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Jennifer Medisch
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<html> <body> <form-template> <fields> <field type="header" subtype="h2" label="Questions for your trip"/> <field type="header" subtype="h3" label="Full name as it appears on your legal travel document, if your middle name is on your document please be sure to include it."/> <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="Preferred name" name="preferred-name" subtype="text" className="form-control"/> <field type="header" subtype="h2" label="Address"/> <field type="text" 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" label="City" name="address-city" subtype="text" className="form-control"/> <field type="text" label="State" name="address-state" subtype="text" className="form-control"/> <field type="text" 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" label="Phone number" name="phone-number" subtype="text" className="form-control"/> <field required="true" type="text" label="Email" name="email" subtype="text" className="form-control"/> <field type="radio-group" required="true" label="Where would you like to travel?" name="where-would-you-like-to-travel" other="true"> <option label="Alaska" value="alaska">Alaska</option> <option label="Bahamas" value="bahamas">Bahamas</option> <option label="Bermuda" value="bermuda">Bermuda</option> <option label="Canada " value="canada-">Canada </option> <option label="New England" value="new-england">New England</option> <option label="Europe" value="europe">Europe</option> <option label="Greenland" value="greenland">Greenland</option> <option label="Hawaii" value="hawaii">Hawaii</option> <option label="Mexico" value="mexico">Mexico</option> <option label="Panama Canal" value="panama-canal">Panama Canal</option> <option label="South America" value="south-america">South America</option> <option label="Transatlantic" value="transatlantic">Transatlantic</option> <option label="Transpacific" value="transpacific">Transpacific</option> <option label="Asia" value="asia">Asia</option> <option label="Australia" value="australia">Australia</option> <option label="New Zealand" value="new-zealand">New Zealand</option> <option label="South Pacific" value="south-pacific">South Pacific</option> <option label="United States" value="united-states">United States</option> </field> <field type="date" 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"/> <field type="date" label="When would you like to return?" description="This just gives me a general idea of when you like to return; it can be changed later." name="ending-at" className="form-control"/> <field type="checkbox-group" required="true" label="Are your dates flexible?" name="dates-flexible"> <option label="Yes" value="yes">Yes</option> <option label="No" value="no">No</option> </field> <field type="text" required="true" label="What is your departure city?" name="departure-city" subtype="text" className="form-control"/> <field type="radio-group" required="true" label="How many adult travelers?" name="how-many-adult-travelers"> <option label="1" value="1">1</option> <option label="2" value="2">2</option> <option label="3" value="3">3</option> <option label="4" value="4">4</option> <option label="5+" value="5">5+</option> </field> <field type="text" required="true" label="Ages at time of travel?" name="ages-at-time-of-travel" subtype="text" className="form-control"/> <field type="radio-group" required="true" label="Will you have children travelers?" name="will-you-have-children-travelers"> <option label="Yes" value="yes">Yes</option> <option label="No" value="no">No</option> </field> <field type="text" required="true" label="Ages of children&nbsp; at time of travel?" name="text-1775613319802" subtype="text" className="form-control"/> <field type="checkbox-group" required="true" label="Does anyone traveling qualify for one or more of the following discounts?" inline="true" name="does-anyone-traveling-qualify-for-one-or-more-of-the-following-discounts"> <option label="Senior Discount " value="senior-discount-">Senior Discount </option> <option label="Military Discount" value="military-discount">Military Discount</option> <option label="First Responder Discount" value="first-responder-discount">First Responder Discount</option> <option label="None" value="none">None</option> </field> <field type="radio-group" required="true" label="What is your budget per person?" description="This just gives me a general starting point and can always be changed later." name="budget"> <option label="$100 to $999" value="100-to-999">$100 to $999</option> <option label="$1,000 to $1,999" value="1000-to-1999">$1,000 to $1,999</option> <option label="$2,000 to $2,999" value="2000-to-2999">$2,000 to $2,999</option> <option label="$3,000 to $3,999" value="3000-to-3999">$3,000 to $3,999</option> <option label="$4,000 to $4,999" value="4000-to-4999">$4,000 to $4,999</option> <option label="$5,000 to $5,999" value="5000-to-5999">$5,000 to $5,999</option> <option label="$6,000 to $6,999" value="6000-to-6999">$6,000 to $6,999</option> <option label="$7,000 to $7,999" value="7000-to-7999">$7,000 to $7,999</option> <option label="$8,000 to $8,999" value="8000-to-8999">$8,000 to $8,999</option> <option label="$9,000 to $9,999" value="9000-to-9999">$9,000 to $9,999</option> <option label="$10,000+" value="10000">$10,000+</option> </field> <field type="radio-group" required="true" label="Would you like to include Travel Insurance in you quote?" name="would-you-like-to-include-travel-insurance-in-you-quote"> <option label="Yes" value="yes">Yes</option> <option label="No" value="no">No</option> </field> <field type="header" subtype="h1" label="Types of travel - Choose all that apply"/> <field type="checkbox-group" label="Types of travel?" description="Choose all that apply" name="types-of-travel"> <option label="Cruise" value="cruise">Cruise</option> </field> <field type="radio-group" required="true" label="Preferred cabin type" name="preferred-cabin-type" other="true" className="field-hidden"> <option label="Interior" value="interior">Interior</option> <option label="Oceanview" value="oceanview">Oceanview</option> <option label="Balcony/Veranda" value="balconyveranda">Balcony/Veranda</option> <option label="Suite" value="suite">Suite</option> </field> <field type="radio-group" label="Will you need hotel accomodations?" inline="true" name="will-you-need-hotel-accomodations" className="field-hidden"> <option label="Before Cruise " value="before-cruise-">Before Cruise </option> <option label="After Cruise" value="after-cruise">After Cruise</option> <option label="Not Needed" value="not-needed">Not Needed</option> </field> <field type="checkbox-group" label="Types of travel?" description="Choose all that apply" name="checkbox-group-1775874338027"> <option label="Lodging" value="lodging">Lodging</option> </field> <field type="checkbox-group" label="Types of travel?" description="Choose all that apply" inline="true" name="checkbox-group-1775874337498"> <option label="All-inclusive resort" value="allinclusive-resort">All-inclusive resort</option> </field> <field type="radio-group" required="true" label="Preferred room type?&nbsp; (Please note that not all room types are available at all resorts)" inline="true" name="preferred-room-type-please-note-that-not-all-room-types-are-available-at-all-resorts" other="true" className="field-hidden"> <option label="Ocean View " value="ocean-view-">Ocean View </option> <option label="Balcony" value="balcony">Balcony</option> <option label="Beach Front" value="beach-front">Beach Front</option> <option label="Swim Up" value="swim-up">Swim Up</option> <option label="Standard" value="standard">Standard</option> </field> <field type="checkbox-group" label="Types of travel?" description="Choose all that apply" name="checkbox-group-1775874336950"> <option label="Rail Travel" value="rail-travel">Rail Travel</option> </field> <field type="checkbox-group" label="Types of travel?" description="Choose all that apply" inline="true" name="checkbox-group-1775874336395"> <option label="Other" value="other">Other</option> </field> <field type="text" required="true" label="Other type of travel" name="other-type-of-travel" subtype="text" className="form-control"/> <field type="text" label="How many rooms/cabins will you need?" name="how-many-roomscabins-will-you-need" subtype="text" className="form-control"/> <field type="radio-group" required="true" label="What best describes your travel preference?" inline="true" name="hotel-preference" other="true"> <option label="Economy" value="value">Economy</option> <option label="Moderate" value="moderate">Moderate</option> <option label="Luxury" value="luxury">Luxury</option> <option label="Boutique" value="boutique">Boutique</option> </field> <field type="checkbox-group" required="true" label="What kind of vibe are you looking for?" description="Check all that apply." name="vibe-preference" other="true"> <option label="Adults Only" value="adults-only">Adults Only</option> <option label="Romantic" value="romantic">Romantic</option> <option label="Rest and relaxation" value="rest-and-relaxation">Rest and relaxation</option> <option label="Off the beaten path" value="off-the-beaten-path">Off the beaten path</option> <option label="Party" value="party">Party</option> <option label="Local culture" value="local-culture">Local culture</option> <option label="Family friendly" value="family-friendly">Family friendly</option> <option label="Food and wine" value="food-wine">Food and wine</option> </field> <field type="radio-group" label="Preferred bedding? (Please note that not all bed type options may not be available)" inline="true" name="preferred-bedding-please-note-that-not-all-bed-type-options-may-not-be-available" className="field-hidden"> <option label="King Bed " value="king-bed-">King Bed </option> <option label="2 Beds" value="2-beds">2 Beds</option> </field> <field type="checkbox-group" label="What activities are you interested in?" description="Check all that apply" name="activity-preferences" other="true"> <option label="Beach and water" value="beach-water">Beach and water</option> <option label="Gambling" value="gambling">Gambling</option> <option label="Scuba" value="scuba">Scuba</option> <option label="Adventure activities" value="adventure">Adventure activities</option> <option label="Golf" value="golf">Golf</option> <option label="Nightlife" value="nightlife">Nightlife</option> <option label="Arts and theater" value="art-theater">Arts and theater</option> </field> <field type="radio-group" required="true" label="Will you require transportation" inline="true" name="will-you-require-transportation" other="true"> <option label="Shuttle to and from airport " value="shuttle-to-and-from-airport-">Shuttle to and from airport </option> <option label="Rental Car " value="rental-car-">Rental Car </option> <option label="Limousine" value="limousine">Limousine</option> <option label="None" value="none">None</option> </field> <field type="text" label="Anything you absolutely must do or see?" name="must-dos" subtype="text" className="form-control"/> <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"/> <field type="conditionalLogic" label="Conditional Logic" name="conditionalLogic-1775609493792" rule="eyJ3aGVuRmllbGQiOiJ3aWxsLXlvdS1oYXZlLWNoaWxkcmVuLXRyYXZlbGVycyIsIndoZW5Db25kaXRpb24iOiJlcXVhbHMiLCJ3aGVuVmFsdWUiOiJ5ZXMiLCJ0aGVuQWN0aW9uIjoic2hvdyIsInRoZW5GaWVsZHMiOlsidGV4dC0xNzc1NjEzMzE5ODAyIl0sInRoZW5GaWVsZHNJbmZvIjpbeyJuYW1lIjoidGV4dC0xNzc1NjEzMzE5ODAyIiwibGFiZWwiOiJBZ2VzIG9mIGNoaWxkcmVuJm5ic3A7IGF0IHRpbWUgb2YgdHJhdmVsPyJ9XX0="/> <field type="conditionalLogic" label="Conditional Logic" name="conditionalLogic-1775873482605" rule="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"/> <field type="conditionalLogic" label="Conditional Logic" name="conditionalLogic-1775873779138" rule="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"/> <field type="conditionalLogic" label="Conditional Logic" name="conditionalLogic-1775874206716" rule="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"/> <field type="conditionalLogic" label="Conditional Logic" name="conditionalLogic-1775874808106" rule="eyJ3aGVuRmllbGQiOiJjaGVja2JveC1ncm91cC0xNzc1ODc0MzM2Mzk1Iiwid2hlbkNvbmRpdGlvbiI6ImVxdWFscyIsIndoZW5WYWx1ZSI6Im90aGVyIiwidGhlbkFjdGlvbiI6InNob3ciLCJ0aGVuRmllbGRzIjpbIm90aGVyLXR5cGUtb2YtdHJhdmVsIl0sInRoZW5GaWVsZHNJbmZvIjpbeyJuYW1lIjoib3RoZXItdHlwZS1vZi10cmF2ZWwiLCJsYWJlbCI6Ik90aGVyIHR5cGUgb2YgdHJhdmVsIn1dfQ=="/> </fields> </form-template> </body> </html>
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Air Macau (Privileges)
Etihad (BusinessConnect)
Gloria Hotels & Resorts (Gloria Partner)
Santos Hotels (Club Santos)
Known Traveler Number (KTN)
Global Entry ID
TSA PreCheck
NEXUS ID
SENTRI ID
American Automative Association (AAA)
Sandals Select Guest (SSG)
Mandarin Oriental Fan
Relais and Chateaux 5C
Four Seasons Preferred
Dorchester Diamond
Peninsula Pen
Belmond Bellini
Silversea Venetian
Oceania Cruise Lines
Regent Cruise Line
Seabourn Cruise Line
Lindblad Expeditions
SeaDream Yacht Club
Cunard
Virgin Voyages Sailing Club
AmaWaterways
Type
Draw
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