Share your information with John Balogh

John Balogh

First Choice Travel Agency

<html>
  <body>
    <form-template>&#13;
	<fields>&#13;
		<field type="header" subtype="h2" label="Contact Information as it appears on your Legal Travel Documents"/>&#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="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;
		</field>&#13;
		<field type="date" required="true" label="Date of birth" name="birthday" className="form-control"/>&#13;
		<field type="text" label="Preferred name (nickname)" name="preferred-name" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Primary email address" name="email" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Primary phone number" name="phone-number" subtype="text" className="form-control"/>&#13;
		<field type="radio-group" required="true" label="Do you have a Passport?" name="do-you-have-a-passport">&#13;
			<option label="Yes, I have a passport. (Passport form will be sent)" value="yes-i-have-a-passport-passport-form-will-be-sent" selected="selected">Yes, I have a passport. (Passport form will be sent)</option>&#13;
			<option label="No, I do not have a passport." value="no-i-do-not-have-a-passport">No, I do not have a passport.</option>&#13;
		</field>&#13;
		<field type="header" subtype="h2" label="Promotional Qualifiers"/>&#13;
		<field type="checkbox-group" label="Please Check all boxes that apply" name="please-check-all-boxes-that-apply">&#13;
			<option label="Age 55+" value="age-55">Age 55+</option>&#13;
			<option label="U.S or Canadian Law Enforcement" value="us-or-canadian-law-enforcement">U.S or Canadian Law Enforcement</option>&#13;
			<option label="Fire Department or EMT" value="fire-department-or-emt">Fire Department or EMT</option>&#13;
			<option label="U.S Military or Canadian Forces" value="us-military-or-canadian-forces">U.S Military or Canadian Forces</option>&#13;
		</field>&#13;
		<field type="header" subtype="h2" label="Address"/>&#13;
		<field type="text" 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" label="City" name="address-city" subtype="text" className="form-control"/>&#13;
		<field type="text" label="State" name="address-state" subtype="text" className="form-control"/>&#13;
		<field type="text" 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="header" subtype="h2" label="Important Dates"/>&#13;
		<field type="date" label="Wedding anniversary" name="wedding-anniversary" className="form-control"/>&#13;
		<field type="header" subtype="h2" label="Travel Preferences"/>&#13;
		<field type="radio-group" required="true" label="What best describes your hotel preference?" name="hotel-preference">&#13;
			<option label="Inside Room Economy" value="inside-room-economy">Inside Room Economy</option>&#13;
			<option label="Ocean View Window Moderate" value="ocean-view-window-moderate">Ocean View Window Moderate</option>&#13;
			<option label="Ocean View Balcony Luxury" value="ocean-view-balcony-luxury">Ocean View Balcony Luxury</option>&#13;
			<option label="Ocean View Balcony Suite " value="ocean-view-balcony-suite-">Ocean View Balcony Suite </option>&#13;
		</field>&#13;
		<field type="header" subtype="h1" label="Do you belong to any Loyalty Memberships (Airlines, Hotels, Casino, Etc..,)"/>&#13;
		<field type="clientLoyaltyPrograms" label="Loyalty Programs" name="loyalty-program" loyalty-program-note="*** This field allows your client to enter multiple loyalty program numbers (you only need one of these per form template) ***" className="form-control"/>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>