Share your information with Leslie Wilson

Leslie Wilson

Travel Obsession Agency

<html>
  <body>
    <form-template>&#13;
	<fields>&#13;
		<field type="header" subtype="h2" label="Questions for your trip"/>&#13;
		<field type="header" subtype="h1" label="Please complete the attached intake form. Once received I’ll prepare and send a detailed trip package that includes pricing, resort details, and available options.You’ll be able to: Review the full itinerary and estimated costs, pay your deposit to secure your rate, and request any changes or customizations before finalizing."/>&#13;
		<field type="text" required="true" label="First name" name="first-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="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="text" label="Additional Traveler (First Name and Last Name)" description="Provide contact information for your roommate" name="additional-traveler-first-name-and-last-name" subtype="text" className="form-control"/>&#13;
		<field type="text" subtype="email" label="Additional Traveler (Email)" description="Email used to distribute important travel communications" name="additional-traveler-email" className="form-control"/>&#13;
		<field type="radio-group" required="true" label="Preferred Room Type &amp;amp; Estimated Cost Per Person (Based on Double Occupancy)" description="Average starting price per person" name="budget">&#13;
			<option label="Ocean Front- $1600" value="ocean-front-1600">Ocean Front- $1600</option>&#13;
			<option label="Partial Ocean View - $1450" value="partial-ocean-view-1450">Partial Ocean View - $1450</option>&#13;
			<option label="Tropical View - $1350" value="tropical-view-1350">Tropical View - $1350</option>&#13;
			<option label="Flexible - No Preference" value="flexible-no-preference">Flexible - No Preference</option>&#13;
		</field>&#13;
		<field type="radio-group" required="true" label="Room Occupancy&amp;nbsp;" description="How many people will be in your room?" name="room-occupancy-">&#13;
			<option label="Single (1 person )" value="single-1-person-">Single (1 person )</option>&#13;
			<option label="Double (2 people" value="double-2-people">Double (2 people</option>&#13;
		</field>&#13;
		<field type="radio-group" required="true" label="Desired Bedding Configuration&amp;nbsp;" description="How many beds would you prefer?" name="bedding-configuration-">&#13;
			<option label="King" value="king">King</option>&#13;
			<option label="Double " value="double-">Double </option>&#13;
		</field>&#13;
		<field type="header" subtype="h2" label="Travel Preferences"/>&#13;
		<field type="select" label="Preferred Airport&amp;nbsp;" description="Airport you typically fly from when traveling" name="preferred-airport-" className="form-control">&#13;
			<option label="" value=""/>&#13;
			<option label="Charlotte, NC (CLT)" value="charlotte-nc-clt">Charlotte, NC (CLT)</option>&#13;
			<option label="Charleston,SC (CHS)" value="charlestonsc-chs">Charleston,SC (CHS)</option>&#13;
			<option label="Atlanta, GA (ATL)" value="atlanta-ga-atl">Atlanta, GA (ATL)</option>&#13;
			<option label="Washington DC (DCA)" value="washington-dc-dca">Washington DC (DCA)</option>&#13;
			<option label=" LaGuardia NY(LGA)" value="-laguardia-nylga"> LaGuardia NY(LGA)</option>&#13;
			<option label="Columbia, SC (" value="columbia-sc-">Columbia, SC (</option>&#13;
			<option label="Seattle, WA (SEA)" value="seattle-wa-sea">Seattle, WA (SEA)</option>&#13;
		</field>&#13;
		<field type="radio-group" label="Seat preference" name="seat-preference">&#13;
			<option label="Window" value="window">Window</option>&#13;
			<option label="Aisle" value="aisle">Aisle</option>&#13;
			<option label="Opposite aisle" value="opposite aisle">Opposite aisle</option>&#13;
		</field>&#13;
		<field type="header" subtype="h2" label="Passport Info"/>&#13;
		<field type="text" label="Full name as it appears on passport" name="passport-name" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Passport number" name="passport-number" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Country of issue" name="passport-country-of-issue" subtype="text" className="form-control"/>&#13;
		<field type="date" label="Date of issue" name="passport-date-of-issue" className="form-control"/>&#13;
		<field type="date" label="Date of expiration" name="passport-date-of-expiration" className="form-control"/>&#13;
		<field type="radio-group" 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" label="Place of birth" name="place-of-birth" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Nationality" name="nationality" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Citizenship" name="citizenship" subtype="text" className="form-control"/>&#13;
		<field type="radio-group" required="true" label="Travel Insurance" description="Prepare for the unexpected - trip delays  cancellations  medical emergencies  or lost baggage." name="travel-insurance">&#13;
			<option label="Yes - Trip Credit (~110 per person)" value="yes-trip-credit-110-per-person">Yes - Trip Credit (~110 per person)</option>&#13;
			<option label="Yes - Full Refund (~$220 per person)" value="yes-full-refund-220-per-person">Yes - Full Refund (~$220 per person)</option>&#13;
			<option label="No - Decline Travel Protection" value="no-decline-travel-protection">No - Decline Travel Protection</option>&#13;
		</field>&#13;
		<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"/>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>