Share your information with Jodie Hoffman

Jodie Hoffman

Lisell Travel, LLC

<html>
  <body>
    <form-template>&#13;
	<fields>&#13;
		<field type="header" subtype="h2" label="Full name"/>&#13;
		<field type="text" required="true" 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" required="true" 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="header" subtype="h2" label="Contact Information"/>&#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="checkbox-group" required="true" label="Preferred Method of Communication" name="checkbox-group-1764679881729">&#13;
			<option label="Email" value="email">Email</option>&#13;
			<option label="Zoom Meeting (Virtual Meeting)" value="zoom-meeting-virtual-meeting">Zoom Meeting (Virtual Meeting)</option>&#13;
			<option label="Phone Call" value="phone-call">Phone Call</option>&#13;
		</field>&#13;
		<field type="text" required="true" label="Where would you like to travel?" name="text-1764680590642" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="What is your departure city?" name="text-1764682002339" subtype="text" className="form-control"/>&#13;
		<field type="radio-group" required="true" label="Do you need a rental car or transportation arranged while in destination?" name="radio-group-1764682059018">&#13;
			<option label="Yes-rental car" value="yesrental-car">Yes-rental car</option>&#13;
			<option label="Yes-transportation" value="yestransportation">Yes-transportation</option>&#13;
			<option label="No, I do not need transportation arranged" value="no-i-do-not-need-transportation-arranged">No, I do not need transportation arranged</option>&#13;
		</field>&#13;
		<field type="radio-group" required="true" label="Are you traveling with anyone else?" name="radio-group-1764680854431">&#13;
			<option label="No, just me!" value="no-just-me">No, just me!</option>&#13;
			<option label="Yes" value="yes">Yes</option>&#13;
			<option label="I'm not sure yet" value="im-not-sure-yet">I'm not sure yet</option>&#13;
		</field>&#13;
		<field type="checkbox-group" required="true" label="Travel Budget (what is your total budget PER PERSON,&amp;nbsp; If you need flights consider this when determining your per person budget)" name="checkbox-group-1764681234608" other="true">&#13;
			<option label="$1500-$2500" value="15002500">$1500-$2500</option>&#13;
			<option label="$2500-$5000" value="25005000">$2500-$5000</option>&#13;
			<option label="$5000-$7500" value="50007500">$5000-$7500</option>&#13;
			<option label="$7500-$10,000" value="750010000">$7500-$10,000</option>&#13;
			<option label="$10,000-$15,000" value="1000015000">$10,000-$15,000</option>&#13;
			<option label="$15,000-$20,000" value="1500020000">$15,000-$20,000</option>&#13;
		</field>&#13;
		<field type="checkbox-group" required="true" label="Checkbox Group" name="checkbox-group-1764681719545" other="true">&#13;
			<option label="All-Inclusive Resort" value="allinclusive-resort">All-Inclusive Resort</option>&#13;
			<option label="Ocean Cruise" value="ocean-cruise">Ocean Cruise</option>&#13;
			<option label="River Cruise" value="river-cruise">River Cruise</option>&#13;
			<option label="Guided Group Tour" value="guided-group-tour">Guided Group Tour</option>&#13;
			<option label="Customized Individual Land Tour" value="customized-individual-land-tour">Customized Individual Land Tour</option>&#13;
		</field>&#13;
		<field type="checkbox-group" required="true" label="Do you have a valid passport? (Expiration date is 6+months after the date you will return home)" name="checkbox-group-1764681803276">&#13;
			<option label="Yes" value="yes">Yes</option>&#13;
			<option label="No" value="no">No</option>&#13;
			<option label="I have applied for my passport &amp; waiting for it to be returned to me." value="i-have-applied-for-my-passport-waiting-for-it-to-be-returned-to-me">I have applied for my passport &amp; waiting for it to be returned to me.</option>&#13;
			<option label="My trip does not require a passport." value="my-trip-does-not-require-a-passport">My trip does not require a passport.</option>&#13;
		</field>&#13;
		<field type="text" required="true" label="Are you celebrating a special occassion during this trip?&amp;nbsp; If so, please provide details" name="text-1764682477143" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="How did you learn about Jade Horizons or who can we thank for referring you to us?" name="text-1764682533169" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Please provide any additional information or details you would like for us to be aware of." name="text-1764682592338" subtype="text" className="form-control"/>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>