" name="from_last_name"
                   data-subscribe='on-error@create-order-form "from_last_name" : show-error' 
                   class="b-input__field" 
                   type="text" placeholder="Фамилия" value="qqq" tabindex="7" />
        </div>
    </div>
    
    <div id="from_second_name_line" class="b-input_width_50-percent h-layout-right h-ml-5">
        <input id="from_second_name" name="from_second_name" 
               data-subscribe='on-error@create-order-form "from_second_name" : show-error' 
               class="b-input__field" 
               type="text" placeholder="Отчество"value="" tabindex="9" />
    </div>
    
    <div id="from_first_name_line" class="b-input h-layout-hidden">
        <input id="from_first_name" name="from_first_name" 
               data-subscribe='on-error@create-order-form "from_first_name" : show-error' 
               class="b-input__field" 
               type="text" placeholder="Имя" value="qqq" tabindex="8" />
    </div>
    
    <div class="h-layout-clear"></div>
    
    <div class="h-mv-20">
        <div id="from_email_line" class="b-input">
            <input id="from_email" name="from_email" 
                   data-subscribe='on-error@create-order-form "from_email" : show-error' 
                   class="b-input__field js-input" 
                   type="email" placeholder="Email" value="e.naumenko+fx@smartweb.com.ua" 
                   maxlength="255" tabindex="10" />
        </div>
    </div>
    
    <div class="h-mv-20">
        <input id="phones_dict" name="phones_dict" 
               data-extend='PhonesInput' 
               data-subscribe='on-error@create-order-form "phones_dict" : show-error' 
               type="hidden" value="380" tabindex="11" />

        <span class="b-input__hint">
            Ваш номер будет использован только для обработки данного заказа.
        </span>
    </div>
    
    <div class="h-mv-20">
        <span data-subscribe='click : show@client-notes-box'
              class="b-shopping-cart__client-notes-toggle medium-text">
            Комментарий к заказу
        </span>
        <div id='client-notes-box' 
             data-extend="Toggler"
             class="b-input js-client_notes-content h-hidden">
            <textarea id="client_notes" name="client_notes" 
                      data-subscribe='on-error@create-order-form "client_notes" : show-error' 
                      class="b-input__field b-input__field_height_100" 
                      placeholder="Комментарий к заказу" tabindex="14"></textarea>
        </div>
    </div>
    
    <div id="send_invoice_line" class="h-mt-5">
        <input id="send_invoice" name="send_invoice" 
               class="check"  
               type="checkbox" tabindex="15" />

        <label for="send_invoice">Выслать счет-фактуру</label>
    </div>

    <div class="h-mv-20">
        <input id="agreement" name="agreement" 
               data-subscribe='on-error@create-order-form "agreement" : show-error' 
               checked="checked" type="checkbox" tabindex="16"
               class="check" />

        <label for="agreement" class="b-order-prepare__medium-text">
            Я соглашаюсь с <a class="b-overlay__link" href="/privacy-policy">политикой конфиденциальности</a>
        </label>
    </div>
    
    <button data-subscribe="click : submit@create-order-form"
            class="b-button-colored b-button-colored_theme_dark-orange b-button-colored_size_big" 
            tabindex="17">
        <span class="b-button-colored__text medium-text">Отправить заказ </span>
    </button>

    <div class="h-layout-clear"></div>
</form>