Share your information with Trinette Mitchell

Trinette Mitchell

Premiere Destinations Travel, LLC

<html>
  <body>
    <form-template>&#13;
	<fields>&#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="Suffix" name="suffix" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Preferred name" name="preferred-name" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Email" name="email" subtype="text" className="form-control"/>&#13;
		<field type="header" subtype="h2" label="Address"/>&#13;
		<field type="text" required="true" 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" required="true" label="City" name="address-city" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="State" name="address-state" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" 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 type="text" required="true" label="Phone number" name="phone-number" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Dates of travel" name="dates-of-travel" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Where are you traveling to" name="where-are-you-traveling-to" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="What is your total travel budget" name="total-cost-of-travel" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="How many travelers" name="how-many-travelers" subtype="text" className="form-control"/>&#13;
		<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"/>&#13;
		<field type="header" subtype="h2" label="Travel Insurance"/>&#13;
		<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."/>&#13;
		<field type="header" subtype="h1" label="  "/>&#13;
		<field type="radio-group" label="Please choose:" name="please-choose">&#13;
			<option label="I ACCEPT Travel Insurance." value="accept">I ACCEPT Travel Insurance.</option>&#13;
			<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>&#13;
		</field>&#13;
		<field type="text" required="true" label="Type your name" name="type-your-name" subtype="text" className="form-control"/>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>

By signing below, I authorize Premiere Destinations Travel, LLC to charge the credit card provided herein.

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