Hopefully this hasn't been answered before, if so I couldn't find it!

I am building a simple shipping request form. I want to have a section with a "SHIP TO" drop down list, but I want a traditional address format for the selections so the address comes out like:

Company ABC
1223 Main Street
City, State ZIP
Phone: xxx-xxx-xxxx
Contact: John Doe

I wanted to build a list of common places we ship to.

Any suggestions?

Thanks for any help.