<div class="field-group">
    <input type="hidden" name="id">
    <div class="field-wrapper">
        <label>Name</label>
        <input type="text" name="name">
    </div>
    <div class="field-wrapper">
        <label>Statement Date</label>
        <select name="statement_date"></select>
    </div>
    <div class="field-wrapper">
        <label>Billing Date</label>
        <select name="billing_date"></select>
    </div>
    <button class="field-group-button">Submit</button>
</div>