<html> <body> <form-template> <fields> <field type="header" subtype="h2" label="Full name"/> <field type="text" label="Prefix" name="prefix" subtype="text" className="form-control"/> <field type="text" required="true" label="First name" name="first-name" subtype="text" className="form-control"/> <field type="text" label="Middle name" name="middle-name" subtype="text" className="form-control"/> <field type="text" required="true" label="Last name" name="last-name" subtype="text" className="form-control"/> <field type="text" label="Suffix" name="suffix" subtype="text" className="form-control"/> <field type="text" label="Preferred name" name="preferred-name" subtype="text" className="form-control"/> <field type="text" required="true" label="Email" name="email" subtype="text" className="form-control"/> <field type="header" subtype="h2" label="Address"/> <field type="text" required="true" label="Line 1" name="address-line-1" subtype="text" className="form-control"/> <field type="text" label="Line 2" name="address-line-2" subtype="text" className="form-control"/> <field type="text" required="true" label="City" name="address-city" subtype="text" className="form-control"/> <field type="text" required="true" label="State" name="address-state" subtype="text" className="form-control"/> <field type="text" required="true" label="Zip" name="address-zip" subtype="text" className="form-control"/> <field type="text" label="Country" name="address-country" subtype="text" className="form-control"/> <field type="text" required="true" label="Phone number" name="phone-number" subtype="text" className="form-control"/> <field type="text" required="true" label="Dates of travel" name="dates-of-travel" subtype="text" className="form-control"/> <field type="text" required="true" label="Where are you traveling to" name="where-are-you-traveling-to" subtype="text" className="form-control"/> <field type="text" required="true" label="Total cost of travel" name="total-cost-of-travel" subtype="text" className="form-control"/> <field type="text" required="true" label="How many travelers" name="how-many-travelers" subtype="text" className="form-control"/> <field type="text" required="true" label="Age of travelers (separate ages with commas)" name="age-of-travelers-separate-ages-with-commas" subtype="text" className="form-control"/> <field type="header" subtype="h2" label="Travel Insurance"/> <field type="paragraph" subtype="p" label="By signing below, I understand that declining travel insurance could result in the loss of my travel cost and/or require more money to correct the situation. I also acknowledge that without insurance, there may be no way to recoup any losses, costs or expenses incurred."/> <field type="header" subtype="h1" label=" "/> <field type="radio-group" label="Please choose:" name="please-choose"> <option label="I ACCEPT Travel Insurance." value="accept">I ACCEPT Travel Insurance.</option> <option label="I DECLINE Travel Insurance. I understand that this could result in the loss of ALL of my travel costs." value="decline">I DECLINE Travel Insurance. I understand that this could result in the loss of ALL of my travel costs.</option> </field> <field type="text" required="true" label="Type your name" name="type-your-name" subtype="text" className="form-control"/> </fields> </form-template> </body> </html>
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