Laurie Johnson

Azure Luxury Travel

<html>
  <body>
    <form-template>&#13;
	<fields>&#13;
		<field type="header" subtype="h2" label="Full name (as on passport)"/>&#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="header" subtype="h2" label="Address"/>&#13;
		<field type="text" required="true" label="Street Number" name="address-line-1" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Street Address" 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/Province" name="address-state" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Postal Code" 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="Email" name="email" 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="header" subtype="h1" label="Accommodation Options"/>&#13;
		<field type="select" required="true" label="Select" name="select-1729760052883" className="form-control">&#13;
			<option label="Casa Espavel bedroom 1" value="casa-espavel-bedroom-1">Casa Espavel bedroom 1</option>&#13;
			<option label="Casa Espavel bedroom 2" value="casa-espavel-bedroom-2">Casa Espavel bedroom 2</option>&#13;
			<option label="Casa Espavel bedroom 3" value="casa-espavel-bedroom-3">Casa Espavel bedroom 3</option>&#13;
			<option label="Casa Jardin bedroom 1" value="casa-jardin-bedroom-1">Casa Jardin bedroom 1</option>&#13;
			<option label="Casa Jardin bedroom 2" value="casa-jardin-bedroom-2">Casa Jardin bedroom 2</option>&#13;
			<option label="Casa Rio bedroom 1" value="casa-rio-bedroom-1">Casa Rio bedroom 1</option>&#13;
			<option label="Casa Rio bedroom 2" value="casa-rio-bedroom-2">Casa Rio bedroom 2</option>&#13;
			<option label="Casa Silva private villa" value="casa-silva-private-villa">Casa Silva private villa</option>&#13;
			<option label="Casa Mar private villa" value="casa-mar-private-villa">Casa Mar private villa</option>&#13;
			<option label="Casa Palma private villa" value="casa-palma-private-villa">Casa Palma private villa</option>&#13;
		</field>&#13;
		<field type="header" subtype="h1" label="Preferred Payment Method"/>&#13;
		<field type="radio-group" required="true" label="payment method" inline="true" name="payment-method">&#13;
			<option label="Bank Etransfer (CAD only)" value="bank-etransfer-cad-only">Bank Etransfer (CAD only)</option>&#13;
			<option label="Credit Card (Visa or Mastercard)" value="credit-card-visa-or-mastercard">Credit Card (Visa or Mastercard)</option>&#13;
		</field>&#13;
		<field type="paragraph" subtype="p" label="Laurie will be in touch to provide instructions for etransfers.&amp;nbsp; If your preferred method of payment is a credit card (this method incurs a fee of 3.45% per transaction), Laurie will send you a form to complete all the details."/>&#13;
		<field type="header" subtype="h2" label="Passport Info"/>&#13;
		<field type="text" required="true" label="Full name as it appears on passport" name="passport-name" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Passport number" name="passport-number" subtype="text" className="form-control"/>&#13;
		<field type="date" required="true" label="Date of birth" name="date-of-birth" className="form-control"/>&#13;
		<field type="text" required="true" label="Country of issue" name="passport-country-of-issue" subtype="text" className="form-control"/>&#13;
		<field type="date" required="true" label="Date of issue" name="passport-date-of-issue" className="form-control"/>&#13;
		<field type="date" required="true" label="Date of expiration" name="passport-date-of-expiration" className="form-control"/>&#13;
		<field type="radio-group" required="true" label="Gender" name="gender">&#13;
			<option label="F" value="female">F</option>&#13;
			<option label="M" value="male">M</option>&#13;
			<option label="X" value="other">X</option>&#13;
		</field>&#13;
		<field type="text" required="true" label="Place of birth (city)" name="place-of-birth" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Nationality" name="nationality" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Citizenship" name="citizenship" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Issuing Authority (city)" name="issuing-authority-city" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Have you attended a retreat with Liz or Linda in the past?" name="have-you-attended-a-retreat-with-liz-or-linda-in-the-past" subtype="text" className="form-control"/>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>