Share your information with Candice Ortiz

Candice Ortiz

Travelmation

<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="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" required="true" 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="Email" name="email" subtype="text" className="form-control"/>&#13;
		<field type="header" subtype="h1" label="Let&#39;s Cruise!"/>&#13;
		<field type="header" subtype="h2" label="Travel Preferences"/>&#13;
		<field type="radio-group" required="true" label="What is your total budget for all travelers?" inline="true" name="what-is-your-total-budget-for-all-travelers" other="true">&#13;
			<option label="$1,500-$2,500" value="15002500">$1,500-$2,500</option>&#13;
			<option label="$2,500-$4,500" value="25004500">$2,500-$4,500</option>&#13;
			<option label="$4,500-$6,500" value="45006500">$4,500-$6,500</option>&#13;
			<option label="$6,500-$8,500" value="65008500">$6,500-$8,500</option>&#13;
			<option label="$8,500-$10,000" value="850010000">$8,500-$10,000</option>&#13;
			<option label="$10,000+" value="10000">$10,000+</option>&#13;
		</field>&#13;
		<field type="text" required="true" label="When are you looking to travel?" description="Please put time of year and/or calendar year." name="when-are-you-looking-to-travel" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="How Many Adults are Traveling?" name="how-many-adults-are-traveling" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="How Many Children are Traveling? &amp;nbsp;Please provide name(s) and age(s) at time of travel." description="If no children are going  please put a 0 or N/A." name="how-many-children-are-traveling-and-what-are-the-ages-at-the-time-of-travel" subtype="text" className="form-control"/>&#13;
		<field type="checkbox-group" required="true" label="Cruise Destination" description="Select your starting location(s) and then we can discuss specific locations." inline="true" name="cruise-destination" other="true">&#13;
			<option label="Caribbean " value="caribbean-">Caribbean </option>&#13;
			<option label="The Bahamas" value="the-bahamas">The Bahamas</option>&#13;
			<option label="Northern Europe" value="northern-europe">Northern Europe</option>&#13;
			<option label="Norwegian Fjords" value="norwegian-fjords">Norwegian Fjords</option>&#13;
			<option label="Mediterranean" value="mediterranean">Mediterranean</option>&#13;
			<option label="British Isles" value="british-isles">British Isles</option>&#13;
			<option label="Bermuda" value="bermuda">Bermuda</option>&#13;
			<option label="Alaska" value="alaska">Alaska</option>&#13;
			<option label="Canada" value="canada">Canada</option>&#13;
			<option label="Mexican Riviera" value="mexican-riviera">Mexican Riviera</option>&#13;
			<option label="Baja " value="baja-">Baja </option>&#13;
			<option label="Panama Canal" value="panama-canal">Panama Canal</option>&#13;
			<option label="Pacific Coast" value="pacific-coast">Pacific Coast</option>&#13;
			<option label="Transatlantic" value="transatlantic">Transatlantic</option>&#13;
			<option label="Hawai'i" value="hawaii">Hawai'i</option>&#13;
			<option label="South Pacific" value="south-pacific">South Pacific</option>&#13;
			<option label="New Zealand and Australia" value="new-zealand-and-australia">New Zealand and Australia</option>&#13;
			<option label="Specialty Cruises (i.e. Marvel Day at Sea, Pixar Day at Sea etc.)" value="specialty-cruises-ie-marvel-day-at-sea-pixar-day-at-sea-etc">Specialty Cruises (i.e. Marvel Day at Sea, Pixar Day at Sea etc.)</option>&#13;
		</field>&#13;
		<field type="radio-group" required="true" label="Ship Location Preference&amp;nbsp;" name="seat-preference">&#13;
			<option label="Forward" value="forward">Forward</option>&#13;
			<option label="Middle " value="middle-">Middle </option>&#13;
			<option label="Aft (back)" value="aft-back">Aft (back)</option>&#13;
		</field>&#13;
		<field type="radio-group" required="true" label="Stateroom Category and Location Preference" description="Please select a category and a preferred deck location." inline="true" name="bed-preference">&#13;
			<option label="Interior " value="interior-">Interior </option>&#13;
			<option label="Ocean View" value="ocean-view">Ocean View</option>&#13;
			<option label="Verandah / balcony" value="verandah-balcony">Verandah / balcony</option>&#13;
			<option label="Concierge (Disney)" value="concierge-disney">Concierge (Disney)</option>&#13;
			<option label="Suite" value="suite">Suite</option>&#13;
			<option label="Undecided " value="undecided-">Undecided </option>&#13;
			<option label="Lower Decks" value="lower-decks">Lower Decks</option>&#13;
			<option label="Middle Decks" value="middle-decks">Middle Decks</option>&#13;
			<option label="Higher Decks" value="higher-decks">Higher Decks</option>&#13;
			<option label="Undecided" value="undecided">Undecided</option>&#13;
		</field>&#13;
		<field type="textarea" label="Preferred Cruise Line(s)" name="preferred-cruise-lines" className="form-control"/>&#13;
		<field type="radio-group" label="Any Special Occasions?" description="Will you be celebrating anything while on the cruise?" name="any-special-occasions" other="true">&#13;
			<option label="Graduation" value="graduation">Graduation</option>&#13;
			<option label="Birthday" value="birthday">Birthday</option>&#13;
			<option label="Engagement" value="engagement">Engagement</option>&#13;
			<option label="Wedding" value="wedding">Wedding</option>&#13;
			<option label="Anniversary" value="anniversary">Anniversary</option>&#13;
			<option label="Bachelorette Party" value="bachelorette-party">Bachelorette Party</option>&#13;
			<option label="Bachelor Party " value="bachelor-party-">Bachelor Party </option>&#13;
			<option label="Honeymoon" value="honeymoon">Honeymoon</option>&#13;
			<option label="Babymoon" value="babymoon">Babymoon</option>&#13;
			<option label="Family Reunion" value="family-reunion">Family Reunion</option>&#13;
		</field>&#13;
		<field type="textarea" label="Preferred ship(s) (if any)" name="preferred-ships-if-any" className="form-control"/>&#13;
		<field type="textarea" label="Anything you&#39;d like me to know?" name="anything-youd-like-me-to-know" className="form-control"/>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>