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 id="autofill-edit-address-fields">
    </div>

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

    <div class="input-group settings-row">
      <div>
        <label>
          <div i18n-content="autofillPhoneLabel"></div>
          <input class="short" field="phone"></input>
        </label>
      </div>

      <div>
        <label>
          <div i18n-content="autofillEmailLabel"></div>
          <input class="short" field="email"></input>
        </label>
      </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>