MOdx Компонент

<form action="" method="post" id="address__form">
    	        <div class="address__name">
        	        <input type="text" name="name_address" id="in_address" placeholder="Название адреса">
        	        <div class="checkbox">
                        <input type="checkbox" name="address_default" id="ad">
                        <label for="ad">Сделать основным</label>
                    </div>
        	    </div>
        	    <div class="address__input">
        	        <input type="text" name="postcode" placeholder="Индекс">
        	        <input type="text" name="city" id="address_city" placeholder="Населенный пункт">
        	        <input type="text" name="street" id="address_street" placeholder="Улица">
        	        <input type="text" name="home" placeholder="Дом">
        	        <input type="text" name="building" placeholder="Корпус">
        	        <input type="text" name="building1" placeholder="Строение">
        	        <input type="text" name="flat" placeholder="Квартира">
        	    </div>
        	    <textarea name="message" id="message" cols="30" rows="5" placeholder="Примечания"></textarea>
        	    <button type="button" class="btn-dark">Сохранить</button>
    	    </form>