Share your information with Robin Miller

Robin Miller

<html>
  <body>
    <form-template>&#13;
	<fields>&#13;
		<field type="header" subtype="h2" label="Questions for your trip"/>&#13;
		<field type="header" subtype="h2" label="Full name"/>&#13;
		<field type="text" label="Prefix" name="prefix" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="First name" name="first-name" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Middle name" name="middle-name" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Last name" name="last-name" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Phone number" name="phone-number" subtype="text" className="form-control"/>&#13;
		<field type="header" subtype="h2" label="Address"/>&#13;
		<field type="text" label="Line 1" name="address-line-1" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Line 2" name="address-line-2" subtype="text" className="form-control"/>&#13;
		<field type="text" label="City" name="address-city" subtype="text" className="form-control"/>&#13;
		<field type="text" label="State" name="address-state" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Zip" name="address-zip" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Country" name="address-country" subtype="text" className="form-control"/>&#13;
		<field required="true"  type="text" label="Email" name="email" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Where would you like to go?" description="If you&#39;re not sure  just give me a few destinations you&#39;re considering." placeholder="ex: Tahiti" name="destination" subtype="text" className="form-control"/>&#13;
		<field type="textarea" label="When would you like to travel?" name="when-would-you-like-to-travel" className="form-control"/>&#13;
		<field type="checkbox-group" label="Are your dates flexible?" name="dates-flexible">&#13;
			<option label="Yes" value="yes">Yes</option>&#13;
		</field>&#13;
		<field type="radio-group" label="How soon are you looking to book?&amp;nbsp;" name="how-soon-are-you-looking-to-book-">&#13;
			<option label="Today" value="today">Today</option>&#13;
			<option label="Within next 7 - 10 days" value="within-next-7-10-days">Within next 7 - 10 days</option>&#13;
			<option label="In a few months" value="in-a-few-months">In a few months</option>&#13;
			<option label="Just considering options" value="just-considering-options">Just considering options</option>&#13;
		</field>&#13;
		<field type="text" label="What is your departure city/airport?" description="Where will you be flying from?" name="departure-city" subtype="text" className="form-control"/>&#13;
		<field type="text" label="How many travelers?" name="number-of-travelers" subtype="text" className="form-control"/>&#13;
		<field type="textarea" label="First/Last Name as on Passport, Birthdate, Gender of entire party" name="firstlast-name-birthdate-gender" className="form-control"/>&#13;
		<field type="radio-group" label="What is your budget for all travelers?" description="This just gives me a general starting point and can always be changed later." name="budget">&#13;
			<option label="$1,500 to $3,500" value="1500-to-3500">$1,500 to $3,500</option>&#13;
			<option label="$3,500 to $6,000" value="3500-to-6000">$3,500 to $6,000</option>&#13;
			<option label="$6,000 to $9,000" value="6000-to-9000">$6,000 to $9,000</option>&#13;
			<option label="$9,000 to $15,000" value="9000-to-15000">$9,000 to $15,000</option>&#13;
			<option label="$15,000 to $25,000" value="15000-to-25000">$15,000 to $25,000</option>&#13;
			<option label="$25,000+" value="25000">$25,000+</option>&#13;
		</field>&#13;
		<field type="radio-group" label="What best describes your hotel preference?" name="hotel-preference" other="true">&#13;
			<option label="Economy" value="economy">Economy</option>&#13;
			<option label="Moderate" value="moderate">Moderate</option>&#13;
			<option label="Luxury" value="luxury">Luxury</option>&#13;
			<option label="Boutique" value="boutique">Boutique</option>&#13;
		</field>&#13;
		<field type="radio-group" label="Are you interested in travel insurance?&amp;nbsp;" name="are-you-interested-in-travel-insurance-">&#13;
			<option label="Yes" value="yes">Yes</option>&#13;
			<option label="No" value="no">No</option>&#13;
			<option label="Maybe" value="maybe">Maybe</option>&#13;
		</field>&#13;
		<field type="text" label="Reward Programs - Tell me if there are any reward programs you want to use? if so, provide reward #." description="Tell me the name of the program (Ex: Marriott, Hilton, AmEx, etc...) plus the program number. We will talk before any program  points are used." name="reward-programs-tell-me-if-there-are-any-reward-programs-you-want-to-use-if-so-provide-reward-" subtype="text" className="form-control"/>&#13;
		<field type="textarea" label="Who can I thank for referring you to me?" name="who-can-i-thank-for-referring-you-to-me" className="form-control"/>&#13;
		<field type="textarea" label="Any Food Allergies/Medical Conditions/Special Needs to be made aware of?&amp;nbsp;" description="(Diabetic  Autism Spectrum  Wheelchair  Gluten-free  Etc.)" name="any-food-allergiesmedical-conditions-to-be-made-aware-of-" className="form-control"/>&#13;
		<field type="textarea" label="What else would you like me to know?" description="What else would you like me to know about your travelers  budget and/or travel preferences?" name="notes" className="form-control"/>&#13;
		<field type="checkbox-group" required="true" label="Preferred method of communication" description="(Click all that apply)" toggle="true" name="preferred-method-of-communication">&#13;
			<option label="Phone" value="phone">Phone</option>&#13;
			<option label="Text" value="text">Text</option>&#13;
			<option label="Email" value="email">Email</option>&#13;
		</field>&#13;
		<field type="checkbox-group" required="true" label="By submitting this quote, you are giving me permission to text the above phone number&amp;nbsp; (or email) with relevant information concerning your request and add your email to my email list.&amp;nbsp;" name="permission-to-text">&#13;
			<option label="Yes, I understand. Please text!" value="yes-i-understand-please-text">Yes, I understand. Please text!</option>&#13;
		</field>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>