Share your information with Ajahnique Richardson

Ajahnique Richardson

Bloom Vacations with Ajahnique

<html>
  <body>
    <form-template>&#13;
	<fields>&#13;
		<field type="header" subtype="h2" label="Client Information"/>&#13;
		<field type="text" required="true" label="First name" name="first-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="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="text" label="Phone number" name="phone-number" subtype="text" className="form-control"/>&#13;
		<field type="checkbox-group" label="Are you interested in joining my travel community? You will receive monthly newsletters, exclusive discounts and much more!&amp;nbsp;&amp;nbsp;" name="are-you-interested-in-joining-my-travel-community-you-will-receive-monthly-newsletters-exclusive-discounts-and-much-more-">&#13;
			<option label="Sign me up" value="sign-me-up" selected="selected">Sign me up</option>&#13;
		</field>&#13;
		<field type="header" subtype="h2" label="Questions for your trip"/>&#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="date" required="true" label="When would you like to depart?" description="This just gives me a general idea of when you like to go; it can be changed later." name="starting-at" className="form-control"/>&#13;
		<field type="text" required="true" label="How many days are you looking to travel?" name="how-many-days-are-you-looking-to-travel" subtype="text" 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="select" label="When are you looking to book?" name="when-are-you-looking-to-book" className="form-control">&#13;
			<option label="Just shopping around" value="just-shopping-around" selected="selected">Just shopping around</option>&#13;
			<option label="Will book within the next 2 weeks" value="will-book-within-the-next-2-weeks">Will book within the next 2 weeks</option>&#13;
			<option label="Will book within the next few months" value="will-book-within-the-next-few-months">Will book within the next few months</option>&#13;
		</field>&#13;
		<field type="text" label="What is your departure city?" description="Where will you be flying from?" name="departure-city" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="How many travelers?" name="number-of-travelers" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Will any children be traveling? If yes, what will be there ages at time of travel?&amp;nbsp;" name="text-1735962579157" subtype="text" className="form-control"/>&#13;
		<field type="select" required="true" label="Do you and all travelers have passports?" description="Some destinations do require a passport and I will need a copy of a current passport." name="do-you-and-all-travelers-have-passports" className="form-control">&#13;
			<option label="No" value="no">No</option>&#13;
			<option label="Yes" value="yes">Yes</option>&#13;
			<option label="Not yet but will by the time of travel" value="not-yet-but-will-by-the-time-of-travel">Not yet but will by the time of travel</option>&#13;
		</field>&#13;
		<field type="radio-group" required="true" 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="Less than $1,500" value="less-than-1500">Less than $1,500</option>&#13;
			<option label="$1,500 to $2,500" value="1500-2500">$1,500 to $2,500</option>&#13;
			<option label="$2,500 to $4,500" value="2500-4500">$2,500 to $4,500</option>&#13;
			<option label="$4,500 to $6,500" value="4500-6500">$4,500 to $6,500</option>&#13;
			<option label="$6,500 to $8,500" value="6500-8500">$6,500 to $8,500</option>&#13;
			<option label="$8,500 to $10,000" value="8500-10000">$8,500 to $10,000</option>&#13;
			<option label="$10,000+" value="10000">$10,000+</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="value">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="checkbox-group" label="What kind of vibe are you looking for?" description="Check all that apply." name="vibe-preference" other="true">&#13;
			<option label="Romantic" value="romantic">Romantic</option>&#13;
			<option label="Rest and relaxation" value="rest-and-relaxation">Rest and relaxation</option>&#13;
			<option label="Off the beaten path" value="off-the-beaten-path">Off the beaten path</option>&#13;
			<option label="Party" value="party">Party</option>&#13;
			<option label="Local culture" value="local-culture">Local culture</option>&#13;
			<option label="Family friendly" value="family-friendly">Family friendly</option>&#13;
			<option label="Food and wine" value="food-wine">Food and wine</option>&#13;
		</field>&#13;
		<field type="checkbox-group" label="What activities are you interested in?" description="Check all that apply" name="activity-preferences" other="true">&#13;
			<option label="Beach and water" value="beach-water">Beach and water</option>&#13;
			<option label="Gambling" value="gambling">Gambling</option>&#13;
			<option label="Scuba" value="scuba">Scuba</option>&#13;
			<option label="Adventure activities" value="adventure">Adventure activities</option>&#13;
			<option label="Golf" value="golf">Golf</option>&#13;
			<option label="Nightlife" value="nightlife">Nightlife</option>&#13;
			<option label="Arts and theater" value="art-theater">Arts and theater</option>&#13;
		</field>&#13;
		<field type="text" label="Anything you absolutely must do or see?" name="must-dos" subtype="text" 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="I Understand that there is a $50 non-refundable fee that must be paid before a proposal is sent.&amp;nbsp;" name="i-understand-that-there-is-a-50-nonrefundable-fee-that-must-be-paid-before-a-proposal-is-sent-">&#13;
			<option label="I Agree" value="i-agree">I Agree</option>&#13;
			<option label="I Do Not Agree" value="i-do-not-agree">I Do Not Agree</option>&#13;
		</field>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>