<div class="control-group">
   <label class="control-label">Location</label>
   <div class="controls">
     <input name="location" type="text" placeholder="City, State, Country" value=""> 
     <input name="location_city" type="hidden" value="">
     <input name="location_state" type="hidden" value="">
     <input name="location_country" type="hidden" value="">
     <input name="location_lat" type="hidden">
     <input name="location_lng" type="hidden">
    </div>
</div>